Note: This article is in press on the “Deliberately Considered”blog.
“PSYCHIATRY’S GUIDE IS OUT OF TOUCH WITH SCIENCE, EXPERTS SAY” : SO WHAT’S NEXT?
By Jeremy D. Safran, Ph.D.
Tuesday’s (May 7, 2013) New York Times published an article with the headline:
“PSYCHIATRY’S GUIDE IS OUT OF TOUCH WITH SCIENCE, EXPERTS SAY.”
Written by science reporters, Pam Belluck and Benedict Carey, the story
describes an important new initiative by the National Institute of
Mental Health (NIMH), the largest source of federal funding for
mental health research.
This initiative will replace the soon to be published fifth edition of the Diagnostic & Statistical Manual of Mental Disorders (DSM-5), with a new framework for guiding research and focusing funding priorities in mental health research. Belluck and
Carey’s article emphasizes the optimism and excitement shared by a
number of prominent experts about the adoption of this new framework,
known as the Research Domain Criteria (RDoC). In order to understand
the true significance of this development, I believe it is important
for us to have a greater appreciation of the broader context in which this
important change is taking place.
Towards the end of May, the American Psychiatric Association will
release its new edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5). This long awaited update of the DSM
(colloquially referred to by some as the “Bible of Psychiatry”) has
been the focus of considerable prepublication controversy among mental
health professionals, has been discussed extensively in important media outlets
including The York Times.Previous editions of the DSM have also received some
degree of media attention. But DSM-5 has raised the intensity of the
controversy to unprecedented heights, in part because of the widely publicized
criticisms of psychiatry insiders including Allan Frances (the chair
of the task force that developed DSM-4) and Robert Spitzer (who chaired the DSM-3 task
force). Criticisms of DSM-5 are similar in nature (if not intensity)
to those which were leveled at both DSM-4 and DSM-3. For example,
claims for the degree of reliability of diagnostic categories are
exaggerated, evidence regarding the validity of the diagnostic
categories is limited, and experiences that are inevitable aspects of the
human condition (e.g., sadness, mourning, anxiety) are increasingly
viewed as symptoms of mental illness to be treated with medication. An
important aspect of the criticism is directed at the rapidly
accelerating tendency to overprescribe medications for emotional
distress with dubious effectiveness and potentially serious side
effects. A more fundamental criticism of DSM-5 (also leveled at the
previous two editions of the DSM) is directed at the disease model of
psychiatry, which views emotional problems as similar in nature to
physical illnesses such as tuberculosis, heart disease or cancer.
Critics are also concerned about the potential for stigmatization of
everyday problems in living.
Motivated by factors including the intensity of the controversy about DSM-5,
the accumulating evidence that the new generation of psychiatric medications
are not delivering on their initial promise, and in all probability
the Obama administration’s avowed intention of investing 100 million dollars
in the field of brain science research, NIMH has held a series of
workshops over the past 18 months, to develop the RDoc framework described in
Belluck & Carey’s article. This shift in NIMH funding policy has taken place so
recently that there has not yet been an opportunity for extensive conversation
within professional circles (let alone the popular media) regarding
its pros and cons. A few informal exchanges I have read on
professional listservs have an approving tone to them. There have, for
example, been expressions of glee about what can be interpreted as a
development heralding the demise of the entire DSM system, with all of
its associated flaws and potentially pernicious side effects.
From my perspective, however, as a psychotherapy researcher and
someone who has served on NIMH grant proposal review committees over
the years, this policy change is nothing to celebrate. Although I have
long been a critic of the DSM system, this NIMH policy change and the
framework for the new RDoc system, make it very clear that the
fundamental premise guiding future NIMH funding priorities is that the
bedrock level of analysis is genetic, biological and brain science
research. As Thomas Insel, Director of NIMH said in an interview
conducted on Monday, May 6: “The goal of RDoc is to “reshape the direction of
psychiatric research to focus on biology, genetics and neuroscience so
that scientists can define disorders by their causes, rather than
their symptoms” (quoted in Belluck & Carey’s NY Times article, May 7,
2013). This is a perpetuation and expansion of a trend that has been
taking place at NIMH for many years now, that privileges the
biological over all other levels of analysis (e.g., psychological,
emotional, social). An important consequence of this trend has been
that the proportion of NIMH funding allocated to psychotherapy
research and other psychosocial interventions (e.g., modifying the nature
of health delivery systems) relative to the brain sciences has been consistently
diminishing over time.
The new paradigm for research that NIMH is adopting, means that the
amount of funding available for the development and refinement of
treatments such as psychotherapy that are not targeted directly at the
brain circuitry (although they do influence it indirectly), is likely
to continue to shrink, I want to be perfectly clear that I do not
question the potential value of brain science research. What
I do question, however, is the single minded emphasis on brain science
research to the virtual exclusion of all other forms of mental health
research. It is important to recognize that funding priorities shape
the programs of research pursued by scientists, and thus the type of
research findings that are published in professional journals and
disseminated to the public. This in turn shapes the curriculum in
psychiatry and clinical psychology training programs, which shapes the
way in which mental health professionals understand and treat
psychological and psychiatric problems. In concrete terms this
explicit NIMH policy shift is likely to mean that despite the large
and growing evidence base that a variety of forms of psychotherapy are
effective treatments for a range of problems, we are likely to
continue to see a decreasing availability of the already diminishing
resources that can provide high quality psychotherapy for those who
can potentially benefit from it.
Jeremy D. Safran, Ph. D. is Co-Chair & Professor of the Department of Psychology, New School for Social Research and former Director of Clinical Training. He is also on faculty at the New York University Postdoctoral Program in Psychotherapy & Psychoanalysis; and Past President of the International Association for Psychoanalysis & Psychotherapy. His most recently published book is: Psychoanalysis & Psychoanalytic Therapies (American Psychological Association Publications, 2012).