MAD

SCIENCE
 MAD
SCIENCE
Psychiatric Coercion, Diagnosis, and Drugs

Stuart A. Kirk,
Tomi Gomory,
& David Cohen

Transaction Publishers
New Brunswick (U.S.A.) and London (U.K.)
Copyright © 2013 by Transaction Publishers, New Brunswick, New Jersey.

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Library of Congress Catalog Number: 2012035176

ISBN: 978-1-4128-4976-0
Printed in the United States of America

Library of Congress Cataloging-in-Publication Data

Kirk, Stuart A., 1945-

Mad science : psychiatric coercion, diagnosis, and drugs / Stuart A. Kirk, Tomi Gomory, and David Cohen.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4128-4976-0 (alk. paper)
I. Gomory, Tomi. II. Cohen, David, 1954- III. Title.
[DNLM: 1. Diagnostic and statistical manual of mental disorders. 2. Mental Disorders--history--United States. 3. Mental
Disorders--drug therapy--United States. 4. Psychiatry--history--United States. WM 11 AA1]
616.89’075--dc23
2012035176
 Contents
Preface

1. Illusions of Psychiatric Progress

2. The History and Historians of Madness

3. The “Therapeutic” Coercion of the Mad in the Community

4. And DSM Said: Let There Be Disorder

5. The Failure of Descriptive Diagnosis

6. Dancing with Drugs

7. From Drugs to Medications—and Back

8. The Structure of Mad Science

Index
 Preface
Over the last fifty years in the United States, there has been a massive expansion of the psychiatric enterprise. According to one
source (Frank & Glied, 2006), the principal group of mental health professionals in 1950 used to be made up of about seven
thousand psychiatrists. Today, using US Department of Labor (2012) figures and selecting professions with the terms psychiatric,
mental health, substance abuse, as well as clinical psychologists and mental health and substance abuse social workers, we have an
army of at least six hundred thousand mental health professionals. By adding psychiatric nurses and a number of other counseling
and therapeutic occupations and their supporting staff, such as medical records keepers and various mental health technicians, the
number would easily top one million. Not surprisingly, the amount spent on what are called mental health services has also
exploded, from about $1 billion in 1956 (Frank & Glied, 2006) to $113 billion today (Garfield, 2011).
The people who are the target of these services—those from infancy to senescence who are considered mentally ill, who consider
themselves mentally ill, and who are encouraged to seek mental health services—is at an all-time high. According to the latest
American Psychiatric Association methods of diagnosing mental illness, nearly one hundred million people, 25 to 30 percent of the
US population, have a mental illness during any one year (Frank & Glied, 2006, pp. 10–11), and half of the population will have a
mental illness during their lifetime. This massive expansion of recognized illness, professional manpower, and services was
accompanied by the rise of state and federally funded programs that provide most funding for mental health services. A growing
number of private health insurance policies also provide psychiatric coverage. Surrounding this expansion is the pharmaceutical
industry, which has immersed the entire mental health service system in a tidal wave of prescription psychoactive drugs, oxygenated
by multibillion-dollar lucre, most of it also paid for by public funds.
Many psychiatric authorities claim that these developments are signs of major medical progress: the growing humanitarianism of
an enlightened society caring for those in need; the advances in methods of accurately identifying and diagnosing all those suffering
from psychiatric illness; and the scientific breakthroughs in understanding and treating mental illness biochemically.
If this grand explanation of progress was accurate, then the following should also be true. There would be less mental illness in
America now than in 1950. Those with mental illness would be much more likely to recover with treatment than before. Those who
are now called the severely mentally ill, who formerly would have been involuntarily committed to state asylums, would now be
more effectively and humanely treated. The use of coercion as a psychiatric intervention would be a method of the distant past. The
techniques of diagnosing mental illness would be more accurate, and valid, than methods used previously. Diagnosis would rest on
biological markers rather than conversation as the “biological basis” of the currently more than three hundred types of mental
illnesses would have been substantiated or disconfirmed. As a result, the remaining actual bodily illnesses formerly called mental
illnesses or mental disorders would be the concern of medical specialties such as neurology or endocrinology. We would have
confirmed methods of preventing and curing these illness that could be employed by any mental health practitioner. With at least
one in four American women and one in seven American men today receiving psychoactive drugs by prescription, there would be
solid evidence that these drugs effectively treat the problems for which the Food and Drug Administration approves them.
If you believe that even one of the above signs of progress has occurred, the review and analysis presented in Mad Science will
be eye-opening, if not disturbing. None of these confirming developments has occurred. Of course, many in the public and in the
mental health professions think that major “advances” in diagnosis and treatments of mental disorders have occurred and are
continually occurring. Agencies such as the National Institute of Mental Health and organizations such as the American Psychiatric
Association regularly tout such advances, which are then widely echoed by the media. Many, perhaps a majority of adults today,
believe that the problem of mental illness is fundamentally a medical problem whose solution lies, through conventional medical
research, in identifying its causes and devising effective treatments (e.g., targeting brains and genes). Most people view modern
drug treatments as an undisputed improvement (more effective and safer) over any previous interventions designed for those
considered mentally ill. Moreover, many people believe (or perhaps merely hope) that those labeled severely mentally ill—and those
who treat them—now operate in an atmosphere of cooperation without the use coercion.
In this book we offer a radically different interpretation of the character of the massive American psychiatric and mental health
expansion and how it came to be. The discrepancy between the views held by the public and many professionals on the one hand
and the actual evidence on the other hand brought the authors of this book together. Our goal was to understand and describe how
psychiatric research and science of the past half century have shaped the public understanding of expressions such as “mental
illness” or “mental disorder” and of the effectiveness of psychiatric treatment. Much of the psychiatric research that has fueled the
expansion of the mental health enterprise has not contributed to a science of madness. Instead, it has fueled mad science, which rests
on unverified concepts, the invention of new forms of coercion, unremitting disease mongering, the widespread use of treatments
with poorly tested and misleading claims of effectiveness, and rampant conflicts of interest that have completely blurred science and
marketing. This is the “madness” of American psychiatry, and of psychiatry in much of the world.
We begin by examining the prevailing language of disease and medicine and its effect on views about the nature of madness and
how it ought to be controlled or managed. By critically assessing whether the claims of scientific advances are supported, we track
the fate of those labeled the severely or seriously mentally ill as they are ushered into purportedly more humane “community
treatment” in which coercion has become redefined as scientifically-elucidated therapy. We examine the nature of the “epidemic of
mental disorders” that was manufactured by the ever-expanding boundaries of mental illness contained in the Diagnostic and
Statistical Manual of Mental Disorders, the well-promoted and profitable guidebook to madness that has allowed those with
institutional and financial interests to claim that existential, interpersonal, and troublesome problems in living are actually
diagnosable brain diseases. We then connect these developments to the explosive growth in the use of prescribed psychoactive
substances, developed and relentlessly promoted by the pharmaceutical industry and delivered to willing and unwilling persons by
licensed physicians and their collaborators in the other mental health professions.
Although the order of the chapters reflects in part the chronological development of coercion, diagnosis, and drug myths in
psychiatry, readers should feel free to read chapters 2 to 7 in any order they wish. Each chapter, as it turns out, contains a mix of
historical observations, conceptual and critical analysis, and discussions that, we hope, dovetail nicely and occasionally overlap with
the other chapters and should augment readers’ appreciation of the interrelatedness of the various topics. We recommend, however,
that chapter 8 be read last, as it draws upon all that preceded.
 Our Collaboration
Before we began working on this book, we had barely met or worked together. We are from diverse origins: one—a Hungarian child
refugee fleeing the failure of that small country’s 1956 fight for freedom from the tentacles of the Soviet Union—grew up in New
York City’s Greenwich Village. The second—a French-speaking Sephardi emigrant from Morocco and then Canada—lives and
works in Florida. The third—with German and Lebanese ancestors—was raised in California. Our moral and religious upbringings
and our political views are dissimilar, and we are in different stages of our personal lives and careers. We have lived in different
states for most of our professional careers. We all happened to be married fathers and professors of social welfare with interests in
human distress, misbehavior, and madness; and we each pursued doctoral studies at Berkeley, although in different decades. We
have each practiced as mental health clinicians, taught at universities, conducted research, and published on mental health topics.
What really brought us together, however, was that we were each writing critically about psychiatric claims that were at odds
with the best empirical evidence, especially the evidence cited by the claims-makers themselves. Each of us struggled to understand
how gross misinterpretations of research evidence were allowed to promote vast policies and practices under the rubric of mental
health progress. Was good science being misused? Was bad science being propagated? Were equivocal findings being exaggerated
for some institutional advantage? Were fake findings being manufactured? Was there merely widespread lack of knowledge and/or
gullibility by the public and mental health professionals, hoping to solve an age-old problem? Or was there some even larger, more
nebulous enterprise, a sort of mass delusion or self-deception? What was going on? Although working individually, none of us had
kept his individual doubts a secret. Quite the contrary, we had each been actively engaged for many years in writing, speaking, and
debating with our opposition in professional journals and media outlets. We began meeting together in 2004 in New York City and
conversing about madness and the madness institutions. In that process, we saw that a broader context was needed to fully
understand the relationship of psychiatric science to psychiatric practice and policy.
This book arose from our conversations, of our effort to tell a broader, more compelling story than we had told individually. The
book is truly a collaborative effort. We took seriously Alexandre Dumas’ motto for his three musketeers, “One for all and all for
one”—the order of authorship representing only an administrative convenience. We spent obsessive months imagining the structure
of the book and ceaselessly reworked that preliminary structure until publication. Although one person had to author a first draft of
each chapter using a collectively developed outline, the chapters were read, revised, edited, and re-read by each of us. Sections of
content were swapped among chapters. Ideas advanced by one of us were sometimes deleted by others or borrowed and expanded.
In the end, we all have our fingerprints on practically every paragraph.
While we developed the book, we presented some of its ideas in academic and professional gatherings, most recently at
University of California at Los Angeles and at Berkeley; the University of Brussels; Florida International University; University of
Tartu, Estonia; University of Pecs, Hungary; University College Cork, Ireland; and in France, Universities of Poitiers, Bordeaux,
Paris-Descartes, and Paris-Diderot. Most surprising was not that our views were challenged, but that so many participants shared our
concerns about the direction of modern American psychiatry.
 Our Benefactors and Helpers
For reasons that will become abundantly clear, our work on this book did not enjoy any direct financial support from the psychiatric-
pharmaceutical complex. Instead, we relied on the support of our universities to pursue our inquiry and on the tolerance of our
colleagues for our perspective, which at times runs counter to their views. In addition, the Marjorie Crump Endowed Chair at UCLA
covered a few of the expenses of finishing our project. Finally, a sabbatical stipend from Florida International University and the
Fulbright-Tocqueville Chair Award to David Cohen in 2011–2012 allowed him to devote time to this project.
In addition to our supportive academic institutions, many small enterprises from coast to coast unknowingly supported our
efforts. Several times a year we met for days of intensive discussion and to examine our evolving work. We gathered in
coffeehouses and restaurants as we argued, bantered, and brainstormed our way through umpteen drafts of chapters. These small,
local establishments provided the ambience, sustenance, service, and espresso for our work, some of them on more than one
occasion. For their tolerance of our antics and appropriation of their tables, it is only fitting that, in gratitude, we thank a few of
them by name. In Greenwich Village (NYC): Café Dante on Macdougal Street with its legendary Latte Macchiato Strong. In Santa
Fe (NM): Café Pasquals, Coyote Café, Downtown Subscription, Mucho Gusto, Plaza Café, and Rio Chama. In South Beach (FL):
Big Pink and News Café. In Big Sur (CA): Deetjens Big Sur Inn and the Ripplewood Café. In Tallahassee (FL): Z. Bardhi’s Italian
Cuisine and Samrat Indian Restaurant. In Ojai (CA): Ojai Emporium Café, and the Ojai Roasting Company. In New Orleans (LA):
Lafitte’s Blacksmith Bar.
We are hardly the first to raise critical questions about the mental health enterprise. For intellectual inspiration we drew on
dozens of authors whose work we cite repeatedly in the text. In addition, we also asked other scholars to review and comment on
draft chapters and discussed our work with others. Their advice and suggestions were wise, constructive, and unfailingly helpful,
although we have undoubtedly disappointed some of them by not fully adopting their suggestions or addressing their concerns. Our
gratitude to Lauren Dockett, Eric Engstrom, François Gonon, Nikki Hozack, David Jacobs, Herb Kutchins, Jeffrey Lacasse, Bruce
Levine, Joanna Moncrieff, David Oaks, Pascal-Henri Keller, the late Thomas Szasz, Robert Whitaker, and several anonymous
reviewers. A special thanks to Professor Eileen Gambrill of the University of California, Berkeley, who shaped our early academic
careers by stimulating a critical attitude toward all conventional assumptions that apply to the study of and responses to human
travail. Finally, we were encouraged early in our project by the late Professor Irving Louis Horowitz, the founder of Transaction
Publishers, who reviewed our book prospectus in 2010. Unfortunately, he passed away the week before our full manuscript was
submitted. We are indebted to him, Mary E. Curtis, the president, and the other editors at Transaction for providing a welcoming
home for our book.
Finally, we have deep personal gratitude for those close to us who encouraged our work and provided the emotional support that
sustained us. While they bear no responsibility for our book, their lives were certainly affected by our entanglement with Mad
Science. Stuart acknowledges and deeply appreciates the tolerance, support, and humor of Carol Ann Koz, who was not blind to
what life with him would be like when he began another book. Tomi could not be the engaged academic critic that he is without the
uncritical, loving support of his life partner Fran and the very best and sweetest two daughters any father could be privileged to love,
Aniko and Rozsa. He owes to those three much more than he could ever express. Throughout his career, David’s most dedicated
support and encouragement has come from his wife Carole and their children, Saskia and Bernard.
Inevitably, coauthoring a book involves time, complexities, and frustrations. Yet, the three of us agree that the deep, meaningful
relationships that we formed among us constitute the major benefit of our effort.

Stuart Kirk, Ojai, CA

Tomi Gomory, Tallahassee, FL
David Cohen, Miami Beach, FL
 References
Frank, R. G., & Glied, S. A. (2006). Better but not well: Mental health policy in the United States since 1950. Baltimore: Johns Hopkins University Press.
Garfield, R. L. (2011). Mental health financing in the United States: A primer. Washington, DC: Kaiser Commission on Medicaid and the Uninsured.
US Department of Labor. (2012). Occupational employment and wages—May 2011. Bureau of Labor Statistics. Retrieved from:
http://www.bls.gov/news.release/archives/ocwage_03272012.pdf
 1
Illusions of Psychiatric Progress

Introduction
Madness poses fundamental problems for every society, past and present. The terms used to describe it—lunacy, insanity, mental
disease, mental illness, nervous breakdown, emotional or psychological distress, mental disorder—carry a cargo of cultural
meanings and spawn countless social reactions. Although each of these terms invokes a different understanding, the concept and the
category of madness serve an essential purpose: they help those not so categorized to feel better about themselves and their
presumed normalcy, while at the same time they earmark others as violating society’s expectations and deserving to be targeted by
professional and state intervention.
Madness also safely subsumes and “explains” behavioral strangeness and violence that threaten social order, such as, for
example, apparently unprovoked mass shootings by solitary individuals harboring deep grudges. The word madness represents some
reality that triggers images for everyone, but hardly any two individuals would agree about its essence. Perhaps madness has no
essence; perhaps it is only a linguistic black hole. Psychiatric historians and others, however, relying on their own personal histories
and presumptions (often unacknowledged), have usually attempted to tell coherent and optimistic tales affirming the belief that
medicine has virtually solved the mystery of madness and has validated it as yet another affliction of nature—a disease.
The current psychiatric establishment, exemplified by the US National Institute of Mental Health (NIMH) and the American
Psychiatric Association (APA), wants the public to believe that disturbing behaviors result from brain diseases, that scientific
research moves ever closer to finding causes and cures for these diseases, and that patients should be treated by approved, expertly-
trained therapists applying certified, evidence-based treatments. This medical language and medicalized apparatus is a bid for
authority over a long-disputed territory of distresses and misbehaviors. The language implies that errors of the past have given way
to steady progress in understanding madness and treating it effectively. The claim for authority covers an immense range of human
emotion, suffering, and behavior, including experiences that can severely frighten a person or those around them, such as panic,
immobilizing despondency, having unusual perceptions, or acting violently in response to (possibly imagined) threats. But the bulk
of the behavioral territory claimed by the modern professions addressing madness—including psychiatry, psychology, and social
work—covers more common experiences, such as feeling irritable, sad, or very sensitive; having difficulty concentrating; feeling
inept; working too much or too little; sleeping too much or too little; eating too much or too little; or feeling discomfort in ordinary
social situations. Contemporary psychiatry claims that these diverse feelings and behaviors—from the rare and extreme to the
common and mild—are symptoms of mental disorder, signs of underlying physiological dysfunction, requiring medical treatment.
In contrast, we will argue that the fundamental claims of modern American psychiatry1 are not based on well-tested research but
on science that is itself a bit mad: misconceived, flawed, erroneous, misinterpreted, and often misreported. Using the cover of
scientific medicine, psychiatry has managed to become the leading legally chartered profession for the management of misery and
misbehavior reframed as an illness (i.e., mental illness). We will demonstrate that the touted achievements of psychiatry in the past
half century—keeping disturbed people out of psychiatric hospitals for extended periods, developing a novel and easily applied
diagnostic approach embodied in the modern Diagnostic and Statistical Manual of Mental Disorders (DSM), and using “safe and
effective” drugs as the first-line intervention for every ill and misfortune—are little more than a recycled mishmash of coercion of
the mad and misbehaving, mystification of the process of labeling people, and medical-sounding justifications for people’s desires to
use, and professionals’ desires to give, psychoactive chemicals. Obviously, then, this book questions the notion that these psychiatric
achievements constitute progress. We argue that until society come to grips with the unscientific nature of the management of
madness, it will perpetuate a “mental health” system that serves the interests of professional and corporate elites while it exacerbates
the very problems it claims to tackle.
Mental health professionals and the public have been well apprised of the notable achievements of psychiatry this past half
century: the near-closing of state asylums in order to provide “evidence-based” care in the community, the expansion of the category
mental illness via the renovation of the Diagnostic Manual of Mental Disorders (especially since DSM-III), and the invention and
marketing of new psychoactive drugs. These achievements have often been described as paradigm shifts that have shaped the
current mental health system. Undoubtedly, their role in shaping this system cannot be taken lightly. However, we argue that these
achievements constitute a trio of illusions, spawned more by the misuse than the progress of science. And, as illusions often do, they
have unleashed a torrent of unanticipated adverse consequences, even as they have benefited organized psychiatry, pharmaceutical
companies, and the proponents of the “mental health movement.”
As with the “unexpected” collapse of Wall Street in 2008, Americans may yet again, much to their consternation, come to realize
that a huge social institution is not as sound as its best and brightest continually claim. The mental health enterprise, like some
banks, is continually propped up by government, the profession, and the media because it has become too big to fail. Yet there is no
question to us that it has failed and continues to fail daily. Our hope in this book is that society may yet learn to minimize
psychiatric coercion and excuses, to offer help to those who need it, and to minimize the manipulation and distortion of science.
 On the Language of Madness

Social scientists have to decide, every time they do research, what to call the things they study. If they choose the terms
decided on by the interested and powerful parties already involved in the situations they are studying, they accept all the
presuppositions built into that language.
(Becker, 2007)

As the sociologist Howard Becker reminds us in the quotation above, we should be skeptical about the rhetoric used by powerful
parties and the assumptions that they may bootleg into public discourse. It is advice that we intend to follow throughout this book.
Let’s begin by examining how the National Institute of Mental Health (NIMH), the federal government’s leading mental health
agency, speaks of madness. Here is a typical excerpt from its website in 2008:

The mission of NIMH is to reduce the burden of mental and behavioral disorders through research on mind, brain, and
behavior. Mental disorders are brain disorders and that means that achieving progress requires a deeper understanding of
the brain and behavior.

Since our inception in 1946, NIMH has been the lead agency for research on mental disorders. Through our research,
enormous gains have been made over the decades, including: establishing that mental disorders are complex brain diseases
and demonstrating that medications and behavioral therapies can relieve suffering and improve daily functioning for many
people. Recent groundbreaking discoveries from mapping of the human genome, sophisticated studies of the brain, and
investigations of cognition and behavior have provided powerful new insights and approaches.

Science now provides opportunities that promise to deliver for each of these needs. Success will require an understanding
of the underlying processes in brain and behavior—from neurons to neighborhoods—to make the discoveries that point the
way to new diagnostics and interventions and, eventually to recovery, prevention, and cure. (From Strategic Planning
Reports, NIMH website, 2/15/08)2

NIMH is explicit about madness: the behaviors are “brain diseases” managed by “therapies” while science moves closer to
finding a “cure.” The language of biomedicine pervades today’s official views: disease, genetics, medications, behavioral therapies,
rehabilitation, cure, recovery. It is as if none of these terms are contested or misleading. And yet great confusion exists at NIMH
and throughout the scientific establishment about what behaviors express brain disorders, how they come about, how they should be
managed, and by whom. As we will see, many experts believe that no scientific evidence exists to describe the vast array of
behaviors corralled in the rubric of mental disorders as “brain diseases.” What NIMH presents as a simple equation is a political, not
a scientific, pronouncement. For fifty years, the bureaucratic language about madness has contained many convoluted, vague, or
tautological attempts at definition, as exemplified by the definition of “serious emotional disturbances” in children taken from the
President’s New Freedom Commission on Mental Health (2002):

A serious emotional disturbance is defined as a mental, behavioral, or emotional disorder of sufficient duration to meet
diagnostic criteria specified in the DSM-III-R that results in functional impairment that substantially interferes with or
limits one or more major life activities in an individual up to 18 years of age. Examples of functional impairment that
adversely affect educational performance include an inability to learn that cannot be explained by intellectual, sensory, or
health factors; an inability to build or maintain satisfactory interpersonal relationships with peers and teachers;
inappropriate types of behavior or feelings under normal circumstances; a general pervasive mood of unhappiness or
depression; or a tendency to develop physical symptoms or fears associated with personal or school problems. (Retrieved
10-17-12 from: http://govinfo.library.unt.edu/mentalhealthcommission/reports/FinalReport/FullReport.htm)

The President’s Commission appears to eschew the terms brain disorder or brain disease in describing children’s behaviors. It
opts to use “serious emotional disturbance” instead, admittedly a more neutral term, but its meaning is itself obscure. For example,
the passage leads to confusion by defining serious emotional disturbance “as a mental, behavioral, or emotional disorder,”
suggesting that three distinct types of “disorders” constitute emotional disturbance, without a wisp of explanation about the nature of
the distinctions. To shore up the ambiguities, the passage borrows language from the DSM and elsewhere regarding “duration” and
“functional impairment” that lead to various inabilities and inappropriate behaviors, feelings, fears, or unhappiness—plunging the
reader into the depths of current psychiatric diagnostic murkiness. This type of descriptive obscurity would be unacceptable, for
example, to cancer researchers trying to distinguish pathological from normal cells, suggesting that despite the official modern
vocabulary of madness, we are leagues away from the logic of medicine. In fact, the more ambiguous the terms used to demarcate
mental disorder from no mental disorder, or emotional disturbance from emotional stability, the more behavioral territory can be
annexed under the jurisdiction of the mental health professions.
In 1980 the APA published its first serious official attempt to grapple with a definition of mental disorder, the current popular
term. This occurred in the third edition and all subsequent editions of what is regularly referred to as the psychiatric Bible, the
Diagnostic and Statistical Manual of Mental Disorders (DSM), readying itself for its seventh face-lift, DSM-5, scheduled for release
in 2013. Admitting that “there is no satisfactory definition that specifies precise boundaries” (p. 5) for mental disorder, the DSM
(APA, 1980) offered the following guidance:
 In DSM each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or
pattern that occurs in an individual and that is typically associated with either a painful symptom (distress) or impairment in
one or more important areas of functioning (disability). In addition, there is an inference that there is a behavioral,
psychological, or biological dysfunction, and that the disturbance is not only in the relationship between the individual and
society. (When the disturbance is limited to a conflict between an individual and society, this may represent social deviance,
which may or may not be commendable, but is not by itself a mental disorder.) (p. 6)

Almost every phrase in this cumbersome definition has been criticized (Kutchins & Kirk, 1997). One critic (Wakefield, 1992) noted
in a widely cited article that the DSM defined disorder as a dysfunction, but without any attempt to suggest what a dysfunction is.
Wakefield’s subsequent attempts to define dysfunction have, in turn, also been questioned as constituting speculative hypotheses
about the functions of human evolution (Bolton, 2008; Boyle, 2002; Lilienfeld & Marino, 1995; McNally, 2011). More recently, a
group of psychiatric researchers (Rounsaville et al., 2002), working under the auspices of the APA in preparation for DSM-5,
concluded that mental disorder as defined in DSM is not an exact term and “is not cast in a way that allows it to be used as a
criterion for deciding what is and is not a mental disorder” (p. 3), and that there is a “contentious” debate about “whether disease,
illness, and disorder are scientific biomedical terms or are sociopolitical terms that necessarily involve a value judgment” (p. 3,
emphasis in original). And finally, they report that the current DSM “…is based on a falsely optimistic assumption: that psychiatric
disorders are discrete biomedical entities with clear . . . boundaries” (p. 8). In other words, even these prominent psychiatric
researchers, trying to improve or fine-tune diagnosis of the presumed entities that make up the very subject matter of psychiatry,
disagree not only with DSM but with the professed certainties of NIMH’s “brain diseases.”
The definition of madness remains in disarray. This dilemma has become abundantly clear as the American Psychiatric
Association struggles to produce DSM-5, which will be discussed in greater detail in chapter 5. Particularly revealing is an article
titled “What Is a Mental/Psychiatric Disorder: From DSM-IV to DSM-V,” written to guide DSM-5 (Stein et al., 2010). The authors
concede the following: there are disagreements about the term mental disorder; the “clinically significant” DSM criterion for mental
disorders is tautological and difficult to operationalize; the boundaries between normal and pathological are complex and
contentious; and the concept of dysfunction is controversial and involves speculative theoretical assumptions about human
evolution. Undeterred, the authors suggest adding additional criteria that are themselves problematic. First, “any disorder in DSM
should have diagnostic validity” on the basis of a number of key validators, which they admit are variable and may not be readily
available, but “in their absence . . . other evidence of diagnostic validity is helpful.” Second, any disorder in DSM “should have
clinical utility,” another potentially tautological or meaningless criterion that would exclude almost no human distress, because
someone somewhere can always claim that an effective treatment for it exists. Allen Frances, the chairperson of the DSM-IV Task
Force (who presided over an enormous expansion of the mental disorder vocabulary and population), surprisingly summarized the
definitional difficulties in the plainest terms: “There is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define
it” (Greenberg, 2011).
In 2007, in one of his many statements about the nature of “mental illnesses as brain disorders,” Thomas Insel, the director of
NIMH, expressed less-than-usual certainty. He speculated that mental disorders may result from brain lesions (i.e., some damaged
areas of tissue), may eliminate the distinction between neurology’s focus on the brain and nervous system and psychiatry’s
traditional focus on thoughts and behaviors, and may arise from abnormal activity in “brain circuits,” even without detectable
lesions (Insel, 2007). Naturally, these conjectures may turn out to be wrong. Nevertheless, they form part of Insel’s active campaign
to push the NIMH even more deeply into framing and pursuing madness as a biomedical entity and to convert psychiatry into a
neuroscience discipline (Insel et al., 2010; Insel & Quirion, 2005), or at least the trappings of one. There is nothing new in Insel’s
claims about madness as brain disease: they have been made for over two hundred years (Bynum, 1974). That such claims are still
being put forth, rather than their precise empirical basis described succinctly for public verification, illustrates how little progress
the biopsychiatric approach has made in understanding or elucidating madness.
Three powerful organizations—the NIMH, the President’s Commission, and the APA—offer us three official languages to define
and describe mental illness. The major institutional players in the field, including the pharmaceutical industry, have so expanded the
kinds of behaviors and emotions now considered symptoms of mental disorder that the term has lost coherence, if it ever possessed
any. For example, common behaviors among schoolchildren, such as fidgeting with hands and feet, difficulty awaiting turn, running
about, and blurting out answers before questions are completed, now make up actual diagnostic criteria of the mental disorder
named Attention-Deficit/Hyperactivity Disorder if they occur “often” (but that last qualifier is completely undefined) (APA, 1994,
pp. 83–85). Yet this incoherence has not led to a loss of legitimacy or power for these major players. To the contrary, the varieties of
meaning and confusion have only helped to expand the psychiatric enterprise.
If we undertook a broader survey of psychologists, social workers, philosophers, historians, and social scientists who study
mental illness about what madness might be and how it should be handled by society, the level of disagreement would rise
dramatically. NIMH and others try to smooth over these disparities, to view the whole issue as a matter of brain disorders requiring
medical interventions. We will show in later chapters that the science for such a sweeping conclusion remains feeble, although the
political effort is exceedingly powerful.
The way in which language has been used to designate madness and its management distorts as much as it illuminates the nature
of the subject. We face the same continuing dilemma: how to illuminate without foreclosing questions that haven’t been sufficiently
answered or pretending that consensus and clarity exist when they do not. No supportable or practical resolutions to this dilemma
exist. Words are human artifacts; their meanings change over time to adjust to changing cultural norms, everyday practices, or new
knowledge. We have chosen to adopt the custom of many historians and sociologists who use various rubrics to discuss phenomena
that range from minor social deviance (e.g., smoking marijuana or conning others) to serious personal distress and suffering (such as
feelings of worthlessness, overwhelming fear, or grossly disturbing behavior). Although all are viewed as symptoms of mental
disorders in the DSM, as a matter of convenience we will very reluctantly use conventional terms for madness interchangeably
—mental disease, mental illness, and mental disorder—without making presumptions about their underlying nature or particular
causes and despite the fact that these terms often seem incoherent to us. We do, however, admit a preference for two general
groupings of human difficulties that we believe encompass as well as any other the psychological disarray and the disruption of
relationships that most people often attribute to madness or refer to when they speak of madness or mental disorder.
 What Is Meant by Madness?
The process of transmogrifying the notion of madness into a medical disease has been essentially linguistic: it has involved verbally
funneling an exceedingly heterogeneous group of individuals needing complex, individualized management or assistance into one
category describing people burdened with a medical illness and requiring technical attention from mental health professionals. The
pedagogic effort has been hugely successful (everyone seems to know what mental illness looks like and that it requires treatment),
whereas the scientific effort to validate madness as a medical entity far less so (no one knows what a mental illness is). For example,
a leading contemporary biological researcher of schizophrenia, psychiatrist Nancy Andreasen (1999), thus commented:

At present the most important problem in schizophrenia research is not finding the gene or localizing it in the brain and
understanding its neural circuits. Our most important problem is identifying the correct target at which to aim our powerful
new scientific weapons. Our most pressing problem is at the clinical level: defining what schizophrenia is. (p. 781)

Given this obvious definitional uncertainty, here is our own view of what is subsumed by the term mental illness. It is a label
used to characterize and organize the many different behaviors that have become the targets of a “biomedical industrial complex”
(Gomory et al., 2011). They include at least two broad types of problems that should be distinguished, although people may
experience or manifest both. On the one hand, there is personally perceived distress: usually situational, life stage-related difficulties
in coping with life’s and society’s demands that often appear as inability or unwillingness to pursue personal goals or to interact
smoothly with other people. When people experience personal distress, they typically seek or accept help voluntarily from whatever
sources they believe will best address these difficulties. Personal distress usually directly burdens no one outside of friends, peers,
immediate family, and co-workers and causes little public notice, nor does it trigger formal public intervention, although when
people fail to meet various personal and social obligations while they are distressed, there are indirect social and economic
consequences.3
On the other hand, there is misbehavior: visibly deviant, uncooperative, morally offensive or socially disruptive behaviors. These
behaviors threaten and therefore mobilize the immediate interpersonal network or the larger society to forcefully restrain and then
exclude (and perhaps re-educate) the offending individual (who may be acting from a variety of possible motives, or from no
discernable motive). Although many people who so misbehave may cross over into frankly criminal activities, and may therefore
also experience simultaneous or successive management by the criminal justice system, many do not.
Both these categories of behavior fall into what sociologist Andrew Abbott (1988) described as the personal problems
jurisdiction, an arena vigorously competed for by several helping professions in the late nineteenth and early twentieth centuries.
These professions included psychiatry, social work, neurology, the clergy, and a nascent clinical psychology. The struggle for
professional supremacy over this jurisdiction was won by psychiatry. Abbott pointedly thinks that psychiatry’s success rested
particularly on its ability to construct a persuasive medicalized rhetoric that combined both social control and therapeutic care, even
though “[o]f its treatments, only incarceration had any effect, and that made the psychiatrists little different from the jailers they had
replaced, despite their reference to the medical model of science, treatment and cure” (p. 295).
In its effort to gain leadership, the failure of psychiatry (and society) to carefully distinguish between personal distress and
public misbehavior and between the responses necessary for properly addressing each, conflated caring and coercing under the
single rubric of “mental health practice.” Efforts to care and efforts to control became hopelessly mixed, and as a small late
eighteenth-century system focused on a small number of misbehaving individuals evolved into a gigantic twentieth-century
biomedical industrial complex, the consequences for those distressed, those misbehaving, and for our society expanded
correspondingly.
 People Seeking Help
Scholars can afford to be skeptical about the pronouncements of experts and authorities on mental illness, but the general public
often becomes engaged with the psychiatric establishment when struggling to contend with personal and family distress. When
individuals and families are in crisis, they must make a series of judgments: How unpleasant is the difficulty to me or others I care
about? If I ignore it or wait, will it resolve itself over time or get worse? Is the difficulty due to my own mistakes or inadequacies or
to challenges thrust on me by circumstances or the actions of others? Can I rectify the difficulty through diligence, self-control, and
perseverance? Would I benefit from asking friends or family for advice, or should I seek professional advice? If I seek professional
advice, whom should I turn to first—a member of the clergy, attorney, nurse, social worker, psychologist, family counselor, or
medical doctor? Should I first speak to someone who experienced a similar difficulty and found a way to resolve it?
These questions raise complicated issues that involve assessments of self, guesses about what is likely to happen if no action is
taken, and estimates of the future consequences of taking different courses of action. These issues, in turn, are heavily constrained
by the options available in one’s community, society, and culture. People with similar troubles may handle them in very different
ways. Although scientific knowledge cannot indicate the best way for people to proceed when troubled, those who enter the current
mental health system seeking help are likely to face a bewildering array of professional beliefs, theories, treatments, and
controversies—and may also find themselves completely removed from decision making about their lives or the lives of their
relatives.
Let us explore three examples of how people who seek help for themselves or for their children become involved with the mental
health system and the consequences their actions bring.
Case 1: Treating “Brain Disease”
The first time the parents noticed anything wrong with their son, Mi, was in the summer of 2004 when, following a fever, the
twenty-one-year-old had trouble sleeping and often felt sick. He was depressed and moody, according to his mother. Mi stopped
going to work at the glass factory where he was an intern. His parents then sought advice from several medical doctors. Some
suggested that Mi had “mental problems”; some reviewed brain scans and told his father that there was little to worry about.
Nevertheless, when Mi’s parents, worried that their son’s condition might worsen, saw a newspaper article about the purported
success of a new brain surgery, they withdrew their life savings, borrowed additional money, and traveled to the hospital mentioned
in the article to seek treatment.
Upon seeing Mi for the first time, the doctor demanded the full payment, asked them to sign a page-long diagnostic report (that
the parents later claimed they had never read and described as bogus). Mi was placed on a gurney, strapped down, and taken away,
presumably for more diagnostic tests. The report by the hospital, however, makes no mention of further tests but instead describes
how frames were fixed onto Mi’s head, holes drilled into his skull, and a seven-inch needle heated to 180 degrees Fahrenheit and
inserted by the physician into the young man’s brain for about one minute to destroy selected areas of brain tissue. At three o’clock
that afternoon, nurses wheeled the son out of the elevator. The doctors told the parents the surgery had gone as planned. Mi vomited
during that night, blood ran from both ears, and, for five subsequent days, he slipped in and out of consciousness. His right arm was
limp and his speech was slurred.
Mi’s treatment inflicted irreversible brain damage. He is still depressed and withdrawn. His parents regret their decision to take
him to the hospital. The surgeon who performed the operation on the day he met Mi claims that the surgery went well and that Mi
was fine when he left the hospital. The surgeon said he has performed nearly one thousand such procedures for patients with
schizophrenia, depression, and epilepsy.
Case 2: The Full Treatment
David was a handsome, smart, and happy youngster who grew up in a middle-class neighborhood, the son of an executive for an
international transportation company. His troubles apparently surfaced when he was twenty-two, after he had enrolled and
withdrawn from three different universities. His father first suspected a drug problem. David wouldn’t talk, claimed to see things,
believed people were out to get him. He could not hold a job for more than a day. On the advice of a personal physician, his father
took David to a psychiatrist, who diagnosed him with acute paranoid schizophrenia. On the advice of this professional, his parents
obtained a court order and had David committed to a psychiatric hospital, where he was kept for forty days, until the family’s
insurance coverage ended.
David’s psychiatric treatment continued. Over the ensuing years, he was repeatedly evaluated by psychiatrists and was forcibly
hospitalized approximately twenty times in different psychiatric hospitals, among the best available in the region. His family also
obtained a court order to treat David involuntarily as an outpatient, but he regularly managed to elude those who were supposed to
monitor his medication usage. He received many drugs commonly used to treat psychiatric patients: lithium, Depakote (valproate),
Haldol (haloperidol), Seroquel (quetiapine), and Zyprexa (olanzapine). He also received electroshock treatment. Often against his
parents’ wishes, David was released from these hospitals after being evaluated as not posing a danger to himself or others.
When his mother was placed in a nursing home, David visited her frequently but caused such commotions that the nursing home
staff became uncomfortable. His father moved his mother to three different care facilities because of David’s disruptive and
threatening behavior. The police took him by force to a hospital after he threatened to kill people at one of these nursing homes. He
left that hospital but, because he was still acting threateningly, his father called the police and David was committed to another
university-affiliated hospital, where he stayed for a while. Several months later, he got in a fight with a hospital guard where his
mother had been transferred, and he was arrested again. He was examined by a doctor who said he did not need to be kept at the
hospital. His father’s ardent efforts with the police and hospital personnel to keep David incarcerated in a psychiatric hospital failed,
and David was released the next day. Several weeks later, David was charged with murdering a female psychotherapist and
attempting to murder a psychiatrist who was her colleague.
Case 3: “Bipolar Is a Lifetime Diagnosis”
Diana was anguished in trying to understand what was happening to her sixteen-year-old son Benjamin, who was sad, afraid, not
sleeping, and doing poorly in school. Where could she turn for help? She contacted Benjamin’s teachers for their observations of his
class performance; then she turned to his pediatrician and to mental health professionals for advice. A psychologist recommended by
the school’s principal concluded that the boy was “deeply depressed” and referred them to a psychiatrist for a medication evaluation.
“The psychiatrist was another nice man, young, in an attractive office,” she reported. The psychiatrist asked them to fill out
questionnaires. When she mentioned to the doctor that her own mother had been hospitalized once with a “nervous breakdown,” had
seen a therapist and seemed to recover, the psychiatrist showed great interest in this family history. After forty-five minutes, the
psychiatrist looked at Benjamin and said: “You’re bipolar. It will only get worse over time unless we begin to medicate you now.
I’m prescribing Abilify.” When asked, the doctor said that Benjamin would have to take the medication for “the rest of his life.
Bipolar is a lifetime diagnosis.”
 Madness and Institutional Dynamics
Each of these help-seeking efforts occurred in a broad social and institutional context. While each individual and family has a
unique personal history and particular circumstances and resources, all encountered the sometimes dehumanizing reality of the
bureaucracies that govern psychiatric care. Throughout psychiatric history, institutions and procedures that appear reasonable
responses to madness by most members of society in one era are often viewed as brutal and ineffective in the next because of the
evolving mores and the democratization of the human experience over time (e.g., women becoming recognized as entitled to equal
human rights as men). Our current arrangements are also likely to suffer in hindsight. Contemporary jurisdiction over those
presumed or pronounced mentally ill is assigned to hospitals, courts, police, insurance companies, the prescribers and the
manufacturers of psychiatric drugs, the psychiatric professional organizations that regulate practitioners, and the government
agencies that fund and shape mental health care, as well as to individual therapists governed by professional ethical codes and state
licensure requirements. The bureaucracies, their requirements, regulations, and funding needs—often more than the so-called
illnesses—are crucial to understanding how each of these cases unfolded. Let’s examine some additional details about how the
institutional dynamics shaped the interventions in these three cases, which have all been described extensively and published in
leading American newspapers, sometimes by several reporters working together.
Case 1: Treating Brain Disease
The patient was Mi Zhantao. His surgery, reported in the Wall Street Journal (Zamiska, 2007), was performed by Dr. Yifang Wang
at No. 454 Hospital of the People’s Liberation Army in Nanjing, China. The Journal explained that a financial incentive exists to
perform these surgeries. When Beijing began privatizing health care in the 1980s and dismantling the social welfare safety net that
characterized that nation, both patients and hospitals had to “fend for themselves.” Almost 10 percent of Hospital No. 454 revenues
come from these surgeries, which the hospital promoted aggressively in pamphlets and feature stories, presumably like the one that
came to the attention of Mi’s parents. Other Chinese hospitals have developed similar surgical profit centers. The assertions that
troublesome behaviors are due to brain disease provide a medical rationale for brain surgery. China’s health-care financing system
provided an external financial inducement to Chinese hospitals and physicians to perform surgery, even when its efficacy is highly
questionable and the consequences on patients are devastating.
A smug Westerner may dismiss this harmful intervention as an example of paternalistic medicine in a rapidly mutating country
with a tradition of deferring to authorities. Yet, according to the New York Times, in the last decade in the United States, more than
five hundred people have undergone experimental procedures involving burning holes into their brains and other forms of brain
surgery for mental illnesses including obsessive-compulsive disorder, depression, and anxiety. The treatments are often ineffective
or harmful (Carey, 2009, 2011).
Case 2: The Full Treatment
For nearly two decades, David Tarloff’s disturbing behaviors were well-known to his family, to medical and psychiatric
professionals, and to the police. During these years—before his arrest a few days after the murder in New York City of therapist
Kathryn Faughey and the wounding of psychiatrist Kent Shinback—Mr. Tarloff received the full gamut of modern psychiatric
evaluations and treatments. His psychiatric records run over ten thousand pages (Jacobs, 2010). By no means is Mr. Tarloff someone
who has been neglected by the psychiatric service system. Rather, he has been both a willing and unwilling recipient of standard
psychiatric interventions for many years. That system was so interested in and concerned about Mr. Tarloff and so convinced that he
needed what the system had to offer that it repeatedly restrained him, secluded him, and forced drugs and shock treatments on him,
with the approval of his family, though as far as we can tell Mr. Tarloff was never accused, tried, or found guilty of any offense.
Although his motivations for the killing and assault remain uncertain, Dr. Shinback was possibly the intended target, as he was
among the first mental health professionals, seventeen years earlier, to have diagnosed Mr. Tarloff as schizophrenic and have him
committed to a psychiatric facility.
Shortly after Mr. Tarloff’s arrest in February 2008, the court at first declared him mentally competent to stand trial. Then, it
forced him to take medications (Eligon, 2008a), and after several months declared him incompetent to be tried (Eligon, 2008b).
After two years of attempts to begin the trial, psychiatrists and his own lawyer convinced court judges that David was still not
mentally fit enough to assist in his own defense (Eligon, 2010a, 2010b). As one newspaper headline summarized it: “In Tarloff
Trial, Both Sides Agree: Lock Him Up” (Eligon, 2010b). In late 2012, state psychiatrists found Tarloff fit to stand trial. His lawyers
did not contest the claim. One of them stated: “The case is not so much about whether he remains in custody—it’s about where he
remains in custody” (Peltz, 2012).
Case 3: Bipolar Is a Lifetime Diagnosis
Benjamin’s story, as told by his mother, a writer (Wagman, 2006), appeared in the Los Angeles Times. Initially in the help-seeking
process, both mother and son were relieved and optimistic because a diagnosis had been made and a drug treatment prescribed.
When they filled the prescription, however, they were startled and confused by the list of adverse effects on the product label. They
googled the drug and became “terrified.” The prescribed drug, branded as Abilify, had not been tested in children or teenagers. A
forty-five-minute appointment with a psychiatrist had pushed Benjamin toward an expected lifetime of drug consumption with
likely harmful short-term effects and unknown long-term effects.
The mother called a cousin—also a psychiatrist—for a second opinion. Her cousin was astounded. “It was a ridiculous diagnosis,
he ranted, impossible after one office visit, especially for a teenager with no prior history.” He directed her to seek out other mental
health professionals. Eventually, after hundreds of phone calls, she found another mental health professional to see Benjamin at a
university clinic. Benjamin began seeing this therapist for weekly psychotherapy sessions, as that therapist did not think medications
were necessary. Benjamin slowly began to feel better, the mother reports, and the following year he went off to college. “As
parents,” Diana acknowledges, “we will do anything to help our children, to keep them from pain, to make them feel better. But we
also are at the mercy of professionals.” In this case, a well-educated, resourceful working mother was confused by conflicting
diagnoses and treatment advice from mental health professionals and startled that one of them could so cavalierly prescribe to her
son a drug that no validated body of evidence had suggested was indicated for his troubles and that could seriously harm him to
boot. She and other family members in these cases feel that they are victims of a psychiatric system that doesn’t always protect or
help them.
These cases identify problems that point to fundamental confusions about how our society has defined troublesome behaviors,
shaped diagnoses, and formulated policies to “treat” these behaviors. In Nanjing, New York, and Los Angeles, distraught parents
sought mental health professionals for help with their children. The patients received diagnoses and the parents received treatment
recommendations that they presumed utilized solid scientific evidence and sound clinical judgment. But the parents quickly learned
that psychiatric judgments are not always sound or scientific, nor do they necessarily aim to protect the best interests of the patient.
The parents of Mi, David, and Benjamin feel rightfully aggrieved by the diagnosis or the treatment advice they received for their
sons. Their complaints, however, should have extended far beyond the clinicians they encountered to the web of government
officials, mental health advocates, health care and insurance policy-makers, scientists, pharmaceutical company executives and their
marketing personnel and lobbyists—all of whom share responsibility for these families’ devastating experiences in seeking help.
These families have, indeed, been at the mercy of professionals, even very distant professionals from Madison Avenue.
Yet we would be off the mark if we portrayed families as uniformly helpless. There is no simple way to characterize the stances,
resources, and desires of families and individuals vis-à-vis the psychiatric system. Families and individuals understand and try to
deal with crises and distress in a variety of ways. Obviously, some individuals who are treated as mental patients have problems in
living. Others are victimized by their families or by society. Still others want to be seen as medically ill patients, including those
who wish to avoid responsibility for their misbehavior or for a burdensome situation or duty. Exploring all of the ways that people
encounter the psychiatric system would take us far afield. As our examples above have suggested, some people seek mental health
services and others have services imposed on them. Some are able participants. They possess well-honed critical skills, prepare
themselves adequately before meeting with any professional, have the means to ask for second and third opinions, or have definite
ideas about helping themselves or their members that keep them out of the orbit of institutional psychiatry. Yet it is fair to say that
most do not. They lack the resources, abilities, and critical thinking skills that might constitute some form of advance protection
from exploitation, or they have learned to trust socially- or government-accredited experts. Many other factors come into play when
people consider seeking help, including their fear of being stigmatized, blamed, or shamed for how one’s children have turned out.
Parents are particularly vulnerable to psychiatric authority when they are coping with a troubled child.
Seen from a distance, however, it is probably fair to characterize the relations between accredited mental health experts and
families as a dance in which each dancer alternately takes the lead. Families respond and listen to experts, but experts certainly
respond and listen to families. The formation and development of the politically powerful National Alliance on Mental Illness
(NAMI), formerly the National Alliance for the Mentally Ill, is a case in point, at least at the policy level. From an initial grouping
of 184 relatives of diagnosed people in 1979, energized by the wish to overcome the stigma they felt at the hands of family-blaming
mental health professionals, its membership purportedly had grown to eighty thousand by 1989, when it constituted one of the most
powerful lobbies in Washington. When Congress allocated an additional $40 million to NIMH for conducting schizophrenia studies
in 1988, the then-NIMH director publicly credited NAMI’s “tremendous lobbying effort” for this decision (McLean, 1990, 2010).
NAMI has remained an extremely powerful association of family members and a key promoter of biological discourse on distress
and misbehavior in the United States.
NAMI’s prominence, however, may not result directly from its “grassroots” support among the mentally ill and their families, as
its promotional literature claims. For example, in its 2010 annual report, NAMI states that it provides “support, education and
empowerment for more than 500,000 members and supporters” (p. 16). This is certainly a most impressive figure for any grassroots
organization, but when one of us (TG) contacted NAMI for an exact membership figure in early 2012, the organization’s
membership services replied the following in an email: “The 250,000 members and supporters number is the publishable number
that we can provide but we do not have exact numbers that we can provide at this time” (Elizabeth Monrad, Information
Coordinator, NAMI, personal email communication April 12, 2012).When we reviewed NAMI’s consolidated financial statements
for 2006 through 2010 (publicly available on its website) for total annual membership dues collected, we calculated an annual
average of approximately 10,500 dues-paying members ($35 per membership) over that period. We conclude that NAMI’s
statements conflating members and supporters exaggerate by twenty-five- to fifty-fold its actual membership. So if NAMI is not
quite the “grassroots” organization representative of the mentally ill citizens of the United States and their families, who does it
represent? According to the New York Times (Harris, 2009), “drug makers from 2006 to 2008 contributed nearly $23 million to
[NAMI], about three-quarter of its donations.” In that news report, NAMI’s executive director Michael Fitzpatrick expressed
contriteness and “promised that industry’s share of the organization’s fund-raising would drop ‘significantly’ next year.” The latest
figure available (2010) on NAMI’s website shows that pharmaceutical companies provided over $4.1 million out of total
contributions of $6.7 million (62 percent of the total donations to NAMI), about 10 percent less than the figure cited in the New York
Times a year earlier.
In this book we have chosen to focus our critique on psychiatric professionals rather than on the dynamics of help seeking by
individuals and families. We think that the evolution of the mental health system over the last fifty years is important to understand,
and we want to particularly highlight the role of what we label “mad science.” Our examination is made possible because the rules
and standards to which scientists, scholars, researchers, and practitioners are held are more public—matters of public discussion and
accountability—than are rules for personal life.
Let us provide an illustration of our approach to examining the mental health system and how institutional actors, such as
professional groups, federal research institutes, the pharmaceutical industry, and established family lobbies operate together to shape
individuals’ experiences when they seek psychiatric help. Let us explore the expanded institutional context of Wagman’s saga about
Benjamin.
 Prescription for Insanity
The day after Wagman’s distressing story appeared in the Los Angeles Times, a full-page, multicolored advertisement was displayed
in the Health section of the same paper (November 6, 2006, section F10). The two-inch banner headline read: “Treating Bipolar
Disorder Takes Understanding.” The top half of the ad, in large print, offered a purported diagnosis: “You’ve been up and down with
mood swings. You want to move forward.” The ad continued: “Maybe ABILIFY can help: control your symptoms of bipolar mania;
stabilize your mood; reduce your risk of manic relapse.” The ad implied that if you experience distinct mood changes and want to
move forward—and who doesn’t?—you are likely to suffer from something called bipolar mania.
The ad then claims that some scientific consensus exists about how ABILIFY “works” in the body: “ABILIFY may work by
adjusting dopamine activity, instead of completely blocking it and by adjusting serotonin activity. However, the exact way any
medicine for bipolar disorder works is unknown.” Why dopamine or serotonin might need adjusting because one’s mood changes,
however, can be left unsaid. What specific sort of adjusting would actually be done by the chemical also need not be stated. The ad
does not indicate that this drug is not approved by the Federal government’s drug-approval agency for children or adolescents. Then,
before presenting a half page of small-print warnings about possible adverse effects, including death, it makes the perfunctory pitch:
“Ask your healthcare professional if once-a-week ABILIFY is right for you.” In the smallest of print, one learns that the ad was
placed by two multinational pharmaceutical companies: Bristol-Myers Squibb and Otsuka Pharmaceutical. Of course, seeking
advice from health-care professionals was exactly what Diana Wagman tried exhaustively to do, but the experienced professionals
sharply disagreed on how to help.
Why would a drug company make a pitch to the lay public about a presumable psychiatric disease, one that even baffles the
experts? And why would a company advertise to the public a drug that no layperson could legally obtain without the permission and
prescription of a physician? As the ad admits, no one has any evidence regarding how or why Abilify “works”—even here it is
implied that it does work, though what this means is left to the copywriters. Moreover, as two of our cases illustrated, professionals
do not agree on how to define mental illnesses, on exactly what kind of phenomena they are, on what causes them, or on how they
should be treated—or even if they exist as entities at all. And certainly, professionals, including the makers of Abilify, don’t
understand the pharmacology of these drugs. (To be more precise, the makers of Abilify have an exquisitely honed understanding of
the pharmacology of their drug, but no understanding of how that pharmacology influences the hypothesized entity bipolar mania.)
Lay and professional ignorance about these matters is the norm, not the exception. But it is precisely this level of ignorance that the
pharmaceutical industry exploits to make billions of dollars. The federal regulatory agency, the Food and Drug Administration
(FDA), rather than protect the public from the marketing campaigns of pharmaceutical firms, is seen by many critics (Angell, 2004;
D. Healy, 2012) as ineffectual, for example, approving Abilify for use with children in February 2008. In addition, in 2007 Bristol-
Myers paid $515 million to settle a lawsuit filed by the federal government over accusations of fraud in which the drug company
employed a kickback scheme to defraud Medicare and Medicaid. Several years later California regulators filed suit, accusing
Bristol-Myers of bribing doctors and pharmacists to use its products, including Abilify (Helfand & Lifsher, 2011).
One week after Wagman told her story, the New York Times’ mental health reporter, Benedict Carey, wrote a long article, “What’s
Wrong with a Child? Psychiatrists Often Disagree” (2006). He reported that many other families echo Wagman’s laments. Parents
seeking help for their children receive shifting and confusing diagnoses accompanied by different regimens of drug treatment;
mental health professionals acknowledge that there is confusion in the field; and advice given to parents is subject to diagnostic and
treatment fads. Bipolar disorder, in particular, was described as being “wildly overdiagnosed.” Carey reports that Jane Costello, a
psychiatry professor at Duke University, stated that “the system of diagnosis in psychiatry was 200 to 300 years behind other
branches of medicine” and that “on an individual level, for many parents and families, the experience can be a disaster.”
One year later, the American Medical Association’s leading psychiatric journal, the Archives of General Psychiatry, published a
report that confirmed what many clinicians and journalists had already discovered: namely, that there has been an explosion of
diagnoses of bipolar disorder for youth and adults. The report, however, offered no conclusive judgments from acknowledged
experts as to why this had occurred (Moreno et al., 2007). In fact, the increase in the use of the bipolar diagnosis was so astounding
that the national press immediately reported it (Carey, 2007; Gellene, 2007). In a survey of outpatient office visits to physicians, a
team of researchers at Columbia University found that youth received bipolar disorder diagnoses forty times more frequently in
2002–2003 than ten years prior, 1994–1995. The number of adults receiving bipolar diagnoses doubled during the same period.
Nine out of ten children and adults diagnosed received psychotropic medications. This was a staggering increase in bipolar disorder
diagnoses, and yet the researchers stumbled in offering possible explanations: the disorder had been seriously under-diagnosed
before; the disorder is over-diagnosed currently; bipolar overlaps symptomatically with other common disorders such as ADHD;
clinicians and researchers do not agree on how to recognize bipolar disorder in children, or recognize it better and earlier in a child’s
life; and so on. The most plausible explanation for the explosion of the use of bipolar diagnoses was not mentioned by the research
team: the generously funded and well-crafted marketing campaigns by drug companies providing financial incentives to
psychiatrists and the public to make bipolar diagnoses among children and to prescribe psychotropic medications such as Abilify (D.
Healy & Le Noury, 2007).
Only two days after media reports of the epidemic of bipolar disorder among children, the Business section of the Los Angeles
Times (“Sales of Antipsychotic Drugs for Kids Surge,” September 6, 2007, section C6) reported that sales of antipsychotic drugs for
children had exploded. Johnson & Johnson, AstraZeneca, and Pfizer were the beneficiaries of the doubling of prescriptions for
children from 2003 to 2006, making children the fastest-growing segment of the $11.5 billion US market for antipsychotic drugs,
which were not then even approved by the FDA for children. Joseph Woolston, chief of child psychiatry at Yale University Hospital,
was quoted by the Los Angeles Times calling the trend “the juvenile bipolar juggernaut” and a “big problem.”
Remarkably, twenty years ago children were never diagnosed with bipolar disorder (or its prior DSM-II moniker: manic
depressive illness/psychosis). Bipolar disorder was only reserved for adults and, even then, to very few. Manic depression/bipolar
was viewed as an exceedingly rare affliction. By 2006, however, the experiences of young Benjamin Wagman were common. What
we suggest actually occurred is not an illness epidemic, but rather what the British describe as disease mongering—the
manufacturing of diseases and disease explanations by those with a financial interest in opening new markets for their medical
products (Moynihan, Heath, & Henry, 2002). The explosion in the psychiatric labeling of children, many younger than five years,
has been so dramatic that it is now routinely the subject of media comment (Groopman, 2007; M. Healy, 2007). These exposés
typically review the rapid spread of labeling children and youth as mentally ill, the confusion among psychiatrists about what these
labels represent, and the trial and error prescription of powerful drugs pushed by Big Pharma without anyone knowing whether they
truly help children or what the lifetime negative consequences may be. John March, a child psychiatrist at Duke University, offers a
partial defense of the increase: “I think the increase shows that the field is maturing when it comes to recognizing pediatric bipolar
disorder,” but acknowledges that the controversies reflect “that we haven’t matured enough” and that bipolar diagnosis for young
children “may or may not reflect reality” (Carey, 2007). Is such ambiguity from a professional leader truly an informed opinion?
Does Dr. March display any more insight into the prescribing situation than anyone else?
Gabrielle Carlson, a professor of psychiatry at Stony Brook University School of Medicine, describes plainly how the drug
companies pressure psychiatrists: “We are just inundated with stuff from drug companies, publications, throwaways, that tell us six
ways from Sunday that . . . we’re missing bipolar” and encouraging parents with difficult children to seek relief in that diagnosis
(Carey, 2007). She estimated that only one out of five children referred to her with bipolar diagnoses actually had it (a seemingly
finer-grained critical judgment, but one which ignores that the bipolar disorder diagnosis cannot be validated), and in some cases the
diagnosis was given in order to obtain insurance reimbursement (Gellene, 2007).
In an extensive analysis of how drug companies can “create a culture that legitimizes practices that would otherwise appear
extra-ordinary,” David Healy and Gabrielle Le Noury (2007) suggest, using the medical language of psychiatry, that we may have
witnessed “a variation on Munchausen’s syndrome, where some significant other wants the individual to be ill and these significant
others derive some gain from these proxy illnesses” (p. 219). We will have much to say about these issues in chapters 6 and 7.
Defenders of this psychiatric expansionism argue that there is now more accurate recognition of mental disorder in children and
adults and a need for a majority of the US population to seek psychiatric help, particularly by consuming daily doses of expensive
psychoactive drugs. For example, Mani Pavuluri, director of the Pediatric Mood Disorders Program at University of Illinois at
Chicago, said the label “bipolar disorder” was often better than any of the other diagnoses typically given to difficult children:
“These kids that have rage, anger, bubbling emotions that are just intolerable for them” and that it is “good that this is finally being
recognized as part of a single disorder” (Carey, 2007).
Within the psychiatric establishment, which has enormously benefited from these erroneous claims, signs of skepticism are
emerging nonetheless. Perhaps members of that establishment recognize that public gullibility, although easily manipulated, is not
limitless. Perhaps that is why even Thomas Insel, the director of NIMH, called the increase in bipolar diagnoses “worrisome”
(Gellene, 2007). Yet the authors of the article in the Archives of General Psychiatry that uncovered the exploding use of bipolar
diagnoses avoided mentioning the most likely explanation: that the rise of bipolar diagnoses may be attributed to how psychiatric
researchers, in conjunction with the drug companies, turned clinicians into pawns of the drug salespeople and tarnished clinicians’
reputations, credibility, and independence (Angell, 2004; Barber, 2008; Petersen, 2008). Insight and recognition of these matters has
come quite late in psychiatry.
By 2008 a congressional investigation (spearheaded by Senator Charles Grassley of Iowa) had uncovered that prominent
university psychiatrists, who had salient roles in promoting psychoactive drugs, had been secretly accepting hundreds of thousands
of dollars from drug companies, in violation of federal and university regulations (Harris & Carey, 2008). The most prominent
American child psychiatrist, Joseph Biederman of Harvard Medical School and Massachusetts General Hospital, considered the
undisputed “inventor” of childhood bipolar disorder—which arguably triggered both the bipolar epidemic in children and their
treatment with antipsychotics—had received over a million dollars in payments from drug companies (as had two of his close
Harvard colleagues and former mentees, Thomas Spencer and Timothy Wilens). This occurred while receiving funds simultaneously
from the NIMH to scientifically evaluate the products of these same drug companies, a fact Biederman failed to disclose to his
Harvard employers as required by that university. This revelation spawned another cascading mini-scandal within American
psychiatry and child psychiatry. A full three years later, the famed doctors’ Harvard employers reported taking “appropriate actions”
to discipline them: they were barred from receiving money for any outside activity for one year, required to obtain their employers’
approval before receiving any outside money for two years, and to undergo additional ethics training, and would not be promptly
considered for further advancement (all three are already full professors, the most senior of academic designations) (Silverman,
2011).
 It’s a Mad, Mad, Madness Establishment
Today millions of people like the parents of David, Benjamin, and Mi turn to medical professionals for help with personal troubles.
They expect experts to possess scientifically informed opinions, to make skilled judgments, and to apply evidence-supported
treatments that will not harm. Moreover, people believe the experts will assist in a personally disinterested way, in which the client’s
best interests are paramount and safeguarded. The psychiatric establishment, in its flood of press releases and presidential
commissions, constantly warn of the dire consequences if people do not recognize their own mental diseases early and seek
approved medical diagnoses and treatments. The families of David, Benjamin, and Mi were the victims of these messages.
The stories of people encountering the mental illness establishment that we have reported in this chapter might be dismissed by
some as rare instances of medical malpractice. Unfortunately, misdiagnosis (or plain diagnosis), misinformation, disinformation,
coercion, and harmful treatments are troublingly common occurrences within standard practice. They are the accumulated outcome
of a series of psychiatric failures: the unquestioned belief that all the problems identified are medical problems; misuses of medical
authority in implementing harmful treatments (e.g., with Benjamin and Mi); inadequately informing patients and family about
options or the limits of psychiatric knowledge and authority (e.g., with David, Benjamin, and Mi); the long tradition of using
involuntary treatment in psychiatry as well as questionable assumptions about its efficacy (e.g., David); misconduct and conflict of
interests among many of the actors in the mental health system; the misuse of psychiatric diagnoses, which appear ill-informed,
unreliable, and useless as guides to effective care; and, finally, the incredibly intricate ways in which the pharmaceutical industries
have confounded thinking about human troubles and individualized psychiatric treatment and what professionals believe they ought
to do as their first response to narratives or observations of distress and misbehavior.
These problems and their assumptions are often intertwined, and claims of major psychiatric breakthroughs remain profound
illusions, built on flawed and misinterpreted research, and worse. Naturally, we suggest that continuing to believe in these illusions
actually retards progress in understanding troubled people and in developing less harmful and coercive ways of helping them. We
expect our claims that the mental health field has been shaped by psychiatric illusions of progress to be skeptically considered by
many mental health professionals. Skepticism in psychiatric matters is appropriate, for there is much to be skeptical about. But the
skepticism, which usually has come from outside critics, is now almost openly expressed by those at the pinnacles of the psychiatric
establishment.
Earlier in this chapter we introduced Thomas Insel, the current director of the NIMH and his attempts to focus his institute on the
operation of brain circuits, from which he thinks future breakthroughs will come. In justifying the new neuroscience direction for
NIMH, Insel was recently impelled to make some profoundly important admissions about the state of psychiatric knowledge and
practice. In a 2009 article in the Archives of General Psychiatry, he admits that the gap between biological knowledge and mental
health care—a gap he would like to close—may be getting wider, not narrower (Insel, 2009). To close the gap, he believes, requires
that the current state of psychiatry be accurately appraised. He offers the following assessment.
First, he argues, “There is no evidence for reduced morbidity or mortality from any mental illness” from new psychiatric
medications developed over the last twenty years, in striking contrast to the “steadily decreasing mortality rates of cardiovascular
disease, stroke, and cancer” (p. 129).
Second, despite increases of 20 to 33 percent in the rate of people in psychiatric treatment, there has been “no change in the
prevalence of mental illness between 1992 and 2002” and “no evidence for decreased disability.” In fact, Insel asserts that “while
more people are receiving treatment, fewer than half of those who are treated receive treatments for which there is any evidence
base” (p. 129).
Third, even when what he considers appropriate and evidence-based treatment is offered (e.g., the latest medications), they often
fail to help. As documented in a series of NIMH-sponsored studies of thousands of patients in dozens of clinical sites, improvements
are more the exception than the rule, and many patients simply discontinue taking their medications (see chapter 6). Insel states that,
“While psychosocial interventions have received far less marketing attention than pharmacological treatments, the results are
arguably more encouraging” (p. 129).
Fourth, he admits that “despite 5 decades of antipsychotic medication and deinstitutionalization, there is little evidence that the
prospects for recovery have changed substantially in the past century.” The data, he concludes, “on prevalence, treatment, and
mortality indicate that mental illness remains an urgent, unmet public health concern” (p. 130).
Insel’s summary of the limited progress made in the prevention or treatment of mental illness over the last fifty years can be
interpreted in several ways. For example, Insel might be correctly recognizing that no outstanding neuroscience discoveries have
improved the treatment of mental disorders, but he also might be hinting that the biomedical approach is still in its infancy and
eventually the understanding and treatment of madness as a disease will be scientifically transformed and many disorders will be
effectively treated medically. Insel’s statements would thus constitute an admission of the difficulties faced, leading up to a plea for
more time and money to confirm the grand biomedical hypothesis of psychiatry and develop medical cures.
An alternative reading is that, while Insel correctly admits the lack of progress in understanding and treating madness and even
in alleviating any of its burdens on patients and their families, he fails to consider that the failure may result from madness not
being, for the most part, a biomedical problem. This simple hypothesis may explain why, after a hundred years of pursuing the
neuroscience hypothesis, so little (actually, nothing) has been discovered of any direct relevance to clinical psychiatric practice. That
Insel does not even entertain this hypothesis in print—even if only to dismiss it—suggests that the NIMH is not a scientific institute.
(See our discussion of “science” ahead.) His criticisms of the state of current knowledge, instead of prompting a reanalysis of the
nature of distress and misbehavior, reconfirms to him, at least in written statements intended for public consumption, that psychiatry
is on the right biomedical track. In the chapters that follow, we attempt to discuss an alternative hypothesis: that much of psychiatric
research actually undermines the biomedical hypothesis of brain disease as an explanation of madness.
 Understandably, as the director of NIMH, Insel must be concerned about the future of his agency. Given NIMH’s commitment to
the “mental illnesses are brain diseases” conjecture, it is unsurprising for him to move more vigorously into studying even more
subtle and hard-to-measure areas of brain circuitry and to mount large studies to gauge infinitesimal statistical variations in genetic
profiles, while continuing to promise that the age-old puzzles of madness will be solved. So, despite acknowledging that fifty years
of biomedical research on madness has uncovered no causes of mental illnesses and a dismal record of effective treatments, Insel
rallies the biomedical faithful by urging more of the same.
Perhaps we ought to examine the past more critically before moving forward with more of the same. How did fifty years of
psychiatric failure get accepted as success and progress by major psychiatric institutions? Until we can better understand how the
mental health professions arrived at their present medicalized views regarding madness and its management, we are unlikely to find
meaningful alternatives. Our aim in this book is to examine how the science of madness—the research, publications, and
professional organizations—became mad science: research that was viewed uncritically, distorted, and misinterpreted to serve
institutional purposes. We will examine three fundamental changes in mental health care as exemplars of mad science: the nature of
deinstitutionalization and community treatment, changes in the methods of diagnosis, and the nature and uses of psychoactive drugs.
These changes have been described as reforms, revolutions, progress, innovations, and paradigm shifts. Many ardent proponents
of these reforms were motivated by the desire to create better and more humane care for troubled people, which they fervently
believed could be done, but always by building upon or extending the view of madness as disease. Between the early 1960s and
1980 the scope, shape, and understanding of mental illness and its treatment were significantly altered in ways familiar not only to
mental health professionals but to the lay public as well. What is less well recognized is that the three “reforms” were mutually
reinforcing and were initially justified on the basis of scientific studies that were seriously flawed and misused, but these flaws were
not easily spotted. As with many other complex issues in which scientists weigh in heavily (climate change, effects of pesticides,
genetic determinism, energy policy, national security) the public relies, understandably since most of its members lack the training
or time to investigate such issues in detail, on the media and the experts to interpret the studies. Even well-trained experts often rely
on the judgments of scientific authors or scan only the summaries (abstracts) of articles. In short, the current landscape of the mental
health industry—its conceptions and services—are built on a trio of scientific claims that appeared at first to mark significant
progress. Decades later, these claims of progress appear illusory. We intend to trace this evolution.
It is noteworthy that during the decades in which these three momentous changes were implemented, psychiatry did not lack
critics from within and from without. Indeed, the major challenge to the validity of the central psychiatric notion, mental illness—
against which psychiatry was forced to respond over the next decades by “remedicalizing” itself—was published in 1961: The Myth
of Mental Illness (Szasz, 1961). It was followed by numerous critiques of psychiatric philosophies and practices and their harmful
effects on people and social institutions (Armstrong, 1993; Breggin, 1991; Cohen, 1990; Conrad & Schneider, 1980; Fisher &
Greenberg, 1997; Goffman, 1961; Kirk & Kutchins, 1992; Kittrie, 1973; Modrow, 1992; Robitscher, 1980; Ross & Pam, 1995;
Scheff, 1966; Torrey, 1974; Wilson, 1997)4. How psychiatry actually dealt with (or ignored) the issues raised by these and many
other scholars and practitioners is described in the rest of this book.
 What Is Science?
Since much of our book is devoted to discussions involving science as if it were the best approach to devise better understandings
and explanations of the workings of our physical and human world, it is fitting to offer briefly our own view of what proper science
is. To begin with, science is a human enterprise and therefore highly fallible. Scientists are not a special class of individuals free
from error, able to set biases aside, able to be completely objective, or concerned mostly with searching for the truth. As the
sociologist of science Thomas Kuhn suggested, most scientists are “normal scientists,” a phrase by which he meant scientists who
do not question the current assumptions of the reigning theoretical paradigm and are mostly not interested in getting at fundamental
truths, but rather who less ambitiously try to solve smaller-scale everyday problems (which he called puzzles) within the current
paradigm. Normal scientists leave the bigger questions to an elite group of scientific authorities recognized by their peers. One of
these bigger questions is the question of when a shift in the scientific paradigm should occur. Usually the shift happens, according to
Kuhn, when members of the old elite die out or retire and are replaced by young Turks; when a consensus is reached among them
that a shift is called for; or when observations from the everyday puzzles that are directly at odds with expected findings accumulate
to such an extent that these contradictory observations can no longer be ignored. But any of these factors succeed only if an
alternative paradigm is readily available to take its place.
One of Kuhn’s main contributions to the history and sociology of science has been to draw attention and scholarship to the
personal nature of activities of scientists: that is, the extent to which the work of scientists is like the work of all humans: shaped by
personal beliefs, commitments, capabilities, skills, and social and cultural expectations. But as the authors of this book we are not
Kuhnians in any strict sense. We are more in line with those who might call themselves falsificationists (exemplified by the work of
Karl Popper). That is, we see all theories (explanations, which include proposed solutions, interventions, programs, and policies)
regarding the world and human behavior as tentative efforts to explain or predict that world, that must be rigorously criticized
(through vigorous debate) and evaluated (by means of logical and transparent experimental tests) before being offered more
generally. And even after being implemented, stringent evaluations should be regularly conducted on these theories and
interventions, keeping in mind that future application of apparently successful theories or treatments and solutions may turn out
ultimately to be more harmful than helpful.
The social science methodologist Donald Campbell suggested that:

[s]cience requires a disputatious community of “truth seekers.” The ideology of the scientific revolution agrees with
Popper’s . . . epistemological sociology of science. . . . Truth is yet to be discovered. Old beliefs are to be systematically
doubted . . . The community of scientists is to stay together in focused disputation, attending to each others’ arguments . . .
mutually monitoring and “keeping each other honest.” (Campbell, 1988, p. 290)

Open and frank attempts to falsify the hypothesized explanations lead, through trial and error, to better and more comprehensive
explanations, allowing us tentatively to claim progress. We will demonstrate in the subsequent chapters the failure of mad science to
meet any of these standards.
 Psychiatric Coercion, Diagnosis, and Drugs
We will begin with a brief history of attempts to understand and treat mental disease and the claims about the effectiveness of
community treatment. We then turn to an analysis of the revolution in defining mental disorders that began with the publication of
the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. Finally, we review the puzzling
scientific terrain of psychoactive drugs.
Coercion and Deinstitutionalization
The movement of people out of state psychiatric hospitals and into various forms of care and control in the community or into other
institutions, called deinstitutionalization, was the most important policy and institutional change in psychiatry in the twentieth
century. Community care consisted of a potpourri of services (e.g., coordination of health and welfare benefits by a case manager),
treatments (crisis intervention, medication monitoring, brief hospitalizations, counseling), and facilities (group homes, board and
care residences, nursing homes, jails and prisons). During the 1960s and 1970s there was a sizeable emptying of state asylums for
the mad, which had many determinants—exposés in the media about inhumane confinement in massive facilities, skepticism about
the effectiveness of custodial treatment, misgivings about involuntary commitment, growing cost of hospital care, and the shift to
federal funding for community treatments, as well as new hopes spurred by the introduction of newer psychoactive drugs. Whereas
coercion had been a major component of psychiatric practice in state asylums, there was hope that community treatment, by using
the new psychoactive drugs to control the mad and misbehaving, could operate without obvious coercion. Proponents of
deinstitutionalization justified it as a method of providing more efficient, effective, and humane treatment for the “chronically
mentally ill” than warehousing them in large, oppressive facilities. The stated goals of deinstitutionalization were to reintegrate the
mad into their communities, normalize their circumstances, and improve their quality of life.
In chapter 2 we provide a succinct history of the rise of community treatment and public psychiatry in America and how private
troubles for individuals and families have become concerns, first of communities, then states, and, finally, the federal government.
But throughout that evolution in responsibility, the language of madness has also changed decisively into a language of medical
disease. In reviewing the history of madness in America, it is notable that the major historians have trapped themselves in a medical
vocabulary that, while it arguably shapes or reflects professional and public views, impairs their ability to provide an objective
account of this history.
We extend this story in chapter 3, where we will examine what we believe is the mainstay of psychiatry—coercion—and its
community-based use that often goes by the persuasive-sounding moniker of evidence-based practice (EBP). EBP is derived from a
currently popular but seemingly already fading movement in medicine called evidence-based medicine (EBM). EBM claims to
identify the most effective medical treatments through a series of workgroups that evaluate the research literature on treatments and
rank them based on their effectiveness through a methodological protocol that includes the use of statistical methods. In selecting
effective medical treatments, EBM is argued to be superior to the traditional reliance on the expertise of individual doctors and the
wishes of their patients. We examine the evidence regarding both EBM’s and EBP’s claimed superiority and find it wanting. To
demonstrate EBP’s failure, we include a close review of the evidence on assertive community treatment (ACT), touted and
promoted enthusiastically by a coterie of academic experts as one of only six evidence-based, gold-standard psychosocial
interventions in mental health. Our analysis shows how the claim for the benefits of community treatment over state mental
institutions rests on the use of administrative tactics and medically and socially sanctioned coercion (currently renamed “leverage”).
Exaggerating the presumed effectiveness of a heavily marketed ACT helped to divert attention from the sorry plight of those
supposedly reintegrated into the community. Jails, inhumane group facilities, and the streets have been the major community
environments for the chronically mad for the past few decades. Community treatment’s failure to deliver on its promises can be seen
by the increasing efforts of psychiatric experts to justify and legitimize coercion as treatment.
Diagnosis
The second major psychiatric development, discussed in chapters 4 and 5, was a response to criticisms that psychiatric diagnoses
lacked validity and were unreliably used by clinicians: in layman’s language, they were inaccurate. These flaws were potentially
ominous for psychiatry as a respected medical profession but were for years rarely discussed because providing scientific evidence
was not necessary for psychiatry to carry out its functions. Nevertheless, in the interest of improving the scientific and political
standing of their profession and to counteract psychiatric critics, a handful of psychiatrists in the mid-1970s strategically used the
vulnerability of the diagnostic system to revolutionize psychiatric diagnosing, culminating in the 1980 publication of the third
revision of the DSM, which provided what appeared to be more scientific detail and guidance for clinicians in making diagnoses.
Unlike the shift to community care, no one had clamored for change in the DSM, and few laypeople even knew it existed. The
new DSM promised a descriptive diagnosis—using symptoms alone, without the need to understand any presumed underlying
causes or dynamics—to defining mental illness. Although fully aware of the limitations of descriptive diagnosis, its proponents
continually affirmed its advantages and their belief that its adoption was a necessary step in investigating and then discovering the
biological bases of madness and misbehavior and in “remedicalizing” psychiatry. The heralded DSM-III hugely enhanced
psychiatric authority, as it formalized a vast expansion of the behaviors, states, circumstances, and emotions indicating mental
disorder. This expansion, in turn, was used to create a manufactured epidemic of mental illness in the United States.
All interested parties relentlessly exploited the new DSM—the pharmaceutical industry for economic gain; related professional
and consumer groups (e.g., National Alliance for the Mentally Ill, Children and Adults with Attention Deficit Hyperactivity
Disorder) vying to share in the reborn power and prestige of psychiatry; and the public, seduced by the ease and appeal of wielding
diagnoses on themselves, just like the experts. The territory of madness thus was greatly enlarged, and many mental disorders
became banal, even normal. When psychiatric experts (Kessler et al., 1994; US Dept. of Health and Human Services, 2011) declared
that half the US population would qualify for a psychiatric diagnosis in their lifetime, validly distinguishing disorder from normality
became largely irrelevant, since practically everyone could be viewed as potentially “in need of treatment.”
The popular fascination with the DSM-III hid the fact that any evidence for its superiority over any previous diagnostic
approaches was seriously flawed, as DSM-III barely made a dent in the acknowledged reliability and validity problems of diagnoses.
Today, as the fifth edition of DSM is being prepared for publication in 2013, a firestorm of criticism has erupted (from, among
others, the former chief architects of DSM-III and DSM-IV) about the continuing expansion of the concept of mental disorder, its
extremely flimsy scientific and medical basis, and the disastrous consequences that widespread use of this medical concept has had
on understanding the troubles of real people seeking help from mental health experts.
Drugs
The third fateful illusion regarding modern madness concerns psychoactive drugs, which we discuss in chapters 6 and 7. While
deinstitutionalization and the DSM brought images of mental disorder into every neighborhood, the promotion of modern
psychoactive drugs capitalized on the public’s desire for medicalized yet familiar solutions to life’s difficulties. Psychoactive drug
cultures are nothing new, given that vast numbers of people have always used drugs to relieve their personal distress, to work more
efficiently, to enhance pleasure, and to find meaning in life. The novelty lies in the successful campaign by the mental health
establishment to convince people that their appreciation of psychoactive drugs proved that their unwanted emotions and behaviors
were symptoms of mental disorders and, moreover, that whatever psychoactive drugs their physicians prescribed were specific
treatments for these disorders.
The campaigns began with the industry promotion of amphetamines (such as Benzedrine) to physicians as antidepressants in the
1940s, closely followed by the marketing success of the benzodiazepines in the 1960s (such as Librium and Valium). In parallel, the
arrival of the stupor-producing antipsychotics in the 1950s (led by Thorazine) radically changed the insane asylums and wedded
psychiatry (then still largely operating and viewed as a custodial enterprise) to a future with drugs. Waves of new-and-improved
“selective serotonin reuptake inhibitors” (led by Prozac and Paxil), “atypical antipsychotics” (led by Risperdal and Zyprexa), “mood
stabilizers” (led by Depakote and Neurontin), and the resurgence of stimulants (led by Ritalin and Adderall) expanded and
strengthened convictions that solving the problem of mental illness (now seen as affecting large segments of the populations of post-
industrialized nations) meant making the drug du jour as widely available as possible. It did not seem to matter that the promoted
drugs differed little—as substances affecting feeling, thinking, and behaving and regularly inflicting physical harm—from the
banished and forbidden drugs on which authorities simultaneously waged a century-long war.
The misuse of science and research in the pursuit of profits from drug sales has been phenomenal, with no stakeholder guiltless.
While the new drugs changed expectations and perceptions, the documented helpfulness of psychiatric treatment has remained
unchanged, despite fifty years of widespread psychiatric drug prescriptions. In comparison with the pre-modern drug era, no
significant improvements on any indicator of any major mental disorder, including depression, schizophrenia, and bipolar disorder
have been demonstrated in studies that have been conducted relatively free of industry design or funding, as we will document in
later chapters (and as the director of the NIMH states explicitly). Still, the marketing of medications has resulted in the daily
drugging of an unprecedented number of children, youths, and adults, converting every mental health practitioner into a potential or
actual drug dispenser. At the same time, the power of placebo, which could account for most of what passes as treatment
“effectiveness,” and the stupendous failings of clinical drug trials to inform about the actual, genuine effects of psychoactive drugs
remain barely acknowledged. Moreover, producing and recycling drugs created new opportunities to invent DSM-style diseases and
to market more drugs, making diagnoses more important to Big Pharma than they had ever been to clinicians or patients.
In chapter 8, we recapitulate our arguments and attempt to discern a way ahead. First, we reflect on our potential biases and how
we attempted to counter them. Next, we identify what we think are the crucial characteristics of mad science. We then call for a de-
emphasis of the current biomedical control over the understanding and management of the mentally ill in favor of a broad
nonmedical system of personal assistance and supports to those seeking help, along with an essential decoupling of coercion from
services. The helping enterprise does not need to pretend that coercion is treatment or that people must be treated against their
wishes, and society must cease expecting those it considers healers to police and sequester the distressed and misbehaving. We also
call for a decoupling of diagnosis from the eligibility and provision for services. There is no inherent need for diagnosing people as
medically defective or pathological with hollow diagnoses in order to offer and to fund information, help, advice, counseling,
support, and other personal, vocational, or housing services (that is, the bulk of what are called mental health services). There is also
no meaningful empirical or rational distinction between (currently) legal and (currently) illicit psychoactive drugs, and no self-
evident justification for allowing any group that claims unique expertise or responsibility to control how people use drugs to relieve
their distress or reduce their misbehavior. We think that psychiatric practitioners have demonstrated—especially over the past half-
century—that they regularly fail to exercise independent, informed judgment about the worth and usefulness of the various
psychoactive medications under their purview.
Although rampant conflicts of interest among psychiatric leaders and institutions make it extremely difficult to disentangle
knowledge from propaganda, this has always been so in the history of psychiatry and of the helping professions. We will suggest
that the monopolistic reign of psychiatric experts over therapeutic resources for troubled and misbehaving people should be
abolished. This will require clear-headedness about the illusions that have encouraged us to believe that the sometimes tragic
challenges and troubles of human life—of living with our self and with other people—are symptoms of eradicable brain diseases
falling under the jurisdiction of medicine. This does not mean that human existence cannot be improved or made more palatable.
Moreover, medicine certainly has a place in a more truly humane system of services for people in need. But we question whether the
current system, dominated by state-sanctioned psychiatric definitions, coercion, and prescription psychoactive drugs and distorted
by financial conflicts of interest, is serving the public very well. This book is a hard-headed examination of the mad science that has
created these psychiatric illusions and failures of the past and present, so that we might begin to move in new directions in the
future.
 Notes
1. It’s far beyond the scope of this book to examine psychiatry from an international comparative perspective. Nonetheless, the peculiar form of American psychiatric
thinking that we describe in the book—which views distress and misbehavior as symptoms of conventional medical diseases, the discovery of their (unknown) etiologies
requiring first and foremost the categorization of their presenting problems, and their treatment requiring the medical prescription of centrally active chemicals—has had a
major influence on psychiatric thinking and practice throughout the world. The publication of DSM-III in 1980 (the third edition of the Diagnostic and Statistical Manual
of Mental Disorders of the American Psychiatric Association), and its widespread dissemination and translations, fostered and in turn was fostered by globalization,
including the expansion of markets for psychiatric drugs by multinational pharmaceutical companies. As it continues to become exported far and wide, this style of
American psychiatry undoubtedly contributes to reducing the number of different existing vocabularies and models of madness, much like opening roads and
transforming forests into farms in the Amazon Basin undoubtedly reduces biodiversity. A similar thesis is made by Watters, 2010.
2. A similar but more elaborate recent statement from NIMH (April 24, 2012) may be found at: http://wwwapps.nimh.nih.gov/about/strategic-planning-reports/index.shtml.
3. Personal distress becomes of public concern when people seek “health” insurance to cover the costs of treatment for personal difficulty (which currently requires them to
receive a clinical diagnosis of a psychiatric disorder), or when chronic or unacknowledged personal distress leads to misbehaviors that physically or emotionally damage
other people.
4. Writings critical of psychiatric thinking and practice run in the hundreds if not thousands. Two bibliographies displaying the breadth and varieties of critiques are
available at the following websites: Philosophy of Psychiatry Bibliography (http://www.uky.edu/~cperring/PPB2.HTM) and Critical Psychiatry Website
(http://www.mentalhealth.freeuk.com/article.htm). But we caution that the mainstream psychiatric literature is considerably larger.
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 2
The History and Historians of Madness

And in my solitude in England, doubting my vocation and myself, I drifted into something like a mental
illness. This lasted for much of my time in Oxford. . . . I was in a state of psychological destitution when—
having no money besides—I went to London after leaving Oxford in 1954, to make my way as a writer.
Thirty years later, I can easily make present to myself again the anxiety of that time: to have found no
talent, to have written no book, to be null and unprotected in the busy world.

V.S. Naipaul, Nobel laureate

 Introduction
Thousands of volumes have been written over the centuries about the true nature and definition of madness. Yet, as the medical
historian Roy Porter notes, our current definitions depend on the same tautology used in the sixteenth century, when Shakespeare
wrote famously in Hamlet, “What is’t but to be nothing else but mad?” (2002, p. 1). Porter’s own definition, the “generic name for
the whole range of people thought to be in some way, more or less, abnormal in ideas or behaviour” (1987a, p. 6) adds nothing of
consequence but suggests that the word madness does have a useful purpose: namely, to capture within a reassuringly resonating
and apparently comprehensive category all those “abnormal” people who significantly disturb society and sometimes themselves.
Porter importantly notes that “even today we possess no . . . consensus upon the nature of mental illness—what it is, what causes it,
what will cure it. That is true even amongst psychiatrists. . . . Short of the discovery tomorrow of the schizophrenia gene, these
controversial issues will not be quickly settled” (1987a, pp. 8–9, see also Andreasen, 1997; Grob, 1983, p. 36; Scull, 1993, pp. 391–
394). Despite heroic or, depending on who is doing the judging, desperate and enormously expensive research efforts over many
decades, no genes or reliable pathophysiology that maps schizophrenia or any other “mental disease” has been found (Andreasen,
1997; Bentall, 1990; Boyle, 2002; Kupfer, First, & Regier, 2002). But even if such pathophysiology were found and some current
“mental disorders” relegated to true physiological pathologies (neurological diseases) and disappear from psychiatric concern (as
occurred, say, with epilepsy, general paralysis of the insane, and pellagra), at best only some people currently diagnosed as afflicted
with a mental disorder would be identifiable by relevant biomarkers. The rest would remain mystifyingly mad.
A multiplicity of theories about madness has been proposed. Is it medical disease; a person’s unfortunate, incompetent handling
of greater and lesser problems in living; social labeling of disapproved behavior; social construction tout court; or, more
provocatively, merely a word for a semantic category referring to all manner of behavior peculiar enough to be publically disturbing
at any given time? The hypothesized causes, determinants, or contributing factors are as perplexingly varied. Are the mad mad
because of unbearable social pressures; because of mental, physical, hereditary, genetic, or environmental vulnerabilities; or because
of some as yet unfathomable combination of all of these (Read, Mosher, & Bentall, 2004)?
Neither the many theories nor the implied causes of madness have been scientifically validated, perhaps because mad science
rests on hundreds of constantly shifting diagnostic categories of “mental illness,” which have little in common (addressed in
chapters 4 and 5). Fifty years of scientific efforts revising these categories, quantifying them, and statistically calculating perceived
differences among them may not be the best analytic approach for understanding what is subsumed under the word madness and its
many linguistic analogs. As the developmental economist Sir Peter Bauer (1981, pp. 262–266) argues, overreliance on numbers and
mathematics devalues a fundamental component of scientific development, namely, conceptual analysis. Those elements of the
social world that can be quantified have taken precedence over those less amenable to quantification.
Despite the failure of scientific attempts to validate the nature or causes of madness, groups with enormous political, ideological,
and economic clout have taken up one theory about madness in particular: that it is medical/bodily disease. This disease theory is
supported by the government mental health bureaucracy under the leadership of the National Institute of Mental Health, the
pharmaceutical companies, mental health lobby groups, the organized profession of psychiatry, and hundreds of thousands of
providers of mental health services from all professional stripes. Their successful effort to reify this medical theory, which we argue
is at best only a useful analogy or explanatory metaphor whose depths already have been plumbed to no scientific avail, endangers
further efforts to understand whatever contents the category of madness may hold.1
But as we dive into the murky historical waters in search of the hypothesized essence or even the specific content of madness, we
emphasize that before anything else, madness is a word. Like all words, it is a human artifact stitched together to represent or echo
something (abstract or concrete) related to human behavior or one’s perception of this behavior. As a linguistic sign, madness
becomes available for our critical manipulation, but like all linguistic signs it need not be anchored to particular aspects of the
material world. The word trees, for example, does not directly locate any specific tree in the observable world, nor does it specify
what the particular limiting attributes of the categorical term trees are. It serves as a label for collecting many disparate types of
plants judged to belong under the category “trees,” though these plants may share few common elements other than their category
name (for example banana trees and oak trees). Such a category might best be called “disjunctive.” According to Bruner, Goodnow
and Austin (1986), “[w]hat is peculiarly difficult about . . . a disjunctive category is that [any] two of its members, each uniform in
terms of an ultimate criterion [for example being living organisms], may have no defining attributes in common” (p. 156).
Words and categories matter. The philosopher Immanuel Kant proposed that categorizing is a fundamental and necessary act of
human survival: it helps us to make sense and perhaps to respond and control the mysterious nonhuman noumena (das Ding an sich,
the thing in itself) that makes up the “out there” that another philosopher, William James (1890), described as “one great blooming,
buzzing confusion” (p. 462).
To recapitulate, words are semiotic tools, but they do not have any fixed meaning or direct connection to material reality or enjoy
any consensus about their usefulness. They are open to variable definitions and interpretations often dependent on the learning
history and cultural background of the definer. So it is with the word madness, because it is a word first and foremost and because as
such it has no immanence, its meaning being primarily determined by those responding to it. Indeed, the history of social responses
to madness suggests an abundance of possible meanings, some contradicting others (e.g., devil possession versus pathological
personality organization versus brain disease versus inept training for social life versus a metaphoric haven for escaping from
wrenching difficulties). Trying to define what madness really is—or what its verbal siblings such as mental disease, mental illness,
or mental disorder really are—has been and may continue to be a failure. Based on the poor track record of progress in objectively
validating madness or its contemporary semantic substitutes, we might consider admitting that ideas and behaviors, even the
strange, troubling, and frightening ones we call mad, are just that: ideas and behaviors.
 Unusual and scary behaviors of our own or those of others that attract our attention and elicit powerful emotions typically
challenge us to provide an explanation for their existence. If no obvious explanation is found, often the best that we can do in
response to our need for knowing why is to manufacture a word or phrase as an explanation that can safely contain all that puzzling
and frightening content to provide ontological comfort in order to regain the existential stability we lost as a result of our encounter.
In short, madness is a disjunctive category label. The term mad has been that universal remedy for disturbing behaviors for hundreds
of years. It is a linguistic black hole that (metaphorically) sucks in all peculiar human behavior that society cannot digest or
normalize but still feels compelled to explain in order to control. The word serves, on the one hand, to instruct reassuringly the
normal that genuine boundaries distinguish the mad from the rest of us. On the other hand, the word strikes a cautionary note about
what might happen if the normal are not vigilant and transgress.
The word also serves to limit inquiry. Its invocation appears to explain by mere assertion, though of course it cannot. “Why is
John’s behavior bizarre?” Answer: “He is mad (mentally ill).” “How can we be sure that John is mad (mentally ill)?” Answer: “He
exhibits bizarre behavior.” This circular process can be recognized by the logical thinker as tautological. However, the strength of
the various institutions aligned to support and validate that logically erroneous judgment—such as government (National Institute of
Mental Health), business (pharmaceutical industry), the professions (psychiatry, psychology, social work, nursing), and the academy
(distinguished professors from the helping professions conducting research)—effectively discourages exploring alternative
explanations for John’s bizarre behavior.
In what follows, we present an overview of how the age-old social problem of madness was transformed into the contemporary
medical problem of mental illness. We also discuss the attendant attempts to ameliorate this problem in America, as reported by
prominent historians of madness. We then conclude with a discussion of the possible impact of the personal beliefs regarding
madness of these very historians on the shaping of their historical accounts.
 In the Beginning
The ancient Greeks were perhaps the first to discuss the problem of madness. For them it probably meant the loss of reason. The
early Greek myths and legends focused on external rather than internal events to explain human action. They told of how heroes
were subjected to the will of the gods who punished from on high, cursed, and sometimes drove them into madness (Porter, 1987a,
p. 10). The Greek philosophers considered reason to be the noblest faculty of man. Socrates’ “know thyself” represented the highest
expression of this ideal through the use of self-critical reason (Popper, 1998). For the Greeks, this faith in reason to successfully
negotiate the human predicament was counterbalanced by its opposite, unreason, seen as a major threat to human survival.
Conceived as made up mostly of powerful primitive forces often dark and destructive—but sometimes constructive (divine madness
to explain genius for example)—madness challenged the understanding of human behavior as being reasonable behavior. Such early
Greek notions have significantly shaped our contemporary Western thought. Western civilization embraces the centrality of reason
for ethical and scientific development while simultaneously battling to minimize the impact of irrationality because of its assumed
causal role in the “senseless” tragedies that constantly confront humankind (Porter, 1987a).
The Greeks, Porter (1987a) argues, citing another psychiatric historian, Bennett Simon, originated the West’s two principal ways
of viewing and treating irrationality. The first sees the human condition as a struggle over “great unbearable elemental conflicts of
life” (p. 12), such as love, hate, jealousy, and greed, and as efforts to cope with their powerful emotions of unreason, relying
principally on spoken language to heal the soul or psyche. Theater in ancient Greece illustrates how treatment under this conception
of irrationality could have proceeded. Greek dramatists such as Euripides, in plays like Medea and Hippolytus, through dramatic
renderings of the individual’s personal struggles against himself and others, brought the demons within to the public-at-large. Not
only could the complex circumstances, conflicts, and emotions required for possible self-discovery be personified on the stage, but
an opportunity was presented for ritual healing of unreason through communal catharsis of the audience. The professional rhetoric
(its form and content calculated to persuade and gain agreement) later used by priests in the confessional and the “talking cure”
practiced by psychotherapists in modern times are direct descendents of this tradition (see Vatz & Weinberg, 1994).
The Greek physicians associated with the Hippocratic school developed the other major way of responding to madness. They
relied on their earlier contention that epilepsy, rather than being a sacred and supernatural disease delivered by the gods, had more
mundane physical causes. They claimed that madness too was just another medical condition caused by humoral imbalances
affecting various organs including the heart and brain (Porter, 1987a, p. 12). These two approaches to madness, rendered by Porter
as “madness as badness and madness as sickness” (1987a, p. 13), are diametrically at odds with one another and to this day not
reconciled, but they remain the models used to conceptualize irrational and frightening behavior and its treatment.
The other constant in “mad treatment,” at least from the late seventeenth century when nation-states began to assume some
formal social welfare responsibilities vis-à-vis their citizens, has been the formal, state-supported, bureaucratic coercion of public
dependents. This emerged as marginal groups, consisting of criminals, the angry jobless, the unemployable, and the religious
extreme, all exhibiting “dangerous and delinquent traits,” were increasingly seen as needing separation from the rest of society to
prevent social unrest. They were first cast as “disturbing” the social order due to their unconventional thinking and behavior, but
because this kind of behavior might be seen as appropriate criticism of the state by the discontented and powerless, it was soon
followed by their being recast as personally disturbed. The calculated separation of these fringe groups from society by authorities
recast them as alien in thinking and feeling as well, justifying their forced confinement (Porter, 1987a, pp. 14–16).
The deviant behaviors subsumed under the “madness as badness” model potentially justify coercive responses because the
deviant’s negative behavior may be seen as intentional and harmful to the polity’s welfare, requiring forceful control by society
since the perpetrator has no intention of controlling himself. The criminal justice system is society’s apparatus to confront this form
of aberrant behavior. However, the second model, “madness as illness,” does not necessarily suggest the same straightforward
imposition of state-sanctioned force. Illnesses (at least in more modern scientific views) are usually seen as involuntary events that
happen to people and over which no self-control is posited. It is ordinarily assumed that ill individuals desire to be rid of illnesses
and to seek treatments or cures proactively. The selection and acceptance of medical treatment in medical practice therefore is
viewed as the prerogative of the person seeking help. The apparent disregard of this general rule by the imposition of involuntary
treatment when the medical model is used to address madness presents a dilemma. The dilemma relates to how “science” is
employed in the explanation and treatment of madness.
Does science and its rigorous empirical approach for fact-finding support the psychiatric claim that the troubling behaviors
subsumed under various mental illnesses are real medical entities, but which, unlike other real medical entities, can nevertheless be
subjected to the routine use of coercion as treatment? Or does the language and imagery of scientific medicine serve to justify the
use of force by the professions vying for control over the highly politicized and contested turf of what sociologist Andrew Abbott
calls “the personal problems jurisdiction” (Abbott, 1982)? Part of the answer may be informed by how mad treatment evolved in the
United States.
 From Social Concern to Medical Treatment
Colonial Americans’ views of madness were shaped by those of their European predecessors relying on the two models developed
by the Greeks. Theirs was a metaphysical mélange combining “religious, astrological, scientific and medical elements” (Grob,
1994b). For over two hundred years, from colonial times till the mid-eighteenth century, America’s mad folk were just one of many
dependent groups designated as the “poor.” The mad were viewed simply as one segment of the population appropriate for
community concern and care; others were orphans, widows, the aged, the sick, and the physically disabled. What mattered in
obligating the local community to provide public assistance was each subgroup’s state of poverty leading to their dependency, not
the particular causes or manifestation of their dependency (Grob, 1973; 1994b; Scull, 1985).
The community response to inexplicable, troubling behavior threatening the public safety on occasion prompted legally
sanctioned coercion. Gerald Grob describes the case of a colonial soldier who murdered his mother but was found not guilty because
he was adjudicated insane. The court required that he be confined for the rest of his life in a small room built for that purpose by his
father, with the public bearing the cost (Grob, 1994b, p. 16).
Very few people were considered to be mad during the early colonial period, although almost no hard data are available and most
of our information is anecdotal (Grob, 1973, chapter 1; also Viets, 1935, p. 395). Communities where the mad resided at first had no
special facilities for their care, with families and occasionally other community members taking responsibility for their welfare.
Later, as the general population and dependent populations grew, the insane were offered the same services provided all worthy
dependents (almshouses and outdoor relief). The first almshouse in America was built in Boston in 1662 (Grob, 1973). Some of
these mad folk worked productively, and the community generally accepted their accompanying bizarre behavior as one of the
vagaries of life. Until the middle of the eighteenth century, medical considerations “played virtually no role” in how the “distracted”
were handled (Grob, 1994b, p. 17).
The mad started to be formally institutionalized during the early part of the eighteenth century. Boston, one of the larger colonial
communities, as early as 1729 sought to develop a separate structure for housing the mad, partly to reduce the physical conflicts
arising when the sane and controllable and the mad and uncontrollable poor were housed haphazardly together (Grob, 1994b, p. 17,
also Scull, 1985, p. 27). Several other communities shortly thereafter began to erect “hospitals.” These facilities were specifically
designed for the care of the destitute ill, including the insane, and were meant to reflect the community’s continuing commitment to
a special personal relationship with this group. But due to gradual demographic shifts and population increases, families and friends
who originally bore the brunt of the care for mad community members were less able to take care of their own, and these hospitals
served as professionally run “surrogate households” that “would help to train medical personnel” who would try, but rarely succeed,
in curing “the sick stranger, the ill-kept resident, and wandering insane” (Rothman, 1990, p. 45). The first such official hospital was
established in Philadelphia in 1752. It should be emphasized that these hospitals were more a segregating managerial response to the
perceived problems of poverty and its impact on the health and welfare of the community “rather than to changes in medical theory
and practice” (Grob, 1973, p. 16). The very first hospital exclusively for mad people was started in Williamsburg, Virginia, in 1773
(Grob, 1973).
The urban population of America steadily grew from just 5.1 percent of the total population in 1790 to 19.8 percent by 1860
(Rothman, 1990, p. 327, note 1). The increased societal and individual stress and displacement that resulted required the
bureaucratic reorganization of the existing social welfare structure, including the approach to the care of the mad.
 The Community—Cause or Cure of “Mental Illness?”
The specific type of organized care developed for the mad in the early 1800s and modeled on the approach taken earlier in England
was the community-based decision to confine them to suburban or rural asylums (later government-funded state mental hospitals) to
avoid the toxic stress of urban living (Grob, 1994a, 1990). The Asylum for the Relief of Persons Deprived of the Use of their
Reason, opened by the Quakers in 1817 in the City of Brotherly Love, Philadelphia (Whitaker, 2002, p. 25) is often identified as our
first nineteenth-century asylum; however, New York Hospital (opened in 1792) in 1808 constructed a building that was known as
the New York Lunatic Asylum (Ozarin, 2006). The approach at these asylums was to remove the person, usually forcibly, from the
hubbub and corruption of urban life, which was deemed to be primarily responsible for their insanity and, through the well-
organized rustic asylum experience, allow for respite and healing before returning if possible to one’s community (Rothman, 1990).
The three principles of asylum treatment that famously became moral treatment were, first, the rapid removal of the insane from
the community; second, assuring that the confining institutions were at a sufficient physical distance from the inmate’s community;
and, third and most important, fulfilling, “[t]he charge of the asylum . . . to bring discipline to the victims of a disorganized society”
(Rothman, 1990, p. 138). To impart order without brutality was the stated aim of moral treatment. The Quakers’ original or ideal
version of this approach in America around 1817 required that the asylum would be situated in a rural setting, housing no more than
about 250 people (Whitaker, 2002, p. 25) under the governance of a paternal superintendant who might be a lay or medically trained
individual. This individual would have a close personal relationship with each inmate and would help guide them together with
supportive staff back to reason through simple, regimented, socially useful yet healthy physical work maintained by a ward system
based on rewards and punishments (Whitaker, 2002).
Over time, the reality of nineteenth-century asylums turned out to be very different than originally conceived. Their populations
routinely exceeded their optimal capacities, often by many hundreds of residents. The superintendents managing these asylums were
primarily trained in designing, organizing, and administering them, not in the art and science of coping with behavioral disturbance.
As Rothman notes, “[The superintendent’s] skills were to be those of the architect and the administrator, not the laboratory
technician” (1990, p. 134). The title of a leading textbook on insanity published in 1854 by one of the more influential
superintendents, Thomas Kirkbride, of the Pennsylvania Hospital for the Insane (On the Construction, Organization, and General
Arrangements of Hospitals for the Insane, with Some Remarks on Insanity and Its Treatment), reveals what professional areas were
thought to be important and in what order.
Even the oft-stated goal of moral treatment, to eliminate harsh physical punishment or restraint, must be viewed skeptically. The
renowned nineteenth-century French alienist, Philippe Pinel, one of the inventors of the traitement moral and considered to be a
visionary who “unchained”2 the incarcerated mad, also believed that successful treatment depended on the employment of
psychological terror and fear to gain the compliance of the insane (see his description in Pinel, 1962, pp. 63–91). Moral treatment at
its core was coercive because it was practiced on involuntary inmates, not willing, help-seeking participants free to come and go at
their leisure, and used “the pervasive authority of the alienist, and his ability to link classification with a system of rewards and
punishments, constitut[ing] an extraordinarily powerful new form of ‘moral machinery,’ a superior mode of managing patients”
(Scull, 1993, p. 379).
The reality was that these patients were confined against their will in (eventually) large physical plants architecturally designed
to separate the inmates into a series of wards that demanded various levels of psychological and physical conformity. Making
progress in this system required obedience and proper behavior by the patients. Failure to follow the rules dramatically undermined
the patient’s social status, institutional privileges, and personal wellbeing by the forced transfer to more remote and less respectable
and comfortable wards. Total control by the alienists/moral managers over the physical and social environment of the inmates was
the mechanism that imposed discipline. Moral treatment originally was marketed by its proponents as a more humane approach for
working with the mad, theoretically relying on minimal physical restraint (if one overlooks their forced sequestering in the asylums)
while emphasizing other methods of behavioral control. By the end of the nineteenth century, it had transformed into a bloated,
highly dysfunctional system utilizing physical punishment and that had almost no resemblance to its original psychological
reeducation approach. Moral treatment became the rallying point for progressive political activists promoting the growth of
government intervention in the care of the insane under the cover of medical science.
 The Growth of the Bureaucratic Medical Management of Mental Health
Scientific medicine became a reality only in the mid-nineteenth century. German physician Rudolf Virchow’s research,
demonstrating the central role of cell pathology in human disease processes, offered for the first time medical treatment that reliably
ameliorated certain physical diseases (Porter, 1997, pp. 304–347). The new scientific medical model of disease that developed as a
result consists of reported (subjective) symptoms, measurable or palpable physiological signs, and demonstrable physical lesions. It
replaced the ancient Greek humoural theory of health and illness prevalent until that time. Humoural theory speculates that the
human organism contains four body humours, blood, phlegm, black bile, and yellow bile (choler), the balancing of which is
necessary for good health (Porter, 1997, p. 9). (The intellectual debris of the humoural theory can be found in current speculations
that “chemical imbalances” in the human brain cause assorted mental disorders.) The new medical disease model emboldened
alienists to claim that “mental illness” was just like other medical disease entities even though “no evidence could in fact be
produced to show that insanity had a somatic origin” (Scull, 1993, p. 241).
Benjamin Rush, a signer of the Declaration of Independence whose portrait appears on the emblem of the American Psychiatric
Association and is considered to be the father of American psychiatry, in 1812 published the first American psychiatric textbook,
Medical Inquiries and Observations upon the Diseases of the Mind. In it he declares “that the cause of madness is seated primarily
in the blood-vessels of the brain” (pp. 11–17). Rush’s statement might be the first published American psychiatric assertion that
“mental illnesses” are brain diseases. This position was also held by most of Rush’s contemporaries in Europe and America, even
though little pathological work was undertaken to identify brain differences between normal and insane people (Rothman, 1990, p.
110). Such claims gradually shifted the thinking about the nature of treatment itself.
The early-nineteenth-century reports claimed impressive successes for moral treatment. “At McLean Hospital, 59 percent of the
732 patients admitted between 1818 and 1830 were discharged as ‘recovered,’ ‘much improved,’ or ‘improved.’ Similarly 60 percent
of 1841 patients admitted at Bloomingdale Asylum (the successor to the New York Lunatic Asylum) in New York between 1821
and 1844 were discharged as either ‘cured’ or ‘improved’” (Whitaker, 2002, p. 27). This success raised expectations about the
possibility of effective nonmedical treatment for insanity. As popular support grew for lay asylum treatment, physicians, feeling
threatened by the potentiality of professional marginalization, intensified their efforts to acquire medical jurisdiction over these
asylums. In 1824 the Connecticut State Medical Society successfully lobbied for government and private funding and built the
Hartford Retreat with Dr. Eli Todd as the medical superintendent in charge. Todd argued that earlier asylum treatment had “placed
too little reliance upon the efficacy of medicine . . . and hence their success is not equal to that of other asylums in which medicines
are more freely employed [and as a result his institution will be adhering] . . . to the lofty conceptions of truly combined medical and
moral management” (Whitaker, 2002, p. 28). As states funded public asylums, they generally supported this integrated
medical/moral approach, which also led to the increased use of physical interventions. Bloodletting, physical restraint, and
psychological terror, originally promoted by Rush, became key treatment components (Porter, 1997, p. 500). By 1844, thirteen
physicians in charge of asylums had organized into the Association of Medical Superintendents of American Institutions for the
Insane, becoming in 1921 the American Psychiatric Association. One of their declared goals was to make sure that asylums would
always have doctors as their executive officers and superintendents.
The traditional roles of hospitals as poor relief institutions for the transient or homeless sick, safe havens for the indigent dying,
and places for custodial care of almshouse inmates sane and mad, also began to change to better fit the emerging, nineteenth-century
scientific worldview. Hospitals became experimental way stations for the new notions of scientific medicine, curative interventions,
and scientific research (Leiby, 1978, p. 61). These progressive ideas provided the empirical justification for recasting some hospitals
into state asylums or hospitals for the insane. The earlier general social control mechanisms of poor relief could now be merged with
the more recent “scientific” claims of psychiatry about the mad, boosting both its police powers and professional stature.
This shift in the United States from the early colonial voluntary concern about social dependents to the “scientific” approach for
managing human problems in the late nineteenth century turned out in practice to consist largely of acts of bureaucratic categorizing
and management. The collection and analysis of quantifiable data about various dependent groups served to confirm the rationality
of administrative and bureaucratic activity. The individuals who helped develop public policy regarding these groups were confident
that their centralized decisions would “promote . . . rationalization and systemization . . . to enhance the presumed effectiveness of
public and private institutions” (Grob, 1983, pp. 81).
The scientific management of madness under this approach, in the United States and elsewhere, required renaming and
categorizing disturbing behaviors as diseases and symptoms of diseases. This led to the development in several countries of various
diagnostic systems for asylum practice and record-keeping. In Germany, the psychiatrist Emil Kraepelin published his first textbook
of psychiatry in 1883, containing his descriptive nosological work, which remained one of the most influential. “Indeed, his
textbook can be seen as the forerunner of today’s Diagnostic and Statistical Manuals” (Porter, 1997, p. 512). Kraepelin’s influence
is discussed in more detail in chapter 4.
The successful nineteenth-century transition from lay to medical control of madness in America energized the mental health
reform movement as it sought to convince the population and state governments to establish more mental hospitals. One of the
leading progressive proponents of hospital treatment was Dorothea Dix. She herself experienced an emotional collapse at the age of
thirty-four that was in her era diagnosable as moral insanity (Gollaher, 1995, p. 105). As part of her recovery, she spent about fifteen
months in England, staying at the home of William Rathbone, III, a close friend of Samuel Tuke, the grandson of the great English
Quaker William Tuke, who developed the by-then famous York Retreat, providing moral treatment for the English mad. Samuel
Tuke’s youngest son, Daniel Hack Tuke, was in charge of Dix’s recovery (spent in part at the Retreat), and he tutored Dix on the
Retreat’s principles (Gollaher, 1995, p. 357). As a result she “adopted them as the basis for most of her later ideas about asylums
and psychiatric treatment” (p. 112).
 Dix’s intentions were admirable. She wanted to help a group of deeply troubled individuals who were often treated miserably by
the prevailing penal authorities. Her solution was to go from state to state in an attempt to convince the legislators to fund public
insane asylums. She claimed, relying on apparently irrefutable data, that insanity was curable, that effective treatment was at hand,
and that only the funding of enough public institutions to take care of the indigent lunatics would eliminate this grave social
problem. So effective was she that thirty-two state mental hospitals were either founded or enlarged as a direct result of her lobbying
(Leiby, 1978, p. 67).
Well intentioned as her approach was, it left something to be desired. To argue her cause Dix relied on false statistics and dubious
claims about the curative powers of treatment. She apparently made no effort to examine or question the scientific data because it
supported her assumptions about “mental illness” (Scull, 1981, p. 112). Rothman (1990) reports, “these statistics were inaccurate
and unreliable. Not only was there no attempt to devise criteria for measuring recovery other than release from an institution [which
was, as we will discuss in chapter 3, an administrative decision] but in some instances a single patient, several times admitted,
discharged and readmitted entered the list as five times cured” (p. 131).
This focused lobbying effort by Dix and fellow progressives to organize and institutionalize publicly funded hospital care for the
insane was a resounding success, serving as an early example of how good intentions and enthusiasm for change in psychiatric
treatment overrides evidence. By 1880, about 140 public and private mental hospitals were managing about 41,000 individuals
(about 90 percent were in public care). Notably, even at the end of the nineteenth century the mad still represented a very small
portion of social dependents, making up less than 0.2 percent of the general population. The census of 1880 listed 91,997 insane
people in the United States out of a total population of fifty million (Grob, 1983).
By the start of the twentieth century, a barely nascent psychiatric profession whose tasks centered entirely on the management of
insane asylums had won the argument that good science demanded the institutional control of madness via state mental hospitals.
However, almost as soon as psychiatry had made this commitment, it began to reconsider this approach to the problem of madness.
 The Mad Population Grows by Federal Fiat
The horrors of World War I traumatized humanity and served as the spawning ground for new psychiatric problems such as “shell
shock” and “battle fatigue.” The phenomena of large numbers of individuals potentially opting out of their forthcoming military
responsibilities during wars by claiming to be mad or by once in service developing psychiatric “disabilities” is well-known.
“Everyone who served in the United States Army of World War II is familiar with the word ‘goldbricking,’ which meant, in military
slang, malingering” (Eissler, 1951, p. 219). Malingering is the term for those who do not want to go and fight in a war or find the
violence abhorrent once in the military and fake being ill3 to avoid participating rather than declaring themselves conscientious
objectors and facing close scrutiny and potential public condemnation.
The political problem of explaining large numbers of reluctant military recruits, when the military needs all able-bodied
individuals for combat, can be greatly reduced by recasting malingering as diagnosable mental disorders and medically treating or
honorably discharging their “victims” rather than court-martialing hundreds, if not thousands, of dissidents. The latest of these war-
related diseases is the Vietnam War–related version, posttraumatic stress disorder (PTSD, Young, 1995).
Redefining the feigning of insanity to avoid combat because of fear of killing or being killed as a mental disorder rather than a
moral dilemma allowed the “ill” individuals to be “diagnosed” then “treated,” followed by either a rapid return to active duty or an
exit from the military with an honorable medical discharge instead of being court-martialed. Joseph Heller’s famed novel Catch 22
tells an extended story of such maneuvers. This approach would mostly take care of those already in the military. But what to do
about those at-risk individuals who were among the yet undrafted?
The passage of the Selective Service Act of 1917 had created a Division of Neurology and Psychiatry under the War Department
to evaluate and reject recruits diagnosed with psychiatric disorders. Psychiatrist Thomas W. Salmon, the medical director of the
National Committee for Mental Hygiene, recommended that the military exclude recruits found to be “insane, feeble-minded,
psychopathic and neuropathic” (as quoted in Pols & Oak, 2007, p. 2133). His suggestion, which became the justification for military
screening of draftees in both world wars, assumed that various war neuroses or mental breakdowns resulted from personal
characteristics (i.e., constitution, genetic makeup, temperament, or early childhood experiences) that tended to be invariant within
individuals and would undermine their ability to function effectively as soldiers (Pols & Oak, 2007). As a result, 103,000
individuals were excluded or discharged from the military in World War I for neuropsychiatric disorders (Jones, Hyams & Wessely,
2003, p. 41) out of approximately 2.8 million who were drafted (Wikipedia, 2011). This screening process was never evaluated, so
we know nothing about its effectiveness or validity. The Division of Neurology and Psychiatry also oversaw “the treatment of
mentally ill service personnel” already in the military (Connery, 1968, p. 15).
The federal involvement continued to grow. In 1930 the Veterans Administration was created to provide ongoing health care,
including comprehensive mental health treatment, to veterans. The Division on Mental Hygiene was also organized within the
Public Health Service around that time. This division’s various roles included studying drug addiction, administering some of the
associated treatment facilities, providing mental health treatment to federal prisoners, and offering diagnostic services to the federal
judiciary (Connery, 1968). This expanded the federal role in mental health to few other client populations beyond the military
personnel. The division served as the institutional center of this still-limited federal involvement until the National Institute of
Mental Health (NIMH) started its work in 1949. World War II helped make the entire nation’s mental health a federal government
concern.
During World War II, the massive recruitment of millions of young draftees for the military focused the country’s attention on
mental health issues as never before. According to the 1945 congressional testimony of General Lewis B. Hershey, then director of
the Selective Service System, the rejections for military service based on mental difficulties included “somewhere around . . .
856,000 . . . for mental diseases, and an additional 235,000 . . . as neurological cases. In addition to that there are 676,000 that have
been turned down for mental deficiency” (as quoted in Connery, 1968, p. 16), totaling approximately 1.8 million recruits rejected
due to neuropsychiatric difficulties out of the 36 million men classified for military service (Flynn, 1993). These numbers aroused
broad public concern among average Americans about the extent of mental illness in the United States. General Hershey presented
these data as part of his dramatic testimony to Congress supporting the ultimately successful effort to pass the National Mental
Health Act of 1946. This act created the previously mentioned NIMH and gave broad authority to the federal government in
developing and implementing national mental health policy and programming (Connery, 1968).
The “discovery” of a staggering number of military-age men with psychiatric problems unveiled by General Hershey
accomplished its intended political and pragmatic aims. It impressed both politicians and the public of the seriousness of the
national menace of “mental illness” and it justified the culling of undesirable individuals from the military for “medical” reasons.
The problem, not unlike the issues raised a century earlier by the efforts of Dorothea Dix to convince state governments to fund state
mental health hospitals based on exaggerated claims and bad statistics, was that this successful expansion of the federal
government’s involvement was based on bad methodology. The military’s diagnosing of hundreds of thousands of citizens as
psychiatrically disturbed was made by understaffed and insufficiently trained personnel, relying on screening procedures and tools
lacking any predictive reliability, in ludicrously brief interviews of two minutes or so, all within a social environment tainted by
eugenics, racism, and homophobia. Grob (1994b) recounts that

The military feared in particular that the inadvertent recruitment of homosexual males would have a devastating effect on
the armed forces and supported any measures that might exclude them. . . . Screening . . . was arbitrary and capricious;
racial and ethnic considerations intruded in the process . . . and personality tests were biased and unreliable. (pp. 192–193)

The screening problems, never resolved, ultimately led to the abandonment of the entire effort under the order of General George
C. Marshall in 1944 (Pols & Oak, 2007, p. 2134). These concerns were quickly superseded by the sharp increase of “nervous
breakdowns” occurring in the battlefield. The most politically expedient explanation for mental problems that were described earlier
as malingering was the impact of the war itself on the personalities of these men. The military psychiatrists argued that
“environmental stress, that is, the actual conditions of combat played a major etiological role; predisposition was not a significant
factor” (Grob 1994b, p. 193). Here was a pretentious and medical-sounding explanation for the common-sense observation that
combat conditions seriously frightened and disabled some people. They recommended first aid psychiatry as the treatment of choice.
Treatment was provided directly in the combat zone instead of in some more permanent but remote military medical facility that
would have, it was argued, weakened the soldier’s ties to his unit and prolonged the sick role. First aid psychiatry included “mild
sedation, a night of sound sleep, and warm food . . . brief psychotherapy, rest and relaxation under psychiatric guidance” (Grob,
1994b, p. 194).
The simplicity and apparent success of such treatment under war conditions (most soldiers returned to their units within a week)
logically suggested to the psychiatrists returning to their practices after the war that “treatment in civilian life, as in the military, had
to be provided in a . . . community setting, rather than in a remote, isolated, and impersonal institution” (p. 195). The emphasis on
environmental causes of mental disturbances helped foster theories of preventing mental disorders through the control of
environmental factors. These efforts fit well with the already successfully established “scientific” public health model for the
prevention and treatment of infectious diseases. Since President Harry Truman’s Scientific Research Board had already expressed
strong interest in having the federal government support biomedical research and insisted on the need for developing a national
health policy, the incorporation of mental health policy into this broader federal health endeavor seemed a natural progression
(Grob, 1994b).
The National Mental Health Act of 1946 embodied this commitment. It declared “mental illness” a serious public health
problem, authorizing for the first time “extensive research, demonstration projects, training programs, and grant-in-aid to the states
for mental health purposes” (Connery, 1968, p. 16). The NIMH, also a result of this act, provided the organizational infrastructure
for centralizing federal authority over the nation’s mental health policy. The act, building on the arguments of the psychiatrists
returning from the Second World War, put the authority of the federal government behind policy efforts to “stimulate a new form of
community mental health activity. . . . [T]reating mental illness in the patient’s normal environment rather than in a mental hospital”
(Connery, 1968, p. 19).
 The Shifting Psychiatric Landscape
These developments were aided and abetted by the various exposés of harmful and coercive institutional psychiatric practices
published in the early decades of the twentieth century. These provocative accounts further highlighted the problems of institutional
care and undermined its optimistic early promise in the eyes of the general public. In the late 1940s, Albert Deutsch described a visit
to a psychiatric ward:

Cots and beds were strewn all over the place to accommodate the 289 mental patients packed into wards intended for 126.
Cots lined the corridors, with restless patients often strapped to them. It appeared that about one-third of all patients . . .
were under mechanical restraint that night—tied down to their beds by leather thongs, muffs or handcuffs linked to chains.
(as quoted in Grob, 1994b, p. 204)

Although according to Grob the actual living conditions of the nation’s state mental hospital systems were apparently improving by
the 1950s, this was ignored for the most part and the emphasis was on expanding community-focused care. The post-war belief in
the primacy of environmental and psychological causes of emotional disturbance supported arguments for early intervention as a
way to avoid developing serious “mental illness” and the inevitable hospitalization accompanying it. This belief went well with the
federal flow of dollars to community care in the late 1950s and 1960s based on the various federal legislative acts mentioned earlier.
There was an intuitive common-sense logic to “curing” through supportive community caring, but it lacked empirical support (Grob,
1994b, pp. 234–236).
Such beliefs reinforced and supported the notion that fragmented state mental health services could only be mended by
comprehensive federal planning and funding. These political, philosophical, and practical developments, together with the
introduction in the 1950s of psychotropic drugs, which were promoted as having great “scientific” promise of managing or
eliminating frightening psychiatric symptoms (and which were functionally understood as increasing socially appropriate behavior
without the need for obvious coercive physical restraint), provided the justification for the commitment to treat in the community
the hundreds of thousands of institutionalized psychiatric inmates. Not only was this seen as an attainable reality but as a significant
moral and social good.
Deinstitutionalization, as this approach came to be known, became the focus and the political agenda of those making mental
health policy from the late 1950s onward. As the federal government expanded its involvement with mental health policy through its
legislative activity, the role of state governments diminished and with it the role of state-funded and -run mental hospital systems.
The Mental Health Study Act of 1955 provided substantial federal dollars ($1.25 million) to “research . . . and study . . . resources,
methods and practices for diagnosing, treating, caring for, and rehabilitating the mentally ill” (Connery, 1968, p. 39). Business
involvement with the management of federal mental health policy began almost immediately. That year, the Smith, Kline, and
French Company, a pharmaceutical powerhouse and distributor of chlorpromazine (Thorazine), the very first antipsychotic ever
approved by the FDA in 1954, provided a grant of $10,000 to subsidize the planning of the coordinating committee to organize the
Joint Commission on Mental Illness and Health (JCMIH). The commission originally consisted of eighteen key organizations,
including representatives from the American Psychiatric Association (APA), the American Medical Association (AMA), the
American Psychological Association, and the American Association of Psychiatric Social Workers. The AMA and APA had five
representatives each, while all the others had one each (p. 40). The membership was skewed toward the medical perspective, which
would strongly influence the commission’s development of their recommendations for mental health policy.
The stated commission agenda was to look at “mental illness” in completely new ways. The JCMIH, although instrumental in
setting up the Mental Health Study Act of 1955, applied for and was selected to conduct a study authorized under it. This selection
highlighted the strong ties already in place between professional interest groups and the government bureaucrats developing federal
policy. The study, costing almost $1.5 million dollars, resulted in a report—Action for Mental Health. It recommended a massive
program to inform and educate the public about mental health problems, and called for a dramatic increase in federal dollars to
cover the cost of developing and implementing their recommendations for improved mental health services (we further discuss the
commission and its report in chapter 3).
These recommendations called for increasing the authority and power of NIMH by becoming the source of the federal dollars for
research on mental illness, by the establishment of academic mental health research centers throughout the country, by increasing
the number of jobs available in the mental health professions, and, finally, by increasing federal spending to support mental health
treatment. These recommendations helped pave the way for the federal government becoming the principal funder of mental health
research and the chief arbiter of the “standards for the quality of care of the mentally ill” in the United States (Connery, 1968, p. 45).
The 1956 amendment to the Public Health Service Act under its Title V continued this effort to centralize mental health policy by
authorizing grants for work improving the methods of diagnosis and treatment of mental illness and for funding NIMH to subsidize
research efforts on better inpatient management and treatment techniques for state hospitals. The concentrated effort by the
leadership of the NIMH to gain control over mental health research and program funding and policy development combined with
the political activities of relevant professional lobbies in support of this federal takeover culminated in the passage of the Mental
Health Acts of 1963 and 1965. These authorized the creation and staffing of comprehensive community mental health centers
throughout the United States with the aim of seamlessly integrating and delivering the necessary mental health services in the
communities where patients lived.
Robert Felix, the then-influential director of NIMH, in his pivotal US Senate testimony for the passage of the 1963 act predicted
that its effect would be to facilitate “the day when the State mental hospitals as we know them today would no longer exist”
(Connery, 1968, p. 51). The act was passed, and his prediction that state mental hospitals would no longer be the same, more or less
has been realized. The state hospital inmate populations eventually plummeted, but the hope that community-based care would
revolutionize the provision of mental health services and improve the independence and the well-being of the mad has not (Scull,
1981a). In fact, it appears that this effort merely shifted many of these inmates into other “museums of madness,” such as nursing
homes and jails. Scull tells us, “By the mid-1970s, nursing homes had become ‘the largest single place of care for the mentally ill,’
[with as many as 900,000 mentally disabled residents] absorbing some $4.3 billion or 29.3% of the direct care costs associated with
mental illness” (1981a, p. 747). In 1998 the US Department of Justice’s Bureau of Justice Statistics (BJS) estimated that 283,800
“mentally ill” prisoners were being held in the nation’s penal institutions (BJS, 1999).
Regardless of the actual long-term outcomes, these activities served as the birthing ground for an “interlocking directorate”—of
professional groups, mental health activists/lobbyists, private individual and foundation donors, government bureaucrats, and the
pharmaceutical industry—that effectively has come to shape and run the “science” of mental illness and its treatments in the United
States:

As a revolution . . . passage of the mental health legislation of 1963 and 1965 had all the earmarks of a coup d’etat,
carefully staged and managed, with the full implications for the country at large to come later, after changing the palace
guard. . . . [T]he 1963 Act was but another episode in the continuing story of the expanding activities and influence of the
National Institute of Mental Health. From its beginnings in 1949, partly the result of bureaucratic instinct, partly the result
of professional dedication, NIMH’s aggressiveness in pursuing its own expansion was exceeded only by its success. . . .
Strategically placed congressmen, . . . who chaired the relevant appropriations subcommittees were carefully cultivated by
Dr. Felix, aided and abetted by interested private groups and individuals. Among the more important of theses surrogates
were the American Psychiatric Association, the National Association for Mental Heath and its state affiliates, and—through
the good offices of Mike Gorman, executive director of the National Committee Against Mental Illness—Mrs. Mary
Lasker, long known for her efforts . . . through the Albert and Mary Lasker Foundation on behalf of medical advances.
(Connery, 1968, p. 61)

These developments led to the strong centrally organized political structure for dealing with madness that is currently in place.
NIMH has cemented its role as the principal distributor of federal mental health research funding (its research budget has grown
from approximately three quarters of a million dollars in 1948 to nearly 1.2 billion dollars in 2006). It is also the agency that closely
coordinates the development of mental health policy. This dual role of the federal government in determining mental health policies
and doling out the research dollars seeking to validate these policies has deeply politicized psychiatric science. NIMH is committed
to biological explanations of madness. Projects relying on that presumption have formal funding priority. Other theoretical
perspectives (related to psychological, social, environmental, and personal explanations of mad behavior) are deemed adjunct or
irrelevant approaches.
Thomas Insel, the current director of NIMH, declared in one of America’s premier academic journals:

Just as research during the Decade of the Brain (1990–2000) forged the bridge between the mind and the brain, research in
the current decade is helping us to understand mental illnesses as brain disorders. As a result, the distinction between
disorders of neurology (e.g., Parkinson’s and Alzheimer’s diseases) and disorders of psychiatry (e.g., schizophrenia and
depression) may turn out to be increasingly subtle. That is, the former may result from focal lesions in the brain, whereas
the latter arise from abnormal activity in specific brain circuits in the absence of a detectable lesion. As we become more
adept at detecting lesions that lead to abnormal function, it is even possible that the distinction between neurological and
psychiatric disorders will vanish, leading to a combined discipline of clinical neuroscience. (Insel, 2007, p. 757)

As we pointed out in the introduction, Insel’s rhetoric smacks of propaganda and wishful thinking rather than good science. After
all, the claim that the distinctions between neurological disorders and mental disorders “may turn out to be increasingly subtle” also
means that they may turn out to be exactly what they are today, categorically distinct.
This concludes the “factual” history we have gleamed, not being trained historians ourselves, from consulting the works of some
of the best-recognized chroniclers of madness. But, before we summarize and conclude what this history may mean, let us take a
look at what is often thought to be unnecessary when using assumed objective historical scholarship: evidence for unacknowledged
personal perspectives of the prominent madness chroniclers, on whom most people rely for their historical understandings of
madness.
 The Modern Historical Chroniclers of Madness
These historians are, in alphabetical order, Norman Dain (1964), Gerald Grob (1973; 1983), Roy Porter (1987a; 1987b; 2002),
Charles Rosenberg (2007), Andrew Scull (1979; 1993) and Edward Shorter (1997). Professor emeritus at Rutgers University,
Norman Dain’s major work is Concepts of Insanity in the United States (1964), which Gerald Grob (1973) believes is the best
academic discussion of early American psychiatric thinking (p. 153), and Andrew Scull (1993) calls one of “the best and most
scholarly . . . accounts from this era” (p. 119).
Gerald N. Grob is the Henry E. Sigerist Professor of the History of Medicine (Emeritus) at the Institute for Health, Health Care
Policy and Aging Research, Rutgers University. The dean of American psychiatric historians, over a thirty-year period Grob
authored five major books (1966; 1973; 1983; 1991; 1994) and dozens of articles detailing the history of American psychiatric care
from its colonial beginnings through the dawning of the twenty-first century. He is also a past president of the American Association
for the History of Medicine (AAHM).
The late Roy Porter (1946–2002) was a professor at the Wellcome Institute for the History of Medicine in London, who edited or
wrote over a hundred books and is probably, because of the rigor and prodigious academic fecundity of his writings, the most cited
historian of medicine. Porter has published more than a dozen books on psychiatry and madness alone. That he managed to
accomplish all of this before his early death at age fifty-five makes his achievement even more impressive.
Charles E. Rosenberg is a professor of history at Harvard University, a fellow of the American Academy of Arts and Sciences,
and a past president of the AAHM and Society for the Social History of Medicine. He has written or edited more than a dozen books
and numerous articles on medical and psychiatric issues.
Andrew Scull is a Princeton-educated academic who currently is the chair of the Department of Sociology at University of
California, San Diego. He has published many books on the history of madness, is a recipient of the Guggenheim Fellowship, and
was the president of the Society for the Social History of Medicine.
Finally, Edward Shorter, a professor of medical history at the University of Toronto, has also written several books on psychiatric
history, the best known being the 1997 work, A History of Psychiatry. In addition to these principal historians, we will reference
other scholars who have contributed to the writing of psychiatric history.
The Problem with Historical Messengers
The field of psychiatric historiography, that is, the history of psychiatric history, is reported to be “passionate, partisan and
polemical” (Micale & Porter, 1994, p. 3). Yet, despite this implied diversity of perspectives, we believe that most historians of
madness accept that what is contained within the category of madness is best understood as a form of illness. That term usually is
understood as medical, and some historians fully accept that madness is brain disease. However, because the term illness may be
vague, its use provides wiggle room for historians who are unsure whether madness is physical disease, but nevertheless feel that
“mental illness” is real illness in some sense. This strategic use of the term illness biases either weakly or strongly their presentation
of the historical “facts” regarding madness. For example, Andrew Scull—in a rebuttal to a psychiatrist’s attack that he, Scull,
considers madness “merely a literary or a philosophical concept”—responds thus:

If I am less inclined than Dr. Crammer to concede that the definition of madness as illness is a pre-social, “natural” feature
of the universe, and instead regard the boundaries of what constitutes insanity as labile and greatly influenced by social
factors, that is not at all the same thing as the assertion that “mental illness” is some sort of literary or philosophical conceit.
(Scull, 1995, pp. 387–388)

Scull’s viewpoint is based, he writes, on the fact that “like many lay people I . . . unfortunately have first hand experiences of the
ravages of mental disorder on those near and dear to me” (p. 387). Scull is an important historian who has through his careful
scholarship exposed some of the most egregious acts of terror and coercion in the field of psychiatry. He appears to consider
madness an illness but is not ready to declare that such an illness is a “natural feature of the universe,” leaving us, his readers,
confused. Is madness to be considered a medical disease like any other? If not, how should his general readership think of it? Since
most contemporary laypeople (with whom he identifies himself in the second quote) think of mental disorder as a medical problem,
his undefined use of mental illness and mental disorder will resonate medically to many of them.
Some of our historians narrate the history of psychiatry as a triumphal progress through time. In their accounts, primitive
ignorance eventually gave way to the development and implementation of a scientific psychiatry through the key “discovery” that
troubling and disturbing behaviors are medical diseases (Deutsch, 1967, pp. 517–518). Other historians take a more cautious
position, believing that “the history of our responses to madness . . . is . . . far from being a stirring tale of the progress of humanity
and science” (Scull, 1993, p. xvii). Finally, perhaps alone among those publishing psychiatric history, Thomas Szasz (1920-2012), a
psychiatrist himself although his own psychotherapeutic practice never relied on medical interventions, attempted to delegitimize
psychiatry as a medical enterprise. He consistently maintained that psychiatry was not a medical discipline to heal sick people but a
unique policing profession. Szasz was often dismissed or excoriated by his psychiatric contemporaries for arguing that the societal
response to madness (including the medical management of madness in all its guises) is primarily a political, legal and moral
endeavor. His works develop in great detail the notion that the metaphors of medicine served to convert state-supported policing
activities of socially disturbing behavior into medical interventions for a public health menace (Szasz, 2007).
These differing accounts of madness and its psychiatric management expose as naïve the idea that psychiatric history proceeds
by reporting the cold, hard facts and nothing but. In their book, Discovering the History of Psychiatry, Roy Porter and his co-editor
Mark Micale write that “both empirically and interpretively, extant histories of psychiatry reveal a vastly greater degree of
difference among themselves than historical accounts of any other [medical] discipline” (1994, p. 5). Over time, they argue, organic
medicine has demonstrated dramatic scientific advances in its understanding of the nature and etiology of disease, but
mental/psychological medicine has failed to provide a similarly unified explanatory framework for its targeted problems (see Micale
and Porter, 1994, ch. 1).
Psychiatry is the sole medical specialty lacking physiological validation for any of its particular entities, including all the serious
and persistent mental disorders (Kupfer et al., 2002). Thus, in our view it remains an open question whether the psychiatric
profession is treating medical diseases, such as diabetes or heart failure (entailing impersonal pathophysiological processes), or
instead responding to the moral and behavioral anguish of individuals failing in the game of life as Szasz and a few others argue.
The various historical texts referenced in the present chapter, while occasionally documenting this ambiguous ontological
understanding of madness, nevertheless routinely employ medically-impregnated language to tell their stories. Expressions such as
lunatic, lunacy, crazy, chronic mental illness, severe and persistent mental illness, mental illness, psychosis, insanity, the insane,
psychotics, mental medicine, psychiatry, psychological medicine, mental disorder, disorder, mental disease, and disease are used
frequently and interchangeably throughout this literature. The habit of comingling words that are prone to ambiguous
interpretations, such as insane, crazy, or illness, with others that also have more formal medical definitions in contemporary
medicine, such as disease or psychosis, has consequences. As Scull suggests, “The concepts which we use to delimit and discuss
any particular segment of reality inevitably colour our perceptions of that reality” (1993, p. 376). We think that the terms that many
historians have adopted in their books have a medical bias.
Micale and Porter’s own characterization of the medical field’s activities toward mad behavior as “mental medicine” exemplifies
some of these conceptual difficulties. Regardless of the empirical reasons for using the phrase mental medicine, when two
distinguished historians matter-of-factly use such terms it affects readers’ understanding. Are readers to think that the authors are
naming and circumscribing a formal domain of medicine, or is the phrase meant as a literary flourish? If intended formally, do
Micale and Porter mean that mental medicine should be held to the same scientific criteria and methodology as the other domain
they identify as organic medicine? If meant metaphorically, should not the metaphorical nature of the expression be pointed out?
Their essay does not provide answers to these questions, and the authors also employ expressions such as psychological medicine,
further adding to the possible confusion.4 It would help if Micale and Porter had explicated their claim that psychological medicine
is “[p]oised precariously between the medical sciences and the human sciences” (1994, p. 5).
Through Metaphors Darkly
As philosopher Murray Turbayne tell us in his important book The Myth of Metaphor (1970):

[w]e tend to forget that there are many subjects that we speak of only in metaphors . . . for example mind and God. The
histories of the sciences of psychology and theology record . . . the unending search for the best possible metaphors to
illustrate their unobservable subjects. . . .We find later theorists objecting to earlier metaphors that . . . have become
obsolete. We find them substituting new metaphors for old ones that are either worn out by over-use or that present an
unappealing picture. But we also find many of these theorists writing as if they were replacing false accounts of these
subjects by true accounts, or as if they were replacing metaphorical accounts by literal accounts. (p. 96)

Political scientist Kenneth Minogue argues that certain words and phrases can effectively give the impression that mere opinions
possess more empirical certainty and stability then they actually do because of the power of their metaphorical imagery. He
identifies these terms as “perceptual metaphors” (1985, p. 141). For example, when watching people, we do not, using our senses,
directly perceive the complex content suggested by the terms lunacy, madness, disease, or illness; instead we see physical behavior
(such as rocking, pacing, screaming, staying immobile) or hear reports and complaints of discomfort (claims of feeling light-headed,
feeling pain, seeing unseen beings and things, receiving verbal commands to commit harm to self or others) or view signs of
physiological processes (hot forehead, abscess, swollen abdomen, rash, and so on).
In order to make sense of these observations, we rely on perceptual metaphors such as disease, madness, or illness to package
and mold them. In choosing to attach the word disease to a set of perceptions that otherwise would be viewed as disturbing or
offensive behavior, we are “implicitly claiming a conclusiveness which has not [necessarily] been demonstrated” (p. 141). And we
are also notifying our audience that we expect them to perceive disease too. Thus, the use of expressions like “mental disease” or
“mental illness” for describing in historical texts certain ideas or behaviors thought (by some) to be in some way abnormal or
disturbing is not a neutral act. In the absence of an explicit clarifying statement by the author (i.e., “disease is here being used
metaphorically”), these terms cannot but put their audiences into a medical state of mind or evoke medical conditions because most
people have been taught and redundantly reinforced throughout their lives to associate those terms with medicine. If they omit such
clarifications, historians may promote a medical interpretation even when striving for neutrality. (The analysis to follow in no way
should be seen as a condemnation of these scholars as inept or incompetent. In fact, we have a great deal of professional respect for
most of them and their painstaking scholarship, on which we rely in the present book. It is precisely because of their fine work on
unearthing the available historical record that we think they should be more cautious in their use of metaphors.)
To make our point more explicit, we would like to further examine some of the work of Andrew Scull. We selected him because
we admire his overall analysis of the historical plight of the mad. We use his work to make the point that even the most able and
critical psychiatric historians may inadvertently promote a medical perspective. In The Most Solitary of Afflictions, Scull (1993)
discusses the sad condition of one group under the purview of the modern mental health care system whom he characterizes as
“younger psychotics” (p. 391). Psychosis can be the direct result of organic diseases like dementias, stroke, brain tumors, infections,
and chemical overdoses, but the term is also applied to individuals who act quite strangely in the absence of any organic cause.
Scull, however, offers no assistance in his text as to how he intends his readers to understand these “younger psychotics.” (Should
they be considered diseased or distracted?) He writes:

Psychiatrists and other social control experts . . . negotiate reality on behalf of the rest of society. Theirs is preeminently a
moral enterprise . . . I would argue that . . . the boundary between the normal and the pathological remains vague and
indeterminate and mental illness . . . an amorphous all-embracing concept. Under such conditions, there exists no finite
universe of “crazy” people. (pp. 391–392)

Scull in this passage seems to support the notion that psychiatry arbitrarily constructs mental illness as a way to conceptualize,
respond, and control marginalized social dependents, and that the enterprise may have no logical limits, resting on an “all-embracing
concept.” But in an earlier section of the book, while criticizing Szasz’s alleged position, he avers, “I cannot accept . . . that mental
alienation is simply the product of arbitrary social labeling or scapegoating, a social construction tout court” (Scull, 1993, p. 5).
What does Scull think mental alienation is the product of? In an earlier article, he includes a long note about the problem of using
conventionally available terms that smack of a medical perspective, such as mental illness, when trying to write more or less
neutrally about madness for a diverse audience. After explaining in some detail why there is no good way out of the dilemma, he
concludes that “[f]aced with this problem, I have chosen to refer almost interchangeably to madness, mental illness, mental
disturbance and the like” (Scull, 1990, p. 307, note 1).
Ordinarily, this would do. But Scull’s note does not just contend that the terms madness, mental illness, mental disturbance, and
the like do not have generally agreed-upon definitions and thus may be in some sense interchangeable metaphorically. He also
asserts that madness itself, despite its ill-defined names, is real. He maintains, “To recognize that, at the margin5, what constitutes
madness is fluctuating and ambiguous . . . is very different from accepting the proposition that mental alienation is simply the
product of . . . social labeling and scapegoating” (p. 307, note 1, italics added). Moreover, Scull believes that accepting mental
illness as a socially-constructed reification would be denying the many visible negative outcomes associated with the problematic
behaviors the mad engage in. Perhaps he is arguing that, for him, madness, when he calls it mental illness, is just another term for
certain extremely troubling or troubled behavior that has dire consequences both for the person and others close to the person, and
not, as often assumed by the laity, a medical problem. (It is hard to know unambiguously what kind of reality mental illness is for
Scull.) Moreover, perhaps “younger psychotics” is referring not to medically ill individuals but to young people who have been
waylaid by life’s exigencies and have been the victims of the failure of our social welfare safety net. If that was Scull’s intent, it
might have been more useful to spell that out rather than resort to terms that have been associated with the medicalization of deviant
behavior (on medicalization of deviance, see Conrad & Schneider, 1992) and therefore easily misunderstood as medical. He depicts
the mad as the recipients of “the enormity of the human suffering and the devastating character of the losses” (Scull, 1990, note 1)
resulting from madness. He suggests that the mad are therefore the “victims of this form of communicative breakdown” (note 1)6.
A few pages after the explanatory note, he goes on to refer to some of the severely troubled individuals he is concerned with as
“chronic schizophrenics” (1990, p. 309). The use of that term usually indicates, at least in psychiatric literature, individuals who are
suffering from what is asserted to be a medical disorder, schizophrenia (APA, 2000). Scull, in his role of psychiatric historian, is
presumably using the term in the same way. His colleague Gerald Grob, based on his reading of Scull, also contends that Scull
“accepts the reality of mental disorders” as a medical issue (1994a, p. 274). For our part, we would characterize Scull’s view as
ambiguous, since as far as we know he has published no explicit statement of his position on the matter, even while continuing to
discuss “those afflicted with the most serious of mental ills” in his latest work (Scull, 2011, p. 124).
Even careful scholars who are generally critical thinkers have a tough time maintaining judgmental neutrality when it comes to
inexplicable human behavior and use terms in their works that have powerful medical connotations (e.g., chronic psychotics,
schizophrenics, disease). This may be done by some authors because the words provide a congenial explanation of mad behavior.
By other authors, medical language may be used to avoid implying any deliberate intention or moral agency on part of the
“sufferers.” Others, on the other hand, may try to uncover a “method to madness,” revealing the possible intention, moral purpose,
and explicit goals to someone’s “mad” behavior. All these efforts involve situating the madman within his context and
circumstances, explicating the madman’s point of view, and the reactions of those around the madman and their points of view. This
is historical work par excellence and of course has been attempted (Porter, 1987a), but when it has, we think that it makes it
extremely difficult to account for psychiatry’s development as a profession learning to identify and treat diseases. Finally, using
medical connotations may be done to ensure that one’s work is published without too much difficulty.
One further complication is these historians’ reticence to make explicit their own beliefs about madness. According to one
younger historian, such reluctance may exist because “autobiography risks functioning as a ‘subversive supplement’ to the author’s
scholarship, in that it can expose personal commitments and experiences which undermine professional authority” (Engstrom, 2000,
p. 423). The reluctance is completely understandable, but some textual exploration can easily identify the personal biases that, left
unexamined and uncontrolled, may slant these histories toward a medical perspective. Let’s turn to them next.
Authorial Beliefs
Roy Porter in his Brief History of Madness claims that “the . . . historical survey [of madness] which follows . . . rests content with a
brief, bold and unbiased account of its history” (2002, p. 4, italics in the original). The use of unbiased seems calculated to reassure
readers that he produces narratives of historical facts as he finds them, with no worrisome distorting assumptions attached. But, in a
publication written some twenty years prior, Mind-Forg’d Manacles, he admits that he “necessarily” makes assumptions regarding
the nature of madness/insanity (1987b, p. 15). Madness, according to him, is best treated “like heart-failure . . . as a physical fact;
but . . . interpret[ed] like witchcraft . . . principally as a socially constructed fact” (p. 15). Porter wants us to think of insanity both as
a “personal disorder (with a kaleidoscope of causes, ranging from the organic to the psychosocial) and . . . [as] also articulated
within a system of sociolinguistic signs and meanings” (p. 16). The labeling of insanity as “personal disorder” is strictly Porter’s
own invention, and we cannot tell if by it he is referring to an organic disease (he offers no references in the text supporting the
substance of his claims) or something else altogether.
Fortunately, we can get some further insight regarding Porter’s beliefs in a later, edited work, A History of Clinical Psychiatry
(1995). He and his co-editor, psychiatrist German Berrios, address the issue of the organic bases of madness in their introductory
chapter. They write that psychiatric historians can make useful contributions to clinical psychiatry by “building on the belief that
mental disorders are complex and distorted reflections of dysfunctional brain sites and states” (Berrios & Porter, 1995, p. xviii,
emphasis added) to establish which past socially mediated descriptions of mad behavior can “validly” be mapped to certain
abnormal biological processes and which cannot. So Porter does appear to believe that madness has a physical basis and that history
can help point out what aspects of past societal labeling of disturbing behavior represents real biological illness and what
“‘psychiatric phenomena’ were noise” (p. xviii). But this belief in the biological underpinnings of mental disease is just that, a belief
—as Porter is careful to state. Porter’s amalgamated medical definition of madness as a condition resulting from brain and/or
psychosocial abnormality and processed through a cultural and semantic filtering system is shared by most of our other historical
sources as we shall see.
Albert Deutsch presumes that mad behavior is mental disease, even if early man was lost in myth and magic to explain it. His
book, originally published in 1937, The Mentally Ill in America (1967) consists of his distillation of much historical material
through the medical sifter. As he asserts, “it is safe to assume that mental disease has always existed among mankind” (p. 2), and,
“[t]he conquest of schizophrenia . . . will surely rank among the greatest of medical triumphs when it is accomplished” (p. 506). The
reality of mental disorder entities is never doubted; he simply equates madness with mental disorder as he tells us that “[i]n early
Greece, as in Egypt, mental disorders were looked upon as divine or demoniacal visitations” (p. 5). As the best example of mental
disorder in ancient Greek mythology, Deutsch offers the inflicting of madness on Hercules by the goddess Hera. This problem,
Deutsch claims, “today would be diagnosed as epileptic furor” (p. 6). Nonetheless, like every other psychiatric historian, Deutsch
also admits, despite his commitment to madness as disease, that “[a] mantle of mystery still hangs over a large area of mental
disorder [although] . . . researchers . . . are striving manfully to tear apart this mantle, to bring light upon the nature of mental
disease” (p. 518).
Another historian, Norman Dain, developed his classic book detailing the evolving historical Concepts of Insanity in the United
States (1964) while working for three years as the research assistant to Eric T. Carlson, the associate attending psychiatrist at the
Payne Whitney Psychiatric Clinic of New York Hospital (Dain, 1964). In it Dain states, “[o]f course even today no one understands
the biology and chemistry of mental illness” (p. 207), but he never seems to question the appropriateness of assuming that the
human problems he is describing are to be understood as mental illnesses. He regrets that most people still do not see that mad
people are really “sick and helpless” (p. xii) and sees his job in Concepts of Insanity as explicating “the problems that confronted
Americans in their early efforts to discard unscientific and unduly pessimistic attitudes and to place insanity under the aegis of
medicine” (p. xii).
More recently, the Canadian historian Edward Shorter, among contemporary psychiatric historians perhaps the most committed
believer in psychiatric disorder as brain disease, was asked if he believed that “clinical depression” was an organic illness. He
responded: “Yes, I believe depression is caused by some kind of brain process. It’s a disease that is in a way just as organic as
mumps or liver cancer” (Shorter, n. d.). This belief directs his presentation of historical data. In his often-cited book, A History of
Psychiatry, Shorter, relying on his academic authority, states unequivocally that “[i]f there is one central intellectual reality at the
end of the twentieth century, it is that the biological approach to psychiatry—treating mental illness as a genetically influenced
disorder of brain chemistry—has been a smashing success” (1997, p. vii).
His uncritical commitment to the reality of biological causes of psychiatric diseases is illustrated by his discussion in A History
of Psychiatry concerning the increases in the frequency of certain psychiatric illnesses during the nineteenth century. He names “in
particular neurosyphilis, alcohol psychosis and . . . schizophrenia” (Shorter, 1997, p. 49). But the facts are that neither of the first
two is a psychiatric disease. Neurosyphilis is a neurological disease with behavioral correlates, a brain infection caused by the
bacteria Treponema pallidum, if untreated leading to death. Alcohol psychosis is caused by toxic chemical poisoning: either too
much alcohol consumption or sudden withdrawal from it. The historical record is clear that both these physiological disease
processes, along with a few others, were analogically applied by nineteenth-century mad-doctors to explain the phenomena they
came to call schizophrenia (see especially Boyle, 2002). About the latter, some anonymous wit famously said that “unlike
neurosyphilis it is a disease where the treating psychiatrists perish before the patients do.” Shorter’s silence concerning the hard
empirical evidence for the reality of the first two entities and the absence of such evidence for schizophrenia (though he lumps all
three together as “mental diseases,” having been demonstrated as biological diseases) can only be attributed to political calculation,
not scientific judgment. What would be needed from him as an honest historical broker are the scientific facts of the matter both pro
and contra, from the historical record, regarding schizophrenia. The current DSM states explicitly that “no laboratory findings have
been identified that are diagnostic of Schizophrenia” (APA, 2000, p. 305). Of course Shorter knows this, as he explains in a later
work when he concedes that “so little is understood about the underlying causes of psychiatric illness. Not having a solid
‘pathophysiology’ or understanding of the mechanisms of disease, psychiatry cannot rigorously delineate disease entities on the
basis of anatomical pathology, as other medical fields do” (Shorter, 2005, p. 9).
The previously identified Gerald Grob is possibly the most well-known American psychiatric historian. In an extended footnote
found in his 1983 book, Mental Illness and American Society, he argues forcefully that the psychiatric definition of mental illness is
not fundamentally different from the medical definition of disease (pp. 35–36). Grob implies that they are both appropriately subject
to medical knowledge and medical authority. Yet, in the ultimate paragraph of that footnote he admits candidly:

In fact, we know relatively little about what is designated as mental illness, and that makes it difficult to prove or disprove
its existence. . . . Assertions about the existence or nonexistence of mental illness represent in large measure acts of faith
which reflect commitments to a particular course or courses of action. (p. 36)

This fence-sitting allows Grob’s early writings to be variably interpreted by his readers, depending on their own individual
predilections, while promoting his standing as an objective historian of mental illness.
In his 1998 presidential address delivered to the American Association for the History of Medicine, Grob states that
“psychiatrists are compelled to deal with individuals whose pathologies are rarely clear cut and certainly never simple. Severe and
persistent mental disorders—like cardiovascular, renal and other chronic degenerative disorders—require a judicious mix of medical
and social support programs” (Grob, 1998, p. 213). This address is an apparently nuanced discussion of a type of difficult health
problem. One could miss the use of perceptual rhetoric and metaphors (severe and persistent mental disorders—like cardiovascular
disorders) to both define and frame his arguments. Although Grob knows that mental disorders are without any of the physiological
markers of the biological diseases, he still analogizes the “severe and persistent mental disorders” to biological diseases.
This medical inclination did not necessarily result from Grob’s historical research but rather from his personal experiences. As he
notes in his Mental Illness and American Society, “I would be less than honest if I did not speak of some personal views which
undoubtedly influence my understandings of the past” (1983, p. xii). In preparation for the writing of his first psychiatric history,
Grob attended Worcester State Hospital’s training, provided to its psychiatric residents. This instructional opportunity allowed him
to become familiar with clinical cases and institutional life at least as portrayed by those running the institution. He writes that his
experience “with severely and chronically mentally ill patients led me to reject many social control and deviance theories and
reflexive anti-psychiatric thinking” (Grob, 1994a, p. 270). He admits that receiving instruction from psychiatrists at a mental
hospital regarding patients “posed a risk of accepting conventional psychiatric claims at face value” (p. 270), but says that he was
able to maintain at least partial distance from these beliefs. This is belied, however, by his use of conventional psychiatric labels to
describe the inmates and their problems at Worcester State Hospital. It is worth noting that while Grob used his mental hospital
experiences to accept the reality of “severe and persistent mental disorders” and to reject social control and deviance theories that
conflict with such an understanding, the sociologist Erving Goffman used similar experiences while conducting ethnographic
research within St. Elizabeth’s Hospital to develop the very theories that Grob rejected (Goffman, 1961).
In his later work Grob has more explicitly “come out” and committed himself to the mental illness as medical/brain disorder
assumption and compromised his scholarly objectivity by getting involved with the highly politicized process of federal health-care
policy. A 2006 article on mental health policy coauthored with a prominent academic psychiatrist, Howard Goldman, presumably
expressing their joint views, defines mental illness according to the US Surgeon General’s Report on Mental Health (US
Department of Health and Human Services, 1999). The article quotes part of that report, as follows: “Mental illness is the term that
refers collectively to all diagnosable mental disorders. Mental disorders are health conditions that are characterized by alterations in
thinking, mood, or behavior . . . associated with distress and/or impaired functioning” (p. 738). The surgeon general’s report adds
that all diagnosable mental disorders are contained in the Diagnostic and Statistical Manual of Mental Disorders IV (1994) (DSM-
IV) and claims that they are all brain disorders even though the report recognizes clearly that no physiological markers are yet
identified for any of them (1999, ch. 1).
Finally, Charles E. Rosenberg is an eminent medical historian who generally tends to be judicious in maintaining an agnostic
perspective toward “the particularly ambiguous status of hypothetical ailments whose presenting symptoms are behavioral or
emotional” (Rosenberg, 2006, p. 408). Nevertheless, in Our Present Complaint (2007), he states that “[m]ost of us would agree that
there is some somatic mechanism or mechanisms . . . associated with grave and incapacitating psychoses” (p. 39). This statement
commits him to a disease model based on biopathological mechanisms for at least these psychoses. He indicates in the quote above,
however, that he is skeptical of the more general trend to convert (medicalize) other behavioral deviance (i.e., homosexuality,
alcoholism, or hyperactivity—see his chapter 3) into disease entities. He neglects in this otherwise critical, thoughtful, and well-
documented book to tell readers why grave and incapacitating psychoses, most probably schizophrenia would be one, should have
such mechanisms credited to them, lacking any current evidential support. (See, for example, APA, 2002, pp. xviii–xix, and other
discussions throughout this book, especially chapters 5, 6, and 7).
Language is the filter through which public knowledge is communicated. The use of certain key words and not of others by
recognized experts lubricates the expectations of audiences about how a social problem may best be understood. The consistent use
of medical labels like mental illness, mental disorder, and mental disease by psychiatric historians as substitutes for the older
descriptors madness or insanity tends to reify the view of madness as medical disease.
Many of these historians’ semantic choices seem to be related to their personal belief or inclination that mental illness is a real
medical entity or process. That belief confuses replacing an old metaphor by a new one with progressing from unscientific beliefs to
scientific facts. Since, at best, the nature of madness is as yet unclear—disease or derangement?—we think it would be better if
psychiatric historians would tell their stories by using more ontologically neutral terms, although we recognize the metaphorical
nature of language. These terms could include: aggression, agitation, anguish, behavioral disorderliness, defiance, demoralization,
derangement, distraction, hopelessness, sadness, severe emotionally distress, stress. Historians should more closely endeavor, as
some do, of course, to contextualize to the fullest extent possible the phenomena that they are attempting to describe by means of
historical records. By using neutral terms in their narratives without prejudging what has been discovered and scientifically
established, historians would signal to their audiences that they are also groping, like other informed citizens, though they are giving
us information to come to our own deeper understandings.
The use of these neutral words would not and should not prevent historians from presenting accurately and completely the views
of all historically important figures, including those who use(d) medical terms and theories to “explain” madness. If any historian
believes that madness is mental illness, that historian should reveal that, so the reader may be fairly and properly put on notice, just
as a believer in phlogiston should put readers on notice when presenting a history of physics or a believer in the divinity of Jesus
should put his readers on notice when presenting a history of Judaism.
The determination of historical facts is always an ambiguous process, depending on a particular historian’s personal beliefs,
agenda, and decisions regarding what evidence to attend to and to ignore in constructing a narrative. (As authors of this book, this
insight also applies to our work and we take up this issue of our own personal or professional biases in the concluding chapter.) As
Engstrom suggests, “the conceptual frameworks we have for thinking about mental anguish are (and likely always will be) woefully
inadequate. That’s what the history of psychiatry has taught me” (E. J. Engstrom, personal communication, October, 9, 2008).
 Conclusion
While keeping in mind caveat lector, due to the inevitably fallible nature of our historical facts, we can conclude that our brief
historical tour of the phenomena called madness and its overall management has brought us close to where we began. The
ontological status of madness remains unsolved in the twenty-first century. Both coercion and concern have periodically animated
society’s treatment of the mad, sometimes concurrently. Early on in America’s history, families took care of their distracted
relatives. As the US became a more economically specialized and politically organized society, the need for bureaucratic structures
for social management became more pressing. The increasing population and urbanization of America led to a more mobile
populace, leaving fewer families intact to take care of mad relatives. These circumstances led to the creation of institutional
substitutes to provide care for these dependents. Simultaneously and in response to these developing institutions, a class of
professional helpers emerged who claimed special expertise in the management of the mad. These helpers at first were lay managers
using more or less authoritarian moral treatment, but over time physicians became interested in the mad trade and offered
medicalesque reasonings and medical analogies for why the mad were mad, and society was persuaded. These physicians, however,
offered no evidence to confirm their reasonings. By the mid-nineteenth century, state governments were gradually taking charge of
mental institutions, which were increasingly medicalized. Government involvement accelerated through the twentieth century with
the federal government taking control from the states by the 1950s. Over the next two decades, the federal government, psychiatric
professionals, various interest groups, and Big Pharma formed an interlocking directorate that managed, through political action
rather than scientifically informed strategy, to shift much of the location of mad treatments from a few very similar, distinct, and
clearly identifiable walled institutions to a plethora of dissimilar, diverse, and dispersed institutions in “the community.” This well-
coordinated enterprise controls the research agenda as well as the policy development in mental health today.
In Shakespeare’s time, when it came to understanding madness one could only offer a tautology. Madness was defined as being
nothing but mad. Today we are left not exactly with a tautology, but with a mystery. The modern term for mad behavior is the
medically encapsulated notion of mental illness, but that term really refers to many different hypothesized syndromes, most of
which the DSM calls mental disorders. The term mental illness is a black box. The medically-oriented argue that these syndromes
are brain diseases, Thomas Insel, the NIMH’s director, speculates that “abnormal activity in specific brain circuits” are the causes of
mental illnesses. Unfortunately, after a hundred years of these hypotheses, not a single biological marker for a single psychiatric
disorder has been identified to validate distress and misbehavior as a medical disease.
Insel and other psychiatric authorities (Andreasen, 1997) reassure the public, despite their continual inability to provide the
evidence, that if the public is just patient for a little while longer and holds on to the descriptive DSM syndromes, diagnostic lesions
underling these syndromes will definitely be identified in the not too distant future, initiating a psychiatric utopia—one in which
psychiatric science will deliver specific cures for our behavioral problems. Despite the failed promises, very few people seem to be
exploring alternative ways to understand and address madness.
If one accepts philosopher Karl Popper’s view that doing good science requires submitting one’s most cherished paradigms and
viewpoints to rigorous empirical tests and criticism to see if they stand up to such scrutiny (Popper, 1989), then at least one
important use of historical knowledge becomes evident. By examining the historical record (even with all its limitations), one can
learn about the many “scientific” psychiatric paradigms and treatments that have regularly failed (e.g., the nineteenth-century
asylum system, moral treatment, and the government-operated state mental hospital system). These failures suggest that all
interested persons should be skeptical of the current conventional wisdom regarding madness because this may, under conceptual
and empirical examination, also prove to be mistaken.
Keeping both these cautionary and hopeful concluding thoughts in mind, let us turn to the current best efforts at managing the
mad: community treatment.
 Notes
1. We tend to agree with Tom Szasz that the better term for the coercive paternalistic approach used by most psychiatrists is the pediatric model, since “(t)ypically physicians
treat adults who seek their services. Only pediatricians and psychiatrists treat persons who do not seek their services” (Szasz, 2004, p. 323). But due to its widespread use,
we will continue for the sake of expediency to refer in the rest of the book to this unique patronizing model relying on force for servicing mad adults as the “medical
model” (to be explicated in more detail in chapter 3).
2. This unchaining is a complete fabrication (see Scull, 1993, p. 377, especially note 4).
3. To clarify what may sound unsympathetic or accusatory: we believe that, when facing difficult or traumatizing life circumstances, wanting to escape is a quintessentially
human response. We even have descriptive terms at the ready to identify these possible responses: “heroic” or “cowardly.” How one responds to such circumstances is not
knowable in advance, and claiming illness is often one of the obvious options to avoid moral condemnation from self and others. Human beings are capable of fooling
themselves as easily as others; it is called “self-deception.” We suggest that the claims of feeling ill often are genuinely held by the claimants and may be just these sorts
of self-deceptions rather than necessarily calculated fraudulent deceptions. Unfortunately, feeling as if we are ill in no way establishes that we have a medical illness. We
go to doctors in part to help us clarify whether our felt “symptoms” are manifestations of objective physical pathological processes qualifying as medical disease.
4. This is similar to the term behavioral health, whose use in the medical and psychological literature first appeared in the 1970s and dramatically spiked starting in the mid-
1990s (see, for example, Google’s ngram using this term). This obvious metaphor appears well-suited for its primary purposes, as far as we can discern them at present: to
justify both the involvement of psychologists and social workers in the health care arena and the renewed involvement of physicians in changing patients’ behaviors.
5. This begs the question of what in madness’ “center” as opposed to its margins is invariable and unambiguous.
6. Thomas Szasz would agree but would also add that, as sentient moral agents involved in transactions with others, they are responsible at least in part for the breakdown in
communication and their subsequent difficulties. Szasz—who has been described by Micale and Porter in their edited volume Discovering the History of Psychiatry
(1994) as “offer[ing] fundamental rereadings of exemplary episodes and topics in the history of mental medicine” (p. 23) worthy of a full chapter in that book—has never
asserted what Scull (1993) and many other of his critics claim to be Szasz’s position, namely, that mental alienation is merely the result of social labeling and
scapegoating and is a myth. Szasz argues that emotional difficulties and tragedies are real, but result from the minor and serious problems that people experience while
trying to make a life, rather than the consequence of biological pathology. He suggested that “[t]o regard ‘minor’ upheavals in living as problems in human relations,
learning and so forth—and more ‘major’ upheavals as due to brain disease, seems to be a rather simple example of wishful thinking” (Szasz, 1961, p. 94). In his first and
most often cited but rarely fully understood classic, the Myth of Mental Illness (1961), Szasz did not write a polemic full of simplistic claims as Scull asserts (Scull, 2011,
p. 100), but rather a detailed and scholarly treatise outlining, as its subtitle states, the “foundations of a theory of personal conduct.” Using a combination of semiotic,
rule-following, and game-model analysis, Szasz proposes a theory of human behavior applicable to both the “normal” and “deviant.”
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 3
The “Therapeutic” Coercion of the Mad in the Community

For more than 200 years now the doctrine has been increasingly held that there is such a thing as mental
illness, that it is a sickness like any other, and that those who suffer from it should be dealt with
medically: they should be treated by doctors, if necessary in a hospital, and not blamed for what has
befallen them. This belief has social uses. Were there no such notion, we would probably have to invent it.
Erving Goffman, 1970

To allow every maniac liberty consistent with safety; to proportion the degree of coercion to the . . .
extravagance of behavior; . . . that bland art of conciliation, or the tone of irresistible authority
pronouncing an irreversible mandate . . . are laws of fundamental importance . . . to the . . . successful
management of all lunatic institutions.

Phillippe Pinel, 1806

 Introduction
This chapter addresses the community-based management and treatment, by public or state-controlled psychiatric agencies, of those
judged to be mad in America. The employment of coercion (force or its threat, not requested or wanted) enabled the emergence of
nineteenth-century American asylums with their state-granted legal authority that allowed mad-doctors to incarcerate people
involuntarily with considerable discretion and little oversight. Today, the legal grounds for involuntary hospitalization have
narrowed to include those who are deemed to be at immediate risk for harm to self or others as a result of a mental illness.
Psychiatric coercion, however, has expanded to include coercing people outside hospital walls, in the community. Coercion made
the emergence of public psychiatry possible. We argue in this chapter that coercion sustains its existence even today.
We believe it essential to differentiate, on the one hand, state supported involuntary psychiatry (the twenty-first century
grandchild of “institutional psychiatry”) based on coercion from, on the other hand, contractual or voluntary psychiatry. In the
second enterprise, the person seeking help and the psychiatrist or mental health practitioner offering it mutually agree to work
together to address the intrapersonal or interpersonal difficulties identified by the help seeker. The relationship, which can be
terminated by either person at any time, is based initially on mutual respect or neutrality, and usually involves persuasive discussion
with no coercion imposed by the practitioner (to the extent that the practitioner shares what he or she knows about the treatments).
This sort of practice occurs more frequently with the “worried well” and those who are more likely to be able to afford to pay for
someone to work with them on their life difficulties.
By arguing that coercion sustains the existence of public psychiatry even today, we are not making the point that psychiatrists are
more malevolent, mean, sadistic, or less caring than other people. Rather, we are making the simpler point that coercion applied with
sufficient force and regularity works—if by working we mean obtaining people’s behavioral compliance. Coercion, we argue, has
always been an essential method for managing the complexities of human misbehavior. Psychiatry, a profession specializing in
managing complex human behaviors, has not only unfailingly chosen to employ coercion in this endeavor, but has unfailingly
claimed that coercion was in the best interests of those coerced.
Getting caught by the police for speeding usually results in an immediate penalty of a steep fine on the driver. For most folks this
penalty “works,” in that at least for a while after receiving the ticket they may not speed or will keep a sharper eye out for the
enforcers. They are quite likely to alter their driving behavior to avoid further coercion or punishment. But do drivers learn as a
result that speeding is fundamentally wrong and dangerous? We doubt it, if the continuing high rate of traffic citations is any
indication (see, for example, Florida, 2010).
Yet few would suggest that what the police do to enforce driving codes is a therapeutic enterprise. No one would mistake this
police activity for the treatment of a medical condition called automobile speeding disorder. The job of the police is to detect and
punish drivers who breech socially and legally expected behavior: in this case, conformity with the traffic laws that manage
potentially lethal activity (driving powerful vehicles). Society expects that punishment will alter the speeder’s behavior and reduce
accidents. Similarly, psychiatry, the government-certified profession for maintaining “normal” behavioral order, is expected to
detect and manage people who manifestly violate intrapersonal and interpersonal norms, codes, or rules. Psychiatry is also
authorized to use force to gain the compliance of recalcitrant individuals.
Ultimately, force may be needed to ensure that people conform to the rules of normal life. The question is: Is the psychiatric use
of force a scientifically derived therapeutic endeavor and is psychiatric coercion any different from other versions of institutional
coercion in society? That is, is it to be considered treatment rather than punishment?
 A Brief Overview
We begin this chapter by examining some of the findings of the 1961 report of the Joint Commission on Mental Illness and Health
(JCMIH), the first federal commission ever created to review society’s formal governance of mad Americans and to propose a
comprehensive national plan to “provide more humane care for the mentally ill” (p. xxix). We first describe the commission’s view
of what mental illness is and then discuss briefly its findings on the historical role of force and coercion in the psychiatric treatment
of mad Americans. Next, we describe how coercion operates in psychiatry, including its foundational role in the creation of public
psychiatry, and review the contemporary literature to describe some of its current manifestations in community treatment. We also
attempt (given the scarcity of national data) to estimate the prevalence of coercive practices in current psychiatry in America. We
then briefly explore how and why the employment of coercion has become a leading area for academic research, especially
regarding its “clinical effectiveness.” To frame that discussion, we found it necessary to examine the notion of evidence-based
practice (EBP), which has gained immense popularity among mental health authorities and academics over the past decade and
which we believe is used to justify the continuation of coercive practices in public psychiatry. We conclude this chapter by
examining one of the most promoted and researched EBPs for those diagnosed with serious mental illness, assertive community
treatment (ACT), exposing its use of administrative and clinical coercion to produce “successful” outcomes in the treatment of its
recipients.
 A Commission on a Failed Mission

A Vacuous Definition of Mental Illness

As America moved into the mid-twentieth century, the Joint Commission on Mental Illness and Health (JCMIH, 1961) was created
under the auspices of the Mental Health Study Act of 1955 to review how mad people were previously managed in the United
States. Its findings were expected to “make recommendations for combating mental illness in the United States” (p. v). Led by Jack
R. Ewalt, chairman of the Department of Psychiatry at Harvard Medical School, the commissioners included notable mental health
authorities like Kenneth Appel, a former president of the American Psychiatric Association; Ernest M. Gruenberg, an expert on the
epidemiology and chairman of the Department of Mental Hygiene at the Johns Hopkins School of Hygiene and Public Health; and
Mike Gorman, the executive director of the National Mental Health Committee (JCMIH, 1961). The commission’s ultimate advice
to the federal government was to fully embrace the medical model of psychiatry and invest in a national mental health program.
Although the commission members subscribed to the medical illness model of disordered behavior, they admitted that “[m]ental
illness is different from physical illness,” being “a disorder with psychological as well as physiological, emotional as well as
organic, social as well as individual causes and effects” (p. xviii) that are “so closely intertwined that so far science has been unable
to unravel the causes and establish their relative importance” (p. 86).
This mid-twentieth-century effort to define or describe mental illness is a perfect example of a panchreston. Dictionary.com
(2011) defines panchreston as “a proposed explanation intended to address a complex problem by trying to account for all possible
contingencies but typically proving to be too broadly conceived and therefore oversimplified to be of any practical use.” To claim,
as the commission does, that madness is a medical illness and that it occurs as a result of the impact of human physiology, sociology,
biology, and psychology or any possible combinations of them (JCMIH, 1961, p. v), is merely making a vacuous statement.
Coercion as the Prime Tool of Public Psychiatric Practice
In contrast to its definition of mental illness, the commission’s historical research on how the mad were managed displayed no
ambiguity whatsoever. It argued that the mad—for centuries, both here and in Europe—have been subjected to “a superstitious and
retaliatory approach . . . The instrument of this approach is punishment” (JCMIH, 1961, p. 25). The commission recognized that this
was attenuated by periodic efforts to employ less directly coercive approaches (i.e., moral treatment) but which rather quickly were
abandoned and replaced by more forceful and outright coercive manipulation and management. An entire section in chapter two of
the commission’s report, “Punishment as Treatment” (pp. 25–28), is devoted to a discussion of its routine employment. The chapter
quotes Benjamin Rush, a signer of the Declaration of Independence, whose visage adorns the official emblem of the American
Psychiatric Association: “Terror acts powerfully . . . and should be employed in the cure of madness” (p. 27).
The report traces how the religiously inspired notion that sinful behavior causes disease justified interventions by the medical
and occasional lay superintendents running America’s nineteenth-century’s madhouses. These interventions included “a wide
assortment of shock techniques” (JCMIH, 1961, p. 28), such as bleeding to the point of fainting, near drowning, rapid spinning,
forced vomiting, and applying an early form of electric shock to the body. The commission members acknowledged that all of these
techniques forced on unwilling mad people were based on “fallacious medical rationales” (p. 28), implying either that some genuine
medical rationales could today justify the employment of coercion on the mad, or else, as we shall see in other statements in the
report, rejecting the use of any medical rationale for coercion and rejecting coercion tout court. In looking at some justifications for
coercion and torture proposed by leading alienists of eighteenth- and nineteenth-century America, it is difficult to tell whether those
who employed it did so because they thought it helped to “cure” or because it produced immediate behavior change, or both.
Benjamin Rush designed a “tranquilizing” chair that he described as follows in a letter to his son:

I have contrived a chair and introduced it to our [Pennsylvania] Hospital to assist in curing madness. It binds and confines
every part of the body. By keeping the trunk erect, it lessens the impetus of blood toward the brain. By preventing the
muscles from acting, it reduces the force and frequency of the pulse, and by the position of the head and feet favors the easy
application of cold water or ice to the former and warm water to the latter. Its effects have been truly delightful to me. It
acts as a sedative to the tongue and temper as well as to the blood vessels. In 24, 12, six, and in some cases in four hours,
the most refractory patients have been composed. I have called it a Tranquilizer. (cited in Scull, 1993, p. 73, footnote no.
104)

Another section of the JCMIH report, “The Tranquilized Hospital,” discussed contemporaneous treatments for the mad, namely,
some chemical agents which the commission believed had “revolutionized the management of psychotic patients in American
mental hospitals” (1961, p. 39). The authors described the effects of these “major tranquilizers” (known as antipsychotics or
neuroleptics today): “tranquilizing patients who are hyperactive, unmanageable, excited, highly disturbed, or highly disturbing . . .
[with] the most noticeable effect of the drugs . . . [being] to reduce the hospital ward noise level” (p. 39). They did not discuss
whether the drugs were ever voluntarily requested or consumed by psychiatric patients. As we note later in this chapter, many of the
coercive psychiatric techniques employed today have the principal aim of forcing patients to take their medications, which they
abandon in large numbers as soon as they are given the opportunity. For example, a recent, major federally sponsored study on the
effectiveness of antipsychotics in the treatment of schizophrenia found that 74 percent of those enrolled quit taking their assigned
drug before the study’s completion due to the lack of drug efficacy, accompanied by many unpleasant and dangerous adverse effects
they experienced (Lieberman et al., 2005, discussed in chapter 6).
The principal purpose of these chemicals was to make highly disturbing individuals “more appealing to all those who must work
with [them]” (JCMIH, 1961, p. 53). These chemicals, contrary to current widely held beliefs that they target specific psychotic
disorders, suppress the central nervous system activity of anyone—normal or diagnosed—taking them (Healy & Farquhar, 1998).
By blunting emotions and dramatically curtailing physical activity, including the disturbing and violent dramatic behavior often
attributed to diagnosed psychotics, they are touted as remarkable medical breakthroughs, rather than less conspicuous methods of
restraint than were used previously for controlling problematic behavior in the asylum. The JCMIH report acknowledged that many
professionals understood the pragmatic purpose of these drugs, having “dubbed them chemical straight jackets” (1961, p. 39). In its
enthusiasm for the use of these new drugs, the commission neglected to discuss—given the long history and experience of
psychiatry with aversive and shock treatments—what sort of morbidity these chemicals, which rapidly produced stupor and physical
immobility, would have in the longer term on their recipients (for a fuller story see Gelman, 1999 and chapters 6 and 7 in the present
book).
In sum, the commission’s overall review of America’s policy toward the mad from colonial times to the mid-twentieth century
found that the policy had been to confine the mad in institutions against their will and subject them to various physically and
emotionally brutal treatments. The commission went further, proposing that institutional confinement (the systematic employment
of coercion) without any other effective means of treatment had “shown beyond question that much of the aggressive, disturbed,
suicidal and regressive behavior of the mentally ill . . . is very largely an artificial product of the way of life imposed on them”
(JCMIH. 1961, p. 47), and that “[t]o be rejected by one’s family, removed by the police, and placed behind locked doors can only be
interpreted, sanely, as punishment and imprisonment, rather than hospitalization” (p. 53). The commission’s point was
unmistakable: America’s approach to madness for the previous two hundred years, whether by a physician or by a policeman, relied
on the use of coercion.
Psychiatry has carefully used medical rhetoric to reinforce its medical image and justify its coercive authority, without
necessarily matching it with humane, effective interventions. This is not merely a feature of our distant past. Assertive community
treatment was invented in Madison, Wisconsin, in an institution that began its life in 1860 as the Mendota Asylum for the Insane.
Renamed in 1935 as Mendota State Hospital, it emerged in 1974 as Mendota Mental Health Institute. These name changes appear to
reflect the changing functions of the institution over 150 years, moving from a place of involuntary custodial “asylum” care to a
venue for conducting scientific research and treatment as a “mental health institute.” Yet the institution does today exactly what it
has always done: manage involuntarily detained mad people. As explained in 2011 on the State of Wisconsin’s website, “Mendota’s
Civil Program provides services to adults who are in need of psychiatric treatment. All admissions are involuntary” (Mendota
Mental Health Institute, 2011).
Decommissioning Institutional Care
Regardless of what they were named, insane asylums and their often inhumane practices had by the early decades of the twentieth
century drawn a great deal of negative attention from the media and advocates. This resulted in the commission’s recommendations
that state mental hospitals be dramatically deemphasized in a public system of care and that the mad be managed principally in the
general community within a system of “integrated community service[s]” (JCMIH, 1961, p. 289). The community was, after all,
where the mad were always expected to return after being released from confinement. The recommendation to move the inmates of
state hospitals back to the community for treatment simply confirmed a visible, numerical shift that had slowly begun in 1955
(Scull, 1976). We often hear, and the commission report suggested, that the shift was due primarily to the introduction of major
tranquilizers. A body of research and analysis since then, however, has established that this shift was more importantly due to the
imposition of administrative policies “to prevent the accumulation of long-stay institutionalized patients” (Scull, 1976, p. 178). The
beginnings of this administrative shift could be noted in some hospitals in the United States as well as in England, especially those
which adopted a policy of “early discharge, or the avoidance of admissions altogether beg[u]n . . . well before the national swing
was noticed in 1955” (p. 178). The initial modest decline in hospital populations began before psychoactive chemicals were
routinely employed1. Gronfein (1985) notes in his analysis of psychotropic drugs and deinstitutionalization that “discharge rates
were increasing before the advent of the drugs” (p. 448) and further demonstrates that the larger-scale transfer of patients truly
began in the mid-1960s, more than a decade after the introduction of these drugs (see chapter 7).
The community was assumed to be, albeit with no real scientific evidence (Grob, 1994, Scull, 1976), a more supportive
environment for enhancing the personal autonomy and freedom of the mad, conditions which it was further assumed would increase
the likelihood of cooperation between mental health providers and their charges. This hypothesized, enhanced therapeutic alliance,
aided by the use of the newly introduced major tranquilizers, was expected to reduce the need for institutional coercion while at the
same time attenuating the problematic behaviors of the mad.
According to Scull (1992), the commission report was “[l]argely written by a specialist in public relations” (p. 568). This would
account for its optimistic tone and its vaguely articulated and surprisingly nonspecific bureaucratic content. The optimism no doubt
reflected attitudes in a country that had recently been victorious in a world war and was brimming over with enthusiasm and the
can-do attitude. America had recently demonstrated its ability to alleviate the physical human suffering that resulted from war.
Following the carnage and destruction that lay waste to the European continent during World War II, America successfully
developed and implemented a European recovery and reconstruction strategy, the Marshall Plan. So it was not a great stretch, when
turning to address another troubling area of human conduct arising at home, madness, that a new, concerted effort was expected to
yield rapid success through energetic central organizing and planning by the federal bureaucracy. For a variety of reasons, however,
detailed by Grob (1991), the commission’s plan failed to be “a precise blueprint that could serve as the basis for legislative action”
(p. 209). Ultimately, it lost some of its credibility among powerful government bureaucrats: it was considered, for example, by the
NIMH’s Philip Sapir, chief of that agency’s Research and Fellowship Branch, to be “pedestrian, platitudinous, rehashes of previous
statements . . . so incredibly bad that there seems almost no point in making specific criticisms” (quoted in Grob, 1991, p. 217).
Nonetheless, in some roundabout way, several basic proposals in the report did find their way into federal mental health policy.
Some ten months after its publication, a special Governors’ Conference of Mental Health endorsed its general findings and stated
“that Federal, State, and local governments as well as private and voluntary efforts must be combined to achieve the goals we seek”
(Connery, 1968, p. 46). This endorsement added impetus to President Kennedy’s appointing a cabinet-level committee on these
issues, which then “developed proposals for action which accepted most of the Joint Commission’s findings and many of its
recommendations, including its urgent pleas for extensive federal participation in combating mental illness” (p. 47). The Joint
Commission findings were echoed by President Kennedy in his “Message on Mental Illness and Mental Retardation” to the US
Congress in 1963, recommending a brand-new, community-focused approach to the problem which, as he stated, was “designed in
large measure, to use Federal resources to stimulate State, local, and private action” (p. 48). We’ve cited the remarks from President
Kennedy and the Governors’ Conference on Mental Health to illustrate, not their particular concern with coercion, but the
redirecting of federal financing efforts toward new social goals identified under the “mental health” rubric.
Despite President Kennedy’s congressional message and the subsequent congressional activity (discussed in chapter 2), the grim
psychiatric reality was that by the mid-1960s the mad, who were previously managed through total institutions and involuntary
confinement, were now being discharged to mostly unwelcoming rather than accepting communities whose “residents . . . fought
hard to ensure that . . . patients . . . released . . . are not released into their neighborhoods” (Scull, 1976, p. 197). This new wave of
hospital discharges was due principally to changing patterns of funding for state mental hospitals and the rising hope about the
psychotropic drugs (Gronfein, 1985) induced in decision-makers and others. This posed a number of professional problems for
psychiatry and the mental health professions.
First, the publicly dependent mad constituted a heterogeneous mix of individuals (e.g., elderly, senile, physically disabled,
abandoned, destitute, deviant) confined together mostly to keep them from disturbing others and also to remove them from the
public’s consciousness (out of sight, out of mind). But the aggregation of such different individuals and their different problems
under the presumption that they were all suffering from medically treatable illnesses was not supported by the research conducted in
or outside institutions (Scull, 1976).
Second, there was no indication that those discharged from the state institutions would voluntarily seek psychiatric help, and yet
state legislatures, beginning in the late 1960s, were tightening criteria for involuntary institutionalization. Third, short of chemical
sedation for subduing and managing agitated behavior (Davis, 1965), no effective treatments existed to bring people to conform or
act normally. In addition, the drugs had a host of debilitating effects (Crane, 1973). And, finally, the psychiatrists actively promoted
the belief that they had a handle on the “medical” problem of madness and that the public mental health system could be responsible
for helping the former asylum inmates to be better off in the community.
In short, psychiatry had to devise a community-based approach of managing their mad patients that appeared to be medical,
noncoercive, humane, and effective. It did this in part by creating a new pseudo-medical rubric for the mad—the severely mentally
ill (SMI)—and concocting new forms of coercion usable in the new settings.
 The Role of Coercion in Institutional Psychiatry
The profession of psychiatry or mad-doctoring emerged in the eighteenth century in parallel with the decision to construct a few
specialized buildings especially for the mad in order to confine and manage them involuntarily. (The first involuntary admission in
America occurred in the City of Brotherly Love, Philadelphia, in 1752 [Anfang & Appelbaum, 2006].) This fortuitous development
allowed for “unparalleled scrutiny of lunatics under controlled conditions, particularly while interacting with keepers, [to form] the
matrix for the practical (experimental) discipline of managing the mad” (Porter, 1987b, pp. 174–175). Many of these keepers turned
out to be medical men looking for stable employment. This early, loosely organized, fledgling economic enterprise for managing the
mad had been institutionalized by the middle of the nineteenth century (see Rothman, 1990, chapter 5), with mad folk “incarcerated
in a specialized, bureaucratically organized, state-supported asylum system which isolated them both physically and symbolically
from the larger society . . . [a]nd . . . now recognized [madness] as one of the major varieties of deviance . . . a uniquely and
essentially medical problem” (Scull, 1993 pp. 1–2). This state-sanctioned confinement gave free reign to mad doctors to experiment
on their charges and claim that these approaches were prima facie scientific medical techniques to control the behaviors of this
group and, coincidentally, confirm the doctors’ authority. These assertions gave credence to psychiatrists’ claim to be doing effective
medical treatment when actually they were constructing a “new apparatus for the social control of the mad” (Scull, 1993, p. 3).
The singular authority granted to psychiatry to imprison mad individuals for treatment in specialized facilities, whether called
asylums, mental hospitals, or community-based mental health clinics, is the key to its professional importance. The undisputed
historical fact of psychiatry’s authority to employ coercion, however, has not been adequately recognized for what it has meant for
mental health practice: police authority makes truly voluntary psychiatric treatment in the current public mental health field a near-
impossibility.2 All the relevant “stakeholders” (the mad, their families, their friends, the psychiatrists that treat them, and society at
large) are on notice that involuntary commitment and the use of force are ready to be deployed on any diagnosed mad person
refusing to follow prescribed psychiatric treatment. That knowledge shapes the behavior of all the parties to the psychiatric
encounter as surely as the knowledge that one’s parent regularly but inconsistently uses physical punishment shapes the behavior of
a child. The uncertainty of not knowing when punishment will be employed makes compliance by the victim more likely. So
voluntary medical treatment, in the sense that most people think of it when they consult their physician for a physical health
problem, is less likely to occur in public psychiatric practice.
Those who can afford medical care or purchase health insurance go to their personal physician by choice, whether for an annual
checkup or over a concern about some possible ailment. Regardless of the doctor’s recommendation, they can choose to follow it
entirely, partly, or reject it all together because the power imbalance between a medical patient and the doctor is only marginally in
favor of the doctor. It is based on the doctor’s presumed better informed opinion about the problem, attributed to her because of her
specialized education, training, and experience—the particular reasons a patient would seek a physician’s advice in the first place.
But once informed about his medical condition and having received advice or even exhortation from the physician, the patient
retains full control over his course of action from that moment onward. This is true even if the health problem diagnosed by the
doctor, if left untreated, will lead to death shortly. (Our physicians cannot force us to take statins for our coronary heart disease or
involuntarily inject insulin into our bodies to control our runaway diabetes.)
In contrast, if the diagnosed mad person resists “emergency” psychiatric treatment (in which the person is deemed to be at risk
for harm to self or others), she knows that she can be rapidly involuntarily hospitalized in a locked facility and treated against her
active protests and physical resistance. This knowledge colors and shapes all engagements between mental health patients and
mental health professionals. No true voluntary treatment can ever occur, because no mad person can freely walk away from the
recommended treatment if there is a serious disagreement between the psychiatric professional and that patient. It is true that the
problematic behavior of the patient must be judged to place the patient or others at risk for harm in order to involuntarily commit
and treat, but only if this behavior is judged to result from a mental illness (e.g., Evel Knievel’s undoubtedly dangerous, death-
defying motorized leaps never earned him the unwanted attention of psychiatrists). Since this judgment is a “clinical decision” (a
statutorily authorized personal judgment of the professional), this is not a difficult standard to meet. In involuntary psychiatric
treatment, psychiatric decisions and legal power intertwine to become virtually indistinguishable.
 Psychiatric Coercion in Contemporary America

Madness Counts
In 1961, when the JCMIH published its report, 527,500 people were inmates in state and county mental hospitals in the United
States (Scull, 1976, p. 176), and fewer than one million people in total were diagnosed mental patients using services in community
mental health clinics and state and county mental hospitals (Grob, 1994, p. 248). Today, the NIMH (2011) declares that “[m]ental
disorders are common in the United States . . . An estimated 26.2 percent of Americans ages 18 and older . . . suffer from a
diagnosable mental disorder in a given year . . . this figure translates to 57.7 million people.” The NIMH further specifies that about
6 percent of those individuals are diagnosable with a major mental illness (3.5 million people). Assuming that these figures are
accurate, and considering that we have almost doubled our population since 1961 to about 310 million in 2010, we are left to
contemplate the meaning of having 3.5 million adult American citizens—equivalent to the population of the State of Connecticut—
diagnosed as having a “major mental illness” or being “seriously mentally ill” (SMI)3, terms used interchangeably in the academic
literature.
Financing Madness
This amazing epidemiological uptick in psychiatric diagnoses (problems regarding the validity of psychiatric diagnoses are
addressed in chapters 4 and 5), especially the functional diagnosis of SMI, has occurred despite the huge increase in the number of
mental health professionals, treatment centers, and funds devoted to preventing or treating mental illness. In 2010 the NIMH budget
was $1.5 billion, most of it earmarked for research on SMIs and their treatments. Almost a third of the funding, about $400 million,
was spent on brain and basic behavioral research (NIMH, 2011), designed to verify NIMH’s institutional assumption that mental
illnesses are brain diseases. The federal government has increased its funding for NIMH (2011) from $288 million in 1986 to $1.5
billion in 2010, making that agency the seventh highest funded of the twenty-seven institutes and centers that comprise the National
Institutes of Health (NIH).
To estimate the total spent by both private and public funding sources annually on behavioral research and services, we use the
data from 2005 (the latest comprehensive national figures available for mental health service expenditures). NIMH research funding
that year was approximately $1.4 billion (NIMH, 2011), while the total national private and public expenditures for mental health
services totaled roughly $113 billion—about 60 percent of it coming from tax revenues (Garfield, 2011). The huge increase in
mental disorder diagnoses in the last few decades suggests that we have failed to effectively treat the problem despite the substantial
dollars spent annually on research and services to develop effective treatments. NIMH director Thomas Insel proclaimed to an
audience of researchers attending the 2006 NIMH Alliance for Research Progress meeting that “[w]e know a lot about evidence-
based treatments” (NIMH, 2006, p. 1). If this is true, what actually is being done with the mad may be surprising.
The Numbers of Mad Coerced
In Hospitals. The threat of involuntary hospitalization and the use of coercion is no idle one. Given how the American tradition and
political system conceive of the loss of liberty, one might expect such loss under any state-sanctioned circumstances to be
meticulously documented, as it is in connection with criminal arrests and incarcerations. Nonetheless, there currently exist no
national data regarding involuntary hospitalization or even unduplicated counts of the number of individuals hospitalized
psychiatrically in a single year. Thus, one is forced to rely on extrapolations from state and local data for any such estimates. In an
earlier publication (Gomory et al., 2011), based on the data released by two large states (California and Florida), we conservatively
estimated that around 1.37 million American adults are the subjects of involuntary hospitalization each year. This number makes up
about 62 percent of those hospitalized for any psychiatric reason but does not include the unknown proportion of those deemed to be
“voluntarily” hospitalized but who are aware that they might or will be forced into hospitalization if they do not submit (Sorgaard,
2007). Our own guess is that the large majority of psychiatric hospitalizations, perhaps all, are involuntary.
In Prisons. Another group of involuntarily confined mad people are those currently confined in US jails. The data are not based
on actual national counts, since no such comprehensive data exist and must be estimated from studies conducted on subsamples of
this population. Recent research (Steadman, Osher, Robbins et al., 2009) suggests that the average prevalence of serious mental
illness among the approximately 2.1 million people incarcerated in US jails, prisons, and penitentiaries is 14.5 percent for men and
31.0 percent for women. Conservatively, these percentages convert to roughly 330,000 mad people confined in our penal institutions
as a result of having been found guilty of criminal offenses.
In the Community. New developments in the application of force and coercion on the mad have emerged from the community,
where the mad mostly live and are treated today. Not surprisingly, here too no national prevalence data exist, but again, by
reviewing some of the most recent studies on community-specific psychiatric coercion, one can make educated guesses. One study
conducted in five US cities (Swartz, Swanson, Kim et al., 2006) found that 44 to 59 percent of the sampled individuals reported
having been subjected to at least one of four coercive measures (the researchers call them “tools,” p. 38) while in outpatient
community treatment.
In Toto. Using the above information, our tentative, evidence-informed guess is that at least 50 percent of the mad in the above
three settings are the regular recipients of at least one form of psychiatric coercion. We can put numbers to this percentage by using
the latest data available from the federal government on “patient care episodes” (the odd name the federal government uses for the
count of the total number of persons under psychiatric care4 in any one year in the United States). We find that there were 9.5
million patient care episodes in 2002 (Manderscheid, & Berry, 2006, p. 209), translating at a minimum to 3 to 4 millions of our mad
citizens subjected to coercion in the name of mental health in any single year.
“Tools” of Community Coercion
Community-based mechanisms of coercion are deployed by the judicial and the public welfare systems—the two major institutions
outside the mental health system in which the mad are located (Monahan, 2008). The judicial system employs several coercive civil
mechanisms on noncriminal mad persons to keep them out of hospitals and force them into community treatment, by far the cheaper
option (Swartz, Swanson, Kim et al., 2006). The most well-known of these is court-ordered outpatient commitment, and it usually
comes in three forms: first, conditional release from involuntary hospitalization if the person is willing to submit to mandated
community treatment; second, as a substitute for involuntary hospitalization for those meeting commitment criteria; and third, as a
form of preventive detention for those who are not legally committable but are considered to be “at risk.”
Mad individuals who are adjudicated of a minor or nonviolent crime are further subjected to mental health courts, such as so-
called “drug courts.” These courts use judges’ recently expanded extralegal role to force some mad criminals into psychiatric
treatment by “play[ing] a hands-on, therapeutically oriented, and directive role at the center of the treatment process” (Monahan,
Bonnie, Appelbaum et al., 2001, p. 1200). The research indicates that such courts appear to have at best a moderate effect in
reducing criminal recidivism among those who complete their programs (a high dropout rate is common). However, because the
participants are often selected by judges “based on personal knowledge of an individual’s history” as those “most likely to succeed,”
even this outcome is not generalizable (Sarteschi, Vaughn, & Kim, 2011, p. 14).
The social welfare system uses two prominent coercive measures to gain behavioral compliance. One is by controlling any funds
to which the mad may be entitled. This is done by appointing for recalcitrant individuals payees, who control the patient’s access to
public disability benefits, predicated on the patient’s level of cooperation with psychiatric treatment. The second measure is by
providing access to subsidized housing only to those who comply with treatment, an effective mechanism of subjugation because
most of the public mental health patients cannot afford to pay fair market rents from their monthly disability checks. These coercive
tactics are today ordinarily called “leverage” by academics (Monahan, Redlich, Swanson et al., 2005). John Monahan, the dean of
psychiatric coercion scholars, goes as far as to argue “that framing the legal debate on mandatory community treatment primarily in
terms of coercion has become counter productive . . . [and it is] unhelpful and [a] misleading assumption that all types of leverage
necessarily amount to coercion” (2008, p. 284). Apparently he forgets that “mandated community treatment” means, if it means
anything, treatment not voluntarily sought but forced on the patient. The scientific work of some eminent scholars of coercion might
be summed up in one phrase: Coercion by any other name is not coercion.
To illustrate how reputable researchers and mental health professionals can come to such judgments, we devote the next section
to examining some of the purportedly scientific bases for the acceptance and dissemination of coercive practical interventions
designed to change the behavior of mad people who reside in the community. This involves looking first at the evidence-based
practice movement and its progenitor, evidence-based medicine.
 The Limits of Evidence-Based Medicine
The relatively recent phenomena of evidence based practices (EBPs) proliferating currently in all of the helping professions are
derived from the dramatic growth and legitimation of their parent movement, evidence-based medicine (EBM). The latter emerged
during the 1990s when its advocates promoted it as a “new paradigm” for selecting the best options among available medical
treatments (Haynes, 2002) and governments saw in it a method to control expenditures on medical care. Looking at the Medline
bibliographic database shows that prior to 1990, zero publications were indexed with the terms evidence-based medicine, evidence-
based treatment, or their abbreviations. For the 2000–2005 period, however, 13,989 hits for EBM and 1,331 hits for EBP or EBT
were recorded (Flaum, 2007). These data indicate the suddenly increased popularity of this new terminology among academics and
clinicians. The terminology is new, but EBM methodology is not.5
EBM is defined by its developers as:

[T]he conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual
patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available
external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment
that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many
ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate
use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care. By best
available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but
especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical
examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive
regimens. (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, pp. 71–72)

It is extremely difficult to resist the allure of a protocol that proposes (1) combining the best objectively derived evidence of
treatment effectiveness, with (2) the application of caring and sensitive clinical expertise of individual clinicians, to (3) choose those
specific treatments that mesh with particular patients’ “predicaments, rights and preferences” while simultaneously (4) ameliorating
specific patient illnesses. Perhaps the popularity of the EBM idea is due to this seductive linguistic combination of all that scientific
medicine aims to accomplish as a healing enterprise and for suggesting that such a utopian research program is actualizable. Clinical
epidemiologist Alvan Feinstein and a colleague warned about EBM in 1997: “[h]ardly anyone can disagree with the goal of getting
clinicians to make ‘conscientious, explicit, and judicious use of current best evidence’ for decisions in patient care” (p. 529). The
devil is in the details.
Despite its popularity, EBM has come under serious criticism. Here are the most problematic issues. First, the randomized
controlled trial (RCT) that EBM identifies as the gold standard for determining effective outcomes uses group aggregated averages
in the data analysis and cannot as a result provide useful information on how to select an effective treatment for any particular
individual, the goal of all clinical practice. Alvan Feinstein, credited by EBM developer and epidemiologist David Sackett (2002)
with putting clinical epidemiology on the scientific map, notes that “randomized trials were not intended to answer questions about
the treatment of individual patients” (Feinstein & Horwitz, 1997, p. 532).
Second, in order for RCTs to be used validly, the sample of patients must be a random sample selected from a population, all
having the same underlying disease. This proves well nigh impossible in psychiatric samples (as we will discuss in the next two
chapters) since psychiatric diagnoses are neither reliable (Kirk & Kutchins, 1992) nor valid (Boyle, 2002), and therefore cannot be
used as a method to identify a sample of people with the same mental disorder (Wolf, 2000, p. 101). As the DSM states, “In the
DSM-IV there is no assumption that each category of mental disorder is a . . . discrete entity . . . dividing it from other mental
disorders or from no mental disorder. . . . [T]herefore . . . individuals sharing a diagnosis are likely to be heterogeneous even in
regard to the defining features of the diagnosis” (APA, 2000, p. xxxi). We understand that our assertion of unreliability and
invalidity may strike some readers as unduly harsh, yet even prominent DSM architects acknowledge it, as we discuss in chapters 4
and 5.
Third, although RCTs may be useful in deciding if an active drug is better than a placebo (i.e., a nonactive pill or process also
known to influence the outcome being researched) to treat, say, an infection, they may not be the best way to evaluate the
effectiveness of socially complex bundles of services usually provided by public social welfare and mental health systems. These
services include various components, such as case management, psychiatric medication monitoring, cognitive-behavioral treatment,
employment training, activities in daily living, and budgeting classes. Depending on a particular agency’s philosophy and funding
requirements, each service package and each component therein may be organized and implemented differently across agencies, and
even within a single agency. The resulting “lack of precision makes it difficult to model the causal pathways of interventions, which
is central to the RCT model” (Wolf, 2000, p. 101). To further complicate the portrait: if attempts are made to test the various
components’ separate effects on the patients, that is, to unbundle bundled services, the strong possibility exists that some important
elements of the bundled intervention will be overlooked because they are hard to measure or so idiosyncratic that they cannot be
standardized and transferred uniformly to another setting. For example, it may be that the most “highly effective aspects of the
intervention are those unmeasured aspects that are associated with highly stylized characteristics of the staff, say their interactional
style or level of motivation” (p. 101).
Fourth, comprehensive evaluations of treatment outcomes from multiple studies carried out by combining data from all the
studies have their own limitations. Such systematic pooling of study results, known as a meta-analysis, has come to be seen in EBM
as the gold standard for deciding on an intervention’s effectiveness. Meta-analyses now number in the thousands in the psychiatric
outcome literature alone. Yet the limitations of meta-analyses need closer scrutiny. One such limitation is that meta-analyses often
take the information given in individual RCT studies as factually accurate. As many scholars have pointed out, those who conduct
meta-analyses do not necessarily assess independently how well each individual RCT was implemented or evaluate the impact of
potentially bad implementations on the quality of the data gathered (Bailar, 1995; Feinstein 1995; Feinstein & Horwitz, 1997;
Oakes, 1986; Rothman, Greenland, & Lash, 2008, p. 682; Williams & Garner, 2002). In addition, no meta-analysis considers the
impact of the administrative organization of an intervention program and its rules and regulations on the success of the intervention.
As we argue later for ACT, these rules and regulations, not its hypothesized clinical6 interventions (the foci of analysis for such
systematic reviews), are often responsible for reported successes. The American statisticians Richard Berk and David A. Freedman
go further and advise:

[W]ith respect to meta-analysis, our recommendation is simple: just say no. The suggested alternate is equally simple: read
the papers, think about them, and summarize them. Try our alternative. Trust us: you will like it. And if you can’t sort the
papers into meaningful categories, neither can the meta-analysts. (2001, p. 21)

In fact, an editorial in January 2012 in the BMJ (formerly known as the British Medical Journal, and perhaps the staunchest
proponent of EBM in the world) introducing a series of articles on missing clinical data and their impact on the methodology of
EBM, noted the flaws of quantitative findings in systematic reviews of clinical trials:

These articles confirm . . . that a large proportion of evidence from human trials is unreported, and much of what is reported
is done so inadequately. . . . What is clear from the linked studies is that past failures to ensure proper regulation and
registration of clinical trials, and a current culture of haphazard publication and incomplete data disclosure, make the proper
analysis of the harms and benefits of common interventions almost impossible for systematic reviewers. (Lehman & Loder,
2012)

A fifth issue regards what kind of evidence is best for determining if the treatment is effective. Should we rely strictly on
statistical analyses of numerical data as EBM advocates urge, or should we more broadly incorporate other systematically reviewed
empirical evidence currently disallowed under EBM? Some doctors argue that “the general priority given to empirical evidence
derived from clinical research is not epistemologically tenable” (Tonelli, 2006, p. 248) but should only be considered as one source
along with others. These other sources could be evidence obtained from well-conducted observational and naturalistic studies,
gathering of individual case studies into a searchable database (sometimes referred to as experience-based evidence), studies on
human and animal physiology, as well as evaluations of patient goals, values, and specific features of the delivery system relevant to
practice (Tanenbaum, 2006; Tonelli, 2006). Even if expanded sources of evidence were considered, how should different forms of
evidence be weighed and in what order in distinguishing better from worse interventions? These methodological conundrums may
have no resolution since each form of evidence may derive from different and irreconcilable theoretical perspectives.
Sixth, the part of the EBM definition urging the need to consider clinical judgment (i.e., the subjective calculation of the helping
professional regarding the problem), as well as the patient’s personal wishes when choosing the proper EBM treatment, greatly
appeals to common sense. EBM proponents, however, have consistently admitted that they have not a clue as to how to incorporate
these two subjective elements into the protocol of EBM (Cohen, Stavri, & Hersh, 2004, Haynes, 2002). Without a procedure for
selecting, organizing, and integrating the best research evidence, best clinical judgment, and patients’ preferences, the EBM
approach for choosing an effective treatment for a given individual presenting with a given illness is no more “scientific” than the
approach used by ethical clinicians in the past. These clinicians carefully weighed the best information available to them from
multiple sources in order to choose the best care based on their education, training, experience, and positive therapeutic alliance
with their patients (Feinstein & Horwitz, 1997). Feinstein and Horwitz note that “most good clinicians have regularly assembled
evidence when they reviewed their own experience, developed clinical judgment, read the medical literature, attended medical
meetings, and had discussions with one another. This activity seems entirely compatible with the . . . practice of EBM” (1997, p.
529).
A seventh crucial issue is that deciding what constitutes EBM requires experts “certified” as authorities in the subject. Such an
EBM certification must be done by authorities who themselves were certified in such expertise by prior certified authorities, and so
on. So, rather than dramatically reducing or eliminating arbitrary or authority-based individual medical decision making or
substituting an objective for a subjective decision-making process in choosing best practices as some have argued (Gambrill, 1999),
EBM has turned out to represent merely another form of expertly justified authority. The subjective judgment of individual
clinicians now becomes the subjective judgment of the authorized EBM evaluators7 who are expected to come to consensus
regarding which studies meet the consensus protocol for systematically evaluating RCTs (see especially, Fenstein & Horwitz, 1997;
Gupta, 2003), leading to a new “orthodoxy” promoted now as scientifically objective (Williams & Garner, 2002). To illustrate this
reliance on inside experts, examine how the authors of one of these “rigorous” systematic reviews (in this case, of intensive case
management), explain their approach:

The authors of this review do include an active pioneer of developing and implementing the experimental intervention
model across the scientific community and clinical world [Dr. Marshall] and one included study is his (Marshall-UK). As a
team we have tried to ensure that decisions are made by rational consensus and not to have an expert in the team would
have been an inadvisable omission. In some cases protocol rules were not clear enough and need for subsequent
clarification arose and post hoc decisions had to be taken. (Dieterich, Irving, Park & Marshall, 2011, p. 50)
They appear to rely on “expert” authority and group consensus in their meta-analysis, precisely the sort of contamination by
authority figures that EBM was supposed to combat.
Finally, and perhaps most problematically, the effectiveness of EBM itself has never been tested according to its own principles.
Do clinicians who practice EBM achieve better outcomes then those who do not? Nobody knows. That question has never been put
to an EBM-favored test, for example, by conducting a controlled trial of evidence-based-medicine–trained clinicians versus those
not trained to assess an ability to select and implement effective treatment to help their patients. Thus, the optimistic claims of EBM
effectiveness are not themselves evidence-based (Cohen, Stavri & Hersh, 2004). The whole EBM project is untested, even though it
has been promoted and marketed for over twenty years. Such uncertainty regarding the validity of EBM would suggest caution in
marketing its wholesale adoption. Unfortunately, there is little doubt that it has been heavily marketed with resounding success,
judging from its adoption as an organizing, pedagogical, and practice principle in Western medicine and the helping professions.
These criticisms have not gone unnoticed, and recent warnings have come directly from some EBM developers. Haynes (2002)
wrote that “accelerating the transfer of [EBM] research findings into clinical practice is often based on incomplete evidence from
selected groups of people, who experience marginal benefits . . . raising questions of the generalizability of the findings” (p. 1) and
that at best it should be “an adjunct to healthcare decisions” (p. 6). The EBM developers have also concluded that “EBM has long
since evolved beyond its initial (mis)conception that EBM might replace traditional medicine. EBM is now [instead] attempting to
augment rather than replace individual clinical experience” (p. 1, emphasis added). This is a more modest stance by the EBM
creators, demoting it to an “adjunct” role in medical decision making, and a withdrawal from their original claims that EBM
represents “[a] NEW paradigm for medical practice” (The Evidence-Based Medicine Working Group, 1992, p. 2420). Nevertheless,
other helping professions continue to view EBM as a research and training panacea.
 Evidence-Based Practice in Mental Health
EBM and its methodology is now the “best practice” approach used in the broad field of mental health, albeit under a slightly altered
name, evidence-based practice (EBP). American researchers working with the SMI explain:

Over the past two decades, we have witnessed amazing strides in the development of effective service models for people
with SMI . . . in 1998 . . . a national consensus panel identified six practices . . . attaining the status of EBP.

. . . EBP in mental health is part of a larger evidence-based medicine movement which quickly has become a dominating
influence in medicine . . . Following the model of evidence-based medicine, EBPs are founded on the meta-principles of (1)
using the best available evidence, (2) individualization, (3) incorporating patients’ preferences and (4) expanding clinical
expertise. (Bond, Salyers, Rollins, Rapp, & Zipple, 2004, pp. 576–577)

Relying on the professionals’ and perhaps the general public’s resonance to the simplicity and seductiveness of the idea of EBM,
implementations of evidence-based mental health practices for the SMI have been moving full steam ahead, its promoters ignoring
the deep questions raised concerning the construct and the application of EBM.
The supporters of evidence-based medicine have developed a sophisticated research infrastructure, including prominently the
Cochrane Collaboration. This enterprise uses volunteer medical professionals and academics who constitute work groups,
conducting systematic rankings and reviews of the numerous randomized controlled trials of treatments available for many
physiological problems, some psychiatric problems, and more general behavioral issues, such as the effectiveness of smoking-
cessation programs. These systematic reviews, used to determine which treatments should be designated as evidence-based, are
stored in Cochrane’s researchable electronic database available by paid subscription and in virtually all medical libraries. The
evidence base for mental health interventions that is subjected to these procedures is far more limited and generally lacks the kind of
consistent methodological scrutiny that physiological medical interventions have usually undergone (Drake at al., 2001).
A further fundamental difference characterizes how EBM and mental health EBP determine their recommended interventions.
EBPs, specifically the ones receiving support from American psychiatric science’s key political patron, the NIMH, are selected
through expert consensus rather than by formal protocols as recommended by EBM: “[strict] rules for designating a practice as an
EBP . . . were not imposed in the Implementing EBPs Project; rather panels of research scientists were asked to review controlled
studies” (Mueser et al., 2003, p. 389). Perhaps to minimize the reaction to such a major alteration of EBM protocol, the participating
researchers promised to disclose their method of arriving at consensus, along with their findings, by publishing them during 2001 in
one of the leading mental health journals, Psychiatric Services (Mueser et al., 2003, p. 389). In reviewing that journal, we could find
no such content regarding what is probably the highest-profile community intervention EBP for the severely mentally ill: assertive
community treatment.
Usually, in reaching consensus, a group, regardless of its purpose or membership, must get all members to agree to one
expressed, or explicit, understanding. This is not a scientific but rather a social and political process. Unless explicit procedural and
methodological criteria of the process are agreed to before starting, consensus reaching is arbitrary and may be captured by those in
the group who are most persuasive rhetorically rather than scientifically. How the expert consensus agreement for the EBPs was
reached is not described in the published literature, but it is noteworthy that this process was carried out with the sanction of NIMH
under the auspices of the Robert Wood Johnson Foundation (Mueser et al. 2003, p. 388), funded by the family fortune derived from
Johnson & Johnson, the eighth largest pharmaceutical company in the world (five former executives of which sit on the foundation’s
board of trustees as of this writing).
Since the identification of EBPs is meant to reduce clinicians’ uncertainty in choosing effective treatments, the certification of
treatments as EBPs by a consensus vote of approved experts should be based on consistently demonstrated success of the
intervention. If, however, the evidence used to make the certification is weak, faulty, or ambiguous, then the certification can have
the unintended consequence of institutionalizing coercive, ineffective, or even harmful treatments with almost no possibility of
reversing those decisions. Statistician Kenneth J. Rothman observes:

Many of the commonly used modes of causal inference are fallacious . . . one such method of inference, the method of
“consensus,” has been embraced, presumably for political reasons, by the National Institutes of Health. . . . The National
Institutes of Health regularly convenes Consensus Development Conferences to address specific questions and draw
inferences. . . . Were consensus a correct basis for inference, then a once flat earth must have become spherical . . .
Consensus itself requires no further justification, and may be based on shared beliefs that are irrational. (Rothman, 1988, p.
6)

This difficulty is illustrated by the fact that among the consensus, some certified mental health EBPs are considered more valid than
others: “[A]mong EBPs identified by the RWJ conference . . . three practices (supported employment, ACT [Assertive Community
Treatment], and family psychoeducation) have strong and convincing evidence for effectiveness whereas the evidence is weaker for
the remaining three” (Bond et al., 2004, p. 580). Unfortunately, whether based on strong or weaker evidence, once an intervention is
labeled an EBP, its authority has immeasurably increased and rarely if ever will it be reevaluated.
The distortion of the original EBM approach in American mental health practice can be seen by the rhetorical turn taken in two
articles published five years apart with the same lead author, psychologist Gary Bond, a leading replicator/evaluator/promoter of
assertive community treatment. As we have earlier noted, Bond et al. stated in 2004 that mental health EBPs were founded explicitly
on the EBM process and its key “meta-principles of (1) using the best available evidence, (2) individualization, (3) incorporating
patients’ preferences and (4) expanding clinical expertise” (Bond, Salyers, Rollins, Rapp, & Zipple, 2004, pp. 576–577). In 2009,
however, Bond and his colleagues declared that those explicit principles were unnecessary for mental health EBPs:

Evidence-based medicine sometimes refers to a process—the judicious use of the best scientific evidence, combined with
clinical expertise and consumer preferences in making decisions in health care . . . The term EBP, has been used similarly in
the mental health field . . . The term EBPs also refers to specific evidence-based (or empirically supported) interventions . .
. (usually randomized controlled trials). Thus the acronym, EBP, is used throughout this article to refer to specific
interventions and not to the process of clinical decision making. (Bond, Drake, McHugo et al., 2009, pp. 569–570)

Providing two distinct and independent definitions of EBP in mental health—one as a specific intervention to be used
preferentially because it has been deemed to be effective and the other definition as a process of clinical decision making identical to
the definition of EBM—allows Bond and his colleagues to change the scientific rules of the game for mental health EBPs. Talking
about mental health EBPs in the first sense as “effective” interventions gives the impression that they are identical to EBPs
identified for physiological medical problems through the EBM protocol (using systematic reviews) and have the same scientific
credibility as the EBM-identified interventions (weak though they may be to informed observers). But the reality is that these mental
health EBPs are not identified through the same procedures (systematic reviews of RCTs, but instead through expert consensus) and
cannot be considered as analogs to EBM-derived treatments.
The various problems regarding mental health EBP that we have discussed here have not been adequately addressed or solved by
the EBP experts. These experts are well aware of most of the problems, an awareness that prompted at least one meeting to gather
and summarize the concerns regarding EBPs “voiced by members of diverse stakeholder groups; consumers, family members,
policy makers, administrators and researchers” (Essock et al., 2003, p. 920). The resultant report was authored by fourteen of the
self-styled leaders of the EBP mental health movement who magnanimously state that they in “the spirit of science being transparent
and welcoming a public discussion . . . offer this collection of concerns [regarding EBPs] . . . hop[ing] that these summaries will be
useful to others” (p. 921).
Their report is a confirmation that the criticisms we have raised are shared by many who are affected by EBPs. But this sort of
mea culpa exercise seems to be geared for public relations more than anything else, since, after admitting that many problems exist
with EBPs, the authors do not suggest revisiting the procedures and methods used to name EBPs or reevaluate their selections.
Instead, they praise their original choices, saying that the “National Evidence-Based Practice Project study groups identified six
EBPs for community mental health treatment of persons with severe mental illness . . . [which] provide a strong foundation for
defining minimal services for people with severe mental disorders” (p. 932). Further, they insist that these EBPs are characterized by
“sensitivity to individual differences, by attention to choices and preferences, by client centeredness, by empowerment, by diversity
of methods, and by reliance on clinical skills and judgment” (p. 937). Evidence-based practice apparently means “trust us.”
 Assertive Community Treatment: Psychiatric Coercion as EBP
Earlier in this chapter we traced the relentless use of coercion to control the mad in America for four centuries, with each iteration
marketed, not as the use of force to manage a disobedient and troubling group, but rather as the application of better and more
progressive treatments to aid a group suffering from a serious medical condition. These treatments are presented as having been
developed through the latest and most advanced science available in any particular era and progressively building upon previous
work to create increasingly more effective treatments that now have arrived in full scientific glory as EBP. We think these claims
were bogus in the eighteenth century and we believe they are bogus in the twenty-first century, as we will demonstrate in our review
of the most “validated” of the EBPs for serious mental illness, ACT.
ACT History
The common claim is that assertive community treatment is “widely recognized as an evidence-based practice for adults with severe
mental illness” (Bond, Drake, Mueser, and Latimer, 2001, p. 155). ACT appears to be well-credentialed, having built its credibility
more than a decade ago on “a research base includ[ing] 25 well-controlled studies” (p. 155). The National Alliance on Mental
Illness states that ACT is the most widely replicated and frequently used community treatment for SMIs throughout the world. Only
five states in the United States do not have ACT teams, while forty-three states make their Medicaid funds available for its
reimbursement (Aron, Honberg, Duckworth et al., 2009). ACT is without question the leading community treatment for SMIs:

Since the deinstitutionalization era began nearly 50 years ago, several models of community-based care for persons with
severe mental illnesses have been developed. Of these models, the assertive community treatment (ACT) program has by
far the strongest empirical support. (Essock et al., 1998, p. 176)

We will now scrutinize the veracity of these claims and the allegedly convincing evidence for its effectiveness. Originally called
training in community living (TCL), ACT was one of those mental health programs developed during the late 1960s and early 1970s
to respond to the federal mandate for shifting the locus of care and control of psychiatric patients from isolated institutions into the
community (Stein & Test, 1985). It was considered to be an immediate success: soon after its first randomized controlled study
(Marx, Test, and Stein, 1973), ACT received the Gold Achievement Award in 1974 from the American Psychiatric Association. Its
developers stated that ACT fit closely the prevailing psychiatric disease model and its concomitant reliance on psychiatric drugs:
“Congruent with our conceptual model, we tell our patients that indeed we believe they are ill, otherwise we would not be
prescribing medication for them” (Stein & Diamond, 1985, p. 272).
The Origins of ACT’s Methods
ACT originated at Mendota State Hospital in Madison, Wisconsin, in the 1960s and 1970s. Key protagonists in the hospital at the
time were: (1) psychiatrist Arnold M. Ludwig, the hospital’s director of research and education; (2) the creators of ACT,
psychiatrists Arnold J. Marx, Leonard I. Stein, and psychologist and Professor of Social Work Mary Ann Test; and (3) less directly,
clinical social worker Frank Farrelly and psychologist Jeff Brandsma. Farrelly and Brandsma together fashioned and tested at
Mendota State a therapeutic approach they called “provocative therapy” (Farrelly & Brandsma, 1974) and influenced the treatment
approaches of those involved with ACT.
In 1985 Stein and Test edited a book reporting on the first ten years of the TCL/ACT effort, The Training in Community Living
Model: A Decade of Experience. They describe the development of their professional thinking this way:

Ideas rarely arise de novo; they are generally formed from the building blocks of prior knowledge and experience. To
become lasting, they must be nourished in an environment that is willing to set aside the accepted attitudes and practices
that resist new concepts. . . . In the mid 1960’s . . . several psychiatrists [Marx and Stein] who had just finished their
residency joined the hospital staff. These psychiatrists were imbued with the therapeutic zeal frequently found in young,
uninitiated physicians. In addition, Arnold Ludwig joined the staff as director of research and education. His first two
projects involved many members of the hospital staff. The projects represented . . . an effort to transform the hospital . . .
into an institute whose primary goals were research, demonstration, consultation and training. (pp. 7–9)

This quote identifies most of the key TCL/ACT players and describes their intimate involvement in the research conducted at
Mendota State after the appointment of Ludwig as director of research and education and suggests that what they learned from these
projects informed their understanding and treatment of patients.
Patient Descriptions
The Mendota State researchers, despite their view that their patients are medically ill (a perspective that ordinarily does not hold the
patient responsible for the consequences deemed to flow from having an illness), appeared to have entertained if not hostile, at least
negative attitudes toward patients. Patients in a locked ward (the STU) at Mendota State Hospital are not described in medical terms
but as adversaries:

Professionals have overlooked the rather naive possibility that schizophrenic patients become “chronic” simply because
they choose to do so . . . If he so desires, he can defecate when or where he chooses, masturbate publicly, lash out
aggressively, expose himself, remain inert and unproductive or violate any social taboo with the assurance that staff are
forced to “understand” rather than punish behavior. (Ludwig & Farrelly, 1967, p. 737–741)

These two authors wrote an earlier article (in 1966) which is entitled “The Code of Chronicity.” The code, according to them, is
employed by the mad, along with other “weapons of crazyness” (p. 565). They concluded that these patients were:

Obviously . . . not . . . a group of fragile, broken-spirited persons but rather . . . tough, formidable adversaries who were
“pros” and who had successfully contended with many different staffs on various wards in defending their title of “chronic
schizophrenic.” (Ludwig & Farrelly, 1966, p. 566)

As a result, Ludwig and Farrelly felt that the only medical cure was to coerce the patients to mimic the “sane” behavior of the
staff:

To become well patients would have to think, feel, and behave . . . similar to staff. The concept of normality and sanity as
therapeutic goals . . . would have to [be] deliberately concretize[d] . . . by insisting that patients employ staff persons as
models for behavior. . . . Furthermore, we would not play at democracy in therapeutic community meetings; not the
majority, but health and sanity, as defined by staff, would rule. (1966, pp. 566–567, emphasis added)

The psychiatric commitment to use coercion to cure, exhibited throughout the profession’s history, could not be better illustrated
than by these experts’ efforts to force their inmates to conform in order “to become well.” The similarity to the later ACT approach,
as described by ACT insider, psychiatrist Ronald J. Diamond, is uncanny:

Paternalism was to a large extent accepted with little question. . . . Staff were assumed to know what the patient “needed.”
Even the goal of getting patients paid employment was a staff-driven value that was at times at odds with the patient’s own
preferences. Current assertive treatment programs continue to be influenced by traditions . . . from this . . . history.
Paternalism continues to be reinforced by mandates from the community to “control” the behavior of otherwise disruptive
patients. (Diamond, 1996, p. 53)
Punishment as Treatment
Leonard Stein, after replacing Arnold Ludwig as the director of research and education at Mendota State Hospital, coauthored a
study with “provocative therapy” advocate Brandsma, entitled “The Use of Punishment as a Treatment Modality: A Case Report”
(Brandsma & Stein, 1973). The study examined the value of using involuntary electric shock to reduce the “unprovoked” assaultive
behavior of a “retarded, adult, organically damaged” (p. 30) twenty-four-year-old woman. This publication appeared during the time
that TCL/ACT community research was already well on its way (see Marx, Test, & Stein, 1973) and was apparently part of a line of
research focused on force and violence as treatment, begun earlier at Mendota State. Ludwig, Marx, Hill, and Browning (1969) had
previously published a single-case study on a paranoid schizophrenic patient, entitled “The Control of Violent Behavior through
Faradic Shock.” The authors justified this study by its “uniqueness,” because “this procedure was administered against the express
will of the patient” (p. 624, emphasis added). They used an electric cattle prod as the “aversive conditioning agent,” because it was
“an excellent device for providing a potent, noxious stimulus . . . capable of producing a faradic shock spike of approximately 1400
volts at 0.5 milliamperes, the resulting pain lasting . . . as long as the current was permitted to flow” (p. 627).
The methodology of Brandsma and Stein’s experiment reveals what can only be termed sadism. To obtain a “baseline” measure
(a requirement of single-subject design research) of this patient’s assaultive behavior, she was baited and ridiculed so she would
respond aggressively:

The patient was required to sit in an armchair throughout. . . . During the base rate week the staff quickly developed a
consistent provocative approach in order to ensure a high frequency of behavior from the patient . . . This consistently
involved: 1) ignoring the patient in conversation; 2) refusing to give the patient candy or snacks when others were eating
them; 3) denying all requests, for example, during the session if she asked if she would be able to go for a walk that
afternoon, she was immediately told, “No you can’t.”; 4) refusing to accept her apologies or believe her promises of good
behavior; 5) The . . . female sitting next to her often leading the provocation; 6) using provocative labels for her behavior,
i.e., “animalistic, low grade”; 7) discussing family related frustrations, i.e., her mother’s refusal to write or visit, how her
dead grandmother would be displeased with her present behavior if she were alive. It should be noted that throughout the
program the patient was kept in a seclusion room at all times except when involved in a baseline or treatment session.
(Brandsma & Stein, 1973, pp. 32–33)

Brandsma and Stein’s research exemplifies mad science at its worst, by daring to torture an imprisoned, nonconsenting subject
and by publishing an article full of scientific misinformation and distortion. Brandsma and Stein cited the classic behavioral study
by Azrin and Holz (1966) to support their use of punishment, stating that “our clinical reports back up the more controlled animal
studies on punishment. For example . . . Azrin and Holz . . .” (Brandsma & Stein, 1973 p. 36). In fact, the Azrin and Holz had
argued that punishment is ineffective as a method of behavioral change, especially for human subjects, listing its primary
disadvantages as follows:

The principal disadvantages of using punishment seem to be that when the punishment is administered by an individual, 1)
the punished individual is driven away from the punishing agent, thereby destroying the social relationship; 2) the punished
individual may engage in operant aggression directed toward the punishing agent; and 3) even when the punishment is
delivered by physical means rather than by another organism, elicited aggression can be expected against nearby
individuals who were not responsible for the punishment. (Azrin & Holz, 1966, p. 441)

Despite this clear refutation of their brand of behavioral treatment that Brandsma and Stein cited to support their own therapeutic
use of an electric cattle prod, they falsely concluded that “the extant literature now supports the assertion that ‘punishment therapy’
is a useful tool to modify certain behaviors” (Brandsma & Stein, 1973, p. 37). Their research demonstrated that “punishment
therapy” was not effective. As they report about their subject, “[u]nfortunately the intensity of her now low frequency, occasional
attacks was still sufficient to relegate her to a life of relative social isolation” (p. 36) and even a year after the intervention “the
punishment contingency continues . . . in seclusion with only a few hours out per day when accompanied by a male aide” (p. 35).
The patient was not better off after the coercive treatment and was relegated to permanent solitary confinement.
What is noteworthy in this publication is how easily actions like baiting, punishment, and torture could be applied to a difficult
patient by “doctors” and be described as scientific research on “treatment.” The early transformations of control and punishment as
treatment at Mendota State appear to have influenced research on ACT over the next several decades.
What Is ACT?
According to Test (1992), ACT has four essential characteristics:

Core Services Team [made up of 3-5 members, with at least a primary case manager, psychiatrist, and backup case manager
per patient]: The team’s function is to see that all the patient’s needs are addressed in a timely fashion. . . . Having one team
provide most of these services minimizes the . . . fragmentation of . . . care systems and allows for integrated clinical
management. . . .

Assertive Outreach and In Vivo Treatment: An essential ingredient . . . is the use of assertive outreach . . . [staff] reaches
out and takes both biological and psychological services to the patient[in the community]. . . .

Individualized Treatment: Because persons with serious mental illnesses . . . are greatly heterogeneous and both person and
disorder are constantly changing over time, treatment . . . must be highly individualized. . . .

Ongoing Treatment and Support: . . . even very intensive community treatment models do not provide a cure for severe
mental illness, but . . . a support system within which persons with persistent vulnerabilities can live in the community and
grow. It appears these supports must be ongoing rather than time limited. (1992, pp. 154–156)
Treatment Effect or Administrative Coercion?
A 2001 article in the journal Psychiatric Services claimed that ACT was to be deemed an EBP because it had shown superiority
over alternate treatments:

Research has shown that assertive community treatment is . . . more satisfactory to consumers and their families. Reviews
of the research consistently conclude that compared with other treatments under controlled conditions, such as brokered
case management or clinical case management, assertive community treatment results in a greater reduction in psychiatric
hospitalization and a higher level of housing stability. (Phillips, Burns, Edgar et al., 2001, p. 771, emphasis added)

The clinical effectiveness of any treatment is usually measured in symptom reduction, reduced disability, better functioning, or
improvements in behavior, self- or other-rated. What is noteworthy about the quote above is that keeping people out of a hospital or
in a community residence is used as the markers of success. It might come as a surprise then that an award-winning “treatment”
program made few claims that it improved patients’ clinical condition. In fact, Philips et al. admit that “[t]he effects of assertive
community treatment on quality of life, symptoms, and social functioning are similar to those produced by these other treatments”
(p. 771, emphasis added). In other words, ACT does not reduce the mad behavior or improve the functioning of the severely
mentally ill any more than any other approach. Decades earlier the ACT inventors admitted: “a change in the site of treatment [from
the hospital to the community] says nothing about whether the patient’s clinical status or functioning has improved. Some would
argue that only the place of a person’s suffering has changed” (Test & Stein, 1978, p. 360).
Nonetheless, ACT aspired to do more. In 1992 Mary Ann Test indicated that they always “target[ed] goals for the model . . .
going far beyond the reduction of time in hospitals. Additionally, improvements in patients’ psychosocial functioning and quality of
life are sought” (Test, 1992, 164). But over time, the ACT model failed to achieve these clinical outcomes that would be routinely
expected of any treatment in medicine. If traditional clinical effectiveness was not achieved by ACT, what was the basis for its
purported success? Let’s examine five core claims of success.
ACT’s “Successes”
Claim #1. ACT significantly reduces hospitalization when compared to alternate treatments.
Evidence. Reduced hospitalization and inpatient treatment costs are the only consistent outcomes found across studies. On the
surface, reducing hospitalization rates can be mistaken as reducing symptomatic behaviors and therefore the need for
hospitalization. But, in fact, ACT methods have no direct bearing on reducing symptoms or the need for hospitalization. They
simply reduced hospital stays by using a fairly strict administrative rule not to admit or readmit any ACT patients for
hospitalization, regardless of the psychiatric symptoms, but to carry out all treatment in the community. The comparison group of
troubled patients at the same time could be freely readmitted.
Test and Stein (1978) provided an early clue to the importance of program control over hospitalization and discharge:
“Community treatment results in less time spent in the hospital. This finding is certainly not surprising since experimental patients
were usually not admitted to hospitals initially and there were subsequent concentrated efforts to keep them out” (p. 354). Many
ACT articles acknowledge that reduced hospitalization in ACT is the result of administrative rules, not clinical treatment. Scott and
Dixon (1995), examining the impact of case management and ACT programs, observe that “the effectiveness of ACT models in
reducing hospitalization may be a function of their capacity to control hospital admissions, length of stay, and discharge” (p. 659).
Several studies have noted that the length of hospital stay returned to pre-intervention levels when ACT team . . . control of
discharge was blocked by hospital authorities” (Craig & Pathare, 1997, pp. 111–112). Finally, Minghella, Gauntlett, and Ford
(2002), discussing the failure of some assertive outreach teams in England to reduce hospitalization, write that “[w]hile the teams
partly adhered to the ACT model, there were major areas of deviation. The teams had little influence over admissions and
discharge” (p. 27).
In short, if one does not allow particular people to be hospitalized, they won’t be. A crucial point to be made here is that the
identical type of psychiatric administrative activity is used either to force people into hospitals for treatment (involuntary civil
commitment), to prevent them from entering hospitals, or to force people out of them into the community for treatment (ACT). All
these approaches are coercive: they do not consider whether any of the patients being forced into the hospital want out or whether
those being kept out want in. Client choice is not an option.
Claim #2. ACT is more cost effective than standard interventions.
Evidence. Since hospitalization is by far the more costly treatment, the cost savings are not dependent on specific ACT clinical
interventions but on keeping people away from hospitals, which, as we have just reviewed, is a byproduct of the ACT administrative
coercion. Cost reduction could occur with any other treatment rigorously pursuing the same objective.
Claim #3. ACT provides significantly greater patient satisfaction.
Evidence. Most people prize their freedom; few prefer to be confined in hospitals. ACT’s clients are the same, but patient
satisfaction appears to be independent of distinct ACT activity. The greater autonomy provided by any community treatment (as
compared to a locked hospital ward), not the particular interventions of ACT, would explain increased satisfaction. In the Australian
study previously mentioned, the patients were surveyed at a twelve-month follow-up: “The majority (80%) of experimental group
patients who were not admitted to the hospital were pleased and grateful about it; only 30% of control group patients were pleased
and grateful about being admitted to hospital, whereas 39% were upset and angry” (Hoult, 1986, p. 142). Stated differently,
“Treatment preference was explored by asking all patients whether they prefer admission to Macquarie Hospital or treatment at
home by a community team. The majority of the project (87%) and control (61%) patients preferred community treatment” (Hoult et
al., 1983, p. 163, emphasis added). A majority (61 percent) of the group that did not experience the ACT treatment still preferred
community treatment rather than incarceration in an institution. In fact, the experimental group reported that the most important
elements of the ACT treatment were the availability of staff for frequent caring; supportive, personal contact; and the enhanced
freedom—therapeutic elements not specific to ACT (p. 163).
Lending further support, a survey of “patient perspectives” on ACT “ingredients” (McGrew, Wilson, & Bond, 1996) identified in
order of preference: “helping relationship, attributes of therapist, availability of staff, and non-specific assistance” as what patients
liked most (p. 16, table 1). These attributes are not ACT specific; they apply to all forms of “helping.” The least liked of the twenty-
five elements associated with ACT was “intensity of service”—the component most representative of ACT-intrusive philosophy.
The survey’s authors, themselves longtime ACT experts, admit, “Somewhat surprisingly, non-specific features of the helping
relationship emerged as the aspects of [ACT] most frequently mentioned as helpful” (McGrew et al., 1996, p. 190).
Claim #4. ACT increases [independent community] housing stability (Bond et al., 2001, p. 149).
Evidence. We conclude, in agreement with most other reviews, that the evidence supports this claim. ACT patients, but not
control group patients, are more likely to find rooms and apartments in the community, rather than using many specialized
residential settings (Test, Knoedler, Allness, Kameshima et al, 1994, p. 4). But just as ACT patients are not allowed to be
hospitalized, ACT patients are administratively directed only to “independent” housing. So what is achieved is not a clinical
treatment success, as much as an assertive administrative rule to help patients find independent-living settings.
Finally and most importantly:
Claim #5. “The assertive community treatment approach never was, and is not now, based on coercion” (Test & Stein, 2001, p.
1396).
Evidence. One of the rationales which the ACT inventors cited to explain the shift from psychiatric institutional care to
community care was the reduction of coercive management and the promotion of autonomy to improve the social functioning of the
SMI (Marx et al., 1973). Another was the desire to reduce the harmful effects of institutional living. Test and Stein’s unequivocal
rejection of accusations that ACT is coercive (as quoted above) was in response to an article in APA’s community psychiatry
journal, Psychiatric Services.
The historical record suggests that the Test and Stein denial is open to debate. For example, here is how Stein (1990) describes
the role of the ACT team:

[S]erves as a fixed point of responsibility . . . and is concerned with all aspects of . . . the patients’ lives that influence their
functioning, including psychological health, physical health, living situation, finances, socialization, vocational activities,
and recreational activities. The team sets no time limits for their involvement with patients, is assertive in keeping patients
involved . . . In addition to the day work . . . the team is available 24 hours a day, seven days a week. (p. 650, emphasis
added)

This methodology appears highly intrusive. ACT activities may include such coercive moves as becoming the representative
“financial payee” of the patient, providing opportunities to blackmail the patients by enforcing medication compliance or
threatening to withhold monies belonging to the patient (Stein & Test, 1985, pp. 88–89). This appears to be forcing treatment on
ACT patients who do not want it (pp. 91–92). Even bribery may be appropriate ACT treatment: “it might be necessary to pay a
socially withdrawn patient for going to the movies in addition to buying his ticket” (Test & Stein, 1976, p. 78).
To validate the use of assertive outreach and treatment, the original ACT researchers rely on two studies, one of which is their
own (Test, 1981, p. 80). The other study is by Beard, Malamud and Rossman (1978), who describe their Fountain House outreach
program as follows: “Phone calls, letters, and home and hospital visits [were] made by both staff and members. Through such
contacts, subjects who dropped out were provided with further information. . . . In those . . . instances when an individual requested
that no further contacts be made, his wishes, of course, were respected” (p. 624). Respect for the wishes of people who choose not to
be involved in the Fountain House program contrasts with the coercive methods used by Test and Stein (1976):

A staff person attempting to assist an ambivalent patient to a sheltered workshop in the morning is likely to receive a verbal
and behavioral “no.” . . . If . . . the staff member approaches the patient with a firm, “It’s time for you to go to work; I’ll
wait here while you get dressed,” the likelihood of compliance increases. The latter method allows less room for the patient
to “choose” passivity. (p. 77)

Two questions come to mind: why is the patient described as ambivalent, when the patient’s reported behavior indicates a
resolute opposition to going to work? Second, why is the patient’s active refusal redefined as “passivity”? The disregard of patients’
expressed wishes and the reinterpretation of their behavior to justify programmatic interventions appear to be characteristics of ACT
—in fact it appears to give meaning to “assertive” treatment. The Fountain House model, by contrast, discontinues patient outreach
efforts if asked.
Coercion and control, despite Test and Stein’s denial, appear to be integral parts of the ACT model when it appears to be
effective. According to the candid admission of Diamond (1996), a close associate of the original ACT group in Madison:

Paternalism has been a part of assertive community treatment from its very beginning . . . Paternalism continues to be
reinforced by mandates from the community to “control” the behavior of otherwise disruptive patients. . . . A significant
number of patients in community support programs . . . have been assigned a financial payee . . . This kind of coercion can
be extremely effective.

. . . Obtaining spending money can be made . . . dependent on participating in other parts of treatment. A patient can then be
pressured by staff to take prescribed medication. . . . [T]he pressure to take medication . . . can be enormous. . . . While
control of housing and control of money are the most common . . . methods of coercion in the community, [and] other kinds
of control are also possible. This pressure can be almost as coercive as the hospital but with fewer safeguards. (pp. 53–58)

The fact is that discussion of ACT coercion is routinely found throughout the psychiatric literature. A large body of literature
now addresses the “therapeutic” value of community-based coercion of mental health patients, an ongoing discussion that can be
tied directly to the existence of ACT. A 1996 edited book legitimated the study and use of such coercion with the title specifically
identifying ACT and its coercive approach: Coercion and Aggressive Community Treatment: A New Frontier in Mental Health Law
(Dennis & Monahan, 1996). More recently, the importance of conventional psychiatric coercion research has been further validated
by a major new book published in 2011, also coedited by John Monahan, Coercive Treatment in Psychiatry: Clinical, Legal and
Ethical Aspects. While some psychiatric experts are busy asking “Is Assertive Community Treatment Coercive?” (Appelbaum &
LeMelle, 2007), ACT experts acknowledge that “assertive engagement” or “assertive outreach” is a core element of ACT. These
concepts are included in the most popular scale for evaluating ACT program replications’ fidelity to the original Madison model, the
Dartmouth Assertive Community Treatment Scale (DACTS). Assertive engagement is measured (in DACTS) primarily by counting
the frequency of formal coercive legal mechanisms (i.e., mandated outpatient treatment or appointed financial payees). Its
developers state transparently that “[i]t should be noted that the criterion for assertive engagement was operationalized in such a
way that it emphasized use of legal mechanisms” (Teague, Bond, & Drake, 1998, p. 229). Davis (2002) has suggested that
“[c]oercion in assertive community treatment may take formal or explicit form, such as the enforcement of conditions of a treatment
order. Usually, however, coercion is less obvious and by extension more difficult for workers to come to terms with” (pp. 245–246).
A report prepared in 2000 for the Federal Health Care and Financing Administration and the Substance Abuse and Mental Health
Services Administration devotes a whole section to ACT coercion. The report notes that “[w]ithin the context of ACT programs,
coercion can include a range of behaviors including, friendly persuasion, interpersonal pressure, control of resources and the use of
force. . . . Research generally suggests that coercion may be harmful to the consumer” (LewinGroup, 2000, p. 43). It is noteworthy
that “friendly persuasion” is included as an example of “coercion” in a federal report on psychiatric treatment. This appears like a
simple error. Or is it in fact part of a strategic effort to broaden the meaning of coercion? Is the inclusion of noncoercive
interpersonal activity (friendly persuasion appears to us as an essential ingredient of voluntary talk therapy) in the preceding list of
coercive activities an effort to domesticate externally imposed force as treatment? Similar strategic inclusions have occurred in
psychiatry before. The most common examples of this are the linguistic efforts to authenticate “mental illnesses” as physical
diseases by lumping together problems such as depression and schizophrenia within lists of common neurological disorders or
“brain-based disorders” that have identifiable neurological signs, such as Parkinson’s disease or Alzheimer’s disease, though neither
depression nor schizophrenia have any such signs.
ACT appears merely as a recent manifestation, adapted to the exigencies of life beyond hospital walls, of the longstanding,
coercive strain that has characterized psychiatric interventions with mad persons to this day and that duplicitously assumes the cloak
of scientific activity and scientific progress.
 Conclusion
Psychiatric practice, by our reading, appears to have lost even the semblance of moral rectitude regarding the employment of
coercion. It used to pretend that when men and women of science, motivated by the desire to heal, forced mad persons to submit to
their ministrations, this was not coercion but medical treatment. Today such a pretense no longer seems necessary. A thriving body
of research, supported among others by the NIMH and the MacArthur Foundation (Dennis & Monahan, 1996, p. 15), fully explores
the therapeutic value of coercion. The deprivation of autonomy and freedom is increasingly being redefined as a therapeutic tool
rather than a violation of human rights.
When we searched the Medline database up to and including 2007 for indexed articles about psychiatric coercion (using
coercion, outpatient commitment, and civil commitment as independent key words), we identified 796 articles. Only 22 articles were
published before 1970, in contrast to 665 articles between 1991 and 2007 (39 articles a year). The first noticeable spike in
publications occurred in 1971, around the time community treatment became a focus of research. In the abstracts, we note only a
handful of voices dissenting from the general view that coercion, though “controversial,” is ultimately just another therapeutic
mechanism deserving examination.
Indeed, some eminent psychiatric scholars have recently unabashedly defended the use of psychiatric coercion, without any
pretense that it is somehow a form of medicine. It is just plain coercion. Jeffrey Geller (2012), professor of psychiatry and director
of public sector psychiatry at the University of Massachusetts Medical School, asserts that “the psychiatrist’s option to employ
coercion is an integral component of functioning in this recovery oriented paradigm . . .” (p. 493, italics added). Geller is candid
about the level and forms of coercion in outpatient treatment:

Coercive interventions, with little or no review by anyone other than a physician or a treatment team or administrator, are
rampant in entitlement programs; they include leveraged housing (for example, “If you want to live in this residence, you
have to take your medication as prescribed and go to a day program”); representative payeeships; “bargained”
psychopharmacologic regimens (for example, “You take your antipsychotic and you can have a benzodiazepine”); waiver
of civic responsibility (for example, jury duty); treatment “contracts” through Individual Service Plans; and threats of
emergency detention (for example, civil commitment). (p. 494)

Geller proposes that regardless of psychiatric status, individuals routinely get coerced in the community, which he finds
equivalent to “prevention and treatment”:

A person who repeatedly gets stopped for speeding loses his or her license and must attend classes to get it back
(treatment). . . . Someone who disrupts a public event is removed from the venue (treatment, behavior modification). If you
park illegally, the car is towed and you get fined . . . (treatment and prevention). (p. 495)

After medicalizing drivers’ education, Geller feels he must now demedicalize forced treatment by medical doctors: “If a person
behaves in a way that is dangerous to others, and the danger can be mitigated by psychiatric treatment, the person gets treatment. . . .
It is coercion in the same way that others in the community are subjected to coercion. It is not coercion because of ‘psychiatric
status’: it is an intervention to address behavior. Just as we all experience” (p. 495).
But Geller is clearly mistaken here. He confuses public laws that all citizens must obey to avoid punishment with coercion that
only the mad endure precisely because they are deemed mad by psychiatrists. Society does not enact special laws to coerce speeding
drivers on the basis that they suffer from a mental illness that is responsible for their speeding. But society coerces dangerous people
into psychiatric treatment only on the basis of special laws that require a diagnostic evaluation by a psychiatrist. Actually, Geller is
on to something, but not what he intended. Geller repeats that coercion occurs everywhere in society, not just in psychiatry, because
he wants to make psychiatric coercion palatable. But as he makes this argument, he is forced to recognize that no existing
psychiatric treatment can compete with coercion: “the notion that we can eliminate all coercive interventions by using our current
array of psychopharmacologic agents, psychotherapies, and rehabilitation interventions is without precedent” (p. 494). Undoubtedly,
Geller is admitting that psychiatry relies on a foundation of coercion.
Another eminent psychiatric scholar, Allen Frances (2012), best known as the Chair of the DSM-IV Task Force and whose views
on diagnosis we discuss in chapters 4 and 5, goes even further than Geller in acknowledging the nature of coercion in psychiatry
and, probably unintentionally, deals a fatal blow to the claim that coercion has anything to do with medical treatment.
In a reply to an article by psychologist Jeffrey Schaler (2012), Frances writes: “I agree completely with Schaler and Szasz that
mental disorders are not diseases and that treating them as such can sometimes have noxious legal consequences.” He singles out
“schizophrenia”: “. . . mental disorders are constructs, nothing more but also nothing less. Schizophrenia is certainly not a disease;
but equally it is not a myth. As a construct, schizophrenia is useful for purposes of communication and helpful in prediction and
decisionmaking—even if . . . the term has only descriptive, and not explanatory, power” (p. 1). If schizophrenia is “not a disease,” as
psychiatry has long claimed, Frances must come to terms squarely with the nature of psychiatric coercion: “I have evaluated
[patients who ‘desperately needed to be protected from hurting themselves or others’] many hundreds of times. While it is never
comfortable to coerce someone into treatment, it is sometimes the only safe and responsible thing to do, and occasionally it is life
saving. . . . Coercive psychiatry, however unpleasant, must be available as a necessary last resort when nothing else will do” (p. 2).
Frances’ makes the simple case for psychiatric coercion, namely, that the functioning of society requires force when the
intermediary social control functions of persuasion and seduction fail (Peckham, 1979). Normally, the imposition of force or
violence is entrusted to soldiers and policemen. When psychiatrists or mental health professionals defend and engage in coercion,
they are essentially police posing as doctors or therapists.
The use of coercion to control the mad in America for four centuries has continually been marketed not as the use of force to
manage a disobedient and troubling group, but as the application of better and more progressive treatments to aid a group suffering
from a serious medical infirmity. The presumed treatments are presented as having been developed through advanced scientific
techniques and building on previous work to create increasingly more effective interventions. Over the last couple of decades, many
of these interventions have been anointed as “evidence-based practices” (EBPs), as we have discussed in this chapter.
It is apparent that coercion is increasingly seen in psychiatry and in other mental health professions and the legal profession as an
acceptable form of treatment needing no critical scrutiny beyond meeting the technical criterion of effectiveness. “Psychiatric
scientific authority” has transformed coercion into a routine intervention, leaving the average psychiatric researcher to focus on the
technical details of the issue (i.e., how well does coercion “work” to produce this or that outcome?) and to lose sight of larger moral
issues regarding human freedom, dignity, and autonomy (Cherry, 2010); of the perspectives of those subject to coercion (Oaks,
2011; Olofsson & Jacobson, 2001); and even of the narrower issues of whether coercion should ever be used as a “tool” of helping
professionals, free of the safeguards that surround its uses outside of the mental health system.
As we have suggested in this chapter, the two roles of psychiatry—that of social management (involuntary psychiatry) and
therapeutic helping (voluntary psychiatry) of the mad—are irreconcilable. In order for one to work the other cannot. Effective social
management may require a coercive social technology (ultimately, incarceration) to enforce compliance if social seduction (i.e.,
friendly persuasive rhetoric or incentives) fails. The availability of psychiatric coercion greatly constrains the choices the mad have
about their treatment. Police are not therapists, even when they act to deescalate anger and potentially violent behavior. But
psychiatrists, rhetorically equipped by medicine—doctor, mental illness, diagnosis, treatment—can use police-like coercion over the
mad. To us, force is force, regardless of how it is labeled. The intentions of those who wield force may be benevolent, but force
hurts equally—whether we call it punishment or “punishment therapy.”
We believe that a voluntary psychiatry and an involuntary psychiatry cannot both be the same enterprise, evaluated by the same
criteria, scientific or otherwise. The small number of dissenting voices concerning the legitimacy of psychiatric coercion does not
indicate the rightness of the approach, only the numbing of moral and critical faculties. The historical role of punishment of the mad
has conveniently been imbedded in the medical model because of the ways in which control and coercion easily slip into the
benevolent rubric of treatment for the relatively powerless and vulnerable. Outside hospital walls, control and coercion have been
embraced by various professionals and institutions in society, justifying it as a relatively small price to pay to ensure proper
“medical” treatment of distress and misbehavior. The next two chapters scrutinize the evolution of one “scientific” tool of psychiatry
that converts personal turmoil into disease and the socially misbehaving into medical patients—the expanding dictionary of
psychiatry, the Diagnostic and Statistical Manual of Mental Disorders.
 Notes
1. The famous study by Erving Goffman described in his 1961 book Asylums discusses the toxic effects of being confined in “total institutions.” Based on Goffman’s field
observations of ward behavior at St. Elizabeth’s Hospital in Washington, DC in 1955–1956, it makes not a single allusion to the use of major tranquilizers. The first of
these drugs, Thorazine was commercially released in the United States less than a year before, in mid-1954. St. Elizabeth’s is best known today for detaining the infamous
John Hinckley Jr., who attempted to assassinate President Ronald Reagan in 1981.
2. Think of the payment of income taxes. Because the Internal Revenue Service is able to enforce the tax code through criminal and civil sanctions, it would be naïve to
conclude that people pay taxes “voluntarily.”
3. The rubric of seriously mentally ill or having a serious mental illness (SMI) (sometimes also referred to as “major mental illness” or “serious and persistent mental
illness”) has been formalized by the federal government. It began to be used in the 1990s. The government definition of SMI “includes all [DSM] diagnoses, substantial
disability, and no required duration (some estimates show this [label] as encompassing 5–7% of the U.S. population ages 18+ [about 3.3 million adults])” (Kuntz, 1995, p.
6). What individuals placed in this category share as a group, despite their differing DSM diagnoses, is their “substantial disability,” which justifies psychiatric
intervention. A “substantial disability” could be physical, such as being blind or having a chronic physical disease such as diabetes or severe coronary disease that may
limit full social participation. In this instance, however, “substantial disability” means lacking skills that cause serious and “specific limitations in work, school, personal
care, social functioning, concentrating, or coping with day-today [sic] stress” (p. 6). Most SMIs are unemployed and may show little ability in maintaining traditional
relationships. They depend on others to take care of them because they appear unable to do basic life chores such as manage their funds, use public transportation, launder
their clothes, cook, or dress conventionally (Test & Stein, 1978). As psychiatric epidemiologists Ronald C. Kessler and Shanyang Zhao explain, “Epidemiologic
information about the prevalence of individual disorders is much less important than . . . the prevalence of functional impairment, comorbidity, and chronicity” (1999, p.
77). The terms comorbidity and chronicity mean having several personal difficulties that have lasted for a long time.
4. The counting of patient care episodes tracked by the federal government since 1955 is a duplicate count, since a person may be admitted to more than one type of service
or can receive the same service more than once in any one year. The number of individuals who receive multiple service episodes is unknown, so we are unable to have a
total unduplicated count of the number of persons under care in any one year.
5. EBM is clinical epidemiology on steroids. David Sackett, EBM’s most well known developer explains: “Clinical epidemiology has played a central or major role in five
recent evolutions (some say revolutions) in healthcare: in evidence generation, its rapid critical appraisal, its efficient storage and retrieval, evidence-based medicine, and
evidence synthesis. As more and more clinicians, armed with the strategies and tactics of clinical epidemiology, cared for more and more patients, they began to evolve
the final, vital link between evidence and direct patient care. Building on the prior evolutions, and manifest in clinically useful measures and often incorporating the
patient’s own values and expectations, the revolution of Evidence-Based Medicine was introduced by Gordon Guyatt. Since its first mention in 1992, its ideas about the
use (rather than just critical appraisal) of evidence in patient care and in health professional education have spread worldwide, and have been adopted not only by a broad
array of clinical disciplines but also by health care planners and evaluators” (2002, p. 1164).
6. Clinical treatment effect is defined as some specified non-administrative clinical/biological/behavioral component(s) of a treatment program that can motivate or cause
internalized/volitional change, or the “acquisition of coping skills” by clients, which leads to clients’ improved functioning that results in reduced hospital stays and
greater “independent” community tenure in a community mental health program such as ACT.
7. The Cochrane Collaboration is the leading organization carrying out and maintaining a database of EBM systematic reviews. It does this through voluntary work groups
whose members apparently are only cursorily checked for expertise before joining. As their website informs the curious:

NOTE: Membership of a Cochrane group is not based on formal qualifications. There are no membership fees. The key
requirements are that you:

have suitable skills (and willingness to learn new ones);

can volunteer some of your time over an extended period;
work as part of a team;
support the aims of the Collaboration; and
share the Collaboration’s spirit of goodwill. (Cochrane Collaboration, n. d. Retrieved from www.cochrane.org).
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 4
And DSM Said: Let There Be Disorder

DSM-III exemplified the antiscientific and irrational approach to perfection; it does not discuss or argue,
but lays down the law as if it were dealing with a paradigm which no rational person could quarrel with.
The fact that such an approach and such an empty, atheoretical, and antiexperimental system can find
acceptance in psychiatry says more about the nature of modern psychiatry than any critic, however
hostile, might be able to say.

Eysenck, 1986, p. 95
 Introduction
The Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM, is owned and published by the American
Psychiatric Association, the APA. For sixty years, the manual has been the classification system of mental illness in the United
States. It is revised every fifteen years or so by a committee of psychiatrists appointed by the APA.
From 1952 until 1980, the DSM never merited serious attention. The manual was a slim, eighty-page, spiral-bound,
administrative codebook. Its primary use was to provide code numbers for the diagnoses that patients received in treatment
institutions. It was based on the common-sense judgments of a small group of appointed psychiatrists. There was no pretense that
DSM’s usefulness extended beyond administrative convenience. It was not a textbook used to train mental health professionals, not
a guide for research, not a tool to decide who would receive services for personal problems, not an instrument of corporate or public
bureaucracies, not the subject of controversy, and certainly not a document whose authors or overseers claimed as a scientific
achievement.
That all changed dramatically in 1980 with the publication of the third edition, DSM-III. In this chapter and the next one, we will
examine that transformation, its scientific claims, its social consequences, and how the manual’s weaknesses are being exploited as
the controversial fifth edition is being readied for publication in 2013.
The current controversies encompass a concern about the meaning, nature, and boundaries of madness. As described in chapters
1 and 2, even the terms most people use—which do not have satisfying definitions—are controversial: insanity, mental disease,
brain disease, brain-based disorder, psychopathology, mental illness, and mental disorder. These terms refer to some presumed, ill-
defined pathological internal condition in individuals that causes personal or social concern. We will continue to use these terms
interchangeably, as all of them remain in play in discussions of madness.
The story in this and the next chapter will center on the evolution of the DSM, which represents psychiatry’s answer to questions
about the meaning of madness. Rather than recounting scientific progress in recognizing and fighting disease, as the NIMH and the
leaders of the psychiatric establishment might suggest, the story is a multilayered tale of competing interests, professional politics,
commercial interests, and pseudoscientific claims. It is also an account of cultural transformation: how a widening array of human
anguish, misbehavior, and travail has come to be viewed as the result of brain disease.
Psychiatrists, although they constitute a minority of mental health workers, literally “own” the contemporary meaning of
madness.1 That ownership is the cornerstone of their profession: its area of responsibility and control. As such, psychiatry must
maintain firm control over the meaning of madness and ensure that it is shared among experts who recognize it as legitimate and
that it remains accepted by the public. In the last forty years, psychiatry periodically has had serious trouble maintaining agreements
about the meaning of madness and the methods for recognizing it. The common site for those troubles has been the DSM. Some
historical context will help.
In politics and our personal lives, we tolerate vague language and concepts held together by no more than tacit agreements in
order to facilitate social cohesion and avoid potentially interminable disagreements. Scientific inquiry, however, requires that
concepts meet higher standards than those expected of political slogans or marketing pitches. Scientific ideas must be subject to
systematic, rigorous, and independent scrutiny, verifying that they have a good correspondence with the real world. Psychiatry is the
leading mental health profession, and, as in medicine in general, the meaning of the core concept of disease and illness must be
broadly shared, specific in content, and have a consistent and verifiable basis in reality. Psychiatrists must establish that they know
what mental illness is and are able to recognize people who are mentally ill and those who are not.
In the language of science, having a firm grip on the meaning and recognition of madness requires that any classification of
mental illnesses, such as the DSM, must possess both reliability and validity. We examine these different but related requirements in
this and the following chapter. For now, suffice it to say that the validity of psychiatric diagnoses refers to whether the definition and
meaning of mental illness can be objectively shown to refer to something that is factually true. The reliability of diagnoses involves
establishing whether mental health professionals can independently agree on which diagnosis applies to people evaluated.
Agreement among observers, however, does not guarantee truth, because people could agree on something that is factually
incorrect. But if people couldn’t agree, for example, on who should be diagnosed as bipolar, it makes it very difficult to establish the
meaning and nature of that disorder (i.e., the validity of that diagnosis). Reliability should be much easier to establish than validity.
Who Is Mad?
Let us begin with a news story that is typical of how madness is commonly represented in the media. In June 2005, the New York
Times reported, based on a recently published study (Kessler et al., 1994), that psychiatric researchers had estimated half the
American population has had or will have a mental disorder at some time in their life and that more than one quarter of the
population had at least one mental disorder in any given year (Carey, 2005). The thrust of the story, and that of many other news
reports, is that madness is even more widespread than previously thought, that many people do not recognize their illnesses, and that
many of those who are ill are not getting the proper treatment. The striking claim in this instance is the remarkably high proportion
of mentally ill that the researchers claimed to have discovered. As described in chapter 2, several generations ago, less than one fifth
of one percent of the American population was described as mentally ill—primarily those in state asylums.
The numbers pointing to this epidemic of madness came from a telephone survey of the general population, one of the most
influential surveys ever undertaken by psychiatry. Certainly, we are familiar with telephone polls of our political opinions and
expected votes in elections, during which our answers are recorded. These polls are usually surprisingly accurate, because people
understand the questions and candidly reveal how they intend to vote. The New York Times article, however, is addressing a much
more complex foundational claim by psychiatry and the NIMH (which sponsored the research); namely, that researchers can ask
people a few questions, actually identify if they are mad, and distinguish one form of madness from another.
Psychiatric telephone interviews, such as the one reported, do not ask respondents if they think that they are mentally ill or about
which mental illnesses they have had in the past. Instead, telephone interviewers asked randomly selected adults a series of
structured questions about rather common behaviors, derived from long lists of behaviors and emotions that are listed as symptoms
of mental disorder in the DSM. Computers then counted the responses of those interviewed to determine whether the answers
matched the DSM criteria to qualify for a mental disorder.
Whether this sort of counting is science or propaganda depends entirely on whether the concept of mental illness represented by
DSM can withstand scrutiny and whether there is persuasive empirical evidence that the diagnoses of mental illnesses in DSM and
the criteria that define them are credible and can be used consistently. Thus, the DSM with its list of disorders and symptoms is the
foundational scientific cornerstone on which psychiatry stands.
When public health officials want to check the prevalence of a disease, they typically have some reliable method of determining
who has and who does not have the disease. For example, populations are screened, not by asking people questions about their
feelings, but by using blood or other biological tests to determine the prevalence of HIV/AIDS, H1N1 influenza, pneumonia, cancer,
and many other diseases. That is because the presence of diseases is identified by examining living cells. Not so with the “diseases”
of madness. There are no biological tests, markers, or pathophysiology for any of the diagnoses listed in DSM.
Even in the twenty-first century, little is known about the presumptive causes of mental disorders in DSM. Although the
psychiatric establishment increasingly claims that mental disorders have some biological causes and has had considerable success in
making the public think that this assertion has been scientifically proven, there is little evidence for this. This particular sleight of
hand can be seen in the evolution of DSM. In the 1980 and prior editions of DSM, the manual set aside a section for “organic mental
disorders” (with known etiology, e.g., delirium caused by alcohol withdrawal or dementia caused by a cerebrovascular accident).
DSM claimed that these disorders were associated with “transient or permanent dysfunction of the brain (APA, 1980, p. 101).
In the most recent edition, the approach is different. The term organic mental disorder has been expunged: “The term organic
mental disorder is no longer used in DSM-IV because it incorrectly implies that ‘nonorganic’ mental disorders do not have a
biological basis” (APA, 2000, p. 135). Little more is said, as if somehow science had established in the intervening twenty years the
biological basis for all mental disorders. In one sentence, DSM appears to disguise ignorance of the etiology for what it calls mental
disorders as firm knowledge of their biological basis. The false implication by the APA is that knowledge of some pathophysiology
of neurological diseases such Alzheimer’s or observations that some people become physiologically dependent on various drugs are
analogous to knowledge of the “biological basis” of all mental disorders listed in DSM. We shall have more to say on this issue in
this and the chapters that follow.
Who is counted as mentally ill depends entirely on the frequently changing list of disorders and an incredibly long checklist of
behaviors, mood states or feelings, and verbalizations that DSM considers as symptoms of mental disorder. We and many other
scholars (Carlat, 2010; Frances, 2010b; Greenberg, 2010; Horwitz, 2002; 2010, Horwitz & Wakefield, 2012) argue that there are
now higher estimates of mental disorders in the United States because the APA keeps adding new disorders and more behaviors to
the diagnostic manual. These are some of the new disorders that have been added to DSM since 1979: panic disorder, generalized
anxiety disorder, posttraumatic stress disorder, social phobia, borderline personality disorder, substance use disorders, gender
identity disorder, eating disorders, conduct disorder, oppositional defiant disorder, identity disorder, acute stress disorder, sleep
disorders, nightmare disorder, rumination disorder, and sexual disorders, including inhibited sexual desire disorder, premature
ejaculation disorder, male erectile disorder, and female sexual arousal disorder.
Each new and old disorder comes with a list of “diagnostic criteria,” the behavioral checklists that constitute the heart of DSM.
As any reader would quickly recognize, these are not lists of strange, bizarre, or inexplicable behaviors. Rather, they appear to
describe behavior and traits frequently self-reported or observed in everyday life. In the DSM, however, just about any behavior can
qualify as a “symptom.” Here is a selection from hundreds of behaviors listed in the DSM as criteria of mental illnesses:
restlessness, irritability, sleeping too much or too little, eating too much or too little, difficulty concentrating, increasing goal-
directed activity, fear of social situations, feeling morose, indecisiveness, impulsivity, self-dramatization, using physical appearance
to draw attention to self, being inappropriately sexually seductive or provocative, requiring excessive admiration, having a sense of
entitlement, lacking empathy, being envious of others, arrogance, being afraid of being criticized in public, feeling personally inept,
being afraid of rejection or disapproval, finding it hard to express disagreement, being excessively devoted to work and productivity,
and being preoccupied with details, rules, and lists.
For children, signs of disorder occur when kids are deceitful, break rules, can’t sit still or wait in lines, have trouble with math,
don’t pay attention to details, don’t listen, don’t do homework, lose their school assignments or pencils, or speak out of turn.
Granted, one momentary feeling or behavior is not expected to qualify you officially for a DSM mental disorder; it requires small
clusters of them, usually for several weeks, accompanied by some claimed serious discomfort to you or those around you.
Nevertheless, these additional criteria are regularly ignored when there are perceived short-term benefits to be gained from
diagnosing someone with a mental disorder.
These new illnesses and extensive lists of behaviors are part of the reason why almost everyone has by now noted that there
appears to be an epidemic of mental disorders in the United States (Whitaker, 2010). But the manufactured epidemic is about to
spread even further. In the early draft of DSM-5 (February 2010) are proposals to broaden the definition of mental disorder, lower
the thresholds for many disorder categories, and create even more illnesses—though a few existing disorders are also slated for
termination. We will have more to say about these matters later in this and the next chapter. Such expansion has its skeptics, who are
suspicious of the motivations of the APA and the drug companies, who view the expanding sweep of mental disorders like a lumber
company lusts for redwood forests. But unlike typical challenges to the physical or political environment, in the mental health arena
there are no legions of watchdogs challenging this medicalization of human foibles. The public’s acquiescence in accepting brain
disease as an explanation for personal troubles is a puzzle that we will address later. For now, we should review how a small, largely
ignored administrative codebook became a massive compendium of human troubles that reshaped psychiatry, mental health
services, and the public culture. Although the psychiatric enterprise claimed that this transformation was based on science, we will
see that, again, the scientific evidence is elusive.
 A Short History of Psychiatric Diagnosis
During the middle of the twentieth century, American psychiatry was heavily influenced by psychoanalysis and paid little attention
to official classifications of mental disorders. Diagnostic categories were of minor importance, useful more for administrative
counting purposes, first in state asylums and later in clinics (e.g., see DSM-I and DSM-II). Diagnostic labels (such as Hysterical
Personality or Depressive Neurosis, from DSM-II) were not emphasized in treatment, research, or training in any of the mental
health professions. Diagnoses were uninteresting and banal, except as administrative shorthand or as a way to discuss the more
interesting psychological dynamics in a patient’s biography and, most importantly, were never claimed to be scientifically valid.
In an ethnographic study of the training of psychiatrists, the anthropologist T. M. Luhrmann (2000) captures the mind-set of
those learning to be psychodynamic psychotherapists. Such a psychiatrist

. . . learns to construct complex accounts of his patients’ loves. He thinks in terms of the way his patients are with other
people and in terms of the emotions and unconscious motivations that lead his patients to hurt themselves. Here there is no
clear-cut line between health and illness. What is wrong with a patient is that his interactions with other people go or have
gone awry, and being a good psychiatrist involves understanding how and why. (p. 83)

By contrast, Luhrmann observed that the biomedical, post-DSM-III psychiatrist in training

. . . learns to memorize patterns and starts to use them in a rough-and-ready way. He learns to think in terms of disease and
to see those diseases as quickly and as convincingly as a bird-watcher identifies different birds. For him, what is wrong
with a patient is that the patient has a disease, and being a good psychiatrist involves seeing the patient in terms of the
disease. For him there is a clear-cut difference between illness and health. (p. 83)

Until 1980 mental disorders were defined as whatever a committee of psychiatrists listed in the DSM. No definition of mental
illness or mental disorder was offered in the manual, and few people were troubled by the absence. The public seemed content to
leave the matter to the discretion of psychiatrists. Even without a definition and only vague descriptions in the manual, troubled
people were referred to mental health providers, patients received diagnoses and were treated, students were recruited and trained to
offer therapies, and research about madness continued to receive funding. In fact, as we describe in chapter 2, the size and scope of
the psychiatric enterprise grew briskly following World War II without much clarity about what constituted mental illness or how to
distinguish it from a vast array of other problems in living—or even whether it was necessary to make such distinctions.
Developing a definition of madness as mental illness/disorder or establishing its validity, when so little was known scientifically
about it, was a conceptual and practical morass. As long as no one demanded clarity, ambiguity had advantages that precision of
thought might lose. For example, without any scientific or conceptual guidance, the early editions of the DSM published in 1952
(DSM-I) and 1968 (DSM-II) were at liberty to list all manner of mental disorder categories, such as Inadequate Personality, Gross
Stress Reaction, Group Delinquent Reaction of Childhood, and Homosexuality. The manuals were silent on what principles were
followed in deciding to include these or any categories. Madness was whatever psychiatrists listed in DSM, whether diagnosis with
some type of neurosis, psychosis, affective or personality disorder, or one of the “transient situational disturbances,” most of which
came with only several sentences of description. Notably, there was little public or professional concern regarding psychiatry’s
singular authority over these matters.
Psychiatric diagnosis is a form of classification, an attempt to group human behaviors that may be disturbing or unwanted into
categories of disease that appear to or actually share essential features (a conjunctive category, as discussed in chapter 2).
Classification is essential for all science. There could be many bases of classification of diseases in medicine and psychiatry, but the
most profound categorizations are grounded in an understanding of the causes of disease (their etiology), because such categories
may suggest effective approaches to prevent or treat what is obviously undesirable. Developing a classification of mental disorders
based on causes, however, has been impossible for several reasons. First, we don’t know what madness is, whether it exists as an
entity, whether what are labeled as mental illnesses are “illnesses” in any medically valid sense, or whether the concept itself is a
semantic trash bin for all that is behaviorally inexplicable (a disjunctive category, as also discussed in chapter 2). Second, one can’t
discover causes for something one can’t define or identify. Third, one might classify according to the essential features or
characteristics of the disorders, but there has been virtually no agreement throughout history and even in the modern age, about what
these essential features might be—as the changing diagnostic criteria themselves of the DSMs over only the past thirty years testify.
Nonetheless, as we have seen in chapter 2, putative classifications of madness have existed since ancient times (Zilboorg, 1941).
During the twentieth century, two dominant approaches to diagnosis coexisted, each spawned by men born in 1856: Emil Kraepelin
and Sigmund Freud.
Creating a Disease
Emil Kraepelin (1856–1926) was a German physician who developed the hypothetical construct of dementia praecox, from which
the construct of schizophrenia is derived. Kraepelin postulated the existence of dementia praecox as some kind of metabolic disorder
as he went about studying patients in his asylum whom he thought suffered from the disorder (Boyle, 2002, pp. 3ff). The asylum
inmates were a heterogeneous population of imprisoned people with a variety of problems who exhibited a diversity of behaviors.
Kraepelin’s general approach was to observe the inmates’ behaviors to find similarities in the way the behaviors changed over time.
He wanted to study the whole course of the presumed disease in order to discover distinctive patterns, natural groupings, or entities.
He believed that the behavioral patterns he hoped to find would later be discovered to have distinctive biological antecedents and
cerebral pathology, as well as a similar onset, course, and outcome (Boyle, 2002, p. 11).2 In this particular ambition, he failed. But
what he succeeded in accomplishing was the creation of an illness label—dementia praecox—which he and other interested
physicians presumed to represent a discrete disorder with some underlying biological cause modeled in part on another presumed
mental illness, general paresis, which later was found to be a late stage of the brain disease neurosyphilis. His observations and
descriptions of those he assumed had dementia praecox did not constitute scientific evidence that dementia praecox existed as a
discrete entity. Its existence was presumed a priori (Boyle, 2002, p. 49). This tactic has been used with all subsequent psychiatric
diagnoses, none of which were grounded on any convincing evidence of ontological reality.
Kraepelin’s approach allowed a fundamental confusion to occur, blurring the difference between, on the one hand, establishing
scientifically the existence of a disease by noting within the general population a previously unobserved and non-randomly
occurring discrete grouping of physical signs (a syndrome), and on the other hand, assuming the existence of a disease and then
describing various odd and disturbing social behaviors as symptomatic of this construction. This confusion provided a platform in
the 1970s for the emergence of the expansion of psychiatric diagnosis. As we will see, Kraepelin (and those later referred to as neo-
Kraepelinians) labeled selected troublesome or unusual behaviors the symptoms of hypothetical diseases and then took these
symptoms as evidence of the existence of the disease, leaving for later the discovery of the hypothesized causative connections
between these “symptoms” and the disease. Making these huge leaps possible is the expectation that at some future point the
physical evidence of these diseases will be known, as occurred in the past when new technologies or methods, such as autopsies,
provided ways of peering into the body itself and uncovered evidence for physical pathology or brain lesions. Indeed, throughout the
twentieth century, new technologies were being developed. The discovery of microorganisms by Pasteur, Koch, and others led to the
delineation of many clinical diseases and their prevention. Later with X-rays, biochemical tests, and diagnostic radiology, the
biological confirmation of the correlations between pathological processes and clinical symptoms could be established. Specific
biological tests, such as the Wassermann Test for syphilis, were then developed as the definitive methods of documenting internal
pathology (Klerman, 1986, pp. 11–12). Kraepelin’s approach to classification was through detailed description of the behaviors
constituting presumed diseases, the existence of which was left for future medical researchers to document scientifically. His
process was to assume that some particular disease existed, identify people who presumably had the disease, then describe their
unusual or problematic behaviors and their evolution. We will discuss the contemporary counterpart of this approach shortly.
Making Madness Normal
A contemporary of Kraepelin, Sigmund Freud (1856–1939) was a neurologist also interested in bizarre behaviors. Unlike Kraepelin,
however, Freud’s work would make him a household word and cultural icon by the middle of the twentieth century. His work not
only influenced psychiatric theory and the mental health professions, but culture, art, and literature around the world, whereas
Kraepelin remained known only to a few psychiatric scholars.
Unlike Kraepelin, however, Freud’s clinical work was not among patients in asylums, but among individual outpatients with less
severe problems, in the sense that these problems rarely brought them into open conflicts with authorities. More important, Freud’s
adult patients could hire and pay him directly and be free to reject his diagnoses or advice if they so wished—something none of
Kraepelin’s patients/inmates could possibly do. Freud had little interest in classification or the detailed description of symptom
patterns. The studies were intensive, in-depth, conversational explorations of what Freud speculated were the intrapsychic worlds of
patients. By means of his case studies and conversations, which he later renamed psychoanalysis, Freud explored the presumed
psychological and cultural dynamics of human behavior, in particular how hypothesized instinctive, biological urges of humans
interacted with the demands of civilization to shape human character. Whereas Kraepelin was a describer and classifier of bizarre,
stigmatized, and unwanted behaviors, Freud was a theoretician of the human condition itself. Whereas Kraepelin was interested in
the madness and degenerative brain diseases affecting people sent to insane asylums, Freud attempted to explain the
psychodynamics of everyday life and civilization.
Freud asserted that curious, strange, or seemingly harmless behavior was potentially an expression of psychopathology. Even
though his theories of mind and psychopathology have fallen out of fashion in most countries, a devoted core of his followers, with
modified psychodynamic approaches, remains and in certain places thrives, and his work continues to have a lasting impact on
psychiatric diagnosis. There are three main elements to his contemporary influence.
First was his ability to make us suspicious about the meaning of behavior. Nothing was what it seemed. Ostensibly loving
behaviors could mask aggression; fastidiousness could cover impending disorderliness; a slip of the tongue could harbor clues to
unconscious, perverted desires. Using the invented notions of unconscious desires and psychic conflicts; the tug-of-war of id, ego,
and superego; and the control functions of defense mechanisms, he argued that what we consciously espouse and how we behave is
unconsciously connected to the same psychological dynamics that cause more obvious and severe problems. Psychopathology, he
suggested, could be lying just beneath the surface of our most mundane behaviors and feelings. Every behavior might be a possible
symptom of latent mental illness.
The second element to his contemporary influence is related to the first. If any behavior might be a symptom, then potentially
everyone might be a little mad. In suggesting that psychopathology was part of the bargain of being human, Freud, in Civilization
and Its Discontents, explained madness as an expected and inevitable part of life. The psychic energy and unconscious conflicts that
were required to repress our most primitive urges so that human society was possible, he conjectured, affected our cognitive and
emotional lives in ways that could produce anxieties, emotional turmoil, and troublesome or inexplicable behaviors. To resolve these
dysfunctional conflicts and subdue the troubling symptoms, Freud and his followers proposed, required in-depth psychoanalysis.
The popularity of psychoanalysis grew into a burgeoning potpourri of therapies by the 1970s, not only for the “worried well” and
middle class, but for those exhibiting bizarre behaviors. Although the evidence for the “effectiveness” of these therapies or their
comparative advantages remained scientifically thin, seeing common behaviors as psychopathology grew in popularity. (In chapter 6
we will see that this is similar to the later popularity of drugs: abundant but thin scientific evidence and growing popularity.)
The third way in which Freud transformed how we viewed disturbing behavior was to further medicalize it. As a neurologist,
Freud relied on the language and methods of medicine to understand and describe human behaviors. The medical language of
“psychopathology” largely supplanted other forms of discourse about human troubles (e.g., the moral, the spiritual, the legal).
Undesirable behaviors, such as excessive elation, sexual interest in children, aggressiveness, or heavy drinking, instead of being
viewed as unwise, immoral, criminal, or sinful—the product of poor upbringing, weak character, or willful deviance—were
transformed into expressions of illnesses of the psyche (or the more familiar reification, mind). Using the idiom of medicine, Freud
may have surmised, allowed for seemingly simple explanations that would deeply resonate with people. Conveniently, Freud offered
a remedy—his own style of treatment. Patients had illnesses which were not entirely controllable on their own. Those afflicted were
not fully responsible for their actions, being based on activity in the “unconscious.” Their behaviors were not willed, any more than
getting pneumonia or polio makes a person culpable. People with troubles should seek treatment. Freud’s later insight (Freud, 1969,
p. 92), that the work of the psychoanalyst was like that of “secular pastoral work,” has often been repeated but was drowned by the
more powerful mythic image of the physician manipulating unconscious material and restoring the helpless patient to healthy
functioning.
In different ways Kraepelin and Freud prepared American culture for the great transformation in psychiatric diagnoses that began
in the 1970s and fully bloomed after the publication of DSM-III in 1980. What they both contributed was a way to classify
hypothesized mental disorders by minute descriptions of the behaviors of those thought to be afflicted, a large list of labels for
presumed illnesses, the use of medical and medical-sounding language to describe hypothesized groupings of common behaviors as
psychopathology, and the notion that countless forms of psychopathology—mental illnesses—were ubiquitous among the populace,
lying beneath the surface and requiring medical detection and treatment.
 The Vulnerabilities of Mid-Century Psychiatry
By the mid-1950s, with the help of Kraepelin and Freud, American psychiatry had acquired a vast territory of behaviors as its
appropriate domain. By 1960 mental disorders had entered the mainstream of American life, under the jurisdiction of the newly
established National Institute of Mental Health and the subject of a major report (Joint Commission, 1961) of a presidential
commission appointed by Dwight Eisenhower and President Kennedy’s mental health initiatives on establishing community mental
health centers across the nation. There were troubling currents, however, within this recognition and expansion of psychiatry.
American psychiatry was always a peculiar profession, whose members initially were the managers of state insane asylums.
Within medicine, psychiatry was situated at the bottom of the totem pole of medical specialties. For the general US public, which
typically venerate physicians and accord them power and status much higher than physicians have enjoyed in other industrial
countries, psychiatrists—shrinks—were frequently the butt of jokes and were depicted in movies and television as impish inquisitors
quick to make wild and seemingly nutty inferences about the underlying motivations of everyday troubles but also willing to use
coercion and brutality (see, for example, the 1948 movie, The Snake Pit). This occasional disparagement reflected an ambivalent
acceptance of the expanded domain of psychiatry and psychoanalysis and recognition of the overt coercive functions of
psychiatrists.
Even Freud’s success in influencing American psychiatry was a two-edged sword. On the one hand, problems labeled as mental
illness gained more national attention. On the other hand, the methods of treatment proposed by psychoanalysts looked like one-
sided, unstructured, nonmedical conversations. For example, psychoanalytic treatment involved no physical examination, no
stethoscope or other medical instruments, no probes of the body or laboratory tests to determine the nature of the ailment or its
disappearance. Instead, the therapy required that the patient merely lie on a couch and talk to the analyst, who would occasionally
make a comment or ask a question. The invention of this sort of “talking therapy” was a creative attempt to reframe interpersonal
help giving. Talking to others about personal problems, however, was hardly novel. It was a universal behavior used by troubled
people in soliciting help from family, friends, clergy, and counselors of all kinds. As we described in chapter 2, psychoanalysis and
its psychotherapy offshoots had the challenge of reinventing talking and discussion as an instrument of medical treatment.
Although Freud was a physician, offering talking therapy did not require the therapist to have the skills of medical doctors, and
even Freud, as we mentioned, thought that it was akin to pastoral counseling. The expansion of outpatient, office-based
psychotherapy made psychiatric treatment more accessible for many people, but it also attracted the involvement of other non-
physicians as purveyors of mental health treatment. Starting with funding to World War II veterans from the GI bill, clinically
oriented psychologists, social workers, and various counselors swarmed to the growing enterprise, far outnumbering psychiatrists
(Goleman, 1990). The threat was not so much that other professions competed for scarce patients, but that these competitors brought
with them various nonmedical interventions that they systematized as therapies, such as family therapy, gestalt therapy, milieu
therapy, reality therapy, cognitive-behavioral therapy, and many, many others. These new forms of interpersonal helping, often used
by psychiatrists as well, further de-medicalized therapy, showing that mental disorders and their treatment need not be the unique
province of medicine or psychiatry. Could not a social worker as well as a psychiatrist help a family with an unruly child or a
substance-abusing spouse? What, if any, unique role did psychiatrists play with regard to troubled clients who were not seen to need
modification by drugs or electroshock? How were medical credentials and training relevant to the new, popular interventions?
By the 1960s psychiatry had succeeded in expanding its domain and acquiring new federal recognition. With the increased
political salience, however, came increased scrutiny of its scientific grounding, effectiveness, and social purposes. At the historic
moment of psychiatry’s broader influence and institutional expansion, the essential core of the psychiatric enterprise came under
attack, producing a broad crisis for the profession. The center of this crisis revolved around the seemingly simple, internal matter of
the definition and diagnosis of mental disorder.
 The Perfect Psychiatric Storm
Despite its greater prominence by 1960, psychiatry was still less prestigious than other fields of medicine, in which there were
scientific discoveries of the causes of common diseases and breakthroughs in the prevention and effective treatment of many of
them, such as the development of antibiotics and the near eradication of polio with a vaccine. In psychiatry, there were few solid
examples of scientific “progress” or breakthrough discoveries, and, despite its political success, psychiatry remained a low-status
branch of medicine. Furthermore, with the movement away from institutional care in state hospitals and toward community
treatment (see chapter 3), psychiatry’s identity was blending into the amorphous, somewhat undifferentiated mental health
professions.
In part, these shortcomings of psychiatry stemmed from the fact that American psychiatry never needed to have a strong
scientific infrastructure. Most psychiatric residents were trained to be therapists rather than scholars and researchers. Because Freud
and his many adherents relied on case studies of individual patients, there was no well-established public health tradition of either
epidemiological studies of the incidence and prevalence of mental disorders in the broad populations or of comparative clinical trials
—carefully controlled experiments of the outcomes of different treatments.
At the same time, the massive discharge of residents of state asylums and the broad promises and claims about the wonders of
community treatment (see chapter 3 for details) produced visibility that wasn’t sought. For example, by the early 1970s there were
constant news stories about the emergence of the visible homeless, many of whom might have resided in asylums in prior decades.
In addition, doubts were raised about the clinical effectiveness or practicality of psychoanalytic therapy (Eysenck, 1952). But
profound new challenges were brewing. The challenges came from many quarters and shook the foundations of psychiatry,
particularly its scientific credibility, and created the perfect psychiatric storm. The questions had been around the halls of academia
for decades but had generally been ignored. What exactly was mental illness? Why was it considered to lie within the jurisdiction of
medicine? What evidence existed that psychiatrists could distinguish the mentally ill from the sane in ways that ordinary people
could not? Paradoxically, Freud’s legacy had so broadened the meaning of madness that psychiatry’s primary construct had become
even more ambiguous. (Although in America psychoanalysis had initially coupled with psychiatry, requiring psychoanalysts to
possess a medical degree and usually a psychiatric specialty, in most of the rest of the world, professionals of all stripes and even
laypersons could call themselves psychoanalysts after a course of study and personal analysis.) Within psychiatry itself, some
mainstream figures recognized that the profession, on the verge of becoming more nationally prominent, was vulnerable in terms of
its ability to define, identify, and diagnose mental illness (Kendell, 1975; Zigler & Phillips, 1961). Psychiatry’s vulnerability was
revealed sharply by a number of frontal assaults within a decade.
Assaults from the Academy
The physician and psychoanalyst Thomas Szasz, who became the most persistent and prolific critic of institutional psychiatry,
argued vigorously that what psychiatrists were calling mental illnesses had no underlying physiological dysfunctions but were
personally or socially unwanted, unpleasant, devalued behaviors (Szasz, 1961). Mental illnesses, Szasz argued, were just the latest
nineteenth- and twentieth-century bogus claims by psychiatrists for defining as “medical” problems what were in reality, social,
economic, ethical, and moral problems that all individuals face in the course of fashioning their existence and attempting to assert
their autonomy. He asserted that mental illness is a “myth,” in the sense that it is only a metaphor, an inappropriate analogy for
describing human problems in living as if they constituted medical diseases, but he was not denying that these problems existed.
This was a frontal attack on the Kraepelinian ambition. Szasz’s publications quickly became some of the most widely read and cited
critiques of psychiatry. His attack hit a nerve among psychiatrists, because no consensus existed on a definition of mental illness,
and no physical evidence existed for classifying problems in living as bodily diseases requiring the attention of physicians. Although
Szasz was quickly marginalized by the psychiatric establishment, his arguments were not easily rebutted and, partly because of his
prodigious output and his longevity (1920–2012), still persist in the vigorous contemporary debates about psychiatric diagnosis, as
they do in this book.
Social and behavioral scientists of many stripes joined the assault. Sociologists who had an interest in social responses to deviant
behavior pushed the criticism of psychiatry further. Erving Goffman, with his collection of illuminating essays, Asylums: Essays on
the Social Situation of Mental Patients and Other Inmates, was one of the first to cast a skeptical eye on psychiatric practices
(Goffman, 1961). State hospitals were categorized, not with other medical institutions, but with “total institutions,” such as prisons,
monasteries, and battleships, in which near total control over every aspect of the lives of inmates transforms their identities. Within
these institutions, patients had “moral careers” and had to devise ways of coping as they contended with the “daily round of petty
contingencies to which they were subject” (p. x). Psychiatrists were part of the “tinkering trades,” tinkering with hospitalized
patients and their problems. As his language makes clear, Goffman debunked psychiatric practice, placing it not in the realm of
science and medicine but squarely among agencies of coercive social control in charge of managing unsightly, unpleasant, and
unwanted behavior.
This was a consistent theme among many other sociologists at the time, who discussed psychiatric treatment squarely as another
form of social control, albeit under the guise of treatment, and theorized about its possible harms to people who might get labeled as
mentally ill, including stigma and social rejection. One particularly provocative and widely read sociologist, Thomas Scheff (1966),
proposed that mental illness was a form of “residual deviance,” a mere collection of unusual behaviors that fit into no other social
categories. Further, he suggested that being labeled as mentally ill could set in place a chain of social dynamics that could produce
the very problems that psychiatrists were trying to treat. Scheff took the heart of psychiatrists’ domain—the construct of mental
illness—and insisted that it really served as a mask for society’s ignorance about the nature of these unusual behaviors. Psychiatric
diagnoses were only fancy labels for describing behaviors that baffled the public and mental health professionals.
Such disconcerting critiques of psychiatry came from other academic quarters as well. Foucault’s Madness and Civilization
(1965), Ivan Illich’s Medical Nemesis (1975), and other popular works offered powerful critiques of psychiatry and medicine
applied to the social world. R. D. Laing in The Politics of Experience (1967) turned madness on its head by suggesting that
schizophrenia was an adaptive response to a disordered society. One young psychiatrist argued that psychiatry and the medical
model it had adopted were dying and deserved a good Irish wake (Torrey, 1974).3 These cultural critiques of psychiatry coincided
with criticism that came from behavioral psychologists (Eysenck, 1952; Ullmann & Krasner, 1969), who argued that some of the
“truths” of psychoanalytic theory (still at that time the main adopted paradigm of academic psychiatry) were bogus and that
psychiatric practice appeared to be therapeutically ineffective.
Overall, these critiques targeted the heart of psychiatry. They suggested that psychiatry’s core concepts were myths, that
psychiatry’s relationship to medical science had only historical connections, that psychiatry was more aptly characterized as a vast
system of coercive social management, and that its paradigmatic practice methods (the talking cure and psychiatric confinement)
were ineffective or worse.
For a decade or so, these criticisms stayed confined to academic debates among scholars critically sifting through evidence and
arguments in the struggle to assert their views or find the truth. As serious as the conflicts were and as important to the psychiatric
enterprise, they were generally ignored or treated as nihilistic. Unfortunately for the American Psychiatric Association, these
debates broke into public view in ways that were entirely unexpected and anxiety-provoking to the psychiatric establishment. Two
seemingly unrelated challenges to psychiatry erupted within a few years of each other, which opened a Pandora’s box of
vulnerability.
Public Embarrassment
The first challenge began in June 1969 with a police raid on the Stonewall Bar in New York City’s Greenwich Village, a gathering
spot for homosexuals. The raid incited a riot in which the gay community fought back, which symbolically marked the beginning of
a new, more assertive phase in the struggle for gay rights. Psychiatry was not the target of gay community’s wrath, although for
some years gay activists had been raising questions with the medical and psychiatry associations about the psychoanalytic
interpretations of homosexuality as a form of psychopathology (Bayer, 1981; Bayer & Spitzer, 1982). But within a year of the
Stonewall Riot, the gay activists began confronting the American Psychiatric Association openly at its annual meetings, demanding
that the APA remove homosexuality as a mental disorder in DSM. Most embarrassingly, their challenges were staged to attract
media attention, which they did with smashing success. The novelty of the challenge was not lost on the media or the public. At a
time when most gays were still in the closet, here was an activist gay group not simply revealing their homosexual identities
publicly but challenging the psychiatric profession on scientific grounds. An entire group of people labeled as mentally ill by the
American Psychiatric Association was disputing its psychiatric diagnosis. At the core of their challenge was a simple, easy-to-
understand question: why was homosexuality a mental illness?
The question revived a serious and complex problem for the APA. What is a mental disorder? What are the criteria used to
diagnose it? Are these criteria social and moral or medical in nature? What is the rationale for including some deviant behaviors and
excluding others as illnesses in the official manual, the DSM? The gay community asked publicly and forcefully whether American
psychiatry knew the difference between a mental illness and normality or social deviance. It was a question directed at the scientific
integrity of psychiatry.
The unwanted media coverage demonstrated that the APA wasn’t able to manage public relations nearly as well as the gay
activists (Kutchins & Kirk, 1997). The APA and the DSM provided no immediate or persuasive answers. The second edition of the
DSM (DSM-II), which was the ostensible target of the dispute, provided no guidance about why homosexuality was listed as a
disorder. What was presumably a question that psychiatry had answered on the basis of psychiatric science was unmasked as a
question of social values and political negotiations. After several years of embarrassing turmoil and fumbling by the APA, the
resolution of the issue came not from science or new research, but from a vote of the members of the APA to drop homosexuality as
a mental disorder in DSM. While this succeeded in ending the immediate controversy with the gay activists, dropping the diagnosis
appeared to confirm that the constructions and the definitions of mental disorders were arbitrary matters—of personal opinions,
group politics, and special interests in the APA—rather than matters of medicine, science, and evidence.
As with all political disputes among contending groups, there was behind-the-scenes scheming, negotiation, and compromise. In
this case, a little-known psychiatrist from New York, Robert Spitzer, who initially believed that homosexuality was a mental illness,
stepped forward as a mediator to manage the conflict about whether the diagnosis should be retained in DSM. Over a period of
several years beginning in 1972, Spitzer inserted himself into the swirling controversy, meeting with gay activists, APA leaders, and
psychiatrists on both sides of the battle on removing homosexuality from the DSM. He organized discussion sessions at psychiatric
meetings and drafted compromise statements in an attempt to find a presentable rationale for removing the diagnosis from the DSM.
In the end, he and others politically engineered the settlement to exclude homosexuality as a mental illness (Bayer, 1981; Kutchins
& Kirk, 1997). Although the conflict did not disappear altogether for many years, it did bring an end to embarrassing publicity over
this dispute. More importantly for Spitzer, he debuted in a role as master of diagnostic disputes, a role that he would reenact many
times in the future.
The second eruption came on the heels of the dispute about homosexuality. It was initiated by a cleverly titled article, “Being
Sane in Insane Places,” that appeared in the world’s most prestigious scientific journal, Science (Rosenhan, 1973). The article
reported a study by Stanford University psychologist David Rosenhan in which he conspired with colleagues and graduate students
to get them admitted to several psychiatric hospitals, without the hospitals knowing about the study. The pseudo-patients posed as
having a minor symptom (hearing a “thud” sound or the word empty) at the emergency room. All were diagnosed as schizophrenic
(one as manic-depressive) and hospitalized. All were prescribed medications. During their hospitalizations, the staff did not
recognize them as sane or as inappropriately hospitalized, and pathologized many of their ordinary behaviors, such as asking staff
when they would be released or writing their field notes. When discharged, the pseudo-patients were diagnosed with “schizophrenia
in remission.” Because it was an intriguing, easy-to-understand study and the findings were so striking, it was widely cited. The
study reinforced the view that psychiatric judgments were not merely inadequate but almost laughable. Once again, the target of the
joke was the scientific pretence of psychiatric diagnosis: psychiatrists could not distinguish the sane from the insane (or the study
demonstrated that it was easy to fake mental illness, at least). Published in Science, the study’s challenge could not be ignored. And
it wasn’t.
Two years after the Rosenhan study, a forceful rebuttal and defense of diagnosis appeared in a prominent psychology journal, the
Journal of Abnormal Psychology, written by Robert Spitzer (1975), who himself had become concerned about the scientific basis of
psychiatric diagnosis. By 1975, however, Spitzer was assuming a leadership role to revise the DSM for the American Psychiatric
Association. He used the controversy created by Rosenhan’s article to not only defend psychiatry, but to advance his own, as yet still
private, agenda in reforming the diagnostic manual.
 Rise of an Entrepreneur of Controversy
Robert Spitzer was a most unlikely rescuer of American psychiatry. His contribution to psychiatric history in the late twentieth
century was not for developing some innovative theory of mental disorder, a new therapeutic approach, influential teaching, or
significant scientific research. Nor was it established by his personal pedigree. His place in psychiatric history came about partially
by chance and very much because of his bureaucratic persistence, single-mindedness, intelligence, and robust skills as a political
actor. His major achievement, as first glimpsed in the homosexuality and Rosenhan disputes, was as an entrepreneur of diagnostic
controversies. The achievement reaches its height as he created and managed a daunting series of political compromises between
1975 and 1980 that resulted in the landmark third edition of the diagnostic manual, the modern DSM (APA, 1980), which
established the character of DSM for over thirty years into our day. He achieved this feat by working tirelessly on the technical
classification of mental disorders, a task peripheral to psychiatric practitioners and largely ignored in academic psychiatry.
In 1966, Spitzer, who had trained as a psychoanalyst, became associated with this obscure codebook almost by accident in the
Columbia University cafeteria while chatting with a colleague, Ernest Gruenberg, who was chairing the small group appointed to
update the first 1952 edition of DSM (APA, 1952). Gruenberg invited Spitzer, who had no particular expertise regarding diagnosis,
to be notetaker on the DSM-II committee. He did well in that role, and, when DSM-II was published in 1968, he was listed as a
consultant. He also was called on to author an article describing the new edition to colleagues (Spitzer & Wilson, 1968, 1969). The
second edition was infused with psychoanalytic terms and assumptions, reflecting the theoretical orientation of the leaders of the
APA. This updating for the second edition of the diagnostic manual received very little notice in psychiatry and almost no publicity.
As we have mentioned, classification of mental illness was not viewed as a vital or interesting topic.
But within a few years of the publication of DSM-II (1968), with the growing criticism of psychiatry in academic circles, the
successful challenge to drop the homosexuality diagnosis, and the Rosenhan article in Science, psychiatric diagnosis would
unexpectedly become ground zero for a major struggle within psychiatry. Spitzer, who had defended the APA and the DSM against
the challenges by the gay community and Rosenhan, had made himself the APA’s house expert on diagnosis. When in the 1970s, the
APA decided it was time to revise the diagnostic manual, it asked Spitzer to serve as chair of the task force to produce the third
edition.
At the time, psychoanalysis remained the reigning paradigm, although a re-emerging academic wing within psychiatry was
emphasizing biological aspects of behavior and the growing use of psychotropic drugs. Spitzer, however, had become keenly
interested in diagnosis and had been prepping for this assignment to revise DSM. He took on the task with gusto, taking strategic
advantage of the fact that no one expected much from the work of this internal APA committee. As we will explain, the result of his
work during the next five years made diagnosis singularly significant in psychiatry; reshaped training, research, and practice; and
elevated the status of American psychiatry in ways that were completely unexpected. It also made the APA an unprecedented bundle
of money. To many of his research colleagues, Spitzer became a psychiatric hero, “the most important psychiatrist of our time,”
according to one of his colleagues (Frances, 2010a).
 The Rhetoric of Reliability and the Modern DSM
Because past revisions of the diagnostic manual were considered of little significance, Spitzer was given a free hand in appointing
members to the DSM-III task force and to the many committees that were used in revising the manual. Selecting members of the
task force was critical to his efforts. He drew heavily on a relatively small group of like-minded research psychiatrists (and a few
psychologists) who also had concerns about the weaknesses of the manual (Kirk & Kutchins, 1992; Millon, 1983, 1986; Spiegel,
2005). Under Spitzer’s firm leadership, within a year the task force had outlined a radically different architecture for the third
edition of the DSM. In the following four years, they furnished this new edifice with thousands of new diagnostic details and
procedures that would in time require political support for the transformation and the approval by various APA committees. Having
recently emerged victorious from controversies surrounding homosexuality, Spitzer was undoubtedly aware of the struggles ahead
as opponents of the revisions got wind of the radical changes that were being undertaken.
The Reliability Rationale
Since he had absolutely no mandate from the APA to engage in a major transformation of the DSM, Spitzer had to develop a
compelling rationale. What was so wrong with DSM-II that required a total makeover? His answer, carefully developed over several
years, was that the current classification system lacked “reliability” (Spitzer & Fleiss, 1974). This reliability problem had been a
concern to only a few research-oriented psychiatrists and psychologists, such as the ones Spitzer had appointed to the task force. As
mentioned previously, reliability refers to diagnostic consistency among clinicians: can psychiatrists using the DSM independently
reach the same diagnoses for the same patients? If they can agree on the diagnoses of patients, there is diagnostic reliability. If there
is substantial disagreement about the diagnoses for the same patients, the diagnostic system is said to be unreliable. Reliability is a
minimal expectation for a science-based profession and is often easily achieved. Unreliability in diagnoses would impede research
on the causes of disorders, on effective treatment for particular disorders, and on studies of the prevalence of disorders. Further,
communication among clinicians about patients and their problems would be stymied, and the veracity of medical records and
reimbursements for services for mental disorders would all be called into question. Psychiatry, which was expected to have
responsibility for diagnosing and categorizing mental disorders, had the most to lose if its diagnostic system was considered
unreliable.
It is important to realize, however, that reliability of diagnoses (consistency) was a simple problem compared to the specter of
demonstrating the empirical existence of a putative category labeled mental illness, particularly since psychiatry’s weak and
inadequate definitions of mental illness were the target of critics. In the 1970s, as currently, the meaning or validity of mental illness
was in dispute.
All members of Spitzer’s task force understood the problem of having an unreliable DSM. Spitzer seized on this vulnerability
and used it to gain crucial leverage in transforming the DSM. Nancy Andreasen, a prominent schizophrenia researcher and one of
the initial members of Spitzer’s task force, reports that at the very first meeting of the task force, as participants were introducing
themselves and indicating what changes they thought needed to be made, the problem of reliability was raised, and, by the end of
the very first meeting, there was unanimous agreement to create a different kind of manual (Andreasen, 1984, p.155).
Kappa: Measuring Unreliability
Spitzer had been issuing warnings about unreliability even before the task force convened and continued to do so until DSM-III was
approved and published. One of his earliest warnings came in 1974 in the influential British Journal of Psychiatry (Spitzer & Fleiss,
1974). Along with his coauthor, the respected statistician Joseph Fleiss, Spitzer cautioned that any classification system, including
DSM, had to be reliable. They emphasized that any unreliability in DSM would undermine its validity. Members of the task force,
whom Spitzer had selected, needed little instruction about this problem; they were researchers and understood that to the extent that
a classification system is unreliable, its validity is weakened. If people with the same troubles cannot be sorted into the same
diagnostic categories, the validity of those categories is completely undermined. And validity is precisely the ingredient required for
the scientific integrity of the concept of “mental illness.” It was the validity of mental illness that had been questioned by Szasz, by
critics of psychiatry, by the gay activists, and by Rosenhan, among many others. Improving reliability, the task force knew, would
prop up the pivotal professional construct of madness until its validity could be more securely established.
Surely, the task force knew that not all problems confronting psychiatry could be addressed even by a major revision of DSM.
But any major renovation, like the one contemplated by Spitzer and his inner circle, had to have a persuasive scientific rationale that
would counter the substantial psychoanalytic faction of the profession who would oppose the changes they would make in DSM.
Improving diagnostic reliability became that scientific rationale and defense of their plans.
Selecting diagnostic reliability for leverage had several advantages. First, no one could argue with the basic scientific principle of
improving reliability. Second, an emerging series of studies were suggesting that diagnostic reliability was problematic, which
provided some independent support for defining unreliability as a crucial problem. Third, focusing on the consistent use of
diagnoses appeared to be a far easier problem to resolve than the conceptual challenges from Szasz, the cultural critics, or the
various social scientists questioning the validity of the construct of mental illness. Fourth, unreliability appeared to many researchers
to be largely a technical problem—getting agreement on diagnoses among clinicians—that seemed to be within the expertise of
those who composed the DSM task force.
Spitzer began a campaign to elevate awareness of the importance of reliability so that he could use it effectively as the primary
justification for the renovation of DSM. Having gained respect within the APA by being both an insider and a defender of
psychiatric diagnosis, his opinion about the perils of unreliability had credibility. In his earlier article in the British Journal of
Psychiatry (Spitzer & Fleiss, 1974), he had reviewed seven available studies on diagnostic reliability and concluded that diagnostic
reliability was troublingly low. The authors stressed that, without solving the unreliability problem, psychiatry was playing into the
hands of the profession’s severest critics. Using the data in the reviewed studies, they claimed that actual psychiatric diagnosis was
in terrible shape and threatened the validity of diagnosis. If this conclusion was not alarming enough, they suggested that in routine
clinical settings, unlike the research settings of the reviewed studies, reliability was probably worse.
Spitzer and Fleiss used a statistic, called kappa, as a tool to summarize the seven reliability studies, which had been published
from the 1950 to the early 1970s. Researchers determine a kappa score by having pairs of clinicians independently assess a series of
people coming into a mental health facility. They then tally up to what extent the two clinicians make the same or different diagnosis
for each client. Of course, as in many games, there will be some level of agreement just by chance. Kappa is a statistical
computation that discounts mere agreement by chance (it is called a chance-corrected measure) and provides a resulting measure of
how close these pairs of clinicians achieve perfect (i.e., 100 percent) diagnostic agreement. Perfect agreement—perfect reliability—
would result in a kappa score near or at 1.0. Levels of agreement that are no better than chance would have kappas of 0.0. Kappa
then provides a method of comparing how much agreement is reached by clinicians and comparing the results of different diagnostic
studies with each other.
Spitzer and Fleiss used this new tool to examine the level of reliability for different broad diagnostic (not the more specific)
categories. This is similar to asking people to identify makes of automobiles using broad categories of automobile makers such as
Ford, General Motors, or Toyota, rather than specific categories of cars, such as Mustang, Buick, or Camry. Using general categories
will always produce higher agreement/reliability scores. For example, if two people looked at the same car and one said it was a
Corvette and the other said it was an Impala, their responses would nonetheless be considered to indicate perfect agreement, since
both cars are made by General Motors.
In the Spitzer and Fleiss review and in most subsequent reliability studies, reliability scores are usually reported for general
diagnostic categories. In this case, they reported that no general categories had kappa levels that were “good,” which appeared to
mean scores somewhat above 0.75. Six kappa scores, averaging 0.74, were considered “only satisfactory,” 12 with an average of
0.56 were “no better than fair,” and the remaining 31, averaging 0.37, were described as “poor.” The overall average mean for the
nine general diagnostic categories was 0.53. Figure 4.1 presents a summary of the Spitzer and Fleiss data.

Figure 4.1
Interpretation of Kappa Reliability Levels: Early Studies (1950–1974)
*Data reported in Spitzer & Fleiss (1974), British Journal of Psychiatry.

These damning conclusions were published just as Spitzer was being asked to chair the DSM-III task force. His attack on the
reliability of DSM-II gave him the leverage he needed in the anticipated struggle to develop a new approach to diagnosis. It was a
risky tactic, unless Spitzer and others had reasons to think that they could remedy the reliability problem. In fact, several small
groups of research psychiatrists at Washington University and Columbia University had been working for years on just that problem
and were about ready to announce in a series of important journal articles that their new approach to diagnosis remedied the problem
of unreliability (Kirk & Kutchins, 1992). This group of like-minded experts formed an “invisible college” that eventually became
referred to as neo-Kraepelinians (Andreasen, 1984; Blashfield, 1982; Klerman, 1986; Millon, 1986). They worked on codifying
psychiatric diagnosis by creating a system of describing symptomatic behaviors, as a means of grouping patients into homogeneous
categories that would facilitate the conduct of research to identify how patients differed biologically from normal people. This was
the fulfillment of Kraepelin’s agenda. The emphasis on improving the reliability of diagnosis, rather than on directly attempting to
understand the causes and dynamics of disturbed behaviors (which Kraepelin assumed were at root distinct biological diseases),
radically distinguished the neo-Kraepelinians from the professionally dominant psychoanalysts.
The neo-Kraepelinians had an explanation for why psychiatrists couldn’t often agree on diagnoses: the diagnostic process was
unregulated, unsystematic, and messy. For example, there was no standard method of conducting a psychiatric interview to reach a
diagnosis. Clinicians gathered information about a patient’s condition in disparate ways: they asked different questions, in different
sequences, and with varying levels of probing. This resulted in different amounts and types of information from a patient. Clinicians
also varied in how carefully they may have reviewed the patient’s existing psychiatric records, whether they gathered information
from other sources, like family members, teachers, employers, or other physicians. Consequently, independent clinicians were likely
to each have information about a patient that differed in quality, extensiveness, and amount of detail. To Spitzer and these research
psychiatrists, such different interviewing practices explained why diagnoses might be so inconsistent, so unreliable.
But there was a more profound reason for unreliability. Even if clinicians obtained exactly the same information, there were no
established criteria for determining whether the person’s behaviors constituted a mental illness, and if so, which type of illness. In
short, there were no guiding criteria for making a diagnosis.
While these ambiguities were of great concern to Spitzer and the neo-Kraepelinians, they were not particularly troubling to
psychotherapists, who viewed differences in clinical style as part of each therapist’s methods of establishing rapport with different
clients in order to provide effective help. Therapists had their own individual ways of interviewing, of understanding the meaning of
what they learned from clients, and their own sense of what the diagnosis might be. The challenge for the DSM-III task force was to
figure out how they could change the diagnostic thinking and behavior of all mental health practitioners, a debate that continues still
(Jaffe, 2010).
Creating Descriptive Diagnosis
The solution that Spitzer and the task force created would become known as descriptive diagnosis. For the first time, they
developed specific behavioral criteria to use for each diagnosis. These diagnostic criteria would represent specific rules for
determining if a mental disorder was present and, if so, which one. They expected, with justification, that this standardization would
improve reliability. By establishing new criteria for each mental disorder, they expected that these criteria would provide a
framework to structure the assessment and diagnostic interviewing process. Structured interview guides were nothing new to social
scientists, who for decades had used structured questionnaires in surveys to obtain more complete information in a standard format
from each respondent. With these two diagnostic innovations—diagnostic criteria and structured interviews—Spitzer fully expected
to greatly improve the reliability of DSM, and with it, the scientific reputation of psychiatry, and to pave the way for the rise of
biopsychiatry.4
Task Force Struggles
The process of constructing the radically new manual and building sufficient support for it was a five-year, full-time struggle for
Spitzer. Few research psychiatrists would have had the creativity, energy, fortitude, and political skill to accomplish such a revision,
and fewer still would have been willing to devote their entire professional life to such a complicated challenge.
Although prior revisions of the manual had been simple administrative updates of a minor pamphlet, this third revision by
comparison was a monumental struggle. As Spitzer and the task force created additional working groups and began circulating
drafts of the work-in-progress, controversies erupted in print and behind the scenes, within psychiatry and elsewhere, demanding
Spitzer’s attention. For example, Spitzer offered a new definition of mental disorder, defined as a “subset of medical disorders,”
which caused an eruption by clinical psychologists who perceived this as an unfounded jurisdictional expansion, sweeping all
manner of behavioral problems into medicine. Psychoanalysts were frequently critics of Spitzer’s efforts, and they vigorously
challenged the removal of the cherished term neurosis from the manual. Compromises had to be fashioned. Similarly, many groups
with an interest in particular “disorders” lobbied the task force: gay activists monitored efforts to reinsert homosexuality as a
disorder; black psychiatrists proposed that racism be included as a mental disorder; veterans pushed successfully for adding
posttraumatic stress disorder; and so on. None of this whirl of interest groups and politicking had characterized prior revisions of
DSM. All the while, Spitzer steadfastly held to his position that revising psychiatric diagnosis and DSM was a scientific enterprise
and no longer an arbitrary exercise in stigma-producing labels.
The Unveiling of DSM-III
After five years and epic struggles, the third edition of the manual, DSM-III, was finally published. DSM-III (APA, 1980) contained
features never seen in any previous edition. First among these was its sheer size, a whopping five hundred pages—over three times
longer than the 1968 second edition (DSM-II) and sold for more than ten times the prior edition’s price. The second notable feature
was the listing of hundreds of names of individual psychiatrists, not only of the task force members, but of the APA officers, and
every member of seventeen advisory committees, many formed after most of the major structural decisions about the manual had
been made. This filled the first five pages of the new manual, deliberately conveying the impression that the manual was the product
of a broad array of psychiatrists, not the handiwork of a few. The listings were also a bid for legitimacy, as the renovation that was
being published had been very controversial. The third novel feature was a notable twelve-page introduction to DSM-III, written by
Spitzer, which covered the history of the manual, the background for the third edition, the process of its development, and its new
features, which were many, including a new multi-axial system, expanded text for each disorder, and scores of new mental
disorders.
For the first time in any edition of DSM, in his introduction Spitzer emphasized that this edition was based on data gathered in
field trials:

“ . . . interest in the development of this manual is due to awareness that DSM-III reflects an increased commitment in our
field to reliance on data as the basis for understanding mental disorders” (APA, 1980, p. 1).

This important claim is echoed several times in his introduction. In justifying the character of the new manual, he notes that other
contemporary classifications (like the ICD-9) were not “sufficiently detailed for clinical and research use” and did “ . . . not make
use of such recent major methodological developments as specified diagnostic criteria” (p. 2). He describes ten goals that the task
force sought to achieve. The first was clinical usefulness, and the second was the reliability of diagnostic categories (p. 2). He
acknowledges that even though the task force tried to rely on research evidence, task force members often differed in their
interpretations of the findings (p. 3). No earlier edition of the manual had even invoked research or data. The great bulk of the new
manual described the nearly three hundred specific mental disorders. Some were making their debut:

Post-traumatic Stress Disorder, which was described as “symptoms following a psychologically traumatic event that is generally
outside the range of usual human experience. The characteristic symptoms involve reexperiencing the traumatic events; numbing of
responsiveness to, or reduced involvement with, the external world; and a variety of autonomic, dysphoric, or cognitive symptoms”
(p. 236).
Borderline Personality Disorder, which was described as a disorder “in which there is instability in a variety of areas, including
interpersonal behavior, mood, and self-image. No single feature is invariably present” (p. 321).

And some old favorites (e.g., Inadequate Personality Disorder) were retired. Its full description in the previous edition of DSM-II
stated that is was

a behavior pattern “characterized by ineffectual responses to emotional, social, intellectual and physical demands. While the patient
seems neither physically nor mentally deficient, he does manifest inadaptability, ineptness, poor judgment, social instability, and
lack of physical and emotional stamina” (p. 44).

All of these above examples are similarly vague and ambiguous. But the most significant differences between the old and new
edition was that for each disorder in the new DSM-III the manual provided detailed lists of diagnostic criteria, borrowing heavily
from the work of the St. Louis and New York groups. These criteria constituted the necessary and sufficient
behaviors/signs/symptoms that must be observed or reported in order to use the diagnoses appropriately. These criteria constituted
the technical strategy designed to bolster the impaired status of psychiatric diagnosis. Figure 4.2 uses a type of depression to
illustrate some of the dramatic changes between DSM-II to DSM-III.

Figure 4.2
Contrast of DSM-II and DSM-III
 There are several noteworthy features in this comparison. The description in DSM-II was only one sentence, contained no
specific criteria, included concepts based on psychoanalytic notions (e.g., neurosis internal conflict, love object), and revealed that
depression was a reaction to something. None of this appears in DSM-III, which provides instead time frames and a list of
supposedly more precise behaviors or feelings, with a minimum number required to make the diagnosis (at least three). This
specificity was designed to aid clinicians in making diagnoses and to greatly improve consistency (i.e., reliability).
A Stunning Success?
The publication of the new manual was accompanied by the rhetoric of scientific victory. In the introduction to DSM-III and in other
articles, Spitzer is explicit that the diagnostic criteria were to serve “ . . . as guides for making each diagnosis since such criteria
enhance interjudge diagnostic reliability” (APA, 1980, p. 8). He announces that for the first time, drafts of DSM had been tested in
reliability field trials, involving over 12,000 patients who were evaluated by approximately 550 clinicians in 212 different facilities
(p. 5). He claims that the data from these field trials indicate “far greater reliability” than had previously been obtained with DSM-II
(p. 5). One publication about the field trials stressed that reliability was encouraging, was much better than had been expected, and
much higher than before (Spitzer, Forman, & Nee, 1979). In other articles, interviews, and presentations around the time of DSM-
III’s publication, Spitzer and others repeated the claims of improved reliability (Spitzer, Williams, & Skodal, 1980; Talbot, 1980).
By 1982 the reliability of DSM-III was said to be “extremely good” (Hyler, Williams, & Spitzer, 1982, p. 1276). At every turn,
Spitzer and others used the prior reliability problems with diagnosis to promote the new manual as a great scientific advance. A few
years later Spitzer boasted that the adoption of DSM-III had marked a signal achievement for psychiatry and represented an advance
toward the fulfillment of the scientific aspirations of the profession and would eliminate the disarray surrounding psychiatric
diagnosis (Bayer & Spitzer, 1985, p. 187).
Spitzer’s rise to a position of control over psychiatric diagnosis had been solidified by his use of the problem of unreliability.
Improving reliability had been his quest; it served as the scientific linchpin for the thorough renovation of the manual. The unique
inclusion in the manual of the reliability appendix was of singular symbolic value. The data tables in the appendix were used as
evidence that the task force and Spitzer had delivered on their promise. It was this claim of greater reliability that appeared to justify
the diagnostic revolution.
This was a momentous scientific and political claim. The euphoria was not Spitzer’s alone. It was infectious among those
celebrating the DSM-III. Gerald Klerman, the highest-ranking psychiatrist in the federal government when DSM-III was published,
gushed:

In my opinion, the development of DSM-III represents a fateful point in the history of the American psychiatric profession .
. . [the adoption of the new manual] represents a significant reaffirmation on the part of American psychiatry to its medical
identity and its commitment to scientific medicine. (Klerman, 1984, p. 539)

Similarly, psychiatrist Gerald Maxmen claimed in The New Psychiatrists that DSM-III marked “the ascendance of scientific
psychiatry” and that more than any other single event it demonstrated that psychiatry “had indeed undergone a revolution”
(Maxmen, 1985, p. 35). With regard to the core problem of unreliability, Klerman made it clear: “In principle, the problem of
reliability has been solved” (Klerman, 1984, 1986, pp. 25, 541).
Even critics of DSM-III readily accepted the claims that reliability was no longer problematic (Andreasen, 1984; Carson, 1991;
Michels, 1984; Vaillant, 1984). For thirty years, there has been no diminishing of the belief that reliability had been greatly
improved if not solved (Buckley, Michels, & MacKinnon, 2006). In 2002 those who would become the architects of DSM-5
continued to praise DSM-III, saying that “the major advantage of adopting [DSM-III] was its improved reliability over prior
classification systems” (Kupfer, First, & Regier, 2002, p. xviii). In the same book, others reaffirm that “when DSM-III was
published in 1980, one of its most important advantages was a radical improvement in the reliability of psychiatric diagnosis”
(Rounsaville et al., 2002, p.13). And in March 2011, Carol Bernstein, president of the American Psychiatric Association, praised
DSM-III for addressing “the pressing problem of interrater reliability in psychiatric diagnosis” and claimed that DSM-III
“contributed significantly to improved diagnostic agreement” (Bernstein, 2011).
 The Mad Science of Diagnostic Reliability
All of these recent claims about DSM-III’s radical improvement in reliability were made without citing a single study or source of
evidence. There was another problem with all these claims: reliability had not improved with DSM-III.
How could such misinformation be so widely believed and disseminated? Apparently, no one actually examined critically the
field trial data, nor tried to compare them with the earlier reliability levels of DSM-II. If they had, the justification for the diagnostic
revolution would have collapsed. What the data actually show undermines what has been claimed about reliability for over thirty
years. We will briefly present these data in summary fashion (for an earlier detailed analysis, see Kirk and Kutchins, 1992). Four
original published sources report the results of different aspects of the DSM-III field trials (APA, 1980; Hyler et al., 1982; Spitzer &
Forman, 1979; Spitzer et al., 1979). In addition, there is one unpublished summary (Williams, 1982) regarding personality disorders,
which was found in a letter in the APA’s DSM archives in Washington, DC. From the data reported in these sources, all of them
developed by the DSM task force leaders, we compare the earlier, pre-DSM-III studies of reliability with the reliability of DSM-III.
The field trial data were collected in 1978–1979 and originally reported in two phases, first in an earlier report and then in an
appendix to DSM-III. Within each phase, the results were organized separately for adults and children and for the major diagnostic
categories of mental disorder (axis I) and the personality disorders (axis II). In summarizing these data, we retain the distinctions
between adults and children, and between the major disorder categories and the personality disorders, but for simplicity we will
combine the data from the two phases. Figure 4.3 consists of a bar graph of the average (mean) kappas (recall the earlier description
of this statistic in which higher kappa scores represent better agreement, i.e., higher reliability) from the field trials for the diagnoses
for adults. On the far left are the interpretative standards developed by Spitzer and Fleiss for the earlier reliability studies that we
described previously (from figure 4.1). On the right are the DSM-III field trial data and a subsequent reliability study of DSM
conducted several years later.
Several cautions should be raised about these data. First, these reliability studies were undertaken while the manual was being
developed. The reports of the design, implementation, and findings were at times inconsistent and ambiguous. Second, aggregating
data from many different clinical sites around the country, with little oversight or monitoring, creates various methodological
problems (e.g., differences in base rates of disorders at different sites) that complicate the interpretation of the reliability statistics
(kappa). Third, as mentioned before, the kappa measures of reliability in the field trials are based on the more forgiving general
diagnostic categories, not on the specific diagnoses made by clinicians. For example, there are twelve types of personality disorder
(e.g., antisocial, narcissistic, compulsive, and so forth). Even if two clinicians disagreed on which type of personality disorder a
patient had, they still would have been scored as having perfect (kappa 1.0) agreement if they agreed that the patient had some type
of personality disorder. Kappas based on the general class of disorder are liberal interpretations of reliability and are always much
higher than the level of agreement with specific diagnoses. For all these reasons, it is prudent to view all the reliability measures as
crude overestimates using crude data. Accordingly, we will use some ranges of average kappas calculated in different reasonable
ways to describe reliability levels.
With that in mind, we now turn to figure 4.3, which contains the summaries of the reliability of adult diagnoses. For the major
mental disorder categories, in both phases of the field trials, depending on how you calculate, the overall average kappa ranged from
0.55 to 0.72. This range of average scores comes from three different methods of calculating overall means. First, there are the field
trial data (0.68 and 0.72 in each phase) in which actual calculation of the overall kappas is not provided, although it appears to be a
kappa weighted by the number of patients in each category.5

Figure 4.3
Comparison of Reliability Levels (Kappa) for Early Studies and DSM-III

*DSM-III field trial data for the major diagnostic categories and personality disorders are taken from appendix F in DSM-III (APA, 1980) and from a letter in the APA archives
(Williams, 1982). Data for the Written Vignette Study comes from the Archives of General Psychiatry (Hyler, Williams & Spitzer, 1982). Data from the DSM-III-R Multi-Site
Study is from the Archives of General Psychiatry (Williams et al., 1992).

A second method is to calculate kappa for all the major categories without weighting by simply adding their kappas and dividing by
the number of total categories (0.63 and 0.55 for each phase). In addition, since many of the major categories had very few patients,
the kappas are quite unstable estimates. So a third method was to recalculate the average kappas for categories that had at least six
patients in each phase (0.59 and 0.66). These various kappas are in the range of kappas presented in figure 4.3 for major diagnostic
categories for the field trials (from a low of 0.55 to a high of 0.72). The dark vertical blocks in figure 4.3 provide the general range
of kappas from all the available sources, calculated in these different ways.
For the adult personality disorders, the kappa range represents the overall kappas from the appendix of DSM-III (0.56 and 0.65
for both phases) and from a mean calculated (0.50) from the list of individual kappas (n = 12) provided in the archival material,
which covered both phases of the field trials.
The case summary study, which used written vignettes instead of live interviews and was conducted as part of the field trials,
provided an additional source of information about diagnostic agreement among clinicians. It found lower levels of agreement
(weighted kappa 0.47; unweighted mean kappa 0.30).
In other words, the DSM-III field trial data for adults do not support the claims that were made about far greater reliability. If
they had, the three dark vertical bars in the center of figure 4.3 would have all been above the dotted horizontal line which Spitzer
and Fleiss (1974) had earlier claimed represented “good reliability.” In fact, by visual inspection one can clearly see that reliability
remained at the same low level that existed before DSM-III. Let us recall that all these data were collected by the originators of
DSM-III, who had a professional and personal stake in demonstrating superior reliability levels.
Perhaps because of these equivocal and disappointing results, another major reliability study was conduct several years after the
publication of DSM-III by Spitzer and his associates. The later study, which its authors describe as the most rigorous and
comprehensive reliability assessment ever conducted of DSM, gathered data in 1985–1986, using multiple clinical sites in Germany
and the United States. It was published in 1992 (Williams et al., 1992), twelve years after the release of DSM-III. The findings were
presented for two samples, one of 390 “patients” already in treatment (average weighted kappa of 0.61 and a range of overall kappas
from the five sites of 0.49 to 0.67) and one of 202 people from a “community sample” (weighted kappa 0.37 and a range of overall
kappas from the two sites of 0.32 to 0.38). These results are shown in the far right section of figure 4.3, under the heading Multi-Site
Study. As the two dark vertical bars show, this later study again documents that no general improvement in reliability occurred in
comparison to DSM-II.
The results do not get any better when we examine the reliability reports for children; in fact, they are worse. Unfortunately, the
field trials included few children: only seventy-one in phase I and fifty-five in phase II. Most of the diagnostic categories had fewer
than five children, and many had only one or two, too few to allow for any meaningful recalculations. Here again, we combine both
phases and provide the summary kappas that were offered in the DSM appendix on the field trials. For the major categories of
disorder (0.72 and 0.43) and personality disorders (0.66 and 0.55), lower kappas were obtained in the second phase. Figure 4.4
provides these estimates. In addition, using only the categories with a larger number of children, we present the range of phase I and
phase II kappas for five of the most common children’s disorders. For example, Attention Deficit Disorder in the two phases had
kappas of 0.58 and 0.50. The five vertical dark bars clearly show that none of the results reach kappa levels in the “good” range, and
they are no better and perhaps worse than the disappointing adult results.

Figure 4.4
Reliability Levels (Kappa) for Children’s Diagnoses with DSM-III

*Data for children’s diagnoses come from appendix F in DSM-III (APA, 1980, p. 471). For the specific diagnoses the range of kappas comes from the means of the first and
second phases of the field trial.
 Achieving Success with Failure
As we have seen, the actual reliability data for the new DSM looks remarkably similar to the old DSM, clustering in the range of “no
better than fair” and “poor.” Almost none of the kappas fall above 0.70, a range earlier described by Spitzer as “good reliability.” In
sum, the often praised “far higher” or “extremely good” reliability of the modern DSM has become an institutionalized myth—
unsupported by any convincing data—although those exaggerations conveniently served the ambitious purposes of the architects of
DSM. The reliability myth, in fact, serves as a prototype of how science is used and misused in revising the manual: the scientific
data really don’t matter that much. The APA and others announced to the world that DSM-III was a scientific slam dunk, when, in
fact, the ball didn’t even come close to the basket.
After claiming success in solving the reliability problem, the topic was largely abandoned, perhaps conveniently because no one
knew how to fix it. There was a plan funded by the MacArthur Foundation to conduct new reliability studies for DSM-IV, but the
leaders quietly abandoned the effort without an explanation; no published results ever appeared (Kirk & Kutchins, 1992; Spiegel,
2005).
In subsequent decades, little evidence has appeared that mental health professionals in typical clinical settings can achieve high
reliability with psychiatric diagnoses using any of the newer editions of the DSM. Nevertheless, a few subsequent studies that bear
some semblance to earlier studies of the whole classification system continued to report diagnostic unreliability at levels similar to
the pre-DSM-III studies (Regier, Kaelber, Roper, Rae, & Sartorius, 1994; Sartorius et al., 1993, p.116; Shear et al., 2000). The
reliability of children’s diagnoses are equally dismal (Spitzer, Davies, & Barkley, 1990; Kirk, 2004; Lahey, Applegate, Barkley, et
al., 1994; Boyle et al., 1993; Ezpeleta, de la Osa, Domenech, Navarro, & Losilla, 1997; Kirk & Hsieh, 2004).
Other studies of diagnostic reliability appear occasionally in the journal literature, but these generally have limited relevance to
the reliability of the DSM classification system as a whole as used by general mental health practitioners. Typically, these studies
test the reliability of special measuring scales developed to identify a particular disorder or measure the consistency of diagnoses
made under highly specialized circumstances or at special clinics focused only on a particular narrow group of disorders. For
example, Mary Zanarini and her colleagues (Zanarini & Frankenburg, 2001; Zanarini et al., 2000) in several articles report generally
high reliability scores (kappa) for personality disorders and other nonpsychotic disorders with DSM-IV. The underlying motive for
the studies appeared to be to demonstrate that personality disorders could be diagnosed as reliably as other DSM disorders.
A careful reading of the studies reveals how high reliabilities were accomplished and why they cannot be generalized to general
diagnostic practice. The results were obtained by maintaining rigorous control over the making of diagnoses. The study took place
in university-related clinics and hospitals at Brown, Columbia, Harvard, and Yale, under the close supervision of the project
coordinators. The study was, by design, a study of the reliability of two highly structured and well-developed interview protocols,
Structured Clinical Interview for Axis I Disorders (SCID-I) and the Diagnostic Interview for Personality Disorders (DIPD-R), one
of them—for personality disorders—developed by the lead author. Interviewers were graduate students (presumably in relevant
disciplines) who were selected by the coordinators and underwent a week of intensive training in the use of the instruments, which
contained over three hundred questions. This training was followed by additional training, supervised practice interviews, and close
supervision throughout the study. Each interviewer had to be “certified” before they participated in the study. The instruments not
only structure the questioning of clients but provide a specific scoring system that produces the “diagnosis.” To test for inter-rater
reliability, those trained to use the instrument participated on conjoint interviews (in which one person conducted the interview and
the other observed), and each completed the instruments. At other times, those trained watched videotapes of prior interviews and
their scores were compared. The patients for these interviews were selected by the project coordinator at each site.
Many structural and procedural aspects of these studies may account for the generally high reliability scores, among them the use
of structured protocols that deliberately focus each interview, the careful selection of patients and interviewers, the use of conjoint
interviews (which, technically, are not independent observations), the highly specialized nature of the research settings with highly
motivated participants, and the leadership of the person who developed one of the instruments and had an obvious stake in its
success. Under these special conditions and full technical control over the interviews and the scoring of answers, it is expected that
interviewers would often reach agreement. Indeed, it would be surprising if they did not.
Does this mean that DSM itself is used reliably? None of these special research conditions apply to the real world of psychiatric
diagnosis, in which individual clinicians with varying levels of training and perspectives are mandated to use DSM to screen a
diverse array of clients walking into medical clinics, mental health centers, family service agencies, and so forth. Clinicians
generally have different styles of interviewing, ask different questions, pursue different avenues for obtaining client information, and
are supervised loosely, if at all. We will have more to say about this in the next chapter when we discuss DSM-5.
The Zanarini et al. (2000) diagnostic studies used the most highly trained and supervised interviewers working under the most
controlled and protected circumstances. The relationship of the Zanarini et al. studies to actual clinical practice is about the same as
comparing professional racecar drivers circling a race track at 150 miles per hour to granny moving her Volvo through city traffic.
All are driving automobiles, just as all clinicians are making diagnoses, but no one ought to claim that there is much in common in
their skills or in the setting.
Such studies of diagnostic instruments, whatever their usefulness for research purposes, have little bearing on the reliability of
DSM as it is used by practitioners who are not mandated to use structured interview protocols and who see diverse patients walking
into a clinic. As far as we know, there have been no new DSM reliability studies of the magnitude that Spitzer and his colleagues
conducted over thirty years ago.6
The summary point is that there is little evidence that the signature objective of DSM-III to improve the reliability of psychiatric
diagnosis was achieved. What was stated over a decade ago (Kutchins & Kirk, 1997) remains true:
 Mental health clinicians independently interviewing the same person in the community are as likely to agree as disagree
that the person has a mental disorder and are as likely to agree as disagree on which of the over 300 disorders is present. . . .
If the unreliability of diagnosis were widely recognized and if there were no scientific patina to DSM, the use of everyday
behaviors as indicators of mental disorders would be more rigorously questioned by the public. The illusion that
psychiatrists are in agreement when making diagnoses creates the appearance of a united professional consensus. In fact,
there is considerable professional confusion. (p. 53)

The claims of achieving diagnostic reliability with the new editions of DSM are a prime example of mad science—a triumph of
hope, marketing, and political rhetoric over the scientific evidence. After five years of bitter struggle to build support for the new
DSM-III, its developers were certainly not about to reveal that the old bogeyman of unreliability was still around, big as life. Too
much investment had already been made in the new manual, too many opponents defeated, too many reputations in jeopardy—and
the business of diagnosis had to move forward. In addition, so few in the mental health professions understood the then-arcane
language of reliability statistics or were in any position to assess the veracity of the developers’ claims. In the process of promoting
DSM-III, the claims were more the advertisements of entrepreneurs preparing to launch a new product, on which all their capital had
been invested. Exaggeration, distortion, and bias should have been expected. In fact, it is a pattern that is replicated in the
exaggerated claims of the effectiveness of community treatment (chapter 3) and drugs (chapters 6 and 7).
Twenty-five years after the launch of DSM-III, Spitzer admitted that he failed to solve the problem. “To say that we’ve solved the
reliability problem is just not true,” he said plainly (Spiegel, 2005, p. 63). “It’s been improved . . . it’s certainly not very good.
There’s still a real problem, and it’s not clear how to solve the problem.” Allen Frances, who worked on DSM-III and later chaired
the task force that developed DSM-IV, pointed out in a 2005 interview that “without reliability the system is completely random, and
the diagnoses mean almost nothing, because they’re falsely labeling. You’re better off not having a diagnostic system” (Spiegel,
2005). Nevertheless, he still claimed inaccurately that reliability had been improved, but acknowledged the ploy:

To my way of thinking, the reliability of the DSM—although improved—has been oversold by some people. . . . From a
cultural standpoint, reliability was a way of authenticating the DSM as a radical innovation. In a vacuum, to create criteria
that were based on accepted wisdom as a first stab was fine, as long as you didn’t take it too seriously. (p. 63)

Unfortunately, the vast majority took it very seriously. In the early twenty-first century, with the modern DSM completely
institutionalized, its architects and entrepreneurs Spitzer and Frances could admit that diagnostic unreliability remains just as it was
in the 1950s, a perplexing and unsolved problem that continues to undermine the validity of DSM.
The flawed new manual, however, became an undisputed marketing success, a runaway psychiatric bestseller. The APA sold
830,000 copies of DSM-III (Carey, 2008) and, given the price, grossed tens of millions of dollars. The APA commissioned a sequel
from Spitzer, published in 1987 as DSM-III-R and in 1994 released DSM-IV and then a text revision in 2000 (DSM-IV-TR). DSM
can now be found on the bookshelf of every mental health professional in America. It is reported that each year, sales of DSMs
exceed $6.5 million (Greenberg, 2011).
The once obscure codebook is now an important instrument in shaping public mental health policy, guiding psychiatric—and
much of psychology and social work—research and training, and determining the prevalence of mental disorders in the population.
Moreover, because of insurance reimbursement requirements, DSM is used as the criteria for the financing of psychiatric treatment,
hospitalization, and the use of medications. Furthermore, its categories have completely seeped into public discourse and shaped
how behavioral problems of many kinds are described, understood, and anticipated to manifest themselves. Absolutely none of these
indicators of acceptance and popularity pertained to its predecessor, DSM-II.
 Troubling Consequences of Success
The success of DSM-III has spawned a cluster of unanticipated and very troubling consequences for people in need in help, for
clinicians, and for our society. These will be explored in the next chapter. First, we will examine whether the descriptive approach to
diagnosis introduced by DSM-III improved the validity of diagnosis as anticipated. Second, we will describe the alliance of
American institutions that exploited DSM for their own purposes, while ensuring its success in the marketplace. For example, the
APA embraced the new manual for restoring scientific respectability to psychiatry. Mental health clinicians and universities found
that DSM provided a scientific-looking book for labeling human troubles and rapidly adopted it to authenticate their training and
practices. The National Institute of Mental Health made the use of DSM’s criteria a requirement for funding research. The politically
powerful drug industry rapidly exploited DSM’s expansive list of mental disorders and behaviors that could be labeled as symptoms
and treated with expensive psychotropic drugs. The health insurance industry relied on the DSM to guide decisions about which
disorders they would cover. The media, in news articles, magazines, and on television, provided a steady diet of stories about the
“discovery” of new disorders and purported scientific advances in psychiatry and the wonders of new medications targeting the
newly discovered disorders. We will then address the latest edition of the manual, DSM-5, and its controversies as it makes its way
to publication in 2013. Is the new edition likely to be a diagnostic breakthrough or the inevitable collapse of descriptive psychiatry
after a thirty-year reign? Finally, the social harms of DSM will be addressed.
 Notes
1. The primary professionals working in mental health include psychiatrists, psychologists, social workers, and nurses. The number of professionals in each profession is
elusive, depending on what levels of education are considered and which mental health service settings are included. One generally accepted estimate reports that in 2000
there were approximately 40,000 psychiatrists, 70,000 nurses, 70,000 social workers, and 88,000 licensed psychologists working in mental health services (Mechanic,
2008, pp. 12–17). Regardless of how these estimates are made, psychiatrists are always a small minority of mental health service providers in American.
2. In this regard, his model for mental illness was based on his work with Alois Alzheimer, who in his work on cadavers, identified the neurological disorder later known as
Alzheimer’s, as well as general paresis.
3. E. Fuller Torrey later became one of the most outspoken promoters of coercive and involuntary treatment in psychiatry, and an adherent of the view that schizophrenia
had a viral origin. The private nonprofit Stanley Medical Research Institute, which he directs, has amassed one of the largest banks of brains in the world, and has spent
over $300 million since 1989 on research on the “brain diseases” of schizophrenia, bipolar disorders, and depression, according to the Institute’s website
(http://www.stanleyresearch.org), but with no diagnostic brain lesions discovered so far through this effort.
4. Indeed, within a decade biopsychiatry had taken hold, as President George H.W. Bush and the NIMH proclaimed that the 1990s would be the “Decade of the Brain,” and
by 2005, the director of NIMH argued that psychiatrists needed to be trained as neuroscientists, not psychotherapists (Insel & Quirion, 2005).
5. Weighted kappa has technical advantages and disadvantages. The advantage is giving greater weight to those diagnostic categories in which more patients were placed.
The disadvantage is that if many patients received their diagnoses in clinical sites with higher base rates for particular disorders (e.g., patients who were referred to an
anxiety disorder clinic and were therefore more likely to be diagnosed with anxiety disorders), the overall kappas from many different sites would be artificially inflated.
Unweighted kappa gives equal status to each general diagnostic category.
6. At least we were unable to locate any, and our queries to key DSM-IV participants revealed none.
 References
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 5
The Failure of Descriptive Diagnosis

Introduction
The last chapter demonstrated how a particularly narrow scientific concern—diagnostic reliability—was used creatively by a few
researchers to justify an entirely new approach to diagnosis. Descriptive diagnosis, as this approach was called, was developed by
capitalizing on the vulnerabilities of psychiatry to scientific criticism. The new approach then benefited, not from improving
reliability, but by merely claiming to have done so, using data that was difficult for outsiders to assess accurately. The details of the
data, moreover, were quickly forgotten in the wave of celebration over the “scientific” nature of the new DSM-III. In this chapter we
continue to follow the story of DSM’s evolution.
For the most part, we, too, will leave reliability behind and move, first, to a much larger and significant problem that emerges at
every turn in the story, the problem of the meaning (i.e., the validity) of the modern DSM classification of mental disorders. Did the
descriptive approach to diagnosis deliver on its promise to more accurately identify and describe valid markers of mental illness—
and of different mental illnesses? Did the new manual improve clinical practice, lead to more effective treatment, and allow
researchers to make scientific breakthroughs in understanding the claimed biological and medical causes of mental disorders? In
short, has all the effort and subsequent celebration been matched by major scientific or clinical advances?
We answer these questions by first examining the “diagnostic criteria” that are the signature characteristic of all DSM editions
since 1980. Then, after understanding how and why the diagnostic criteria have failed to ensure diagnostic validity, we turn to the
institutional investors and supporters of DSM, who collectively ignored these scientific failures, thus ensuring that the flawed
manual became viewed as indispensible to mental health thinking and practice. With this as background, we finally examine the
current efforts to produce the DSM-5, due in 2013. The controversies surrounding the DSM-5 illuminate many of the inherent and
inevitable problems of descriptive diagnosis and the profound mistakes that are made when the anguishes, fears, worries, and
sufferings of human beings are—on the basis of no more than the beliefs of psychiatric observers in late-twentieth-century America
—classified as disorders of the brain.
 Are Psychiatric Diagnoses Valid?
Unreliability is an important diagnostic problem because it undermines the validity of the construct of mental disorder. The
diagnostic criteria were attempts to improve reliability, but, more importantly, to buttress validity. The gay activists who asked the
APA why homosexuality was defined as a mental disorder were questioning the validity of a psychiatric diagnosis. They wanted to
know exactly how DSM distinguished between mental disorder and non-disorder, that is, how DSM established diagnostic validity,
or the truth of diagnosis. As discussed, DSM-III first addressed this problem by dodging it, then by removing homosexuality from
the diagnostic manual, and later by providing criteria for each disorder. DSM-III, as we noted in chapter 1, also for the first time
offered a definition of the concept of mental disorder. Unfortunately, this definition invoked other undefined notions. For example,
in addition to meeting specific criteria, all disorders had to be “clinically significant,” associated with “distress” yet not be an
“expectable . . . response to an event,” and also had to be the result of biological, behavioral, or psychological “dysfunction.” The
problem was that none of these additional requirements was defined at all. So rather than clarifying or anchoring the concept of
mental disorder in a solid foundation, the DSM definition further obscured matters (Bolton, 2008; McNally, 2011). In order to know
what the APA/DSM considers a valid mental disorder, one must therefore examine the diagnostic criteria for each disorder, which
themselves do not represent any coherent framework.
Scientific tradition requires that assertion about the validity of concepts, such as “mental illness,” cannot rest on mere personal
opinion or even group consensus but must be supported by an independent body of theory and evidence. This is an extremely
important point to note, as misunderstandings about how validity is established may blind many to a fundamental problem with the
DSM. To state that mental illness is a valid concept (that it truly identifies a phenomenon of nature), means that some body of
evidence has been amassed according to the guidelines of a specific biomedical theory, and then has survived rigorous tests devised
upon the notion that the specific theory might be false. Then and only then might we entertain with some confidence that behaviors
now defined as symptoms of mental disorders might “truly” be the manifestations of diseases or brain disorders. This has not
occurred. But history, of course, is littered with people’s assumptions and even certainties about things that later are shown to be
untrue, to be invalid.
The classification of mental illnesses, such as DSM, must be tested if it is to be considered valid. Unlike a pontifical statement, it
cannot be accepted on faith. The modern DSM, beginning in 1980, could identify no neuropsychological or medical or remotely
physiological criteria for any of its categories of mental illness—which would buttress the idea that these categories pointed to real
phenomena of nature rather than being mere ideas arising out of speech, faith, belief, or expediency. It offered no explicit theory of
cause, nor pointed to any body of evidence to justify its claim that its description of mental disorders was scientifically valid.
Instead, it offered (false) claims of greatly improved reliability, which was really only a preliminary issue to the central issue of
whether the hundreds of specific diagnostic criteria had any bearing on the validity of presumed illnesses. The claims of improved
reliability were false, but even if true, they were not adequate pillars on which to rest claims that psychiatric diagnosis was now
“scientific.”
To be sure, the diagnostic practices of its predecessor DSM-II were a hodgepodge; that 1968 version of the manual offered little
specific guidance in making diagnoses, giving at most a few sentences, although these sentences did suggest prototypes of the
disorders. But to the research psychiatrists who dominated the deliberations that produced DSM-III, such brevity in describing
diagnostic categories undermined claims that diagnosis was scientific and that “real mental disorders” actually existed out there,
independently of the ideas American psychiatrists might have about such matters. The new descriptive formats that they developed
were expected to add more precision to diagnosis, improve reliability, and buttress claims about validity.
Although DSM avoids making any definitive statements about the actual meaning of the lists of diagnostic criteria, their primary
function surely was to identify presumably valid cases of mental illness, or, conversely, screen out cases in which mental disorder
was not present. The criteria are the essence of descriptive diagnosis. That is why NIMH and psychiatric leaders routinely use these
criteria in research that determines how many people in the population are mentally ill and why clinicians use the criteria to claim
reimbursement from insurance companies for the treatment of mental disorders. In short, DSM’s diagnostic criteria are the
established definitions of mental disorders in the United States.
Do these criteria ensure diagnostic validity? The answer is, no. DSM’s diagnostic criteria do not establish the validity of any
disorders. If they did do so, the controversy over homosexuality could have been quickly resolved by a simple diagnostic list of
homosexual feelings and behaviors. But a simple listing of behaviors would not have convinced the scientific community or gay
activists why the behavior represented a mental illness. Describing a set of behaviors and labeling them as pathological symptoms
never establishes the validity of an illness. At a minimum, one would need to identify a cluster of medical signs and symptoms
consistently occurring together (a syndrome)—the minimal requirement for a medical disorder—and linking them empirically to an
underlying, demonstrable physiological dysfunction. DSM offers behavioral diagnostic criteria as if they confirm the existence of a
valid disorder, when the criteria merely describe what is claimed a priori to be an illness. Descriptive diagnosis is a tautology that
distracts observers from recognizing that DSM offers no indicators that establish the validity of any psychiatric illness, although they
may typically point to distresses, worries, or misbehaviors.
Many other reasons help explain why lists of criteria for DSM disorders have not established the validity of the illness categories.
Over the following pages we will discuss some of the major ones.
Ambiguity of Criteria
Throughout the DSM the diagnostic criteria are ambiguous, which can be problematic. For example, if the Internal Revenue Service
stipulated that taxpayers were expected to pay their “fair share” of taxes without providing guidance about what that meant,
individuals and tax professionals would have vastly different interpretations of the meaning of fair share and how to determine it.
The diagnostic criteria in DSM generally fail to specify the conditions under which the criteria would be met, meaning that
clinicians ultimately provide their own interpretation. For example, the first two criteria for Generalized Anxiety Disorder include
“excessive anxiety” that the person finds “difficult to control.” How exactly does a clinician determine what is excessive or how
difficult it is to control? How much control? Similarly, with Histrionic Personality Disorder, which can be identified by criteria such
as when a person “is uncomfortable in situations in which he or she is not the center of attention,” “displays rapidly shifting and
shallow expressions of emotions,” or “shows self-dramatization.” How uncomfortable? What is a shallow expression? What exactly
constitutes self-dramatization? Clinicians and others would find it very difficult to know exactly when such criteria are sufficiently
manifested, thus producing unreliability in diagnosis and undercutting the validity of the presumed personality disorder.
Redundancy of Criteria
DSM requires that disorders meet multiple criteria. The ostensible purpose is that multiple criteria are supposed to raise the
threshold for the use of each diagnosis, making it appear that the DSM standards will ensure validity (i.e., those diagnosed with a
disorder would be clearly different from those without a diagnosis). For example, using only one behavioral criterion would be
viewed as unjustifiable because it would produce many false negatives (cases diagnosed with the disorder but not “really” having
the disorder). By using multiple criteria, DSM conveys that it is enhancing the validity of diagnosis. Any careful reading of these
lists of criteria, however, finds that many supposedly different criteria are merely the same stated differently. For example, the first
of five criteria for the diagnosis “Social Phobia (Social Anxiety Disorder)” is:

a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or
to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be
humiliating or embarrassing. (APA, 2000, p. 456)

So the first criterion is whether the person if fearful and anxious about some social situation. We will ignore that the DSM provides
no specification about the nature of “fear” or its many different contexts and types.
The additional four criteria just reiterate elements of the first criteria:

“a feared social situation provoking anxiety;

the person recognizes that there is unreasonable fear;
the feared situation is avoided or endured with anxiety; and
the feared social situation interferes with the person’s normal routine or he is distressed about the phobia (APA, 2000, p. 456).”

In other words, there are not five criteria to be met but only one—and that one criterion is actually contained in the title of the
disorder. This redundancy is so blatant that one thinks this must be a rare mistake in the manual. But it is not.
One of the most common diagnoses for children is Attention-Deficit/Hyperactivity Disorder (ADHD). There are three subtypes:
Inattention, Hyperactivity, and Impulsivity. For each type there are supposedly different criteria. For Inattention six criteria must be
met to use the diagnosis. The first criterion for Inattention is:

“often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.”

But this is restated in other criteria:

“difficulty sustaining attention,”

“does not seem to listen,”
“fails to finish school work,”
“avoids . . . tasks that require sustained mental effort,”
is “easily distracted,” and
is “forgetful in daily activities (APA, 2000, p. 92).”

Six of the nine criteria are explicit or clearly implied by the first criteria. What at first appears to be a stringent threshold for use of
the diagnosis, supposedly enhancing validity, is in reality one criterion restated in different ways. Little wonder that 10 percent of
schoolchildren in the United States are labeled with the diagnosis (Pastor & Reuben, 2008).
The redundancy also occurs in the criteria for Hyperactivity, where six of nine criteria must be met. The first criterion is “often
fidgets with hands or feet or squirms in seat.” Other criteria are implicit in the first:

“often leaves seat,”

“often runs about,”
“has difficulty playing . . . quietly,”
“often on the go,” and
“often talks excessively (APA, 2000, p. 92).”

Apparently, the developers of this list then ran out of synonyms for fidgeting, which The Random House Unabridged Dictionary
(Author, 1987) defines as: “to move about restlessly, nervously, or impatiently.”
Similarly, there are three criteria for Impulsivity, which also reflect, upon a cursory inspection, the same criterion:

“often blurts out answers before questions have been completed,”

“often has difficulty awaiting turn,” and
“often interrupts or intrudes on others (APA, 2000, p. 92).”

In the case of ADHD, therefore, there is really only one or maybe two criteria, and they are both implied in the title of the disorder.
The title of the disorder says all the architects of DSM intended to say about this category. The point is that lists containing multiple
criteria provide a false sense of validity by appearing to use substantively different criteria. Using synonyms as criteria does not
enhance validity any more than using a checklist of synonyms for ghost—spirit, ghoul, or poltergeist—would enhance the validity
of the category ghost.
Ignoring Social Context of Behaviors
Descriptive psychiatry requires the implausible belief that the meaning and causes of observable behaviors can be understood and
used as symptoms of mental disorder without paying attention to the social context of the behaviors themselves, and of course the
meaning of the behaviors to the person and those who observe the person. For example, is it a sign of mental illness if a devout
Christian converses intimately with God, a young woman becomes extremely morose after learning that she is afflicted with a
terminal illness, or a child severely misbehaves in an abusive, alcohol-drenched, chaotic household? DSM’s almost total neglect of
the interpersonal, social, cultural, and physical environment ensures that the diagnostic criteria are susceptible to what psychologists
have called the fundamental attribution error. That common error is interpreting the behaviors of others as due to their own
personality and personal tendencies, rather than as responses to their social circumstances (Levy, 2010; Ryan, 1971; Weiner, 1995).
That error, of course, is compounded when those making the attribution lack the time, the skills, or the genuine interest to listen to
people’s own uncertain, groping explanations of why they behave as they do.
DSM has placed the fundamental attribution error as the cornerstone of descriptive diagnosis. For example, all the major
epidemiological surveys that purport to establish the prevalence of mental illness in the population rest on simple counts of whether
the diagnostic criteria are met or not. DSM assumes that individuals’ social class, past life experiences, current social context, ethnic
and cultural identity, religious beliefs, loves and losses, aspirations and frustrations, intentions and excuses, competence and failure,
joys and heartaches—as these individuals see them and understand them and have acted on these perceptions and as others have
responded—are irrelevant to the issue of knowing precisely what ails them. None of these dimensions of experience is explored in
determining whether people’s behavior meets the established criteria for some presumed mental disorder. The diagnostic criteria, for
the most part, are devoid of context (Jacobs & Cohen, 2010). Certainly some clinicians rightfully explore these personal and
contextual dimensions in their assessment interviews, but when they need to make a diagnosis, they are required to assume that
some mental illness exists and then to conform only to the checklists of criteria. Descriptive psychiatry, in fact, was designed to
minimize clinical intuition and inferences and to push clinicians into assuming that human troubles inevitably constitute signs of
disorder. Neglecting to value the importance of social context in understanding human behavior is absurd and only undermines the
validity of DSM (Bolton, 2008; Greenberg, 2010; Horwitz & Wakefield, 2007; Horwitz & Wakefield, 2012; Hsieh & Kirk, 2003;
Jacobs & Cohen, 2012; Kirk, Wakefield, Hsieh, & Pottick, 1999; Kirmayer & Young, 1999; Lane, 2007; Wakefield, Pottick, & Kirk,
2002).
Arbitrary Cutting Points and False Positives
Apart from their ambiguity, redundancy, and neglect of social context, using multiple diagnostic criteria supposedly helps to identify
valid cases of mental illness. Some DSM disorders require that only a few criteria are met, whereas other disorders require many.
The number of required criteria is arbitrary: just as disorders are created and deleted with each revision of the manual, so too are the
type and number of criteria. There is no established method or standards that DSM uses in deciding how many criteria should be
required for any disorder. This is because no scientific links or any other indicators exist that psychiatric researchers themselves
consider important between the diagnostic criteria and any specific biological pathology (or anything biological). Without that
scientific foundation, the decision about the number of criteria is essentially a practical and public relations problem.
It is self evident that when more criteria are required, fewer people will qualify as having the disorder (if, as we have shown
earlier, the criteria are not merely synonyms); with fewer criteria, more people will be labeled as mentally ill. For example, DSM-IV
requires that any three of fifteen criteria be met to diagnose a child with Conduct Disorder. Why three and not two, five, or seven?
Probably, if only one was required many children would qualify for the mental illness, but if seven were required fewer would be
defined as ill. The makers of DSM recognize this, and use cutoff numbers so that not too many children are defined as disordered—
causing public skepticism and scientific rebuke—and not so few children that funding for research and services might be decreased
because the problem seems rare. Again, this is not a decision driven by scientific findings but rather a public relations, economic,
and political judgment.
In general, the developers of DSM select cutoff points that boost the number of people that can be labeled as mentally ill using
the DSM. Even by their own estimates, which assume that DSM is describing valid “disorders” (an assumption that we do not
make), they acknowledge that the diagnostic system makes two types of misdiagnosis. The first, mentioned previously, is what is
called a false negative, which is to falsely identify a child as not having a presumed “disorder” when they actually do have such a
disorder. The second, called a false positive, is falsely identifying some child as having a presumed “disorder” when they do not
have that disorder. Using several standard computations, the rate of both types of errors can be calculated. For example, looking at
the list of criteria for disorders for children and adolescents in DSM-IV (Kirk, 2004), the misdiagnosis or error rate for the diagnosis
of ADHD is about 38 percent, for Conduct Disorder about 11 percent, and for Oppositional Defiant Disorder about 21 percent. (Of
course, these computations assume that the diagnostic categories are valid.) The overwhelmingly more frequent error is identifying
children as mentally ill who are not. For example, with ADHD, for every 1,000 children screened using the DSM criteria, about 4.5
with ADHD would be incorrectly diagnosed as not having it (false negatives), but 370 kids who don’t have ADHD would be
misdiagnosed with it (false positives). These errors rates were known before the criteria for DSM-IV were selected. In other words,
the makers of DSM-IV chose cutoff points for DSM children’s disorders that routinely exaggerate the prevalence of presumed mental
disorder in the population. The ambiguity and redundancy of criteria, the neglect of social context in identifying the meaning of
behaviors, and the arbitrary method of establishing cutoff points contribute to additional, more profound problems with validity of
DSM categories.
Heterogeneity within Categories
The fundamental objective of DSM’s categorical approach was to capture people who all had the same presumed mental illness.
Studying them as a group, it was hoped, would lead to the validation of the disease category by discovering some underlying
biological marker that would validate the categories as existing in nature by distinguishing those who have the illness from others
without the illness (Rounsaville et al., 2002). This was the Kraepelinian goal: to discover biological markers (hopefully causal) to
confirm the existence of the diseases in those in whom diseases were hypothesized to exist and the inexistence of such markers in
others.
This hasn’t happened. There are no known biological markers for any category. This observation is not only a Szaszian attack on
the myth of the validity of mental disease; it is today the oft-repeated conclusion of current leaders of psychiatry. After thirty years
of research using the modern DSM categories, there is agreement among the researchers who have looked at the problem that the
DSM categories do not group together people with distinguishing characteristics (Regier, Narrow, Kuhl, & Kupfer, 2009; Jablensky,
2012; Rounsaville et al., 2002).
It is easy to understand why this lack of homogeneity within categories arose. First, there may be no distinguishing characteristic
underlying the DSM madness categories to be found. If the categories themselves are invalid, precisely sorting types of behavior
into them won’t make them meaningful. Recall that many women were identified and sorted into an earlier category of “witches,”
but that sorting did nothing to establish the validity of the idea of witches. Second, as we have said, the criteria used for the sorting
are ambiguous, redundant, and arbitrary. Third, the use of multiple criteria, that is, multiple behaviors, provides many entrances into
the same category. For example, for Conduct Disorder for children, any three of fifteen different behaviors must be observed. But
three of fifteen allows for many different combinations. In fact, it allows for precisely 455 different combinations of children’s
behaviors in diagnosing a child with Conduct Disorder. Heterogeneity of children should be expected. The only consistency to be
observed with Conduct Disorder is that clinicians use the same diagnosis for many different types of children and behaviors.
Common problems such as this undermine the validity of DSM categories.
Comorbidity among Categories
In addition to heterogeneity within categories, there is comorbidity across DSM categories. Comorbidity refers to people having
more than one “disease,” more than one morbid condition. Since some DSM categories share diagnostic criteria (behaviors asserted
to be representative “symptoms”), some people either meet the required criteria for more than one category or have some but not
enough symptoms to “qualify” for any one DSM disease category. In short, many people don’t fit neatly into the DSM categories.
This is not merely the case of the occasional person having more than one “independent” illness at the same time. This is a much
more extensive and common problem, undermining the DSM assumption of discrete categories of illness. In fact, studies (Kessler,
Chiu, Kemler, & Walters, 2005) have found comorbidity in about half of people diagnosed, suggesting, as one researcher said, that
“there is no empirical evidence” for “natural boundaries between major syndromes,” and that “the categorical approach is
fundamentally flawed” (Cloninger, 1999, as cited in Rounsaville et al., 2002, p. 12).
DSM provides various tactics for categorizing messy cases. One is a catchall option within most categories: NOS “Not Otherwise
Specified.” If a person doesn’t meet the required specific criteria demanded by DSM, clinicians can use NOS. Another tactic, added
in DSM-IV (p. xxiii) allows clinicians to use a category even if the problem “falls just short” of the full criteria. In these ways, the
entire effort of the modern DSM to specify required diagnostic criteria can be ignored at any time by any clinician by using NOS or
the “just falls short” options.
Underlying Dimensionality
The categorical system has not carved nature at its joints, as is expected of any scientific classification system. The evidence is
accumulating that there may not be joints to be found for presumed mental illnesses. There is growing recognition among
researchers, including those crafting the DSM-5, that almost all of the phenomena of concern to psychiatry—behaviors, moods,
perceptions, emotions, cognition—are better conceptualized as continua, ranging from the less intense (more frequently noticed) to
the more intense (less frequently noticed), without any clear discontinuities along the way. If sharp discontinuities of feelings and
behaviors were found, it might suggest some natural cutoff points at the boundaries of normal and unusual, lend some empirical
validation to the disease categorical approach. We find this in most categories of serious physical illness, where there are
independent tests to determine whether one has a cancerous tumor or not, pneumonia or not, tuberculosis or not. The exceptions
tend to be around “illnesses” for which drug companies with a profitable product to sell until the patent on the product expires have
lobbied powerfully to establish lower cutoff scores from physical tests for such things as bone density, high blood pressure, and
cholesterol levels (Healy, 2012). In doing so, these drug companies greatly reshape the understanding of disease while extending
their markets and profits (Greene, 2007).
In psychiatry, by contrast, we do not find natural discontinuities or bimodal distributions of anxiety, insomnia, irritability, or
sadness or most other relevant experiences. Even hearing voices or thinking that others mean to harm us is a widely distributed
phenomenon (Luhrmann, 2010). The dimensionality of the “symptoms” used in DSM suggests that the categorical system is
problematic and that the attempt to distinguish disorder from nondisorder is arbitrary (Bolton, 2008). As we will see, most of the
struggles over DSM-5 are, in fact, disputes over where the arbitrary boundaries should be drawn between phenomena that have not
been validated as disease categories.
Description Is Not Explanation
The modern DSM purports to provide guidance in identifying valid instances of mental illness. The manual explicitly claims that it
is “atheoretical,” terminology that was used to imply that the categories did not contain any inferences about the “causes” of the
disease, no theory about what it is or why it occurred. That’s why it is known as “descriptive diagnosis.” This is about all the manual
could officially claim, because there is no convincing scientific evidence concerning what causes people to feel or act in ways that
are uncomfortable to themselves or bothersome to others. But in practice, clinicians use DSM, because it does offer “medical”
explanations for behavior, although it does so in a tautological manner.1
Imagine that you go to your physician complaining of a sore throat. The physician listens to your complaint and explains that you
have Sore Throat Disorder. You inquire how he reached the conclusion about your illness, and he responds, “Because you have a
sore throat.” This diagnostic reasoning would strike you as a joke, because, in medicine, when possible symptoms are noted, the
physician uses independent procedures to gather information about the presence of some underlying disorder that might explain
your symptom. For example, he might give you a physical exam or order blood tests, X-rays, throat cultures, or various invasive
physical probes. If the physical tests and probes confirm that there is some underlying pathology, the physician can then conclude
reasonably that your symptoms were caused by the pathology, perhaps in this case an infection triggered by some virus or bacteria.
Even if the ultimate cause of the pathology is unknown, we can explain the symptoms as a result of the observable, tested pathology.
The point here is that a symptom (a complaint, a behavior) explains nothing by itself. The symptom might have several underlying
causes. And in the absence of a physical sign—which itself may also have several different underlying causes—the symptom is an
extremely poor guide to determine what, if anything, is the matter.
Contrast this with diagnosis in psychiatry. You take your young son to a psychiatrist and complain that he doesn’t pay attention,
doesn’t listen, and is fidgety most of the time. The psychiatrist listens to your story and shares that disturbing news that your child’s
behaviors are due to a mental disorder: Not Paying Attention Disorder. You may be comforted to learn of the diagnosis that explains
your child’s behavior, but you ask the psychiatrist how he reached this conclusion. He explains that he reached the diagnosis
because the boy doesn’t pay attention.
This is precisely how children are diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD). To use the diagnosis of
ADHD, a child must exhibit at least six behaviors from a longer list in DSM, such as he often fidgets or “often fails to give close
attention to details” or “often does not seem to listen”—redundant criteria—as we have pointed out in detail. If the child meets the
criteria, the child is said to “have” the underlying disease of ADHD. But no independent tests can verify any underlying mental
disorder; the very symptoms used to construct the alleged mental disorder confirm the presence of the disease. Why does the child
fidget and not listen? Because he has ADHD, the construct that uses these descriptions as its defining criteria. How do we know he
has ADHD? Because parents and teachers state that he fidgets and doesn’t listen. The acceptance of this patently circular reasoning
by countless experts, authorities, and parents in America and increasingly around the world is a sad measure of the scientific
“progress” that has been achieved in mental health.
This tautological ruse with ADHD is not confined to children’s disorders. Psychiatric diagnosis in general is the equivalent of
Sore Throat Disorder. It is description masquerading as explanation. In psychology, this is called the nominal fallacy, in which
naming is presented as explaining (Levy, 2010). DSM has made the nominal fallacy another foundation stone. Naming and
describing a phenomenon as a mental disorder does not in any way confirm the validity of diagnosis or of the existence of a
presumed disorder.
 The Successful Marketing of Failure
One would reasonably expect that these glaring weaknesses of descriptive psychiatry—unreliability and invalidity due to ambiguous
and redundant criteria that ignore social context; the lack of homogeneity within categories and comorbidity across categories;
arbitrary decisions about cutoff points biased in favor of false positives; and where merely naming is passed off as explaining—
would have completely undermined the credibility of the modern DSM and that the APA’s ownership and monopoly over the terrain
of madness would be called into question.
When such serious flaws are found with other consumer products, such as were allegedly seen with Toyota’s automobiles, this
would justify a recall, a suspension of sales, an independent scientific review, and a search for a different manufacturing approach.
Instead, DSM has been a huge success and created an epidemic of labeling people as mentally ill (Whitaker, 2010). In thirty years,
DSM went from a meaningless codebook to a veritable bible on madness and misbehavior. Ironically, the serious flaws of DSM have
been exploited to extend its use. If there are no solid conceptual or empirical standards for what should be considered a psychiatric
“brain” disorder, if the diagnostic criteria are ambiguous, if any troublesome behavior can be designated as a “symptom,” and if
clinicians have wide latitude and financial incentives to find disorder, the DSM becomes a handy dictionary of disorders with a
scientific patina only provided by the APA. It is then understandable that with each edition, the list of disorders and the criteria
expand, the thresholds for diagnosis become less stringent, and proposals for new “recently discovered” brain disorders pour in—
binge eating, shopping disorder, psychosis risk syndrome, road rage, temper dysregulation disorder, and more. Many people,
professions, and programs are stakeholders, and they relentlessly push for more psychiatric brain disorders—that is, for more names
of entities to be accepted as brain disorders.
Nothing in the turgid text or detail of the modern DSM can possibly account for its huge success. Nor was there ever any solid
scientific evidence of its vast superiority. Its success was that it found an eager market among powerful groups, institutions, and
organizations, and perhaps fed on an insatiable urge to medicalize that which is difficult to understand. Let’s look briefly at these
groups and institutions and some of their actions.
American Psychiatric Association
The boosters of DSM in 1980 skillfully used the professional journals of the American Psychiatric Association as part of the
promotion of the manual. Instead of a scientific journal functioning as an arbiter of truth and tests for truth, the APA-sponsored
American Journal of Psychiatry promoted a commercial product in which it had a financial stake (for details, see Kirk & Kutchins,
1992: 185–187). Rarely would you see in a scientific article, as one did in 1980, a footnote directing readers to the sales department
of the APA and instructing them in precisely how much money they needed to send to the APA for a copy (Spitzer, Williams, &
Skodal, 1980). The APA’s leadership, however, had not given Spitzer a mandate to radically change the diagnostic system, not
sanctioned the methods he used to accomplish it, or welcomed the controversies he created behind the scenes and publicly.
Nevertheless, by the time the new manual was approved, the APA rallied behind Spitzer’s efforts.
Spitzer had proved himself an able advocate and a tireless crusader. The task force he chaired and the committees he created and
coordinated were composed of many of the rising scientific elite of psychiatry. Although psychoanalytic factions of the profession
and many psychologists were skeptical about the nature of the new manual, the APA could hardly turn its back on a diagnostic effort
that was being billed as a great scientific achievement and as a way for psychiatry to take the upper hand in a battle with critics.
Spitzer offered irresistible products: scientific respectability and the illusion of supportive data. After 1987, however, Spitzer’s
personal stamp on the manual and strong control over the processes of revision began to grow uncomfortable for the APA and the
APA replaced Spitzer as the chief DSM guru with another DSM insider, Allen Frances, an expert on personality disorders, who was
chosen to guide the development of DSM-IV (Spiegel, 2005).
The APA’s rapid embrace of the DSM was only part of what propelled its success. Mental health professionals were easy
converts or draftees, and it was their purchasing of the manual that created a multimillion-dollar commercial windfall for the APA.
Psychiatrists were only a small proportion of the professionals in the burgeoning mental health professions during these decades
(Goleman, 1990). Although most clinicians weren’t embroiled in the academic debates over the meaning of mental illness or the
reliability of diagnoses, they were aware of the growing attention of the public to mental health and the growing popularity of
psychotherapy in its many forms. The reestablishment of the credibility of psychiatric diagnosis, under the medical imprimatur of
the APA, provided a plausible defense for all these clinicians, not only for psychiatrists. The new DSM gave them all a handy
scientific-looking codebook that provided a rationale for labeling human troubles as true “mental disorders” and a medical
justification for their helping services, along with a renewed sense of respectability and status. Whatever the concerns of
psychologists about the increased medicalization of behavioral problems or of social workers about the emphasis on internal
pathology to the neglect of the social environment, clinicians eventually lined up to buy the new tome and to use it, in part because
they had little choice. The more DSM was used, the more it had to be used. The use of DSM was rapidly adopted and required by
clinics and agencies, and those in private practice needed it as well, since filing a specific, recognizable, and codified diagnosis
quickly became a requirement for insurance reimbursement for services rendered. For clinicians, DSM migrated from codebook to
bankbook.
National Institute of Mental Health
In addition to the APA, a chorus of institutional voices sang praises to the biomedical revolution in psychiatry and helped establish
DSM’s dominance (see, for example, Whitaker, 2010, pp. 276–280). The first was the NIMH. As the federal government’s major
advocate for mental health research and services, NIMH played a marginal role in the development of DSM-III, although indirectly
it funded many of the psychiatric studies that brought attention to the problems of psychiatric diagnoses. NIMH, after all, had a
stake in finding a better scientific grounding for diagnoses as a way of organizing knowledge about mental illness. The claims made
about DSM-III were music to the bureaucratic ears of officials at NIMH, and NIMH signed on as a booster. Shortly thereafter,
NIMH made the use of DSM’s criteria a virtual requirement for those seeking funding for research on treatment, diagnoses, and
epidemiology.
Big Pharma
The second institutional investor was comprised of multinational drug companies. Although the role of pharmaceutical companies in
psychiatric research is now pervasive (Carey, 2006; L. Cosgrove, Krimsky, Vijayaraghavan, & Schneider, 2006; Healy, 2012), as it
is in most areas of medical research, the role of the drug industry in the original development of DSM-III is obscure (though some
studies, as in the case of panic disorder, do exist, see Jacobs, 1995, pp. 441–442). Nevertheless, the creation of DSM-III and the
expanding number of disorders with lists of vague diagnostic criteria was an incredible gift to the pharmaceutical industry, offering
not only scientific respectability to diagnosis, but also an opportunity for the expansion of the range of behaviors that might be
legitimately labeled as symptoms of disorders and thereby treated with patented and prescribed psychoactive medications (see
chapter 6 and 7). DSM gained prominence as these companies, part of one of the largest and richest industries in the world,
exploited the expansion of mental disorders (Angell, 2011a, 2011b).
Health Insurance Industry
The third institutional investor in DSM was the health insurance industry, both public (e.g., Medicaid) and private. As more
insurance policies began to include coverage for psychiatric treatment of some mental disorders, the insurance industry relied on the
DSM to guide decisions about what distinguishes a mental disorder from other human problems. Also, the industry appreciated the
lists of diagnostic criteria, which put constraints on mental health professionals using diagnostic labels indiscriminately. Thus, the
appearance of a new “reliable” diagnostic system with lists of diagnostic criteria provided guidance to insurance companies sorting
out whether reimbursement claims from mental health clients represented help with “genuine” psychiatric illness or merely with
ordinary problems in living for which insurance would not pay. For example, parents seeking help for managing an unruly child
might consult friends, teachers, or members of the clergy but would normally not seek, nor would companies pay for, professional
services unless that child was officially labeled as having a mental disorder, such as Attention-Deficit Disorder. The new revised
DSM gave insurance companies two tools. One was a list of specific behavioral criteria that had to be met before a diagnosis was
used, providing the appearance that objective criteria, rather than clinicians’ vague judgments, were employed to distinguish illness
from other problems in living. Second, the expanded list of disorders forced insurance companies to select which specific disorders
they would pay for and which they would not cover. Few insurance plans will cover all of the disorders in DSM; most cover only the
more “serious” ones or the more popular ones; and most impose sharp limits on the number of treatment visits in a given time
period. Thus, despite the potential expansion of disorders that the drug companies encouraged, the insurance companies could use
DSM selectively to regulate their exposure to financial risk and costs.
Two federal laws, the Mental Health Parity and Addiction Equity Act of 2008 and the Patient Protection and Affordable Care Act
of 2010 are likely to alter the insurance terrain in unpredictable ways. The first legislation insists that insurance coverage for mental
disorders have “parity” with the coverage for physical diseases, and the second is the massive health reform legislation introduced
by President Barack Obama. Although too early to know as of this writing, it is likely that DSM’s uses will increase through these
initiatives and that the demand for and cost of treatment for mental disorders will increase. Conversely, to limit their costs, insurance
companies might begin to insist that, in addition to diagnoses, measures of actual disability or impairment and their reversal
determine eligibility for insurance coverage of mental disorders. Similarly, measures of efficacy as determined by clients, rather than
only asserted in the professional literature, might be used by insurance companies to determine whether a given treatment for a
mental health problem receives coverage. We will return to some of these issues in the concluding chapter of this book.
News Media
The fourth institutional investor was the news media, which has provided the public with a steady diet of stories about purported
scientific advances in psychiatry since the 1960s. If one had asked ordinary people on the street in 1960 whether they had ever heard
of the Diagnostic and Statistical Manual of Mental Disorders, only a few would have expressed any recognition. Today, many
would not only say that they had heard of it, but most likely they would also be able to say which DSM disorders they qualify for.
The DSM criteria sets for psychiatric diagnosis frequently appear in magazine and newspaper articles and are featured in stories on
television. Pharmaceutical companies advertise these criteria in ubiquitous TV ads to increase their markets of people seeking and
taking psychiatric drugs.
The APA, mental health professions, NIMH, drug and insurance companies, and the news media were all using DSM for their
own disparate and often inconsistent institutional purposes: as a declaration of professional jurisdiction; medical dictionary of
disorders; compendium of human troubles; administrative codebook; textbook and training manual; protocol for research funding;
justification for prescription medications; insurance reimbursement claim form; and as a legal tool in forensic settings. Together this
alignment of powerful professional, governmental, and commercial institutions—perhaps accurately termed the biomedical or
biopsychiatric industrial complex—ensured the expansion of DSM because, even though each member may have had a different
agenda, all were united to promote the idea that deviant or strange behavior should be understood as a medical illness subject to
government-supported medical authority and intervention. Remarkably, little public opposition arose. Although DSM-III and DSM-
IV completely failed to deliver on their scientific promises and claims, their marketing was effective, pervasive, and unstoppable.
 DSM-5 and the “Best and Latest Scientific Research”
Science is always the ostensible rationale for revising DSM. Ever since Robert Spitzer first claimed science as the rationale to
reform the DSM in the 1970s, each subsequent revision (DSM-III-R, DSM-IV) was justified by claiming that the manual needed to
incorporate new scientific knowledge. As implausible as that rationale has been, it is nearly impossible to assess before the revision
is published. Even afterward, the manual contains no footnotes directing the curious to the scientific data on which hundreds of
decisions were made. Despite criticisms of each edition, the promoters of DSM hope that among the vast armies of users the manual,
like religious dogma, will be accepted gratefully and uncritically.
Something different emerged for the next edition, DSM-5. Work on DSM-5 began five years after the publication of DSM-IV in
1994. Discussion about the next revision began among the director of NIMH, the medical director of the APA, and the chair of the
APA’s committee on psychiatric diagnosis who jointly organized a DSM-5 Research Planning Conference in 1999 to “set research
priorities” (APA, 2008). Over the next years, they set up planning work groups, commissioned a series of white papers, and
sponsored over a dozen conferences to discuss and develop a research agenda for DSM-5. The APA stressed the global nature of the
efforts, which involved consultations with the World Health Organization (WHO), the World Psychiatric Association (WPA), and
others. NIMH was asked to fund a series of “research planning conferences that would focus on the research evidence for revisions
of specific diagnostic areas” (APA, 2008). NIMH, the National Institute on Drug Abuse (NIDA), and the National Institute on
Alcoholism and Alcohol Abuse (NIAAA) provided over $1 million. Originally expected by 2010, the publication of DSM-5 has
been pushed back several times as political and scientific problems have mounted. The latest date posted by the APA as of this
writing is May 2013, making the gestation period for the next edition nearly three times longer than it took Robert Spitzer to give
birth to DSM-III.
Selected experts were invited to participate in the important initial planning conference, but, curiously for a purportedly scientific
effort, those closely involved in the development of DSM-IV were not included, “to encourage thinking beyond the current DSM-IV
framework” (APA, 2008). We will return to this matter shortly.
In 2006 the APA president appointed Drs. David J. Kupfer and Darrel A. Regier, prominent insiders at the APA and NIMH who
had key roles in prior DSM editions, as the chair and vice chair of the DSM-5 task force. Kupfer and Regier then nominated other
APA members as chairs of the various work groups and as members of the central task force. The rhetoric of the APA was similar to
that used in prior revisions. There were assurances that the diagnostic categories “will evolve to better reflect new scientific
understanding,” that there were “no pre-set limitation on the nature and degree of change that work groups could recommend,” that
their work would encourage “research questions and hypotheses . . . that can be “investigated through literature reviews and
analyses of existing data,” and that “they will also develop research plans, which can be further tested in DSM-V field trials
involving direct data collection.” Based on this “comprehensive review of scientific advancements, targeted research analyses, and
clinical expertise, the work groups will develop draft DSM-V diagnostic criteria” (APA, 2008).
In May 2008 the APA announced the appointment of most members to all the major committees, “more than 120 world-
renowned scientific researchers and clinicians” to “examine the extent to which this new research warrants modifying the current
organization of disorders, descriptions of disorders and the criteria for diagnosis” (from APA press release: “APA names DSM-V
work group members: Experts to revise manual for diagnosis of mental disorders” May 1, 2008).
Conflicts of Interest
One element of these APA announcements, however, had never appeared in prior DSM revisions, namely, that in order to avoid any
“conflicts of interest” all task force and work group members had to “disclose all significant relationships with entities that have an
interest in psychiatric diagnoses and treatments.” Further, no participant was allowed to be paid more than $10,000 per year from
“industry sources” while working on the revision. The APA press release provided reassurance that “we have made every effort to
ensure that DSM-V will be based on the best and latest scientific research, and to eliminate conflicts of interest in its development”
(May 1, 2008; emphasis added). Investigative journalists had already documented that the pockets of the APA, psychiatric leaders
and organizations, and leading officials at NIMH and elsewhere were bulging with drug money (Willman, 2004a, 2004b; see
chapters 6 and 7). The APA’s announcement about avoiding conflicts of interest and voluntary disclosures had the appearance of a
requirement forced onto the APA after a series of disturbing public revelations (see also Cosgrove et al., 2006).
For years drug industry ties to psychiatry had been hidden, although there was increasing evidence of financial conflicts of
interest in medical research (Bekelman, Li, & Goss, 2003; Campbell et al., 2007; Campbell et al., 2006; Rothman, 2008). Drugs
firms make billions of dollars marketing psychoactive drugs to primary care physicians and psychiatrists. For example, prescriptions
for powerful antipsychotic drugs rose to 54 million in 2011, with total US sales of $18.2 billion (Friedman, 2012). As the DSM-5
revision got underway, however, there was a cascade of negative revelations about psychiatry and the drug industry. For example, in
2007, it was revealed that psychiatrists top the list of medical specialists in accepting gifts from drug companies (Harris, 2007), and
in 2010 a study in the Archives of Internal Medicine found that nearly 80 percent of psychiatrists had some kind of a relationship
with drug companies (Graham, 2010). A congressional investigation, led by Senator Grassley, uncovered a series of conflicts of
interest in psychiatry, which were reported by most major newspapers. These articles documented hidden financial payments by
drug companies to influential psychiatrists at Harvard, Stanford, and Emory universities, and elsewhere.
Take the case of Charles B. Nemeroff, who resigned from his position as chair of the psychiatry department at Emory University
after it was disclosed (Harris, 2008b) that he had received funds from drug companies without revealing them as required by the
university and by NIMH, which also funded his research. In this and other cases, the universities and the NIMH began internal
investigations. To the authors of this book, the reactions of the universities and of NIMH appear as disingenuous as that of the APA.
For example, Emory University claimed to have been misled about Nemeroff’s extensive involvement with drug companies though
he was hardly secretive about his conflicts of interest (which were probably taken to constitute business-as-usual in that academic
field). For example, in his 2004 book, The Peace of Mind Prescription: An Authoritative Guide to Finding the Most Effective
Treatment for Anxiety and Depression (Charney, Nemeroff, & with Braun, 2004), Nemeroff provides a footnote in the introduction
that lists the drug companies (and one research group primarily funded by the drug industry) from whom he received support. They
include the following:

Abbott Laboratories
AFSP
AstraZeneca
Bristol-Myers Squibb
Corcept
Cypress Biosciences
Eli Lilly
Forest Laboratories
GaxoSmithKline
Janssen Pharmaceutica
Merck
NARSAD
Pfizer
Wyeth-Ayerst
Acadia Pharmaceuticals
Neurocrine Biosciences
Novartis
Organon
Otsuka
Sanofi
Scirex
Somerset

As an indicator of how little Nemeroff’s history of undisclosed payoffs bothered the psychiatric community, shortly after he was
forced to resign from Emory University as department chair and his NIMH funding was suspended, Nemeroff was recruited by the
University of Miami as chair of its psychiatry department. Thomas Insel, the director of NIMH, even recommended him for that
position (Basken, 2010).
Another scandal involved P. Trey Sunderland, the head of the NIH’s geriatric psychiatry branch, who was charged by federal
prosecutors for taking $285,000 in fees from a drug company, Pfizer, without the permission or knowledge of NIH (Wilson, 2006).
Another public embarrassment was caused by Frederick Goodwin, the former director of NIMH, who was a radio celebrity on
National Public Radio (NPR). In 2008, NPR fired him when it learned that he promoted the off-label use of mood stabilizers for
children on the radio without disclosing that he had received more than $1 million from drug manufacturers since 2000 (Harris,
2008a).
Still another public relations disaster involved Harvard psychiatrist Joseph Biederman, the leading promoter of labeling children
with bipolar disorder, a diagnosis which had rarely been applied to children (Harris & Carey, 2008). His promotion was credited
with the dramatic increase of the use of that unusual diagnosis, which directly encouraged the off-label use of antipsychotic and
anticonvulsant drugs for children—drugs with commonly dangerous effects. It was revealed by the congressional investigation that
Biederman and his drug industry-funded research center had received millions of dollars from companies that profited handsomely
from his advocacy (Harris, 2008c).
Although the APA is not directly responsible for these unethical practices by individual members, universities, or federal
research institutes that regularly choose to look the other way or do not enforce their own rules, it also benefits from drug industry
money. The US congressional investigation requested that leading medical associations reveal details about the amount of money
that they and their directors receive from drug makers (Harris, 2009b). The APA receives 30 percent of its $62 million budget from
pharmaceutical companies in ad revenues, convention support, and other income. Its own president in 2010, Alan Schatzberg of
Stanford University, had $4.8 million in stock holdings in a drug company that he had cofounded. A huge proportion of the costs for
the required continued education of psychiatrists and other physicians are paid by drug companies (Carlat, 2007). In addition, the
APA and other publishers of medical journals have been faulted for failing to reveal conflicts of interest among authors of research
articles funded by or conducted by drug companies; failing to prevent the publishing of articles ghostwritten by drug company
employees (Wilson, 2009), and failing to reveal that drug companies’ studies that don’t support their products have been suppressed
or manipulated (The Economist, 2008). Even when an APA committee made fourteen recommendations designed to regulate and
significantly curtail conflicts of interest between psychiatrists and the pharmaceutical industry, the APA Assembly, its governing
body, quashed the report before it could even be discussed and debated (Cassels, 2010). Universities, too, are not blameless; they
have also failed to control conflicts of interest (Basken, 2009b; Harris, 2009; Monastersky, 2008), because they too are not immune
to the attractions of money.
The actions of many drug companies have been described as criminal and have resulted in about $7 billion in fines or penalties
for illegal off-label marketing and overcharging government health programs between 2004 and 2009 alone (Bloomberg.com, 2009;
New York Times, 2010). There is rising concern that drug companies have corrupted medical research (Angell, 2004; Barber, 2008;
Whitaker, 2010). A coalition of concerned scientists and ethicists petitioned NIH to investigate the many conflicts of interest that
pervade medicine, including ghostwritten articles, physician payoffs, and the use of hired academic opinion leaders, such as
Goodwin, Biederman, and Nemeroff, to increase markets for drugs (Basken, 2009a).
It was then—as a defensive reaction to these unfolding investigations of corruption and conflict of interest and to a study that
uncovered that a majority of the psychiatrists who had served on the DSM-IV task force had financial ties to drug companies
(Cosgrove et al., 2006)—that the APA responded with a conflict-of-interest policy for those working on DSM-5. (Note: in 2010, the
APA officially changed DSM-V to DSM-5.). A response from the APA was needed, since another study had shown that psychiatrists
were more likely than other medical specialists to receive payoffs from drug companies. To defend the profession, the APA
requested that all of the participants in the DSM-5 work groups sign a pledge (APA, 2012) to limit the income they receive from
pharmaceutical companies. But the agreements are hardly reassuring. Each task force member pledged to take no more than $10,000
a year from drug manufacturers during the at least five-year process. Few observers would doubt that $50,000 or more might
influence judgment. Among some public figures or public servants, such conflicts could lead to criminal conviction and prison
sentences. There are other loopholes: there is no limit to the amount of money that participants can receive in “unrestricted” research
funds from the same companies, nor is there a limit to how much they had received in prior years or will be paid in years
immediately following the release of DSM-5.
Many principal members of the DSM-5 task force have had lucrative relationships with many drug companies. The Center for
Science in the Public Interest reported that twenty-eight members of the DSM-5 task force are reported to have drug industry ties
(Kaplan, 2009). The APA disclosure forms were incomplete and misleading, according to a report in U.S. News and World Report
(Garber, 2007). For instance, they didn’t reveal the drug industry funds that were funneled through other companies to the task force
chair, David Kupfer. Also, the forms do not reveal how much money changed hands—as if the difference between $500 and
$500,000 is irrelevant. Finally, disclosures were voluntary. In short, the APA’s feeble attempt to control conflicts of interest in the
revision of DSM only called attention to the wave of influence from the drug industry that permeates the psychiatric establishment.
In fact, the most recent study (Cosgrove & Krimsky, 2012) of conflicts of interest among those working on DSM-5 reports that 69
percent of the participants have ties with pharmaceutical companies, a one-fifth increase over the previous edition.
Secrecy and Attacks from Insiders
Although Robert Spitzer was removed from DSM oversight by the APA in the late 1980s, he resurrected himself with DSM-5. This
time, instead of effectively managing political controversies created by outsiders, he created one himself. In September 2008 Spitzer
sent an open letter (via e-mail) to a wide swath of mental health professionals, accusing the APA and the DSM-5 task force of
revising the next edition of DSM in secret (Spitzer, 2008). His letter was the purported outgrowth of his frustration in attempting to
have the task force leaders, David Kupfer and Darrel Regier, make public the minutes of DSM meetings. Apparently they had
refused his requests by invoking the need “to maintain DSM-V confidentiality.” In his letter, Spitzer revealed that all those involved
in the DSM revision process had been required to sign a confidentiality agreement that prohibited them from disclosing anything
about the DSM-5 to anyone, including the spiritual godfather of the modern DSM, Spitzer himself. Spitzer found this unprecedented,
puzzling, and “ludicrous.” He argued that an open and transparent process would allow for wide critical review—the very
“foundation of science.” He stated:

It is ironic that one of the most widespread (and in my view unfair) criticisms of DSM-III and progeny has been the process
of decision-making by committee. This silly new “confidentiality” policy plays right into the hands of these critics and
fuels cynicism about the decision-making process—except that in this case, in contrast to decision making for the revision
of prior DSMs, the cynicism may be well justified. (Spitzer, 2008)

It was clearly Spitzer’s intention to create a political controversy for the APA and the DSM-5 participants. And he did.
Newspapers picked up the story (Carey, 2008; Grossman, 2008; Lane, 2008). But so did the other DSM guru, Allen Frances, who
had guided the development of DSM-IV. Both Spitzer and Frances, the two psychiatrists in charge of DSM for thirty years, opened a
public attack on those working on DSM-5. Their attack is worth describing in some detail, because it borrows heavily from those
who have been psychiatry’s severest critics, portending yet another impending crisis in American psychiatry.
For years, outside critics and some marginalized psychiatrists have been accusing psychiatry of engaging in the systematic
medicalization of normality (Boyle, 2002; Breggin & Breggin, 1994; Caplan, 1995; Caplan & Cosgrove, 2004; Chodoff, 2002;
Cohen, 1990, 1994; Conrad, 2007; Kutchins & Kirk, 1997; Szasz, 2007). Now those accusations were coming from insiders who
had promoted and worked for the American Psychiatric Association. On June 19, 2009, Spitzer circulated a new long essay by Allen
Frances that struck at the very heart of DSM’s weaknesses. Frances forecast “grave problems in the DSM-V goals, methods and
products” that if not corrected would “lead to many damaging unintended consequences,” and he described a psychiatric debacle
that he feared was in the making (Frances, 2009c). Someone who spent decades developing and strengthening the DSM enterprise
had transformed himself into a critic of that enterprise. As Greenberg (2011) quipped, Frances was “hurling grenades into the bunker
where he spent his entire career.”
First, Frances accused the leaders of DSM-5 of soaring ambition and remarkably weak methodology. He thought the task force
leaders’ claim that the next revision would be a “paradigm shift” was absurd. The simple truth, he said, is that “there can be no
dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental
disorders.” The advances in neuroscience, he said, “are still not relevant to the clinical practicalities of everyday psychiatric
diagnosis.” He reminded them of the “disappointing fact that not even one biological test is ready for inclusion in the criteria sets of
DSM-5.” No paradigm shift can occur now, he argued, because “descriptive diagnosis is simply not equipped to carry us much
further than it already has” (Frances, 2009c). He questioned the advantage of moving toward dimensional ratings, arguing that
introducing more complexity into the manual would not be a paradigm shift and would probably be ignored by busy clinicians.
Most of his essay focused on the great risks to psychiatry if the rumors behind the secret revision process were true. First, if the
revisions were not based on substantial evidence, any “innovations” would likely be trivial and arbitrary while requiring
unnecessary efforts by clinicians, educators, and researchers to adopt new diagnostic procedures.
Frances went further: he cautioned in an astounding mea culpa that changes in the DSM-IV diagnostic criteria had created three
false epidemics: those of autistic disorder, ADHD, and bipolar disorder. He warned that the drug industry was ready to pounce on
every change in criteria that “could conceivably lead to a marketing advantage . . . to promote drug sales.” He predicted “many new
‘epidemics’ based on changes in DSM-V” (Frances, 2009c).
Frances worried that little new research or field testing of DSM-5 using any new criteria sets or studies of reliability or
prevalence would occur (eventually there were field trials, as we will discuss in a moment). He discounted research in university
settings as not generalizable to normal practice settings. He faulted the DSM-5 work groups for using inconsistent standards to make
changes and of ignoring many research papers prepared in the last revision. He fretted about DSM-5’s “shallow foundation” and
“embarrassing post publication surprises.” He pointed to some representative examples of DSM-5’s “most reckless suggestion,”
namely its inclusion of many new categories to capture “the milder subthreshold versions of the existing more severe official
disorders.” He argued that recognizing milder versions of disorders would “flood the world with new false positives” and prevalence
rates would “skyrocket,” resulting in “a wholesale imperial medicalization of normality . . . a bonanza for the pharmaceutical
industry.” (emphasis added). “Psychiatry,” he asserted, “should not be in the business of inadvertently manufacturing mental
disorders.” Frances also criticized the proposal to add a “prodromal” or so-called pre-psychotic category. “This is a drug company’s
dream come true,” providing “ways of penetrating the huge new markets with medications having largely unproven benefit and very
substantial side effects” (Frances, 2009c).
As if this weren’t damning enough, Frances continued to press his concerns about what appeared to be a runaway train of
diagnoses. He castigated the task force for even considering the expansion of the “behavioral addictions” (to shopping, sex, food,
internet, etc.) and other proposals for new, questionable disorders or expansion of existing ones. He concluded by worrying about
the “extremely puzzling” secrecy of the whole process and confided that he had “little confidence” in the current DSM-5 leadership.
He and Spitzer called on the APA to establish an external review committee to monitor the progress of DSM-5 (Frances, 2009c).
This early and unexpectedly forceful public attack on DSM-5 did not go unanswered by the APA and the task force leaders
(Schatzberg, Scully, Kupfer, & Regier, 2009), who nonetheless avoided responding to the core of Frances’s critique. The APA
leaders claimed that the DSM-5 process was “the most open and inclusive ever,” implicitly comparing theirs to the prior ones of
Spitzer and Frances, and that their new process was “scientific.” They explained that the key difference was that their “focus is not
on keeping things as they are” but on determining what was wrong with the current DSM and trying to correct it, implying that
Spitzer and Frances were merely wedded to their own prior work. Instead, the APA leaders said without providing specific details,
the DSM-5 would optimize clinical utility and be guided by research evidence. They then counterpunched: “The DSM-III
categorical diagnoses with operational criteria were a major advance for our field, but they are now holding us back because the
system has not kept up with current thinking” (Schatzberg et al., 2009). The APA leaders ended their rebuttal by implying that
Spitzer and Frances’s critique was motivated by financial conflicts of interest, noting that the two were still getting royalties on
earlier DSM-associated products that would end with the publication of DSM-5.
Warning the Research Community
Spitzer’s reply to the APA focused on terrain that he knew well: field trials. After acknowledging that the APA’s response had “taken
an ugly turn” (Spitzer, 2009), Spitzer resumed his attack on the APA’s secrecy. If the DSM-5 process was the most open and
inclusive ever, he asked, why were the leaders of the APA unwilling to reveal any details of the field trials that were scheduled to
begin imminently? As Spitzer knew from personal experience, the field trials were complicated to conduct in the process of a
manual revision, but they also were useful in providing a scientific patina to the hundreds of decisions that were being made. There
was no conceivable reason that the plans for the field trials should not be made public. He asked pointedly: what proposals are being
tested in trials; what is the empirical basis for the trials; what is the planned methodology of the trials; and what are the questions
being asked of the trials—reliability, validity, rate of false positives? Spitzer offered two possible reasons why the APA remained
silent concerning these simple scientific questions: (1) the APA leaders were shielding themselves from criticism or (2) they did not
yet know the answers to those questions. In short, Spitzer was striking at the heart of the APA’s scientific pretense.
The rancor continued in the Psychiatric Times between the prominent inside defenders and inside critics of the DSM-5 process.
(See the variety of responses at http://www.psychiatrictimes.com.) Allen Frances was compelled to defend his motivations for his
criticisms, pointing out that his royalties on products from DSM-IV were no more than the conflict-of-interest policies for everyone
working on DSM-5. He argued that there were profound risks to psychiatry of making ill-considered changes to the diagnostic
manual. He also reiterated that “descriptive psychiatry had reached its limits of usefulness” and that at best the new task force
should strive to “do no harm” (Frances, 2009b). Six months later, Frances issued an alert to the research community, based on his
“several converging, anonymous . . . sources” (Frances, 2009a).
Using the gambit of an investigative reporter relying on insider informants, he relayed to the psychiatric community that the APA
was about to release a draft of options for DSM-5 on the web in January and February 2010 and that the research community would
only have a month to respond, an exceedingly brief review period for such an important document. He also leaked the news that the
field trials had been postponed, that the proposal for external funding for the trials had been rejected, that early drafts of diagnostic
criteria sets displayed their drafters’ inability to write clearly and consistently, and that the final publication of DSM-5 had been set
back to 2013. He repeated his warnings that there was much harm that an ill-considered DSM could bring to the practice and
research communities in the form of the further “medicalizing normality and trivializing psychiatric diagnosis” and again noted the
influence of the drug industry and the excessive use of medications that are potentially dangerous. He ended by encouraging the
research community to be prepared to apply “pressure” on the DSM-5 process by pointing out specific problems when the draft was
released. And then Frances stated:

The APA realizes that it holds the franchise to publish the DSMs only by historical accident, and that this is easily
revocable if enough interested organizations lose confidence in its competence and its ability to control its inherent conflict
of interest. (Frances, 2009a)

Frances’s warnings proved correct. In February 2010 the APA released a draft of DSM-5 on its website, which contained scores
of pages and documents and solicited comments. It provided less than two months for comments on the exceedingly complex
document. And, as forecast, it announced the postponement of both the field trials and the publication of DSM-5. The media
immediately began covering issues raised by the draft (Carey, 2010b).
What even a cursory review of the draft of DSM-5 revealed was that Spitzer and Frances’s fears were well grounded. Everything
that Frances fretted over was included in the draft and more. While the developers of DSM-5 invited private comments about the
draft directly on its own website—comments that would be available to them alone and not to the interested psychiatric community
—Frances immediately began publishing scathing critiques of its contents (Frances, 2010a, 2010d). He said that the plans for field
trials had at least six “seriously disabling limitations” and one fatal one (Frances, 2010b). Among the six disabling limitations, three
focused on reliability: namely, that unclear diagnostic criteria would lower reliability, that field trials in average clinical settings
were likely to show low reliability and “undercut the credibility” of diagnosis, and that reliability studies in special research settings
would not be generalizable. Two other limitations were that the design of the field trials were unfocused and would not provide
much useful information and that the complexity and logistics of the field trials would postpone the manual by at least a year. The
most serious and fatal problem was that the new manual would lead to a tsunami of overdiagnosis.
In another article, Frances argued that normal grief would be diagnosed as a mental disorder in DSM-5 and would invite harmful,
unneeded medical intervention (2010c). Other critics jumped on the proposed changes to the personality disorders section of DSM,
in which five of the ten existing disorders would be eliminated and the others would be given different names (Carey, 2010a; Zanor,
2010). This proposal was a stunning admission of the invalidity of one of psychiatry’s key set of disorders. In a commentary in the
APA’s flagship journal, seven prominent experts questioned the changes being proposed for the personality disorders (Shedler et al.,
2010; Shedler et al., 2011; Skodal, 2011). Even members of the DSM-5 task force worried about “monumental screwups that will
turn the field into a laughingstock,” but would not go on record for fear of retaliation, according to Gary Greenberg, who
interviewed them (Greenberg, 2011).
On several critical fronts, the leaders of the DSM-5 had to acknowledge limitations, some profoundly unsettling, while acting as
if great progress was being made. For example, in a commentary in the APA’s flagship journal, Kupfer and Regier acknowledge that
when they began planning the revision they expected that scientific advances in genetics, neuroimaging, and pathophysiology
during the last twenty-five years would “mitigate” the known limitations of DSM (Kupfer & Regier, 2011). They anticipated that
this knowledge would help to provide a more valid classification of mental disorder, one at long last grounded on some neuroscience
findings. They conceded that this was currently not possible. Rather than admit failure, they noted proudly that NIMH would be
continuing to search for this elusive neurobiology and that “we believe this initiative will be very informative for subsequent
versions” (p. 673) of the manual. They acknowledged that “it is difficult to assess how quickly progress will come about . . . but
genetic data are clearly not yet ready for clinical applications” (p. 673). They continued: “Can we ask psychiatrists to use genetic
markers to assist in diagnosing a patient with schizophrenia? At this point in time, the answer is no.” But they reassured readers that
the time is “soon coming,” that like the Bible, DSM is a “living document,” a “work in progress” that will incorporate “dramatic
neuroscience discovery” (p. 674). This is DSM’s, and psychiatry’s, perennial promise: valid psychiatric diagnosis is just around the
next (neuro)science corner.
Even if neuroscience isn’t ready for prime time, the DSM-5 task force posted on its website the proposed changes to the DSM
and invited feedback from any interested parties. This posting was itself claimed as some achievement, although it was, for the most
part, a public relations process. In periodic reports, Kupfer offered positive and upbeat news of DSM-5 developments, largely
ignoring the storms that were brewing. For example, in the August 2011 commentary (Kupfer, 2011), he says that the “feedback was
so successful” that they received “visits” from 125,000 individuals. He mentions, however, that only 2,120 (less than 2 percent)
made comments or asked questions. Curiously, most frequent comments were about sexual and gender identity disorders. Some
comments were concerned with insurance reimbursement, some with pathologization, some promoted particular diagnoses, and
others were from consumers talking about their own experiences. Nonetheless, Kupfer conveys excitement about these comments
and reassures everyone that they are “sorting through all submissions.” He asserts, “The importance of public and professional input
into DSM-5 cannot be understated” (Kupfer, 2011). The importance, of course, is in appearing to be responsive, while keeping the
work and the decision processes of the committees essentially private.
But the appearance of openness and vacuous press releases didn’t quell concerns about the revisions of the DSM; in fact, the
concerns intensified as questions arose about the “science” of diagnosis and its social implications. One unlikely example was the
emergence of controversy about Asperger’s syndrome, a “disorder” that DSM-IV had defined as a mild form of autism.
Like childhood bipolar disorder, the likelihood that children were diagnosed with autism, defined as a pervasive developmental
disorder, had been increasing rapidly for at least a decade, without convincing evidence about whether this was due to increasing
incidence, better surveillance by clinicians, or the overuse of DSM’s broadened definition of autism (Carey, 2012d; New York Times
Editorial, 2012; Steinberg, 2012; Zarembo, 2011). The DSM-5 task force proposed that the definition of autism be narrowed (DSM
Task Force, 2012) to avoid defining socially awkward children (i.e., shy, timid, or having trouble relating to peers) as autistic. This
proposal provoked a public battle that played out in blogs and newspapers across the country (e.g., Nugent, 2012), pitting those
questioning why social awkwardness, whatever its disadvantages, should be considered as a serious mental disorder against those
concerned that more restricted boundaries of autism would disqualify some children for state-funded education and support. This
controversy highlighted that defining any behaviors as symptoms of a mental disorder provides a medical rationale for providing
services. Drawing the arbitrary boundaries for mental disorders controls the allocation of billions of dollars in health, educational,
and social services (Carey, 2012b).
As mentioned above, another controversy emerged about the diagnosis of depression. In prior editions of DSM, the criteria for
Major Depressive Episode (APA, 1994, p. 323) acknowledged that “symptoms” of depression could result from the loss of a loved
one but that normal sadness should not be viewed as a mental disorder. Excluding normal bereavement from mental disorders was a
rare acknowledgment by the developers of the manual that the social context of behaviors should be taken into account. The new
DSM-5 proposal, however, eliminated the bereavement exclusion and thus would allow normal grief to be considered a mental
disorder.
The media and the experts immediately challenged this proposal (Carey, 2012a; Frances, 2010c), suggesting that the APA
appeared to be pathologizing normal sadness following the death of a loved one. The controversy was furthered by a detailed
analysis of the empirical evidence (Wakefield & First, 2012), which showed that the DSM-5 proposal was based on faulty and
misinterpreted data and rested on no convincing scientific evidence.
Such concerns about the DSM-5 proposals came not just from a few newspaper columnists, concerned families, or psychiatric
experts, nor did they include only a few controversial categories. Mental health professional organizations began questioning the
entire medical orientation of the DSM. For example, the Society for Humanistic Psychology (2012) of the American Psychological
Association circulated a ten-page detailed critique and petition online against the DSM-5. The American Counseling Association
(2012) publicized its own concerns. The British Psychological Society distributed a detailed document questioning the
“medicalization of . . . natural and normal responses” of people, “which do not reflect illnesses so much as normal individual
variations.” Their response continues:

The putative diagnoses presented in DSM-V are clearly based largely on social norms, with “symptoms” that all rely on
subjective judgments, with little confirmatory physical “signs” or evidence of biological causation. The criteria are not
value-free, but rather reflect current normative social expectations. . . . diagnoses are plagued by problems of reliability,
validity, prognostic value, and co-morbidity. (British Psychological Society, 2011, p. 2)

Even the prestigious medical journal Lancet joined the fray, publishing an (anonymous) editorial calling the medicalization of grief
in the forthcoming DSM-5 “not only dangerously simplistic, but also flawed” (Lancet, 2012).
Among the whirl of criticism, few voices were as persistent or public as that of Allen Frances, the former leader of the DSM-IV.
Nor could other critics match his “insider” status. Frances first began writing regular blogs appearing in the online Psychiatric Times
(available at www.psychiatrytimes.com) and another series entitled “DSM5 in Distress” for Psychology Today (available at
www.psychologytoday.com). In dozens of blog posts, he relentlessly criticized the DSM-5 task force, dozens of proposals for
changes in the manual, and the APA for ignoring or mishandling the rising chorus of public and expert criticisms. In March 2012, he
wrote:

In fact, my criticisms of DSM-5 arise precisely from its obvious failure to be an impartial, meticulous, and consensus
academic endeavor. DSM-5 has suffered from a fatal combination of excessive ambition, sloppy method, and closed
process. It fully deserves the concerted opposition it has generated from 47 professional organizations, the world press, the
Society of Biological Psychiatry, The Lancet, and the general public. (Frances, 2012a)

Even long-forgotten scientific issues stimulated new conflicts. After thirty years of neglect since the publication of DSM-III, the
DSM-5 task force created an unexpected controversy over the reliability of diagnoses. The DSM-5 designers had decided to conduct
field trials that would include tests of the reliability of the proposed diagnoses. As these trials were nearing completion, but before
any results were reported publicly, the co-chairs and other members of the DSM-5 task force published a commentary in the January
2012 issue of American Journal of Psychiatry (AJP), lowering the expectations for “acceptable” levels of reliability (Kraemer,
Kupfer, Clarke, Narrow, & Regier, 2012). As we described in chapter 4 (table 4-1), the standards previously promulgated for
interpreting studies of reliability were that “good” reliability was achieved with kappa scores above 0.70; “no better than fair” for
scores around 0.50; and “poor” for scores around 0.40 and less. For DSM-5, however, Kraemer et al (2012) now suggested that
scores of 0.80 “would be almost miraculous”; between 0.60 and 0.80 “would be cause for celebration”; between 0.40 and 0.60
would be a “realistic goal”; while “between 0.20 and 0.40 would be acceptable” (p. 14). With this type of grade inflation, “poor”
scores disappear. This effort to significantly lower expectations—presented as dispassionate technical analysis—did not go
unnoticed. In a letter to the editor in AJP, Robert Spitzer and associates questioned depicting kappas around 0.4 as “the standards of
what is acceptable reliability in medicine” (Spitzer, Williams, & Endicott, 2012). They concluded: “Calling for psychiatry to accept
kappa values that are characterized as unreliable in other fields of medicine is taking a step backward” (p. 537).
Allen Frances reminded Psychiatric Times readers that the chair of the DSM-5 task force, responding to those who worried that
final decisions about diagnoses had already been made prior to the field trials, had reassured them that the early draft of the manual
contained proposals that wouldn’t necessarily “end up in the DSM-5. If they don’t achieve a level of reliability, clinician
acceptability, and utility, it’s unlikely they’ll go forward” (Frances, 2012c). Similarly, the head of the DSM-5 oversight committee
stated in an interview in 2010, “It’s going to be based on the work of the field trials—based on the assessment and analysis of them.
I don’t think anyone is going to say we’ve got to go forward if we get crappy results” (as quoted by Frances, 2012b). Apparently, in
the continuing mad science of diagnostic reliability, one approach to avoiding “crappy results” is simply to redefine them as
acceptable results.
In May 2012 at the APA annual meeting in Philadelphia, the DSM-5 task force unveiled some preliminary reliability findings
from the field trials. With the announced lowering of standards as the prelude, it shouldn’t have surprised observers that the
findings, appearing to be “crappy,” were now defined as “acceptable.” Medscape Medical News called them “mixed,” and Darrel
Regier, the task force co-chair, offered various explanations for disappointing results (Brauser, 2012). For example, in the limited
data released,2 only a single category reached the standards applied to DSM-II and DSM-III (“good” kappas were at or above 0.70):
Major Neurocognitive Disorder (for organic mental disorder), with a kappa of 0.78. The other results were as follows:

Adults Diagnoses
Schizophrenia 0.46
Schizoaffective 0.50
Bipolar I Disorder 0.54
Major Depressive Disorder 0.32
General Anxiety Disorder 0.20
PTSD 0.67
Alcohol Use Disorder 0.40
Borderline Personality Disorder 0.55
Antisocial Personality Disorder 0.22
Obsessive-Compulsive
Personality Disorder 0.31
Children and Adolescence Diagnoses
Autism Spectrum Disorder 0.69
ADHD 0.61
Oppositional Defiant Disorder 0.41
Conduct Disorder 0.48
Disruptive Mood Disorder 0.50
Major Depression Disorder 0.29
What is readily apparent from this partial peek at the initial data is that the DSM-5 task force had nothing to cheer about.
Conducting a few limited studies usually provides a scientific patina to the development of new editions of DSM, but in this case the
results undercut the efforts. Forty years after the invention of descriptive diagnosis, with the major objective to greatly improve
reliability, the DSM-5 field trial results, no matter how they were spinned, showed that there was no general trend toward higher
reliability over the 1980 DSM-III. In addition, with some high-profile diagnostic categories, there were worrisome findings.
Schizophrenia, Schizoaffective, and Bipolar disorders for adults—the bedrock diagnoses of psychosis—were between 0.46 and
0.54, which would have placed them in the lower range of major diagnostic classes in the DSM-III field trials (see table 4-3). Major
Depressive Disorder and General Anxiety Disorder presented enormous scientific and political problems, with kappas of 0.32 and
0.20, a range that by every past standard would easily be classified as unacceptable or poor, raising the problem of how to justify
even including these diagnostic categories in DSM. The task force is hardly likely to abandon these diagnoses, regardless of their
unstable scientific grounding. They constitute two of the most prevalent diagnoses made (Kessler et al., 2005) and provide an
enormous population target for the marketing of psychiatric drugs. Despite the earlier struggles to alter and improve the diagnosis of
personality disorders, their reliability was dismal, lower than the DSM-III field trials (see table 4-3). Similarly, the children’s
disorders saw no improvement over the middling levels of DSM-III (see table 4-4).
The release of information about the field trials at the annual convention and the growing concerns and protests over the
direction of DSM-5 was reflected in generally negative media coverage (Jabr, 2012; Urbina, 2012). The prior week, the Washington
Post ran an op-ed by Paula Caplan: “Psychiatry’s bible, the DSM, is doing more harm than good” (Caplan, 2012), and Allen
Frances’s op-ed in the New York Times on May 12, 2012, blasted the DSM-5 and proposed that the APA “should no longer be
permitted to call all the shots” and that ownership of the DSM needs to be lodged in an independent, scientific organization, such as
the Department of Health and Human Services or the World Health Organization (Frances, 2012b).
In the face of widespread criticism, the task force, “in a rare step,” according to the New York Times (Carey, 2012c), backed away
from several controversial proposals that they vigorously championed for several years. Frances blogged on Psychology Today,
“Wonderful news: DSM 5 finally begins its belated and necessary retreat” (Frances, 2012d). Although Frances was encouraged, he
listed a dozen other proposals that he thought had serious flaws. The APA had backed away from a new “psychosis risk” disorder,
tweaked slightly major depression in response to concerns that it was pathologizing normal sadness, and nixed a new “mixed
anxiety depressive disorder.” But it held firm to the narrowing of its definition of autism and to much of the rest of its proposals.
Whether there will be other proposals withdrawn or significantly modified by the task force is unclear as this is written. In May
2012 the task force gave the public only several more weeks to review the hundreds of changes to the manual, perhaps the last
public exposure to DSM-5 until it is publicly released at the APA annual meeting in May 2013. David Kupfer, the co-chair, invited
“patients and their loved ones, professionals, and the general public . . . to review the proposed changes, and let us know their
thoughts” (Kupfer, 2012). There is no reason to assume that the controversies will cease during the final year, nor that the APA will
conduct new field trials on all or any of the recently altered diagnostic categories, because it would again delay publication.
What is most striking about all the controversies over DSM-5 and all its prior editions is that the conflicts are not really about
science or empirical evidence about the reliability of psychiatric diagnoses. The evidence suggests that reliability has worsened over
time, undermining the validity of the classification system. In a truly scientific endeavor, this would send the DSM-5 task force back
to the drawing board. True science does not require publication deadlines, press releases, public relations specialists, reviews by the
public nor by patients or their loved ones. Science stands or falls on the empirical outcome of rigorous tests of claims, regardless of
popular opinion.
On the other hand, proposals in a democracy to fundamentally alter social and economic policy do require such public scrutiny,
precisely because the decisions are rooted deeply in social values that may be informed by science but cannot be decided by
scientific evidence. For example, revising the United States tax code can only be accomplished in a process that involves many
strong institutional stakeholders concerned primarily with their own self-interests and their own social values. In such a process,
controversy, conflict, distortions, and public relations campaigns are unavoidable.
DSM is like a tax code masquerading as a scientific classification system. Contending psychiatric factions and opinion leaders
argue over specific criteria for substance, mood, anxiety, or personality disorders, as if through debate or field trials they can “get it
right,” can truly “discover” the true nature of medical disease categories of mental illness. The various criteria being debated are
largely meaningless. This is because, as we have argued, the existence of a disease of mental illness has never been established or
satisfactorily defined, so on what basis can anyone “scientifically” judge the validity of one classification of an illusion against a
slightly revised one? The self interests of the psychiatric stakeholders—the APA, mental health professions, clients, insurance
companies, pharmaceutical industries, and government—will inevitably determine the decisions that are made, as would be the case
in any major tax code revision. Madness, whatever its nature and whatever its social uses, resides deeply in human distress and in
our social norms and values. The current squabbles about DSM are largely scientifically meaningless, although they are certainly
meaningful in terms of the threats to the dominance of American psychiatry in controlling the business of mental illness.
We have documented in detail the controversies over the revision of DSM-5 because they are more visible than the diagnostic
controversies of the past, although the dynamics are similar. The Internet, of course, has magnified that visibility, making it easier to
see how the leaders of the latest DSM revision maneuver through a political minefield of contending parties while steadfastly
claiming that they are being driven by “scientific evidence.” And, similar to prior revisions, it remains unclear what exactly the
evidence is or how it is connected to any of the task force’s decisions. DSM is more than a classification system of purported
disease; it is also an expression of professional power within American psychiatry and the pharmaceutical industry, as both seek
relentlessly to expand the reach of the manual among the US population as a target of medical intervention.
 Harms of DSM
DSM provides a method of identifying presumed afflictions, as the APA, pharmaceuticals, and NIMH expand surveillance of the
population, screening children in schools and enlisting general medical practitioners to be on the lookout for mental troubles among
children and adults. Psychiatric experts are expected to find hidden diseases in people harboring mental illnesses by noting signs
that often consist of common expressions of emotions and behaviors. These experts claim to act in the best interests of the
community and the person in need, although in some cases the remedies they offer may involve considerable harm.
Part of DSM’s success can be attributed to the willingness of the public, disordered and non-disordered alike, to accept this
psychiatric reframing of what is the matter and when intervention is needed. It seems clear that the public has generally accepted the
medicalization of many problems in living. Part of this undoubtedly started with the popularization of psychology in American
society, which communicated an essentially hopeful message. The language of psychology encourages the public to view myriad
personal troubles as normal events in the struggles of living, not—as in former times—as signs of immorality, failure, or personal
weakness. Self-help and self-improvement books encourage people to be optimistic that life is malleable and that things can be
improved. The public is told that they are not prisoners of fate, that although human travail and anguish have many sources—
poverty, bad parenting, troubled childhoods, and the common stresses of life—people can overcome adversity and improve their
circumstances. This view accepts human pain and struggle as inevitable but within the abilities of people, perhaps with assistance, to
overcome. Human agency is emphasized.
Psychiatry’s discourse of brain disorder is rapidly supplanting the psychological perspective, though the conquest is not yet
complete. The discourse of disease removes normal troubles from an arena in which the individual can overcome personal problems
with encouragement, support, education, and discipline. In its place, human troubles are sequestered in an arena of disease,
pathology, and medical prescriptions. The NIMH, the APA, and the pharmaceutical companies, using the modern DSM, have
forcefully promoted the view that even mild forms of discomfort, anxiety, sadness, and misbehavior should be redefined as illness or
impending disease, and those with difficulties should ask their doctors for the medication that “is right for you,” before their
“condition” deteriorates and they become targets of coercive intervention. Human agency has shrunk to require only that the
individual seek professional help, as directed by state and other agencies working in tandem with psychiatric organizations. The
doctor will take responsibility from there. Capitalizing on the high prestige of medical science and on people’s obvious and natural
desire to lessen pain and disability, psychiatry encourages the fantasy that human anguish is a disease that can be effectively treated.
The DSM facilitates this ideological maneuver with a novel method of counting troublesome behaviors and converting them into
treatable pathology. With the development, recycling, and marketing of psychoactive medications (see chapters 6 and 7), descriptive
diagnosis has melded parallel systems of beliefs for physical and mental illnesses. Without definitively identifying the existence of
its putative brain disorders or understanding their presumed causes, the DSM provides the illusion that the diagnostic criteria validly
distinguish pathology from normality. And many people, including mental health professionals, unable or unwilling to exercise their
critical faculties, mistake the illusion for reality. In addition to how psychiatry and DSM shaped popular views of life’s struggles and
the role of human agency, the DSM has distorted other realms of activity.
Distortion of Research
Ironically, one of the early criticisms of DSM was that it was designed as a research, not a clinical, tool. In fact, the DSM became a
prominent clinical tool for financing care and marketing medications, but its scientific weaknesses, as we have seen, have distorted
and undermined research.
The DSM’s diagnostic criteria have shaped psychiatric research for thirty years, but, because of its unreliability and thus its
indeterminable validity, DSM has undermined the integrity of the studies it has spawned. Having valid categories of disorder matters
fundamentally in epidemiological research, for example, which must sort people consistently into categories (i.e., the disordered
versus the non-disordered) on which predictions and other scientific or practical efforts will rest. If the diagnostic criteria do not or,
as we have argued, cannot validly identify who is disordered, epidemiological research based on them is largely meaningless, except
as a sociopolitical tool for psychiatric expansionism (Horwitz & Wakefield, 2007; Whitaker, 2010).
Other forms of research are also impaired when they rely on DSM. For example, in research that compares the effectiveness of
different forms of treatments, often using complex designs called randomized clinical trials, patients must be carefully selected with
similar problems and then randomly assigned to different treatment or control groups. Following several weeks or months of
treatment, patients are assessed to see how they are functioning and whether those receiving different treatments had different
outcomes. If their diagnoses are unreliable or invalid, the patients selected for the study would be too heterogeneous in general and
in their responses to the same treatment, undermining the conclusions that the researchers may reach. There is emerging evidence
that this, in fact, has happened.
For example, several years before the official launch of the DSM-5 task force, the APA and NIMH commissioned six white
papers to stimulate research and planning for the upcoming edition to “fundamentally alter the limited classification paradigm
[DSM-IV] now in use” and to “. . . search for new approaches to an understanding of the etiological and pathophysiological
mechanism . . . to improve the validity of our diagnoses” (Kupfer, First, & Regier, 2002). These quotes are from the opening of the
introductory paragraph of the volume containing the white papers and written by two of the psychiatrists who would eventually be
selected to co-chair the DSM-5 task force. Why would they suggest the need to fundamentally alter DSM, search for new
approaches, or improve validity, unless, after thirty years of monumental commercial success and dominance, the current DSM is,
after all, fundamentally flawed and based on a defective approach that has limited validity?
In fact, the opening chapters of their book, A Research Agenda for DSM-V, Kupfer and his associates (2002) admit that research
has not been able to document the validity of the DSM classification system (Kupfer et al., 2002). They note the following: that
research has not discovered common etiologies for the major DSM disorder categories; that not one laboratory marker has been
discovered for any DSM-defined syndrome; that studies have found disorder categories overlap, undermining the belief that these
disorders have distinct causes; that there are high degrees of short-term instability for many disorders; that there is lack of specific
treatments: the same treatment, drugs, or psychotherapy are used for many supposedly different disorders; and that even studies of
twins have contradicted the DSM assumption that different disorders have different underlying genetic bases.3 All of these findings
suggest that the DSM classification system is of questionable validity.
No modern (or older) edition of DSM has produced scientific breakthroughs. Kupfer et al. (2002) conclude that “researchers’
slavish adoption of DSM-IV definitions may have hindered research in the etiology of mental disorders,” and that “research
exclusively focused on refining the DSM-defined syndromes may never be successful in uncovering their underlying etiologies.”
They argue that the reification of DSM entities “is more likely to obscure than to elucidate research findings” (pages xviii–xix).
More recently, in attempts to gain leverage to make dramatic changes, the developers of DSM-5 continue to attack the validity of
prior editions of DSM (Regier et al., 2009; Schatzberg et al., 2009). They argue that because of fundamental validity problems, DSM
has hindered psychiatric research. With so much concern about the validity of DSM, even those at the center of the DSM enterprise
appear to admit that they don’t know what the DSM-defined disorders really are. Unfortunately, however, they want the public to
believe that they can solve these problems by tinkering yet again with the diagnostic criteria. Can they really believe this? These
scholars read and understand the same literature that the authors of this book read and understand. In our view, the most plausible
reason for more tinkering with DSM categories is that psychiatry must go on.
Distortion of Records and Help
The psychiatric research enterprise is not the only institutional investor to be misled by a false sense of diagnostic accuracy. With
the wholesale adoption of DSM by hospitals, clinics, and private and government insurance programs, inaccurate and invalid
psychiatric diagnoses have been indelibly written into the medical records of millions of children and adults who seek help with all
manner of human troubles, many of which neither the clinicians nor the clients themselves view as mental illnesses. Nonetheless,
because medical insurance coverage requires that a diagnosed physical or mental disease is being treated, primary care physicians,
psychiatrists, and other mental health professionals routinely scan the DSM looking for a diagnosis that can be used for
reimbursement (Braun & Cox, 2005; Greenberg, 2010; Kirk & Kutchins, 1988; Rost et al., 1994). Regardless of the validity of the
diagnosis, clinicians are paid to provide services to these clients. Clinicians, clinics, hospitals, and clients may accrue some benefits,
but the residue of false and misleading psychiatric diagnoses distort the medical records of many whose only distinguishing feature
was to have requested assistance from a service or professional who formally diagnosed them, which can easily cause future legal
and employment problems. Moreover, the practice of deliberate misdiagnosis raises ethical issues for the mental health professionals
who use questionable diagnoses to gain reimbursement for services.
The harms of surveillance and misleading diagnoses extend far beyond psychiatry. Much disagreement exists in the medical
community about the costs and benefits of mammograms to detect breast cancer in women and the PSA blood test to detect prostate
cancer for men. The diagnostic tests are not definitive; very few of those screened will enjoy any benefit, and many of those
screened will be subjected to medical procedures that are worrisome, costly, and probably unwarranted (Aschwanden, 2011;
Woolston, 2011).
In psychiatry the problems are probably more severe, because the diagnostic gamesmanship that is common to many clinicians
and clinics is totally unnecessary to provide help for people who actually need it. Psychiatric diagnosis is, in fact, not needed in
order to help the vast majority of those currently labeled as mentally disordered. A former president of the APA was asked in a
recent interview how he used DSM. He said that his secretary had just asked him for the diagnosis of a patient he’s been seeing in
treatment for several months in order for her to send a bill to the insurance company. He “hadn’t really formulated it,” but scanned
DSM and suggested that the patient had obsessive-compulsive disorder.

Interviewer: “Did it change the way you treated her?”

Psychiatrist: “No.”
Interviewer: “So what would you say was the value of the diagnosis?”
Psychiatrist: “I got paid.” (Greenberg, 2011)

A case for requiring a psychiatric diagnosis for the receipt of services would only be legitimate if an identifiable medical problem
existed, the diagnosis pointed to a specific underlying “pathology” causing the “symptoms,” and if without knowing the diagnosis,
clinicians might provide harmful, less effective help for the person. None of these conditions is true for the vast majority of people
who seek assistance for problems in living from clinical psychologists, social workers, marriage and family counselors,
psychiatrists, or others. DSM diagnoses describe behaviors unconnected to any known biological causes or medical conditions; the
treatments used on those diagnosed with mental disorders are nonspecific to the diagnosis (including the uses of psychoactive drugs,
as discussed in the next chapters); and clinicians provide similar services and interventions across diagnostic categories, from
bipolar disorder to mood, anxiety, and personality disorders. In fact, the placebo effect may rank as the most generally effective
treatment in psychiatry and certainly the one with the fewest and least harmful side effects (Fournier et al., 2010; Greenberg, 2010).
Moreover, providing help to children, adults, and families who may be troubled generally consists of offering support, advice,
clarifying emotions and thoughts, exploring options, and linking the person to other supports and helping resources. Clinicians have
known for decades that the natural ingredients of helping come from providing a tolerant and safe environment, conveying a sense
of respect and trust, and offering assistance in a manner that is warm, nonjudgmental, and empathic. A DSM diagnosis is largely
irrelevant to the helping relationship.
Counseling and psychotherapy do not require a specific diagnosis, are not improved by a specific diagnosis, and are not made
more effective by a specific diagnosis. The helping relationship is certainly enhanced when clinicians develop a broad understanding
of the person’s life space, family, friends and social ties, struggles, pain, and failures, and of sources of strength and resiliency. This
was true prior to the transformation of DSM and remains true today. In a recent study by the World Health Organization and the
World Psychiatric Association (Reed, Correia, Esparza, Saxena, & Maj, 2011), an overwhelming majority of the nearly 5,000
psychiatrists from forty-four countries preferred classifications that were designed for clinical use, not research purposes, which
allowed for more flexible diagnostic criteria and fewer than a hundred categories, versus the current three hundred. Whether they
favor one hundred or three hundred diagnoses, these clinicians may not be critiquing the dominant disease model. However, they
seem to be suggesting that DSM-type classifications add little except administrative distraction to the generic helping process. We
know of no evidence showing that people diagnosed by DSM are more likely to receive effective treatment than they would
otherwise receive.
 Conclusion
Thirty years after DSM-III revolutionized American psychiatry by claiming to have solved the fundamental problem of diagnostic
reliability and thus to have taken a great leap toward establishing diagnostic validity, mental health professionals still can’t reliably
agree on diagnoses—or even on what constitutes a mental disorder, much less establish diagnostic validity. The rhetoric about
diagnosis has never matched the actual science. The old promises of progress have remained unfulfilled, as yet more new promises
are made by the architects of the forthcoming DSM-5.
The quest of biological psychiatry, adopted and aided by DSM, is to claim a brain disease for every human trouble. From
Kraepelin to NIMH’s Decade of the Brain, the perennial promise is that brain diseases will be discovered. Despite decades of failure
to confirm that misbehaviors and emotional turmoil are caused by disordered brains—a search floated on the massive stream of
funding from the federal government and the drug industry—the effort has never lost momentum and even enthusiasm, as if the key
to human misery will be discovered. The failure for the enterprise to deliver on its promises has not discouraged efforts to support it,
which suggests that it is at its core a moral crusade.
A corollary illusion is that every “symptom,” every expression of anguish and anger, hurt and heartache, exuberance and despair
is presumed to be linked to some unknown biochemical pathology. And while the causal links are elusive, those who are anxious,
scared, sad, lonely, inept, or frustrated, can, in the meantime, occasionally find comfort in any one of a number of pharmaceutical
remedies.
The APA and the pharmaceutical industry appear to be on a quest to find disease and disorder everywhere. Descriptive psychiatry
has enticed the public to swallow the myth that all manner of human troubles are not the inevitable nature of the human comedy:
they are expugnable illnesses. The implicit ideal of the healthy, normal, and truly happy camper is someone who, properly treated,
will harbor no serious worry or animosities, no sadness over losses or failed ambitions, no disappointments with children or spouses,
no doubts about themselves or conflicts with others, and certainly no strange ideas or behaviors. Children should be well-behaved,
bright and attractive, and have flawless DNA. These “normal” people will only have orgasms that are perfectly controlled and
properly timed and directed. Their moods will be mellow in all circumstances, and bad hair days will be a thing of the past.
Could anyone truly be swayed by these illusions, duped into believing that problems are solved when they are not? The history
that we have reviewed previously and mankind’s perennial follies suggest a resounding yes. DSM has become so encrusted into the
American public’s and professionals’ views of madness, into how services are arranged and financed to help people, that it has
become almost impossible to think about a world without a diagnostic manual of mental disorders. But perhaps it is time to consider
a radical alternative by asking some questions. Are we really well-served by a DSM that provides a dictionary of fictitious brain
disorders as a guide to describe, name, understand, or cope with human adversity? Is it really necessary to place people into illness
categories to provide them with humane and effective help if they need and request it?
 Notes
1. Even clinicians who do not have a medical orientation, or are uninterested in making a DSM diagnosis, or even those who believe DSM diagnoses are invalid frequently
end up making such diagnoses, because these clinicians and their patients operate within a biomedical industrial complex (see Gomory, Wong, Cohen, and Lacasse, 2011).
See also discussion in this chapter under “Distortion of Records and Help.”
2. The initial presentation of these data took place at the annual meetings, with PowerPoint slides of the data. Neither the full data nor the methodological details have been
published as this is written. Published news accounts have presented slightly different kappas, thus these initial partial results are tentative.
3. It is beyond the scope of this book to undertake a critique of genetic hypotheses of mental disorders, and especially the validity of twin studies upon which the inadequate
notion of “heritability” rests and is used misleadingly and incoherently to claim that various human behaviors and actions have “genetic causes.” For this purpose, see, for
example, Jay Joseph, The gene illusion.
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 6
Dancing with Drugs

Introduction
Like other “advances” in community treatment and diagnosis that we deconstruct in this book, the promises of the scientific drug
treatment of distress, madness, and misbehavior rest on uncritically accepted claims, not well-tested evidence. The popular success
of prescribed psychoactive drugs does not rest on scientific demonstrations of efficacy in the treatment of medical disorders. The
success results from the synergistic combination of ideological, cultural, and commercial forces. Bearing down from above came
shoddy science, uncritical practitioners with a monopoly on drug prescriptions, the minting of new mental disorders, ubiquitous
drug marketing, co-opted regulatory agencies, and plain fraud. Surging up from below and augmented by a newly emerging health
consumerism came people’s indefatigable desires for psychoactive drugs, the powerful but dismissed power of placebo, and the
reverberation of myriad personal narratives of drug-induced transformation, recovery, and cure.
The merging of these forces created the conviction among the educated and not-so-educated that such popular success could only
rest on a solid scientific foundation. It was and remains inconceivable to many observers that consumers and insurers might spend
billions of dollars on placebos with brand names—or worse, on drugs that produce waves of iatrogenic (that is, doctor- or treatment-
induced) diseases. Indeed, over the past half century the psychoactive medicines enterprise was constantly justified by appeals to
science, but its foundations did not rest on science as a search for truth, as an effort to test hypotheses rigorously, or as a means to
understand biological or social facts. As for the specific field directly concerned with the investigation of psychiatric drug treatment,
clinical psychopharmacology, many of its practitioners and researchers engaged in nothing less than the studious avoidance of
evident facts about distress, psychoactive drugs, healing, and the power of suggestion.
In this chapter, we lay out the mental health system’s current crisis with regard to psychiatric drugs: the emerging consensus that
the latest prescribed psychiatric drugs do not necessarily improve the targeted symptoms of people diagnosed with major mental
disorders. We review recent studies conducted with United States federal government funding that attempted to assess what sort of
improvement the major modern classes of psychiatric drugs were actually bringing about in such people. We then place their
findings in the context of the long-standing promotion of drugs by the pharmaceutical industry, and psychiatry’s enthusiastic role as
the industry’s junior partner. Yet as our initial comments in this chapter suggest, the story of the widespread adoption of apparently
ineffective drugs as paradigmatic treatments is complex and involves many other interacting forces and players. It is also not a new
story in psychiatry. We try to paint this more complex yet recurring story in chapter 7, which also looks at the dubious distinctions
made between “dangerous drugs” and “approved medications” throughout the century and examines how some particular
psychoactive substances become constructed and promoted as FDA-approved medications.
We present two complementary but different critiques of the current disease-centered approach to conceiving of the beneficial
effects of prescribed psychiatric drugs. The first, in this chapter, focuses on the continuously documented but continuously avoided
power of placebo. The second, focusing on the striking and subtle psychoactive effects of psychiatric drugs, suggests that placing
these drugs squarely within the broader ecological niche of all psychoactive drugs could go far to increase our understanding of how
drugs “work” to relieve distress while creating new opportunities for a truly patient-centered psychopharmacology (Moncrieff &
Cohen, 2009; Moncrieff, 2008).
 Yet Another “Seige Cycle”
That psychoactive drugs used as prescribed medicines often do not have the beneficial impact on mental disorders (however
defined) claimed by proponents and promoters of drugs is relatively easy to demonstrate: the most touted studies show that the
desired outcomes of modern drug treatment do not reveal improvement when compared with outcomes of treatments from the pre-
drug era, or with outcomes from older or discarded drugs, and in some cases the recent outcomes appear worse. For example, when
followed for one year, depressed persons who are drug-treated experience more depressive episodes, and longer ones, than
depressed persons who remain drug-free (Patten, 2004). Very long-term follow-up studies of ten years’ duration or more of
depressed people show no worse outcomes for drug-free than drug-treated individuals (Hughes & Cohen, 2009). In the largest real-
world study of the drug treatment of depression funded by the NIMH, it appears that not more than 3 percent of the more than four
thousand subjects who underwent drug treatment managed to stay in the study, improve, and be considered to stay well for one year
(Nierenberg et al., 2008). Improvement rates in drug treatment studies of schizophrenic patients during the late 1980s to the mid-
1990s were identical to rates observed in studies conducted between sixty and one hundred years earlier (Hegarty et al., 1994).
When British psychiatrist David Healy (2009) investigated changes over the past fifty years around his own hospital in North Wales,
he observed the following: compulsory psychiatric detentions were up 300 percent, admissions for serious mental illness were up
700 percent, while admissions overall were up 1500 percent. Suicide rates among patients diagnosed with schizophrenia were up
2000 percent. General death rate among patients considered seriously mentally ill had “risen substantially.” Healy added that all
studies find that the death rate of schizophrenic patients increases with the number of drugs given. He concluded: “What we are
seeing now is not what happens when treatments work” (2009, pp. 32–33).
Such assessments have not only come from mental health professionals known for their critical views. Thomas Insel, director of
the NIMH, acknowledged in 2009 the failure of the pharmacological agents that have dominated mental health treatment since the
1960s. Insel asked: “Is there any evidence to support that progress in psychiatry leads to reductions in morbidity or disability in
people with serious mental illness?” To answer, he reviewed recent US national studies involving interviews with participants in
several thousand households. He made the dramatic assertion that “there is no evidence for reduced morbidity or mortality from any
mental illness” (2009, p. 129). “The results demonstrate no change in the prevalence of mental illness between 1992 and 2002, but
increased rates of treatment. . . . Curiously, despite increased treatment, there was no evidence for decreased disability” (pp. 128–
129). Concerning mortality, Insel noted that persons diagnosed with serious mental illness die from thirteen to thirty-two years
earlier than people in the general population, and that suicide rates have not decreased.
In this respect, the official realization of disappointing effects from widely promoted drugs fits what French historians Christian
Bachman and Anne Coppel have called the “path of stigmatization” (1989, p. 109), which they believe characterizes how
psychoactive drugs move over time in society. More pointedly, Dutch historians Toine Pieters and Stephen Snelders (2005) have
named this a “Seige cycle,” after German psychiatrist Max Seige, who suggested as early as 1912 the idea of a cyclical dynamic of
the careers of such drugs. A Seige cycle is characterized by initial enthusiasm and therapeutic optimism leading to widespread use,
subsequent negative appraisal, and finally, limited use or an outright ban. Seige’s insight is notable, given the few drugs he must
have considered as examples by this date. The opiates, morphine especially, exemplify this path: at the start, a “uniquely
efficacious” drug; at the end, “addicted victims”1 (Chast, 1995).
Thomas Szasz (1974) as well as drug scholar Richard DeGrandpre (2007) have also commented on the trajectories of drugs from
panaceas to panapathogens (but sometimes also back to panaceas as is the case with the medical use of morphine today and the
renewed psychiatric interest in hallucinogens, see Tierney, 2010), despite an identical scientific understanding of their pharmacology
at the start as at the end of the trajectory. These authors argue that the social-ceremonial aims of psychoactive drugs may far
outweigh—whether in personal lives, professional interest, or public policy spheres—their actual pharmacological effects. We find
these insights intriguing and will be applying them throughout our analysis of psychiatry’s portrayals of the prescription of its
favorite psychoactive drugs as evidence-based treatment.
The preceding paragraphs suggest that there is nothing unusual about the inability to show, in scientific studies conducted after
psychoactive drugs have been in widespread use for years and decades, that these drugs do not necessarily decrease disability—that
in fact they may be responsible for excess disability. This pattern may have occurred with every class of drugs introduced in
psychiatric practice since the turn of the twentieth century. Disappointing findings of effectiveness and findings of excess
(iatrogenic) morbidity have also regularly been used to justify and promote the adoption of newer drugs or drug classes, on the
promise of improved effectiveness and reduced toxicity. Being unfamiliar with history or being too closely wedded to a particular
school of thought, or both, many people within and outside of the mental health system may therefore have confused the popularity
of psychiatric drugs with the validity of the claim that psychiatric drugs constitute specific, effective treatments for specific
disorders. In our view, this latter belief is a major impediment to understanding any genuine treatment functions and
accomplishments of psychiatry today, and we deconstruct it in this and in the following chapter.
 One Drug after Another
Starting roughly in the 1920s with the introduction of the sedative barbiturates into routine medical practice, crops of new-and-
improved psychiatric drugs have been prescribed to an increasing number of people. The stimulating amphetamines were introduced
in the 1940s. In the 1950s came the neuroleptics (or antipsychotics) and the tricyclic antidepressants (TCAs), launching a new
confidence in biological psychiatry. In the 1960s the tranquilizing benzodiazepines were introduced, making large new inroads into
general medical practice. In the 1980s, the serotonin-reuptake inhibitors (SSRIs), initially approved as antidepressants, extended
biological psychiatry’s conquest-by-medication and in the 1990s, the second-generation antipsychotics and anticonvulsant “mood
stabilizers” mopped up virtually all remaining pockets of resistance. Insel’s appraisal of progress, or the lack thereof, was published
in 2009.
Prescriptions written for antidepressants in the United States numbered about 40 million in 1988, the year Prozac was launched,
compared to 264 million in 2011 (IMS Health, 2012). Five years earlier, antidepressants had become the most prescribed class of
drugs in the United States (Centers for Disease Control and Prevention, 2006)—more often prescribed than antibiotics or drugs to
treat heart disease. Looking only at the short interval between 1998 and 2004, the number of noninstitutionalized Americans
purchasing products from the psychiatric drug classes of antidepressants, antipsychotics, benzodiazepines, and stimulants increased
from 22 million to 38 million (Stagnitti, 2007). The really notable changes occurred among children. In the mid-1980s, less than 1
percent of children were taking any psychiatric drugs, usually stimulants and benzodiazepines. Twenty years later, depending on the
specific age group considered, 8–12 percent of youths were being medicated with psychiatric drugs. Indeed, in 2009, over 40
million prescriptions or refills were written for youths under nineteen years of age: 24.3 million for stimulants, 9.6 million for
antidepressants, and 6.5 million for antipsychotics (Mathews, 2010).
Industry/Psychiatry
Only recently have academics and journalists described the role of the pharmaceutical industry in these trends without being
dismissed as antiestablishment radicals with a grudge against profitable industries. The industry did not merely bring new drugs to
market, it made every effort to ensure that physicians would view whatever latest drug or drug class was being promoted as
indispensably beneficial and would prescribe them readily for the widest range of patients’ complaints and presenting problems.
This involved “disease mongering”—broadening the boundaries of treatable problems and creating anxieties about the seriousness
of ordinary ailments (Moynihan, Heath, & Henry, 2002)—as well as purchasing the hearts and minds of practitioners and those
leaders and organizations who could influence the ideas and behavior of practitioners. Psychiatry, which already embodied the
medicalization of deviance and distress, wholeheartedly embraced its partnership with the drug industry, to the point, we think, of
becoming virtually indistinguishable from it.
During the first decades of the twentieth century, in order to present their products as more scientifically-based, drug
manufacturers began to voluntarily relinquish the option to advertise drugs directly to the public. This made direct marketing to
physicians indispensable, and the appearance of science in marketing grew correspondingly. Amphetamine, first developed in the
1920s as an oral anti-asthma drug, was actively promoted the next decade by the Smith, Kline and French firm among
“neuropsychiatrists” for the treatment of mild depression, from whence it spread to general medicine. “By the 1930s,” writes
historian Nicholas Rasmussen (2006), “leading firms like Smith Kline and French had learned to involve themselves in the medical
research literature to a remarkable extent, from conceiving and designing clinical studies that targeted particular medical audiences,
to overseeing their execution by competent or even eminent researchers, to managing their writing, illustration, and publication in
top journals” (p. 301). Thus began the “remarkable extent” to which the pharmaceutical industry is involved in the design, conduct,
and dissemination of clinical trial research today.
Over the century, the drug industry has developed and employed systematic drug-detailing techniques to convince individual
doctors to prescribe its latest products. The basic techniques—gifts, flattery, and persuasion—have not changed much since the
1930s. Today, however, drug manufacturers can target virtually every practicing physician in the United States with laser-like
precision and maximum efficiency. Using computerized databases purchased from a plethora of commercial medical information
firms and from professional organizations such as the American Medical Association, drug firms closely monitor the effects of their
promotional strategies on drug sales or prescriptions at national, regional, and even local pharmacy levels. It is no exaggeration that
an entire multinational pharmaceutical firm can adapt or customize its marketing strategies down to a single prescriber if necessary
(Fugh-Berman, 2008).
To support these techniques, the industry proceeds by mass infusion of money, dozens of billions of dollars each year (Gagnon &
Lexchin, 2008). The money facilitates the professional activities (studies, travels, hostings, communications, disseminations) of
students, clinicians, educators, researchers, legislators, policymakers, drug regulators, journal editors and reviewers, hospital
administrators, and consumer advocates—as long as the endpoint of the activity is perceived as favorable to the industry’s products
or completely neutral (by which we do not mean objective). The money comes in myriad forms, such as salaries, prizes, awards,
donations, reimbursements, unrestricted educational funds, research grants, endowments, equipment grants, seed grants, travel
allowances, and bribes. This fuel keeps the drug industry’s views, interests, and agenda active or quiescent in the mind of every
player and potential player in the mental health system. (A more detailed analysis of drug-industry funding appears in the next
chapter.) Thus, by the early 1990s, the multinational pharmaceutical industry had cemented an intricately complex, multilevel
partnership with the profession of psychiatry, both at the level of psychiatric institutions and educational centers and at the level of
individual practitioners, and with national, state, and local opinion leaders in the mental health movement. With every passing year,
as more patented drugs sold, more profits accrued to the industry, and more funds were plowed back into making friends,
influencing people, and generating “evidence,” the partnership grew in breadth and depth.
As discussed especially in chapter 5, starting sometime after 2005, signs of a backlash against this alliance appeared. Rumblings
were heard from some newspapers, some legislators, and some outspoken members of various professional groups. In 2008, for the
first time, the crusading US Senator Charles Grassley asked the American Psychiatric Association to disclose precisely how much of
its annual budget came from the drug industry. The APA (2008) divulged that 28 percent (approximately $14 million of its budget
the previous year) were industry contributions, primarily paid in advertising in APA journals and funds for continuing medical
education (CME) courses offered by the APA.
As public acceptance of industry control begins to decline, psychiatric associations are beginning to clean house, for example by
reducing the number of industry-funded symposia offered as CME at their annual meetings (Carlat, 2009). For the foreseeable
future, however, if psychiatry wishes to maintain itself as the flagship mental health profession, it has little choice but to maintain its
financial and intellectual dependence on the pharmaceutical industry. The APA’s ability to attract substantial industry funding
outside of membership dues to promote its image and its activities has been unique among all the mental health professions. This is
not difficult to understand. In the absence of scientific demonstrations of the validity of its particular medical approach, all
psychiatry can unequivocally show is the popularity of psychoactive drugs that physicians prescribe after opinion leaders in
psychiatry show them the way. But the popularity of drugs is a double-edged sword. Though it has propelled biological psychiatry
to undreamed heights, a number of recent trends suggest that it may eventually engulf the profession—render psychiatry obsolete, in
other words—in a rising wave of industry-promoted and consumer-directed medication choices.
Drugs for Everything
With the allowance by the Food and Drug Administration (FDA) of direct-to-consumer advertising of prescription drugs in the
United States beginning in full force in 1997, psychoactive drugs became yet another consumer product advertised to the public in a
myriad of artfully produced television, magazine, newspaper, and internet ads. In all of these, the message that doctors are somehow
in control is unfailingly transmitted (“Ask your doctor . . .”), but its repetition has finally served to underscore its absurdity.
Advertisers and “drug reps,” not doctors, are now the actual middlemen between people and their drugs, just as they were a century
ago, in the wild era of “patent medicines” (Young, 1961).
Daily, with the full blessings of medical and educational authorities, millions of parents give their prepubescent children
psychoactive drugs—some of which, like amphetamines (e.g., Adderall), were banned only twenty years earlier in the United States
and whose use or distribution without a medical prescription can elicit draconian penalties.2 The boundary between licit and illicit
psychoactive drug use is vanishing: celebrities like Michael Jackson, Heath Ledger, and Anna Nicole Smith “accidentally” die from
ingestions of duly prescribed medications, and experts in mental health, law, and ethics call for the prescription of psychoactive
drugs to the healthy for cognitive enhancing or “neuroenhancement” (Greely et al., 2008). Several factors are interacting in complex
ways to produce these trends. They include the increased role of consumer preferences and choices, the reverberation of popular
discourse, direct-to-consumer advertising campaigns, and the pronouncements of experts. This is not unlike factors such as
consumer preferences, the price of fuel, and advertisements interacting to influence individual purchases of consumer goods such as
automobiles.
Moreover, the once-hallowed market approval of a drug by a powerful regulatory agency like the FDA has become, from the
viewpoint of pharmaceutical firms, the last obstacle to promoting drugs aggressively with only the barest connection to the
indication and age group for which the FDA approved the drugs. Doctors who might claim to practice “evidence-based psychiatry”
routinely prescribe drug cocktails (combinations of two or more psychiatric drugs) whose effects no published controlled study has
ever probed (Bhatara et al., 2004).
As for the published studies themselves—as David Healy has suggested and as we explore ahead, “There is probably no other
area of medicine in which the literature is so at odds with the raw data” (cited in Leo, 2006, p. 31). And, the most vulnerable—
children covered by Medicaid because of low income—are four times more likely to receive antipsychotic drugs and for less severe
“conditions,” than children with private insurance (Wilson, 2009). According to most available estimates, about two-thirds of all
money spent to purchase psychotropic drugs (and mental health and substance abuse treatment in general) in the United States is
spent by government programs, prominently Medicaid and Medicare (e.g., Donohue, 2006).
“The Care We Provided Was Appropriate . . .”
National headlines were made in 2007 by the heartbreaking case of Rebecca Riley, a four-year-old child found dead on her parents’
bedroom floor from a drug overdose. The Riley parents were unemployed, and the family was almost wholly supported by Social
Security benefits. Starting at age two, Rebecca was diagnosed as suffering from attention-deficit/hyperactivity disorder and bipolar
disorder, almost entirely on the basis of the accounts of her behavior given by her mother to Kayoko Kifuji, a child psychiatrist
employed by Tufts-New England Medical Center. Dr. Kifuji also prescribed to Rebecca (and her two slightly older siblings, also
diagnosed with bipolar disorder by Dr. Kifuji) the antipsychotic quetiapine (Seroquel, $3 billion in US sales that year), the
anticonvulsant depakote, and the antihypertensive drug clonidine (used in child psychiatry for its sedative properties, often
prescribed in tandem with the stimulant methylphenidate, or Ritalin). Rebecca also was given two over-the-counter cold remedies
(both of which were, a year later, in an unrelated action, “voluntarily” withdrawn by drug manufacturers for use in very young
children). None of the three prescribed drugs were FDA-approved for psychiatric use with children because the FDA had never
considered any evidence of even their short-term, superficial behavioral benefits for children.
Yet, immediately after Rebecca’s death, her medication regimen was defended by Tufts-New England Medical Center, whose
spokesperson stated: “The care we provided was appropriate and within responsible professional standards” (WCVB TV, 2007). As
recounted in a series of grim reports, Rebecca’s father had a confirmed history of abusive behavior. Both parents were chronically
unemployed and seemed intent on declaring the whole family mentally ill to increase their financial support from state agencies.
Moreover, they appeared to ignore Rebecca’s complaints during her last painful hours of life. This shielded Dr. Kifuji from criminal
prosecution, and in separate trials the Riley parents, Michael and Carolyn, were convicted of first- and second-degree murder,
respectively (Wen, 2010). Dr. Kifuji continues to practice as a child psychiatrist. Kaitlynne Riley, Rebecca’s older sister by two
years, away from her parents and Dr. Kifuji since her sister’s death, was said to have “recovered” from her bipolar disorder,
symptom-free and drug-free (Diller, 2010).
In another case, Nada Stotland, then president of the American Psychiatric Association, commented on the simultaneous
prescription of the antidepressant Prozac, the tranquilizer Xanax, and the sleeping pill Ambien by a psychiatrist to a tormented
twenty-seven-year-old man, Steven Kazmierczak, who eventually went off the drugs and then went on a shooting rampage at
Northern Illinois University, where he had formerly been a student. Although some observers might interpret Kazmierczak’s actions
as evidence that the drugs were helping him, others could point to the unusual reactions occasionally reported as triggered by
combinations of psychoactive drugs and by the rebound and withdrawal reactions triggered by medications stopped abruptly.
Stotland was quoted as stating: “It is not unusual for doctors to prescribe anti-anxiety agents and sleep medication along with
antidepressants, since [antidepressants] can cause anxiety and interfere with sleep” (CNN, 2008).
That very young children could be psychiatrically diagnosed and medicated so arbitrarily and that national psychiatric authorities
could state matter-of-factly that the drugs they prescribed to treat anxiety and depression “can cause anxiety and interfere with
sleep” in effect meant that society had given psychiatry a blank check. As the biological wing of psychiatry and the mental health
movement had ascended during earlier decades, new catch phrases and slogans justified the ancient human rituals of taking and
giving drugs. Everywhere, chemical imbalances, neurotransmitter malfunctions, and impaired neural circuits were corrected,
balanced, modulated, or stabilized by evidence-based treatments. These vague, medical-sounding phrases cloaked people’s
unquenchable desires for psychoactive drugs in the explanatory language of people’s need for essential treatments provided by
medically informed experts.
 The Chickens Are Coming Home to Roost
Starting in the fall of 2005 and still continuing as these lines are written, a series of articles appeared in the major American
psychiatric and medical journals, reporting the results of three exceptionally large NIMH-funded studies evaluating the effectiveness
of state-of-the-art psychiatric drug treatments for schizophrenia, depression, and bipolar disorder. The three studies, reportedly
costing taxpayers over $100 million, provided what a Boston Globe journalist described as “the most realistic look ever at the state
of psychiatric medicine” (Allen, 2006). The studies showed unambiguously that drugs do not make most people considered
psychiatrically impaired significantly better for any sustained period of time. Since the studies appeared, mainstream popular and
professional reactions suggest that the demonstration has been absorbed, digested, and recycled like every such negative finding
over the past sixty years: it appears to have made only a tiny dent in the myth of psychiatric progress.
New Antipsychotics: A Bust
The first article appeared in the September 18, 2005, issue of The New England Journal of Medicine. Its lead author, Jeffrey
Lieberman, chairman of the Department of Psychiatry at Columbia University, and the coauthors read as a list of the “Who’s Who”
of schizophrenia drug treatment in the United States (Lieberman et al., 2005). The article was the first of many reporting on the
results of a psychiatric mega-study, Clinical Antipsychotic Trials of Intervention Effectiveness, since known by its acronym, CATIE.
The general aim of the study was to compare five different antipsychotic drugs in the treatment of nearly 1,500 patients diagnosed
with psychosis and schizophrenia and recruited from fifty-seven different sites. Four of the drugs were second- or third-generation
antipsychotics (olanzapine, quetiapine, risperidone, and ziprasidone), approved by the FDA between 1994 and 2002. The fifth was
perphenazine, a nearly forgotten antipsychotic introduced in the late 1950s, almost never prescribed today.
To place the findings of this study in some context, one should note that schizophrenia is one of the few conditions that
psychiatry can be said to “own”; nothing better exemplifies the application of psychiatric knowledge than treating schizophrenia. It
is widely held that psychiatry came of age in the 1950s when it stumbled upon chlorpromazine (named Thorazine in the United
States) and similar drugs that suppressed the agitation of asylum inmates. Since then, the drugs, first named neuroleptics and
eventually antipsychotics, have been given to hundreds of millions of people throughout the world and are consecrated as having
ushered in the “psychopharmacological revolution”—the very subject of this chapter and the next. Although schizophrenia is
considered to affect about 1 percent of the population, during the first decade of the twenty-first century, antipsychotics ranked
among the five top-selling classes of all prescription drugs in America. This was because most of their prescriptions were for
problems outside schizophrenia and bipolar disorder, the drugs’ approved indications by the FDA, and because their manufacturers
had accurately gauged that third-party payers would spend hundreds of dollars monthly for individual courses of treatment
prescribed by appropriately primed physicians.
In CATIE, each entering patient was randomly assigned to receive one of the drugs and was followed for up to eighteen months
or until he or she dropped out of the study or was switched to another drug. Notably, the primary outcome reported in the 2005
article was not a measure of the drugs’ intended benefits. The researchers did not convey effectiveness by the usual means used in
clinical trials: ratings of what the researchers believe disturbs the participants or marks their behavior as abnormal (psychiatric
symptoms), or of the participants’ reports about their ability to fulfill conventional social, occupational, and interpersonal roles
(degree of impairment) over the course of the study. Instead, researchers emphasized only how long subjects remained on their
assigned drug.
This simple outcome reported in the first CATIE report would suggest that the benefits of antipsychotic drugs are so well
established that only a crude proxy measure is needed to demonstrate that they actually improve the diagnosed problem in the
population studied. (If that were the case, of course, the CATIE trial would have been unnecessary.) The measure is deceptive,
however, because the actual benefits of giving people psychoactive drugs are difficult to ascertain objectively, especially if the drugs
are given to people who do not want to take them for long. Typically, antipsychotics are subjectively experienced as producing
sedation, heavily clouded cognition, emotional dampening, and abnormal involuntary movements (Moncrieff, Cohen, & Mason,
2009). Moreover, people with diagnoses of psychotic disorders are relentlessly pressured or coerced to take and stay on
antipsychotic medications, regardless of their feelings about doing so—which takes away much of the validity of the outcome
measure in this CATIE study. Finally, as we discuss later, researchers in psychiatry have invested precious little creativity in
determining how to assess the complex effects of psychoactive drugs taken daily over months and years. Yet for all its limitations
the outcome measure was self-evidently practical, as a person who stops taking a drug cannot benefit from any of the drugs’
potentially desirable effects.
In any case, the proxy measure in this CATIE study painted an unfavorable portrait of the drug’s effectiveness: by study’s end, an
average of 74 percent of patients on each drug (range, 69 to 84 percent) had “discontinued their assigned treatment owing to
inefficacy or intolerable side effects or for other reasons” (Lieberman et al., 2005, p. 1209). Patients on olanzapine (Zyprexa) did
stay longer on that drug, but they were also more likely to gain significant weight and show abnormalities in glucose and lipid
metabolism. Trilafon (perphenazine), the obsolete antipsychotic selling for about 3¢ a dose, lost only slightly more patients from its
group than Zyprexa, selling for three hundred times as much and ranked just two years earlier as the world’s most prescribed
antipsychotic (between 1996 and 2002, its first six years on the market, Zyprexa’s gross sales were $13 billion, and it has gone on to
gross over $45 billion as of this writing).
New Antidepressants: If at First You Don’t Succeed . . .
In January 2006, the American Journal of Psychiatry published one of the largest studies ever conducted on the drug treatment of
depression (Trivedi et al., 2006). Also characterized by its acronym, STAR*D (for Sequenced Treatment Alternatives to Relieve
Depression), this study recruited over 4,000 participants (the Trivedi et al. article reported on a first wave of 2,900 followed for
fourteen weeks of planned treatment). Unlike carefully screened subjects in shorter clinical trials, most participants in STAR*D
resembled ordinary patients who would ordinarily end up treated with antidepressants in outpatient doctors’ offices. They were
recruited only when they sought care from over forty different outpatient general medical and psychiatric clinics across the United
States.
All patients in STAR*D were first treated with Celexa (citalopram), a selective serotonin reuptake inhibitor (SSRI) approved in
1998 by the Food and Drug Administration to treat major depressive disorder (MDD). Celexa was chosen by the investigators
because it is the most serotonin-selective of the SSRIs. Dosage was flexible and individually tailored by each patient’s own doctor,
based on ongoing feedback from the patient. The results, then, were expected to be more representative of ordinary practice
situations than the results from controlled clinical trials, which normally used fixed doses and rarely last beyond eight weeks. Also,
to provide a relatively unambiguous outcome measure that would be immediately relevant to anyone, remission (or virtual
disappearance of symptoms, rather than relative improvement compared to a placebo-treated control group, as in controlled clinical
trials) was employed in STAR*D to determine the outcome. In sum, here was what appeared as a fairly “realistic” test of an already
extremely popular drug treatment. The findings: a bit more than one quarter of the participants (29 percent) receiving a full course
of SSRI drug treatment for depression (which lasted on average about eighty-three days), were reported by Trivedi and colleagues to
have experienced a remission, while 47 percent were said to have shown a “response.”
Two months later, on March 23, 2006, a second article from the same study was published in the New England Journal of
Medicine (Rush et al., 2006). It reported on a subsample of 727 left over from the original 2,900 participants. The subsample was
made up of still depressed individuals who had immediately agreed to undertake a second course of drug treatment, to last another
fourteen weeks, despite their failed attempt with Celexa. These subjects had then been randomly assigned to receive one of three
other antidepressants: Effexor (venlafaxine) or Wellbutrin (bupropion) in extended release forms, or Zoloft (sertraline). Slightly less
than half of the people in each antidepressant group also received concomitant psychotropic drugs, described as trazodone (for
sleep), anxiolytics (excluding alprazolam), and sedative-hypnotics. (This raises the question: what drugs, or drug combinations,
were actually being tested?) By the end of that continuation study, an average of 21.2 percent of the patients in each group (varying
from about 18 to 27 percent, depending on the measure used by the investigators) had experienced a remission (with no statistically
significant difference between any of the groups). However, more patients dropped out of the study for intolerance of the drugs than
experienced a remission. More than half of people in each group experienced adverse effects of greater than “moderate” intensity.
About half of the people in each drug group experienced adverse effects for more than half of the time they remained on treatment,
including about one quarter who reported experiencing them 90 to 100 percent of the time.
The mainstream media universally put a positive spin on the disappointing findings, as illustrated by this comment from the
medical newsletter MedPage Today (Osterweil, 2006): “STAR*D investigators demonstrated that in the treatment of major
depression, patience and persistence can pay off.”
The STAR*D Reassessment
Despite STAR*D’s lackluster reports, the findings should have painted an even worse portrait of antidepressants’ effectiveness.
“Publication bias” is the name given to the practice of skewing, hiding, suppressing, twisting, or cooking data in order to inflate the
apparent value—the “efficacy”—of marketed drugs. In a series of publications and in a blog, psychologist Ed Pigott (2011a; 2011b)
has conducted his own review and reanalysis of the STAR*D trial findings, as have other researchers (Cohen, 2010; Leventhal &
Antonuccio, 2009; Pigott, Leventhal, Alter, & Boren, 2010). These authors have reported a disturbing pattern of publication bias,
including the following examples, most of which involve deviations from the prespecified STAR*D research protocol.

Patients who dropped out of the first antidepressant treatment step without completing a second Hamilton Rating Scale for
Depression (HRSD) were to be counted as treatment failures. Instead, these patients were simply excluded from analyses, thus
inflating the reported success rates.
Patients with an HRSD score below 14 points were to be considered too mildly depressed for inclusion in the study. Instead, they
were included. An additional 324 patients lacking an initial HRSD score were later included. In all, 931 of 4,041 patients (23
percent) failed to meet the prespecified eligibility criteria but nonetheless were included in the analyses, again inflating the drugs’
reported efficacy.
Also contrary to the STAR*D research protocol, the authors switched to using a proprietary assessment measure, the Quick
Inventory of Depressive Symptoms–Self Report (QIDS-SR) as the sole measure to report outcomes in the key summary article from
STAR*D. This switch inflated published remission and response rates. In the QIDS-SR, a patient reporting, “I feel sad more than
half of the time” or “Most of the time, I struggle to focus my attention or to make decisions” and “I rarely eat within a 24 hour-
period, and only with extreme personal effort or when others persuade me to eat” would earn a score of 5 on the QIDS-SR—
qualifying that patient as remitted. More than 90 percent of such remitters had at least one residual symptom (as a group, remitters
showed a median of three symptoms), usually sleep disturbance, appetite or weight disturbance, sad mood, fatigue or decreased
energy, and decreased concentration.
As of mid-2011, despite over a hundred articles having been published from the STAR*D findings, eleven prespecified research
measures collected to evaluate outcomes at entry and exit from each treatment step and every three months of follow-up still had not
been reported.

These deviations from protocols, presentations of ad hoc findings as the prespecified outcomes of interest, and uses of explicitly
excluded strategies to inflate apparent drug efficacy show how unwilling elite researchers and their institutional collaborators are to
telling it like it is. The STAR*D investigation stands out from others due to its breadth and scope, but some of its reports provide
more of the same endless psychopharmacological spinning that debases countless studies in the field by doing everything possible to
avoid challenging the ideological, intellectual, and clinical status quo. Whether the investigators were deceiving themselves or
deceiving others or both, the published STAR*D findings exemplify the sad but stark fact that an undetermined portion of
psychopharmacological studies—especially those conducted by researchers who have made a successful career of promoting
psychiatric drugs—cannot be trusted unless their findings are checked and rechecked (though the original data may never be
available).
“Mood Stabilizers”: Still Unbalanced
Findings from the third study to consider, the largest ever of the treatment of bipolar disorder (known as manic depression since the
1890s), first appeared in the February 2006 issue of the American Journal of Psychiatry (Perlis et al., 2006). The study was named
the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Manic depression refers to alternating periods of
depression and mania. Although as bipolar disorder it has been extensively researched and discussed in the psychiatric literature and
although that moniker has fully penetrated popular discourse, very little seems to be known about the condition. In a 2006 editorial
in the American Journal of Psychiatry entitled “What Is Bipolar Disorder?” psychiatrist Alan J. Swann could only answer the
question by saying it was “recognized as a potentially treatable psychiatric illness that has substantial mortality and high social and
economic impact.” Swann continued, “Every aspect of its definition, boundaries, mechanisms, and treatment, however, is subject to
debate. In fact, there is no objective measure that can determine if one has bipolar disorder or does not have it” (p. 177). Naturally,
as we have discussed earlier in this book, lacking objective measures to define or even detect the condition objectively should pose
considerable problems for evaluating its treatment. The condition came to prominence in the 1970s when some psychiatrists claimed
(and still do) that ordinary lithium salts were a specific and preventive treatment for it, conjuring the image of lithium-deficient
madpersons transformed by a mineral supplement. When later studies showed that people taking lithium experienced mania or
depression virtually as often as patients not taking any drug and when lithium toxicity showed itself to be insidious and potentially
fatal, lithium begin falling out of favor (Healy, 2008). For the pharmaceutical industry, lithium also carried the enormous
disadvantage of not being patentable, which may have doomed the intensive commercialization of that substance. Older and newer
anticonvulsant drugs used in the treatment of epilepsy and other seizure disorders, but also for a variety of behavior problems in
adults and children, started to replace lithium as the name and the presentation of manic depression changed to bipolar disorder,
starting with DSM-III in the early 1980s. These drugs have been viewed since the early 1990s as the best available treatment for
bipolar disorder.
Experts justified the shift to prescribing anticonvulsants by analogizing an episode of mania to an epileptic seizure. In seizure
disorders, anticonvulsants seem to stop the “kindling” of seizures in the brain of many affected persons and reduce the likelihood of
future seizures. Some psychiatrists hypothesized that anticonvulsants could similarly suppress an episode of mania while reduce the
likelihood of future manic episodes. Rigorous demonstration of this claim was lacking, especially since studies of anticonvulsants
used comparisons with poorly performing lithium. Like lithium, however, anticonvulsants are powerful depressants of the activity of
the central nervous system (a property that explains their anti-seizure action, just like benzodiazepines). As such, they typically
tranquilize and sedate their users. Also, relative to placebo, tranquilizing drugs will almost inevitably produce “improvement” on
virtually any of the short-term symptom rating scales used in psychiatric drug trial research, because such scales contain many items
related to nervousness, insomnia, agitation, and spontaneous verbalizations of variously offending or disturbing thoughts—all of
which “respond” to sedative drug effects.
Moreover, the rebranding of anticonvulsants as “mood stabilizers” by clever pharmaceutical company executives gave a
tremendous boost to marketing these drugs, as well as the bipolar diagnosis itself (Healy, 2006). The new name implied that
anticonvulsants could directly “raise” depressed mood. Although it has no official standing in any drug nomenclature, “mood
stabilizer” is an instantly recognizable designation of some psychiatric drugs today, and it appears in dozens of reports published
each year. Its popularization must rank as one of the great marketing feats of the past decades.
As in STAR*D, the STEP-BD investigators tried to emulate real-world treatment conditions. They employed a best-available
treatment protocol, including individually tailored monitoring of a broadly representative sample of almost 1,500 patients given
anticonvulsants, typically with other drugs such as antidepressants, antipsychotics, lithium, and benzodiazepines (only 10 percent of
the patients were prescribed a single drug). The patients’ treatment and response were then monitored for up to twenty-four months.
As with the contemporaneous CATIE and STAR*D concerning psychosis and depression, respectively, STEP-BD constituted
perhaps the largest group ever of people diagnosed with bipolar disorder and followed so carefully for such a length of time.
The main findings of STEP-BD were also eerily consistent with those of its two large sister studies. By study’s end, less than
one-third of the sample (31 percent) were reported to have experienced a remission of their manic or depressive episode with no
recurrence during the rest of the study period.
While writing this book, we did not compare the study protocols of CATIE and STEP-BD with the published findings, nor have
we crosschecked the published methodologies across separate articles to assess the coherence and consistency of the findings. Yet,
given what has been uncovered regarding STAR*D and given previous statements from other established researchers—that their
own co-investigators in other landmark federally-funded studies have tried to suppress disturbing findings of drugs’ dangers (see,
for example, one account by Vedantham, 2009)—readers should exercise due caution in accepting any claim of drug efficacy put
forth in our drug-soaked culture (Healy, 2012).
 Psychotropic or Placebo?
The findings from CATIE, STAR*D, and STEP-BD were actually not too surprising to knowledgeable observers, because they were
almost identical to findings from countless short-term (six to twelve weeks) clinical trials that make up the contemporary psychiatric
treatment literature since the 1980s. For example, dropout rates in some short-term olanzapine (Zyprexa) trials that led to that drug’s
market approval by the FDA in 1996 showed that 73 percent of subjects had left the study after four weeks, a rate the FDA reviewer
called “overwhelming” (cited in Jackson, 2003). The average CATIE dropout rate was 74 percent. As to the rate at which subjects
responded positively to drugs, during the first treatment phase of STAR*D, 47 percent of recruited subjects were rated as
responders, much like the average 50 percent responder rate among antidepressant-treated subjects estimated by the Food and Drug
Administration in 2006 from its database of 189 randomized, short-term placebo-controlled clinical trials of antidepressants
involving over 53,000 patients (Stone & Jones, 2006).
When a drug manufacturer wishes to market its product, the very best of these trials are submitted to the FDA so that claims of
efficacy and safety can be verified. FDA regulations require only two multisite randomized controlled trials that have produced
positive results, regardless of how many negative trials were conducted. Randomized controlled clinical trials became the standard
test for drug makers to demonstrate the efficacy (and some of the safety) of drugs for specific DSM disorders, which would grant an
FDA approval to market drugs for these indications. In a randomized controlled trial, “Patients should be randomized to matching
groups; be tested using both the active therapy and a control, or placebo; should not know which group they are in, nor be aware of
whether they are getting an active drug or a placebo. They must be blinded from the doctor who might influence the treatment”
(Nesi, 2008, p. 121). These precautions are essential in principle, but the actual conduct and reporting of clinical trials (whether for
antipsychotics, antidepressants, or stimulants) has always left much to be desired, as review after review has observed (e.g., Jaddad
et al., 1999; Larkin, 2010; Thornley & Adams, 1998). This problem has been magnified as the drug industry increased its already
considerable involvement in funding, designing, conducting, and disseminating results of clinical trials of its own products.
For the FDA, moreover, “efficacy” has only meant demonstrating some kind of effect, or so-called proof in principle. Cure, or
extended recovery, or remission has never been the anticipated outcome in the clinical trials evaluated by the FDA. On the contrary,
therapeutic effects from psychoactive drugs have always been expected to be relatively small, and the problems being treated have
always shown large, spontaneous variations across and within individuals. That is why phase III trials (the multisite, randomized
controlled trials) had to be quite large in order to show some kind of effect (Healy, Langmaark, & Savage, 1999). If a drug were
clearly efficacious, this could be shown in very small trials (think of an antibiotic treating a bacterial infection), and the results of
efficacy should be easily replicable. Clinical trials of some of the century’s best-selling prescribed psychotropics, the SSRIs, never,
ever demonstrated anything near this level of efficacy. The SSRIs showed weak, marginal effects in comparison to placebo.
In 2002 and again in 2008, Irving Kirsch and colleagues reanalyzed all data they obtained using Freedom of Information laws
from the FDA’s evaluations of the forty-seven RCTs funded and submitted to it by the makers of the six most widely prescribed
antidepressants approved by the FDA between 1987 and 1999. Nearly 5,200 individuals had participated in these trials, including
3,300 randomized to receive drugs and 1,800 to receive placebo. The reanalysis found that 82 percent of the response of medicated
patients was duplicated in placebo-treated patients. This occurred despite the FDA allowing researchers to replace people on some
of the drugs who were not improving after two weeks into the trial. Moreover, in most trials, tranquilizers were also prescribed to
the participants whose insomnia and agitation increased (probably as an adverse effect of the SSRIs). Despite these methodological
breaches (which might serve to explain why only 82 percent of the drug response was duplicated by placebo), on the chief outcome
measure, the patient’s score on the Hamilton Depression Rating Scale (HAMD), the mean difference between drug and placebo
groups was 1.8 points (the version of the scale most often used in the trials has a maximum 50-point score). In their later reanalysis,
Kirsch and colleagues (2008) did observe that among people with the highest HAM-D scores (suggesting the most severe depressive
symptoms), the outcome difference (just about 4 points on the HAM-D) favored the drug-treated groups. But this was shown to
reflect a waning of the placebo effect among such people, not an increased efficacy of the SSRIs. In other words, drug response
scores among the most severely depressed were similar to scores among the less depressed, but placebo response scores were not
(perhaps because when one feels quite bad it is much harder to summon a positive outlook).
Obviously, the very small average difference between groups could not in itself mean a clearly superior gain for most patients
who take SSRIs. On a large enough sample of people, however, given the laws of probability, it could show statistical significance.
In this case, statistical significance meant that the 3 percent smaller uselessness of SSRIs compared to placebo would be quite
unlikely to result from chance and should be observed almost every time drugs are compared to placebo. Because of this
mathematically conclusive but probably clinically negligible difference, the FDA followed its rule that the manufacturers had
provided evidence, in at least two clinical trials for each drug, of the drugs’ efficacy to treat whatever was treated in the clinical
trials.
As noted, the high placebo response rates were obtained despite a number of strategies deliberately designed to reduce placebo
responses from the participants (Cohen & Jacobs, 2007). First, almost every study used placebo-washout or placebo-lead-in periods,
wherein all subjects are abruptly discontinued from any drugs they might be taking and placed on a pill-looking placebo. The idea is
to identify people who are likely to improve early when they believe that they are receiving a genuine treatment—and to exclude
these people from those who will then be randomized for the “start” of the “actual” study. For example, in the forty-seven SSRI
trials reviewed by Kirsch and colleagues, any subject whose HAM-D score improved 20 percent or more during this early period
was excluded from the study. But since the point of a trial is to compare the efficacy of active drugs to placebo, it is by no means
clear what the rationale could be for excluding people who tend to respond to placebo early on. To be fair, those who respond to
drugs early on should also be excluded.
Second, all studies employed inert rather than active placebos. An inert placebo might contain yeast, sugar, or lactose. An active
placebo might contain caffeine, benztropine, or diphenhydramine. Why use one or the other? Certain drug effects, such as dry
mouth, dizziness, sleepiness, or increased heart rate can serve as early cues to patients and clinicians about which treatment
condition patients are in. This would “break the blind,” threatening the trial’s internal validity (the confidence to draw conclusions
about what is causing what). One way around this problem is to use active placebos: substances that give some physical sensations
to people, who might therefore think that they are receiving the “real” medication, but which do not produce the sort of psychoactive
effects of the tested drug.
Results from some antidepressant trials in the 1970s and early 1980s showed that active placebos did indeed produce greater
placebo response than inert placebos (Fisher & Greenberg, 1993a, 1993b). It therefore seemed likely that the subtle physical
sensations produced by active placebos had tricked subjects into thinking that they were taking “real” medication, thus possibly
amplifying the subjective feeling of improvement that they would communicate to the clinician raters during their brief structured
encounters. This would translate as higher scores of these subjects on rating scales—the major outcome of the clinical trials. A
different dynamic would occur in a study comparing a drug to an inert placebo. Here, noticeable physical sensations are more likely
to be experienced by those taking the drug, which would give clinicians a cue about which treatment condition subjects are in, and
might tilt clinicians’ expectations toward observing improvement in drug-treated patients.
Reviews and reanalyses of these earlier trials (Moncrieff et al., 2004; Petovka et al., 2000) have not settled the matter of the
precise role of inert versus active placebos, and one author suggests ignoring this issue altogether because the studies are too old
(Quitkin, 2003). But the issue remains profoundly relevant: if mere sugar pills produce equivalent or nearly equivalent responses in
the most sophisticated controlled trials of antidepressants today, wouldn’t active placebos do at least as well and probably much
better? That is, wouldn’t active placebos lay waste to antidepressants’ effectiveness nearly every time? This question has no known
answer, because as of this writing in late 2011, one still cannot find a single major randomized controlled trial comparing a modern
SSRI antidepressant with an active placebo. By contrast, in neurology, controlled trials of pain treatments routinely use active
placebos. This fact alone should bracket clinical psychopharmacology as a studiously unscientific enterprise. Let us restate the point
differently and explicitly.
Pain researchers, who know that pain often responds to placebo, appear truly interested to discover whether new analgesics work
better than placebo. Thus pain researchers stack the deck against their proposed analgesics by using placebos that superficially
create a sensation to trick the patient into thinking that an analgesic may have been taken. The hurdle that must be overcome by the
proposed analgesic is thus raised higher. By contrast, psychiatric researchers, who also know that depression often responds to
placebo, appear uninterested to discover whether modern psychiatric antidepressants work better than placebo. Thus psychiatric
researchers stack the deck against placebo. The hurdle that must be overcome by the proposed antidepressant is thus lowered. From
either a scientific or clinical perspective, the absence of rigorous comparisons between drugs and active placebos in psychiatry
makes no sense. It may nonetheless be easily understood when ideological or commercial imperatives—for example, or the
compulsive need to suggest that genuine illnesses are being targeted by specific treatments or the compulsive need to demonstrate a
profit every quarter to satisfy mutual fund investors—shape the pursuit of knowledge.
In controlled trials designed to minimize placebo response, inert placebos given to subjects who meet the DSM’s Major
Depressive Disorder criteria benefit up to half of subjects, exactly as antidepressant drugs are shown to benefit subjects: by steady
reductions in depression rating scale scores, from the very start of the trial and every week thereafter (Walsh et al., 2002). Nor are
placebo effects confined to the treatment of depression and anxiety with antidepressants and anxiolytics (Shear et al., 1995). For
example, in March 2009, Eli Lilly and Company announced results from a phase II clinical trial of its new investigational
antipsychotic, named LY2140023, against its blockbuster drug olanzapine (Zyprexa). The press release stated: “In Study HBBI,
neither LY2140023 . . . nor the comparator molecule olanzapine, known to be more effective than placebo, separated from placebo.”
As a result, “neither drug performed better than the placebo” (Eli Lilly and Company, 2009, p. 1). Over the last two decades,
placebo response rates have steadily increased in trials of antipsychotic drugs, in parallel with a steady decrease in drug response
rates. In some trials, 50 percent of participants (diagnosed with schizophrenia and experiencing an acute psychotic episode) taking
inert placebo pills show at least a 20 percent improvement on their psychosis rating scale score relative to baseline, the criteria
sometimes used in the past to demonstrate efficacy of antipsychotic drugs (Kemp et al., 2008). Various factors may account for this
steady diminishing of drug-placebo differences, ranging from the extra attention given clinical trial participants to differences in
scoring methods used in foreign study sites, which are increasingly used today for drugs to be approved in America. Official
discussions of the trend, however, conform to a predictable line: drug response is a true and worthy “signal,” while any placebo
response is a distracting, confusing, confounding “noise” (Kemp et al., 2008).
How and why placebos produce such results in comparison to drugs whose psychoactive effects sustain them through years of
animal and clinical testing (see next chapter) remains an utterly fascinating question. By themselves, the cost-savings and reduction
in adverse effects implied by the possible amplification of the placebo effect could justify reorienting but a small part of the
stupendous research activities in psychopharmacology toward understanding and harnessing placebo effects. Yet it is obvious that
the psychopharmacology field as a whole has been much less interested in answering the placebo question than in disposing of it
methodologically. This is not astonishing, as using placebos in the practice of medicine is a most controversial topic. Using placebos
is at odds with the image that medicine has projected of itself—that of a scientific profession having discovered and devised, based
on the scientific method, effective and specific treatments for genuine diseases. Within psychiatry, more than other branches of
medicine, in which placebo effects may constitute most of clinical practice, systematically understanding the role of placebos would
threaten the entire profession.
Because the placebo is unpretentious and nameless, its competitors—compounds that have passed the FDA-approval hurdle and
been given branded identities as genuine medications—can claim placebo’s benefits, and any deception basically remains
unexposed. One might view the placebo effect in many different ways: as a vital human capacity for self-restoration, a complex
form of self-deception, and anything in-between. Either way, it is difficult to dismiss it as “no treatment” or “nothing.” One can
dismiss placebo effects as noise only if one is resolutely committed to finding uses for a commercially-funded investigational drug
—a different aim than being resolutely committed to finding out what people say helps them, or what helps people despite what they
say helps them.
Here is Charles Medawar and Anita Hardon’s social view of the placebo effect:

All sorts of human beliefs, motivations and styles of organization make medicines work as they seem to do. These factors
are typically invisible, go largely unrecognized and have no other name. They go largely incognito . . . The fact that they
have no collective name underlines that their impact is generally unrecognised and therefore poorly understood. Probably
the main reason is that the word placebo has come to stand for all the non-drug factors that affect treatment outcomes. It
does not seem an appropriate word: it does not take into account many non-pharmacological factors on treatment outcomes.
(2004, p. 175)

How much are expectations of patients amplified when virtually all authoritative discourse about a drug consists of statements
that it has positive effects on those who receive it from their doctor? The felt effectiveness of a medicine has to do not only with the
relationship between user and drug. Doctors’ and patients’ experiences and history, their values, statuses, and roles, their faith and
hope—not to mention suggestion from their peers and from advertising, drug company sponsorship of doctors’ events, the names
given to drugs—these and other factors must also count as important, interacting determinants in drug “effectiveness,” as they
introduce themselves in still largely unknown ways into the clinician-patient relationship.
It is sobering to realize that the technique of testing a drug in a double-blind trial against a placebo, a so-called dummy pill, is at
present the only existing scientific guarantee that the drug does not work somehow through suggestion, hope, and belief. Today,
without such a trial, a mere chemical compound could not become a “medication,” as bestowed by FDA approval (and this, for
conditions ranging from migraine to Parkinson disease to multiple sclerosis). Without comparing the tested drug to something that
can elicit improvement from the patient merely by appearing to be a genuine medication, one cannot confidently determine the true
effects of the tested drug. This makes the placebo especially necessary when testing treatments for conditions with a substantial rate
of spontaneous or developmental improvement, such as depression and anxiety or a first episode of psychosis. But the nature of the
placebo effect remains largely unknown (Benedetti, 2009). Something or a combination of many things does appear to be there, and
it begs explanation. Of course, we cannot yet rule out that the placebo effect may turn out to be another colossal reification, much
like mental illness, an idea whose concrete reality is assumed merely because it has a name and because alternative explanations for
its associated features have not been widely understood or disseminated.
But even if we stick to the placebo effect as traditionally defined in drug trials (the measurable therapeutic changes induced by
pharmacologically inactive or inert substances), we may consider the conclusion reached by psychologists Seymour Fisher and
Roger Greenberg. After one of the most insightful, restrained, and evidence-informed reviews in the entire literature on
antipsychotics, stimulants, antidepressants, and anxiolytics, these two authors stated, “that when proper controls are introduced [in
research studies] the differences in therapeutic power between the active drugs and placebos largely recede” (1997, p. 382). It is
sobering for anyone to reflect that merely introducing “proper controls” in scientific research would doom the modern
psychopharmacologic enterprise.
New Cost, New Hype, Old Myths
In an editorial accompanying STEP-BD’s first publication, psychiatric researcher J. Raymond DePaulo, Jr. (2006) observed that “the
results are so similar to those observed in lithium treatment studies of 20 to 35 years ago that the question of whether today’s best
available treatments for bipolar disorder are better than older treatments begs for an answer” (p. 175). But the study actually did
answer the question—in the negative. DePaulo omitted to mention that a few earlier, long-term observational lithium studies had
themselves suggested that lithium was no better than lithium’s predecessors—shock treatments and barbiturates—and even, in some
investigations, no better than no drugs at all (Harrow et al., 1990). DePaulo did generously allow for the possibility that “modern
pharmacological treatments may be no more beneficial than older ones, despite their added cost” (p. 175). And, one might add,
despite their added hype.
Indeed, exaggerated publicity intended to excite public interest has characterized the portrayal of psychiatric drug treatments
these past few decades. Who has not heard that drugs have revolutionized the treatment of mental illness, that newer medications are
safer and more effective than older ones, that they can make their users “better than well,” and that drugs have removed the stigma
of psychiatric labeling? It has even been said that drugs can be so helpful that not forcing them on certain disturbed people
constitutes negligence or worse. In sum, experts and their followers have stated that psychiatric medications have brought society
immeasurably closer to solving the problem of mental illness once and for all.
With unremitting support from many partners in the mental health movement, such claims were transformed into robust cultural
beliefs or myths. The power and purpose of myths to give meaning to our lives and societies cannot be understated. In the age of
science, myths are often portrayed as scientific truths. Myths unify people by expressing themes that resonate with people’s
longings. When experts and laypersons continually reaffirm a myth, they convey their wish to belong to the group of believers. They
may also convey that, as far as they are concerned, debate about the essential truth of the myth has ended and that one need only be
concerned with technical details arising from the application of its essential truth.
That is how CATIE, STAR*D, and STEP-BD were greeted. Three large, exemplary studies conducted by the clinical and
research elite of American psychiatry and funded by the world’s largest mental health research institute, the NIMH, to the combined
tune of almost 100 million dollars, demonstrated dismal results, if not failure, of the paradigmatic biological treatments for the
paradigmatic mental disorders. Yet, as far as one can tell, no prominent mental health authority (neither an investigator from one of
the studies or a NIMH official) suggested re-evaluating the routine drugging, these past fifty years, of madness and misbehavior, or
launching an intensive analysis of the practical uses of placebo effects in the drug treatment of all manners of mental distresses.
Quite the contrary, experts and commentators only lamented the heavy burden of mental disorders and stoked the ever-so-great
imperative to find newer, better drugs or biological treatments. In the world of mad science, the myth of treatable mental illnesses
must go on.
To illustrate the persistence of probably wrong-headed thinking despite the facts, we turn again to NIMH director Thomas Insel.
In 2009, Insel thus summarized the findings from the CATIE, STAR*D, and STEP-BD studies:

Given that these trials used evidence-based treatments of well-documented efficacy that were administered with optimal
clinical standards, the results show the significant limitations of current pharmacological interventions. This point bears
emphasis. These limited outcomes, in terms of recovery and remission, are not due to suboptimal delivery of care. Instead,
with optimal care using today’s medications, too many people will not recover. (p. 129).

Insel nonetheless went on to announce a new program of research to uncover the “molecular pathophysiology” underlying mental
disorders by focusing research on brain circuits, genes, and personalized medicine focusing on individual moderators of treatment
outcomes such as “genetic traits, imaging results, plasma proteins, or clinical features” (p. 131).
The connections between the uses of drugs and the sort of biological thinking exemplified by Insel’s new call to action obviously
need to be restated. Chemical substances with powerful effects on thinking, feeling, and behaving ushered an era of biological
theorizing about madness as the consequence of chemical imbalances in the brain. In turn, that biological thinking was used to
promote the usefulness of psychoactive drugs to treat mental distress and misbehavior of every stripe and variety. Then, the mental
health system was entirely reorganized to encourage drug use among the distressed and strict compliance with one’s prescribed
medication regimen thereafter. After decades of this arrangement, the drugs (“evidence-based treatments of well-documented
efficacy”) are formally acknowledged by authoritative experts citing authoritative evidence to have little of the usefulness so long
attributed to them. Yet the same experts and institutions who touted drugs’ benefits with certainty, tolerating no dissent and
suppressing alternative viewpoints, today urge their constituencies to adopt even more far-flung biological thinking strung together
by bits of medical technology and corporal components. We believe that these experts should pause to identify what may have gone
wrong and what future errors might be avoided, but we do not think this appears anywhere in the official agenda.
In the following chapter, we develop the argument that the effort to develop a scientifically-based drug treatment of specific
mental disorders has mainly consisted of the recycling of perennial human drugging practices. We also propose that despite all the
hoopla, an understanding of psychiatric medications as psychoactive substances capable of producing complex mental and physical
states regardless of why they are taken by people or prescribed by doctors appears wholly sufficient to explain drugs’ observed
therapeutic effects (and adverse effects) in “mental disorders” (Jacobs & Cohen, 1999; Moncrieff, 2008; Moncrieff & Cohen, 2009).
The notion of drugs specifically targeting identifiable or soon-to-be-identified pathological substrates of mental disorders remains a
hypothesis supported by an exceedingly tiny amount of evidence. To paraphrase psychiatrist Peter Breggin and co-author Ginger
Breggin (1994), to respond to any drug (that is, to like it, to find it helpful for some purpose, to want to keep taking it), a human
being does not need a chemically imbalanced or an electrically short-circuited brain; just a brain will do. If so, then the modern
psychiatric discipline of clinical psychopharmacology, having mostly tied its scientific fortunes to the validity of biological
psychiatric theorizing, rests on the flimsiest of foundations and needs to be reconstructed, from scratch.
 Notes
1. First isolated from opium at the start of the 1800s, morphine was massively used for the first time during the Austro-Prussian War of 1866 and found to be an unsurpassed
painkiller. About a dozen years later, some physicians began to see it as causing a state of hellish chemical servitude they called morphinomania. By the end of the 1800s,
morphine was condemned as a “main scourge of humanity” (Chast, 1995, p. 112).
2. We remain astonished at encountering parents who would balk at serving their nine-year-old child a single cup of coffee but who would feel less unease to give that child
a daily dose of prolonged-action amphetamine, for several months.
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 7
From Drugs to Medications—and Back

Introduction
Since time immemorial, humans have used substances that noticeably alter mood, consciousness, and behavior. Today we call these
substances psychoactive or psychotropic drugs1. The main psychoactive compounds in use throughout the world roughly until the
last decade of the nineteenth century were alcohol, coffee, tea, tobacco, opium, cannabis, coca, iboga, kola, khat, as well as
countless species of mushrooms. People used these and other psychoactive drugs to work, to relieve pain, to induce sleep, to stay
awake, to fraternize, to endure sadness and loss, to experience euphoria or joy, to reach or heighten states of transcendence and
spiritual contemplation, and to perform religious rituals (Meyers, 1985). These manifold uses indicate that psychoactive drugs touch
directly and deeply on what it means to live as a human being. Put another way, psychoactive drugs have helped many human
beings to bear, to make meaning of, to celebrate, or to temporarily escape their circumstances. Observing the universality of
psychoactive drug use among humans, Andrew Weil (1970) wondered whether it reflected an inborn drive to alter one’s
consciousness.
If psychoactive drug use did not provide the user or the user’s group with some perceived benefit in enduring or enjoying life, it
seems hardly possible that it would continue, century after century, regardless of migratory patterns or the nature and pace of social
and cultural changes. This is an especially compelling consideration, given that the dangers of psychoactive drug use were never lost
on their users. As far as we can determine from observations of indigenous peoples around the world, use of psychoactive drugs in
premodern societies typically involved communal preparations, elaborate precautions, and rituals that served simultaneously to
elevate and restrain drug taking (Naranjo, 1979). In our contemporary society, precautions against much of psychoactive drug use
still involve informal rites of passage in families and peer groups, legal drinking ages, as well as formal sanctions, such as laws
against impaired driving and public inebriety. Increasingly, however, precautions have involved the transfer of authority and
responsibility for psychoactive drug use onto the physician and the addiction specialist. The consequences of this shift have
transformed users’ motives to use drugs into diseases or disorders, the use of drugs into a treatment, and the user of drugs into a
patient. Of the utmost importance, the physician writes a prescription that allows licit access to various psychoactive drugs. (As
more and more “healthy” people want to use certain psychoactive drugs available only by prescription, the rationale for the medical
prescription system might be strained beyond credibility, but we are getting ahead of our story.)
Precisely because of psychoactive drugs’ fluid but obvious appeal, rulers, healers, and priests throughout history have never
ceased to promote or repress particular drugs, and (by definition) their users (Tracy & Acker, 2004; Porter & Teich, 1997).
Psychiatrist Thomas Szasz (1974) has most consistently and clearly made this case. He has argued that using forbidden drugs is the
simplest way by which some individuals can affirm their autonomy vis-à-vis authorities. As societies encountered foreign drugs and
as social customs and conventions changed, certain psychoactive drugs became socially and legally accepted, rejected, and accepted
again, in cycles of varying durations. Almost every psychoactive drug legally banned in America today was, at some point over the
last century, freely available for purchase or import or prescribed or dispensed by physicians to their patients. This includes heroin,
cocaine, LSD, and methamphetamine. The latter drug is still available by prescription as Gradumet, a brand-name drug indicated for
ADHD while considered the “gravest drug threat” by 57 to 80 percent of state and local law enforcement agencies in most of the
United States (US Department of Justice, 2010).
 Separating Medications from Drugs
The major turning point occurred at the end of the nineteenth century, when the opium derivative morphine, first greeted by
physicians as an unequalled painkiller, became demonized. This transformation probably marked the beginning of the linguistic and
conceptual separation of “dangerous drugs” from “psychoactive medications.” With time, the first phrase came to designate
disapproved substances traded illicitly and about which almost no one cared to distinguish “use” from “abuse.” The second phrase
came to designate approved substances that eventually became dispensed under medical supervision and government regulation.
Progress in chemistry and pharmacology refined these “medications” as they were brought to market using techniques of mass
production, with the goals of treating, preventing, and combating mental disease (Chast, 1995).
No intrinsic material property will ever distinguish a “drug” from a “medication” because the difference rests not on
pharmacology but on social, legal, and medical norms and linguistic usage. Those who establish these norms, however, have either
tacitly or explicitly supported the opposite view—that “drugs” differ intrinsically from “medications”—shielding the norms from
scrutiny. As a result, as both Szasz (1974, 2001) and DeGrandpre (2007) amply document, views and prejudices about drugs have
been conflated with chemical properties of drugs. Such a grave confusion could only lead to contradictions and inconsistencies.
Amphetamines and methamphetamine, classified legally as controlled Schedule II addictive substances and characterized as
“scourges” in the field of drug abuse, are simultaneously prescribed by physicians as essential treatments to children and adults said
to suffer from attention deficits. Similarly, some individuals, groups, and states advocate or permit access to “medical marijuana”
while supporting or enforcing the ban on marijuana. Regularly, the Drug Enforcement Administration (DEA) hounds physicians for
prescribing “excessive” doses of perfectly licit narcotic painkillers (Rosenberg, 2007). As for tobacco, it occupies several roles
simultaneously: ordinary agricultural product freely grown with state subsidies; the world’s deadliest drug; illegal drug when used in
certain public spaces; addictive psychotropic drug when the FDA wishes to regulate smoking; or approved medication when its
ingredient nicotine is prescribed as an aid to quit smoking (Cohen, 1995).
These ambivalences and inconsistencies are reflected in what American authorities have been warning the public about at the
start of the second decade of the twenty-first century, though they acknowledge it is not a new problem: prescription drug abuse.
The title of a White House call to action uses the appropriate rousing words: Epidemic: Responding to America’s Prescription Abuse
Crisis, and the opening words announce the “Nation’s fastest growing drug problem” (Executive Office, 2011, p. 1). Here, the
dangerous drugs are not obtained illegally, they are legal remedies found in our home pharmacy cabinets. Their nonmedical or
idiosyncratic use constitutes the current public health scourge (Janofsky, 2004). No less than 10 percent of state and local law
enforcement agencies now view diverted uses of controlled prescription drugs as their “gravest drug threat” (U.S. Department of
Justice, 2010). The National Institute on Drug Abuse (2011) defines prescription drug abuse as “the intentional use of a medication
without a prescription; in a way other than as prescribed; or for the experience or feeling it causes” (p. 1).
In addition to wildly inflating the population of potential and actual abusers, prescription drug abuse blends two perspectives that
authorities have taken pains to keep separate: the imagery and logic of the war on illegal drugs with the imagery and logic of the
medical prescription of approved medicines. Even more than mere drug abuse, prescription drug abuse opens a fruitful terrain for
drug experts and drug warriors, in which public health and repressive measures can mix in any manner and quantity and in which
patients and prescribers can come under equal scrutiny. Presently, the drugs of concern are opiates, sedatives, and stimulants
dispensed under prescription. In principle, however, there is no barrier to extending the concern to antidepressants, antipsychotics,
and anticonvulsants, the paradigmatic psychiatric or psychotherapeutic drugs of the past half century.
Escaping and Entering Normality
With the arrival of Prozac, introduced to the US market in late 1987 and prescribed a few years later to over ten million people, the
New York Times was announcing in a front-page article the rise of a “legal drug culture” (Rimer, 1993), as if such cultures had not
always existed in this country and elsewhere. Testifying to the enduring but unarticulated social ambivalence toward psychoactive
substances, the author took pains to distinguish the use of medications from that of drugs. Similar distinctions were being made
across the Atlantic shortly after the arrival of Prozac to France. In a magazine article, psychiatrist Marc Bourgeois asked rhetorically
whether “the proportion of 11% of users of psychotropics [is] scandalous?” Bourgeois answered reassuringly: “These are not drugs,
but of course approved medications” (1994, p. 9).
Undoubtedly, most of the millions of citizens using antidepressants prescribed by their doctors would not have thought that they
were “altering their consciousness.” Still, during the early 1990s, media-amplified evaluations by some users and promoters of
Prozac and the SSRIs (e.g., “I am free to be me,” “I am better than well”; Kramer, 1993) did sound eerily like the benefits claimed
by some users of illicit psychoactive drugs. There was, however, an important difference, as French sociologist Alain Ehrenberg
(1995) was one of the first to note: the stated goal of using Prozac was admission to, not escape from, ordinary consciousness; it was
“fitting in,” not “dropping out.” The modern user of prescribed psychoactive drugs wished to function better. The search for ecstatic
highs morphed into the hope of “cosmetic psychopharmacology.”
 The Psychoactive Effects of Psychiatric Drugs2
We may now more fully consider the notion, repeated several times so far in this book, that prescribed psychiatric drugs should first
and foremost be considered as psychoactive drugs. This notion rests on the conclusion that the usual explanations for how
psychiatric drugs are supposed to work in the treatment of problems called psychiatric disorders can barely account for the only
pertinent effects that can be attributed with any certainty to these drugs: their psychoactive effects (Moncrieff & Cohen, 2009).
Most people have a reasonable understanding of the psychoactive effects of substances that are typically used for recreational
purposes, such as alcohol and cannabis. Besides the pleasant or often euphoric effects that lead people to use them, most people
understand that these drugs modify how they think or reason, how they speak, how vigilant or forgetful they become, how they
experience emotions, and, certainly, how they behave. Most people understand that these drug-induced changes can be quite subtle
and relatively easy to hide from observers who do not know them, just as they can be dramatic and obvious. Most people understand
that drug-induced changes from recreational drugs can be persistent, if the drug use is persistent. Most people come to recognize and
anticipate some effects from these drugs and use them to reach certain ends that might not be considered purely recreational, such as
falling asleep more easily, ignoring unpleasant circumstances, completing necessary but annoying tasks, or acting more or less
sociably. People also understand that, however pleasurable drug effects might be initially, they might become unpleasant with
persistent use or in different circumstances. Similarly, people know from their experience and that of others that with prolonged use,
users of recreational drugs often experience difficulty trying to cease using these drugs, even when their effects have become
unpleasant.
A similar understanding applied to prescribed psychoactive drugs—popularly called psychiatric medications—is mostly absent,
however, because there are virtually no authoritative summary descriptions in psychopharmacology textbooks of how these drugs
alter our normal thoughts, emotions, and behavior. This state of affairs results from the single-minded effort in psychiatry over the
past half century to portray psychiatric drugs as conventional medical remedies (targeting physiological abnormalities) and those
who take psychiatric drugs as conventional medical patients (affected by physiological abnormalities). This has been called the
“disease-centered model,” wherein drugs’ therapeutic effects are believed to stem principally from their action on (presumed)
disease states or physiological pathways to such states (Moncrieff, 2008). This disease-centered model, as we argue throughout this
book, has numerous weaknesses, especially so with respect to understanding and predicting the effects of psychiatric drugs, both in
humans and in animal tests (Moncrieff & Cohen, 2005).
We know, however, that drugs used in psychiatry have psychoactive effects because people prescribed these drugs have described
such effects, because healthy volunteers given only one or two doses of such drugs have described such effects, and—importantly—
because countless experiments with animals from many species unmistakably show that these drugs alter normal animal behavior
(make animals more or less active, more or less indifferent, more or less exploratory, more or less avoidant, more or less aggressive,
and so on).
The nature of these drug effects appears to depend largely on the particular drug ingested. Each drug seems to trigger a particular
sort of altered consciousness, inextricably linked to some altered physiology, and this global effect, though varying somewhat from
user to user and often based on how much of the drug is ingested, seem relatively easy to identify when drugs are first investigated
in human users and when the investigators are appropriately curious and open-minded about what they expect to observe.
Accumulated observations with psychiatric drugs confirm that certain psychiatric drugs have pleasant, initially desirable,
euphoric effects. This is the case notably with stimulants (such as amphetamines and methylphenidate, or Ritalin) and
benzodiazepines (such as alprazolam, or Xanax, and clonazepam, or Klonopin). For these reasons, many people interested in
experiencing such effects chemically seek out these drugs and may use them “excessively.” These drugs, though prescribed by
physicians, are therefore widely available on the black market. Other psychiatric drugs, however, rarely or simply do not produce
euphoric sensations. On the contrary, they are reliably observed or reported to produce strongly unpleasant, undesirable, or
“dysphoric” sensations. This is the case with antipsychotic or neuroleptic drugs, the tricyclic antidepressants, lithium, and many
anticonvulsants. To a lesser but still unmistakable degree, it is also the case with modern antidepressants (usually the SSRIs), as one
can tell from the few investigations that note that their subjective effects are judged rather negatively by normal volunteers as well
as by diagnosed patients (reviewed by Moncrieff, 2008; Goldsmith & Moncrieff, 2011). Of course, it is crucial to realize that even if
these latter groups of drugs do not easily produce euphoric, generally pleasant effects and even if they have almost no value on the
black market (i.e., extremely few people seek them out for recreational purposes), this does not mean that they are not psychoactive
drugs.
All psychiatric drugs in common use affect how people think, how they feel, and how they behave. Antipsychotic drugs produce
states of psychological indifference, clouded cognition, stunted emotions, and sedation. Anticonvulsants, today part of the standard
maintenance treatment of bipolar disorders, show a panoply of dysphoric effects, ranging from strong sedation and cognitive
slowing to anxiety and agitation (Cavanna et al., 2010). Antidepressant drugs include a large range of substances with effects
ranging from mild sedation to severe, mania-like agitation. It remains difficult to characterize them in psychological or subjective
terms, as their psychoactive effects have not been seriously investigated up to now. A study by Goldsmith and Moncrieff (2011)
examined comments by nearly five hundred users of fluoxetine (Prozac) and venlafaxine (Effexor) posted on a website and
categorized the most frequent described effects as sedation (about 26 percent), activation (about 25 percent), and reduced libido
(about 20 percent). Benzodiazepines typically produce sedation, relaxation, and indifference. Their deleterious effects on memory
are notable. Stimulants typically produce euphoria, wakefulness, increased concentration, and a feeling of endurance—
characteristics which combine to give stimulants a privileged place as performance enhancers in several societies.
With only the above cursory observations, one can see that drugs can affect people with and without a psychiatric diagnosis in
similar ways, but we can also see how the psychoactive effects of psychiatric drugs can be useful to people undergoing
psychological crises or who are misbehaving (and therefore whom others wish to control). This possibility and its implications have
been termed the drug-centered model of psychotropic drug action, as an alternative to the disease-centered model (Moncrieff &
Cohen, 2005, 2006, 2009).
Cohen and Hughes (2011), for example, suggest that by inducing much-needed sleep, all drugs with sedative effects can trigger
positive changes in well-being. All drugs with stimulating or activating effects may help people complete unfinished frustrating
tasks or bring about people’s exposure to social situations that provide opportunities for reinforcement and practice of social skills.
Emotional blunting, observed with most classes of psychoactive medications but especially with antipsychotics, lithium, and
anticonvulsants, may help people distance themselves from sources of stress in their environment. Conversely, it is possible to see
how the persistent production of such effects over time, whether of an activating or deactivating sort, may turn into frank
disablement. For example, where psychological indifference and cognitive clouding can help an individual and his or her relatives
during an acute emotional crisis, it can also impair a person from functioning normally. Where wakefulness and increased activity
can help someone focus efficiently on a task, it can lead them to be impetuous or aggressive in unpleasant environments. Where
decreased vigilance and increased relaxation can help one during informal social gatherings and before bedtime, it can be
deleterious if these effects persist while driving or when having to perform at the office or simply when having to make a decision.
It is extraordinary that such considerations regarding the obviously useful or impairing effects of chemically triggered
psychoactive states, depending on one’s psychological problems, situation, or circumstances have not been taken seriously in
modern psychopharmacology. Given that psychiatric medications modify thinking, feeling, and behaving, it follows logically that
these effects interact with the thoughts, the feelings, and the behaviors that are said to constitute the symptoms or the diagnostic
criteria of mental disorders as described in the DSM and other diagnostic manuals. One nonetheless can peruse dozens of manuals of
psychopharmacology without encountering any mention, let alone clear acknowledgment, of this possibility. Still, during the
introduction of the first modern psychotropics during the 1950s, several clinicians and researchers, regardless of their theoretical
orientation, became quite interested in these psychoactive effects and how to distinguish them (e.g., Cole, 1960). In the case of
antipsychotics, for nearly two decades, the production of psychic indifference and abnormal involuntary movements became
accepted as the very mechanism of action in psychosis (review by Cohen, 1997a, 1997b; Jacobs & Cohen, 1999; Moncrieff, 2008).
The fact is that these psychoactive effects are simply not controlled nor are they accounted for in interpretations or discussions of
the results of clinical trials of psychiatric drugs—which are supposed to investigate how these drugs affect symptoms. In other
words, we do not know, from the results of countless clinical trials, how sedation, activation, or reduced libido (to use only
commonly reported subjective effects of antidepressants) would lead to the conclusion that antidepressants effectively reduce
symptoms of depression. Because of the lack of controls for psychoactive effects, no one is really in a position to assert that
psychotropic medications have, in reality, any other pertinent action in the treatment of psychological distress over and above their
common psychoactive effects.
There have been no discoveries of any sort that indicate how psychotropic medications might, in fact, be modifying any (still
unknown) physiological processes hypothesized by psychiatrists and psychopharmacologists to cause psychological distress and
misbehavior. Therefore, the failure to investigate rigorously and creatively how psychoactive effects of psychiatrically prescribed
drugs—including the effects of tolerance, dependence, and withdrawal—affect psychological and behavioral states called mental
disorders seems like a remarkable form of scientific denial.
 The Lure of the Magic Potion
It is instructive to review with a twenty-year hindsight how the enormous publicity generated around claims that Prozac could
“transform” personality or around narratives of persons affected by Prozac led many social commentators to claim that society had
entered a “new era” of widespread personal transformation by means of drugs. The expression “cosmetic psychopharmacology,”
coined somewhat ironically by American psychiatrist Peter Kramer in his 1993 bestseller Listening to Prozac, quickly took hold
during that decade (Farr, 1994; Rothman, 1994).
Cosmetic psychopharmacology promised the design of drugs targeting specific neuronal receptors, a specificity of action
expected to produce desired effects with few or no unwanted effects. As a result, it was claimed, people would be able to modify
their personalities regularly: they would improve their intelligence, their memory, and their concentration—shape their brain at will
(Restak, 1994). Twenty-some years later, the Prozac revolution stands not as a genuine clinical or scientific breakthrough but instead
as a stupendous advance in the marketing of drugs (and of psychiatric diagnoses to market even more drugs). The Prozac revolution
appears merely as a modern version of the ever-alluring myth of the magic potion.
Optimistic scenarios of the implications of the Prozac revolution seemed to ignore history. Cosmetic psychopharmacology,
described by the Prozac faithful as an advance unique to late-twentieth-century psychotropics, had a longer past. Already in the
1880s, as he accustomed himself to using cocaine daily for five years, Sigmund Freud enthused that the drug was transforming his
entire personality for the better, made him more “normal,” gave him abundant energy for work, and produced not a single unwanted
effect (Byck, 1976). In contrast with the official history of antidepressant drugs as “discovered” in the early 1950s by dedicated
biochemists, as early as 1937, the Smith, Kline and French pharmaceutical firm was creating the first antidepressant, by mailing a
pamphlet to ninety thousand doctors (the majority of American general practitioners as well as neurologists and psychiatrists), to
promote amphetamine, stating that “the main field for Benzedrine Sulfate will be its use in improving mood” (cited in Rasmussen,
2006, p. 311). From that time until well into the 1960s, the amphetamines (Benzedrine, Dexedrine) were actively promoted in
medical journals and prescribed by doctors across America and the world for conditions and ailments including depression, fatigue,
and being overweight (Breggin & Breggin, 1994; Pickering & Stimson, 1994). Only fifteen years before these drugs became strictly
controlled substances considered by medical and legal authorities to have limited medical value and high potential for abuse and
dependence, readers of a medical textbook were reminded how, “Gradually, as experience with amphetamines has ripened, they
have become firmly established as versatile and helpful remedies, given to millions of people, and under such conditions as to offer
remarkably low potential for causing harm or unwanted effects” (Leake, 1958, p. 18). The use of amphetamines as performance
enhancers by athletes, pilots, drivers, and soldiers had of course already been well-established and discussed before then (Rosen,
2008).
In truth, during the 1990s on both sides of the Atlantic, commentators raised concerns about the challenges for individuals and
society of an anticipated wave of post-Prozac substances. “If one can modify mental perceptions without endangering self or
others,” asked Ehrenberg (1995, p. 34), “will our societies be made up of ‘normal’ individuals permanently assisted by psychic
products?” For French psychoanalyst Pierre Fédida (1995, p. 95), a seemingly omnipotent psychopharmacology triggered “the
anguish of a loss of psychic identity,” in which the individual “would conserve his appearance, while being dispossessed of all that
constitutes him genuinely.” For medical historian David Rothman (1994, p. 36), the use of Prozac fed what he termed a typically
American illusion, “the possibility of a single act of redemption, of victory without struggle or suffering.”
Despite some of these fears, however, whatever future scenario these authors envisaged rested on rosy renderings of the history
of psychopharmacology, especially concerning the discovery of the antipsychotics and the invention of most of today’s psychiatric
pharmacopeia. The psychiatric discourse on the progress represented by these accomplishments was accepted lock, stock, and barrel
by virtually every commentator on the Prozac phenomenon.
Even as enthusiasm about the SSRIs waned significantly, as it did at the start of the twenty-first century (Scott, 2008),
knowledgeable observers could not bring themselves to call the enterprise a scientific failure. Sharon Begley (2010), in a cover story
in Newsweek, “The Depressing News about Antidepressants,” summarized the research showing that placebos produce equivalent
outcomes, minus the adverse effects. Calling the drugs “basically expensive Tic Tacs” and citing experts acutely aware of the
“disconnect between the scientific evidence and public impression,” especially concerning the serotonin-deficit theory of depression
“built on a foundation of tissue paper,” Begley nonetheless expressed sympathy for those who would keep patients in the dark. She
characterized the truth-propaganda disconnect as a “moral dilemma.” After all, patients who suffer from what Begley termed “a
devastating, underdiagnosed, and undertreated disease” and who find their medications helpful “need to believe in their pills.” But it
isn’t a “belief in pills” that Begley was promoting, more than a belief in what patients and the public have been told by organized
psychiatry and the mental health establishment about pills as specific treatments for depression. Psychiatry, in short, is too big to
fail.
It seems to us, on the other hand, that clinical psychopharmacology—the medically sanctioned use of psychoactive drugs for the
treatment of medically legitimated distress and misbehavior (termed mental disorders)—has always been a pseudoscientific
enterprise. We argue in the rest of this chapter that what has been passed off as the “psychopharmacological revolution” of the 1950s
has consisted, at bottom, of the taming of madness via the remote chemical control of madpersons and the strengthening of
psychiatry’s medical self-image. The wholesale application of biological language to old psychiatric practices and perennial
personal problems constitutes merely the latest pseudomedical façade to the edifice of psychiatry. Besides psychiatric physicians’
singular ability to forcibly medicate and incarcerate, their indispensability as mental health practitioners rests on an exceedingly
simple and obvious fact: they alone provide access to licit psychoactive medications. And all this, we and a growing chorus of
observers can now affirm with support from abundant evidence, was made possible—indeed, was actively encouraged or
manufactured—by psychiatry’s enthusiastic enlistment as a satellite branch of the multinational pharmaceutical industry and the co-
optation of the FDA as an agency aiming, not merely to protect the public, but rather to advance the drug industry’s interests and
reinforce mainstream cultural notions that nonspecific psychoactive drugs (demons) are, in the hands of medical prescribers,
conventional medical remedies (angels) targeting specific mental disorders.
To make this case, we first address the idea that tremendous, rapid advances in the fields of molecular biology and
pharmacogenomics may have provided psychopharmacology with a secure scientific basis.
 Progress in Molecular Biology?
The development of molecular biology seems to represent a radical break contrasting a current era of “rational drug design” from a
previous one of chance discoveries. Molecular biology has enabled the amazing feat of designing a molecule introduced into the
body from the outside to bind itself on a particular type of cell membrane receptor, thus triggering changes within and around the
cell and throughout the pathways comprised of similar cells that communicate with each other. Paradoxically, this feat merely
confirms that in the domain of brain-behavior interactions, we are taking our first baby steps. As philosopher of science Isabelle
Stengers observed, “Between the richness of the psychic effects of a drug and the hypothesis that it disturbs the effects of a type of
neurotransmitter, there exists a gulf that no contemporary theory can cross” (1995, pp. 134–135).
The future of all medications is often said to depend on biotechnologies. These techniques consist of mapping and then mastering
the genetic code and functioning of a bacterium, a cell, or a whole living organism in order to make it produce various substances at
will. A well-known example is the synthesis of human insulin from bacteria. However, not even a miracle of genetic engineering
could contribute to the design of psychiatric drugs that do not merely sedate, stimulate, render indifferent, or provide nonspecific
subjective relief for emotional distress or mental disorder. This is because there are no demonstrated biological anomalies for any
drug to target to “cure” the mental disorders in question.
Such biological targets, a sine qua non for rational drug design, would be identified from a detailed knowledge of the cellular and
molecular biology of a disease. Nothing of the sort exists in the case of psychiatric “diseases” and drugs. Not only does the field
lack basic biological understanding of any presumed disease process, psychiatric researchers that we cited earlier in the book—who
have committed their careers to developing this biological understanding—state flatly that nothing biological has been reliably
associated with any DSM diagnosis that aids to make the diagnosis or to predict how someone will respond to drug treatment. There
are no biomarkers for psychiatric disorders—no biological signs that can be used reliably to measure the presence, change,
improvement, or worsening of the condition that one might deem “pathological.” To be sure, every month, investigators propose
new biological measures in the literature as candidate biomarkers, but none survives for long. Most telling, none is used in any
clinical trial testing a drug for the treatment of any psychiatric condition.
Comparing Psychiatric Progress with Neurological Progress
We repeat: no distinct biological determinism has been demonstrated in any mental disorder. For decades this was occasionally
acknowledged, but discreetly, deep in textbooks and professional articles, rarely by experts in popular discourse. According to a
survey of a probability sample of the US population, conducted by the American Psychiatric Association (2005), 75 percent of
people believe that mental disorders result from “chemical imbalances.” But, already, chemical imbalances are passé, at least
according to the director of the NIMH.
Given the belief that mental disorders are brain disorders, a good way to assess the concrete scientific fruits of the decade of the
brain for psychiatry and for understanding mental disorders is to compare what Thomas Insel as the director of the National Institute
of Mental Health, and Story Landis as the director of the National Institute of Neurological Disorders and Stroke state about
progress in their respective fields. Neurological disorders, by definition, are diseases of the brain. Mental disorders are claimed to be
diseases of the brain. Both Insel and Landis were invited by the Dana Foundation to summarize, in one thousand words, what the
massive investments into research in their respective fields had produced.
Insel (2010) wrote: “If scientists introduced mental disorders as brain disorders in the Decade of the Brain, researchers in the past
10 years have demonstrated the importance of specific brain circuits” [emphasis added]. The caveat: “Unlike neurological disorders,
which often involve areas of tissue damage or cell loss, mental disorders have begun to appear more like circuit disorders.” As
evidence for his statement, Insel writes that “specific brain pathways are involved in major mental disorders.” Also, “deep brain
stimulation has shown promise as a treatment for depression and obsessive-compulsive disorder.” Due to laser technology, “for the
first time, researchers can conduct specific tests of theories about brain circuits and behavior.” About schizophrenia, Insel states that
“The disorder might result from excessive loss of synapses in a critical cortical pathway.” He reasserts: “recent research suggests
that mental disorders are really developmental brain disorders, caused by disruptions in the circuitry map of the developing brain.”
Finally, he concludes: “The answer for psychiatry will likely be the same as the answer for the rest of medicine: Basic discoveries
regarding genes and proteins will point the way to molecular and cellular mechanisms, which in turn will yield new targets for
treatment and prevention.”
In her assessment of progress in neurological research, Story Landis (2010) states that “in the past decade, the list of gene defects
that contribute to neurological disorders grew at an extraordinary pace, leading to almost an embarrassment of riches.” She gives a
specific example: “Classification for ataxias by genetic profile has replaced the clinical classification based on time of onset, rate of
progression, and subtleties of the clinical exam.” At least six additional Parkinson’s-related genes “appear to underly the disease in
as much as 35 percent of patients with Parkinson’s disease.” For some diseases, Landis writes, “An inexpensive genetic test can now
bring [patients’ odysseys in search of a diagnosis] to a rapid and conclusive end.” Then, Landis counters with the sobering
assessment that “to date this translation has proved to be much more difficult than we had imagined. For example, in 1987,
researchers discovered that mutations in the dystrophin gene cause Duchenne muscular dystrophy [a fatal disease in affected boys
usually before the age of twenty]. Despite two decades of research and the availability of both mouse and dog models, the only
treatment currently in use is corticosteroids.”
We note Insel’s assertion that the long-held view of mental disorders as conditions characterized by “loss of cells” should now
give way to one of conditions characterized by “disruptions in the circuitry map.” In essence, Insel states that the dominant
neurobiological hypothesis of mental disorder has been abandoned. Will the 75 percent of Americans who believe in “chemical
imbalances” be informed that circuitry has dethroned chemistry? Does it matter to anyone? Yet it indicates an important scientific
event: the failure of research to support the biochemical paradigm. Touting a new conduction paradigm, however, Insel gives no
example of any “circuit disorder,” nor of any mechanisms underlying any such disorder. The transformation brought about by the
decade of the brain, we have grounds to conclude from Insel’s exhibit, is mainly metaphorical.
Landis names actual discoveries of genetic markers that definitively replace clinical diagnosis of various neurological disorders
—something psychiatry can still only dream of concerning its “brain-based” disorders. Yet, progress notwithstanding, Landis sounds
an important cautionary note: in one specific disorder, the identification of no less than a causative gene resulted in no improvement
in palliative, let alone curative, treatments. The gap between neurology and psychiatry, even between hoped-for psychiatry and
actual neurology, appears quite large.
The Promise and the Reality
In the general area of drug development, however, molecular biology has enormously helped researchers to screen for molecules
that would resemble one or more aspects of currently (commercially) successful drugs, so that these can be copied. This was the
case with the various SSRIs and the second-generation or atypical antipsychotics, designed to copy the initial leader in their class.
The sophistication and efficiency of the screening tools have increased exponentially, so that the stock of potentially testable
molecules (designed by computer) is nearly infinite. As one or another neurotransmitter pathway becomes more intently discussed
(in the literature by key opinion leaders hired as consultants by drug companies) as a potential target for drug action in one or
another mental disorder, scientists can use supercomputers to model molecules that could bind themselves to the desired target.
Also, as gene-to-behavior and environment-to-gene pathways and interactions are increasingly understood, the effects of drugs on
the expression of genes are also beginning to be better understood.3 In principle, this knowledge might help to reduce the risk of
harm from drugs based on individuals’ genetic profiles. But, to repeat, no radical innovation based on genetic knowledge is leading
the way to find any curative compounds in psychiatry, because there is simply no idea about what specific part of the body, if any,
needs fixing when people suffer or misbehave.
None of the products derived from current biotechnologies are psychiatric medications, and the number of FDA approvals for
psychiatric drugs over the past decade has significantly declined (Cutler et al., 2010), as has, in general, the number of new
molecular entities (drugs never used before in clinical practice) approved by the FDA, from thirty-one in 2004 to seventeen in 2008
(Dorsey et al., 2010). That number had risen back to thirty in 2011, but included only a single drug approved for a mental disorder
(FDA, 2012). The tendency in psychiatry has mostly consisted in recycling existing drugs for expanded uses. To illustrate, a drug
evaluated by the FDA for approval for the treatment of sleepiness in narcolepsy in the mid-2000s was merely an old stimulant on the
European market for more than forty years (Provigil, or modafinil). The second-to-last antipsychotic approved by the FDA in late
2007 was paliperidone (Invega), the major active metabolite (a byproduct formed during metabolism) of risperidone—itself on the
market since 1994 and whose patent of exclusive marketing to its manufacturer, Janssen, was expiring.
In the spirit of providing the illumination that often comes from visiting old exhibits of the future, here is how a Newsweek
article by Sharon Begley published in 1994 announced imminent drug breakthroughs. The author described the use of five “new
mind drugs”—though none were new at the time. In the article, beta blockers, largely used around the world to lower blood
pressure, were renamed “anxiolytics”; Ritalin, on the United States market since the late 1950s, was promoted to increase
concentration in adults (part of the intriguing shift to “adult ADD” starting in the mid-1990s); dexfenfluramine, another stimulant
long available in Europe as a diet pill, was renamed a “mood stabilizer”; phenytoin (Dilantin), one of the oldest antiepileptic drugs
on the market, was dubbed a “stress reducer”; and phenelzine, prescribed sporadically since the 1950s as an antidepressant, was
presented as an innovative treatment for “hypersensitive patients.” What happened to these drugs? Of the five, dexfenfluramine was
later withdrawn from the market for toxic cardiac effects, and phenytoin and phenelzine are barely used.
To Begley’s list one might add the antipsychotic clozapine, prescribed modestly in Europe since the end of the 1960s, but
launched in North America in 1990 as a “revolutionary new treatment for schizophrenia,” with a publicity campaign that included a
Time magazine cover (July 6, 1992) and a story displaying a photograph of a young man diagnosed with schizophrenia dancing
wildly and happily at a party. In reports to the FDA between 1998 and 2005, however, health professionals named clozapine as a
suspected cause in nearly 3,300 deaths—more than any other prescribed psychoactive drug (Moore, Cohen, & Furberg, 2007).
Several observers of the rise of Prozac in the 1990s predicted that the psychopharmacologist would soon hold the keys to
understanding the brain and to shape it at will. Another analogy seems more fitting during the second decade of the twenty-first
century: facing the somewhere around 100 trillion glia, neurons, receptors, and synapses in the brain, the psychopharmacologist
resembles the astronomer facing the cosmos.
 The Complex Life Cycle of Medications
Most medications have a long, complex, and unpredictable lifecycle. Although modern psychoactive medications are implicitly and
explicitly portrayed as pure substances whose indications for prescription are intrinsic to their chemical structure, no such
medication appears to have ever existed. Psychoactive drugs, let us note, are prescribed in the absence of demonstrated physical
pathology. Thus, how and why drugs end up being prescribed for one clinical indication in psychiatry rather than another is the
result at least as much from trial and error and marketing as from clinical necessity (Cohen et al., 2001; Horwitz, 2010).
The Elusive Costs of Developing Drugs
To transform a molecule into a medication approved by the FDA for marketing and prescription takes several years. Of thousands of
molecules screened in the laboratory, only a handful start the journey to approval. The most widely cited estimate of the average
cost of the process to approval for a single drug—what is commonly referred to as research and development (R & D)—was $802
million in 2000, updated to $1.32 billion in 2006 (cited in Light and Warburton, 2011, p. 3), and again to $1.8 billion in a 2010
NIMH report (“From Discovery to Cure,” 2010). However, Donald Light and Rebecca Warburton have demonstrated that the $802
million estimate constitutes a hodge-podge of unverifiable early development costs, costs of “profits foregone” by choosing to
invest in R & D (about half of the $802 million estimate), largely inflated costs of clinical trials, exaggerated time for R & D, and
other questionable strategies, such as using mean rather than median costs. Despite this, the R&D estimates are immediately 100
percent deducted from taxable profits for the companies involved, a convenient federal incentive for them to exaggerate the actual
costs.
Light and Warburton’s analysis deserves close reading. They suggest that “based on independent sources and reasonable
arguments, one can conclude that R&D costs companies a median of $43.4 million per new drug, just as company supported
analysts can conclude they are over 18 times larger, or $802 million” (2011, p. 14). They conclude that, “Readers should appreciate
the constructed nature of R&D cost estimates and always ask very closely about where the data for an estimate come from, how they
were assembled and whether they can be verified” (p. 14). Our view is that this caution also applies to claims of drug effectiveness
and safety as we will describe below.
The FDA Obstacle Course
For a new molecule (one that has not already been approved by the FDA for any indication), the approval process includes
overlapping phases involving many players. Each phase is well-outlined in the literature, but only the latter phases—large,
randomized controlled clinical trials (RCTs) in humans—have been examined by scholars in any depth. Under the legally enforced
principle that drugs are proprietary products and that competitors in the drug industry may unfairly benefit from a company’s
disclosures of its commercial practices, most of the activities during the early phases of drug development remain shielded from
serious scrutiny. The components of the various phases, and regulatory agencies’ expectations about them are well-known in theory,
but how the phases are orchestrated in practice is not. Over the last decade, however, more glimpses have been obtained as
confidential documents have been unsealed or leaked during lawsuits against drug companies.
Animal Tests and Phase I Human Tests. The first step in drug development consists of preclinical testing. Computers
simulating the precise chemical structure of the chosen molecule allow investigators to make predictions about its affinity for certain
receptors in the body and its resemblance to other molecules with known effects. Then, testing on several animal species (rodents,
cats and dogs, occasionally primates) is undertaken to rule out the drug’s potential to cause obvious physical damage, including
genetic or chromosomal mutations, birth defects or malformations, and cancer.
Preclinical studies may be conducted in the manufacturer’s own facilities or contracted out to private research labs and university
departments. Typically, the initial work is conceived in a university laboratory receiving government funding. Breakthrough
pioneering work is inherently unpredictable, and few drug companies are willing to invest in such uncertainties, especially, as in the
case of mental disorders, if there is no understanding of how the “disease” works and thus no established path to breakthrough
drugs. Thus, once a potentially useful substance is discovered or identified in a university lab, the drug firm, betting on the potential
clinical value of the particular substance, enters into a commercial agreement with a researcher and/or the university to pursue its
development. After having amassed the required data indicating that the drug is not likely to cause gross physical damage to animals
and outlining general neurochemical and behavioral effects of the molecule as determined through in vitro and in vivo tests on
animals, the sponsor might then apply to the FDA to begin testing it on humans.
If the FDA agrees and the sponsor decides to undertake human testing, phase I of clinical trials may begin. The aim now is to
determine the major parameters of the drug’s effects in humans. Starting with tiny doses, the drug might be administered to
approximately twenty to a hundred younger, healthy men. Close medical monitoring is necessary, since the first administration in
humans—despite the extensive animal studies that preceded it—may lead to completely unforeseen effects. An example was
revealed in March 2006 when six volunteers receiving the first-ever injections to humans of TGN1412, tested as a potential remedy
for autoimmune diseases, became desperately ill and suffered multiple organ failures. Five of the six recovered only after a full
month in intensive care. Doses up to 500 times as high as those received by this first group of volunteers had been given to animals,
with no sign of toxicity whatsoever (Wood & Darbyshire, 2006).
Testing for “abuse liability” might take place during phase I. At the urging of the FDA, the sponsor might be asked to determine
whether the substance is pleasurable to take, whether experienced users (“abusers”) of illicit substances report some equivalence of
effect with the new substance, or whether ordinary participants in clinical trials diverted it to friends. This reflects one of the rare
instances of interest in specifically psychoactive effects by any responsible authorities. A clear indication that a new drug intended
for prescription creates euphoria in a few users or is diverted by a few clinical trial participants to their relatives or friends would
certainly delay if not doom its prospects of obtaining FDA approval as a prescription medication. Yet, that a drug creates dose-
dependent dysphoria (unpleasant emotions or behavior such as depression, agitation, restlessness, or anxiety) in more than a few
users would evoke absolutely no concern among regulators unless the effects are clearly and repeatedly described as dramatic or
observed frequently in the trials’ reports submitted to the FDA. The implied reasoning is that these unpleasant effects are most likely
manifestations of the subjects’ pre-existing psychiatric disorders and need not be considered from the start as attributable to the
drugs.4
Banishing the Psychoactive. Based on the results of animal trials, it is likely that a distinctive profile of the psychoactive drug
has begun to emerge: the drug has either energized, or sedated, or paralyzed, or rendered animals indifferent, or inhibited some
learning and memory tasks, or increased or decreased various species-like or un-species-like behaviors in contrived settings. At
present, it is impossible to imagine a drug with no noticeable behavioral effects in animals being viewed as a potentially useful
psychiatric medication and thus proceeding to human testing. Despite these definite observations that drugs intended for psychiatric
use have clear behavioral effects in animals, no systematic search of equivalent psychoactive effects in humans takes place during
the drugs’ clinical trials. Neither drug firms nor the FDA have developed (or publicized) methodical procedures to test, in human
volunteers, emotional, cognitive, and behavioral effects—which psychoactive drugs produce and are expected to produce, by
definition. The case of Strattera (atomoxetine), a claimed “nonstimulant” approved by the FDA for the treatment of ADHD in 2002,
is illustrative. Records and data released by the FDA show that atomoxetine was administered to nearly three hundred healthy
volunteers during phase I studies. Yet in several hundred pages of FDA evaluation summaries, neither the drug firm nor the FDA
reviewers who pored over these data made a single comment on anticipated psychoactive effects besides those related to the
potential abuse of the drug. This bears restating: No exploration of Strattera’s effects on mood, attention, memory, or any other
emotional or intellectual quality in healthy humans was reported in the FDA review of the sponsor’s application for marketing
(Cohen, 2011).
In any case, based on a combination of animal and phase I observations, on the resemblance of the tested substance to others on
the market, and on whether its use can be justified by marketable theoretical considerations such as dopamine, serotonin, or other
still-undiscarded hypotheses related to the anticipated indication, a testable clinical indication in humans has been proposed, worded
by means of the DSM psychiatric disorder. This is obligatory because federal regulations define a drug as something intended for the
prevention or treatment of “disease.” A drug cannot be approved by the FDA because it has potent or potentially useful stimulant or
sedative effects—it must be judged efficacious for a recognized disease or disorder: for example, Attention Deficit-Hyperactivity
Disorder, General Anxiety Disorder, or Schizophrenic Disorder. (There are exceptions to this rule, as for example when the FDA
approved risperidone for the treatment of “irritability” associated with autistic disorder in 2006.)
In this connection, it is noteworthy that the FDA has explicitly recognized that psychiatric diagnoses have no validated
physiopathology. A consumer queried the FDA on whether it agreed with a statement by Health Canada, the Canadian government’s
drug regulatory agency, that “For mental/psychiatric disorders in general . . . there are no confirmatory gross, microscopic or
chemical abnormalities that have been validated for objective physical diagnosis.” In its reply to the consumer, the FDA’s Center of
Drug Evaluation and Research agreed that “psychiatric disorders are diagnosed based on a patient’s presentation of symptoms that
the larger psychiatric community has come to accept as real and responsive to treatment. We have nothing more to add to Health
Canada’s response” (cited in Pringle, 2009, p. 1). This statement by the FDA explains why any discussion by the sponsor of the
expected or presumed biological mechanisms by which the tested psychiatric drug might reduce symptoms of the mental disorder of
interest in the clinical trial is itself reduced to an absolute minimum in the sponsor’s application for drug approval. For example,
Cohen (2011) observed that in approximately 695 pages making up the FDA-released evaluation of Strattera, the presumed
biochemical rationale of Strattera as a treatment for the proposed indication, ADHD, was discussed in two sentences, with no
references.
Phase II Trials. Phase II consists of relatively small trials, lasting about two to eight weeks, usually including anywhere from
fifty to three hundred people diagnosed with the DSM condition for which the sponsor hopes to market the future medication. Thus
phase II trials attempt to establish that the drug will, indeed, improve the officially designated symptoms of an officially designated
psychiatric condition. To determine for which disorder the drug will be tested is, as we have mentioned earlier, probably based on a
combination of factors, none of which appears in the literature as decisive. It is possible to suggest that the decision is not an
inherently complicated clinical matter (although it may be a risky marketing matter). For example, looking at a number of previous
drug approvals, it may be that drugs having revealed a distinctive behavioral profile of sedative effects (and a molecular activity
profile somewhat consistent with that of other sedative drugs on the market) will likely be tested for the treatment of DSM disorders
characterized by symptoms of anxiety or agitation, for which sedating drugs are often found useful. Similarly, drugs having revealed
a distinctive profile of deactivating effects will likely be tested for DSM disorders characterized by delusions, loss of control, and
severe agitation.
Phase II studies vary greatly in methodological rigor and are usually “open,” meaning that if the studies involve control groups
of participants receiving a comparison drug or placebo, investigators know who these participants are. To measure outcomes, rating
scales that usually list the appropriate DSM symptoms of the particular disorder—as well as other symptoms of general
psychological distress (especially anxiety, agitation, and depression)—are used. From the sponsor’s perspective, phase II trials must
succeed to justify the next phase of testing, phase III, because this is where the most examined trials will take place. It appears that
less than one-tenth of substances that enter phase I trials make it to approval. Over half of the failures apparently result from an
inability to demonstrate efficacy during phase II trials: that is, superior response of patients on the drug compared to placebo, even
in open trials (Hurko & Ryan, 2005).
Controlled Trials out of Control. Phase III trials are often called “pivotal” trials because they employ what experts in medicine
widely consider the gold standard design: the randomized, controlled clinical trial (RCT). In RCTs for most psychiatric drugs,
eligible participants (about five hundred to three thousand people in total, recruited from multiple sites in different cities and,
increasingly, different countries) are randomly assigned to receive either the drug or an alternate treatment, usually an inert placebo.
Because random assignment is the strongest way to ensure similar groups and thereby minimize important threats to the
methodological (logical or internal) validity of a study, RCTs are believed to produce the highest-grade evidence to determine how
much observed change in participants is due to the treatment rather than to any confounding variables.
The validity of the RCT rests on several assumptions, one of which is that participants in the trial are all the same on the key
reason why they have been enrolled in the trial (i.e., they all have the same “mental disorder” to be treated). The point of the RCT is
to determine the specific influence of a treatment on the outcome of the trial; therefore one needs to rule out the influence of other
factors (within and outside the participants) that could cloud this determination. Thus, FDA clinical trials of psychoactive drugs
always specify that the participants meet the specific diagnostic criteria necessary for mental disorder X, as determined by a
structured DSM psychiatric diagnostic interview and confirmed by experienced clinical psychiatrists. Yet that participants meet the
DSM criteria for the disorder in question does not in any way guarantee the sameness of their problem. The issue is not merely one
of the “heterogeneous presentation” of a disorder, just as one person with lung cancer might differ from another person with lung
cancer. At issue here is the nature of the problem. The sadness or despondency experienced by one person’s unemployment and by
another’s realization of a spouse’s infidelity might both meet the DSM’s diagnostic criteria for “Major Depressive Disorder” or its
synonyms, but they are worlds away in cause, meaning, and experience (Jacobs & Cohen, 2010). The sameness that characterizes
lesions or infections in physical disorders cannot exist in the case of psychological problems that are only diagnosed based on an
individual’s subjective view of their own circumstances and predicament, a view that develops and differs according to
circumstances (including the very circumstances of a clinical trial). If this is the case, the whole point of conducting a psychiatric
drug RCT and randomizing participants in separate groups in order to ensure that only treatment (drug or no drug) differs between
groups so that only treatment can be implicated in the outcomes is exposed as nonsensical. This foundational issue is not, to our
knowledge, ever discussed in the psychiatric clinical trial literature, so strong is the tacit acceptance of DSM disorders as
conventional medical diseases, impersonal and invariant medical disorders, the same in every person.
 A well-known refinement of the RCT involves double-blind placebo-control, wherein neither researchers nor participants are
supposed to know who is receiving an active drug and who an identical-looking but inert placebo. This precaution is meant to
counter the potentially enormous impact of researcher and participant expectations on the outcome. But the actual effect of the
precaution is rarely if ever tested or reported in modern psychotropic drug trials, possibly to avoid knowing that patients and
clinicians can guess correctly (apparently, more than 80 percent of the time in older trials of benzodiazepines or antidepressants)
which treatment they are receiving (Even et al., 2000). Blindness in psychotropic drug trials is therefore a completely relative
notion, which means that the scientific value of the RCT in the enterprise must also remain a relative notion. This bears repeating:
although the whole preapproval drug-testing process culminates with phase III randomized controlled trials with their obligatory
double-blind feature, the breach of blindness in these trials may be routine and widespread, tainting impartiality of the raters
(assuming such impartiality can exist in the sponsor-controlled clinical trial environment) and rendering the whole exercise no
different than phase II open trials. For example, Benson and Hartz (2000) compared RCTs and merely “observational” studies of
nineteen different treatments (excluding psychotropic drugs) but found estimates of treatment effects from the lesser-grade studies to
be neither larger nor qualitatively different than those from RCTs. In sum, the RCT, erected as a massive stone guardian of the
medical validity of testing psychoactive drugs for mental disorders by the FDA and the drug industry, has feet of clay.
Besides their larger size and supposedly more rigorous design, phase III trials are essentially similar to phase II trials in length
(about two to eight weeks) and outcome measures (a predefined average percentage improvement on rating scale scores in the drug-
treated group that should exceed any improvement seen in the non-drug-treated group and not be attributable to chance, as
determined by statistical tests).
Finally, phase IV trials (also known as post-marketing surveillance trials) might be undertaken after the drug has received market
approval from the FDA. Regularly, the FDA requires the sponsor to promise to conduct such trials as a condition for approval. Phase
IV trials serve as an explicit recognition that the premarketing clinical trial process is inherently limited as the types and numbers of
patients studied, the durations of treatment, and the overall conditions of use differ greatly from the real-world patients, durations,
and conditions of use expected once the drug hits the market. Only after several years or decades of such use might one expect a
more realistic safety profile to be established. The three major drug studies discussed in chapter 6 (CATIE, STAR*D, and STEP-
BD) may all be considered phase IV trials. As of 2006, 71 percent of phase IV trials that sponsors had promised the FDA to conduct
as a condition of the approval of their drug had not yet started (Avorn, 2007).
 On the Market
We mentioned earlier that choosing the tested indication for a drug (e.g., the “disease” that it will be officially approved for) may be
a more risky marketing than clinical issue. This is because, years before the possibility of market approval, the drug maker must
anticipate future therapeutic needs in the field—or, if necessary, create such needs—so that the medication appears to clinicians and
the public to arrive just in time to allay a serious problem and that a respectable return on investments (or better, blockbuster status
for the drug, usually defined as $1 billion or more in yearly sales) is obtained. After having received a brand name, the psychotropic
medication will now be the subject of a promotional blitz targeted to all persons, groups, and institutions who might have some
interest in its use. A key part of this campaign involves formulating a simple way to understand how the drug works and why it is so
essential (Nesi, 2008). From these strategies are born or reborn invented phrases such as “chemical imbalance,” “mood stabilizer,”
and “treatable medical condition.” The money spent on this marketing will greatly exceed the sums invested in all the phases of
preclinical and clinical testing that led to the drug’s approval by the FDA and any subsequent studies once on the market (Gagnon &
Lexchin, 2008).
The drug will be placed in a therapeutic class corresponding to the disorder for which the FDA approved it for prescription (such
as antipsychotic, antidepressant, anxiolytic). This classification may at first matter to doctors, pharmacists, patients, and journalists,
as it will be the first and perhaps the only formally advertised indication for that drug. Quickly, however, this classification will
mean little in practice, as nearly all psychotropic drug classes end up prescribed for all groups of disorders (Bezchlibnyk-Butler &
Jeffries, 2005). Rapidly, by means of the tools and techniques of pharmaceutical promotion, the drug’s uses will expand in the form
of off-label prescribing (use of the drug for different problems than its official label specifies), which constitutes the principal means
for psychotropic drugs to reach blockbuster status. A couple of years after Neurontin (gabapentin) was approved by the FDA as an
adjunctive treatment for epileptic seizures, 90 percent of its prescriptions were for conditions such as ADHD, bipolar disorder,
migraine, and depression (Fullerton, Busch, & Frank, 2010). In its heyday, Prozac, initially approved in 1987 for depression, then
bulimia and obsessive-compulsive disorder, became prescribed for more than a dozen other conditions, in and out of psychiatry. As
Eli Lilly’s patent on selling Prozac neared expiration, the company resubmitted Prozac to the FDA for approval as a treatment for
Late Luteal Phase Dysphoric Disorder (later renamed Premenstrual Dysphoric Disorder in the DSM-IV). Prozac re-emerged in 2000
as Sarafem. Lilly then changed the coating on the Prozac pill so that it would only dissolve fully in the intestine, keeping it longer in
the body, and changed its name to Prozac Weekly, which the FDA approved in 2001.
Once on the market, the observation of undesirable or absence of desirable effects not previously detected (or detected during the
drug’s journey to FDA approval but suppressed from publication) can transform the medication into a public health hazard and limit
its use—if patients are lucky. A drug might be available only by prescription for years and then become available for purchase over-
the-counter. Immediately, its price, its indications, its usual dosage, and how the public perceives its risks and benefits will
dramatically change (Mahecha, 2006).
 From Chemical Straitjacket to Happy Pill
Different years have been proposed as marking the start of the twentieth century’s so-called psychopharmacological revolution.
According to Frankenburg (1994), it’s 1931, year of the first studies of rauwolfia serpentina, a plant whose extract, reserpine, had a
meteoric rise and fall as a treatment for mental illness in the 1950s. According to Strassman (1995), modern biological psychiatry
started in 1943, when Albert Hoffman discovered the hallucinogenic lysergic acid diethylamide (LSD). The year 1949 has also been
proposed, when psychiatrist John Cade first published his account of administering lithium salts to the inmates of his mental
hospital in Australia. Most everyone else, however, has chosen 1952 as the start of the revolution, when the first observations were
made public in France that a drug called chlorpromazine could subdue agitated inmates in insane asylums.
Striking Effects on Madmen and Their Keepers
Chlorpromazine was the first to be baptized “neuroleptic” (“that seizes the nerve”). Without putting the subject to sleep, the drug
induced a state that its pioneer observers termed “psychic indifference” and which sometimes progressed to a stupor. The unique
emotion dampening and behavior subduing effects of neuroleptics (still unequaled by any other drug class) radically changed the
internal organization of the asylums and the relations between inmates and their keepers (Cohen, 1997b; Freyhan, 1955).
Over a ten-year period, neuroleptics began to replace impaludations, (a method of treating psychosis by injecting blood infected
with malaria), sleep cures, barbiturate comas, insulin comas, electrically-induced seizures, and lobotomies, treatments that had been
vogue since the end of the 1910s but had done little to change a popular perception of madness as incurable or of psychiatry as only
vaguely related to medicine. In the 1950s, by enabling psychiatrists to prescribe pills to suppress psychosis, chlorpromazine allowed
psychiatry to officially accede to the rank of a medical discipline. According to the late French psychiatrist Edouard Zarifian, “There
is no medicine without prescriptions. To be medical, psychiatry needed drugs” (1995, p. 74).
Within a year of chlorpromazine’s introduction, however, psychiatrists began describing how its tranquilizing action seemed
inseparable from newly-appearing neurological impairments, notably parkinsonism and various types of abnormal involuntary
movements termed dyskinesia, akinesia, and akathisia. Intriguingly, as a group these movements closely resembled the sequelae of
encephalitis lethargica, an epidemic that swept through the world between 1915 and 1926. Pierre Deniker, the French psychiatrist
credited with Jean Delay for the first psychiatric uses of chlorpromazine without other drugs, stated he and his colleagues had long
realized that, although the neuroleptics were new drugs, their adverse effects were not: “All the side effects of neuroleptics had
already been described between 1920 and 1935 as a sequelae of encephalitis” (Deniker, 1989, p. 255). Such realizations, however,
did not raise concerns for the simple reason that psychiatrists were not surprised that their treatments could cause damage, even
extremely serious damage. Indeed, since the very beginnings of hospital psychiatry, an “effective” treatment was one that could
disable the person receiving it. Psychiatrists were completely familiar with the amnesia provoked by electroshocks, the occasional
deaths or anoxia produced by prolonged hypoglycemia from insulin coma, and the emotional blunting and loss of volition following
lobotomy, a procedure some of them openly described as “partial euthanasia” (see Constans, 1992).
Consider the reminiscences of Heinz Lehmann, who introduced chlorpromazine to North America in 1953, on the sorts of
interventions that he used in his Montreal hospital in the 1940s:

“Our two major therapies were insulin-induced hypoglycemic coma and electric shock therapies . . . Paraldehyde and the
barbiturates were about our only means to quell agitation and violence in addition to seclusion and restraint . . . 70% to 80%
of [patients] relapsed” (1993, p. 294).

Lehmann therefore experimented with procedures “that would be impossible to repeat today” (p. 295). In an earlier paper, he
mentions, among others, “brain biopsies” done on “randomly selected psychotic patients”; “carbon dioxide treatment”; the use of
“very large doses of caffeine. . . of course with no results”; nitrous oxide “to the point where there was complete loss of
consciousness”; injections of sulphur in oil and typhoid antitoxin, both of which only produced high fevers; injections of “turpentine
into the abdominal muscles which produced—and was supposed to produce—a huge sterile abscess and marked leucocytosis”
(1989, p. 263). Lehmann’s candid accounts, which are here obviously truncated and deserve to be read in full, illustrate how, in
devising treatments for their forgotten and socially devalued wards, asylum doctors had little incentives, desires, or training to
choose treatments causing least harm.
Most retellings of the revolution brought about by neuroleptics completely ignore that it was only in comparison to these other
extremely damaging yet consecrated treatments that neuroleptics were first appraised, and this, inside the twisted world of the
asylum (Breggin, 1983; Cohen, 1997b). The ease of administering pills and the indisputable gains in bringing order to the asylum
carried the day over any strictly medical considerations. Within ten years after the first psychiatric use of chlorpromazine, about
thirty similar drugs had been brought to market. The damaging effects of neuroleptics came to preoccupy psychiatry only thirty
years later, when an epidemic of tardive dyskinesia (and its legal consequences in the United States in particular) had to be faced
and when the modest therapeutic gains from neuroleptics were discussed unambiguously in professional journals and meetings
(Cohen & McCubbin, 1990). Until that occurred, neuroleptics were universally lauded as the decisive psychiatric advance of the
century.
In 1994 a team of four American research psychiatrists analyzed 368 studies spanning the century (published between 1896 and
1992) that reported on clinical outcomes for individuals diagnosed with schizophrenia (or dementia praecox, as it was known or
recorded until the 1920s–1940s) and who had received whatever treatment was in vogue during their time (Hegarty et al., 1994).
These authors found that overall, 46 percent of patients were rated as improved with antipsychotics, 42 percent with convulsive
treatments (electric, insulin, or cardiazol shocks), and 28 percent with lobotomy. The small difference between drugs and shock,
considering the reputation held by neuroleptics as uncontrovertible advances over all existing treatments against psychosis, is quite
revealing. Moreover, Hegarty and colleagues also found that 29 percent of patients were rated as improved with “nonspecific”
interventions, which they defined as “placebo trials, psychotherapy, hydrotherapy, fever therapy, and nonneurological surgery” (p.
1411). This 29 percent might be considered a baseline improvement rate in psychotic disorders, regardless of—or despite—any
intervention. If so, one would be justified to subtract it from each of the other totals, to get a better sense of their net value, just as in
a two-group clinical trial one may deduct placebo response rates from drug response rates to approximate the net response from
drugs.
Also, when Hegarty and colleagues examined the twenty studies published just before the end of their review (1986–1992), they
calculated an improvement rate (36.4 percent) that they termed “statistically indistinguishable from that found in the first half of the
century [35.4%]” (p. 1412). Hegarty and colleagues’ investigation provided a unique long-term view showing—just as the twenty-
first century CATIE study—that a full generation of antipsychotic drug treatment of schizophrenia did not appear to be any more
effective than interventions in vogue during the pre-drug era.
 Enter the “Atypicals”
Starting in the early 1990s, forty years after chlorpromazine, a new generation of antipsychotic drugs, called “atypicals” by their
promoters, made its appearance. The occasion allowed many psychiatrists to finally rail openly against classical neuroleptics, now
portrayed as ineffective and exceedingly toxic, and to express the hope that the newer drugs would solve the problem of psychosis.
The atypicals—so called because their makers claimed (1) that their biochemical actions were much broader than those of the older
drugs, (2) that they effectively suppressed psychotic symptoms yet did not cause the typical neurological impairments of the older
drugs, and (3) that they actually helped reverse the apathy observed in treated patients—were greeted enthusiastically as a new dawn
in the treatment of schizophrenia.
One by one, except for clozapine, the five atypical antipsychotics introduced between 1994 and 1999 became blockbusters, their
off-label use flourishing due to extremely aggressive marketing. In most cases, this occurred despite early signs that the drugs
increased risks of inducing weight gain and metabolic complications such as diabetes. A few dissonant analyses and observations
(e.g., Geddes et al., 2000; Cohen, 2002) also showed that the perceived therapeutic progress rested on strained tests or ignoring
evidence and common sense, but these were drowned out. One advertisement for Risperdal (risperidone) in the American Journal of
Psychiatry went as far as to claim that the drug was as harmless as a placebo pill (appeared in April 1994, p. A11).
The atypicals experienced an unprecedented surge in use, spreading to children and older persons and to any diagnosis in which
the existing drugs seemed less than satisfactory. We have mentioned that Zyprexa (olanzapine), first approved in 1995 for the
treatment of acute schizophrenic episodes, had grossed $45 billion dollars by 2011, becoming one of the world’s most profitable
medications. However, the publication of the CATIE study in late 2005 and of several other large and non-industry-funded studies
around the same time confirmed that these new antipsychotics were neither more effective nor better tolerated than the drugs they
had so quickly replaced.
Most observers agreed that, among children and adolescents (targets for off-label prescriptions in the United States during the
two decades straddling the centuries), aggressive or hostile behavior probably accounted for most antipsychotic prescribing (Patel et
al., 2005). Yet one controlled study of a classic antipsychotic (haloperidol), an atypical antipsychotic (risperidone), and an inert
placebo among three groups of youths with intellectual disabilities who showed “challenging aggressive behavior” found that
“aggression declined dramatically in all three groups by four weeks, with placebo showing the greatest reduction (79%) (vs. 57% for
combined drugs)” (Tyrer et al., 2007). Here again, demonstrations of clinical gains under real-world conditions lagged far behind
the claims that drug manufacturers and their proxies made even before their drugs had passed the FDA approval hurdle.
It is still too soon to know the full story of the atypical antipsychotic debacle and to understand how the owners of the drug
treatment of schizophrenia,—tens of thousands of highly educated medical practitioners—swallowed drug industry propaganda that
the exceedingly complex problem of schizophrenia could be solved by the industry’s latest drugs. Jeffrey Lieberman (2006), the lead
CATIE investigator and a previously unabashed proponent of the atypicals, summed up the affair:

The claims of superiority for the [atypicals] were greatly exaggerated. This may have been encouraged by an overly
expectant community of clinicians and patients eager to believe in the power of new medications. At the same time, the
aggressive marketing of these drugs may have contributed to this enhanced perception of their effectiveness in the absence
of empirical information. (p. 1070)

It is tempting to let this quote speak for itself. Still, Lieberman not only described presumably rational psychiatrists “eager to
believe in the power of new medications” and embracing “greatly exaggerated” claims “in the absence of empirical information,”
but doing so fifty years after the arrival of the first antipsychotic, during the flowering of clinical psychopharmacology as the
foundational, “evidence-based” activity of psychiatry.
 “Beautiful Picture, Isn’t It?”
In 1962, researchers showed that antipsychotics bound to neuronal receptors that normally attracted the neurotransmitter dopamine.
The drugs were blocking dopamine’s flow through its habitual neuronal pathways. Thus was born the “dopamine hypothesis,”
according to which an excess of dopamine activity causes schizophrenic psychosis. This hypothesis (modified and refined) remained
dominant, though it has never enjoyed any directly supporting evidence. In other words, no dopamine abnormality in the brains of
never-medicated people diagnosed with schizophrenia has ever been confirmed reliably (Tandon, Keshavan, & Nasrallah, 2008).
As we’ve discussed, the search for new drugs (for physical disorders) uses animal models to test possibly curative compounds on
animals with the disease or to analyze biological causes. The ease with which animals can be studied and sacrificed is the obvious
perceived advantage here. “Depressed mice” or “psychotic monkeys,” however, can hardly serve as adequate models for depressed
or psychotic states in humans (even putting aside the definitional and diagnostic problems covered throughout this book). In
psychiatric drug studies, therefore, “animal models” typically consist of observing drug effects on various instinctive or conditioned
animal behaviors that only have a tenuous connection to the problems purportedly treated in people. Many animal tests merely
screen for drugs that will produce similar effects to those produced by commercially successful drugs on the market, which is how
“me-too” drugs appear.
One reason for the focus on neurobiology in the absence of definitive findings may be the extent to which descriptions of
biomedical facts over the last two decades have become tied to technological advances that dazzle observers with their appealing
images of brain function. Finding that the brains of different people seem to function differently has provided endless fascination for
those who see in these differences confirmation that biology “explains” everything disordered in humans. That taxi drivers or
musicians show different brain activity on certain spatial or musical tasks than other people seems merely interesting. That
depressed people occasionally show different brain functioning than other people, however, “proves” that they’re diseased. This
logic is erroneous, because subtle physiological difference might arise from experience or learning; it might be a consequence, not a
cause, of the person’s problem diagnosed as a psychiatric disorder. And such a difference does not mean “disease” unless the
meaning of disease is—as we have been suggesting—distorted beyond recognition.
Other advances in molecular biology, especially the ability to label drug molecules with radioactive tracers, allowed scientists to
deepen their knowledge on the micromechanisms of neurotransmission and to chart a drug’s distribution in the brain. Whereas five
to ten substances were identified as neurotransmitters in the 1960s, more than one hundred are identified today, and their multiple
functions are only beginning to be revealed. For example, in the 1970s, psychiatrists used to write generally about “dopamine
receptor blocking.” Dopamine cells are now known to possess five different families of receptors, each of which seems to have quite
different functions. For serotonin, at least five subfamilies of receptors have been cloned for only a single of the fourteen families of
receptors for that neurotransmitter already identified. But receptor pharmacology, the Holy Grail of psychiatric drug development in
the 1990s, is passing on. The post-genomic focus is on proteins and genes whose expressions appear to affect physiological
processes that, in some theoretical or in some animal model, might be related to the core physiopathology that—the whole field has
committed itself to assume—underlies the DSM disorder for which the drug is tested. Moreover, the latest insights within
conventional psychopharmacology suggest that current thinking about the importance of neuronal transmission be reevaluated to
consider “the other brain,” that is made up by glia, the once-thought-inconsequential neural glue that holds the brain together
(Fields, 2009).
The notion of chemical imbalance evaporates when reproducible evidence must be provided about the exact nature of
pathophysiology in the serotonin or dopaminergic system. The enormously complex play, interplay, and counterplay of the cascades
of alterations triggered by drugs binding to receptors and subreceptors has no connection to the claims made for years in
advertisements, oft-repeated by journalists, that certain “drugs restore the balance of the serotonin system,” as if this balance was
actually known or charted (Leo & Lacasse, 2008). Furthermore, as each newly identified neurotransmitter has been immediately
considered as a possible player in depression, anxiety, or psychosis, the number of biochemical hypotheses of these problems
increased radically during the 1980s, though few lasted for more than a few years. It is difficult to overemphasize how much value
these hypotheses, and the new brain imaging technology, had for marketing drugs. Psychiatrist and historian David Healy (2008) put
it this way: “When in the 1990s neuroscience threw up colorful images of the brain, marketers found these invaluable for
purportedly showing the cleaner effects of SSRIs compared to older antidepressants. There was little neuroscientific value to the
images—but they provided wonderful marketing copy” (p. 226). In Healy’s view, the monoamine hypothesis of depression—
positing a lowering of neurotransmitters that drug treatment corrected—was abandoned by the science of psychopharmacology as
early as 1970, but “the serotonin hypothesis was resurrected within the marketing departments of SSRI companies, because it was
marketing copy par excellence” (p. 226).
In practical terms the discovery of neuroleptics gave birth to modern biological psychiatry and provided a springboard to develop
the neurosciences generally. Yet do we understand psychosis? The inescapable answer is no. Neuroscientifically, after decades of
intensive research, it remains completely mysterious why about 1 percent of young people develop “schizophrenia.” Scientists
merely repeat, mantra-style, that schizophrenia results from an interplay of genetic, biochemical, and environmental factors. A
recent review purports to identify no less than seventy-seven distinct “facts” about schizophrenia, yet its authors cannot mention a
single universal biological abnormality, let alone specify a single necessary or sufficient cause (Tandon et al., 2008). The authors
nonetheless conclude their article by emphasizing the importance of calling schizophrenia a disease.
At the level of the day-to-day management of very disturbed persons, the discovery of neuroleptics marked a change: the
management began to operate from inside patients’ bodies even if their keepers and clinicians were physically distant. Centuries
ago, controlling the madman meant restraining his body at close proximity, for inside the madman resided a wild beast thought to
require restraints and beatings. Later, with electroshock and insulin coma, the “treatments” were directed more specifically toward
the brain, but their administration still required close contact between the inmate and the clinician/keeper, a contact that even elicited
psychodynamic interpretations of why inmates were terrorized to receive shocks (Dunham & Weinberg, 1960, pp. 181–182). Giving
a pill to swallow makes control more efficient because it involves still less contact: hundreds of patients could be treated daily in a
single institution. Finally, with the development of long-acting injectable neuroleptics by the late 1960s, a single intramuscular
injection every four to six weeks sufficed to maintain the patient under the medication’s effect. Between injections, no need to see
the patient, to talk with him, to know what he did—he was, after all, deinstitutionalized and others were taking care of his “social
integration into the community.” Taking in these linear developments, one of us speculated fifteen years ago that the administration
of antipsychotic drugs would take a logical next step: subcutaneous implants allowing continuous, unmonitored drug administration
for months or years (Cohen, 1996). It should come as no surprise that this option has been studied seriously (Irani et al., 2004;
Metzger et al., 2007).
 The Other Opium of the Masses
Tranquilizers and sedatives such as the barbiturates and chloral hydrate were widely used prior to the neuroleptics (Lopez-Munoz et
al., 2005). Starting in the mid-1950s, two other classes of psychoactive drugs were named: the antidepressants—originally, some
anti-tuberculosis medications but mostly modifications of neuroleptics—and the “minor tranquilizers” or “anxiolytics,” originally
identified because of their muscle-relaxing properties.
The first modern anxiolytic was meprobamate, introduced in 1955 into clinical practice under the brand names Miltown and
Equanil. Within five years, it was the most widely used prescription drug in the United States and many other countries. Then came
chlordiazepoxide (Librium) in 1960, and diazepam (Valium) in 1963 (Ban, 2006). These two drugs and their cousins, known as
benzodiazepines, became hugely popular in primary care medicine, and their prescription increased 100 percent in most Western
countries between 1965 to 1970, compared to about 20 percent for other classes of psychotropics (Lader, 1978). The drug industry’s
promotional efforts, extending a variety of techniques of mass marketing to doctors, has been proposed to explain much of this
success (Smith, 1981). Valium appeared in more medical advertisements than any other drug and—cause and effect relation
according to some (Krupka & Vener, 1985)—climbed to the rank of number one prescribed drug in the world by 1970.
Observing this phenomenon, sociologists began to produce accounts of the social control function of a growing “medical-
industrial complex.” They proposed hypotheses that have remained fruitful: tranquilizers medicalize the daily hassles of modern life
(especially for women), pacify those people with legitimate grounds for making social and political claims, and distract
professionals from discerning any social determinants of psychological distress (Koumjian, 1981). Crowning the 1970s as the “era
of benzodiazepines,” British psychiatrist Malcolm Lader (1978) designated these drugs as “opium of the masses.”
As with other tranquilizers in previous decades, however, a consensus emerged within the medical profession in the 1980s that
benzodiazepines carried a risk of dependence with prolonged use (including a withdrawal syndrome when stopped abruptly). These
concerns about unwanted effects of benzodiazepines stabilized, then decreased their use in most Western countries, as health
authorities enacted various measures (such as triplicate prescriptions, with copies sent to state justice agencies to monitor
“unorthodox” scripts) to dissuade doctors from prescribing them. Recently, a spike in prescriptions of Valium was observed in Great
Britain, but a comment from Professor Steve Field, chairman of Britain’s Royal College of General Practitioners, nicely illustrated
the change in attitudes since Valium was number one: “In my own practice we have reduced dramatically the amount of prescribing
we do of these kinds of drugs, because they are horrifically addictive, and people can get hooked on them within just a few days”
(cited in Donnelly, 2010, para. 8). Similarly, in Louisville, Kentucky, Seven Counties Clinic decided to stop writing all prescriptions
for its three thousand patients on Xanax (alprazolam), and some of these patients have been switched to clonazepam (Klonopin),
described as “a longer acting benzodiazepine that does not kick in as quickly and is thought to pose less risk of addiction.” One
doctor stated that on clonazepam, “They don’t get the high that’s associated with Xanax, nor the withdrawal associated with it”
(Goodnough, 2011).5 The benzodiazepines too followed the path of stigmatization, or the Seige cycle.
The rise of a medical and social debate about tranquilizers and sleeping pills did not mean that doctors abandoned these drugs.
Probably because of their quick onset of relaxing effects, benzodiazepines have remained a staple for people in acute distress
(especially over losses of spouses, relatives, jobs, and status) who want rapid tranquilization or sleep but not stupor. The drugs
provide more than respectable revenues to their manufacturers and are also actively traded on the black market. Importantly, about
one quarter of older persons who were introduced to benzodiazepines a generation ago still use them regularly, and fully 40 percent
of these users view themselves as “dependent” (Voyer et al., 2010). They generally have no difficulty obtaining benzodiazepines
from doctors, who are in effect maintaining these users’ dependence. Alprazolam (Xanax), considered one of the most addictive
benzodiazepines, vigorously traded in the illicit drug trade, and the subject of extremely little advertising to doctors today, was the
sole psychoactive drug appearing among the top fifteen most frequently dispensed (i.e., sold or delivered by pharmacies)
prescription drugs in the United States in 2008 (41.5 million prescriptions, up from 33.5 million in 2004; IMS National Prescription
Audit, 2010).6
Starting in the late 1980s, the backlash against benzodiazepines prompted industry-influenced “key opinion leaders” to
encourage general practitioners to alter their prescription of a psychotropic drug (usually to a woman in distress), away from
benzodiazepines and toward the new SSRI antidepressants exemplified by Prozac. Precisely as occurred previously and would occur
again, the new disorder of concern—depression—was presented as widespread and damaging, and the new class of drugs promoted
as effective and harmless—and without the bothersome effects (dependence) that were stigmatizing the existing drugs. Perhaps
something else a bit more encompassing did happen, as Pieters and Snelders (2009) aptly summarized: “The age of anxiety and
blaming society gave way to the age of depression and blaming your own brain” (p. 71). But the new fashion probably would not
have occurred without at least two other overlapping events: the arrival in 1980 of the third edition of the Diagnostic and Statistical
Manual of Mental Disorders of the American Psychiatric Association, and an ever-deepening involvement of the pharmaceutical
industry in every facet of psychiatric thinking, research, and practice.
 The Waltz of Drugs and Diagnoses
By the 1970s psychiatrists were prescribing about fifty different psychoactive drugs to their patients but could not claim that they
had any validated diagnoses. As has been discussed previously in this book, there is still no clinical, radiological, electrical, or other
physical test or exam that can reveal, during life or after death, reliable markers in the body of a purported condition called a mental
disorder—except of course for drug intoxications and organic psychoses still inexplicably called “mental disorders” in the DSM.
Thus, how was psychiatry to ensure that diagnoses did not remain merely subjective judgments about distressing thoughts or
behaviors, robbing the profession of its medical aspirations?
As we have seen in chapter 4, the DSM-III listed criteria for each diagnosis, defined each mental disorder as distinct from others,
and added eighty new diagnoses to the previous edition of the DSM. The new manual was adopted fairly quickly by other
professions sharing the treatment turf. This was a truly significant event because psychology, social work, and counseling had
evolved precisely by adopting nonmedical perspectives on deviance and distress. Their embrace of the DSM-III began to perfect a
theoretical, financial, and bureaucratic integration of the mental health industry, with psychiatry at the top (Kutchins & Kirk, 1988).
More relevant for our discussion of psychoactive drug use, by modifying its diagnostic manual, psychiatry and its institutions of
leadership, research, and treatment strengthened their already close association with the pharmaceutical industry into a full-fledged
partnership. The whole question of classification and diagnosis did not concern clinicians when conversation (psychotherapy) was
the prototypical treatment. With the arrival of new drugs and the regulatory requirement that drugs must be effective to treat a
“disease,” clinicians were directed to classify presenting problems as specific diagnoses, so that their prescribing would resemble
prescribing in other branches of medicine (Eisenberg, 1995; Klerman, 1978).
Drug treatment fit beautifully with the DSM-III, which presented on the surface a descriptive, symptom-based approach to
diagnosis. Mental illnesses became mental “disorders,” defined as “not culturally sanctioned” distressing or impairing “symptoms”
that resulted from undefined physical, behavioral, or psychological dysfunctions (though the dysfunctions could not be ascertained
independently of the symptoms). These symptoms constituted the criteria to make a diagnosis. In turn, the criteria were—in a
perfect lateral move—used to compose the items in rating scales that would help to evaluate patients’ states in clinical drug trials.
Each mental disorder named in the DSM-III was automatically assumed to be a clinical entity, the pathophysiology of which was
unknown but assumed to be elucidated with future research.
The technological advances we briefly described earlier, which allowed researchers to trace drug molecules until they reached
cell membrane receptors, stimulated the development of speculative animal models and of molecules synthesized to bind more
tightly to receptors. As psychiatrist Edouard Zarifian remarked, pharmacologists and neurobiologists “formulate hypotheses on the
causes of a disorder and, once they have invented a molecule, explain to the doctor the effects that they are expected to observe”
(1994, p. 88).
Thus, during most of the century no one seemed to complain of “panic attacks” and doctors could not name this problem when
they saw it, nor did they easily assimilate it within the realm of anxiety. But two drugs (imipramine, an old tricyclic antidepressant
and alprazolam [Xanax], a new benzodiazepine anxiolytic) began to be promoted as specific treatments for DSM-III’s new panic
disorder in the early 1980s. According to Kramer (1993), psychiatrists had to re-create anxiety in theoretical terms. Several authors
have described the symbiosis between drug makers and the diagnosis: the Upjohn drug company apparently funded the entire effort,
culminating the creation of the diagnosis of Panic Disorder in DSM-III with the sole intention of obtaining approval to market
Xanax as specific treatment for . . . panic disorder (Elliott, 2003; Lane, 2007). Almost instantly, panic disorder acquired an
incontestable “reality.” This made psychologist David Jacobs (1995) observe how remarkable it was that problems without distinct
boundaries, created with the pragmatic aim of drug treatment, came to be promoted as if medicine possessed discriminating data on
their pathophysiology.
In the background, psychiatric epidemiology was reporting an increase in the prevalence of mental disorder, notably depression.
In 1984, using DSM-III criteria, the vast Epidemiological Catchment Area Survey of the National Institute of Mental Health
estimated the prevalence of depression during a person’s life to be 6 percent, the highest rate ever reported (Robins & Regier, 1991).
Ten years later, another national survey using DSM-III-R criteria reported the rate as 17 percent, and for all mental disorders, 48
percent (Kessler et al., 1994).
At the level of populations, psychological distress waxes and wanes and is affected by political and economic instability (Cross-
National Collaborative Group, 1992). Nonetheless, this new increase seemed inflationary, reflecting medicalization and the
promotion of antidepressant drugs. According to business journalist James Krohe (1994), who wrote in the midst of the Prozac
craze, “Depression is the latest product—and the most promising—of the wellness industry” (p. 24). In the workplace, concern
about depression began to replace concerns about alcohol and substance abuse, creating new possibilities for counselors and
administrators. Krohe described a web of phone hotlines, support groups, conferences and seminars for health administrators, free
anonymous screening programs, infomercials, and public interest TV shows launched “to catch the two out of three depressed
Americans who are not seeking treatment—almost 7.5 millions people who, in their misery, persist in confusing treatable depression
with life” (p. 24). The National Depression Screening Day was inaugurated in 1991 on a college campus, subsidized by the maker of
Prozac. By 1995, “In each of the 50 states and the District of Columbia, people can be tested for free to see if they are depressed or
are at risk of so becoming” (Screening the Public, 1995, p. A42).
Its territory greatly enlarged, mental disorder became banal. Abnormality became, well, normal. Validly distinguishing whether
someone truly had a mental disorder became somewhat irrelevant, given that half the population of the United States was designated
as diagnosable with a chronic, recurrent, unpredictable mental disorder. Indeed, how could one even distinguish disorder from
nondisorder if the former was characterized by impossible-to-detect variations of neurotransmitter circuits? Pieters and Snelders
(2009) have also alluded to what they call this “democratization of mental disorders.” They recall that a drug company once
advertised depression as “the most democratic of all disorders. It can affect everyone at any moment, for shorter or longer duration,
without a recognizable course” (p. 71).
Two decades earlier, self-styled antipsychiatrists were claiming that everyone was sane, or everyone was insane. Their goal had been
to abolish boundaries between sanity and madness, pushing society toward their ideal of equality. In some fashion, that goal was
realized with the arrival of the SSRI antidepressants of the late 1980s and the widespread popular acceptance that despair, deviance,
and distress were actually symptoms of medically treatable mental disorders. The drugs and the DSM seemed to have energized a
new societal project of moral leveling, in which everyone is equal because everyone is diagnosable and treatable. Society and
government could not be changed, but neurochemistry certainly could (Greenberg, 2010).
 Does Cure Prove Anything?
By focusing on the many symptoms of disorders finely chopped by the DSM and by invoking variations in neurotransmitter
functioning that were becoming more easily imaged and presumably targeted by drugs, psychiatry could cease pursuing an elusive
goal required for unquestioned membership in the realm of scientific medicine: to validate traditional diagnostic entities according
to cellular models of disease. The new psychiatric diagnoses and their symptoms multiplied the possibilities to observe, in any
behavior the least bit disturbing to a person or their network, a symptom calling for drug treatment. Mere descriptions of the habitual
neuronal effects of drugs were recast as demonstrations that symptoms hid specific neurochemical imbalances. The way was open to
validate a diagnosis by medicating a complaint.
American journalist James Wright (1994) illustrated the sway of this logic when he indicated that American policymakers who
wished to provide equal insurance coverage for mental health as for physical health claimed that “the simple fact that pharmacology
gives results is proof that mental illness are bona fide illnesses.” Wright asked approvingly: “But if a successful chemical treatment
constitutes the distinctive sign of an illness, why are not all conditions treated by means of cosmetic psychopharmacology
considered as illnesses? And why shouldn’t they be?” (p. 25). Scientific demonstration of the existence of disease had been turned
on its head, replaced with circular definitions. What is an illness? Whatever a medication treats “successfully.”
The necessity of a medication was indicated by its positive results. In turn, these were demonstrated by the medication’s
widespread use, especially by an increasing chorus of users’ appreciative testimonies. Consumers wanted and were incited by
marketing to ask for antidepressants, drugs only available from physicians. As a result, scientific constraints on psychiatrists were
loosened. They were again freed from justifying why one scientific/clinical model is worthier than another. Comforted by their
patients’ narratives of relief, improvement, or recovery, psychiatrists could view the whole point of their enterprise as prescribing
drugs in response to patients’ complaints. Predictably, such use of drugs bred dependence on drugs, and an avalanche of well-
publicized clinical trials demonstrating contrived improvements for other complaints isolated remaining skeptics. Other
interventions besides prescription grew more unfamiliar, and trying them would trigger uncomfortable discussions about the point of
looking at distress as medical pathology.
If consumerism does indeed drive prescription, if patients receive just what they ask for, how then can we distinguish
psychopharmacology from quackery? For philosopher of science Isabelle Stengers (1995), modern medicine is defined by the
awareness of a single fact, itself stemming from the scientific repudiation of Anton Mesmer’s “magnetic treatment” at the end of the
eighteenth century. The fact is this: “Cure proves nothing” (p. 121, italics in original). Then, as now, reports by people that they felt
better or cured as a result of exposure to some intervention (then, magnets, trees, or objects “magnetized” by Mesmer; today,
psychoactive drugs consecrated by clinical trials and FDA approval) cannot constitute proof that the people suffered from genuine
diseases or that magnets or drugs are genuine treatments. Stengers adds a corollary to her fact: “The aim pursued by medicine (cure)
does not suffice to distinguish between rational practice and quackery” (p. 121). In other words, the physician’s intention to cure the
patient also cannot distinguish medical practice from that of the charlatan who merely seeks profit or aggrandizement. Yet, in
psychiatry, as exemplified by the success of Peter Kramer’s Listening to Prozac, it was precisely the personal testimony of symptom
relief, the narrative of transformed personality—in sum, the tale of the “cure”—that was put forth as the irrefutable proof of the
validity of psychopharmacology.
 What Psychoactive Drugs Seem to Do
The long history of drugs and medications amply demonstrates the richness of their effects on users as well as on the experts and
authorities charged with regulating drugs. No discovery in neurobiology is necessary to grasp that psychoactive drugs have powerful
effects that people might find desirable or undesirable or both. With a high enough dose, a psychoactive drug will affect virtually all
people who take it. Yet its effects can vary slightly or greatly between individuals and are often unpredictable in any one person or
even in the same person at different times. Depending on a person’s state of distress, for example, a drug effect might be
experienced positively, and the person might decide that the drug is beneficial to him or her. Is there any reason to think that this
person is reacting in a way that indicates underlying pathophysiology? We believe not.
We have argued so far that a great deal of the measurable success of a prescribed psychotropic medication appears to rest on a
placebo effect—admittedly an inadequate concept insofar as it refers to something that can include suggestion from oneself,
suggestion from other people and institutions, spontaneous remission of one’s troubles, as well as active self-improvement through
deliberate and unknown methods triggered by the mere fact of having ingested what one believes to constitute a genuine treatment.
But, in a complementary though not similar line of thought, we have also argued that another ingredient seems necessary for the
success of a psychoactive drug, and that is, of course, a psychoactive effect. We have argued that psychoactive effects of prescribed
drugs are ubiquitous, but that clinical trials and conventional psychiatric investigations have rarely if ever focused on the nature of
such psychoactive effects, and especially how psychoactive effects as reported by users are related to the occasional evaluations of
therapeutic benefits reported by users or inferred by clinicians. Thus we conclude that very much remains to be discovered about the
nature of the varied psychoactive effects produced by the panoply of psychiatric medications on the market today. We venture what
we consider to be reasonable observations, but their limitations will be immediately apparent.
In the case of nonconsenting or disturbing individuals (for example, children, psychotics, and the demented elderly in nursing
homes), the aim of drugging is simply the control of outward behavior that bothers or offends other people or hampers the smooth
functioning of institutions. In these cases, the finality of the prescription is to please these other people, and the favored
psychoactive and behavioral effects for the conditions displayed by such individuals therefore usually consist of some form of
compliance, reduced spontaneity, on-task-performance (stimulants), sedation or drowsiness, or indifference (neuroleptics). How the
drug users themselves might appreciate the drug is of secondary concern, if at all.
The aim of drugging obviously differs in the case of consenting, consumerist adults, but here the situation gets increasingly
murky and difficult to understand. The SSRIs, exemplars of the modern consumerist medications, may have succeeded partly
because in the social, cultural, and economic context since their FDA approval, their most marketed psychoactive effects seemed to
consist of a mild arousal believed to enhance the competitive capacities of citizens in the West, “exhausted by work, scared by
unemployment, anxious about the future, [and] spellbound by the media” (Ramonet, 1995, p. 13). But with hindsight, the picture
must be much more complex, as the SSRIs appear to produce sedation as much as they produce activation and arousal, and the latter
are not seen by users as improving but rather as impairing function. And what to make of another important psychophysiological
effect of SSRIs, the suppression of libido or sexual desire (the prevalence of which might suggest classifying the SSRIs primarily as
sex-drive reducers)? It is tempting to speculate how such an effect might have dovetailed with many adults’ anxiety-laden
experiences of sexuality in the age of AIDS and on-demand online pornography.
But neither placebo nor psychoactive effects can fully account for how Valium, Prozac, and Zyprexa became blockbuster drugs
that dramatically altered or reinforced professional practices, popular perceptions, and pharmaceutical profits. Another ingredient
has been necessary, especially in the age of science. We have referred to it repeatedly throughout this book, and we turn presently to
examine it in more detail, paying special attention to its intertwining with research in psychiatry. This ingredient is the marketing of
drugs by the pharmaceutical industry. The topic has been covered admirably in scholarly, insider, and journalistic accounts over the
past decade (e.g., Critser, 2005; Elliott, 2010; Healy, 2012; Moynihan & Cassels, 2005; Petersen, 2008), and we have little original
analysis to add to these, except to reinforce the notion that it is today no longer possible to discern where psychiatry and psychiatric
science begin and where drug industry marketing ends.
 Paradisio Promotion
Since the passage in 1951 of the Humphrey-Durham amendment to the Pure Food, Drug, and Cosmetic Act of 1938, getting certain
psychoactive drugs inside people’s bodies has required a physician’s prescription (Abood, 2011). Accounts of pharmaceutical
marketing agree on one thing: the pharmaceutical industry has magnificently honed its ability to make physicians “decide” to
prescribe its products. Given the time, effort, and money spent by the industry to promote drugs, this should surprise no one.
As noted earlier, Canadian accountant Marc-André Gagnon and emergency physician Joel Lexchin (2008) analyzed several
databases and proprietary expenditure reports to generate a startling estimate of the US pharmaceutical industry’s total spending to
push pills in 2004: $57.5 billion. This gargantuan amount is in addition to the $31.5 billion that the industry said it spent that year on
clinical trials and tests for its products. With total sales of pharmaceuticals in the US that year totaling $235.4 billion, promotional
spending therefore made up 24.4 percent of sales (nearly double the spending on research and development). In 2011, sales of
antipsychotics, antidepressants, stimulants, and anticonvulsants in the United States were reported to total $43.0 billion (IMS
Health, 2011). Using 24.4 percent of sales for promotional spending as our yardstick gives the sum of nearly $10.5 billion spent by
the industry to promote only these four classes of drugs in America. Using Gagnon and Lexchin’s breakdown of the categories and
proportions of marketing expenses for all pharmaceutical products, table 7-1 gives one idea how the $10.5 billion might have been
spent to promote antipsychotics, antidepressants, stimulants, and anticonvulsants.

Table 7-1
Estimate of Promotional Spending on Four Classes of Prescribed Psychotropic Drugs, USA, 2011

Type of promotion Spending (in $ billions) % of total spending

Detailing by sales representatives 3.73 35.5
Drug samples 2.9 27.7
Unmonitored promotion 2.6 25.0
Direct-to-consumer advertising .73 7.0
Continuing medical education .37 3.5
Journal advertising .11 ∼1.0
E-promotion, mailings .05 ∼0.5

The billions of dollars spent each year obviously show how industry marketing can operate on a gigantic scale. The marketing of
no other treatment or intervention comes close to drugs in terms of the support that these products enjoy and in terms of the creative
energies continually invested to make everyone view them as indispensable. The success of the enterprise hereby appears not as
natural or self-evidently justifiable. Rather, it appears to require these billions of dollars to ensure that, first, prescribers cooperate,
and second, the public asks for or is willing to accept drugs, to keep the American psychiatric drug enterprise moving along
smoothly each year. But the figures suggest that at least (and probably much more than) three-quarters of all promotional spending
targets physicians or health care professionals. One might conclude that it has been relatively easy to turn the public into a willing
participant, a willing believer.
 How Industry Marketing Shapes Everything
The monies spent on drug marketing operate in myriad ways. One way is via free or subsidized continuing education courses
offered to physicians by key opinion leaders. Communication companies earned over $1 billion in 2004 to deliver industry-
sponsored continuing medical education. Industry-sponsored courses find subtle but effective ways to highlight sponsors’ drugs and
are associated with increased prescriptions of those drugs (Elliott, 2004; Wazana, 2000). The US Senate expressed concern over
drug firms’ influence on continuing medical education and its impact on off-label drug prescriptions. The Committee on Finance
(2007) of the US Senate describes how pharmaceutical firms have “too much influence” over the content of “supposedly
independent educational programs.” At least one quarter of all accredited CME providers fail to ensure independence of content.
The courses are described as forms of “veiled advertising.”
Pharmaceutical companies’ money is used for lobbying at all levels of government and making donations to political parties and
to senators’ and congressmen’s re-election campaigns. The money influences legislators and government agencies to approve drugs
and create favorable conditions for the industry (such as deducting opportunity costs to develop drugs that fail to gain approval). In
addition, the drug industry agreed with the provisions of the Prescription Drug User Fee Act, which requires drug manufacturers to
pay substantial user fees to the FDA’s Center for Drug Evaluation and Research to finance the process of government approval of
the manufacturers’ drugs, in return for speedier approval times. In 2011, users fees were expected to add up to $707 million, fully 65
percent of the budget of the FDA department responsible for evaluating the efficacy and safety of prescription drugs and about 25
percent of the total FDA budget (Dutton, 2011). It is easy to understand how such fees, presented as natural payments for services
rendered, make the FDA a stakeholder in the commercial success of the pharmaceutical industry.
Looking at lists of the recipients of funds from some drug companies’ charitable foundations (which some states have been
requiring be disclosed and federal legislation has mandated as of 2011), one gets a sense of the intimate penetration of drug
company money into the widest-ranging activities and to countless groups, organizations, and individuals (Cohen, 2008). These
funds paid for scholarships; fellowships and research awards for medical students, young researchers, and established senior
researchers; consulting and teaching opportunities for clinicians; endowed chairs for professors in academia; large research project
and other centers within academia and university-affiliated hospitals; mental disorder screening initiatives and events in universities,
workplaces, and communities; continuing education courses for health care professionals on “diseases” in the public eye for which
particular drugs are now being advertised; professional and consumer magazines and newsletters; diagnostic task force committee
members; grand rounds in hospital departments; breakfasts and lunches in medical schools, clinics, and hospitals; encyclopedias,
books, prescription guides, and subscriptions to journals; funds (and sometimes lent personnel) for operation, research, and
promotion of small, medium, and large nonprofit interest and advocacy groups that can be counted on to propagate a pro-drug
message to their constituencies. In this connection, for example, the National Alliance for Mental Illness, widely considered the
nation’s leading family and patient advocacy organization and therefore obligatorily represented in any mainstream policy forum,
received no less than 81 percent of its 2009 funding from drug firms, becoming, for all practical purposes, more of an advocate for
drug companies rather than for families of patients (NAMI’s Pharma Funders, 2010).
Table 1 shows that visits to doctors by drug reps constitutes the key marketing vehicle in the drug industry. The amount devoted
to drug reps is consistent with estimates of their number in the United States, with about 85,000–100,000, or one rep for every six to
ten doctors (Oldani, 2004; Greene, 2004; Fugh-Berman & Ahari, 2007). A Time Magazine guest column entitled “Attack of the
Pharma Babes” emphasized the personal attractiveness and seductiveness of many drug reps (Haig, 2007). In a first-rate account of
the tactics drug reps use with physicians and of the psychology of gift-giving in these relationships, physician and ethicist Carl
Elliott (2006) writes:

When an encounter between a doctor and a rep goes well, it is a delicate ritual of pretense and self-deception. Drug reps
pretend that they are giving doctors impartial information. Doctors pretend that they take it seriously. Drug reps must try
their best to influence doctors, while doctors must tell themselves that they are not being influenced. Drug reps must act as
if they are not salespeople, while doctors must act as if they are not customers. And if, by accident, the real purpose of the
exchange is revealed, the result is like an elaborate theatrical dance in which the masks and costumes suddenly drop off and
the actors come face to face with one another as they really are. Nobody wants to see that happen.

Drug marketing via individual detailing influences physicians to prescribe drugs essentially by offering them gifts, such as free
drug samples. The importance of drug samples, again indicated by the amount of money that drug companies spent on them, lies in
the simple fact that the sample introduces a drug into a doctor’s office for the first time. This will influences both patients’ and
doctors’ brand choices, and later generate sales. The return on this investment can be substantial, with studies suggesting that up to
$10 in sales can result for every $1 spent on samples (Chew et al. 2000; Adair & Holmgren, 2005; Backer et al. 2000). Contrary to
common sense, small and relatively inexpensive gifts (such as pens, pads, and meals) may be a powerful form of influence: in some
studies, the more small gifts a doctor received, the more the doctor believed that they had no influence on his prescribing (Reist &
VandeCreek, 2004; Dana & Loewenstein, 2003; Oldani, 2004). These studies suggest that the small gift, precisely because it is
inexpensive and therefore easy to accept, has enormous strategic significance. It simultaneously confirms (for the rep) and masks
(for the doctor) the realization that the doctor can be bought.
Direct-to-consumer advertising (DTCA)—which took off in the United States in 1997 when the FDA dropped its requirement
that any advertisement for a prescription drug must contain the complete list of adverse reactions—would be likely to increase
psychiatric drug use via three main mechanisms: it encourages people to visit doctors for ailments portrayed; it encourages patients
to request drugs advertised; and it influences doctors’ behavior through patient requests. There is evidence that physicians “are
frequently unaware of and denied the degree to which their thinking was biased by patient requests [for antidepressants]” (Tentler et
al., 2008), alongside evidence from controlled trials that patient requests for an antidepressant—either brand-specific or in general
—“have a profound effect on physician prescribing in major depression and adjustment disorder” (Kravitz et al., 2005, p. 1995).
The argument has been made that the most heavily advertised drugs are the newest drugs, by definition, those about which least is
known, and also by definition the costliest drugs, thus increasing spending by stimulating their sales (Donohue & Bernd, 2004;
Gellad & Lyles, 2007).
The accuracy of DTC ads has regularly been questioned by the FDA, whose mandate includes reviewing ads for accuracy of
content. Only people who believe that ads are an easily accessible form of information and education might be surprised that they
are frequently misleading. From 1995 to 2004, the FDA sent 1,359 warning letters to drug companies for what it deemed false or
misleading advertising. Throughout the early 2000s, four FDA staffers reviewed thousands of ads (Zalesky, 2006). Between 2001
and 2005, the FDA found ads for a hundred and fifty different drugs false or misleading. Misleading messages mostly targeted
doctors; 35 percent of the ads misrepresented the degree of risk from the drug, 22 percent promoted unproven uses, and 38 percent
made unsupported claims. For example, according to the FDA, a 2007 ad for Geodon (atypical antipsychotic) aimed at doctors
neglected to mention the risks of neuroleptic malignant syndrome (a potentially fatal explosive neurological and metabolic attack),
tardive dyskinesia (permanent abnormal movement disorders), hyperglycemia, and diabetes. The ad also exaggerated claims of
efficacy of Geodon over older, unbranded generic antipsychotics (think back to the CATIE study). To what extent the FDA succeeds
in enforcing its requests for drug companies’ conformity to the law remains completely unclear, as, despite some massive financial
penalties imposed on various manufacturers for not divulging safety data, for misbranding drugs, and for illegal marketing, the same
companies are observed to be in violation year after year.7
Pharmaceutical companies or their subcontractors enlist academics to form expert panels to construct guidelines and algorithms
that assert or argue that newer, more expensive drugs (SSRIs and atypical antipsychotics) are more effective and must become first-
line treatments in the absence of definitive data or the presence of contradictory data (Healy, 2006a). In some states, such algorithms
are promoted by means of covert, illicit cash payments to state officials responsible to make the drugs eligible for government
funding (Moynihan, 2004). In other cases, generous payments—licit and later disclosed—are made to members of state advisory
panels that help select the billions worth of drugs that Medicaid programs will reimburse for the poor and disabled (CBS News,
2007). In his later analyses, Healy (2012) has made the more encompassing and worrying argument that industry-paid academic
panels as well as independent government-funded councils always appear to agree to recommend the industry’s latest drugs for
whatever ailment is being considered, for the simple reason that the “evidence” (the studies and clinical trials) these different
sources review is, in large measure, industry-generated.
On the one hand, the drug industry’s marketing efforts and its massive infusions of money to support psychiatric activities, and
on the other hand psychiatry’s enthusiastic acceptance of the partnership, have completely subsumed psychiatry as a satellite branch
of the multinational pharmaceutical industry. Undoubtedly, several branches of medicine are “on the take” (Kassirer, 2005), with
many of their practitioners, researchers, and professional associations awash in (mostly undisclosed) conflicts of interests that
destroy the credibility of their pronouncements and the trustworthiness of their conduct (Committee on Finance, 2011). Yet, as we
have indicated throughout this chapter, psychiatry may be unique in the extent to which intellectual and practical innovations and
fashions in that field center around the industry’s introduction of new drugs, the “discovery” and marketing of new uses for recently
introduced drugs, and the expansion of DSM disorder categories both to accommodate and to stimulate the popularity of new drugs.
Some partial data from Minnesota appear to illustrate the special impact on psychiatry of the industry’s funds. In that state between
1997 and 2005, not only did psychiatrists as a group receive more money from drug companies than any other types of physicians
(Harris, 2007; Ross et al., 2007), but within the group of psychiatrists, those who received more than $5,000 wrote on average four
times more prescriptions of atypical antipsychotics off-label to children than those receiving less than that amount (Harris, Carey,
and Roberts, 2007).
 The Paralysis of Science
The virtually complete blurring of marketing and science has paralyzed science—or what has passed as science. Conflicts of interest
permeate the FDA and its advisory committees, scientific journals, and the scientific literature. Telling an infomercial from a
scientific article requires analysis of primary (usually proprietary) sources (Jureidini, McHenry, & Mansfield, 2008), most of which
are only revealed accidentally, during legal proceedings, for example (Steinman, Bero, Chren, & Landfeld, 2006). Commenting only
on ghostwriting—the practice of paying academics to lend their names to publications without having seen or collected the data
reported (Lacasse & Leo, 2010)—the PLoS Medicine editors (2009) lamented that marketing campaigns now

center on “evidence” provided by seemingly respectable academic review articles, original research articles, and even
reports of clinical trials. What, a cynical reader might ask, can I truly trust as being unbiased? The answer is that, sadly, for
some or even many journal articles, we just don’t know. (p. 1)

More recently, however, Healy (2012) has provided some extremely sobering estimates, with supporting sources, to answer the
PLoS Medicine editors’ question: “We also now know that close to 30 percent of the clinical trials that have been undertaken remain
unreported, and that of the 50 percent that are reported almost all will be ghostwritten and roughly 25 percent of the published trials
altered to the extent that a negative result for a drug will have been transformed into evidence the drug works well and is safe. In
100 percent of cases, the data from trials remain inaccessible to scrutiny” (pp. 252–253).
When the editor of the New England Journal of Medicine sought a research psychiatrist with no ties to the drug industry to
evaluate an SSRI trial, she could find none (Angell, 2000). When the American Journal of Psychiatry published a pediatric trial of
citalopram (Celexa) that reported positive results, neither the authors nor the editors disclosed (or knew) that a previous unpublished
pediatric trial funded by the same sponsor had observed opposite results (Meier, 2004). When an article in JAMA warned pregnant
women not to stop taking antidepressants because of the risk of re-experiencing depression, most of the thirteen authors did not
disclose their financial ties to makers of antidepressants (DeAngelis, 2006). Medical journals appear to struggle to manage
disclosure but not necessarily with great success, as virtually no negative consequences are imposed, or even threatened, on
violators (Lacasse & Leo, 2010). Occasionally, the editors of prominent journals shoot themselves in the foot in full view of their
readership and constituencies, asserting that they fully control the problem while simultaneously failing to screen obvious violations
and then awkwardly managing the consequences (Leo, 2009).
It has now become well established that the funding source of a drug’s clinical trial is associated with the trial’s formal
conclusion that the drug should be used. Als-Nielsen and colleagues (2003) showed that in RCTs in eight medical disciplines,
regardless of the magnitude of the drug’s effect relative to placebo or the presence of adverse effects, trials funded by for-profit
organizations were 5.3 times more likely to recommend the drug than trials funded by not-for-profit organizations. In the case of
antipsychotics, researcher Stephan Heres and colleagues (2006) examined the outcomes of thirty head-to-head comparisons of
different atypical antipsychotics and looked for relationships with sponsorship. In twenty-seven comparisons (90 percent), the
outcome favored the sponsor’s drug. This pattern “resulted in contradictory conclusions across studies when the findings of studies
of the same drugs but with different sponsors were compared” (p. 185). In other words, when Eli Lilly funded a study comparing its
Zyprexa with Janssen’s Risperdal, Zyprexa came out ahead. When Janssen funded the exact same comparison, Risperdal came out
ahead.
In light of their own observation of “biased interpretation of trial results,” Als-Nielsen et al. warned readers to “carefully
evaluate whether conclusions in randomized trials are supported by data” (2003, p. 921). Indeed, when Australian child psychiatrist
Jon Jureidini and colleagues (2004) published their groundbreaking review of pediatric SSRI trials that concluded that benefits had
been exaggerated while risks downplayed, they had (not yet) found a smoking gun (Leo, 2006). They had simply underlined
misleading conclusions in the original publications, such as their authors’ pronouncing a 10 percent drug-placebo difference as
“clinically significant” and downplaying strikingly high rates of serious adverse effects in drug-treated children relative to placebo.
But what if the study’s data are not published, or a report of the study is published with different data than were actually collected?
Psychiatric researcher Erik Turner and colleagues (2008) retrieved seventy-four FDA-registered antidepressant trials of several
antidepressants and compared their data to what had appeared in refereed journal publications. They found that thirty-six of thirty-
seven trials with positive results had been published, compared to three of twenty-two with negative results. For eleven other trials
with negative or questionable results in the FDA database, their journal publications spun the results positively. Overall, 94 percent
of published trials showed drugs as superior to placebo, whereas only 51 percent of the full dataset of seventy-four trials showed
such positive results. The problem here is simply that the published trial reports are much more easily available and distributed with
the approval and review of peer reviewers and prestigious scientific journals and therefore are customarily taken as the record of the
trial, the scientific literature. (Most readers might not know that an FDA record exists and is usually available to them from the FDA
website, though it might need to be searched for within a voluminous FDA review of a particular drug.)
The authors of the two major reviews of psychiatric trials we have discussed, Turner and colleagues (2008) and Heres and
colleagues (2006), make some seemingly obligatory hedging statements in their articles, wanting to appear to be completely fair by
considering all possibilities, or perhaps having acquiesced to an editor or reviewer’s request. Turner et al. (2008) state that selective
publication of data and trials misleads all those who rely on the scientific literature, but they state that they cannot establish for
certain just why negative trials of antidepressants are not published. Similarly, Heres et al. (2006) identify a dozen possible sources
of bias in the head-to-head comparisons of antipsychotics but cannot state which might end up favoring the sponsors’ drugs and
“limit the validity” of such comparisons. It is, of course, entirely appropriate and even desirable for scientists to be cautious in
drawing conclusions. Perhaps they are personally unsure about which conclusions should be reached. They may entertain doubts
about the purposes of the drug industry and the extent to which the industry might plot to alter outcomes of studies to favor its
products. But in this case, researchers’ and editors’ and conscientious practitioners’ willingness to hedge, to consider every possible
interpretation, to step back from what is the most probable reality, leaves only one player in this drama that has no doubt, no
hesitancy, no incentive to pursue the truth, and no ambivalence about its goals and the behavior of other players—and that is the
drug industry.
In our view, what has occurred and what is occurring is the systematic manipulation of the scientific process to reach
predetermined conclusions, which means, the paralysis of science as an unbiased enterprise to advance knowledge or even as a
pragmatic enterprise to improve the quality of human life. The current trend is toward increased disclosure and transparency in
scientific publications and increased verification (for example, via the constitution of clinical trial registries in which the aims and
protocols of drug trials are announced in advance) of the drug industry’s claims. New rules, however, require broader enforcement,
while existing rules have yet to be enforced consistently. In any case, increased scrutiny often leads violators to search new outlets
to practice their reproachable but enormously profitable behavior. This being the case, increased transparency is bound to trigger, at
least temporarily, even more creative marketing efforts designed to mislead and seduce professionals and the public with the
appearance of science.
 Conclusion
Does the psychiatric drug treatment of emotional distress and misbehavior constitute a genuine improvement over the practices of
the past, or is it merely the recycling of age-old tendencies to palliate distress and control disturbing behavior by psychoactive
sedation or stimulation? Are clinical psychopharmacologists members of a scientifically driven discipline or merely the willing
executors of mad science, the vast, well-orchestrated advertising campaigns by the pharmaceutical industry to increase market
shares of the drug du jour? Our questions purposefully impose a dichotomous template on complex and multilayered issues because
the former positions have been too uncritically promoted and accepted as self-evidently true. Still, if simple answers were to be
given, we think the evidence overwhelmingly supports the latter positions in both of these questions.
As psychoactive drugs continue to be promoted as harmless and essential products for modern citizens, but as the boundaries
between licit and illicit drug use continue to blur, more profound changes may be in the works. For example, the Internet has helped
to democratize to some extent the conversation between doctors, patients, and regulators. Online, laypersons now frequently
disseminate their views and reviews of psychoactive drugs, unfiltered by professionals, and freely offer each other advice on using
this or that drug in this or that way, obtaining it this or that way, or ceasing to take it this or that way. Some consumer-constructed
websites (e.g., askapatient.com) offer thousands of individual patient reviews for hundreds of drugs, including real-time graphs and
charts of efficacy and adverse effect evaluations from large groups of users (e.g., patientslikeme.com). No comparable data has ever
existed before, anywhere.
A first comparison of discourse about two prescribed psychotropic medications (an antidepressant and an antipsychotic)
appearing on consumer-constructed and professionally controlled websites on the Internet found that both types of sources
“generally reported similar effects” of the two medications “but differed in their descriptions and in frequency of reporting.
Professional medication descriptions offer the advantage of a concise yet comprehensive listing of drug effects, while consumer
reviews offer the advantage of greater context and situational examples of how effects may manifest in various combinations and to
varying degrees” (Hughes and Cohen, 2011). No one can tell where the trend regarding consumer contributions is headed, but these
and many other findings we have discussed throughout this book make one thing clear: knowledge about psychiatric drugs is
increasingly being constructed completely outside the usual expert disciplines and will involve possibly as-yet-unknowable players.
Public cynicism concerning the integrity of psychiatric knowledge continues to grow, in parallel with the democratization of
information and the appeal of self-care and self-directed performance enhancement that have always characterized much of the use
of psychotropic drugs throughout history and culture. As a result, psychiatric-professional assertions of unique or specialized
knowledge in psychopharmacology will become increasingly contested, just as they have been in this and the previous chapter.
But there is more. Periodic revelations concerning the profession’s unjustified, scientifically unsophisticated, and crassly bought
enthusiasm over this or that psychoactive drug class, and the sweeping under the carpet of the victims of the enthusiasm may also
threaten drug prescription authority—the key legal prerogative presently resting on the assumption of medical and psychiatric
expertise and accountability. We find it intriguing that two of the best-known psychiatric critics, the late US psychiatrist Thomas
Szasz, and UK psychiatrist David Healy, whose views on the nature of mental illness and the legitimate sphere of state-sponsored
psychiatry differ dramatically, have nonetheless both proposed the abolition of medical prescription privileges (and not merely their
redistribution to clinical psychologists, for example). Do people really need psychiatrists (or anyone else claiming special
knowledge) to give them permission to take the psychoactive drugs they want?
 Notes
1. Although we use these two words interchangeably in this chapter, the careful speaker might wish to distinguish them. We borrow here from Thomas Szasz (2007), who
notes that according to Thomas Ban (2001), the first person to use the word psychotropic was Ralph Waldo Gerard (1900–1974), an American physiologist, in the late
1950s. Under the new moniker, Gerard included only the six then-modern psychiatric drugs: “neuroleptics, i.e., chlorpromazine and reserpine . . . antidepressants, i.e.,
iprionazid . . . and imipramine . . . an anxiolytic, i.e. meprobamate . . . and a mood stabilizer, i.e., lithium carbonate” (Ban, 2001, p. 712). Szasz points out: “All of these
drugs were introduced in a 6-year period, 1949–1957. Note that chlorpromazine heads the list and that not one of these drugs is a substance a healthy person uses, or
would want to use, as a recreational drug” (p. 173–174). Szasz’s point is that psychotropic is a modern semantic confusion designed to bracket modern psychiatric drugs
from other psychoactive substances, that is, to avoid putting all psychoactive drugs—drugs that have a direct effect on mental activity and behavior—on an equal footing
for accurate comparison purposes. Google’s N-gram database shows that the use of both terms between 1960 to 2000 in American English runs parallel, with
psychoactive experiencing a relative decline between 1980 and 1990. Our own impression is that authors who use both terms use them interchangeably. However, we
think authors usually favor psychotropic, especially when discussing prescribed psychoactive drugs.
2. This section is drawn from a number of books and articles written by and with British psychiatrist Joanna Moncrieff (Moncrieff, 2008; Moncrieff & Cohen, 2005, 2006,
2009; Moncrieff, Mason, and Cohen, 2009; Moncrieff, Porter, & Cohen, 2012).
3. Although this is far beyond the scope of this chapter and this book, we note that biochemists and molecular biologists increasingly discuss drugs as acting not merely on
cells’ membrane receptors to change processes inside and around the cell but also—in some as yet not well-understood manner—changing the expression of genes. Gene
expression is the process by which a gene’s encoded information is used to create proteins that shape or dictate the structures and functions of cells. In principle, by
modifying gene expression, the potential effects of drugs on the human body and human functions, short- and long-term, grow exponentially.
4. In the world of illicit psychoactive drug use, drug users have no difficulty attributing unpleasant or pleasant experiences mainly to the drug, with acknowledgments that
the setting and the user’s preparation may shape the experience. Popular and scholarly writings about marijuana, LSD, or ecstasy illustrate this point. However, in the
controlled world of testing of psychoactive drugs to conform to the psychiatric and regulatory vision of these drugs as conventional medical remedies, researchers and
regulators have the greatest difficulty to treat them as capable of producing complex and unpredictable experiences from individual to individual. Here, the presumed
sameness of the subjects’ mental disorders, the moralistic opposition to intoxication, and the channeling of the subjects through evaluation procedures copied directly
from the world of physiological medicine—all combine to dictate the expectation that pleasant or euphoric psychoactive effects originate in drugs and will probably
create drug addicts, while unpleasant psychoactive effects probably originate in psychiatrically disturbed subjects and can be tolerated or further treated.
5. In the experience of one of us (DC), however, clonazepam withdrawal is always extremely difficult. Working with over a dozen individuals who had been taking
clonazepam for periods ranging from six years to nineteen years, and who had previously tried different methods, sometimes including inpatient hospital-based
detoxification, it was found all of them experienced excruciating withdrawal symptoms and none were able to reach their goal of being completely clonazepam-free.
6. Recent repeated associations of chronic benzodiazepine use with the onsent of dementia in careful cohort studies (see, most recently, de Gage and colleagues, 2012) will
hasten the demise of these drugs and will lead to increases in the promotion of other tranquilizers and sedatives to physicians and patients. Although benzodiazepines
have long been observed to cause memory problems, such problems are reported with virtually all psychotropic drugs on the market today.
7. Since 1991, pharmaceutical manufacturers in the United States have paid the staggering sum of $30 billion to settle allegations of wrongdoing, notably illegal marketing
of drugs and deliberate overcharging of government health programs like Medicare and Medicaid (Almashat & Wolfe, 2012). The pace of such criminal and civil suits
from the federal government and states has increased: of the 239 settlements and court judgments occurring during that period, 74 (totaling $10.2 billion) occurred
between November 2010 through July 2012. As the authors point out, these financial penalties “still continue to pale in comparison to company profits and a parent
company is only rarely excluded from participation in Medicare and Medicaid for the illegal activities . . .” (p. 5). While overcharging of public health programs has been
the most common alleged violation, illegal (off-label) marketing has resulted in the largest settlements. The three largest settlements involved accusations of the illegal
marketing of the antidepressants Paxil and Wellbutrin by Glaxo Smith Kline, the antipsychotic Risperdal by Johnson & Johnson, and the anticonvulsant Depakote by
Abbott Laboratories.
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 8
The Structure of Mad Science

A critical attitude needs for its raw material, as it were, theories or beliefs which are held more or less
dogmatically. Thus science must begin with myths, and with the criticism of myths, neither with the
collection of observations, nor with the invention of experiments, but with critical discussion of myths and
of magical techniques and practices.

Karl Popper, Conjectures and Refutations, p. 50.

 Introduction
In this book we have, indeed, taken a critical attitude toward the conventional understandings and treatments of madness over the
last fifty years in America. We sought to examine the three major psychiatric “revolutions” that scholars often use to define and
characterize the mental health system. These revolutions are often proclaimed to be the results of enlightenment, humanitarianism,
and scientific progress. For each revolution we found that the particular rhetoric used by the psychiatric establishment to claim
progress in the management of madness was and is pseudoscientific. It does not describe a science based on independent inquiry,
transparency, objectivity, or the skeptical scrutiny of assumptions and evidence, but a distorted science, a make-believe science, one
used to advance a welter of particular institutional agendas and cultural schemes. Instead of a science of madness, we documented a
mad science.
 Examining Our Own Assumptions
As scholars and researchers, we recognize that our personal unexamined assumptions affected how we shaped this book. As we
indict the self-interest of countless actors in the mad science enterprise, our own self-interest must be scrutinized. Indeed, each of us
has not only written critically about these issues for decades but has built an academic career on critical writings, especially ones
challenging the disease model of distress and misbehavior and practices based on this model. We think that we have accurately
communicated the recognized absence of biological verification of the Western scientific model of disease—disease as cellular or
molecular pathology—applied to distress and misbehavior. Nonetheless, perhaps we bring a presumptive bias against disease as a
first-line explanation for any complex, negatively perceived human behavior.
Still, our book does not privilege our own data but rather our serious effort to assess what psychiatry itself has presented as its
best evidence for the disease model of distress and misbehavior. We have looked at the disease model and found the scientific
evidence wanting. In drawing our conclusions, we did not seek out obscure studies conducted by outsiders. Rather, we analyzed
what psychiatry has promoted as its best evidence, the most notable studies published in the leading journals of medicine and
psychiatry, what psychiatric leaders and promoters in government and elsewhere have stated and written publicly. Although many
critical books about psychiatry and the disease model have been published, especially recently,1 we think our book is the first to
examine systematically the links among three major arenas that typify psychiatric practice and thinking today: coercion in
institutional and community settings, DSM diagnoses, and drugs. We are not aware of any important, substantive, independent
studies that we have overlooked.
Perhaps we hold psychiatry to unreasonable expectations of scientific rigor, when some merely claim psychiatry to be a clinical
art that tries to use science. For example, when Louis Menand in The New Yorker (March 1, 2010) raised the question, “Can
psychiatry be a science?” the APA’s president at the time, Alan Schatzberg, responded (March 22, 2010) by stating that no medical
specialty, including psychiatry, is a science. “Psychiatry,” Schatzberg wrote, “rests on a foundation of scientific findings . . . but
must employ both clinical judgment and their empathic skills in diagnosing and treating patients.” Revealingly, Schatzberg omitted
to mention involuntary hospitalization and treatment—which no other medical specialty but psychiatry uses. Although his depiction
of some psychiatric practices as art makes sense to us and could benefit patients and society were it taken literally, it is definitely
not the depiction that psychiatry itself promotes and presents. We think that, here again, we have not misrepresented psychiatric
sources. Self-servingly, when trying to explain failure to deliver on promises of factual understandings, novel treatments and
improved outcomes, individual psychiatrists might claim occasionally to be only practicing an art—or an art mixed with guesswork,
placebos, and something else. But, beyond any doubt the profession’s consistent message has been that its accomplishments rest on
the best scientific thinking. Furthermore, it is by claiming psychiatry as a medical science that authorities justify funding its
activities and enforcing the coercive recommendations of its practitioners.
Although our story of the last fifty years of the mental health movement is not a tale of progress—if such is possible in the realm
of human affairs—we have not argued in this book that the mental health system is monolithic. We are too steeped in systems
thinking to ignore that social systems (open systems by definition) change over time, sometimes radically and unpredictably.
Moreover, although we observe that groupthink and herd behavior characterize much of what passes as mental health practice, the
fact is that the mental health institutional infrastructure manages to accommodate critics like ourselves, who have been funded by
governmental institutions such as public state universities and federal research institutes as well as private foundations. Realistically,
we believe this accommodation is extremely small, but it does suggest a potential for change. Of course, as this book demonstrates,
change in and of itself may not represent progress in the eyes of different stakeholders. But we do confess to worrying about the
increased efficacy of institutions that rely on control by coercion and use mystification to expand their jurisdiction and power. Is it
unwarranted to be anxious about that sort of progress—the possibility of a nightmarish therapeutic state in which all misbehavior or
ineptitude is defined by presumed defective physiology and managed by empowered quasi-medical bureaucrats? This is no fantasy.
America and its legal, political, and mental health authorities have previously come together to handle human “defectives” by
legitimating involuntary sterilization of innocent citizens. As late as 1927, during a time ironically called the Progressive Era, one of
America’s most famous Supreme Court justices, Oliver Wendell Holmes Jr., wrote the opinion for a court majority (that included
Justice Louis Brandeis and the chief justice, former president William Howard Taft) to uphold the right of a state to sterilize mental
defectives. By 1941, about 36,000 men and women had been sterilized or castrated (Black, 2003, p. 121–123).
One final potential bias to consider is that we are social workers, not psychiatrists or other medical doctors. We think that this
bias, really our professional training as social workers, shows in our consistent attention to interactions and transactions between
individuals and their environments over time. Having said this, we think, first, that being social workers gives us pertinent inside
knowledge of the field of mental health services, treatment, and research, if only because more social workers are involved in
delivering mental health services in the United States than any other profession. Second, while we have no expertise in treating
patients for their physical illnesses, each of us has been professionally trained to work and has worked as a clinical social worker
with people who are very distressed, who misbehave badly, or both, which we’ve argued throughout this book is the real stuff of
madness—if madness can be said to be made up of any thing. Also, together we’ve amassed over seventy-five years of teaching
mental health courses in graduate schools of social work to thousands of students and practitioners (and learning from them), and as
academics we’ve published scores of articles in journals of all of the mental health disciplines. In sum, we are not exactly outsiders
to the madness enterprise.
 Recapitulations
Any assessment of the psychiatric enterprise over the last fifty years depends primarily on assessing the success of
deinstitutionalization and community treatment, descriptive diagnosis, and the prescription of psychoactive drugs.
The Language of Madness
Our analysis of the psychiatric state of affairs past and present is a linguistic attempt at persuasion, an argument by three individuals,
each with his own fallible nature, earnestness, background, experiences, knowledge, and biases regarding the book’s subject matter.
“Authoritative” historians of madness are not that different from us; they are as earnest, conscientious, and flawed. They may fail to
recognize where they imply (absent any demonstrations) that madness is self-evidently a medical problem by using medically
tainted language. As we described, despite their differences (see Scull, 1985), virtually all infuse their texts with medicalized terms
such as mental illness, disorder, or disease, as analogs for madness, even when they recognize the inability of these concepts to
capture the range of heterogeneous behavioral content that is subsumed under the disjunctive category of madness. Their message to
their readers is therefore likely to be: you are reading an account of the laborious journey to the scientific discovery of the true
nature of madness as medical illness amenable to medical supervision.
However, an alternative vision of madness recurs throughout history. It accepts of course the mental and behavioral
consequences of well-defined diseases such as pellagra, neurosyphilis, Alzheimer’s dementia, or alcohol poisoning resulting in
delirium tremens. It portrays madness not as a medical issue (disease/illness) or a phenomenon of nature as much as a human locus
for a wide variety of existential struggles and deviant human actions. That conception requires a willingness to see the vast majority
of mad persons, those whose behavior has not been scientifically linked to pathological processes, as poorly, sometimes very poorly,
prepared actors (or sometimes evil actors) in a complex world, who try their best to deal with problems in living, sometimes very
grave ones. We suggest throughout this book that this conception remains a wholly valid contender, despite its old-fashioned
appearance, because, after more than ten decades of determined research and the expenditure of untold sums, no one can verify that
madness is a medical disease. But even were we to accept psychiatry’s basic premises about madness, we would be forced to
conclude that its approaches to the mad are steeped in coercion (by which we mean deliberately and forcefully interfering in their
lives), mystification (by which we mean propagating false or unverifiable statements about their problems and their solutions), and
intoxication (which means according to standard dictionary definitions, “stupefaction or excitement by the action of a chemical
substance,” and “poisoning by a toxic substance”). These have extremely little connection with scientific inquiry or medical
treatment.
Language is a human construction. Words do not necessarily represent a tangible reality and often rest on “perceptual
metaphors,” all the while giving listeners directions for response. The use of disease in reference to madness suggests that we
should respond to many disparate behaviors as if they were diseases (e.g., schizophrenia) or the personal and social harm caused by
diseases (e.g., suicide caused by post-psychotic depression). These words instruct their speakers to view some actors in the drama of
life as nonvolitional and to excuse them from responsibility for behaviors that otherwise would be considered vexing or inept but
motivated. Simultaneously, these words instruct their speakers to view other actors as healers motivated only by the desire to help,
surely an absurd proposition. The language of disease permeates all aspects of the psychiatric enterprise and distorts how we think
about deviance, distress, and suffering, and about responding to these.
That is why psychiatric language has been essential to that profession’s economic and political success. For psychiatrists and all
the allied mental health professionals, the mere application of the language of disease has managed to give madness a scientific
verity, because the language’s abstractions were easily treated as if they had a concrete existence. This was accomplished through
the simple substitution of one metaphor for another, with people attributing more material reality to each new expression. Perhaps it
went something like this: From about the late Middle Ages (circa 1350 CE) we have had useful if murky terms in the English
language such as madness, lunacy, and craziness (Merriam-Webster.com, 2011) for troubling or troubled behavior. When the social
order expected more formal codification to enforce the organized control of persons who could not resist their labeling by these
terms, the terms were changed to the legal and perhaps more definitive-sounding insanity. Later, under the control of medical
managers of the insane, that term was changed to our contemporary terms, mental disease, illness, and disorder. No change ever
involved demonstrating the material referent of the words, but each change deeply shaped—while also reflecting—society’s
understandings and responses to human travails. So it was with the change to illness and to medical conceptions of madness, which
has beguiled even historians perhaps because we are all still steeped in it. It is difficult for anyone to disentangle the embedded
assumptions in the language from the story that is told. And to complicate matters further, the stories serve professional, institutional
purposes.
The metaphor of disease is extremely seductive, not only because it distances a person from volition and responsibility while
absolving “helpers” of political fallout when they take sides in interpersonal conflicts, but because it refers to something
immediately recognizable. Without comment we ask our readers to reflect on the following few words and how they are viscerally
experienced simply when reading them: illness, brain disease, research, doctor, patient, diagnosis, prescription, treatment, therapy,
evidence-based, medication, safe, effective, hospitalization. We think this vocabulary transforms the awesome threat of madness—
confusion and bewilderment—into the still challenging but more understandable and controllable threat of disease. It is as if these
words (just like the words marketing firms employ to claim laundry detergents can, impossibly, clean “whiter than white”) do much
of their work just by being intoned regularly.
The Enduring Role of Coercion
Coercing the mad into madhouses to separate and detain them occurred long before physicians were authorized to manage that
enterprise, and coercion continues to distinguish “scientific” psychiatry to our day. Though many people might know that madmen
and madwomen used to be confined, beaten, tied, shocked, or whirled into submission, fewer might realize that the physical control
of “dangerous” mental patients remains today a central if not the only function of the public mental health system, with more people
being coerced now than ever.
About half a million people were involuntary residents of state and county asylums and mental hospitals by the mid-1950s.
Today, about three times that many experience shorter periods of involuntary detention in psychiatric wards and other mental health
facilities for examination and evaluation of their dangerousness to self or others. They are part of the approximately four million
people who experience coercive measures from mental health workers, including those treated involuntarily in the community, the
place once proffered as the obviously more humane alternative to long-term hospitalization of the mad. Coercion runs deep and
wide throughout psychiatry and the mental health system, creating an unavoidable yet strangely silent climate of intimidation and
acquiescence among clients and professionals and the media, whose job used to be to alert us to human rights abuses and scrutinize
the functioning of the state.
Beginning slowly in the 1950s and extending throughout several decades, with encouragement from federal and state
governments, the inmates of state mental hospitals were forcefully discharged to communities, even when they wished to remain
institutionalized. The ostensible rationale was to remove them from coercive and inhumane total institutions and usher them into
more therapeutically effective community-based programs. Assertive community treatment, one of the best-known such programs,
was developed by a few mental health professionals steeped in the use of force on psychiatric inmates in one particular Wisconsin
institution for the mad between the 1950s and 1970s. However, the only consistent outcome for patients uncovered by ACT
proponents then and now is that of reduced hospital stays. This was not achieved by improving patients’ functioning or reducing
their distress and misbehavior but by forcing ACT patients to stay in the community while allowing comparison patients to be
hospitalized. Understandably, “reduction in hospital stays” made policy makers, agency administrators, and government funders
happy because it appeared to save money. It also allowed ACT promoters to enjoy continued authority because uncritical observers
implicitly assumed that ACT accomplished other objectives, such as providing humane, noncoercive, effective interventions. Yet no
consistent improvement in autonomous motivated behavior regarding education, vocation, or “symptoms” can be attributed to ACT,
nor can it be distinguished from other less expensive and less coercive community programs used nationwide (reduced hospital
stays disappeared when ACT programs did not force patients to stay in the community for treatment). Needless to say, ACT has
been anointed as an evidence-based treatment.
Extremely few authors today discuss openly the extent of psychiatric coercion in America (Oaks, 2011). The first recorded
involuntary confinement in an American mad hospital occurred in 1752. Two hundred and fifty-five years later, psychiatrist Robert
Drake explained that the majority of the severely mentally ill opt out of mental health care because “They’re afraid of the
coerciveness of the system” (cited in Wiencke, 2007, p. 4). Today, coercion has been reinvented and institutionalized as a
scientifically valid therapeutic approach for managing madness and as a proper subject for scientific investigation by psychiatric
clinicians. Coercion might be presented as an unpleasant but necessary extra push to make patients use the range of available
effective treatments for their mental illnesses. Our analysis, however, leads us to conclude that outside coercion, public psychiatry
has no effective approaches to handle the existential difficulties of those who don’t ask for help with their travails but whom
nevertheless psychiatry claims under its jurisdiction. Coercion is the only intervention to have endured since the birth of psychiatry.
We suggest that coercion (sometimes verbally airbrushed into the term leverage) and the threat of coercion persist because coercion
is all there is for those who are behaviorally disobedient or wish to be left alone.
Once an acknowledged ethical and legal problem in psychiatry given its use against the helpless, the hopeless, or the legally
innocent (Szasz, 2007), coercion is now a therapeutic tool, and discussions of coercion increasingly focus on the technical strength
and effectiveness of its leverage effects (Monahan, 2008) and whether those who are coerced might not necessarily perceive it as
such. Further, as we discussed in chapter three, some psychiatric authorities are beginning to argue that no medical justification is
really needed for what psychiatric coercers do since this is identical to what other state sanctioned coercers, such as the police, do to
maintain civil order. The police maintain that they catch and punish lawbreakers. However, psychiatry has originally and
consistently maintained that it coerces not to punish but to treat, because it deals with problems constituting a special subset of
medical disease that impairs its victims’ ability to judge and discern rationally, thus requiring coercion when all else fails.
Coercion directly affects the freedom of mental health professionals. To receive payments from government programs and
insurance companies, practitioners must generate DSM diagnoses, constraining the reluctant or skeptical to conform even though the
diagnostic system—now openly recognized as deeply flawed, even caricatural—does arguably little to help their work. Designating
some interventions as “evidence based” through a nonscientific, consensus-authority based arrangement also restricts professionals
to use only these, if they want to keep their professional credibility. This would be especially the case in slow-to-change agencies
dependent on public funds. Other interventions that are not yet anointed as acceptable by experts but which may prove to be or are
useful to particular clients are discouraged. Few professionals will risk employing such interventions or risk sanctions by some
supervisory agency. If the attitude prevails that “we already know what works best,” innovation becomes even less probable, unless
it promises to accommodate to or take a subsidiary position toward dominant interventions (inevitably, drugs).
More importantly, the recognition in public psychiatric practice that coercion is always at hand if persuasion fails creates an
atmosphere of surveillance and expected compliance, making it difficult for a professional and a client to develop a meaningful
working alliance. Deeply troubled persons will be careful to censor their thoughts and feelings, even if expressing them might be
essential to their well-being, because they fear involuntary measures that could lead to psychiatric detention, involuntary drugging,
and occasionally involuntary electroshock (Snyders, 2009). As stated earlier, involuntary measures keep many of the mad from
seeking help in the first place (Hahm and Segal, 2010).
Instructed by tradition and by law, mental health professionals, too, will be hypervigilant for any sign from the patient of
thoughts of suicide or harm in order to safeguard the patient’s existence. Despite the fact that most state statutes concerning civil
commitment are discretionary rather than mandatory (that is, professionals are not automatically required to take measures in
response to perceived dangerousness), in our experience, extremely few mental health professionals actually know the letter of these
laws.2
We see no legitimate role for coercion in the helping enterprise. It is obvious that societies must use coercion and force in
particular circumstances. Our police and military have the authority to maintain civil order and defend against threats to our
survival, while our legal and political systems are charged with supervising its appropriate use. We question why psychiatry, under
the guise that it is a medical discipline, persists in using coercion in the mental health system and why other medical disciplines,
who reject coercion in their own practice, turn a blind eye to it in psychiatry. Before homosexuality’s sudden redefinition from
feared condition and mental disorder to merely a variant of normal sexual preference, was it proper to coerce homosexuals to change
their sexual behavior?
The Emptiness of Descriptive Diagnosis
Compared to the historical uncertainties about the nature of madness, the disease model of madness offered the rubric of medicine to
classify, understand, and control various misbehaviors as one would do with symptoms of brain diseases. To mimic research and
practice of physical medicine, psychiatry needed a method of identifying and categorizing types of mental illnesses. The initial
invention and subsequent attempted refinements of the DSM embodies this effort to name and classify.
The first edition of the DSM was ignored, the second scorned, and by the 1970s the DSM had become a battleground of
contending interest groups and ideologies. A subgroup of biologically oriented research psychiatrists wrestled control of the DSM
from the dominant psychoanalytic faction, claiming that diagnosis must become more scientific (as they understood the term) if
psychiatry as a profession was to endure and thrive. This new leadership cadre emphasized making the classification system more
reliable (i.e., consistent), conveniently ignoring the far more important criterion of validity (i.e., establishing the reality of the
disorders). They created “descriptive diagnosis,” exemplified by the 1980 DSM-III and its subsequent editions. It simply assumed
that mental disorders existed and focused on getting clinicians to agree on who fit into which DSM diagnosis. For thirty years, the
leaders of the APA claimed that descriptive diagnosis succeeded in making the DSM more scientific. They convinced policy makers
and the public to trust their claims. The medical model of madness became further institutionalized, supported, and promoted by
NIMH, mental health professionals, Big Pharma, insurance companies, and virtually everyone else.
Yet, as the unfolding controversies over the DSM-5 illustrate, descriptive diagnosis has been an utter scientific failure. It led
neither to more reliable or valid diagnoses, nor to any sort of scientific breakthrough in identifying hoped-for biomarkers of the
elusive disorders that would begin to validate the medical model of madness. Moreover, in an effort to ape medical reasoning, by
removing contextual clues about person’s situations and circumstances to produce neutral- and objective-sounding “diagnostic
criteria sets,” understanding living persons became a quaint and irrelevant enterprise in the new psychiatry, where studying
contrived DSM diagnoses substituted for studying persons and the possible functions of their disturbing behaviors. Much of this
failure has remained hidden behind hopeful promises that the causes and cures for madness are just around the next biomedical
corner. More deleteriously, descriptive diagnosis has allowed for widespread financial conflicts of interest among the APA,
government, mental health practitioners, and leading researchers. By making it exceedingly easy to name new disorders and expand
the scope of existing ones, the latter editions of the DSMs have manufactured an epidemic of mental illness and a huge expansion in
the uses of lucrative but questionably useful psychochemicals. Improving the psychiatric diagnostic system was supposed to bring
accuracy to psychiatric judgments, and for a while it was a public relations triumph. But instead of serving as a scientific
cornerstone for research and practice, the DSM has become a mainstay of mad science, in which professional interests and power
regarding diagnosis trump logic and scientific evidence.
The Madness of Medications
The modern prescribed psychoactive drugs are associated with nearly identical outcomes as all biological psychiatric treatments
have always been. At best, about 30 percent of people diagnosed with the major clinical madnesses of our time (persistent depressed
mood, called Major Depressive Disorder, persistent depressed mood punctuated by euphoric mood, called Bipolar Disorder, and
extremes of despair and deviance, called Schizophrenic Disorder) appear to show sustained improvement while taking these
treatments. This proportion is very similar to that obtained today and in the past in observational or controlled studies by placebos,
by seclusion and restraints, by excision of various bodily organs, by prolonged barbiturate-induced comas, by lengthy baths and
showers, by surgical mutilations of the brain, by epileptic seizures induced by chemical or electrical shocks, by conversation, by
seemingly irrelevant activities, or by the mere passage of time. The latest drug treatments—the SSRI antidepressants, the mood
stabilizers, and the second-and third-generation antipsychotics administered under whatever conditions and in whatever
combinations their adherents have proposed—have had no additional positive impact whatsoever on any measurable indices of pain
and burden associated with madness and may have had negative impacts.3
This total failure has been the dirty little secret of psychiatric drug treatment for decades, but starting in 2005 with publications
from the largest drug trials using real-world patients, doctors, and outcomes, funded by the NIMH and conducted by the drug
industry-soaked clinical and research elite of American psychopharmacology, it could no longer remain shrouded. Some leaders of
the mental health movement professed surprise at the findings, and some admitted that prescribers had accepted exaggerated claims
of drugs’ effectiveness in the absence of evidence. But the findings came as no surprise whatsoever to careful observers of the drug
treatment scene. The disconnect between findings from reasonably well-conducted studies and lay and professional claims about the
powers of the latest psychotropic medications suggests that much prescribed psychoactive drug use is today as it has always been:
fundamentally ceremonial, fulfilling deep social needs, and needing no scientific justification whatsoever (Szasz, 1974).
The history of psychoactive substance use throughout time and throughout the world highlights the elemental fact that some
users appreciate the effects of a drug, some users don’t, and still more users have no particular responses. Instead of building upon
this observation, drug experts and authorities invented artificial divides between “approved medications” and “dangerous drugs.”
Not only were the same drugs separated linguistically, they were made unequal politically. Authorities then justified desires for
approved drugs by postulating that these drugs corrected chemical imbalances in their users, thereby ameliorating mental illnesses
and enhancing population health—and should be prescribed by duly licensed physicians. As for the unapproved drugs, experts
warned that these caused chemical imbalances, thereby creating mental illnesses and disrupting the fabric of society—and should be
proscribed by any reasonable person. No genuine science, medicine, or public health could ensue from such a ridiculous dichotomy.
To maintain the dichotomy, a scientific and administrative apparatus was established, within which psychiatry was offered a
retainer. The apparatus included the procedures and experiments testing psychoactive drugs’ effectiveness in treating DSM-defined
madnesses, all of them modeled to duplicate procedures used to evaluate conventional medical treatments for medical diseases. The
Food and Drug Administration promised to verify the integrity of these procedures to ensure “safe and effective” prescribed
psychoactive drugs, while the Drug Enforcement Agency promised to wage war on those who persisted on using unapproved
psychoactive drugs. The puzzling fact that unapproved drugs could cross over into approved territory, or vice versa, or occupy both
spaces simultaneously, seemed to puzzle no one.
Already blinded by unquestioned assumptions of madness as disease, experts confused the effects of stupefying drugs producing
quiet on oppressive asylum wards with a revolutionary new medical understanding of psychosis. They confused dazzling images of
our living brains with discoveries of the physiological substrates of the specific mental illnesses served up by new editions of the
DSM. They took doctored reports of drugs’ effectiveness as scientific validations of the guesses or marketing slogans proposed to
explain the (presumed) drug effectiveness. They chose not to see how drug industry largesse made them indentured servants.
Finally, because most of them had given up engaging in disciplined conversation with distressed persons (but could not fathom
abandoning coercion), they lost the ability to conceive of psychiatric practice and research as anything other than prescribing drugs
and waiting for new drugs. In these ways, American biological psychiatry became a state- and corporate-funded cult of psychoactive
drug use.
That people might find psychoactive drugs helpful to them is obvious and cannot be contested. Nonetheless, and incredibly so,
much of this power of psychoactive drug use went completely unnoticed and unmentioned—let us say, repressed—in the prodigious
psychopharmacological research effort. By definition, psychoactive drugs change people’s thoughts, feelings, and behavior. Yet,
psychopharmacology continually assumed that if the bearer of a psychiatric diagnosis reacted positively to a drug, this confirmed
the presence of disease. That psychoactive drugs sedate, calm, tranquilize, desensitize, stupefy, awaken, arouse, or excite people
who take them, and thereby may help some people temporarily or permanently to traverse daunting circumstances, disappeared from
the official psychiatric understanding of psychiatric medications. As a result, this official understanding also neglected the rigorous
detection of drug-induced harm in psychiatric practice.
 The Structure of Mad Science
In the academic literature on any complex subject, careful readers can find examples of the misinterpretation of data, conclusions
only partially supported by the evidence, and inadequate methodologies. Occasionally, someone uncovers deliberate falsification of
data or unscrupulous behavior by a researcher, although recently there has been an alarming increase in reports of such behavior
(Zimmer, 2012). These discoveries usually make newspaper headlines. Names are noted, careers are ruined, institutions are tainted,
and the truth-seeking of science is reaffirmed.
This is not the story we have told in this book. When it comes to the understanding and treatment of madness, the distortions of
research are not rare, misinterpretation of data are not isolated, and bogus claims of success are not voiced by isolated researchers
seeking aggrandizement. In our detailed analyses of community treatment, diagnosis, and drugs, these characteristics of bad science
are endemic, institutional, and protected. They are what we have labeled “mad science.” Here are some of its major ingredients and
the institutional arrangements that promote it.
Amnesia and the Recycling of Problems
The mental health field displays an uncanny tendency to sweep under the carpet vexing issues that threaten the status quo, only to
treat them as novel problems once they resurface. We have discussed, for example, how by the early 1980s the architects of DSM-III
had managed to deflect the scientific gaze off the central problem in psychiatric diagnosis—the lack of validity—onto the more
manageable, less threatening problem of lack of reliability. By 2010, however, no less than the chair of the DSM-IV task force could
lament that the DSM’s imperialism had created “false epidemics” of childhood disorders and could assert that the very definition of
the key concept in the DSM, and arguably in all of psychiatry—mental disorder—was “bullshit” (Greenberg, 2011). We have cited
the informed director of the NIMH professing surprise that the best conducted trials of optimally administered drug treatments had
shown that these had reduced neither symptoms nor impairment. Yet such results characterized the longer-term fate of every major
biological psychiatric treatment in the last hundred years. We have seen that coercion as the key mechanism ensuring compliance
with treatments for the seriously disturbed has continually been downplayed publicly or rendered benign through verbal anesthesia
and promoted as another helpful mental health technique called leverage, while its widespread employment never wavered.
The Medical Imprimatur
Psychiatry via the APA and NIMH has continuously proclaimed that, despite conflicting evidence, great scientific strides were made
in community treatment, diagnosis, and drug treatments. These claims would have no shelf life without their acceptance and
repetition by the mental health professional organizations and practicing clinicians. This acceptance rests on a few factors.
The first is the sheer power and prestige of the medical enterprise in the United States. Psychiatry used its links to medicine to
capitalize on the technical breakthroughs and successes of this powerful social institution. Everyone has at least some vague
appreciation of brain imaging, microsurgery, and other impressive technical advances in physiological medicine. The medical
imprimatur stamped on psychiatric coercion, misdiagnosis, and ineffective drugs as the latest technological advances for helping the
mad goes a long way in producing uncritical acceptance.
Second, psychiatric claims are not easily verified by other scholars, clinicians, or the public. Both the methods of scientific
studies and the complex and arcane statistical analyses of data that fill the medical and psychiatric journals are a challenge to
comprehend, even for the best-trained professionals, as articles in The Economist (2012) and elsewhere recently noted (Zimmer,
2012). Only a handful of psychiatrists, psychologists, social workers, or other mental health clinicians have the time, skills, or
motivation to scrutinize the deluge of claims published weekly. Most rely only on popular media sources for soundbites of
progress.4 And when the media broadcast “advances,” why should the clinicians be skeptical? In fact, they have seemed quick to
become boosters, exploiting their membership in an enterprise that appears to be advancing.
Finally, professionals and the public are not simply gullible to shaky claims but have found many ways to benefit from them. The
mental illness metaphor, whatever its possible uses for thinking, speaking, and coercing, is accepted as a statement of fact. But even
if it is not, clients and professionals widely use it to justify insurance reimbursement from third parties, to get services to those who
they think need help, and to earn a living. They collude with psychiatry to do something that the rest of medicine cannot do: to
diagnose as an illness “behavior that society doesn’t like,” allowing assumed pathology to replace morality. The public, confounded
and discomfited by these behaviors, goes along with the ruse, relinquishing or outsourcing responsibility for one’s behavior to
experts. Irwin Savodnik, a UCLA psychiatrist and philosopher, has written that “the erosion of personal responsibility is, arguably,
the most pernicious effect of the expansive role psychiatry has come to play in American life” (Savodnik, 2006, p M3).
Distorted Science and Exaggerated Claims
As we have described, many psychiatric studies take on the trappings and the appearance of scientific investigations, even when
they are seriously flawed or interpreted much more positively than justified. Concerning diagnosis, it is the very rare study that
actually tests average clinicians’ agreement on DSM diagnoses for the same patients. Instead, the reliability literature is awash with
tests of structured scales and checklists of presumed mental illnesses. Moreover, the vast majority of these studies are conducted
among groups of clients or in narrowly focused research settings where it is expected that the problem being studied will be the
chief presenting complaint (i.e., where there are likely to be high base rates of behaviors that are the diagnostic criteria of a
particular disorder category). These studies are the equivalent of shooting fish in a barrel. Finally, without valid methods to verify
the existence of “mental disorders,” what exact purpose besides conformity or indoctrination is served by teaching clinicians to
agree with published diagnostic criteria sets?
The durations of clinical drug trials are truncated to avoid showing that the drugs are ineffective over more than a couple of
months of use. Double-blind procedures are rarely tested. Inconvenient subjects who respond to placebo early on are dropped. Only
inert placebos, never active placebos known to evoke more powerful responses, are used as comparisons to drugs with sometimes
stupefying behavioral effects. Adverse effects are investigated and reported with approximately one-tenth the energy devoted to
assess hoped-for beneficial effects. It is a rare study that compares a drug treatment with a well-administered psychosocial
alternative. The methodologically sound use of no treatment comparison groups is considered to be unethical in psychiatric
research, and such groups are never used in experiments. But if one is attempting to determine whether a treatment is effective, than
it would be crucial to know if that treatment (which typically produces some toxic adverse effects) is better than doing nothing at all
(recalling medicine’s commitment to “First, do no harm”). Finally, when results are unacceptable or deemed too financially
threatening to sponsors, results have been doctored or suppressed.
We have illustrated throughout the book how even studies that are repeatedly cited to confirm claims of scientific progress are
seriously flawed. Of course, all studies, no matter how meticulously conducted, have limits. Still, studies with profoundly serious
flaws are presented as highly credible breakthroughs, sponsored by NIMH, authored by esteemed scientists at prestigious
universities, and supported by the research community. That community praises the findings and exaggerates their significance:
reliability is greatly improved; community treatment is effective and noncoercive; medications are safe and effective. The
psychiatric lobbyists insert these conclusions into repositories of “evidence-based practices,” “practice guidelines,” or “best
practices,” thereby institutionalizing some of the weakest science (Medical Guesswork, 2006).
The exaggerated claims today are often about neuroscience. The public and professionals appear to suspend judgment in the face
of “the seductive allure of neuroscience explanations” (Weisberg, Keil, Goodstein, Rawson, & Gray, 2008). About five hundred
brain-imaging studies are published each year, and researchers for thirty years have been promising that “snapshots of the living
brain” will unlock the mysteries of madness and will be used for diagnosing mental disorders (Carey, 2005). Although many of
these studies may help scientists to understand more about brain functioning, to date, no standardized brain imaging tools exist for
diagnosis or treatment in psychiatry. (No biomarker appears as a diagnostic criterion for any primary mental disorder in the DSM.)
Harvard psychiatrist and former director of NIMH, Steven Hyman, admits that “the community of scientists was excessively
optimistic about how quickly imaging would have an impact on psychiatry . . . people forget that the human brain is the most
complex object in the history of human inquiry” (cited in Carey, 2005). The writer Diane Ackerman, in An Alchemy of Mind,
captured this strange optimism well while offering an apt analogy for what brain imaging offers the understanding of persons:

. . . we may lift the lid off the brain with PET, MRI, fMRI, or MEG and peer inside, but that still leaves us voyeurs, distant
viewers. . . . We measure its blood flow, hunger for glucose and oxygen, its radioactivity or magnetism. Regions light up
and offer us some illumination. But the porch light can be on without telling you who is at home. When it comes to brain
mapping “our knowledge is akin to looking out of the window of an airplane,” neuroscientist William Newsome, of
Stanford University, explains. “We can see patches of light from cities and towns scattered across the landscape, we know
that roads, railways, and telephone wires connect those cities, but we gain little sense of the social, political, and economic
interactions within and between cities that define a functioning society.” (Ackerman, 2004, p. 251)
Big Science
Jonathan Cole, a prominent Columbia University sociologist and former provost, resigned in protest from the National Research
Council’s committee charged with evaluating PhD programs in the United States, just before the committee’s final report (sponsored
by the National Academy of Sciences) was due to be published in 2010, after seven years of committee effort. Cole (2011)
concluded that it “was not worthy of publication” and had succumbed to “faulty assumptions, poor analysis, political pressure from
the academy, and unexamined preconceptions.” Cole’s protest highlights an all-too-common disappointment with large scientific
undertakings. The members of the committee, Cole believes, were unwilling to acknowledge that their study had failed (recall
Donald Campbell and Karl Popper’s methodological urgings):

There are many examples . . . of large studies thought too big to fail, despite insufficient data. One can find such failures,
which lead to policy changes based on poor data, in medical experiments about drugs, public-health studies, and a variety
of assessments of health risks . . . A crowd psychology emerges within committees where individuals don’t want to be
perceived as spoilers. Discussion of why a study has failed is truncated—to the detriment of learning from our mistakes. An
attitude has developed in American society, and it plagues research efforts as well.

The mantra is, “It’s better than nothing. But is it?” (p. B12)

Has psychiatry simply become better than nothing? Is it too big to fail? Consider the size and character of psychiatric research.
Nearly all studies published in the major psychiatric journals are big studies, involving sizeable teams of researchers at multiple
clinics and hospitals across the nation, funded by big sponsors such as the pharmaceutical industry, the NIH, and foundations, and
recruiting very large samples of patients. Like the NRC study described by Cole, the studies take years of planning and years of data
collection. Decision making is done by teams and committees, which are carefully selected and supervised by the study directors
and by the funding bodies. This is Big Science in psychiatry, and many institutions and individuals have a significant and personal
stake in making it a success.
Big Science, however, is an insider’s game. The leading players move easily among positions in the major arenas or psychiatric
power. Top university scientists have their research funded by NIMH, are later appointed to review panels at NIH, are selected to
serve on important APA committees such as the DSM task force, all the while earning increasing amounts of money serving as
consultants or speakers for multiple pharmaceutical companies. Universities thrive on the large grants from NIH, foundations, and
Big Pharma, as does the APA and other organizations such as NAMI. These individuals and institutions, woven tightly together by
personnel, money, and self-interest have an additional shared goal, namely to consistently portray the vast enterprise as a scientific
success and to ensure that it doesn’t fail, no matter what.
The insiders’ preferred world view is, of course, the biomedical model of madness: mental disorders are prevalent and spreading,
caused by soon-to-be-discovered brain defects (themselves caused by soon-to-be-discovered genetic variations); palliation,
prevention, and cures are just around the corner or already available but used by too few; and all that is needed to eradicate madness
is more money, more time, and fewer critics. All evidence to the contrary, this worldview has been a runaway success.
The success results partly from the ways Big Science can annihilate potential opposition. By controlling almost all sources of
funding, no rival scientific efforts gain traction. Funded and published studies are too big to replicate except by the insiders
themselves. Outsiders, especially if they have no clinical appointments within medical institutions, may have a very difficult time
conducting outcome studies on patients. This is especially so for studies on controversial topics, such as evaluating the outcomes of
electroconvulsive treatment or involuntary commitment (McCubbin, Dallaire, Cohen, & Morin, 1999). The power-elite insiders
control appointments to decision-making committees, to grants review panels, and to what gets published in the main journals.
Academic enthusiasts of assertive community treatment, for example, receive federal and state funding to create ACT programs, and
they also implement them and design the training manuals and tools to ensure that replications cohere to the ACT model. Then these
same individuals evaluate the programs for effectiveness. Because of all of these ACT-related activities, these insiders become the
experts. Thus they sit on the consensus committees that “objectively” validate their own treatments as evidence-based practices. All
this allows them to buttress the status quo, reinforcing the view that they are promoting the “correct” view of madness and its
management, reassuring the public that the experts have it under control and brushing off outcroppings of dissent.
As we write these lines one example occurs in the latest data brief from the US Centers for Disease Control and Prevention
(CDC) bearing on usage of antidepressants in the United States (Pratt, Brody, & Gu, 2011). The report documents an increase from
1988–1994 to 2005–2008 of approximately 400 percent in the use of antidepressants in the general population, finding use in one in
six women and one in sixteen men over the age of twelve years. The increase is observed in both genders, all age groups, and in the
major races and ethnicities (though white users largely predominate). We have made many sorts of comments on these trends in this
book. The authors of the CDC brief, however, chose to make a single comment, and it bears on their subfinding that “only” one-
third of individuals with severe depressive symptoms were using antidepressants:

According to American Psychiatric Association guidelines, medications are the preferred treatment for moderate to severe
depressive symptomatology. The public health importance of increasing treatment rates for depression is reflected in
Healthy People 2020, which includes national objectives to increase treatment for depression in adults and treatment for
mental health problems in children. (p. 5, references omitted).

The authors of this brief ignore the mountain of data on the near-equivalence of antidepressants (i.e., the numerous different
substances gathered under that inappropriate moniker) to placebos in addressing feelings of depression. They ignore concerns that
led the FDA to place black box warnings on antidepressants’ labels starting in 2004 warning of agitation, agressivity, and suicidal
ideation, especially in children. They cite guidelines produced by the most interest-conflicted professional organization in the United
States on the subject of whether people ought to take antidepressants for what ails them. And for the final seal of approval to get
even more people on antidepressants, they cite an official government policy. For sheer errancy or inanity, it would be hard to top
this Big Science comment under the imprimatur of the CDC.
Has mainstream psychiatric thinking permeated all agencies devoted to protecting us from disease? Are there no countervailing
sources of dissent within the established madness institutions? Psychiatry, unfortunately, may not be an only child in the medicine
family to be harmed by the central planning of the biomedical industrial complex in this regard. The journalist Gary Taube (2007)
conducted an exhaustive review of the research literature on nutrition and health and questions whether the research is deemed
worthy of being called science.

The institutionalized vigilance . . . is nowhere to be found in the study of nutrition, chronic disease and obesity, and it hasn’t
been for decades. For this reason, it is difficult to use the term “scientist” to describe those individuals who work in these
disciplines, and indeed, I have actively avoided doing so in this book. It’s simply debatable, at best, whether what these
individuals have practiced for the past fifty years, and whether the culture they have created, as a result, can reasonably be
described as science, as most working scientists or philosophers of science would typically characterize it. . . . Practical
considerations . . . have consistently been allowed to take precedence over the dispassionate, critical evaluation of evidence
and the rigorous and meticulous experimentation that are required to establish reliable knowledge. . . . The urge to simplify
a complex scientific situation . . . has taken precedence over the scientific obligation of presenting the evidence with
relentless honesty. (p. 451)

The leaders of the bureaucracies in which many scientists work are not accustomed to honesty when it might reveal weaknesses
and cause trouble, nor are they good at promoting innovation. Their organizations are much more adept at protecting their flanks by
the control of information. The few signs of countervailing influences come not from contending organizations but from the
relatively uncontrollable Internet. Communities of dissent now have direct access to the public. These include networks of former
psychiatric patients, blogs offering pointed criticisms of establishment thought, broadly distributed critical e-mails from
whistleblowers and insiders, and websites brimming with detailed personal reviews of medications. Of course, the Internet is also
itself an arena for battles between established sources and upstarts, especially as concerns “health information” (Hughes & Cohen,
2011).
But Big Science in psychiatry is trying hard to be absorbed into neuroscience, largely abandoning sociology and psychology,
drawing the wagons around a biomedical fortress at NIMH. Thomas Insel, the director of NIMH, (as reported by Kaplan, 2011),
explained that the new direction seeks to identify biomarkers of individual responses to drugs in order to develop “preemptive
treatments . . . to prevent disability.” He is following guidance provided by a report of a high-level National Mental Health Advisory
Council, From Discovery to Cure: Accelerating the Development of New and Personalized Interventions for Mental Illness. The co-
chair of that council, John March from Duke Clinical Research Institute, describes the report as advancing the “transformative
neurodevelopment research in mental illness.” In the report all mental illnesses are considered brain disorders and virtually all are
called “developmental disorders.” March wants the NIMH to invest in “translational neuroscience” based on drugs being developed
by NIH, as Big Pharma has signaled its withdrawal from psychiatric drugs since most lucrative patents from the 1990s are expiring
or have expired. March describes this new direction as “incredibly exciting.” He states that the report “points the field toward the
molecular origins of mental illness in early development” and he adds, “it becomes possible for the first time to envision preemptive
treatments, a world without mental illness. How wonderful is that?” (cited by Kaplan, 2011).
 Conflicts of Interest
There is now a broad recognition that psychiatry and psychiatric research—the heart of mad science—is awash in money that
distorts honest inquiry. In medicine, in general, it is estimated that 25 percent of practitioners take cash payments from drug and
medical device companies, and nearly 66 percent receive routine “gifts” from them (Pear, 2012). Among psychiatric leaders and
researchers, the proportion is probably greater. The federal government has enacted regulations mandating as of 2012 drug
companies receiving funds under Medicare and Medicaid programs to collect data on all payments and gifts to doctors and hospitals
and to make this information publicly available. The research enterprise should be an arena that prizes free and open inquiry,
independence of thought, and unbiased research. Instead, as we and many others have described, psychiatry has become engulfed in
a thicket of distortions. On Big Pharma’s payroll are most prominent psychiatrists as speakers, consultants, researchers, and
marketeers in every state. It funds the APA and its major conferences; shapes the research agendas of scientists; censors what data
may be published and when; manipulates studies to ensure positive results; pays for ghostwritten articles; hides its sponsorship of
spokespersons and events; forges corrupting ties with universities; attacks critics; floods the professional and public media with ads
for drugs; constrains and manipulates the FDA; and ensures that expensive but ineffective drugs remain the dominant treatment in
psychiatry as they are sought by millions of people. At the cost of dozens of billions of dollars, Big Pharma and its allies in the
biomedical industrial complex finance mad science and own a profession.
The entanglement of researchers and clinicians in financial conflicts of interest means that the interests and welfare of consumers
and the public are ignored. Senator Charles Grassley’s recent congressional investigations of the madness establishment were a
welcomed exposé of the corruption of science.
 The Therapeutic State
Big Pharma and Big Science are supported by a much larger entity: Big Government. The federal government’s size, power, and
influence make it the number-one funder of mad science and buyer of Big Pharma’s products. For instance, the federal Medicare and
Medicaid programs for older adults, the disabled, and poor purchase more than $100 billion a year of drugs and devices (Pear,
2012). With regard to the biomedicalization of human distress and suffering, the pharmaceutical industry and the federal
government function as corporate partners in supporting the therapeutic state.
The federal government collaborates with the APA on many fronts, serves as patron of institutional psychiatry via the NIMH, and
utilizes the myth-enhancing DSM in its proclamations. Moreover, through regulation and funding of medical and social services in
conjunction with the states and through its “public health” policies identifying “mental health” goals, it has institutionalized,
sanctioned, and legitimized the disease model of madness. Through policies governing health care, Medicaid, Supplemental
Security Income (SSI), and Social Security Disability Insurance (SSDI), and making both public and private health insurance
programs offer “parity” coverage for the mentally ill, the federal government has provided enormous financial incentives to states,
hospitals, clinics, and providers of mental health services to interpret human distress as symptoms of brain disease. The boom in
rates of mental disability for adults and children are striking. Angell (2011) notes an increase of 250 percent for adults between 1987
and 2007, and a thirty-five-fold increase for children. The offer of insurance coverage for psychiatric help and cash supplements for
those in poverty if they are “disabled” is seductive and exploited by all players in the system. Robert Samuelson in the Washington
Post calls Social Security’s disability program a budget-busting, expensive “political quagmire” (Samuelson, 2012). The
mechanisms for creating these huge increases in mental disability are the focus of many of our chapters: confusing the illness
metaphor with reality, accepting brain disease as the ultimate cause of misery sans evidence, reifying arbitrary DSM categories, and
creating the illusion that safe and effective medications are available. The government has become a full partner with psychiatry in
medicalizing human problems.
The problem is this: people who need assistance are labeled as mentally ill in order to receive income supports, health care, and
social services. Why do so many people need assistance? The economy is stalled or spiraling down, fewer unskilled jobs are
available and unemployment has increased, inflation-adjusted wages for the average middle-class family have not increased in two
generations, record numbers of families have lost their homes, and services from nonprofits and local and state governments have
been sharply cut in the Great Recession. Millions of adults and children, normally living in relatively precarious circumstances, are
now under enormous social stress. This stress does not result from the increasing incidence of brain defects, but from economic and
policy defects. These people need opportunities and assistance, and social workers and mental health clinicians would like to help
them with some of their problems so that they might seize opportunities or bear discomfort more constructively until circumstances
improve. But to help an increasing number of these individuals today can only be done after fulfilling one enormously silly
requirement: diagnose them with some form of mental disability or mental disorder. As one psychiatric blogger noted
(thelastpsychiatrist.com, 2011):

If, however, you abolish SSI then you will reduce psychiatry to the size of neonatal endocrinology [very small]. If you
uncouple social services from “medical disability”—not abolish them, just find some other, better, more logical way to
distribute them—you’ll change America forever. . . . Psychiatry serves at the pleasure of the government.

Change of all kinds prompts resistance. The familiar, even if uncomfortable, often trumps the unknown; uncertainty causes
understandable feelings of anxiety. Institutions as well as people are suspicious and defensive of calls for reform, even when they
can expect the change to be beneficial. They might lie and confabulate to keep things the same. None of this is surprising. Even
scientists trained in critical thinking, as Thomas Kuhn (1962) argued in his famous book, The Structure of Scientific Revolutions,
resist findings suggesting that their theories are inadequate.
This is certainly the case in trying to suggest an alternative to the medical and public health model of madness. Biomedicine is a
great success story. Epidemics of infectious disease were averted or prevented, fatal afflictions became treatable or were eradicated,
infant mortality was reduced and life-span accordingly increased. Science has triumphed over nature by producing knowledge that
has greatly improved the quality of life for billions of individuals. There is no question about this. Thus, we understand why it is so
alluring to view madness as a brain disease that awaits a miraculous cure.
But the available empirical research literature, corroborated by even the most enthusiastic supporters of the notion that
disturbances of behavior are diseases, provides no convincing evidence that this is so. Yet the public is as quick as NIMH and the
APA to nourish this illusion. The seduction is easy to appreciate. The medical explanation of human travails provides comfort,
solace, and hope. It suggests that personal distress, inadequacy, and failure are really due to internal neurological defects that once
fixed will eradicate these failings, much as antibiotics cure bacterial infections. It promises that people will not be held responsible
for their failings. It promises John March’s happy myth of “a world without mental illness.” This illusion also helps all the
institutions and bureaucracies that must count and categorize people and their troubles in the process of trying to help and support
them. Even invalid classifications grounded in myth can ease the work of organizations, particularly once they become dependent on
them to rationalize their operation. There is also a dark side to using mental illness as the focus of scientific efforts, and that is to
scapegoat those who are called mentally ill. In the second debate of the candidates in the 2012 US presidential campaign, President
Barack Obama actually mentioned the “mentally ill” on three occasions, surely an unusual occurrence in such a forum. Twice, he
proposed keeping guns out of the hands of “the mentally ill.”5 Although, as we have cited earlier, the APA claims that 25 percent of
the US population in any given year, and 50 percent over their lifetime, will be mentally ill, we suspect that the president was not
slyly introducing a new gun control strategy.
 Imagining Alternatives
Despite the described difficulties of mad science and how its results have become institutionalized in mental health policy and
practice, there are alternative ways of thinking about and reimagining the provision of services for people in need. Some of these
alternatives already exist, although at the margins of mental health practice. We offer here a few suggestions for a different roadmap
for charting a more reasonable and humane future for those in the current mental health system.
Individuals and families in distress have always turned to others for advice, explanations, and solutions. Historically, help was
sought from members of the extended family, neighbors, village elders, spiritual healers, witchdoctors, and priests. The assistance
provided by these traditional sources of help was sometimes effective and gratefully received. At other times, the effects were
illusive, questionable, or harmful. Faith in the healer, good fortune, and placebo effects undoubtedly aided helping efforts. By the
late twentieth century, however, such traditional sources of help were devalued, as the biomedical industries encouraged people to
turn first to medical professionals. Assistance with personal and family problems was moved under the jurisdiction of the new
mental health professions and the medical establishment. Interpersonal supports were transformed into medical interventions,
talismans into pharmaceuticals.
During this cultural transformation, the definition of normal was narrowed, and the perimeter of pathology was expanded. In the
old normal, one recognized that existence is a struggle, an effort to be engaged with the world. Everyone’s life had its ups and
downs; people had strengths and weaknesses; and all experienced times of loss, disorientation and restoration, failure and resilience.
Some dealt better than others with these challenges. This was viewed as part of the textured variation and diversity of human life.
But, as we have described in this book, much of this diversity of life, some of it quite troublesome, has been redefined as an
ominous sign of incipient brain disease. To a great extent, the public accepts this medicalized view that traumas, fears, dilemmas,
conflicts, and misbehaviors are not inevitable parts of the human comedy but expugnable illnesses. The new implicit definition of a
normal or “healthy” person is someone who will harbor no serious worries or animosities, no undue sadness over losses or failed
ambitions, no failures or disabilities, no serious disappointments with children or spouses, no doubts about themselves or conflicts
with others, and certainly no strange ideas or behaviors. Those who fall short of these lofty expectations become candidates for
psychiatric labeling. By reframing personal troubles or differences, especially serious ones, as psychiatric illness, as expressions of
brain disease, people can be released from individual responsibility for imperfections of mood and behavior. They are given a
temporary pass. Unusual behavior is a result of disease; foul moods the outcome of chemical imbalances.
It is incontrovertible that many, if not all, people face distress of many types and from diverse sources. People try to cope with
distress in many different ways, some by seeking professional help. This is natural and prudent, because many may benefit from
such professional help and support. Nothing we have argued in this book is an attempt to ignore or deny these elemental facts.
Seeking professional help, especially voluntarily and in an informed manner, can be a positive method of coping. Psychotherapy
(structured conversations or activities focused on the client) with caring, capable, and committed helpers of all stripes, even
nonprofessionals, can be extremely helpful. Psychoactive drugs may be perfectly effective, if informed and willing clients choose
them based on clearly announced profiles of effects.
The fact is, however, that assistance for those who need and want it can be offered without using the DSM’s list of contrived
mental disorders. A fidgety boy or an adult who thinks the devil is out to kill him does not need to be labeled as suffering from a
brain disease called Hyperactivity Disorder or Delusional Disorder. They are more usefully and honestly called . . . a fidgety boy
and a person with incredible, scary beliefs. People who are distressed or misbehaving can be helped without inferring some, as yet
undiscovered, neurological defects. Exhibiting an arbitrary number of ambiguous “symptoms” from a DSM checklist and, thereby,
qualifying for a mental disorder label and insurance reimbursement, is neither necessary nor perhaps the best way to allocate
assistance. Our current system has many drawbacks. First, labels of mental disorder imply that the needed help is “medical,” which
currently results overwhelmingly in a prescription for one or more medications written quickly by physicians who are not paid to
investigate realistically what is the matter with the patient (Carlat, 2010; Greenberg, 2010; Harris, 2011). Second, the labels
incorrectly imply that a specific medication can be effectively used with all people having the same label (Moncrieff & Cohen,
2005). Third, it disregards the vastly different skills and personal resources that each person may have that bear directly on their
capacities to contend with their own weaknesses and fears (Saleeby, 1992). Forcing those who are most socially vulnerable—the
poor, the uninsured, the marginal, or inept—to submit to becoming officially mentally ill in order to receive financial assistance,
health care, social services, educational services, and other forms of assistance is medically and socially improper and unnecessary.
This sorting may be bureaucratically useful and politically safe, but both scientifically and as a matter of social policy it is deeply
flawed. We realize that changing that entrenched system, with so many stakeholders gripping firmly to the illusion that human
suffering is merely a matter of disease, is a tall order. But the only possible way that Dr. March’s wish for a world without “mental
illness” will be achieved is by abandoning that very term.
The alternative view is that the array of misbehaviors, mistaken and disturbing feelings experienced by those now labeled with
brain disorders are better viewed as normal human experiences in all their varieties, as described by scholars in sociology,
psychology, anthropology, history, philosophy, and other disciplines that study the human condition, than by neuroscience. We
realize that this view is not as seductive, comforting, or immediately useful, even if it is more accurate. Such an expanded view does
not dismiss human agency or personal responsibility. It recognizes that individuals are inextricably rooted in and influenced by the
social environments in which they struggle and flourish. It acknowledges the power of cultural and social learning and accepts the
imperfections of the human condition. It also embraces the power of individuals and communities to provide compassionate
assistance to others when needed. There are no silver bullets for the human condition, only collective and personal striving to cope.
As a result we think that psychiatry must abandon one of the two foundational roles allocated to it. First, the two professional
roles that have been sanctioned by society for psychiatry must be decoupled: the pseudomedical coercive police or social
management of behavioral deviance (involuntary treatment and involuntary hospitalization)6 from the therapeutic or helping role for
people seeking to ameliorate their minor and serious problems in living (voluntary treatment). This would put psychiatry on par with
all other medical and helping professions, who are judged as providing help, or not, by the recipients of their services.
Because the scientific evidence for the reality of mental diseases is nonexistent, no rationale for such entities causing harm to
others should be advanced, and so psychiatry’s police and social management role must be integrated back into the already-existing
legal system, where bad behavior toward others beyond a certain level of intensity is deemed either a civil or criminal offense
subject to penalties ranging from probation to community service to fines to imprisonment and, ultimately in American society at
present, to death. This approach makes clear to all that bad behavior deemed directly harmful to others has consequences and that
outside of the legal (not psychiatric) finding that the individual lacks mens rea (a guilty mind) and therefore is not responsible, the
proper penalty is imposed. This in no way should prevent someone who wishes voluntarily to be helped to change behaviors that
might have caused the harm from seeking and receiving help either during or after their punishment.
With regard to individuals who are at risk of harming themselves or threatening suicide, which is understandably deeply
frightening to others, helping professionals should continue to reach out vigorously and offer help but not engage in forced
treatment. With adults7 there are ethical concerns about whether professionals should act solely on their own assessment of an
identified self harmer, without full knowledge of why that person chooses to self harm. This is particularly the case since the
extensive research literature on suicide suggests that involuntary treatment in any form can neither predict when or if someone will
kill themselves, nor prevent a committed person from the act of suicide (Sher, 2004). Involuntary treatment may, of course, delay
that act. We think that mental health professionals should offer only voluntary help, free of coercion (since coercive “help” does not
work). Only in this way can helper and client honestly confront what is known and unknown about volitional human behavior, and
only in this way can troubled human beings seek self-understanding and realistic options to deal with the complexities of existence.
The regulation of psychoactive drugs could also use some bold rethinking. It’s obvious that medical practitioners do not engage
in any sort of sophisticated biomedical reasoning when they prescribe these drugs to distressed people and may actually engage in
illogical reasoning. Further, the collective judgment of psychiatric practitioners has been hijacked by the drug industry, and little
exists to ensure that individual prescribers’ decisions aim to protect individual patients’ best interests. Prescribers, it seems, are the
very last players to catch on to knowledge about the ill effects of the drugs they prescribe. With polypharmacy becoming the norm
and any class of drugs being prescribed for any presenting problem, the question is raised why a psychiatric diagnostician stands
between a patient and a drug. Whatever diagnosis-treatment pairings do exist (e.g., antipsychotics initially for psychosis,
antidepressants initially for depression, etc.) can be easily memorized by the average junior high school student. Moreover, with
direct-to-consumer ads now ubiquitous, prescription drugs have fully become consumer products. Finally, the Internet has already
revolutionized access to and dissemination of information about medications and can revolutionize how prescribers and users can
minimize unintended harm to users (Healy, 2012). This means that knowledge about drugs—about taking, continuing to take, or
ceasing to take them—is now distributed and being constructed far beyond the offices or authority of traditional medical experts.
For these and other reasons, one of the principal arrangements for providing access to psychoactive medications to people has
not served them well. In fact, granting physicians a monopoly on prescribing drugs is probably causing excess harm and needs to be
seriously challenged. Our own preference is to abolish prescription privileges. We don’t think they should be merely redistributed,
say, to clinical psychologists, who have lobbied their state legislatures since the 1990s to obtain them. We cannot justify that any
profession should possess a state-enforced monopoly to grant or deny people permission to use psychoactive drugs. Overall,
prescription privileges have hindered the discovery of psychoactive drugs’ potential benefits by hindering personally creative ways
to employ drugs (self-medication). Prescription privileges also help to perpetuate patients’ exposure to toxic effects and excessive
drug combinations that patients otherwise would probably never attempt on their own. Although we guess that medical prescription
privileges are widely seen as a “natural” arrangement for which no alternatives could possibly exist, the facts are that an explicit
argument for the existence of this arrangement cannot be found, and the notion that they comprehensively “protect the public” has
never, ever been critically tested (Cohen, 2008). Thomas Szasz and David Healy are two psychiatrists who differ fundamentally on
their understanding of madness and the proper spheres of psychiatry as a profession. However, it happens that both have analyzed—
the first from a libertarian perspective and the second from a public health perspective—the prescription psychoactive drug system.
Both have proposed abolishing prescription privileges (Healy, 1997, 2012; Szasz, 1992).
Regardless of who is licensed to prescribe drugs, safety should be the primary formal concern of the FDA, and perhaps its only
concern. The 1962 Kefauver amendments mandated the FDA to establish both efficacy and safety of drugs before their approval for
marketing. We think the FDA has failed miserably in its mandate to establish the efficacy of psychiatric drugs currently on the
market. From the perspective of a potential or actual user of these drugs, establishing their efficacy via randomized clinical trials has
been a colossal waste of money and resources. Worse, clinical trials have radically restricted the understanding of psychoactive
drugs as substances with psychoactive (and other) effects and created the absurd impression that every psychoactive drug that
someone might find useful must fit to a “disease.” And all this occurred despite the “efficacy” established by the drug’s
premarketing investigation having practically no bearing on how the drug will be prescribed once it’s on the market. “Efficacy” is to
clinical trials as “protecting the public” is to prescription privileges—a ruse.
If people were allowed to determine for themselves how to use chemical aids for the vicissitudes of life—with all the guidance,
advice, and recommendations that experts and authorities wish to provide them and should be able to provide them—any genuine
psychological benefits deriving from drug use are more likely to be discovered and then nurtured by users. Without the arbitrary
obstacles and barriers erected to benefit pharmaceutical companies that have been documented in this book, information about
drugs, their uses, their effects, their advantages, and their disadvantages should flow more freely. Individual consumer preferences,
rather than clinical or regulatory commercial prerogatives or strategies, should determine the value of a psychoactive drug. Adverse
effects—so defined by whoever would wish to so define them, rather than by industry-sponsored researchers and bureaucracies
aided and abetted by the FDA—should be immediately publicized. This would reduce use of bad drugs, just as investors recoil from
a bad stock if the system isn’t manipulated to withhold or suppress information about the genuine value of stocks. In sum, no one
would need to take a useless or harmful drug merely because only an overwhelmed and disinformation-vulnerable doctor controlled
access to pharmaceuticals.
So-called clinical trials could be broadened to include many other ways to evaluate the impact of drugs ingested for long periods
of time on complex biopsychosocial beings. This would help to establish safety as the genuine central concern of a drug regulatory
system. As to ascertaining benefits of drugs, clinical trials would have to define these benefits from users’ perspectives rather than
employ contrived outcome measures of short-term “symptomatic improvements” decided upon by psychiatric investigators. The
range of tested drugs would, of course, have to encompass more than just the chemicals that drug companies can patent, to include
the countless psychoactive drugs that may have important benefits for people experiencing psychological distress. Of course, this
proposal is not nearly as practical as it is logical, as it comes up against the century-old wall of drug prohibition. As Szasz (2004)
aptly reminds,

In the absence of a free market competition between legal and illegal psychoactive drugs—say, lithium and opium—the
benefits of psychiatric drugs, as the patient defines benefit, will remain unknown and unknowable. (p. 178)

If one were interested in conducting genuine real-world trials of psychotropic drugs, one should compare realistic options,
including drugs with other forms of help, tailored to broad groups of individuals with varying preferences. To accomplish this,
different stakeholders (the federal and state government, insurance companies, Consumer Reports, family lobbies, independent or
charitable foundations) must get involved in funding clinical trials—especially since establishing so-called efficacy for a “disorder”
would not drive the entire process of bringing a drug to market. Moreover, as former British Medical Journal editor Richard Smith
(2005) has already suggested, medical journals should agree not to publish company-funded clinical trials, only critical reviews of
such trials, and only if their data are publicly available for reanalysis. Such reforms would help to free disciplined psychoactive drug
use (i.e., drug use as therapy) from its current pseudoscientific pretensions, its disease justifications, and its medico-legal guardians.
Enhanced by a rapidly developing technological matrix, it’s possible that a truly consumer-oriented “cosmetic
psychopharmacology” would bloom. Though we think cosmetic psychopharmacology remains a mythical, hopeless pursuit, society
might have an easier time to regard it as such. The availability of psychoactive drugs by prescription is a monopolistic arrangement
that remains extraordinarily sheltered from critical examination. Perhaps this is so because the arrangement sweeps—under the
veneer of medical experts directing diseased people toward efficacious treatments too dangerous to understand by anyone but the
self-styled experts—a mountain of painful, exceedingly complex personal and social ethical and practical choices. Our society is
hesitant to tackle these choices forthrightly because they rest on ill-clarified values concerning the availability of chemical
performance enhancement in education, working, and sports.8
 How Change May Come
Despite all of our concerns just expressed about the difficulties ahead for alternate ways to handle madness, we still remain
optimistic. As far as we can tell mad science has failed: it informs us that madness has grown, not shrunk, with about one in five
American adults diagnosable as mentally ill today. We don’t know much more—and perhaps less—about madness after the famed
decade of the brain than we did before. Medications must obviously be beneficial for some people who take them, but that is not
saying much, given the extent of iatrogenic harm and the baseline level of appreciation of any and all psychoactive substances by
their users.
We think, keeping in mind our conviction that all forms of psychiatric coercion must be disavowed and disallowed, the first step
is to get this information out to the population at large. Some of this has already begun and is accelerating, and unsurprisingly it is
being led by some mainstream psychiatric insiders who provide a steady flow of articles and books about much that is wrong with
psychiatry and the way it handles its charges. This expands public awareness, fueling further debates, which in turn encourage
further critical examinations. We believe that this cycle cannot but be self-reinforcing (as previous cycles of reform that we have
criticized have been). We can imagine a future time when a forward-thinking foundation or a Silicon Valley billionaire funds a series
of well-crafted commercials adeptly communicating to ordinary people the scientific and moral emptiness of the mental health
enterprise in our society.
When the information and the wasteful expenditure of public funds are more broadly disseminated, we believe that both mad and
“normal” citizens will be energized. The so-called grassroots mental health recovery movement is the first sign that mad people can
take care of themselves if they so desire. The surgeon general’s report on mental health (US Department of Health and Human
Services, 1999) recognized that the recovery movement is helping the mad to have “a more optimistic view of the possibility of
recovering.” Official recognition of this movement by psychiatric authorities has likely resulted from “the contemporary wave of
writings [with] their critical mass, organizational backing, and freedom of expression from outside the institution” (pp. 97–98). This,
together with the massive failure of institutional psychiatry to successfully deal with the problem of madness, triggered a lobby
powerful enough to gain the attention of experts and authorities. We believe, however, that the official recognition of the recovery
movement occurred also because its main spokespersons did not directly question the reality of mental illness and only mildly
challenged the medical management of mental patients. So, as long as the foundational belief in madness as mental disease is
apparently assented to by this movement, institutional psychiatry can appear gracious to recognize some of its tenets, that mad
individuals can be helped to “build full meaningful, and productive lives . . . [by] a focus on life goals, consumer involvement, a
diversity of treatment options, an emphasis upon consumer choice, and individually tailored services” (Kidd et al., 2010, p. 343).
Again, we think that this agenda ultimately must be met with the absence of coercion and without superfluous diagnoses (unless
helpers and their contracting clients wish to use “diagnoses” they agree upon).
We are also impressed by the fact that knowledge that was once the prerogative of medical professionals is now discussed with a
high level of intelligence and wisdom by ordinary consumers who are seeking to acquire information and to share information with
others. We’ve briefly reviewed in an earlier chapter how the aggregate, first-person reviews of prescribed psychoactive medications
by consumers may resemble much of what official and “authoritative” medical accounts disseminate, with the useful added
dimension of providing contextual clues and insights to people trying to make treatment decisions. As technological progress
increases the ability to use these freely available databases and to allow even more focused and individualized contributions from
laypersons, many pseudoscientific pretensions of clinical psychopharmacology might be laid bare.
We believe that these cracks in the fortress of the medical model can be used to engage both the mad and their families to move
further away from the current system. This is absolutely essential, because the system will not be changed entirely from within.
Power is not voluntarily relinquished, but those in power respond when the formerly powerless coalesce around critical issues that
cannot be ignored. If the extent of the failure of psychiatric practice is made clear to the mad, their families, and friends, the critical
dialogue may become more earnest. There is, of course, the unpredictable but remote possibility that the psychiatric system
produces its “Gorbachev,” a widely acknowledged leader and spokesperson who says plainly and loudly that the emperor has no
clothes, that while many people could use help for their distress or have their disturbance contained to preserve our peace of mind,
there is no mental illness.
The current worldwide economic crisis and the related serious debates about health-care costs will directly affect the issues of
change in the mental health system. Since most mental health costs are paid for by public monies, the system appears unlikely to
sustain the current infrastructure based on the medical model, although societies have in the past and in our time pursued
wrongheaded policies that nearly ruined them. If our analysis is correct, moving toward an increasingly demedicalized, voluntary
approach could reorient the services needed (even a moderate reduction in involuntary hospitalizations will reduce expenditures by
billions of dollars, though it could increase expenditures by other social control systems).
Our suggestions may seem radical, but we think that both ethics and science are on our side. There can be no cutting-edge
science in this field as long it rests on the unverified but reified concept of mental disease or mental disorder. Society’s response to
personal distress and misbehavior should be guided by the ideals of compassion, justice, tolerance, education—and yes, protection
of society. Human existence, the struggle for survival and for fulfillment, entails an effort to improve the troubled and fallible world
of human beings. That effort must be tempered by the oft-confirmed realization that solutions lead rarely to their intended
consequences. And even then, they entail other, unimagined consequences that must be resolved, creating other new problems . . .
ad infinitum. In place of gleaming but illusory promises of medical cures for madness, we would all be better served by recognizing
the inevitable precariousness of the human condition. To move society forward in the service of others who request help, the best
that human beings are capable of is taking courageous steps based on honest critical analysis and debate, and constant scrutiny to
minimize harm and monitor unintended consequences.
 Notes
1. Some of these books include the following: Psychiatry: The Science of Lies (Szasz, 2010), Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations about a
Profession in Crisis (Carlat, 2010), Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (Whitaker, 2010),
The Emperor’s New Drugs: Exploding the Antidepressant Myth (Kirsch, 2010), Pharmageddon (Healy, 2012), Manufacturing Depression: The Secret of a Modern
Disease (Greenberg, 2010), and The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment (Moncrieff, 2009).
2. State laws vary, but jurisprudence has established that professionals’ actions do not depend directly or entirely on the patient’s behavior. Rather, they depend on a variety
of factors, including: the duration of the relationship established with the patient; the implicit and explicit promises professionals have made; the type of consent provided
by patients; the usual responsibilities of the setting in which the relationship occurs; and other factors. A competent technical description of one large state’s commitment
laws is found in Behnke et al., 2000. A first-person account by a practicing psychiatrist of coercion and commitment in the psychiatric emergency room is found in Linde,
2010.
3. In a remarkably thorough and well-documented book, Robert Whitaker (2010) argues that the modern psychiatric drug treatments have created an enormous swell of
iatrogenic injury in the form of neurobiological dysfunctions. Thus, the antipsychotics have damaged the dopaminergic systems, and SSRI antidepressants have damaged
the serotonergic and monoaminergic systems, of people who take them for long periods of time. Whitaker also argues that these neurological dysfunctions explain the
increase in counts of what he calls mental illness, principally as inferred from the number of people receiving social security funds for mental or behavioral disability in
the United States since the widespread use of these drugs. We think that Whitaker’s arguments concerning iatrogenic damage are persuasive, but we question calling drug-
induced injury “mental illness.”
4. French researchers from University of Bordeaux and one of the authors of this book (DC) teamed up to analyze how the media echoed scientific findings. They identified
the ten scientific studies on ADHD most-often echoed by English-language newspapers during the decade of the 1990s, as well as sixty-seven subsequent scientific
studies that investigated the same questions until 2011. While 223 newspaper articles covered the first 10 studies, only 57 articles covered the subsequent related studies.
More important, the authors found that the findings in eight of the top ten studies were either refuted or strongly attenuated in the subsequent studies. This fact, however,
was acknowledged in only a single of the fifty-seven newspaper articles covering these subsequent studies. The authors conclude: “Because newspapers preferentially
echo initial ADHD findings appearing in prominent journals, they report on uncertain findings that are often refuted or attenuated by subsequent studies. If this media
reporting bias generalizes to health sciences, it represents a major cause of distortion in health science communication” (Gonon et al., 2012).
5. According to the transcript of the October 16, 2012 debate, published by the Commission on Presidential Debates, President Obama’s three mentions were the following:
1) “So my belief is that, (A), we have to enforce the laws we’ve already got, make sure that we’re keeping guns out of the hands of criminals, those who are mentally ill;”
2) “And so what I want is a—is a comprehensive strategy. Part of it is seeing if we can get automatic weapons that kill folks in amazing numbers out of the hands of
criminals and the mentally ill;” 3) “We’re not going to eliminate everybody who is mentally disturbed, and we’ve got to make sure they don’t get weapons.” (Retrieved
from http://www.debates.org/index.php?page=october-1-2012-the-second-obama-romney-presidential-debate)
6. This would necessitate abandoning all statutory authority for involuntary hospitalization and treatment.
7. Children, the largest coerced minority in the world, have exceedingly few rights to make autonomous decisions. Regarding their self-harming behaviors or actions, like
any of their other actions, children should continue to be subjected to parental authority and “treated” according to that authority’s best judgment, except where that
authority is deemed judicially not to operate in the child’s best interest, in which case the standard legal procedures as exist today would be applied.
8. Perhaps this critical examination might be triggered by what we think are three important and extremely unusual newspaper publications, all appearing in late 2012 in the
New York Times and the Washington Post. The first is a series of six brief position papers arguing the pros and cons of having various prescription medications available
to patients over the counter, without a doctor’s prescription. The position statements appeared in the Times’ Room for Debate forum on September 16, 2012, under the
title “Getting Your Prescriptions, Without A Prescription,” and thoughtful reader comments were appended (Available from
http://www.nytimes.com/roomfordebate/2012/09/16/getting-your-prescriptions-without-a-prescription). The second Times article, written by reporter Alan Schwartz,
appeared on October 9, 2012, with the title “Attention Disorder or Not, Pills to Help in School” (Available from http://www.nytimes.com/2012/10/09/health/attention-
disorder-or-not-children-prescribed-pills-to-help-in-school.html?pagewanted=all). This article laid bare, for the first time as far as we know in a major media outlet, the
reality that both psychiatric diagnoses and medical prescription for drugs are merely convenient pretexts for making various psychoactive drugs available to users for their
own ends. Over seven hundred reader comments were quickly appended to that article. The third, an opinion piece by Brad Allenby, a professor of ethics and engineering
at Arizona State University, appeared in the Post on October 26, 2012, under the title “Lance Armstrong’s Fall: A Case for Allowing Performance Enhancement”
(available, along with nearly eight hundred reader comments, from http://www.washingtonpost.com/opinions/lance-armstrongs-fall-a-case-for-allowing-performance-
enhancement/2012/10/26/6f7cccf0-1d41-11e2-b647-bb1668e64058_story_1.html).
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 Index

AAHM (American Association for the History of Medicine), 56, 57

Abbott, Andrew, 9, 42
Abilify, 12, 14, 17–18, 19
abuse liability (for drugs), 257
Ackerman, Diane, 313
ACT (assertive community treatment). See assertive community treatment (ACT)
Action for Mental Health, 53–54
ADHD (Attention-Deficit/Hyperactivity Disorder). See Attention-Deficit/Hyperactivity Disorder (ADHD)
Affordable Care Act (2010), 177–178
Albert and Mary Lasker Foundation, 55
Alchemy of Mind, An (Ackerman), 313
alcohol, 168, 179, 241
alcohol psychosis, 65
Alcohol Use Disorder, 193
almshouses, 43
alprazolam (Xanax), 219, 270–271, 271, 273
Als-Nielsen, B., 283–284
Ambien, 219
American Association for the History of Medicine (AAHM), 56, 57
American Association of Psychiatric Social Workers, 53
American Medical Association (AMA), 18, 53
American Psychiatric Association (APA)
conflicts of interest and, 182–183
on definition of mental disorder, 5, 7
DSM and, 121, 126, 156, 174, 175–176
DSM-5 and, 179–180, 186–187
formation of, 47
gay rights and, 136–137
JCMIH and, 53
on mental disorders as brain diseases, 1
NIMH and, 55
share of budget from pharmaceutical industry, 216
American Psychological Association, JCMIH and, 53
amphetamines, 215, 217, 243, 249
Andreasen, Nancy, 8, 140
Angell, M., 318
animal tests, 256–257, 267
anticonvulsants, 225–226, 246, 247, 277–278
antidepressants
effects of, 246, 248
increase in use of, 315–316
introduction of, 269–270
marketing of, 29, 277–278
multiple prescriptions with, 219
placebos vs., 229–230, 232, 250
prevalence of, 214–215
trials for, 228
See also Sequenced Treatment Alternatives to Relieve Depression (STAR*D); serotonin-reuptake inhibitors (SSRIs)
antipsychotic drugs
atypicals, 265–267
children and, 266
description of, 246–247
hopes for, 249
marketing of, 277–278
See also drug treatments; individual drugs
anxiolytics, 223, 270
APA (American Psychiatric Association). See American Psychiatric Association (APA)
Appel, Kenneth, 77
Asperger’s syndrome, 190
assertive community treatment (ACT)
absence of report on, 95
characteristics of, 102–103
claims of success of, 104–109
coercion and, 77
early patients of, 99–100
effectiveness of, 103, 304–305
failure of, 27–28
history of, 97–99
invention of, 80, 304
patient responses to, 105
 See also community care
AstraZeneca, 19
Asylum for the Relief of Persons Deprived of the Use of their Reason, 44
asylums
criticism of, 135
doctors as superintendents of, 46–47
in early America, 44
integrated medical/moral approach and, 46–47
neuroleptics and, 263–265
shift toward, 68–69
state mental hospitals as, 48–49
Asylums (Goffman), 135
atomoxetine (Strattera), 257–258
Attention-Deficit/Hyperactivity Disorder (ADHD)
adults and, 254
criteria for, 7, 167–168, 173–174
drug treatments for, 242–243
false epidemic of, 185
kappa measures and, 152, 193
R. Riley and, 218
atypicals, 265–267
Austin, G. A., 39
autistic disorder, 185, 190, 193, 194
Azrin, N. H., 101–102

Bachman, Christian, 213

Ban, Thomas, 287n1
battle fatigue, 49
Bauer, Peter, 38
Beard, J. H., 106–107
Becker, Howard, 3
Begley, Sharon, 249–250, 254
Benson, K., 261
benzodiazepines, 246, 270–271
Berk, Richard, 91
Bernstein, Carol, 149
Berrios, German, 63
beta blockers, 254
biases, psychiatric historiography and, 63–68. See also conflicts of interest
Biederman, Joseph, 21, 182
Big Science, 313–317
biological targets
drug treatments and, 251
See also biomarkers
biomarkers, 38, 251, 307, 317
biopsychiatry, 144
bipolar disorder
advertising and, 17–18
children and, 182, 218
drug treatments, 224–226
drug treatments and, 220
epidemic of, 21, 185
kappa measures and, 193
overdiagnosis of, 18–21
Bond, Gary, 96
borderline personality disorder, 146, 193
Bourgeois, Marc, 244
Brandeis, Louis, 301
Brandsma, Jeff, 98, 100–101
Breggin, Ginger, 235
Breggin, Peter, 235
Brief History of Madness (Porter), 63
Bristol-Myers, 18
Browning, R. M., 100
Bruner, J. S., 39
bupropion (Wellbutrin), 223, 288n7
Bureau of Justice Statistics, 54

Cade, John, 263

Campbell, Donald, 26
Caplan, Paula, 194
Carey, Benedict, 18
Carlson, Eric T., 64
Carlson, Gabrielle, 20
Catch 22 (Heller), 49
catharsis, 41
CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness). See Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE)
Celexa (citalopram), 222
Centers for Disease Control and Prevention (CDC), 315–316
chemical imbalances, belief in, 251–252
children
antipsychotic drugs and, 19
bipolar disorder and, 19–21. See also Wagman, Benjamin
disease mongering and, 19–20
 pharmaceuticals and, 17, 18
serious emotional disturbances and, 4–5
chlordiazepoxide (Librium), 270
chlorpromazine, 220, 263–264, 287n1
chronicity, 99–100, 113n3
citalopram (Celexa), 222
Civilization and Its Discontents (Freud), 130
classification, 127–128, 141
Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), 220–222, 226–227, 233–234, 266
clinical treatment effect, 113n6
clonazepam (Klonopin), 270–271
clonidine, 218
clozapine, 254, 265
coca, 241
cocaine, 242, 248
Cochrane Collaboration, 94, 113–114n6
“Code of Chronicity, The” (Ludwig and Farrelly), 99–100
coercion
ACT and, 106–109
concern regarding, 301
development of ACT and, 100
emergence of, 75
endurance of, 304–307, 311
forms of, 87–88
impact of, 84–85
justification for, 78–79, 305–306
overview of, 26–28
purpose of, 76–77
reliance on, 80, 109–111
statistics on, 86–87
See also confinement, forced; hospitalization: involuntary; treatments: involuntary
Coercion and Aggressive Community Treatment (Dennis and Monahan), 108
Coercive Treatment in Psychiatry (Monahan), 108
coffee, 235, 241
Cohen, D., 247, 258
Cole, Jonathan, 313–314
combat conditions, 51. See also military service
Committee on Finance, 279
community care
coercion and, 87–88
military service and, 51, 52
overview of, 26–28
shift toward, 52–53, 54, 81, 304
See also assertive community treatment (ACT)
comorbidity, 113n3, 171–172
Concepts of Insanity in the United States (Dain), 56, 64
confinement, forced, 41–42, 83–84. See also asylums; coercion; hospitalization: involuntary
conflicts of interest, 282, 307–308, 317–318
continuing medical education, 278–279
controlled trials, 259–261. See also randomized controlled trial (RCT)
convulsive treatments, 264–265
Coppel, Anne, 213
cosmetic psychopharmacology, 248–249, 326
Costello, Jane, 18
cure, meaninglessness of, 274–275

Dain, Norman, 56, 64

Dartmouth Assertive Community Treatment Scale (DACTS), 108
Davis, J. M., 108
DEA (Drug Enforcement Agency), 243, 309
DeGrandpre, Richard, 213–214, 243
deinstitutionalization, 26–28, 53, 69, 81, 82–83, 133, 304
Delay, Jean, 263
dementia praecox, 128, 265. See also schizophrenia
Deniker, Pierre, 263
Dennis, D. L., 108
depakote, 218, 288n7
DePaulo, J. Raymond, Jr., 232–233
depression
drug treatments and, 212, 220, 222–224, 271
DSM and, 190
rates of, 273–274
Deutsch, Albert, 52, 64
dexfenfluramine, 254
diagnosis
descriptive, 28, 144, 163, 165, 307–308
development of, 28–29
DSM and, 2
heterogeneous nature of, 90
history of, 126–131
irrelevance of, 199–200
process of, 143–144
reliability of, 122–123
revision of, 28–29
Diagnostic and Statistical Manual of Mental Disorders (DSM)
background of, 121–122
on definition of mental disorder, 5–6
diagnostic criteria in, 125, 165
dissemination of, 31n1
drug trials and, 259–260
early editions of, 127
effect of on diagnoses, 272–273
example of changes to, 147
expansion of, 2, 125–126, 139–140, 145–146, 174–175. See also Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5)
field trial data and, 149–156
harms of, 195–200
homosexuality and, 137
reliability of, 147–149
research distortion and, 197–198
revision of, 2, 307–308
social context and, 168–169
Spitzer and, 138–141, 145
surgeon general’s reference to, 67
telephone study and, 123–124
validity and, 164–165, 198
on variation in diagnoses, 90
See also diagnostic criteria
Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5)
conflicts of interest and, 180–184
controversy over, 307
on definition of mental disorder, 5–6
diagnostic reliability and, 191–193
draft of, 188–191, 195
field trials and, 187–188, 192–194
planning for, 179–180
Spitzer and Frances’s criticism of, 184–188
diagnostic criteria
ambiguity of, 166
comorbidity and, 171–172
creation of, 144, 146–147
cutoff numbers and, 169–170
dimensionality and, 172–173
heterogeneity within, 170–171
redundancy of, 166–168
social context and, 168–169
validity and, 163–164, 165–166, 312
Diagnostic Interview for Personality Disorders (DIPD-R), 153–154
Diamond, Ronald J., 100, 107
diazepam (Valium), 270, 277
Dilantin (phenytoin), 254
direct-to-consumer advertising (DTCA), 280–281, 324
Discovering the History of Psychiatry (Porter & Micale), 58
disease-centered model, 212, 245–247
disease model of distress and misbehavior, 300
disease model of madness, 38, 200, 245, 307, 318, 320
disease mongering, 19, 215
distress, meaning of mental illness and, 8
Dix, Dorothea, 48, 50–51
Dìxon, L. B., 104
dopamine, 267, 268
double-blind placebo control, 260–261
Drake, Robert, 305
drug cocktails, 218–219
Drug Enforcement Agency (DEA), 243, 309
drug reps, 280
drug samples, 280
drug treatments
aims of, 276–277
deinstitutionalization and, 82–83
DSM and, 272–273
history of, 214–215
lack of efficacy of, 23, 30, 212–213, 220
overview of, 29–30
popularity of, 211, 218
promotion of, 277–282
psychoactive effects of, 234–235
purpose of, 79–80
studies on, 79, 220–231
tranquilizers, 79
See also Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE); pharmaceutical companies; Sequenced Treatment Alternatives to Relieve Depression
(STAR*D); Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)
drug trials
biases in, 282–285
distortion of, 312–313
See also randomized controlled trial (RCT)
drug-centered model, 247
DSM. See Diagnostic and Statistical Manual of Mental Disorders (DSM); Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5)
DSM-5 Research Planning Conference, 179–180. See also Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5)
dysfunction, attempts to define, 5
EBM (evidence-based medicine), 27, 77, 88–97
EBP (evidence-based practice), 27, 94–97
ecstasy, 287n4
Effexor (venlafaxine), 223, 246
Ehrenberg, Alain, 244, 249
Eisenhower, Dwight, 131
electric shock experiment, 100–102
Elliott, Carl, 280
Engstrom, E. J., 68
environmental factors, as cause of mental illness, 51
Epidemiological Catchment Area Survey, 273
Equanil (meprobamate), 270
Euripides, 41
evidence-based medicine (EBM), 27, 77, 88–97
evidence-based practice (EBP), 27, 94–97
Ewalt, Jack R., 77

false negatives, 166, 170

false positives, 170
falsificationists, 26
families, institutional dynamics and, 15–16
family care, 68
Farrelly, Frank, 98, 99–100
Faughey, Kathryn, 11
FDA (Food and Drug Administration). See Food and Drug Administration (FDA)
Federal Health Care and Financing Administration, 108
Fédida, Pierre, 249
Feinstein, Alvan, 89–90, 92
Felix, Robert, 54, 55
Field, Steve, 270
field trials, funding of, 314–315. See also Food and Drug Administration (FDA): approval process and; randomized controlled trial (RCT)
financial incentives, 106, 107
for brain surgery, 13
See also pharmaceutical companies: payments from
first aid psychiatry, 51
Fisher, Seymour, 232
Fitzpatrick, Michael, 16
Fleiss, Joseph, 141, 142–143, 149, 151
fluoxetine (Prozac), 246
Food and Drug Administration (FDA)
advertising and, 281
approval process and, 254, 256–261, 309
co-option of, 250
criticism of, 18
efficacy and, 227–229, 324–325
user fees and, 279
force. See coercion
Ford, R., 104
Foucault, Michel, 135
Fountain House program, 106–107
Frances, Allen, 6, 110–111, 155–156, 175, 184–188, 191, 192, 194
Frankenburg, R., 262–263
fraud, 18. See also conflicts of interest
Freedman, David A., 91
Freud, Sigmund, 129–131, 132, 133, 248
From Discovery to Cure (NIMH), 317
fundamental attribution error, 168–169
funding issues, 85–86. See also financial incentives; pharmaceutical companies: payments from

gabapentin (Neurontin), 262

Gagnon, Marc-André, 277–278
Gauntlett, N., 104
Geller, Jeffrey, 109–110
gene expression, 287n3
general paresis, 128
General/Generalized Anxiety Disorder, 166, 193–194
Geodon, 281
Gerard, Ralph Waldo, 287n1
ghostwriting, 282–283
glia, 255, 268
Goffman, Erving, 66, 112n1, 135
Goldman, Howard, 66
Goldsmith, L., 246
Goodnow, J. J., 39
Goodwin, Frederick, 182
Gorman, Mike, 55, 78
Governors’ Conference of Mental Health, 82
Gradumet, 242
Grassley, Charles, 21, 181, 217, 318
Greenberg, Gary, 185, 189
Greenberg, Robert, 232
Grob, Gerald, 43, 51, 52, 56–57, 62, 65–67, 82
Gronfein, W., 81
group aggregated averages, 89–90
Gruenberg, Ernest M., 77–78, 138

haloperidol, 266
Hardon, Anita, 231
Hartford Retreat, 46
Hartz, A. J., 261
Haynes, 93
health insurance, 157, 176, 177–178, 199–200, 318
Healy, David, 20, 213, 218, 268–269, 282, 283, 286, 324
Hegarty, J., 265
Heller, Joseph, 49
help-seeking efforts
alternatives for, 320–326
examples of, 9–15
Heres, Stephan, 283, 284
heroin, 242
Hershey, Lewis B., 50
heterogeneity within DSM categories, 170–171
Hill, P. A., 100
Hinckley, John, Jr., 112n1
Hippolytus (Euripides), 41
History of Clinical Psychiatry, A (Porter & Berrios), 63
History of Psychiatry, A (Shorter), 57, 64–65
Histrionic Personality Disorder, 166
Hoffman, Albert, 263
Holmes, Oliver Wendell, Jr., 301
Holz, W. C., 101–102
homogeneity within DSM categories, lack of, 170–171
homosexuality, 51, 136–137, 139, 145, 164, 306–307
Horwitz, R. I., 92
hospitalization
ACT and, 103–104
involuntary, 75–76, 80, 84, 86, 300
See also asylums; coercion; confinement, forced
housing, 88, 105–106
Hughes, S., 247
humoural theory, 41, 46
Humphrey-Durham amendment, 277
Hyman, Steven, 313

iatrogenic injury, 211, 214, 327, 329n3

iboga, 241
ignorance, exploitation of, 18
Illich, Ivan, 135
inadequate personality disorder, 146
incarceration, 86–87
Insel, Thomas
assessment of psychiatry by, 22–24
on biomarkers, 317
on EBTs, 86
on increase in bipolar diagnoses, 20
on inefficacy of treatment, 213, 214
on mental disorders as brain diseases, 6–7, 55–56, 69, 252, 253
Nemeroff and, 182
on studies of drug treatments, 234
institutional dynamics, 12–17
institutions
disillusionment with, 52
in early America, 43
See also asylums; deinstitutionalization; hospitalization
irrationality, views of, 41

Jacobs, David, 273

James, William, 39
JCMIH (Joint Commission on Mental Illness and Health), 53–54, 77–80, 81–82
Johnson & Johnson, 19, 95
Joint Commission on Mental Illness and Health (JCMIH), 53–54, 77–80, 81–82
judicial system, coercion and, 87–88
Jureidini, Jon, 284

Kant, Immanuel, 39
kappa measures, 142–143, 149–151, 192–193
Kazmierczak, Steven, 219
Kefauver amendments, 325
Kennedy, John F., 82, 131
Kessler, Ronald C., 113n3
Kifuji, Kayoko, 218, 219
Kirkbride, Thomas, 45
Kirsch, Irving, 228–229
Klerman, Gerald, 148
Klonopin (clonazepam), 270–271
Koch, Robert, 129
kola, 241
Kraemer, H. C., 192
Kraepelin, Emil, 47, 128–129, 130, 131, 143, 171
Kramer, Peter, 248, 273, 275
Krohe, James, 273
Kuhn, Thomas, 25, 319
Kupfer, David J., 179, 184, 189–190, 194, 198

Lader, Malcolm, 270

Laing, R. D., 135
Landis, Story, 252–253
Lasker, Mary, 55
Le Noury, Gabrielle, 20
Lehmann, Heinz, 264
Lexchin, Joel, 277–278
Librium (chlordiazepoxide), 270
Lieberman, Jeffrey, 220, 266–267
life cycle of medications, 255–262
Light, Donald, 255
Listening to Prozac (Kramer), 248, 275
lithium, 225, 233, 246, 247, 263
lobotomies, 264–265
LSD, 242, 263, 287n4
Ludwig, Arnold M., 98, 99–100, 100

MacArthur Foundation, 109, 153

Madness and Civilization (Foucault), 135
madness/mental illness
ancient Greeks on, 40–41, 64
attempts to define, 67, 78, 274–275
biological explanations for, 124
as brain disease, 46, 69. See also Insel, Thomas
definition of, 37–38, 39–40
history of, 40–56. See also Psychiatry
in early America, 42–44
importance of definition of, 122–123
language of, 1, 3–8, 302–304
as linguistic sign, 39
statistics on, 85
transition from lay to medical control of, 45–47
views of, 302–303
what is meant by, 8–9
Major Depressive Disorder/Episode (MDD), 190, 193–194, 222
Malamud, T. J., 106–107
malingering, 49
March, John, 20, 317, 320, 322
marijuana, 243, 287n4
Marshall, George C., 51
Marshall Plan, 82
Marx, Arnold J., 98, 100
Maxman, Gerald, 148
Medawar, Charles, 231
Medea (Euripides), 41
Medicaid, 18, 98, 218, 282, 317, 318
Medical Inquiries and Observations upon the Diseases of the Mind (Rush), 46
Medical Nemesis (Illich), 135
medical records, distortion of, 198–199
Medicare, 18, 218, 317, 318
Menand, Louis, 300
Mendota State Hospital/Mendota Mental Health Institute, 80, 98–99
mental disorder, definitions of, 5–6, 145, 164
Mental Health Acts (1963, 1965), 54–55
Mental Health Parity and Addiction Equity Act (2008), 177–178
Mental Health Study Act (1955), 53, 77
mental hospitals, research at, 66
mental illness. See madness/mental illness
Mental Illness and American Society (Grob), 65, 66
mental medicine, use of term, 59
Mentally Ill in America, The (Deutsch), 64
meprobamate, 270
Mesmer, Anton, 275
meta-analyses, 91, 93
metaphor, 59–63, 303–304
methamphetamine, 242, 243
Micale, Mark, 58, 59, 70n6
military service, 49–51
Miltown (meprobamate), 270
Mind-Forg’d Manacles (Porter), 63
Minghella, E., 104
Minogue, Kenneth, 60
misbehavior, meaning of mental illness and, 8–9
misdiagnosis, 170, 199
molecular biology, 250–251, 252–253, 268
Monahan, John, 88, 108
Moncrieff, J., 246
morphine, 213, 214, 242
Most Solitary of Afflictions, The (Scull), 60–62
mushrooms, 241
Myth of Mental Illness, The (Szasz), 25, 71n6
Myth of Metaphor, The (Turbayne), 59–60
myths, 299
drug myths, 232–233
Greek, 40–41
psychiatry’s core concepts as, 136

NAMI (National Alliance on Mental Illness), 16, 98, 279–280

National Alliance for the Mentally Ill, 16
National Association for Mental Health, 55
National Committee Against Mental Illness, 55
National Institute of Mental Health (NIMH)
biological explanations of madness and, 55
biopsychiatry and, 157n4
coercion and, 109
disease theory and, 38
DSM and, 157, 176, 179
EBPs and, 95
funding of, 85–86
increase in power of, 54–55
on mental disorders as brain diseases, 1, 3–4, 6–7, 24
neuroscience and, 317
on rate of mental disorders, 85
start of, 50, 52, 131
telephone study and, 123
See also Insel, Thomas
National Institute on Drug Abuse, 243
National Mental Health Act (1946), 50, 52
Nemeroff, Charles B., 181–182
neo-Kraepelinians, 143–144
neuroleptics, 214, 220, 246, 263, 264–265, 269–270
Neurontin (gabapentin), 262
neurosyphilis, 128
New Psychiatrists, The (Maxman), 148
New York Lunatic Asylum, 44
news media, 178, 329–330n4
Newsome, William, 313
NIMH (National Institute of Mental Health). See National Institute of Mental Health (NIMH)
nominal fallacy, 174
nursing homes, deinstitutionalization and, 54

Obama, Barack, 178, 320

olanzapine, 220, 222, 226–227, 230, 266, 277
opium, 235, 241, 242, 269, 270, 326
organic mental disorders, 124
Our Present Complaint (Rosenberg), 67

panic disorder, 273

Pasteur, 129
patient reviews, 285–286, 328
Pavuluri, Mani, 20
Paxil, 288n7
Peace of Mind Prescription, The (Nemeroff), 181
penal institutions. See prisons/prisoners
perphenazine (Trilafon), 222
personal problems jurisdiction, psychiatry and, 9
Pfizer, 19
pharmaceutical companies
advertising and, 17–18, 19
APA and, 217
clinical trials and, 215–216
conflicts of interest and, 180–184
continuing medical education and, 278–279
disease theory and, 38
drug treatment development and, 29–30
drug trials and, 282–285
DSM and, 126, 157, 176–177
fines paid by, 183
fraud and, 18
gifts from, 280
illegal payments from, 21
marketing and, 215–216, 217, 226, 261–262, 277–282
NAMI and, 16
overdiagnosis of bipolar disorder and, 20–21
partnership with, 272–273
payments from, 180–182, 216, 281–282, 317–318
testing cutoff points and, 172
phase I human tests, 256–258
phase II trials, 258–259
phase III trials, 259–261
phase IV trials, 261
phenelzine, 254
phenytoin (Dilantin), 254
Philips, S. D., 103
physical interventions, 47
Pieters, Toine, 213, 271, 274
Pigott, Ed, 223–224
Pinel, Philippe, 45
placebos
active vs. inert, 229–230
in drug trials, 260
effects of, 231–232, 276
increase in response rates for, 230–231
social view of, 231
placebo-washout periods, 228–229
Politics of Experience, The (Laing), 135
Popper, Karl, 26, 69
Porter, Roy, 37, 41, 58, 59, 63, 70n6
posttraumatic stress disorder (PTSD), 49, 145, 146, 193
prescription drug abuse, 243
Prescription Drug User Fee Act, 279
prescription privileges, 286, 324, 325
President’s New Freedom Commission on Mental Health, 4–5, 7
prisons/prisoners, 26, 50, 54, 86–87, 135
Prozac (fluoxetine), 214, 219, 244, 246, 248, 249, 254, 262, 271, 273, 277
psychiatric historiography
biases within, 63–68
field of, 57–59
psychiatry, field of appraisal of, 22–23
assaults on, 134–138
expansion of, 133, 311–312
history of, 131–133
vulnerability of, 133–134
psychoactive/psychotropic drugs
costs of developing, 255
deinstitutionalization and, 82
disease-centered model of, 212, 245–247
drug-centered model of, 247–248
“drugs” vs. “medications”, 242–243, 309
effects of, 244–248, 275–277, 309–310
knowledge of, 324
lack of efficacy of, 308
path of stigmatization of, 213
precautions regarding, 241–242
regulation of, 323–326
reliance on, 250
uses of, 241
See also drug treatments; individual drugs
psychoanalysis, 130–131, 132, 134
psychosis, description of, 61
psychotics, younger, 61, 62
psychotropic drugs. See psychoactive/psychotropic drugs
PTSD (posttraumatic stress disorder). See posttraumatic stress disorder (PTSD)
Public Health Service Act amendments (1956), 54
publication bias, 223–224
punishment, 77, 78, 84, 100–101
Pure Food, Drug, and Cosmetic Act (1938), 277

Quakers, 44
quetiapine, 218, 220

racism, 145
randomized controlled trial (RCT), 89–91, 93, 197, 227–229, 259–261, 325
Rasmussen, Nicholas, 215–216
Rathbone, William, III, 48
RCT (randomized controlled trial). See randomized controlled trial (RCT)
reason, faith in, 40–41
receptor pharmacology, 268
recovery movement, 327
reforms, flaws in, 24–25
Regier, Darrel A., 179, 184, 189, 192
reliability, diagnostic, 140–143, 147–149, 149–156, 165, 188, 191–192, 310
Research Agenda for DSM-V, A (Kupfer et al.), 198
reserpine, 263
Riley, Rebecca, 218–219
Risperdal (risperidone), 266, 288n7
risperidone, 220, 254, 258, 266, 288n7
Ritalin, 254
Robert Wood Johnson Foundation, 95
Rosenberg, Charles E., 56, 57, 67
Rosenhan, David, 137–138, 139
Rossman, E., 106–107
Rothman, D. J., 44–45, 48, 249
Rothman, Kenneth J., 95
Rush, Benjamin, 46, 47, 78, 79

Sackett, David, 90
Salmon, Thomas W., 49
Samuelson, Robert, 318–319
Sapir, Philip, 82
Savodnik, Irwin, 312
Schaler, Jeffrey, 110
Schatzberg, Alan, 182, 300
Scheff, Thomas, 135
Schizoaffective, 193
schizophrenia
as adaptive response, 135
atypicals and, 265–266
case study on, 11, 14
defining, 8
dopamine and, 267
drug treatments and, 30, 212–213, 220–222
kappa measures and, 193
Kraepelin and, 128
pathophysiology and, 37, 65
pseudo-patients and, 137–138
study of treatments for, 264–265
science
description of, 25–26
distortion of, 312–313
Scientific Research Board, 51–52
Scott, J. E., 104
Scull, Andrew, 54, 56, 57–58, 59, 60–62, 81
sedative-hypnotics, 223
Seige, Max, 213
Seige cycle, 213, 271
Selective Service Act (1917), 49
self-interest, authors’, 299–300
self-medication, 324
Sequenced Treatment Alternatives to Relieve Depression (STAR*D), 222–224, 226–227, 233–234
serious emotional disturbances, definition of, 4–5
serious mental illness (SMI)
definition of, 112n3
rates of, 85
serotonin, 268
serotonin-reuptake inhibitors (SSRIs)
effects of, 246
introduction of, 214, 274
lack of efficacy of, 249–250
marketing of, 244, 268–269
molecular biology and, 253
placebos vs., 227, 228–229, 230
shift toward, 271
success of, 276–277
See also Sequenced Treatment Alternatives to Relieve Depression (STAR*D)
sertraline (Zoloft), 223
Shakespeare, William, 37, 69
shell shock, 49
Shinback, Kent, 11
shock techniques, 78–79
Shorter, Edward, 56, 57, 64–65
Simon, Bennett, 41
SMI (serious mental illness)
definition of, 112n3
rates of, 85
Smith, Kline, and French Company, 53
Smith, Richard, 326
Snelders, Stephen, 213, 271, 274
social context, 168–169, 190, 322
Social Phobia (Social Anxiety Disorder), 167
Social Security, 318–319
social welfare system, coercion and, 88
Society for the Social History of Medicine, 57
Socrates, 40
Spencer, Thomas, 21
Spitzer, Robert
APA and, 175
definition of mental disorder by, 145
descriptive diagnosis and, 144
diagnostic reliability and, 149, 151, 152, 155, 156
DSM and, 138–141, 145–146, 147–148, 184–185, 186–187, 192
homosexuality and, 137
kappa scores and, 142–143
SSRIs (serotonin-reuptake inhibitors). See serotonin-reuptake inhibitors (SSRIs)
STAR*D (Sequenced Treatment Alternatives to Relieve Depression). See Sequenced Treatment Alternatives to Relieve Depression (STAR*D)
Stein, Leonard I., 98–99, 100–101, 104, 106–107
Stengers, Isabelle, 251, 275
STEP-BD (Systematic Treatment Enhancement Program for Bipolar Disorder). See Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)
sterilization, involuntary, 301
stigmatization, path of, 213
stimulants, 246, 247, 277–278
Stonewall Riot, 136
Stotland, Nada, 219
Strassman, R., 263
Strattera (atomoxetine), 257–258
Structure of Scientific Revolutions, The (Kuhn), 319
Structured Clinical Interview for Axis I Disorders (SCID-I), 153
structured interviews, 144
subcutaneous implants, 269
Substance Abuse and Mental Health Services Administration, 108
substantial disability, definition of, 112–113n3
Sunderland, P. Trey, 182
Surgeon General’s Report on Mental Health (US Department of Health and Human Services), 67
surgery, as treatment, 10–11
Swann, Alan J., 225
Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), 224–226, 232–234
Szasz, Thomas
on drug treatments, 213–214
on drug use, 242, 243, 286, 287n1, 324, 326
on meaning of “psychotropic”, 287n1
Frances and, 110
on myth of mental illness, 134
on psychiatry, 58, 59, 70n1
Scull and, 61, 70–71n6

Taft, William Howard, 301

tardive dyskinesia, 264
Tarloff, David, 11, 13–14
Taube, Gary, 316
TCAs (tricyclic antidepressants), 214, 246
tea, 241
telephone study on prevalence of mental illness, 123–124
terminology, biases and, 63–68
Test, Mary Ann, 98–99, 102–103, 104, 106–107
Thorazine, 112n1, 220
tobacco, 241, 243
Todd, Eli, 46
Torrey, E. Fuller, 157n3
Training in Community Living Model, The (Stein and Test), 98–99
training in community living (TCL), 98. See also assertive community treatment (ACT)
tranquilizers, community care and, 81
tranquilizing benzodiazepines, 214
“tranquilizing” chair, 79
trazodone, 223
treatments
evolution of in United States, 42–44
failures in, 10–12
Insel on, 23
involuntary, 42, 45, 75–76, 100–101, 306, 323
lack of evidence for, 23
moral, 44–45, 46
See also coercion; confinement, forced; drug treatments; hospitalization: involuntary
tricyclic antidepressants (TCAs), 214, 246
Trilafon (perphenazine), 222
Trivedi, M. H., 222
Truman, Harry, 51
Tuke, Daniel Hack, 48
Tuke, Samuel, 48
Tuke, William, 48
Turbayne, Murray, 59–60
Turner, Erik, 284

unreason, 40–41
urban life, as cause of illness, 44

validity, 163–165, 310

Valium (diazepam), 270, 277
venlafaxine (Effexor), 223, 246
Veterans Administration, creation of, 50
Virchow, Rudolf, 45–46

Wagman, Benjamin, 12, 14–15, 19

Wagman, Diana, 14, 17–18
Wakefield, J. C., 5
Wang, Yifang, 13
Warburton, Rebecca, 255
Weil, Andrew, 241
Wellbutrin (bupropion), 223, 288n7
Whitaker, Robert, 329n3
Wilens, Timothy, 21
Woolston, Joseph, 19
World War I, 49, 50
World War II, 50, 82, 132
Wright, James, 274

Xanax (alprazolam), 219, 270–271, 271, 273

York Retreat, 48

Zanarini, Mary, 153–154

Zarifian, Edouard, 263, 272–273
Zhantao, Mi, 10–11, 13
Zhao, Shanyang, 113n3
ziprasidone, 220
Zoloft (sertraline), 223
Zyprexa (olanzapine), 222, 226–227, 230, 266, 277