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It’s usually a pretty lame intervention, as that example indicates, and to the extent that it’s successful, it’s often because you are bolstering the patient’s self-esteem by pointing out that he’s better off than the next guy. Schadenfreudian therapy, you might call it.
You can’t exactly blame psychiatrists for grasping at this straw. But some straws are flimsier than others. Take that 85 percent number. The Midtown Manhattan Study team, which was headed by sociologist Leo Srole, never said 85 percent of its subjects were mentally ill. In fact, Srole and his colleagues had not set out to diagnose New Yorkers at all. Indeed, they wrote, they didn’t want to use the DSM or any other diagnostic system because they were “designed for classifying full-blown pathology” and didn’t do such a good job of defining it in the first place.
So rather than ask about symptoms of mental illnesses, they asked about childhood fears of thunder and strangers, and current attitudes toward drinking and gambling. They solicited subjects’ worries about the atom bomb and old age. They asked whether they thought people talked behind their backs or if they wondered whether “anything is worthwhile” or if they believed that “most people think a lot about sex.” They paid attention to whether the interviewees were sloppy or neat, nervous or relaxed, if they were facetious, dull, or rambling. They attempted, in other words, to capture the everyday experience of the average citizen and to determine how much psychological suffering it entailed.
To make their assay, Srole’s team devised a six-point classification of symptom formation. People at the “healthy extreme” got a zero. At the next two stages were people who had “emotional disturbance without apparent constriction or disability,” and the last three ratings “span[ned] the morbidity range of the mental health spectrum.” These were the people whose symptoms had “crippling effects on the performance of…daily life roles”—as close to a working definition of mental illness as Srole’s team ventured.
Like most mainstream psychiatrists and sociologists at the time, Srole and his colleagues subscribed to the Freudian notion that between the dynamics of our psyches and the demands of civilization, virtually everyone was bound to be troubled, and that, as they wrote, “mental illness and mental health [differed] in degree rather than in kind.” So when it turned out that something like 85 percent of the subjects (the actual number is 81.5 percent) scored more than a zero, the researchers could have been no more surprised than the audience at a Woody Allen movie would be to discover that most Manhattanites are at least a little neurotic.
But Srole and his team were not making the ridiculous claim that 85 percent of us are mentally ill. Rather, they were reporting the unremarkable finding that if you sit down with people and ask them about their emotional lives, you will find that most of them will confess to some difficulty. The abnormal people in this study, as in most studies, were those at the ends of the spectrum—the 15 percent who claimed to be free of psychic turmoil and the 23.4 percent who scored in the morbid range.
This latter finding, Srole noted, was a bit of a surprise. It was more than double the rate of mental illness found in an earlier study of Baltimoreans. But it was fully one-third less than the number of people who would, 25 years later, turn up as mentally ill in Regier’s ECA study, and surely nowhere near 85 percent.
Regier knows that Srole’s study did not really conclude that 85 percent of its subjects were mentally ill. Indeed, he cited the 23 percent figure accurately in a 1978 report to a presidential commission on mental health. He also knows about the Baltimore study, and about a National Institutes of Health study conducted by his mentor, the psychiatrist Michael Shepherd, which found a prevalence rate of around 15 percent. That, in fact, was the figure he used in his report to the president: On any given day, he wrote, about 15 percent of Americans were mentally ill.
Regier thinks Shepherd’s study is “a classic” and the 15 percent figure “wonderful.” It’s easy to see why he didn’t lead his presentation to the Post editors with his conviction, based on a quarter century of studying the subject, that prevalence rates had been inflated by the DSM—published, remember, by his employer. Or why he wouldn’t volunteer that the categorical approach to diagnosis did not reflect the reality of mental illness. He and Mirin had a guild to represent, and telling the editors that parity laws would force insurers to pay for the treatment of people who didn’t necessarily have illnesses would probably not have been the most convincing way to sell national mental health policy.
This article is adapted by arrangement with Blue Rider Press, a member of Penguin Group (USA) Inc., from The Book of Woe by Gary Greenberg, Copyright © 2013 by Gary Greenberg.