Shrinks (20 page)

In September of 1977, a liaison committee was formed consisting of four or five psychoanalysts from the APsaA who began to pepper Spitzer and the Task Force with requests. At about the same time, another group of four or five psychoanalysts from the powerful Washington, DC, branch of the APA also began to lobby for changes in the
DSM-III
. The Washington branch was probably the most influential and best organized unit of the APA, owing to the large number of psychiatrists in the nation’s capital drawing business from the superior mental health benefits offered to federal employees. For the next six months, Spitzer and the psychoanalysts jousted over changes to the definitions of disorders.

At one point, Spitzer informed the Task Force that he was going to concede to some of the psychoanalysts’ requests as a political necessity to ensure the adoption of the
DSM-III
. To his surprise, the other Task Force members unanimously voted him down. Spitzer had chosen his Task Force because of their commitment to sweeping changes, and now their uncompromising devotion to these principles exceeded his own. Emboldened by his own team to hold the line, Spitzer repeatedly informed the psychoanalysts that he could not fulfill their requests.

As the critical vote drew near, psychoanalytic factions presented alternative proposals and engaged in frenzied efforts to pressure Spitzer into accepting their demands. But Spitzer, having devoted almost every waking hour to the
DSM
for four years, was always ready with a response that drew upon scientific evidence and practical arguments to support his position, while the psychoanalysts were often left stammering that Freudian psychoanalysis needed to be upheld on the basis of history and tradition. “There were disputes over the placement of each word, the use of modifiers, the capitalization of entries,” Spitzer told historian Hannah Decker. “Each adjustment, each attempt at fine tuning, carried with it symbolic importance to those engaged in a process that was at once political and scientific.”

Spitzer plowed through the testy negotiations and contentious wordsmithing until he had a final draft in early 1979. All that remained was for it to be ratified at the May meeting of the APA Assembly. With the vote looming, the psychoanalysts finally appreciated just how high the stakes were and ratcheted up the pressure on both the Task Force and the APA Board of Trustees with fierce determination, frequently warning that the psychoanalysts would abandon the
DSM-III
(and the APA)en masse if their demands were not met. As the long-awaited date of the vote approached, the final counterassault launched by Spitzer’s opponents targeted a critical component of psychoanalysis—
neurosis
. Neurosis was the fundamental concept of psychoanalytic theory and represented to its practitioners the very definition of mental illness. It was also the primary source of professional revenue in clinical practice, since the idea that
everyone
suffers from some kind of neurotic conflict drove a steady stream of the worried well onto shrinks’ couches. As you can imagine, the psychoanalysts were horrified when they learned that Spitzer intended to expunge neurosis from psychiatry.

The influential and iconoclastic psychiatrist Roger Peele was the head of the DC branch of the APA at the time. While Peele generally supported Spitzer’s diagnostic vision, he felt obligated to challenge Spitzer on behalf of his psychoanalytic constituency. “The most common diagnosis in DC in the 1970s was something called depressive neurosis,” Peele said. “That was what they were doing day after day.” He put forward a compromise plan called the Peele Proposal, which argued for the inclusion of a neurosis diagnosis “to avoid an unnecessary break with the past.” The Task Force shot it down.

In the final days before the vote, a flurry of other proposals were put forth to save neurosis, with names like the Talbott Plan, the Burris Modification, the McGrath initiative, and Spitzer’s own Neurotic Peace Plan. All were rejected by one side or the other. At last, the fateful morning arrived—May 12, 1979. Even at this late stage, the psychoanalysts made one final push. Spitzer countered with a compromise: While the
DSM
would not include any neurosis-specific diagnoses, it would list alternative psychoanalytical names for certain diagnoses without changing the criteria for the diagnoses (such as “hypochondriacal neurosis” for hypochondriasis or “obsessive-compulsive neurosis” for obsessive-compulsive disorder), and one appendix would include descriptions of “Neurotic Disorders” in language similar to the
DSM-II
. But would this paltry concession satisfy the rank-and-file psychoanalysts of the APA Assembly?

Three hundred and fifty psychiatrists gathered together in a large ballroom in the Chicago Conrad Hilton Hotel. Spitzer stepped onto the two-tiered stage, explained the goals of the Task Force, and briefly reviewed the
DSM
process before presenting the final draft of the
DSM-III
to the assembly, parts of it typed up mere hours before. But the psychoanalysts squeezed in one last Hail Mary.

Psychoanalyst Hector Jaso made the motion that the assembly adopt the draft of the
DSM-III
—with one amendment. “Depressive neurosis” would be inserted as a specific diagnosis. Spitzer retorted that its inclusion would violate the consistency and design of the entire
Manual
, and besides—the existence of depressive neurosis simply wasn’t supported by the available data. Jaso’s motion was put to an oral vote and was resoundingly defeated.

But was the assembly rejecting a last-second change, or voicing disapproval of the entire
DSM-III
project? At long last, after tens of thousands of man-hours of labor, the product of Spitzer’s visionary framework, the
DSM-III
, was put to a vote. The assembly was virtually unanimous in their response:
YES
.

“Then a rather remarkable thing happened,” Peele reported in
The New Yorker
. “Something that you don’t see in the assembly very often. People stood up and applauded.” Shock spread across Spitzer’s face. And then: “Bob’s eyes got watery. Here was a group that he was afraid would torpedo all his efforts and aspirations, and instead he got a standing ovation.”

How did Spitzer manage to triumph over psychiatry’s ruling class? Even though the psychoanalysts vigorously resisted his efforts to eliminate Freudian concepts, for most Freudians the benefits of Spitzer’s transformative book outweighed its shortcomings. They were, after all, fully aware of psychiatry’s public image problem and the threat posed by the antipsychiatrists. They realized that psychiatry needed a makeover and that this makeover had to be grounded in some form of medical science. Even Spitzer’s adversaries recognized that his radical new
Diagnostic Manual
offered a lifeline to the entire field, a chance to restore psychiatry’s battered reputation.

The
DSM-III
’s impact was just as dramatic as Spitzer hoped. Psychoanalytic theory was permanently banished from psychiatric diagnosis and psychiatric research, and the role of psychoanalysts in APA leadership was greatly diminished thereafter. The
DSM-III
turned psychiatry away from the task of curing social ills and refocused it on the medical treatment of severe mental illnesses. Spitzer’s diagnostic criteria could be used with impressive reliability by any psychiatrist from Wichita to Walla Walla. The Elena Conways and Abigail Abercrombies of the world, neglected for so long, once again assumed center stage in American psychiatry.

There were unintended consequences as well. The
DSM-III
forged an uneasy symbiosis between the
Manual
and insurance companies that would soon come to influence every aspect of American mental health care. Insurance companies would only pay for certain conditions listed in the
DSM
, requiring psychiatrists to shoehorn ever more patients into a limited number of diagnoses to ensure that they would be reimbursed for the care provided. Even though the Task Force intended for the
DSM-III
to be used only by health care professionals, the
Manual
’s anointed diagnoses immediately became the de facto map of mental illness for every sector of society. Insurance companies, schools, universities, research funding agencies, pharmaceutical companies, federal and state legislatures, judicial systems, the military, Medicare, and Medicaid all yearned for consistency in psychiatric diagnoses, and in short order all of these institutions tied policies and funding to the
DSM-III
. Never before in the history of medicine had a single document changed so much and affected so many.

I wasn’t at the momentous Chicago meeting when the APA Assembly approved the
DSM-III
, though I had the good fortune of presiding over the last public appearance that Spitzer ever made. Bob was forced into retirement in 2008 by a severe and debilitating form of Parkinson’s disease. To mark his retirement, we organized a tribute to celebrate his remarkable achievements that was attended by psychiatric luminaries and Bob’s protégés. They took turns speaking about the man who had so profoundly shaped their careers. Finally, Bob rose to speak. He had always been a powerful and disciplined orator, but as he began his remarks he broke into uncontrollable sobs. He was unable to go on, overwhelmed by the sincere show of affection and admiration. As he continued to weep, I gently took the microphone from his trembling hand and told everyone that the last time Bob was speechless at the assembly meeting in Chicago was when the APA passed the
DSM-III
. The audience rose to their feet and gave him an ovation that rolled on and on and on.

Festschrift for Robert Spitzer. From left to right: Michael First (psychiatrist and protégé of Spitzer who worked on
DSM-III, IV
, and
5
), author Jeffrey Lieberman, Jerry Wakefield (professor of social work at New York University), Allen Frances (psychiatrist, Spitzer protégé, and chair of the
DSM-IV
Task Force), Bob Spitzer (psychiatrist and chair of the
DSM-III
Task Force), Ron Bayer (professor of sociomedical science at Columbia University and author of a book on the removal of homosexuality from the
DSM
), Hannah Dekker (historian and author of
The Making of DSM-III
), and Jean Endicott (psychologist and colleague who worked with Spitzer). (Courtesy of Eve Vagg, New York State Psychiatric Institute)

Part II

The Story of Treatment

If only his mind were as easy to fix as his body.

—H
AN
N
OLAN

Chapter 5