Kevin Vail Making Us Crazy 1

Making Us Crazy

Kevin Vail

P 637 – Psychopathology and Assessment

Dr. Liesel Polizi – instructor
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Introduction

The last 100+ years have seen the rise to prominence of the science of psychology

and the practice of psychotherapy. American and other Western societies turn to the

psychologist to explain human behavior in nearly all its facets. A psychiatric diagnosis of

pathology can affect everything from your personal freedom, to your employment and the

custody of your children. The tool used by the psychiatric community to validate these

life-altering decisions is called the “Diagnostic and Statistical Manual of Mental

Disorders” (henceforth the D.S.M.). The D.S.M. is open to critique on a number of fronts.

Herb Kutchins and Stuart A. Kirk explore several of them in their book Making Us

Crazy: DSM The Psychiatric Bible and the Creation of Mental Disorders. Some of the

areas they explore in their critique include: its lack of empirical foundation; the

politicized nature of its’ content; and its’ imbedded racism, sexism and Western cultural

bias. The authors offer scathing, if at times polemical, analyses of these problems but

few solutions. This paper will explore their criticism and offer a few criticisms of its own

of both the D.S.M. and of Kutchins’ and Kirk’s critique itself.

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The Science
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The first part of Kutchins’ and Kirk’s critique charges that the D.S.M. lacks

empirical foundation. The authors assert that the diagnoses within the D.S.M. lack

both reliability and validity. The authors of the constructs in the D.S.M. have gone

to great lengths to give their formulations the appearance of scientific certainties

but fail to provide the users with information on any supporting research.

Kutchins and Kirk argue that the D.S.M. is not a carefully formulated work based

on peer-reviewed scientific research but is rather “a strange mix of social values,

political compromise, scientific evidence and material for insurance claim forms”

(1997, p. x). The authors deconstruct the D.S.M. definition of “mental disorder”,

which appears in the last three editions of the D.S.M., concluding that the

definition “does not govern what conditions get included as disorders”; “the

content and number of criteria that must be met to qualify for each disorder are

largely arbitrary”; and it “has no consistent requirements that everyday behaviors

used as diagnostic criteria actually be the result of mental disorder and not the

result of other life experiences” (pp. 36-37). The construction of the psychiatric

nosology has been more a process of negotiation “among contending interest

groups of theoreticians, researchers, clinicians, hospitals, clinics, and drug

companies” than a compiling of objective psychological and clinical research (p.

37). The process of revising the D.S.M. has become a “cycle of denigration,

enthusiasm, and denigration” (p. 38). Each revision requires that the prior

revisions be made to appear “antiquated”. The first edition to undergo this cycle

was the D.S.M.-III published in 1980. The developers of this edition hailed it as a

major breakthrough in the field of clinical psychiatry. It had removed the

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theoretical biases of the two previous versions and for the first time presented a

detailed symptomology for each diagnosis, which was intended to improve

reliability. According to Kutchins and Kirk, it was the increase of the involvement

of the pharmaceutical industry and third-party payers for psychiatric care

influenced the developers to emphasize both reliability and validity of the

constructs. The D.S.M.-III sought to define the mentally ill as “those seen by

psychiatrists” and “desired for every client a reimbursable diagnosis” (p.43). The

D.S.M.-III radically expanded the number of psychiatric diagnoses to 265 and

included “information about age of onset, course, impairment, complications,

predisposing factors, prevalence, sex ratio and familial pattern” which gave it the

appearance of scientific validity. (p. 45). However, the authors argue that “there is

still not a single major study showing that [the] D.S.M. (any version) is routinely

used with high reliability by regular mental health clinicians. Nor is there any

credible evidence that any version of the manual has greatly increased its

reliability beyond the previous version”. (p. 53). The process of revision from the

D.S.M.-III to the D.S.M.-IV-tr (the current version) “ratified the sweeping

changes first incorporated into the D.S.M.-III”, despite the “shaky empirical

foundation” of those changes. (p. 48).

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At the root of this controversy appears to be the need for psychiatry to present

itself as “objective science”. This has been its attitude and goal since the first

writings of Sigmund Freud. Modern psychology was born into the cultural

Weltanschauung of empiricism of the 19th century. But if indeed “we have had a

hundred years of psychotherapy – and the world’s getting worse” as James

Hillman lamented in his book of that title, is it not time to evaluate these largely

unacknowledged assumptions of modern psychology? Kutchins’ and Kirk’s

critique exposes the deceptive and even fraudulent claims of empiricism in the

D.S.M. constructs but is this the right question? Has psychology lost itself and

any hope of understanding its object by distancing itself from the non-

quantifiable? A number of writers have directly questioned these empiricist

assumptions and have argued for a return to a fuller definition of “science”. Dr.

Wolfgang Smith, a prominent physicist and philosopher of science has argued that

due to the metaphysical assumptions which underlie this cultural Weltanschauung

of empiricism, “scientists have promulgated philosophic opinions of the most

dubious kind as established scientific truths, and in the name of science have

thrust upon an awed and credulous public a shallow world-view for which in

reality there is not a shred of scientific support” (2000).

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Nearly 2500 years ago Aristotle formulated a definition of science as “an

organized body of knowledge of things through their causes” (McKeon, 2001).

For “the master of those who know” those causes were four – the material, the

formal, the efficient and the final. Modern science, including the science of

psychology, typically limits itself to discussions of only one, the efficient cause.

Kutchins and Kirk stumble upon this when they noted that in order to classify

something as a “dysfunction”, this “requires that the natural function of mental

mechanisms be known before claims of dysfunction can be made” (1997, 35). This

is what is known as teleology, or among Aristotle’s causes, it is known as the

“final” cause. It is precisely the final cause that psychology is most reluctant to

ask about and since modern psychology “does not have a solid foundation in an

authentic view of man…[it] has made little real progress in helping the mentally

ill” and “cannot help but produce useless and sometimes even harmful theories

and remedies for mental illness” (Ripperger, 2003, xiii). A truly “post-modern”

approach to psychology must transcend this assumption and embrace a greater

epistemological pluralism if it hopes to understand its object.

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If then the diagnostic categories of the D.S.M. do not rest on empirical

foundations, as Kutchins and Kirk contend, what do they rest on? The authors of

Making Us Crazy argue that the D.S.M.’s formulations were attempts by

psychiatry to make “claims about what is normal” and what is psychiatry’s

legitimate domain. Instead of an objective process of compiling research data, the

development of the D.S.M.’s constructs has been a process of political

compromise between various special interest groups, which represent mental

health practitioners, the pharmaceutical industry and third-party payers including

insurance companies and government agencies. This process often took place

surrounded by an aura of secrecy with handpicked committees and “tightly

controlled” processes. The D.S.M.-IV in particular was created in an atmosphere

that sought to avoid public controversy and “to reap the huge and unexpected

profit that [the] D.S.M.-III … generated” (1997, p. 49).

The authors subsequently detail the political wrangling and infighting which

surrounded such issues as the removal of the term “neurosis” from D.S.M.-III; the

removal of homosexuality as a disorder; the inclusion of a new disorder, Post-

Traumatic Stress Disorder (P.T.S.D.); and the unsuccessful attempt to create a

“Masochistic Personality Disorder” all of which illustrates the various factions

and ideologies that have to be satisfied in order to arrive at a finished product.

Arguably the most sinister factor in these debates has been the lobbying of

pharmaceutical companies and insurance companies for the creation or exclusion

of certain diagnostic constructs.

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Finally, Kutchins and Kirk describe the history of racism and Western cultural

bias that is imbedded in many of the diagnostic constructs. They cite studies

which demonstrate that even when clinicians are presented with identical

symptomologies, racial minorities and women receive more and more severe

diagnoses than white men. The D.S.M. – IV did include “(1) a discussion of

‘cultural variations in the clinical presentation’ in the description of each of the

official diagnoses and (2) an appendix that contains both an ‘Outline for Cultural

Formulation’ and a ‘Glossary of Culture-Bound Syndromes” (1997, p. 233)

However, they argue that the effect of this approach “implies there is a universal

quality to the D.S.M.-IV diagnoses that is not to be found in culture-bound

syndromes, even if a certain example of the latter occur in areas of the world that

encompass a billion or more people and many cultures” (p. 236). In other words,

the disorders of white American males are “universal” while those that pertain to

those living in Asia or Africa are “culturally-bound”. This would seem to not

differ significantly from the terminology used in 19th and early 20th century

psychology texts that differentiated between “advanced” and “primitive” cultures

or peoples.
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For the immediate future it would seem the dominance of the D.S.M. is nearly

assured but as we move into post-modernity and away from the outdated or worse

conceptions of mental illness, diagnosis, and treatment, mental health

professionals should begin asking hard questions as Kutchins and Kirk have.

People such as Dr. Wolfgang Smith, Fr. Chad Ripperger, Dr. Paul Vitz, who have

illuminated the unspoken metaphysical and epistemological assumptions in

modern science in general and modern psychology in particular, have taken the

first steps. Students in graduate programs and practitioners in the field should be

made aware that simply going along with the status quo is to tacitly participate in

its racism, sexism and cultural imperialism.

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Bibliography

Kutchins, H. & Kirk, S.A. (1997). Making Us Crazy. DSM: The Psychiatric Bible
and the Creation of Mental Disorders. New York, NY: Free Press.

McKeon, R. (ed.). (2001). The Basic Works of Aristotle. New York, NY: Modern
Library.

Ripperger, C. Fr. (2003) Introduction to the Science of Mental Health. Vol. 1:

Philosophical Psychology 2nd Ed. (w/ Forward and Imprimatur by Rev. Fabian
Bruskewitz). Lincoln, NE: Fraternity Publications.

Smith, W. (2000). The Plague of Scientistic Belief. Homiletic & Pastoral Review, Vol. C,
No. 7. Retrieved May 5, 2008, from
http://www.catholic.net/rcc/Periodicals/HPR/April%202000/belief.html.