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A Scientific Alternative to Psychiatric Diagnosis

Welcome to From Insults to Respect.

Regular readers know that I have, from time to time, been dealing with a conflict regarding psychiatric diagnosis. Said briefly, there are many people who immediately lose respect for anyone who questions the validity of the mental illness/mental disorder theoretical construct. On the other hand, many people have lost respect for the psychiatric profession because of its pathologizing approach of addressing concerns related to thinking, mood, behavior, or challenging life situations. Amidst this conflict, I have been trying to put forth on this blog, and in a number of other publishing outlets, an alternative approach with which the disputing parties can live in relative peace.  

Last year, I presented a paper on this topic at the American Psychological Association convention in Denver (see HERE). That paper defended my alternative approach by focusing on the reasons it would, when compared to the current psychiatric approach, be more respectful, beneficial, and fairer to those seeking mental health services while being just as practical for mental health service providers.  This year, I will soon (8/5/17) be presenting a paper at the American Psychological Association Convention in Washington D.C. on this topic, but this time I plan to focus on the scientific merits of my alternative. I am hoping to get some feedback about my preliminary draft. So, if you will, please take a look at it. All are encouraged to provide suggestions for improvement or to raise any questions.

My Speech

Albert Einstein created a revolution in the branch of science known as physics. Prior to the 20thcentury, physicists explained the propagation of light with the use of a theoretical construct known as the ether. There were experts in the ether who described ways to define it, along with its various characteristics. It was thought, for example, that the ether didn’t move in any direction, but it could vibrate. There was much discussion about an ether wind. And then Einstein came along and described the nature of light without resorting at all to the ether.

There was a great deal of resistance to Einstein’s theory at first, but in time his theory came to be accepted as a distinct improvement. Today I want to make the case that the theoretical construct known as mental disorder is the ether of psychology. Here’s a little of what I mean by that.

For a long time now, when people seek to access mental health services, they find that in most settings the concern they want addressed must be converted into mental disorder terminology. In the United States, the text used for this purpose is typically the DSM.

Criticism of the mental disorder construct began at the very beginning of American psychology when William James declared that it was nothing more than superficial medical talk. Criticism continued throughout the 20th century, and when the latest version of the DSM came out, there was a ton of media and professional articles that once again pointed out its numerous scientific shortcomings. Many throughout general psychology expressed deep concerns that psychologists utilizing the DSM approach had sold out to psychiatry and the pharmaceutical industry. Moreover, they bitterly complained that a paradigm that utilizes the mental disorder construct brings down respect for psychology as a legitimate branch of science. What can be done about this?

Well, in thinking about this I hasten to mention that Thomas Kuhn’s (1972) classic book, The Structure of Scientific Revolutions, rightly points out, for real change to occur in a branch of science, it is not enough to point out the weaknesses of a paradigm, there needs, as well, a new approach that is a distinct improvement over the old paradigm. So, is it possible to really come up with a distinct improvement over the current DSMapproach? I think our APA can do this easily if it set its mind to it, and it can do so within a year.

What would this new approach look like? Well, for your consideration, I offer you the Classification and Statistical Manual of Mental Health Concerns, or, for short, the CSM. Let’s look at a summary of what it would contain.

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.”

Now think about this for a moment. The expression of a mental health concern is a clearly observable event that occurs at a specific time and place. Thus, by making it the event being classified, it beautifully solves the reliability problems that have been plaguing the DSM’s far more abstract theoretical construct of “mental disorder.”

Here’s the CSM’s definition of its main construct:

A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern about thinking, mood, behavior or challenging life situation.

That’s it—that’s its definition. If a service provider is not certain if a mental health concern has been expressed, he or she could easily verify that it has indeed occurred. Here’s a simple example of what that would look like.

Let’s say Mary Doe comes to a licensed practicing psychologist and says she has been feeling a great deal of sadness much of her days. The psychologist, for verification purposes can say, “I hear you saying that you are concerned about how sad you have been feeling much of your days, and you would like us to work together to address this concern, is that correct?” If the service seeker says yes, this would verify that a mental health concern has been expressed, and what the concern is.

In the CSM, the various concerns would be provided, along with a code for insurance company record keeping. Concerns that would be included in the first edition of the CSM would be selected empirically from survey data that asks practicing psychologists to identify the types of concerns they were asked to address in their practice over the past year, but to avoid utilizing pathologizing words.

The creation of the CSM would provide a common, jargon-free language for mental health service providers that utilizes a distinctly more scientific alternative than the DSM approach. It would stimulate research programs that compare outcomes for services that utilized the DSM approach with that of the CSM approach. Moreover, it would provide a new choice to mental health service consumers, challenge old ideas, and stimulate fresh perspectives.

The scientific merits of the CSM approach, when compared to the DSM approach are numerous. Unfortunately, there is not enough time here to go into them in any detail. For those of you who are interested in the details, you can readily find an article that I recently wrote that is now published in The Journal of Humanistic Psychology. Up on the screen is the reference. [Click HERE to access the journal article]

Call for Feedback

Well, there you have it. I only have seven minutes to present the paper, so many of the essential points that I would love to make have to be left out. There will be some time for questions and discussion, so some additional information could be shared then. And, for those who are interested, as I point out in my paper, they can now readily retrieve a far more complete presentation of my proposal by assessing the journal article I wrote that was just published last month.

Chiefly, my objective in presenting my paper at this year’s APA convention is to stir up the interest of as many psychologists as I can in the hope that a coalition will begin to form that can lead us toward making a significant improvement in the state of the current conflict. Again, I urge readers to let me know their thoughts on this topic, and to make any suggestions they would like aimed at improving my presentation.

The Creation of The Cool Steve Stories

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.

10 Comments

  1. I like the concept of an alternative particularly because of the learning from neuroscience. Why confine the research to psychologists only. Are you not re-enacting how the DSM is formulated by doing this? Will the CSM therefore become another costly labelling system? I invite you to include psychotherapists and psychologists also.

    • Hi Anne Brennan,
      I like your support for making the CSM useful for those other than just psychologists. It is for this reason that I refer to “mental health service providers” when describing who would use the CSM. Keep in mind that I will be speaking to psychologists in my speech, so if I focussed a little more on their issues in my speech, it is for that reason.

  2. I am an italian psychotherapist with almost 40 years of practice, i was the only sono of a suicide mother who was treated with elettroshockterapie and drugs until her death….i solved several cases of mental and psychosomatic disorders ( Mike Arons, Scott Churchill, Natalie Rogers, Tobin Hart, Donadrian Rice , Skip Robinson, Art Warmoth and other wonderful colleagues, knew my work) ….my sons and daughters are vera sensitive and brave to interact with persons affected with various desease….we live in an Ecovillage ( Southern Italy) were the first philosophers fonded the roots of therapy…..am i (us) a clinical case? Or a real antipsychiatric terapist? Please visit http://www.palmirotta.com and http://www.solinio.com
    Thank you to exsist

  3. There is a conflict in many minds between the healthy skepticism of the ostracism dealt to anyone receiving a diagnosis of mental disorder and respect for the psychiatric industry. As there is no scientific acceptance of a right or wrong way to deal with how each individual thinks, our moods, behaviors, and how we react to challenging life situations…

    There can be no scientific pronouncement that any reaction to such things is right or wrong. Many of us are confused by how a mental illness diagnosis for an individual becomes a cross for that individual to bear for a lifetime.

    Unless and until the system changes it seems better to avoid all psychiatry and psychiatrists than to trust that our mental health is confidential, especially since the most commonly prescribed therapy consists of drugs for the rest of our lives.

  4. Dr Rubin,

    I applaud and thank you for providing a constructive step forward in this fundamentally important area of practice. As a clinician, I have long been frustrated by the imposed need to provide DSM diagnosis when doing so adds little or no benefit to the patient’s care and often adds damaging stigma. I agree that what has driven the DSM movement from the beginning is psychiatry’s need to be better accepted among their medical peers and the pressure of the pharmaceutical industry. Your work is an excellent step in addressing this problem and offering a step in a corrective direction.

    • Hi Martin,
      Much thanks for your kind words of support.

  5. Thanks Dr. Rubin. Best of luck with your presentation: 7 minutes!

    Do you think that the CSM scheme would be strengthened, perhaps particularly for Insurance providers, if you included two scales of impact: the first being your existing -5 to +5 personal impact scale and the second being a similar social or external impact scale. This second might include the concerns of those socially involved with the patient (personal danger, effort, time, expense, …) and the impact on the health system (admissions, medications, ER visits, GP visits…).

    Again, Best of Luck and I hope you are heard.

    • Hi Simon,
      Although there is some merit to your suggestion, because of confidentiality it would be difficult to carry your proposal out. How can I, as a counselor, begin to ask anyone other than the person seeking services to evaluate the service seeker without violating his or her confidentiality. I suppose I could ask for permission to do this from the service seeker, but in many cases this would be refused. Moreover the practicality of seeking out others to do this type of assessment could reduce the desirability of many service providers to utilize the CSM. Still, I like the way you are thinking about these issues. Warm Regards.

  6. My main concern is that this still is in the pseudo-science model. A lot more work needs to be done before anyone can reliably be diagnosed. And the categories of illness stay the same? What is the evidence for the boundaries between illnesses, say depression and anxiety, falling the way they do? Can you go into using the S (statistical) component a bit more, and how that would affect diagnoses?
    This tiny step is probably how the discussion needs to start, but a lot of the main problems aren’t mentioned. And if all people who admit to an emotional difficulty are included, isn’t that watering down the pot? And what if someone admits no difficulty?
    Good luck in your endeavor, and I hope some participants forego the golf course to listen to talks. I know how these things go.

    • Hi Paisley,
      I agree with you that a lot more work has to be done before anyone could be reliably diagnosed for why he or she is experiencing the concerns that they seek mental health services for. That’s why the CSM does not seek to diagnose anyone. It instead classifies the expressed concern that service seekers wish to have addressed by the mental health service provider.

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