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.