Listening to Stories Patients Tell: Beyond DSM-5

Always consider the interplay between psychosocial forces and brain function.

Posted Oct 24, 2013

There have been many recent public debates about mental health treatment:  psychotropic medications vs. psychotherapies, cognitive-behavioral vs. psychodynamic approaches, short- vs. long-term treatments. These discussions coincide with the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the decision by the National Institutes of Mental Health (NIMH) to focus funding efforts on projects studying genetics and neural circuitry underlying mental function and dysfunction.

One crucial element has been absent from these discussions: How does our society conceptualize mental function and dysfunction? How we frame the issues determines how they are addressed.

Conceptions of mental disturbances have varied over time and place. In Western culture, prior to the Enlightenment, mental illness was attributed to supernatural phenomena, such as the person being in possession by evil spirits that needed exorcising, like the 17th-century Salem witch trials. Since then, the pendulum has swung between considering either the brain or the environment as the primary cause of mental disorders. As if the twain shall never meet. In our time we prioritize the brain over the environment.

At the turn of the 19th century, Philippe Pinel, the first psychiatrist, theorizing that human experience determined mental disorders, proposed a more humane approach to patients (“moral treatment”). By the middle of that century and into the 20th, the brain became the focus of interest. The discovery that syphilis causes mental disturbance led to a hope that biological causes would be found for other mental disorders, which were ascribed to brain lesions (“degeneration theories”). The great descriptive psychiatrist Emil Kraepelin hoped to account for schizophrenia and manic-depressive illnesses this way.

Sigmund Freud (a neurologist early in his career) argued against degeneration as the sole cause of mental disturbance and developed a theory and therapy based on how children consciously and unconsciously understood their early relationships. The stories a child creates about close personal bonds affects the nature of interactions later in life, determining adult psychological functioning. During the greater part of the 20th century, influenced by Freud, mental health practitioners focused their efforts on studying the impact of the early familial environment on the child. The individual’s life story is critical to both diagnosis and treatment.

By the 1970s, the pendulum began to swing from psychosocial factors towards a focus, once again, on brain factors. Kraepelin’s work, which for most of the 20th century had been considered dated, inspired an important group of researchers in St. Louis studying manic-depression (bipolar illness) and schizophrenia with a view toward increasing diagnostic reliability. This “re-Kraepelinization” of American psychiatry was institutionalized in 1980 with the publication of DSM-III, creating sharp categorical distinctions among mental disorders, considering them as conceptually equivalent to all medical illnesses.

Concurrently, we saw an explosion in the development and utilization of psychotropic medications and the emergence of cognitive neuroscience and genetics as cutting-edge scientific fields. These angles of vision on mental suffering fostered an implicit conceptualization of the brain as the main source of mental dysfunction and the target of interventions. Attention to a person’s life experience as either cause or cure decreased. Psychiatry became more and more constricted within a biomedical model.

This paradigm shift is now crumbling. Ordinary clinicians have become increasingly aware that real people with real mental distress do not fit into the DSM’s neat categories. Pharmacological interventions, useful for illnesses such as bipolar disorder and schizophrenia, have proven less effective for ordinary depression, the most common of all disorders, for which placebo effects are powerful and for which the therapeutic relationship makes more difference than type of intervention. The effectiveness of many cognitive-behavioral treatments has been established. More recently, the effectiveness of the psychodynamic “talking cure” has been empirically demonstrated. Research on interactions between genes and environment shows that childhood adversity can have ongoing ramifications for development; and psychosocial interventions can help overcome the effects of a negative genetic predisposition. The Psychodynamic Diagnostic Manual (PDM), published in 2006 by an international consortium of experienced therapists and researchers, exemplifies one effort to counteract the negative consequences of total reliance on DSM’s descriptive/categorical classification system.

Is the mental health field ready to start to really integrate the biomedical model with the psychosocial model? Or will we continue to ricochet between falsely polarized attention to either the brain or the social environment?

The biopsychosocial modelwas developed to integrate psychological and social factors into general medicine, without undoing biomedical advances. The new field of narrative medicine, an offshoot of the biopsychosocial model, has begun to demonstrate that understanding and addressing psychosocial factors, especially how patients talk about their medical illness, can, in fact, accomplish this.

DSM-5 and the current NIMH initiative for the study of the brain include exploring the effect of social processes; but only in a secondary way. Psychiatry needs to devote more energy and funds to study the interplay between psychosocial forces and brain functioning, most importantly stressing the centrality to the diagnostic process of listening to a patient describe the story of his or her life. To provide the best treatment for people suffering with mental problems, the twain must meet.


Leon Hoffman is Director Pacella Parent Child Center and co-Director Research Center, New York Psychoanalytic Society and Institute. This article is adapted from a book essay about DSM-5 to appear in the Journal of the American Psychoanalytic Association.


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