IPT Book Reviews

Title: The Selling of DSM: The Rhetoric of Science in Psychiatry  Positive Review Positive Review
Authors: Stuart A. Kirk and Herb Kutchins
Publisher: Aldine de Gruyter, 1992

Aldine De Gruyter
200 Saw Mill River Road
Hawthorne, NY 10532
(914) 747-0110
$39.95 (c); $19.95 (p)


The authors, who are professors of social work, want to describe how it happened that a new nosology, DSM-III, has taken over not only psychiatry but the mental health professions.  In nine chapters and 270 pages they critically analyze the process by which DSM-III came to be the dominant taxonomy in American mental health services and the issues raised by the process they describe.  In Chapter 1, they set forth the problem and state their position that social problems and social issues are created by a social process.  The basic problem is the reliability of psychiatric diagnosis compounded by the amazing, if not alarming, increase in the number of mental health professionals active in the society.

Chapters 2 and 3 present the political and scientific context in which DSM-III developed.  The historical progression is described along with the manner in which the APA (American Psychiatric Association) was manipulated to produce and endorse this product.  The history includes tracing the development and use of the new statistic, kappa, to shift the issue of reliability from a serious conceptual, scientific problem to a relatively innocuous technical issue.

Chapter 4 presents the step-by-step account of how a small band of research psychiatrists accomplished such remarkable success in influencing the course of American psychiatry.  Chapters 5 and 6 are the meat of the book.  The authors demonstrate that careful analysis of the data from the field trials used in developing DSM-III indicates that these trials do not show what it is claimed they show.  Rather than improving the reliability of psychiatric diagnosis, DSM-III either does not show any better reliability or is worse than DSM-II.  The few studies of reliability that have been done after DSM -III show a high level of unreliability.

Chapter 7 presents a way of understanding how so many could come to believe DSM-III was a great improvement when it is not.  Chapter 8 discusses how DSM-III-R and DSM-IV protect the frequent shifts.  Rapid revisions, while serving to keep the pot churning, do not improve the ability to diagnose disorders reliably nor advance the cause of scientific understanding.  The final chapter, 9, is a realistic but seldom heard exploration of the real world in which clinicians make diagnoses, not for accuracy or prescription of treatment, but for nonscientific considerations such as getting third party reimbursement and protecting clients.


This book is essential for every professional who deals with psychiatric diagnosis.  Getting a clear understanding of this material is a necessary antidote both to misplaced confidence in the validity of diagnostic concepts and the potential misuse of psychiatric diagnosis in a variety of settings.  The impact of medical testimony in the justice system is almost always greater than is warranted by the nature of the venture itself.  Finders of fact, judges, attorneys, social workers, and psychologists are often overawed by medical and/or psychiatric testimony and grant it some special cachet of verisimilitude.  This is the besetting sin of the mental health professions reification.  A concept is believed to be real, rather than hypothetical, and it is then used to explain behavior which is then used to show how real the concept is.

Mental health professionals appear in courtrooms with increasing frequency.  Diagnostic labels and claimed etiology become crucial in more and more trials.  In addition to psychiatrists, social workers, psychologists, and, in some instances, police officers, are qualified as experts and make diagnostic statements with confidence and conviction.  Almost always the classifications offered are from DSM-III-R.  Hardly anyone raises the issue of the validity of these postulated entities but psychologists at least should know that the validity of any construct cannot exceed what is allowed by the reliability of the concept.  This book raises serious questions about the current reliability of psychiatric diagnosis and thus also raises questions about their validity.

The report of the Task Force of the American Psychiatric Association (Halleck, Hoge, Miller, Sadoff, & Halleck, 1992) includes this conclusion. "Here, a diagnosis based on a DSM-III-R category is used to conclude that criminally actionable conduct has occurred.  In the absence of a scientific foundation for attributing a person's behavior or mental condition to a single past event, such testimony should be viewed as a misuse of psychiatric expertise" (p. 495).  The history and data contained in this book enable a reasonable assertion that almost all mental health testimony offered in courtrooms today falls under that indictment and is a misuse of the nosology.

The other strength of this book is the presentation of the social side of the scientific endeavor.  As the philosophers of science have shown, science is not a way of knowing truth and so it proceeds by falsification, not verification.  The reality that science is subject to human passions and follies is often overlooked.  This book is a calm and sympathetic description of the reality of scientific ventures and how our shared humanity may affect it.  Understanding what is contained here about how systems of knowledge actually work explains all manner of phenomena from the success of fad diets to jurisprudential errors in accepting folk psychology.  This wide applicability makes it an excellent general book for all professionals.


Halleck, S. L., Hoge, S. K., Miller, R. D., Sadoff, R. L., & Halleck, N. H. (1992). The use of psychiatric diagnoses in the legal process: Task force report of the American Psychiatric Association. Bulletin of the American Academy of Psychiatry and Law, 20(4), 481-499.

Reviewed by Ralph Underwager, Institute for Psychological Therapies, Northfield, Minnesota.

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