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Letter to a Foreign Psychiatrist

Letter to a Foreign Psychiatrist

I write to you as an American who was once not an American. Of course, all Americans, at one time, were not Americans, but there is still a prototype: the Christian American of European descent. I’m not in that majority, so I write to you as something of an American, but also as a non-American.

You ask me what I would advise a young psychiatrist beginning a career in another country? I would first bring to your attention what you already know: the world has one great power—America. This country is not just a military power; it is a cultural force. In psychiatry, it has taken over almost every country at least as effectively as its political forces vanquished Soviet communism.

All psychiatry, anywhere in the world, is American psychiatry. This is both bad and good.

First the bad. DSM is a primary source of American domination of world psychiatry. It may not have been meant to be so: it is, after all, the diagnostic system for the American Psychiatric Association. But, as the Soviet Union fell, DSM rose: America’s political triumph translated on all levels, including medicine and psychiatry. The changes of DSM-III in 1980 had become worldwide in their influence by the post–Cold War years of the 1990s.

I went to Quebec about a decade ago. Older French-speaking psychiatrists listened to their “American” visitor politely, and then one of them commented privately to me: “Young man,” he said, “our residents used to read the classic French thinkers: Pinel, Morel, Esquirol. They read Henri Ey’s textbook of psychopathology. Now they only read DSM. Ey’s textbook was 700 pages long; the major illnesses in DSM can be read in 70 pages.” He shook his head in disgust.

Honest American psychiatrists know and admit that DSM, by simplifying psychopathology and diagnosis to a bare minimum of criteria, has ruined a generation of clinicians who haven’t heard of anything not included in the manual and whose knowledge of the manual itself is limited to baldly described criteria. A few years ago, Nancy Andreasen, a force in DSM-III, admitted that phenomenology—the field of careful attention to symptoms, the kind of work Ey exemplified—had literally been killed by DSM-III.1 This is like a cardiologist who can no longer discern heart sounds, or a neurologist unable to use a reflex hammer.

Psychiatry is simple, so simple: like being a Volkswagen mechanic, a New York clinician infamously stating the painful truth.2 This false sense of simplicity hides a complex truth: We have lost the ability to accurately recognize our patients’ signs and symptoms; hence, we routinely misdiagnose, then we mistreat. And throughout the process, we have little clue that we might be wrong. And most of the blame has to do with DSM-III onward: simplistic criteria that are often wrong, partly because they are explicitly non–research-based; and when they might be right, DSM’s baleful influence of being a teaching tool, replacing careful phenomenology, has dumbed down the clinical capacities of my generation.


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