Welcome to From Insults to Respect. A few weeks ago I asked for some feedback on a presentation I was preparing to deliver at the American Psychological Association’s 2017 Convention in Washington DC. I here want to thank all who chimed in.
After reading the many comments, mostly from Facebook and Google+ members of groups/communities that I belong to, I thought long and hard on what to include, and what to leave out. Many of the suggestions that were excellent could not be included in the presentation because only 10 minutes were provided for me to read my paper. Nevertheless, many suggestions that I didn’t incorporate into my formal talk were utilized when I responded to questions afterwards. I plan to be writing far more about this topic in the future, and so many of the proposed suggestions will be fully developed at that time.
How did my presentation go? I thought it went well and I received a warm round of applause. Here’s what the final draft ended up looking like:
Final Draft
The CSM: A Revolutionary Alternative to the DSM
Albert Einstein created a revolution in the branch of science known as physics. Prior to the 20th century, physicists tried to explain the propagation of light with the use of a theoretical construct known as the ether. There were experts in the ether. They sought ways to define it, along with ways to describe its various characteristics. It was thought, for example, that the ether didn’t move in any direction, but it could vibrate. There was much discussion about an ether wind. And then Einstein came along and described the nature of light without resorting at all to the ether.
Oh, there was a great deal of resistance to Einstein’s theory at first, but in time his theory came to be accepted as a distinct improvement compared to the old paradigm. Today I want to make the case that the theoretical construct known as mental disorder is the ether of psychology. Oh, I expect a great deal of resistance to this. Nevertheless, here’s a little of what I have in mind.
For a long time now, when people seek to access mental health services, they find that in most settings the concern they want addressed must be converted into mental disorder terminology. In the United States, the text used for this purpose is typically the DSM.
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 it’s numerous scientific shortcomings. Some within general psychology expressed concerns that psychologists utilizing the DSM approach had sold out to psychiatry and the pharmaceutical industry. Moreover, the continuing subservient acceptance of the DSM approach brings down respect for psychology as a legitimate branch of science.
Jonathan D. Raskin and Michael C. Gayle surveyed psychologists who regularly use the DSM, and published their findings in the Journal of Humanistic Psychology (DSM-5: Do Psychologists Really Want an Alternative? 2015, pages 1-18). Here’s their summary:
Only two published studies, both from the early 1980s, have specifically examined psychologist attitudes toward the Diagnostic and Statistical Manual of Mental Disorders (DSM). The current article rectifies this by presenting the results of a recent survey of attitudes toward the DSM-IV-TR and DSM-5. Though the DSM has changed over the years, psychologist attitudes toward it have remained remarkably consistent. Although more than 90% of psychologists report using the DSM, they are dissatisfied with numerous aspects of it and support developing alternatives to it—something that psychologists over 30 years ago supported, as well. The finding that almost all psychologists use the DSM despite serious concerns about it raises ethical issues because professionals are ethically bound to only use instruments in which they are scientifically confident.
That said, is there anything that we can do?
Well, in thinking about this, I hasten to mention that Thomas Kuhn’s (1972) classic book, The Structure of Scientific Revolutions, rightly points out, for real change to occur in a branch of science, it is not enough to point out the weaknesses of a paradigm. There needs, as well, a new approach that is a distinct improvement over the old paradigm.
So, is it possible to really come up with a distinct improvement over the current DSM approach? I think our APA can do this easily if it set its mind to it, and it could do it in as little as a year.
What would this new approach look like? Well, for your consideration, I offer you the Classification and Statistical Manual of Mental Health Concerns, or, for short, the CSM. Not the DSM, but the CSM! Let’s look at a summary of what it would contain.
It would begin with the following statement: “The developers of the CSM fully recognize that individuality outruns any classification system. It is for this reason that the CSM does not seek to classify anyone. Instead, it classifies the expressed concerns of individuals seeking to have their concerns addressed by a mental health service provider.”
Now think about this for a moment. The expression of a mental health concern is a clearly observable event that occurs at a specific time and place. Thus, its use beautifully solves the reliability problems that have been plaguing the DSM’s far more abstract theoretical construct of “mental disorder.”
Here’s the CSM’s definition of its main construct:
A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern about thinking, mood, behavior or challenging life situation.
That’s it’s definition, plain and simple.
It is important to note that in the CSM there would be two classes of mental health concerns—The first of which is concerns expressed about one’s self. The second would be, concerns expressed about someone else.
In the CSM, the various concerns would be provided, along with a code for third party payer record keeping. Concerns that would be included in the first edition of the CSM would be selected empirically from survey data. For example, practicing psychologists would be asked to identify the types of concerns they were asked to address in their practice over the past year, but to avoid utilizing psychopathologizing words.
So, the CSM, with its survey data, would provide the basis for identifying the primary mental health concern in a word or brief phrase that would be convenient for use as search engine terms to retrieve relevant research studies. The CSM also provides a process for developing a psychological formulation. This is a three-paragraph narrative co-constructed by the person seeking services and the mental health professional. It consists in identify the service seeker’s strengths, other concerns he or she would like to have addressed, and how he or she is functioning in major life areas such as interpersonal relationships, sleep, eating, and workplace or educational setting.
Okay, those are the basics of the CSM. I contend that it would achieve all the benefits that the supporters of the DSM approach claim for it while having significantly fewer shortcomings.
I already touched upon the well-recognized reliability problems of the DSM and how the CSM would be a significant improvement in that crucial area. Here’s another area of improvement over the DSM. Supporters of the DSM approach say that it is a classification system that has been helpful because it provides a common language for mental health professionals to communicate about those utilizing their services. The CSM also provides a common language, but in an easier to understand and jargon free manner. To see if this is true, I field tested the CSM approach for years. When I worked in mental health centers I found that I had no need to use DSM terms to communicate with my colleagues. When a colleague would ask me to tell him or her about my cases, I would reply with words like, “My 9:00 a.m. case is concerned about feeling depressed, my 10:00 case is concerned about his failing grades, my 11:00 case is concerned about how anxious she is in social situations. If a colleague wanted to know more about a case, we went into the psychological formulation type of information. I found that communication flowed easily and my colleagues readily understood me.
So, the creation of the CSM would provide a common, jargon-free language for mental health service providers that utilizes a distinctly more scientific alternative than the DSM approach. It would also stimulate research programs that compare outcomes for services that utilized the DSM approach with that of the CSM approach. Moreover, it would provide a new choice to mental health service consumers, challenge old ideas, and stimulate fresh perspectives.
For a more complete description of the CSM, you can readily find an article that I recently had published that greatly expands on these ideas. Up on the screen is the reference. It is available in the current OnlineFirst version of the Journal of Humanistic Psychology. The titled is “The Classification and Statistical Manual of Mental Health Concerns: A Proposed Practical Scientific Alternative to the DSM and ICD.” [Click HERE to read the journal article]
Conclusion
Well, there you have it. I’m hoping that in time I can develop a large enough coalition of folks who are willing to request a meeting with APA’s leadership and at that meeting we advocate that we move forward in making a real change. For those of you who would like to join in this effort, please feel free to contact me at jrubin@stny.rr.com. Until next time, have a great week.
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.
Dr. Kandel’s credentials are pretty impressive–he’s a Nobel Prize laureate and professor of brain science at Columbia University. Therefore, if you are among those who believe a person’s credentials should determine who is right and who is wrong, you need not read any further. You must simply conclude that what is referred to as mental illnesses are indeed brain diseases because you would be hard pressed to find someone with better credentials disagreeing with Dr. Kandel.
The argument that such labeling practices are not scientific, but, rather, value judgments, was intelligently made by William James when he defended the religious sentiment. He explained that pathologizing these sentiments as mental diseases was superficial medical talk. He called the reasoning doctors used to declare religious beliefs a type of mental illness, “medical materialism.”
assumes as a convenient hypothesis that the dependence of mental states on bodily conditions must be thoroughgoing and complete. If we adopt the assumption, then of course what medical materialism insists on must be true in a general way, if not every detail…. But now, I ask you, how can such an existential account of facts of mental history decide in one way or another on their spiritual significance? According to the general postulate of psychology just referred to, there is not a single one of our states of mind, high or low, healthy or morbid, that has not some organic process as its condition. Scientific theories are organically conditioned just as much as religious emotions are; and if we only knew the facts intimately enough, we should doubtless see “the liver” determining the dicta of the sturdy atheist as decisively as it does those of the Methodist under conviction anxious about his soul. When it alters one way the blood that percolates it, we get the Methodist, when in another way, we get the atheist form of mind. So of all our raptures and our drynesses, our longings and pantings, our questions and beliefs. They are equally organically founded, be they religious or of non-religious content.
All states of mind are related in extremely complex ways to neural functions. There is a crucial distinction to be made between a brain difference and a brain pathology. The significance of each state of mind must be tested, not by some neurological difference, but by the value of its fruits. When the term “pathological” is applied to an experience, rather than an identified physiological pathology, it wrongly implies a neutral science classification.
In contrast to biological arguments, 
Today, if your behavior, thoughts, or feelings begin to concern you or a family member, for a fee many doctors will translate your experiences into mental illness terminology. Synonyms for mental illness, are mental disease, mental sickness, mental disorder, and psychopathology. These terms, as metaphors for experiences someone doesn’t like, have been with us for centuries. When used in this way, it can communicate something about an experience that others relate to. However, when we move from using these types of concepts as metaphors to believing wholeheartedly that they are proper scientific terms, we begin to lose the respect of those well grounded in the principles of science.
Let’s consider The Tragedy of Hamlet, Prince of Denmark, which William Shakespeare wrote in about 1604. This play offers its audience a magnificent tale of adultery, fratricide, revenge, and feigned madness by a protagonist. When reading Hamlet, we see how Shakespeare uses metaphors to vividly evoke in us the experiences of his characters. Thus, when Hamlet becomes dissatisfied that his mind keeps identifying flaws in his plans for action, he describes these plans as becoming “all sicklied o’er with pale cast of thought.” By extension, the reader senses that when Hamlet’s plans become “all sicklied o’er,” he, too, becomes in a sense, “sicklied o’er” with feelings of frustration, anguish, and helplessness.
Literature regularly uses this type of metaphor. Ralph Waldo Emerson, to take another example, once wrote:
I actually like Emerson’s disease terminology here because the context in which he uses it so obviously reveals that he is using it metaphorically. Notice how he cleverly uses diseases associated with childhood to evoke the feeling that individuals who worry themselves over problems of original sin and so on are acting, in his view, childishly. In this context, disease, to Emerson, was a metaphor for immaturity. If he were a man of science, in contrast to a literary personality, we would expect that he would use terms with clearly defined, objective meaning, that avoid value judgements.
At the time, medical writers were already heavily pathologizing a great number of experiences. Thus, James cited W. Griesinger, the author of The Pathology and Therapy of Psychological Illnesses, and T. S. Clouston, author of Clinical Lectures on Mental Diseases. As James delved further and further into the experiences being pathologized in this way, he came to believe such terminology was “simple minded” and “superficial medical talk.”
Does it make sense to say that when people are suffering, they have a “mental disorder?” Well, consider the experience of giving birth. It is typically accompanied by suffering, and yet it makes more sense to classify this experience as a natural part of creating new life rather than a pathological condition.
When writers receive rejections from publishers, or a loved one dies, suffering often accompanies these experiences. Yet, we do not typically describe them with pathological terms.
For example, cortisol levels in saliva and heart rate variability has some connection with a person’s self-reports of how much stress they have experienced in recent days, while hair cortisol levels have some connection with longer term exposure to stressful experience. Other measures of stress utilize a list of stressors, such as the recent death of a loved one, living in poverty, etc. The person being assessed places a check mark next to each of the stressors on the list that applies to him or her. These check marks are then used to calculate how much stress the person has been experiencing.
Having indicated some of the problems of unambiguously, and non-subjectively applying the descriptors of suffering to the concept of mental disorder, we now turn our attention to the descriptor, “dysfunction.” As with the notion of suffering, the pathologizers almost never use the various scientifically validated measures of functioning to determine if someone has a mental disorder. A pretty good such measure is the Scales of Independent Behavior-Revised. It has norms for functioning in such areas as social interaction (communication skills, language comprehension, language expression), personal living skills (eating and meal preparation, toileting, dressing, personal self-care, domestic skills), community living skills (time and punctuality, money and value, work skills), and gross and fine motor skills. Rather than using measures of this type, pathologizers rely on their professional privilege to make a subjective estimate of dysfunction.
In the most current edition of the DSM, someone who is experiencing abnormal levels of distress might be considered to have a mental disorder. But the issue of the boundary between normal and abnormal experiences lies at the heart of the most contentious disputes in the field of psychopathology today. A major problem with using the term abnormal as one of the defining attributes of mental illness is that it leads us to forget the fact that natural to all organisms is substantial variability across individuals and within individuals. Having above average or below average functioning in various areas of our many areas of functioning is normal. Displaying rare behavior patterns that are highly valued, such as the great altruism of Mother Teresa, are not viewed as mental disorders. Psychopathology is applied when someone does not like a particular experience. Thus, a term that masquerades as a scientific term is really a value judgment masquerading as a scientific term.
Although there are some fairly well developed scientific measures of the three major factors (suffering, functioning, and abnormality) that the psychopatholgizers tend to claim are usually part of the mental illness experience, these measures are almost never used in their “diagnostic” determination. Instead, subjective indicators of these three factors are combined into an even more subjective abstraction called “mental illness.” This process is not scientific despite claims to the contrary.
Rather than a scientific concept, the mental illness concept has been very useful as part of a highly lucrative business plan for the pharmaceutical industry and medical doctors, which includes psychiatrists. This plan has doctors first convincing people that the experiences referred to as mental illnesses are scientifically real illnesses just like physiological pathologies. It then provides license for doctors, in as little as fifteen minutes, to declare that they have provided their patients a diagnosis, and to send them on their way with a prescription for pills. With this plan, billions of dollars flow their way.
The following year, Dr Szasz published a best selling book by the same name. Some loved it while others writhed in anger. One reviewer, for example, gave it five stars out of five, and wrote:
Here is my curse on you, Thomas: May you suffer ten minutes of acute clinical depression. Ten minutes in that “over-heated room”, that “bell-jar”, that “bed of nails” which we sufferers know oh too well.
I was initially puzzled about the anger that appears to come from many who genuinely believe, and demand others believe as well, that without any doubt mental illness is an illness like any other illness. My puzzlement stemmed from my experience that oftentimes when someone proposes a different way to describe something, it doesn’t create great uproars. The proposal is either met with feelings that the new way to describe something is either helpful, or not.
William James, in his book, Pragmatism, tells us the following story. 
This human witness tries to get sight of the squirrel by moving rapidly round the tree, but no matter how fast he goes, the squirrel moves as fast in the opposite direction, and always keeps the tree between himself and the man, so that never a glimpse of him is caught. (p. 43)
“Which party is right,” I said, “depends on what you practically mean by ‘going round’ the squirrel. If you mean passing from north of him to the east, then to the south, then to the west, and then to the north again, obviously the man does go round him, for he occupies these successive positions. But if on the contrary you mean being first in front of him, then on the right of him, then behind him, then on his left, and finally in front again, it is quite obvious that the man fails to go round him, for by the compensating movement the squirrel makes, he keeps his belly turned towards the man all the time, and his back turned away. (p. 44)
Once the process of comparing and contrasting two or more descriptive approaches gets underway, it can lead to an understanding of just how vague some of the descriptions were, and they can be abandoned for more precise descriptions. Of course, the new description may also be so terribly vague as well, and nothing positive occurs. In such cases, a little time was wasted, and people get on with their lives without furious reactions.
Let me begin here by asking you to note that in the squirrel anecdote, those who discussed whether or not the squirrel went around the tree were not going to lose their job, money, freedom, or any other highly significant valued thing depending on who ended up being proved correct. Once everyone declared their positions, each might have had a little sense of prestige that might be derived if they could convince others that they came up with the most respected answer. But for people who like to discuss issues, learning from the discussion is typically the most important reward for them, and they can well handle their emotions that come from having taken a position that ends up being faulty.
The pharmaceutical companies make billions of dollars convincing people that their experiences are illnesses like any other illnesses. Thus, they claim that taking a pill to manage their illness is not any different than taking insulin for diabetes. Psychiatrists and other doctors who prescribe these drugs have an enormous financial interest in keeping this position unchallenged.
The facts are that there are numerous examples of people who could have easily been classified as having a mental illness who come to a state of enormous improvement either through a religious experience, a philosophy such as Buddhism, a delightful romantic love, an exciting new job, a support group such as AA, counseling, etc., You don’t see diabetes being “cured” by changes in relationships, work settings, religious beliefs, and thinking patterns. The fear of those invested in pharmaceutical company profits and the prescribing of their pills leads to great resistance to any descriptive changes that are not in line with the illness approach.
The second consequence that I think people fear is that people who now have access to mental health services might lose them if people stop thinking that the patterns now viewed as real illnesses are really not illnesses. Dr. Szasz’s “problems in living” alternative and my “mental health concerns” approach, they fear, will trivialize these experiences.
Some argue that 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 insurance policy costs would soar. Because insurance companies 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, I believe that third-party-payer executives would readily come to understand, with a little explaining, that mental health service providers now using the current mental illness approach do not turn anyone away who has mental health insurance coverage and comes to their office expressing what my approach refers to as a mental health concern. Professionals are in the business of increasing their clients. The current relevant definitions are so vague that with little imagination, anyone can be “diagnosed” as having 
Similarly, people who seriously hurt others while drinking alcohol or in some furious fit might be blamed for their actions. Thinking that they have an illness, somehow makes them blameless.
This process involves learning that there is a dramatic difference between taking some responsibility for what has occurred and blaming oneself for what has occurred. Blame suggest that you should be punished for your actions. Taking some responsibility for your actions allows one to realize that there may indeed be some very strong conditions that are out of your control regardless of whether or not you have an illness. Blaming yourself for these is not helpful, but allowing yourself to experience deeply the dissatisfied feelings about whatever control you do have can spur you to make valued changes.
Okay, so those are the three feared consequences that I have come to believe ignite anger whenever there is a discussion about conceptualizing the set of concerns now called mental illnesses. In my view, “mental health concerns” are a more apt way to conceptualize these concerns than “illnesses.” However, I fully support that for those who prefer the illness approach, that they be free to access services using that model. At the same time, I believe that ending the monopoly of the illness approach could very well stir up some valuable competition that will improve services for all.
