At first, the president of the big APA, Charles Kiesler, wrote to the American Psychiatric Association in diplomatic fashion: “I do not wish partisan conflict between our associations. In that spirit, the American Psychological Association wishes to offer its complete services to assist the American Psychiatric Association in the further development of the DSM-III.” Spitzer’s response was equally cordial: “We certainly believe that the American Psychological Association is in a unique position to help us in our work.” He included, with his reply, the latest draft of the DSM-III—which unambiguously asserted that mental illness was a medical condition. Now President Kiesler cut to the chase:
Since there is an implication that mental disorders are diseases, this suggests that social workers, psychologists, and educators lack the training and skills to diagnose, treat, or manage such disorders. If the current approach is not altered, then the American Psychological Association will embark on its own truly empirical venture in classification of behavioral disorders.
Kiesler’s thinly veiled threat to publish his own (nonmedical) version of the DSM had an effect other than the one intended: It provided Spitzer with an opening to retain his medical definition. Spitzer wrote back and politely encouraged him and the American Psychological Association to pursue their own classification system, suggesting that such a book might be a valuable contribution to mental health. In reality, Spitzer guessed (correctly) that the formidable demands of pursuing such an undertaking—which he was in the midst of himself—would ultimately prevent the big APA from pulling it off; at the same time, his endorsement of Kiesler’s project provided Spitzer with cover for the DSM-III ’s medical definition—after all, the psychologists were free to put their own definition of mental illness in their own book.
But Spitzer’s biggest battle by far—truly a battle for the soul of psychiatry—was a winner-take-all clash with the psychoanalysts. Psychoanalytic institutions did not pay much attention to the DSM-III Task Force for the first two years of its existence, and not just because they didn’t care about the classification of mental disorders. They simply had little to fear from anyone: For four decades, the Freudians had ruled the profession unchecked. They controlled the academic departments, university hospitals, private practices, and even (so they assumed) the American Psychiatric Association; they were the face, voice, and pocketbook of psychiatry. It was simply inconceivable that something as insignificant as a classification manual would threaten their supreme authority. As Donald Klein, a member of the DSM-III Task Force, put it, “For the psychoanalysts, to be interested in descriptive diagnosis was to be superficial and a little bit stupid.”
The Midstream conference had roused the psychoanalysts from their apathy, though, forcing them to confront the possible effects of the DSM-III on the practice and public perception of psychoanalysis. Shortly after the conference, one prominent psychoanalyst wrote to Spitzer, “The DSM-III gets rid of the castle of neurosis and replaces it with a diagnostic Levittown,” comparing Spitzer’s Manual to a cookie-cutter housing development being built on Long Island. Two other prominent psychoanalysts charged that “the elimination of the psychiatric past by the DSM-III Task Force can be compared to the director of a national museum destroying his Rembrandts, Goyas, Utrillos, van Goghs, etc. because he believes his collection of Comic-Strip Type Warhols has greater relevance.”
But on the whole, since the psychoanalysts still had such a hard time believing that anything meaningful would come out of Spitzer’s project, there was never any great urgency behind their response. After all, the publication of the DSM-I and DSM-II had produced no noticeable impact on their profession. It took more than nine months after the Midstream conference for the first group of psychoanalysts to approach Spitzer with a formal request. The president and president-elect of the American Psychoanalytic Association sent a telegram to the APA asking that they postpone any more work on the DMS-III until the American Psychoanalytic Association had a chance to thoroughly evaluate its existing content and review the process by which any additional content would be approved. The APA refused.
In September of 1977, a liaison committee was formed consisting of four or five psychoanalysts from the APsaA who began to pepper Spitzer and the Task Force with requests. At about the same time, another group of four or five psychoanalysts from the powerful Washington, DC, branch of the APA also began to lobby for changes in the DSM-III. The Washington branch was probably the most influential and best organized unit of the APA, owing to the large number of psychiatrists in the nation’s capital drawing business from the superior mental health benefits offered to federal employees. For the next six months, Spitzer and the psychoanalysts jousted over changes to the definitions of disorders.
At one point, Spitzer informed the Task Force that he was going to concede to some of the psychoanalysts’ requests as a political necessity to ensure the adoption of the DSM-III. To his surprise, the other Task Force members unanimously voted him down. Spitzer had chosen his Task Force because of their commitment to sweeping changes, and now their uncompromising devotion to these principles exceeded his own. Emboldened by his own team to hold the line, Spitzer repeatedly informed the psychoanalysts that he could not fulfill their requests.
As the critical vote drew near, psychoanalytic factions presented alternative proposals and engaged in frenzied efforts to pressure Spitzer into accepting their demands. But Spitzer, having devoted almost every waking hour to the DSM for four years, was always ready with a response that drew upon scientific evidence and practical arguments to support his position, while the psychoanalysts were often left stammering that Freudian psychoanalysis needed to be upheld on the basis of history and tradition. “There were disputes over the placement of each word, the use of modifiers, the capitalization of entries,” Spitzer told historian Hannah Decker. “Each adjustment, each attempt at fine tuning, carried with it symbolic importance to those engaged in a process that was at once political and scientific.”
Spitzer plowed through the testy negotiations and contentious wordsmithing until he had a final draft in early 1979. All that remained was for it to be ratified at the May meeting of the APA Assembly. With the vote looming, the psychoanalysts finally appreciated just how high the stakes were and ratcheted up the pressure on both the Task Force and the APA Board of Trustees with fierce determination, frequently warning that the psychoanalysts would abandon the DSM-III (and the APA)en masse if their demands were not met. As the long-awaited date of the vote approached, the final counterassault launched by Spitzer’s opponents targeted a critical component of psychoanalysis—neurosis. Neurosis was the fundamental concept of psychoanalytic theory and represented to its practitioners the very definition of mental illness. It was also the primary source of professional revenue in clinical practice, since the idea that everyone suffers from some kind of neurotic conflict drove a steady stream of the worried well onto shrinks’ couches. As you can imagine, the psychoanalysts were horrified when they learned that Spitzer intended to expunge neurosis from psychiatry.
The influential and iconoclastic psychiatrist Roger Peele was the head of the DC branch of the APA at the time. While Peele generally supported Spitzer’s diagnostic vision, he felt obligated to challenge Spitzer on behalf of his psychoanalytic constituency. “The most common diagnosis in DC in the 1970s was something called depressive neurosis,” Peele said. “That was what they were doing day after day.” He put forward a compromise plan called the Peele Proposal, which argued for the inclusion of a neurosis diagnosis “to avoid an unnecessary break with the past.” The Task Force shot it down.
In the final days before the vote, a flurry of other proposals were put forth to save neurosis, with names like the Talbott Plan, the Burris Modification, the McGrath initiative, and Spitzer’s own Neurotic Peace Plan. All were rejected by one side or the other. At last, the fateful morning arrived—May 12, 1979. Even at this late stage, the psychoanalysts made one final push. Spitzer countered with a compromise: While
the DSM would not include any neurosis-specific diagnoses, it would list alternative psychoanalytical names for certain diagnoses without changing the criteria for the diagnoses (such as “hypochondriacal neurosis” for hypochondriasis or “obsessive-compulsive neurosis” for obsessive-compulsive disorder), and one appendix would include descriptions of “Neurotic Disorders” in language similar to the DSM-II. But would this paltry concession satisfy the rank-and-file psychoanalysts of the APA Assembly?
Three hundred and fifty psychiatrists gathered together in a large ballroom in the Chicago Conrad Hilton Hotel. Spitzer stepped onto the two-tiered stage, explained the goals of the Task Force, and briefly reviewed the DSM process before presenting the final draft of the DSM-III to the assembly, parts of it typed up mere hours before. But the psychoanalysts squeezed in one last Hail Mary.
Psychoanalyst Hector Jaso made the motion that the assembly adopt the draft of the DSM-III—with one amendment. “Depressive neurosis” would be inserted as a specific diagnosis. Spitzer retorted that its inclusion would violate the consistency and design of the entire Manual, and besides—the existence of depressive neurosis simply wasn’t supported by the available data. Jaso’s motion was put to an oral vote and was resoundingly defeated.
But was the assembly rejecting a last-second change, or voicing disapproval of the entire DSM-III project? At long last, after tens of thousands of man-hours of labor, the product of Spitzer’s visionary framework, the DSM-III, was put to a vote. The assembly was virtually unanimous in their response: YES.
“Then a rather remarkable thing happened,” Peele reported in The New Yorker. “Something that you don’t see in the assembly very often. People stood up and applauded.” Shock spread across Spitzer’s face. And then: “Bob’s eyes got watery. Here was a group that he was afraid would torpedo all his efforts and aspirations, and instead he got a standing ovation.”
How did Spitzer manage to triumph over psychiatry’s ruling class? Even though the psychoanalysts vigorously resisted his efforts to eliminate Freudian concepts, for most Freudians the benefits of Spitzer’s transformative book outweighed its shortcomings. They were, after all, fully aware of psychiatry’s public image problem and the threat posed by the antipsychiatrists. They realized that psychiatry needed a makeover and that this makeover had to be grounded in some form of medical science. Even Spitzer’s adversaries recognized that his radical new Diagnostic Manual offered a lifeline to the entire field, a chance to restore psychiatry’s battered reputation.
The DSM-III ’s impact was just as dramatic as Spitzer hoped. Psychoanalytic theory was permanently banished from psychiatric diagnosis and psychiatric research, and the role of psychoanalysts in APA leadership was greatly diminished thereafter. The DSM-III turned psychiatry away from the task of curing social ills and refocused it on the medical treatment of severe mental illnesses. Spitzer’s diagnostic criteria could be used with impressive reliability by any psychiatrist from Wichita to Walla Walla. The Elena Conways and Abigail Abercrombies of the world, neglected for so long, once again assumed center stage in American psychiatry.
There were unintended consequences as well. The DSM-III forged an uneasy symbiosis between the Manual and insurance companies that would soon come to influence every aspect of American mental health care. Insurance companies would only pay for certain conditions listed in the DSM, requiring psychiatrists to shoehorn ever more patients into a limited number of diagnoses to ensure that they would be reimbursed for the care provided. Even though the Task Force intended for the DSM-III to be used only by health care professionals, the Manual’s anointed diagnoses immediately became the de facto map of mental illness for every sector of society. Insurance companies, schools, universities, research funding agencies, pharmaceutical companies, federal and state legislatures, judicial systems, the military, Medicare, and Medicaid all yearned for consistency in psychiatric diagnoses, and in short order all of these institutions tied policies and funding to the DSM-III. Never before in the history of medicine had a single document changed so much and affected so many.
I wasn’t at the momentous Chicago meeting when the APA Assembly approved the DSM-III, though I had the good fortune of presiding over the last public appearance that Spitzer ever made. Bob was forced into retirement in 2008 by a severe and debilitating form of Parkinson’s disease. To mark his retirement, we organized a tribute to celebrate his remarkable achievements that was attended by psychiatric luminaries and Bob’s protégés. They took turns speaking about the man who had so profoundly shaped their careers. Finally, Bob rose to speak. He had always been a powerful and disciplined orator, but as he began his remarks he broke into uncontrollable sobs. He was unable to go on, overwhelmed by the sincere show of affection and admiration. As he continued to weep, I gently took the microphone from his trembling hand and told everyone that the last time Bob was speechless at the assembly meeting in Chicago was when the APA passed the DSM-III. The audience rose to their feet and gave him an ovation that rolled on and on and on.
Festschrift for Robert Spitzer. From left to right: Michael First (psychiatrist and protégé of Spitzer who worked on DSM-III, IV, and 5), author Jeffrey Lieberman, Jerry Wakefield (professor of social work at New York University), Allen Frances (psychiatrist, Spitzer protégé, and chair of the DSM-IV Task Force), Bob Spitzer (psychiatrist and chair of the DSM-III Task Force), Ron Bayer (professor of sociomedical science at Columbia University and author of a book on the removal of homosexuality from the DSM), Hannah Dekker (historian and author of The Making of DSM-III ), and Jean Endicott (psychologist and colleague who worked with Spitzer). (Courtesy of Eve Vagg, New York State Psychiatric Institute)
Part II
The Story of Treatment
If only his mind were as easy to fix as his body.
—HAN NOLAN
Chapter 5
Desperate Measures: Fever Cures, Coma Therapy, and Lobotomies
What can’t be cured must be endured.
—ROBERT BURTON
Rose. Her head cut open.
A knife thrust in her brain.
Me. Here. Smoking.
My father, mean as a
devil, snoring—1000 miles
away.
—TENNESSEE WILLIAMS, ON HIS SISTER ROSE’S LOBOTOMY
The Snake Pit
For the first century and a half of psychiatry’s existence, the only real treatment for severe mental illness was institutionalization. In 1917, Emil Kraepelin captured the pervasive sense of hopelessness among clinicians when he told his colleagues, “We can rarely alter the course of mental illness. We must openly admit that the vast majority of the patients placed in our institutions are forever lost.” Thirty years later, things had hardly improved. The pioneering biological psychiatrist Lothar Kalinowsky wrote in 1947, “Psychiatrists can do little more for patients than make them comfortable, maintain contact with their families, and, in the case of a spontaneous remission, return them to the community.” Spontaneous remission—the only ray of hope for the mentally ill from the 1800s through the 1950s—was in most cases about as likely as stumbling upon a four-leaf clover in a snowstorm.
At the start of the nineteenth century, the asylum movement barely existed in the United States, and there were very few institutions dedicated to the mentally ill in which to confine affected individuals. In mid-century the great crusader for the mentally ill, Dorothea Dix, persuaded state legislatures to build mental institutions in significant numbers. By 1904 there were 150,000 patients in asylums, and by 1955, there were more than 550,000. The largest institution was Pilgrim State Hospital, in Brentwood, New York, which at its peak housed 19,000 mental patients on its sprawling campus. The institution was a self-contained city. It possessed its own private water works, electric light plant, heating plant, sewage system, fire department, police department, courts, church, post office, cemetery, laundry, store, amusement hall, athletic fields, greenhouses, and farm.
The ever-expanding number of institutionalize
d patients was an inescapable reminder of psychiatry’s inability to treat severe mental illness. Not surprisingly, when so many incurable patients were forced together, the conditions in asylums often became intolerable. In 1946, a forty-one-year-old writer named Mary Jane Ward published an autobiographical novel, The Snake Pit, which depicted her experience in Rockland State Hospital, a mental institution in Orangeburg, New York. After being erroneously diagnosed as schizophrenic, Ward was subjected to an unrelenting stream of horrors that seem the very opposite of therapeutic: rooms overcrowded with unwashed inmates, extended periods in physical restraints, prolonged isolation, raucous noise around the clock, patients wallowing in their own excrement, frigid baths, indifferent attendants.
While the conditions of mental hospitals were undeniably wretched, there was precious little the staff could actually do to improve their patients’ lot. The government-supported budgets for state institutions were always inadequate (though they usually ranked among the most expensive items in any state budget), and there were always more patients than the underfunded institutions were built to handle. The bleak reality was that there was simply no effective treatment for the illnesses that afflicted institutionalized patients, so all the asylums could hope to accomplish was try to keep their overcrowded patients warm, well-fed, and free from harm.
Shrinks Page 14
