“Saving Normal” is a provocatively titled book by the equally provocative Allen Frances. He has at times been demonized in the autism community, particularly for his views about the over-expansion of the autism diagnosis; whereas many in the autism community fear too few are diagnosed and fear the reduction of the diagnostic category, Frances believes too many are incorrectly diagnosed and that the diagnosis has hit “fad” status. I have read many of his articles and have consistently found him to be a very considered thinker and writer, and someone who is often misunderstood – his messages get over-simplified by others in a way that makes it an easy (but misguided) target. I think much the same of this book: It is a well-considered and thoughtful book, with a message that would be easy to attack and dismiss if you overlook the complexities that he tries hard to identify and address.
With that warning in mind then, the briefest way to explain the key concern of the book is that Frances would like us to “save normal” – to recognise that diagnostic over-inflation is unhelpful, even dangerous, and only getting worse. He argues that the boundaries of normal are being ever-eroded, with the backing of many interest groups, and particularly due to the influence of “Big Pharma.”
Before I go any further, I want to point out one rather glaring factual error that is relevant here and that gets repeated three times in the book: Frances claims “Manipulating the market is particularly easy in the United States because we are the only country in the entire world that allows drug companies the freedom to advertise directly to consumers” (my emphasis). I just happen to live in the only other country in the world that allows exactly this – and we have been doing it since 1981, ie well before the USA stumbled into the mire. It’s a shame Frances has missed this point, because I suspect there are strong lessons to be learned by (a) comparing NZ and the USA to other countries who don’t allow the advertising (he focuses on just the USA, limiting his relevant pool of data for his conclusions), and (b) comparing the USA to NZ to see why the two countries have had (somewhat) different outcomes with the same freedoms. This error made me a bit suspicious of what else he may have got wrong in the book, but having now noted it I will put that to the side for the rest of the review.
Frances looks at a number of past, present, and predicted future fads, to support his case. Obviously of most interest to me – and no doubt to my readers – is his look at autism. As the chair of the DSM-IV task force, and a vocal critic of the DSM-5, his views on what is happening to the autism diagnosis is an important and well-informed one. Here though – as in other parts of the book – I was frustrated by the lack of detailed analysis that I had hoped for from someone with his background and experience. Nevertheless he does effectively use autism – alongside other conditions – to make a strong case that while many people are over-diagnosed, many do go undiagnosed, and he does explain why that is.
Even though his examples are almost always ones drawn from what he is most familiar with – the situation in the USA – I was able to see how it related to me here in New Zealand too. I found some of his solutions to fix the problems he sees, particularly frustrating though, because I see some of his “fixes” in place here in New Zealand, and a huge number of families suffer the consequences of the ridiculous bureaucracy and lost funding that then gets poured into those “corrective” measures. For example, Frances advocates assessing children on actual need for school services and funding instead of basing it on a diagnosis, however we here are in the position of watching endless millions pouring into the salaries and structure of a system that guards our families from accessing much-needed funds unless we continually prove the ongoing nature and severity of a condition; it is never enough to have a diagnosis from a highly-trained professional, our families are forever having to prove themselves, even for children with life-long and severe conditions. Obviously if you put a system like this in place to correct the existing USA issues of so much (too much) power being put in the hands of a quick and one-off diagnosis, you need to make sure you don’t further harm the very people you are trying to help.
Even though I took issue with some of Frances’ suggestions for improving or correcting the system, it is obvious that something does need to be done in the face of the current trends of pathologising what is in fact “normal,” a trend that is perhaps most obvious in the USA but is growing elsewhere too (I recently read “Crazy Like Us” by Ethan Watters which had a good look too at the westernization of mental illness, that is also worth a read). Furthermore, Frances has the bravery and foresight to at least suggest some fixes, instead of simply identifying the problem. “Brave” is a word that I think does apply more generally to Frances too: he is a very honest man, who puts himself on the line in this book – exposing his past failures, and putting his own neck out when he could have just as easily kept quietly to himself and not caused a fuss with his colleagues around these issues. It takes a certain openness and integrity to do what he has done in this book; the sort of person you’d want to be present and active in the discipline of psychiatric diagnosis.
After the book has made its way through definitions, fads, and fixes, Frances ends with a few rather more intimate stories and suggestions, that changed the tone of the book and – I think – further reveals the complexities of the issues themselves and of Frances’ views. He gives advice for how we as individual consumers of mental health services, can aid ourselves to be better informed and more careful about quick diagnoses and quick fixes. He also shares some stories that are both sad and hopeful about what can go so right with a careful diagnosis, and what can go so wrong with careless diagnosis. It would be hard to read those final sections of the book, and not be emotionally affected by them. Through these stories and his eventual book conclusion, Frances makes his case that even though there are serious issues with the current trends of over-diagnosis, there is also very much good that can come from the field of mental health and psychiatry. Essentially, he implores us not to throw the baby out with the bath water.
In my own conclusion then of the value of this book, I would say this: No matter your views on Frances himself, on over-diagnosis, on autism and its trends, or psychiatry in general, this book is a valuable resource that makes arguments we should not ignore or be ignorant of. Whether you are convinced by him or not, Frances has some important things to say, and has put his neck on the line to say them. I am glad I made the time to read this book; it challenged me to see things differently, it annoyed me at times, it amused me and made me sad and hopeful, and – perhaps most importantly – further convinced me that there is something deeply wrong with the way psychiatry and the DSMs are currently progressing. There is a public conversation that must be had about this issue, and this book forms a good launch-pad for that vital conversation.