Kutchins, Herb and Stuart A. Kirk. Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders.
Much can be said about the modern movement of psychology in the history of the Western world. Psychological thought and language is pervasive in Europe and
Because of the great growth of psychology and psychologist, there had to be a way developed to keep the whole system under check. There had to be a way to regulate mental disorder classifications and treatments. Out of such a need came the Diagnostic and Statistical Manual of Mental Disorders (DSM). With its first publication in 1979, the DSM has gone through three additional additions, with slight revisions in between. In Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders, authors Herb Kutchins and Stuart A. Kirk discuss the many revisions, why they came, and the multiple problems caused by and with the DSM.
Kutchins is professor of social work at
and served on the Task Panel on Deinstitutionalization, Rehabilitation and Long-Term Care of President Carter's Commission on Mental Health. He also served as Dean of the
Summary
The DSM’s birth belongs to Robert L. Spitzer, “the godfather of modern psychiatric diagnoses” (4). Spitzer’s aim was to create a manual that was “scientifically sound” (5) to help with the development and treatments in the field of psychology. As the manual grew in popularity it became “a claim for professional jurisdiction by the American Psychiatric Association” (11). No longer could someone classify or treat a person without the DSM’s approval. This is important because money is involved.
The “DSM is the psychotherapist’s password for insurance reimbursement” (12). Secular counselors could not received payment from a patient’s insurance company for just talking with them. However, if a “psychotherapist” classifies someone as a mental patient according to the DSM, any treatment can be understood as equal to that of a medical physician and get paid for their services by insurance companies. This also became of great importance for drug companies wishing to profit from those with different issues (13).
Though the DSM has benefit to the psychiatric institution by giving them a fame work within to evaluate and treat patients, what has become very clear is that the DSM has more error than it would like to admit. This is why the DSM has gone through three complete revisions (46). That is why Kutchins and Kirk ask the question, “Is DSM reliable?” (49). They assert the “reliability using DSM is not particularly good. 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 DSM disorders is present...The unreliability of DSM is a chronic problem that the psychiatric establishment tried unsuccessfully to solve and would now rather ignore” (53-4).
To display the range of disagreement and change within the DSM, the authors first look at the issue of homosexuality (one time considered a mental disorder). The authors go to show that the change of homosexuality from bad to normal was not based on any sort of scientific research. The change was made because of militant acts of the homosexual community (61) and political pressure from within the APA (66). Because of these agents the DSM removed homosexuality from the DSM and replaced it with “sexual disorder not otherwise specified” (91) as a general diagnosis for those who might be homosexual, yet are not satisfied with it. Now, according to the principles of the DSM, if you are homosexual and happy, you are fine. This is completely different than was once stated by the DSM. Can the new diagnosis be trusted?
Other issues treated the same way by the author are war related mental disorders, masochistic personality disorder, and borderline personality disorder. These chapters focus and attempt to display how the DSM has went through many changes and why these changes are taking place. Most often, they do not change because of some new great scientific study that gives grand evidence and reason for the change, but because of pressures on the APA to change its findings.
Kutchins and Kirk also discuss the abuses of psychology against those of another race. In 1840 a census was taken of those who were in mental institutions. What was shocking was the difference in the ratio of African-American patients in the North and South. The number of African-American patients in the North far exceeded those in the South. In the South, “they believed that slavery made the difference!” (204). Based on this issue, as article was written in The Southern Literary Messenger which prescribed slavery for the sake of those enslaved (204). John C. Calhoun said, “Here is the proof of the necessity of slavery. The African is incapable of self-care and sinks into lunacy under the burden of freedom. It is a mercy to give him the guardianship and protection from mental health.” (205). Sadly, this sort of psychological thought was not limited only to those of African decent. Hitler used the same poor method against the Jews (214).
To end their work, Kutchins and Kirk argue that the DSM is not adequate to determine whether or not someone is mentally ill or has a “normal, nonpathological variance” (294); it is not specific enough to limit the diagnosis to a proper one, leaving researchers and clinicians “plenty of room to arrive at different diagnostic conclusions (unreliability) based on the same information” (255); and the “DSM’s definition of mental disorder is flawed, the claims of validity and reliability of the manual as a whole are shaky, and the causes of most mental disorders are unknown” (264). Thus they state with confidence, “Clearly, as we have shown in this book, psychiatrists and other mental health professionals benefit from DSM’s unrelenting expansion of domain, its attempts to sweep all manner of personal troubles under the medical umbrella and to rationalize those moves on the basis of research and science…Certainly, there are plenty of problems that we all have and a myriad of peculiar ways that we struggle…But could life be any different? Far too often, the psychiatric bible has been making us crazy—when we are just human” (264-5). Thus, they argue that the DSM is about power and money more than it is about helping people.
Critical Evaluation
Making Us Crazy is a fine work and should be read by anyone who is serious about the world of psychology or the counseling ministry in general. Its review of the history of the DSM is informative and useful in evaluating the how the psychiatric bible came into being and whether or not it is proving to be a helpful aid in helping people with their problems.
Positive Evaluations
One of the strengths of Making Us Crazy are its ability to show the history and backdrop of what caused to the multiple revisions the DSM has gone through. In chapter three, “The Fall and Rise of Homosexuality”, one of the most fascinating chapters of the book, the authors do a great job of showing how the DSM was challenged and eventually changed.
It should come as no surprise that the DSM would have changes along the way. It is only normal for scientific study to evolve as new information is gained and evaluated. What makes this book so powerful is the magnitude of research done by Kutchins and Kirk that shows that this change, and many changes, is accomplished no because of new research once hidden, but by a powerful movement that pressured for the changes in the DSM. They show that in 1971, the first major step was taken when “gays asked to meet with the APA’s Committee on Nomenclature to present a demand to delete homosexuality from DSM” (66). During this time, the number of gay psychiatrists was growing and they were beginning to put pressure on the committee to change. Finally, in December of 1973 “the board voted unanimously to delete Homosexuality from the diagnostic manual” (71).
Such findings go to show how unreliable DSM is. The diagnoses of the book are more governed by pressures than by science to often. Not to mention the other changes that happen at such a rapid rate, ones that might be more related to science, show the unstable nature of DSM. Kutchins and Kirk do a great job of showing the weakness of DSM and why it needs major work before it should be trusted as the primary means of diagnosing and treating patients.
Negative Evaluation
The primary weakness of Kutchins and Kirk’s work is that they fail to follow the road they start to the destination it leads. One of the primary flaws to the DSM that they point out is its rapid changing nature and its failed attempt at a definition (264). However, one could ask, on what ground can anyone declare that another person is mentally ill? By what standard can we rightfully make such a statement?
This is seen clearly in the issue of homosexuality. At one time, the majority of people saw homosexuality as a flaw in the makeup of some people’s minds. However, as time developed and homosexuality either grew or just became more socially acceptable, the APA was forced to change DSM’s claim that it was a mental disorder.
The question that has to be asked is how does a world governed by atheistic thought come to the conclusion of whether or not anything is right or wrong. In a world absent of God and supreme truth, we are left in a globe of atoms and molecules that are randomly bouncing back and forth without rhyme or reason. Take God out of the cosmos and you are left with moral and ethical suicide. No longer can someone make a claim that homosexuality is wrong because there is no external witness against it. What will be okay next?
The fact is, without moral absolutes brought on by a supreme being that is external to us, a DSM cannot exist. The DSM is dependent on the idea that people should act a certain way and think a certain way. But who is to say how that action should be? In the case of homosexuality, it was once seen as wrong and an illness, but now it is common and another healthy lifestyle for some. What other disorders will one day be wiped out of DSM because a large enough group of people have the so called disorder and live perfectly healthy lives? Could psychotherapist take the DSM and go to other lands and expect it to work, given the great differences between our culture and others? It does not seem likely.
Conclusion
In conclusion, Making Us Crazy should be an influential book and will hopefully stir many in the world of psychology to rethink the DSM. Kutchins and Kirk prove themselves to be experts in this area of study and will hopefully continue to press people to rethink how mental health is understood. Those who are serious about counseling should take their words seriously and think critically about the agenda of the APA. However, the reader should not fall short where the writers do and seek answers that Kutchins and Kirk fail to discuss.
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