Category: mental health concern model

Categories
CSM Diagnostic and Statistical Manual of Mental Disorders-5 DSM mental disorders mental health concern model Mental Illness

Mental Illness or Mental Health Concern?

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

Professor William James

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?

Dr. Jeffrey Rubin

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:

  1. How distressing is each of the concerns that were mentioned on a scale of 1 to 7?
  2. When and in what situations is the concern most problematic?
  3. When and in what situations is the concern least problematic?
  4. What are personal strengths?
  5. Levels of functioning in the areas of sleep, eating, employment, education, relationships, on a 1 to 7 scale?
  6. 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

When I was doing my PhD practicum at the University of Minnesota’s Counseling Center, I worked there for a whole year and we had no need to use the “mental disorder” jargon of the DSM and ICD to communicate. When my advisor asked me to quickly tell him about my morning 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 my advisor wanted to know more about a case, we went into the psychological formulation type of information. This informal way to communicate among the professionals and graduate students at the counseling center flowed smoothly while we provided a wide range of mental health services.

The CSM Is Practical Because It Maintains the Concept of “Mental Health”

Currently, we have such enormous organizations as Mental Health America and its state and regional affiliates, the National Institute of Mental Health, university and college programs offering degrees in mental health counseling, and states offering certifications in this field. Psychologists, social workers, counselors, and psychiatrists regularly refer to themselves as providing services under the umbrella of “mental health service providers.” For these reasons, the CSM would maintain the concept of “mental health” so it can be comfortably and realistically accommodated into the many large organizations currently using it.

However, the CSM would use the term “mental health” in a way that is different from what is implied in the DSM and the ICD. The CSM would explicitly reject the idea that the opposite of mental health is mental illness. Rather, the word “health” in the CSM’s “mental health” would be phrased in a manner that indicates that professionals dealing with mental health concerns are part of the allied health professions. The reason for thinking of these professionals as health providers follows.
Many of the concerns that would fall under the CSM’s list of related topics have been identified in scientific studies as “physical health risk” factors. For example, people who express a concern about being addicted to alcohol are at increased risk of developing sclerosis of the liver (O’Shea, Dasarathy, & McCullough, 2010). Those who express concerns about eating more than average may be at greater risk of diabetes and heart disease (Mokdad et al., 2003). Quality of interpersonal relations, lack of sleep, depression with thoughts of suicide, and various other concerns or clusters of concerns can be studied for the degree of physical health risk that they pose.

A major goal of mental health providers under the proposed CSM system is to turn “physical health risk” factors into “physical health protective” factors. The degree to which this is successful can be studied using currently available methodologies. It is in this very specific sense that the mental health concern topics are viewed not merely as mental concerns but also mental health concerns. By being explicit about this change in conceptualizing mental health, we have good reason to believe that the CSM proposal holds promise for avoiding most of the negative baggage that comes with this type of terminology.

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

———————————
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.

Categories
conflict resolution Dealing with insults Mental Health mental health concern model Mental Illness

A Kinder Approach to Mental Health

Welcome to From Insults to Respect. Today, we take a look at the question, Can psychologists come up with a kinder, more respectful, healthier approach for dealing with the types of concerns people seek mental health services?

The current approach, often referred to as the “medical model” or the “mental disorder model,” is promoted by the American Psychiatric Association (APA), the World Health Organization (WHO) and the pharmaceutical industry. Mental health service providers, to be reimbursed for their services by third party payers, are required to select from a variety of the “disorders” listed in the APA and WHO mental disorder manuals and then place its code on the service user’s third party form. To access mental health service in an affordable manner, most service users rely on a third party payer, such as a government universal health plan or a private health insurance program.

We begin to wrestle with this question about an alternative model with some concerns about the current medical model.

Concerns about the Medical Model

Here’s a quote from my favorite psychologist and philosopher, William James:

William James

“Individuality outruns all classification, yet we insist on classifying everyone we meet under some general head. As these heads usually suggest prejudicial associations to some hearer or other, the life of philosophy largely consists of resentments at the classing, and complaints of being misunderstood.”

The various “mental disorders,” falls under the head of “diseases” in the WHO’s International Classification of Diseases. Not everyone feels at home with this. Here is one service user expressing her discomfort:

“By the time I was entering my second decade of service use, the medical model, which I had initially found reassuring, seemed increasingly unsatisfactory, without the capacity to encompass the complexity of my interior or exterior life and give it positive value. As a result, I began to actively explore frameworks that better met my needs.”

Note that she was looking for a framework that would give her complex life positive value. We shall return to this issue shortly. But first, I think it would be helpful if I share my own concerns about the medical model.

My Experience: My original exposure to the pathologizing medical model occurred when I took a course in Abnormal Psychology as an undergraduate at Brooklyn College. Shortly afterwards, I found that my classmates began to use the new terms that they learned in the course as insults whenever someone did something they didn’t like. One person was called a narcissist, another–a manic depressive, another–psychotic, and on and on.

This insulting behavior didn’t sit well with me. As an undergraduate I had, at various times, the typical troubling emotional experiences of teenagers that could easily be framed as various mental disorders. The stigmatizing mental disorder labels being used as insults could readily be applied to me.

Then, as a PhD graduate student, I was required to take a course titled, “Descriptive Psychopathology.” There I learned that because of a vote, mental health professionals had first declared that being what they termed “homosexuality” was a mental disorder, but recently they voted to no longer view it as a disorder. Although I’m not gay and happily married to a wonderful woman, I was glad to hear this, for I had since met some gay folks and felt the psychopathologizing of them didn’t seem right. I also thought that classifying people as having a disease based on a vote, rather than on some objective evidence of an infection, tumor, organ blockage, or tissue tear also wasn’t quite right.

Then I began to read books by William James. He had advocated that mental health service providers should not take their terminology too seriously, referring to it as superficial medical talk. This viewpoint of James began as early as 1896. In his Lowell Lectures on Exceptional Mental States (which were reconstructed by Eugene Taylor in 1984 from James’s notes), the good professor 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.” He went on from there to note that,

“medical writers 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?

Upon graduating and serving in various roles as a psychologist, I learned about the various shortcomings of the pathologizing approach:

  1. It is stigmatizing to mental health service users.
  2. It privileges the clinician’s perspective over that of the mental health service user.
  3. It has serious reliability and validity problems.
  4. By focusing on what’s wrong with the individual it tends to miss their strengths, the complex relational context they find themselves in, and malfunctioning social structures.
  5. By framing these concerns as mental disorders it misses the fact that the greatest advances of human being has been borne out of strife. There are numerous examples that suggest the possibility that these challenging experiences often serve an adaptive function. In framing these concerns as opportunities to expand possibilities, rather than suppress “symptoms,” we could increase self-efficacy and resilience.
  6. By pathologizing psychological concerns, it promotes the use of psychiatric drugs that in many situations worsen outcomes.

Regarding this last shortcoming, I became aware that the pharmaceutical industry has had a huge financial interest in promoting the idea that psychological concerns are real “illnesses” that require drug treatments just like physical illnesses. Cosgrove, and her team of researchers have made a compelling case that this can be seen by how the industry has been exerting a great deal of influence on psychiatric research and practice, resulting in publications and news reports that exaggerate claims of its drug treatments’ effectiveness while minimizing harms. For example, the “Clinical Practice Guidelines (CPG)” for mental health services provides the “standard of care” for health care providers. The confidence in the benefits of these drug treatments, if it were free of industry influence, would be more convincing but Cosgrove’s team found,

“Ninety percent of the authors of 3 major guidelines in psychiatry had financial ties to companies that manufacture drugs which were explicitly or implicitly identified in the guidelines as recommended therapies for the respective mental illnesses. None of the financial associations of the authors were disclosed in the CPG”.

Now, I know millions of people like taking drugs, whether they be prescribed by doctors or not. So, any alternative to the medical model that interferes with this desire is going to meet with a tsunami of resistance. So, the medical model as an option to service users is likely to continue. The best we might hope for, is that third party payers that now require a mental disorder “diagnosis” also cover services under a more kinder, respectful framework.

A Proposed Alternative

For people who have come to believe the medical model is too stigmatizing, and drugging problems away is not for them, what might a more acceptable alternative look like? One idea comes from a recent study by Schroder, et al. (2023).

“We describe the historical development of popular messages about depression and draw from the fields of evolutionary psychiatry and social cognition to describe the alternative framework that depression is a “signal” that serves a purpose. We then present data from a pre-registered, online randomized-controlled 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.”

As we have discussed above, the medical model conceptualization of the types of concerns that is classified under the disease heading often fails to motivate active coping beyond taking a pill. Moreover, it fails to honor the labeled person’s perspective. The above study suggests that framing these concerns as a potentially healthy functional signal can lead to less self-stigma, and perhaps greater self-efficacy in making healthy life-style improvements.

Dr. Jeff Rubin

Consistent with this suggestion, in several of my earlier posts, I provide numerous examples of people who found various experiences typically labeled as “mental disorders” as helpful. For example, Joshua Wolf Shenk in his biography of Abraham Lincoln, makes the case that his depression fueled his greatness. Similarly, the music legend, Joni Mitchell, upon discussing her frequent bouts of depression observed,

Joni Mitchell

“Depression can be the sand that makes the pearl. Most of my best work came out of it. If you get rid of the demons and the disturbing things, then the angels fly off, too. There is the possibility, in that mire, of an epiphany.”

In a paper I published in the Journal of Humanistic Psychology, I describe in detail one proposed alternative that is consistent with this way of thinking. This alternative involves creating a manual for a classification system that replaces the disease overarching concept of mental disorders with mental health concerns that potentially serve an adaptive function. Those seeking mental health services would be given a choice to have their concerns addressed utilizing the pathologizing approach or the mental health concern approach. Both types of services would be equally covered by third party payers. I argued that, in contrast to the pathologizing approach, this alternative would increase the self-efficacy of individuals struggling with these concerns. Additionally, it would be kinder, more respectful, improve outcomes, provide a new choice, stimulate fresh perspectives, and open new avenues of research.

The first chapter of the manual would explain that the mental health concern approach begins from the perspective of the person seeking services. It does not classify anyone. Instead, each person is viewed as a unique individual. What is classified is the concern expressed to a mental health service provider. Then, the manual would clearly define its main overarching construct:

“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, 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 reliability and validity problems of the vague definitions provided in both the APA and WHO mental disorder manuals.

Two types of data sources would be utilized to identify the list of concerns that would appear in this alternative manual. The first would come from a large sample of mental health service providers that ask them 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. The second source would come from another survey that would ask the membership of mental health service user organizations to list the various concerns that led them to seek mental health services. They, too, would be asked to avoid psychopathological terminology.

Some have argued that there is no need to have any classification system. According to this argument, a “psychological formula” approach consisting of a few paragraphs describing the case without pathological labels is sufficient to replace the medical model. But note that the vast majority of current third-party payer systems do use the mental disorder codes. The codes are used in the following manner. Third party payer systems utilize forms that must be filled out whenever someone seeks mental health services under their plan. These forms typically have a little box that reads, “Diagnosis.” In that box, mental health professionals must fill in a short code that corresponds to some specific “mental disorder.”

Utilizing just the psychological formulation approach, which involves the creation of several paragraphs as an alternative to these codes, would be far too cumbersome. The concern approach, like the medical model approach, provides a short descriptive phrase coupled with a code and is therefore far more workable.

With the concern proposal, all that third-party payer institutions would need to do differently to add value for their customers is to slightly change that little “Diagnosis” box. Instead of just reading “Diagnosis,” that box would add two simple words, so it would read, “Diagnosis or Concern.” Then, when mental health professionals fill in the box, they would be given the choice to either write in the letters “D” and the code number that corresponds to the so-called diagnosis, or they would write the letters “C” and the code number that corresponds to the specific concern. imgMental health consumers would be given the choice to go to pathologizing mental health service providers or those using the concern approach. This is all the change that would be required to increase value for a significant number of mental health service users. The cost and effort for third party payers to make both the pathologizing and concern approaches available would be minimal.

Moreover, a short word or phrase that could replace terms like “major depressive disorder” or “attention deficit hyperactivity disorder” is necessary for other practical means of communication. For example, if I want to write a title for a research article, it would not be practical to insert several of the formulation paragraphs into the title. The psychological formulation approach would be far more widely used if it had some practical way of providing some standard short terms for conceptualizing an individual’s mental health concerns arranged in a valid scientific classification manual.

Some may argue that the mental health concern approach is not practical because if everyone could go to a mental health professional merely to have their concerns addressed, then the system would soon be overloaded with clients, and third-party payers’ costs would soar. Because third party payers made up of insurance companies and national health services only cover people with more serious conditions known as mental disorders, so the argument goes, this limits the number of people who can get to see a mental health professional. However, how do mental health service professionals honestly determine if a person has a serious enough condition to warrant “treatment?”

The process with the pathologizing approach is suppose to be as follows. When someone who expresses a concern (which is referred to as a “symptom”) to the mental health professional, the professional is to decide if the symptom arises to the vague level of “clinical significance.” Only if it does is the symptom considered serious enough to warrant a “mental disorder diagnosis.”

I have been a PhD level psychologist for over forty years. Not once have I heard of an occasion in which an individual who made an appointment for mental health services and then showed up for it, leave the appointment without a mental disorder diagnosis. This intuitively makes perfect sense because mental health professionals are in the business of increasing the number of their clients. Given that they have over 300 vaguely described “mental disorders” to choose from, and the only way they will get paid for their services is to declare that the person seeking services has a “clinically significant” disturbance, who can doubt that no one is turned away.

The professional status of the service provider leads the public to think something more serious has been established when a diagnosis is declared. Although it is true that some expressed concerns are more serious than others, a mental disorder diagnosis is not indicative of this.

So, the alternative “Mental Health Concern” approach more honestly describes what is actually going on in easy to understand language. It is one proposal for a more kinder, respectful, and healthier way for people to have their expressed concerns addressed by a mental health provider and covered by third party payers. Criticism of this approach and suggestions for some other alternatives are highly encouraged.

My Best,
Jeff
———————————
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.
Categories
conflict resolution CSM Diagnostic and Statistical Manual of Mental Disorders-5 Mental Health mental health concern model

Alternatives to Psychiatric Diagnoses

Welcome to From Insults to Respect.

Dr. Jeffrey Rubin

From time to time I have written about the growing lack of respect for the current manner in which people seeking to obtain mental health services are treated. Particularly upsetting to many is the requirement that they be labeled as having a mental disorder.

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.

Unfortunately, there are a number of serious weaknesses with this approach. 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.

Adding fuel to these types of concerns about negative effects of ingesting these drugs are the recent findings indicating that despite the fact that more Americans than ever are being prescribed so called antidepressants, the rate of suicide has climbed to an all-time high. Is the increased use of antidepressants causing this increased rate of suicide? Although definitive evidence is not yet available, it is a well known research finding that these drugs do increase the risk of suicidal thinking in many patients.

Meanwhile, the DSM/ICD approach has created a monolithically wealthy pharmaceutical industry, with all of the drawbacks associated with such institutions.

Given these problems, an international effort has been seeking to come up with some reasonable alternative that could provide all of the perceived practical benefits of the DSM/ICD approach, while having significantly fewer shortcomings. 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 HERE). Today, I shall summarize my approach, and then we’ll look at some of the published discussions on this topic that have come out after my article first appeared.

A Summary of My Approach

My proposed alternative to the DSM/ICD approach calls for the development of The Classification and Statistical Manual of Mental Health Concerns (CSM). In contrast to the DSM/ICD approach’s overarching concept of “mental disorders,” the CSM’s overarching concept is “mental health concerns.”

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.

The CSM, in addition to coming up with a brief label for the expressed concern and a code for third party payers, describes a collaborative approach between the person expressing the concern and the mental health service provider for creating a psychological formulation narrative of a few paragraphs that eschews the DSM/ICD pathologizing jargon. 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.

The Latest Discussions

Since my article on the CSM was published, the Journal of Humanistic Psychology (JHP), in its May 2019 issue, has several articles that discuss my approach as well as a few others. Let’s take a look at some of what was said, and as we do so, I’ll share a few thoughts about my reaction.

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.

What would be a better alternative for psychotherapists and counselors than the DSM/ICD approach? According to Dr. Raskin, it would have to be a system that allows them to contextualize psychosocial and biological aspects of human suffering in a more nuanced manner. And then he writes,

Dr. Jonathan D. Raskin

“Jeffrey Rubin (2018) has proposed that we classify concerns that clients bring to therapy, not disorders they have. Identifying concerns is very different from identifying disorders. Concerns are things such as feeling anxious about one’s job, unhappy about one’s marriage, emotionally distraught about past abuse, or unable to move past what one witnessed while fighting in a war. The current diagnosis system encourages clinicians to translate these concerns–which are clearly contextual and not reducible to biology alone–into disorders that afflict people. But therapists and counselors do not actually treat disorders. Instead, they talk to people about their concerns–some of which are quite serious and lead to extremely challenging and intransigent difficulties.”

To Dr. Raskin, any alternative to the DSM/ICD approach must be a better fit with what therapists and counselors actually do. The CSM approach admirably achieves this.

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.

Despite this finding, Dr. Cooper expresses pessimism about any alternative becoming accepted for funding psychotherapy via health care insurance. Among the factors that make it particularly challenging is the marketing of psychopharmaceuticals, which heavily promotes the idea that certain drugs treat the specific conditions listed in the DSM and ICD. The sum of money being acquired with this approach, she points out, makes producing a competitor classification far beyond the reach of most organizations.

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,

“I think that Rubin’s optimism is misplaced. The fact that some (but by no means all) therapists currently get away with recording DSM diagnoses to facilitate payment even in cases where a diagnostic criteria may not be met will not be news to insurance companies. It is a practice that insurers have long known about and usually try to prevent. I think it unlikely that insurers would easily agree to cover Rubin’s ‘Mental Health Concerns.'”

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.

Moreover, the ICD actually encourages mental health professionals to come up with a diagnosis when criteria are not met. Thus, it states, “When the requirements are only partially fulfilled, it is nevertheless useful to record a diagnosis for most purposes” (WHO, 1992, p. 8).

I do agree, however, with Dr. Cooper when she says that getting the change that I have been advocating for is not going to be easy. Nevertheless, I believe we–professionals, service users, and service users’ relatives and neighbors–have a responsibility to try. Moreover, I have been encouraged by the steady increase in the influence of mental health service user advocacy groups who are becoming more and more vocal about the need for their members to be treated respectfully. And whenever I am invited to speak to professional organizations about the CSM approach, the rousing applause that I receive at the end of my presentation, along with the positive comments from audience members afterwards, keep my hope alive.

——————————-

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.

 

Categories
conflict resolution Depression Leo Tolstoy mental health concern model

Leo Tolstoy’s Experience With Depression

Welcome to From Insults to Respect. Today, let’s see if we can tie together some of the loose threads of my last post, which chronicled Joni Mitchell’s experience of depression. There we found that she explicitly rejected the idea that her experience indicated that she was mentally ill. Instead, she came to believe that, “Most of my best work came out of it. If you get rid of the demons and the disturbing things, then the angels fly off, too. There is the possibility, in the mire, of an epiphany.”

We also discussed that in contrast to Joni’s position is the medical model, which views people who experience depression as having an illness that requires, as the first line of treatment, taking pills that are called “antidepressants.”  Many who hold this view have absolutely no respect for people who hold the view expressed by Joni.

Upon publishing my post about Joni, one person that has impressed me over a period of time as being highly intelligent expressed a concern that attitudes like Joni’s will lead people to view depression as perfectly normal. The consequences of so doing, he feared, will lead to all of the efforts to increase access to mental health services getting flushed down the toilet. If depression is normal, why wouldn’t the majority of people decide to ignore this group of sufferers and their needs?

Well, in my opinion, this is a legitimate concern, and before this post draws to a conclusion I intend to address it. But first, let’s take a look at another example of someone who, like Joni Mitchell, came to believe that the experience of depression can be of enormous value.

Leo Tolstoy’s Experience

In his painfully personal book, My Confession, the great Russian writer Leo Tolstoy tells us about his two-year period of despair. At about the age of 50, his life had become “flat, more than flat: dead.”

“I felt that something had broken within me on which my life had always rested, that I had nothing left to hold on to, and that morally my life had stopped. An invincible force impelled me to get rid of my existence, in one way or another…. Behold me then … hiding the rope in order not to hang myself from the rafters of the room where every night I went to sleep alone; behold me no longer going shooting, lest I should yield to the too easy temptation of putting an end to myself with my gun.”

All of this took place at a time when Tolstoy’s outer circumstances seemed excellent.

“I had a good wife who loved me and whom I loved; good children and a large property which was increasing with no pains taken on my part. I was more respected by my kinsfolk and acquaintances than I had ever been; I was loaded with praise by strangers; and without exaggeration I could believe my name already famous.”

Tolstoy goes on to explain how his melancholy stimulated a gnawing questioning that eventually led to one insight after another. His trouble had not been with life in general, not with the common life of common men, but with the life of the upper, intellectual, artistic classes, the life that he had personally always led, the cerebral life, the life of conventionality, artificiality, and personal ambition. He had lived wrongly and had to change.

Then, one day in early spring, while he was alone in the forest listening to its mysterious noises, he was filled with a sense of deeper meaning. “After that,” he wrote, “things cleared up within me and about me better than ever, and the light has never wholly died away.”  According to Tolstoy, his suicidal feelings disappeared, and he went on to live a productive life until he passed away at the age of 82 of natural causes.

Some Thoughts on Tolstoy’s Experience

The great psychologist and philosopher William James was someone who viewed the pathologizing of human experience as simple minded and nothing more than superficial medical talk. Rather than resorting to mentally ill jargon, the good professor explained in his monumental book, Varieties of Religious Experience, his view of Tolstoy’s experience:

It was logically called for by the clash between his inner character and
his outer activities and aims. Although a literary artist, Tolstoy was
one of those primitive oaks of men to whom the superfluities and insincerities, the cupidities, complications, and cruelties of our polite civilization are profoundly unsatisfying, and for whom the eternal veracities lie with more natural and animal things. His crisis was the getting of his soul in order, the discovery of its genuine habitat and vocation, the escape from falsehoods into what for him were ways of truth. It was a case of heterogeneous personality tardily and slowly finding its unity and level.

Tolstoy’s anguishing experience appeared at first to come on him as if out of the blue. Later, Tolstoy came to understand it as having been due to living wrongly. Only by questioning deeply and repeatedly the meaning of his despair did he come to this understanding.

Now, with all of this as background information, let’s return to the concern that came up at the beginning of this post–if we don’t accept the medical model, might it provide a perfect justification for not funding mental health services?

In my view, the medical model actually gets in the way of adequately funding services.

Viewing someone in the midst of an anguishing experience as someone with an illness that is no different than any other illness leads many prescribing doctors to most often send the client home with some pills. That is viewed as sufficient. The patient is left with a host of negative side effects, and maybe in time, the patient will begin to feel better and attribute the improvement to the pills. If not, they go back to the doctor who will try adjusting the dose, trying a different pill, or adding other pills.

It is my view that even when people learn to value, even treasure, depression experiences, they don’t say that’s all there is to life. These experiences lead them to more deeply delve into their personal concerns thereby potentially leading them to seek more effective, efficient, economical, and beautiful ways to address their concerns.

Although Tolstoy did manage to successfully work out his most pressing concerns without professional help, keep in mind that he was an extraordinarily gifted person with a great deal of supportive people around him, and he was financially comfortable. Even with all of that, a well trained mental health service provider who avoided pathologizing his experience may have been of enormous help.

In my previous post, we saw that Joni Mitchell was not only experiencing the physical sensations of depression. Fully part of her experiences was to delve deeply into several concerns– “How am I going to get back in the saddle? And what about the audience? Would you still love me if you knew what I was really like?” She sought help from a psychotherapist.

As someone who provided mental health services for many years, let me present an example of what I am trying to get at.

Phil, not his real name, came to my office troubled about how depressed he had been feeling. After some time listening in a caring way to his concerns, I discussed this notion that depression can be viewed as a valued experience. He was pleased to learn this. At the same time, he didn’t in the slightest bit come to the conclusion that with this interpretation of the nature of depression there was no more need to continue to see me. However, I do think that framing depression as often a very valuable experience that many of our most gifted people put to good use was far more hopeful than framing it as due to defective genes.

Over the course of a year I found that the concerns Phil was most troubled about was his drinking, and that he had trouble developing close relationships. Both of these concerns are genuine health risk factors. My job was to help Phil to transform these risk factors to “health protective factors.” By doing so, this could prevent far more serious health issues down the line.

So we explored what was interfering with his developing close friends. It soon became apparent that he was very critical of people he met, and his style of criticizing was very nasty. For example, he would call people he disagreed with stupid in a very nasty way. And it also became apparent that he would criticize himself in the same disturbing manner.

I explored with Phil options that have been helpful to others. He selected learning to meditate, and to get more exercise in order to work off his anger in a positive, healthy manner. He learned the value of saying more supportive things to people he met, and to himself as well. He came to realize the value of minimizing the negative criticism that he provided, and when he did criticize, to do so in a far more charming manner. In the end, he made a new group of friends, joined AA, and was in a far more healthy state when my services came to an end.

So, as this example illustrates, rather than a mental illness model, in which pills are often viewed as sufficient, we can utilize a mental health concern model to advocate additional support for mental health services. With a mental health concern model, counselors and psychotherapists can be viewed as valued members of the allied health profession because they help to transform health risk factors into health protective factors.

The need for these types of mental health services, therefore, need not be reduced by framing depression as a valued experience. Rather, it allows us to move on from this understanding to advocate that our services fully address real mental health concerns.

——————————-

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.