Welcome to From Insults to Respect. I hope the beauty of spring is helping to make your daily challenges more pleasant.

Regular readers know that from time to time I write a post advocating that mental health service providers change the way people access their services so that it becomes more respectful and more consistent with the principles of science. What I mean by this, is that currently those who have a health insurance policy that includes mental health services discover that when they seek to access those services they have to first be declared as a person with a mental disorder. Not everyone is happy about this, as the following parable suggests.

The Parable of Julianne and Dr. Robles

“Hi Julianne,” says Dr. Robles, as he greets his new counselee. “What can I help you with?”

“Well, Dr. Robles, I…I….” Tears begin to form in Julianne’s lovely hazel eyes. She takes out a tissue, blows her nose, wipes her eyes, and continues. “You see, I have two young children, age 3 and 5, and my husband left us a couple of months ago. I’ve been trying to keep it together, especially for the children, you know, and, well, it’s been so hard.”

“I can imagine it would be,” Dr. Robles replies gently. “Raising two kids even under the best of circumstances is quite a challenge.”

“Yes. And now I’m trying to do it all by myself, and I’ve been feeling so depressed, and if I get any worse…. I mean I thought I better come in to prevent myself from crawling into bed and not getting out. I have to think of the children. I checked and I have mental health coverage on my insurance policy.”

“Yes, my secretary looked into that, and you do have mental health service coverage. Your insurance company requires that I must place a diagnosis on your health insurance form for you to access that service. I hear, so far, that you are concerned about….”

“Wait! What do you mean you have to place a diagnosis on my health form? You aren’t going to write in there that I have some sort of mental disorder, are you?”

“Well, I wish we didn’t have to get into this labelling issue. Personally, I think it’s best to treat each person that I provide counseling to as an individual. It is understandable that many people don’t want to be placed in a diagnosis box, especially one known to be stigmatizing. But the insurance companies do require a diagnosis.”

“That’s not fair! I’ve been paying insurance premiums for years and I never signed any agreement that to access this service I had to be labeled like this?”

“Well, I can easily see why you feel that it is unfair. I actually agree with you. Perhaps it would help if I let you know that in the vast number of cases the information in your medical records remains confidential?”

“No, it doesn’t help! Even the most confidential government records have been hacked, and my husband and I are in a legal fight over custody of the children. If he petitions the court to see my medical records, what guarantee do I have that the court won’t end up seeing them?”

“Computer hacks do occur, and I have heard about very rare instances when courts did manage to view a person’s medical records over the patient’s objections, so your concerns are reasonable. I wish I knew of  some way around this labelling requirement, but for now we are stuck with this system.”

The Purpose of the Above Scenario

In today’s scenario, we see an example of both the person seeking counseling and the mental health service provider desiring that a certain requirement of accessing mental health services be eliminated.

Unlike them, some people actually find it reassuring when a doctor declares that they have a diagnosable condition, and they experience no objection when they learn that this condition is to be placed in their medical records.

For those who believe the current mental disorder classification system is helpful, I seek not to interfere with their ability to access services in the manner that they prefer. What I do seek is that for the significant number of people who do object to the current psychiatric labelling system, they nevertheless have equal access to mental health services without the mental disorder labelling requirement.

The above scenario provides readers an example of why some object to this type of labelling, but recent surveys indicate there are many others as well. In an article published in the Journal of Humanistic Psychology (Click HERE to access the article), I discuss these surveys.

For example, here’s what Jonathan D. Raskin and Michael C. Gayle wrote when they summarized their survey data of psychologists who regularly use the standard mental disorder classification system known as the DSM (DSM-5: Do Psychologists Really Want an Alternative? 2015, pages 1-18).

“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.”

In my journal article, I go on to propose a practical, more scientific alternative to the DSM. I call this alternative, the Classification and Statistical Manual of Mental Health Concerns (CSM). The first words in the CSM would be: “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.”

After publishing my journal article, I discovered at a number of forums that many people after hearing me out, expressed that the CSM approach makes a great deal of common sense. Some also readily saw that its scientific merits are enormous because the expression of a mental health concern is a clearly observable event that occurs at a specific time and place, and therefore its use would beautifully solve the reliability problems that have been plaguing the DSM’s far more abstract, vague, theoretical construct of “mental disorder.”

On the other hand, some resisted the CSM approach. As I began to question them, seeking to figure out where exactly the disconnect was, I discovered that for some, it had to do with their belief that the DSM is a classification system based on solid principles of science and nothing could possibly be better. As I questioned them further, I discovered that their understanding of what a scientific classification system is designed to do was a bit incomplete. So, in today’s post, I explain in an easy to understand manner the nature of scientific classification systems, beginning with a description of a classification system with which we are all so very familiar–birds. This will enable us to see clearly why the bird classification system is useful as a scientific instrument. We will then look at the DSM classification system in light of what we learned about the bird system, and this will reveal the DSM‘s serious scientific shortcomings. Finally, we will compare and contrast the DSM system with the proposed CSM system in a manner that can make the superior scientific merits of the latter crystal clear.

The Bird Classification System

A branch of science begins with something some people are so interested in that they want to study it carefully and share what they find with others, while at the same time learn from others what they find out. As it turns out, there are some people very interested in birds.

The next thing that happens in a branch of science is careful observation of the topic of interest. After some early observations, the scientists begin to put together a classification system, which is also known as developing a taxonomy. This begins with explicitly defining what that something is that they are interested in. Said in another way, they describe that something of interest in a clear and detailed manner, leaving no room for confusion or doubt. So, in our example of “birds,” scientists have decided that they are a group of endothermic vertebrates, characterized by feathers, toothless beaked jaws, the laying of hard-shelled eggs, a high metabolic rate, a four-chambered heart, and a strong yet lightweight skeleton.

Once scientists carefully define their general topic of interest, they describe different types of what they are interested in. So in our bird example, the scientist interested in them came up with a taxonomy that lists bluejays, pigeon, sparrow, and so forth as subtypes of the general category of birds, describing each subtype in a precise manner that can reliably distinguish each from the others on their list. Why bother to do this?

The main reason is that when they discuss their findings with others, they want to make sure they are using words that mean the same thing, and it is a great time saver. For example, let’s say John is a bird scientist and he says to Judy, another scientist, “I  saw a bird the other day and I didn’t know what type it was; can you help me figure out what it is?” Notice that since both of these scientists know the meaning of a bird, it saves John quite a few words. Just imagine if instead every time John uses the word bird he had to say, “I saw something that had an endothermic vertebrae, characterized by feathers, toothless beaked jaws, the laying of hard-shelled eggs, a high metabolic rate, a four-chambered heart, and a strong yet lightweight skeleton.” That’s quite a mouthful to have to say each and every time you refer to a bird. In this example, just saying bird saves a scientist about 30 words each time the word bird is used.

The word bird, once explicitly defined also saves time in other ways. For example, let’s say there was no agreed upon definition of what a bird is and no classification systems at all. And let’s say John, the scientist, wants to find in a library some information about a particular type of bird. He would have to waste time looking at every single book in his library until he found one that seemed to be talking about what he was interested in.

As another example of the time saving value of classification systems, let’s say “bird” was vaguely defined as a flying creature. This would result in John having to unnecessarily wade through numerous books on flying insects, of which there are hundreds of thousands of types, bats, and some fish that sort of can fly. With the current bird classification system, anyone can go to a library and quickly find the specific section that houses information on just birds. Similarly, placing the word “bird” in a search engine enables John to more quickly retrieve relevant information than would a less explicit definition.

The DSM Classification System

The DSM‘s overarching topic of interest is something it calls “mental disorders.” Dr Ralph Slovenko was a renowned psychiatrist. Prior to his death in 2013, he  authored hundreds of articles and more than 10 books, including Psychiatry in Law/Law in Psychiatry, which went into a second edition in 2009. Let’s take a look at how he described the definition of mental disorder:

“Although this manual [the DSM] provides a classification of mental disorders, it must be admitted that no definition adequately specifies precise boundaries for the concept of “mental disorder.” The concept of mental disorder…lacks a consistent operational definition that covers all situations. All medical conditions are defined on various levels of abstraction–for example, structural pathology (e.g., ulcerated colitis), symptom presentation (e.g., migraine), deviance from a physiological norm (e.g., hypertension), and etiology (e.g., pneumonoccal pneumonia). Mental disorders have also been defined as variety of concepts (e.g., distress, discontrol, disadvantage, disability, inflexibility, irrationality, syndrome pattern, etiology, and statistical deviation). Each is a useful indicator for a mental disorder, but none is equivalent to the concept, and different situations call for different definitions.”

Dr. Slovenko goes on from here to tell us what the definition was used in the edition of the DSM back in 1994.

“In the DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significant increase risk of suffering death, pain, disability, or an important loss of freedom.”

Now I ask you, does this definition meet your standard for being explicit? To me, it is like saying that the definition of a bird is, something that has feathers, or scales, or teeth, or is beaked, or is warm blooded. It is actually worse than that, because the difference between such descriptors as teeth and a beak can be determined with excellent reliability. Can we determine the difference between “clinically significant” and “not clinically significant” with the same degree of precision? Clinically significant is subjective, in contrast to being objective, and science requires objective definitions.

The latest edition of the DSM (DSM-5) is just as vague. It begins, “Although no definition can capture all aspects of all disorders in the range contained in the DSM-5, the following elements are required.” Although it says the following elements are required, it then makes it clear that the elements that it lists are not required. As I provide the rest of the definition, notice the use of the word “or” and “usually.”

“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. Mental 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.” 

Again, the descriptor “clinically significant” is used, as it was in the previous edition of the DSM. This is about as vague a descriptor as one can possibly conjure up. How about the descriptor “dysfunction?” This, too, is left to the subjective opinion of mental health providers who often have financial interests in declaring that someone has a mental disorder.

My above critique of the mental disorder definition begs the question, Can scientists reliably distinguish those with a mental disorder from those who do not?

There is a simple scientific way to determine this. It involves randomly selecting a few hundred people from the population. Then, perhaps 20 scientists familiar with the definition would interview each in the time period usually devoted to making a so-called diagnosis in clinical practice. After each interview, each scientist would separately indicate on a piece of paper his or her decision about whether or not the person has, or does not have, a mental disorder. Each decision would be made independently from the other scientists, that is, without knowledge of the other scientists’ decisions. After this data were collected, statisticians would look to see how well the different scientists agreed with each other.

Recently, I tried to retrieve this type of study using Google Scholar by putting in the search window, “Reliability of determining who has a mental disorder and who does not.” Nothing of value came up. I tried other search terms to retrieve this basic scientific information. Again, nothing.

Eventually I found some relevant information.  The vast majority of mental disorders listed in the DSM were never assessed for reliability, and the few that were indicate that this is a major area of weakness for this classification system.

Relevant to this issue is a recent peer reviewed article by Barbara S. Held in the Review of General Psychology (2017) that discusses the various mental disorder categories (p. 82-94). She states that these heterogeneous categories have produced a lack of scientific progress because of their “internal incoherence, such that any given instance (diagnosed person) may share few and, in some cases, none of the category-defining features of other persons given that same categorical label.” (p. 83)

Dr. Held goes on to say:

“This is called the problem of “polytheticity” in the theoretical/philosophical clinical literature, and is seen as a primary source of obstacles to building a progressive science of mental disorder; it is also seen as related to the daunting problem of comorbidity, which calls into question the presumably discrete nature of disorder categories.”

So, boiling down the above critique of the mental disorder construct to its basics, the construct violates principles of science because its definition is neither explicit nor objective.

The CSM Versus the DSM

I, for one, am interested in a phenomenon that I, and others, call mental health concerns. Obviously there is wide interest in this. After all, there are numerous educational institutions that provide training to people so they can become credentialed to address mental health concerns. Numerous people actually voluntarily go to these educational institutions, devoting considerable time and expense. Once completing the credentialing requirements, they apply to their state credentialing board, pay a fee, and then after the board checks to see if all of its requirements have been fulfilled, it grants a license permitting the person to legally provide mental health services. That person then sets up a practice that offers mental health services. People wishing to access these services first devote some time to decide where to go. They then make an appointment, show up for the appointment, and then express their mental health concern to the mental health service provider. Aspects of all of this occur each and everyday and involves tens of thousands of people working in a coordinated fashion to have mental health concerns addressed in a professional manner.

Now, as someone interested in this mental health concern phenomenon, I have spent some time observing the phenomenon by matriculating into undergraduate and graduate programs, and then meeting all of the requirements to provide some mental health services in my state. I’m not permitted to prescribe psychiatric drugs, and if you think electroconvulsive shock treatment is a mental health service, I can’t provide that service either.

But other then those two services, people have made appointments with me for over thirty years and expressed various mental health concerns, and I did my best to work with them to address these concerns.

So, now that I carefully observed this something that I am keenly interested in, I’m ready to put together a classification system with others interested in scientifically studying the same something. To begin the process, I first proposed in a peer-reviewed format a tentative proposal which was accepted for publication (see HERE). It defines my something of interest as follows:

A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern that he or she wants to have addressed.

This definition of a mental health concern requires all of the following items for a mental health concern to exist:

1. A person seeking mental health services
2. A mental health service provider offering his or her services
3. The mental health service provider had to fulfill undergraduate and graduate training that meets the standard of his or her state licensing department.
4. The person seeking services expresses a concern to a mental health service provider with the desire that he or she will work to address the expressed concern

Notice that the phenomenon that I am talking about requires that all of the various items listed exist in order for a mental health concern to be present. It is therefore far more explicit about what constitutes a mental health concern than the DSM‘s set of criteria for a mental disorder which uses language indicating that a disorder can’t really be defined clearly, but sometimes this is present, or maybe this, or maybe this, unless it is this other thing….

Also notice that no one doubts that each of the 4 listed items that, taken together, make up the mental health concern concept exists. Everyone agrees that there are people who seek mental health services in our society. Everyone agrees there are people licensed to provide mental health services. If you go further down the list, there is no question whatsoever, that these other conditions also exist. So the definition, I contend, meets the scientific standard that it describes the something of interest (mental health concern) in a clear and detailed manner, leaving no room for confusion or doubt. Once the CSM classification system comes to be fully developed, people would be able to use the term “mental health concern” as a short way to indicate a phenomenon that contains all four of its defining characteristics.

With regards to the various types of concerns that mental health service providers are asked to address by those seeking their services, two major types would be, 1. concerns expressed about oneself, and 2. concerns expressed about someone else. Under the headings of each of these two major types would be concerns regarding behavior, emotion, mood, meaning of life, death, dying, managing chronic pain, addiction, work, relationships, education, eating, cognition, sleep, hearing voices others don’t hear, and challenging life situations. This, of course, is just a preliminary list of types, and through survey data that ask psychologists and mental health advocacy groups about the various mental health concerns that they are asked to address, the list would become more fully developed.

Conclusion

The above explanation was designed to clarify just one of the reasons why the proposed CSM’s mental health concern concept provides a far more solid scientific foundation on which to build a classification system than the DSM‘s mental disorder concept. Despite the fact that many people have become convinced that the DSM‘s classification system is a sound scientific instrument, its definition is far more vague than how I propose defining a mental health concern.

Many people, including professionally trained psychiatrists and psychologists, have long argued that the mental disorder concept fails to meet the very basic principles of a valid scientific concept. We can do better by using the basic scientific standard of explicitly defining core concepts in our mental health classification system, and giving people seeking mental health services a choice about whether or not their expressed mental health concerns are to be converted into pathologizing language.

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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 and social intelligence. To begin at the very first post you can click HERE.

 

DSMmental health concernsmental illnessThe Classification and Statistical Manual of Mental Health Concerns