On December 25, 2015, renowned psychiatrist Robert Spitzer died. Spitzer was a giant in world psychiatry, best known as the architect of the third edition of the psychiatry’s diagnostic bible — The Diagnostic and Statistical Manual of Mental Disorders (DSM-III) — the edition that effected a turnaround and became the template for how psychiatric diagnosing has proceeded ever after. As such, this death has hardly gone unnoticed, with stories about him proliferating. Most of what is written is highly laudatory. We are told, for instance, that he placed psychiatric diagnosis on a scientific foundation, that he introduced rigor (see, for instance, this article in the New York Times), that he was a “pro-gay psychiatrist” who “campaigned to remove homosexuality from the Diagnostic and Statistical Manual of Mental Disorders.” (Newsman. This article takes serious issue with the most significant of the claims.
To be clear, it is always sad when someone dies — and I in no way wish to detract from the personal tragedy. Nor do I intend to make any pronouncement about Spitzer the individual. What concerns me in this article is one thing only — how to understand his “psychiatric contribution” to society. Now no one denies that Spitzer was enormously influential. However, it is precisely because his legacy endures and because vulnerable people are forced to live with what was set in motion that I felt compelled to write this article.
So what are we to make of the claims? And what in fact is Spitzer’s legacy?
Claim: Spitzer Was Enlightened and Opposed the Pathologizing of Gays
It is claimed that Spitzer was largely responsible for removing “Homosexuality” as a disorder from the DSM. This claim has some merit. Nonetheless, the situation is not as straightforward as it appears.
The American Psychiatric Association (APA) was in difficulty at the time. Gay rights activists were skillfully protesting the inclusion of said disorder, interrupting meeting after meeting of the APA (see Teal, 1971). Spitzer was called in to help. His actions eventually culminated in a postal vote and the concomitant removal of the offending diagnosis from the DSM. That this is an important legacy is without question.
At the same time, Spitzer was hardly the great liberator suggested by most who tell this story. What is significant in this regard; he went on to introduce another disorder which also pathologized gay life — ego-dystonic homosexuality. This was a particular worrisome diagnosis for it pathologized discomfort with being gay — a reaction totally expectable in a homophobic world. Herein we find an unfortunate default mode which characterized Spitzer and those who followed him — totally ignoring context. As for the question of gay existence per se, for most of his professional career, Spitzer flip-flopped on it. In the early 2000s, for example, mounting a study in support of a therapy to “cure” people of being gay, and in 2012 retracting said study — albeit only after it was exposed for shoddy scholarship (see this article in the Washington Post).
The Major Claim: With the DSM-III, Spitzer Introduced Rigorous Science and Thereby Made Diagnostic Psychiatry Credible
This brings us to the main claims and without question the central “contribution” for which Spitzer is known – the revolution that constitutes DSM-III. On this “contribution” clarity is critical — for to misunderstand it is to misunderstand the nature of the psychiatric quagmire that we as a society are facing to this day.
The claim put forward by almost all psychiatrists, including those of a reformist bent, is that Spitzer placed psychiatric assessment on a more or less solid scientific foundation. States “psychiatric reformer” Dr. Allen Frances in this regard, “He [Spitzer] saved the field … from a crisis of credibility, raising its scientific standards.
There are two sets of claims involved. The first is that psychiatry was suffering a crisis of credibility, that Spitzer introduced a new approach to diagnosis with DSM-III, and that in the process he shepherded psychiatry through the crisis. To start at the beginning, there was indeed a crisis at the time: Psychiatric diagnoses had been shown to have extremely low inter-rater reliability. That is, the chance of different psychiatrists assigning the identical diagnostic category to the same patient was low — little more than chance. Moreover, a major experiment by Rosenhan (1973) had exposed psychiatry on an even more basic level.
The experiment involved Professor Rosenhan sending students pretending to be disturbed into hospitals. While the students proceeded to act “normal” except for initially telling staff that they had heard a voice saying, “hollow,” “thud,” and “empty,” all were kept a sizeable time and all were assigned major diagnoses. When the results of the experiment became known, the public’s reaction was that psychiatrists could not even distinguish between “real patients” and “pseudo-patients” — never mind between different “disorders.” And as such, the credibility of the diagnoses, and by extension, psychiatry itself, was at an all-time low.
Did the reputation of each improve after the introduction of DSM-III (1980)? Yes, it very much did. And was this because of how DSM-III was constructed? To a significant degree, yes. And was this because, as claimed, psychiatric diagnosing had finally been placed on a sound scientific footing? In a word; no.
By way of explanation; Spitzer for sure created discrete diagnoses. Correspondingly, unlike in the past, they came complete with explicit sets of criteria, superficially at least reflecting how physical disorders are delineated. And for sure, tests were conducted and validity thereby “claimed” for each of the included disorders. The point is, however, that mirroring the trappings of medicine — that is, using medical-sounding language — has no bearing on validity.
Aside from the inherent persuasiveness of medicalized language, what exactly was Spitzer’s claim to validity? Quite simply, that the research conducted by his team had established high inter-rater reliability. The problem here is that high inter-rater reliability similarly has nothing to do with validity. To quote a passage from Burstow (2015) in this regard:
“The fact that people can be trained to apply a label in a consistent way, note, does not mean that the label points to anything real. To use an extreme example, let us say that we want doctors to be able to identify people walking about who secretly hail from Mars. We might provide clear criteria for such people and so carefully train the doctors that they achieved a high level of agreement when making their determinations. None of this gets around the problem that there are in all likelihood no people from Mars walking the earth.” (p. 78)
A still further problem enters in with Spitzer’s very claim to high inter-rater reliability. At their most successful, there was miniscule difference between the reliability ratings for DSM-III diagnoses and the rating for previous “disorders.” Often there was no difference at all, and at times the DSM-III scores were lower. This despite the fact, as Kirk and Kutchins (1997, p. 52 ff.) demonstrate, that experiments were rigged so as to create superior results, including providing the DSM-III raters with extensive training so that their scores would be bolstered. Additionally, different criteria were used when re-evaluating the DSM-II studies than when interpreting the DSM-III studies — thereby creating the impression/misimpression that the DSM-III categories yielded superior results. One obvious example is that the very same level of agreement that was deemed “only satisfactory” in the reevaluation studies (e.g., 7) was deemed “high” or “very high” in the studies involving the DSM-III categories.
This is not medicine. This is not science. And this is not rigor.
So if the claim to high scientific standards will not hold—and, as you can see, it will not — exactly what was the revolution that DSM-III constituted?
What was introduced was a classification schema that was avowedly neo-Kraepelian (see Kraepelin, 1907 and Burstow, 2014) — that is, an etiology-free schema which has little tie-in with the realities of people’s actual lives and, as such, is largely classification for classification’s sake. In the DSM as it emerged, there is no thought to why people are acting as they are. The not-so-hidden benefit to psychiatry is that the new schema put an end to most internal squabbles, for it is precisely when it comes to issues of cause and what something is “about” that arguments break out. The ramification of such a system, correspondingly, is that the label or diagnosis itself ends up being treated as causal. The circularity thereby engendered is visible in this comment which I made in a recent interview:
“[The DSM) sets practitioners up to look at distressed and/or distressing people in certain ways. So, if they go into a psychiatric interview, they’re going to be honing on questions that follow the logic of the DSM, or to use their vocabulary, the “symptoms” for any given “disease” they’re considering. In the process it rips people out of their lives. And so now there’s no explanation for the things people do, no way to see their words or actions as meaningful because the context has been removed. In essence, the DSM decontextualizes people’s problems, then re-contextualizes them in terms of an invented concept called a “disorder.” Let me give you an example. “Selective Mutism” is a diagnosis given to people who elect not speak in certain situations. So, if I were…trying to get a handle on what’s going on with somebody—I would try to figure out what situations they aren’t speaking in, try to find out if there’s some kind of common denominator, to ascertain whether there’s something in their background or their current context that would help explain what they are doing. You know, as in: Is it safe to speak? Is this, for example, a person of color going silent at times when racists might be present? Alternatively, is this a childhood sexual abuse survivor who is being triggered? Whatever it is, I would need to do that. But this is not what the DSM, as it were, prompts. In the DSM, “Selective Mutism” is a discrete disease. So, according to psychiatry, what causes these “symptoms” of not speaking? Well, “Selective Mutism” does.” (Burstow’s response in Spring and Burstow, 2015)
Combine this vacuousness and this circularity with medicalized language, such is the revolution that was DSM-III.
I began this article by taking issue with claims about Spitzer’s legacy. Clearly Spitzer’s most formidable contribution to psychiatry is his overall contribution to diagnostic psychiatry via introducing a whole new way of constructing diagnoses, as spearheaded in DSM-III. On this, everyone agrees. However, what is it that Spitzer — and his colleagues — set in motion? Contrary to the claims being made, through the use of scrupulously medicalized terms and through the pretense of carefully conducted research they created “the appearance” of science, medicine, and rigor. That is, they set psychiatric diagnosing decisively on a path where it would look scientifically rigorous; where it could claim the authority of medicine on the basis of appearance, while in point of fact being vacuous. Correspondingly, subsequent DSMs have continued in the same vein — hence the difficulty confronting psychiatry.
In ending, I would remind readers once again that a human life has been snuffed out. At the same time, I invite readers not to lose sight of the real legacy of Spitzer and his brainchild, the DSM-III.
Otherwise, how are we to keep our bearings in the struggle ahead?
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Burstow, B. (2014). Neo-Kraepelinian Psychiatry. In Cultural Sociology of Mental Illness (Andrew Scull, Ed.). (pp. 575-576). Thousand Oaks, California: Sage.
Burstow, B. (2015). Psychiatry and the business of madness. New York: Palgrave Macmillan.
Rosenhan, D. L. (1973). On being sane in insane places. Science, 179, 250-258.
Kraepelin, E. (1907). Clinical psychiatry. (Ross Diefendorf, Trans. and Ed.). New York: Macmillan.
Kutchins, H. and Kirk, S. (1997). Making us crazy. New York: The Free Press.
Spring, L. and Burstow, B. (2015). Probing Psychiatry and the business of madness. Retrieved January 5, 2016 from http://rabble.ca/books/reviews/2015/07/probing-psychiatry-and-business-madness
Teal, D. (1971). The gay militants. New York: Steiner and Day.