Treating the elusive diseases

15 May

Today sees the occurrence of a once-a-decade event for the mental health profession: the release of a new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). First published in 1952 and now up to its fifth incarnation, the DSM is the ‘bible’ of psychiatry and psychology, and provides the categorisation of behaviours and symptoms that are used to diagnose mental disorders.

Over the years the usefulness, validity and future of the DSM has been increasingly under debate. Sandwiched between opposing viewpoints, it is as frequently criticised for being too inclusive (does the DSM pathologise normal human experiences, allowing feelings such as shyness and grief to be mislabelled and treated as anxiety and depression?) as it is for being too exclusive (do narrow diagnostic criteria prevent children with Autistic Spectrum Disorders from accessing treatment?).

DSM crushing difference

DSM crushes difference

Recent attacks on the DSM, however, suggest  that the tool itself is not only faulty but fatally flawed; an unscientific method of applying medical knowledge and a failed attempt to assist the mentally ill.

The alternative that’s been suggested: to place research firmly back in the realm of ‘science’. This rejection of the DSM as unscientific and the implication that psychiatry must find a ‘new’ home in scientific research carries a seductive potential: the temptation to reject experience and fall into biological essentialism.

Stay with me here.

Mental health is and has always been a minefield of scepticism, passion, subjectivity, research, statistics, lived experience, biological essentialism and compassionate support. From the community support worker to the neuroscience lab-researcher, the profession is stretched over such diverse theory and practice as to almost reach breaking point.

Psychiatry/psychology has always had a chip on its shoulder. As a psychology student I was constantly reminded that the discipline had long ago abandoned its unscientific, Freudian roots and was now living in the light: a field with a soul closer in character to biology than social work.

Over a 6-year degree I was alternately caught up in this hyperactive self-defence and deflated by the way it derailed discussion of genuinely interesting questions. When we were tackling motivation at the chemical level, with rats, stats and minutely changing experimental variables, where did we lose experience? What is it like to have a functioning mind? Or one that is broken?

I always felt like there was too much pressure on psychology: too great an expectation for such a young science. Competing with physics, biology, chemistry (those wizened, millennia-old ancients of natural history), 100-year old psychology is a baby. Watching people rage at its ineffectiveness is like watching a 5-year-old kid being chastised by insanely unreasonable parents for not growing facial hair. It’s just too young to keep up. The result is that this unsubtle, raw, child-like discipline is crippled with self-doubt and self-loathing. It turns away from what makes it unique and pretends to be the adult it admires.

The result is that many see neuroscience as the holy grail. Ferris Jabr of Scientific American says that ‘The ultimate goal [of the discipline and its research] is to provide new biological targets for medication’. This is the pull of biological essentialism that promises to solve all our problems and neatly categorise people. How seductive: looking at a brain scan and immediately diagnosing a patient as suffering from schizophrenia. Or as experiencing mere grief, not the major depression that the patient had reported. No more grey areas: each person could be labelled ‘disordered’ or ‘just another form of normal’.

But where is the person in this process? When we have such good evidence that cognitive-behavioural, family and other therapies work in many cases of mental illness, why do we insist on reaching for medical solutions?

More disturbingly, I wonder if it might also be desperate attempt to corroborate the very existence of mental disorders: to see mental ill-health and thereby justify its treatment. Does mental health really exist if it’s just a cluster of symptoms and experiences?

The sad reality is that the promise of biological essentialism is a hollow one. Mental illness is a flexible continuum of experience, which can be reflected in a myriad of different ways within the grey matter that conducts it. Our understanding of the brain is improving rapidly, but until our understanding of the experience of mental disorder is as well understood, we can find no correlation between the two. Mental health research is under incredible pressure to ‘objectify’ those experiences. We are at a permanent crossroads: in the search for their disorder, do we abandon the patient themselves?

Psychology and Psychiatry are not perfect, and the DSM, despite its popular label, is no ‘bible’. Torn between objectivity and subjectivity, mental health professionals struggle daily to balance this philosophical tightrope; but ultimately, they are the people in contact with those who suffer. They are best placed to understand the DSM – both its capacity to help and its many limitations. It is sufficient to know that it is not, and professionals do not employ it as, an infallible guide. It would do skeptics well to acknowledge that other approaches are also fallible.

We need to give psychology a chance to develop, to spread its wings. In a world of instant facts about almost anything we should wish to plug into a search engine, it comes as not only a shock, but an incomprehensible one, that we could be so woefully ignorant of our own minds. To learn and begin the long road to understanding, we must acknowledge the subjective, and turn to ask questions of those with both mental health difficulties and successes: ourselves.

EDIT: This article from Sydney University’s Paul Rhodes does a much better job of articulating similar ideas 🙂

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