My Direct Experience with Dr. Frances
I am a clinical and research psychologist with a specialty in research methodology, and I have also for decades been involved in social justice work. I graduated from Radcliffe College, Harvard University, in 1969 and received my Ph.D. in Psychology from Duke University in 1973. I was licensed to practice psychology in the province of Ontario during the years when I lived in Toronto, and I served as an ethics consultant to the Ontario Board of Examiners in Psychology, the province’s licensing body. Currently, I am a licensed psychologist in the Commonwealth of Massachusetts.
Much of the information given in this section is documented in great detail in my published writings, and I would be glad to provide full references for all of this work upon request from you.
I attended my first meeting with members of DSM committees when the DSM-III-R was in preparation. After it was published, when Dr. Frances was placed in charge of DSM-IV, I telephoned Dr. Frances. I told him that with regard to two categories listed in the DSM-III-R’s new appendix for categories requiring further study, my graduate students and I would be doing further study during the time when he would be preparing DSM-IV, and I made the following offer: In order to avoid duplicating each other’s work, and because I prefer to work with people, we would send him our reviews of the new research as we produced them, and perhaps he and his committee would like to send us their work; ideally, we could find ways to collaborate. He said that he had a better idea, that I should become a consultant or advisor to two DSM-IV committees. I replied that I thought I should tell him that I had coordinated the petition campaign protesting the categories of Late Luteal Phase Dysphoric Disorder (later renamed Premenstrual Dysphoric Disorder) and Masochistic Personality Disorder (later renamed Self-defeating Personality Disorder) that were in that provisional appendix. He responded that he was aware of that fact, but, he said, this time, for this new edition, decisions would be based on science, and there would be open and honest debate. I told him that, in light of that assurance, I would be delighted to join his committees. I did so and remained on them for about two years. In that same conversation, I told him that in all fairness, I wanted him to know that if I did not feel comfortable with what happened on those committees, I would have to resign and would feel free to speak publicly about what I had learned.
I would vastly have preferred to remain on the committees and work with Dr. Frances to make the manual truly scientifically grounded, as I assumed at the beginning might be possible. However, during my two years on those committees, I became deeply troubled by the ways that the high-quality studies were ignored if they failed to fit with what the most influential DSM people wanted, and the poor-quality studies were cited as though they were of high quality if they could be used to advance their aims. I also became deeply troubled by Dr. Frances’ continual failure to acknowledge or take steps to prevent harm or likely harm. I could not uphold my ethical responsibilities as a clinician or a researcher and remain a part of the DSM process, and so I resigned. As I saw directly, Dr. Frances was in the most powerful position to ensure that their procedures conformed to scientific rigor and that significant steps were taken with regard to the harm. He did not do so.
During those years, as documented in the chapter about DSM-IV gatekeeping techniques, although I was a consultant to those committees, my repeated work in pointing out serious problems with the lack of scientific rigor in what they were doing, as well as their ignoring of the harm and potential harm due to those categories, was not just not taken into account but was explicitly and publicly denied, as I have documented. I resigned from those committees in 1988. However, because of the work I have done since then to try to educate professionals and the public about the unscientific nature of the manual and the harm that it has caused and is likely to continue to cause, I have through the years and certainly in the past ten years been contacted by many people who share these concerns, especially some who have themselves been harmed. I have through the years in a variety of ways made Dr. Frances aware of these problems, including in direct conversations with him, so I know a lot about what he knows and what has been drawn to his attention, and I know that in spite of this, he has continued to shirk his ethical responsibilities to take the initiative to disclose forthrightly to professionals and the public the largely unscientific nature of his manuals, to solicit and gather information about the harm they have caused, and to seek ways to redress that harm.
Here is just one example that disturbingly reflects both Dr. Frances’ nonchalant attitude toward scientific research and his disinclination to learn about and act to stop harm. In one telephone conversation, I said to Dr. Frances that, rather than allowing this work to be adversarial, I hoped that we could work together for the sakes of the patients. Referring to Premenstrual Dysphoric Disorder, I said that I had heard from many women who had been harmed by having this label applied to them, including one who had been driven to attempt suicide because of the results of getting the label. I had in fact sent in such information before. I said that at least if he could tell me there was evidence of more people being helped than harmed by getting that diagnosis, that would be somewhat reassuring. The response—from the man who had persuaded me to join his committees by assuring me that decisions would be based on science—replied, “Well, of course there’s no way of knowing that.” Since scientific procedures are perfectly suited to exploring just such questions, his answer was stunning, as was his attempt to wave away concerns about harm by alleging the impossibility of finding out about it.
One rather strange indication of the extent to which Dr. Frances knew that all of these concerns were amply documented is reflected in the following incident. I had said publicly that I was willing to allow anyone wishing to learn about psychiatric diagnosis and the DSM to have access to all of my files. I was contacted by a young man who told me his name and said simply that he was an undergraduate history major writing about the DSM and would like to look at my files. I welcomed him to my home, gave him free access to my DSM files, and agreed to his request to be allowed to take all of the documentation out to be photocopied. I allowed him to take the files out for that purpose. I asked him what specifically his thesis would be about. He was evasive. He asked what I thought were the reasons the DSM people were acting as they were, and I told him what I told everyone who asked that question, i.e., that I thought some genuinely believed they were helping people, some wanted power and money, and some did not know how to understand scientific research. I asked him to send me a copy of what he would write. He never did. Some time later, a journalist called to interview me and mentioned that Dr. Frances had urged her to speak to his nephew, who was writing his thesis about the manual. When she told me the nephew’s name, I learned that that was the young man who had been sent, as a “mole,” to inspect my documentation. This is an unprofessional way to go about obtaining information that I would in any case have freely provided Dr. Frances’s nephew or his great-great aunt even had they disclosed their connection with him. What is more important is that it reveals yet another route through which Dr. Frances has been fully aware of the concerns about the unscientific nature of his work and the harm it causes.
In 2011, I contacted Dr. Frances to tell him that I thought it was great that he was expressing concerns about the next edition of the manual. I was more than willing to give him credit for pointing out problems. However, subsequently, I have seen him—despite occasionally acknowledging problems with a few of the categories in his editions of the manual—writing as though his editions were in fact stunningly scientific (as detailed in the following section of this complaint).
As I have continued to hear from people harmed by labels in Dr. Frances’s editions even since he has so publicly and trenchantly attacked those who are preparing DSM-5, and as many people asked me what I think accounts for his attacks on a book that promises to be in many ways exactly like his editions, I wrote to him directly to ask. Here below is our correspondence, where you will note his uninformative reply.
From: Paula Caplan <firstname.lastname@example.org>
Date: Wed, 4 Jan 2012 05:22:50 -0800
To: Allen Frances<email@example.com>
Subject: quick question
Many people are asking me why you are suddenly criticizing the DSM-5 editors for doing exactly what you did with DSM-IV, and I confess that I do not know what accounts for either your sudden turnaround or your making these criticisms as though they have sprung full-blown from your head rather than that they are repetitions of what many people criticized editors of previous editions for doing.
I would love to hear how this came about, so that I can accurately respond to those questions rather than having just to scratch my head in puzzlement and say nothing, which seems strange, or having to speculate.
I hope, too, that you will reconsider the very public statement that you made demeaning anti-psychiatry people. Since their position comes from the suffering to which they or their loved ones have been subjected precisely because of the kinds of things that many of us—and now recently, you—have been expressing concern about for decades, I also would appreciate your letting me know how I can explain how you reconcile your new critique with your offensive reference to these people.
Will look forward to hearing from you.
Paula J. Caplan, Ph.D.Fellow, Women and Public Policy Program, Harvard Kennedy School, Harvard University and
Associate, DuBois Institute, Harvard University
Date: Wed, Jan 4, 2012 at 5:32 AM
Subject: Re: quick question
To: Paula Caplan <firstname.lastname@example.org>
If you can't immediately tell the obvious differences between DSM IV and DSM 5, I despair of being able to explain them to you now. I have written pretty extensively on this and don't need to repeat what I have already said in print. Best place for you to start- Psychiatric Times I think May 2009- Warning On Road To DSM 5- Beware The Unintended Consequences. It is laid out pretty clearly.
Sent from my Verizon Wireless BlackBerry
As a psychologist, I am ethically bound to communicate directly with any professional I suspect of unethical conduct. I have been doing this with regard to Dr. Frances since I joined his committees. And more than a year ago, when a psychologist/author who has written extensively about the DSM asked if I would be willing to meet in person with him and Dr. Frances, so that Dr. Frances and I could ask each other anything we might wish, I replied that I would be glad to do that, and I told him that I considered it important for the exchange to be civil on all sides. We were to do that last summer. When I did not hear further about this and made an inquiry, I was told that it looked like it was not going to happen. Related to this, one of the APA’s ethical standards refers to the importance of peer review. Dr. Frances has shown himself to be singularly resistant to legitimate peer review, and I have experienced this directly for decades. There is a world of difference between getting approval from peers who do not know how to think critically about research or are afraid to upset Dr. Frances and getting approval from unbiased peers who do know how to think critically about studies. Peer review is particularly important for psychiatrists, because as reported in my book and as many psychiatrists have acknowledged, medical school training includes little or no instruction about doing or thinking critically about research, thus making it difficult without such training to follow scientific rigor in creating a diagnostic manual.
In summary, I am filing this complaint only after many years, including very recently, of efforts to urge Dr. Frances to be completely forthright about the unscientific nature of so much of what appears in his manuals and the harm that has resulted. I have watched for him to begin vigorously to educate the public about the unscientific nature of his work and to redress the harm and prevent future harm, but that did not happen. Instead, even in his most recent writings, he has too often continued to portray his work as largely scientific but for a few errors and to take no steps to solicit information systematically and widely about the harm that has been done or to redress harm that has been done or to prevent future harm. Instead, his diatribes against DSM-5 have resulted in focusing professionals and the public on fears about the forthcoming edition of the manual (fears which I share and have written about often) and in taking the focus off the people who have been harmed by his own editions and who will continue to be harmed by them until the next edition appears. The next edition will undoubtedly simply reprint much of his unscientific and harmful work, as his editions simply reprinted much of the unscientific and harmful work from previous ones.
The actions I request (later in this complaint) from Dr. Frances would help to redress some of the harm that results from a serious failing of the whole DSM enterprise and that, as I saw from my position on those two DSM-IV committees, characterizes the work that Dr. Frances has overseen and has failed to remedy. Dr. Frances himself describes that failing in his 2012 article as follows:
.…It would appear that it is largely up to respective work group members whether or not they will provide systematic, comprehensive, and objective reviews of the relevant literature.
Persons who have themselves been diagnosed have suffered the most direct harm. But others who have suffered include their loved ones and a whole country (and increasingly, as the DSM'’s markets increase, many other countries) that is too much consumed with calling every kind of suffering mental disorder, with all of the damaging consequences—and almost nothing helpful—that follow from doing that.
Others who suffer because of the DSM-IV and DSM-IV-TR are the many deeply caring psychiatrists and people in other helping professions, who went into their fields precisely because of wanting to help and who have been devastated to discover that the bulk of their training, which revolves around the DSM, does not, in fact, give them a scientifically-derived foundation for understanding human suffering and learning the most effective ways to help. As just one example, a psychiatrist who financially supports his family went into his field because he wanted so much to alleviate human suffering. His training, like most psychiatric training, was heavily based on the DSM. He began to learn from his own experience that the DSM was not scientific and that it caused far more harm than benefit, and he is utterly devastated by this discovery, for he finds himself rooted in a system that does so much damage.
Far less important than all of the above is the harm caused to me, but for purposes of completeness, I will address that as well. For more than two decades, I have found myself in the position of hearing from people whose lives have been destroyed by use of the DSM, who know that I was on two of Dr. Frances's committees and have written and spoken copiously about the truths that the DSM is largely unscientific and often harmful, and who come to me for an answer to the questions, “Don't Dr. Frances and the APA care about the damage that they do? Since they know the truth about their work and its consequences, why don't they make that widely known? And since they know they cause harm, why aren't they, like the drug companies, required to keep records of and publicly report on the harm and try to redress past harm and minimize future harm?” After more than a quarter of a century of doing this work, I have no way to answer them without conveying the message, “The people with all that power have chosen not to do what you ask about. The traditional mental health system cannot be assumed to be safe. As for why does no one who contributed to the way you were harmed take steps to apologize or redress the harm? I wish I knew. It is tragic that that does not happen.”
I live day and night with the knowledge of the pain of all those people, and it became even more salient to me when I recently worked with some who found their voices and are bravely filing complaints with your committee. These people were already suffering, which was why they turned to the mental health system, reasonably expecting help. Instead, their lives were in many ways destroyed, some forever. Some of the people who initially said they would file complaints later were too afraid to continue, so damaging had the DSM system been to them, and they feared retribution by those in charge of the DSM and perhaps even your committee. Understandably, they fear to place their trust again in these kinds of authorities, even though psychiatrists are members of what is called one of the helping professions. Some of those who are filing complaints wrote that they were struggling to write their stories, because it had been so horrific to go through the events that resulted from getting DSM labels that it was a retraumatizing experience just to have to think back over what they went through. Others, though, have said that having the chance to speak the truth and to ask that those responsible for some of the harm finally be held accountable has been the first good thing to come out of their nightmarish times. Like them, I hope that the APA Ethics Committee will take steps to repair what has been damaged and to prevent harm to others, for that would bring the APA itself into the realm of those who act on their care for those who suffer. The Hebrew term tikkun olam means “repairing the world,” and it represents the principle that everyone should take some responsibility for that repair. It seems little enough to ask that the association that has created what needs repair and watched mostly in silence and inaction while the harm was done should now participate in tikkun olam.
 Caplan, P.J. (1995). They say you’re crazy: How the world’s most powerful psychiatrists decide who’s normal. Reading, MA: Addison Wesley. See also part 3. of this complaint.
 Caplan, P.J. (1995).
 Caplan (1995), pp. 131-33 for full description of these events.
 Caplan (1995).
 Frances, A.J., & Widiger, T. (2012). Psychiatric diagnosis: Lessons from the DSM-IV past and cautions for the DSM-5 future. Annual Review of Clinical Psychology 8, 109-130.