Meet the new boss, same as the old boss: The NIMH rejects DSM categories, but continues to give short shrift to psychosocial perspectives

NIMH-color-logo-300x217The National Institute of Mental Health will reportedly discourage the use of DSM categories for its future research projects. NIMH Director Thomas Insel is promoting a new approach, the Research Domain Criteria (RDoC), which is based on three guiding principles: 1) Pathology is conceived in terms of dimensions ranging from normal to abnormal; 2) Classification of disorders will be generated from basic behavioral neuroscience, not current DSM categories; 3) Multiple units of analysis (i.e. physiological activity, behavior, self-reports of symptoms) will be used in defining constructs for study. In a recent article by Maia Szalavitz, Insel is quoted as saying:

I look at the data and I’m concerned. I don’t see a reduction in the rate of suicide or prevalence or mental illness or any measure of morbidity. I see it in other areas of medicine and I don’t see it for mental illness.

As I understand it, the basic idea behind RDoC is that researchers will likely be more successful in understanding the neurological and genetic underpinnings of psychiatric disorders if they focus on specific symptoms, which may occur across multiple disorders, rather than continue to focus on disease categories based on complex groupings of various symptoms. This makes sense to me as a better way to approach the biological dimensions of mental health, but it also implies that the NIMH, like the American Psychiatric Association, is content to downplay the subjective, interpersonal, and sociocultural dimensions of mental health and distress, at least when it comes to research funding. As Benjamin Wachs puts it:

The NIMH isn’t offering a real alternative to the DSM:  rather, they’re doubling down on the fallacy that the DSM was pursuing in the first place.  That the mind is best understood as a computer, and when your computer breaks you don’t talk to it or ask it how it feels.  In fact, you don’t even let the computer decide whether it’s broken or not.  If it’s not behaving according to spec, you get it fixed.

DSM-IV Chair Allen Frances said the following his recent analysis of the topic:

APA and NIMH are both on the sidelines, doing nothing to help restore humane and effective care for those who most need it. DSM-5 introduces frivolous new diagnosis that will distract attention and resources from the real psychiatric problems currently being neglected. NIMH has turned itself almost exclusively into a high power brain research institute that feels almost no responsibility for how patients are treated or mistreated in the here and now.

There seems to be two major viewpoints in the mental health field these days. The first, typified by highly influential organizations like the APA and NIMH, sees mental health as primarily a matter of brain functioning. Lip service is often paid to “cultural factors,” but the subjective, intersubjective, and sociocultural dimensions of humanity are given short shrift in terms of emphasis and resource allocation. The second major trend in mental health is the integrative or integral view, which insists that every dimension of humanity must be fully taken into account in all mental health theory, research and practice. The NIMH’s new research direction will hopefully bear fruit, but it will miss the big picture if the narrow focus on neuroscience is not placed within a broader biopsychosocial context.

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Allen Frances vs. DSM-5

Screen-shot-2012-06-05-at-12.00.37-PMThe new version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is about to drop, and those of us in the mental health field will have to respond and/or adapt to the changes in some way. In my graduate program, the most prevalent response seems to be annoyance at having to learn a new system. Strangely, I’ve heard very little buzz among students and faculty regarding the many critiques of the new manual that have been sprouting up daily across various media outlets over the past year or so. It’s as if students are resigned to accepting whatever dictates come down from the American Psychiatric Association because, well, “that’s the way it is” and “what can we do about it anyway?” I’m not always the most socially engaged student, so perhaps there’s more engaged critical discussion going on than I’m aware of. I hope so.

Foremost among DSM-5 critics is Allen Frances, the chair of the task force that produced the version of the manual, DSM-IV, that has been in use since 1994. Frances came out of retirement out of a concern that the proposed changes in DSM-5 would lead to a dangerous level of diagnostic inflation, and he’s been blogging, writing articles and books, and giving talks all over the world encouraging people to seriously question the DSM-5′s safety and legitimacy. In a recent opinion piece for New Scientist, Frances summarizes his scathing critique:

In my opinion, the DSM-5 process has been secretive, closed and sloppy – with confidentiality restraints, constantly missed deadlines, botched field testing, the cancellation of an important quality control step, and a rush to publication. A petition for independent scientific review endorsed by 56 mental health organizations was ignored. There is no reason to believe that DSM-5 is safe or scientifically sound.

A more detailed critique (and a mea culpa for the mistakes in DSM-IV) is explored in the following talk, which I find to be very impressive and persuasive:


Psychiatrist and author, Allen J. Frances, believes that mental illnesses are being over-diagnosed. In his lecture, Diagnostic Inflation: Does Everyone Have a Mental Illness?, Dr. Frances outlines why he thinks the DSM-V will lead to millions of people being mislabeled with mental disorders. His lecture was part of Mental Health Matters, an initiative of TVO in association with the Centre for Addiction and Mental Health.

Of course, Frances is not alone in criticizing the DSM-5. See my twitter feed for the most credible and thoughtful (in my view) critiques being published on the web.

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Psychiatric diagnostic system challenged by genetic research

Vaughan Bell (of the terrific blog, Mind Hacks) has posted a couple of fascinating articles highlighting recent evidence from genetics that is challenging the field of psychiatry to rethink how it views diagnosis. In a post published in The Guardian, Bell frames psychiatry’s current diagnostic dilemma as follows:

[Do] different diagnoses such as schizophrenia, bipolar or depression represent distinct disorders that have specific causes or [are these] just convenient and perhaps improvised ways of dividing up human distress for the purposes of treatment?

Bells reminds us that the diagnosis debate is typically framed in terms of two opposing models, a medical model that views psychiatric disorders in terms of diagnosis, medication and biomedical science, and a social model that stresses individual experience, psychotherapy and social interventions. This debate has been heated and politicized, and now it may be further complicated (or elucidated) by evidence from medical genetics that suggests that psychiatric diagnoses do not, in fact, represent distinct disorders, but rather they represent a variety of possible problematic outcomes each stemming from a similar genetic starting point that has been uniquely shaped by an individual’s life experiences.

Dr. Michael Owen

Dr. Michael Owen

Bell interviewed Dr. Michael Owen, a psychiatrist and researcher from Cardiff University’s School of Medicine who had studied genetic research related to psychiatric diagnosis in depth. Owen concludes that “It is no longer tenable to regard these as discrete disorders, or sets of disorders, with specific causes, symptoms and consequences.” Interviewing Owen for a follow-up article, Bell explores the possibility of an expanded neurodevelopmental theory suggesting the likelihood that “genetics determines how sensitive we are to life events as the brain grows and develops.”

Dr. Owen and his colleagues gathered and analyzed a great deal of evidence showing that certain genetic differences raise the chances of developing a whole range of psychiatric problems – from epilepsy to schizophrenia to ADHD – rather than these differences being linked to a specific psychiatric disorder. Asked to expound on what the current categories of psychiatry diagnosis (i.e. per the DSM) represent, Owen said:

They are broad groupings of patients based upon the clinical presentation, especially the most prominent symptoms and other factors such as age at onset, and course of illness. In other words they describe syndromes (clinically recognizable features that tend to occur together) rather than distinct diseases. They are clinically useful in so far as they group patients in regard to potential treatments and likely outcome. The problem is that many doctors and scientists have come to assume that they do in fact represent distinct diseases with separate causes and distinct mechanisms. In fact the evidence, not just from molecular genetics, suggests that there is no clear demarcation between diagnostic categories in symptoms or causes (genetic or environmental).

Interesting stuff! I’ll keep my ear to the ground for any new developments.

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Integrative trends in counseling education

Theory-and-Practice-of-Counseling-and-Psychotherapy-Corey-Gerald-9780495102083This semester I’m taking a “Counseling Theory and Practice” course as part of my graduate training. One of my big worries going into the program was that I wouldn’t be able to situate myself within the “mainstream” discourse in the field. When I graduated from college in the early 90s, it seemed as if there weren’t any conventional psychology graduate programs that acknowledged and appreciated an integral or integrative approach to mental health, which was one of the reasons I ended up studying East/West Psychology at the California Institute of Integral Studies in San Francisco. I thought of myself as being on the cutting edge back in those days, as one of the few who could see through all the reductionistic b.s. of “mainstream” or “conventional” psychology. And there was probably a little bit of truth to that. It’s only been in the last ten years or so that topics once thought of as woo-woo, like mindfulness, have been appreciated and embraced by mental health professionals outside of a few outposts in California, Colorado, and Massachusetts. But today, assuming the textbooks we’re using at New Mexico State University are any indication of wider trends, it seems that a full-on biopsychosocial, integrative approach to counseling theory and practice is at long last having its day. Here’s a quote from Chapter 1 of Gerald Corey’s Theory and Practice of Counseling and Psychotherapy:

To understand human functioning, it is imperative to account for the physical, emotional, mental, social, cultural, political, and spiritual dimensions. If any of these facets of human experience is neglected, a theory is limited in explaining how we think, feel, and act.

Shit, that sounds an awful lot like the blurb on the front page of this website! Could it be that this integral health stuff is no longer such a radical idea?!?! Perhaps I’ll have to let go of this notion that I’m part of the avant-garde! I can live with that, I suppose… :O)

My other textbook, Hackney and Cormier’s The Professional Counselor, has also alluded to an integral-ish perspective right off the bat, within the first few pages:

Each individual is an ecological existence within a cultural context, living with others in an ecological system. One’s intrapersonal dimensions are interdependent with others who share one’s life space.

Sounds a lot like the “woo” I studied in San Francisco back in the day! I can only hope this integrative vibe continues as the semester unfolds. It’ll sure make having to read hundreds of pages per week a lot less painful.

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Embracing Pain: Ronald Siegel’s prescription for psychophysiological disorders

I finally made time to finish reading Mindfulness and Psychotherapy, and I was particularly struck by the chapter on “Psychophysiological Disorders” written by Ronald D. Siegel. As a long-time student of Somatics, specifically Thomas Hanna’s Clinical Somatics, I have been intrigued by how repeated triggering of the stress response can lead to habitual patterns of muscle tension, which can in turn lead to a variety of problems and limitations in how our bodies function. (For those who are unfamiliar with the concept, “somatic” basically refers to our interior, directly-sensed experience of the body.) While Hanna acknowledged the psychological dimension of somatic issues in his writing and theories, his clinical method does not include an explicitly psychological dimension, and I personally have found this to be a limitation in the effectiveness of his program of somatic education. Siegel’s notions of the “chronic back pain cycle” and the “recovery cycle” dovetail nicely with Hanna’s sensory-motor perspective, bringing in a psychotherapeutic approach that can be applied to wide range of clinical issues.

Siegel points out some interesting parallels between the chronic back pain cycle (which he defines as “a cycle of psychological stress, muscle tension, and fear-based avoidance of activity”) and anxiety disorders:

They both result from overactivity of the fight-or-flight system. The also both involve future-oriented maladaptive fear responses, experiential avoidance, and false assumptions about the nature of the problem.

So, according to Siegel, both chronic back pain and chronic anxiety can often be exacerbated by (if not caused by) a fight-or-flight stress response system that has become stuck in overdrive. Whereas Somatics approaches the physical manifestations of stress, especially patterns of muscle tension, it does not directly deal with the psychological side of the coin, namely the fearful avoidance of experience and distorted thought patterns that so often keep the stress fires burning. Siegel’s approach uses mindfulness-based psychotherapy to address the problem on both a psychological and somatic level, but I wonder if the sensory-motor techniques of Somatics might be better suited to deal with the neuromuscular side of stress. I’ll have to read Siegel’s Back Sense and experiment with his principles and techniques to see if/how they might fit in with my current integral health regimen.

When I find the time, that is! For now, it’s time to get ready for the new semester and start diving into my counseling books. This coming week I start Counseling Theory & Technique and Group Work Theory & Technique. Looking forward to it!

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Therapeutic Lifestyle Changes

Dr. Roger Walsh recently wrote a landmark article in the American Psychological Association’s flagship journal, American Psychologist. The article, Lifestyle and Mental Health, outlines eight major lifestyle factors that are woefully under-appreciated in the field of mental health, despite overwhelming evidence of their psychological (and physical and social) benefits.

Here’s the abstract:

Mental health professionals have significantly underestimated the importance of lifestyle factors (a) as contributors to and treatments for multiple psychopathologies, (b) for fostering individual and social well-being, and (c) for preserving and optimizing cognitive function. Consequently, therapeutic lifestyle changes (TLCs) are underutilized despite considerable evidence of their effectiveness in both clinical and normal populations. TLCs are sometimes as effective as either psychotherapy or pharmacotherapy and can offer significant therapeutic advantages. Important TLCs include exercise, nutrition and diet, time in nature, relationships, recreation, relaxation and stress management, religious or spiritual involvement, and service to others. This article reviews research on their effects and effectiveness; the principles, advantages, and challenges involved in implementing them; and the forces (economic, institutional, and professional) hindering their use. Where possible, therapeutic recommendations are distilled into easily communicable principles, because such ease of communication strongly influences whether therapists recommend and patients adopt interventions. Finally, the article explores the many implications of contemporary lifestyles and TLCs for individuals, society, and health professionals. In the 21st century, therapeutic lifestyles may need to be a central focus of mental, medical, and public health.

In my opinion, Walsh’s article has the potential to influence and unify the fields of mental health, public health, and medicine in much the same way as Dr. George Engel’s biopsychosocial challenge for biomedicine did back in 1977. The following is a list of resources related to Walsh’s article:

PDF of the article in American Psychologist

Lifestyle and Mental Health topic page on Dr. Walsh’s website

Dialogue between Roger Walsh and philosopher Ken Wilber (Part one)

Dialogue between Roger Walsh and Ken Wilber (Part two)

Full video presentation at University of California, Irvine

UC Irvine presentation in ten parts via YouTube:

(1) Impact of Lifestyle on Mental Health
(2) Exercise Benefits Body, Brain and Mind
(3) Eating for Mental Health: What Kind of Diet Is Best for Brain and Mind?
(4) Fish Oil and Vitamin D: Supplements That Benefit Body, Brain and Mind
(5) The Effects of Nature and Technology on Mental Health
(6) Relationships: The Most Powerful Factor Affecting Wellbeing
(7) Recreation and Mental Health: Good Times Make for Good Minds
(8) Relaxation and Stress Management:The Benefits of Letting Go and Letting Be
(9) Religion, Spirituality, and Mental Health
(10) Helper’s High—Feeling Good by Doing Good

There is also a documentary multimedia project in development, 8 Ways to Wellbeing, that will feature Walsh’s work on TLCs. Here’s the promotional video:

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Embodiment of social context – “Sites of Shaping”

Here’s another wonderful and fascinating presentation from Staci Haines of the Strozzi Institute. (Thanks to Mark Walsh for the heads-up.)


[From StrozziInstitute]We are always living inside of a social context. We embody our social contexts, just as we are shaped by and embody our family contexts, communities and the land/environments that influence us. When we are looking at transformation, social context is one of the most influential forces, whether we are focused on personal, community or systemic change.

For another great presentation by Staci Haines (on Somatic Transformation), see this video.

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Integral seeds found in my Human Development textbook

I took a course this summer in Human Development as part of my graduate program in counseling. I had taken a similar course as an undergraduate, back in 1990, and I was pleasantly surprised by how much more integral/holistic the field has become in the last twenty years, at least as put forth by Dr. Laura Berk in her Development Through the Lifespan book. Berk summarizes the lifespan perspective on development as follows:

…a balanced view that envisions development as a dynamic system. It is based on assumptions that development is lifelong, multidimensional (affected by biological, psychological, and social forces), multidirectional (an expression of both growth and decline), and plastic (open to change through new experiences). (p.41)

Sounds pretty integral-ish to me!

Dr. Berk continually reminds the reader of the complex, biopsychosocial nature of development, which challenges any simplistic conclusions we might draw based on any single factor, like heredity, for instance. An example of this is the study (Caspi et al, 2002) referenced where boys, even when they had a gene known to predispose people toward aggression, did not in fact show abnormal levels of aggression as long as they were raised in an family environment free from abuse.

I was struck by the degree to which psychological and social factors were shown to influence human development, even at the prenatal stage of life. Considering the number of factors— environmental, relational, political, etc.— that can impact the emotional stress of pregnant women, it is mind-blowing to contemplate the number of things that can indirectly put babies at risk for a wide range of potential problems. One study (Yehuda et al., 2005) showed how the events of 9/11 indirectly affected cortisol levels in infants’ saliva (which can impact the developing child’s susceptibility to a wide range of developmental problems later in life) by causing extreme anxiety in some mothers who happened to be pregnant during the terrorist attacks. So, even something as seemingly remote as our political relations with other countries can have an impact (indirectly) on the physiological development of our children. This understanding is, of course, consistent with the models of integral health presented here on this site.

While I was heartened by the general trend toward a more comprehensive, biopsychosocial approach to the modern study of human development, I was troubled that healthy development in adulthood is still for the most part described as if it’s a matter of conforming to conventional roles and social norms, while poor adjustment is linked to being out-of-step with societal expectations. At one point in the book, an adult’s inability or refusal to conform to society’s age-graded expectations (the “social clock” marking life events like first job, marriage, having kids, etc.) is linked not only to increased psychological stress, but also to undermining the stability of society:

…the stability of society depends on having people committed to social-clock patterns” (p.471)

This, of course, gets to the deeper questions, such as What does it really mean to be an adult?, that are still largely ignored in mainstream academic inquiry. Personally, I’ve never defined my adult status and development in terms of education, career goals, jobs, intimate relationships, parenthood, home-ownership, or even age. Rather, I conceive of maturity and personal growth as a process of continually getting deeper in terms of 1) my self-awareness/self-knowledge, and 2) my capacity for love and compassion. That said, it’s still good to see the mainstream study of human development embracing a more holistic approach in recent years.

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Stephen Fry – All about I

An interesting interview with actor/author/comedian Stephen Fry. His main point here, I think, is to emphasize the spiritual value of shifting focus from oneself to others. This is an insight I understand intellectually, but I often forget about it in my zeal to delve ever deeper into my own subjective experience in search of truth and wisdom. Reflecting back on the most profoundly transformative times in my life, I must admit that this inward focus often took a back seat to an intense engagement with other people. Of course, it’s not an either/or scenario, and we can all benefit from inner, self-focused work as well as from passionate social engagement. Fry’s commentary is a good reminder, though, for folks like myself who tend toward an overly-individualistic, me-against-the-world style of bootstrap spirituality.

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Reflections on radical acceptance

While I was jogging this morning a few thoughts floated through my mind related to the notion of radical acceptance. Whenever I start thinking about such things, it’s all too easy to get stuck in semantics, allowing the rules of grammar and the limitations of linear thinking to distract me from the heart of the matter. For instance, I often describe the state of radical acceptance as one characterized by a “letting things happen of their own accord” as opposed to “me making things happen or me resisting things as a willful agent.” Obviously, this sets up a dichotomy between me, on the one hand, and experience, on the other. Once the dichotomy is set up, I too often get lost in a confused attempt to philosophically reconcile to the two poles, forgetting that the dividing line between the two is non-existent, except as way of perceiving experience from a particular perspective, namely the perspective of ego identification, which implicitly entails a certain degree of disidentification with non-egoic dimensions of experience. From the perspective of ego identification, I have experiences; experiences happen to me.

When I move into a state of radical acceptance, I’m moving from a state of relative non-acceptance where I’m fighting against life, trying to deny what is, hoping to somehow transform it into what I want it to be. So, at first, the shift to acceptance feels as if there is an I who is allowing experience or life to happen without any interference or resistance from me. This dividing line between myself and the flow of life experience begins to blur as I move deeper into a state of acceptance, eventually bringing me to state of being where such distinctions no longer hold sway, no longer make sense, and no longer characterize how I feel. The “problem” of ego identification isn’t really solved. It just disappears (temporarily). The differentiation between myself and life ceases to seem relevant, if only for a moment.

Consider the following reflections (Yes, this is really what I thought about during my jog!):

You need to find your way to a soccer field that is located on the border of two towns. You pull out your trusty road map and make your way there. The lines on the map are useful for finding your way to the field, but once you get there, they are no longer relevant to your next objective, i.e. to play a game of soccer with your friends. The town line cutting the field in half helped you get there, but once you get onto the field it disappears from your mind, and now the only relevant lines are the ones marking the field. After the game, you might decide to have a picnic on the field, or maybe later that evening an outdoor concert will be held there. At that point, the markings on the field also become irrelevant. They, like the lines on the map, were useful conventions in a specific context, served a function in pursuit of a specific purpose, but during the concert they lose all relevance. I think ego identification is like lines on a map or lines on a field. The distinction between me and my experience has relevance and reality only from the perspective of ego identification, and that perspective is merely a convention, like lines on a map or a field, that is useful for certain objectives and not useful for others.

The problem with being stuck in a state of ego identification is that you get stuck with the sense of separation and disconnection from life that goes hand in hand with the state. Differentiating and separating out a me from the rest of life (not-me) is the action of attention that defines and generates the sense of being a self. When we are engaged in purposeful activities, when we’re “getting things done,” it’s probably useful to set down some imaginary lines to create an image of oneself as distinct from the flow of life. But when the job is done, the destination reached, it just confuses matters to keep generating those imaginary lines, as it would be confusing to play soccer on a field marked with lines not relevant to the rules of soccer — i.e. football yard markers, town borders, and/or concert rows. Radical acceptance, like other deployments of attention that might be considered meditative, can be strengthened through practice to the point where it becomes an enduring pattern, a healthy habit, an available perspective through which we can experience life in its seamless glory.

My intention as I began my jog this morning? To stay aware of bodily sensations and to avoid getting lost in thought! And just in case anybody’s wondering: Normally I get lost in far more mundane mental distractions, like fantasies of winning Olympic medals or snippets of random pop songs from the 80s.

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