Welcome to From Insults to Respect.

The two dominant manuals for “diagnosing mental disorders” are the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases. (ICD). Their overarching concept is mental disorders. Synonyms are psychopathology, and mental illness. To access mental health services, most people are required to accept being labelled as having a mental illness. Not everyone respects this requirement.

These manuals continue this pathologizing despite the long history of such terminology being cogently criticized. In contrast to this pathologizing concept, there exists a peer reviewed published article that advocates an alternative method for accessing services, one that replaces the “mental illness” overarching concept with “mental health concerns” that includes the idea that these concerning experiences often serve adaptive functions. It is argued that this approach is a significant improvement over the pathologizing concept.

Criticism of the Mental Illness Concept

William James (1902/1961) was an early critic of the concept of psychopathology, referring to it as “simple minded” (p. 29) and “superficial medical talk” (p. 324). In his 1896 Lowell Lectures on Exceptional Mental States (which were reconstructed by Eugene Taylor in 1984 from James’s notes), he stated that experiences that are commonly viewed as unhealthy or morbid are really “an essential part of every character” and give life “a truer sense of values” (p. 15). James went on from there to note that medical writers tend to,

represent the line of mental health as a very narrow crack, which one must tread with bated breath, between foul friends on the one side and gulfs of despair on the other…. There is no purely objective standard of sound health. Any peculiarity that is of use to a man is a point of soundness in him, and what makes a man sound for one function may make him unsound for another…. The trouble is that such writers use the descriptive names of symptoms merely as an artifice for giving objective authority to their personal dislikes. The medical terms become mere appreciative clubs to knock a man down with…. The only sort of being, in fact, who can remain as the typical normal man, after all the individuals with degenerative symptoms have been rejected, must be a perfect nullity. Who shall absolutely say that the morbid has no revelations about the meaning of life? That the healthy minded view so-called is all? (pp. 163-165)

In more recent time, Schroder, et al. (2023), carried out a relevant study. It presents data from a study in which participants with self-reported depression histories viewed a series of videos that explained depression as a “disease like any other” with known biopsychosocial risk factors (BPS condition), or as a signal that serves an adaptive function (Signal condition). The Signal condition led to less self-stigma, greater offset efficacy, and more adaptive beliefs about depression.

Additional recent criticism of the mental illness concept has been presented by the World Health Organization (WHO) and the United Nations (UN). In its jointly published report titled “Mental health, human rights, and legislation: guidance and practice” (2023), it states:

The biomedical model of mental health is based on the concept of mental health conditions being caused by neurobiological factors (1, 2). As a result, care often focuses on diagnosis, medication, and symptom reduction, rather than considering the full range of social and environmental factors that can impact mental health. This can lead to a narrow approach to care and support that may not address the root causes of distress and trauma (p. xiii).

The same report also states:

Every person should have the opportunity to define what recovery means for them, and which areas of their life they wish to focus on as part of their own recovery journey. Recovery considers the person and their context as a whole, and no longer adheres to the idea or goal of the person “being cured” or “no longer having symptoms” (p. xiv).

Is it possible to respectfully address these issues?

I have proposed an alternative classification system (Rubin 2018; Rubin in press) titled “Classification and Statistical Manual of Mental Health Concerns” (CSM). This approach does not simply exchange the mental illness concept with mental health concerns; rather, the mental health concerns concept is different in several important ways.

The CSM assumes each person seeking to access services as a unique individual. Rather than labeling anyone, it labels expressed concerns. Whereas the mental illness concept declares there is something wrong with the person, the CSM emphasizes, mental health concerns often turn out to be indispensable stages in acquiring valued fruits.

A mental health concern, as defined in the CSM, occurs when a person seeking mental health services expresses to a mental health service provider a concern about any of these topics: behavior, emotion, mood, addictions, meaning of life, death, dying, managing chronic pain, work, relationships, education, eating, cognition, sleep, and challenging life situations. This is an observable event that occurs at a specific time and place, and therefore avoids the well documented reliability and validity problems of the mental illness concept.

Once it has been established what the concerns are, a collaborative effort between the mental health service provider and service seeker, begin creating answers to a semi-structured psychological formulation that looks at:

How distressing is each of the concerns that were mentioned on a scale of 1 to 7?
When and in what situations is the concern most problematic?
When and in what situations is the concern least problematic?
What are personal strengths?
Levels of functioning in the areas of sleep, eating, employment, education, relationships, on a 1 to 7 scale?
What is a tentative theory of cause or causes, jointly created, that considers the full range of social and environmental factors.

Arguments for the Practicality of the CSM

In Some Settings Using Expressed Concerns Has Worked Fine

When I was doing my PhD practicum at the University of Minnesota’s Counseling Center, I worked there for a whole year and we had no need to use the “mental disorder” jargon of the DSM and ICD to communicate. When my advisor asked me to quickly tell him about my morning cases, I would reply with words like, “My 9:00 a.m. case is concerned about feeling depressed, my 10:00 case is concerned about his failing grades, my 11:00 case is concerned about how anxious she is in social situations.”

If my advisor wanted to know more about a case, we went into the psychological formulation type of information. This informal way to communicate among the professionals and graduate students at the counseling center flowed smoothly while we provided a wide range of mental health services.

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

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

However, the CSM would use the term “mental health” in a way that is different from what is implied in the DSM and the ICD. The CSM would explicitly reject the idea that the opposite of mental health is mental illness. Rather, the word “health” in the CSM’s “mental health” would be phrased in a manner that indicates that professionals dealing with mental health concerns are part of the allied health professions. The reason for thinking of these professionals as health providers follows.

Many of the concerns that would fall under the CSM’s list of related topics have been identified in scientific studies as “physical health risk” factors. For example, people who express a concern about being addicted to alcohol are at increased risk of developing sclerosis of the liver (O’Shea, Dasarathy, & McCullough, 2010). Those who express concerns about eating more than average may be at greater risk of diabetes and heart disease (Mokdad et al., 2003). Quality of interpersonal relations, lack of sleep, depression with thoughts of suicide, and various other concerns or clusters of concerns can be studied for the degree of physical health risk that they pose.

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

So, in brief, the CSM approach promises to reduce stigma, improve care, increase self-efficacy, and open new avenues of research. In going forward, I encourage people to begin the process of reconceptualizing what has been promoted as mental illnesses to a mental health concerns. Moreover, for those who have any influence with those in the world of psychology and psychiatry, please encourage them to adopt the CSM approach.

My Best,
Jeff

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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional intelligence. To begin at the very first post you can click HERE.

Welcome to From Insults to Respect.

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 HERE). That paper defended my alternative approach by focusing on the reasons it would, when compared to the current psychiatric approach, be more respectful, beneficial, and fairer to those seeking mental health services while being just as practical for mental health service providers. This year, I will soon (8/5/17) be presenting a paper at the American Psychological Association Convention in Washington D.C. on this topic, but this time I plan to focus on the scientific merits of my alternative. I am hoping to get some feedback about my preliminary draft. So, if you will, please take a look at it. All are encouraged to provide suggestions for improvement or to raise any questions.

My Speech

Albert Einstein created a revolution in the branch of science known as physics. Prior to the 20^th 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.

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. Today I want to make the case that the theoretical construct known as mental disorder is the ether of psychology. Here’s a little of what I mean by that.

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 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.

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. 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, by making it the event being classified, it 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—that’s its definition. If a service provider is not certain if a mental health concern has been expressed, he or she could easily verify that it has indeed occurred. Here’s a simple example of what that would look like.

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.

In the CSM, the various concerns would be provided, along with a code for insurance company record keeping. Concerns that would be included in the first edition of the CSM would be selected empirically from survey data that asks practicing psychologists to identify the types of concerns they were asked to address in their practice over the past year, but to avoid utilizing pathologizing words.

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 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.

The scientific merits of the CSM approach, when compared to the DSM approach are numerous. Unfortunately, there is not enough time here to go into them in any detail. For those of you who are interested in the details, you can readily find an article that I recently wrote that is now published in The Journal of Humanistic Psychology. Up on the screen is the reference. [Click HERE to access the journal article]

Call for Feedback

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.

Chiefly, my objective in presenting my paper at this year’s APA convention is to stir up the interest of as many psychologists as I can in the hope that a coalition will begin to form that can lead us toward making a significant improvement in the state of the current conflict. Again, I urge readers to let me know their thoughts on this topic, and to make any suggestions they would like aimed at improving my presentation.