He rewrote the handbook of modern psychiatry
Doctor brokered key 1973 vote that removed homosexuality from list of mental disorders
In the tumult of the 1960s, psychiatry found itself under siege. Critics said the field lacked scientific standards — failing to help many truly troubled people while medicating or institutionalizing others who suffered from nothing more serious than nonconformity.
As he sat listening to his patients talk through their problems, a fledgling Columbia University psychiatrist named Robert L. Spitzer was nagged by doubts, too.
“I was always unsure that I was being helpful,” he told the New Yorker years later, “and I was uncomfortable with not knowing what to do with their messiness.” He struggled to find a place in his profession and ended up transforming it.
Spitzer died on Dec. 25 at 83 in Seattle of complications from heart disease. He also had Parkinson’s disease.
In his prime, he dived headfirst into one of the era’s most heated debates, brokering the American Psychiatric Association’s landmark 1973 vote to stop treating homosexuality as an illness. Then, taking the helm of the APA’s Diagnostic and Statistical Manual of Mental Disorders — regarded as the profession’s bible — he led an unprecedented push for uniform standards in an often ambiguous discipline.
He added dozens of mental disorders to the psychiatric lexicon: anorexia, bipolar disorder, panic disorder, PTSD and many other nowfamiliar maladies. It’s not that these ailments didn’t exist before the 1970s, but they had no agreed-upon names or definitions until Spitzer branded them in two new editions of the DSM. The book tripled in size (from a 134-page paperback to a 567page doorstop) and at least as much in influence under his leadership.
Spitzer’s work changed the treatment of many mental illnesses, and also opened the door to new epidemiological research.
The cumulative effect of his work also raised public awareness, as newly christened disorders were showcased on the cover of Time or hashed out on television talk shows.
Spitzer liked to provoke, and that may have shortened his reign at the top of his field. He sparred with oldline Freudians when he banned their cherished word “neurosis” — Spitzer, fixated on tangible symptoms, had no patience for the mysteries of unconscious conflict. He enraged feminists when he tried to classify PMS as a mental illness.
And he nearly undermined his social justice legacy when, late in his career, he championed therapies to “cure” homosexuals. His 2001 study on the topic was pilloried by colleagues and gay rights activists alike for shoddy methodology, and in 2012, he retracted it.
The traits that made Spitzer a magnet for controversy were the same that fuelled his psychiatric revolu- tion: a desire to challenge the establishment, a mania for data and order, and a perpetually curious mind.
His career was somewhat aimless, though, until a chance encounter in the Columbia faculty dining room in 1966. A colleague mentioned that he was serving on a committee for the DSM-II — the first major revision of the APA’s 1952 directory of disorders — and asked if Spitzer would help.
His initial role was modest, but it gave him a front-row seat to the debates roiling his profession. After the 1969 Stonewall riots, gay activists were energized to agitate for more rights, and in the early 1970s, they noisily invaded APA conferences to protest homosexuality’s classification as a mental illness.
It wasn’t just a stigma on paper: some gay men and lesbians couldn’t get treatment for depression or anxiety because doctors focused solely on their orientation; others were pressured into therapies involving hormones or electric shocks.
After a clash at a 1972 meeting of behavioural therapists in New York, Spitzer decided to hear the protesters out. Personally, he believed then that homosexuality was an illness, he later told the radio show This American Life. But forever the devil’s advocate, he organized a panel for both sides to air their arguments at the 1973 APA conference in Honolulu.
There, an activist brought Spitzer to a secret tiki-bar gathering of closeted gay psychiatrists. Many had prestigious credentials, which convinced Spitzer that homosexuality was not some crippling condition.
Ultimately, Spitzer’s was the loudest voice arguing to drop homosexuality from the DSM. When old-guard psychiatrists pushed back, Spitzer appealed with logic.
“A medical disorder,” he explained to the Washington Post at the time, “either had to be associated with subjective distress — pain — or general impairment in social function.” If gays were happy being gay, then where was the disorder? But he offered a deft compromise: in subsequent printings of the DSM-II, homosexuality was replaced with “egodystonic homosexuality,” the condition of gays or lesbians unhappy with their orientation.
His success in handling the gay rights uproar paved the way for Spitzer to chair the task force for the next edition of the DSM.
The medical establishment was realizing it had little grasp on how many people had mental illnesses or what kind. One study found that London had much higher rates of schizophrenia than New York, which saw many more patients with manic depression. Something in the water? No — it was just that doctors in the two cities defined those illnesses differently.
What psychiatry needed, Spitzer believed, was a common language to describe mental illnesses. He filled the DSM-III committees with psychiatrists who shared his fervour for data and description. In somewhat chaotic meetings, they would shout suggestions for new disorders, which often went straight into Spitzer’s typewriter for publication.
“Anxiety neurosis” was replaced by panic disorder, social phobia and generalized anxiety disorder. Judgmental terms such as “frigidity” were swapped out for clinical ones such as “inhibited sexual desire.”
The DSM-III was a sensation upon its 1980 release; along with a 1987 revision that Spitzer also oversaw, it sold one million copies. But as the APA geared up for the manual’s fourth edition, the leadership replaced Spitzer, regarded by some as too dominant and heavy-handed. He remained with the DSM as a senior adviser — but also, occasionally, a critic. In 2012, he publicly fretted that the hyper-detailed system he had birthed was becoming too vast and ran the risk of pathologizing utterly normal behaviour.