🎧You Learn Why Recovery Isn’t the Norm | Chapter 31

Sarah Fay

Nov 02, 2023

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The 2000s could have been the decade of recovery. It included the President’s New Freedom Commission Report on Mental Health (2003), the National Consensus Statement on Mental Health Recovery (2006), and SAMHSA’s Recovery to Practice Initiative (2009). The 1990s, which had been hailed as the “decade of the brain,” had produced lots of misinformation: the mistaken ideas that psychiatric diagnoses are biological, valid, caused by a “chemical imbalance,” and lifelong. The government, it seemed, was finally going to move away from the biomedical model and adopt the recovery model.

The President’s New Freedom Commission sought to transform mental health care. It had six goals:

Americans understand that mental health is pivotal to health.
Consumers and their families become the center of mental health care.
Disparities in mental health services no longer exist.
All Americans have access to screening, assessment, and referrals.
People receive services and research increases.
Technology is used to full advantage.

But the commission did so much more.

It gave those with lived experience of mental illness a voice. Dr. Dan Fisher, who recovered from schizophrenia, was on the Commission. The Commission sought out feedback from consumers, as we were referred to in the report. We were experts too.

In February 2006, SAMHSA officially endorsed the recovery model. The press release announced, “Recovery must be the common, recognized outcome of the services we support.” It called for the mental health system to “move towards operationalizing recovery from a public policy and public financing standpoint.” It outlined ten core components to recovery: self-direction, person-centered care, empowerment, holistic care, non-linearity, strengths-based treatments, peer support, respect, responsibility, and hope.

Almost as a reminder, as if to say, Hey, it’s been a decade since we made recovery the most important part of our mental health care system, and yet it still isn’t, SAMHSA adopted its Recovery to Practice Initiative in 2009. It sought to provide training and resources on recovery to clinicians. Headed by Larry Davidson of Yale’s Program for Recovery and Community Health, it didn’t take root though not for lack of trying.

The 2010s could have been the decade of recovery too. Psychiatry was besieged by controversy. The insidious relationship between psychiatrists and pharmaceutical companies reached the public. Publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) brought protests not primarily from patients and consumers and their families but powerful biopsychiatrists, two of whom essentially wrote the DSM.

In 2011, Marcia Angell helped bring the nefarious relationship between psychiatry and pharma to the public. The former editor of the esteemed New England Journal of Medicine published a two-part review/outcry. She highlighted the scathing criticisms of psychiatry put forth in three books: Irving Kirsch’s The Emperor's New Drugs: Exploding the Antidepressant Myth, Robert Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, and Daniel Carlat’s Unhinged: The Trouble with Psychiatry—A Doctor's Revelations About a Profession in Crisis. Others had tried to blow the whistle, but Angell’s critique appeared in a lay albeit literary media outlet. The three books might otherwise have been viewed as fringe, anti-psychiatry diatribes, but Angell, because of her status in the medical community, legitimized their findings and critiques.

Though Angell’s aim was to make people aware of the dangers in the ways psychiatry was being practiced and its reliance on psychotropic medications, her review brought to light the many ways the biomedical model was failing the American public, primarily because of the influence of pharmaceutical companies. They paid academic psychiatrists, referred to by drug companies as “key opinion leaders” (KOLs). Angell writes: “[T]hese are the people who through their writing and teaching influence how mental illness will be diagnosed and treated. They also publish much of the clinical research on drugs.” One-fifth of the American Psychiatric Association’s funding came from pharma, which also subsidized psychiatric meetings, conferences, and research studies. These biopsychiatrists in pharma’s pocket, Angell writes, “largely determine the content of the DSM. In a sense, they are the best sales force the industry could have, and are worth every cent spent on them.”

In 2013, the most recent full edition of the DSM sparked a veritable uproar. Criticisms ranged from the authors’ ties to Big Pharma to the way the DSM pathologized normal thoughts, behaviors, and emotions and invented new diagnoses to how criteria were loosened to make disorders easier to diagnose to the fact that political wrangling, not science, dictates the diagnoses we receive.

The DSM-5 professed to be more “scientific” than the previous editions. It rebranded with the Arabic 5 instead of the Roman numeral V to signal a “new” approach that distinguished it from previous editions and said to the public, yes, this time, these diagnoses are scientific (for sure) even though they weren’t. Everyday behaviors like childhood temper tantrums (disruptive mood regulation disorder), mood changes before menstruation (premenstrual dysphoric disorder), and overeating (binge eating disorder, which states that anyone who has “binged” and felt bad about it once a week for the past three months has a mental illness) became mental illnesses.

In mainstream media outlets like The New York Times, powerful biopsychiatrists, including former DSM Task Force Chairs Robert Spitzer and Allen Frances, filleted the DSM-5. They tried to inform the public that the DSM doesn’t define what a mental disorder is. It doesn’t provide a measure to gauge if a person’s symptoms are severe enough to qualify as being labeled “disordered.” Its authors can’t show at what point normal thoughts, feelings, and behaviors cross over into abnormal. Frances writes: “There is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it.”

In his 2013 book Saving Normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, Big Pharma, and the medicalization of ordinary life, Allen offered a kind of mea culpa for the mistakes made in previous editions of the DSM. He acknowledged the DSM-IV’s role in creating the false epidemics of bipolar II, autism, and ADHD. The DSM-IV could have prevented those “epidemics” by requiring more symptoms of longer duration with greater impairment. In 2019, he explained, “[T[he diagnostic exuberance of DSM-5 confuses mental disorder with the everyday sadness, anxiety, grief, disappointments, and stress responses that are an inescapable part of the human condition.”

Scholars documented the prejudice in the DSM—how, historically, diagnoses have served to try to help some people and control, alienate, and persecute others—setting off a practice of viewing the psychiatric diagnoses not through a lens of biology but social injustice. In his 2011 book The Protest Psychosis: How Schizophrenia Became a Black Disease, the psychiatrist Jonathan Metzel meticulously outlines how schizophrenia, one of the most stigmatizing diagnoses, has been used as social control over Black men. Andrew Scull would later document the many brutal and unproven experimental therapies—lobotomies, forced comas, and the removal of internal organs (really)—inflicted primarily on women. Add to this the long history of “mad women” being exorcised, raped, and burned to death. Scholars would continue to explore the contradictory and damaging reasoning that allowed the American Psychiatric Association to pathologize homosexuality as a mental illness until 1973.

Some of the most prominent biopsychiatrists admitted that DSM diagnoses are abstractions. Thomas Insel remarked, “[W]e actually believe [diagnoses] are real. But there’s no reality. These are just constructs. There’s no reality to schizophrenia or depression . . . [W]e might have to stop using terms like depression and schizophrenia, because they are getting in our way, confusing things.” The psychiatrist and Columbia University professor Michael First has said people “take diagnosis too seriously . . . It is a convenient language for communication, and nothing more.” Others have referred to DSM diagnoses as placeholders. Steven Hyman, another former NIMH director, called DSM diagnoses “fictive [categories].” Allen Frances has said that a psychiatric diagnosis is a fiction sold to the public as fact.

With biopsychiatry’s failures on display, the time was right to finally (finally) move to the recovery model called for a decade earlier. In 2018, SAMHSA pledged recovery services and support to those with mental illnesses. Finally.

Yet mental health clinicians, the American Psychiatric Association, and the World Health Organization still haven’t adopted the recovery model. They continue to press upon us the biomedical model that says all we can do is cope, not hope.