In the 1970s, the psychiatrist Robert Spitzer was embarrassed.

He — and many of his colleagues— were embarrassed by their profession. They felt psychiatrists must change how they diagnosed people. The early versions of the DSM I/II were, in their view, deficient. The older psychoanalytic way of diagnosing people, through interpretation of a story,  was scientifically embarrassing, because three psychiatrists who interviewed the same patient might arrive at very different conclusions.

After all, if psychiatrists cannot agree, how is the profession respectable?

Psychiatry from its inception in the 1800s already had a longstanding inferiority complex. Internal medicine relied on blood tests… but psychiatry relied only on stories. And stories just aren’t impressive, in the way anatomy is impressive.

William James pointed this out in 1910 when he called psychology a ‘bastard science.’ That is, it is an impure science. A soft science. A science mixed in with theories of mind, ideas about instincts, the unconscious, free will… ideas well beyond the scope of science.  But what was simply the unavoidable nature of the thing to William James, was a profound embarrassment to Robert Spitzer in the 1970s.

If all psychiatrists agreed with one another, he thought, then psychiatry would be more medically respectable.

But there is a problem with that.

How do you get them to agree? Psychiatrists are not measuring the size of red blood cells. They aren’t measuring fever. Anxiety and depression have no temperature, color, or size. There aren’t any yardsticks to measure the mind with. The only way is to ask for the story.

And notice that it is only another interested mind (a person) that can ask a question. Furthermore, people can clam up. It is often the case that the most interesting information only comes out when a ,, curious person is asking questions.

Harry Stack Sullivan pointed this out in the 1950s. He maintained that only a ‘participant observer’ could get good data. Doctors must be warm, relational, interpersonal, and actively engage with the patient, in order to get the info they want. But if they coldly surveyed the patient, they’d only get low quality info. E.g. “Do you have much hope for the future?” when asked in a distant way, it likely to get a response like: “Yeah, I guess so… like everyone I suppose”. But when the same patient is asked by a truly curious, warm inquirer, who seems interested in their life, the same patient may burst into tears, explaining that her infertility means that she feels her life is totally ruined.

Many of today’s mental health workers do not understand this. They passively perform the  yes/no DSM-V checklist of symptoms. The patient usually already knows the checklist. So the whole exercise often has an element of futility to it, a silly ruse— and the patient knows it. Psychometrics, as well intentioned as it is, can be quite silly. This is all largely the fault of what happened in the 1970s, with Spitzer’s efforts to eliminate the full story (i.e. childhood) from the diagnosis process. Today, we have a situation where most psychiatrists get the same info, but it’s often garbage info.

Who cares if we all agree, if what we’re agreeing on, is the fact that one patient will give the same perfunctory answers to ten different doctors?

As G.K. Chesterton once said:

“The human soul is the only thing that one cannot properly study, because it is at once both the study and the student. We can analyze a beetle by looking through a microscope, but we cannot analyze a beetle by looking through a beetle.”

When a doctor takes a psychiatric history, he uses the only tool at his disposal: his mind. But the problem is that the object he’s observing is another mind, just like his. The psychologist uses a mind to look at a mind, which is just as problematic as analyzing a beetle by looking through a beetle.

In psychology, the data stares back up at the scientist, so to speak. Does this happen in any other area of science? Do red blood cells tell an evasive story? Does an appendix change its shape, or pretend to be healthy as it’s being observed? Most sciences involve problems that can be solved with more and more observation. But in psychiatry, observation itself changes the data. Sort of like in quantum physics, where the act of observation seems to change how a particle behaves.

Gabriel Marcel quipped:

“A mystery is a problem that encroaches on its own data.” And human minds, human beings, with their sufferings, are mysteries indeed…

To get back to the issue at hand: today’s diagnostic process in psychiatry has been cheapened by the need for consensus.

Somehow, the disagreement between doctors was viewed as an embarrassment to the profession. And, to solve this problem, they intentionally dumbed down the DSM.  The latest DSM, the DSM-V, was revised and published not by any single genius, but by a mere vote. It is actually true that in psychiatry, science occurs by vote. The vote is held by the board of trustees of the American Psychiatric Association.

Who does that diagnostic process serve? The patient’s needs? Or the need of doctors to appear united?

Why do they have a need to be so united, I wonder? When it is basically the business of doctors to argue and to disagree?

When doctors and scientists try their best to agree, something sinister may be going on. Why do they need to be so self-promoting? Why the insecurity? Why not allow ongoing debate? Why aren’t they comfortable admitting that theirs is not an exact science, and that their conclusions may be vigorously debated?

We see this furious insistence on ‘consensus’ outside of psychiatry as well.

Around 2020 and 2021, the term came up a lot in response to dissenting views of the COVID lockdown. Dissenting doctors were actually censored and ostracized, and ‘consensus’ was said to be the way of true science.

Michael Crichton— author of Jurassic Park, and physician— once attacked the notion that science is based on consensus. “Consensus is the business of politics… In science consensus is irrelevant. The greatest scientists in history are great precisely because they broke with the consensus. There is no such thing as consensus science. If it’s consensus, it isn’t science. If it’s science, it isn’t

consensus. Period… Whenever you hear the consensus of scientists agrees on something or other, reach for your wallet, because you’re being had.”

Furthermore, Crichton pointed out: “and notice that consensus is only invoked when the science is weak.”

Ignaz Semmelweis was the doctor who in 1848 first believed that women dying after childbirth were in fact dying from infection. He strenuously promoted hand-washing before any woman in labor was touched.

Doctors felt that by advancing a hand-washing theory, he was blaming them. They were threatened by the new theory.  Instead of debating Semmelweis, they instead ostracized him from the medical community, stripped his license, called him a Jew in the press, and finally threw him into an asylum where he was beaten to death. Forty years later, they realized he was right.

True story.

Are there more examples? There are many.

Alfred Wegener was the originator the theory of ‘continental drift.’ Around 1920, he proposed the idea that South America neatly fits inside of Africa. Most expert geologists of the day mocked Wegener openly. It was only long after his death, in the 1960s, that geology recognized Wegener was right. As Max Planck said, “science advances one funeral at a time.” For a new scientific theory to be accepted, it’s not about the data being good enough. It’s literally more the case that the older scientists have to die off. There are many more such stories in the history of science. Alice Stewart, the woman who discovered in the 1950s that X-raying pregnant women’s bellies was causing leukemia in children. Her discovery was met with skepticism. But the X-raying of pregnant women continued until the 1970s! Scientific ‘consensus’ was upset, and pushed back…

Scientists and physicians aren’t pure.

They can be competitive, envious, even back-stabbing. They can be motivated by fear of litigation or the wish for money. The idea that science is automatically self-correcting, datadriven, humble—an idea often promoted by atheists— just isn’t true. I would call it an illusion.

As scientist Richard Feynman put it, “Science is a belief in the ignorance of experts.”

And the same with psychiatry today… I do as much un-diagnosing as I do diagnosing. A lot of patients come to me burdened with a diagnosis that they carried for years, which fundamentally harmed their self-esteem, and that was based on a couple of shoddy interviews by a person with bare minimum training.

You aren’t ever going to truly understand yourself by a consensus document. But only with the help of a warm, curious, and interested person. And: one who isn’t afraid to disagree with his or her colleagues.