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The Ethics of Psychiatric Diagnoses

EmpowermentThis blog seeks to empower its readers, many of whom are directly involved in the mental health arena or will become so in the future. Others are, or will become, involved indirectly because of someone they care about. Thus, it makes sense to spend some time learning how to effectively engage with mental health service providers.

ethicsOne way to achieve this is to be aware of some of the arena’s major ethical challenges. Today, we will focus on three involving psychiatric diagnoses.

We will begin by noting that there is no clear line for mental health providers to distinguish between those they claim have a mental disorder and those who they claim do not have a mental disorder. This vagueness, as we will see, opens the door to the arena’s major ethical problems.

We will then look at three of the most serious psychiatric diagnoses ethical problems. An alternative way to look at the concerns that now lead to a psychiatric diagnosis will then be presented, along with an explanation of how this alternative can be empowering.

The Vague Line

Vague 1

DSMThe American Psychiatric Association provides a definition of a “mental disorder” in its most recent version of the Diagnosis and Statistical Manual of Mental Disorders (DSM-5). Let’s take a look at it:

Although no definition can capture all aspects of all disorders in the range contained in the DSM-5, the following elements are required:

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognitive, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning. confusedMental disorders are usually associated with significant distress in social, occupational, or other important activities.  An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.  Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. (p.20) 

vague2Notice how broad this definition is. It makes mention of a “disturbance” that reflects a “mental dysfunction in the individual.” We all run into some disturbances in our life. How can a professional reliably tell if the disturbance is due to a “mental dysfunction?” We are left in the dark about this. The process described in the DSM-5 for assessing the subjective notions of “clinical significance,” “disturbance” and “dysfunction in the individual” provides clinicians an opportunity to include anything that benefits their set of values.

Certain socially deviant behavior and conflicts are not mental disorders, although they may be. DysfunctionIf the social deviance or conflict results from a “dysfunction in the individual,” then a mental disorder exists in the individual. Once again we are left in the dark about how this distinction is made. It is left to the subjective judgment of the clinician.

Another distinction that the definition attempts to make between what is a mental disorder and what is not appears in the following sentence:

deathAn expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.

Let us try to apply this sentence to the following situation. A soldier in combat has his vehicle blown up. soldierAlthough he survives, he suffers the loss of a leg and an arm. Moreover, in the attack, two of his closest team members had burned to death in front of his eyes. This soldier seeks psychological help. He tells his story with tears running down his face and his one hand that he has left is shaking. He reports having nightmares and difficulty functioning in social situations. The clinician is well aware that such stressful experiences are fairly common under the set of circumstances faced by this soldier. And yet can anyone imagine the clinician denying services to this soldier because his response to the stressor is expected and culturally approved? If the clinician does agree to provide services, he or she would have to provide some mental disorder “diagnosis” on an intake form.

ignoreIn my view, clinicians routinely ignore the “expected or socially approved” clause. It might have sounded like a good idea to insert into the mental disorder definition for those who developed the DSM-5, but I think few people genuinely believe that in practice clinicians are turning away paying customers when someone seeks help after having experienced the death of a loved one, or any other common stressor. To see such clients, clinicians are required in most mental health settings to assign a mental disorder “diagnosis.”

Now, let me make a couple of other quick points about the DSM-5‘s definition. First, note that clinicians are not at all required to follow even this vague definition. They are free to use any definition that suits them. Second, from my experience, the vast majority of clinicians can not even state the DSM-5‘s definition. Some that I have asked say they had glanced at it when their copy of the book arrived, but are at a loss at taking a guess at what it precisely says. Most say that the American Psychiatric Association’s definition is simply of no interest to them.

So, keeping in mind how loose the definition of a mental disorder is even among clinicians, let’s take a look at some ethical problems that exist in the mental health arena.

Conflicts of Interest

conflcit of interestMost clinicians have a financial interest in deciding whether or not those seeking their services have a “clinically significant” condition. When they judge that their clients’ conditions are indeed significant, they indicate this on the third party intake forms by assigning a mental disorder “diagnosis” and this allows them to continue to see these clients and to get paid for additional visits.

On the other hand, clinicians who work in an underfunded community government clinic that is being swamped by those seeking to access mental health services might apply a more stringent standard for what constitutes a mental disorder. Thus, we can hypothesize that this type of clinical judgment may often be more of a self-interest decision than one based purely on some objective criteria.

Stigma

StigmaClinicians refer to mental health service users with “mental illness” and “mental disorder” terminology. These are the same terms that many people use as insults and the media regularly pairs with the most heinous crimes. The stigma associated with such terminology is well recognized. There would be some justifiable reasons to continue to use such terminology if it provided scientific precision to those who wish to communicate about those utilizing mental health services, but as we have seen, this is not the case.

Violating the Respect of Service Users     

got respectThe current psychiatric diagnoses approach focuses on the “dysfunctions” of individuals accessing mental health services rather than human strengths within a cultural context. Moreover, it seeks to legitimize the privileging of the “expert” who supposedly has access to the truth and who can see the truth of the truth. We see this reflected in the mental health arena when we find that it is the clinician that makes the so-called “diagnosis.” The expert is thus seen as always equipped with technical knowledge and jargons without which the truth of knowing would be imponderable. This perspective can paralyze the power of choices for mental health service users.

An Alternative Way to Look at the Concerns that lead to a Psychiatric Diagnosis

In my opinion, there is a much better alternative way to conceptualize the types of concerns addressed by mental health service providers than the one provided in the DSM-5. APA conventionIn an earlier post I provided readers of this blog a copy of a paper on this alternative that I presented at the last American Psychological Association’s Convention that was held in Toronto. APA denverSince then, I tweaked a few ideas, and submitted a new proposal for a presentation at the next APA Convention to be held this August in Denver. I’m happy to report that my proposal has been accepted. Here’s the title and abstract of the paper:

The CSM: A Person Centered, Culturally Sensitive, Recovery Oriented Alternative to the DSM

The Classification and Statistical Manual of Mental Health Concerns (CSM) is a proposed alternative to the DSM. It would begin with the following statement: “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.” A mental health concern, as defined in this proposal, 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, meaning of life, death, dying, managing chronic pain, addiction, work, relationships, education, eating, cognition, sleep, and stressful situation. The classification process of the proposed CSM respects the perspective of persons seeking services, recognizing that they have far more expertise about what is going on in their lives than any expert can have by interviewing them. In addition to classifying mental health concerns, the CSM would describe a collaborative approach between the person expressing the concern and the mental health service provider for creating a psychological formulation narrative that eschews the DSM psychopathologizing jargon. In contrast to the CSM, the DSM seeks to legitimize the privileging of the “expert.” We see this reflected in its classification systems when we find that it is the clinician that makes the “diagnosis.” This perspective hinders the empowering of mental health service users. It is argued that when compared to the DSM, the use of the CSM would be less stigmatizing, as well as more person centered, culturally sensitive and recovery oriented.

KEYAlthough the CSM has not yet been fully developed, becoming familiar with its basic ideas are empowering. Combining these ideas with knowledge about the three psychiatric diagnoses ethical challenges–conflicts of interest, stigma, and violating the respect of mental health service users–can assist people to become far more effective in interacting with mental health service providers.

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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.

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.

11 Comments

  1. I just read this article which was posted on the Radical Psychology Network’s listserv for which I am moderator. I agree with all of it. I’ve written a lot on this subject and several years ago wrote a short parody titled “Who’s Normal? If you would like a copy, please send an e-mail to me at the URL below.

    • Please would you send me a copy of “Who’s Normal”
      Thanks

  2. Hi Robert. Your parody sounds interesting. I’ll send you that email so I can see a copy. Glad to learn of your Radical Psychology Network listserve. I hope to hear more from you soon,
    Jeff

  3. A friend of mine has just decided to seek for a professional help in a psychiatry clinic after a few years of psychotherapy without success. She is still hanging in the pain of past and struggling between fighting for a new life and committing suicide. She is only 24.

    I have listened to her stories, understand her problems as more or less I’ve been there, but I’m not a psychologist, nor a psychiatry to be able to help her properly.

    Last weekend I visited her at the clinic. After knowing how she got in there, I’m much confused. Exactly as the picture above, they “diagnosed” her with depression after asking some questions from a checklist book, and because she was thinking of suicide, they put her in the clinic with an ambulance and three guards.

    In the clinic they put her in a room which is connected to an isolated room – which locks any patients who are aggressive. My friend doesn’t need to take medicine as she promised to inform the nurses whenener she’s in bad mood. And the lady in the isolated room just knocks on the door, asks for release, sings, talks, shouts, and even throws herself into the door all day and night. Would a mental healthy person be able to bear that without feeling nerved? Let along a depressed person who needs to rest. I don’t see any good arguments there for my friend’s recovery. Can you please give me some?

    Your post really touched my heart. It gives me a hope that my friend will be treated to be a healthy person, that is person centered, culturally sensitive and recovery oriented, and not to be an insane one.

    • Much thanks for your comment, Thuy Franke. It is important for people to hear what can occur in the type of place you describe. I agree with you that your friend needs some rest, rather than to be subjected to the very disturbing experience of being in close quarters with someone so agitated. It seems to me that a safe, quiet place that has a counselor gently inviting from time to time your friend to discuss how he or she might help your friend through what she is experiencing would be a much better course of action.

  4. The DSM has lost all credibility as the years have gone by. Changes to the DSM has been less about science and more about society. Gender Identity Disorder has been changed to Gender Dysphoria strictly because society has demanded it. Clear autism classifications have resulted into such a broad spectrum with so few qualification conditions that anyone could really fall into the ASD spectrum. ASD is the result of funding demands and financial circumstances. The list goes on.

    I worked in the psychology industry (and it is definitely an industry) for 5 years and that experience has made me understand why the DSM keeps changing. It certainly is a manual to justify someone’s “expertise” in a given subject.

    • Thanks, Anonymous, for giving us the perspective of one who worked in the psychology industry. The current practice, from my perspective, is that it has too often abandoned its mission to be a science based practice in order to better achieve financial goals.I’m doing my best to urge psychologists back to their original stated mission.

  5. The soldier isn’t shaking his hands but hand because he lost one arm (and a leg). I wonder how you could overlook this fact while you yourself dramatized the soldiers (and readers) experiences by fantasizing his bodily dismay and then visualizing his shaking hands (where there is just one hand left)…

    • Hi Alain Bos,
      I see what you mean about the “shaking his hands” clause and the picture not matching up all that well. Thanks for pointing it out. I didn’t mean any disrespect. My apologies to anyone who feels my oversight was insensitive.
      Jeff

      • I’m sorry too for being so harsh with you, I was thinking about a soldier who thought that people didn’t even look-listen-realized he is missing two limbs and yes I imagined that would mean so much sorrow for the soldier but I over-reacted and am quite sure that if this man really existed and you would have met him you would never ever have made such oversight when/while writing.
        So I apologize for my inconsiderate respons, I should have incorporated an insight of how my comment would make you feel and consequently change my demeanor.
        Sometimes (a lot of times the past few months, I’ve given myself the freedom (luxury) to blatantly say anything and intentionally discard the fact that my comments and-or thoughts are hurtful.
        I’ve almost toughed myself a kind of narcissism where everything I say is justified by the fact that I have been and am being hurt.
        My feelings are thankfully changing back to compassion and I truly hope I can regain my previous sensitivity or even obtain a better one … (this may sound awfully repenting and it is but I’ve always been quite hard on-to myself so to me crawling is the only way I can make myself pay attention and suggest a change I should make + since I’m used to be this way with myself , it’s not such a big thing & when reminded, I’ll only remember my shame and intentions as a feeling without the explicit text I just wrote. I cannot explain fully that to repent is a beautiful thing if I adhere it’s solution-conclusion.)
        Anyways, TY Jeff !-)

        • Hi Alain,
          Your last comment indicates a kind heart. I do want to add that you were absolutely right, as far as I am concerned, with letting me know about my mistake. There is no reason to apologize for that. As far as the style that it was presented, I know that dealing with some very challenging experiences can put even the best of us in an irritable mood from time to time, and even as we try to transcend this, some rough waves can throw us off our balance. I, myself have taken a few rough hits in my life, and I have been far from perfect as I try to deal with some recurring memories.

          By the way, as a result of your comment, I now have dropped the “s” off of the word “hands” in the post we have been discussing.

          Wishing you a colorful spring, and hoping to hear from you again,
          Warm Regards,
          Jeff

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