The Selling of DSM

The Rhetoric of Science in Pschiatry

Stuart A. Kirk & Herb Kutchins

reviewed by Mira de Vries

Kirk & Kutchins are known for their critiques of the DSM. After this book they published Making us Crazy in 1997 (with their names turned around, Kutchins & Kirk). Neither of the university libraries in Amsterdam have the 1997 book, because they are underfunded, or because criticizing psychiatry has become taboo? Either way, I was motivated to read The Selling of DSM because I kept running into this title in other books critiquing the DSM, such as by Boyle, Caplan, and Horwitz.

It opens promisingly with a delightful quote from Lewis Carroll’s Through the Looking Glass:
“What’s the use of having names,” the Gnat said, “if they won’t answer to them?” “No use to them, said Alice, but it’s useful to the people that name them, I suppose.”
Throughout the book I found myself nodding, not only in agreement, but also because I kept falling asleep. The book is incredibly boring. It needn’t have been that way. Many names that become familiar once you’ve been reading on this subject for a while march across its pages, such as Sabshin, Andreasen, and the Big Star of the DSM, Robert Spitzer. The book could have read like a psychiatric soap. I don’t know whether to praise the authors for resisting the temptation or criticize them for failing to highlight the personal intrigues involved. Boring or not, rest assured that I read it from cover to cover, as I do not wish to join the ranks of reviewers who publish reviews of books they have not (completely) read.

Among the intrigues the authors do mention are the mutual hostilities between research psychiatrists and clinicians – the latter being the ones who actually deal with the people who will wind up with diagnoses. The authors bracket clinicians with the general public in regard to their ability to understand research psychiatrists’ methods and jargon. They suggest that mystification is in fact a conscious aim of the research psychiatrists who are instrumental in creating the DSM. The DSM-III was also intended to hammer the final nail into the coffin of psychoanalysis, settling that long-running controversy within the American Psychiatric Association.

Most of this book deals with the revision of the DSM-II into the DSM-III even though the DSM-III-R was by this time already published, and the DSM-IV already planned and mentioned in the book. It was the DSM-III which launched the DSM into the position of authority it enjoys today. The key word employed by its proponents to justify and promote the DSM-III was reliability. That is what you achieve when different clinicians (the DSM carefully avoids the word “psychiatrist”) independently from each other arrive at the same diagnosis for the same patient at the same time. Reliability is crucial to research, which was the stated aim of the DSM-III, though not at all how it is actually used. But reliability says nothing about validity. What’s the point of attaining high reliability of invalid diagnoses? The point is that it squelches criticism.

Reliability was found to be low due to the variation in clinical information gathered for specific patients, and the criteria used by individual clinicians. To tackle this, the DSM makers set out to do two things: limit the criteria at clinicians' disposal, and restrict the information employed to judge those criteria by creating standard questionnaires. This is of course working backwards. One might expect that a disease or disorder is first thoroughly investigated and only afterwards a method is devised for identifying it, not that the existence of the disorder is decided upon only after the criteria have been set. Furthermore, to achieve this aim, clinicians have to be discouraged from establishing a rapport with the patient or allowing him to lead the discussion.

Nonetheless, reliability remains an illusion, supported neither by the data provided by the DSM makers themselves nor by outside researchers. The research was marked by a low number of participants and various procedural techniques ensuring that only outcomes favorable to the aim would be reported. Kirk & Kutchins put it this way:
The developers of the DSM-III repeatedly asserted that careful, systematic field trials established the improved scientific reliability of DSM-III. However, important information about the methods and findings of the field trials was never reported. Some of the reports were inconsistent and unclear. The field trials themselves could more accurately be described as uncontrolled, nonrandom surveys in which several hundred self-selected and unsupervised pairs of clinicians throughout the country attempted to diagnose nonrandomly selected patients and, after some sharing of information, made “independent” assessments of these patients.
The triumphant mood around the reliability of the DSM-III was, according to Kirk & Kutchins, structured rhetorically much like a political campaign.

Politics, indeed, very much entered into the matter, as gay activists staged protests at APA conventions to have homosexuality removed from the DSM, and feminists demonstrated to prevent diagnoses specific and disparaging to women from being included. The authors fail to comment that gays and feminists seemed quite content to leave all the other diagnoses unquestioned.

So what has psychiatry gained from the revisions in the DSM, besides a false air of science and the accompanying respectability? It has gained regulation of the client flow (meaning that psychiatrists control who they take on); the power to attain certain services or protections for their clients; acquisition of fiscal resources (otherwise known as tax money) and reimbursement from insurance companies; rationalization of decision-making; and the fulfillment of a political agenda. That magic word reliability, which supposedly was what the DSM-III was all about, dropped out of the APA's vocabulary at the very next revision.

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