This year’s American Psychological Association Convention has us focus on justice. It comes on the heels of the Hoffman report which came out one year ago. The Hoffman report’s actual title is, Report to the Special Committee of the Board of Directors of the American Psychological Association Independent Review Relating to APA Ethics Guidelines, National Security Interrogations, and Torture.
On page 10 of that report, it concludes that the principal motive for APA officials who played lead roles in what is now declared unethical involvement with torture was to curry favor with the Defense Department for two main reasons: because of a very substantial benefit that the department had conferred and continued to confer on psychology as a profession, and because APA wanted a favorable result from a critical policy the department was in the midst of developing.”
APA has now taken some major steps toward preventing psychologists from ever again participating in helping others to participate in torture. But could APA be involved in other serious misdeeds because its leaders recognize there are benefits to be gained for just going along.
Today, I want to consider if something similar to the torture issue is going on with regards to APA’s participation in the labelling practices promoted by the other APA–the American Psychiatric Association. Because both organizations have the same initials, for the purpose of this article, APA-1 will be used to briefly identify the psychologist organization, and APA-2 will be used for the psychiatric organization.
The American Psychological Association’s Emphasis on Science
Please note the emphasis that APA-1 places on a scientific approach for psychologists. This is evident when we look at how APA-1 describes itself. The very first sentence of the home page of its website states that it is “the leading scientific and professional organization representing psychology in the United States.” As we can see, the first descriptor that APA-1 employs is “scientific.” Obviously, keeping the profession as scientific as possible is very important to the organization’s leadership. Despite that, most psychologists providing mental health services are required to “diagnose” a person seeking mental health services with an approach supported and promulgated by APA-2. This so called diagnosis then must be placed on the patient/client insurance form.
As part of APA-1’s strong interest in science, pretty much anyone entering an APA-1 approved doctoral psychology program is required to study the ideas of Thomas Kuhn’s thesis on The Structure of Scientific Revolutions. Such revolutions, we learned, come about after a period of time when a field presupposes a conceptual and instrumental framework accepted without question. Then, more and more, members of the community begin to see a buildup of anomalies in the framework until a “crisis” which can no longer be resolved within the pre-established framework.
It just so happens that the APA-2’s diagnostic system, which is described in its Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5), has huge anomalies that have been recognized for years, and despite this, APA-1 continues to utilize it without taking substantive steps to create a more scientific alternative. Let’s take a quick look at these anomalies. Afterwards, we’ll look at the benefits to APA-1 that may be motivating it to continue to go along with APA-2’s approach despite its major scientific weaknesses.
The Scientific Shortcomings of the DSM-5
Science demands objective definitions, but the DSM-5 approach relies on the completely subjective definition of a mental disorder. Its definition of a mental disorder is, in large part, and I quote, “a syndrome characterized by a clinically significant disturbance in an individual.” Now, I ask you, what can be more subjective than this?
The process described in the DSM-5 for assessing the subjective notions of “disturbance” in the individual is left to the clinician who decides if these are “clinically significant.” Thus, it provides clinicians an opportunity to include anything that benefits their set of values.
Now we all know that many clinicians have a financial interest in deciding whether or not their clients have a clinically significant condition. When they judge that their clients’ conditions are significant, they indicate this on the third party intake forms and this allows them to continue to see these clients and to get paid for additional visits. On the other hand, clinicians who work in an underfunded community government clinic that is being swamped by those seeking to access mental health services might apply a more stringent standard for what constitutes a mental disorder. Thus, the DSM-5 approach to the definition of a mental disorder obviously leaves room for enormous bias by clinicians, rather than anything that looks objective and free from bias.
All psychologists are taught that if a hypothetical construct, such as a mental disorder, is to have any validity, it must first demonstrate that it can be reliably identified. Upon reading the DSM-5, we find that there is no documentation that people, whether they are clinicians or not, can reliably distinguish between those who have mental disorders and those who do not have mental disorders. Thus, the lack of this documentation is analogous to a classification system of birds that has no documentation that people can reliably distinguish birds from non-birds.
With regards to reliably distinguishing between the different types of mental disorders, some field trials did look at this. Keep in mind that the DSM-5 defines over 300 different mental disorders. Approximately 270 of them were not tested at all for reliability but are nevertheless included in the DSM-5. The field trials tried to look at the reliability for thirty-one “disorders” included in the DSM-5, probably selected because these were ones that its developers thought would be most likely to make the DSM-5 look as good a possible. The results indicate that eight disorders had to be dropped altogether from the analysis because the researchers were unable to get enough data to support any analysis at all. Three others had reliability estimates that, according to the authors, fell in the “unacceptable range.” Six others had reliability estimates that fell in the “questionable range.” The remaining fourteen mental disorders had, according to the authors, “good to very good” reliability, despite the fact that there are no generally accepted standards for what counts as reliable enough against which the DSM-5 criteria can be judged. Among the “disorders” that were found to have very low reliability were “major depressive disorder” and “generalized anxiety disorder,” two of the most common “diagnoses.”
As I already mentioned, a classification system for a hypothetical construct must first demonstrate it is reliable. Then we look at the “validity” of the system. Upon examining the validity of the DSM, Thomas Insel, a recent NIMH director, stated:
The weakness [of the DSM] is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half-century, as we have understood that symptoms alone rarely indicate the best choice of treatment.
In addition to the DSM’s shortcomings with regards to its classification system’s reliability and validity, there are also serious shortcomings with regards to its claim of being a diagnostic system. A diagnostic system speaks to etiology, that is, the cause, set of causes, or manner of causation of a disease or condition. But the DSM-5 specifically states that it is not designed to identify the cause of the various “disorders” it classifies. Then why use the term “diagnosis” rather than the more scientifically defensible term, “classification?” As we will see, this gets us back to our larger question, why does the APA-1 accept the use of the DSM-5 given its problematic record of reliability and validity, as well as its use of the word “diagnosis” in a misleading, imprecise manner?
Why Does the American Psychological Association Continue to Go Along with the Use of the DSM-5?
In answering this question, in the interest of fairness to APA-1, it is crucial to point out that it has not, to my knowledge, interfered with discussions about this issue. In fact, it has even, on occasion, supported these discussions. For example, in 2002, it published a book titled, Rethinking the DSM: A Psychological Perspective. There we find well researched critiques of the DSM approach, and some preliminary alternatives proposed. Moreover, at the last APA Convention, and the upcoming one to be held this August, a team of individuals proposed to the APA Convention organizers a symposium on this issue, and both were accepted (see HERE for a description of one well thought out alternative that will be proposed at this years symposium).
But once these discussions and proposals are made, no action by APA-1 has been done to bring anything of substance to fruition. APA-1 certainly has the resources to commission the development of a far more scientific approach to classify individuals who seek mental health services, but it has never done so. How come? Here’s one theory.
A well recognized usefulness of the DSM-5 is that by using its medical sounding terms to refer to all of the experiences that this approach classifies as “mental disorders” it legitimizes in the minds of many the prescribing of drugs for these experiences.
There is an enormous amount of money being made from this approach because it takes less than a penny to manufacture each pill, and yet each pill can be sold for hundreds of times that amount. This is a rather unique business situation. Typically, if a company can sell its products or services for a 10 percent profit it is doing super well. Compared to such companies, the pharmaceutical companies are Jonathan Swift’s Brobdingnag Giants. With so much money being generated from this enterprise, the drug companies have managed to make it clear to powerful groups that what benefits the drug companies also benefits them. Examples are, major media outlets gain enormous revenues from drug company advertisements, and political campaigns get substantial support from industry lobby groups. Whenever a university wants to build a new building, often a pharmaceutical company offers financial support, and a number of professorship positions would not exist without its support.
Now keep in mind that the psychiatric association membership consists largely of psychiatrists who make their living by prescribing these drugs. Moreover, there are several reports indicating that the majority of the major players who developed the DSM-5 were on the payroll of the pharmaceutical industry. So, it makes sense to theorize that APA-2 may very well be influenced by all of this wealth. But what about APA-1, the psychological association?
APA-1 has a division called “Psychopharmacology and Substance Abuse” which depends, to a large extent, on grants provided by drug companies. Many psychologists get referrals from psychiatrists. More and more psychologists are getting the right to prescribe psychiatric drugs. And, as I already mentioned, the drug companies have powerful lobbyists working to influence government decisions about mental health practices.
Now recall, if you will, why APA-1 went along with the torture program: “…because of a very substantial benefit that the department had conferred and continued to confer on psychology as a profession, and because APA wanted a favorable result from a critical policy the department was in the midst of developing.” In trying to understand why APA-1 has continued to go along with the DSM-5 approach despite its clear violation of principles of science, it seems plausible that a similar set of motivations might be at work. I therefore think that it’s long time that an independent review be commissioned by APA-1 that is similar to the makeup of the Hoffman Report that would examine this question.
Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional intelligence. To begin at the very first post you can click HERE.