The DSM is dead! Long live the … wait a minute …

Gustave Dor%C3%A9   Miguel de Cervantes   Don Quixote   Part 1   Chapter 1   Plate 1  A world of disorderly notions%2C picked out of his books%2C crowded into his imagination  - The DSM is dead! Long live the ... wait a minute ...

For years we in the Existential Psychology have been shouting at the top of our lungs that the DSM is a fatally flawed approach to mental health. 

We’ve pointed out that there are no empirical bases for its categories, that its treatment approaches are often arbitrary, and that the entire exercise takes time, energy, and money, away from more useful approaches.  The emperor not only has no clothes:  he’s ugly, too.

It looks like we’ve won that battle.  This week the National Institute of Mental Health announced that it will no longer be focusing its grant money on DSM categories. 

“The weakness,” Thomas Insel wrote on the NIMH website, “is its lack of validity.”

Well, yeah.  You’re a little late to that party.

There should be dancing in the streets.  But oh, be careful what we wish for.  Instead of turning away from the fallacy that the best way to understand the mind is ro treat it the way you’d diagnose a radiator or a timing belt, the NIMH has decided it will invest in research to create new diagnostic categories that will leave out any and all need to actually talk to patients. 

“Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,” Insell writes.  “Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.” 

What this means, if the NIMH has its way, is that you won’t tell your doctor your depressed:  your doctor will tell you.  Your neural patterns and genetic markers will tell them everything they need to know. 

Imagine that world:  mental health care professionals will tell you when you’re depressed, and when you’re happy, and when you should be satisfied with life.  Don’t even think of arguing:  they’re professionals.  They don’t need to hear from amateurs.

Even as it notes that the DSM approach has no validity, not once does the NIMH suggest ever taking a truly different approach, or better researching the outcomes of therapeutic interventions, or thinking of human beings as people with unique aspirations and a drive to live a meaningful life. 

That is to say, the NIMH isn’t offering a real alternative to the DSM:  rather, they’re doubling down on the fallacy that the DSM was pursuing in the first place.  That the mind is best understood as a computer, and when your computer breaks you don’t talk to it or ask it how it feels.  In fact, you don’t even let the computer decide whether it’s broken or not.  If it’s not behaving according to spec, you get it fixed.

Doubling down on a failing delusion is a sadly common strategy.  Therapists see it in patients all the time.  No one has yet found a biological basis for it, though:  sometimes human beings just delude themselves.

Now to be clear:  some very clever people will no doubt do some very clever research under these premises, and some useful things will be learned.  The brain can indeed malfunction, and when it does a biological fix is sometimes … sometimes … the best treatment. 

But all the critiques of the DSM made by existential-humanistic psychologists – which the NIMH now acknowledges were RIGHT – are equally valid when applied to this new approach.

Just because some mental problems correlate to biogenetic issues doesn’t mean all mental problem are caused by them.  In fact, the vast majority of what people seek help for – mild-to-medium depression, anxiety, a search for what’s important in life, self-knowledge, self-sabotage, and yes let us not forget marital conflicts (to name just a few) – have no basis in biology at all, beyond our common humanity.

Nor is it clear that many major symptoms are in fact caused exclusively by biology instead of a highly mediated combination of biology and culture.  An increasing body of research is suggesting that every aspect of how “mental illnesses” manifest, from where to when to howto how they go awayare in fact highly influenced by culture.  “Mental illness” may in that sense be like epigenetics:  biology and environment are so inter-twined that any attempt to minimize the impact culture and environment has on the expression of genes is absurd.

An Afghanistani woman living under the Taliban who is depressed because she isn’t allowed to read doesn’t suffer from a brain disorder.  Neither does a middle-aged American man who’s sad because he no longer loves his wife, or a Japanese teenager who isn’t sure if she wants to live up to her parents’ expectations, or an Israeli soldier struggling to keep his conscience in the midst of conflict.  They don’t’ need pills and they don’t need gene therapy or neuro-enhancement..  What they’re looking for, when they look for help, is something much more like therapy.

To be human is to suffer.  To struggle with that suffering is equally human, and vitally important.  How we respond to those in the midst of that struggle, how we help them, says a great deal about who we are.

By all means study the brain, study genetics, study the body and its chemicals.  But never forget that “mental health” cannot be reduced to these things, or found in them.  The mind is not a valve, or an engine, or even a computer.  Treating it as such leads only to absurdity. 

We were right about that decades ahead of the NIMH.  We’re still right, and will just have to keep proving it until the search for a quick fix … a form of mental health that alleviates the need to know and understand patients as people … is finally revealed as one more windmill that’s been tilted at for too long.


— Benjamin Wachs

Benjamin Wachs archives his writing at

Read more Benjamin Wachs at The New Existentialists


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