Welcome to From Insults to Respect. A few weeks ago I asked for some feedback on a presentation I was preparing to deliver at the American Psychological Association’s 2017 Convention in Washington DC. I here want to thank all who chimed in.

After reading the many comments, mostly from Facebook and Google+ members of groups/communities that I belong to, I thought long and hard on what to include, and what to leave out. Many of the suggestions that were excellent could not be included in the presentation because only 10 minutes were provided for me to read my paper. Nevertheless, many suggestions that I didn’t incorporate into my formal talk were utilized when I responded to questions afterwards. I plan to be writing far more about this topic in the future, and so many of the proposed suggestions will be fully developed at that time.

How did my presentation go? I thought it went well and I received a warm round of applause. Here’s what the final draft ended up looking like:

Final Draft

The CSM: A Revolutionary Alternative to the DSM

Albert Einstein

Albert Einstein created a revolution in the branch of science known as physics. Prior to the 20^th century, physicists tried to explain the propagation of light with the use of a theoretical construct known as the ether. There were experts in the ether. They sought ways to define it, along with ways to describe 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.

Oh, 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 compared to the old paradigm. Today I want to make the case that the theoretical construct known as mental disorder is the ether of psychology. Oh, I expect a great deal of resistance to this. Nevertheless, here’s a little of what I have in mind.

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.

William James

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 20^th 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 it’s numerous scientific shortcomings. Some within general psychology expressed concerns that psychologists utilizing the DSM approach had sold out to psychiatry and the pharmaceutical industry. Moreover, the continuing subservient acceptance of the DSM approach brings down respect for psychology as a legitimate branch of science.

Jonathan D. Raskin and Michael C. Gayle surveyed psychologists who regularly use the DSM, and published their findings in the Journal of Humanistic Psychology (DSM-5: Do Psychologists Really Want an Alternative? 2015, pages 1-18). Here’s their summary:

Only two published studies, both from the early 1980s, have specifically examined psychologist attitudes toward the Diagnostic and Statistical Manual of Mental Disorders (DSM). The current article rectifies this by presenting the results of a recent survey of attitudes toward the DSM-IV-TR and DSM-5. Though the DSM has changed over the years, psychologist attitudes toward it have remained remarkably consistent. Although more than 90% of psychologists report using the DSM, they are dissatisfied with numerous aspects of it and support developing alternatives to it—something that psychologists over 30 years ago supported, as well. The finding that almost all psychologists use the DSM despite serious concerns about it raises ethical issues because professionals are ethically bound to only use instruments in which they are scientifically confident.

That said, is there anything that we can do?

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 DSM approach? I think our APA can do this easily if it set its mind to it, and it could do it in as little as 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. Not the DSM, but 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, its use 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’s definition, plain and simple.

It is important to note that in the CSM there would be two classes of mental health concerns—The first of which is concerns expressed about one’s self. The second would be, concerns expressed about someone else.

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

So, the CSM, with its survey data, would provide the basis for identifying the primary mental health concern in a word or brief phrase that would be convenient for use as search engine terms to retrieve relevant research studies. The CSM also provides a process for developing a psychological formulation. This is a three-paragraph narrative co-constructed by the person seeking services and the mental health professional. It consists in identify the service seeker’s strengths, other concerns he or she would like to have addressed, and how he or she is functioning in major life areas such as interpersonal relationships, sleep, eating, and workplace or educational setting.

Okay, those are the basics of the CSM. I contend that it would achieve all the benefits that the supporters of the DSM approach claim for it while having significantly fewer shortcomings.

I already touched upon the well-recognized reliability problems of the DSM and how the CSM would be a significant improvement in that crucial area. Here’s another area of improvement over the DSM. Supporters of the DSM approach 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. The CSM also provides a common language, but in an easier to understand and jargon free manner. To see if this is true, I field tested the CSM approach for years. When I worked in mental health centers I found that I had no need to use DSM terms to communicate with my colleagues. When a colleague would ask me to tell him or her about my 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 a colleague wanted to know more about a case, we went into the psychological formulation type of information. I found that communication flowed easily and my colleagues readily understood me.

So, 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 also 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.

For a more complete description of the CSM, you can readily find an article that I recently had published that greatly expands on these ideas. Up on the screen is the reference. It is available in the current OnlineFirst version of the Journal of Humanistic Psychology. The titled is “The Classification and Statistical Manual of Mental Health Concerns: A Proposed Practical Scientific Alternative to the DSM and ICD.” [Click HERE to read the journal article]

Conclusion

Well, there you have it. I’m hoping that in time I can develop a large enough coalition of folks who are willing to request a meeting with APA’s leadership and at that meeting we advocate that we move forward in making a real change. For those of you who would like to join in this effort, please feel free to contact me at jrubin@stny.rr.com. Until next time, have a great week.

CSMDSMmental illnessThe Classification and Statistical Manual of Mental Health Concerns