Allan Victor Horwitz, born August 22, 1948, in Minneapolis, Minnesota, spent more than five decades at Rutgers University asking a question that sounds simple but turns out to be hard: where does ordinary suffering end and mental illness begin?
Horwitz grew up to earn his B.A. from Dickinson College in 1970, graduating magna cum laude and Phi Beta Kappa after a year at the London School of Economics. He moved to Yale for graduate training in sociology, receiving his M.Phil. in 1973 and his Ph.D. in 1975. His dissertation tracked the social networks and institutional pathways that channel people into psychiatric care. He arrived, he later recalled, as “a very naive 22-year-old” who was “so naive that I didn’t even apply for financial aid,” and got his fellowship because the head of the program had one nobody had used.
What he found in those Connecticut Mental Health Center files became the seed of everything that followed. “It was much easier to gain access to people’s records, shockingly easy from a contemporary standpoint,” he told Brendan Howard. “I would find files of children of my professors in there, which I really shouldn’t have been reading but of course avidly did.” The substance mattered more than the access. “Diagnoses were just not an important aspect of the problems,” he said. “Many of the files had no diagnosis at all. Sometimes it was sort of an afterthought. What was really primary was their marital difficulties, difficulties with parents, with jobs, with emotions. It just was not an important consideration at the time.”
Ten years later that world was gone. “All of a sudden diagnosis became primary,” he said. “The first thing a psychiatrist or some other mental health professional would do is ask, well, what diagnosis does this person have? I thought this was just exceedingly strange. How could this change come about in such a short period of time, when diagnoses were almost non-existent, to being at the very center of psychiatric practice? I’ve sort of been writing about that ever since.”
That early framing placed him in the tradition of labeling theory and social control analysis that ran through Erving Goffman, Edwin Lemert, and Howard Becker. But Horwitz pushed that tradition further. Where his predecessors focused mainly on how deviance is managed after it is identified, he wanted to understand how categories of illness form and expand. The Social Control of Mental Illness, published by Academic Press in 1982, examined how families, communities, and formal institutions respond to behavior deemed mentally disordered. The argument was not that mental illness is fiction but that its identification and management are always mediated by social norms and institutional incentives.
During these same decades Horwitz built Rutgers into a home for the sociological study of mental health. He chaired the sociology department twice, co-directed the Rutgers Postdoctoral Mental Health Training Program with David Mechanic for more than three decades, and served as Dean of Social and Behavioral Sciences from 2006 to 2011.
The decisive turn in his career came in the early 2000s. In Creating Mental Illness, published by the University of Chicago Press in 2002, he moved from analyzing how society manages psychiatric categories to interrogating whether those categories are justified. His argument was pointed: only a small subset of conditions psychiatry classifies as disorders, mainly severe psychoses with plausible biological substrates, fit a disease model. Most of what appears in the DSM represents contextually intelligible responses to stress, loss, failure, and social dislocation. The framework used to interpret ordinary suffering had drifted, quietly and without adequate scrutiny, toward pathologizing normal human experience.
The forces that produced DSM-III were not primarily scientific. Psychiatry in the 1970s faced attack from Thomas Szasz and R.D. Laing, contempt from the rest of medicine, and a new financial reality. “Before the 1970s, third-party insurance basically didn’t exist,” Horwitz said. “Patients paid for their treatment out of their own pockets, so no third-party insurer required a diagnosis. But beginning in the 1960s and expanding greatly in the 1970s, the majority of patients begin to have to pay for their therapy through these third-party insurers, and they require some kind of a diagnosis. It became a financial necessity.” The Food and Drug Administration added the other blade. Drug companies “could no longer advertise their products for the stress of life,” he told Ricardo Lopes. “They had to prove effectiveness with particular kinds of conditions like depression or anxiety.”
“The DSM-III diagnoses weren’t based on any real body of evidence,” Horwitz said, “because there was only a small amount of studies the developers could use, and they yielded different results. There wasn’t consensus. You have a manual built to be extremely specific but with just not very much evidence. It’s really built on quicksand.”
One casualty was the category psychoanalysis had built its authority on. “The major goal of the researchers behind implementing the system was really to destroy anxiety,” he told Dr. Josef Witt-Doerring, “because anxiety is so tied up with the analytic perspective. What they did was divide anxiety into nine distinct conditions. There’s just one kind of depressive condition that’s not psychotic, defined by symptoms that are extremely common in the population. When the DSM-III definitions are applied in epidemiological studies, you get huge prevalence of depression. All of a sudden depression becomes the center of the mental health professions.”
His partnership with Jerome C. Wakefield, a philosopher and social worker at New York University, sharpened this critique into its most influential form. The Loss of Sadness, published by Oxford University Press in 2007, argued that the DSM-III and its successors had erased the distinction between depressive disorder and normal sorrow by eliminating contextual criteria. A diagnostic checklist that counts symptoms without asking what produced them generates false positives on a large scale. Grief after a death, demoralization after a failure, exhaustion after a prolonged ordeal all become major depression once the symptom threshold is crossed. The cultural consequence is that the vocabulary for endurance, mourning, and recovery begins to erode.
Horwitz described major depressive disorder to Robert Whitaker as “a terrible diagnosis from any scientific point of view. The reason it’s so bad is that you need five of eight symptoms for only a two-week period. Anyone who for two weeks has been feeling down, had a loss of appetite, has trouble sleeping, is basically having a normal reaction to any kind of loss event and can easily qualify.”
The numbers make his strongest argument, and it is an evolutionary one rather than a sociological one. Before symptom-based diagnosis, roughly three percent of the population qualified for a depressive disorder. After DSM-III the figure jumped to about seventeen percent. Longitudinal studies now put it near half. “There’s nothing like this in physical illness,” Horwitz said. “Lots of people have serious physical problems, but these generally arise when people are older and their cells and chromosomes are breaking down. By far the highest rates of depression are found in young people, in people in their twenties, in people in their prime reproductive years. This is evolutionarily virtually impossible. You can’t find any physical problems that afflict such a high proportion of people while they’re in their prime reproductive years. Evolution wouldn’t have allowed that to happen.” If half the population develops a genuine disorder at peak fitness, selection would have removed the vulnerability. The disorder claim refutes itself on its own biological terms.
Horwitz and Wakefield extended the argument to fear in All We Have to Fear, published by Oxford in 2012. Natural anxieties that served evolutionary functions, fear of strangers, of heights, of social rejection, had been reclassified as anxiety disorders requiring clinical management. The same logic held: detaching symptoms from context produces apparent epidemics of pathology that are partly artifacts of classification rather than increases in suffering. What made this collaboration distinctive was its structure. Horwitz brought sociological sensitivity to historical context and institutional process; Wakefield brought conceptual precision about what it would mean for something to count as a disorder in a non-arbitrary way. Together they produced a critique that was harder to dismiss than either partner might have managed alone.
When they published a study in the American Journal of Psychiatry arguing that bereavement was one instance of a broader class of loss responses rather than a singular exception, the reaction told them what they had touched. The paper “upset a lot of people,” Horwitz said, “because if much of what’s getting diagnosed as depression is really just a normal response to loss, that’s pretty threatening to psychiatry’s core condition.” The DSM-5 committees agreed the argument made sense and then eliminated the bereavement exclusion entirely. “They certainly listened, and they certainly made changes,” Horwitz told Howard, “and the changes were absolutely in the wrong direction.”
What separates Horwitz from most critics of medicalization is his refusal to pick sides in the standard debate. He does not deny that severe mental illness is real, that schizophrenia or bipolar disorder at its most acute causes profound biological disruption, or that psychiatric treatment helps many people. He also refuses the opposite temptation, the sweeping social constructionism that treats all diagnosis as an instrument of power and all psychiatry as professional imperialism. He holds a narrower and more demanding position: serious mental illness is real, diagnostic expansion is a social process driven by institutional and cultural forces, and the difference between those two things matters enormously. That double insistence gave him unusual credibility because he was resisting both the pharmaceutical industry’s expansionism and the anti-psychiatry movement’s nihilism at the same time.
Asked whether mental illness varies across cultures, he answered that “there’s far more variability in mental disorders than there is constancy. One of the only major exceptions would be what we now call melancholic depression, very serious kinds of depression that are different from grief. They’re not necessarily connected to some kind of precipitant, they are not time limited, they have profoundly serious symptoms. Those seem to be found pretty much everywhere and from the beginning of recorded medical history. But those are the exceptions rather than the rule.” Uncaused, unremitting, severe, cross-culturally invariant. That is the boundary he spent fifty years defending, and it is narrow.
The historical timing of his rise amplified his impact. His most influential work appeared during the years when American psychiatry was consolidating DSM-style diagnostic authority, when antidepressants and anxiolytics were becoming among the most prescribed drugs in the country, and when diagnostic categories were being standardized for insurance reimbursement and clinical protocols. In that context, Horwitz functioned as an internal intellectual check on an expanding regime. He was not writing abstract sociology. He was analyzing a major institutional transformation in real time, showing that the apparent epidemic of mental illness was partly an artifact of the categories used to measure it.
The naming of the drugs was itself a marketing decision. “The antidepressants don’t have anything more to do with depression in particular than the anxiolytics had to do with anxiety in particular,” Horwitz said. “They work across very broad conditions. It was much more a question of marketing than of how the drugs actually work.” The benzodiazepines had been stigmatized by the 1970s, so the new serotonin drugs needed a different category to sell into. Peter Kramer supplied the aspiration. Kramer “promoted them not just as relief for any kind of psychic problem but as making you better than well,” Horwitz said. “Who doesn’t want to be better than well?”
A thread running through his entire career is the power of naming. Once grief becomes depressive disorder and fear becomes anxiety disorder, something changes not just in clinical practice but in how people understand their own experience. Patients come to see themselves through the diagnostic frame. Institutions allocate resources accordingly. Insurers reimburse some conditions and not others. The label reorganizes social identity and shapes expected life course. Horwitz’s work is a sustained account of how language backed by institutional authority reshapes both individual lives and collective understandings of normality.
Sometimes the naming precedes the market. Social anxiety disorder, he said, “was almost completely the creation initially of the pharmaceutical industry, which saw a potential gold mine if you can convince people that things like getting nervous before giving a talk is a sign of a mental disorder that requires taking a pill. There were just enormous advertising campaigns around social anxiety disorder that were hugely successful. Social anxiety disorder is perhaps the best example of the creation of a new kind of psychiatric disorder.”
Sometimes the drift produces absurdity. DSM-5 merged substance abuse and substance dependence into a single category requiring fewer symptoms than either predecessor. “If you drive across a state line from a state where marijuana use is legal into one where it’s illegal, you put yourself at greater risk of getting a mental illness diagnosis,” Horwitz observed. “That’s completely crazy. The merging has created this possibility where having negative social consequences is now grounds for a mental disorder.”
“The single major difference between now and fifty years ago in terms of the labeling of mental illness is exactly the pathologization of childhood,” Horwitz told Whitaker. “The number of kids with ADHD taking medication, or autism spectrum disorders, childhood bipolar disorders, all of these have soared. I really don’t think it’s because there’s any fundamental difference in kids now compared to prior eras. Parents want these diagnoses, they seek out medication to medicate their kids. It’s a way of controlling bad behavior and makes their jobs easier. But I think they’re doing a real disservice to their kids in the long run.”
His later books broadened the analysis into historical synthesis. Anxiety: A Short History, published by Johns Hopkins in 2013, traced shifting cultural meanings of fear across centuries. What’s Normal? Reconciling Biology and Culture, published by Oxford in 2016, confronted directly the question his whole career had circled: how do biological vulnerabilities and cultural categories interact in producing what societies count as disorder? PTSD: A History of a Disorder in Time, published by Johns Hopkins in 2018, examined how post-traumatic stress became a diagnostic category through a particular historical and political moment rather than through the gradual accumulation of medical evidence. DSM: A History of Psychiatry’s Bible, published by Johns Hopkins in 2021, offered the first comprehensive scholarly history of the manual that reshaped American psychiatry after 1980.
Biology and culture are both real, neither reducible to the other, and the boundary between normal variation and pathology is historically contingent rather than fixed by nature. Institutions maintain that boundary, and when institutional incentives shift, the boundary moves, often in ways that serve administrative or commercial interests more than patients.
What’s Normal? works out that framework across territory well beyond psychiatry, and the results are sharper than the mental health writing because nothing professional rides on them. Consider courage. “Cowardice, if we define it most generally as moving away from dangerous situations, is possibly the most innate kind of reaction,” he told Lopes. “All living organisms are naturally designed to be cowardly. Whereas socially just the opposite. From an evolutionary point of view that’s suicidal. One geneticist put it that yes, he could see getting killed for the benefit of two of his brothers or eight of his cousins, because there’s a net genetic benefit. But in almost every occasion courageous people are sacrificing themselves for those they have no genetic ties with. Courage makes no evolutionary sense whatsoever, but it is incredibly admired culturally, and just the opposite for cowardice. Cowardice is evolutionarily programmed but subject to tremendous shame.” Armies, he notes, “have to go to tremendous lengths to try and instill a completely unnatural value into combatants.” Speaking with Paul Mason, he extended the parallel: courage in men and thinness in women are both culturally mandated, biologically unnatural, and enforced through shame.
The harmful dysfunction framework requires both criteria, and he illustrates why with cases from outside psychiatry. Infertility is a dysfunction by any evolutionary measure but is not harmful in cultures where people do not want children. Deafness is a dysfunction, yet “in modern culture deaf culture can be flourishing, and it’s not harmful under certain conditions.” The reverse cases are equally instructive. “For centuries left-handedness was seen as extremely deviant, and very strong measures were made to convert left-handed people into right-handed people. So it’s very harmful, but there’s no dysfunction. Evolution couldn’t care less whether people were left-handed or right-handed.” Masturbation supplies the same lesson. “Into the 19th century people who masturbated were seen as prone to all sorts of dreadful diseases, even death. So it was associated with an extreme amount of harm, but clearly there was no dysfunction. So people who said masturbation was a disorder were simply wrong.”
Overdiagnosis does not only generate questionable science. It alters the cultural vocabulary available for making sense of difficulty. If ordinary grief is depression and ordinary fear is anxiety disorder, then the language for describing endurance, mourning, adaptation, and ordinary human struggle begins to thin. People lose access to frameworks that once allowed suffering to be bearable without being pathological. Horwitz’s work implicitly defends the moral significance of normal suffering, not to minimize it, but to insist it deserves a different kind of attention than clinical management.
Critics note that the distinction between normal and pathological distress can be difficult to operationalize in clinical settings, where decisions must be made quickly and context is often murky. Horwitz clarified what the problem is. Whether any particular clinician can solve it in a fifteen-minute appointment is a separate question. He does have a proposal, modest enough to be implementable. “If I were the depressive diagnosis dictator, the first thing I would implement would be watchful waiting,” he told Howard. “Even if somebody meets the overly generous diagnostic criteria, wait for a while and see. If the depression has happened while somebody is undergoing divorce proceedings or has broken up with a long-term partner, wait several weeks and see what happens with the symptoms. If they persist, if they’re not getting better, then go ahead and give a prescription.”
By his own account the field now defends a manual almost nobody believes in. The DSM-5 revision was attempted by the same researchers who had built DSM-III and had come to regard it as invalid, and it was defeated by the clinicians who had originally opposed the system and now needed it for billing. “The sides have completely reversed themselves,” Horwitz said. The result was a volume nearly identical to its predecessor. “What you have now is a volume that’s been deeply discredited. Researchers no longer believe in the conditions. The clinicians never really believed in them but have to use them just for instrumental purposes. But the DSM lives on and it’s completely institutionalized.” Asked what surprised him most in writing the book, he pointed to the gap between what the profession knows and what it can say. “They can’t now at least publicly say that. It would just put the profession in a completely unsustainable political situation. Just how much mental health practice and mental health rhetoric differ from each other. It’s just such a false front that people are putting forward.”
The DSM manual has vanished from public argument at the moment its categories have become universal. “The last time psychiatry was really very much in the news was around 2013 when DSM-5 was being debated,” he said. “Since then, while mental health culture has exploded, you just don’t see very much about the psychiatric profession or the DSM. That seems to have gone underground at the same time that mental health culture is now everywhere. That situation has puzzled me.” The categories no longer need the manual to sustain them. They have been absorbed into ordinary language, which is where PTSD now sits: “When everybody gets traumatized by, oh, I got a bad grade on my exam, the term becomes meaningless.”
What he recommends to individuals is what he spent fifty years recommending to institutions. “Taking particular diagnoses a little less seriously would be a good thing,” he told Lopes. “Thinking that you’re having problems with relationships is maybe a more positive way of dealing with a problem than saying I have anxiety disorder or I have major depressive disorder. Looking at your own circumstances and how you’re dealing with people, how you’re feeling generally, is a healthier way to approach your life than looking for a particular diagnosis.”
He showed the modern expansion of mental illness categories to be a social event, not only a scientific development. He made visible the institutional, cultural, and classificatory processes by which ordinary suffering gets transformed into diagnosable disorder. In doing that, he did not dismantle psychiatry. He forced it to confront what it was doing when it drew the line between sickness and sorrow, and to ask whether the line was in the right place.
Stephen Turner’s convenient beliefs framework holds that people adopt beliefs not because evidence compels them but because those beliefs serve the coalitions, institutions, and social positions they occupy.
Horwitz’s account is primarily conceptual and institutional. He shows that the DSM erased contextual criteria, that symptom checklists produce false positives, and that diagnostic inflation serves insurance reimbursement and pharmaceutical markets. But Turner might push further and ask about the belief structure of the professionals who built and maintained this system. Psychiatrists, clinical psychologists, pharmaceutical researchers, and DSM committee members did not experience themselves as cynics manufacturing disorder for profit. They believed they were discovering real conditions, helping suffering people, and advancing scientific medicine. Turner’s frame asks what made that belief convenient, and for whom.
The answer becomes visible once you map the jurisdictional interests at stake. American psychiatry in the late twentieth century faced a serious legitimacy problem. Psychoanalysis had lost credibility. Insurance payers wanted standardized, replicable diagnoses rather than interpretive clinical judgment. Biological psychiatry needed discrete categories to justify drug trials and regulatory approval. A broader diagnostic net served all of these pressures simultaneously. It gave psychiatry scientific respectability by mimicking the disease categories of internal medicine. It gave pharmaceutical companies billable conditions to treat. It gave clinicians clear protocols. The belief that depression and anxiety disorder werediseases, present in large proportions of the population, was not merely self-serving in a crude sense. It was the belief that made the whole institutional arrangement cohere.
Horwitz maps those pressures himself, and the map is precise. “Before the 1970s, third-party insurance basically didn’t exist,” he told the New Books Network. “Patients paid for their treatment out of their own pockets, so no third-party insurer required a diagnosis. But beginning in the 1960s and expanding greatly in the 1970s, the majority of patients begin to have to pay for their therapy through these third-party insurers, and they require some kind of a diagnosis. It became a financial necessity.” The Food and Drug Administration supplied the other pressure. Drug companies “could no longer advertise their products for the stress of life,” he told Ricardo Lopes. “They had to prove effectiveness with particular kinds of conditions like depression or anxiety.” Three constituencies wanted the same thing for different reasons: “the psychiatric researchers, the drug companies, and the insurance companies all clamoring for a much more specific kind of diagnostic manual.”
What the manual did not have was evidence. “The DSM-III diagnoses weren’t based on any real body of evidence,” Horwitz said, “because there was only a small amount of studies the developers could use, and they yielded different results. There wasn’t consensus. You have a manual built to be extremely specific but with just not very much evidence. It’s really built on quicksand.” A framework adopted with that little empirical support, by a profession under that much institutional pressure, is a good candidate for Turner’s analysis.
Horwitz explains the structural conditions that produced diagnostic inflation: the DSM model, the pharmaceutical industry, insurance reimbursement. But he treats the professionals inside those structures as largely responding to incentives rather than as believers whose epistemic lives are shaped by coalition membership. The psychiatrist who cannot see why context should matter to diagnosis is not simply wrong about symptoms. He holds a belief that his entire professional formation, his training, his peer network, his journal literature, his funding sources, his institutional identity, all converge to make compelling. Challenging it feels not like updating an hypothesis but like betraying a community.
Robert Spitzer understood something Turner would recognize: adoption does not require belief. “Spitzer realized that to implement a new diagnostic system he couldn’t just rely on his allies who agreed with his narrow, biologically oriented approach,” Horwitz told Greg LaBlanc. “Many fervently opposed the implementation of DSM-III. But once it was implemented, they saw tremendous advantages. They didn’t believe in the symptom-based approach, but it didn’t matter whether they believed in it or not. They would get their reimbursement from insurance companies that required diagnoses. They could get their research funded by the government, which also required diagnoses. It turned out not to hamper their actual practices. So it turned out to be political genius on Spitzer’s part, who did this not so much because of his beliefs as because it was an enormously clever way to have a profession that was generally skeptical of his aims nevertheless accept his proposals.” Theory neutrality was not an epistemic commitment. It was the price at which a skeptical majority could be bought.
When beliefs are convenient, evidence against them does not function the way standard epistemology says it should. The response to The Loss of Sadness was not a reconsideration of contextual criteria. It was a defense of the existing framework on largely procedural grounds, appeals to reliability, to clinical feasibility, to the impossibility of standardizing context. These defenses were not irrational given the institutional stakes. They were the predictable response of a coalition protecting the beliefs that hold it together.
The DSM-5 outcome was worse than resistance. Horwitz and Wakefield argued that bereavement was one instance of a broader class of loss responses and that the exclusion should be widened. The committees agreed the argument made sense and eliminated the exclusion instead. “They certainly listened, and they certainly made changes,” Horwitz told Howard, “and the changes were absolutely in the wrong direction.” The paper that made the case, published in the American Journal of Psychiatry, “upset a lot of people,” he told Dr. Josef Witt-Doerring, “because if much of what’s getting diagnosed as depression is really just a normal response to loss, that’s pretty threatening to psychiatry’s core condition.” An argument that threatens a core condition does not get refuted. It gets absorbed and inverted.
By insisting that severe mental illness is real while denying that ordinary sadness is depression, Horwitz refused the convenient beliefs available on both sides of the debate. Anti-psychiatry offered its own convenient belief, that diagnosis is pure social control and psychiatry is pure power, a position that served certain academic and political coalitions as reliably as biological reductionism served pharmaceutical ones. Horwitz held a position that was convenient for nobody, which is partly why his work earned respect across lines without generating a movement. A belief that serves no coalition’s immediate interests tends to circulate among intellectuals without being institutionalized.
Horwitz notes that the DSM-III eliminated contextual criteria partly for reasons of reliability and partly because context was hard to standardize. Turner might ask whose beliefs made that trade-off seem acceptable, and what made the resulting categories feel scientifically legitimate rather than administratively convenient. The answer involves the sociology of expert communities: committee members trained in biological psychiatry, socialized into its assumptions, accountable to its journals and funders, surrounded by colleagues who shared its commitments. In that environment, the belief that discrete symptom clusters constitute real diseases is not a hypothesis under active scrutiny. It is the background assumption against which everything else gets evaluated. Turner calls this tacit knowledge, and it functions precisely by not being available for explicit challenge.
Stephen Turner argues that what looks like shared background understanding is a convergence of individually acquired dispositions, trained into people through similar formation processes but never literally transmitted from mind to mind. The implication is unsettling: what feels like bedrock, the obvious, the self-evident, the things that go without saying, is a product of formation rather than perception.
Horwitz shows that DSM committees eliminated contextual criteria and that this elimination produced diagnostic inflation. He treats this as a conceptual error with institutional causes. Turner might say it is something harder to correct than an error. The psychiatrists and clinical researchers who built the DSM-III and its successors were not simply making a mistake about symptoms. They were operating from a set of trained perceptions about what counts as scientific, what counts as reliable, and what counts as a real disease category. Those perceptions felt like clarity. The idea that context should modify a diagnosis felt, from inside that formation, like a concession to subjectivity, a retreat from science toward interpretation. It did not feel like a choice. It felt like the obvious thing.
Horwitz describes the older formation from the inside, because he saw its last years. His dissertation gave him access to patient files at the Connecticut Mental Health Center in the early 1970s, and what struck him in retrospect was an absence. “Diagnoses were just not an important aspect of the problems,” he told the New Books Network. “Many of the files had no diagnosis at all. Sometimes it was sort of an afterthought. What was really primary was their marital difficulties, difficulties with parents, with jobs, with emotions. It just was not an important consideration at the time.” Clinicians then were not declining to diagnose. Diagnosis was not a thing their training had made them see. “There was what I would call a psychosocial view of patients,” he told Robert Whitaker, “that combined particular life histories with particular kinds of life situations. In one sense each patient really had a different set of circumstances. But it turned out to be a real problem for psychiatry, because how can you form a reliable and generalizable diagnostic system if psychiatry is going to be a respected branch of medicine?” Within a decade the file that recorded a marriage and a job loss recorded a code instead. “All of a sudden diagnosis became primary. I thought this was just exceedingly strange. How could this change come about in such a short period of time?”
This is why Horwitz’s careful arguments had limited institutional effect. He was making an explicit, propositional case against people whose resistance was not primarily propositional. They were not holding a thesis about context that could be updated by counter-evidence. They were operating from trained perceptions that made the contextual approach look unscientific before the argument even began. Turner calls this the problem of essentialism in the sense that communities project their tacitly acquired dispositions onto reality as if those dispositions were simply accurate readings of how things are. The DSM framework did not present itself as one possible approach to mental illness. It presented itself as what mental illness looks like when you study it properly.
The formation runs deep enough to survive the abandonment of the belief it was built to serve. When DSM-5 researchers tried to replace categories with dimensions, clinicians who agreed with them on the science defeated the proposal anyway. “Clinicians may fully believe the same thing that researchers do,” Horwitz told Ricardo Lopes. “They see mental illnesses as overlapping, not distinct, as dimensional and not categorical. But they have no choice but to use diagnoses. They need to say this person has major depressive disorder. They can’t say well they have a little bit of depression but maybe not enough for a real diagnosis. That just doesn’t allow them to function as professionals.” Part of that is billing. Part of it is perception. “Psychiatrists are medically trained, and in medicine you basically have a condition or you don’t have a condition. People are just trained to think in terms of what kind of disease does this person have. Their whole way of thinking was too foreign” to accommodate gradations. The dimensional proposals also came from statistically oriented psychologists whose methods were “almost the antithesis of what a clinician does, which is look at the individual person.”
Turner also helps explain something Horwitz observes but does not fully theorize: the asymmetry between how obvious the contextual argument seems to sociologists and how peripheral it seems to clinicians. Sociologists trained in labeling theory, social control, and the construction of deviance bring a formation that makes context seem indispensable. They cannot imagine why you would diagnose grief without knowing what caused it. Clinicians trained in biological psychiatry bring a formation that makes symptom clusters seem primary. They cannot imagine why the cause of a symptom should change whether it is a symptom. Neither side is simply reasoning badly. Each is perceiving through a trained apparatus that the other does not share, and because tacit formation feels like perception rather than assumption, each side tends to experience the other as obtuse rather than differently trained.
The asymmetry is visible in what each side finds too obvious to argue. Horwitz reaches for the cough. “Physicians are much more likely to understand that symptoms do not necessarily indicate a disorder,” he told Greg LaBlanc. “If somebody is coughing, a cough is an adaptive response to clear the lungs. Fevers or physical pain are nature’s way of telling you that something’s wrong, but in themselves they’re not pathological. In fact they’re just the opposite. Psychiatry is much less likely to recognize that symptoms can be adaptive and sees them as indicators of diseases.” To a sociologist of deviance this is elementary. To a clinician trained on symptom checklists it is a category the training did not supply.
Horwitz could see across the tacit divide because his training was hybrid, combining psychiatric epidemiology with the sociology of deviance. That dual formation gave him access to what each community took for granted. His own account of it is blunt: “The people I learned the most from weren’t in the psychiatric or mental health area at all. They were students of law, criminology, and deviant behavior. I’ve really been applying perspectives I learned in an entirely different area to the study of mental health.” Tacit formation is how communities reproduce themselves. A thinker whose formation cuts across communities produces arguments that each community can partially recognize and partially use, but that neither absorbs.
He is unusually aware of formation as formation, because he has had to work against his own. “From the way I was socialized in my graduate education in sociology in the 1970s, biology was almost a curse word,” he told Paul Mason. “No one would have thought there’s a biological dimension to human social life. In anthropology at least there was a subfield of biological anthropology. There was not a subfield of biological sociology. So to me the most unusual thing about my own feelings is to realize how important biological functioning and natural selection is to human activity, which wouldn’t surprise people in many fields, but just goes so against the way I was trained.” This is Turner’s point stated by a man reporting it about himself: the curse word was not a conclusion he had reached but a reflex his training installed, and undoing it took decades.
Wakefield’s philosophical concept of disorder as harmful dysfunction was an attempt to make explicit, in propositional form, the criteria that should govern the boundary between normal response and pathology. Turner might note the difficulty of that project: what Wakefield tried to articulate explicitly was precisely the kind of thing that operates tacitly in clinical judgment. Good clinicians have a sense, acquired through training and experience, of when someone’s distress has crossed a line. That sense resists full propositional capture. The DSM tried to replace it with checklists, which lost the sense entirely. Wakefield tried to recover it through philosophical analysis, which is more promising but still faces the problem that tacit perception cannot be fully translated into explicit criteria without losing something. Horwitz and Wakefield identified the problem with remarkable precision. Turner might say the solution is harder than either proposed, because the thing that needs recovering is not a rule but a trained capacity, and trained capacities are rebuilt through formation, not argument.
Horwitz’s own proposal concedes as much without saying so. Asked what he would do with the authority to change practice, he did not offer criteria. He offered a delay. “If I were the depressive diagnosis dictator, the first thing I would implement would be watchful waiting,” he told Brendan Howard. “Even if somebody meets the overly generous diagnostic criteria, wait for a while and see. If the depression has happened while somebody is undergoing divorce proceedings or has broken up with a long-term partner, wait several weeks and see what happens with the symptoms. If they persist, if they’re not getting better, then go ahead and give a prescription.” Watchful waiting is not a rule that identifies disorder. It is a procedure that buys time for a clinician’s judgment to develop. The remedy for lost perception is not a better checklist. It is a slower clock.
Why is diagnostic inflation so difficult to reverse? It is not primarily a political problem, though it is partly that. It is not primarily a commercial problem, though pharmaceutical interests matter. It is an epistemic problem rooted in formation. The people who would need to redraw the boundary between sorrow and sickness are trained to perceive the current boundary as no boundary at all, just reality. Changing that requires changing how clinicians are formed, what they read, who they train with, what cases they are exposed to early, and what their senior colleagues model as obvious. That is a generational project, not an argumentative one. Horwitz made the argument with great clarity. Turner explains why clarity is not enough.
David Pinsof’s Alliance Theory
The diagnostic expansionists form a coalition with boundaries and stakes. Biological psychiatrists, pharmaceutical companies, DSM committee members, clinical psychologists seeking parity with medical doctors, insurance administrators who need standardized categories, patient advocacy groups who gain legitimacy and sympathy through diagnosis, all converge on the broad disease model not because they conspired but because the model serves each member’s coalition interests simultaneously. The belief that depression is a brain disease present in roughly one in five Americans is not just convenient in Turner’s sense. It is a coalition signal. Holding it marks you as scientifically serious, clinically compassionate, and institutionally legitimate. Challenging it marks you as a threat to patients, a tool of stigma, or a sociologist overreaching into medicine. Coalitions generate moral vocabularies that make dissent costly, and the diagnostic expansionist coalition generated a powerful one: to question whether ordinary sadness is really depression is to seem to deny suffering, to gatekeep care, to leave sick people untreated.
Horwitz names the convergence, and notes that the members wanted the same thing for different reasons. “The psychiatric researchers, the drug companies, and the insurance companies all clamoring for a much more specific kind of diagnostic manual,” he told Ricardo Lopes. Robert Spitzer built the coalition by making belief irrelevant to membership. “Many fervently opposed the implementation of DSM-III,” Horwitz told Greg LaBlanc. “But once it was implemented, they saw tremendous advantages. They didn’t believe in the symptom-based approach, but it didn’t matter whether they believed in it or not. They would get their reimbursement from insurance companies that required diagnoses. They could get their research funded by the government, which also required diagnoses. So it turned out to be political genius on Spitzer’s part, who did this not so much because of his beliefs as because it was an enormously clever way to have a profession that was generally skeptical of his aims nevertheless accept his proposals.” A coalition that requires only interest, not conviction, is harder to break than one held together by shared belief.
The DSM-5 revision showed the coalition’s shape by inverting it. The researchers who had established the categorical system tried to replace it with dimensions; the clinicians who had originally fought the system defended it. “The political dynamics are almost exactly the opposite of what they were in DSM-III,” Horwitz said. “The sides have completely reversed themselves.” Positions had swapped while interests stayed put. The clinicians needed billing codes and the researchers needed constructs that tracked their data. Neither side’s stance in 2013 followed from anything either believed in 1980.
Horwitz spent five decades making a careful, empirically grounded, conceptually precise argument that the boundary between normal suffering and disorder had been moved in ways that harmed people. The argument was largely right, widely acknowledged as serious, and institutionally ineffective. Horwitz’s position served no major coalition’s interests. It did not give pharmaceutical companies a market. It did not give clinicians a billing code. It did not give patient advocates a disease to rally around. It did not give anti-psychiatry activists the sweeping indictment they wanted. It gave sociologists a rigorous framework and gave thoughtful clinicians a useful provocation.
Critics argued that distinguishing normal sadness from depressive disorder would discourage help-seeking, stigmatize the ill, and provide cover for insurers to deny treatment. These arguments have some merit as practical concerns. But Pinsof would note that they function primarily as coalition moves. They reframe a conceptual disagreement about diagnostic criteria as a moral failing, casting Horwitz and Wakefield as people who would leave the depressed untreated. That reframing protects the coalition by making the intellectual challenge seem dangerous.
Wakefield’s harmful dysfunction account tried to provide a principled, non-coalitional definition of disorder, one that would hold regardless of institutional interests. Pinsof would regard that project with some skepticism, not because the definition is wrong but because definitions do not float free of the coalitions that adopt or reject them. The DSM committees that declined to restore contextual criteria were not primarily evaluating Wakefield’s philosophical argument on its merits. They were protecting a classificatory system around which an enormous coalition had organized itself. A definition of disorder that would exclude millions of current diagnoses is not just a conceptual revision.
The bereavement fight is the clean test. Horwitz, Wakefield and colleagues published a study in the American Journal of Psychiatry arguing that grief was one instance of a broader class of loss responses and that the exclusion should therefore be widened. The paper “upset a lot of people,” Horwitz told Witt-Doerring, “because if much of what’s getting diagnosed as depression is really just a normal response to loss, that’s pretty threatening to psychiatry’s core condition.” The committees conceded the logic and moved the other way. “They certainly listened, and they certainly made changes,” he told Brendan Howard, “and the changes were absolutely in the wrong direction.” DSM-5 eliminated the exclusion. An argument accepted on its merits and inverted in its effect is not a failure of persuasion. It is a coalition removing an anomaly the argument had made visible.
Patients who receive psychiatric diagnoses are not simply passive recipients of medicalized categories. They join coalitions organized around those diagnoses. Depression communities, anxiety disorder communities, PTSD communities all develop shared narratives, mutual support structures, advocacy organizations, and political identities. A diagnosis gives access to this coalition, and the coalition provides real goods: solidarity, legitimacy, legal protections, treatment access. Pinsof would say that once a diagnosis becomes a coalition membership card, the stakes of losing it extend far beyond medical accuracy. Patients who have organized their identity and social world around a diagnosis have strong alliance-theoretic reasons to resist any argument that the diagnosis was too broad, regardless of that argument’s empirical merits. Horwitz’s work threatened not just psychiatric institutions but the coalitions of sufferers those institutions had inadvertently organized.
The most consequential patient coalition is one that speaks for others. “The single major difference between now and fifty years ago in terms of the labeling of mental illness is exactly the pathologization of childhood,” Horwitz told Whitaker. “The number of kids with ADHD taking medication, or autism spectrum disorders, childhood bipolar disorders, all of these have soared. I really don’t think it’s because there’s any fundamental difference in kids now compared to prior eras. Parents want these diagnoses, they seek out medication to medicate their kids. It’s a way of controlling bad behavior and makes their jobs easier. But I think they’re doing a real disservice to their kids in the long run.” When the autism criteria came under review in DSM-5, “you had parents up in arms because they were afraid their children were going to lose diagnoses which brought about treatment and other research resources.”
Jerome Wakefield’s work generated misunderstanding claims primarily around a formal philosophical definition that could be precisely stated and precisely misread. Horwitz’s work generated misunderstanding claims around a sociological argument whose very nature made it easier to caricature, harder to pin down, and more vulnerable to the particular form of misunderstanding claim that says you are attacking something you support.
The most persistent misunderstanding claim directed at Horwitz was that he denied the reality of depression and wanted to leave suffering people untreated. This reading circulated widely enough that it became the default critical response to The Loss of Sadness in clinical and popular contexts. Horwitz spent considerable effort correcting it. His argument was not that depression is unreal or that treatment is unwarranted. It was that the DSM had erased the distinction between depressive disorder and contextually expectable sadness, and that this erasure produced diagnostic inflation.
He says so in nearly every interview, in language nobody could mistake. Depression “has always been recognized as a very serious mental health problem where people have suicidal thoughts, where they find nothing in life is worthwhile,” he told Robert Whitaker. “It can be a very serious disorder.” Asked whether mental illness varies across cultures, he named the one category that does not: “melancholic depression, very serious kinds of depression that are different from grief. They’re not necessarily connected to some kind of precipitant, they are not time limited, they have profoundly serious symptoms. Those seem to be found pretty much everywhere and from the beginning of recorded medical history.” The man supposedly denying depression exists has spent fifty years specifying what it is.
This misreading was not primarily a failure of comprehension. It was a coalition move by the diagnostic expansionist coalition that found the caricature more useful than the argument. A Horwitz who denies depression exists is easy to dismiss and slightly disreputable. A Horwitz who argues that the DSM systematically misclassifies normal grief as disorder is harder to dismiss and requires engagement.
The caricature is also cheaper than the real argument because the real argument attacks from the direction the coalition cannot easily defend. Horwitz claims the severely ill are the ones a loose definition fails. “The relatively small proportion of people who really are depressed, those people get overlooked and do not get the treatment they need,” he told Brendan Howard. “The best studies show that the antidepressants really do work with the most severely ill people. They are not much better, or maybe not any better, than placebos for most of the people who take them. By having such a loose and large and general definition of what constitutes depression, it’s those people who really are depressed who suffer.” A critic who answers the caricature never has to answer that.
Horwitz’s responses to this misreading also deployed the misunderstanding frame, arguing that his critics had missed the distinction between denying that depression exists and arguing that the criteria for identifying it had drifted. Pinsof would ask what coalition function the correction served beyond its intellectual content. The answer is that it allowed Horwitz to maintain a posture of having been misread rather than having been engaged and found wanting. The misunderstanding claim protected the argument from having to account for why the field did not change in the direction his work implied it should. If the DSM-5 eliminated the bereavement exclusion despite Horwitz’s sustained argument for retaining and extending it, one explanation is that his argument was heard and rejected. Another explanation, more coalitionally comfortable, is that it was misunderstood.
To his credit Horwitz does not take the comfortable option. His own account of the bereavement fight concedes that the committees followed him and moved the other way regardless. “They certainly listened, and they certainly made changes,” he told Howard, “and the changes were absolutely in the wrong direction.” Elsewhere he is blunter about what his best-known book accomplished. “I do think in particular The Loss of Sadness had some direct influence on psychiatry’s diagnostic system, but it was exactly the opposite influence I would have liked to have seen. They made the criteria even worse in the newest edition. Has it had any positive impact? I’d like to think maybe among readers, but certainly not among the discipline of psychiatry.” That is heard and rejected, stated plainly by the man with the strongest incentive to claim he was misread.
The sociological character of Horwitz’s argument made it vulnerable to a particular kind of misunderstanding claim that Wakefield’s more formally philosophical work largely escaped. Sociological arguments about medicalization are easy to assimilate to a pre-existing template that clinical communities find familiar and dismissible: the sociologist who does not understand medicine, who reduces clinical judgment to social construction, who privileges structural analysis over patient welfare. That template was applied to Horwitz repeatedly despite fitting his position poorly. He was not arguing that clinical judgment is mere social construction. He was arguing that the categories through which clinical judgment operates had been shaped by institutional forces in ways that distorted rather than served good clinical practice. The template was more coalitionally convenient than the argument, because the template could be dismissed through professional identity rather than through engagement.
When a sociologist makes an argument about psychiatric categories, each disciplinary community receives it through its own formation and finds it easy to claim partial misunderstanding at the boundary. Psychiatrists could say Horwitz misunderstood clinical realities. Sociologists could say psychiatrists misunderstood the institutional argument. Philosophers could say both sides misunderstood the conceptual issues. The interdisciplinary argument that crossed all these boundaries could always be accused of misunderstanding by each community it entered, because each community’s tacit formation made different things obvious and different things invisible.
The Loss of Sadness was received by many readers as primarily Wakefield’s book, since the philosophical framework of harmful dysfunction was the most formally novel element and Wakefield was the more prominent figure in philosophy of psychiatry. Horwitz’s sociological contribution, the institutional history of how the DSM erased contextual criteria and why that erasure served specific interests, was frequently underweighted in the reception. Horwitz could legitimately claim that this reception misunderstood the collaborative structure of the argument, treating the philosophical framework as the book’s core when the sociological analysis was equally central. But Pinsof would note that this misreading also served the diagnostic expansionist coalition’s interests. A book about a philosophical definition of disorder is easier to contain within academic philosophy than a book about how institutional interests shaped psychiatric classification. The second book is more threatening because it names specific processes and specific beneficiaries. Receiving The Loss of Sadness as primarily a philosophical intervention rather than a sociological-institutional critique was a misunderstanding that happened to be convenient.
The institutional half of the argument names people. Spitzer “appointed his buddies,” Horwitz told the New Books Network, filling the task force from Columbia and Washington University and excluding the analysts, who “weren’t interested in diagnosis” and did not notice until 1978 that something had happened to them. Social anxiety disorder “was almost completely the creation initially of the pharmaceutical industry, which saw a potential gold mine.” Third-party insurance made diagnosis “a financial necessity.” None of that is a philosophical thesis. It is an account of who did what and who benefited, and it is the half of the book that mostly did not travel.
In Creating Mental Illness, Horwitz argued that only a small subset of conditions psychiatry classifies as disorder fit a disease model, and that most DSM categories reflect contextually intelligible responses to stress and loss that are reframed as pathology. Critics responded that this argument misunderstood the biological basis of mental illness, that Horwitz was importing a sociological framework into a domain where biological evidence should be decisive. That response is a misunderstanding claim: it positions Horwitz’s argument as arising from disciplinary limitation rather than engaging with what he argued. Horwitz was not denying biological bases for severe mental illness. He was arguing that the expansion of diagnostic categories far outran the biological evidence available to support them. The critic who says he misunderstood biology is using the misunderstanding frame to avoid the harder question of whether the biological evidence supports the expanded diagnostic categories.
Horwitz’s work carries an implicit moral argument: that overdiagnosis does not merely generate bad science but erodes the cultural vocabulary for understanding normal suffering, making it harder for people to experience grief, disappointment, and hardship as meaningful rather than pathological. That moral argument was frequently misread as cold or dismissive, as if Horwitz were telling depressed people their suffering was not real. The misreading allowed critics to occupy the emotionally sympathetic position, defending suffering people against a sociologist who seemed to minimize their pain, while avoiding the moral argument Horwitz was making, which was that medicalization itself diminishes suffering by converting it from something to be lived through into something to be treated away.
Turner explains why clinical communities could not perceive what Horwitz perceived when he looked at diagnostic inflation: their formation built different things into their seeing. Pinsof explains what they did with that perceptual gap when it became socially relevant. They converted it into a misunderstanding claim, positioning Horwitz as someone who had failed to see what was obvious to clinicians rather than as someone whose different formation made different things visible. You cannot easily refute someone whose perception differs from yours at the level of formation. But you can claim they misunderstood, which is cheaper and produces the same protective effect for the coalition.
Understanding Horwitz would have required acknowledging that the boundary between normal suffering and clinical disorder had been moved by institutional forces rather than evidence, and that acknowledgment carried costs too large for any major coalition to absorb. Misunderstanding was cheaper. It remained cheaper for fifty years. That is not a failure of reading. It is a success of coalition management.
Pinsof’s charisma essay argues that charisma is a social relationship in which an audience projects heroic qualities onto a figure who appears to resolve a tension the audience cannot resolve. The charismatic figure occupies a position in a social field where projection becomes possible and necessary. What looks like personal magnetism is a structural effect: the right person in the right position at the right moment when a group needs someone to carry its contradictions without collapsing under them. The charismatic figure succeeds not by being extraordinary in some absolute sense but by appearing to transcend the dilemma that ordinary members of the group cannot transcend.
Groups need hierarchy but resent it. They need conformity but punish those who conform too visibly. They need leaders but destroy leaders who become too dominant. The paradoxes get managed, displaced, or personified, and the figures who personify them become socially significant in ways that exceed their individual qualities.
Horwitz occupied a structural position in the field of mental health scholarship that had charismatic potential. He appeared at the moment when American psychiatry was consolidating its diagnostic authority, when the DSM model was becoming the administrative infrastructure of mental health care, and when the expansion of pharmaceutical treatment was normalizing clinical responses to ordinary distress. That moment created a tension within the broader culture that a charismatic figure might have resolved or at least personified. On one side, people increasingly understood their suffering through clinical categories and found relief and community in those categories. On the other side, there was a diffuse but real unease about the medicalization of ordinary life, a sense that something was being lost when grief became depression and shyness became social anxiety disorder. That tension was widely felt but poorly articulated. A charismatic figure positioned at that fault line, one who could appear to resolve the contradiction between the reality of suffering and the institutional distortion of its interpretation, might have generated significant public resonance.
Horwitz did not become that figure, and Pinsof’s charisma essay helps explain why. Charisma requires a particular relationship between the figure and the audience’s need for resolution. The figure must appear to transcend the dilemma, to stand above it in a way that makes the tension feel dissolved. Horwitz’s intellectual style worked against this. He did not transcend the tension between the reality of suffering and the distortion of its clinical interpretation. He inhabited it carefully, refusing to resolve it in either direction, insisting that both things were true simultaneously. Severe mental illness is real and the diagnostic framework has drifted. Suffering deserves recognition and the categories used to recognize it have been corrupted by institutional forces. That double insistence is intellectually the most defensible position. It is charismatically inert because it offers the audience no resolution, only a more precise description of the problem they already feel.
His habit of arguing against himself in public is the clearest evidence of this. Asked by Greg LaBlanc whether Americans are actually getting sicker, he gave his position first, that the increases are “not entirely but for the most part artifacts of the way we measure them,” and then supplied the counter-case himself. Kids “spending literally hours looking at a computer screen” might be genuinely worse off. “If you’re always seeing these TikTok videos of much more impressive people than you are, it can make you feel inferior.” Then, unprompted: “So I’m sort of arguing against myself there.” Asked whether the field might arrive at valid criteria, he offered flexibility as a candidate and demolished it in the next sentence: “You’re going to have a hundred psychiatrists making a hundred different diagnoses if you use such a general criterion. Whether you can have an optimal diagnostic system which is both valid and reliable, I would not put any money on that.” This is what intellectual honesty sounds like. It is also the opposite of what an audience needing resolution can use.
Robert Whitaker, whose books on psychiatric medication reached large popular audiences, generated something closer to charismatic response by appearing to resolve the tension in one direction: the system is corrupt, the medications harm more than they help, patients have been betrayed. That resolution is too simple and in important respects wrong, but it gives the audience what the charismatic relation requires, the feeling that the contradiction has been cut through. On the other side, figures like Andrew Solomon, whose writing on depression reached large audiences by validating the medical model and the experience of disorder, generated charismatic response by appearing to resolve the tension in the other direction: suffering is real, diagnosis is meaningful, treatment is legitimate. Solomon’s resolution is also too simple in ways Horwitz’s work makes visible, but it gives the audience the emotional relief that charisma trades in. Horwitz, positioned between these resolutions and refusing both, generated intellectual respect without the emotional charge that charismatic authority requires.
The Mad in America interview stages the difference. Whitaker hosts; Horwitz supplies the history; Sarah Fay supplies the testimony. Fay was diagnosed with anorexia at twelve while her parents were divorcing, then read a novel about an anorexic girl that was “really a cheat sheet on how to be an anorexic. I learned how to do it and I became one. It really became my identity.” Five more diagnoses followed over three decades until a new psychiatrist looked at her and said he did not know what she had. “My whole world changed. That afternoon I remember walking out of his office and walking down Chicago Avenue and it just seemed crisper. It was colder but it was also more vibrant. It was like someone had just told me the truth.” That is a story with a wound, a betrayal, and a moment of release. It travels. Horwitz’s contribution to the same conversation is an account of how third-party insurance and FDA advertising rules reshaped a diagnostic manual between 1968 and 1980. Both are true. Only one is a story.
Medical sociology depends on maintaining critical distance from the institutions it studies. But it also depends on those institutions taking its findings seriously enough to justify the enterprise. A sociology of psychiatry that psychiatry ignores is professionally marginal. A sociology of psychiatry that psychiatry absorbs becomes a tool of the institution. Horwitz occupied this paradox throughout his career. His work was serious enough that psychiatry could not simply ignore it. It was sufficiently critical that psychiatry could not simply absorb it. The result was a permanent condition of acknowledged marginality: cited, respected, discussed, and institutionally ineffective. Pinsof’s paradoxes paper would say this condition is not Horwitz’s personal failure. It is the structural position that critical sociology of medicine necessarily occupies, and Horwitz personified it with unusual dignity and persistence.
He describes the position without complaint and without illusion. “I’m a sociologist, not a clinician, so it was easy for me to be saying these things because the people I’m basically arguing against are not my own peers,” he told Dr. Josef Witt-Doerring. “In a sense it’s easy for me to be a critic because I don’t have to come into face-to-face contact with these people. I can sort of critique from afar.” Then, almost as an aside: “Although I have given some talks at American Psychiatric Association meetings, and actually found quite a welcoming reception there.” Welcomed and unheeded. That is the paradox in a sentence.
The second paradox is what might be called the normalization trap. Horwitz’s central argument was that normal suffering had been pathologized. But making that argument required him to specify what normal suffering looks like, which required drawing a boundary between normal and pathological that was itself a normative judgment. Every time he defended the space of normal suffering against medicalization, he was implicitly policing the boundary of that space, deciding what counted as ordinary grief and what counted as disorder. That boundary-drawing exercise reproduced at the conceptual level exactly the kind of classification work he was criticizing at the institutional level. He could not argue against diagnostic boundaries without drawing his own, and drawing his own exposed him to the same criticism he directed at the DSM: who decides where the line goes, and by what authority? Anyone who argues that a boundary is in the wrong place must implicitly argue that they know where the right place is, which requires the very kind of authority the criticism was meant to challenge.
He knows the trap is there. Asked by Ricardo Lopes how validity could ever be established across cultures, he conceded that the general criteria available are too general to apply and the specific ones too specific to travel. The line he defends is narrow, uncaused and unremitting melancholia, “found pretty much everywhere and from the beginning of recorded medical history.” But narrowness is not neutrality. He has still decided, for everyone, which suffering counts.
The third paradox is the institutionalization paradox that runs through Horwitz’s entire career. His work argued that institutional forces had corrupted psychiatric classification. But that work was itself produced within institutions, validated by institutional awards, published by institutional presses, taught in institutional settings, and sustained by institutional salaries. The critique of medicalization was institutionally housed and institutionally rewarded. It is the unavoidable condition of any serious institutional critique. The critic who operates entirely outside institutions has no audience. Horwitz maintained his critical position within Rutgers and the American Sociological Association while directing that position outward at psychiatry and the DSM. That navigation was successful enough to sustain a fifty-year career. But it also meant his critique was always partially contained by the institutional structures that housed it, which is one reason it generated acknowledgment rather than transformation.
The fourth paradox: Horwitz’s work was most powerful when it documented the harm done by diagnostic inflation to ordinary people whose normal suffering was being medicalized. That documentation required him to speak on behalf of people who were being misclassified, to argue that their suffering was real but their diagnosis was wrong. But those people, many of whom had organized their identities and social worlds around those diagnoses, frequently did not want to be spoken for in that way. The patient coalition that Horwitz’s argument implied should exist, people who recognized that their grief had been misclassified as depression and wanted their suffering honored without being pathologized, was largely not available as a constituency. This was not a natural absence. The diagnostic expansion had arrived first, and it brought real goods with it: community, legitimacy, insurance coverage, legal protection, and a vocabulary for distress that felt validating rather than dismissive. By the time Horwitz’s argument was fully developed, the people whose interests it served had already been organized into a different coalition, one built around the diagnosis. The constituency his argument required had been recruited away before it could form.
Horwitz occupied a significant position in a field experiencing tension between the reality of suffering and the distortion of its institutional interpretation. He articulated that tension with unusual precision and sustained it across five decades without resolving it in either direction. That refusal to resolve was intellectually courageous and charismatically inert. It generated the kind of authority that accrues to someone who is persistently right about a difficult problem without ever appearing to transcend it. The paradoxes his career personified, critical authority versus institutional effectiveness, normalization versus pathologization, institutional critique versus institutional housing, were not resolved by his work. They were made more visible and more precise. Charisma dissolves paradoxes in the audience’s perception. Horwitz’s career made them harder to dissolve, which is why he matters to scholars and why he never became a public figure in the way the tension his work identified might have produced.
His own summary of the field he leaves behind carries no resolution at all. “Everyone agrees it’s a mess but we don’t know how to get rid of it,” he told Whitaker. Asked whether humility could be built into a diagnostic manual, he answered: “Probably not.” The popular press runs “breakthrough after breakthrough and discovery after discovery and miracle after miracle,” and the newest of them is prolonged grief disorder, which, he noted dryly, is going to solve all our problems. “There’s a true lack of humility when humility is what is called for. But I’ll believe it when I see it.”
Cultural Trauma and Collective Identity
Jeffrey Alexander’s cultural trauma framework argues that trauma is not a natural response to overwhelming events but a social achievement.
The DSM model’s cultural success was not primarily a scientific achievement. It was a trauma process in Alexander’s sense, though the wound it claimed was individual. The claim that depression and anxiety disorder are diseases affecting large proportions of the population required exactly the kind of carrier group, narrative work, and institutional recognition that Alexander describes. Patient advocacy organizations, pharmaceutical companies, psychiatric associations, celebrity disclosures, public health campaigns, and media coverage all participated in a sustained process of claiming that a wound existed, that it had a name, that the name corresponded to a real condition, and that the condition deserved medical recognition and treatment. By the early twenty-first century, the cultural recognition of depression as a disease affecting one in five Americans had achieved the kind of institutional embedding that Alexander associates with successful trauma claims: it organized identities, shaped institutional responses, generated legal protections, and restructured moral expectations about how sufferers should be treated.
The numbers track the process rather than any change in the population. Before symptom-based diagnosis, Horwitz told Brendan Howard, “studies showed about three percent of the population had some sort of depressive disorder. That rose by a factor of about six times immediately after the publication of DSM-III in 1980, where about seventeen percent of the population qualifies. The best studies, ones that follow people over longer periods rather than getting at symptoms at one point in time, find that about half the population qualifies.” Nothing happened to Americans in 1980. Something happened to the criteria.
Horwitz’s argument was that this cultural process had overreached, that the wound being claimed was in many cases not a wound in the relevant sense but ordinary suffering being reframed through a clinical vocabulary. Alexander’s framework helps explain why that counter-argument was so difficult to land. To challenge a successful trauma claim is not merely to offer a competing analysis. It is to appear to deny the wound, to tell the claimants that what they experienced was not what they said it was, to withdraw the recognition that the trauma process had worked to secure. Alexander notes that trauma claims, once institutionally successful, generate fierce resistance to revision because the recognition is bound up with collective identity in ways that make challenge feel like attack. The patients who had organized their identities around depression diagnoses, the clinicians who had built practices around those diagnoses, the researchers who had built careers around them, all had stakes in the wound’s recognition that went far beyond scientific accuracy.
Challenging a successful trauma claim feels like an act of cruelty to those whose identity is organized around it. The clinician who insists that Horwitz’s argument would leave depressed people untreated is not only protecting a coalition. He is defending what feels like the moral achievement of having gotten the wound recognized in the first place. The trauma process produced moral obligations alongside institutional ones: to take suffering seriously, to provide treatment, to extend compassion to those whose wound had been recognized.
Horwitz grants the achievement. Stigma “certainly has lessened tremendously,” he told Greg LaBlanc. “The most common conditions no longer involve the stigmatization they once had, and certainly being traumatized and having PTSD is probably the least stigmatizing condition of all.” Speaking with Robert Whitaker he weighed the ledger without settling it: someone suicidal who once would have felt shame at speaking up “may be more likely to seek help,” and on the other side is “a system that is so quick to medicate people” and a dependency problem that has grown accordingly. “What’s the net gain? It’s difficult to know.” A man who thought the wound claim was pure loss would not have to hesitate there.
Alexander’s framework also illuminates something Horwitz himself observed but did not theorize with full force: the role of carrier groups in sustaining the expanded diagnostic categories against challenge. Alexander argues that trauma claims require carrier groups, organized actors with the resources, motivation, and cultural access to keep the claim alive and extend its recognition. The diagnostic expansionist coalition functioned as exactly such a carrier group, maintaining and extending the claim that depression and anxiety disorder were diseases requiring treatment. Pharmaceutical companies funded research that kept the claim scientifically active. Patient advocacy groups kept it politically active. Media coverage kept it culturally active. Clinical training kept it professionally active.
The most effective carriers are those with nothing obvious to gain. Mental health advocates “like promoting high estimates of any disorder including depression because their notion is that it helps destigmatize the condition,” Horwitz told Howard. “If up to half the population can be depressed, then certainly there’s nothing wrong, we shouldn’t be ashamed to get a diagnosis. It’s almost more normal than it is abnormal.” Parents carry the claim into childhood. When DSM-5 considered tightening the autism criteria, “you had parents up in arms because they were afraid their children were going to lose diagnoses which brought about treatment and other research resources.” Gay organizations that fought to strike homosexuality from DSM-II in 1973 fought to keep gender dysphoria in DSM-5, “not because anybody thought it was a mental disorder,” Horwitz said, but because transition surgery requires one. A wound claim that survives its own beneficiaries’ disbelief is a claim that has won.
It has won thoroughly enough that the manual sustaining it has dropped out of sight. “The last time psychiatry was really very much in the news was around 2013 when DSM-5 was being debated,” Horwitz told Howard. “Since then, while mental health culture has exploded, you just don’t see very much about the psychiatric profession or the DSM. That seems to have gone underground at the same time that mental health culture is now everywhere. That situation has puzzled me.” The categories no longer need their carriers. They circulate in ordinary speech, where the vocabulary thins as it spreads: “When everybody gets traumatized by, oh, I got a bad grade on my exam, the term becomes meaningless.”
Alexander distinguishes between what he calls the progressive narrative and the tragic narrative in trauma claims. The progressive narrative says that the wound was inflicted, that it was recognized, and that recognition is the first step toward healing and redemption. The tragic narrative says that the wound cannot be healed, that its recognition changes nothing about the underlying conditions that produced it, and that the most one can hope for is honest acknowledgment of irreducible loss. The medicalization of depression was narrated progressively: once we recognize depression as a real disease, we can treat it, reduce suffering, restore function, and move toward recovery.
Peter Kramer supplied the arc its most expansive version. Kramer promoted the SSRIs “not just as relief for any kind of psychic problem but as making you better than well,” Horwitz told Dr. Josef Witt-Doerring. “Who doesn’t want to be better than well?” The television advertising that followed carried the same arc in pictures. Not hospital beds but beaches, and a beautiful companion waiting at the end. Recognition, treatment, and a life improved past the baseline it started from.
Horwitz’s argument was that the recognition of ordinary sadness as depressive disorder did not lead toward healing but toward a particular kind of cultural loss: the erosion of the vocabulary for enduring normal suffering, the weakening of the frameworks through which grief, disappointment, and hardship had been understood as meaningful rather than pathological.
What he offers in place of the arc is a delay. “If I were the depressive diagnosis dictator, the first thing I would implement would be watchful waiting,” he told Howard. “If the depression has happened while somebody is undergoing divorce proceedings or has broken up with a long-term partner, wait several weeks and see what happens with the symptoms.” He knows how that sounds. Told it runs against a culture with a bias toward action, he did not dispute the point. Progressive narratives promise repair. His promises time and an accurate description, which is the tragic form in Alexander’s sense and travels accordingly.
Alexander argues that charismatic figures in trauma processes are typically those who most powerfully narrate the wound and most convincingly promise that recognition leads toward repair. The figures who generated cultural authority around mental illness were those who narrated suffering most vividly and connected that narration to a redemptive arc: diagnosis, treatment, recovery, advocacy, meaning.
Sarah Fay, sitting beside Horwitz on the Mad in America podcast, narrates a wound of a different kind and demonstrates the point by inversion. Diagnosed with anorexia at twelve while her parents divorced, she read a novel about an anorexic girl that was “really a cheat sheet on how to be an anorexic. I learned how to do it and I became one. It really became my identity.” Five more diagnoses followed. The release came when a new psychiatrist told her he did not know what she had. “My whole world changed. That afternoon I remember walking out of his office and walking down Chicago Avenue and it just seemed crisper. It was colder but it was also more vibrant. It was like someone had just told me the truth.” Her arc has a wound, a betrayal, and a moment of deliverance. It is Horwitz’s argument turned into a story, and the story is what the culture can carry.
The elimination of the bereavement exclusion from DSM-5 was not just a diagnostic decision. It was a move in a cultural trauma process. Including the exclusion implied that some grief was too normal to count as disorder, which felt to many participants in that process like a qualification on the wound’s legitimacy. If grief after loss is normal, then the suffering of bereaved people who sought clinical help was being partially de-recognized. The pressure to eliminate the exclusion came partly from the internal logic of the trauma claim: a fully recognized wound does not come with asterisks about context. Horwitz and Wakefield’s argument that the exclusion should be retained and extended was heard within that cultural process not as a conceptual correction but as an attempt to re-qualify the wound, to restore conditions under which some suffering would not count.
The exclusion had rested on evidence. Paula Clayton’s bereavement studies found that about half of the recently bereaved met the criteria for depression, that most were improving by three months, and that almost none still qualified at six. Horwitz and Wakefield asked the obvious next question: “Is bereavement isolated, is it a special kind of loss, or what about people who just lost their job, what about people who are getting divorced?” Their paper in the American Journal of Psychiatry found little difference between bereavement and other losses. It “upset a lot of people,” Horwitz told Witt-Doerring, “because if much of what’s getting diagnosed as depression is really just a normal response to loss, that’s pretty threatening to psychiatry’s core condition.” The committees resolved the anomaly by removing it. Once the wound had been fully recognized, the last remaining asterisk was the thing that had to go.
The new claims arrive on the same logic. Prolonged grief disorder entered DSM-5-TR in 2022, which prompted Horwitz’s driest line about the profession. There is “breakthrough after breakthrough and discovery after discovery and miracle after miracle,” he told Whitaker, and now prolonged grief disorder “is going to solve all our problems.” Turning to Fay, whose depression diagnosis followed two years of mourning a cat she had kept for sixteen: “If you had it now they’d know what to do about it.”
Interaction Rituals Chains by Randall Collins
Creating Mental Illness by Allan Horwitz argues that psychiatry has systematically expanded the domain of disorder by stripping away context. Normal distress responses to loss, failure, conflict, and threat get classified as disorders when the DSM focuses on symptoms alone and ignores whether those symptoms make sense given what the person is going through.
Collins might say that this expansion is not simply a conceptual error or a product of pharmaceutical industry pressure. It is also what happens when the interaction ritual chains of professional psychiatry become decoupled from the interaction ritual chains of ordinary social life. In everyday life, people calibrate distress responses relationally. A friend who cries for weeks after a divorce is read against the context of the divorce; the emotional response is charged with meaning because the people around him share the situational focus. The sadness makes sense within their common ritual history. Collins might say that this contextual reading is itself a product of sustained interaction ritual chains between people who share enough common ground to interpret each other’s emotional signals accurately.
Psychiatric diagnosis, particularly in its post-DSM-III form, strips that context away. The goal was reliability across clinicians who share no common ritual history with the patient. You get a standardized symptom checklist that any trained clinician anywhere can apply. Collins might observe that this is precisely what happens when a professional coalition optimizes for internal ritual coherence, meaning agreement and emotional solidarity among psychiatrists, at the expense of connection to the ritual chains that give symptoms their meaning in the patient’s life. The DSM becomes a sacred object charged with emotional energy within the psychiatric community, which is exactly why challenges to it feel like attacks on professional identity.
This helps explain a puzzle Horwitz identifies but does not fully account for sociologically: why did the expansion of disorder categories accelerate after DSM-III, given that the explicit goal of DSM-III was to make diagnosis more scientifically rigorous? Collins might say that the operationalized symptom criteria, by making diagnosis reliable and teachable, intensified the professional ritual chains. More clinicians could participate in the same diagnostic conversations. Pharmaceutical companies could run trials on cleanly defined populations. Insurance systems could reimburse against recognized codes. Each of these developments created new ritual chains that reinforced the existing categories and created strong emotional and material incentives to expand them. The sacred symbols of the DSM accumulated more and more emotional energy precisely because more and more ritual chains ran through them.
Horwitz also documents how the removal of the grief exclusion from DSM-5 extended major depressive disorder to cover normal bereavement. Collins might frame this as a failure of what he calls mutual focus and shared mood. The grief exclusion had preserved a link between symptom presentation and shared situational understanding; clinicians were required to ask whether the distress made sense given what had happened. Removing the exclusion severed that link, allowing the diagnostic ritual to proceed without any grounding in the patient’s interaction ritual history. The result is that the diagnosis charges a normal emotional response with the status of disorder, which is precisely what Wakefield’s HDA says should not happen because normal responses, however distressing, do not involve dysfunction.
Horwitz identifies the forces driving expansion but is somewhat puzzled by the resistance to correction even when the conceptual errors are pointed out clearly. The diagnostic categories have been charged with emotional energy through decades of ritual chains involving training, publication, clinical practice, and institutional reimbursement. Challenging them feels like desecration of a sacred object. The emotional resistance is not irrational; it is the predictable response of people whose professional identity and ritual solidarity depend on the symbols under attack. Much of what clinicians know about how to apply diagnostic categories is carried in practice rather than in explicit criteria, which means the categories are even harder to dislodge than a purely propositional argument might suggest.
On what coalition Horwitz depended on for status and income: Rutgers, which housed him for fifty years and provided the institutional base from which everything else followed. The American Sociological Association’s medical sociology and mental health sections, which gave him his primary scholarly community, validated his work through awards, and provided the peer networks through which his books were reviewed, cited, and taught. The sociology of mental health subfield more broadly, which he helped build into a serious academic enterprise and which therefore had a stake in his success that was partly reciprocal. Oxford University Press and the University of Chicago Press, whose imprimatur gave his books standing in the prestige economy that mattered to his career. David Mechanic at Rutgers, whose influence in health policy sociology amplified Horwitz’s institutional position in ways that would not have been available to him alone.
Crucially, none of these coalitions depended on the diagnostic categories he was criticizing. His income came from a sociology department, not from clinical practice, pharmaceutical research, or insurance administration. This gave him a structural freedom that clinicians, DSM committee members, and pharmaceutical researchers did not have. He could maintain an inconvenient argument without economic consequence to himself, which is a significant and underappreciated feature of his career.
On who he risked angering by speaking plainly: The diagnostic expansionist coalition, which included biological psychiatrists, pharmaceutical companies, DSM committee members, clinical psychologists, patient advocacy organizations, and insurance administrators. This coalition controlled clinical practice, research funding, diagnostic standards, and the cultural infrastructure through which millions of people understood their own distress. Speaking plainly meant telling all of them simultaneously that the categories they depended on were systematically inflated. The anger this generated was not primarily personal. It was structural. The coalition did not need to find Horwitz objectionable as a person to resist him effectively. It needed only to protect what it had built.
He knew exactly which nerve he was touching. The American Journal of Psychiatry paper extending the bereavement logic to job loss and divorce “upset a lot of people,” he told Witt-Doerring, “because if much of what’s getting diagnosed as depression is really just a normal response to loss, that’s pretty threatening to psychiatry’s core condition.” Not a category among three hundred. The one the profession had organized itself around after 1980.
He also risked angering patients who had organized their identities around the diagnoses he was questioning. This anger was different in character from the institutional resistance of the professional coalition. It was moral rather than economic, felt rather than calculated. To those patients, Horwitz’s argument was not a conceptual correction but a withdrawal of recognition they had worked hard to obtain. That anger was diffuse, largely unorganized, but culturally significant in ways that shaped the popular reception of his work.
He also named the group most likely to take his argument personally, and did it in the least diplomatic way available. “Parents want these diagnoses, they seek out medication to medicate their kids,” he told Robert Whitaker. “It’s a way of controlling bad behavior and makes their jobs easier. But I think they’re doing a real disservice to their kids in the long run.” A sociologist worried about his reception would have found a softer formulation for that.
He risked a subtler form of anger from within sociology itself. Medical sociologists who had built careers on the study of mental illness as a genuine clinical phenomenon, who had worked to establish the field’s credibility with psychiatric and public health institutions, sometimes experienced Horwitz’s critique as a threat to the collaborative relationships that sustained the subfield’s institutional standing. A sociology of psychiatry that psychiatry found adversarial was harder to sustain than one that psychiatry found useful, and some colleagues had more invested in that usefulness than in the critique.
On who benefits if his framing wins: Primarily people with little institutional power over the things his framing was designed to reform. Careful clinicians who wanted a principled basis for contextual diagnosis would benefit, but they were a minority within a profession whose economic incentives ran against contextual criteria. Patients whose normal grief had been misclassified would benefit from a more accurate understanding of their experience, but many of those patients had already organized their lives around the diagnosis and would not experience the correction as a benefit. The severely depressed would benefit most and are the least able to lobby a DSM committee. Medical sociologists and historians of psychiatry would benefit from having their analytical framework validated against the claims of biological psychiatry. Public health budgets would benefit from a threshold that reduced unnecessary treatment, though that benefit accrues to institutions rather than to anyone with a voice in the debate.
The deeper problem is that Horwitz’s framing winning would have required the people who benefited from it to be willing and able to fight for it against the people who lost from it. The winners were scattered, institutionally weak, and in many cases did not recognize themselves as winners. The losers were organized, institutionally powerful, and had immediate economic and identity stakes in resisting. This asymmetry is not incidental to why his argument was acknowledged and not adopted. It is the central structural fact of his career.
On what truths would cost him his position: Several, arranged again by severity.
The mildest costly truth is that his distinction between normal suffering and genuine disorder, however conceptually defensible, is difficult to operationalize in clinical settings in ways that would not create serious problems for patients who need care. He concedes versions of this readily, and further than the framework can comfortably absorb. Pressed on whether a valid diagnostic system is achievable at all, he answered that he would not put money on it. What he does not concede is that the trade-off between validity and reliability is structural rather than a failure of institutional will. If it is structural, the problem sits outside the reach of any reform his critique implies, and the critique becomes a description of a permanent condition rather than a case for change.
A more costly truth is that the sociological analysis of diagnostic inflation cannot by itself generate the institutional reform it implies. Horwitz described what happened to the boundary between sorrow and sickness and explained why in terms of institutional incentives, coalition interests, and the power of naming. The description did not generate a program the relevant institutions could implement without dismantling the structures that sustained them. He never claimed it did, but the gap between diagnosis and remedy is larger than his framework acknowledges.
By the end he says the quiet part. Asked what should replace the DSM, he answered that “what sort of manual we need as opposed to what sort of manual is possible are very different things,” and that the conflict between what clinicians require and what researchers require is one he does not see resolving. “I would say the current situation is pretty much of a mess.” Asked whether humility could be built into a manual: “Probably not.” His concrete recommendation is directed not at the profession but at individuals, and it is modest to the point of resignation. “Taking particular diagnoses a little less seriously would be a good thing.” Fifty years of institutional analysis arriving at advice for the reader.
The costliest truth concerns his own coalition, and the standard case for it is too crude. Horwitz is not blind to sociology as an interested party. He turns the analysis on his own discipline more readily than most of its members would, tracing its aversion to biology to social Darwinism and the Nazis rather than to any finding, and describing the aversion as something his training installed rather than something he reasoned his way to. That is the sociology of knowledge applied to the field that credentialed him.
The gap runs elsewhere. He applies coalition analysis to what sociology refuses to see and never to what sociology is rewarded for seeing. Sociology’s biology-aversion costs the discipline something, so naming it is a form of intellectual courage that also raises his standing among the rigorous. The discipline’s appetite for finding medicalization is a different matter. Medical sociology has staked its claim to relevance on the critique of medicalization; a finding of medicalization is what the field is organized to produce and what it rewards. Horwitz has named the incentives operating on every party to the diagnostic expansion except the one paying him. Whether the belief that inflation is driven by industry and classificatory drift rather than by any real increase in need is correct is a separate question from whether it is convenient, and it happens to be both.
He is capable of the move and stops one clause short. “Every discipline, and I certainly would include sociology as well as psychiatry and psychology, has its blind spots,” he told Greg LaBlanc, and then, without pause: “I certainly hope that my book helps to reveal psychiatrists’ blind spots.” He names sociology first and moves past it in the same sentence. That is the whole gap in nine words.
What Horwitz would have lost by extending the analysis is not the respect of his most serious readers but the clean rhetorical force of his critique. A Horwitz who said that biological psychiatry’s expansion serves pharmaceutical interests and that medical sociology’s critique of that expansion serves academic sociologists would have produced a more accurate and more discomfiting analysis. It would also have been harder to use as an argument for reform, because it would have placed the author outside the coalition whose work it was validating.
He would not have lost his position. He would have lost the simplicity of his stance, the clarity of the line between the critical analyst and the object of analysis, and the usefulness of his work to the reform coalition that found in it a legitimating framework. Those are real losses. They are not the same as losing tenure or scholarly recognition. But they are costs that a fifty-year career of unflinching analysis chose not to pay.
Genetics
Horwitz’s framework is organized around the claim that diagnostic categories have drifted away from genuine disorder toward the medicalization of normal suffering. That claim requires him to specify what genuine disorder looks like, and his answer gestures toward severe conditions with plausible biological substrates, mainly psychoses. But he does not develop a serious account of what those biological substrates are or how they interact with environmental and social factors to produce outcomes. This is partly a disciplinary limitation. Sociologists are trained to analyze social processes, institutional forces, and cultural categories. Behavioral genetics is not their formation, and Horwitz’s formation did not include it. But it is also a structural feature of his argument. A serious engagement with behavioral genetics would complicate the distinction between normal suffering and genuine disorder in ways that might undermine the clarity his framework depends on.
He is not silent on the question. He reports a verdict, and the verdict serves his position. “The main thrust of research in psychiatry has certainly turned to behavioral genetics, looking for the genes that are responsible, and the results have been very surprising even to critics,” he told Brendan Howard. “They just don’t seem to be important genetic influences on mental illnesses, even schizophrenia, where it would make sense that there would be. Many many genes are related, each contributing a tiny proportion, and altogether it’s not a huge impact on any condition including depression.” He gave Ricardo Lopes the same account: the search for particular genes underlying particular disorders “has turned out to be almost a complete failure,” and the single-gene model “is now rejected.”
The premise is right and the inference is not. Genome-wide association studies did retire the candidate-gene model, and the architecture of depression is polygenic in the extreme, thousands of variants each of negligible individual effect. None of that reduces the aggregate. Twin and adoption studies put heritability for major depression around thirty to forty percent, higher for recurrent and early-onset forms, and those estimates do not fall because the causal contribution is distributed rather than concentrated. Reading “no single gene of large effect” as “no important genetic influence” is a conflation, and it happens to remove the strongest obstacle to Horwitz’s central claim. This is precisely the kind of move his own framework is built to detect in others.
The behavioral genetics literature complicates his argument rather than refuting it. If genetic vulnerability contributes substantially to who becomes depressed under similar environmental conditions, then the distinction between a broken system and a healthy system responding to loss becomes harder to draw than his framework suggests. Two people experiencing identical losses may respond very differently because of genetic differences in stress reactivity, emotional regulation, and neurobiological resilience. The person with higher genetic loading may develop a condition that looks clinically indistinguishable from the contextually expectable grief Horwitz wants to protect from medicalization, but whose trajectory, severity, and treatment responsiveness differ significantly from ordinary mourning.
His strongest argument runs the other way and does not depend on any of this. Prevalence rose from roughly three percent before symptom-based diagnosis to seventeen percent after DSM-III, and longitudinal studies now put it near half. “There’s nothing like this in physical illness,” he told Howard. “Lots of people have serious physical problems, but these generally arise when people are older and their cells and chromosomes are breaking down. By far the highest rates of depression are found in young people, in people in their twenties, in people in their prime reproductive years. This is evolutionarily virtually impossible. Evolution wouldn’t have allowed that to happen.” If half the population developed a genuine disorder at peak fitness, selection would have removed the vulnerability. That argument survives whatever the heritability estimates turn out to be, because it constrains how much of the diagnosed population can plausibly be disordered rather than how disorder is transmitted.
Wakefield engages the biological question more directly through the harmful dysfunction analysis, but the engagement has its own limitations. His dysfunction criterion requires that an internal mechanism fail to perform its naturally selected function. That framing presupposes that we can identify what the mechanism is supposed to do, which in turn requires some account of the mechanism’s biological basis. Wakefield draws on evolutionary psychology rather than behavioral genetics, which is a significant choice. Evolutionary psychology reasons about function from selective pressures and adaptive logic. Behavioral genetics reasons about individual differences from heritability and gene-environment interactions. These are related but distinct enterprises, and Wakefield’s framework is more comfortable with the former than the latter.
Horwitz uses the evolutionary apparatus fluently. He divides the field into three categories rather than two: “true dysfunctions, which nature never intended people to have,” then “adaptive conditions that aren’t diseases at all, responses to the context people are in,” and then “a third category of mismatches, responses that were adaptive in the environment of evolutionary adaptedness but are completely inappropriate for the way we live now.” He illustrates the third with Darwin at the reptile house, leaping back from a snake behind thick glass, unable to override a fear he knew to be groundless in a country with almost no dangerous snakes. He extends the framework well past psychiatry in What’s Normal?, where obesity is a healthy appetite in an unnatural food environment and courage is an evolutionary absurdity that every army must manufacture at great cost. What he does not do is bring individual differences into any of it. The mismatch account explains why a population responds as it does. It says nothing about why two people in the same environment respond differently.
That gap is where the third category becomes unstable. A person with high genetic loading for depression may have a system functioning exactly as designed, producing a depression response under conditions of loss, but producing it more readily, more severely, and more persistently than someone with lower vulnerability. Is that a dysfunction or a normal variant? Wakefield’s framework wants to say that a mechanism responding to its designed inputs is not dysfunctional even when the response is painful. Genetic variation in the threshold and intensity of that response complicates the answer. The person whose grief becomes prolonged and debilitating partly because of genetic factors sits uncomfortably in a framework built to distinguish contextual response from biological failure.
Neither man engages the gene-environment interaction literature, which is where the relevant science has developed. Findings that certain variants interact with stressful life events to produce depression in some individuals but not others suggest that the boundary between normal response and genuine disorder may be partly constituted by factors neither framework has the tools to address. The stress-sensitization model, in which early adversity interacts with genetic vulnerability to produce lasting changes in stress reactivity, cuts across the distinction both men rely on between a system responding normally to its environment and a system that has malfunctioned.
Heritability does not map cleanly onto that distinction in any case. High heritability is compatible with a condition being a normal variant, a disorder, or something between. Color blindness is highly heritable and generally considered a normal variant. Huntington’s disease is highly heritable and clearly a disorder. Depression sits between these poles and heritability data alone cannot locate it. But neither Horwitz nor Wakefield develops the apparatus to use heritability evidence at all, which means both are working with a partially specified account of what biological dysfunction means.
The one place he does not follow biology where it leads is the place where following it would cost him his argument. Conceding substantial heritability for depression would mean conceding that some proportion of the diagnosed population has a genuine vulnerability his framework classifies as normal suffering. It would not overturn the prevalence argument or the evolutionary one. It would blur the line, and the line is the point.
Allan Horwitz presents the framework’s cleanest academic case. Where Wax and Sailer produced signals the coalition’s immune system classified as pathogen, Horwitz produced signals the coalition absorbed as useful self-correction. His work attacks core premises of the psychiatric profession and of the medicalization industry more generally, has done so for four decades, and has produced the institutional rewards that academic life offers its most successful practitioners. Chair of the sociology department at Rutgers. Board of Governors Professor. Prestigious press contracts. Translation into multiple languages. Invited lectures. The standard markers. The case raises the question of why his crossings, which cut at their subject matter as sharply as Wax’s cut at hers, did not trigger the immune response her crossings triggered. The framework supplies several answers that work together.
Start with the niche his training produced. Horwitz came out of Yale’s sociology department in the 1970s, trained in a medical sociology tradition that had absorbed the anti-psychiatry critiques of Goffman, Szasz, and Scheff without adopting them wholesale. The tradition was already positioned critically toward psychiatric institutions. It had absorbed the intellectual raw material of the 1960s critique, processed it through institutional sociology frameworks, and produced a sub-niche within academic sociology that specialized in critical examination of mental health categories, institutions, and practices. Horwitz inherited this sub-niche. He did not construct it. He extended it.
He is explicit about where the tools came from. His formal advisers were the psychiatric epidemiologists August Hollingshead and Jerome Myers, but “the people I learned the most from weren’t in the psychiatric or mental health area at all,” he told the New Books Network. “They were students of law, criminology, and deviant behavior. I’ve really been applying perspectives I learned in an entirely different area to the study of mental health.” His advice to young researchers is the crossing stated as method: don’t stay narrowly focused on one area, “see if perspectives from other areas can be helpful in illuminating whatever problems it is that you’re studying.”
The crossing his work performs runs between sociology of knowledge and empirical examination of psychiatric categories. The first parent tradition studies how professional groups construct their authority, how knowledge claims serve coalition interests, how scientific categories reflect the purposes of the communities that produce them. The second parent tradition examines whether specific psychiatric categories survive the kind of empirical scrutiny their proponents claim they should survive. Sociology of knowledge alone produces general critique that specialists can dismiss as philosophical. Empirical examination alone produces particular findings that do not add up to structural criticism. Horwitz’s crossings combine them so that each particular empirical finding gets interpreted within the sociology of knowledge framework, and the framework gets grounded in specific empirical demonstrations.
The empirical half arrived first, and by accident. His dissertation gave him access to patient files at the Connecticut Mental Health Center at a moment when access was casual. “It was much easier to gain access to people’s records, shockingly easy from a contemporary standpoint,” he told Brendan Howard. “I would find files of children of my professors in there, which I really shouldn’t have been reading but of course avidly did.” What he found was an absence he could not have predicted. “Diagnoses were just not an important aspect of the problems. Many of the files had no diagnosis at all. Sometimes it was sort of an afterthought.” A decade later diagnosis was the first thing a clinician recorded. He had a before-and-after that almost nobody else in the field possessed, and he spent fifty years explaining the transition.
Creating Mental Illness in 2002 showed what the hybrid could do. The book argued that the DSM’s expansion across its successive editions has produced categories that do not track natural kinds, that the expansion serves professional and pharmaceutical interests, and that the categories thereby produced medicalize normal human suffering in ways that harm the people they purport to help. Each claim drew on both parent traditions. The sociology of knowledge supplied the frame that treated DSM categories as professional artifacts. The empirical work supplied the specific demonstrations that particular categories failed to meet the reliability and validity standards psychiatry claimed for them. The book was widely reviewed, adopted in courses, translated, and cited. It won the American Sociological Association’s Best Publication Award in mental health in 2003 and was later named one of the seven best books of the decade in the field. It damaged no institutional relationship Horwitz needed to preserve.
The Loss of Sadness in 2007, coauthored with Jerome Wakefield, narrowed the attack to the category of major depressive disorder. The argument was that the DSM’s diagnostic criteria for depression fail to distinguish depressive disorder from normal sadness in context-sensitive ways, producing false positives at scale and medicalizing responses to loss that do not represent dysfunction. The profession registered the critique as serious. Robert Spitzer, who had chaired the DSM-III task force, wrote the foreword and, in Horwitz’s account, “basically repudiated what he had done in DSM-III and said these guys are right.” The critique did not result in the profession’s immune system classifying the authors as pathogens. They continued to publish, continued to be cited, continued to hold their positions. The bereavement exclusion they wanted widened was eliminated instead.
All We Have to Fear in 2012, also with Wakefield, extended the same analysis to anxiety disorders. What’s Normal? in 2016 took on the broader question of the normal-pathological distinction. PTSD in 2018 traced the construction of post-traumatic stress disorder from its emergence in the DSM-III through its subsequent institutional career, arguing that the category combines genuine cases of traumatic dysfunction with a wide range of cases that do not fit the category’s original logic but get absorbed into it because the category serves interests the profession rewards. Each book targeted a specific psychiatric construct. Each made the argument sharply. None triggered institutional punishment.
The framework supplies the first explanation. Horwitz’s critiques attack professional categories, not coalition markers. The distinction runs deep. Psychiatric categories are the working tools of a professional guild. Criticizing them damages the guild’s interests but does not damage the broader progressive coalition’s interests in the ways that criticizing coalition markers would. The guild can absorb the critique, defend its categories through its own internal processes, and treat Horwitz as a sociologist whose disciplinary perspective differs from psychiatry’s clinical one. The coalition’s broader immune system does not activate because no coalition marker has been attacked.
Horwitz attacks the DSM, the pharmaceutical industry, and the professional authority of psychiatry. These are institutional interests and guild practices. The coalition’s broader immune system does not treat criticism of these as threats to coalition integrity. It may even welcome the criticism, since the pharmaceutical industry and clinical psychiatry are ambiguously positioned within the coalition’s moral hierarchy. The coalition’s progressive wing is often suspicious of pharmaceutical profits and of medical authority. Horwitz’s critique can be absorbed as a useful contribution to a debate the coalition is willing to have.
Sociology of mental health is a sub-niche within sociology, which is itself a discipline positioned with some institutional distance from both psychiatry and the broader medical establishment. The sub-niche permits critical examination of psychiatric categories because critical examination is what the sub-niche exists to perform. Horwitz’s work is unusual within the sub-niche for its sharpness and its productivity, but it is not heterodox to the sub-niche. It is what the sub-niche produces at its most accomplished. The immune response that might activate against a psychiatrist making the same arguments does not activate against a sociologist making them, because the sociologist occupies an institutional position in which such arguments are expected.
Horwitz’s work signals costliness in ways the coalition values. The books are rigorously empirical. They engage the psychiatric literature extensively. They make their arguments through painstaking analysis. They publish with university presses whose imprimatur the coalition treats as authoritative. The signal the work produces is the signal of scholarly rigor performed on a topic the coalition permits to be scrutinized. The costliness of producing such work is real. The cost purchases legitimate scholarly standing. The standing survives the critique because the critique was performed in the register the coalition recognizes as scholarly.
Horwitz’s position is that specific psychiatric categories do not track mental illness well, and that the profession has expanded its categories in ways that sweep up non-dysfunction into its diagnostic nets. This is a narrower critique than the Thomas Szasz position that mental illness is a myth. Horwitz acknowledges genuine psychiatric dysfunction. His disagreement is with how the profession defines and handles it. The narrowness of the critique permits the profession to engage with it as a revision proposal. A critic who says the profession is fundamentally illegitimate triggers a different response than a critic who says the profession’s categories need tightening. Horwitz is the second kind of critic. He has stayed the second kind of critic across four decades. The consistency of this positioning preserves his standing while allowing him to mount the strongest version of the narrower critique he is making.
He rejects the wider critique explicitly rather than declining to make it. Szasz and Laing get their due as historical figures, but the social-control reading of diagnosis he treats as empirically dated. “For the most part they are overwhelmingly popular,” he told Lopes. “People are seeking treatment voluntarily. Mental health has now become a major positive rallying cry.” Psychiatry today “is reactive to the wishes of laypeople who want psychiatric treatment.” He told Greg LaBlanc the same thing more bluntly: “These drugs are not being imposed on a resistant population. People are eagerly trying to get them.” This is the sentence that most disqualifies him from the anti-psychiatry coalition, and he repeats it in interview after interview.
The endosymbiotic relationship Horwitz has with the professional communities he critiques deepens this analysis. Clinical psychiatrists cite him because engaging with his critique is the mark of a serious clinician attentive to the field’s conceptual foundations. The DSM task forces have referenced his work. Medical schools teach some of his books in their history of medicine or medical sociology units. Psychology programs assign him. The profession he critiques has incorporated his critique into its own self-examination process. The relationship is mutualistic. Horwitz provides the profession with rigorous external scrutiny that the profession can cite as evidence of its own openness to criticism. The profession provides Horwitz with a continuing subject matter whose public salience keeps his work relevant. Each organism gains from the relationship.
What has changed is vocabulary and registered consciousness. Some clinicians discuss diagnostic inflation with more nuance than in the 1990s. The concept of medicalization has broader currency. What has not changed is the rate at which Americans receive psychiatric diagnoses, the rate at which they take psychotropic medications, the institutional dominance of the medical model, or the pharmaceutical industry’s role in shaping research priorities. The homeostatic set point has held. The organism absorbed the critique, adjusted its surface rhetoric, and continued operating where it was.
The most striking evidence of absorption is that the profession now privately agrees with him and functions unchanged. “What you have now is a volume that’s been deeply discredited,” Horwitz told the New Books Network. “Researchers no longer believe in the conditions. The clinicians never really believed in them but have to use them just for instrumental purposes. But the DSM lives on and it’s completely institutionalized.” The researchers cannot say so publicly because it “would just put the profession in a completely unsustainable political situation,” which produces what he calls “such a false front.” A critique that wins the argument, converts the leadership, and leaves the machinery running at full capacity is not a critique the immune system needed to reject. It is one the organism found nourishing.
The Set
Allan V. Horwitz belongs to the postwar generation of American medical sociologists who came up through the study of deviance and social control. He trained at Yale in psychiatric epidemiology, landed at Rutgers in 1975, and stayed for half a century. His set is the sociology of mental health and illness: the people who publish in the Journal of Health and Social Behavior, who chair the mental health and medical sociology sections of the American Sociological Association, who pass through the Society for the Study of Social Problems, and who sit at the seam between sociology, psychiatry, and public health. His long partner inside that world was David Mechanic (1936-2016), with whom he co-directed an NIMH postdoctoral program for more than thirty years. His intellectual ancestors are Erving Goffman (1922-1982), Thomas Scheff, Thomas Szasz (1920-2012), and the labeling tradition that treated diagnosis as a social act rather than a neutral reading of nature. His frequent co-author Jerome Wakefield gave the camp its sharpest conceptual tool.
He got there by an accident he tells with some relish. He arrived at Yale “as a very naive 22-year-old,” he told the New Books Network, “so naive that I didn’t even apply for financial aid.” August Hollingshead, who “looked ancient to me although he was then younger than I am now,” called him in and offered a mental illness fellowship nobody had claimed. He said yes. His formal training ran through Hollingshead and Jerome Myers in psychiatric epidemiology, but the debt he claims is elsewhere. “The people I learned the most from weren’t in the psychiatric or mental health area at all. They were students of law, criminology, and deviant behavior.”
What this set values is the social context of suffering. They want diagnosis to account for where a person stands, what happened to him, and what his sadness or fear answers to. They prize empirical care and a long memory for how categories got made. They hold a standing suspicion of professional guilds and drug money, and they treat the ordinary man’s experience as something that expert power tends to annex. They honor the scholar who can sit with a category like depression or anxiety and ask whether the thing named is one thing or a dozen things wearing one label.
Horwitz saw the world they mourn while it still existed. His dissertation gave him access to patient files at the Connecticut Mental Health Center in an era before confidentiality rules, “shockingly easy from a contemporary standpoint,” including files belonging to the children of his own professors, “which I really shouldn’t have been reading but of course avidly did.” The files recorded marriages, jobs, parents, emotions. “Diagnoses were just not an important aspect of the problems. Many of the files had no diagnosis at all. Sometimes it was sort of an afterthought.” Ten years later the same clinic opened with a code. That before-and-after is the set’s founding memory, and he is one of the few who has it firsthand.
Their hero is the careful empiricist who defends normal suffering from medical capture. He draws boundaries and holds them with evidence. He does this without sliding into Szasz, who denied mental illness had any reality, and without joining the biological psychiatrists who call every expectable response a disorder. The honored figure stands between those poles and keeps his footing. Horwitz built his name as that man. The Loss of Sadness, written with Wakefield, argued that the DSM since 1980 cannot tell grief and disappointment apart from disorder because it strips away cause and counts only symptoms. Anxiety: A Short History and PTSD: A History of a Disorder in Time extend the same argument across other categories. The hero restores a distinction the manual erased.
The status games run on the usual academic currency. Citation counts. Named chairs. Section chairmanships at the ASA. University press books at Johns Hopkins and Oxford, which carry more weight in this world than journal output alone. Lifetime honors such as the Leonard Pearlin Award, which Horwitz took in 2006. Deanships and program directorships. The richest prize is to be the critic whom the psychiatrists themselves must cite, the sociologist whose objection landed inside the discipline he was criticizing. Co-authorship with Wakefield, a philosopher and social work scholar, works as an alliance across fields that lets each man reach readers the other could not.
Horwitz won that prize. Robert Spitzer, who built DSM-III, wrote the foreword to The Loss of Sadness and there, in Horwitz’s account, “basically repudiated what he had done in DSM-III and said these guys are right.” Allen Frances, who ran DSM-IV, turned into an ally and blurbed a later book. Horwitz has spoken at American Psychiatric Association meetings and “actually found quite a welcoming reception.” Every marker of the prize is his. The bereavement exclusion still went.
Their normative claims are plain. Psychiatry over-diagnoses. The DSM inflated its categories after 1980 and turned expectable distress into illness. Normal sadness should not be treated as depression, and normal fear should not be treated as an anxiety disorder. Context belongs in diagnosis and the manual cut it out. The guild and the drug companies have interests that bend classification toward more disease and more treatment.
Horwitz and Wakefield insist that real disorders exist. Their idea of harmful dysfunction holds that a true disorder is the failure of a mental function shaped by natural selection, a failure that also harms the person. Beneath the social labels lies a natural kind. That commitment does the heavy work. To say the boundary sits in the wrong place, a man must believe a right place exists in nature for it to sit. So the set that taught everyone to see diagnosis as social construction also keeps a hidden floor of biological realism under its feet, and Horwitz stands on that floor.
The critique of medicalization was housed in institutions, paid by institutional salaries, blessed by institutional awards, and printed by institutional presses. The man who argued that institutional forces had corrupted classification made that argument from a Board of Governors chair and a deanship. The honor and the target shared an address.
‘The Social Conditioning of Normality’ (Feb. 10, 2021)
Around 35:03-36:14, on his own formation, in response to a question about personal transformation: “Just from the way I was socialized in my graduate education in sociology in the 1970s, biology was almost a curse word. No one would have thought there’s a biological dimension to human social life. In anthropology at least there was a subfield of biological anthropology. There was not a subfield of biological sociology, and it’s still quite uncommon for sociologists to look. So to me the most unusual thing about my own feelings is to realize how important biological functioning and natural selection is to human activity, which wouldn’t surprise people in many fields, but just goes so against the way I was trained.”
Around 42:34-43:33, on the historically unique inversion: “We’re in a historically totally unique situation where it’s probably easier to change biologically rooted phenomena than culturally rooted phenomena. Cultural norms are very deeply embedded and difficult to change, whereas now through surgeries we can change someone’s sex, we can restore a deaf person’s hearing, we can have previously infertile people have biologically related children. Our ability to change biology now is perhaps greater than our ability to change culture. That’s never been remotely the case in any previous historical era.”
Around 16:28-16:50, the parallel he draws and then corrects: “You might say that thinness for females might be the equivalent of cowardice for males. I mean that’s something that is culturally undesirable but really goes against, I’m sorry, I meant courage for males, and thinness for females would be both culturally desirable but biologically unnatural.”
Around 18:26-20:32, on age: “Biology doesn’t care what happens to organisms when they can no longer reproduce. Once they are old to reproduce, biology just doesn’t care.” And then the correction when pressed: “It’s biological indifference. Biology isn’t hostile to post-reproductive people. It just doesn’t care because they can no longer reproduce.”
Around 24:26-25:20, on why the concept of normality is recent: “For the longest periods in humanity people lived with others who were pretty much just like them, who shared the same customs, the same language, the same behaviors. There was no need for a concept of normality because it was just taken for granted. Those who weren’t normal were in different groups that were generally enemies you fought wars against. They were so truly abnormal, as opposed to the in-group normality, that there wasn’t a need to have a more specific definition.”
‘Allan Horwitz: What’s Normal? Reconciling Biology and Culture’ (March 21, 2021)
Around 1:53-2:12, on his own field: “It’s certainly true that historically sociologists have tended to either ignore biology or, if they weren’t ignoring it, actively say it doesn’t matter.” Then, asked whether that handicaps the discipline: “Oh absolutely.”
Around 6:38-8:00, on why sociology fled biology: “At the end of the 19th century Darwinism became social Darwinism, which was a frankly racist way of studying different cultures, ranking the white northern European as superior to other cultures. Nazi Germany actually put that into practice and truly discredited social Darwinism completely. Then the pendulum swung completely in the other direction. Biology was equated with racist views and just fell out of the picture completely, and culture came to dominate. Between World War II and the 1970s that was pretty much the dominance of the cultural point of view.”
Around 17:12-18:42, on the two normalities: “I develop two quite different portrayals of what is normal. The first would be biological normality, what natural selection leads humans to naturally want to do. When you have a dysfunction of those naturally designed factors, that would be biologically unnatural. But there’s a second very different way of viewing normality, through cultural norms, where cultures define certain things as normal or abnormal. Unlike the biological universals, these are widely variable across societies, they change over historical time, you have to learn them through socialization. There’s nothing genetic about normality and abnormality as there is for natural and unnatural.”
Around 30:17-31:50, on harm without dysfunction: “For centuries left-handedness was seen as extremely deviant, and very strong measures were made to convert left-handed people into right-handed people. So it’s very harmful, but there’s no dysfunction. Evolution couldn’t care less whether people were left-handed or right-handed. Masturbation would be another example of something that for centuries was seen as extremely harmful. Into the 19th century people who masturbated were seen as prone to all sorts of dreadful diseases, even death. It was one of the most shameful things somebody could do, so it was associated with an extreme amount of harm, but clearly there was no dysfunction. So people who said masturbation was a disorder were simply wrong.”
Around 28:37-30:10, on dysfunction without harm: “Infertility is clearly from an evolutionary point of view about the worst kind of dysfunction you can have. But under modern circumstances it’s not necessarily harmful, because many people don’t want to have children. So infertility would not be a disorder in some cultures although in other cultures it’s extremely harmful. Deafness would be another example. All living species are designed to hear, so it’s clearly a dysfunction, but in modern culture deaf culture can be flourishing, and it’s not harmful under certain conditions.”
Around 32:03-34:56, on cowardice and courage: “Cowardice, if we define it most generally as moving away from dangerous situations, is possibly the most innate kind of reaction. All living organisms are naturally designed to be cowardly. Whereas socially just the opposite. For centuries, for males in any case, courage was associated with exposing yourself to dangerous situations. From an evolutionary point of view that’s suicidal. No evolutionarily designed organism would ever act in a courageous way except under extremely rare circumstances. One geneticist put it that yes, he could see getting killed for the benefit of two of his brothers or eight of his cousins, because there’s a net genetic benefit. But in almost every occasion courageous people are sacrificing themselves for those they have no genetic ties with. Courage makes no evolutionary sense whatsoever, but it is incredibly admired culturally, and just the opposite for cowardice. Cowardice is evolutionarily programmed but subject to tremendous shame.”
Around 36:25-39:18, on gender as social construct: “No. At the heart of evolution is survive and reproduce, and to reproduce you have to have males and females. That’s basic biology and it’s always been basic biology. Pregnancy happens in females not in males. The optimal evolutionarily designed male strategy would be to spread sperm among as many women as possible. The optimal female strategy would be just the opposite, because they’re pregnant for nine months and restricted for much longer after that, so their major strategy would be investment in one faithful partner.” A flat no to the majority position in his own discipline, delivered without hedging.
Around 40:41-41:28, on cross-cultural constants in mental illness: “There’s far more variability in mental disorders than there is constancy. One of the only major exceptions would be what we now call melancholic depression, very serious kinds of depression that are different from grief. They’re not necessarily connected to some kind of precipitant, they are not time limited, they have profoundly serious symptoms. Those seem to be found pretty much everywhere and from the beginning of recorded medical history. But those are the exceptions rather than the rule.”
‘Allan Horwitz and Sarah Fay – The Impact the DSM Has Had On All of Us’ (April 6, 2022)
Around 4:51-5:25, on the pre-DSM-III world: “There was what I would call a psychosocial view of patients that combined particular life histories with particular kinds of life situations. In one sense each patient really had a different set of circumstances. But it turned out to be a real problem for psychiatry because how can you form a reliable and generalizable diagnostic system if psychiatry is going to be a respected branch of medicine?”
Around 10:09-12:13, on major depressive disorder as a terrible diagnosis: “Major depressive disorder is probably the central diagnosis in DSM-III. It’s a terrible diagnosis from any scientific point of view. The reason it’s so bad is that you need five of eight symptoms for only a two-week period. Anyone who for two weeks has been feeling down, had a loss of appetite, has trouble sleeping, is basically having a normal reaction to any kind of loss event and can easily qualify. On the other side, depression has always been recognized as a very serious mental health problem where people have suicidal thoughts, where they find nothing in life is worthwhile. It can be a very serious disorder.”
Around 46:10-47:09, on humility: “When you read the popular press about mental illness it’s exactly the opposite of humility. There’s breakthrough after breakthrough and discovery after discovery and miracle after miracle. Prolonged grief disorder is going to solve all of our problems. If you had it now they’d know what to do about it. There’s a true lack of humility when humility is what is called for. But I’ll believe it when I see it.”
Around 49:09-50:19, on the pathologization of children: “The single major difference between now and fifty years ago in terms of the labeling of mental illness is exactly the pathologization of childhood. The number of kids with ADHD taking medication, or autism spectrum disorders, childhood bipolar disorders, all of these have rates that have just soared in recent decades. I really don’t think it’s because there’s any fundamental difference in kids now compared to prior eras. Parents want these diagnoses, they seek out medication to medicate their kids. It’s a way of controlling bad behavior and makes their jobs easier. But I think they’re doing a real disservice to their kids in the long run.”
Around 19:42-20:17, on adopting the behavior of a diagnosis: “I read Stephen Levenkron’s The Best Little Girl in the World. It’s really a cheat sheet on how to be an anorexic. I learned how to do it and I became one. It really became my identity. I started to cut my food up in a certain way, to move food around on my plate and stuff it in the cuffs of my pants. I really learned how to do it.”
Around 29:19-30:36, on the psychiatrist who said “I don’t know”: “I waited at the end for him to tell me and proclaim from on high what diagnosis I had. He looked at me and said I don’t know what you have. My whole world changed. I was so grateful to him for his transparency. That afternoon I remember walking out of his office and walking down Chicago Avenue and it just seemed crisper. It was colder but it was also more vibrant. It was like someone had just told me the truth.”
Around 34:44-35:38, on wanting to bring back the word neurosis: “I kind of want to bring back the word neurosis because I think being the DSM-1 and DSM-2 terms of depressive reaction and anxiety reaction, there were times when I was simply reacting to my environment. When we say something is biological it allows us to sidestep not just context but the social and economic injustices that lead to mental instability. That lead to the kind of pressure that can cause someone to break.”
‘The Changing Definition of Mental Illness feat. Allan Horwitz’ (Dec. 15, 2022)
Greg LaBlanc pushes Horwitz on questions the other interviewers didn’t.
Around 1:34-1:56, on disciplinary blind spots: “Every discipline, and I certainly would include sociology as well as psychiatry and psychology, has its blind spots. I certainly hope that my book helps to reveal psychiatrists’ blind spots.”
Around 12:49-14:20, on Spitzer’s political genius: “It was more of a political stance. Spitzer realized that to implement a new diagnostic system he couldn’t just rely on his allies who agreed with his narrow, biologically oriented approach. He had to convince non-biological psychiatrists to go along with this. Many fervently opposed the implementation of DSM-III. But once it was implemented, they saw tremendous advantages. They didn’t believe in the symptom-based approach, but it didn’t matter whether they believed in it or not. They would get their reimbursement from insurance companies that required diagnoses. They could get their research funded by the government, which also required diagnoses. It turned out not to hamper their actual practices. So it turned out to be political genius on Spitzer’s part, who did this not so much because of his beliefs as because it was an enormously clever way to have a profession that was generally skeptical of his aims nevertheless accept his proposals.”
Around 24:07-25:16, on the cough analogy: “Physicians are much more likely to understand that symptoms do not necessarily indicate a disorder. If somebody is coughing, a cough is an adaptive response to clear the lungs. Fevers or physical pain are nature’s way of telling you that something’s wrong, but in themselves they’re not pathological. In fact they’re just the opposite. Psychiatry is much less likely to recognize that symptoms can be adaptive and sees them as indicators of diseases.”
Around 25:24-26:50, on the three categories: “In psychiatry you have three fundamentally different kinds of conditions. You have true dysfunctions, which nature never intended people to have, equivalent to diseases. You also have adaptive conditions that aren’t diseases at all, responses to the context people are in. Grief would be a good example of a non-pathological and totally appropriate response to losing a loved one. But you also have a third category of mismatches, responses that were adaptive in what evolutionary psychologists call the environment of evolutionary adaptedness but are completely inappropriate for the way we live now.”
Around 20:50-23:00, on whether we are actually getting sicker: “My own view is that the purported increases in conditions like anxiety and depression and PTSD are not entirely but for the most part artifacts of the way we measure them. The meaning of the questions used changes over time. In the 1980s notions of anxiety and depression were sort of new in the culture. Now pretty much everyone knows what they are, and they’re not nearly as stigmatizing, so people will be more likely to answer the questions positively even if the actual levels have not changed.” Then, immediately: “There is however a counter argument. With kids growing up spending literally hours looking at a computer screen, that can have real consequences for mental health. There’s reason to think it could make people more anxious. So I’m sort of arguing against myself there.”
Around 30:56-32:56, on validity across cultures, in response to LaBlanc’s challenge about the Amish and the Berkeley academic: “Someone would have to be using very general criteria. The notion of flexibility, an enormously general thing, would be different from culture to culture, but the ability to respond to different situations with different emotions is probably essential to being an adequately functioning human being. That might provide a very general way to say this person has a mental disorder because they can’t change their behavior to respond to the situation. Of course the problem is you’re going to have a hundred psychiatrists making a hundred different diagnoses if you use such a general criterion. Whether you can have an optimal diagnostic system which is both valid and reliable, I would not put any money on that.”
Around 39:03-40:22, on the dimensional cutoff problem, with LaBlanc’s framing: “You have this continuum, but at what point do you prescribe a drug, do you say somebody has to enter treatment? There’s got to be a cutoff somewhere.” LaBlanc then adds: “And given that all of the incentives are to have as low a cutoff as possible, everyone has a personality, so you could pathologize a hundred percent of the population.” Horwitz does not dispute this. The incentive-gradient argument, that continuum models do not solve diagnostic inflation because the cutoff will be set wherever the incentives point, is a limitation on the reform proposal.
Around 41:14-42:16, on whether economics or culture drives expansion: “They’re certainly interdependent. For the last couple of decades they’ve been going in the same direction. More and more people are not only ready to accept a psychiatric diagnosis, they often actively seek out diagnosis, and that is their ticket to get the kinds of drugs they want to take. These drugs are not being imposed on a resistant population. People are eagerly trying to get them.”
‘Allan Horwitz studies sadness, depression’ (March 21, 2023)
Around 7:52-9:50, the prevalence numbers and the evolutionary argument: “Before 1980, studies showed about three percent of the population had some sort of depressive disorder. That rose by a factor of about six times immediately after the publication of DSM-III, where about seventeen percent qualifies. The best studies, ones that follow people over longer periods rather than getting at symptoms at one point in time, find that about half the population qualifies for a diagnosis of depression. There’s nothing like this in physical illness. Lots of people have serious physical problems, but these generally arise when people are older and their cells and chromosomes are breaking down. By far the highest rates of depression are found in young people, in people in their twenties, in people in their prime reproductive years. This is evolutionarily virtually impossible. You can’t find any physical problems that afflict such a high proportion of people while they’re in their prime reproductive years. Evolution wouldn’t have allowed that to happen.”
Around 37:18-39:00: “The main thrust of research in psychiatry has certainly turned to behavioral genetics, looking for the genes responsible, and the results have been very surprising even to critics. They just don’t seem to be important genetic influences on mental illnesses, even schizophrenia, where it would make sense that there would be. Many many genes are related, each contributing a tiny proportion of why someone would develop a mental illness, and altogether it’s not a huge impact on any condition including depression. This is both surprising and disappointing.”
Around 15:20-16:53, on why mental health advocates want high prevalence: “Mental health advocates like promoting high estimates of any disorder including depression because their notion is that it helps destigmatize the condition. If up to half the population can be depressed, then certainly there’s nothing wrong, we shouldn’t be ashamed to get a diagnosis. It’s almost more normal than it is abnormal.” Then, on the pharmaceutical side: “The major antidepressants have now lost their patents, so to a certain extent the drug industry has lost the fervent interest it once had in depression, because now you could take the same medicine in generic form. Depression isn’t as profitable as it once was.”
Around 18:59-20:12, on who gets harmed: “The relatively small proportion of people who really are depressed, and there’s no question that there is major depressive disorder, those people get overlooked and do not get the treatment they need. The best studies show that the antidepressants really do work with the most severely ill people. They are not much better, or maybe not any better, than placebos for most of the people who take them. By having such a loose and large and general definition of what constitutes depression, it’s those people who really are depressed who suffer.”
Around 24:04-25:46, on watchful waiting: “If I were the depressive diagnosis dictator, the first thing I would implement would be watchful waiting. Even if somebody meets the overly generous diagnostic criteria, wait for a while and see. If the depression has happened while somebody is undergoing divorce proceedings or has broken up with a long-term partner, wait several weeks and see what happens with the symptoms. If they persist, if they’re not getting better, then go ahead and give a prescription.”
Around 34:37-35:34, on the disappearance of the DSM from public discussion: “The last time psychiatry was really very much in the news was around 2013 when DSM-5 was being debated. Since then, while mental health culture has exploded, you just don’t see very much about the psychiatric profession or the DSM. That seems to have gone underground at the same time that mental health culture is now everywhere. That situation has puzzled me.”
‘Why is Everyone Now Diagnosed with Depression | An Interview with Prof. Allan V. Horwitz’ (July 26, 2023)
Around 6:00-8:00, on why depression replaced anxiety as the target condition: “The antidepressants don’t have anything more to do with depression in particular than the anxiolytics had to do with anxiety in particular. They work across very broad conditions. It was much more a question of marketing than of how the drugs actually work.” This is the convenient belief argument, and he names the category switch as a marketing decision.
Around 11:00, on Peter Kramer and the legitimation of cosmetic psychopharmacology: “Kramer promoted them not just as relief for any kind of psychic problem but as making you better than well. Who doesn’t want to be better than well?” This is the Alexander cultural trauma narrative in miniature: the progressive arc from sick to better than well, which is more expansive than the arc from sick to normal.
Around 18:00-20:00, on the DSM-III’s destruction of anxiety as a category: “The major goal of the researchers behind implementing the system was really to destroy anxiety, because anxiety is so tied up with the analytic perspective. What they did was divide anxiety into nine distinct conditions. There’s just one kind of depressive condition that’s not psychotic, defined by symptoms that are extremely common in the population. When the DSM-III definitions are applied in epidemiological studies, you get huge prevalence of depression. All of a sudden depression becomes the center of the mental health professions.”
Around 27:00-29:00, on the study he and Wakefield published in the American Journal of Psychiatry: “We were trying to show empirically that bereavement was not a singular exception but an example of a much broader category of loss responses. The paper upset a lot of people because if much of what’s getting diagnosed as depression is really just a normal response to loss, that’s pretty threatening to psychiatry’s core condition.” The phrase “psychiatry’s core condition” is precise and quotable. Depression is the professional anchor around which the DSM model organized itself after 1980.
Around 51:00-53:00, on his comfort as a sociologist criticizing psychiatry: “I’m a sociologist, not a clinician, so it was easy for me to be saying these things because the people I’m basically arguing against are not my own peers. In a sense it’s easy for me to be a critic because I don’t have to come into face-to-face contact with these people.”
Around 53:00-54:00, on Bob Spitzer: “Spitzer, who was the mastermind of DSM-III, wrote a foreword to The Loss of Sadness in which he basically repudiated what he had done in DSM-III and said these guys are right.” The man who created the system Horwitz criticized endorsed the critique. That endorsement did not change the system. The coalition had outgrown its founder.
‘Allan V. Horwitz, “DSM: A History of Psychiatry’s Bible” (Johns Hopkins UP, 2021)’ (Jan. 12, 2024)
Around 4:49-5:33, on his earliest data from Yale patient files: “Diagnoses were just not an important aspect of the problems. Many of the files had no diagnosis at all. Sometimes it was sort of an afterthought. What was really primary was their marital difficulties, difficulties with parents, with jobs, with emotions. They weren’t given a diagnosis. It just was not an important consideration at the time.”
Around 7:01-7:55, on his intellectual formation: “The people I learned the most from weren’t in the psychiatric or mental health area at all. They were students of law, criminology, and deviant behavior. I’ve really been applying perspectives I learned in an entirely different area to the study of mental health.”
Around 28:44-29:20, on the DSM-III’s evidentiary foundation: “The DSM-III diagnoses weren’t based on any real body of evidence because there was only a small amount of studies the developers could use, and they yielded different results. There wasn’t consensus. You have a manual built to be extremely specific but with just not very much evidence. It’s really built on quicksand.”
Around 34:11-36:19, on the reversal of sides between DSM-III and DSM-5: “The political dynamics are almost exactly the opposite of what they were in DSM-III. You have the researchers now trying to overthrow the diagnostic system they had originally established, and the clinicians defending the existing diagnoses. The sides have completely reversed themselves.”
Around 41:32-42:16, on the current state of the DSM: “The volume that finally comes out after a decade of sharp political conflicts is very little changed from the previous DSMs. What you have now is a volume that’s been deeply discredited. Researchers no longer believe in the conditions. The clinicians never really believed in them but have to use them just for instrumental purposes. But the DSM lives on and it’s completely institutionalized.” And then around 42:32: “Nobody really believes in it anymore.”
Around 44:00-46:37, on diagnoses becoming valued commodities, with the gender dysphoria example: “LGBT organizations were the most fervent defenders of the gender dysphoria diagnosis. Of course it wasn’t because they thought people with gender dysphoria are mentally ill. They don’t believe that. But they have to consider them as such if they’re going to have a diagnosis that will pay for gender transition surgery.”
Around 47:21-49:18, on his most surprising discovery: “I really hadn’t been aware of how deeply the psychiatric researchers came to discredit this manual, to think there’s just almost nothing useful about the current manual, even though they can’t now at least publicly say that. It would just put the profession in a completely unsustainable political situation. And from the point of view of clinicians, how they never really believed in the reality of the DSM diagnoses but nevertheless need them. Just how much mental health practice and mental health rhetoric differ from each other. It’s just such a false front that people are putting forward.”
Around 52:50-53:57, on his next project after the personality disorders book: “Clinicians are about intuition, about a clinician looking at a particular patient trying to interpret their life stories. It’s really more of a humanistic and intuitive field. But yet in the 21st century the only thing that gets respect is science. You have to portray the mental health fields as scientific disciplines, which is just not really what they do. It would be looking at this basic contradiction between trying to understand a particular person, which is what clinicians attempt to do, and developing general laws that refer to everyone and don’t depend on any individual’s perspective. It’s almost an impossible contradiction to overcome.”
‘Allan Horwitz – DSM: A History of Psychiatry’s Bible’ (Dec. 15, 2022)
Around 30:21-31:19, on the genetics failure: “When the DSM-III was published in 1980, genetics in a serious way was just starting to flourish. The belief was that particular genes would be found to underlie various kinds of disorders. That has turned out to be almost a complete failure. What has been found, when you look at schizophrenia for example, is that an enormous number of genes are connected to it instead of a single gene, many genes each with a very small effect. The initial thinking that there was some gene that would underlie different mental disorders is now rejected.”
Around 33:01-33:44, on social anxiety disorder as pharmaceutical creation: “Social anxiety disorder was almost completely the creation initially of the pharmaceutical industry, which saw a potential gold mine if you can convince people that things like getting nervous before giving a talk is a sign of a mental disorder that requires taking a pill. There were just enormous advertising campaigns around social anxiety disorder that were hugely successful. Social anxiety disorder is perhaps the best example of the creation of a new kind of psychiatric disorder.”
Around 36:17-37:16, on why dimensional diagnosis failed clinically: “Clinicians may fully believe the same thing that researchers do. They see mental illnesses as overlapping, not distinct, as dimensional and not categorical. But they have no choice but to use diagnoses. They need to say this person has major depressive disorder. They can’t say well they have a little bit of depression but maybe not enough for a real diagnosis. That just doesn’t allow them to function as professionals. They require diagnoses even though many or possibly even most of them don’t fully believe in the reality of the diagnosis. They realize they need them as a practical necessity.”
Around 44:11-45:02, on the substance use disorder example: “Now in the United States where you’re seeing such major changes in marijuana laws, in a number of states its use is completely legal. If you drive across a state line from a state where marijuana use is legal into one where it’s illegal, you put yourself at greater risk of getting a mental illness diagnosis. That’s completely crazy. The merging of substance dependence with substance abuse has created this possibility where having negative social consequences is now grounds for a mental disorder.”
Around 47:38-48:31, on the irreconcilable conflict: “There’s a real disconnect between the nature of what’s emerging as the true nature of mental illnesses, which are very broad, very overlapping, not discrete diseases at all, and just the practical need to have discrete diseases as the basis of a diagnostic system. There’s this almost irreconcilable conflict between what the mental health professions require in their day-to-day work and what researchers need. I would say the current situation is pretty much of a mess.”
Around 52:11-53:56, on his personal recommendation: “Taking particular diagnoses a little less seriously would be a good thing. There’s really a strong tendency for people to think well I have post-traumatic stress disorder or I have major depression. In fact you don’t feel good, but maybe you’re not using specific diagnoses as a way to interpret your experiences would be a positive development. Thinking of you know you’re having problems with relationships is maybe a more positive way of dealing with a problem than saying I have anxiety disorder or I have major depressive disorder. Looking at your own circumstances and how you’re dealing with people, how you’re feeling generally, is a healthier way to approach your life than looking for a particular diagnosis.”