- Email: [email protected]
Creating Mental Illness
BOOK
REVIEWS
Assistant Editor: Christopher R. Thomas, M.D.
[Another] way that facilitated growth in the number of diagnoses was through focusing on the technical issue of reliability, rather than on issues of validity… If a professional wants to argue, for example, that there is an entity called “compulsive television watching (CTW)” she can easily come up with specific criteria—at least five hours per day, at least six days a week, limits outside activities, friends and family comment on the behavior, etc.—and train observers to measure the disorder in a consistent way. The high reliability would be meaningless, however, without a demonstration that CTW is a mental disorder (p. 74). Like so many extremist movements of the twentieth century, antipsychiatry can be blamed for its own demise. By the time that the social constructionist model of mental illness initially put forth by Michael Foucault had made its way through the writings of R.D. Laing and Thomas Szasz, little more than emphatic prose appears to have survived. In fact, what seems today most readily criticizable in these writers is the fact that— despite calling themselves psychiatrists—their ideas in print suggest that they had rarely, if ever, seen a live patient. For example, the schizophrenia they describe does not come across as the real, living and suffering thing, but rather as shadows projected onto the walls of their Platonic caves of rarefied academic pursuit. And so, their rantings and ravings on the relativity and fallacy of mental illness, and on the futility of psychiatric treatment more broadly, ended up falling on deaf ears and being summarily dismissed. As its title suggests, Creating Mental Illness can be construed as belonging within the antipsychiatry framework: one in which psychiatric illness is not real so much as constructed. But to peg the book onto that cultural heritage (as many prospective readers within the mental health field doubtless will) not only does a shortsighted disservice to the book, but in the process takes away a critical perspective we can ill afford to loose. To “think outside the box” may be an expression trite and overused to the point of meaninglessness, but it is one that places the book in a more accurate context. A sociologist who has devoted much of his career to charting mental illness within broad cultural and historical coordinates, Allan Horwitz provides an epistemology notably absent from the “party line” of today’s psychiatric establishment. Although it is true that Horwitz is not a clinician, to do him justice it must be said that he never claims to be one. Moreover, the depth and reach of his scholarly activity, together with a patent sense of compassion toward the mentally ill, more than
make up for the fact. It is precisely because of these credentials that his critique on the state of our field is believable and hard to ignore: if it hurts, it is not only because he is onto something, but given that he has the proper standing and intelligible arguments to say it. The central thesis of the book has to do, to paraphrase three of its chapter titles, with the “extension, expansion, and proliferation” of mental disorders, rather than with their existence. The point is more than merely semantic, as Horwitz is not one to question the fundamental reality of major psychiatric conditions. What he does instead is provide a critique of what he sees as the unjustifiably large reach of our field’s nosology: in his view, psychiatry has gone well beyond its legitimate domain by labeling much of human existence into diagnosable entities. When viewed under this light, the DSM reincarnations represent “not a triumph of science over ideology, but rather a use of the ideology of science to justify current social practices” (p. 74). At a more mundane level, DSM (and IV in particular) is viewed as an adept and effective solution to a crisis long in the making in contemporary psychiatry. The origins of that crisis are largely traced to dynamic psychiatry (a movement on which Horwitz minces no words). With the prevailing force of asylum-based, Kraepelinian psychiatry devoted to the study of the psychoses giving way by mid-century to a largely office-centered practice that intentionally blurred the boundaries between normal and neurotic behavior, psychiatry is seen as having effectively transferred the “jurisdiction of the mental health professions from people with serious mental illnesses to those with problems in their everyday lives” (p. 53). At its extreme, analysis became a worldview more than a therapeutic approach, threatening in the process to leave psychiatry outside of the medical mainstream. Indeed, diagnostic psychiatry emerged partly in response to the realworld need to provide a paradigm compatible with the prevailing scientific method of medicine. At least as evidenced by the DSM series, the shift from dynamic to diagnostic psychiatry was rapid, if not precipitous: the first two editions were based in the former, whereas the third and subsequent ones were clearly steeped in the latter (Kraepelin dominating over Freud in the end; St. Louis over Vienna). As the flag bearer of the new diagnostic paradigm, DSM provided a convenient solution to competing demands by addressing the “intellectual needs of research psychiatrists” (i.e., establishing the medical legitimacy of the field) “and the political and economic necessity of including all disorders that were found in clinical practice” (i.e., maintaining an existing patient base) (p. 82).
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 7 , J U LY 2 0 0 3
877
Creating Mental Illness. By Allan V. Horwitz. Chicago: The University of Chicago Press, 2002, 264 pp., $32.50 (softcover).
BOOK REVIEWS
In addition to the pathologization of normal behavior (with its consequent expansion of the purview of psychiatry, and the inflation of disease prevalence rates), structuring is argued as a second way toward the creation of mental illness. Whereas the former is a quantitative phenomenon, structuring is qualitative in nature. It helps to explain how a common vulnerability to mental illness can lead to very different manifestations, depending on the environment it gets to unfold in, given that “cultures provide publicly available and shared meanings that facilitate certain kinds of symptom interpretation while discouraging others” (p. 116). Unlike their rather fixed and stable underlying vulnerabilities, structured symptom clusters are malleable and changing across time and place. The best historical examples are those of hysteria in late nineteenth century Europe, or of multiple personality, recovered memory, or alien abduction syndromes more recently. In each instance, a shared underlying liability (to dissociation, for example) is expressed through very different and highly structured narratives recognized (and thus reinforced) by prevailing medical and popular views. Mass media can provide an especially fertile ground for the provision of illness templates, as exemplified by phenomena as varied as adolescent copycat suicides, or the di novo emergence of eating disorders in television-naïve communities upon initial exposure to the medium. A third possible pathway toward the creation of mental illnesses is pure semantics. With few “hard” endpoints available, the measurement of any psychiatric illness largely depends on the way in which it is specifically defined. Subtle changes in the wording of definitions can have dramatic effects on prevalence rates, as suggested by the unheralded recent increase in sexual dysfunction or social phobia diagnoses (changes in turn not unrelated to the aggressive marketing of pharmaceuticals aimed at said conditions). In the end, it is as improbable as it is understandable that many psychiatrists (let alone of the child and adolescent persuasion) will read Horwitz’s book. His views are not only provocative and unpopular, but likely to be seen as going against the fundamental grain of the profession. At a time when guild identity and survival are on people’s minds, few will have the mental energy to engage in “big picture” deep thinking about the fundamental nature of the diseases we aim to alleviate. The omission would be an unfortunate one, as this book badly needs to reach the audience so likely to spurn it. Take as a final example that un-DSM-able category, psychiatric disorders du jour. Two of pediatrics’ own, prepubertal mania and Asperger’s syndrome, are conditions as real as nephrocalcinosis, for sure, but ones whose veritable explosion can be ill explained as entirely real. Although recognition of previously unsuspected and legitimate conditions does represent real progress, diagnostic labeling can be a fickle servant, true to many masters. Among those can be counted responsiveness to third party payers (and their natural predilection for discrete
entities, as “continua are not reimbursable” [p. 75]), or the provision of specialized school services for certain, but not for other conditions. The role of the pharmaceutical juggernaut’s marketing practices is particularly important in the reclassification of a broad range of behaviors into specific conditions (shyness, social phobia, and Paxil come to mind). Those who have not fallen into any of the traps described herein need not read this book. The rest of us cannot afford to ignore it.
878
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 7 , J U LY 2 0 0 3
Andrés Martin, M.D., M.P.H. Yale Child Study Center New Haven, CT DOI: 10.1097/01.CHI.0000046879.27264.5B
Stand By Me: The Risks and Rewards of Mentoring Today’s Youth. By Jean E. Rhodes. Cambridge, MA: Harvard University Press, 2002, 163 pp., $20.00 (hardcover). Stand By Me is a clear presentation of theory and practice of mentoring. It provides practical guidelines for maximum benefits for our youths. It is a rich source of useful information for individuals and organizations about the science and art of mentoring at its every stage. It portrays a realistic picture of mentoring, its success, rewards, and also its failure and disappointments. Perhaps the most important feature of this book is its emphasis on empirical findings supporting recommendations in the mentoring process. Across chapters, the author provides an excellent review of the scientific literature investigating the effectiveness of interventions tailored to boys and girls in need of mentoring, including meta-analysis studies, which are generally considered the best approach when summarizing empirical findings across studies on a particular area (e.g., mentoring). Chapter one (“Inventing a Promising Future”) presents an overview of the concept of mentoring and its importance in today’s society. The author also looks critically at the effectiveness of mentoring and finds that even though there are no rigorous scientific studies available to show “statistical” effectiveness of such programs, the over all impact on the youth who are fortunate enough to get some form of mentoring show less involvement of high-risk behaviors and fair well in adult life compared with those who do not. The author finds that before the existence of systematic mentoring programs, such as Big Brothers Big Sisters of America, mentoring was a natural phenomenon in certain cultures. This is particularly true in the case of AfricanAmerican and Latino families, in which adults in these families provided some form of guidance to adolescents and youths. The changing face of society, with suburban migration of pop-
REVIEWS
Assistant Editor: Christopher R. Thomas, M.D.
[Another] way that facilitated growth in the number of diagnoses was through focusing on the technical issue of reliability, rather than on issues of validity… If a professional wants to argue, for example, that there is an entity called “compulsive television watching (CTW)” she can easily come up with specific criteria—at least five hours per day, at least six days a week, limits outside activities, friends and family comment on the behavior, etc.—and train observers to measure the disorder in a consistent way. The high reliability would be meaningless, however, without a demonstration that CTW is a mental disorder (p. 74). Like so many extremist movements of the twentieth century, antipsychiatry can be blamed for its own demise. By the time that the social constructionist model of mental illness initially put forth by Michael Foucault had made its way through the writings of R.D. Laing and Thomas Szasz, little more than emphatic prose appears to have survived. In fact, what seems today most readily criticizable in these writers is the fact that— despite calling themselves psychiatrists—their ideas in print suggest that they had rarely, if ever, seen a live patient. For example, the schizophrenia they describe does not come across as the real, living and suffering thing, but rather as shadows projected onto the walls of their Platonic caves of rarefied academic pursuit. And so, their rantings and ravings on the relativity and fallacy of mental illness, and on the futility of psychiatric treatment more broadly, ended up falling on deaf ears and being summarily dismissed. As its title suggests, Creating Mental Illness can be construed as belonging within the antipsychiatry framework: one in which psychiatric illness is not real so much as constructed. But to peg the book onto that cultural heritage (as many prospective readers within the mental health field doubtless will) not only does a shortsighted disservice to the book, but in the process takes away a critical perspective we can ill afford to loose. To “think outside the box” may be an expression trite and overused to the point of meaninglessness, but it is one that places the book in a more accurate context. A sociologist who has devoted much of his career to charting mental illness within broad cultural and historical coordinates, Allan Horwitz provides an epistemology notably absent from the “party line” of today’s psychiatric establishment. Although it is true that Horwitz is not a clinician, to do him justice it must be said that he never claims to be one. Moreover, the depth and reach of his scholarly activity, together with a patent sense of compassion toward the mentally ill, more than
make up for the fact. It is precisely because of these credentials that his critique on the state of our field is believable and hard to ignore: if it hurts, it is not only because he is onto something, but given that he has the proper standing and intelligible arguments to say it. The central thesis of the book has to do, to paraphrase three of its chapter titles, with the “extension, expansion, and proliferation” of mental disorders, rather than with their existence. The point is more than merely semantic, as Horwitz is not one to question the fundamental reality of major psychiatric conditions. What he does instead is provide a critique of what he sees as the unjustifiably large reach of our field’s nosology: in his view, psychiatry has gone well beyond its legitimate domain by labeling much of human existence into diagnosable entities. When viewed under this light, the DSM reincarnations represent “not a triumph of science over ideology, but rather a use of the ideology of science to justify current social practices” (p. 74). At a more mundane level, DSM (and IV in particular) is viewed as an adept and effective solution to a crisis long in the making in contemporary psychiatry. The origins of that crisis are largely traced to dynamic psychiatry (a movement on which Horwitz minces no words). With the prevailing force of asylum-based, Kraepelinian psychiatry devoted to the study of the psychoses giving way by mid-century to a largely office-centered practice that intentionally blurred the boundaries between normal and neurotic behavior, psychiatry is seen as having effectively transferred the “jurisdiction of the mental health professions from people with serious mental illnesses to those with problems in their everyday lives” (p. 53). At its extreme, analysis became a worldview more than a therapeutic approach, threatening in the process to leave psychiatry outside of the medical mainstream. Indeed, diagnostic psychiatry emerged partly in response to the realworld need to provide a paradigm compatible with the prevailing scientific method of medicine. At least as evidenced by the DSM series, the shift from dynamic to diagnostic psychiatry was rapid, if not precipitous: the first two editions were based in the former, whereas the third and subsequent ones were clearly steeped in the latter (Kraepelin dominating over Freud in the end; St. Louis over Vienna). As the flag bearer of the new diagnostic paradigm, DSM provided a convenient solution to competing demands by addressing the “intellectual needs of research psychiatrists” (i.e., establishing the medical legitimacy of the field) “and the political and economic necessity of including all disorders that were found in clinical practice” (i.e., maintaining an existing patient base) (p. 82).
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 7 , J U LY 2 0 0 3
877
Creating Mental Illness. By Allan V. Horwitz. Chicago: The University of Chicago Press, 2002, 264 pp., $32.50 (softcover).
BOOK REVIEWS
In addition to the pathologization of normal behavior (with its consequent expansion of the purview of psychiatry, and the inflation of disease prevalence rates), structuring is argued as a second way toward the creation of mental illness. Whereas the former is a quantitative phenomenon, structuring is qualitative in nature. It helps to explain how a common vulnerability to mental illness can lead to very different manifestations, depending on the environment it gets to unfold in, given that “cultures provide publicly available and shared meanings that facilitate certain kinds of symptom interpretation while discouraging others” (p. 116). Unlike their rather fixed and stable underlying vulnerabilities, structured symptom clusters are malleable and changing across time and place. The best historical examples are those of hysteria in late nineteenth century Europe, or of multiple personality, recovered memory, or alien abduction syndromes more recently. In each instance, a shared underlying liability (to dissociation, for example) is expressed through very different and highly structured narratives recognized (and thus reinforced) by prevailing medical and popular views. Mass media can provide an especially fertile ground for the provision of illness templates, as exemplified by phenomena as varied as adolescent copycat suicides, or the di novo emergence of eating disorders in television-naïve communities upon initial exposure to the medium. A third possible pathway toward the creation of mental illnesses is pure semantics. With few “hard” endpoints available, the measurement of any psychiatric illness largely depends on the way in which it is specifically defined. Subtle changes in the wording of definitions can have dramatic effects on prevalence rates, as suggested by the unheralded recent increase in sexual dysfunction or social phobia diagnoses (changes in turn not unrelated to the aggressive marketing of pharmaceuticals aimed at said conditions). In the end, it is as improbable as it is understandable that many psychiatrists (let alone of the child and adolescent persuasion) will read Horwitz’s book. His views are not only provocative and unpopular, but likely to be seen as going against the fundamental grain of the profession. At a time when guild identity and survival are on people’s minds, few will have the mental energy to engage in “big picture” deep thinking about the fundamental nature of the diseases we aim to alleviate. The omission would be an unfortunate one, as this book badly needs to reach the audience so likely to spurn it. Take as a final example that un-DSM-able category, psychiatric disorders du jour. Two of pediatrics’ own, prepubertal mania and Asperger’s syndrome, are conditions as real as nephrocalcinosis, for sure, but ones whose veritable explosion can be ill explained as entirely real. Although recognition of previously unsuspected and legitimate conditions does represent real progress, diagnostic labeling can be a fickle servant, true to many masters. Among those can be counted responsiveness to third party payers (and their natural predilection for discrete
entities, as “continua are not reimbursable” [p. 75]), or the provision of specialized school services for certain, but not for other conditions. The role of the pharmaceutical juggernaut’s marketing practices is particularly important in the reclassification of a broad range of behaviors into specific conditions (shyness, social phobia, and Paxil come to mind). Those who have not fallen into any of the traps described herein need not read this book. The rest of us cannot afford to ignore it.
878
J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 7 , J U LY 2 0 0 3
Andrés Martin, M.D., M.P.H. Yale Child Study Center New Haven, CT DOI: 10.1097/01.CHI.0000046879.27264.5B
Stand By Me: The Risks and Rewards of Mentoring Today’s Youth. By Jean E. Rhodes. Cambridge, MA: Harvard University Press, 2002, 163 pp., $20.00 (hardcover). Stand By Me is a clear presentation of theory and practice of mentoring. It provides practical guidelines for maximum benefits for our youths. It is a rich source of useful information for individuals and organizations about the science and art of mentoring at its every stage. It portrays a realistic picture of mentoring, its success, rewards, and also its failure and disappointments. Perhaps the most important feature of this book is its emphasis on empirical findings supporting recommendations in the mentoring process. Across chapters, the author provides an excellent review of the scientific literature investigating the effectiveness of interventions tailored to boys and girls in need of mentoring, including meta-analysis studies, which are generally considered the best approach when summarizing empirical findings across studies on a particular area (e.g., mentoring). Chapter one (“Inventing a Promising Future”) presents an overview of the concept of mentoring and its importance in today’s society. The author also looks critically at the effectiveness of mentoring and finds that even though there are no rigorous scientific studies available to show “statistical” effectiveness of such programs, the over all impact on the youth who are fortunate enough to get some form of mentoring show less involvement of high-risk behaviors and fair well in adult life compared with those who do not. The author finds that before the existence of systematic mentoring programs, such as Big Brothers Big Sisters of America, mentoring was a natural phenomenon in certain cultures. This is particularly true in the case of AfricanAmerican and Latino families, in which adults in these families provided some form of guidance to adolescents and youths. The changing face of society, with suburban migration of pop-