1 Boring Old Man

"After about two years on the job, the plans for change were becoming clearer in my mind. Some ideas about the Diagnostic and Statistical Manual of Mental Disorders [DSM] had begun to be formulated just before I came to the APA, as discussed in Chapter 10 ["Evidence Based Diagnosis and Treatment"]. The awareness of how the DSM and Practice Guidelines could radically effect the image of the field and its scientific status struck me as a powerful insight during my second year in office. The interaction of a new medical and scientific identity for psychiatry coalesced with plans to build coordinated Offices of Research, Education, Government Relations, Public Affairs, and Business Administration. This made sense in thinking how to achieve a newly clarified mission"…
Dr. Mel Sabshin, in Changing American Psychiatry

Dr. Sabshin was the respected Medical Director of the American Psychiatric Association from 1974 through 1997 – both architect and long-running project director of the radical changes in the specialty that came to the stage in 1980 with the release of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition [DSM-III]. And at this point, no one would question that "the DSM and Practice Guidelines could" [and did] "radically effect the image of the field and its scientific status." There are still many versions of this story, but too many still carry a personal take on the journey to pull out the kind of summary we might get from some future history book surveying the 35 years between then and now. The main narrative is of a revolt against the dominant ideology of the time, psychoanalysis, and a move into the world of "Evidence Based Diagnosis and Treatment" – the scientific mainstream of medicine. A contrary version describes it as the unfounded assumption of a biological causality for mental illness and the primacy of medication in treatment, fueled by grossly inappropriate commercial interests. Surely that future history book will have a more nuanced version that parses the many other forces that have bearing on the topic. But this post isn’t about the a priori reasons or legitimacy of what happened in those days. And it’s not about the ad hoc consequences of the change itself [intended or otherwise]. It’s about the consequences of the method.

"How could a professional organization engineer a scientific revolution that changed its core? According to conventional wisdom, organizations respond; they do not initiate. By the 1970s psychiatry in the United States had begun to undergo massive changes. The postwar glow had been replaced by the new pressure for accountability on all of medicine, Many leaders in psychiatry deplored the ideological rifts that had divided the field, and they called far a more unified, scientifically based profession. They deplored the "demedicalization" of psychiatry and its severe loss of credibility… The field’s ideological schisms had weakened us seriously, and psychiatrists bitter public disagreements were self-destructive. To cover up these differences or to act solely because of the criticism was not in itself sufficient; psychiatry had to adopt a genuine commitment to science rather than to ideology. It needed to change the profession fundamentally if it was to become a respected part of medicine. To accede to the pressures without radical modifications of the field would not have convinced others that the profession had changed. A new strategy was essential! Producing the DSM-III stated emphatically that psychiatry in America chose an evidence-based practice rather than ideology"…
Dr. Mel Sabshin, in Changing American Psychiatry

At the time all of this happened, I was too otherwise-engaged to offer much wise commentary on the climate of those times [directing a psychiatric residency in a time of Cholera in Atlanta and in the middle of a psychoanalytic training program in New York]. What I recall was receiving copy of the DSM-III and being mystified by its thickness and content. By the time I finished my psychoanalytic training in 1984, I had already resigned from my academic position and was spending a lame-duck year setting up a practice. If asked about all of this back then, I would’ve had nothing much to coherent to say. I remember thinking about my parents’ lives, so heavily shaped by the Great Depression and World War II. I guess I saw what was happening in psychiatry as my turn to be swept along by forces too big to really understand and my job was to personally adapt as best I could. I do know that academic psychiatry, our journals, and the American Psychiatric Association [APA] quickly became foreign to me, and I gradually withdrew from that arena that had been central to my life for a few good learning years. The other personal thing to add is that I now think my first medical specialty, Internal Medicine, privately remained my primary identity, and my somewhat immigrant status added to my sense of viewing the changes in psychiatry from afar, an additional alienation of sorts [primary identities can be sticky]. In spite of all of those personal provisos, I still think that my impression that the APA became and remained the central driving force in the shape and course of the American psychiatry that followed 1980 is a valid observation.

Following the DSM-III publication, the APA seemed to quickly biologize, neoKraepelinize, and medicalize in its meeting agendas, its journals, its leadership, and the books that flowed from the APPI [its new publishing arm, also founded by Dr. Sabshin]. The speed of that change as I saw it may well have been partially a local illusion, because where I was, it coincided with the retirement of a long-standing [department-founding] Chairman, and the arrival of a young new DSM-III-etc convert. So it was abrupt for me. And the -izes I described weren’t the most obvious things at the time, more in the range of something seen through a retrospectoscope. What it felt like at the time was that psychiatry homogenized, and organized around a new religion. And while the DSM-III, DSM-IIIR, and DSM-IV may have remained etiologically neutral, the APA everything-else gradually became strongly biomedical. However things happened, after successfully taking over control of psychiatry with its publication of the DSM-III, the APA hierarchy continued to be a power-base unto itself that controlled the directions of the specialty – at least that’s how it felt to me. "The field’s ideological schisms" and "psychiatrists bitter public disagreements" miraculously seemed to evaporate – at least from the front burners. But as time passed, the APA, academic psychiatry, and the NIMH shared in their complicity with the growing influence of the pharmaceutical industry in the ways and means of psychiatry [though that wasn’t so apparent at the outset] – something I wouldn’t have even imagined [and didn’t]. The Managed Care industry and the Hospital Corporations were also part of that story. Yet, from my perspective as a semi-outsider, I’ve should’ve noticed that I never never saw the APA, academic psychiatry, or the NIMH take a strong ethical stand countering the growing misbehavior of industry or the participation of some of their own higher-ups [sometimes highest-ups], no matter how questionable the practices.

By 2002, the APA’s DSM-V [soon to be DSM-5] Task Force announced it was going to add biological correlates to the new Diagnostic Manual and initiated an elaborate series of symposiums in preparation [see dreams of our fathers VII…]. It was to be a paradigm changing revision, realizing the dream of at least some of its neoKraepelinian founders – some even called psychiatry Clinical Neuroscience. The Task Force sauntered along unopposed until it finally hit some blowback – ironically, from two strong, Robert Spitzer [architect of DSM-III and DSM-IIIR] and Allen Frances [Director of the DSM-IV revision]. Spitzer weighed in about the [secret] secrecy of the DSM-V Task Force in 2008, and Frances entered the fray in 2009 over multiple issues in the DSM-V process as well as some of the emerging changes [and omissions] as they became apparent [semi-apparent]. The APA response to the criticism was anything but pretty [see the summer of 09… and dangerous men…]. The premise of this post is that the APA’s power play with the DSM-III under Dr. Sabshin never really ended. What began as something of the emergency assumption of power and control in the wake of a crisis ["A new strategy was essential!"] became a chronic way of life.

An understanding of Crisis Intervention is an essential ingredient in the tradecraft of any mental health professional. We don’t intervene in crisis states just to eliminate painful symptoms, nor to solve the particular situation underlying the crisis at the moment. People resolve crises with or without any help to escape the pain and fear. Crisis Intervention comes under the heading of Preventive Psychiatry, so first it’s important to know what is being prevented. In crises, emotions maximize and can become the problem themselves – so people jump to their deaths instead of waiting for the fireman’s ladder being raised to save them. On the other hand, they sometimes solve the problem too well based on the moment, and set the stage for the next problem [that they didn’t anticipate]. So the point of crisis intervention is to make sure that the sense of urgency and fear doesn’t cloud the senses and create future not-so-hard-to-see-coming "unintended consequences." If the Crisis Interventionist solves the problem for the patient, all that’s learned is for the patient to return with the next crisis for some more magic. As an example, Robert Spitzer was, in my opinion, so worried that the psychoanalysts and psychotherapists would reframe any equivalent of the former "depressive neurosis" to fit their own models, that he left it out altogether. By lumping together widely diverse groups of patients into his Major Depressive Disorder [MDD] category, he created a category exploited to the tune of billions by industry, got many people overmedicated, shut down promising research avenues by dilution, deprived some people of the kind of "talking" therapy they could have used, and created a thirty-five year fiction. By my read, that was hardly Robert Spitzer’s intent. But it still happened [is happening].

Mel Sabshin, Robert Spitzer, and many others were pleasantly surprised at the positive reception they received with the DSM-III, which I’m sure felt like a reward for a job well done confirming the rightness of their path. That may well have even been partially true at the time. The turmoil abated – surprisingly quickly. The psychoanalytic and psychotherapy types either converted or went quietly elsewhere, and the evidence-based metaphor swept through the specialty, followed in a few years by drugs from an industrial pipeline. Many psychiatrists changed their spots and became evidence-based medication managers, treating patients referred by their other mental health therapists, from within networks constructed by managed care MBAs, prescribing drugs from the pharmaceutical companies, approved for specific DSM-III diagnoses by the FDA, based on evidence-based clinical trials with academic psychiatrists as principle investigators, advertised by articles with academic psychiatrists on their bylines, published in peer reviewed journals. And evidence-based came to mean statistical significance in a Randomized Clinical Trial of a drug or a treatment. The Clinical Trial was usually designed and financed by a pharmaceutical company on its own drug, conducted by a contracted Clinical Research Organization, turned into an article by a contracted medical writing firm, then submitted to a peer reviewed journal by guest-author psychiatrist[s] with academic credentials.