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Psychiatry
Is NIMH Brilliant, Stupid, or Both? Part 2
How I learned to stop worrying about diagnosis and love voles, part 2
Posted October 8, 2013
As I described in Part 1, the National Institute of Mental Health (NIMH) has no use for DSM-5. It recognizes that its diagnostic categories do not help us understand mental suffering. The basic premise of DSM—that mental health conditions can be classified meaningfully on the basis of overt symptoms—is simply wrong.
From now on, NIMH will do what sophisticated clinicians have always done: look beyond overt symptoms and focus on underlying causes. But this is where sophisticated thinking at NIMH ends and naïveté—shocking naïveté—begins.
In NIMH’s new worldview, all mental suffering must be understood in terms of biology and only biology. There is nothing to understand that is not biological. This is not just a decision about funding priorities or resource allocation. It is an a priori assumption about the nature of mental suffering: all mental suffering is biological brain disease.
As NIMH Director Thomas Insel explained in a recent blog, the first assumption underlying NIMH’s new policy is that DSM cannot serve as a foundation for research. The second assumption—here I quote his words to avoid any possibility of misunderstanding—is that “Mental disorders are biological disorders involving brain circuits.” He repeats the word “circuit” or “circuitry” nine times in a one short blog post.
As a clinician, I treat people who struggle with intimacy and relatedness, or have difficulty recognizing or expressing emotional needs, or unwittingly sabotage themselves, or feel a sense of inner emptiness, or find themselves repeating painful life patterns without knowing why. Research shows that such psychological issues are a central focus of most mental health treatment, underlying official diagnoses and complaints. In NIMH’s view, research on brain circuits will explain all such difficulties.
What brain circuits? Where is research showing that the problems that bring most people to treatment are best understood—indeed, are understandable at all—in terms of brain circuits? There is no such research. NIMH’s new direction does not reflect a conclusion drawn from scientific evidence. It is, rather, an assumption, an insistence, a worldview, an ideology: All mental suffering is biological. It must be. There is no other way to understand it.
No seasoned clinician—no one who has spent meaningful time talking to patients—could possibly think this way. And indeed, the director of NIMH is not a seasoned clinician. He has spent far more of his professional life examining rodent brains than treating human patients. Voles, specifically. (I had to Google that; a vole is a little rodent, somewhat stouter than a mouse.)
It is unfortunate that the NIMH policymakers never encountered the concept of supervenience, or did not understand it. Supervenience has a technical definition but is best illustrated through example. Imagine watching a movie, say Star Wars. At one level it is a movie. At another level, it is a pattern of pixels. The key point is that the relationship between the two levels is asymmetric: movie supervenes on pixels. We could know everything there is to know about pixels and the circuitry (circuitry!) that controls them and understand nothing of the movie. We would have no concept of Luke Skywalker, Darth Vader, or the battle for the empire.
Just as movie supervenes on pixels, mind supervenes on brain. They are of a different order. Knowledge of one may have little bearing on the other. I learned of supervenience through Harvard neuroscientist and philosopher Joshua Green, who makes just this point about the relation between mind and brain. Green is not a fluffy psychotherapist; he is a neuroscientist whose experiments rely on fMRI, transcranial magnetic stimulation, and genotyping. (Supervenience is also described in a New York Times column on, ironically enough, scientific concepts that could improve everybody’s cognitive toolkit.)
For argument’s sake, suppose NIMH’s plan is 100% successful and that in 10 years, or 20, or 50, we know everything there is to know about neural circuitry. Supervenience tells us we may know little more than now about how to help the majority of patients who seek mental health treatment.
NIMH should invest in neuroscience research. I believe it will lead to scientific and medical breakthroughs, especially for conditions where mind does not supervene on brain, or supervenes only partially. Schizophrenia and bipolar disorder may be examples.
But I also believe our field is unique because it straddles biological and humanistic modes of thinking and understanding. There is a creative, dynamic tension between natural science and humanistic perspectives on human experience. This dynamic tension makes our field vital, fascinating, and wonderful. I fear NIMH would do away with this creative dynamic tension and substitute simplistic biological reductionism.
Sophisticated clinical practitioners shift fluidly between biological and humanistic lenses. A patient takes psychoactive medication. It has a biological effect on certain neural synapses. The medication also holds psychological meanings. It may be experienced as a gift, a symbol of love, confirmation of defect, a piece of the doctor’s strength and goodness to “take in” and make part of oneself, a piece of the doctor’s badness that constitutes an attack from within, and so on. The psychological meanings powerfully affect the patient’s response to the treatment. (In the case of antidepressants, the psychological meanings appear more powerful than the biological effects of the medication—but that is a topic for another blog). Sophisticated clinicians (and researchers) think both/and, not either/or.
Leon Eisenberg, an early pioneer in psychopharmacology at Harvard, once remarked that “In the first half of the 20th century, American psychiatry was virtually ‘brainless’… In the second half of the 20th century, psychiatry became virtually ‘mindless.’” By “brainless,” he referred to early psychoanalytic theories that ignored brain biology and viewed even phenomena like schizophrenia, bipolar illness, and autism as the product of intrapsychic conflict. By “mindless,” he referred to biological reductionism that regards mind as an irrelevancy and leaves many psychiatrists clueless about how to help patients in any way that does not involve a prescription pad.
NIMH has taken mindlessness to a level that would have once been unthinkable.
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Jonathan Shedler, PhD practices psychotherapy in Denver, CO and online by videoconference. Dr. Shedler is a Clinical Associate Professor at the University of Colorado School of Medicine. He lectures to professional audiences nationally and internationally and provides online clinical consultation and supervision to mental health professionals worldwide.
