Last week, I posted an article titled “Name Calling by Psychiatrists: Is it Time to Put a Stop to it?” It created quite a stir and it’s currently challenging my two previous most popular posts—“Teaching Children How to to Deal with Criticism” and “Is it Wise to be Assertive?”—for the number one spot.
The article points out that by using the term “diagnosis” in psychiatric terminology it misleads people in a variety of ways. For example, when psychiatrists provide their patients a so-called diagnosis many people believe there is now a valid explanation for why they are struggling with their personal difficulties. Instead, all that has really happened is that the psychiatrist has converted the expressed concern of the patient into pathologizing language.
The manual that psychiatrists use when deciding which words to use when converting concerns to “diagnoses” is called The Diagnostic and Statistical Manual of Mental Disorders (DSM). Of course as this manual was developed there was a huge financial interest to utilize language that encourages the perception that an expressed concern is a very, very serious life-long condition that requires medical treatment for a lifetime. Consequently, when patients express a concern about being depressed, the psychiatrist informs them that they have “major depressive disorder,” and often couple this with statements such as, “This is a serious lifetime condition that must be managed for a lifetime.” Any language that suggests that there is substantial evidence that most people recover even without treatment runs counter to the psychiatric business plan.
Among the many comments that I received about the name calling article are those that point out that most of the doctors who are using the psychiatric terminology provided in the DSM are not psychiatrists. Pediatricians, general practitioners, internists, psychologists, and neurologists daily call people these names. Other comments present the argument that it is the pharmaceutical companies that promote the pathologizing of human concerns in order to convince people to ingest their drugs.
I’ll be exploring these issues in coming weeks. But today, let’s focus in on the argument that the real group of people at fault for this type of name-calling is the third party payers such as insurance companies, Medicaid, Medicare, and Social Security. After all, by far, the DSM terms are used most by these types of entities.
The DSM and Third Party Payers
Most people in the United States who seek mental health services don’t directly pay for them. Instead, they have insurance policies that cover some, or all, of the fees; or they qualify for Medicaid, Medicare, or Social Security benefits. Insurance companies and these other agencies are called third party payers.
Third party payers currently have a form that must be filled out whenever someone seeks mental health services under their plan. That form has boxes for the name of the person seeking services, his or her contact information, policy number, some information about who is being asked to provide services, and then, imbedded in all of this, is a little box that currently says, “Diagnosis.” In that box, mental health professionals must fill in the DSM code that corresponds to their “diagnosis” of the person seeking services.
Third party payers initially developed their form for people who were seeking medical services for physical complaints. Physicians would fill in the diagnosis box with a code that corresponded to a list of diagnoses in their pathology manuals based on a visual inspection of a tissue tear, the results of x-rays, blood test, or a pathologist examining a tissue sample of a tumor under a microscope. Sometimes it was based on a report from a toxicologist because it was theorized that the patient had been exposed to some toxic substance. In each of these cases, the diagnosis that was provided actually did provide some understanding for why patients were struggling with their expressed physical complaints.
However, I hasten to point out that in many cases physicians were unable to uncover the reason for the physical complaint. At such times they often did pretty much what psychiatrists do today—they converted the physical complaint into medical jargon, typically using Latin derived syllables, and then stuck them into the third party payer’s “diagnosis” box on the third party payer forms, prescribed some treatment, and low and behold, third party payers paid the doctors just like they did when a real diagnosis was provided.
A physician once confided in me that for the majority of his cases he was unable to identify the reason for the physical complaint but he nevertheless provided some diagnosis and a prescription for a pill. “If I didn’t,” he said, “my patients would feel that they wasted their money by coming to see me.” I then asked him how he felt about misleading his patients in this way. “Well,” he replied, “if my patients feel that I have made a real diagnosis and prescribed some pills, they feel a sense of being reassured and the pills can have a placebo effect which may be very curative in its own way.”
“The pills that you prescribe,” I replied, “are not simply substances with no physical effects beside the placebo effect, they have a number of real serious side effects associated with their use. Is that really ethical?”
“Well, the physical side effects often help the placebo effect because the patient feels something is really physically happening. It is part of what reassures them that what was prescribed has a powerful effect. When weighing the risk of serious side effects versus the minor side effects that can be helpful, I make my decisions on what to prescribe.”
And so, that’s a little of my understanding of the reasoning behind this type of misleading name-calling and prescribing practices of physicians dealing with physical complaints. I prefer honesty. However, for those who prefer this fatherly treatment that is mixed with huge financial interests, I’m advocating that they continue to get what they want.
Now, once third party payers began to provide coverage for mental health services, their administrative forms didn’t have to be changed. There was already a precedent for placing in the “diagnosis” box on the form fake diagnoses, and psychiatrists seeing that this business model was a source of a great deal of money created the DSM.
What would be a Reasonable Alternative to the DSM?
For those who prefer to be treated honestly, can an alternative to the DSM be developed? There is an international group working on this.
The alternative’s working title is called The Classification and Statistical Manual of Mental Health Concerns, or, for short, the CSM. With this approach, no individuals would be classified, only their expressed concerns.
With the CSM proposal, all that we would be asking insurance companies to do differently in order to add value to their customers, is to slightly change that little box that currently requires a diagnosis or a word pretending to be a diagnosis. Instead of just saying “Diagnosis” as it currently says, that box would just add two little words, so it would end up saying “Diagnosis or Concern.” Then, when mental health professionals fill in the box, they would be given the choice to either write in the letters DSM and its code number that corresponds to its so- called diagnosis, or they would write the letters CSM and its code number that corresponds to the expressed concern.
The cost and efforts for insurance companies would be minimal, and we would have numerous testimonials from customers that documents that this change would be viewed as a significant improvement.
Now, some of the insurance company executives might pause and say, “Wait a minute. You’re asking us to permit the use of the CSM as an alternative to the DSM. Just wait a minute. The DSM has been developed by mental health experts and is backed by a major mental health professional organization—the American Psychiatric Association. Does the CSM have that type of authority to back it up?”
If we prepared for this, we will be able to answer that the CSM was also developed by mental health experts and does have several mental health professional organizations backing up its use as an alternative to the DSM. I believe this can be achieved. We have in our alternatives group several people who would qualify as mental health experts, and I think we can get some more involved as well. And when the latest edition of the DSM was released several professional organizations expressed a strong desire that an alternative to the DSM be developed. I think it’s reasonable to assume that at least some of them would agree to back this alternative, especially if we involve them in its development.
In short, the creation of the CSM permits us to present to insurance company executives and other third party payer administrators a real alternative to the DSM. It would be virtually cost free for them to permit its use, it would have the authority of being developed by experts in the mental health field, the backing of mental health professional organizations, and it adds value for a significant number of their customers.
The CSM Would also Help Mental Health Service Providers
Now, besides the insurance companies and other third party payers, the other big group of people in America that is currently using the DSM is mental health services providers. How would they react to being given the choice to replace the DSM code with the CSM code on third party payer forms when they felt in their professional judgment that it was appropriate? Well, we get a little sense of what their reaction would be from a survey Paula Caplan tells us about in her book, They Say You’re Crazy. According to this survey, over 70 percent of those practitioners who responded to the survey said that the only way they use the DSM is to fill out the insurance form. Other than that, it doesn’t help them at all.
To those who believe that the use of the current DSM terminology helps to enhance the placebo effect of treatment, keep in mind that this is a testable theory. We can arrange for studies that compare the outcomes of service providers that utilize the DSM coding system with service providers that employ the CSM coding system. But that would be an approach that employs basic principles of science, rather than unsupported claims backed by enormous financial interests.
Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional and social intelligence. To begin at the very first post you can click HERE.