40th Anniversary of “Homosexuality” Being Removed from DSM

Alfred M. Freedman, M.D>
Alfred M. Freedman, M.D.

DSM-II-Homosexuality1December 15th 2013 is the 40th anniversary of the historic event of “homosexuality” being removed from DSM ( Diagnostic Statistical Manual of the American Psychiatry Association )

In 2007 I interviewed Dr. Alfred M. Freedman who had been President of the American Psychiatric Association in 1973 when this event occurred. He described the details of how this resolution was passed by the APA Assembly . The interview was part of  a video podcast series which I was doing at New York Medical College. It was subsequently transcribed in the Journal of Gay & Lesbian Mental Health Volume 13 Number 1 January -March 2009 pages 62-68. The interview is available on the Internet in 5 short segments. Segments  3-5 deal mostly with this issue. In view of the historical significance of this event. I have put links to this interview below:

Interview with Dr. Freedman – Segment #1 – 6 minutes 20 seconds  http://www.youtube.com/watch?v=jhiyDAprlP4

Interview with Dr. Freedman – Segment #2 – 9 minutes 58 seconds http://www.youtube.com/watch?v=smvDA_9GJyE

Interview with Dr. Freedman – Segment #3 – 8 minutes 41 seconds http://www.youtube.com/watch?v=bmtr5kmpBus

Interview with Dr. Freedman – Segment #4 – 7 minutes 59 seconds http://www.youtube.com/watch?v=zLREZflrQrA

Interview with Dr. Freedman – Segment #5 – 4 minutes 24 seconds http://www.youtube.com/watch?v=z5YsWT48lEE

For more information about Dr. Freedman see an earlier blog .

 

Michael Blumenfield, M.D.

mblumenfield@aol.com

 

 

 

Unhinged-by Dan Carlat-Book Review

Dr. Daniel J. Carlat’s controversial book book about the psychiatric profession titled , “Unhinged” is reviewed followed by a Q&A with the the author.

The following is a book review that  I wrote which was recently published in the Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry. It is followed by a brief Q & A with the author.

UNHINGED Daniel J. Carlat, M.D. Free Press 255 pages 2010

Dan Carlat, in addition to practicing psychiatry, writing his popular newsletter and blog, editing a series of psychiatry books for Lippincott/Klowers (one of which I co-authored) and writing monthly blogs for Psychiatric Times periodically (as do I)   has written expose pieces about psychiatry for the N.Y Times and other widely circulated publications. He has spoken out about the influence of the pharmaceutical industry on the practice of psychiatry and particularly the large amount of money earned by psychiatrists from the drug companies  often without disclosures. This latter point has been considered to have  ethical and legal ramifications. Knowing this background, I eagerly approached the opportunity to review his new book Unhinged published by Free Press    (2010) and given a subtitle of  “The Trouble with Psychiatry-A Doctor’s Revelations about a Profession in Crisis.”

Early in the book, Dr. Carlat shared his own experience as a practicing psychiatrist where he specialized in prescribing medications and referred patients in need of talk therapy to a “psychotherapist.” He expressed his view “that most people are under the misconception that an appointment with a psychiatrist will involve counseling, probing questions and digging into the psychological meaning of one’s distress.” He goes on to site data which shows that 1 out of 10 psychiatrists offer therapy to all their patients. (I am not sure if this is a valid point since some patients clearly don’t need or want psychotherapy.) He then talks about the well known income differential which favors providing psychopharmacology treatment over psychotherapy. He provides a case history where he did not tell a patient that psychotherapy might work just as well as medication. He said that he decided upon medication because he received little training in  psychotherapy during his three years of psychiatry residency (Mass General) and that he “ doesn’t do psychotherapy  because “I can’t do psychotherapy.” One of the themes of this book is Carlat’s odyssey to ultimately deciding to learn more about psychotherapy and follow a mode of his father who is a psychiatrist and develop a practice which combines psychopharmacology and psychotherapy even if he doesn’t make quite as much income as he did in the past. He shares the interactions with colleagues, teachers and mentors as well as patient vignettes, which lead him to this decision.

This book also examines other controversial issues. For example, Dr. Carlat discusses DSM which he calls “ The Bible of Psychiatry.” He believes that the tradition of psychological curiosity has been dying a gradual death and that DSM is in part the cause and the consequence of this transformation of our profession. He argues that as a result psychiatrists are less interested in “why” and more interested in “what”. (I thought that psychiatrists could chew gum and do other things at the same time. If we continue to use and refine it, DSM allows us to communicate better, do research and get paid.) Carlat interviewed both Bob Spitzer and Alan Francis, the leaders of DSM III and IV respectively who are  both quite critical of the emerging DSMV.

Not surprising, knowing of the previous writings of the author, a good part of the book dealt with the relationship between psychiatry and the pharmaceutical industry starting off with a chapter on “How Medication Became the New Therapy.” There is a  description of the evolution of various drugs used  in psychiatric  practice including the story of Prozac as well as examples of how and why new drugs are introduced as patents on old ones expire. While most of these stories are fairly well known to psychiatrists, it may be surprising to see the behind the scenes descriptions of how side effects such as sexual dysfunction and suicidality were initially minimized and ultimately handled.

The chapter on “How Companies Sell Psychiatrists on their Drugs” reflects some of the writing that Carlat has made in the popular media. He personalizes this important topic by describing his own  previous  relationship with various pharmaceutical representatives. He also reveals the fact that drug representatives have access to each doctors’ prescribing pattern before they visit him or her. He discusses how friendliness and  bringing little gifts such as books or one’s favorite Starbucks coffee have played a subtle but distinct influence on doctors and their prescribing habits. (There have been recent restrictions on these practices.)

Dr. Carlat also outlines his own experience of being a “hired gun” where he gave paid talks to primary care doctors and psychiatrists earning as much as $30,000 in one year. He told how he and his wife were flown to NY and stayed at luxurious hotels and ate in fine restaurants paid for by the pharmaceutical firm for which he was a speaker. He eventually decided that this was morally wrong and stopped this practice. He did go on to write about other psychiatrists whom he reports have made millions of dollars and in some cases were also receiving research grants.  He told  how they were not reporting to their universities, the income that they were receiving which was required. He details Iowa Senator Grassley’s investigations into very well known psychiatrists. He raises ethical questions about doctors taking pharmaceutical money while promoting off label use of various medications for treatment of ADHD and bipolar disorders in children.

There is a discussion of what Carlat calls “the seduction of technology”, specifically referring to the promotion of Vagal Nerve Stimulation and Trans Magnetic Stimulation.    (I observed how the latter technique was actively being promoted at the recent APA Meeting in New Orleans).  Interestingly, Carlat concludes this chapter with a statement that “psychiatrists  need to reacquaint themselves with the missing skill of psychotherapy.”

Perhaps one of the most interesting and controversial thesis of this book is the author’s conclusion that “medical school is the wrong place to train psychiatrists.” He believes that there should be programs that integrate psychopharmacology and psychological technique from the beginning of the training of psychologists . He goes on to say that  psychologists should ultimately prescribe medication as well as do psychotherapy. He describes one experimental model that was briefly used in the 1970s  at  a teaching institution in California but failed to be accepted as a model for licensed care. .

Whether or not you  agree with the arguments, analysis or conclusions of Dr. Carlat, there is no doubt that he has written a very thought provoking book that is based on his own experience with a reasonable attempt at documenting many of his statements .(There are 16 pages of notes and references).  His discovery of psychotherapy as a valid form of treatment will not surprise many of the readers of the journal where this review is appearing. His idea that that psychiatry at this time is troubled and in crisis is probably best judged by a longer historical view. However I suspect that this book will be used by historians to reflect some of thinking of the time as will be  another book written by the psychiatrist Peter Kramer  which came out  17 years ago titled Listening to Prozac . In the meantime Dr. Carlat’s views are out there for discussion and debate.

Take Five With the Author

Following are the answers to five questions I recently asked Dr. Carlat for this blog:

Dr B:  Can you describe the reaction of your colleagues to this book?

Dr. C: The reaction from colleagues has been mixed. Most have agreed with the central idea, which is that psychiatry has moved too far into psychopharmacology and has largely abandoned therapy. Many have disagreed with my fairly radical proposals, such as creating an entirely new training system that would be an alternative to medical school and residency. And of course, some have become positively apoplectic at the idea that psychologists can prescribe from a limited formulary safely. So I’ve had my share of fan mail and hate mail.

Dr. B: Do you believe that at present there  is enough transparency about possible conflicts of interest in national presentations at meetings and in journal articles ?

Dr. C: No, all we get is the name of the company. We don’t get the amount of money, nor the name of the product that the presenter has promoted. These pieces of information are critical for the audience to judge the likelihood that money is affecting the accuracy of a presentation.

Dr. B: Do you have any ideas how the new healthcare legislation  (Obamacare) will impact on the practice of psychiatry ?

Dr. C:It will increase the demand for psychiatrists, simply because we will be adding about 30 million people to the health insurance rolls. Some have argued that the emphasis on gate-keepers and accountable care organizations will take business away from psychiatrists, but I can’t imagine PCPs have either the time, interest, or expertise to deal with our patients.

Dr.B:  Do you see psychotherapy by psychiatrists being viable in over the next 5- 10 years.?

Dr.C: Not unless psychiatrists are willing to take a drastic pay cut. There’s way of prettying this one up. Insurance companies are never going to pay nearly as much for an hour of therapy as for 3 or 4 psychopharm visits. So the more therapy you choose to do, the less money you will make in direct proportion. That’s assuming, of course, that you are taking insurance. As many as a third of psychiatrists have opted out of insurance and charge their regular fees for therapy, much higher than what they get reimbursed by insurance. Personally, I don’t think that’s a viable option from the standpoint of ethics and health care policy. And it’s demeaning to us. We’re saying, essentially, “our skills are not valuable enough for your health insurance to pay what we think we’re worth, so we don’t take insurance.” I’m not one of those who villainizes insurance companies, partly because many of my trusted psychiatrist colleagues work for insurance companies, and I know what they are up against. They make a serious attempt to come up with a fair market price for therapy, and they have found no compelling empirical evidence to suggest that a psychiatrists’ therapy session is worth double a social workers’

Dr. B:  Can you tell us about any new books or projects with which you are involved?

Dr. C: I am just extremely busy managing my publishing business right now. I wish I had time to write another book, but I have nothing in the wings.

Alfred M. Freedman (1917-2011)

On April 17, 2011 Alfred M. Freedman died in New York at the age of 94. Dr. Freedman had been the 102nd President of the American Psychiatric Association and also had been the Chairman of the Department of Psychiatry at New York Medical College.

A Gentle Giant in American Psychiatry

On April 17, 2011 Alfred M. Freedman M.D. died in New York at the age of 94. He left behind a wife, two children, two grandchildren, innumerable colleagues whose careers were greatly influenced by him as well as a mental health community with untold numbers of patients most of whom will never know how his career has led to improvements in  their care.

I first met Dr. Freedman in 1980 when he hired me to be on the faculty of New York Medical College. He was at an age at that time when one might mistakenly think he was in the twilight of his great career. He had already edited what was clearly the definitive textbook in Psychiatry. Generations of psychiatrists learned psychiatry and prepared for their board examinations by reading Freedman and Kaplan. New psychiatrists to this day read the later versions of this book which he originated. When I met him, six years previously, he had been elected the 102nd President of the American Psychiatric Association after his name had been placed on the ballot through an unusual membership initiative. After his  arrival at New York Medical College, he built the Department of Psychiatry from a part time faculty to a major institution on both the local and national scene with innovative programs in many areas particularly in substance abuse. He had moved the departmental office to Westchester where I would be working in consultation liaison psychiatry  and integrated the department into Grasslands Hospital which would become known as Westchester Medical Center and the Psychiatry Department as the Behavioral Health Center. He also supported the New York Medical College Psychoanalytic Institute. His welcoming words of advice to me were to tell me that I should always remember that we are team players in this department. While there was never a doubt that he was the leader, he ran the department allowing the Associate Chairs and the division heads to all be creative and reach their full potential. He supported and personally encouraged the most junior faculty members. He was always very generous to his faculty.

I recall at one time when I had developed some expertise and experience in disaster psychiatry he decided to make me the head of a small subdivision in the department, which he called an  “institute” in this area and he insisted that I design some stationery to show this. He gave me the opportunity to write a paper with him in 1984 about depression, which was ultimately translated into German. Having my name on paper with him is one of the very special moments of my career. There are many other colleagues who have similar stories as he always made you feel as if you were an equal working together on the same team. The residents always loved him and he was a role model for every young psychiatrist who trained at any of the hospitals, which were part of the New York Medical College consortium.

Dr. Freedman’s parents where immigrants from Poland and they worked long hours in a small family store to send all their children to college and two of them to medical school. I only now realize that Dr. Freedman was an undergraduate at Cornell at the same time as was my father in law David Groner. It is a pleasing thought to me that somehow their paths may have crossed.

I would like to  reprint a section about Dr. Freeman’s training and early career from a biographical piece written by Dr. Freedman’s friend Dr. Leon Eisenberg on the occasion of Dr. Freedman’s term as President of the American  Psychiatric Association 1973-1974 (Am J Psychiatry 131:7, July 1974) ….

During his college years, Sir Arthur Eddington’s lectures briefly inspired thoughts of a career in atomic physics, but the call to medicine could not be denied. Yet those were days when an unofficial “numerus clausus” prevailed in American medical schools: a would-be physician had reason for anxiety about his chances for admission despite impeccable grades and recommendations. The list of schools that rejected our future President is long and distinguished. By great good fortune he applied to the medical school of the University of Minnesota and was accepted.

The early years in medical school were somewhat of a letdown in comparison to the exciting intellectual horizons college had opened. What made them more tolerable were the evenings and weekends he spent as research assistant in neurophysiology with Professor Herman Kabat, work which resulted in his first two publications on experimental shock. Once his clinical rotations began, medical school came to life: he can still recall many of his first cases in medicine and psychiatry. His commitment to care for urban poor led him to take his internship at Harlem Hospital, where he became aware of the problems as well as the challenges in providing medical care to neglected populations. The year also began his love affair with New York City. He enlisted in the Army right after Pearl Harbor and was assigned at the end of his internship to Arthur Mirsky’s laboratories at Miami.

The most important consequence of this duty station stemmed from a routine assignment to accompany a troop train to Colorado Springs. On his return journey he had gotten as far as St Louis, where he found himself momentarily stranded. Just before the departure of the next train, the ticket clerk called him frantically to offer him a last –minute cancellation. On that tain he was introduced to a Miss Marcia Kohl, who was returning to her home in Miami from college in Ann Arbor. Neither one had any difficulty recognizing that his chance encounter had been fated. Within six months, they were married and have remained, happily so, to this day….

Alfred’s army years were completed at the station hospital of the Third Air Force in Gulfport, Mississippi and he was discharged as a major in 1946. He undertook training in pathology at Mt. Sinai Hospital in New York City (1946-1947) in pursuit of a plan to prepare himself for the study of the biological basis of human behavior. He briefly contemplated completing his training in pathology but he left it upon receiving an invitation from Dr. Harold Himwhich, whom he had met when he was a medical student, to join him as a medical physiologist at the Army Chemical Center at Edgewood. His studies of acetylcholine and cholinesterase, with the use of diisopropylfluorophosphate as an enzymatic poison led to significant publications in the American Journal of Physiology and the American Journal of Psychiatry on the mechanisms of convulsions. Satisfying as he found laboratory work to be, he was drawn again to clinical activities and began his general psychiatry residency training at Bellevue Hospital in July 1948. Upon completing his basic training, he joined Dr. Lauretta Bender as a Fellow, then as staff psychiatrist on the Child Psychiatry Unit (1950-1954). From that period stem Alfred Freedman’s important papers on childhood schizophrenia and his first publications on pediatric psychopharmacology.

At that point Alfred faced a major watershed in his career. He had a half-time position on the Bellevue staff and spent half time in practice. Wedded to New York, he saw no immediate openings for a full-time academic career, although he was the author of some 20 publications including the first one on the psychiatric aspects of familial dysautonomia. Fate intervened in the person of Professor Richard Day, who invited him to head a pediatric psychiatry service at Downstate Medical Center, Brooklyn, N.Y.  From ground zero, Alfred built a major unit. In addition to the continuation of his earlier research interests in schizophrenia and pharmacology in childhood, he began a major study on the influence of biological and social factors during pregnancy and the neonatal period of child development. He demonstrated the markedly greater effect of neonatal hyperbilirubinemia on male infants in contrast to female infants. In a series of classic papers, Helen Wortis and Alfred Freedman have portrayed in unforgettable fashion the bitter dregs of life for children reared in urban slums; they have drawn attention to the interactions between biological and social factors that are so powerful that the combined biosocial insults have proved to be multiplicative rather than simply additive in effect. The splendid fulfillment of his tenure at Downstate, though only five years in duration was a tribute to Dr. Day’s judgment in selecting for chief of service a man only three years beyond his residency…

After Dr. Freedman stepped down from Chairmanship at New York Medical College he seemed to be as active as ever. I would frequently see him and Marcia at various gatherings and psychiatric meetings. He was always warm and friendly. He was also quite vigorous and had taken up the cause of human rights, which I know was never far from his heart. During his APA Presidency he had led a delegation to the Soviet Union and had spoken out about the detention of political prisoners in psychiatric hospitals in the USSR. In his later years he became one of the leading spokespersons, along with his friend and colleague Abe Halpern, in advocating that psychiatrists do not take part in execution in any manner and also that psychiatrists do not take part in the interrogation of prisoners. Their well reasoned ethical arguments continues to influence discussion on this very important topic. Dr. Freedman made very important contributions to revising the World Psychiatric Association Code of Ethics. He also received the APA’s Human rights Award. In the course of his academic work and his advocacy of human rights, Dr. Freedman has lectured all over the world.

It is well known that during Dr. Freedman’s presidency of the APA, homosexuality was eliminated as a designated psychiatric disorder in the official diagnostic statistical manual (DSM). At the time this was a momentous change with far reaching social and legal  implications for people with a homosexual orientation. The beneficial effects is still being played out today as we see the armed forces finally eliminating discrimination of gays and lesbians in the military. Four years ago I had a Podcast on the Internet where I would interview various psychiatrists. During one of his visits to Valhalla (New York Medical College) I invited Dr. Freedman to be my guest on the Podcast. He was then 90 years old and  graciously accepted the invitation.  He shared with me the behind the scenes activities on how he influenced this important event in American Psychiatry. He also spoke of other important issues in his career. I would like to provide the links to the full audio broadcast of that interview and the You-tube video presentation which is divided into segment one, two and three. In it you will hear and see Alfred M. Freedman, a modest, gentle giant of American psychiatry.

Don’t Ask Don’t Tell-Not Psychiatric Topic

There are very few reasons that a psychiatry blog should discuss the recent change in policy of “Don’t Ask Don’t Tell.” After all, homosexuality is not a mental disorder and this is a case of righting a wrong of discrimination and an example of social justice. However, until 1973 American psychiatry considered homosexuality as a psychiatric diagnosis. The behind the scenes story of how the American Psychiatric Association reversed it’s official policy towards homosexuality is explained in an interview that Dr. Blumenfield had with Dr. Alfred M. Freedman who at the time was President of that organization. There are links to a transcript of that interview as well as a 3 part video broadcast on You-Tube or the entire audio of the interview on Shrinkpod which is a podcast.

Recently the US Congress passed a law and the President signed it repealing Don’t Ask Don’t Tell. We are told that it is on fast track for implementation. This means that that another discrimination barrier has been broken and gay Americans will be able to serve our country in the US military as other Americans may do.

There is very little reason that I should have to mention this in a psychiatry blog. After all homosexuality is not a mental disorder. Except perhaps for the fact that Don’t Ask Don’t Tell has caused a great deal of psychological pain to those who have had to hide their identify for fear of being kicked out of the military or  suffering other repercussions. This should not be minimized, but overall it is a discrimination issue and one of social justice but not a significant psychiatric one.

However, it was not always this way. Up until 1973, the psychiatric profession considered homosexuality a mental disorder. There was a DSM code for it. The predominant official psychiatric thinking included various theories how certain types of child rearing may have brought about this sexual orientation. Many psychiatrists believed that therapy could change homosexuality and bring about “normal heterosexuality.”

Obviously there were many psychiatrists and other mental health professionals who did not hold this view. There was an increasing amount of research which did not support it . In fact, some experts believed  that homosexuality was founded on genetic and  biological determinants. There was also a great deal of clinical experience which supported the idea that sexual orientation could not be altered by therapy.

There was an historic meeting of the American Psychiatric Association in 1973 where the APA Assembly debated and passed a position paper stating that homosexuality was not a disorder and an equally historic debate within the Board of Trustees which took this position. It then became the official position of the American Psychiatric Association which has been reflected in subsequent DSM publications.

A few years ago I was broadcasting a podcast on the Internet and I interviewed Alfred M. Freedman who was the President of the American Psychiatric Association in 1973. I asked him about the background and the details of this famous debate. It was a very revealing interview in which he shared with me the behind the scenes activities involved with this event. A transcript of this interview was reproduced in theJournal of Gay & Lesbian Mental Health 13(1) 2009.

Alfred M. Freedman, M.D.

Dr. Freedman was Chairman of the Department of Psychiatry of New York Medical College and hired me on the faculty there in 1980. He is now in his 90s living in Manhattan and still attends meetings of the APA.

I am pleased to be able to provide the links to this video interview which can be seen on You Tube in three sections or heard on Shrinkpod in it’s entity.