1 Boring Old Man

In his Psychology Today blog posts, Dr. Frances offered some explanations. The Task Force was heavily populated with researchers, primarily biological researchers, rather than clinicians. And perhaps their close proximity to all the exciting new technology and findings in neuroscience influenced them. Sales of the DSMs are a big financial resource for the American Psychiatric Association, and maybe the rush to print was driven by financial need, particularly in the face of waning membership and dramatically falling revenue from drug company sponsorship. I expect we all think that the heavy representation on the Task Force from people with ties to the pharmaceutical industry was a factor.  Age-wise, the majority of psychiatrists have spent most of their careers in an era of biology and neuroscience in psychiatry. So another possibility is that they really believe that mental illness is largely biologically determined. Certainly, the combination of the alliances with the pharmaceutical industry and the extreme restrictions of the third party carriers have painted psychiatrists into a specific corner – doing medication management for patients who are primarily being treated by therapists in other disciplines. So there’s something about professional survival to be considered.

All of those things might be important factors and I’m not the person to parse them out. I’m just too negative about the product [DSM-5] to trust my objectivity. But there’s one infrequently mentioned factor that I personally put in the center of the circle. I began this little series with a quote from Dr. Melvin Sabshin’s book Changing American Psychiatry: A Personal Perspective who asked "How could a professional organization engineer a scientific revolution that changed its core? According to conventional wisdom, organizations respond; they do not initiate." He took on the job of changing American psychiatry as Medical Director of the American Psychiatric Association. While he was a disaffected psychoanalyst, he was strong on the bio-psycho-social model and not an ideologue. But he lent the power of the APA to Dr. Spitzer and the neoKraepelinians and they collectively did exactly what his book title said they did. He’s right that "conventional wisdom" would not have put him or the revision of the DSM in a position to do that. It was a singular and unexpected move for the APA itself to take the reins and direct the course of the specialty’s history.

I’m not complaining about that move on their part. The crisis was real and the position of organized psychoanalysis was as unhelpful and rigid as they said it was. Some kind of negotiated settlement was as unlikely as the DSM-5 Task Force listening to Drs. Spitzer and Frances turned out to be. When all of this was happening, I was a candidate in a traditional institute, but I agreed myself that things needed changing badly. I saw my training as a way to learn to be a better psychotherapist – which it was, but have always been more psychiatrist than analyst. I didn’t expect the purge that followed, but that’s how such things go apparently. I didn’t care for the DSM-III, but I didn’t care much about it either. I sure didn’t see that it would become a vehicle for the overuse of medications or some of the other awful things that came in its wake. The only part I really had much energy for was the way they dealt with depression, but I’ve said more than enough about that already. My point here isn’t really about the DSM-III itself, or even that Drs. Sabshin, Spitzer, and others did a power grab to make it happen. My focus here is that once the APA took control, they never let it go. I think power in organizations and governments must be like that – once seized, it’s rarely relinquished. So the APA has continued to direct the course of things for the last thirty years. I didn’t drop out of the APA because of the DSM-III, I left because the APA became a club I didn’t want to be in, run by a clique with its own agenda, and frankly seemed the agent of problems rather than a forum for solutions.

So I think a major reason the DSM-5 revision has gone so badly and has been so unresponsive is rooted in the arrogance of the APA itself persistent since the 1970s. The APA has done nothing about the problem of the industry aligned KOLs, about ghost writing, about conflicts of interest, about over-medication, about much of anything that has to do with the front running issues of the time. When Senator Grassley investigated blatant conflicts of interest and unreported income, the APA president elect was on the list, yet he served his term and remains active in APA affairs. Psychiatry and psychiatric treatment has been at the center of not just controversy but public scandal and corruption, and the APA has taken no real action, said little that mattered, and continued to push the specialty in the same directions. The DSM-5 is a compendium of ill-advised changes and missed opportunities, yet the Board of Trustees largely rubber stamped the product – axing only a few obvious disasters [like the dimensional system].