Have you ever had a new client come to a first session and announce—with a formality that seems right out of the DSM—exactly what his diagnosis is? Perhaps this client is also certain about what symptoms are the result of a “chemical imbalance” and thus can be immediately treated with medication, not therapy. He may be willing to talk about some things in therapy, like his job or his marriage—but in terms of his anxiety, that’s what the pills are for.

When it comes to treating depression, neuropsychologist John Preston, author of Clinical Psychopharmacology Made Ridiculously Simple, says that psychoactive medication is only one alternative and often not the most effective. In addition to his integrative approach—which includes exercise, combating social withdrawal, family involvement, and possibly meds—he’s always on the lookout for toxic relationship issues in the client’s life.

Amid the many controversies surrounding the influence of the drug companies on the quality of mental health care, one important fact about the medications brought to market over the past 25 years has received little attention—few represented any real advance in the science of psychopharmacology or any real expansion of our understanding of how to regulate the nervous system with chemicals.

Over the last 150 years or so, we’ve seen successive waves of mass infatuations with psychotropic drugs—morphine, heroin, cocaine, amphetamines, barbiturates, tranquilizers, and antidepressants. While all these drugs are different, the story arc they follow—their rise, triumph, ascendancy, and gradual decline or sudden collapse—does follow a roughly predictable course.

However much we all might like to discuss and debate DSM-5, the field of psychotherapy continues to move forward.