There is an ongoing debate whether the flow of history is pushed forward more by ineluctable forces or by the prominent people who represent them. I usually subscribe to the former opinion, but must admit the relevance of the latter in the one small piece of history I got to watch from ringside.
Bob Spitzer, who died at age 83 on Christmas day, shaped psychiatry far more than anyone else in the past half century. Rarely have so many owed so much to just one. Bob was a great force of nature able to turn improbable ambitions into standard psychiatric practice. His impact was wide, deep, pervasive, and enduring- guiding the work of millions of mental health practitioners and improving the lives of hundreds of millions of patients all over the world. Had Bob never existed, psychiatry would have meandered gradually toward its present course, but much more slowly and indirectly, cutting channels with very different depths and directions.
Bob entered world history before his fortieth birthday, accomplishing a feat whose scope went far beyond psychiatry to influence religious, legal, societal, and popular attitudes and practices. ‘Homosexuality’ had previously been vilified by religions as sin; by legal systems as crime; by society as deviation; by the average person as weakness; and by the diagnostic system in psychiatry as mental disorder. Bob led a courageous and difficult struggle to recognize that different sexual preferences were no more than normal variants of human potential- not manifestations of depravity, deviance, impairment, or psychiatric illness. People attracted to same sex partners were no more and no less psychologically healthy than heterosexuals. Any special difficulties they faced in life arose not from inherent internal deficit, but rather from ignorant and blind societal prejudice.
The removal of ‘Homosexuality’ from DSM II in 1973 was engineered by Bob- the result of his single-minded and almost single-handed crusade to eliminate the psychiatric stigmatization of difference. Without Bob, such liberation and validation would have taken additional decades. There was no one else in the field who combined his package of passionate fairness, knowledge of the science, stubborn determination, political acumen, debating skills, and pure delight in heated controversy. Bob was the irresistible force that eventually was able to remove the immovable object. And this one first step turned out to be a tipping point, leading to a cascade of more general destigmatization. Once the error of mislabeling ‘Homosexuality’ as illness was accepted, why not reconsider the legitimacy of labelling it as crime or as sin. Bob opened the door that led forty years later to Supreme Court decisions that turned the world upside down by legalizing gay marriage and criminalizing discrimination against gays. Without Bob, ‘Homosexuality’ might still be considered a mental disorder and society might not be granting full marital status and child custody rights.
Bob’s other major accomplishment was to save psychiatry from a crises of credibility. Two widely publicized studies in the early 1970’s made clear that psychiatrists could not agree on diagnosis and were keeping patients in hospital who didn’t belong there. It looked like psychiatrists didn’t know what they were doing. Bob happened just then to be working on a criteria based method for assessing and sorting psychiatric symptoms. The man was poised to meet the moment when, in desperation, the usually conservative American Psychiatric Association turned to Bob and gave him enormous power and discretion to accomplish a radical task. Could he adapt his method to achieve reliability, intended originally for use only in research settings, to the very different needs of everyday clinical practice. The great advantages would be diagnostic agreement among clinicians; improved clinical communication; facilitation of research and education; forensic utility; and more accurate statistics. The great risk would be the creation of a cumbersome system no one would use.
Only a master psychometrician could create DSM III and only a master salesman could convince clinicians of the necessity for accepting and using it. It had many limitations and caused its own set of problems, but DSM III had the great virtue of raising the scientific standards of psychiatry and rescued it from the arbitrariness and lack of credibility of warring and unsupported opinions
Unexpectedly, DSM became a cultural phenomenon and has been among the best selling books every year for the past thirty five years. The explicit diagnostic criteria sparked great (perhaps too much) public interest and self diagnosis. Psychiatric research flourished. DSM was (perhaps too) influential in education and the courts. The advantages of the DSM system must be balanced by its disadvantages. Meant as a mere clinical guide, it has been worshiped as a "bible". Diagnostic criteria have been misused by the pharmaceutical industry marketing in disease mongering campaigns. Clinical interviewing and education is too often reduced to a checklist approach that ignores what is special and individual about the patient. Focus on symptoms underplays strengths.
No one in my experience has ever been more passionately focused on his work than Bob Spitzer. He literally lived DSM 24/7 for more than 50 years. Bob never tired of discussing diagnostic issues during the day and dreamed about them at night. The thousands of hours I spent with Bob at work, meetings, meals, on planes and car rides, at parties, and while walking or jogging were rarely quiet and almost always devoted to his curious, restless, and incessant probing of diagnostic questions.
Bob and I often disagreed, on rare occasions heatedly, but I always felt love, respect, and admiration- both for the man and for his accomplishments. On a personal level Bob was an unpredictable mixture of great charm, infectious gaiety, saturnine moods, and abrasiveness. He treated everyone equally, without respect to rank or previous accomplishment. He would give his highest attention and respect to a smart, if lowly student- but could be dismissively arrogant with senior professors if he deemed them dumb or wrong. To the end, Bob retained an appealing boyishness, an impish sense of humor, a winning smile, and an intense joy in living.
Thank you Bob for the memories. I smile as I complete this tribute to you and also shed a tear. You are missed.
This is an excerpt from the complete tribute to Bob Spitzer at THE LANCET Psychiatry.
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