Welcome to From Insults To Respect. As several of my earlier blog posts have indicated, many professionals, mental health service users, involuntary patients, and the general public have little, to no respect, for the American Psychiatric Association’s most recent version of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Just before the DSM-5 was published, early drafts were made available, and in 2011 the British Psychological Society (BPS) and the American Psychological Association’s Society for Humanistic Psychology expressed concern that:
…clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation…
Additionally, many researchers have pointed out that psychiatric diagnoses are plagued by problems of reliability, validity, and prognostic value.
These concerns, among others, appeared in an Open Letter to the DSM-5 developers that was endorsed by over 15,000 mental health professionals and other individuals, as well as by over 50 professional organizations, including 15 additional divisions of the American Psychological Association. These concerns were largely ignored by the DSM-5 developers.
Since then, we have seen the development of a few proposals for alternative frameworks. Most of them continue to pathologize those seeking mental health services.
In contrast, there is now my own proposed alternative, the Classification and Statistical Manual of Mental Health Concerns (CSM) which I presented at the American Psychological Association’s Annual Convention, and published in a peer reviewed psychology journal (see HERE). The CSM approach recognizes mental health professionals require some classification system for providing a common language for them to communicate about those utilizing their services. These terms must, for practical purposes, be short phrases that are convenient for placing them into titles and search engines, and for efficient/streamlined communication in the often hectic environments of many hospitals and clinics.
However, unlike the CSM, other frameworks being proposed use the term “diagnosis,” which implies that the mental health professional, once providing the diagnosis, now knows the cause of the concerns being expressed by the person seeking services, which is simply not true. Instead, they may have some tentative theory for the cause or be completely puzzled. Nevertheless, to access services, the misleading diagnosis is provided. Moreover, the “diagnostic” terms used identify and locate problems within individuals and labels the individual as having a mental disorder, which is often stigmatizing.
In contrast, the CSM does not seek to label anyone. Instead, it classifies the expressed concerns of those seeking mental health services, using the typical non-jargon phrases employed by them. These phrases would become the short phrases that would be used by mental health professionals for titles and search engines, and for efficient/streamlined communication.
Beyond creating this practical classification system, the CSM then relies on a psychological formulation approach that opens the door to finding causes for these types of concerns in the circumstances of the service seeker’s lives. Locating problems within only individuals, as the DSM-5 does, misses the relational context and undeniable social and structural influences on many of these concerns.
I developed the CSM approach while working with the Task Force on Diagnostic Alternatives of the American Psychological Association’s Division 32 (Society of Humanistic Psychology). That group has not officially supported, as of yet, any single alternative. Instead, it has wisely decided that its next step is to send out a new open letter hoping to garner support for starting a process that will involve all of the mental health stakeholders including former and current mental health service users, individuals who experienced involuntary treatment, their family members, and mental health professionals.
Why bother to create a new open letter to those who are in positions that can really make meaningful changes since the last one was largely ignored? It is because of a deep understanding of how meaningful positive changes do occur. Advocates for change are, at first, largely ignored. Then, through continued advocacy, some meaningful discussions do get underway. And finally, positive changes occur. The process by which women obtained the right to vote is one notable example of this.
So, this letter was created with the flame of hope still flickering within the hearts of many of us.
The letter is addressed to:
Co-Chairs of the World Health Organization Joint Task Force (JTF) on the ICD-11 for Mortality and Morbidity Statistics,
Stefanie Weber, MD
Head, Medical Vocabularies
German Institute for Medical Documentation and Information (DIMDI)
Waisenhausgasse 36-38A
50676 Cologne, Germany
James Harrison
Director, Research Centre for Injury Studies
Flinders University, Adelaide Australia
GPO Box 2100 Adelaide SA 5001 Australia
Chair, DSM Steering Committee:
Paul S. Appelbaum, MD
Elizabeth K Dollard Professor of Psychiatry, Medicine & Law
New York State Psychiatric Institute
1051 Riverside Drive, #122
New York, NY 10032
Coordinator, RDoC:
Bruce N. Cuthbert, PhD
National Institute of Mental Health
NSC BG RM 6200
6001 Executive Boulevard
Rockville MD 20852
I was one of the consultants that helped to craft the letter. Among the main points that it seeks to make are:
In practice, diagnoses are not conferred in a contextual vacuum. The criteria are not culture or value-free but instead reflect current normative social expectations. At the same time, psychiatric diagnoses have substantial impact on the social and occupational lives of those to whom they are applied. And reductionist biomedical diagnoses obscure the social determinants of our distress. This is important: as the United Nations Special Rapporteur concluded in 2017, we are under an international obligation to ensure that mental healthcare adequately addresses social contexts and relationships.
The letter concludes:
As a next step to address these concerns, we request an online, telephone or in-person meeting to discuss these issues in more depth. We look forward to your response.
Readers of this blog are invited to read this letter HERE.
My Best,
Jeff
This labeling process relies on descriptions provided in the Diagnostic and Statistical Manual of Mental Disorders–Fifth edition (DSM) and the International Classification of Diseases–Tenth edition (ICD). Both are manuals that are conceptually similar, utilizing as their core concept, mental disorders, and both share the same “diagnostic” codes. Because of their similarities, I will simply refer to them as the DSM/ICD approach.
Many professionals defending the use of this approach explain that it provides a common language for mental health professionals to communicate about those utilizing their services; its various classification terms, such as major depressive disorder, anxiety disorder, and so on, are short phrases that are convenient for placing into titles and search engines, and for efficient/streamlined communication in high-speed hospitals and clinics; third-party payers of mental health services have found that their coding system works well as part of a practical method for their record keeping; with the aid of these codes, people manage to access mental health services, mental health service providers manage to get paid, and for-profit health companies tend to make a profit.
It tends to be stigmatizing to mental health service users. The lack of reliability and validity of the various so called diagnoses violate basic principles of science. The process of coming up with a psychiatric label privileges the clinician’s perspective over that of the mental health service user. It ignores the fact that many people who have been labeled with these stigmatizing psychiatric terms come to realize that the experiences which led to their seeking services, rather than being an indication of a pathological condition, are really an essential element to their creative development. Many have also expressed concerns about the “mental illness” terminology which medicalizes mental health concerns, thus leading to an incredible number of people being prescribed psychiatric drugs, the use of which leads to numerous serious side effects.
Just as I was writing this post, major news outlets began to report that researchers found nearly a 50% increased odds of dementia for those taking the most popular drugs for treating depression and other mental health concerns. Although the study could not prove conclusively that these drugs caused the increased risk of developing dementia, because these same drugs had already been linked to confusion or memory issues, the new evidence is deeply troubling. The researchers expressed concerns that if this association is causal, it “would equate, for example, to around 20,000 of the 209,600 new cases of dementia per year in the United Kingdom.” With the population of the US being 6 times larger, this could mean that over 100,000 cases of dementia may be attributed to these drugs every year here in my own country.
As part of this effort, I have come up with one alternative proposal which I discuss most extensively in a peer reviewed article published in a 2018 volume of the Journal of Humanistic Psychology (see 
The CSM approach begins with a full recognition that individuality outruns any classification system. It is for this reason that the CSM does not classify anyone. Instead, it classifies the expressed concerns of individuals seeking to have their concerns addressed by a mental health service provider. A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern about any of these topics: behavior, emotion, mood, meaning of life, death, dying, managing chronic pain, addiction, work, relationships, education, eating, cognition, sleep, and challenging life situations.
Classifying the expressed concern would provide mental health service providers a common language that is helpful when communicating among other professionals. So, a professional might say to a colleague something like, “My 9:00 a.m. case is concerned about feeling depressed, my 10:00 case is concerned about his failing grades, my 11:00 case is concerned about how anxious she is in social situations.” Such communications are straightforward and easy to understand, not only for professionals, but for the general public as well.
Each expressed concern listed in the CSM would be a sufficiently short phrase so that it can be conveniently used in titles and search engines to retrieve valued relevant information. Along with each classified expressed concern, there would be a numerical code that would be convenient for third-party payer bureaucratic record keeping.
This process involves a mental health service user and a mental health service provider co-constructing a hypothesis or “best guess” about the origins of the mental health service user’s concerns in the context of his or her relationships, social circumstances, cultural heritage, life events, and the sense that he or she has made of them. Once it has been established what the concerns are, the immediate next question is, “How do we jointly understand these experiences, why they arose, and how we might be able to address them?” This formulation is not something that is shared with third party payers of mental health services, but is utilized exclusively by the mental health service user and service provider.
With the CSM approach, no one is viewed as mentally ill, having a mental disorder, or having some psychopathological condition. Instead, it highlights that the progress of society is due to the fact that individuals naturally vary from the human average in all sorts of directions, that the originality is often useful, while, at the same time, being different can create a variety of concerns. Moreover, some people become concerned about how they are handling enormously stressful and traumatic experiences. Still others are living in unhealthy ways, such as making unhealthy choices in what they consume, or getting insufficient exercise. Mental health professionals, with the CSM approach, are viewed as seeking to address these types of concerns that arise from these conditions in a supportive setting while relying on a variety of wisdom traditions. Central to this approach, is an honoring of what Ralph Waldo Emerson referred to as the grand sweep of humanity.
Compared with the DSM/ICD approach, the use of the CSM would be less stigmatizing, more respectful to those seeking services, and more practical because of the ease of understanding the words and phrases that it utilizes. Moreover, it would be more consistent with principles of science because instead of using as its core concept the vaguely defined “mental disorders,” the CSM uses as its core concept “mental health concerns,” which is a clearly recognized event that occurs at a specific time and place. Finally, the CSM approach would provide a new choice to both mental health service users and providers, challenge old ideas, stimulate fresh perspectives, and open new avenues of research.
In an article titled, “What Might an Alternative to the DSM Suitable for Psychotherapists Look Like?” Jonathan D. Raskin notes that recent surveys of psychologists and counselors indicate they are dissatisfied with the DSM/ICD approach and are interested in coming up with alternatives better suited to their professions. Nevertheless, more that 90% said they will use the DSM/ICD; after all, that is how they get paid by third party payers.
In a commentary on Dr. Raskin’s article that appears in the same JHP issue, Rachel Cooper, a senior lecturer in philosophy at the United Kingdom’s University of Lancaster, and author of Diagnosing the Diagnostic and Statistical Manual of Mental Disorders, puts in some of her own thoughts on this topic.
She begins by agreeing with Dr. Raskin that most psychologists and counselors would be keen for an alternative classification to be developed. She then reviewed research indicating that social workers should be included among the professionals unhappy with having to use the DSM/ICD approach. In surveys, most indicated they would not use it if it was not required for insurance purposes.
She then refers to my CSM approach, stating that I suggest that insurance companies could be persuaded to pay for “Mental Health Concerns,” as they would readily come to understand, with a little explaining, that mental health service providers now using the current DSM/ICD approach do not turn anyone away who has mental health insurance coverage and comes to their office expressing what the CSM refers to as a mental health concern. She then writes,
First of all, when Dr. Cooper says insurance companies usually try to prevent mental health providers from recording diagnoses to facilitate payment even in cases where a diagnosis criteria is not met, I strongly disagree with her. I’ve never in my entire career heard of an insurance company questioning a diagnosis, and on what basis could they possibly do so? Insurance funders are not present in the room when a so called diagnosis is made. All that they get as documentation for a given diagnosis is a code indicating the diagnosis.
Well, in thinking about this, I hasten to mention that Thomas Kuhn’s (1972) classic book, The Structure of Scientific Revolutions, rightly points out, for real change to occur in a branch of science, it is not enough to point out the weaknesses of a paradigm. There needs, as well, a new approach that is a distinct improvement over the old paradigm.
Regular readers know that I have, from time to time, been dealing with a conflict regarding psychiatric diagnosis. Said briefly, there are many people who immediately lose respect for anyone who questions the validity of the mental illness/mental disorder theoretical construct. On the other hand, many people have lost respect for the psychiatric profession because of its pathologizing approach of addressing concerns related to thinking, mood, behavior, or challenging life situations. Amidst this conflict, I have been trying to put forth on this blog, and in a number of other publishing outlets, an alternative approach with which the disputing parties can live in relative peace. 
Last year, I presented a paper on this topic at the American Psychological Association convention in Denver (see 
Albert Einstein created a revolution in the branch of science known as physics. Prior to the 20th century, physicists explained the propagation of light with the use of a theoretical construct known as the ether. There were experts in the ether who described ways to define it, along with its various characteristics. It was thought, for example, that the ether didn’t move in any direction, but it could vibrate. There was much discussion about an ether wind. And then Einstein came along and described the nature of light without resorting at all to the ether.
Criticism of the mental disorder construct began at the very beginning of American psychology when William James declared that it was nothing more than superficial medical talk. Criticism continued throughout the 20th century, and when the latest version of the DSM came out, there was a ton of media and professional articles that once again pointed out its numerous scientific shortcomings. Many throughout general psychology expressed deep concerns that psychologists utilizing the DSM approach had sold out to psychiatry and the pharmaceutical industry. Moreover, they bitterly complained that a paradigm that utilizes the mental disorder construct brings down respect for psychology as a legitimate branch of science. What can be done about this?
Well, in thinking about this I hasten to mention that Thomas Kuhn’s (1972) classic book, The Structure of Scientific Revolutions, rightly points out, for real change to occur in a branch of science, it is not enough to point out the weaknesses of a paradigm, there needs, as well, a new approach that is a distinct improvement over the old paradigm. So, is it possible to really come up with a distinct improvement over the current DSM approach? I think our APA can do this easily if it set its mind to it, and it can do so within a year.
Let’s say Mary Doe comes to a licensed practicing psychologist and says she has been feeling a great deal of sadness much of her days. The psychologist, for verification purposes can say, “I hear you saying that you are concerned about how sad you have been feeling much of your days, and you would like us to work together to address this concern, is that correct?” If the service seeker says yes, this would verify that a mental health concern has been expressed, and what the concern is.
Well, there you have it. I only have seven minutes to present the paper, so many of the essential points that I would love to make have to be left out. There will be some time for questions and discussion, so some additional information could be shared then. And, for those who are interested, as I point out in my paper, they can now readily retrieve a far more complete presentation of my proposal by assessing the journal article I wrote that was just published last month.
Welcome to “From Insults to Respect.” Regular readers know that I have some serious objections to how mental health service providers treat those seeking their services. As things stand now, unless you can afford to completely pay for such services without any insurance coverage, to access services you are very likely to be required to be labelled as having a mental disorder.
This blog seeks to empower its readers, many of whom are directly involved in the mental health arena or will become so in the future. Others are, or will become, involved indirectly because of someone they care about. Thus, it makes sense to spend some time learning how to effectively engage with mental health service providers.
One way to achieve this is to be aware of some of the arena’s major ethical challenges. Today, we will focus on four involving psychiatric diagnoses.
The American Psychiatric Association provides a definition of a “mental disorder” in its most recent version of the Diagnosis and Statistical Manual of Mental Disorders (DSM-5). Let’s take a look at it:
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. (p.20) 
Notice how broad this definition is. It makes mention of a “disturbance” that reflects a “mental dysfunction in the individual.” We all run into some disturbances in our life. How can a professional reliably tell if the disturbance is due to a “mental dysfunction?” We are left in the dark about this. The process described in the DSM-5 for assessing the subjective notions of “clinical significance,” “disturbance” and “dysfunction in the individual” provides clinicians an opportunity to include anything that benefits their set of values.
If the social deviance or conflict results from a “dysfunction in the individual,” then a mental disorder exists in the individual. Once again we are left in the dark about how this distinction is made. It is left to the subjective judgment of the clinician.
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.
Although he survives, he suffers the loss of a leg and an arm. Moreover, in the attack, two of his closest team members had burned to death in front of his eyes. This soldier seeks psychological help. He tells his story with tears running down his face and his one hand that he has left is shaking. He reports having nightmares and difficulty functioning in social situations. The clinician is well aware that such stressful experiences are fairly common under the set of circumstances faced by this soldier. And yet can anyone imagine the clinician denying services to this soldier because his response to the stressor is expected and culturally approved? If the clinician does agree to provide services, he or she would have to provide some mental disorder “diagnosis” on an intake form.
In my view, clinicians routinely ignore the “expected or socially approved” clause. It might have sounded like a good idea to insert into the mental disorder definition for those who developed the DSM-5, but I think few people genuinely believe that in practice clinicians are turning away paying customers when someone seeks help after having experienced the death of a loved one, or any other common stressor. To see such clients, clinicians are required in most mental health settings to assign a mental disorder “diagnosis.”
Most clinicians have a financial interest in deciding whether or not those seeking their services have a “clinically significant” condition. When they judge that their clients’ conditions are indeed significant, they indicate this on the third party intake forms by assigning a mental disorder “diagnosis” and this allows them to continue to see these clients and to get paid for additional visits.
Clinicians refer to mental health service users with “mental illness” and “mental disorder” terminology. These are the same terms that many people use as insults and the media regularly pairs with the most heinous crimes. The stigma associated with such terminology is well recognized. There would be some justifiable reasons to continue to use such terminology if it provided scientific precision to those who wish to communicate about those utilizing mental health services, but as we have seen, this is not the case.
The current psychiatric diagnoses approach focuses on the “dysfunctions” of individuals accessing mental health services rather than human strengths within a cultural context. Moreover, it seeks to legitimize the privileging of the “expert” who supposedly has access to the truth and who can see the truth of the truth. We see this reflected in the mental health arena when we find that it is the clinician that makes the so-called “diagnosis.” The expert is thus seen as always equipped with technical knowledge and jargons without which the truth of knowing would be imponderable. This perspective can paralyze the power of choices for mental health service users.
Although the CSM has not yet been fully developed, becoming familiar with its basic ideas are empowering. Combining these ideas with knowledge about the three psychiatric diagnoses ethical challenges–conflicts of interest, stigma, and violating the respect of mental health service users–can assist people to become far more effective in interacting with mental health service providers.
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.
