The May 12 New
York Times editorial titled: “Shortcomings of a Psychiatric Bible” is both
revealing and distressing. After briefly discussing the recent National
Institute of Mental Health (NIMH) decision to replace DSM-5 with their new Research and Diagnostic Criteria as a guiding
framework for funding future research, the editors conclude with the following
assertion: “The underlying problem is that research on mental disorders and
treatment has stalled in the face of the incredible complexity of the brain.
That is why major pharmaceutical companies have scaled back their programs to
develop new psychiatric drugs; they cannot find new biological targets to shoot
for. And that is why President Obama has started a long-term brain research initiative
to develop new tools and techniques to study how billions of brain cells and
neural circuits interact; the findings could lead to better ways to diagnose
and treat psychiatric illnesses, though probably not for many years.”
This conclusion
reflects an unquestioning acceptance of what has become the received wisdom
that further advancement of our understanding of both the etiology and
treatment of mental health problems is completely dependent on our ability to accurately map out the
associated brain chemistry and neural circuitry. This belief is in keeping with
the disease model of psychiatry which holds that psychological problems are no different in kind than diseases such as cancer or
tuberculosis, and that both the underlying causes and relevant targets for
treatment are biological in nature. This assumption was also one of the
important factors that led to the major revision of the Diagnostic and
Statistical Manual for Metal Disorders (DSM-3) by the American Psychiatric
Association in 1980 that laid the groundwork for the forthcoming fifth edition
of the DSM that the NIMH is now abandoning because its lack of validity. NIMH
is assuming that the failure to find relevant biological targets for psychiatry
to focus on is the byproduct of a diagnostic system such as the DSM which cannot
be assumed to reflect the way in which “nature is carved at the joints.” What
they are failing to consider is the possibility that a more
fundamental problem is the assumption that the underlying causes and relevant
targets for treatment are exclusively biological.
It is one thing to hypothesize that psychological and emotional problems are associated with changes at the biological level (e.g., specific patterns of brain activity or levels of neurotransmitters) or that symptom remission is associated with biological changes It is another, to assume that the underlying causes of psychological problems are always or exclusively biological in nature. While it may be the case that biological factors play a more significant causal role in some psychological problems (e.g., schizophrenia) than others, the assumption that the major causal factor (and thus the appropriate target for and level of intervention) for mental health problems is always biological is a form of simplistic reductionism. Nevertheless, it appears that the disease model of mental illness has become the dominant narrative in our culture – a narrative that the editors of the New York Times apparently accept in an unquestioning fashion. Some readers may assume that an article such as “Shortcomings of a Psychiatric Bible,” which is signed by the editorial board of the New York Time reflects the newspaper’s official position on the topic. If they do I hope they are mistaken.
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