I was at a party once of non-medical people. A woman we’ll call Jill comes up to me. She’s a teacher, 28 years old, and talks to me about her teaching middle schoolers. I mention what I do, and I get a surprised look.
She’s intrigued, but then brings up all the complaints she’s heard. “My friend went to a psychiatrist, and they were horrible… And isn’t it true that the DSM is run by drug companies?” “So you’re pushing pills all day?” “Why can’t psychiatry figure it out better?”
Where do I start in addressing so many myths? Ultimately it’s hard to convey how difficult this field is.
In fact I hear critiques about my field (psychiatry) all the time. How it’s such a mystery. How it’s a soft science, and wondering why it can’t be more like cardiology. It would be nice for psychiatry and understanding the mind and brain to be finished. Nothing left to learn. But where’s the fun in that?
The truth is that the brain is the most complex “thing” on the planet, and with all we know (which is a lot), we still are only getting started. Mastering the information we do have is still a process, and it’s hard for those outside the field to comprehend how it’s not quite a linear process. It’s hard for them to understand that the brain can’t be understood linearly.
Understanding the mind/brain, as best I can find an analogy, is like learning physics.
At a grade school level, we learn a simple rule: nothing is smaller than an atom. We learn about how molecules are combined atoms, and the way they combine make up everything in the universe. That rule seems straightforward. And at that level it’s absolutely right.
Then as we grow older we learn that that rule wasn’t exactly true, and that really atoms are made of particles called neutrons, protons, and electrons. And the number of these in an atom determines what type of element it is, its weight, its charge, and so on. And we had to unlearn the first rule to accept the next. But in a way the first rule was a good foundation to move to the more complex. It’s easier to first learn about molecules when only thinking about atoms.
Then we continue, and we have to unlearn that electrons are particles. In fact they’re more like clouds, and don’t even exist in one place, but have “probabilities.” But being able to think about them like particles first was useful before unlearning the lesson, in order to understand them relative to protons and the net charge of an atom.
And with each step we learn a rule then unlearn it as we get more complex. Electrons aren’t even clouds, really. And then there’s quarks. And superstring theory. And so on. And it isn’t exactly that each rule was untrue, but just a simplified view was useful for that step of learning, to understand the larger picture, before moving into the more complex and detailed.
So it is with the mind/brain. But even less linear. At an early level is the DSM. It’s a guidebook, and its the best common language to describe illnesses so everyone can have some common language. But even the contributors know its far from the whole picture. It’s a fine starting point, so we can have a reference from which to deviate.
Then with each mental illness there is a body of research literature. Hundreds or thousands of published research papers on an individual topic. Every paper has data, some of it contradictory, that adds to the complexity of the picture. As each of us learns more, we learn to read between the lines in the research, to see some of the bias inherent in different papers. Often the data isn’t even applicable to the real world. Researchers each take different tacks on a specific question or dilemma. I’ll get into this more in future blogs, but suffice it to say that no one take is ever the whole picture. The more sophisticated we get, the better we can recognize which data is useful, and which isn’t.
And then there’s the brain models, from the ways the brain is wired in different conditions, to having larger areas of the brain in some conditions and not others, to more or less neurotransmitters in some conditions in some areas of the brain. And as interesting as it all is it doesn’t tell us enough. It tells us little aside from a hope it’ll pan out to something viable down the road.
Understanding the problem tells you very little as to how to change it. Reading the DSM tells us almost nothing about interventions (meds, therapy). So then comes training and incorporating various ways to actually deal with problems. The process of medication management of problems must incorporate what the pills are approved to do, what they do in addition, and everything else about them (research on them, side effects, how they affect other body systems). And then comes psychotherapy, from learning how to connect to a person, to the myriad of different therapy approaches (behaviorism, psychodynamic, CBT, DBT, IPT, and many many others).
In most ways understanding the mind/brain is not like physics. There’s not higher math. Physics is considered a “harder” science. But they both deal with the mundane, what’s right in front of us, and yet with the intangible. And the more complex aspects of physics and chemistry examine that which can’t be quantified with the senses alone.
So when people complain that the DSM seems incomplete, I agree. And when people tell me about bad psychiatrists, or therapists, I understand why. There’s a lot of information to “master,” and right now we do alright even with just simplistic uses of the information as a minimum.
We’re still looking for our grand unified theory to tie it all together.