He is best known for serving as chair of the American Psychiatric Association task force overseeing the development and revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
During the development of the current diagnostic manual, DSM-5, Frances became critical of the expanding boundaries of psychiatry and the medicalization of normal human behavior, problems he contends are leading to the overdiagnosis and overtreatment of the "worried well" and the gross undertreatment of the severely ill.
Frances is the author or co-author of multiple books within the fields of psychiatry and psychology, including: Differential Therapeutics (1984),[1] Your Mental Health (1999),[2] Saving Normal (2013),[3] Essentials of Psychiatric Diagnosis (2013),[4] and Twilight of American Sanity (2017).
[10] Frances' early career was spent at Cornell University Medical College, where he rose to the rank of professor, headed the outpatient department, saw patients, taught, established a brief therapy program, and developed research specialty clinics for schizophrenia, depression, anxiety disorders, and AIDS.
In 1991, he became chairman of the Department of Psychiatry at Duke University School of Medicine, where he helped to expand the research, training, and clinical programs that had been initiated by his predecessor as chair, Dr. Bernard Carroll.
[16] Robert Spitzer, later the major force behind DSM-III, was one of Frances' teachers during his psychiatric residency at Columbia University and attempted to recruit him to participate in his research developing standardized criteria for mental disorders and interviewing instruments for diagnostic assessment.
He wrote a number of papers on the uses and misuses of DSM-III and predicted DSM would eventually adopt a dimensional model of personality disorder diagnosis.
funding from the MacArthur Foundation allowed dozens of reanalyses of unpublished data sets to help answer questions pertinent to DSM-IV changes; and 3.)
Frances initially declined to join Spitzer's criticism, but after learning about the changes being considered,[21] he wrote an article in July 2009 (A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences[22]) expressing multiple concerns including the unsupported paradigm shift, a failure to specify the level of empirical support needed for changes, their lack of openness, their ignoring the negative consequences of their proposals, a failure to meet timelines, and anticipate the coming time pressures.
[23] In March 2010, Frances began a weekly blog in Psychology Today, DSM-5 in Distress: The DSM's impact on mental health practice and research,[24] often cross-posted in the Psychiatric Times[25] and the Huffington Post.
[27] The elimination of the bereavement exclusion from the diagnosis of major depressive disorder was another particular concern, threatening to label normal grief as a mental illness.
So while the task force was focusing on early detection and treatment, Frances cautioned about diagnostic inflation, overmedication, and crossing the boundary of normality.
Besides the original complaint that the DSM-5 Task Force was a closed process, Frances pointed out that they were behind schedule and even with a one-year postponement, they had to drop a follow-up quality control step.
The APA Board of Trustees eliminated a complex "Cross-Cutting" Dimensional System, but many of the contested areas remained when the document was approved for printing in December 2012 for a scheduled release in May 2013.
[29] Frances's writings were joined by a general criticism of the DSM-5 revision, ultimately resulting in a petition calling for outside review signed by 14,000 and sponsored by 56 mental health organizations.
In 2018, he wrote, The money saved from closing the custodial state hospitals was often misallocated to tax cuts and prison construction—depriving the mentally ill of adequate community treatment and housing.
[34] Regarding electroconvulsive therapy, Frances argues that the treatment can be lifesaving in cases of severe, unrelenting depression and in some other psychiatric disorders, such as malignant, or lethal, catatonia.
[35][36] Frances has expressed his belief that both lithium carbonate and clozapine are underutilized in the treatment of bipolar disorder and schizophrenia,[34] respectively, often in favor of newer, more profitable second-generation antipsychotic drugs.
[37] The current consensus in global psychiatry is that both lithium and clozapine remain the most effective agents in the treatment of their respective conditions; among academic psychiatrists, their underutilization is widely recognized.
[41] Giving others permission in advance to impose treatment, should it become necessary, takes away much of the anger, mistrust, helplessness, and humiliation patients feel when they have no say in their fate.
Accepting that future relapses can occur provides patients with the strongest possible incentive to reduce their probability by participating fully in preventive disease management.
Discussion of advanced directives might help restore a fractured therapeutic relationship by explaining why the coercion seemed necessary in the past and suggesting how it can be avoided in the future.
He counts, among others, Silvano Arieti, Sherv Frazier, Nathan Ackerman, Lawrence Kolb, John Talbott, Leon Salzman, Howard Hunt, Harold Searles, Aaron Beck, and Marsha Linehan as his greatest mentors on psychotherapy.
[18] Although Frances was trained as a psychoanalyst and taught a course on Freudian theory for a decade, he is an enthusiastic supporter of brief psychotherapy as the treatment of choice for most patients.
And finally, Frances feels that brief therapy is a wonderful training device allowing acquisition of cognitive, behavioral, psychodynamic, and family systems techniques.
[45] Since 2022, he has co-hosted with psychologist Marvin Goldfried a podcast titled Talking Therapy, which covers a wide range of topics on psychotherapy and is available on Youtube.
[46] In their analysis of his comments, Politifact reported that a 2011 calculation by Yale University history professor Timothy Snyder said Hitler killed over 11 million people, and the U.S.