Welcome to From Insults to Respect.
The two dominant manuals for “diagnosing mental disorders” are the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases. (ICD). Their overarching concept is mental disorders. Synonyms are psychopathology, and mental illness. To access mental health services, most people are required to accept being labelled as having a mental illness. Not everyone respects this requirement.
These manuals continue this pathologizing despite the long history of such terminology being cogently criticized. In contrast to this pathologizing concept, there exists a peer reviewed published article that advocates an alternative method for accessing services, one that replaces the “mental illness” overarching concept with “mental health concerns” that includes the idea that these concerning experiences often serve adaptive functions. It is argued that this approach is a significant improvement over the pathologizing concept.
Criticism of the Mental Illness Concept
William James (1902/1961) was an early critic of the concept of psychopathology, referring to it as “simple minded” (p. 29) and “superficial medical talk” (p. 324). In his 1896 Lowell Lectures on Exceptional Mental States (which were reconstructed by Eugene Taylor in 1984 from James’s notes), he stated that experiences that are commonly viewed as unhealthy or morbid are really “an essential part of every character” and give life “a truer sense of values” (p. 15). James went on from there to note that medical writers tend to,
represent the line of mental health as a very narrow crack, which one must tread with bated breath, between foul friends on the one side and gulfs of despair on the other…. There is no purely objective standard of sound health. Any peculiarity that is of use to a man is a point of soundness in him, and what makes a man sound for one function may make him unsound for another…. The trouble is that such writers use the descriptive names of symptoms merely as an artifice for giving objective authority to their personal dislikes. The medical terms become mere appreciative clubs to knock a man down with…. The only sort of being, in fact, who can remain as the typical normal man, after all the individuals with degenerative symptoms have been rejected, must be a perfect nullity. Who shall absolutely say that the morbid has no revelations about the meaning of life? That the healthy minded view so-called is all? (pp. 163-165)
In more recent time, Schroder, et al. (2023), carried out a relevant study. It presents data from a study in which participants with self-reported depression histories viewed a series of videos that explained depression as a “disease like any other” with known biopsychosocial risk factors (BPS condition), or as a signal that serves an adaptive function (Signal condition). The Signal condition led to less self-stigma, greater offset efficacy, and more adaptive beliefs about depression.
Additional recent criticism of the mental illness concept has been presented by the World Health Organization (WHO) and the United Nations (UN). In its jointly published report titled “Mental health, human rights, and legislation: guidance and practice” (2023), it states:
The biomedical model of mental health is based on the concept of mental health conditions being caused by neurobiological factors (1, 2). As a result, care often focuses on diagnosis, medication, and symptom reduction, rather than considering the full range of social and environmental factors that can impact mental health. This can lead to a narrow approach to care and support that may not address the root causes of distress and trauma (p. xiii).
The same report also states:
Every person should have the opportunity to define what recovery means for them, and which areas of their life they wish to focus on as part of their own recovery journey. Recovery considers the person and their context as a whole, and no longer adheres to the idea or goal of the person “being cured” or “no longer having symptoms” (p. xiv).
Is it possible to respectfully address these issues?
I have proposed an alternative classification system (Rubin 2018; Rubin in press) titled “Classification and Statistical Manual of Mental Health Concerns” (CSM). This approach does not simply exchange the mental illness concept with mental health concerns; rather, the mental health concerns concept is different in several important ways.
The CSM assumes each person seeking to access services as a unique individual. Rather than labeling anyone, it labels expressed concerns. Whereas the mental illness concept declares there is something wrong with the person, the CSM emphasizes, mental health concerns often turn out to be indispensable stages in acquiring valued fruits.
A mental health concern, as defined in the CSM, 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, relationships, education, eating, cognition, sleep, and challenging life situations. This is an observable event that occurs at a specific time and place, and therefore avoids the well documented reliability and validity problems of the mental illness concept.
Once it has been established what the concerns are, a collaborative effort between the mental health service provider and service seeker, begin creating answers to a semi-structured psychological formulation that looks at:
- How distressing is each of the concerns that were mentioned on a scale of 1 to 7?
- When and in what situations is the concern most problematic?
- When and in what situations is the concern least problematic?
- What are personal strengths?
- Levels of functioning in the areas of sleep, eating, employment, education, relationships, on a 1 to 7 scale?
- What is a tentative theory of cause or causes, jointly created, that considers the full range of social and environmental factors.
Arguments for the Practicality of the CSM
In Some Settings Using Expressed Concerns Has Worked Fine
The CSM Is Practical Because It Maintains the Concept of “Mental Health”
So, in brief, the CSM approach promises to reduce stigma, improve care, increase self-efficacy, and open new avenues of research. In going forward, I encourage people to begin the process of reconceptualizing what has been promoted as mental illnesses to a mental health concerns. Moreover, for those who have any influence with those in the world of psychology and psychiatry, please encourage them to adopt the CSM approach.
My Best,
Jeff
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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.
“Crazy” is a concept used when people are puzzled about the actions of others or themselves. By using this type of name calling, it really doesn’t provide any clarification, but to some, they think it does. So, we might hear something like the following conversation:
Nevertheless, I would like you to consider the following possibility.
Trump’s supporters, in addition to being called crazy, have repeatedly been called mentally ill as a way to make sense of what seems to be irrational. Because the mental illness concept is supported by many doctors, including many psychiatrists and psychologists, some folks have been left with the impression that it must be a more sound, scientific concept than “crazy.” Is it?
When psychiatrists use their mental illness classification system and call it a diagnostic system, they do so despite numerous scientific arguments about its shortcomings (see 
You have trouble starting your car. You bring it to Fred, your friendly local mechanic. On hearing your concern, he provides an initial theory of what is causing this—perhaps your car needs a new starter. This is the initial “theoretical” diagnosis. Then, Fred inspects the starter and finds that it is in fine shape. Thus, his original theory of what is wrong proves incorrect. He then theorizes that your spark plugs are dirty. He takes a look and finds that they are indeed dirty. He cleans them up, puts them back in their proper place, and the car starts right up. In the end, he “diagnosed” what was wrong with your car—it had dirty spark plugs.
The psychiatric mental illness diagnostic system is described in a manual published with the title, Diagnostic and Statistical Manual of Mental Disorders (DSM). There it refers to itself as a manual for making diagnoses. This masks the difference between the following three types of statements:
The DSM does not claim its so called “diagnostic classifications” are just a theory of what the cause is for the expressed concern; it doesn’t even provide a theory. The manual’s developers explicitly say it is theory neutral. The DSM labels are just type 3 statements, that is, just statements that restate expressed concerns into medical jargon. Thus, the lack of reliability and validity for the DSM classifications and applying the word “diagnosis” to them in a misleading, imprecise manner are just three of its many serious principles of science violations.
Contrast psychiatry’s DSM “diagnosis” system with a diagnosis system used by other doctors. If someone comes to a virologist expressing a concern about being feverish, having difficulty breathing, and loss of taste, the doctor will label these as the patient’s medical complaints, rather then simply translating the complaints into medical jargon and then claiming the jargon constitutes the diagnosis. Instead, the virologist, after writing down the various complaints, will then look for the cause for these complaints. If it is found that there is the presence of the Covid 19 virus, the doctor will say the diagnosis is a Covid 19 infection.
On one fine spring day, I was sitting on a Central Park bench and two women were sitting one bench just to my right reading their newspapers. Suddenly, one of them cried out, “Sophie, can you believe this! The story I’m reading here, oh my God! This young boy, seventeen years old mind you, the same age as my Jonathan, he’s struggling with ideas about suicide. Seventeen years old, his whole life before him and he wants to kill himself. What would lead a boy to this?”
With that explanation, the two women nodded to one another, and continued on to another story, seemingly satisfied that they now knew why the boy was dealing with this issue.
In my opinion, even a play, which lasts but two or three hours, can only provide in its narrative a simplified account of what real life stories are all about. And yet, in today’s world, for many people a very different type of play is sufficient for providing the reason why someone is dealing with a challenging concern. This new type of play begins with the curtain rising. A character says to the audience he is struggling with feelings of suicide. A psychiatrist then proclaims the character has the mental disorder known as major depressive disorder, and then the curtain comes down. That’s the whole play. And people walk away fully satisfied that an adequate explanation has been provided.
That said, I leave you with the following suggestion: If you have a theory of why people continue to support Trump and his continued claims that he won the 2020 presidential election by a landslide, let those with whom you want to share your theory know it is a “theory,” and forgo the mental illness name calling. By doing so, you may not get as many cheers from people who agree with you. Nevertheless, among people truly seeking to deepen their understanding of this difficult to understand phenomenon, you will be more respected. Moreover, for those who may disagree with your theory, they will appreciate your ability to distinguish fact from theory. You’ll come across, I theorize, as more open-minded and you will be modeling a higher level of discourse than what we have been hearing from many of our political leaders.
This labeling process relies on descriptions provided in the Diagnostic and Statistical Manual of Mental Disorders–Fifth edition (DSM) and the International Classification of Diseases–Tenth edition (ICD). Both are manuals that are conceptually similar, utilizing as their core concept, mental disorders, and both share the same “diagnostic” codes. Because of their similarities, I will simply refer to them as the DSM/ICD approach.
Many professionals defending the use of this approach explain that it provides a common language for mental health professionals to communicate about those utilizing their services; its various classification terms, such as major depressive disorder, anxiety disorder, and so on, are short phrases that are convenient for placing into titles and search engines, and for efficient/streamlined communication in high-speed hospitals and clinics; third-party payers of mental health services have found that their coding system works well as part of a practical method for their record keeping; with the aid of these codes, people manage to access mental health services, mental health service providers manage to get paid, and for-profit health companies tend to make a profit.
It tends to be stigmatizing to mental health service users. The lack of reliability and validity of the various so called diagnoses violate basic principles of science. The process of coming up with a psychiatric label privileges the clinician’s perspective over that of the mental health service user. It ignores the fact that many people who have been labeled with these stigmatizing psychiatric terms come to realize that the experiences which led to their seeking services, rather than being an indication of a pathological condition, are really an essential element to their creative development. Many have also expressed concerns about the “mental illness” terminology which medicalizes mental health concerns, thus leading to an incredible number of people being prescribed psychiatric drugs, the use of which leads to numerous serious side effects.
Just as I was writing this post, major news outlets began to report that researchers found nearly a 50% increased odds of dementia for those taking the most popular drugs for treating depression and other mental health concerns. Although the study could not prove conclusively that these drugs caused the increased risk of developing dementia, because these same drugs had already been linked to confusion or memory issues, the new evidence is deeply troubling. The researchers expressed concerns that if this association is causal, it “would equate, for example, to around 20,000 of the 209,600 new cases of dementia per year in the United Kingdom.” With the population of the US being 6 times larger, this could mean that over 100,000 cases of dementia may be attributed to these drugs every year here in my own country.
As part of this effort, I have come up with one alternative proposal which I discuss most extensively in a peer reviewed article published in a 2018 volume of the Journal of Humanistic Psychology (see 
The CSM approach begins with a full recognition that individuality outruns any classification system. It is for this reason that the CSM does not 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 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 challenging life situations.
Classifying the expressed concern would provide mental health service providers a common language that is helpful when communicating among other professionals. So, a professional might say to a colleague something 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.” Such communications are straightforward and easy to understand, not only for professionals, but for the general public as well.
Each expressed concern listed in the CSM would be a sufficiently short phrase so that it can be conveniently used in titles and search engines to retrieve valued relevant information. Along with each classified expressed concern, there would be a numerical code that would be convenient for third-party payer bureaucratic record keeping.
This process involves a mental health service user and a mental health service provider co-constructing a hypothesis or “best guess” about the origins of the mental health service user’s concerns in the context of his or her relationships, social circumstances, cultural heritage, life events, and the sense that he or she has made of them. Once it has been established what the concerns are, the immediate next question is, “How do we jointly understand these experiences, why they arose, and how we might be able to address them?” This formulation is not something that is shared with third party payers of mental health services, but is utilized exclusively by the mental health service user and service provider.
With the CSM approach, no one is viewed as mentally ill, having a mental disorder, or having some psychopathological condition. Instead, it highlights that the progress of society is due to the fact that individuals naturally vary from the human average in all sorts of directions, that the originality is often useful, while, at the same time, being different can create a variety of concerns. Moreover, some people become concerned about how they are handling enormously stressful and traumatic experiences. Still others are living in unhealthy ways, such as making unhealthy choices in what they consume, or getting insufficient exercise. Mental health professionals, with the CSM approach, are viewed as seeking to address these types of concerns that arise from these conditions in a supportive setting while relying on a variety of wisdom traditions. Central to this approach, is an honoring of what Ralph Waldo Emerson referred to as the grand sweep of humanity.
Compared with the DSM/ICD approach, the use of the CSM would be less stigmatizing, more respectful to those seeking services, and more practical because of the ease of understanding the words and phrases that it utilizes. Moreover, it would be more consistent with principles of science because instead of using as its core concept the vaguely defined “mental disorders,” the CSM uses as its core concept “mental health concerns,” which is a clearly recognized event that occurs at a specific time and place. Finally, the CSM approach would provide a new choice to both mental health service users and providers, challenge old ideas, stimulate fresh perspectives, and open new avenues of research.
In an article titled, “What Might an Alternative to the DSM Suitable for Psychotherapists Look Like?” Jonathan D. Raskin notes that recent surveys of psychologists and counselors indicate they are dissatisfied with the DSM/ICD approach and are interested in coming up with alternatives better suited to their professions. Nevertheless, more that 90% said they will use the DSM/ICD; after all, that is how they get paid by third party payers.
In a commentary on Dr. Raskin’s article that appears in the same JHP issue, Rachel Cooper, a senior lecturer in philosophy at the United Kingdom’s University of Lancaster, and author of Diagnosing the Diagnostic and Statistical Manual of Mental Disorders, puts in some of her own thoughts on this topic.
She begins by agreeing with Dr. Raskin that most psychologists and counselors would be keen for an alternative classification to be developed. She then reviewed research indicating that social workers should be included among the professionals unhappy with having to use the DSM/ICD approach. In surveys, most indicated they would not use it if it was not required for insurance purposes.
She then refers to my CSM approach, stating that I suggest that insurance companies could be persuaded to pay for “Mental Health Concerns,” as they would readily come to understand, with a little explaining, that mental health service providers now using the current DSM/ICD approach do not turn anyone away who has mental health insurance coverage and comes to their office expressing what the CSM refers to as a mental health concern. She then writes,
First of all, when Dr. Cooper says insurance companies usually try to prevent mental health providers from recording diagnoses to facilitate payment even in cases where a diagnosis criteria is not met, I strongly disagree with her. I’ve never in my entire career heard of an insurance company questioning a diagnosis, and on what basis could they possibly do so? Insurance funders are not present in the room when a so called diagnosis is made. All that they get as documentation for a given diagnosis is a code indicating the diagnosis.
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.
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 
Albert Einstein created a revolution in the branch of science known as physics. Prior to the 20th century, 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.
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 DSM approach? I think our APA can do this easily if it set its mind to it, and it can do so within a year.
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.
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.
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.
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?