Reflections on attention, self-knowledge, and the mental health profession.
In this episode of the Integral Health Resources Podcast, I review an excellent article by Allen Frances in which he excoriates us all for turning a blind eye to those in our society who need mental health services the most.
Here is the article that was referenced in this discussion:
What Drives Our Dumb and Disorganized Mental Health Policies? by Allen Frances
In this episode of the Integral Health Resources Podcast, I discuss an important paper by Noel Hunter and William Schultz called A Response to the Hyper-focus on Brain-based Research and “Disease”.
Here are some other media resources that may be helpful/relevant to this discussion:
Here are the quotes from the white paper that I cited throughout this podcast:
The brain-based initiatives for clinical research rely on a disease model that is based on erroneous logic, a faulty reductionistic view of human nature, and a contradiction of the most robust research findings within the mental health field. The brain research conducted thus far actually appears to indicate that most of the conditions referred to as “mental illnesses” are likely otherwise healthy adaptive processes in response to extreme environmental experiences. So while it appears that such adaptive processes often do correlate with changes within the brain, and that they may lead to certain long-term problems for the individual, these changes do not necessarily signify biological disease. Furthermore, brain research has ironically reinforced the benefits of certain psychosocial interventions, such as yoga, meditation, and psychotherapy, thereby negating the assumption that the resolution of such distressing conditions requires psychopharmological or other related biological interventions.
But, is it really necessary to have “evidence” from brain scans to know that mediation, exercise, and eating healthily have beneficial effects on one’s wellbeing? The only thing this research really seems to show is how much the brain is constantly adapting to its environment. In fact, one could even interpret the findings of many of the brain differences in traumatized and distressed individuals as signs of adaptive functioning— the complete opposite of disease!
Three prominent negative consequences of focusing on biological, brain-based etiologies of “mental illness” are that it results in skewed research funding, biased treatment preferences, and clinically harmful impacts.
Many of the biological anomalies that one finds with chronic sufferers of “mental illness” are directly caused by the very biological interventions thought necessary to decrease distress.
So not only are brain-based etiologies of psychological distress unsupported by the evidence and related to the excessive use of dangerous medications, they also have powerful psychological impacts that can adversely influence treatment.
The resources available for mental health research and care are limited, and that every dollar and person-hour spent pursuing brain-based solutions to psychological distress comes at a direct cost to those resources available for psychosocial research and support.
When we consider the vast disparity between the predominant research and interventions within the mental health field on one hand, and the actual needs of distressed human beings on the other hand, we recognize that our mental health field is in dire need of a radical paradigm shift—from trying to make sense of psychological distress from a biologically reductionistic framework to one that is more humanistic and needs-based. This essentially involves shifting the general stance within the mental health field from “diagnosis and treatment” to one of “assessing needs and offering support.” This would mean focusing our resources on providing psychosocial support for individuals, families, and communities and working towards a social system in which meaningful and rewarding activity, education, and work is accessible to everyone.
Even in those cases in which the specific needs or other causal factors are unable to be identified, the evidence suggests that when a person’s basic needs are addressed, such conditions of psychological distress still naturally recede over time. And in those rare cases where such factors are unable to be identified and addressed, and in which the condition does not naturally recede over time, some psychoactive drug support may be beneficial, as long as it is used in minimal dosage for minimal duration and only with the individual’s fully informed consent.
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.
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. 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.
1. 20 years after onset of alcohol dependence, about three-fourths of individuals are in full recovery; more than half of those who have fully recovered drink at low-risk levels without symptoms of alcohol dependence.
2. About 75 percent of persons who recover from alcohol dependence do so without seeking any kind of help, including specialty alcohol (rehab) programs and AA. Only 13 percent of people with alcohol dependence ever receive specialty alcohol treatment.
These conclusions, based on the largest study of people’s life histories of alcohol use ever conducted (43,000 people), completely undercut the accepted wisdom that addiction (to alcohol, at the very least) is a “relapsing brain disease,” and they also bring into sharp relief the utter ineffectiveness of the most commonly utilized treatment programs. Beyond this study, the accepted wisdom regarding addiction also fails the tests of sound reasoning, common sense, and an honest appraisal of existing evidence — a case that Peele has been persuasively making for decades. And yet when Americans want the best available information and recommendations about addiction to alcohol and other drugs, we’re told by Dr. Drew, HBO, and the NIH that addicts have a relapsing brain disease, that they can never learn to moderate their drug use, and that their incurable diseases can be most effectively treated by checking into rehab and attending twelve-step meetings. Is it any wonder why our best efforts to help people with drug problems are so ineffective?
Sadly, if we instead look to the most renowned non-government authority on matters of mental health, the American Psychiatric Association, we’ll find only further confusion. In another blog post, Peele describes the APA’s latest attempts to redefine the concept of addiction for the latest version of the Diagnostic and Statistical Manual, DSM-5. Peele was an advisor for the substance abuse disorders section of the current version of the DSM, DSM-IV, so he understands the process well. The upshot is that the DSM-5 Substance-Related Disorders Work Group, chaired by University of Pennsylvania psychiatrist Charles O’Brien, is proposing some major changes, including ditching the term “dependence” in favor of “addiction” (a term not used in the DSM-IV to describe substance abuse problems). Beyond that, the group also wants to create a whole new category–Behavioral Addiction–to refer to pathological gambling. The rationale behind designating only pathological gambling as an addiction (but not pathological sex-having or video game playing or anything else) is that, according to O’Brien, “substantive research” indicates that “pathological gambling and substance-use disorders are very similar in the way they affect the brain and neurological reward system.” Peele, as he’s done his entire career, clearly shows the fallaciousness of O’Brien’s reasoning, which suffers from the same confusions and category errors that have been holding our understanding of addiction (and mental health, more broadly) hostage for decades:
O’Brien’s statement represents a rear-guard effort to frame addiction as a brain disease. There is, indeed, imaging research on the ways various drugs affect the brain. But that’s not the key to addiction. I designed and administer an addiction treatment program, and I can assure you that not one person is sent to our program—or any other program—because of a PET scan. People enter rehab because of regular, habitual screwups connected to substance use—compulsive involvement and continued use of a drug (or other involvements) despite chronic harm.
Indeed, as O’Brien points out, powerful experiences like gambling impact the same “neurological reward system” that drugs do. But so do many other rewarding activities. If there is some such higher level “neurological reward system,” then it can’t be said to exclude anything, from sex to food to gambling to video games.
Nor is O’Brien correct in suggesting that cocaine, nicotine, alcohol, and marijuana follow the same neurological pathways in the brain. Each substance has a very different chemical profile, including the timing of effects and the rewards people derive.
And if gambling affects the same brain reward system as substances, as O’Brien claims, why is it a “behavioral” addiction and not simply an addiction? DSM-5 further muddies understanding of addiction in its handling of two other non-drug appetites—“hypersexuality” and “binge-eating.” Neither is regarded as an addiction. Is this because they do not follow the same “neural reward pathways” as drugs and gambling? Binge-drinking can bring on addiction, but not binge-eating? How come? And is gambling really more neurologically, or intensely, rewarding than sex?
The problem with the DSM-5 approach is in viewing the nature of addiction as a characteristic of specific substances (now with the addition of a single activity). But think about obsessive-compulsive disorder (OCD): People are not diagnosed based on the specific habit they repeat—be it hand-washing or checking locked doors. They are diagnosed with OCD because of how life-disruptive and compulsive the habit is. Similarly, addictive disorders are about how badly a habit harms a person’s life. Whether people use OxyContin or alcohol, people aren’t addicted unless they experience a range of disruptive problems—no matter how addictive the same drug may be for others.
Unfortunately, misunderstanding and misinformation are becoming part and parcel in health education across-the-board in our society. As with our political system, the agencies and organizations responsible for informing the public about matters of health and well-being have been way too corrupted by special interest groups (particularly) and the profit motive (more generally). Moving toward a sensible, fact-based, integral understanding of health requires that we critically appraise and analyze all information that comes to us, not only from the media, but also from the “leading experts” themselves. I have no doubt that the vast majority of individuals working at the NIH, the APA, as well as the countless mental health professionals across the country serving people in need, have only the best of intentions and want above all else to make a positive difference in the world. The same can be said of the members of the United States Congress, but a system can become corrupt, broken, and ultimately ineffective (even destructive) despite the good intentions of most individuals within the system. Our current way of understanding and treating addiction — like the broader “war on drugs” we’ve been impotently waging for years — just isn’t cutting it. Stanton Peele may not have all the answers, but his approach makes a lot of sense to me.