On October 28, Allen Frances, MD, Chairperson of the DSM-IV task force, published an article on Psychology Today. It is titled Does It Make Sense To Scrap Psychiatric Diagnosis? and is essentially a response to the British Psychological Society’s Division of Clinical Psychology’s (DCP) call to abandon the medical model in situations where it is not appropriate, and to embrace a psychosocial approach. You can see a copy of the DCP’s May 13, 2013, statement here.
Dr. Frances identifies Dr. Lucy Johnstone, PhD as the “most articulate and energetic supporter” of the DCP position, and most of his article is directed towards material Dr. Johnstone has recently written on these matters. For ease of reference, Dr. Frances reproduces Dr. Johnstone’s material in his own article.
Dr. Frances sets the tone in the first sentence:
“I am always sceptical of suggested new ‘paradigm shifts’ and worry that ambitiously striving for them will wind up causing more harm than good.”
Dr. Frances lists three examples of proposed paradigm shifts that, in his view, have caused, or will likely cause, more harm than good.
“DSM 5 failed so badly precisely because it promised a ‘paradigm shift’ in psychiatric diagnosis.”
In support of this position, he suggests that the revised manual:
“…may mislabel as mentally ill millions of normal enough people who would do better left alone.”
This, of course, is an interesting perspective, though in my view DSM-5 is failing, not particularly because it sought a paradigm shift or because it continued the APA’s long-standing expansionist agenda, but because psychiatric concepts and practices generally are being exposed as spurious and destructive. The publicity surrounding the release of DSM-5 gave impetus to this movement, but the general anti-psychiatry sentiment was already well established when the manual was printed. It is also arguable that DSM-IV, of which Dr. Frances was the architect, widened the diagnostic net at least as much as DSM-5 is likely to do.
“The National Institute of Mental Health has neglected the current needs of the mentally ill because of its preoccupation with producing a ‘paradigm shift’ in understanding the neural networks that cause psychiatric problems.”
“Dreams of the future potential of a neuroscience ‘paradigm shift’ have blinded NIMH to the crying needs of patients in the present.”
I could quibble with some of Dr. Frances’s terminology here, but at a more substantive level, I think it is inaccurate to describe the NIMH’s RDoC program as a paradigm shift. It’s actually just an extension of what psychiatry has been promoting for decades: that human problems are best conceptualized as brain illnesses and are best treated with drugs, ECT, and lately, other biological interventions. Dr. Insel and the NIMH may like to think of RDoC as a paradigm shift, but it isn’t.
“… the Division of Clinical Psychology (a sub-section of the British Psychological Society) has issued a statement announcing its own opposite brand of radical ‘paradigm shift.’ While paying superficial lip service to the role of brain in generating mind, the DCP suggests abandoning altogether what it regards as an overly restrictive biomedical model- it would eliminate any role for psychiatric diagnosis and instead focus on the role of external stressors in generating symptoms.”
Somewhat by way of an aside, there is a confusion here that needs to be clarified. Under the present psychiatric system, the primary objective of the initial interview is the assignment of a “diagnosis.” This “diagnosis” then becomes the basis of “treatment.” If the “diagnosis” is, say, depression, then the “treatment” will be an antidepressant; if schizophrenia, the treatment will be a neuroleptic, and so on. Then as treatment progresses, the drugs are changed, doses adjusted, etc., in response to client feedback. The presenting problem(s) are conceptualized (spuriously) as caused by the diagnosis, and little or no attention is paid to other matters such as personal history, social supports, lifestyle, economic issues, etc… This is what’s meant by the medical model. What’s particularly noteworthy about this model is that in medical matters, it is very effective. If a person has complete kidney failure, for instance, his likely diagnosis will be end-stage renal disease (ESRD), and this diagnosis gives the nephrologist a great deal of the information he needs to provide excellent care. The nephrologist will, of course, gather additional data in order to tailor make the treatment to the patient, but an accurate diagnosis constitutes the bulk of what he needs to know in order to design good and effective treatment.
But, and this is a crucial point, problems of thinking, feeling, and/or behaving that are not biologically caused, are so varied and individualized as to their source and presentation, that they simply are not amenable to this kind of approach. A DSM diagnosis, which is nothing more than a notoriously unreliable label, provides very little of the information that a helping professional needs in order to provide good and effective help, and often presents no useful information at all. In fact, it is frequently a hindrance.
So when Dr. Frances characterizes the DCP’s position as calling for the elimination of “…any role for psychiatric diagnosis and instead focus on the role of external stressors in generating symptoms…,” he is simplifying the DCP’s position to the point of caricature, as even a cursory reading of the DCP’s paper will attest.
The charge of “paying lip-service to the role of brain in generating mind” reflects a misunderstanding of the DCP paper. The paper clearly acknowledges the role of the brain in the production of thoughts, feelings, and behaviors, and specifically recognizes the value of the DSM’s system in “conditions with an identified biological aetiology.” [emphasis added] What the DCP paper challenges is the assignment of “an unevidenced role for biology as a primary cause” [again, emphasis added] in mental problems generally.
But to get back to the main thread, essentially what Dr. Frances is saying is that what’s needed is a middle way. Those who see mental problems as purely biological, he tells us, are in error, as are those who see these problems as purely psychosocial. He advocates a biopsychosocial approach, and he develops this theme for the rest of the article.
Dr. Frances begins this discussion by listing the areas in which he is in agreement with Dr. Johnstone and the DCP.
- Biomedical reductionism is simplistic and misleading.
- Mental distress must be understood in its context.
- There are many ways of dealing with emotional difficulties, and excessive professional competition is unhelpful.
- Limitations in current knowledge of the brain and behavior call for humility.
Then he turns to areas of disagreement.
“But then there are our areas of continuing disagreement. I fear that you [Dr. Johnstone] would replace biological reductionism with a psychosocial reductionism that is equally incomplete, and potentially harmful to patients. Human nature encompasses the complex interaction of biological, psychological, and social factors and understanding and treating psychiatric symptoms requires adequate recognition of each. The biological model has been greatly oversold and medication has been greatly overused- but both remain essential if kept in their proper place.”
It should be noted that psychosocial reductionism is a kind of contradiction in terms – at least as the term is being used here. This has already been pointed out by Duncan Double in a recent post. But I think it is reasonably clear that Dr. Frances means focusing on psychosocial factors to the exclusion of biological factors.
“Human nature encompasses the complex interaction of biological, psychological, and social factors…”
This part of the sentence is true, but doesn’t say very much. All it says is that we humans are made up of biological tissue; and that we can think, feel, learn, etc.; and that we interact a good deal with one another. But Dr. Frances uses this obvious truism as a springboard for the second part of the sentence:
“… and understanding and treating psychiatric symptoms requires adequate recognition of each.”
This assertion is the central issue of the entire debate, but Dr. Frances has just tucked it in under the biopsychosocial platitude as if it followed logically therefrom, which it does not.
Let’s consider the analogy of Mr. Jones, a businessman, who is in financial difficulty. He goes to his banker to negotiate an extension to his line of credit. Imagine if the banker said something like this:
“Mr. Jones, you are a biopsychosocial organism, and for that reason, I need to factor all of these perspectives into your loan application. So let’s start with your childhood illnesses.”
Or take the case of a person who consults a lawyer to sue his employer for false dismissal. Would it be reasonable for the lawyer to begin the interview by reviewing the individual’s medical and social history, purely on the grounds that the client is a biopsychosocial organism?
Or if a person went to see a surgeon to have a hernia repaired, how appropriate would it seem for the surgeon to perform a detailed survey of the person’s psychosocial history, again on the grounds that the patient is a biopsychosocial organism.
One can readily think of hundreds of similar examples. The central point is: yes, we humans are indeed a complex composite of biological, psychological, and social factors. We can also be conceptualized from political, economic, historical, evolutionary, artistic, ethnic, linguistic, etc., perspectives. But this doesn’t mean that all of these factors have to be addressed every time a person seeks help. To the surgeon, I am primarily a biological entity; to the lawyer, I am primarily a citizen with certain statutorily-defined responsibilities and rights; to Wal-Mart, I’m a consumer with money in my wallet; to a teacher, I’m someone seeking knowledge; etc…
The essential point here is that each practitioner focuses on those aspects of my human nature that are appropriate to the situation. Of course a certain amount of spillover is warranted in certain cases. For instance, a surgeon working with a frail, elderly person might want to ensure that the person will have adequate post-surgical care at home, but these kinds of matters, though often important, are usually incidental rather than central.
From this perspective, let’s take another look at “…understanding and treating psychiatric symptoms requires adequate recognition of each.”
My position is simple: if a problem of thinking, feeling, and/or behaving stems from a biological illness or malfunction, then it should be treated biologically. Some “spillover” into the psychosocial area might be warranted, but it would be incidental and secondary. The problem is a genuine medical matter, and a medical model is appropriate.
On the other hand, if the problem is a function of psychosocial factors, which, I contend, the vast majority of these problems are, then it is along those lines that the problem should be conceptualized and addressed. Here again, spillover will occur. For instance, if a person has been neglecting his health because of a psychosocially-induced problem, then some medical care might be needed. But the problem itself is not medical in nature. The medical model is not an appropriate conceptual framework, and medical interventions are not called for.
At the present time (with the exception of the due-to-a-general-medical-condition category and some of the substance abuse categories), no DSM “diagnosis” has been definitively linked to an identifiable biological illness or malfunction. No psychiatric drug in current use fixes or resolves any biological malfunction, and there is growing evidence that the drugs are doing a great deal of harm.
Dr. Frances mentions other areas of disagreement and discusses them briefly. He cautions against over-reliance on psychiatric diagnosis, but warns also against abandoning it altogether. He agrees that psychiatric drugs are over-used, but stresses that sometimes they are needed.
He concludes his piece with a very reasonable-sounding summary:
“The integrated bio/psycho/social model has a long tradition and remains the best guide to clinical practice. It has always been threatened by reductionisms that would privilege one component over the others- but this interacting tripod of bio/psycho/social approaches is unstable and incomplete without the firm support of all three of its legs. In my view, it is equally mistaken to call for a premature ‘paradigm shift’ tilting toward biology (as was suggested by DSM and NIMH) or a ‘paradigm shift’ tilting toward the psychosocial (as was suggested by the DCP). An integrated bio/psycho/social model is essential to understanding each patient and also to unite the mental health professions.
And we certainly need to be united. Mental health care is terribly disorganized and grossly underfunded, especially (but not exclusively) in the US. I think we should find a unified voice to advocate for better care, not be distracted by debates about paradigm supremacy—especially since all three paradigms are absolutely necessary.”
All of this sounds very reasonable, but let’s take a look at the details. Firstly, the “integrated bio/psycho/social model” does not have a long tradition – at least not here in the US. In this regard, the only mental health tradition that I am aware of is the inexorable expansion of the diagnostic net through successive revisions of DSM, and the corresponding medicalization of an increasing array of human problems. Lip service is paid to psychosocial factors, but in practice they are trivialized or ignored.
“An integrated bio/psycho/social model is essential to understanding each patient and also to unite the mental health professions.”
Here again, this sounds very good, but I suggest that it simply isn’t true. If a person is going “crazy” because of late-stage syphilis, then, I suggest, psychosocial factors have little or no relevance. On the other hand, if a person is depressed because his wife has left him, his daughter is in jail, and he hates his job, then, I suggest, biological factors are largely irrelevant. There might, of course, be “spillover” in each case as discussed earlier, but this is incidental to the general position.
“…to unite the mental health professions.”
This is a complex issue, but I don’t think there will be any significant easing of tension between psychiatry and the other mental health professions until psychiatry abandons what has clearly been its mission for the past 50 years: the medicalization and commandeering of an ever-increasing range of human problems. Some problems of thinking, feeling, and/or behaving are indeed medical matters. Others (probably most) are not. At the present time, psychiatry is giving no indication that they appreciate this distinction. In fact, I would argue that the very act of putting a problem in the DSM medicalizes the matter.
Dr. Frances himself acknowledges that “…the biological model has been greatly oversold and medication has been greatly over-used…,” but he doesn’t seem to take on board just how damaging and destructive these developments have been and continue to be, both to individuals and to society in general. Against this background, his notion that an “integrated bio-psycho-social model” will unite the mental health professions strikes me as fanciful, if for no other reason than the fact that psychiatry appears to be moving further and further from such a model with each passing year. On September 29, Jeffrey Lieberman, MD, President of the APA, was interviewed on 60 Minutes. The reporter asked him:
“This [schizophrenia] is really a disease of the brain. Not a disease of the mind?”
To which Dr. Lieberman replied:
Dr. Frances suggests that we find “…a unified voice to advocate for better care, not be distracted by debates about paradigm supremacy…”
Here again, in my view, he’s missing the point. This is not some kind of turf war, where we all need to just stop squabbling and sit down and work together. It is precisely because we “advocate for better care” that we challenge the psychiatric orthodoxy, and call for a paradigm shift. Decades ago, psychiatry formed a destructive and corrupting relationship with pharma, the results of which persist to this day. The expansion of the “diagnostic” net was not an accident – it was policy. The prescribing of drugs for an ever-increasing range of human problems (even to the point of giving neuroleptics to 2-year-olds!) was also policy. The rift between psychiatry and the other mental health professions is of psychiatry’s making, and it emphatically is not a matter of perceptions, professional rivalry, or turf wars. It is a real rift. There is a fundamental incompatibility between the bio-reductionist approach that psychiatry has so avidly embraced, (and shows no sign of relinquishing), and the approach of most other helping professions. Most of the non-psychiatric professionals I encountered during my career saw the DSM diagnosis as an inane procedure mandated by psychiatry, for its own self-aggrandizing purposes, to which all must conform if they wish to have a seat at the table.
It is obvious (or at least obvious to me) that the medical paradigm is supreme in medical matters, and the psychosocial paradigm is supreme in psychosocial matters. The only professional group that disagrees with this position are the psychiatrists, who insist that the medical paradigm is supreme in all matters.
What has changed in recent years is simply this: psychiatry has pushed its spurious and destructive practices so far that survivors and non-psychiatric mental health workers are no longer willing to just go along.
Sometimes a paradigm shift – meaning a sea-change in concepts and practices – is what’s needed. When the oxygen theory of combustion supplanted the old phlogiston theory, there was no question of a compromise. There was no possibility of the two sides sitting down, recognizing the value of each other’s contribution, and agreeing to respect each other’s position. There was no oxy-phlogistonic approach, nor should there have been. The simple fact is that some explanatory concepts are better than others. And psychosocial concepts provide a better framework for understanding and responding to psychosocial matters than do medical concepts.
Psychiatry’s medicalization agenda should have died a natural death (from lack of evidence) decades ago, but has been kept alive through pharma money and psychiatric lobbying and hegemony. It is truly time for a paradigm shift, and the DCP’s paper is a very good starting point. Dr. Frances makes the point that the DCP’s approach is untried and unproven, and for that reason should be treated with caution. I suggest that he talk to social workers, counselors, psychologists, case managers, job coaches, and other non-psychiatric professionals working in the mental health field. I believe he will find that few if any of them rely on psychiatry’s medical model as a conceptual basis for their work. They pay lip service to it, of course, because in the end of the day, they need their jobs. But the concepts and practices that drive their day-to-day interactions with their clients are emphatically psychosocial. And if Dr. Frances will listen very carefully, I think he will find that these concepts and practices are very similar, though perhaps not as formally stated, as the DCP proposals.
Far from being untried and unproven, the DCP’s paradigm is the unspoken philosophy of the non-psychiatric mental health workers. These are the dedicated backbone of the mental health system, who for decades have watched with consternation as increasing numbers of their clients have been sucked into the insatiable maw of pharma-psychiatry.
I don’t doubt Dr. Frances’s sincerity. He appears to believe that the widening rift between psychiatry and the other helping professions can be resolved through dialogue and mutual respect. Perhaps, in this regard, he sees himself in a mediator role. But no amount of discussion, however amiable or well-intentioned, will alter the fact that problems that are psychosocial in their origin and in their nature are not amenable to medical intervention. In fact, medical intervention has proven disastrous for many of psychiatry’s clients, and psychiatric survivors are speaking out with increasing frequency and vigor against the stigmatizing and destructive treatment that they received at the hands of psychiatrists. To the best of my knowledge, psychiatry is the only medical profession that has a survivor movement.
But again, Dr. Frances doesn’t seem to get it. In his October 21, 2013, dialogue with Patrick Bracken, an Irish psychiatrist and a founding member of the Critical Psychiatry Network, Dr. Frances expressed the belief:
“Psychiatry is still by far the most human and humane of the medical specialities.”
In response to which I can only shake my head in disbelief.