Archive for the ‘ discussion ’ Category

Viggo Mortensen visits the Freud Museum

A few days ago, actor Viggo Mortensen visited the Freud Museum in London and participated in a lively Q&A session about his latest film, A Dangerous MethodThe Hollywood News published an article about this session, conducted by Chair of the Museum, Lisa Appignanesi:

It’s a mid-week evening at the Freud Museum just off Finchley Road in London, and the institute is hosting a screening of David Cronenberg’s very apt A DANGEROUS METHOD; before all that, Viggo Mortensen spends a few minutes talking about his portrayal of Sigmund Freud within the film, and the process of making it all happen. THN was there to listen in.

To read the entire article, click here.

To view pictures of the event, click here.

Psychiatry and the History of Riots

In the wake of the recents riots in England, social scientists and journalists have been quite prominent in offering their explanations for the looting and destruction.  Social psychologists and sociologists have, by and large, dominated the more scholarly discussions.  So it is interesting to recall that, as Hans Joachim Schneider pointed out in a 1992 article, two other sets of theories about riots have historically drawn their inspiration from clinical psychology and psychiatry:

2. According to the psychoanalytic social contagion theory, participants in riots are carried away by their subconscious, by their feelings, affects, or instincts.

3. Following the psychopathological convergence theory, individuals who share similar characteristics or abnormal traits, predispositions, or attitudes, or else members of social fringe groups gather in the riot situation.

Schneider cites no studies in this context, but it might be interesting to trace the history of these lines of argument emphasizing psychopathology, ones which now seem to be largely out of favor.  One might mention, for instance, Charles Mackay’s popular Memoirs of Extraordinary Popular Delusions, first published in 1841.  Perhaps readers can suggest other primary and secondary works in this area?

Debate: Should Psychoanalysis Be in the Science Museum in London?

To be sure, this is likely familiar territory to many readers of H-Madness, but the New Scientist features a debate on the topic of whether psychoanalysis should be included in the Science Museum in London.  Speaking in favor is Robert Bud, principal curator of medicine at the Science Museum; voicing his opposition is Mario Bunge, a philosopher at McGill University in Montreal, Canada and a long-standing critic of psychoanalysis.

The exhibition Psychoanalysis: The Unconscious in Everyday Life, featuring art and artefacts from the collections of the Science Museum, the Wellcome Library, and the Freud Museum, opens on 13 October and runs until April 2011. The museum’s Dana Centre will hold an associated discussion series. For more information visit the Science Museum website.

Announcement: Course Syllabi for the History of Madness and Psychiatry

With the start of the fall/winter university semester on the horizon in the United States and Europe, H-Madness will be hosting a series of posts featuring course syllabi in field of the history of madness, mental health, and psychiatry.   During the last week of August/first week of September, H-Madness will be posting syllabi from a number of universities and colleges, along with comments by their instructors.  Gareth Evans, Andreas Killen, Paul Lerner, Elizabeth Lunbeck, and Mark Micale, among others, will be sharing their course syllabi and their thoughts about teaching courses in the field.

The editors at H-Madness welcome your input as well. If you teach a course that deals with the history of madness, mental health, and/or psychiatry and are interested in sharing your syllabus and thoughts about teaching, please contact editor Greg Eghigian (gae2@psu.edu).  We would be delighted to post them and include you in the series.

We hope to make this a regular feature of H-Madness.  In addition, we plan to set up an archive of course syllabi that can serve as a resource for those interested in developing similar courses at their institutions.

The Editors

Vers une réforme du dispositif de soins sous contrainte en France

Le 5 mai dernier la ministre de la santé française Roselyne Bachelot a présenté en conseil des ministres un projet de réforme de la loi du 30 juin 1990 sur l’hospitalisation sous contrainte, qui pourrait être discuté au Parlement à l’automne. Si les velléités réformatrices n’ont pas manqué depuis qu’existe un dispositif de contrainte en psychiatrie en France, l’événement tient aujourd’hui à deux choses, que les mois qui viennent devront confirmer : d’une part au caractère plus abouti que jamais du projet : alors que l’on ne compte plus les commissions qui ont réfléchi aux manières de faire évoluer la loi y compris au cours des vingt dernières années, c’est la première fois depuis 1990 et la deuxième depuis 1945 qu’un projet est allé aussi loin dans le parcours législatif ; d’autre part au fait que s’il aboutit, le changement introduit dans le dispositif sera probablement le plus significatif que celui-ci aura connu depuis plus d’un siècle.

L’innovation introduite dans le projet porte en effet essentiellement sur un point, mais il est de taille puisqu’il concerne l’objet même de la contrainte. Comme la plupart des législations occidentales, la loi de 1990, reprenant les grandes lignes de la loi fondatrice du système psychiatrique français en 1838, est une loi d’internement ou d’hospitalisation sous contrainte. La contrainte y prend la forme d’une restriction de la liberté d’aller et venir, d’une collocation à un lieu clos, peut s’exercer une surveillance continue sur la personne, avec les multiples significations que revêt cette surveillance – protection de la personne contre elle-même, protection de la personne contre la société, protection de la société contre la personne, protection en particulier de la famille. Le projet qui circule redéfinit cette contrainte pour en faire une contrainte au soin, sans comporter nécessairement de restriction aux libertés d’aller et venir et indépendamment du lieu où ce soin est dispensé – hôpital, hôpital de jour, consultation privée. La loi ne définissant évidemment pas le contenu du soin, du ressort des professionnels, c’est, profondément, l’organisation ou l’encadrement de la relation médecin malade par l’autorité publique qui est en jeu : en fin de compte c’est à une sorte de parrainage ou de chaperonnage au caractère éventuellement coercitif que l’on a affaire.

Dans ses grandes lignes, le projet de loi reprend en fait les préconisations d’un rapport de l’Inspection Générale des Affaires Sociales de 2005. Si ce dernier était passé relativement inaperçu, le texte actuel suscite depuis début avril abondance de débats et de réactions dans les milieux psychiatriques. Les associations professionnelles ont pour certaines d’entre elles critiqué ses dispositions : c’est en particulier le cas des praticiens hospitaliers et des personnels des secteurs, qui ont souligné le risque d’une dérive sécuritaire en pointant l’allègement de certains des contrôles du dispositif et d’autant de garanties pour les libertés civiles – et en critiquant par ailleurs le contexte d’élaboration de ce projet, à la suite d’un discours du président de la République Nicolas Sarkozy en 2008, à teneur de fait hautement sécuritaire. Les deux principales associations d’usagers de la psychiatrie en France, l’UNAFAM, représentant les familles, et la FNAP-Psy pour les patients eux-mêmes, ont à l’inverse plutôt favorablement accueilli le projet, qui leur paraît susceptible de garantir de meilleures conditions de traitement. Dans l’ensemble le texte ne paraît cependant pas avoir soulevé la même indignation que de précédentes initiatives – et en particulier une tentative de Nicolas Sarkozy, alors ministre de l’Intérieur, de modifier le dispositif dans une loi de sécurité intérieure en 2006.

Si l’on tente de s’extraire de ces débats, la signification historique de ce projet et l’interprétation de ces débats peut probablement être analysée à deux niveaux différents, à partir de deux perspectives chronologiques :

1. La première correspond à une perspective de longue durée. En matière de soins sous contrainte, la France hérite globalement du dispositif créé en 1838 par les fondateurs de la psychiatrie moderne. Cela ne signifie cependant pas que le dispositif ou que la loi de 1838 soient restés globalement tels qu’ils avaient été pensés ou planifiés par leurs créateurs au XIXe siècle. En plus d’un siècle et demi l’un et l’autre ont largement changé de signification et de nature, même si la lettre de la loi est en apparence restée peu ou prou la même. La loi de 1838 organisait en effet l’assistance psychiatrique : elle créait un statut pour des personnes assignées à l’asile. C’est vers la réforme de ce statut que se sont dirigé les efforts des principaux réformateurs de la psychiatrie durant une bonne partie des XIXe et XXe siècle, avant que dans la seconde moitié du XXe siècle le dispositif n’évolue de manière pragmatique : d’abord par la généralisation progressive des hospitalisations psychiatriques sans contrainte, ensuite par la réforme du dispositif de tutelle et enfin par l’alignement du statut des hôpitaux psychiatriques et de leurs personnels sur celui des hôpitaux généraux. De sorte que ne reste plus aujourd’hui de la loi de 1838 qu’un noyau, le dispositif de contrainte, délié des autres aspects du texte initial, et notamment de la protection de la personne.

Cela permet de comprendre et de situer la nouveauté et l’originalité de l’évolution suggérée par le projet. Elargir la palette des possibilités de contrainte n’est certes pas une nouveauté. En 1945, dans ce qui fut probablement la dernière tentative de repenser dans son ensemble le dispositif de 1838 dans l’ensemble de ses dimensions, un groupe de psychiatres avaient proposé d’élargir les modes de placement à d’autres formules que l’hospitalisation dans un asile, tels par exemple que le placement familial, les colonies agricoles. Mais précisément leur projet consistait en l’organisation d’un placement, d’une forme d’assistance, c’est-à-dire, pour reprendre une expression de l’un de ces psychiatres, de l’aménagement des conditions de vie les mieux à même de permettre à la personne de développer un niveau de fonctionnement optimal. Et en ce sens, la proposition s’inscrivait dans le cadre d’une psychiatrie sociale qui insistait sur le rôle thérapeutique du milieu.

A cet égard, l’idée que la contrainte puisse porter sur les soins même suppose une conception renouvelée de l’intervention psychiatrique, de ses moyens comme de ses fins, qui renvoie de toute évidence aux manières dont la biomédecine contemporaine produit et agit sur ses entités, et singulièrement aux innovations pharmaceutiques : c’est précisément cela que veulent dire les acteurs lorsqu’ils soulignent qu’il s’agit de mettre le droit en conformité avec les pratiques. Encore cette approche n’estelle pas non plus d’une radicale nouveauté : la notion de soins sous contrainte a en effet été introduite il y a plus d’un demi siècle pour une catégorie spécifique – les alcooliques dangereux – avant d’être mobilisée d’autres populations présentant un profil proche les toxicomanes dans les années 1970, plus récemment les délinquants sexuels. La généralisation à l’ensemble des clientèles de la psychiatrie marque en ce sens certes une étape supplémentaire mais pas une redéfinition en profondeur du droit. Elle signale toutefois de façon symbolique le passage vers un autre régime de contrôle social de la maladie mentale ou de biomédicalisation de la société, qu’une analyse foucaldienne pourrait qualifier de société de contrôle ou de politique de la vie elle-même. Notons toutefois que cette évolution n’est pas exclusive du maintien de formes de contrôle social ressortant aux disciplines et à la réclusion : la rétention de sûreté introduite dans le droit français en 2008, qui permet de maintenir dans une structure fermé un délinquant pour une durée indéterminée après qu’il eut purgé sa peine en cas de risque de récidive, suggère que l’on n’a pas abandonné les approches les plus traditionnelles de la notion de dangerosité.

Cela peut au demeurant expliquer en partie l’opposition des professionnels. En remettant en cause l’institution comme lieu d’élection du soin psychiatrique, le projet touche à un aspect central des manières dont la psychiatrie française a construit ses pratiques depuis l’après guerre. Cela pose plus largement une question importante : celle du sens de l’hospitalisation psychiatrique aujourd’hui. Si le soin peut se passer de l’hospitalisation, quelle est la fonction de celle-ci, quelle est sa valeur ajoutée, si ce n’est la possibilité de contrôle et de surveillance continue.

2. Le deuxième niveau d’analyse porte sur la conjoncture actuelle et les raisons qui expliquent que le projet soit effectivement en passe d’aboutir. De ce point de vue l’aspect le plus spectaculaire du texte en circulation est qu’il ne tranche pas les débats qui étaient au cœur des discussions sur la loi du 30 juin 1990 jusqu’au début des années 2000. Le projet introduit certes une période de 72 heures préalable à la décision de mettre en branle la contrainte, qui rappelle un dispositif proposé en 1997 par la commission Strohl chargée d’évaluer les effets de la loi de 1990. Mais ce rapprochement n’est qu’apparent : puisque dans les propositions de 1997 la période était un sas nécessaire pour une personne amenée sans certificat aux urgences, qui pouvait être maintenue contre son gré et à l’issue de laquelle la décision intervenait comme un jugement. On se rapprochait ainsi du dispositif nord américain. Ici la demande d’hospitalisation, sous la forme d’un formulaire rempli par un tiers ou par l’autorité publique et d’un certificat médical, reste préalable à cette période d’observation et de façon plus générale l’équilibre entre intervention médicale et position administrative reste inchangé : l’obligation de soin est mise en œuvre sous le contrôle des représentants de l’Etat, sous l’impulsion conjointe des praticiens et d’un tiers ; ceux-ci initient la mesure, qui les met dans un second temps sous le contrôle de l’autorité publique. En regard d’une autre proposition portée notamment par le rapport Piel Roelandt de 2001 de déspécifier la loi pour en faire une loi générale de traitement sous contrainte qui ne se limite pas au cas de la psychiatrie, là encore le projet actuel adopte une position que l’on pourrait qualifier de conservatrice puisque les motifs des soins sous contrainte restent fondamentalement les mêmes.

Ce pas de côté pourrait s’expliquer par le rôle nouveau que jouent les associations d’usagers dans l’élaboration et l’animation des politiques publiques en psychiatrie en France, et de façon plus générale l’importance politique qu’elles ont prise depuis une dizaine d’années. On est frappé en effet par le fait que nombre des dispositions du projet reprennent des préoccupations historiques des familles, qu’il s’agisse du problème de l’accessibilité des services ou de la question du tiers demandeur, pour lequel le projet propose d’alléger les contraintes. En ce sens ce projet pourrait être une illustration de plus, après la reconnaissance et la mise en œuvre d’un nouvel ensemble de politiques publiques autour de la notion de « handicap psychique » en 2005, du nouveau régime de production de la santé mentale dans lequel est entré le pays.

Il est trop tôt pour savoir ce qu’il adviendra du projet. La poursuite du processus législatif dépendra à la fois de la volonté du gouvernement de donner à ce texte une priorité suffisante pour l’inscrire sur l’agenda du parlement et de la mobilisation que ses opposants sauront susciter parmi les parlementaires. La procédure pourrait par ailleurs être retardé par la masse de problèmes qui pourront être associé au projet – on parle ces jours-ci de réformer le dispositif encadrant l’irresponsabilité pénale. On peut cependant penser qu’il a une chance d’aller à son terme, dans quel cas il conviendra d’être attentif à l’interprétation qui lui sera donné par les acteurs sur le terrain.


Nicolas Henckes

post-doctorant CERMES3 (Villejuif, France)

henckes@vjf.cnrs.fr

Gender and the History of Integrated Wards

Coverage of some recent violent attacks on female patients in mental health facilities in Milwaukee County in the U.S., prompted a medical journalist to contact me with an interesting set of questions – ones for which I had no ready answers.  Perhaps, some readers and subscribers of H-Madness have some thoughts on the subject.  When did mixed-gender wards and units begin to emerge in psychiatric facilities?  How widespread have these historically been?  Were they the results of institutional pressures in the wake of de-institutionalization?  Were they a function of changing ideas about reintegrating institutional patients in society following World War II?  Or do they have a longer history?

A MOMENT OF CRISIS IN THE HISTORY OF AMERICAN PSYCHIATRY

N.B. The DSM currently being constructed is referred to in this article both as DSM-V and DSM-5.  The APA at first used the appellation DSM-V, but later on began calling the document DSM-5.

Rarely has the medical world—and the general public, for that matter—been witness to an open drama such has taken place over the past two years in response to a medical association’s announcement that it was going to revise its diagnostic categories.  A war broke out with unlikely sides: Two former editors of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual (DSM) on the one side and, on the other, the officers of the APA and the leaders of the APA’s current Task Force that is revising the DSM.  Because of the Internet, the battle has been very public, and the APA has found itself on the defensive as it became repeatedly bombarded by open letters and columns in various media outlets.  These missives were immediately seized on by multiple bloggers.  The hallmark of the campaign by the former editors has been marked by unrelenting, inescapable repetition, which has added strength to their broadsides.

The scenario started simply and privately in April 2007, five years before the revised manual was scheduled for publication.  Robert Spitzer, the psychiatrist who had headed the  APA’s Task Force that revised the association’s third diagnostic manual in 1980 (DSM-III), dropped a two-line request to a colleague, Darrel Regier, Vice Chair of the Task Force that is currently updating the Association’s fifth manual (DSM-5).  Would it be possible for Regier to forward to him a copy of the minutes of the Task Force’s first two meetings?

Regier answered Spitzer quickly, saying summary minutes would be available to individuals like him for private use, but asking him to wait until the APA Board of Trustees formally approved the membership of the Task Force.  After an interval, having received no minutes, Spitzer renewed his request.  But nine months passed before Regier gave Spitzer a definitive answer in February 2008: Due to “unprecedented” circumstances, including “confidentiality in the development process,” David Kupfer, Chair of the Task Force, and Regier had decided the minutes would be available only to the Board of Trustees and the Task Force itself.  However, said Regier, the APA membership would be kept aware of DSM developments at professional meetings and through reports in various psychiatric publications.  But an article four months later in the Psychiatric News, the APA’s official news magazine, propelled Spitzer into public action.  We are now at June 2008, fourteen months after Spitzer’s original request.

In a letter to the editor, June 11, 2008, Spitzer began: “The June 6th issue of Psychiatric News brought the good news that the DSM-V process will be ‘complex but open.’”  And, he added, just a few weeks before, the outgoing president of the APA had stated that in the development of DSM-V the APA is committed to “transparency.” Then Spitzer expostulated:  “I found out how transparent and open the DSM-V process was when [Regier] informed me that he would not send me a copy of the minutes of DSM-V task force meetings . . . because the Board of Trustees believed it was important to ‘maintain DSM-V confidentially.’”  Spitzer then made available in his letter a paragraph from the Acceptance Form that all Task Force and Work Group members had signed stating that during their term of appointment and after, they would not “make accessible to anyone or use in any way any Confidential Information.” “Confidential Information” was defined in broad legal terms.

Spitzer continued: “I didn’t know whether to laugh or cry.  Laugh – because there is no way Task [F]orce and Work Group members can be made to refrain from discussing the developing DSM-V with their colleagues.  Cry – because” to revise a diagnostic manual in secrecy destroys the scientific process, “the very exchange of information that is prohibited by the confidentiality agreement.” Spitzer asserted that the making of DSM-III, III-R, and IV, by contrast, had been open processes where the widest exchange of information with all colleagues was encouraged.  Spitzer did not stop with this letter. Once galvanized into action, he began an unrelenting campaign against the “secrecy” of the fifth DSM revision process and urging “transparency,” soon forcing the APA to defend itself.  (Eventually, as I will discuss below, Spitzer was joined by Allen Frances, the editor of DSM-IV and its revision, DSM-IV-TR.  They were able to mount a highly visible battle by publishing their manifestos in a psychiatric news magazine independent of the APA, the Psychiatric Times.  Frances came to urge action on a wide variety of issues, publishing continual and frequent warnings of dire results if the APA leadership continued on the path it had chosen.  The latest as of this writing is centered around a critique of the “impossible complexity” of the new DSM-5 section on Personality Disorders.)

But before Frances joined the fray, Spitzer hammered on certain themes and charges tirelessly in a variety of publications spread over many months.  The repetition itself, rather than appearing redundant, added intensity to his challenges, which can be summarized as follows: (1) The DSM was being developed in secret because the Task Force and Working Group (specialty committees) members had had to sign confidentiality agreements.  (2) Revising a diagnostic manual behind closed doors defeats the very scientific process that is supposed to ensure the best possible scientific outcome.  (3) His repeated attempts, he charged, to get the DSM-V and APA leadership to explain their departure from the past policies that had been employed by the editors of DSM-III and IV, had brought forth answers that made little sense.  The leadership, Spitzer would often state, maintained that the working groups and Task Force needed privacy to freely discuss and candidly exchange views with others without worry that tentative views might be made public.  But, he asserted, it is unprecedented that distinguished researchers and clinicians would be reluctant to speak candidly, something they did openly all the time.  The APA had also argued that making minutes of meetings and conference calls would jeopardize the APA’s intellectual property rights, but it had not explained how this would happen. Finally, (4), the APA should return to the policy that the participants in the DSM  process be encouraged to interact freely with their colleagues and that summaries of DSM-V meetings and conference calls be made available to interested parties.  In addition to Spitzer’s concerns, other commentators began to question whether the participants in the DSM-V process had conflicts of interest because of ties to the pharmaceutical industry.

In vain did the APA and its supporters repeatedly–in public presentations, in postings online, and in written articles and letters–recount information about the history of the DSM-V revision process.  They pointed out that work had been going on since 1999, which in itself, they argued, showed the process was “open and inclusive.” As evidence they cited the publication of two volumes of white papers that, starting in 2002, discussed in detail the many psychiatric issues that would have to be addressed.  The APA also reported that it had publicly worked in conjunction with the World Health Organization (WHO) and the World Psychiatric Association to develop an NIMH conference grant application to review the research base for mental disorder diagnoses.  Several governmental organizations dealing with public health had subsequently joined this effort, and the five-year grant supported thirteen international conferences, which had produced over 100 scientific articles.  Many 100s of scientists and clinicians, it was emphasized, had been involved in these activities.  Such factual data from the APA, however, did little to stem the vigor of the attacks by Spitzer, and other critics became attracted.

Spitzer kept repeating his calls for “full transparency” and the posting of the minutes of all meetings and conference calls. “Anything less,” he stated, “is an invitation to critics of psychiatric diagnosis to raise questions about the scientific credibility of DSM-V.” [Spitzer post of Nov. 26, 2008] By early 2009, Spitzer’s campaign began to bring results, and the APA said it would post Task Force and Work Group reports (though not minutes) on the DSM-V web site, and it explained its vetting procedures to weed out those psychiatrists with excessive ties to pharmaceutical companies.  Also, spelling out what they had done already, the APA pointed out that the American Journal of Psychiatry had been steadily publishing editorials on a variety of DSM-V diagnostic issues.  The APA president again declared that the DSM-V process was more open than any previous process and that APA members as well as the public would have the opportunity to comment on the web site.  And in the Wall Street Journal Health Blog, under the heading “Psychiatrists Bash Back,” David Kupfer, the Chair of the DSM-V Task Force, was quoted as saying he wanted to set the record straight because “some of us have gotten . . . sick enough about playing defensive ball and being taken out of context.” The confidentiality clause, he explained, was not keeping the revision process secret but rather protecting, as the WSJ blogger wrote, “the intellectual property of the DSM . . . . The intention was to prevent someone involved in the process from, say, writing a book about his or her experience about the revision process prior to the DSM-V’s publication.”

This did not silence Spitzer.  He wrote again in the Psychiatric Times, repeating his usual arguments and now comparing the DSM-V process unfavorably to those of DSM-III and IV, accusing the DSM-V leadership of certain “restrictions on the appointment of advisors and consultants.” By contrast, he declared, during the making of DSM-III and IV, in order “to get the widest possible opportunity for input, essentially anyone interested in becoming an advisor was appointed.” Finally, he registered astonishment that Darrel Regier had stated that “DSM-V will be more etiologically based than DSM-IV,” proclaiming, “there is insufficient evidence to justify making the DSM more etiologically based.” (One of the crucial—and ultimately revolutionary– objectives of Spitzer’s DSM-III had been to make DSM diagnoses purely descriptive on the grounds that in psychiatry little is known about the etiology of mental disorders.)

At this point the APA decided to go on the offensive.  In a “Commentary,” “The Conceptual Development of DSM-V,” in the American Journal of Psychiatry in June 2009, four prominent officials and advocates of the DSM-V process laid out a lengthy essay that included the history of the DSMs, a presentation of psychiatric advances in recent years, and the authors’ plans for DSM-V.  Prominent were their statements that they were poised to carry out field trials and had decided that “one, if not the major difference between DSM-IV and DSM-V will be the more prominent use of dimensional [not purely categorical] measures in DSM-V”.  The authors of the Commentary, also traced specifically the intellectual origins of DSM-III and of the Research Diagnostic Criteria (RDC) that had preceded it, both of which had been under the leadership of Spitzer.   But the Commentary pointedly avoided mentioning his name.

At just this juncture, Allen Frances dramatically entered the fray.  He had stuck his toe in once, eight months previously, in a short editorial in the American Journal of Psychiatry, co-authored with someone else who also had already worked on the DSMs.  They told of a “mistake” that had been made in DSM-IV that had brought about “serious problems” in the diagnosing of sexual offenders, and they advised the DSM-V Task Force to beware the “unintended consequences of small changes.”   But now, in June 2009, Frances echoed the same theme in a lengthy and far-reaching article in the Psychiatric Times, warning, among numerous other caveats, that some of the proposed revisions for DSM-V might well produce more harm than good.  DSM-V, he predicted, was on the road to a “wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments—a bonanza for the pharmaceutical industry . . . .” As things stood now, the whole revision process was “badly off track” and could not meet its announced publication date of May 2012.  Not only did Frances echo many of Spitzer’s challenges, but he concluded by calling on the Board of Trustees of the APA to establish an external review committee to monitor the work on DSM-V.

The response of the APA, also in the Psychiatric Times, was swift.  Under the lead authorship of its president, it declared that Frances’ “factual errors and assumptions about the development of DSM-V . . . cannot go unchallenged.”  It took on Spitzer as well.  It repeated its position that “the process for developing DSM-V has been the most open and inclusive ever.”  It excoriated Frances for ad hominem attacks and defended the goals of DSM-V as against those of DSM-IV, which he had edited.  That revision, it said, had sought merely to mark time.  The APA hit out against the categorical diagnoses of DSM-III, fine for their time, but now “holding us back.”   Finally, it accused Spitzer and Frances of being motivated in their attacks on DSM-V by monetary considerations.  Both men, it was pointed out, stood to lose their royalty payments once DSM-V appeared and publications related to DSM-III and IV were no longer sold.

Spitzer answered the next day, on the “ugly turn” the debate had taken, with the APA’s claiming that his and Frances’ motivations in critiquing DSM-V were financial.  He seconded Frances’ assertion that a May 2012 publication date was chimerical.  Field tests were slated to start immediately, he pointed out, but no drafts of DSM-V had been made available. The public should be informed immediately “the specifics of where DSM-V is going.”

Within a few days—we’re now in early July 2009– Spitzer and Frances followed up with a bold open letter to the APA Board of Trustees.  DSM-V was headed for “disastrous unintended consequences,” they charged. “The rigid fortress mentality” of the DSM-V leadership meant it had “lost contact with the field . . . by sealing itself off from advice and criticism.” They warned that if DSM-V stayed on its path, increasing public controversy would arise, and the APA’s publishing monopoly of the DSM would come under scrutiny.  The Board of Trustees should “save DSM-V from itself before it is too late,” and Spitzer and Frances offered several recommendations that ought to be pursued.  (1) “Open the DSM-V process to full transparency.  Scrap all the confidentiality agreements.  Actively recruit a large circle of advisors.” (2)  Before field trials, there had to be input from individuals outside the Work Groups.  (3) Appoint an oversight committee that would monitor the DSM-V process.  (4) Make the publication date of the manual “flexible.”

A firestorm now erupted.  Both defenders and detractors of the APA weighed in.  The Psychiatric Times published retorts on almost a daily basis.  The bloggers were busy.  Daniel Carlat, a psychiatrist at the Tufts Medical School, wrote: “What began as a group of top scientists reviewing the research literature has degenerated into a dispute that puts the Hatfield-McCoy feud to shame.” The wider press began to report on the conflagration.  Of note, Christopher Lane, an avowed critic of the DSMs since 2007, accusing the APA of medicalizing normal states such as shyness, had a lengthy column on Slate summarizing the history of the controversy and supporting the attacks of Spitzer and Frances, his former bête noires.  The APA defended itself in its own Psychiatric News, disputing Spitzer and Frances, and responded to their accusations “point by point.”

Throughout the summer and fall, Frances published steadily in the Psychiatric Times, plus once in the British Journal of Psychiatry.  By December 3, 2009, he was claiming victory in yet another Psychiatric Times article.  He cited “anonymous sources” from whom he had learned that within a month or two, the APA would post a draft version of DSM-V and tshen allow an additional month for comments.  The same sources, he went on, had informed him that a new timeline was about to be announced that would have field trials following—not before–the period of receiving comments and would push back the date of publication of DSM-V one year to May 2013.  Frances pointed out that only “external pressure” had brought about these “improvements” which also included the APA’s Board of Trustees appointing an oversight committee to monitor the work on DSM-V.  He concluded by urging the “research community” as well to apply pressure for continued caution by the DSM leadership.  The APA, he suggested somewhat ominously, would be “exquisitely sensitive” to researchers’ pressure since it needed their support if it wished to keep the “franchise” to continue to publish the DSMs.

The APA showed that it was ready to bow to the inevitable by giving Frances space in its American Journal of Psychiatry to publish a short editorial, “The Limitations of Field Trials: A Lesson from DSM-IV.” And on December 10, the APA issued a press release announcing that they were extending the date of publication of DSM-5 a year, until May 2013.   (This is the point at which the APA seems to have shifted from calling the new manual “DSM-V” to “DSM-5,” as if to show that the revision signified a departure from the “old” DSM-III and IV.)  To cover over an embarrassing situation, the President of the APA bravely declared this lengthening of the timeline would allow “more time for public review, field trials, and revisions.” The press release gave as an additional reason for the time extension that it would allow the APA to better cooperate with WHO as it worked to release its next revision of the International Classification of Diseases (ICD) due out in 2014.

Two months later, on February 10, 2010, the APA posted the DSM-5 draft online (www.dsm5.org) and declared it would accept public comments until April 20.  The day after the draft appeared, Frances and Spitzer (although in later postings Spitzer’s name no longer appeared) joined forces to publish in the Psychiatric Times “Opening Pandora’s Box: The 19 Worst Suggestions for DSM5.” (http://www.psychiatrictimes.com/print/article/10168/1522341?printable=true)  Obviously, they had not composed this lengthy broadside on “Problematic New Diagnoses” overnight.  And not surprisingly, their article did not end just with their critique but with five new suggestions to the APA’s Oversight Committee advocating: extending the time allowed for public review; careful editing “of each word; ”public review of the field trial methods; establishing three Oversight subcommittees to monitor “forensic review, risk benefit analysis, and field trials;” and posting the plans for cooperation with WHO.

The public revelation of the DSM-5 draft triggered immediate reaction from the print and Internet media as well as from the blogosphere reporting on the history of the two-year controversy that had surrounded the revision of the manual and analyzing the draft itself.  Public advocacy groups that had been campaigning for their own wishes for or against the inclusion of certain diagnoses sent out bulletins to their members.  Well known commentators like George Will were recruited by major newspapers (in this case the Washington Post) to give their opinions.  NPR had a half-hour broadcast, including an interview with David Kupfer and questions and comments from the audience. The online news outlets were numerous, among the major of them: Huffington Post, MedPage Today, abcNews, AP, Psychology Today, PsychologyOnLine, University of Chicago Medical Center (Science Life Blog), YouTube, and PsychCentral.  The print publications included The Economist, Science, New Scientist, TIME, the  New York Times, Wall Street Journal, Washington Post, Los Angeles Times and USA TODAY.

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Within three weeks of the APA press release, Frances returned to pressing his cause, sometimes every other day, not only in the Psychiatric Times, but in latimes.com, British Medical Journal, Psychology Today, and the Journal of the American Academy of Psychiatry and Law.  In a five day span, in the middle of March, he warned against DSM-5’s worsening the “epidemic” of ADD (Attention Deficit Disorder), attacked the new diagnoses proposed by the Sexual Disorders Work Group, and argued against the medicalizing of normal grief.  He continues to this moment.

A few observations seem in order:

The APA leadership was slow to assess and respond to the strong voices and skillful arguments of Robert Spitzer and Allen Frances and has learned a bitter lesson about the adroit use of the Internet.

The role of the Internet in popularizing and spreading the arguments and charges made by Robert Spitzer and Allen Frances cannot be overstated.  Without the Internet, the ease and rapidity of their frequent attacks and challenges would have been impossible.  It is worth repeating the trite observation that the Internet is the printing press of the 21st century, well adapted to fomenting upheavals.

I have not documented the innumerable blogs the many lay advocacy groups sent to their members nor the fervid online discussions of controversial matters by the public at large.  Examples of the latter would be the proposed autism spectrum under which Asperger’s Syndrome would be subsumed or the wished for inclusion in DSM-5, by scores of divorced fathers, of the diagnosis of Parental Alienation Syndrome.  The attempt by the public to weigh in on scientific decisions is here to stay.  The only question remaining is how scientific and medical groups are going to react to ever-louder lay voices which will only increase as they are facilitated by Facebook and Twitter or other social and professional networking sites.

The Psychiatric Times, founded 18 years after the APA’s Psychiatric News, has profited greatly as a result of its being the main vehicle by which the two former DSM editors circulated their views.  This print and online news magazine has perhaps catapulted itself into being the leading news source in American psychiatry.

It is too soon for accurate and coherent public discussion of internal events in the APA that brought about its seeming capitulation.  This is, however, a story impatiently awaited by the thousands of readers who followed its unfolding.  A knowledgeable and full exploration of Allen Frances’s ongoing intense critiques of the making of DSM-5 may take longer.

It has been speculated by some that the much-discussed Confidentiality Agreement was designed especially to prevent Task Force and Work Group members from publish anything about DSM-5 unless it was through APPI—the APA’s publishing arm which provides the APA with millions of dollars of additional revenue.

The greatest curiosity attaches itself to events yet to unfold as the revision process of DSM-5 goes on.  There are many who hope to hear more from the official leadership of the Manual and the APA itself than has been the case up to now.  However, Allen Frances’ contribution will not diminish if he has anything to say about it.

Hannah S. Decker

To read the other posts on the DSM-V, click here.

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