Welcome to “From Insults to Respect.” Regular readers know that I have some serious objections to how mental health service providers treat those seeking their services. As things stand now, unless you can afford to completely pay for such services without any insurance coverage, to access services you are very likely to be required to be labelled as having a mental disorder.
Now, many mental health professionals and service users are fine with this labelling requirement, and for those who are, I’m not seeking to do anything to interfere with them going about this practice to their hearts content. But there are many other mental health professionals who would much prefer to treat each person seeking their services as an individual, and one of the last things they desire is to label people with a “so called” diagnosis well known to be stigmatizing. At the same time, many who seek mental health services, when hearing about the requirement that they be labelled as having a mental illness, object to this, and discover that despite having paid their insurance premiums that cover such services for decades, cannot access these services without accepting this stipulation.
Last year, the American Psychological Association Convention was held in Toronto, and I was invited to present a paper on a proposal that would solve this problem for mental health professionals and those seeking services. I was invited back again this year to speak on this topic for this year’s APA Convention, which was held in Denver last week. A couple of months ago, I provided a summary of what I was planning to say. I now provide to you the full text of my entire speech.
My 2016 APA Speech
As most of you surely know, the DSM and ICD are pretty much the same approach for classifying people who seek mental health services. Mental disorder is the overarching theoretical construct for both, and both share the same coding system used by third party payers. Supporters of the DSM and ICD 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; its various diagnostic terms, such as Major Depressive Disorder, Anxiety Disorder, etc., are short phrases that are convenient for placing them into search engines to retrieve valued relevant information, and into titles of book and articles; third party payers of mental health services have found that the DSM-ICD 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, those are the basic reasons supporters of this approach say that it is useful.
Now, it seems to me that if we are to have any hope that an alternative to this approach might be widely adopted, we would have to be able to make an excellent case that the alternative would be at least just as helpful while, at the same time, have significantly less shortcomings.
So, is it really possible to come up with such an alternative? 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 of the CSM would contain.
Chapter 1: The CSM Basics
This first chapter would begin with the following statement: “The developers of the CSM fully recognize that persons seeking mental health services have far more expertise about what is going on in their lives than any mental health service provider. Moreover, 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 and ICD approach’s far more abstract theoretical construct of “mental disorders.”
After this statement, the CSM would clearly define its main construct, which is mental health concerns:
A 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, interpersonal relationships, intrapersonal relationships, education, eating, cognition, sleep, and challenging life situation.
So, there’s a summary of the basic ingredients of Chapter 1.
Chapter 2: Classification of Mental Health Concerns and Codes
This chapter would begin by explaining that the CSM has two classes of expressed concerns–Concerns expressed about oneself, and concerns expressed about someone else.
An 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.
An example of the second class is Bob, a father, upon seeking counseling for his son, expresses a concern about his son’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 titles and search engines.
Concerns that would be included in the first edition of the CSM would be selected from survey data. For example, mental health service providers would be asked to list the various concerns that they have been asked to address in their practice in the past year without couching them in psychopathological language and to stick as closely as possible to the language used by those seeking their services.
Chapter 3: The CSM Approach to Psychological Formulation
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 two or three paragraph psychological formulation approach that is designed to fill in additional details about the expressed concern.
Thus, 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.
Defending the CSM
Okay, those are the basic chapters of the CSM. I contend that it would achieve all of the benefits that the supporters of the DSM-ICD approach claim for it. It would provide a common language. And, in fact, I actually tested the CSM approach for years. When I worked in a mental health center, although I capitulated to the requirement that I inserted a DSM diagnosis in its proper place on the insurance form, other than that, I had no need to use DSM terms to communicate. 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, I contend that the CSM would provide an easy to learn, non-pretentious, dogma free, common language. Additionally, it would provide a practical approach for third party payers’ record keeping. Let me explain clearly how easy and simple this could work.
Third 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 typically says, “Diagnosis.” In that box, mental health professionals are required to fill in the DSM or ICD 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 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 letter “D,” thus indicating a diagnosis code will be entered into the box, or they would write the letter “C” thus indicating a concern code will be entered into the box. Once the letter “D” or “C” is written into the box, the appropriate code number would be entered.
With the creation of the CSM, not only will mental health providers have a new option to choose from, but so too will people seeking mental health services. They would be given the choice to go to psychopathologizing mental health service providers or to those using the CSM approach.
So, we would of course have to convince third party payers to make just this small change on their insurance form in order to increase value for a significant number of mental health providers and service users. The rest of their form would remain exactly the same.
In making the case to insurance companies, and others as well, that this choice would be beneficial, we could point to a March, 2008 research article titled, “The Effects of Choice on Intrinsic Motivation and Related Outcomes: A Meta-analysis of Research Findings.” Published in Psychological Bulletin, here we find that 41 studies were examined for the effect of choice on a variety of outcomes in a variety of settings. Results indicate that providing choice enhances intrinsic motivation, effort, task performance, and perceived competence, among other positive outcomes. There are a few studies out there that suggest that if you provide an enormous amount of bewildering options to a targeted population, the typical positive effects begin to diminish, but keep in mind that the CSM proposes just one additional option for mental health professionals and service users.
Here’s another benefit of the CSM approach in contrast to the DSM-ICD approach. The DSM-ICD approach, by using the “mental disorder” construct, simplistically devalues all of the experiences it refers to as mental disorders, providing a cognitive set that they are “bad” experiences. It does so 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. With the CSM approach, we instead begin by addressing someone’s “concern.” Thus, there is no automatic need to assume that the experience that led to the concern is necessarily bad. Together with the mental health service provider, service users may come to understand that these experiences are part of a useful process; they may be a different than an average process with strengths and weaknesses. Though perhaps not bad, there may be a better approach to be discovered, etc. The DSM-ICD approach that pathologizes these types of experiences tend to close people to such possibilities. The CSM approach opens up these possibilities.
Conclusion
Now my time is almost up, so in closing, I’ll leave you with this; The CSM can do everything that the DSM-ICD approach can do with regards to providing a common language for mental health professionals to communicate about those utilizing their services, providing short phrases convenient for placing into search engines and titles, and providing a practical method for third party payer record keeping. Additionally, when compared to the DSM and ICD approach, the CSM approach would be less stigmatizing, as well as more scientific, person-centered, culturally sensitive and recovery-oriented. Therefore, it is my sincere hope that in the name of justice, we psychologist can fire-up the will to break out of the monopolistic DSM-ICD approach. I’m hoping we can fire up the will to make a real change by having us psychologists roll up our sleeves and then getting down to do the necessary work simply because we believe this is in the best interest of those we seek to help.
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.
First of all, I should note that I am a member of the American Psychological Association, and have been so for over forty years. Nevertheless, there is one particular aspect of the association that is deeply troubling to me.
As part of the psychological organization’s strong interest in science, pretty much anyone entering its approved doctoral psychology program is required to study the ideas of Thomas Kuhn’s thesis on The Structure of Scientific Revolutions. Such revolutions, we learned, come about after a period of time when a field presupposes a conceptual and instrumental framework accepted without question. Then, more and more, members of the community begin to see a buildup of anomalies in the framework until a “crisis” which can no longer be resolved within the pre-established framework.
It just so happens that the psychiatrist’s stigmatizing diagnostic system, which is described in its Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5), has huge anomalies that have been recognized for years, and despite this, psychologists continue to utilize it without taking substantive steps to create a more scientific alternative. Let’s take a quick look at these anomalies. Afterwards, we’ll look at the benefits to psychologists that may be motivating it to continue to go along with the DSM-5 approach despite its major scientific weaknesses.
The process described in the DSM-5 for assessing the subjective notions of “disturbance” in the individual is left to the clinician who decides if these are “clinically significant.” Thus, it provides clinicians an opportunity to include anything that benefits their set of values.
All psychologists are taught that if a hypothetical construct, such as a mental disorder, is to have any validity, it must first demonstrate that it can be reliably identified. Upon reading the DSM-5, we find that there is no documentation that people, whether they are clinicians or not, can reliably distinguish between those who have mental disorders and those who do not have mental disorders. Thus, the lack of this documentation is analogous to a classification system of birds that has no documentation that people can reliably distinguish birds from non-birds.
The weakness [of the DSM] is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half-century, as we have understood that symptoms alone rarely indicate the best choice of treatment.
In addition to the DSM’s shortcomings with regards to its classification system’s reliability and validity, there are also serious shortcomings with regards to its claim of being a diagnostic system. A diagnostic system speaks to etiology, that is, the cause, set of causes, or manner of causation of a disease or condition. But the DSM-5 specifically states that it is not designed to identify the cause of the various “disorders” it classifies. Then why use the term “diagnosis” rather than the more scientifically defensible term, “classification?” As we will see, this gets us back to our larger question, why does the psychologist organization accept the use of the DSM-5 given its problematic record of reliability and validity, as well as its use of the word “diagnosis” in a misleading, imprecise manner?
Moreover, symposium proposals on this issue are oftentimes accepted for presentations at its national convention. (See 
A well recognized usefulness of the DSM-5 is that by using its medical sounding terms to refer to all of the experiences that this approach classifies as “mental disorders” it legitimizes in the minds of many the prescribing of drugs for these experiences.
Now keep in mind that the psychiatric association membership consists largely of psychiatrists who make their living by prescribing these drugs. Moreover, there are several reports indicating that the majority of the major players who developed the DSM-5 were on the payroll of the pharmaceutical industry. So, it makes sense to theorize that the psychiatric organization may very well be influenced by all of this wealth. But what about the psychological association?