Shrinks (37 page)

In truth, the APA really was caught flat-footed by the mounting online criticism. Not only were they ill-equipped to use the Internet to respond in an organized or effective fashion, they were completely taken by surprise by the level of public interest. After all, during the development of the
DSM-IV
there had been precious little controversy among medical professionals, while public discussion had been virtually nonexistent. But now there were hundreds of voices calling for the
DSM
leaders to pull back the curtain and explain exactly how the next generation of psychiatric diagnoses were being created.

Despite the outcry, it was possible for the Task Force chairs and APA leadership to dismiss the complaints as the usual carping and hyperbole coming from rabid antipsychiatry critics and special interest groups. After all, many of the objections leveled against the
DSM-5
process weren’t all that different from the griping during the construction of the
DSM-III
and (to a lesser extent) the
DSM-IV
; they were simply amplified by the digital megaphone of the Internet. With so many individuals and entities holding a stake in the Bible of Psychiatry, any revision was sure to ruffle feathers and provoke kvetching. The APA hoped that they might be able to weather the online storm without getting wet… until a most unexpected pair of critics spoke out with the force of a hurricane.

These psychiatrists stunned the
DSM-5
leadership with a series of excoriating online missives that would eventually force the APA to alter the course of the book’s development. The first psychiatrist was the chair of the
DSM-IV
, Allen Frances. The second was the legendary architect of the modern Kraepelinian
DSM
, Robert Spitzer himself.

Critics Emeritus

In April of 2007, one year after work on the
DSM-5
officially began and six years before it was scheduled for publication, Robert Spitzer sent a two-line message to
DSM-5
vice chair Darrel Regier. Would it be possible for Regier to forward to him a copy of the minutes of the Task Force’s initial meetings?

After completing the
DSM-III
, Spitzer’s role in the
DSM
process had become diminished. He had lobbied hard to lead the
DSM-IV
but was passed over in favor of Allen Frances, then a professor of psychiatry at Cornell Medical College. Nevertheless, Frances had treated Spitzer respectfully, appointing him to the
DSM-IV
Task Force as a “special advisor” and including him in all meetings. But as the
DSM-5
was gearing up, Spitzer was excluded from any involvement (as was Allen Frances). Just as Spitzer had done thirty years ago, it appeared that Kupfer and Regier wanted to make a clean break with the past and create something new. In order to achieve their ambitious goal, they felt they needed to keep any previous
DSM
leadership at arm’s length.

Regier responded to Spitzer by saying that minutes would be made available to the public after the conflict of interest process had been finalized and the Task Force fully approved. Spitzer wrote to Regier again a few months later but received no response. In February of 2008, almost a year after his initial request, Spitzer finally got a definitive answer to his inquiry: Due to “unprecedented” circumstances, including the need for “confidentiality in the development process,” Regier and Kupfer had decided that the minutes would only be made available to the board of trustees and the members of the Task Force itself.

This wasn’t merely a personal snub directed at the architect of the modern
DSM
but a severe departure from Spitzer’s policy of transparency and engagement, a policy he had maintained even when confronted with pitched resistance to the
DSM-III
. Allen Frances had continued Spitzer’s policy of openness during the development of the
DSM-IV
. Concerned that Regier and Kupfer’s decision to close off all proceedings from public view would endanger both the legitimacy and quality of the
DSM-5
, Spitzer did something that no one expected: He took his concerns to the Web.

“The June 6th issue of
Psychiatric News
brought the good news that the
DSM-5
process will be complex but transparent,” Spitzer wrote in an open letter to the editor of APA’s online news service. “I found out how transparent and open when Regier informed me that he would not send me the minutes of the
DSM-5
Task Force meetings because it was important to ‘maintain
DSM-5
confidentiality.’ ” Galvanized into action, Spitzer began an unrelenting online campaign against the “secrecy” of the
DSM-5
process and urging full transparency. “Anything less,” he wrote in 2008, “is an invitation to critics of psychiatric diagnosis to raise questions about the scientific credibility of the
DSM-5
.” He also criticized the use of the “confidentiality agreements” that all Task Force and work group members had been required to sign, prohibiting them from discussing the
DSM-5
outside of the Task Force and work groups.

Apparently Kupfer and Regier believed they could more effectively control the creation of a new
DSM
by shielding its Task Force and work groups from public scrutiny while they labored at the complex and potentially contentious job of improving psychiatric diagnoses. Spitzer himself had maintained an iron grip on the development of the
DSM-III
, but he had balanced his obsessive governance with an open and responsive operation, sending out a continuous stream of updates and reports. Even when he faced overt hostility in the latter stages of the
DSM-III
’s development, he famously responded to every letter, article, and phone call that inquired about the
DSM-III
, no matter how critical.

Spitzer wasn’t the only one vexed by the secrecy of the
DSM-5
process. Allen Frances shared his former mentor’s skepticism. Frances had trained at Columbia under Spitzer and was one of the youngest members of the
DSM-III
Task Force before becoming chair of the
DSM-IV
; the general opinion among mental health professionals was that Frances had done a respectable job as steward of psychiatry’s most important book. Frances reached out to Spitzer, and in 2009, the two psychiatric luminaries posted a joint letter to the APA Board of Trustees warning that the
DSM-5
was headed for “disastrous unintended consequences” because of a “rigid fortress mentality” by which its leadership “sealed itself off from advice and criticism.” They urged the APA to scrap all confidentiality agreements, increase transparency, and appoint an oversight committee to monitor the
DSM-5
process.

A firestorm erupted. At issue was the question of how to define mental illnesses in the digital age. Not only did far more empirical data and clinical knowledge exist than ever before, but there were myriad powerful stakeholders—including commercial, governmental, medical, and educational institutions, as well as patient advocacy groups—who would be significantly affected by any changes in the
DSM
. Would the public’s interests be served by allowing experts to work on revisions behind a protective veil? Or was it better to allow the debates over diagnoses (which would inevitably be heated and contentious) to play out before the public eye—which now consisted of a whole wired world of bloggers, tweeters, and Facebook users?

Both defenders and detractors of the APA weighed in. The
Psychiatric Times
, an online magazine independent from the APA, published retorts on a regular basis. Daniel Carlat, a psychiatrist affiliated with Tufts University School of Medicine, described the ensuing conflict on his blog: “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 media, animated by the spectacle of the most prominent practitioners in the field warring with one another with the same rancor as the Republicans and Democrats in Congress, added fuel to the fire. Cable news shows invited talking heads to debate the merits of the
DSM
, and psychiatry in general. Prominent commentators from David Brooks to Bill O’Reilly weighed in. “The problem is that the behavioral sciences like psychiatry are not really sciences; they are semi-sciences,” wrote Brooks in an op-ed piece in the
New York Times
.

From 2008 until the launch of the
DSM-5
in 2013, almost three thousand articles about the
DSM-5
appeared in newspapers and major online news outlets. It got to the point where minor milestones in the development of the
DSM-5
drove the news, while any news event related to mental illness was immediately referred back to the controversial status of the
Manual
. In 2011, for instance, there was an explosion in news coverage of the
DSM-5
when Congresswoman Gabrielle Giffords was shot at an Arizona shopping mall by a psychotic young man. Another
DSM-5
media frenzy followed the horrific 2012 school shooting in Newtown, Connecticut, once reports suggested that the perpetrator, Adam Lanza, had some form of autism. Much of the coverage suggested that psychiatry was not doing a good job of figuring out how to diagnose or treat mental illness.

The APA hadn’t experienced this kind of public pressure since the early 1970s, when the Rosenhan study, the homosexuality controversy, and the antipsychiatry movement compelled the APA to move away from psychoanalysis and endorse a radically new paradigm for psychiatric diagnosis. But what would the APA do this time?

The APA Responds

Throughout the development process, Kupfer and Regier had repeatedly assured the APA Board in their regular reports that—despite all the internal grumbling and external noise—everything was going well with the
DSM-5
. But when Spitzer and Frances joined the online fray and the rumors about poor leadership drifting out of the Task Force and work groups failed to abate, the board began to wonder if there might be a fire behind all that smoke. Were there serious problems with the
DSM-5
development process that Kupfer and Regier were not admitting—or even worse, problems they were not aware of?

To find out, the APA Board of Trustees appointed an oversight committee in 2009. The new committee would examine the
DSM-5
process and inform the board whether there were in fact problems requiring the board’s intervention. Carolyn Robinowitz, former dean of the Georgetown University School of Medicine and a previous APA president, was appointed chair of the committee. I was also appointed to the committee.

We attended the
DSM
Task Force meetings, where we were updated by the
DSM-5
chair and vice chair, and then met separately with task force members without Kupfer or Regier present. It quickly became apparent that the situation was as bad as the rumors had suggested. The
DSM-III
team had been unified in their vision of a new
Manual
and had complete confidence in Robert Spitzer’s leadership. With the
DSM-5
, many team members were openly critical of both the process and its leaders.

Regier and his staff seemed disorganized and uncertain, while Kupfer was remote and disengaged, delegating operational responsibility to Regier. This was a very different management style from the obsessive hands-on involvement of Spitzer, later emulated by Frances. Robinowitz reported back to the APA Board the sobering conclusions of the oversight committee: “There is a serious problem with the
DSM
, and we’ve got to fix it.”

The board of trustees took Robinowitz’s comments to heart but was unsure what to do. To change horses in midstream when the process was being publicly questioned might lend credence to the criticism and undermine the credibility of the
DSM
. Instead, the board fashioned a workaround by establishing two ad hoc review committees: one to review the scientific evidence justifying any proposed change, and another to review the clinical and public health implications of any change. While adding new committees is hardly an ideal solution to a management problem, it did serve to deflect much of the criticism coming from within the psychiatry profession itself.