Cause and Effect in Modern Mental Healthcare

Jason Moheringer and I wrote this piece

For several years now, psychiatry, psychology, and the related mental health fields have been awaiting the release of the newest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) which is being published by the American Psychiatric Association later this month. This text forms the basis for diagnosis in mental health, as the DSM contains all of the diagnostic criteria, prognostic data, and treatment recommendations for each disorder. It strives to reflect the most up-to-date empirical and conceptual knowledge of mental illness and its many manifestations, and attempts to provide a foundation for consensus in the field.

This will be the fifth (or seventh, depending on how you count things) attempt to create such a universally-acceptable manual for mental health providers. Clearly, finding consensus in a field as diverse and fractious as mental health is difficult, and the DSM can merely reflect the controversies and biases of its day. As such, we were much more interested in a press release offered by Thomas Insel, the director of the National Institute of Mental Health (NIMH), which provides the majority of funding for mental health research in the United States. In this statement, he announces that the NIMH will begin guiding mental health research away from the symptom-based diagnostic categories of the DSM, and instead toward as-yet-to-be-determined categories based on “Research Domain Criteria (RDoC).” In his rationale for this move, which we have reproduced below, he captures many of the assumptions that underlie much of modern mental health treatment in the US:

NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system. This approach began with several assumptions:

• A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
• Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
• Each level of analysis needs to be understood across a dimension of function,
• Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.

We have already seen some interesting critiques of this position (for example, on the Scientific American website, of all places). What can be seen in this set of assumptions is that mental illness can be reduced (in the sense of being reductionistic) to genetic mutations and imperfections in the brain, and the problematic thought patterns that result from these physiological realities. Therefore, repairing the genetic structure or brain physiology of someone with a mental illness will result in the disappearance of the disorder. (Parenthetically, this confirms psychosis researcher John Read’s notion that the supposed bio-psycho-social model of psychological disorders is really a bio-bio–bio-model).

This goal is probably impossible to reach. I (Jason) have read Brave New World, and couldn’t help thinking of soma as one possible outcome of the reasoning of the NIMH. My first reaction was predictably hyberbolic and non-constructive, something like, “Hey everybody! Go ahead and beat your kids, because we can just zap their brains and they will feel fine about it!” Normally I try and get this out of my system and move on to something more reasonable; however, in this case I am not convinced that my reaction was far off.

We cannot see the place for trauma, much less milder forms of environmental failure, within the NIMH’s theoretical construction. When a retired soldier has recurring nightmares of his war experience, what, exactly, does it mean to say that this happens because his brain wiring changed due to his exposure to combat? Or when a woman who was repeatedly sexually abused as a child hears voices, what does it do to tell her that she carries a genetic vulnerability for psychosis? How far can we divorce cause from effect within human relationships before we conclude that you can do whatever you want to anybody, because there’s a pill for that? It doesn’t take a pessimist to conclude that people are universally capable of atrocious behavior to one another in the right circumstances, and in petty aggressiveness in all circumstances. However, modern mental healthcare has become so intensely focused on not blaming the victim that it has begun to reject assigning responsibility to the aggressor. It is obviously trite to say that actions have consequences, but we think this may have been forgotten within the hallowed halls of the NIMH.

Furthermore, in the rush to destigmatize individuals who have been diagnosed with mental illness (i.e. “It’s not your fault, or anybody else’s!”), are we not paying the price of hopelessness? In other words, psychiatry is saying “there is something fundamentally wrong about you and the way you have been wired over which you have no control. Your problems are not sane adaptations to insane circumstances, but rather these symptoms indicate that your brain is broken.” Psychiatry seems to believe that it is better to tell “the mentally ill” that all they can hope for is the ability to manage their mental illness because there is no recovery (even when clinical data do not support such unwarranted pessimism). Furthermore, it is realistic – not to mention profitable – for you to give up hopes of working a full-time job because your illness will be a chronic lifelong problem with which you are eternally afflicted. Management, in this sense, says that the individual’s suffering is meaningless, justice can never be realized, and that pain will go on without end. But at least you will be alive to go through all that.

Finally – and this is where psychoanalysis comes into play – it seems that psychiatry is constantly derided for being inaccurate, unreliable and unscientific. Psychiatrists have to rely on such unstable things as words and language to understand the patient’s experiences. Ignoring for the moment that medical practitioners are reliant on the same information for their own work, the notion that mental health problems are issues to be solved by biological interventions completely misses out on an unfortunate fact: symptoms emerge from within human beings. While objectivity and science are obviously values to which we aspire, human beings who struggle with psychological problems have to put their symptoms into language. Language always fails to be objective because many problems are so painful and confusing that words are unable to capture the rawness of those difficult subjective experiences. The desire to avoid the linguistic (and thus the interpersonal) obscures the fact that many – if not most – psychological problems are due to intrapsychic and interpersonal realities that are not driven by faulty brains but by trauma (defined broadly as abuse, neglect, loss, etc.). Let us not forget that the body can express and remember what the mind wants to forget. Psychoanalysis began with the startling discovery that the “talking cure” could somehow alleviate mysterious somatic symptoms. Somehow the encoding of experiences and traumatic memories into a language that is created between patient and analyst facilitates psychological growth.

As psychologists, we are always pressured to acknowledge that psychological disorders have a biological or genetic component, lest we be labeled radical or unscientific. We can accept that many disorders, especially diagnoses like bipolar disorder and schizophrenia, include biological and genetic vulnerabilities. However, why is it that psychiatric and neuroscience researchers are never called radical for jettisoning a century of research on the vast power of psychotherapy and its ability to treat psychiatric disorders with language? Are our experiences not valuable and worthy of being considered? We think this proposal by the NIMH represents a radicalization of mental health that threatens to reduce psychiatry to neurology. Radical proposals deserve extreme responses and we’d like to think that we can remember that the plasticity of the brain and the way in which it can be morphed and changed based on environmental experiences indicates that mental disorders are not merely “biological” in origin.