Over the last fifty years in the United States, there has been a massive expansion of the psychiatric enterprise. According to one source (Frank & Glied, 2006), the principal group of mental health professionals in 1950 used to be made up of about seven thousand psychiatrists. Today, using US Department of Labor (2012) figures and selecting professions with the terms psychiatric, mental health, substance abuse, as well as clinical psychologists and mental health and substance abuse social workers, we have an army of at least six hundred thousand mental health professionals. By adding psychiatric nurses and a number of other counseling and therapeutic occupations and their supporting staff, such as medical records keepers and various mental health technicians, the number would easily top one million. Not surprisingly, the amount spent on what are called mental health services has also exploded, from about $1 billion in 1956 (Frank & Glied, 2006) to $113 billion today (Garfield, 2011).
The people who are the target of these services—those from infancy to senescence who are considered mentally ill, who consider themselves mentally ill, and who are encouraged to seek mental health services—is at an all-time high. According to the latest American Psychiatric Association methods of diagnosing mental illness, nearly one hundred million people, 25 to 30 percent of the US population, have a mental illness during any one year (Frank & Glied, 2006, pp. 10–11), and half of the population will have a mental illness during their lifetime. This massive expansion of recognized illness, professional manpower, and services was accompanied by the rise of state and federally funded programs that provide most funding for mental health services. A growing number of private health insurance policies also provide psychiatric coverage. Surrounding this expansion is the pharmaceutical industry, which has immersed the entire mental health service system in a tidal wave of prescription psychoactive drugs, oxygenated by multibillion-dollar lucre, most of it also paid for by public funds.
Many psychiatric authorities claim that these developments are signs of major medical progress: the growing humanitarianism of an enlightened society caring for those in need; the advances in methods of accurately identifying and diagnosing all those suffering from psychiatric illness; and the scientific breakthroughs in understanding and treating mental illness biochemically.
If this grand explanation of progress was accurate, then the following should also be true. There would be less mental illness in America now than in 1950. Those with mental illness would be much more likely to recover with treatment than before. Those who are now called the severely mentally ill, who formerly would have been involuntarily committed to state asylums, would now be more effectively and humanely treated. The use of coercion as a psychiatric intervention would be a method of the distant past. The techniques of diagnosing mental illness would be more accurate, and valid, than methods used previously. Diagnosis would rest on biological markers rather than conversation as the “biological basis” of the currently more than three hundred types of mental illnesses would have been substantiated or disconfirmed. As a result, the remaining actual bodily illnesses formerly called mental illnesses or mental disorders would be the concern of medical specialties such as neurology or endocrinology. We would have confirmed methods of preventing and curing these illness that could be employed by any mental health practitioner. With at least one in four American women and one in seven American men today receiving psychoactive drugs by prescription, there would be solid evidence that these drugs effectively treat the problems for which the Food and Drug Administration approves them.
If you believe that even one of the above signs of progress has occurred, the review and analysis presented in Mad Science will be eye-opening, if not disturbing. None of these confirming developments has occurred. Of course, many in the public and in the mental health professions think that major “advances” in diagnosis and treatments of mental disorders have occurred and are continually occurring. Agencies such as the National Institute of Mental Health and organizations such as the American Psychiatric Association regularly tout such advances, which are then widely echoed by the media. Many, perhaps a majority of adults today, believe that the problem of mental illness is fundamentally a medical problem whose solution lies, through conventional medical research, in identifying its causes and devising effective treatments (e.g., targeting brains and genes). Most people view modern drug treatments as an undisputed improvement (more effective and safer) over any previous interventions designed for those considered mentally ill. Moreover, many people believe (or perhaps merely hope) that those labeled severely mentally ill—and those who treat them—now operate in an atmosphere of cooperation without the use coercion.
In this book we offer a radically different interpretation of the character of the massive American psychiatric and mental health expansion and how it came to be. The discrepancy between the views held by the public and many professionals on the one hand and the actual evidence on the other hand brought the authors of this book together. Our goal was to understand and describe how psychiatric research and science of the past half century have shaped the public understanding of expressions such as “mental illness” or “mental disorder” and of the effectiveness of psychiatric treatment. Much of the psychiatric research that has fueled the expansion of the mental health enterprise has not contributed to a science of madness. Instead, it has fueled mad science, which rests on unverified concepts, the invention of new forms of coercion, unremitting disease mongering, the widespread use of treatments with poorly tested and misleading claims of effectiveness, and rampant conflicts of interest that have completely blurred science and marketing. This is the “madness” of American psychiatry, and of psychiatry in much of the world.
We begin by examining the prevailing language of disease and medicine and its effect on views about the nature of madness and how it ought to be controlled or managed. By critically assessing whether the claims of scientific advances are supported, we track the fate of those labeled the severely or seriously mentally ill as they are ushered into purportedly more humane “community treatment” in which coercion has become redefined as scientifically-elucidated therapy. We examine the nature of the “epidemic of mental disorders” that was manufactured by the ever-expanding boundaries of mental illness contained in the Diagnostic and Statistical Manual of Mental Disorders, the well-promoted and profitable guidebook to madness that has allowed those with institutional and financial interests to claim that existential, interpersonal, and troublesome problems in living are actually diagnosable brain diseases. We then connect these developments to the explosive growth in the use of prescribed psychoactive substances, developed and relentlessly promoted by the pharmaceutical industry and delivered to willing and unwilling persons by licensed physicians and their collaborators in the other mental health professions.
Although the order of the chapters reflects in part the chronological development of coercion, diagnosis, and drug myths in psychiatry, readers should feel free to read chapters 2 to 7 in any order they wish. Each chapter, as it turns out, contains a mix of historical observations, conceptual and critical analysis, and discussions that, we hope, dovetail nicely and occasionally overlap with the other chapters and should augment readers’ appreciation of the interrelatedness of the various topics. We recommend, however, that chapter 8 be read last, as it draws upon all that preceded.
Before we began working on this book, we had barely met or worked together. We are from diverse origins: one—a Hungarian child refugee fleeing the failure of that small country’s 1956 fight for freedom from the tentacles of the Soviet Union—grew up in New York City’s Greenwich Village. The second—a French-speaking Sephardi emigrant from Morocco and then Canada—lives and works in Florida. The third—with German and Lebanese ancestors—was raised in California. Our moral and religious upbringings and our political views are dissimilar, and we are in different stages of our personal lives and careers. We have lived in different states for most of our professional careers. We all happened to be married fathers and professors of social welfare with interests in human distress, misbehavior, and madness; and we each pursued doctoral studies at Berkeley, although in different decades. We have each practiced as mental health clinicians, taught at universities, conducted research, and published on mental health topics.
What really brought us together, however, was that we were each writing critically about psychiatric claims that were at odds with the best empirical evidence, especially the evidence cited by the claims-makers themselves. Each of us struggled to understand how gross misinterpretations of research evidence were allowed to promote vast policies and practices under the rubric of mental health progress. Was good science being misused? Was bad science being propagated? Were equivocal findings being exaggerated for some institutional advantage? Were fake findings being manufactured? Was there merely widespread lack of knowledge and/or gullibility by the public and mental health professionals, hoping to solve an age-old problem? Or was there some even larger, more nebulous enterprise, a sort of mass delusion or self-deception? What was going on? Although working individually, none of us had kept his individual doubts a secret. Quite the contrary, we had each been actively engaged for many years in writing, speaking, and debating with our opposition in professional journals and media outlets. We began meeting together in 2004 in New York City and conversing about madness and the madness institutions. In that process, we saw that a broader context was needed to fully understand the relationship of psychiatric science to psychiatric practice and policy.
This book arose from our conversations, of our effort to tell a broader, more compelling story than we had told individually. The book is truly a collaborative effort. We took seriously Alexandre Dumas’ motto for his three musketeers, “One for all and all for one”—the order of authorship representing only an administrative convenience. We spent obsessive months imagining the structure of the book and ceaselessly reworked that preliminary structure until publication. Although one person had to author a first draft of each chapter using a collectively developed outline, the chapters were read, revised, edited, and re-read by each of us. Sections of content were swapped among chapters. Ideas advanced by one of us were sometimes deleted by others or borrowed and expanded. In the end, we all have our fingerprints on practically every paragraph.
While we developed the book, we presented some of its ideas in academic and professional gatherings, most recently at University of California at Los Angeles and at Berkeley; the University of Brussels; Florida International University; University of Tartu, Estonia; University of Pecs, Hungary; University College Cork, Ireland; and in France, Universities of Poitiers, Bordeaux, Paris-Descartes, and Paris-Diderot. Most surprising was not that our views were challenged, but that so many participants shared our concerns about the direction of modern American psychiatry.
For reasons that will become abundantly clear, our work on this book did not enjoy any direct financial support from the psychiatric-pharmaceutical complex. Instead, we relied on the support of our universities to pursue our inquiry and on the tolerance of our colleagues for our perspective, which at times runs counter to their views. In addition, the Marjorie Crump Endowed Chair at UCLA covered a few of the expenses of finishing our project. Finally, a sabbatical stipend from Florida International University and the Fulbright-Tocqueville Chair Award to David Cohen in 2011–2012 allowed him to devote time to this project.
In addition to our supportive academic institutions, many small enterprises from coast to coast unknowingly supported our efforts. Several times a year we met for days of intensive discussion and to examine our evolving work. We gathered in coffeehouses and restaurants as we argued, bantered, and brainstormed our way through umpteen drafts of chapters. These small, local establishments provided the ambience, sustenance, service, and espresso for our work, some of them on more than one occasion. For their tolerance of our antics and appropriation of their tables, it is only fitting that, in gratitude, we thank a few of them by name. In Greenwich Village (NYC): Café Dante on Macdougal Street with its legendary Latte Macchiato Strong. In Santa Fe (NM): Café Pasquals, Coyote Café, Downtown Subscription, Mucho Gusto, Plaza Café, and Rio Chama. In South Beach (FL): Big Pink and News Café. In Big Sur (CA): Deetjens Big Sur Inn and the Ripplewood Café. In Tallahassee (FL): Z. Bardhi’s Italian Cuisine and Samrat Indian Restaurant. In Ojai (CA): Ojai Emporium Café, and the Ojai Roasting Company. In New Orleans (LA): Lafitte’s Blacksmith Bar.
We are hardly the first to raise critical questions about the mental health enterprise. For intellectual inspiration we drew on dozens of authors whose work we cite repeatedly in the text. In addition, we also asked other scholars to review and comment on draft chapters and discussed our work with others. Their advice and suggestions were wise, constructive, and unfailingly helpful, although we have undoubtedly disappointed some of them by not fully adopting their suggestions or addressing their concerns. Our gratitude to Lauren Dockett, Eric Engstrom, François Gonon, Nikki Hozack, David Jacobs, Herb Kutchins, Jeffrey Lacasse, Bruce Levine, Joanna Moncrieff, David Oaks, Pascal-Henri Keller, the late Thomas Szasz, Robert Whitaker, and several anonymous reviewers. A special thanks to Professor Eileen Gambrill of the University of California, Berkeley, who shaped our early academic careers by stimulating a critical attitude toward all conventional assumptions that apply to the study of and responses to human travail. Finally, we were encouraged early in our project by the late Professor Irving Louis Horowitz, the founder of Transaction Publishers, who reviewed our book prospectus in 2010. Unfortunately, he passed away the week before our full manuscript was submitted. We are indebted to him, Mary E. Curtis, the president, and the other editors at Transaction for providing a welcoming home for our book.
Finally, we have deep personal gratitude for those close to us who encouraged our work and provided the emotional support that sustained us. While they bear no responsibility for our book, their lives were certainly affected by our entanglement with Mad Science. Stuart acknowledges and deeply appreciates the tolerance, support, and humor of Carol Ann Koz, who was not blind to what life with him would be like when he began another book. Tomi could not be the engaged academic critic that he is without the uncritical, loving support of his life partner Fran and the very best and sweetest two daughters any father could be privileged to love, Aniko and Rozsa. He owes to those three much more than he could ever express. Throughout his career, David’s most dedicated support and encouragement has come from his wife Carole and their children, Saskia and Bernard.
Inevitably, coauthoring a book involves time, complexities, and frustrations. Yet, the three of us agree that the deep, meaningful relationships that we formed among us constitute the major benefit of our effort.
Frank, R. G., & Glied, S. A. (2006). Better but not well: Mental health policy in the United States since 1950. Baltimore: Johns Hopkins University Press.
Garfield, R. L. (2011). Mental health financing in the United States: A primer. Washington, DC: Kaiser Commission on Medicaid and the Uninsured.
US Department of Labor. (2012). Occupational employment and wages—May 2011. Bureau of Labor Statistics. Retrieved from: http://www.bls.gov/news.release/archives/ocwage_03272012.pdf