Close

MY APA Speech On An Alternative to Psychiatric Jargon

Jeff Rubin

Jeff Rubin

On August 8, 2015, I spoke at the American Psychological Association’s annual convention that was held in Toronto, Canada. My speech was part of a two hour symposium titled: “Beyond the DSM–Current Trends in Devising New Diagnostic Alternatives.” The DSM’s letters stand for the Diagnostic and Statistical Manual of Mental Disorders.  It is currently used by most mental health professionals to classify people seeking mental health services.

When the latest version of this manual came out, it was widely criticized. Consequently, a group of psychologists began to work together to think about possible alternatives. Several members of that group spoke at this symposium.

My Speech

DSMOf late, I have been discussing today’s symposium theme with quite a few people. I have found that supporters of the DSM say that it is a classification system that has been helpful because it provides a common language for mental health professionals to communicate about those utilizing their services; its various diagnostic terms, such as Major Depressive Disorder, Anxiety Disorder, etc., are short phrases that are convenient for placing them into article titles, book titles, and search engines to retrieve valued relevant information; third party payers of mental health services have found that the DSM coding system works well as part of a practical method for their record keeping; with the aid of these codes, people do manage to access mental health services, mental health service providers do manage to get paid, and for-profit health companies do tend to make a profit.

So, from my discussions, those are the basic reasons supporters of the DSM say that it is useful. Actually, there is another usefulness of the DSM that, interestingly, I never hear supporters of the DSM mention, and yet critics of the DSM often mention. pillsThat usefulness is this: by using medical sounding terms to refer to all of the experiences that the DSM classifies as “mental disorders” it legitimizes in the minds of many the prescribing of drugs for these experiences.

There is an enormous amount of money being made from this approach because it takes less than a penny to manufacture each pill, and it can be sold for more than one thousand times that amount. With so much money being generated from this enterprise, the drug companies have managed to make it clear to powerful groups that what benefits the drug companies also benefits them. Examples are, major media outlets gain enormous revenues from drug company advertisements, and political campaigns get substantial support from the industry.

elephant-in-the-roomSo this benefit is in a sense the elephant in the room. I fully see it, but nevertheless, I want to move it off to the side of the room for now, and ask you all to briefly ignore it. After I complete my main ideas, I’ll return to the elephant in my concluding remarks.

Keeping in mind just the usefulness of the DSM that its supporters tend to mention, it seems to me that if we are to have any hope that an alternative to the DSM might be widely adopted, we would have to be able to make an excellent case that the alternative would be just as helpful while, at the same time, have significantly less shortcomings.

What are these shortcomings? psych labelsWell, in brief, critics of the DSM have expressed concerns that it tends to be stigmatizing to mental health service users; the DSM also simplistically devalues all of the experiences that it classifies as mental disorders despite the fact that there are a great number of people who have testified that having gone through these very types of experiences it brought forth valued fruits.

Leo Tolstoy

Leo Tolstoy

For example, Leo Tolstoy reported it his biography, My Confession, that by going through a period of suicidal depression, it led to one valued insight after another.

Joni Mitchell

Joni Mitchell

As another example, the fine song writer, Joni Mitchell apparently went through, during her life, a number of very challenging emotional experiences that first received the full DSM psychopathologizing treatment. In time, her perspective changed, and at one point she expressed her new perspective in a song titled, “Hejira.” She wrote, “There’s comfort in melancholy where there is no need to explain, it’s just as natural as the weather in this moody sky today.” Thus, for many, the framing of their experiences as mental disorders dramatically misses the mark; critics of the DSM also point out that it violates basic principles of science because of its vaguely defined constructs and thus low inter-rater reliability; the DSM also violates basic principles of humanistic psychology; and within the mental health field the DSM is a monopoly, with all of the drawbacks associated with such an organizational situation.

So, those are, in brief, the DSM shortcomings. Keeping them in mind along with its perceived benefits, is it possible to come up with an alternative that indeed does achieve all of the benefits that the DSM supporters claim for it, while, at the same time, has far fewer shortcomings? Well, for your consideration, I offer you the Classification and Statistical Manual of Mental Health Concerns, or, for short, the CSM. Not the DSM, but the CSM! Let’s look at what each chapter would contain.

Chapter 1

individualityThe first chapter would begin by stating that the developers of the CSM fully recognize that individuality outruns any classification system. It is for this reason that the CSM does not seek to classify anyone. Instead, it classifies the expressed concerns of individuals seeking to have their concerns addressed by a mental health service provider.

This first chapter would go on from here to explain that the CSM begins from the perspective of the person seeking services. Because the expression of a mental health concern is a clearly observable event that occurs at a specific time and place, by making it the event being classified in the CSM it solves the reliability problems that have been plaguing the DSM’s far more abstract concept of “mental disorders.”

After this statement, the CSM would clearly define its main construct:

concerns 1A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern about any of these topics: behavior, emotion, mood, addictions, meaning of life, death, dying, managing chronic pain, work, relationships, education, eating, cognition, sleep, and challenging life situation.

So, those are the basic ingredients of Chapter 1.

Chapter 2 

Chapter 2 would begin by explaining that the CSM has two classes of expressed concerns–Concerns expressed about oneself, and concerns expressed about someone else.  social-anxietyAn example of the first class is, Sally is seeking mental health services and expresses a concern to a mental health service provider that she has been experiencing a great deal of anxiety when she enters social situations. Father-and-SonAn example of the second class is Bob, a father, upon seeking counseling for his son, expresses a concern about his child’s behavior.

Each of these two classes of concerns would have under each of its headings a list of specific concerns, along with an assigned code to be used for third-party payer record keeping.

So, let’s quickly return to the example of Sally expressing a concern that she has been experiencing a great deal of anxiety in social situations. This would be referred to, for classification purposes, as a “social situation anxiety” concern. Notice that “social situation anxiety” is just three words, thus it is short enough to be used in article titles, book titles and search engines.

Each of the actual expressed concerns would be just as useful as the DSM terms for providing those in the mental health profession a common language for communication about those utilizing their services.

In this chapter 2, it would be explained how the creators of the CSM identified the list of concerns included in the CSM.  SurveyTimeThese concerns would be identified by a survey of a sample of mental health service providers. Those filling out the survey would first read the definition of a mental health concern. Then they would list, in order of frequency, the various concerns that they had been asked to address in their practice over the course of the previous year. At the back of the CSM would be a summary of the findings of this survey and its related statistics.

Moving on to Chapter 3

As noted, the previous chapter would be designed to provide the method for identifying and coding a set of brief mental health concern descriptors suitable for a number of practical purposes. Once this is achieved the CSM then provides a method to develop a lengthier psychological formulation approach that is designed to fill in additional details about the expressed concern. collaborationThus, Chapter 3 of the CSM would be devoted to describing good practice guidelines for the use of a type of psychological formulation that is consistent with the CSM’s philosophy of not psychopathologizing individuals.  This type of psychological formulation provides an approach that expands on the brief expressed concerns of individuals by developing a narrative of several paragraphs. It can be defined as the process involving a mental health service user and a mental health service provider co-constructing a hypothesis or ‘best guess’ about the origins of the mental health service user’s concerns in the context of his or her strengths, relationships, social circumstances, cultural heritage, life events, and the sense that he or she has made of them.

Defending the CSM

Okay, these are the basic chapters of the CSM. Now let’s quickly recall that supporters of the DSM believe that it is a classification system that is useful because it provides a common language for mental health professionals to communicate with one another. I hope from what I have already said, that you can plainly see that the CSM would provide an alternative plain, humane language that would be just as practical as the DSM. But let’s look a little more closely at this via an example.

unversityWhen I was doing my practicum at the University of Minnesota’s Counseling Center, I worked there for a whole year and we had no need to use the “mental disorder” jargon of the DSM to communicate. When my advisor asked me to quickly tell him about my morning cases, I would reply with words like, “My 9:00 a.m. case is concerned about feeling depressed, my 10:00 case is concerned about his failing grades, my 11:00 case is concerned about how anxious she is in social situations. If my advisor wanted to know more about a case, we went into the psychological formulation type of information. Communication flowed easily. This is how the CSM would work in practice.

The idea that the DSM’s coding system is a practical approach for third party payers’ record keeping is an essential point made by DSM supporters. With the following description, I think you will readily see that the CSM approach is just as practical.

insurance formThird party payer systems have a form that must be filled out whenever someone seeks mental health services under their plan. This form has a little box that currently says, “Diagnosis.” In that box, mental health professionals are required to fill in the DSM code that corresponds to their so-called diagnosis of the person seeking services.

With the CSM proposal, all that we would be asking third-party payer institutions to do differently in order to add value for their customers, is to slightly change that little box. Instead of just saying “Diagnosis” as it currently says, that box would add two simple 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-5” 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.

With the creation of the CSM, not only will mental health providers have a new option to choose from, but so too will mental health consumers. They would be given the choice to go to psychopathologizing mental health service providers or those using the CSM approach.

So, for third party payers, that’s all the change that would be required in order to increase value for a significant number of mental health providers and service users. And a major goal that all third-party payers have is to increase value for their customers. The cost and effort for adding this new option for these payers would be minimum.

Conclusion

In conclusion, the creation of the CSM would improve value for consumers of mental health services. It would provide a practical approach that offers a new choice for those mental health service users and providers who are dissatisfied with the DSM. It does so in a manner that is more scientific and humanistic. Moreover, the creation of the CSM would break up the DSM monopoly.

pills2Now, let’s return to the elephant in the room. Let’s bring it forth, front and center.

Yes, the DSM’s medical jargon has an enormous benefit to the pharmaceutical industry. However, with the creation of the CSM, the elephant would still get fed. Those who prefer the DSM to the CSM would be able to continue to use it. The pharmaceutical industry will still be able to promote the drugs with images of a patient looking miserable and family members distraught, all in grey, black and white, followed by images of the same patient taking a pill, now smiling in vibrant living color, with the sun shining, and family members gathered around, and bouquets of flowers brightening the whole world. There will be plenty of people who will still seek to have their concerns washed away with the ease of swallowing a pill.

Despite drug companies being able to still make a great deal of money even if the CSM was to become widely adopted, no doubt the industry as a whole would still seek to try with all its might to maintain the monopoly it currently enjoys. No doubt, big money can be very influential in putting a stop to competition. I get that. But to help us to think a little more clearly about this, let’s use a metaphor fitting to our country’s current enormous interest in the presidential primary campaigns.

You all know about the discussions going on about how a few billionaires has so much influence on who will get to win. There is much truth to this concern, but I ask you to keep in mind that every now and then, a dark horse comes along that does manage to win despite all of the big money that went to supporting the favorite of the super-rich.

dark-horseIn my view, the CSM has the potential to be that type of dark horse. I’m hoping that this is so because there exists enough psychologists out there who are willing to roll up their sleeves and get down to do the necessary work of joining their efforts with those of other allied professionals and mental health consumer advocacy groups because they believe this is in the best interest of those they seek to serve.

——————–
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 intelligence. To begin at the very first post you can click HERE.

 

Psychiatric Name Calling: What Do People Say About It?
Mental Illness or Below Average Functioning?

About the Author

Jeffrey Rubin grew up in Brooklyn, received his PhD from the University of Minnesota and has taught conflict resolution there as well as at a psychiatric clinic, a correctional facility and a number of public schools. He has published articles on anger and conflict resolution and has authored three novels.

13 Comments

  1. Keep going, Jeffrey. You are definitely on to something strategic and very helpful. What you are doing by elevating the authority of the individual when it comes to helping people is very similar to what Suzette Misrachi refers to as the Third Wave of Literature. Suzette is an Australian practitioner whose master’s thesis, “Lives unseen: unacknowledged trauma of non-disordered, competent Adult Children Of Parents with a Severe Mental Illness (ACOPSMI)” is at the very heart of what you are trying to do as well.

    You two should connect. Here is a link to her thesis:

    https://minerva-access.unimelb.edu.au/handle/11343/37852

    • Much thanks for your kind words of support–very much appreciated. I’m very busy preparing for the upcoming APA convention for now, but I’ll try to take a look at her thesis shortly afterwards.

  2. Hi Dr. Rubin, Thank you for this important evolution towards stopping the abuse that is part and parcel of pathologizing human experience.

    In reading your proposition, I am struck by the realization of how intimately the term “mental health” is synonymous with “mental illness”. One conjures the other conjoined and inseparable twin.

    Although the CSM presents a potentially workable alternative that the industry uses as a convenient excuse for failing to evolve in a humane manner, the stain hence stigma will always remain unless and until the “handle” itself is abolished and replaced with a more accurate, respectful one that honors diverse human experience as NORMAL. The stink is firmly ingrained in the popular culture and in fact has twisted our perspective to the point that we ourselves are doing psychiatry’s dirty work for it. En mass, we diagnose others with “mental health” slurs to attack their character to ostracize and justify abusing them. As such, retaining the term “mental health” would be akin to turning a blind eye to the legacy of abuse with the pretense of making it all better. The language IS the problem.

    It is further problematic in that the term “mental health” sets up an automatic and false hierarchy of superiority over and above “users” by “providers”. It builds an us and them divide that encourages discrimination. In preserving the label, you preserve the implications.

    Normal has been co-oped as ‘mentally ill” to such a pervasive degree that it would be like saying, we’re all going to use the ‘N’ word now, but as of today, everyone is expected to agree and assume that we mean it in a loving and respectful manner. Today we wash away everything vile, ugly, cruel and abusive about it. From here on in the ‘N’ word has no historical context and can be used by all as an endearing term of solidarity.

    I imagine the response that would have on the Black community would be about the same as it would be from the Psych survivor community. It fails to consider the victims and historical roots. It fails to appreciate the power of the words themselves that have been used to harm us. And as such it cannot lead to real meaningful change or healing.

    If one is serious about creating a safe alternative stream whose intention is to circumvent the harm, it needs to be a unique entity with a new name; not a unique concept with the exact same historically ingrained ‘crazy” connotations attached to it. As much as I support the need for the alternative you are proposing, I would NEVER attend upon anyone claiming to be a “mental health” worker. To me it smacks of voodoo, fraud, quackery and is laughably devoid of credibility. I would further suggest that those doing the work would not be able to break with the their past training and the way in which they “judge” other people. You are really talking about a shift in ideology that only ppl who embrace a humane vrs a paternal approach to life could honestly embrace.

    Please keep considering a more thorough and cleaner break from the abuse that includes a humane LABEL so that ppl are not still automatically stigmatized simply because they are human beings who inevitably experience human problems.

    Thank you for your important work and contribution in attempting to humanize psychiatry .
    Looking forward to learning how the APA responds.

    • Hi Judy Gayton,

      I appreciate your thoughtful comment regarding my proposed alternative to the current psychiatric labeling system. I am largely in agreement with all that you wrote, especially the part about how the term “mental health concern” is so easily connected with the term, “mental illness,” which, as you rightly point out, has a stink to it. The trick is to try to move toward the direction that both of us wish to be heading, while being practical. I am open to hearing alternatives. The practical problems I run into when trying to come up with alternatives is very challenging.

      I first suggested “psychological concerns,” rather than “mental health concerns,” thinking that one would not so readily connect this to mental illness. There is a large group of people involved in positive psychology and this change could be, with some promotion efforts, connected to that part of psychology. But at an international conference where I first made this proposal, there was a social worker who felt that “psychological concerns” would not get the support of fellow mental health workers such as social workers and counselors. She felt that because I am a psychologist, I was trying to position my profession over other legitimate professions that currently use the psychiatric labels.

      It was also pointed out to me that currently we have such enormous organizations as Mental Health America and its state and regional affiliates, the National Institute of Mental Health, university and college programs offering degrees in Mental Health Counseling, and states offering certifications in this field. There are laws that date back at least to the Kennedy administration (1961) referring to the establishment of “Community Mental Health Centers,” etc. Psychologists, social workers, counselors, and psychiatrists regularly refer to themselves as providing services under the umbrella of “mental health service providers.” Those in the international group felt “mental health concerns” was more inclusive of the various allied professionals. For these reasons, the CSM, as currently envisioned, maintains the concept of “mental health” so it can be comfortably and realistically accommodated into the many large organizations currently using it.

      However, the CSM would use the term “mental health” in a way that is explicitly different from what is implied when using the DSM and the ICD terms. The CSM would explicitly reject the idea that the opposite of mental health is mental illness. Rather, the word “health” in the CSM’s “mental health” would be phrased in a manner that indicates, and underscores the following point; that professionals dealing with mental health concerns are part of the allied health professions. The reason for thinking of these professionals as health providers follows.

      Many of the concerns that would fall under the CSM’s list of related topics (behavior, emotion, mood, addictions, meaning of life, death, dying, managing chronic pain, work, relationships, education, eating, cognition, sleep, and challenging life situations) have been identified in scientific studies as “physical health risk” factors. For example, people who express a concern about being addicted to alcohol are at increased risk of developing sclerosis of the liver (O’Shea, Dasarathy, & McCullough, 2010). Those who express concerns about eating more than average may be at greater risk of diabetes and heart disease (Mokdad, et al., 2003). Quality of interpersonal relations, lack of sleep, depression with thoughts of suicide, and various other concerns or clusters of concerns can be studied for the degree of physical health risk that they pose.

      A major goal of mental health service providers under the proposed CSM system is to turn “physical health risk” factors into “physical health protective” factors. The degree to which this is successful can be studied using currently available methodologies. It is in this very specific sense that the mental health concern topics are viewed not merely as mental concerns, but also mental health concerns.

      By being explicit about this change in conceptualizing mental health concerns, I, and those whose support will be necessary to make a valued change, believe that the CSM proposal holds promise for avoiding most of the negative baggage that comes with this type of terminology. It is clearly not perfect, but it may be the necessary next step toward making significant improvements when it comes to accessing certain services many people desire to utilize.

      • I understand the dilemma Dr. Rubin, but respectfully disagree. Other than completely abolishing the fraud that psychiatry and ALL its off-shoots are, the CSM offers a hopeful answer to the problem.

        The need to pathologize, is pathological. It is the real disease causing the damage here. It cannot be ignored that defaulting back to “psychological” or ‘mental” tags is problematic. People using this service, for what ever reason, (and ultimately because it is the only game in town) still end up under the thumb of the same drug pushing label makers that support the abuse and torture as treatment. Streaming ppl into what looks like a safe alternative and calling it the same pathologizing names, is dangerous.

        Sending the “alternative” stream of ppl to the same sick “caregivers” who get off on and profit from destroying the lives of others, using the same pathogizing words to say (this is what it really is and where one is really going) leaves the door wide open to the same abuses by the same industry. The deeper systemic problem remains. The ROOT CAUSE of the problem isn’t challenged, exposed, held accountable and removed.

        It begs the question, is there really any safe place to be human in an inhumane system? Given the nature, scope and seriousness of the problem, Is this alternative divorced enough from the root of the problem that it does not become yet another version of the initial problem it already created? Can cleaning up a river, save a toxic ocean? I don’t think so. The survivor community will see through it in a heart beat. This needs eyes on at the UN level.

        Was the psych survivor community included Dr. Rubin? Or were victims voices excluded?
        Has the CSM posted at Mad In America?

        • Hi Judy Gayton,

          I believe your concerns are legitimate and that it is vital that they be heard. How to get to a place where improvement begins to occur is where we have some differences.

          In response to your question, two of my post that discuss the CSM have been picked up by Mad in America’s website. Also, I have met Robert Whitaker, am a huge admirer, have discussed his books in my blog on several occasions, and participated with him in a conference about the issues you have raised. Also, I have worked with people in the survivor movement for many years, and am a dues paying member of MindFreedom International. I have heard the concerns of survivors, relate very much to what they have to say, and am seeking to do something positive about this.

          Wishing you well,
          Jeff

          • Thank you for answering my questions Dr. Rubin.

            I appreciate your willingness to hear survivors and understand your approach. I sent your work to thousands of people who have a personal interest in the outcome- assuming one is manifest. Thank you for your work in the public interest and a safer more realistic way of treating human beings with human concerns.
            God’s speed

  3. In your chapter 2 above you wrote: In this chapter 2, it would be explained how the creators of the CSM identified the list of concerns included in the CSM. SurveyTimeThese concerns would be identified by a survey of a sample of mental health service providers. Those filling out the survey would first read the definition of a mental health concern. Then they would list, in order of frequency, the various concerns that they had been asked to address in their practice over the course of the previous year. At the back of the CSM would be a summary of the findings of this survey and its related statistics.

    and my only complaint, concern or request for improvement or more progressive style would be instead of surveying the providers to find out what people have suffered, why not survey the people being served?…. Ask them how They would classify what their needs have been… wouldn’t this likely render an understanding and knowledge of our needs that is even closer to what they really are and the best voice to use for authority?….

    • Hi Renee,

      I fully agree with your suggestion. Much thanks.

  4. ….the most progressive way to begin?….

    • Yes, Renee, I agree that it is the most progressive way to begin.

  5. No Sale Mr Rubin. Thank you Judy Gayton for attempting to stimulate Jeff, who i admire for his passion and intentions. I gave up dialoguing with him last year after exhaustively attempting to encourage more respect and focus on what it seems you speak to. I raised to question his beliefs and what seems to me a rather obsessive over complicating, labelling, and pigeon holing all the simple choices of self talk, inner dialogue, and beliefs one freely chooses or habitualizes oneself emotionally in doing oneself with. Thanks again for reminding me of this fellows curious passion, for overcomplicating and overtalking 🙂

    • Hi Larry,
      Thanks for putting in your two cents on this issue. I know that there are some people who share your views. My blog is always open for people who agree, question, or disagree with me. Wishing you well,
      Jeff

Write Your Comment

You may use these HTML tags and attributes:
<a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>