A Post-DSM Research Agenda
I have been arguing for many years in books like Rethinking Depression that the DSM ought to be repudiated. In recent months this idea has been gaining tremendous momentum and just recently the National Institute of Mental Health essentially repudiated the DSM.
This is great news and perhaps the beginning of a movement in the direction of a smarter and more truthful understanding of human distress. But where should we go next in this movement? Below are some thoughts on what a “new agenda for mental health” might look like.
- If we want to start fresh and do a much better job of conceptualizing “mental health” and “mental disorders” so as to provide more help to sufferers, what sort of research agenda might we set? First, what do we mean by “research” in this context? Do we mean experiments involving human beings? Do we mean white coat science? Do we mean observation and empiricism? Do we mean statistical analysis? Do we mean thought experiments, as in theoretical physics? As a corollary question, ought graduate students who are obliged to do research be allowed to tackle large “meta questions” even if those efforts look more like natural philosophy than science?
- How might we conceptualize the task of rethinking mental health if research turns out to be out of the question? How, for example, could we research the nature of the complete or original endowment with which each individual arrives in the world? How could we research what quantity of sadness got generated by a stray cloud passing in front of the sun twenty years ago in the life of a given individual? How could we research what we mean by “normal” and “abnormal”? What if much of what we need to know can’t be researched? What, if any, are the alternatives to scientific research and by what criteria would we want to judge the soundness, reliability, or usefulness of each of these alternative approaches?
- What various definitions of “mental health” might be proposed? How might we characterize the underlying idea of each definition? If a given definition of mental health rested on some other construct like “good coping skills,” “resilience,” “high functioning in society,” “absence of undue emotional distress,” or “self-report of contentment,” what is our rationale for choosing that underlying construct rather than a competing one? Who would decide which definition of “mental health” ought to be used and by what authority would that entity get to make such a decision? As a corollary question, what category of person should be considered “expert” in the matter of defining “mental health,” given the poor record of current and past putative experts?
- What are the various possible relationships between “mental health” and “mental distress”? For example, is it reasonable to suppose that a person could be mentally healthy but also mentally distressed? Is it reasonable to suppose that a person could mentally unhealthy, whatever that phrase might mean, and also not mentally distressed at all? For example, might not a mentally healthy person be considerably distressed by the famine affecting his society and a mentally unhealthy person experience no distress as he commits a murder? If the relationship between “mental health” and “mental distress” isn’t straightforward, such that we are entitled to say that “the presence of mental distress means the absence of mental health,” what are various ways that we might conceptualize the relationship between the two? To put the research question differently, is there any “amount” of emotional distress the presence of which “generates” the label of “mentally unhealthy” or “mentally disordered?
- What are the current psychological models, how do we judge their strengths and weaknesses, and how do we tease out what we want a knowledgeable service provider to know from these models? What do we want to “do” with all the extent models? As a corollary idea, what constructs or concepts within a given psychological model are the strongest, truest, or most sensible? Even if a given theory, vision or set of opinions is not strong in its aggregate, how might we judge if a given idea within in it is useful? For example, might the idea of a “midlife crisis” be a useful or true concept irrespective of whether or not any other Jungian ideas are useful or true? How can we judge the strength, truth or importance of the countless concept that have already been generated?
- To what extent do we currently rely on self-reports to “diagnose mental disorders” and if that reliance is very high (or even total), on what else might we rely? What do we rely on in medicine to make diagnoses and to what extent is any of that apparatus currently available or logically applicable when it comes to “mental distress” or “mental disorder”? If what we are talking about has little or nothing to do with “the brain” and everything to do with “the mind,” on what should we rely in addition to or separate from self-reports from the individual? As a corollary idea, if we designate someone as entitled to “diagnose mental disorders,” what ought we demand that he or she rely on separate from or in addition to the self-report of the individual? If he or she says, “I observed the individual,” by what criteria shall we judge that what was observed amounted to a “mental disorder” and not something else? If he or she says, “I tested the individual,” by what criteria shall we judge the appropriateness or soundness of the test itself, given the way that psychological tests are constructed?
- How might we conceptualize an individual’s contribution to the maintenance of his or her emotional distress? If, for example, an individual agrees that she would feel less sad if she did x but is reluctant to do x, how might we conceptualize that reluctance? Might we say, for example, that it is “hard to make a change, even a desired one,” that there are “unconscious reasons for her reluctance,” that “not rocking the boat is more important to her than reducing her sadness,” and so on? What (presumably very many) hypotheses might we put on the table as to why people do not do what they know to do to reduce their mental distress and/or improve their lives? As a corollary idea, how might we ascertain, gauge or measure an individual’s contribution to the maintenance of his or her emotional distress? How can we know when and to what extent an individual is participating in the maintenance of his or her distress?
- What do we take “behavior” to stand for? What sort of marker is bed-wetting, “excessive” hand washing, “alcoholic” drinking, or a suicide gesture? What are the arguments for linking any given behavior to a construct called a “mental disorder” or a “disease”? If we claim that it is some single necessary linkage, like “lack of control,” how do we know if the individual lacks that control or isn’t exerting that control (see 6 above)? If an individual can go from “drinking alcoholically” one day to “entering recovery” the next, what did we mean by “lack of control” when and if we used it as a criterion for labeling? What, if any, are the ways that we can get at a true or accurate picture of the relationship between observed behavior and the generating cause or causes of that behavior?
- How should we conceptualize the differences between or the relationships between a behavior and an inner state? Tossing aside the book you’re reading is a behavior. Tossing it aside because it bores you or because it angers you reflects an inner state of mind, tossing it aside because it has become electrified is a behavioral reflex, tossing it aside because a policeman orders you to toss it aside reflects a social interaction, and so on. Tossing the book aside is an “observable behavior” but what is means is not known simply by observing such an action out of its human context. How can we conceptualize the task of relating observable behavior to the “causes” or “sources” of that behavior?
- How do we retain the sense that a human being is involved here? Humanistic psychology, person-centered psychology, and existential psychology, to name a few “psychological orientations,” explicitly state that the individual is a member of a certain species with certain human desires and challenges, that he or she must be consulted, respected, and understood, and that a “real person” is different from a “patient.” Other orientations take different stances and in the current “medical model” we have lost the person entirely. How might a human being’s “individuality and instrumentality” be conceptualized, do we know enough to do that conceptualizing, and if we don’t know enough where should we err, on the side of “acting as if” the individual is a person, a collection of dynamic forces, a symptom generator, or something else? How might we tease apart “the place of the person” with respect to the provision of mental health services?
- In line with the above, what shall we call a person who walks into the office of a “mental health service provider”? Since there are many compelling reasons not to call that person a “patient,” shall we call that person a “client,” as that is the other term most often used in this context? Is there a better word to use than “patient” or “client” and what are the arguments for that better word or those better words? In some contexts we call a person a customer (when she enters a store), in some a client (when she hires a lawyer), in some a patient (when she sees her dentist), in some a parishioner (when she sits with her priest), in some a student (when she takes a class), and so on. What is the relationship with a mental health provider most like; and if it is different from all of the above, do we need a new word to communicate that difference?
- What will a “new mental health service provider” provide? If it is wise and necessary to repudiate the DSM “medical catalogue” approach and if we come to see that it is not appropriate or wise to act as if the interaction between client and provider is the “diagnosing and treating of mental disorders,” what will a person currently called a “psychotherapist” be doing or providing? Will in fact his or her “talk” not need to change at all? Has he or she been “simply providing counsel” all along and never really “diagnosing and treating mental disorders”? Will some providers need to completely overhaul what they do, insofar as they were operating from and invested in the “medical catalogue” model, but will perhaps other providers not need to change what they do much at all? As a corollary idea, what should the state claim to be sanctioning? If it acts as if there are “mental disorders to be diagnosed and treated” and demands that its licensed or certified professionals “play along” with this idea even if in their office they simply “offer wise counsel,” should this shadow game end? If so, what would the fall-out be and what might replace that model?
- If it turns out that the “wise counsel” model is the most appropriate model for service provision, how do we train “wise counsels,” how do we change curricula to reflect our new understanding about the logic and content of courses like “introduction to abnormal psychology” or “understanding the DSM,” and how do we genuinely distinguish between “coaching” and “psychotherapy”? In short, how do we conceptualize the change in the naming and training of “mental health service providers” to reflect the changes that might be considered? What do we do “with” or “about” all the existing psychiatrists, psychologists, marriage and family therapists, clinical social workers, and other “mental health service providers”? Do we allow them to continue on “as is” even if the game has changed? Do we demand that they make certain changes in their outlook and their practices, changes that they must somehow “prove” have occurred? If, to put it simply, it becomes common wisdom and our general understanding that there is no “mental disorder of depression,” can we allow mental health service providers to keep “diagnosing and treating depression”? What are our options in this regard?
- Whether or not we ever understand “what is really going on in the mind,” we nevertheless want to be of help to people seeking help with their “emotional problems.” Given that, what helps? How shall we research the “best treatment methods” given that we may well not be talking about organic problems but reactions to life challenges? How can we tease out the relationships between a given problem (say, deep sadness or chronic anxiety) and the best, most logical, or most appropriate “treatment methods” or “helping methods”? What do we take “work” to mean in this context: that a “symptom is removed,” that a person’s life is radically changed for the better, that the presenting problem (like grief) still remains but the individual can tolerate it better, and so on? We need a smart exploration of what “help” means in this human context, which “help” helps the most, and which “help” we ought to offer according to the problem presented (is the same “help” best for sadness, anxiety, “addiction,” etc.?)
- What might be the rationale for a given helping strategy or tactic? What is the legitimacy of that rationale? Can we perhaps employ strategies without knowing their rationale or without granting the legitimacy of that rationale if individuals report that the strategy has helped them? For example, should we grant dream interpretation a place at the helping table even if there is no proof that “dreams are the royal road to the unconscious” and even if the practitioner has no rationale at all for using it except to say, “I know it helps”? Is a self-report of reduced emotional distress or disturbance or some other self-report of ratification on a client’s part “enough” to validate helping methods? Or is perhaps such a self-report actually “the only” validation necessary? Would it even matter if it were “only” a placebo effect? How might this matter be conceptualized?
- What is cause and what is effect? When, for example, we see a certain pattern in a brain scan, how should we go about deciding whether the individual’s sadness caused that brain look or whether the brain look is actually telling us anything about the cause of his or her sadness? Is our sleeplessness a cause of our anxiety or is our anxiety a cause of our sleeplessness? What is cause and what is effect, what is chicken and what is egg, and how can this problem be best articulated and addressed? If perhaps we can’t ever know what is cause and what is effect, what helping strategies might we nevertheless employ in that absence of that knowledge?
- What do we mean by “reducing emotional distress” or “improving our mental health”? Is “feeling better” always the highest good or can the side effects or consequences of “feeling better” outweigh the so-to-speak undeniable benefit of not experiencing certain emotional distress or certain unwanted behaviors? For example, if a lobotomy would reduce or eliminate your emotional distress but also make you a zombie, is that too high a price to pay for “feeling better”? What are the “right” or appropriate prices to pay for feeling better? Is “feeling better” even the goal? How can these matters be conceptualized?
- How do we manage to “step back” and seize this moment as an opportunity to “change the game”? Given the variety of stakeholders, the history and customs of the trade, and the fact that the welfare and emotional health of hundreds of millions of human beings worldwide will be affected by any changes to the model and the system (including all the people taking “medication” for what may no longer be seen as “medical disorders or diseases”), how should we handle this moment and who handles this moment? An institution like the National Institute of Mental Health is obliged to go in a “scientific” direction but what is needed is meta-organizing by individuals who understand this moment, who are not tied to the need to do “more bad science,” and who have the ear of policymakers and a worldwide population. Maybe this is a moment for a “blue ribbon panel” but let us pray that not only the usual players are on it! If they are, it is unlikely that we will be able to seize this opportunity to rethink mental health.