The 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.
You are expecting too much from medical science.
Do you remember ever hearing the story about the blind men all trying to “understand” the elephant? They all had an incomplete experience, only together could they have a reasonably good understanding of the animal.
When factors which, obviously to everyone, affect either physical and/or mental health, and they are “given short shrift” in terms of resource allocation, it is usually because those factors are not suited to the kind of measurement the available resources for medical science research can obtain. It’s not because scientists are willfully giving them short shrift.
If we extend the argument on which you base your complaints against the NIMH, I see it going toward the conclusion that, since any disorder involves all four quadrants, any research which does not tap into all four in its methodology is invalid. Would you also say that criminal courts can’t legitimately define theft, or murder, because they haven’t completely described it in a way that pays equal attention to the cultural factors, the psychological factors, etc. which pertain to it?
A better solution to the quest for understanding of mental illnesses would include an UBERgroup to meta-analyze the input of all entities involved in its identification and treatment, impact on society, etc. The NIMH would do what it does best, which is science, not sociology or cultural anthropology. It’s just one of the blind men trying to describe the elephant.
The blind men/elephant metaphor makes perfect sense to me, and I agree that research into the neurobiological aspects of psychological disorders is completely valid and should continue full force. Where I disagree, and the reason behind my complaint in this post, is that the NIMH often willfully (in my opinion) promotes the idea that their piece of the elephant is indeed the WHOLE elephant, or at the least by far the most important part. Consider the National Institute of Drug Abuse (part of the NIH). Here’s how they answer the question “What is drug addiction?”:
Elsewhere, in their bio of Nora Volkow, the NIDA site says this: “Dr. Volkow’s work has been instrumental in demonstrating that drug addiction is a disease of the human brain.”
I don’t think it’s too much to expect from the leading authorities on addiction to refrain from promoting their one segment of the elephant as the entire elephant. The idea that NIDA pushes is that addiction IS a matter of neurophysiology, not that neurophysiology is merely an important piece to the puzzle that they’re focused on. What I believe they should say is the truth, which is the same truth that you alude to, namely that “addiction is a super complicated biopsychosocial affair, and we here at NIDA are focusing on the neurological/biological aspects of addiction. Here’s what we are finding.”
NIDA and the NIMH are, in my opinion, negligent and self-serving in obscuring the psychosocial aspects of mental health. I don’t expect them to change their methodologies, because their research is perfectly valid as it is, and super useful. But I do expect them to honestly frame their work in a larger context, because consumers of mental health information look to these authorities for answers to basic, fundamental, general questions, like “What is addiction?” and “What is a mental disorder?”. Currently the answers to these questions given by the NIMH and NIDA are misleading at best, deliberately false and self-serving at worst.