An Interview with Gregory Murray, Ph.D. on the Diagnostic and Statistical Manual (DSM)
David Van Nuys, Ph.D. Updated: Jan 31st 2012
Professor Gregory Murray, head of Psychological Sciences and Statistics at Swinburne University of Technology in Australia, discusses some of the ins and outs of the American Psychiatric Association Diagnostic and Statistical Manual, known as the DSM. He's the editor of the forthcoming book, A Critical Introduction to DSM, which will be published by Nova Science, which aims to develop an appropriately skeptical attitude to the use of the dominant psychiatric taxonomy. Dr. Murray explains that there are two major diagnostic schemes in the world: there's DSM and there's the European ICD. He says that they largely align, but there are small differences in wording and some definitions that do, in fact, lead to quite different prevalence rates. The DSM is produced by the American Psychiatric Association, and the ICD is produced by the World Health Organization. Dr. Murray discusses that he believes the DSM has certain biases in it and certain tendencies, some of which has entirely to do with who wrote it, and some of which are entirely pragmatic for the group of people who wrote it and for whom it is designed. The DSM texts, the various editions, he thinks are best seen as a part of an ongoing project of the American Psychiatric Association. He believes it's very useful to take a step back and say, "Well, who wrote the book, what's the aim of the book?" And once you've done that, you're starting to get a better sense of how the manual works.
David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.
On today's show, we will be talking with Professor Gregory Murray, head of Psychological Sciences and Statistics at Swinburne University of Technology in Australia, about some of the ins and outs of the American Psychiatric Association Diagnostic and Statistical Manual, known as the DSM.
Professor Greg Murray is head of Psychological Sciences and Statistics at Swinburne University of Technology in Australia. He's convener of the highly respected clinical psychology programs at Swinburne University and a practicing clinical psychologist. Dr. Murray has been teaching psychologists and therapists for 20 years and is currently a member of a consortium revisioning the clinical psychology curriculum in Australia.
He's the editor of the forthcoming book, A Critical Introduction to DSM, which will be published by Nova Science. And this book aims to develop an appropriately skeptical attitude to the use of the dominant psychiatric taxonomy. Since taking out his Ph.D. from the University of Melbourne in 2001, he's published over 70 peer-reviewed papers and chapters, won additional awards for teaching and research, and been a chief investigator on national competitive grants totaling more than $3 million.
The majority of his research is collaborative and multidisciplinary. In Australia he works with researchers investigating psychosocial treatments, both live and online, for bipolar disorder. Internationally he is a founder member of the Canadian CREST Group, investigating determinance of well-being in people with bipolar disorder. He collaborates with colleagues at UC Berkeley, Harvard, and the University of Massachusetts on the studies of sleep, circadian rhythms, and mood.
Now, here's the interview.
Professor Greg Murray, welcome to Wise Counsel.
Greg Murray: Well, thank you very much, David.
David: I was contacted by one of your graduate students, Anthony Mackey [sp], who suggested that you'd make a great guest for the show.
Greg Murray: Oh, that's very nice of him.
David: Yeah, he thought you'd be a good person to talk about the DSM, and I think that Anthony framed it really well. He thought that we might discuss -- "Among other things," he writes -- I quote from him -- "I've heard wildly different views about the DSM being expressed by various Wise Counsel guests" -- that's true -- "over the years, ranging from mildly-concealed contempt to unthinking acceptance of the DSM as a taxonomy of 'discovered disease entities.' And I think that this range of perspectives reflects the unease amongst practitioners," he says, "especially psychologists, about just what to make of this behemoth that sits among us."
Greg Murray: [Laughs]
David: So I liked his way of expressing that. So maybe a good place for us to start is for you to give us a bit of an overview on the history of the DSM -- what it is and why it came to be.
Greg Murray: Yeah, look, absolutely right -- we do have to start with that, I think. We have to start with what sort of text the DSM is, and there's a few things to say about that. Firstly, it's clearly a product of the American Psychiatric Association, with all that that implies. The American Psychiatric Association is a guild and, like all guilds, it has a couple of different types of goals. Every guild has the goal of the sort of substantive work that the guild is meant to do, so one of the goals of the American Psychiatric Association is to improve patient outcomes. And, of course, another goal of the American Psychiatric Association is to look after and defend the rights of its members.
And so immediately, once you realize that, you -- and I think we really need to start there -- you realize that the manual, the DSM, is going to have certain biases in it and certain tendencies, some of which has entirely to do with who wrote it, and some of which are entirely pragmatic for the group of people who wrote it and for whom it is designed. The DSM texts, the various editions, I think are best seen as a part of an ongoing project of the American Psychiatric Association.
And some of the content of the texts is clearly there entirely for pragmatic reasons; that is, for example, if I'm a psychiatrist in the United States -- and, of course, I'm a long way from that; I'm a psychologist in Australia -- but if I'm a psychiatrist in the United States, I want my manual to describe absolutely everything that could walk in my door in terms of patient problems -- and that makes perfect sense.
But then, if you look at that from another perspective, if you were going to design a perfect taxonomy or categorical scheme for describing mental distress, you would not use that principle. You would not use the principle of "let's put everything in there to make sure that psychiatrists can name everything that walks in their door." That's going to lead to lots of redundancy and co-morbidity and effectively set up the manual to have poor reliability and validity. So immediately we see, I think, it's very useful to take that step back and say, "Well, who wrote the book, what's the aim of the book?" And once you've done that, you're starting to get a better sense of how the manual works.
David: Now before you go on, you mentioned that you're in Australia, and this is the product of the American Psychiatric Association. So, just as an aside, how much sway does that document have in Australia?
Greg Murray: Yeah, that's a great question. It has enormous sway. So, as your listeners probably know, there are two major diagnostic schemes in the world: there's DSM and there's the European ICD. And they largely align. They've been trying to align themselves for a long time, and largely they do, though there are small differences in wording and some definitions that do, in fact, lead to quite different prevalence rates. But they largely align.
So these are the two dominant taxonomies of mental distress in the world. One's produced by the American Psychiatric Association, and the other is produced by the World Health Organization. In Australia, both of those systems can be found. So, for example, here at my university and most of the universities in Australia, when we teach psychopathology, we normally introduce it through the DSM. But when my students go out -- what's that sound?
David: I'm sorry. That was my cell phone that I forgot to mute. Yeah, you can keep going.
Greg Murray: Okay. But when my students go out into the world and see clients, see patients, and get funding for that through Medicare, the Australian government rebate scheme, they will be using ICD diagnoses. So both are present in Australia. What most people say is DSM has had an enormous impact on the research environment and is probably the tool that is most commonly used if you read the literature about psychiatric problems and mental distress; whereas ICD still carries a lot of weight, in that mental health statistics world wide -- including in the United States -- are presented in ICD format.
David: Okay. Well, take us through the DSM I, II, III, IV in terms of what that evolutionary process was.
Greg Murray: Yeah, so the really interesting part of that story -- and I think this is one of the great insights that you get from looking back historically -- is that DSM I and DSM II were very, very different to DSM III, so most people talk about a sort of significant shift in focus that occurred with DSM III. In fact, some people talk about DSM III and DSM IV as being the "modern" DSM, and DSM I and II being some earlier version.
But the key thing that we discover from that distinction between I and II, and III and IV, is that I and II were strongly psychodynamically grounded, and in fact they were strongly influenced by a particular psychodynamic theorist, a guy called Meier or Mayer, M-E-Y-E-R -- I'm not sure how that's pronounced in the United States -- who had what us psychologists would call a very sensible, biopsychosocial view of mental distress.
So, for example, schizophrenia didn't appear in I and II, but schizophrenic reaction did; that is, the terms and concepts that we used in I and II strongly emphasized that distress was the result of the interaction between the individual's vulnerabilities and environmental events, which is a standard way that all of us psychologists tend to think -- that what might be called the diathesis-stress model or the vulnerability-stress model, very much about the interaction between the person --
David: Yeah, and my reaction, to me, also implies that it's not necessarily a permanent condition.
Greg Murray: Exactly. And it's not sounding very medical, is it? And, in fact, the other feature of the sort of paradigm, if you like, that underpinned I and II was a notion of the continuum between normal responses and disordered responses; that is, a dimensional approach was explicit there. So that's very important to appreciate.
One of the reasons that it's important to appreciate is that, even within American psychiatry -- as I understand it; I'm really obviously not a member of the American psychiatric fraternity -- but everything I read tells me, and you can sort of read this through the historical accounts, that even within American psychiatry, there has been a long-standing tension around this issue of the medicalization of distress, where within American psychiatry, there was a huge debate about moving from the paradigm of DSM I and II to the paradigm of DSM III, where things changed substantially.
So you've probably seen in recent times the open letter from the American Psychological Association to DSM V, and the open letter from the British Psychological Society to DSM V. And both of those open letters, we could summarize, are criticizing the apparent medicalization of distress in DSM. So I think it's -- I was very excited when I discovered that, in fact, a lot of American psychiatrists have the same concern and continue to have the same concern.
David: Oh, that's interesting. So I wasn't aware of the division within the psychiatric association, although it's not too surprising. Maybe we'll talk some more about that petition towards the end of the interview. I still want to work forward, so tell us about III and what III brought into the picture then.
Greg Murray: Yeah, fantastic, because this is where it -- when we understand the shift from II to III, then I think we understand the current manual much better. What happened in the 1970s -- you know, there are various histories, right? There are lots of different histories that one can tell.
Greg Murray: And DSM is no different from an account of any other history; that there are multiple views on the history of DSM. But the dominant view in the literature, and I personally find it a compelling story, is that American psychiatry was in a bit of a mess in the 1970s. Using the biopsychosocial approach of Meyer that had underpinned I and II, American psychiatry was starting to look not very medical.
The biopsychosocial model of American psychiatry, as exemplified in I and II, was really quite humanistic. And a lot of psychiatrists spent their time on things like prevention of mental health problems. And they started to work in educational settings because they thought this is where we should build resilience and build psychological strength, and this will prevent -- so there was all this common sense stuff that you and I would probably think is perfectly sensible. But it was looking quite unmedical.
The other thing that happened around in the '70s was that famous study -- and I'm blanking on the name now -- where the university students presented to a psychiatric hospital with just one symptom.
David: Oh, yes.
Greg Murray: And were admitted and held there for many weeks, even though their behavior was perfectly normal. Now, you might think this was a bit of a gimmick study, and in some ways I think it probably was a bit of a gimmick study. However, it was published in an extremely high-profile journal and got an enormous amount of media. So people started to say, "Well, what is this psychiatry thing? Does it know anything about its terms?"
And then the third thing that happened that was a sort of challenge to American psychiatry in the 1970s was that other professions started to say, "Well, we can do this stuff better than you can," especially since in the 1970s that was when mental institutions were being closed down, largely because of the invention of chlorpromazine, and we could, as it were -- at least to some extent -- moderate the symptoms of serious mental illness, so people were being released into the community. So, all of a sudden, there are all these patients out in the community and other professions saying, "We can treat these people better than you psychiatrists can."
So that's the context. So if I was psychiatry, one of the things I might do at that point is say, "We've got a crisis here, and the crisis is that we are insufficiently medical. We need to align ourselves back to our medical roots, and perhaps we need to become more clearly biological in our focus."
David: Ah hah.
Greg Murray: And that "perhaps" there is important, because it doesn't -- I think sometimes the biological focus of DSM is overstated. But let's just go on with this story to start with. So a group of researchers, clinician researchers in the United States, basically developed a manifesto for how they were going to, as it were, "save" psychiatry from itself.
And the manifesto said, very sensibly -- they did something that we do in psychology a lot: they said, "We don't understand very much about the problems of our patients. So, step one in trying to improve our understanding and move us onto a more sound scientific footing is to define, in clearly operationalized terms, what these disorders are." And they called themselves neo-Kraepelinian in deference to Kraepelin, who was an early psychiatrist who was actually trained by Wundt, the psychologist, and put a big emphasis on operationalization; that is, clear, unambiguous measurement of the phenomena under study.
And so DSM III, the first of the modern DSM IIIs, was completely different to DSM I and II. And just on the surface, if you pick up DSM II and pick up DSM III and look at how the manual looks, it looks completely different because DSM III all of the diagnoses are tightly operationalized. You've seen the diagnosis of major depressive disorder, for example. It's quite mechanical. You get a diagnosis of major depressive disorder if you've have one major depressive episode; and a major depressive episode is defined by the presence of this and four of the following list of symptoms, etc. Very black and white, unambiguous description of the conditions under study. That is, DSM III was a very deliberate and strategic attempt to make psychiatry stand on more sound scientific footing by defining its terms.
David: Well, I know that, along the way, there have been various studies of reliability and validity; and that, back when I was in graduate school, the correlations weren't terribly good for the ability of different diagnosticians to arrive at the same diagnosis. So did this operationalization improve upon those correlations?
Greg Murray: Yes, it did. For most of the well-recognized diagnoses, the integrator of reliability -- and, as you say, that's a very meaningful statistic -- the integrator of reliability did improve substantially from DSM II to DSM III. In DSM II, the characterization of the disorders was sort of vignettes; archetypal presentations were given. And it does seem that moving towards this operationalized system improves reliability, especially if you use structured diagnostic interviews; that is, if you don't rely on the clinician to ask all the right questions. It is a fairly mechanical system, and so, in fact, if you have a structured set of questions, or even, in fact, if you get the patient to respond on a computer which does the branching logic for them, the reliability of the diagnosis definitely did improve.
David: Okay. So at least, on the surface, it looks like an advance, but there still could be some hidden philosophical problems in there, it sounds like.
Greg Murray: Well, that's exactly right. And that's when the story gets really interesting. So let me jump to what I say in my first blurb when I stand up in front of students and start to talk about DSM, because I've been teaching DSM for a number of years to psychologists and counselors and all sorts of health workers. And most of the people in the room start with a healthy skepticism or even an unhealthy dislike of this manual.
David: Right. Sure.
Greg Murray: And I myself definitely did when I was first exposed to it. I thought it was just -- I didn't know exactly why I didn't like it, but I simply didn't like it, and I was certain that I couldn't be bothered learning it because it was a bloody tedious task learning it. So I was coming from a long way behind. But when I teach this now, and I'm happy to say that I think by the end of -- when I give a class on this or a series of classes, I think most people have a very different perspective on DSM.
But I start by saying the best way to read DSM is that it is like a dictionary, not an encyclopedia. It's a set of definitions of terms, not a set of discoveries about the world. And I'll tell you something interesting about that: that's what the authors of DSM III say. The authors of DSM III are absolutely unambiguous about that. They say, "What we have aspired to do here is just define our terms, and we are waiting for validation data."
The mistake comes when people pick up the manual and believe that this is a listing of discoveries of what the mental disorders are. It's not. It was never intended as that. It was intended as a first step in defining terms. And, as a first step in defining terms -- as you pointed out -- it was kind of successful, in that integrator reliability went up. Validity is a separate question, and we can talk about the issue of validity because there are some twists in that story as well. But if you would see it as just a list of definitions of terms and don't make the mistake of reifying these concepts -- you can't really talk about the DSM problem without using the word "reify," which is kind of an unusual word. It means to treat a concept as if it's a thing.
David: Right. And it's a human propensity that is difficult to avoid somehow.
Greg Murray: Absolutely. In fact, some of the major players in the DSM project are pulling their hair out a bit, and they say, "How can we possibly --? What do we do to minimize the human propensity to reify these concepts?" I mean, it's very easy to see why the concepts -- or hypotheses, perhaps, would be another way to describe the diagnostic terms? It's easy to see why they get reified. They're put in this important looking book, which has roman numerals -- you know, DSM IV in roman numerals like it's a gladiator or something. And courts make their decisions on the basis of these things. Insurance companies -- "things" -- I said it then -- on the basis of these concepts. Federal funding for research is based on the use of these concepts. You can't ignore it, of course.
And perhaps the most pointed situation where we're tempted to reify these concepts is when someone we know is in extreme distress. It makes perfect sense. There's time in my life people close to me have suffered very, very extreme states of psychological distress, and when that happens, I'm prone to think in terms of boxes as well -- what's wrong, what can we do about it, what's the future gonna be like? -- very categorical thinking.
When we're under a lot of pressure, when we're emotionally connected to an outcome, we will very much lean on this old human tendency to put things in boxes and not think in more -- not be more appreciative -- sorry, that's a clumsy sentence. We're tempted to put things in boxes, and it's much harder for us to hang on to this more subtle idea that these are just concepts and their validity is poorly understood.
David: Okay. Now, then along comes DSM IV and it, I gather, is trying to make up for some perceived shortcomings in DSM III which you've been telling us about. What does DSM IV add, and does it do it successfully or not?
Greg Murray: You're absolutely right. So you know we've described the instigation of DSM III as a strategic attempt to change the foundations of American psychiatry so they were more scientific. Basically, that's what happened in DSM III, but there really wasn't much science to support the change. So a lot of the concepts in DSM III were tidied up and operationalized, but they weren't -- that process of tidying them up and operationalizing them weren't based on much data. So, still, expert belief and sort of clinical law was the major driver of the content of DSM III.
With DSM IV there had been more field trials and there was more relevant data to feed into the process, but it's generally agreed that there was a lot of decisions in DSM IV that were still based on insufficient data. Which leads me to say something else that I think is an important contextual point. If you think of DSM as -- well, firstly, it's a project and it's had multiple editions, so it's changing all the time. But what this broad project is about is creating a categorization of mental disorders, right?
Greg Murray: Now, it's a categorization. It's a taxonomy. We need to understand that the science that might inform this taxonomy -- and the science is called psychopathology, right? -- the study of mental disorders. It's the science of psychopathology. That's where DSM would get its data from on the nature and the boundaries and the definitions of mental disorders.
Greg Murray: The science of psychopathology is a pretty crap science. When was the last time you heard a major discovery from the science of psychopathology? It's actually a long way behind where the general public thinks it is. We don't even have full [?] very good descriptive data about how mental distress is disbursed across different populations. Much less do we have good quality information about the causes or optimal treatments of mental distress.
So the science of psychopathology, which is where DSM and any other taxonomy would turn for its data, does -- it continually lets down anyone who is trying to organize information about psychiatric or psychological distress into some sort of categorization scheme. We simply don't know much about mental distress and when that warrants the term "disorder."
So, for DSM III, it was very obvious that there was very little data ready to be fed into the DSM III process. For DSM IV, there was a lot more data that was fed into the DSM IV process, but it would be true to say that the science underpinning DSM IV was still not sufficient to drive the majority of decisions that needed to be made to organize a taxonomy or a classification scheme. So DSM IV was an advance in terms of scientific content, but by no means was there a sort of revolution in the quality of the scientific data about the description and explanation of mental disorders that makes DSM IV qualitatively different from DSM III.
David: So what is driving the move now towards DSM V? What voices, what constituencies have said it's time to revise DSM IV and to strike out? And is it striking out in a different direction, or is it simply building upon in small ways?
Greg Murray: Yeah, that's a great question. I don't actually know, within American psychiatry. I think that there is just a continuous assumption that revision is part of this process. The project of developing a classification scheme is conceptualized quite rightly as an ongoing process; that it's not fixed. Which is why, for example, in the current DSM one of the appendices is "Diagnoses under Consideration." It's the guys who are sitting on the bench who may get a gurney in the next edition. It's understood as a dynamic process that is meant to be continually revised as more information comes in.
That would be my -- I don't know about the more pressing drivers, but the broad fact is that DSM is meant to be continually revised in the light of new information. So that's the broad driver. I don't know when -- at what point the APA says, "Okay, time to move; time to appoint committees to work towards the new one." So it's not as if there's any clear scientific trigger for moving from one version of the manual to the next. It's conceptualized as an ongoing process. I don't know what the immediate triggers are that say, "All right, we've had enough of DSM IV. Let's make sure we're getting on moving with DSM V."
David: Okay. Let me take you back, because you were saying that when you introduce the DSM to students, there are those who reflexively reject it and others who perhaps reflexively embrace it too strongly. So give us a brief overview of your -- because I gather that, even though you've already said some critical things, you don't totally discard it. So what do you see as the overall strengths, advantages, and the overall limitations?
Greg Murray: Yeah. Clearly, the strengths are that we have some terms that we all pretty much know the names of, and that enables us to talk and reflect about our patients and talk and reflect about the terms themselves. So having a dictionary in this area is a huge success of human beings, I think. You can imagine what a mess we would be in if we didn't have some consensus about starting terminology for describing the realms of human distress.
So that is an enormous benefit. And, in fact, the proponents of the DSM project, that's normally the first thing they say. Normally the first thing they say about the DSM is it's designed to improve communication. And there's no doubt that having a set of terms that most people know the meanings of, and that we can then critique, is a huge advance over not having those terms.
Now, for people who are currently training in the field, the particular importance of having those terms is most of what we know about mental distress is actually framed in those terms. So, for clinical psychologists in particular, who are kind of aligned to diagnosis as part of their specialization, you simply can't be unclear about your own views on DSM. You really need to work out what your views are because just about everything we know, all our evidence base about our practice, is framed in DSM terms. So I have - I think the strengths are enormous.
The weaknesses are also very, very obvious. So, one of the weaknesses -- and this is a weakness that can really deeply offend psychologists -- is who wrote it. It's written by a particular bunch of people with a particular training history and set of biases and internal politics. And it's a bit of a pain in the rear end to have to live with a manual that was written by a bunch of other people who don't share your training, don't share your own biases, and don't share some of your core assumptions.
David: I was under the impression that they invite some psychologists into the process.
Greg Murray: They definitely do. On most of the committees there would be psychologists present. However, the main drivers of the -- you know, it's a product of the American Psychiatric Association, so it's like if you get General Motors to do a review of the history of the motor car, there are a few General Motors products in there. Why wouldn't they, you know? I think that's a no-brainer. I think that's perfectly understandable. But that is something that I think we just need to appreciate rather than take offense at. There will be a medical bias in a manual that is a product of a medical specialization. Why wouldn't there be?
But I think the problem comes if one feels that one is the victim. You know, if I'm a psychologist and I'm approaching DSM, if I feel that I'm the victim of that medical bias and have no room to move, if I feel -- for example, if I have falsely reified those constructs, if I read the DSM as if it is a list of mental diseases, then I'm going to find it very hard to swallow because, at some level, the notion of human distress being analogous to a disease is very offensive to some people, particularly people of a psychological background. So that's where we get that strong reaction against DSM.
David: Well, one of the things that you've written in that regard is that DSM is confounded by the mind/body problem. How so?
Greg Murray: Well, there are a number of different ways to approach that. In terms of the history of psychiatry and psychology working with mental problems, there are essentially two dominant strains in that work in terms of how do we view our work. And one emphasizes the brain in particular, so that's the part of the body that is of most interest. And the other emphasizes the mind, by which I mean perhaps subjective experience, experience from the viewpoint of the sufferer.
And these are two very, very different approaches to understanding human beings; one being what you might call phenomenological: that is, to understand human beings, I must firstly try and put myself in their shoes and see how the world looks and feels to them. That's an emphasis, perhaps, on the mind or the subjective. And another way to go, the contrasting way to go, which is often polarized with that, is to say, no, we need to be more objective about this target of our investigation, the human being, and we need to be able to measure things from the outside, like measuring brain function or brain structure or the dopaminergic system. And these are two very different pathways to understanding mental distress.
David: Yes, and all the new brain imaging technology that's come along -- the fMRI and other kinds of tools -- have really, I think, swung the balance maybe in that medical direction, at least in some people's minds. And probably in the general public -- if there is that perception of we're making great advances in psychopathology -- it would be because they're reading about all these things that brain imaging is correlating to various kinds of experiences.
Greg Murray: That's right. So these are very sexy pictures, aren't they?
David: Yeah, right.
Greg Murray: But they are -- the science of that stuff is not as sexy as the newspaper articles, and so, yes, there might be a trend in -- there is, perhaps, a trend to over-biologize mental distress. But my personal view on that is, you know, as a psychologist. I really don't buy into a polarity of mind versus body. I think it's most useful to talk about a continuum between mind and body. And some things are very embodied, and some things are effectively quite disconnected from the brain or the body. But it is very important to think about a continuum.
For example, in my work with clients with bipolar disorder, we will talk about the importance the sleep and exercise. Now, sleep and exercise could be construed as purely biological interventions for bipolar disorder because it's easy to describe sleep and exercise at a biological level. But, equally, they're psychological interventions for bipolar disorder; in that, if I successfully run around the block tonight, I'm going to feel a lot better about myself. So this polarity between the mind and the body, it has a long history in the human sciences, but it's actually not that useful, I think.
I think we actually can have a genuinely holistic understanding of the human being, where I don't mind looking at photos of bits of the brain lighting up and wondering if that might give me a hypothesis about which feature of my clients' cognitive functioning is most disturbed. I don't mind that. And similarly, I don't mind a purely cognitive or purely subjective description of my clients' quality of life experience as they go around managing their bipolar disorder. I think it is very important for psychologists to feel confident across that range from mind to body, and not to buy into unproductive polarization that somehow says DSM and medicine and brain imaging fall into a little group of bad guys who are somehow minimizing the importance of subjective experience and the psychosocial aspects of what's going on.
I personally -- you know, my aim as a psychologist and an academic has been to really try and be comfortable across the range of different levels at which human beings can be described. And so I don't really mind when I'm reading DSM and in DSM V, for example, they've used the term "neurobiological" -- you know, in terms of some development disorders. I don't feel like a psychological view of developmental disorders is threatened just because a medical manual happens to use a medical sounding term to describe it. That's just the way they're going.
Now, in an ideal world, we would have a taxonomy that isn't just a product of a medical group -- because medical groups do have their biases, and they're trained in a particular model, and they have particular expertise. We would, in an ideal world, have a taxonomy of mental distress that really aimed to bridge across these camps. And they are really camps in both science and professional practice. We don't have that currently, and I don't know whether we ever will.
David: Right. Now earlier you referred to this petition that's being circulated here in this country -- and also you said that the British association also has mounted a petition -- about DSM V, which is, I gather, close to being finished. And what is it that the people who are upset, what is it that they're upset about?
Greg Murray: Yeah. To some extent they're upset the same stuff they've always been upset about since DSM III. They're upset that this looks like a medicalization of human distress. And, to that extent, I completely agree with them, but as I've just said, I actually don't find that a problem because why wouldn't a medical organization medicalize human distress? That's their job. That's what they're trained to do. I don't have to do it just because they do. So that's the general theme.
But there are couple of -- there has been some significant scientific advances over the last decade which have really challenged a couple of the key features of DSM, and of all the -- of the modern DSM. And the main issue is the categorical versus dimensional debate. So, one of the things that goes with a medical view of mental distress is diagnoses are given categorically: they're either present or absent. You either have bipolar disorder or you don't have it. And that's consistent with a sort of organic disease sort of language, and it's consistent with what happens in most of medicine generally outside psychiatry -- this categorical you either have the disorder or you don't.
What's changed in the last decade is there's now a huge amount of data that, in fact, fairly clearly shows that, for the majority of presenting problems, that isn't the structure of them; that most problems are dimensional, in that diagnosable levels of a problem are really just the high end of a dimension that runs back to normality. So that there are continua of -- the classic example would be unipolar depression. That what's called major depressive disorder in DSM isn't, in fact, categorically distinct from the lower levels of depression and sadness and blueness that we all feel. There's actually a continuum there or a dimension from normality out to disorder.
Now, the important thing about that finding -- and it really is quite robust -- is psychology has been thinking along those lines forever, so I'm sure you were trained in Eysenck and Costa and McCrae, dimensional views of the human being. This is how psychology has always thought. What's changed is that psychologists and psychiatrists have been working together, and it really does look like that most of what we call psychiatric disorders are not well-described as categorical present versus absent. They're actually best conceptualized as dimensions with quantitative dimensions ranging from normality out to disorder.
Now, the important thing about that is DSM recognizes it. In fact, even in DSM IV, if you read DSM IV, it's very interesting. They say, "Just because the diagnoses in here are presented as categorical doesn't mean we think nature is actually that way." They make an explicit statement. They say there is lots of evidence that these things are really best understood as dimensional. And then you think, "Gee, how did they decide to keep with categorical?" And what they say -- which I think is nicely open of them -- they say, "The reason we've kept categories is because that's what medicine does."
Greg Murray: Yeah.
David: Let me raise another issue in terms of the petition that's being mounted. I think we could agree that Big Pharma has perhaps an undue influence over the whole process. Managed-care companies -- if you want to get reimbursed, you have to go through the managed care, so they assert political pressure. And my impression is that one of the objections is that the DSM V, in some categories, has lowered the bar in such a way that more people would need to get pills.
Greg Murray: Yes. DSM V has definitely lowered the bar, and a long-standing criticism of the DSM is they've been getting fatter every time they come out. And so --
David: I was going to ask you about that, if they were getting fatter, yeah.
Greg Murray: Yeah. They're getting much fatter. Obesity is a serious problem for DSM. The number of diagnoses has increased exponentially. And, in a way, if you've been tracking my personal view on this through our discussion, you'll realize that I don't feel personally that this represents an invasion, but some people do. Some people view that, as DSM expands the number of its diagnoses and as it lowers the bar for entry into these diagnoses, the response of many in the psychological profession is that this is a further expansion of the medicalization of normal distress. That is, people are saying, "They're going even further now," so --
David: Yeah, I think I would tend to be in that direction myself.
Greg Murray: Hmm. Well, it's --
David: You know, follow the money. I'm sitting watching TV and suddenly I'm hearing about shaky leg syndrome, that I'd never heard of in my life. And I suspect that there's a similar thing happening in the psychological realm. We know that certain pharmaceutical interventions get expanded to treat conditions for which they originally had not been used for, and so on.
Greg Murray: Absolutely. I completely agree. And the fact of non-scientific influence on the DSM process is well known and well appreciated. And there's no doubt that, just like any other human endeavor, the practice of science in DSM is not that scientific. And one of the major drivers of the content of DSM almost -- well, undeniably -- is Big Pharma because Big Pharma is the major funder of research into mental distress. So if they want things to appear in DSM, they just set it up three years down the track and offer a few million dollars of grants and, sure enough, it will be in DSM.
But I suppose what I'm -- you know, the point I would like to add to that is I don't know if this a legitimate criticism of DSM. In a way, I wouldn't be writing a letter to them. I'd be saying to psychologists, "Well, if we think that a medicalized view of human distress is not optimal" -- as you say, probably the reason it's not optimal is it might tend to lead to pharmacological treatments, right? "Then, it's our job to set up an alternative description of how we think mental distress should best be conceptualized and handled." And I think that is really a political agenda that the psychology profession would be setting itself.
And I'd be saying, "Anyone who has the energy to do that, to really fight that political war of elevating a psychological construction -- an anti-medical construction of these concepts or of mental distress -- I'm happy to sign on board, and I do have that sort of energy." But, in a way, I wouldn't be putting my energy into attacking the medical textbook for its over-medicalization. Of course that's going to be its preference. And I don't know if that's a great use for our energies.
David: Yeah. I think that psychologists -- there have certainly been individuals who have tried to do that, but not on as systematic a basis as the DSM. So I think you're right that a larger project could, maybe should, be mounted by the American Psychological Association. However, that organization is very divided in its viewpoints and all sorts of political pressures. And there's always been this tension between clinicians and the more scientifically-inclined within the profession, and psychology has this history of what's been characterized as "physics envy." [Laughter]
Greg Murray: Absolutely. And ironically, right, we're returning to that same polarity we were talking about before, the humanist versus the positivist, right?
Greg Murray: And it is kind of neat, I reckon, when you see the same tensions and polarities in these two organizations which at one level seem to be polarized themselves. But the same tensions exist in psychology the world over. Clinicians essentially are phenomenologists and they want to understand the world from their client's viewpoint. And academics and researchers are more positivist in their orientation and want some reliable data, and there will be tensions there.
David: And it even goes back further. I'm remembering -- and I'm going to forget a lot of the important data -- but C.P. Snow, who wrote about the gulf between the humanities and the sciences.
Greg Murray: Absolutely.
David: And it kind of comes down to two very different, fundamental philosophical views about the nature of what it is to be human.
Greg Murray: Absolutely. And those are the sorts of questions that I think psychologists should be thinking about. And I think we're -- and I personally have a big interest in that, and if you speak to philosophers of mind, you'll hear a lot of excitement about the notion of embodied and embedded cognition, which is an attempt to resolve this -- the Descartian tension between mind and body. There's a whole lot of interesting stuff going on there, and I personally would call for psychology to bite the bullet on those tough questions that it faces, rather than lobbing rocks at the opposition party because they seem to have landed on a position which kind of offends us.
David: Yeah. Well, you know what? I think we probably need to start to wind down here, and I wonder if there's anything else that you'd like to say.
Greg Murray: I'm probably going to thing of a million things I'd like to say as soon as we hang up. But there is one obvious thing. We were talking before about limitations of DSM. It's a no-brainer that something that won't be in DSM, that is critically important in terms of the assessment and description of human beings, is strengths.
David: Oh, yes. I'm glad you're bringing that up, because I've been very interested in the whole positive psychology movement.
Greg Murray: Exactly. But you would be pretty dumb to think that DSM, a psychiatric manual put out by a medical fraternity, is going to have a huge section on the optimal description of human strengths and flourishing. It's just not going to be there.
David: Right. And yet that seems like such an important part of the picture.
Greg Murray: Absolutely.
David: For, as you say, a holistic approach, strengths is a good place to start.
Greg Murray: Absolutely. And I suppose the other thing that I just wanted to mention, is you made a little link before between a medicalized view of mental distress and the prescription of medications. Just to underline, that doesn't have to be the case. So you're probably right from a political view -- I think you are right. From a political viewpoint, the reason that medical type metaphors keep being used in the area of psychological distress, as one of the major drivers of the narrative about mental distress, is companies who make money from pills. There's no doubt about that.
But you can use the current DSM, and you will be able to use the next DSM V, which has a medicalized tone to it, no doubt. It won't move towards radical dimensions as the data would suggest. It still has categorical diagnoses, and a lot of the phrases in there do sound very medical. But you don't have -- just because something sounds medical, doesn't mean you have to prescribe drugs for it. This is another of those polarities or oversimplifications that people indulge in. Just because we're describing a problem at the biological level or from a medicalized sort of paradigm, doesn't tell us at all what the best treatment for it is. So a condition may be framed as a psychiatric disorder, and what we call psychological treatments may be the best treatments.
I just don't like that assumption that a biological tone in the description of something necessitates a biological explanation of that phenomenon or a biological intervention for it. It's very important to separate out the description of something, and the sort of tone or the flavor of that description, with what we do about it. So when I teach people to use DSM, I say, "You really need to know these terms because most of our psychological interventions, the evidence we have for them, is framed in these terms."
David: I totally agree with you, and it's a good, strong, affirmative statement for us to close with. So, Professor Gregory Murray, thanks so much for being my guest on Wise Counsel.
Greg Murray: It's been a real pleasure, David. And if you don't mind, I'll ring you tonight when I think of the 10 other things I wanted to say.
David: Okay. Just be mindful of the difference in time zones. [Laughter]
Greg Murray: Okay. Nice to talk to you.
David: Likewise. Bye.
I hope you found this conversation with Professor Gregory Murray as enlightening as I did. I think he brings an especially balanced approach to his presentation of the DSM. I wish I could share with you the advanced chapter from his forthcoming book that I was able to read. Here's a quote I particularly liked: "DSM is one important lens on the field of psychopathology. The challenge is to use this tool while understanding how it bends the light." I think that any clinical psychology students or practitioners out there will want to keep an eye out for his forthcoming book, which, again, will be titled A Critical Introduction to DSM, and it will be published by Nova Science.
You've been listening to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net. If you found today's show interesting, we encourage you to visit Mentalhelp.net, where you can add a comment or question to this show's web page, view other shows in the series, or simply page through the site, which is full of interesting mental health and wellness content. Access the show's page and show archive information via the podcast box on the Mentalhelp.net home page.
If you like Wise Counsel, you might also like ShrinkRapRadio, my other interview podcast series, which is available online at www.shrinkrapradio.com. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.
About Gregory Murray, Ph.D.
Professor Greg Murray is head of Psychological Sciences and Statistics at Swinburne University of Technology, Australia. He is convenor of the highly respected clinical psychology programs at Swinburne University and a practising clinical psychologist. Dr Murray has been teaching psychologists and therapists for 20 years and is currently a member of a consortium revisioning the clinical psychology curriculum in Australia. He is the editor of the forthcoming book "A Critical Introduction to DSM" (Nova Science), which aims to develop an appropriately sceptical attitude to use of the dominant psychiatric taxonomy. Since taking out his PhD from The University of Melbourne in 2001, he has published over 70 peer-reviewed papers and chapters, won individual awards for teaching and research, and been a chief investigator on national competitive grants totalling > $3 million. The majority of his research is collaborative and multi-disciplinary. In Australia he works with researchers investigating psychosocial treatments (live and online) for bipolar disorder. Internationally, he is a founder member of the Canadian CREST group investigating determinants of well-being in people with bipolar disorder. He collaborates with colleagues at UC Berkeley, Harvard and University of Massachusetts on studies of sleep, circadian rhythms and mood.
Second comment - Tim Baxter - Feb 24th 2012
Also, Dr Murray mentions "Clinical Psychologists" at some point and their model which apparently includes "diagnosis", do you really think that psychologists who happen to have been trained by a specific clinical masters degree (obviously just in Australia) do anything different to non-endorsed psychologists? Is there really a difference in training/what psychologists do/what about phds who had previously been considered more qualified?
What is your opinion of the 150% difference in medicare rebate/reimbursement of patients for "clinical" vs psychologists? Doesn't this suggest that a false hierarcy of knowledge/skill/understanding is being promoted in our industry? Based on medical views that are largely irrelivant to what patients/clients actually experience in terms of care/support/treatment? Do you believe it is useful to compare treatment/care/support given by one psychologist to another based on a specific degree (rather than the general academic distinctions that have been used in the past which could also be assessed/subsituted with related to one's experience in the field)?
I would appreciate any comment and hope that my question doesn't offend.
Thanks again Dr Dave!! - Tim Baxxter - Feb 24th 2012
I just wanted to say thanks again Dr Dave for getting this stuff out there. I also wanted to let you know that your interviews are again flowing into my inbox through the Process Work community. We love you! Thanks Dr Dave, Tim
Gregory Murray- What a fantastic guest!! - Kate Hollingsworth - Feb 24th 2012
Hi Dr Dave,
I have listened to your podcasts for many years now and love many of them. But this one stood out to me so much that I wanted to write to you and let you know how much I enjoyed it.
Gregory was so clear in his explanations and I can't wait to read his book when it comes out. And the questions you asked him to guide the interview had me punching the air at times because you asked the very questions that were arising in me as I listened to the interview.
You have a great interviewing style and thank you for folowing the suggestion and asking Gregory to be a guest on your show.