“To a man with a hammer, everything looks like a nail.”
Whether you attribute the quote to Mark Twain or to Abraham Maslow, the meaning is clear. Which brings me to Aaron Beck, Sigmund Freud, and Tom Insel [OK, actually to Tom Insel]. When a new chairman appeared in my department in the early 1980s, there was a period when we had some interesting discussions. I was a psychoanalytic candidate, was directing a major program in his department [the residency], and was also teaching the major medical school course. We talked about a lot of things in the getting-to-know-you period. He was pretty iconoclastic about almost anything I said, talking excitedly about the future with genetics, biomarkers, PET Scanners, and psychopharmacology. When our honeymoon was over, I was moving on, but I never forgot those talks – because I’ve heard them in one form or another from one person or another for the ensuing decades. The classic version came from Dr. Insel’s Psychiatry-as-Clinical-Neuroscience meme where he literally plotted out our future based on the same new technologies my new chairman had outlined twenty years earlier. If there were ever a man with a hammer, it was Tom Insel:
In 2009, Dr. Insel started writing his Director blogs, many of which were about even newer technologies and the progress they promised. About that same time, we began to hear about something new:
“Can we develop a clinically useful diagnostic system based on neuroscience and genetics? Not yet. But, in the spirit of beginning a long journey, NIMH is taking its first step with the Research Domain Criteria [RDoC] project. RDoC makes no assumptions about current categories”…“Our vision is a new classification with high reliability and validity based on a deep understanding of the neural basis of mental disorders.”Re-Thinking Classification of Mental Disorders |February 1, 2010|
Then just prior to the release of the DSM-5 in 2013, he announced that the RDoC was replacing it as the official diagnostic system of the NIMH [Transforming Diagnosis]. Time passed, and in August of last year, he returned from a tour of high-tech companies, enthusiastic about what he’d seen in this travels:
“While the focus of wearable technology and online apps has thus far mostly been for managing heart disease and diabetes, the tech approach may be best suited for mental health. The biomarkers for depression and psychosis and post-traumatic stress disorder are likely to be objective measures of cognition and behavior, which can be collected by smartphones. Some of our most effective interventions are psychosocial treatments that can be delivered or extended by smartphones and tablets. Most important, the sensors and the interventions can be integrated into a closed loop so that care is continuous and iterative. Increasing symptoms, suicidal impulses, and paranoid thoughts lead immediately to an intervention.”Look who is getting into mental health research |August 31, 2015|
We didn’t yet know it, but his summer tour of the high tech world was also a job search, and within a few weeks, he announced he was stepping down [ambivalence…] to sign on with Google. In the multiple interviews about why he was leaving, this one sounded close to the center to me:
Why did you leave the National Institute of Mental Health to work for Google?I have to confess that after giving heart and soul to mental-health problems over the last 13 years working in government, I have not seen any improvement for either morbidity or mortality for serious mental illness – so I’m ready to try a different approach. If it means using the tools available in the private sector, let’s go for it.Are you saying Google is a better place to do mental-health research than the NIMH?I wouldn’t quite put it that way, but I don’t think complicated problems like early detection of psychosis or finding ways to get more people with depression into optimal care are ever going to be solved solely by government or the private sector, or through philanthropy. Five years ago, the NIMH launched a big project to transform diagnosis. But did we have the analytical firepower to do that? No. If anybody has it, companies like IBM, Apple or Google do – those kinds of high-powered tech engines…Brain expert: Why I jumped ship to Google |Nov 4, 2015|
You could read his comments as blaming, like the NIMH let him down – didn’t live up to his expectations – didn’t provide him with "the analytical firepower" he needed to develop his RDoC. For most of us, all we know is what the RDoC isn’t, but only know about what it is in the vaguest of general terms. So we can’t possibly have a clue what he’s talking about, how the absence of "the analytical firepower" let him down. Is he saying that the RDoC is a bust too, like the DSM-5? It has seemed to me that the question at hand is pretty clear. Is the RDoC an Insel-ism, a part of his clinical neuroscience monomania? something that needs to exit along with him and his hammer? already an anachronism before we even got to know it? Or is it a viable and valuable legacy that ought it be pursued?
Somebody in the NIMH must’ve known some of us were thinking these thoughts, because this month’s issue of Psychophysiology is devoted entirely to the RDoC. It starts with a couple of articles explaining the RDoC and how it came to be in existence, followed by a number of investigators using this new system. The whole issue is freely avaliable on-line. So I guess we can’t complain that they haven’t really told us what’s going on. The ball’s in our court now, and here are the links:
I really meant to read one all the way through. I just didn’t.
In youth, I failed to get even 25% of the way through The Magic Mountain (Thomas Mann) every few years.
These are its foothills.
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Insel moved to California to open a whinery? Take this!
Letter to Baltimore Sun from an impoverished self-described mentally ill man : http://articles.baltimoresun.com/2013-08-05/news/bs-ed-nih-20130805_1_longevity-gap-social-science-research-funding-nih
“Regarding Sandra Hofferth’s recent column on funding for the National Institutes of Health, I agree that “closing the longevity gap depends on behavioral and social science research” (“Budget cuts and the politics of research,” July 15).
However, Ms. Hofferth is merely talking about the longevity gap, whereas I am living in it, and I believe people like her and the researchers at NIH are the source of the problem rather than the solution.
As a taxpayer and a mentally ill individual, I cannot support her requests for additional funding for “behavioral and social sciences.” It is simply a waste of money and it saps valuable resources out of the economy into programs that falsely raise peoples’ hopes and foment an elitist class of academics who exploit human misery for financial gain without directly taking responsibility for delivery of real-world solutions.
[…]
[…T] he gap between the real world and the world of NIMH researchers and staff is too wide, and there is a quality control crisis in public mental health, not a funding crisis as many would like us to believe.
I sat down and wrote a description of my own experiences and the breakdown in the role of the mental health profession, and I submitted it to NIMH after President Barack Obama called for a national conversation on mental health in June.
Someone needs to tell President Obama that it is a one way conversation — I talk and the National Institute of Mental Health ignores me — kind of like a session with a psychiatrist at a community mental health center.
Does the president want a “national conversation?” I say the time is now and the place is here.
Sam Mela, Gainesville, Ga.
“…there is a quality control crisis in public mental health, not a funding crisis as many would like us to believe.”