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 of 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 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.