I’m a long-time developer and promoter of social therapy and other cultural and relational therapeutic approaches—and a long-time critic of the medical model of relating to emotional distress, of diagnosis, and of the DSM-5.
I’ve written blog posts, articles and books on these topics (see loisholzman.org). For this column though, I’ve chosen to give a psychiatrist, Tad Tietze, “the floor.”
Paradigms lost: NIMH & DSM-5’s failure
By Tad Tietze
This is an abridged version of a post at Left Flank.
Last week the National Institute of Mental Health delivered a body blow to the authority of the American Psychiatric Association’s diagnostic “bible”, the Diagnostic and Statistical Manual of Mental Disorders, by announcing that it was abandoning the DSM-5 in favour of its own Research Domain Criteria.
This is a new phase in the controversy that has dogged the DSM-5, which led even the psychiatrists who headed DSM-III and DSM-IV— Robert Spitzer and Allen Frances — to attack the project. Its contents will reflect the failure to create a “scientific” basis for psychiatry through symptom-based diagnoses, as NIMH director Thomas Insel has argued on his blog.
When the authors of DSM-5 started work over a decade ago they also wanted to go beyond simply describing disorders in terms of symptoms and behaviours, and to align diagnoses to “underlying” genetics and neurobiology. Yet as they proceeded it became obvious there was insufficient evidence for this shift. More importantly, the biomedical model was increasingly being challenged by scandals involving kickbacks from drug companies to psychiatric “thought leaders”, public concern about over-diagnosis and overmedication, and growing evidence that many top-selling medications worked little or no better than placebo.
In the end politics hobbled the DSM-5 because the “objective” scientific advances its developers saw as being just around the corner proved to be a mirage.
Nevertheless, this is far from being a defeat for the dominant neurobiological model of psychiatry. The last half-century is proof of how profoundly that model shapes research and practice. You can see this in Insel’s alternative program for devising new diagnoses:
- A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
- Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
- Each level of analysis needs to be understood across a dimension of function,
- Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.
Such assumptions are little more than speculative, yet they are presented as conclusive. They serve to close off avenues of research that fall outside their boundaries rather than open them up. They point to the imperviousness of the dominant biological paradigm to evidence that contradicts it. In the words of Samuel Beckett, “Try again. Fail again. Fail better.”
Such approaches are not solutions because they fail to accurately diagnose the sources of the crisis. Because psychiatry, like the rest of medicine, is deeply imbued with scientific positivism (that real science is free of social values) and methodological individualism (that social processes are merely the aggregate outcome of individual behaviours), it cannot fully grasp that all health and illness — mental and physical — is both socially embedded and socially constructed. Therefore it cannot critically reflect on its own social nature, its own ideologies and practices that are inextricably bound up with wider social conflicts.
The reaction by American psychiatry to its 1970s crisis was to use diagnostic “reliability” to strengthen the appearance of the profession’s “scientificity”. That model served powerful interests in the psychiatric profession, academia, government bureaucracies, and the pharmaceutical industry, but has unraveled when so many of its claims to help those with mental health problems have been exposed as hollow. A new paradigm that doesn’t simply repeat those flaws cannot be built from above, not by DSM committees nor NIMH directors. It can only be built through the struggles of patients and clinicians for a mental health system driven by quite different social priorities.
Tad Tietze is a Sydney psychiatrist who blogs at Left Flank and was the co-editor (with Elizabeth Humphrys & Guy Rundle) of On Utøya: Anders Breivik, Right Terror, Racism and Europe. He tweets as @Dr_Tad.