The Book of Woe: The DSM and the Unmaking of Psychiatry (32 page)

And here’s where Frances had me dead to rights: in my worldview, for which I cannot blame Paula Caplan, there are more choices to explain events than Parallax or Keystone, conspiracy or coincidence. We are in the grip of history, I believe, and if its long arc does not bend in any foreordained direction, it is also not random. Which means that hamartia—the fatal, unrecognized flaw—is always tragedy waiting to happen and needs only the right story to be seen for what it is.

Frances might not agree with that. He’s a literary man, but he also constantly warned me against reading meaning into the DSM. Still, our dispute wasn’t only about the significance of the flaw, but about its nature as well, about what exactly it consisted of and where it was to be found. Since we’d met, he had been urging me to read
A Canticle for Leibowitz
, a novel by Walter Miller. At the end of November, I told him over the phone that I’d just finished the book, which turned out to be a pretty good piece of science fiction squarely in the postapocalyptic tradition. The title character, an electrical engineer named Isaac Leibowitz, has survived a twenty-sixth-century nuclear holocaust that has led to the Simplification, an era in which the elite and educated have been exterminated by the Simpletons, who have outlawed learning and destroyed books. But Leibowitz, along with a band of “bookleggers,” has set out to preserve the world’s scientific knowledge in a monastery library. (Leibowitz converted to Catholicism after the war.) That effort earns Leibowitz martyrdom and beatification, but his Memorabilia lives on, and by the thirty-eighth century, the knowledge contained in it has escaped the monastery, once again wreaking a holocaust, but not before a small group manages to blast off from Earth in a rocket ship, carrying, so we presume, the Leibowitzian Memorabilia and its destructive knowledge to another world.

“
What’s the ending mean
²²
?” he asked.

“That you have your choice between ignorance and survival or knowledge and death.”

“And?”

“And what?”

He told me that Miller had been a tail gunner in World War II who had participated in the destruction of Montecassino, a Benedictine abbey in Italy. “He wrote the book as an expiation. He’s writing about wise guys like you and me throwing hand grenades at traditions that we think are stupid. But those traditions have a value we might miss,” he said. “It’s the intellectuals who create the nuclear weapons. The dumb traditionalists turn out to have it right. A lot of false beliefs help people cope with life.”

Frances’s thin voice descended nearly into a growl. “So don’t throw grenades unless you know what you are doing, Gary. Don’t throw grenades. There are some traditions if you fuck with . . .” He trailed off. “You wouldn’t want to tell a placebo responder he’s on placebo.”

•   •   •

The APA wasn’t so happy with me, either.

Early in November, just about when Frances was admonishing me, I contacted its press office to clarify a point from my interview with Regier and to nail down the exact order of events that resulted in banishing the drug companies from its educational programs and from the stock portfolios of DSM contributors. I also asked if an APA official would comment on the psychologists’ petition, now that it had amassed so many signatures. So far the press office had stayed silent, except to note that the petition was just one of the “thousands of comments” that had been heaved over its transom—all of which were “being reviewed by task force and work group members.”

After a few days,
I received this message
²³
from the APA’s director of communications, Eve Herold.

Dear Gary,

We have received several requests from you for access to APA experts and positions on issues related to the DSM for the book you’re writing. I wanted you to know that we will not be working with you on this project. Last year we gave you free access to several of our officers and DSM experts for the article you wrote for
Wired
. In spite of the fact that we went to considerable lengths to work with you, the article you produced was deeply negative and biased toward the APA. Because of this track record, we are not interested in working with you further as we have no reason to expect that we would be treated any more fairly in your book than we were in the
Wired
article.

I think she meant “biased against.”

Glad as I was to be spared the APA’s talking points, I didn’t understand why it would preemptively surrender its opportunity to correct my errors or respond to its critics, who they had to know were talking to me. I also wondered how Herold was going to stop her “experts”—at least the ones who didn’t work directly for her organization—from being in contact with me, which many of them had been doing all along, gladly and forthrightly. The confidentiality agreement hadn’t stopped them. Would a communiqué from headquarters?

But mostly I was wondering if I would lose my job as a Collaborating Investigator in the field trials. I’d already put in eight hours or so, completing the Field Trials Human Subjects Protection Basic Training and mastering the Informed Consent Process, learning how to fill out the Patient Log, how to Register the Patient, how to log onto the Portal, how to Push the Data to the Clinician Database, looking over the REDCap Flowchart and Disorder Quick Reference Troubleshooting Guide, reading the sixty-page System Manual, and sitting through the ninety-minute Webinar. I’d taken the quizzes and practiced on the case vignettes, and finally, just a week before Herold’s blow-off, I’d received an e-mail from the field trials team, informing me that I had completed the training and would soon be given access to the “LIVE database.” Had I worked so hard and come so far, only to be cut from the team just as I was about to take the field?

I had my answer the next day in an e-mail from the field trials’ operations manager. It wasn’t a pink slip at all, but rather a congratulations on my having successfully completed the DSM-5 field trials training, and a new login and password for the field trials site.

It was astounding that the APA would forgo the opportunity to spin its story to me—not to mention so baldly display its Kremlin tactics, and in writing no less—and yet let me in for an unfiltered look at their prized field trials. Most likely, no one had figured out that the biased writer and the Collaborating Investigator were the same person (although I made no effort to conceal this fact, using the same contact information in both capacities). But another e-mail from the operations manager—a note that had come just a few hours after Herold’s—suggested a different explanation. That message told me to disregard any e-mail I might have just gotten from her. As it happened, I hadn’t received anything. But just in case I wanted an opportunity to disregard it, she attached the errant e-mail. It was a note from Kupfer and Regier, thanking me (for the third time) for participating in the field trials, but also urging me to complete the training, and letting me know that the task force had extended the deadline to do so. “
We realize how challenging it is
²⁴
for practicing clinicians to find time to participate in research,” they wrote, before reminding us about the CME credits and the free copy of the DSM-5, complete with our names listed in the back, that awaited us in May 2013.

It sounded as if they were having trouble getting those five thousand clinicians on board. Perhaps, like Michael First, who told me it was “hard to find a spare six hours to do it,” they were just too busy, or maybe they thought a free book and their name in agate type were insufficient compensation for the task. Whatever the explanation, it appeared that I was among the very few. I may have been persona non grata in the communications department, but over at the research department, people like me were much in demand. Plague rat or not, they couldn’t afford to toss me overboard.

Recruiting my first trial patient was easy enough. Lee and I were still in that phase of therapy in which we really liked each other—positive transference/countertransference, the Freudians would call it. She would not want to displease me—a good thing, as it turned out, when the test proved to take an hour and forty-five minutes to complete.

Not that Lee got nothing out of the deal. She did seem pretty thrilled to sit at my desk and use my computer. Back in the psychoanalytic days, surrendering my chair and my equipment would have been a meaning-rich event. What was it like for her to sit in my chair and use my computer? How did it feel to be asked for a favor by her therapist? That conversation is either silly or significant, depending on whether or not you believe that the secrets of who we are come into view most clearly in dreams and slips of the tongue and reactions to the unexpected, and deserve to be illuminated.

Lee and I did eventually talk about some of that. But those subjects hadn’t been covered in my training as a Collaborating Investigator. Instead, I’d been drilled on the necessity of obtaining explicit informed consent, which meant acknowledging that “there may be no benefit for the patient from participating,” and some risk—“that the patient may feel uncomfortable answering personal questions about thoughts and feelings.” But, I was to assure the subject, those risks were minimal, and the patient could always “talk to the clinician about any concerns or upsetting feelings,” and could bail at any time. I’d been warned to make sure she could not, while using my computer, gain access to confidential information. And, in the Webinar and the online training and the manual, I’d been given all the fine points of the software, how to save and retrieve and submit. Technical and legal considerations had replaced those hoary concerns about the actual meaning of the experience.

It’s hard to imagine Lee was finding much meaning as she clicked on the Level 1 cross-cutting measures and the Level 2 measures for the Level 1 domains—mood, anxiety, sleep, and substance use—she’d flagged as troublesome, and answered the WHO Disability Assessment Schedule questions about “getting along with people” and “participation in society.” Neither were we talking about what it meant for her to give me my chair and computer back, or watch me fumble through the next hour or so, opening the modules and going down the checklists and reading boldfaced alerts like this one:

To make the diagnosis of Major Depressive Disorder, one has to rule out whether the major depressive episode is better accounted for by Schizoaffective Disorder and is superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. To do so you SHOULD inquire about history of schizoaffective disorder, schizophrenia, and/or any psychotic symptoms!!

I navigated the menus and proceeded through the forty-nine pages of mood disorders and the thirty-one pages of anxiety disorders, the eighteen pages of sleep-wake disorders, the sixty-three pages of substance use disorders (many pages of which could be skipped simply by deciding that I did not want to explore the possibility that Lee suffered from cannabis use disorder or circadian rhythm sleep disorder, but it wasn’t entirely clear how I was supposed to know exactly which ones to skip; in all that training, I’d been left to my own devices to study up on the diagnoses themselves), and I concluded that she suffered from Major Depressive Disorder—Severe and Insomnia Disorder and Alcohol Use Disorder—in Full Remission, all the while feeling retroactive sympathy for Bill Narrow, who knew long before he put hand to mouse that Virginia Hamm was a hoarder just as much as I knew that Lee was a depressed insomniac with a drinking problem, but had to go through with the exercise anyway.

On the other hand, Narrow had a part in designing this 501-page monster and I didn’t.

But what about when the fix wasn’t in? What about someone I didn’t really know? The second interview I was supposed to conduct was with a new patient, and Claudia fit the bill. She had shown up on a rainy night twenty minutes late for her first visit after three increasingly frenzied phone calls in which I assured her that her GPS was correct about how to get from where she was to my building and one more as she wandered the hallways looking for my office, which she did not find until, after another phone call, I went out to meet her. She was easy enough to spot, a tiny woman with a pixie haircut, frantically flitting from doorway to doorway like a lost Tinker Bell. When I found her, she pressed her hands together under her chin
Namaste
-style and bowed slightly, my credibility as guru evidently established simply by my knowing my way around my building. It was a gesture she repeated three or four times in the course of our visit, just after I’d made a comment. After she left, I tried but could not for the life of me recall what those comments might have been. It’s possible my memory got lost in the jumble of details that poured out of her mouth at top speed (she suffered from what we therapists call
logorrhea
), but more likely, I hadn’t said anything particularly insightful, being too busy absorbing her distress and confusion, her depression and anxiety and paranoia, her fragmented stories of her fraught love affairs with men and women, the way she flew from bed to bed like a hummingbird, alighting just long enough to sip some nectar, searching for the next flower before she was even finished with the last—the most recent being a man whom she had, after a flurry of texts and e-mails and aborted trysts, accompanied to a hotel room, only to find his girlfriend already installed, and she, for reasons she couldn’t quite explain, but maybe it was the three martinis they drank, went ahead with his suggested sexual encounter with the girlfriend—and her troubles at her graphic design job, which she was afraid she was about to lose, or maybe she had lost already, she wasn’t sure, but she was too afraid to ask her boss, with whom she had been having sex, but who was leaving the company and his replacement was gay, so he probably wasn’t going to exchange job security for sex (not, she assured me, that this was what she’d been doing with the boss). Plus which she somehow had ended up with the boss’s pet birds, three squawking cages full, who needed care and feeding beyond what she could give any longer, and what she really wanted to know from me was what to do about the birds.