Initially published June 18, 2019 at https://www.madinamerica.com/2019/06/critique-diagnostic-terminology/ Please note that this was written about the publication MadInAmerica (MIA) and its policy about naming psychiatric diagnosis. Robert (Bob) Whitaker is the founder of the publication and the author of the extremely important book, Anatomy of an Epidemic, a scrupulously researched book about the truth about psychiatric drugs.
By Paula J. Caplan, PhD
June 18, 2019
I appreciate Bob Whitaker's encouraging me to write this essay after I had written to him several times over the years to express concern about how Mad In America deals with psychiatric diagnoses. Below, I will report his responses to my concerns and my replies to those.
I need to begin with some history, so that readers will understand why I feel so passionately about an MIA practice that might seem to some to be relatively trivial.
In 1985, I had been teaching the Diagnostic and Statistical Manual of Mental Disorders as an advocate, believing the advertising produced by its publisher, the American Psychiatric Association, and by its Task Force leader Robert Spitzer, to the effect that it was a scientifically-grounded document. Then, through a series of events described in They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal, in 1988 I accepted the invitation of DSM-IV Task Force head Allen Frances to serve on two DSM-IV committees. In that capacity, over two years I received internal communications, mostly but not solely with regard to the two DSM labels "Self-defeating Personality Disorder" and "Premenstrual Dysphoric Disorder," and through these I was shocked to learn that the ways that "abnormality" and its varieties were chosen and described within the manual were extremely far from scientific (this troubled me all the more because I am an author of a textbook about research methods) and that those heading the Task Force minimized and even denied harm that getting any of their labels could cause. When I utterly failed to persuade them to come clean with the public about the unscientific nature of the labels and their criteria and to warn of the harm they could cause, I felt I had no choice but to resign on moral, ethical, and professional grounds.
Since then, the more I have spoken and written publicly about these matters, the more I have learned two kinds of things. One is that there is a vast array of approaches to reducing human suffering that do not involve calling sufferers 'mentally ill' and that are proven to be effective. The other is that I have received letters, email messages, and in-person reports from thousands of people whose lives were variously harmed or ruined and from loved ones of labeled people whose lives were ended due to sequences of events that began with a psychiatric label.
I have called psychiatric diagnosis "the first cause of everything bad in the mental health system." https://www.youtube.com/watch?v=-qIQqRl94_Y&t=22s If they don't diagnose you, they cannot "treat" you, whatever that means in various contexts. But once they give you even what sounds like the most innocuous label (often Adjustment Disorder is named as the least dangerous), there is almost no limit to what they can do to you in the name of "treatment"… and too often, they escape all accountability because the diagnosing and the kinds of treatment that tend to follow are considered "standard of care."
Since few laypeople (and even surprisingly few professionals) have any idea about these facts concerning psychiatric diagnosis, when they are suffering and seek help in the mental health system, they rarely even know to ask the therapist such questions as, "Do you have to give me a diagnosis? If so, which one will you be giving me? What steps are you taking to protect me from the many kinds of harm that can result from getting a psychiatric label? If you are going to recommend ways for me to feel or function better, how are you going to decide what to recommend, given that treatments based on assumptions about unscientific categories might help me but might be harmful and might not work?"
Furthermore, the mental health establishment that uses these labels and falsely claims that they are "scrupulously scientific" (in the words of DSM-IV head Allen Frances describing his edition), helpful, and not harmful has vast wealth and media access. Mad in America has reached huge audiences and successfully educated untold numbers of people about the truth, but even MIA and other publications that challenge traditional practices still have a long way to go to reach and persuade as many people as does the establishment.
As a result, when anyone in the few challenging publications uses any psychiatric diagnosis without signaling that they are constructs and unscientific, I feel alarmed for those who will be strengthened in their mistaken beliefs about the labels. An example would be an article about a researcher's study of "children who have ADHD." Some people have learned to challenge what the DSM and APA brass claim, but for those who trust that what they read on MIA is far more likely to be well thought out and true and thus not misleading, I am especially concerned about their vulnerability to the reification of the categories by MIA specifically.
There are simple ways to signal that these diagnoses are constructs and unscientific, and over the years, I have repeatedly expressed my concerns to MIA when they publish pieces in which psychiatric diagnostic terms are used without a single mention of the fact that they are NOT scientific, that it is NOT helpful to use these terms when trying to alleviate suffering or help people change their behavior IF THEY WANT TO, and that getting ANY psych label exposes one to a vast array of kinds of harm, and that there are MANY other approaches that do NOT involve pathologizing or drugging and that have few or no risks and are shown to be effective. I have begged MIA to stop this practice and instead, for instance, simply to put all such labels in quotation marks or to include a simple sentence such as, "This is a review of a research report about children who have been given the ADHD label, which is not a scientifically supported entity" or "Our study was of people who had been given the Bipolar Disorder label, so since it is known that this label does not represent a scientifically supported entity, we ensured that our participants all reported struggling with changes in mood they felt they could not control."
In the June 9, 2019 MIA weekly newsletter, an article is described as showing "how genetic models of 'schizophrenia' explain very little." This is a perfect and very simple and unobtrusive way to solve the problem. And in articles, the first time a psychiatric label is used, it can be put in quotation marks followed by a note that it is in quotation marks this first time it appears in the article because it has not been shown to be a scientifically valid category, but that the reader is urged to think of quotation marks going around the label each time it appears in the piece.
MIA reader and longtime advocate Amy Smith suggests a couple of other approaches: One is to run a succinct header or footer on every page of articles that include mention of psychiatric diagnoses, making MIA's positioning clear, and, in her words, "proudly wearing their ideology on their sleeve," since it is clear from most of the content of the publication's articles that they aim to publish the truth. Her other suggestion is that for specific articles that are glaring in their use of unscientific constructs, MIA could insert a "Note from the editor" in between the title of the article and the body of the text to make this kind of point as it relates to that article.
Bob Whitaker, who knows I have tremendous respect for his own many scrupulous pieces of research and writing, has replied to these suggestions by stating that he sets the editorial rules for MIA and does not plan to change in response to my concerns. He replied further that MIA has "many blogs published deconstructing [psychiatric diagnoses], and published reviews of articles published in journals with that theme." Given the overpowering and pervasive extent to which "psychiatric diagnosis as truth" has permeated Western culture and is fast spreading to other parts of the globe, and given that not every reader reads everything published on MIA, I don't think this is sufficient justification for failing sometimes or at all to implement the kinds of solutions suggested above.
Bob also wrote to me that MIA is using psychiatric diagnostic terms because they signal "societal speaking about this diagnosis that exists in our society, and not because we are saying it is valid." I find this frankly alarming. There are many terms that, for instance, are sexist, racist, ageist, etc., that either now or previously have been widely used, and the harm that goes with their use is perpetuated and can rub off on readers. In addition, how in the world is a reader supposed to know that in a particular MIA piece, a diagnostic term is not supposed to be thought to be valid if there is no disclaimer to make that clear?
Finally, Bob wrote that "To put quotes around [psychiatric labels] every time just becomes superfluous, and in reviews of science articles reporting on that diagnosis, would just put us in the position of wearing an ideology on our sleeves that would discredit our reviews." I have two responses to this:
(1) As a longtime editor myself, I am aware that one of the solutions suggested above allows for more editorial elegance than do the others. Fine. I don't care which solution is implemented when. Just please consistently convey the truth rather than helping perpetuate harmful untruths.
(2) I would think a greater concern about ensuring that MIA publishes credible assessments of scientific research would be not avoiding "wearing ideology on its sleeve" but rather omitting the extremely important information that the studies under review were based on the use of psychiatric categories that have been shown to be unscientific, unhelpful, and often harmful. Doing the latter means that such reviews would include the whole truth, not omitting the parts that someone is scared will make them look biased.
I hope that Bob will reconsider the MIA policy about this matter.