The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association is as important to the therapeutic discipline “as the Constitution is to US government or the Bible is to Christians,” wrote Gary Greenberg in a 2010 article for the magazine Wired. The text enumerates every form of suffering and psychosis recognized as a mental illness by American professionals, categories that carry enormous implications for the tens of millions of Americans with diagnoses, as well as for the pharmaceutical and insurance industries that treat their symptoms and profit from their care. But according to Greenberg, a psychotherapist and social critic, the DSM is not a medically or scientifically valid text, but rather a “strange chimerical document” whose definitions of pathology change with shifting social values—as was evidenced by homosexuality’s overlong tenure on its pages.
Greenberg is certainly not the first to call attention to the social nature of disease, either in terms of origins or medical interpretations. But he may be among the first to get the DSM’s former editor, Allen Frances, on the record as saying, “There is no definition of a mental disorder. It’s bullshit.” Exploring the various elements underpinning this statement and their varied repercussions constitutes the basis of Greenberg’s most recent project: an examination of how America’s mental health industry became linked to “fictive placeholders” that masquerade as fact.
It’s not that Greenberg denies that there is such a thing as mental illness. His 2010 work, Manufacturing Depression: The Secret History of a Modern Disease, casts a critical eye on the most widespread mental illness in the United States—affecting some 10 percent of adults, according to the Centers for Disease Control—and argues that these figures list heavily toward the absurd. It’s not because people don’t suffer from depression, he says, but rather that their depression is not necessarily disease. It’s a normal, and perhaps even healthy, response to living in an insane world.
In his most recent work, The Book of Woe, whose release was timed with the publication of the DSM-5, Greenberg hones in on the argument that there is no medical distinction between mental health and mental illness, and maintains that as a result, the DSM is a volume of myth. And yet, he argues, these fictions are the basis of psychiatrists’ authority and legitimacy—it’s what allows them to collect billions from insurance companies, what secures funding from federal research agencies, and what compels pharmaceutical companies to research and develop treatments. As the DSM evolves over time, it intrudes more deeply into our lives—more than one-quarter of Americans satisfy the requirements for mental illness—transforming idiosyncrasies and untidy details into potential markers of pathology.
One consequence of this system, Greenberg argues in the interview that follows, is that our melancholy becomes couched in chemical explanations, leaving little space for individuals to grapple with the reality of their worlds, which in these days of economic insecurity is becoming increasingly dire. Speaking by phone between New London and New York City, Greenberg and I discussed what’s at stake in our evolving mental health industry, and how mainstream ideologies of care may, to our detriment, shelter us from truth.
—Katherine Rowland for Guernica
Guernica: You’re a psychotherapist, and you have a practice. Was there a time when you were a faithful participant in what you call the “diagnostic enterprise”?
Gary Greenberg: Nope. I never had a conversion experience; I was not struck on the road to Damascus.
You’ve got to understand that virtually nobody believes in the DSM, particularly in the value of diagnoses. The manual is held in universal contempt, and the attitude toward it is almost universally one of cynicism. So it’s not so much that I’ve had a conversion experience—my relationship with the DSM didn’t change—but what has happened is that I’ve become increasingly unhappy with myself for being involved with a book that is so obviously bogus—and almost purely for money.
Guernica: In an article in Wired that you wrote a few years ago, you describe the DSM as being “as important to psychiatry as the Constitution is to the US government, or the Bible is to Christians.” But what I’m hearing now, which echoes what you expressed in a recent interview in the New York Times, is that the DSM is not held in high regard. I’m having trouble making sense of these two assertions.
Gary Greenberg: To say it’s important doesn’t mean it’s popular. [Psychiatrists] need something, nobody likes it. It’s not beloved like the Constitution. In that New York Times Q&A, something that they cut out was a question about when I realized I was going to write this book. The real answer was when somebody gave me a contract, so I said that it was as if the College of Cardinals had decided to talk about how bad the Bible was. That’s the point: you can have the importance and the authority without the faith.
There’s also the fact that we’re hungry for myth, and as impoverished and deracinated and downright uninteresting a mythology as it is, the DSM is a mythology.
Guernica: In The Book of Woe, you explore how the DSM’s diagnoses are “fictive placeholders,” clinical names ascribed to human suffering, but also discuss how psychiatrists spend so much time diagnosing certain conditions that they begin to think that they’re real. Would you elaborate on that?
Gary Greenberg: There are so many vectors that move in the direction of the DSM having more authority than it deserves, despite the efforts of psychiatrists to reduce expectations about belief in the DSM. It’s sort of like the sorcerer’s apprentice: it has a life of its own, it got out of hand. So why did that happen? Well, first of all, it happened because it was supposed to. The modern DSM was created expressly to bolster the authority of psychiatry by making it seem like it’s treating identifiable illnesses, by making it seem like it worked the same way as the rest of medicine.
But there’s more than that. There’s also the fact that we’re hungry for myth, and as impoverished and deracinated and downright uninteresting a mythology as it is, the DSM is a mythology. It provides a framework for understanding mental suffering. Myth is a kind of knowledge that helps people negotiate the world, and the particular kind of myth-making that the DSM is engaged with is one of the oldest forms of myth-making in Western Civilization, which is naming things. Go back to Genesis: God tells Adam to name the plants and the animals. This is a very primordial way of attempting to know the world, to name and to distinguish among the phenomena with which we’re presented. What that really means is that when you name something you are in some way claiming to know it.
Guernica: Allen Frances, the chair of the Task Force that produced the last version of the DSM, told you “there is no definition of a mental disorder. It’s bullshit.” Coming from someone of his standing that seems like a huge assertion. Where did that position come from?
Gary Greenberg: Allen Frances is a very smart, compassionate, humane guy. He’s steeped in the history of Western Civilization and he has very sophisticated understanding of what we’re talking about, and he claims he hasn’t had a conversion experience either. He’s always known there is no way to draw the line between mental health and mental illness, and to do so has always been more about ass-covering than anything else. If you could come up with that definition then you could have valid mental illness. You would be able to say this set of symptoms is a disease because it meets the criteria for the disease. So Frances understands why there’s a fantasy that you can do that. But he’s also clear on the side of the fact that it’s not possible. That it’s always been an attempt to square the circle, to give psychiatry what it’s never had.
Guernica: While our suffering resists the measurable…
Gary Greenberg: And yet at the same time we demand that our healers be participating in a discourse of measurement. And before you even get to the point of evidence, on the one hand you’ve got yourself a document that presents itself as fact but it’s really mythology, and on the other hand you’ve got a system in which only when it’s fact does psychiatry have any authority.
Guernica: I’d like to probe that “authority” amid fiction. You’re arguing that psychiatry has to maintain its scientific validity in order to preserve its prominence?
Gary Greenberg: Since it doesn’t have any scientific validity, it’s got to maintain its prominence because if it doesn’t then psychiatry collapses like a house of cards. I don’t actually believe that, but I think that’s what psychiatrists are worried about. But it’s not that complicated, just be honest with people. Do the same thing that any doctor does when you go to them with migraine or lower back pain. Say, I don’t know what’s going on, but here’s what helps. Lower back pain: rest, ice, the occasional narcotic. With the case of migraine, same deal: find out what triggers them. But there’s no claim there that we know what’s going on.
Guernica: Why is psychiatry so different from medicine? My internist wouldn’t cobble together my symptoms and declare that I have a condition that I don’t. Why does psychiatry fall into another pattern?
People come to think of their unhappiness as a disease, rather than as a result of the material conditions of their world.
Gary Greenberg: Because they don’t have a choice. There’s nothing there. Psychiatry doesn’t have any slam dunks. Let’s go back. You go into a doctor with chest pain and if that doctor can’t diagnosis it, you’re not going to get an angioplasty, nobody is going to be jamming a catheter up your aorta. And if they are, they’re going to be guilty of really bad malpractice. So the problem here is that psychiatry doesn’t have that intermediate step. They’d say here are your symptoms, here’s your chest pain, here’s your drug, and that’s where the problem is. How the DSM figures into that is that it’s the justification for doing it.
Guernica: So as the DSM evolves, categories of mental illness expand and take different shapes, potentially recruiting more people into different diagnoses. What’s at stake there and why’s that a bad thing?
Gary Greenberg: The reason why this is a bad thing is that this is how people make their identities. The problem isn’t that people get stigmatized, the problem is that they get identities, and those identities are provided to them under the mythology that we’re talking about. If Manufacturing Depression is about how this discourse about depression shapes who we are, what’s at stake—especially with something as widespread and amorphous as depression—is that people come to think of their unhappiness as a disease, rather than as a result of the material conditions of their world.
Guernica: So these categories can be like a barrier to confronting the conditions in which they’re living?
Gary Greenberg: Yeah, at the very least to be able to say, I’m worried about how the fuck I’m going to retire. And I’m feeling really powerless because these idiots in Washington are thinking it’s totally okay to hold the whole country hostage to their parochial interests. Maybe that is something that I don’t take as seriously if I have an illness. Or I don’t even feel it as intensely if I’m on one of these drugs. At the end of Manufacturing Depression I wrote a little riff on this, about how we don’t know how many of these people who broke the economy were on these drugs. The profile of someone who’s on these antidepressants is someone who’s too confident, who’s sort of numb to the effects of their behavior and to the suffering of the world around them, who is not worried about rejection. It’s not really a fair argument, and I’m not proud of it, but there’s a very straightforward and upsetting correlation in the rise of antidepressants and the rise in the monetization of everything.
Guernica: I can’t help but almost succumb to conspiratorial thinking in processing all this. So, diseases are invented to describe our feelings, and these feelings are oftentimes those of being sane in an insane world, and they’re followed by the invention of pills to assuage these feelings. Who or what is culpable here?
Gary Greenberg: Well, let’s round up the usual suspects. Clearly, the DSM is all about money. If it weren’t for money, nobody would give a rat’s ass. But it’s all about money and so is the drug industry, and so, frankly, is the therapy industry. I don’t think I’d spend my days with unhappy people voluntarily if I wasn’t getting paid for it. It’s not that I don’t like the people, but day in day out it’s all about money. And who really benefits from that cycle you just described? Well, primarily the drug industry.
Where I happen to have my office is in New London, which used to be the home of Pfizer Research and Development. In my experience of Pfizer people, I’ve yet to meet one who wants to manipulate people’s consciousness, who’s really rubbing their hands in glee when people get sick. They’re basically as humane as the next guy. So what’s really going on for me is ideology at work. If ideology is working behind the scenes then all the good intentions in the world go pave the way to hell.
Guernica: Can you talk about that ideology?
Gary Greenberg: Some of it has to do with the idea that unhappiness is a disease. But the ideology that’s really at stake in all of this is how all of our suffering can be understood as being caused by something biological. That belief has to do with scientific mastery and the wish for immortality and the desire not to suffer, that our psychology has secrets to yield and when they yield they’re going to be yielded to doctors. This is a very deeply ingrained set of beliefs we have when it comes to medicine. Historically, you can identify the rise of this ideology as an outgrowth of the Enlightenment, but you can identify it specifically when medicine moved away from being an empirical profession—the healers who worked by trial and error based on what they observed—to a profession that professed to have found the essence of disease; the whole modern idea that underneath the appearance is the essence. When they found germs in the nineteenth century and realized that they were actually seeing the world behind the symptoms, this was so profound. You could actually probe into the unseen, the invisible, the causes of suffering, and then treat them with a drug—I don’t think we’ve begun to grapple with how powerful that idea has been. And it fits so nicely into the Enlightenment notion of science.
Guernica: In public health there’s been a huge push recently to do more patient-centered research, and the medical establishment has increasingly been more yielding toward the idea that the way you best measure the efficacy of treatment is seeing how the patients themselves are actually responding to it. Are you treating what you set out to treat and are people healing in a way that actually improves their quality of life. Have similar measures been taken up in psychiatry?
Gary Greenberg: There have been studies using a different approach to measuring what antidepressants do, that instead of looking at mood have looked at personality. And they come up with what seems to be pretty obvious, but to drug companies is very disquieting, that their main effect is personality—not chemistry—and the reason that they have a positive effect when they do is that people like themselves better. And why do people like themselves better? Well, because the things that it does to personality are much more in keeping with our expectations of what you’re supposed to be: confident, resilient, happy, optimistic. And the argument can be made of cognitive behavioral therapy [a widespread form of talk therapy] that the reason it works is not because it somehow treats depression, but because it’s sort of an ideological reorientation.
There is a moral subtext to the DSM, and by moral I don’t mean having to do with good and evil, I mean having to do with there being an understanding of the good life.
Guernica: It makes you more content with your lot?
Gary Greenberg: Yes, and the convergence between the cognitive behavioral therapy with the mainstream ideology of American capitalism and American society is really striking.
Guernica: How so?
Gary Greenberg: Cognitive behavioral therapy sees anything other than resilience and optimism as pathology. The idea behind it is that changing how you think about something changes the nature of the thing. Nothing is good or bad, but thinking makes it so. I know that it wasn’t an American who said that, but that idea is very consistent with the whole enterprise.
Guernica: What about the DSM as a whole? Does that also reflect ideology, with regard to designating norms and pathology?
Gary Greenberg: Yes, in form and content. The form is easier to see. There’s this idea that you can in a meaningful way understand suffering in a very pragmatic, straightforward, bullet-point approach. That strikes me as really a part of American can-do optimism. You can take these incredibly frightening, confusing, inchoate experiences, schizophrenia for example, or depression, and put them in terms that lend themselves to pragmatic understanding and pragmatic approaches to treatment.
Content is a more interesting question. There is a moral subtext to the DSM, and by moral I don’t mean having to do with good and evil, I mean having to do with there being an understanding of the good life, as there is in any text that’s going to tell you about heath and illness. You should recognize that the whole DSM is culture-bound. For instance, borderline personality disorder is a failure to achieve a kind of autonomy that is a very recent invention, a recent expectation of human beings—we talk about the idea of object constancy as if it were a hardwired developmental model, but there are cultures on the face of the planet today for whom autonomy in that sense is not how society is organized.
Guernica: So they’re sort of culture-bound assumptions about how the self is constituted…
Gary Greenberg: Yes, exactly. You see it especially in the personality disorders because they’re the ones that are most about the self. But the whole book could be deconstructed in that fashion.
Guernica: An issue that kept on coming up for me reading your book is that we have what by all accounts is an epidemic of over-diagnosis in our country. You point out that by epidemiological standards, a third of the American public would have a mental illness according to DSM standards. But on the other hand, there also seems to be an epidemic of genuine suffering—suicide in this country now overtakes car accidents as a cause of death. It made me wonder if psychiatry is missing its mission to heal?
You’re only here for a certain amount of time and there is something out there called truth that’s worth engaging with, even if it’s upsetting.
Gary Greenberg: In the last chapter of The Book of Woe, there is an interview with Tom Insel [the director of the National Institutes of Mental Health]—he’s saying this, that whatever we’re doing is not working. His elucidation of the problem is exactly what you were just saying, that if psychiatry is really to whom we have entrusted our mental health, then we may be barking up the wrong tree. It’s not doing a very good job, and that may be because it’s stuck in that epistemic prison, and I don’t just mean with respect to diagnosis, I mean with respect to its understanding of human suffering. But it could also be because maybe human suffering is not curable. And that the social conditions under which we live are increasingly atrocious. It could be that the reason we’re all getting whatever it is we’re getting is because the world truly is in some way progressing toward catastrophe.
Guernica: If psychiatry is so off base, how can you write what you write and still engage in your clinical practice?
Gary Greenberg: Most of what I write about and criticize is not what I do. Part of therapy to me is orienting them away from diagnoses and toward the idea that whatever’s happening has meaning. It’s not just electrochemical noise, and I have to do that because otherwise it’s become a default. I still have people who think of themselves in overwhelmingly diagnostic terms—they think of themselves as having these mental disorders.
But the other part of it is, what is therapy? Therapy tends to reckon with the truth about who we are and what our lives are like and what the world is really about. And the fact is, if we didn’t have such a fucked up society, I’d be out of a job. Not only because it creates stress, but because it creates the need to go into this world for an hour and have that opportunity to engage with nothing but the truth. And I’d be the first person to tell you that it’s really a shame, a terrible commentary on us that the profession is necessary. But given that it is, I think it’s really valuable because there is nothing quite as empowering as being in possession of truth about yourself, even if it’s dismaying, even if it turns out that you’re a bundle of contradictions, even if it turns out that you’re a disappointment to yourself. As far as I can tell, that’s the only way to get through human life. You’re only here for a certain amount of time and there is something out there called truth that’s worth engaging with, even if it’s upsetting.
Guernica: If we’re living in more dire times, has there been an accompanying push to approach suffering as a social problem rather than a chemical problem, a problem of living rather than a problem of the mind? Is that kind of argumentation gaining hold?
Gary Greenberg: It may be regaining hold. The Second World War was really transformative for psychiatry because all these guys came back from the War really, really fucked up. And so one of things that did was redirect psychiatry’s attention to war. If you’re exposed to the horrors of battle, what happens to you? If you’re traumatized in this way, maybe what we should be thinking about are the ways that society is traumatizing. Let’s think of all mental illness as the same thing, as a way that your vulnerability is expressed when you’re exposed to what social arrangements can create. And for twenty-five to thirty years, there was a very strong movement.
But unfortunately today you don’t find it within psychiatry, or really within the mainstream mental health industry at all. There are small pockets of questioning. Without wanting to claim that there is no such thing as mental illness, people are saying there is such a thing, but it isn’t what you’re telling us it is, and we want to be free to figure it out for ourselves. And there are other approaches, especially when it comes to psychotic disorders, where people are doing research now that is interested in the meaning of psychosis, both the content and the existence of it.
Guernica: But in general, it’s pretty small compared to the mainstream model?
Gary Greenberg: It is infinitesimal. And the momentum continues in the direction of neuroscience, despite the fact that so far it’s been a bust. Of course neuroscience is important and it’s going to someday yield something that is useful. But the idea that we’re going to MRI our way to an understanding of mental illness and how to treat it is just mind-boggling to me. It’s important to be researching this stuff, but there are some issues that are just more immediate and relevant and can actually be dealt with.
The difficulty of the average American life is so underestimated and the obvious psychological sequelae of huge dislocations, like the diminishing middle class, like the loss of manufacturing jobs, all of these things that are happening right in front of us about which the only solution is what—have a better attitude? Turn it into an illness that’s treated with resiliency training or with drugs? It’s like you want to take the people who have their hands on the levers of power and shake them, and say What the fuck is the matter with you? How much do you think we’re going to take? But the answer is, obviously, tragically, an infinite amount.