When I was still in my idealistic 20s, I took up a fight that turned out – most would say inevitably so – to be a losing battle. That battle was essentially to save “normal” and hold “bad” accountable.
That battle started during my postgraduate studies when I uncovered a pernicious practice in the Australian Public Service (APS) of compelling internal whistleblowers to undergo psychiatric assessments in an attempt to undermine their credibility so that no one would listen to them and to scare them into silence. Usually a diagnosis would be reached in only one session with the psychiatrist, the production of the assessment report would be at a cost of around $3,000 to the Australian tax payer, the assessments were quite often undertaken by psychiatrists that fit the bill of hired guns, and the psychiatrists were sometimes given secret dossiers that contained prejudiced and false statements about the employee being assessed, in order to paint them in the worst possible light.
The whistleblowers I spoke with were, for all intents and purposes, patently “normal”. They were simply showing inevitable signs of stress from experiencing the full force of the “system” unjustly coming down on them. In addition to uncovering this Soviet-like scandal, I had also identified numerous other formulaic victimisation tactics that APS agencies used against targets.
I’ve always had a strong sense of social justice. This ultimately explains why I made the career-suicidal move (I had got up to the first executive level in the APS in Canberra) to publish my findings online, along with suggested countermoves, to help APS victims minimise the damage caused to their careers, finances, reputations and health. APSbullying.com was a big success for a grassroots movement that was started by a young person with no notable influence or connections in Canberra, and I am quite proud of that. During its three-year run, it had nearly 80,000 page visits, reaching people in many different federal and state government departments. Most heartening were the dozens of messages I received from readers who expressed feeling relief upon finding an information source that methodically dissected the madness their employer was putting them through.
Another aspect of the website was legal and public policy reform advocacy, where I argued why the existence and use of compulsory medical referral powers under public service legislation could be unlawful and should be abolished in this enlightened age. My arguments went towards helping a group of victims in the South Australian Public Service persuade the South Australian Government to introduce safeguards to limit abuse of its equivalent legislative power.
The federal public service was also listening to what I had to say, but I should have known better to think decency would prevail in the upper echelons of the powerful old boys club in Canberra. The APS’s reaction was to strengthen and “justify” the laws to make it even easier to compel an employee to undergo a psychiatric assessment!
I was gut-wrenched! Here I was trying to help the underdog, but, in the end, the noise I made resulted in making things worse for APS employees. I no longer harboured any delusions that I could change the system: the status quo in Canberra would always prevail. I also now had first-hand awareness of just how much the rhetoric around the virtues of democratic processes grossly mismatched the reality in Australia. Soon after I dropped the cause, changed careers and sought new lands. Whilst APSbullying.com doesn’t exist anymore, much of it has since been published in the form of a paperback and e-book, called “Bad Behaviour in the Public Service”.
However, recently, I read a book that piqued my interest again in the misuse of psychiatry: a book that every person in the English-speaking world should read. It’s called “Saving Normal” by Professor Allen Frances, a prominent American psychiatrist who had headed up the taskforce that produced the fourth revision of the Diagnostic and Statistical Manual (DSM-IV) – “the object of undue worship as the ‘bible’ of psychiatry”, as Frances puts it.
Frances articulately and persuasively argues for the need to protect normality from being pathologised and medicalised, and to protect psychiatry from over expansion. He says diagnostic inflation is expanding far beyond psychiatry’s competence. He reminds us that psychiatry is a soft science: “We still do not have a single laboratory test in psychiatry”, which “means that all of our diagnoses are now based on subjective judgments that are inherently fallible and prey to capricious change”. Frances points out that, because of diagnostic inflation, an excessive proportion of the normal-enough “worried well” have come to rely on antidepressants, antipsychotics, antianxiety agents, sleeping pills and pain meds, which have dangerous side effects such as obesity, diabetes, heart disease and a shortened life span.
A secondary problem with diagnostic inflation (which many politically correct minds often like to pretend is not a serious problem) is the stigma that comes from being labelled with a mental disorder. Frances states:
“Stigma takes many forms, comes from all directions, is sometimes blatantly overt, but can also be remarkably subtle. It is the cruel comment, the unkind smirk, the extrusion from the group, the lost job opportunity, the rejected marriage proposal, the ineligibility for life insurance, the inability to adopt a child, or pilot a plane. But it is also the reduced expectation, the helping hand when none is needed or wanted, the solicitous sympathy that one cannot really be expected to measure up. And the secondary psychological and practical harms of having a mental disorder label come only partly from how others see you. A great deal of the trouble comes from a change in how you see yourself - the sense of being damaged goods, feeling not normal or worthy, not a full-fledged member of the group.”
Indeed, as Frances puts it, “the power to label is the power to destroy”.
Frances argues that psychiatry done well takes a nuanced approach, not a checklist approach. Having a few psychiatric symptoms does not mean having a psychiatric disorder. Frances reminds us that “many people have some symptoms some or all of the time – this is just part of life, not psychiatric disorder”. “The full cluster of symptoms at a sufficient level of severity and duration” is needed before a person can be considered to have a mental disorder. Even then, you need to take into account that the DSM definitions “do not include personal and contextual factors, such as whether the symptoms are an understandable response to a loss, a terrible life situation, psychological conflict, or personality factors”. This is a pertinent, but all-too-forgotten, fact. Accordingly, applying this to a workplace context, all employers should take serious note of workplace abuse targets’ pleas to be transferred out of a toxic work environment, if the environment cannot be sufficiently detoxified, as stress symptoms frequently result from situational factors rather than internal factors.
Something that many targets of bad behaviour in the workplace should remember, in order to not fall into the traps of Western society’s artificial sickness push, is the following apt statement made by Frances:
“We can feel sadness, grief, worry, anger, disgust, and terror because these are all adaptive. At times (especially in response to interpersonal, psychological and practical stresses), our emotions may temporarily get out of hand and cause considerable distress or impairment. But homeostasis and time are great natural healers, and most people resiliently right themselves and regain their normal balance. Psychiatric disorder consists of symptoms and behaviours that are not self-correcting - a breakdown in the normal homeostatic healing process. Diagnostic inflation occurs when we confuse the typical perturbations that are part of everyone’s life with true psychiatric disorder (which is relatively uncommon, perhaps affecting 5 to 10 percent of the population at any given time). Mental disorders should be diagnosed only when the presentation is clear-cut, severe, and clearly not going away on its own. The best way to deal with the everyday problems of living is to solve them directly or to wait them out, not to medicalise them with a psychiatric diagnosis or treat them with a pill. Prematurely resorting to medication short-circuits the traditional pathways of restorative natural healing: seeking support from family, friends, and the community; making needed life changes, off-loading excessive stress; pursuing hobbies and interests, exercise, rest, distraction, a change of pace. Overcoming problems on your own normalises the situation, teaches new skills, and brings you closer to the people who were helpful. Taking a pill labels you as different and sick, even if you really aren’t. Medication is essential when needed to reestablish homeostasis for those who are suffering from real psychiatric disorder. Medication interferes with homeostasis for those who are suffering from the problems of everyday life.”
Quite damning is the evidence Frances presents that supports his claim that the DSM has been greatly oversold and overbought by the medical profession and society at large. He goes over a detailed chronology of the development of the DSM.
Published in 1980, the DSM-III was based on very limited scientific evidence. It was produced out of a chaotic process involving a small group of experts on each disorder thrashing out their ideas. They were virtually locked down in a room and could not emerge until they had reached agreement. Whenever controversy did persist, the advantage went to whoever was most loud, confident, stubborn, senior, or spoke to the taskforce head, Professor Robert Spitzer, last. Frances espouses that the finished product was “overly inclusive – with many new mental disorders describing mild symptom presentations at the populous boundary with normality”.
In the 1990s, the approach Frances’s team took to writing up DSM-IV was minimalist: changes would only be made if there was supporting scientific evidence. As a result of the sparsity of evidence, few changes were made. However, in hindsight, Frances laments that he and his team did not save normal, or even protect it, because of failure to tighten diagnostic thresholds (requiring more symptoms, longer durations and greater impairment).
“Being evidence-based rather than opinion-driven helped us avoid contributing to new inflation, but it also prevented us from reducing the inflation that was already in place. Knowing what I know now, this was probably a mistake. It would have been better to create a double standard, with less evidence required to effect deflation than to promote inflation. Admittedly, deflation would have been difficult and arbitrary, but it now seems preferable to the excessive diagnosis and treatment that have since been protected by our adherence to evidence.”
“Our changes contributed directly to the false epidemic of autistic, attention deficient, and adult bipolar disorders; we did nothing to prevent the overdiagnosis of several other disorders that have been puffed up by the drug companies; and our one outright mistake was a disaster - a sloppily worded paraphilia section that has allowed the widespread unconstitutional abuse of involuntary psychiatric hospitalisation.”
The story Frances has to tell about the most recent development of DSM-5 is the most frightening. The intentions of the team behind DSM-5 were to add many new mental disorders and loosen the rules on how to diagnose existing ones. Frances amusingly points out that he personally qualified for many of the new disorders that were being suggested for inclusion in DSM-5: “My gorging on the delectable shrimp and ribs was DSM-5 ‘binge eating disorder’. My forgetting of names and faces would be covered by DSM-5 ‘minor neurocognitive disorder’. My worries and sadness were going to be ‘mixed anxiety/depressive disorder’. The grief I felt when my wife died was ‘major depressive disorder’. My well-known hyperactivity and distractibility were clear signs of ‘adult attention deficit disorder’.” Indeed, diagnostic inflation risks becoming diagnostic hyperinflation under DSM-5.
On the administrative side, Frances exposes the sloppiness and lack of accountability in producing DSM-5:
“All along, the American Psychiatric Association (APA) has treated DSM-5 more as a private publishing asset than as a public trust. First there were confidentiality agreements to protect ‘intellectual property’, then an inappropriately aggressive protection of trademark and copyright, and finally the unseemly rush to prematurely publish because this was necessary to fill the budgetary hole. ”
In expanding on the first point of confidentiality, Frances states:
“The DSM-5 design of the field trials were created behind closed doors and never subjected to the much-needed peer review that would have corrected its obvious flaws.” As a result, the “reliability of the diagnoses tested in the DSM-5 field trials were far below what had been achieved in the past and what could be achieved in the present if the project had been conducted competently.”
In expanding on the last point of rushing to publication, Frances states:
“DSM-5 had to cancel its crucial quality control step when work fell so far behind there was no time left to complete it by the deadline.” “The original plan had included a quality control step. If diagnoses had poor reliability in Stage 1 (as many did), Stage 2 (rewriting and retesting) would correct them. But Stage 1 came in so late, there was no time left for Stage 2 if the 2013 publication date were to be met as required to meet APA budget projections for publishing profits.” “APA was not only sacrificing its own credibility, but also putting patient safety at risk and unfairly tainting the whole mental health enterprise.”
All in all, the process behind the development of DSM-5 did not have the necessary transparency and checks needed to produce a safe and high quality DSM. And this is on the back of the two DSMs before it that still had questionable aspects in relation to their reliability and credibility.
Now, the danger lies in a book given undue “bible” status in the medical profession and society at large that, more than ever before, encourages the pathologising of “symptoms that are part of everyday life and commonly encountered in the general population”, and contains definitions not precise enough to “prevent the mislabeling of many people now considered normal”. Frances foresees “the aggregate effects will be overdiagnosis, unnecessary stigma, overtreatment, a misallocation of resources, and a negative impact in the way we see ourselves as individuals and as a society”. And, despite all of this recent controversy, the APS is still prepared to force their employees into psychiatric assessments.
We are already seeing Frances’s predictions coming into fruition. As he points out, Australia is leading the charge in introducing a nationwide program, spending about half a billion dollars, to treat “psychosis risk” – even though it is not an official diagnosis. Frances provides five compelling strikes against this public policy:
“Strike 1: Most people getting the scary-sounding diagnosis ‘psychosis risk’ would in fact be mislabeled. In the normal course of events, only a very small proportion would ever become psychotic. Strike 2: There is no proven way to prevent psychosis, even in those really at risk for developing it. Strike 3: Many people would suffer collateral damage – receiving unnecessary antipsychotic drugs that can cause obesity, diabetes, heart disease, and likely a shortened life expectancy. Strike 4: Think of the stigma and worry caused by the completely misleading implication that psychosis is just around the corner. Strike 5: Since when is having a ‘risk’ the same as having a ‘disease’?”
This public health policy is quite reflective of the typical Canberra bureaucrat mindset: an eager embrace of an artificially sick society rather than a resolutely resilient one.
Frances fears that to fight against making it hard for people to be considered well is to fight a losing battle. He says “we opponents to inflation are too few, weak, unfunded, disorganized, and face odds that are impossibly imposing”. But he says we “have a big advantage on our side – our cause is right, and right sometimes does make might”. Thus, if you care about saving normality, I urge you to read Frances’s book and think about what you can do to help this all-so-important cause.
I would like to finish with a quote from Frances that deeply resonated with me, particularly after living and working in Canberra, which often felt like living in a human monoculture; where vivid differences were washed out, where those who drifted colourfully away from the beige mean were either unappreciated, mocked or pathologised.
“Human diversity has its purposes or it would not have survived the evolutionary rat race. Our ancestors made it because the tribe combined a wide variety of talents and inclinations. There were leaders high on their own narcissism and followers content enough to be dependent on them; people who were paranoid enough to sniff out hidden threats, compulsive enough to get the job done, and exhibitionistic enough to attract mates. It was good to have some who would avoid dangers, others who could ruthlessly exploit them. Perhaps the healthiest individuals were those who best balanced all these traits somewhere near the golden mean, but the best bet for the group was to have outliers always ready to step up to the plate as the particular occasion demanded.”
“It takes all types to make a successful tribe, and a full palette of emotions to make a fully lived life.”