Do We Need to See Inside the Box?

Sandra Steingard, MD
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Recent reviews have painted a dismal picture of treatment development for mental disorders.  This week, Dr. Thomas Insel, Director of National Institute of Mental Health announced that new guidelines will be used to determine what research gets funded.  Treatment studies will be required to “test for target engagement itself as a potential mechanism of disease,” i.e., there will need to be a focus on a “target” (brain function) with any new treatment study.  The intention is to insure that research will “speed the translation of emerging basic science findings of mechanisms and processes underlying mental disorders.” This is part of Dr. Insel’s response to the “dismal picture of treatment development for mental disorder.”

I once took it as axiomatic that it was important to understand the brain in order to reduce suffering of those who experience extreme (or even mild) emotional distress. But I am no longer so sure. I have written about this before “Is it all in your head?” I revisited this again when discussing a New Republic article about loneliness studies, “Thoughts on the meaning of neuroscience.”

What brought me back to this again today was a lovely article in the New York Times written by Ron Suskind about his son Owen who has experienced communication problems typical of young person who is diagnosed with autism. Suskind eloquently describes not only the family’s despair but their efforts to make contact with their son. The route into his world was in the careful attention they paid to his fascination with Disney movies. He was obsessed with them and in a process he describes in the article as Disney therapy, they were able to turn this observation into a road map of discovery. Along the way, the family had the help of many technicians – doctors, teachers, therapists. But it seems that it was the family’s interactions, their dedication to finding a way in, their curiosity abut knowing Owen’s world, and Owen’s receptivity to their overtures that was so important.

I am not an autism expert. I do believe that the brains of people labeled with autism are different from those of us who do not have those sorts of problems. I also believe that autism is not likely to be one thing but many things and it exists in the world in many shapes and forms and people with this label have varying degrees of impairment. I am not anti-research that tries to understand this from a basic neuroscience perspective. I imagine that the families of children who experience these problems would want to understand why their children have such problems. I know I would. If this happened in my family, I would want to know if there was a way my child could have been spared. None of us want our children to suffer.

But with Dr. Insel’s new proposal, I do not think they would fund an investigation into why the Suskind’s were able to be so helpful to their son. At least they would not do it if they did not also link it to some sort of imaging protocol. How many kids might opt out for that reason alone? How many fewer kids could participate due to the expense put into the imaging or blood tests or whatever it was that was linked to the study?

My favorite researcher is Daniel Kahnemann who summarizes his work and that of many others in his remarkable book, “Thinking, fast and slow.” He is a Nobel prize winner and his field of research is cognitive psychology. Over many years, he and his colleagues have learned what influences us to form conclusions about the world and make decisions. Although some of the work ultimately linked to imaging studies, the core of the work did not require any understanding of how the brain work at a cellular or network level. Yet his work has profoundly informed and enriched our understanding of human behavior.

I have learned that there is rich and important work being done around the world. Many of us know of Open Dialogue. But there is more: reflecting therapies of northern Norway, Carina Hakansson’s Family Care Foundation, Emotional CPR, Intentional Peer Support, Hearing Voices Network to name just a few. I recently read Michael White’s Maps of Narrative Practice and Jim Wilson’s The Performance of Practice. These were books of great humanity and wisdom. Even Gerry Hogarty and Deborah Greenwald’s Cognitive Enhancement Therapy, although firmly nested in the neurodevelopmental model of schizophrenia, is nevertheless largely about social engagement and perception.  The basic research did not inform this work nearly as much of the observations about what was difficult for people.

Frankly, I surprise myself with the conclusion that it is not essential to understand the brain in order to be of help to people experiencing emotional distress even in its most severe forms. It counters assumptions that seemed fundamental to me for so long. Yet, I am no longer sure we need to see inside the box, although I understand why we want to look.  The brain is such a remarkable organ. But as Dr. Insel points out, funding is not unlimited and priorities need to be made. Psychiatry is nowhere near to being the clinical neuroscience that he envisions it to be, and prematurely acting that way is not without hazards.

Perhaps we would need resources outside of the federal government to explore them, but there are important avenues of exploration that – although less technological – are worthy of our interest.

42 COMMENTS

  1. Thank you Sandra for this most beautiful post, describing some very essential things about being a human and the problems which come when we tend to behave as if it would be possible to catch human life into a box and give a name to it. Former Tom Andersen used to talk about how language sometimes bewitch us in the sense that we give a name to a phenomena as if we by doing so think we know the truth. As for example the psychiatric diagnosis used each and every day by a lot of people as IF something called schizophrena or ADHD really exists.
    My experience from many years of practice, research and lived life is what you describe, the importance of presence and participation and to come from an authentic place when meeting another person. This does not mean that we shall not try our very best to understand human dilemmas and difficulties, but it means that we have to find out a better way to do it. As for example what is done on this webpage started by Robert Whitaker in order to examine research and practice. and in lots of other ways and places all over the world. We “just” have to see and value that it exists and that it is a brilliant alternative to the still dominant way of relating to human beings and human life.

  2. Perhaps Dr. Insel needs reminding that the brain is not the mind, nor the spirit. Families can be a great source of help, were we not so routinely discouraged by the professionals. In the Disney therapy article, Ron Susskind writes: “The speech therapist tamped down our enthusiasm. Dr. Alan Rosenblatt, our trusted developmental pediatrician, did, too. He explained that echolalia is a common feature in kids like Owen.” The Disney article reminds me a lot of the wonderful memoir, The Horse Boy, by Rupert Isaacson. Isaacson tells an unusual story of riding horses in Mongolia and visiting Siberian shamans in a search of healing. He had early on noticed that his son had an affinity with horses and shamans so decided to immerse himself in what his son was interested in to see if this had a curative effect. Isaacson makes the point that if your son or daughter is interested only in trains and numbers, then indulge their love for trains and numbers by joining them in their pursuits. The same applies to other mental health labels. Find out what your relative loves, and indulge them in their pursuit. Unfortunately, family empowerment is not the stuff that gets funded by the NIMH. If not supported in their efforts, families can be easily eroded in their beliefs that there relative can fulfill their potential. Support can simply take the form of hearing how others have helped their own family members. Not sexy enough for the NIMH since it doesn’t involve hard science.

  3. CBT is a straighforward psychotherapy that works for ‘Schizophrenia’. This means that ‘Schizophrenia’ is for the most part psychological or emotional. Or that ‘Schizophrenia’ does not really exist.

    I think the ‘Diagnosis’ and the Brain Research is just a Fraud on the Tax Payer. Theres enough evidence now to say that with basic help most people can recover productive lives.

  4. Thank you for this article. Even though Insel has criticized the DSM 5, this “research” initiative supports its nonsense just the same.

    I actually believe that in a few situations, the distress and dysfunction that some people have living in the world probably has a physical basis, and maybe studying that might be helpful.

    As for the other 95% of the emotional problems people may have, the NIMH initiative really means nothing, or worse. A child talking back to her parents or an elderly man grieving the loss of his wife of sixty years don’t have “disorders” or brain dysfunction, and of course I’m not saying anything here that pretty much any reader of MIA would disagree with. But the question is, what if anything does psychiatry have to offer for these problems?

    Brain studies, if done honestly, will be useless, and there is no reason to doubt either that results showing a correlation between brain function and emotional distress will be announced as showing causation.

    How do we move forward to a system of genuine helping or really, a society where people take their responsibility to their fellow human beings seriously?

    I am just groping with these questions myself now, but I do think we need less intellectual analysis and more moral commitment to find our way to that kind of helping.

    I apologize for this vagueness, but I think issues like this will always force us to struggle to find an answer. I wouldn’t trust anyone, including myself, who would claim to know what to do.

    Anyway, thank you again for this article.

    • “How do we move forward to a system of genuine helping or really, a society where people take their responsibility to their fellow human beings seriously?”

      Right, Ted. The Quakers had a pretty good success rate with their “moral therapy” in which they treated people like human beings and supported them until they were able to engage fully with life once again. It’s not rocket science. I agree with Sandra; we don’t necessarily need to know how everything works to be able to walk with people into healing and well being.

  5. Thanks for the thoughtful article. I have to say, I think Insel’s observation of the truth regarding the DSM is quite on target, but his solution continues to be based on an unproven assumption, namely, that out mind and our brain are synonymous. (I think Rossa said something similar above). It denies the obvious impact of what for lack of a better word I will call the spiritual being on the body and specifically the brain. I am not going to indulge in speculation on the nature of this apparent being, but merely point out that whatever it is, it appears to have a profound influence on our health and well-being. Or perhaps it is more correct to say that it is the agency that DETERMINES what health or well-being even means to us.

    To be more explicit, let’s take the “placebo effect.” Apparently, believing that something can help us can actually help us. So a BELIEF is healing. It should be obvious, and has been shown also, that beliefs can also be harmful or debilitating. How would any of this be “measured” in the brain? What is the target area for “trust” or “confidence” or “sense of purpose?” These things have no apparent correlates in the brain. And yet they obviously impact how we think, feel and behave, every bit as much and moreso than the profession’s sacred psychiatric pills.

    Another example is neurofeedback – apparently, a person can intentionally alter his/her own brainwaves to fit a particular pattern if they get feedback about when they’re being successful in approximating that pattern. And a person can be trained to do this eventually without any further feedback. So WHO IS ALTERING THE BRAINWAVES? If the brain is all, how can the brainwaves alter themselves? Obviously, there is an agent external to the brain, or superior to it, that can tell the brain what to do.

    Again, I don’t pretend to know what this agency is, but it is apparent that human beings have an agency that is able to dramatically influence brain function, both intentionally and unintentionally. If we only study the brain, we miss that boat completely before we even start. Which is why no one will every get money to study why “Disney Therapy” worked for that family. There is something at work in that example that transcends brain function. Something to do with meaning and dedication and purpose and unbending intention to solve the problem. There is no measurement of such things and no “genetic or molecular target” for them, either. They are aspects of the human spirit, whatever that is. And the human spirit, in my view, is something that measures, not something to be measured, and it will always transcend any efforts to quantify it. Until we admit that simple and obvious fact, our “research” efforts are doomed to failure.

    Sometimes it has nothing to do with the box at all. It has to do with who is controlling what goes in the box.

    —- Steve

    • Excellent points, Steve, and so articulately stated! I think you’ve hit on perhaps the central rotten core underlying all the peripheral problems in conventional biopsychiatry: the assumption, with apparently no acknowledgement that it is an assumption, that “we are our brains”. Or as one of my grad school psychology professors stated was the belief of some researchers, “all human behavior can be described as ‘squirts and twitches'” (i.e., neurons in action).

      So, am i my brain, or do i have a brain? And if it’s the latter (which i believe), what is this “i” that has the brain…and all the other intricately interrelated parts that comprise my incredibly complex physical body? Even if you leave out the spiritual dimension (which i do not) and deal strictly with the phenomenon of consciousness, it should be clear that human consciousness is not a biological entity. It seems that modern Western culture has been so steeped in materialism and reductionism that it can neither recognize or appreciate the absurdity of this!

  6. I haven’t really tried any of these official therapies, but as an analogy, I’ve greatly benefitted from my own system of diet, exercise (trekking, hiking, train running), basic stuff about creating new habits and meditation, all of these interrelated. I’ve read through books such as James Austin’s Zen and the Brain, which I’ve found quite interesting, though they haven’t probably greatly influenced the way I practice. It’s mainly interesting to me, though I guess there are some general level ideas about how the body or brain work that have been useful, things such homeostasis, neuroplasticity, etc. Actually, when talking of biology, I’ve lately been much more interested in what’s happening in our bodies also outside the brain, things such as metabolism, liver, glucose, ketogenic amino acids, cytokines, inflammation, fatty acids, etc. Also things such as epigenetic changes in body. I guess some of that stuff has been more useful than much of the neurostuff related to psychiatry, since they at least can help a bit in navigating the optimal things that may help.

  7. We are born to search for meaning, to reach out and to communicate with the world that surrounds us and do that our brain and mind are capable of changing and adapting to the environment we find ourselves in, in amazing ways. This does not occur in a vacuum. Our relationships are of such profound importance that our very lives depend on it including whether we grow into those we are meant to be or become stunted struggling to survive. Alice Miller talks about the fact that a child who grows up in a cruel and unloving family will have a different brain than that of a child who grows up in a kind and loving home. That to me is just so obvious yet, to look into the brain, scan it and see what lights up, add chemicals, shock it and cut and slice it up, is psychiatric everyday practice but that will never reveal just where in the brain the life story of a person can be found. Psychiatry has done untold damage by its insistence that the brain is a crude machine with a simple neurochemical wiring that they can ‘fix’.

    So no, we do not need to look inside “the box”, because the box is constantly changing to adapt to peoples unfolding life stories and peoples unfolding lives is something we can and do affect every single day through our relationships. Thank you for your post.

    • Olga

      I agree with what you say and appreciate the beauty of how you express it so very well.

      I’d like to hear how psychiatry accounts for neuroplasticity and the wonderful things it can accomplish for people. I suspect it throws a big monkey wrench into their little “chemical imbalance” theory.

  8. Sandy,

    If you are still around for this post, I would like to ask you if you are aware of the new book, Grain Brain

    Grain Brain: The Surprising Truth about Wheat, Carbs, and Sugar–Your Brain’s Silent Killers Hardcover

    by David Perlmutter (Author) , Kristin Loberg (Contributor)

    1,385 customer reviews

  9. Hi Sandy,

    I posted this above by accident before I completed it. Anyway, you may know that the author of this book, Dr. David Perlmutter, is a neurologist and he has been speaking on PBS about the nasty effects of wheat, gluten, bad carbs, sugar and the usual suspects that can contribute to many of the so called “mental illnesses” including “ADHD,” “schizophrenia,” “depression,” “bipolar,” etc. (As you must know it kills me to use these stigmas so they are in quotes! Grin.)

    Anyway, Dr. Perlmutter like many doctors including Dr. Mark Hyman, Dr. Joel Fuhrman and many others believe that diet/exercise plays a huge role in eliminating or exacerbating these symptoms. The web site Safe Harbor (Alternative Mental Health) takes a similar approach with mental health. I am very impressed with the above doctors and find their recommendations very helpful in achieving better health and well being. He advocates for exercise to help the brain as most experts do.

    Here is a link to Dr. David Perlmutter’s book:

    http://www.amazon.com/dp/031623480X/ref=rdr_ext_tmb

    Another favorite of mine for the neuroplasticity of the brain when changing bad habits is:

    You Are Not Your Brain: The 4-Step Solution for Changing Bad Habits, Ending Unhealthy Thinking, and Taking Control of Your Life Paperback by Jeffrey M. Schwartz (Author) , Rebecca Gladding MD (Author).

    You may know that Dr. Schwartz is a psychiatrist and I especially like and admire him because he has great faith that we can change our brains by understanding self defeating thoughts and mind sets that cause “OCD,” addictions and bad habits in general while not being a big fan of drugs and stigma. He also has web sites and articles on the web and has written other books I admire as well such as Dear Patrick.

    Here’s a link to Dr. Schwartz’ book:

    http://www.amazon.com/You-Are-Not-Your-Brain/dp/1583334831/ref=sr_1_1?s=books&ie=UTF8&qid=1394679278&sr=1-1&keywords=you+are+not+your+brain+the+4-step+solution+for+changing+bad+habits

    In keeping with our last exchange of comments, I am glad you reminded me of the articles you wrote about Is It All In Your Head? and Thoughts On the Meaning of Neuroscience you cited above. I thought these articles were great when I initially read them and I especially liked the latter article and the issues you raised about relationships and other factors being so important. You were right that you have been giving considerable and very worthwhile, encouraging attention to a wide range of factors and issues that are “outside of the box” of the rigid biopsychiatry stigmatizing and drugging agenda alone.

    The last time we exchanged comments, you had a pretty full reading agenda, but if you get the chance I recommend the top two books and/or at least checking them out on Amazon and other web sources along with reviews to get a better idea about them and how they might enhance brain function, thinking and well being in general.

    By the way, I just read an article in a science publication that if you took an extra minute when making decisions, you will make better decisions because you will be more focused and less distracted by other competing agenda. I thought of your being so impressed with Thinking Fast And Slow and this seems to fit into that concept. Would you agree?

    Have a nice night. Hope you get these comments and I look forward to hearing your thoughts.

    P.S. Looks like Dr. Nardo is doing some great things in his practice that are “outside the box” of just stigmatizing and drugging too, which made me quite pleased (especially when he “mentioned” three times that bipolar is greatly overdiagnosed and made my day!).

  10. Hi Sandy,

    Thanks for your response. I knew from your past comments that you are very interested in food and its effects with one of your most influential favorites Michael Pollan. I would certainly be interested in hearing from you about the types of recommendations about food you make regarding intertwined emotional and physical health in future posts. I was also aware and honored that you bought Hyman’s book and you said it convinced you to cut out more sugar. I liked the fact that Hyman included many parts to his program including spirituality that might not have been appealing to you though it can be crucial to others, especially the lonely you wrote about. Dr. Fuhrman below may be more your type. See, “I’m listening,” as Frasier Crane would say. Speaking of Frasier, I think humor and laughter can be one of the best medicines too.

    I agree with you that diet needs can be personal in that some people suffer more from allergies to things like gluten and milk products like me, but many experts are exposing these and other products can effect all people in negative ways. Sugar and especially high fructose corn syrup are getting much attention for being toxic poison for one and all as you’ve pointed out.

    I agree with you that it is important not to jump on bandwagons too quickly and our food diet is a great example given that there is often so much conflicting advice. That’s why I am careful to consider many different views and reviews of authoritative experts and “take what I need and leave the rest.” Like you, I try to keep my mind open to new evidence as it comes out.

    Is the book on the gut biome you cited a really technical book? I would appreciate it if you could share the title if you get a chance. Actually, my favorite food expert is Dr. Joel Fuhrman who is highly recommended by doctors for not only achieving a healthy weight, but also health in general:

    http://www.amazon.com/Eat-Live-Amazing-Nutrient-Rich-Sustained/dp/031612091X/ref=sr_1_1?s=books&ie=UTF8&qid=1394722586&sr=1-1&keywords=joel+fuhrman+eat+to+live

    My son and I became walking ads for this approach when we both lost lots of weight/got in shape and everyone wanted to know the “secret.” Our doctors had a high regard for this approach too. I learned the hard way from those like Fuhrman that it isn’t just a matter of eating less and exercising more if one’s diet was filled with sugar and junk food in general causing “toxic hunger and food addiction” per those like Fuhrman and Hyman. .

    Here’s a great book researched by a journalist exposing the truth about the fallacy of mere moderation in all things and the delusion that all calories are equal:

    http://www.amazon.com/Good-Calories-Bad-Controversial-Science/dp/1400033462/ref=sr_1_1?s=books&ie=UTF8&qid=1394722867&sr=1-1&keywords=taubes+good+calories+bad+calories

    Finally, my favorite posts from you are those that focus on thinking outside the box. It dawned on me that I was an English major with a life long love of books while subjects like chemistry and geometry were often torture for me in my youth because I found them very boring. I arrived at the conclusion that there are literary/fine arts types versus science/engineering types in a sense, so that could be why some of us have trouble communicating. When I see really technical articles that also involve junk science, my eyes glaze over, but articles that deal with the human side of life and their emotions/psychology are fascinating to me.

    Anyway, I forced myself to get a master’s degree in business administration in addition to my humanities and other more technical degree to prove to myself that I could “master” such courses as quantitative methods and managerial economics, but I’ll take Shakespeare as one of the greatest psychologists of all time any day. It strikes me that Dr. Philip Thomas may be of the latter category too. That’s why I enjoyed your article on neuroscience you cited above. Do you think that this could be part of the problem on why people have trouble communicating in such areas as human psychology, emotional distress, etc.? I think that is the case with me anyway.

    We all appreciate having you here and I admire your willingness and courage to tough out these challenging issues with us.