Category: The Classification and Statistical Manual of Mental Health Concerns

Mental Disorder or Mental Health Concern?

Post author By Dr. Jeffrey Rubin
Post date October 10, 2017
No Comments on Mental Disorder or Mental Health Concern?

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

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

The Parable of Julianne and Dr. Robles

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

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

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

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

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

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

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

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

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

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

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

The Purpose of the Above Scenario

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

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

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

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

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

“Although more than 90% of psychologists report using the DSM, they are dissatisfied with numerous aspects of it and support developing alternatives to it—something that psychologists over 30 years ago supported, as well. The finding that almost all psychologists use the DSM despite serious concerns about it raises ethical issues because professionals are ethically bound to only use instruments in which they are scientifically confident.”

In my journal article, I go on to propose a practical, more scientific alternative to the DSM. I call this alternative, the Classification and Statistical Manual of Mental Health Concerns (CSM). The first words in the CSM would be: “The developers of the CSM fully recognize that individuality outruns any classification system. It is for this reason that the CSM does not seek to classify anyone. Instead, it classifies the expressed concerns of individuals seeking to have their concerns addressed by a mental health service provider.”

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

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

The Bird Classification System

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

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

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

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

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

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

The DSM Classification System

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

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

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

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

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

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

“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognitive, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”

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

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

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

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

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

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

Dr. Held goes on to say:

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

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

The CSM Versus the DSM

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

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

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

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

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

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

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

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

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

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

Conclusion

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

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

——————————-

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.

Tags DSM, mental health concerns, mental illness, The Classification and Statistical Manual of Mental Health Concerns

conflict resolution CSM Diagnostic and Statistical Manual of Mental Disorders-5 psychopathology The Classification and Statistical Manual of Mental Health Concerns

APA 2017 Speech on Psychiatric Diagnoses

Post author By Dr. Jeffrey Rubin
Post date August 9, 2017
3 Comments on APA 2017 Speech on Psychiatric Diagnoses

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 20^th 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 20^th 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.

Tags CSM, DSM, mental illness, The Classification and Statistical Manual of Mental Health Concerns

American Psychological Association conflict resolution CSM Diagnostic and Statistical Manual of Mental Disorders-5 mental disorders Mental Illness Psychiatric jargon The Classification and Statistical Manual of Mental Health Concerns

My 2016 APA Speech On Psychiatric Diagnoses

Post author By Dr. Jeffrey Rubin
Post date August 11, 2016
5 Comments on My 2016 APA Speech On Psychiatric Diagnoses

label-jars-not-people Welcome to “From Insults to Respect.” Regular readers know that I have some serious objections to how mental health service providers treat those seeking their services. As things stand now, unless you can afford to completely pay for such services without any insurance coverage, to access services you are very likely to be required to be labelled as having a mental disorder.

Now, many mental health professionals and service users are fine with this labelling requirement, and for those who are, I’m not seeking to do anything to interfere with them going about this practice to their hearts content. But there are many other mental health professionals who would much prefer to treat each person seeking their services as an individual, and one of the last things they desire is to label people with a “so called” diagnosis well known to be stigmatizing. At the same time, many who seek mental health services, when hearing about the requirement that they be labelled as having a mental illness, object to this, and discover that despite having paid their insurance premiums that cover such services for decades, cannot access these services without accepting this stipulation.

Last year, the American Psychological Association Convention was held in Toronto, and I was invited to present a paper on a proposal that would solve this problem for mental health professionals and those seeking services. I was invited back again this year to speak on this topic for this year’s APA Convention, which was held in Denver last week. A couple of months ago, I provided a summary of what I was planning to say. I now provide to you the full text of my entire speech.

My 2016 APA Speech

As most of you surely know, the DSM and ICD are pretty much the same approach for classifying people who seek mental health services. Mental disorder is the overarching theoretical construct for both, and both share the same coding system used by third party payers. Supporters of the DSM and ICD approach say that it is a classification system that has been helpful because it provides a common language for mental health professionals to communicate about those utilizing their services; its various diagnostic terms, such as Major Depressive Disorder, Anxiety Disorder, etc., are short phrases that are convenient for placing them into search engines to retrieve valued relevant information, and into titles of book and articles; third party payers of mental health services have found that the DSM-ICD coding system works well as part of a practical method for their record keeping; with the aid of these codes, people do manage to access mental health services, mental health service providers do manage to get paid, and for-profit health companies do tend to make a profit.

So, those are the basic reasons supporters of this approach say that it is useful.

Now, it seems to me that if we are to have any hope that an alternative to this approach might be widely adopted, we would have to be able to make an excellent case that the alternative would be at least just as helpful while, at the same time, have significantly less shortcomings.

So, is it really possible to come up with such an alternative? Well, for your consideration, I offer you the Classification and Statistical Manual of Mental Health Concerns, or, for short, the CSM. Not the DSM, but the CSM! Let’s look at what each chapter of the CSM would contain.

Chapter 1: The CSM Basics

This first chapter would begin with the following statement: “The developers of the CSM fully recognize that persons seeking mental health services have far more expertise about what is going on in their lives than any mental health service provider. Moreover, the developers of the CSM fully recognize that individuality outruns any classification system. It is for this reason that the CSM does not seek to classify anyone. Instead, it classifies the expressed concerns of individuals seeking to have their concerns addressed by a mental health service provider.”

This first chapter would go on from here to explain that the CSM begins from the perspective of the person seeking services. Because the expression of a mental health concern is a clearly observable event that occurs at a specific time and place, by making it the event being classified in the CSM it solves the reliability problems that have been plaguing the DSM and ICD approach’s far more abstract theoretical construct of “mental disorders.”

After this statement, the CSM would clearly define its main construct, which is mental health concerns:

A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern about any of these topics: behavior, emotion, mood, addictions, meaning of life, death, dying, managing chronic pain, work, interpersonal relationships, intrapersonal relationships, education, eating, cognition, sleep, and challenging life situation.

So, there’s a summary of the basic ingredients of Chapter 1.

Chapter 2: Classification of Mental Health Concerns and Codes

This chapter would begin by explaining that the CSM has two classes of expressed concerns–Concerns expressed about oneself, and concerns expressed about someone else.

An example of the first class is, Sally is seeking mental health services and expresses a concern to a mental health service provider that she has been experiencing a great deal of anxiety when she enters social situations.

An example of the second class is Bob, a father, upon seeking counseling for his son, expresses a concern about his son’s behavior.

Each of these two classes of concerns would have under each of its headings a list of specific concerns, along with an assigned code to be used for third-party payer record keeping.

So, let’s quickly return to the example of Sally expressing a concern that she has been experiencing a great deal of anxiety in social situations. This would be referred to, for classification purposes, as a “social situation anxiety” concern. Notice that “social situation anxiety” is just three words, thus it is short enough to be used in titles and search engines.

Concerns that would be included in the first edition of the CSM would be selected from survey data. For example, mental health service providers would be asked to list the various concerns that they have been asked to address in their practice in the past year without couching them in psychopathological language and to stick as closely as possible to the language used by those seeking their services.

Chapter 3: The CSM Approach to Psychological Formulation

Thus, Chapter 3 of the CSM would be devoted to describing good practice guidelines for the use of a type of psychological formulation that is consistent with the CSM’s philosophy of not psychopathologizing individuals.

Defending the CSM

Okay, those are the basic chapters of the CSM. I contend that it would achieve all of the benefits that the supporters of the DSM-ICD approach claim for it. It would provide a common language. And, in fact, I actually tested the CSM approach for years. When I worked in a mental health center, although I capitulated to the requirement that I inserted a DSM diagnosis in its proper place on the insurance form, other than that, I had no need to use DSM terms to communicate. When a colleague would ask me to tell him or her about my cases, I would reply with words like, “My 9:00 a.m. case is concerned about feeling depressed, my 10:00 case is concerned about his failing grades, my 11:00 case is concerned about how anxious she is in social situations. If a colleague wanted to know more about a case, we went into the psychological formulation type of information. I found that communication flowed easily and my colleagues readily understood me.

So, I contend that the CSM would provide an easy to learn, non-pretentious, dogma free, common language. Additionally, it would provide a practical approach for third party payers’ record keeping. Let me explain clearly how easy and simple this could work.

Third party payer systems have a form that must be filled out whenever someone seeks mental health services under their plan. This form has a little box that currently typically says, “Diagnosis.” In that box, mental health professionals are required to fill in the DSM or ICD code that corresponds to their so-called diagnosis of the person seeking services.

With the CSM proposal, all that we would be asking third-party payer institutions to do differently in order to add value for their customers, is to slightly change that little box. Instead of just saying “Diagnosis” as it currently says, that box would end up saying, “Diagnosis or Concern.” Then, when mental health professionals fill in the box, they would be given the choice to either write in the letter “D,” thus indicating a diagnosis code will be entered into the box, or they would write the letter “C” thus indicating a concern code will be entered into the box. Once the letter “D” or “C” is written into the box, the appropriate code number would be entered.

With the creation of the CSM, not only will mental health providers have a new option to choose from, but so too will people seeking mental health services. They would be given the choice to go to psychopathologizing mental health service providers or to those using the CSM approach.

So, we would of course have to convince third party payers to make just this small change on their insurance form in order to increase value for a significant number of mental health providers and service users. The rest of their form would remain exactly the same.

In making the case to insurance companies, and others as well, that this choice would be beneficial, we could point to a March, 2008 research article titled, “The Effects of Choice on Intrinsic Motivation and Related Outcomes: A Meta-analysis of Research Findings.” Published in Psychological Bulletin, here we find that 41 studies were examined for the effect of choice on a variety of outcomes in a variety of settings. Results indicate that providing choice enhances intrinsic motivation, effort, task performance, and perceived competence, among other positive outcomes. There are a few studies out there that suggest that if you provide an enormous amount of bewildering options to a targeted population, the typical positive effects begin to diminish, but keep in mind that the CSM proposes just one additional option for mental health professionals and service users.

Here’s another benefit of the CSM approach in contrast to the DSM-ICD approach. The DSM-ICD approach, by using the “mental disorder” construct, simplistically devalues all of the experiences it refers to as mental disorders, providing a cognitive set that they are “bad” experiences. It does so despite the fact that there are a great number of people who have testified that having gone through these very types of experiences it brought forth valued fruits. With the CSM approach, we instead begin by addressing someone’s “concern.” Thus, there is no automatic need to assume that the experience that led to the concern is necessarily bad. Together with the mental health service provider, service users may come to understand that these experiences are part of a useful process; they may be a different than an average process with strengths and weaknesses. Though perhaps not bad, there may be a better approach to be discovered, etc. The DSM-ICD approach that pathologizes these types of experiences tend to close people to such possibilities. The CSM approach opens up these possibilities.

Conclusion

Now my time is almost up, so in closing, I’ll leave you with this; The CSM can do everything that the DSM-ICD approach can do with regards to providing a common language for mental health professionals to communicate about those utilizing their services, providing short phrases convenient for placing into search engines and titles, and providing a practical method for third party payer record keeping. Additionally, when compared to the DSM and ICD approach, the CSM approach would be less stigmatizing, as well as more scientific, person-centered, culturally sensitive and recovery-oriented. Therefore, it is my sincere hope that in the name of justice, we psychologist can fire-up the will to break out of the monopolistic DSM-ICD approach. I’m hoping we can fire up the will to make a real change by having us psychologists roll up our sleeves and then getting down to do the necessary work simply because we believe this is in the best interest of those we seek to help.

——————————-

Tags APA, CSM, DSM, mental health, mental health concerns, Psychiatric Diagnosis, The Classification and Statistical Manual of Mental Health Concerns

conflict resolution CSM DSM ICD The Classification and Statistical Manual of Mental Health Concerns The Diagnostic and Statistical Manual of Mental Disorders

My Upcoming APA Speech on Psychiatric Diagnosis

Post author By Dr. Jeffrey Rubin
Post date July 10, 2016
12 Comments on My Upcoming APA Speech on Psychiatric Diagnosis

Last year at the American Psychological Association Convention, I presented a paper on a proposal for an alternative to the current psychiatric diagnosis system, which can be read HERE. It provoked supportive comments, suggestions for making some improvements, and an invitation to write up my approach for an article in the Journal of Humanistic Psychology.

Now I have been invited to present an update to my proposal at this year’s APA convention in Denver. My remarks will be part of a three hour symposium titled, “The Future of Diagnosis: Ethics, Social Justice, and Alternative Paradigms.”

I am currently in the midst of preparing the final touches on my presentation. As I do so, I’m hoping to get some feedback from my blog readers. To that end, below you will find a summary of what I plan to say. Please look it over, and I’m inviting all of you to let me know what you think about it. Feel free to raise questions, to present as much negative criticism as you wish, and of course positive comments are also welcomed.

Title of 2016 APA Convention Paper: The CSM: A Person-Centered, Culturally Sensitive, Recovery-Oriented Alternative to the DSM and ICD

Presenter: Jeffrey Rubin, PhD

Paper Summary

The Classification and Statistical Manual of Mental Health Concerns (CSM) is a proposed alternative to the American Psychiatric Association’s DSM and the mental disorders section of the International Classification of Diseases (ICD). Both the DSM and ICD seek to legitimize the privileging of the “expert” by having the clinician making a mental disorder diagnosis. It is argued that that perspective hinders the empowering of mental health service users. The CSM, in contrast, would respect the perspective of persons seeking services by beginning with the following statement: “The developers of the CSM fully recognize that persons seeking mental health services have far more expertise about what is going on in their lives than any mental health service provider. Moreover, 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, as defined in this proposal, 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 situation. In addition to classifying mental health concerns, the CSM would describe a collaborative approach between the person expressing the concern and the mental health service provider for creating a psychological formulation narrative that eschews the DSM and ICD psychopathologizing jargon. It is argued that when compared to the DSM and ICD, the use of the CSM would be less stigmatizing, as well as more scientific, person-centered, culturally sensitive and recovery-oriented.

——————-
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.

Tags Alternative to the DSM and ICD, CSM, DSM, The Classification and Statistical Manual of Mental Health Concerns

conflict resolution CSM DSM Mental Illness Psychiatric jargon psychiatrists psychiatry psychologists The Classification and Statistical Manual of Mental Health Concerns The Diagnostic and Statistical Manual of Mental Disorders

My APA Speech On An Alternative to Psychiatric Jargon

Post author By Dr. Jeffrey Rubin
Post date August 16, 2015
13 Comments on My APA Speech On An Alternative to Psychiatric Jargon

On August 8, 2015, I spoke at the American Psychological Association’s annual convention that was held in Toronto, Canada. My speech was part of a two hour symposium titled: “Beyond the DSM–Current Trends in Devising New Diagnostic Alternatives.” The DSM’s letters stand for the Diagnostic and Statistical Manual of Mental Disorders. It is currently used by most mental health professionals to classify people seeking mental health services.

When the latest version of this manual came out, it was widely criticized. Consequently, a group of psychologists began to work together to think about possible alternatives. Several members of that group spoke at this symposium.

My Speech

Of late, I have been discussing today’s symposium theme with quite a few people. I have found that supporters of the DSM say that it is a classification system that has been helpful because it provides a common language for mental health professionals to communicate about those utilizing their services; its various diagnostic terms, such as Major Depressive Disorder, Anxiety Disorder, etc., are short phrases that are convenient for placing them into article titles, book titles, and search engines to retrieve valued relevant information; third party payers of mental health services have found that the DSM coding system works well as part of a practical method for their record keeping; with the aid of these codes, people do manage to access mental health services, mental health service providers do manage to get paid, and for-profit health companies do tend to make a profit.

So, from my discussions, those are the basic reasons supporters of the DSM say that it is useful. Actually, there is another usefulness of the DSM that, interestingly, I never hear supporters of the DSM mention, and yet critics of the DSM often mention. That usefulness is this: by using medical sounding terms to refer to all of the experiences that the DSM classifies as “mental disorders” it legitimizes in the minds of many the prescribing of drugs for these experiences.

There is an enormous amount of money being made from this approach because it takes less than a penny to manufacture each pill, and it can be sold for more than one thousand times that amount. With so much money being generated from this enterprise, the drug companies have managed to make it clear to powerful groups that what benefits the drug companies also benefits them. Examples are, major media outlets gain enormous revenues from drug company advertisements, and political campaigns get substantial support from the industry.

So this benefit is in a sense the elephant in the room. I fully see it, but nevertheless, I want to move it off to the side of the room for now, and ask you all to briefly ignore it. After I complete my main ideas, I’ll return to the elephant in my concluding remarks.

Keeping in mind just the usefulness of the DSM that its supporters tend to mention, it seems to me that if we are to have any hope that an alternative to the DSM might be widely adopted, we would have to be able to make an excellent case that the alternative would be just as helpful while, at the same time, have significantly less shortcomings.

What are these shortcomings? Well, in brief, critics of the DSM have expressed concerns that it tends to be stigmatizing to mental health service users; the DSM also simplistically devalues all of the experiences that it classifies as mental disorders despite the fact that there are a great number of people who have testified that having gone through these very types of experiences it brought forth valued fruits.

For example, Leo Tolstoy reported in his biography, My Confession, that by going through a period of suicidal depression, it led to one valued insight after another.

As another example, the fine song writer, Joni Mitchell apparently went through, during her life, a number of very challenging emotional experiences that first received the full DSM psychopathologizing treatment. In time, her perspective changed, and at one point she expressed her new perspective in a song titled, “Hejira.” She wrote, “There’s comfort in melancholy where there is no need to explain, it’s just as natural as the weather in this moody sky today.” Thus, for many, the framing of their experiences as mental disorders dramatically misses the mark; critics of the DSM also point out that it violates basic principles of science because of its vaguely defined constructs and thus low inter-rater reliability; the DSM also violates basic principles of humanistic psychology; and within the mental health field the DSM is a monopoly, with all of the drawbacks associated with such an organizational situation.

So, those are, in brief, the DSM shortcomings. Keeping them in mind along with its perceived benefits, is it possible to come up with an alternative that indeed does achieve all of the benefits that the DSM supporters claim for it, while, at the same time, has far fewer shortcomings? Well, for your consideration, I offer you the Classification and Statistical Manual of Mental Health Concerns, or, for short, the CSM. Not the DSM, but the CSM! Let’s look at what each chapter would contain.

Chapter 1

The first chapter would begin by stating that the developers of the CSM fully recognize that individuality outruns any classification system. It is for this reason that the CSM does not seek to classify anyone. Instead, it classifies the expressed concerns of individuals seeking to have their concerns addressed by a mental health service provider.

This first chapter would go on from here to explain that the CSM begins from the perspective of the person seeking services. Because the expression of a mental health concern is a clearly observable event that occurs at a specific time and place, by making it the event being classified in the CSM it solves the reliability problems that have been plaguing the DSM’s far more abstract concept of “mental disorders.”

After this statement, the CSM would clearly define 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 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 situation.

So, those are the basic ingredients of Chapter 1.

Chapter 2

Chapter 2 would begin by explaining that the CSM has two classes of expressed concerns–Concerns expressed about oneself, and concerns expressed about someone else. An example of the first class is, Sally is seeking mental health services and expresses a concern to a mental health service provider that she has been experiencing a great deal of anxiety when she enters social situations. An example of the second class is Bob, a father, upon seeking counseling for his son, expresses a concern about his child’s behavior.

Each of these two classes of concerns would have under each of its headings a list of specific concerns, along with an assigned code to be used for third-party payer record keeping.

Each of the actual expressed concerns would be just as useful as the DSM terms for providing those in the mental health profession a common language for communication about those utilizing their services.

In this chapter 2, it would be explained how the creators of the CSM identified the list of concerns included in the CSM. These concerns would be identified by a survey of a sample of mental health service providers. Those filling out the survey would first read the definition of a mental health concern. Then they would list, in order of frequency, the various concerns that they had been asked to address in their practice over the course of the previous year. At the back of the CSM would be a summary of the findings of this survey and its related statistics.

Moving on to Chapter 3

As noted, the previous chapter would be designed to provide the method for identifying and coding a set of brief mental health concern descriptors suitable for a number of practical purposes. Once this is achieved the CSM then provides a method to develop a lengthier psychological formulation approach that is designed to fill in additional details about the expressed concern. Thus, Chapter 3 of the CSM would be devoted to describing good practice guidelines for the use of a type of psychological formulation that is consistent with the CSM’s philosophy of not psychopathologizing individuals. This type of psychological formulation provides an approach that expands on the brief expressed concerns of individuals by developing a narrative of several paragraphs. It can be defined as the process involving 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 strengths, relationships, social circumstances, cultural heritage, life events, and the sense that he or she has made of them.

Defending the CSM

Okay, these are the basic chapters of the CSM. Now let’s quickly recall that supporters of the DSM believe that it is a classification system that is useful because it provides a common language for mental health professionals to communicate with one another. I hope from what I have already said, that you can plainly see that the CSM would provide an alternative plain, humane language that would be just as practical as the DSM. But let’s look a little more closely at this via an example.

When I was doing my 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 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. Communication flowed easily. This is how the CSM would work in practice.

The idea that the DSM’s coding system is a practical approach for third party payers’ record keeping is an essential point made by DSM supporters. With the following description, I think you will readily see that the CSM approach is just as practical.

Third party payer systems have a form that must be filled out whenever someone seeks mental health services under their plan. This form has a little box that currently says, “Diagnosis.” In that box, mental health professionals are required to fill in the DSM code that corresponds to their so-called diagnosis of the person seeking services.

With the CSM proposal, all that we would be asking third-party payer institutions to do differently in order to add value for their customers, is to slightly change that little box. Instead of just saying “Diagnosis” as it currently says, that box would add two simple words, so it would end up saying “Diagnosis or Concern.” Then, when mental health professionals fill in the box, they would be given the choice to either write in the letters “DSM-5” and its code number that corresponds to its so-called diagnosis, or they would write the letters CSM and its code number that corresponds to the expressed concern.

With the creation of the CSM, not only will mental health providers have a new option to choose from, but so too will mental health consumers. They would be given the choice to go to psychopathologizing mental health service providers or those using the CSM approach.

So, for third party payers, that’s all the change that would be required in order to increase value for a significant number of mental health providers and service users. And a major goal that all third-party payers have is to increase value for their customers. The cost and effort for adding this new option for these payers would be minimum.

Conclusion

In conclusion, the creation of the CSM would improve value for consumers of mental health services. It would provide a practical approach that offers a new choice for those mental health service users and providers who are dissatisfied with the DSM. It does so in a manner that is more scientific and humanistic. Moreover, the creation of the CSM would break up the DSM monopoly.

Now, let’s return to the elephant in the room. Let’s bring it forth, front and center.

Yes, the DSM’s medical jargon has an enormous benefit to the pharmaceutical industry. However, with the creation of the CSM, the elephant would still get fed. Those who prefer the DSM to the CSM would be able to continue to use it. The pharmaceutical industry will still be able to promote the drugs with images of a patient looking miserable and family members distraught, all in grey, black and white, followed by images of the same patient taking a pill, now smiling in vibrant living color, with the sun shining, and family members gathered around, and bouquets of flowers brightening the whole world. There will be plenty of people who will still seek to have their concerns washed away with the ease of swallowing a pill.

Despite drug companies being able to still make a great deal of money even if the CSM was to become widely adopted, no doubt the industry as a whole would still seek to try with all its might to maintain the monopoly it currently enjoys. No doubt, big money can be very influential in putting a stop to competition. I get that. But to help us to think a little more clearly about this, let’s use a metaphor fitting to our country’s current enormous interest in the presidential primary campaigns.

You all know about the discussions going on about how a few billionaires has so much influence on who will get to win. There is much truth to this concern, but I ask you to keep in mind that every now and then, a dark horse comes along that does manage to win despite all of the big money that went to supporting the favorite of the super-rich.

In my view, the CSM has the potential to be that type of dark horse. I’m hoping that this is so because there exists enough psychologists out there who are willing to roll up their sleeves and get down to do the necessary work of joining their efforts with those of other allied professionals and mental health consumer advocacy groups because they believe this is in the best interest of those they seek to serve.

——————–
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.

Tags CSM, DSM, mental health, psychiatric jargon, psychiatry, psychologists, The Classification and Statistical Manual of Mental Health Concerns, The Diagnostic and Statistical Manual of Mental Disorders