Tag: DSM

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.

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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 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 disorders Mental Illness psychopathology Thomas Szasz William James

Are Mental Illnesses Really Illnesses?

Post author By Dr. Jeffrey Rubin
Post date June 16, 2016
8 Comments on Are Mental Illnesses Really Illnesses?

In 1961 psychiatrist Thomas Szasz published an article in the American Psychologist titled, “The Myth of Mental Illness.” There he proposed that the set of experiences, behaviors, and thoughts viewed as “mental illness” are more aptly construed as “problems in living.”

The following year, Dr Szasz published a best selling book by the same name. Some loved it while others writhed in anger. One reviewer, for example, gave it five stars out of five, and wrote:

Incredibly eye opening book. Shows how “mental illnesses” are not illnesses at all. Mental illness is best viewed as a metaphor. This isn’t to say that what we normally refer to as “mental illness” doesn’t exist, clearly these many psychological experiences do exist…but they are not genuine illnesses and when they are assumed to be this can lead to profound misunderstanding.

In contrast, another reviewer wrote:

Here is my curse on you, Thomas: May you suffer ten minutes of acute clinical depression. Ten minutes in that “over-heated room”, that “bell-jar”, that “bed of nails” which we sufferers know oh too well.

Why were there such strong reactions to a proposal for describing something in a new way? I began to get some understanding of this when I recently began to advocate that the phrase “mental health concerns” is a more apt alternative for referring to the patterns now referred to as either mental illnesses or mental disorders.

More specifically, my proposal, which was published in a peer reviewed journal (see HERE) calls for the development of a scientifically defensible classification system that would be called, “The Classification and Statistical Manual of Mental Health Concerns,” or, for short, the CSM. With this alternative, people who have mental health service insurance coverage would be given a choice–they could access this service either by going to a mental health service provider who requires that they be labeled as having a mental disorder (which is currently their only option), or they could choose to go to one that would only label their expressed mental health concerns. Like Dr. Szasz’s proposal, mine, too, has been met with enthusiastic support from some, while others have angrily called me a mental illness denier and dangerous.

I was initially puzzled about the anger that appears to come from many who genuinely believe, and demand others believe as well, that without any doubt mental illness is an illness like any other illness. My puzzlement stemmed from my experience that oftentimes when someone proposes a different way to describe something, it doesn’t create great uproars. The proposal is either met with feelings that the new way to describe something is either helpful, or not.

After much thought and discussions with others, I now see that this mental illness conflict is not purely about how to describe what is now typically called mental illness. Rather, it is about the feared consequences that may flow from any new way to describe this set of phenomenon.

To help others to see this clearly, today I’ll present a William James anecdote illustrating why definitional issues often don’t lead to conflict, but rather clearer understandings. Then I’ll seek to explain the unique resistance to questioning whether or not the patterns now called mental illnesses are best construed as illnesses.

A Definitional Issue Anecdote

William James, in his book, Pragmatism, tells us the following story.

One day the good professor, being with a camping party in the mountains, returned from a solitary ramble, and found everyone engaged in a dispute about a squirrel. The squirrel is clinging to a tree trunk trying to hide from a person by moving to the opposite side of the tree where the man is looking.

This human witness tries to get sight of the squirrel by moving rapidly round the tree, but no matter how fast he goes, the squirrel moves as fast in the opposite direction, and always keeps the tree between himself and the man, so that never a glimpse of him is caught. (p. 43)

So, given this set of agreed upon facts, the dispute was about this: Does the man go round the squirrel or not? Apparently everyone agreed that the man does go around the tree, and the squirrel is on the tree; but does he go round the squirrel?

Half the participants involved in the dispute felt the man did go round the squirrel, and half disagreed. Upon returning to the campsite, each side appealed to William James to help explain who was right.

“Which party is right,” I said, “depends on what you practically mean by ‘going round’ the squirrel. If you mean passing from north of him to the east, then to the south, then to the west, and then to the north again, obviously the man does go round him, for he occupies these successive positions. But if on the contrary you mean being first in front of him, then on the right of him, then behind him, then on his left, and finally in front again, it is quite obvious that the man fails to go round him, for by the compensating movement the squirrel makes, he keeps his belly turned towards the man all the time, and his back turned away. (p. 44)

Once James simply explained to those involved in the dispute that there are these two different ways to define the verb “to go round” the majority appeared to think that the distinction settled the dispute. One or two who had strongly taken a different position before James showed up, mumbled an objection to his argument, stating the decision really should be made based just on plain honest English, but this soon passed.

I tell this anecdote because it clearly illustrates that when someone describes a new way to look at a phenomenon, it has the potential to clarify the nature of the phenomenon. Disagreements that had sprung up because of vague descriptions may have gone on and on with no progress in sight. Once the process of comparing and contrasting two or more descriptive approaches gets underway, it can lead to an understanding of just how vague some of the descriptions were, and they can be abandoned for more precise descriptions. Of course, the new description may also be so terribly vague as well, and nothing positive occurs. In such cases, a little time was wasted, and people get on with their lives without furious reactions.

So, with this in mind, why do people so angrily resist even considering an alternative to describing the set of phenomenon now referred to as mental illness? In the next section, I’ll try to provide some answers.

The Three Major Consequences that People Fear Might Flow from a Change in Descriptive Terms

Let me begin here by asking you to note that in the squirrel anecdote, those who discussed whether or not the squirrel went around the tree were not going to lose their job, money, freedom, or any other highly significant valued thing depending on who ended up being proved correct. Once everyone declared their positions, each might have had a little sense of prestige that might be derived if they could convince others that they came up with the most respected answer. But for people who like to discuss issues, learning from the discussion is typically the most important reward for them, and they can well handle their emotions that come from having taken a position that ends up being faulty.

How about the issue of whether or not mental illness is, or is not, really an illness? From my discussions with supporters of the mental illness descriptor, I theorize that they fear three major consequences of any change.

Diminished Profits of the Pharmaceutical Industry and Prescribing Physicians

The pharmaceutical companies make billions of dollars convincing people that their experiences are illnesses like any other illnesses. Thus, they claim that taking a pill to manage their illness is not any different than taking insulin for diabetes. Psychiatrists and other doctors who prescribe these drugs have an enormous financial interest in keeping this position unchallenged.

For me, I find this sales pitch unconvincing. The facts are that there are numerous examples of people who could have easily been classified as having a mental illness who come to a state of enormous improvement either through a religious experience, a philosophy such as Buddhism, a delightful romantic love, an exciting new job, a support group such as AA, counseling, etc., You don’t see diabetes being “cured” by changes in relationships, work settings, religious beliefs, and thinking patterns. The fear of those invested in pharmaceutical company profits and the prescribing of their pills leads to great resistance to any descriptive changes that are not in line with the illness approach.

The Risk of Losing Access to Services

The second consequence that I think people fear is that people who now have access to mental health services might lose them if people stop thinking that the patterns now viewed as real illnesses are really not illnesses. Dr. Szasz’s “problems in living” alternative and my “mental health concerns” approach, they fear, will trivialize these experiences.

Some argue that if everyone could go to a mental health professional merely to have their concerns addressed, then the system would soon be overloaded with clients, and insurance policy costs would soar. Because insurance companies only cover people with more serious conditions known as mental disorders, so the argument goes, this limits the number of people who can get to see a mental health professional. However, I believe that third-party-payer executives would readily come to understand, with a little explaining, that mental health service providers now using the current mental illness approach do not turn anyone away who has mental health insurance coverage and comes to their office expressing what my approach refers to as a mental health concern. Professionals are in the business of increasing their clients. The current relevant definitions are so vague that with little imagination, anyone can be “diagnosed” as having a mental illness.

Fears About Blame

Finally, many people believe that the mental illness conceptualization absolves them of any blame for certain actions. For example, many parents believe they were unfairly blamed for the serious actions that their children began to display. They think that by saying that their children have an illness they are no longer blamed, or at least shouldn’t be blamed.

Similarly, people who seriously hurt others while drinking alcohol or in some furious fit might be blamed for their actions. Thinking that they have an illness, somehow makes them blameless.

In my view, not everyone who hears that their conduct is due to an illness suddenly feels relief from any guilt that they may be feeling. There is a process that one must undergo to learn how to effectively handle guilt feelings and this can occur at least as well with a mental health concern approach as with an illness approach.

This process involves learning that there is a dramatic difference between taking some responsibility for what has occurred and blaming oneself for what has occurred. Blame suggest that you should be punished for your actions. Taking some responsibility for your actions allows one to realize that there may indeed be some very strong conditions that are out of your control regardless of whether or not you have an illness. Blaming yourself for these is not helpful, but allowing yourself to experience deeply the dissatisfied feelings about whatever control you do have can spur you to make valued changes.

Giving people the opportunity to choose a mental health concern approach rather than an illness approach does not necessarily mean that people will be blamed any more or less for certain actions. The competition between these two models can improve outcomes for both approaches.

Conclusion

Okay, so those are the three feared consequences that I have come to believe ignite anger whenever there is a discussion about conceptualizing the set of concerns now called mental illnesses. In my view, “mental health concerns” are a more apt way to conceptualize these concerns than “illnesses.” However, I fully support that for those who prefer the illness approach, that they be free to access services using that model. At the same time, I believe that ending the monopoly of the illness approach could very well stir up some valuable competition that will improve services for all.

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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.

Tags DSM, mental disorders, mental health, mental health concerns, mental illness, The Myth of Mental Illness, Thomas Szasz, William James

conflict resolution Ethics in Mental Health Care Ethics in psychiatry

The Problematic Ethics of Psychiatric Diagnoses

Post author By Dr. Jeffrey Rubin
Post date March 6, 2016
13 Comments on The Problematic Ethics of Psychiatric Diagnoses

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.

We will begin by noting that there is no clear line for mental health providers to distinguish between those they claim have a mental disorder and those who they claim do not have a mental disorder. This vagueness, as we will see, opens the door to the arena’s major ethical problems.

We will then look at the most serious psychiatric diagnoses ethical problems. An alternative way to look at the concerns that now lead to a psychiatric diagnosis will then be presented, along with an explanation of how this alternative can be empowering.

The Vague Line

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:

Although no definition can capture all aspects of all disorders in the range contained in the DSM-5, the following elements are required:

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. (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.

Certain socially deviant behavior and conflicts are not mental disorders, although they may be. 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.

Another distinction that the definition attempts to make between what is a mental disorder and what is not appears in the following sentence:

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.

Let us try to apply this sentence to the following situation. A soldier in combat has his vehicle blown up. 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.”

Now, let me make a couple of other quick points about the DSM-5‘s definition. First, note that clinicians are not at all required to follow even this vague definition. They are free to use any definition that suits them. Second, from my experience, the vast majority of clinicians can not even state the DSM-5‘s definition. Some that I have asked say they had glanced at it when their copy of the book arrived, but are at a loss at taking a guess at what it precisely says. Most say that the American Psychiatric Association’s definition is simply of no interest to them.

So, keeping in mind how loose the definition of a mental disorder is even among clinicians, let’s take a look at some ethical problems that exist in the mental health arena.

Conflicts of Interest

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.

On the other hand, clinicians who work in an underfunded community government clinic that is being swamped by those seeking to access mental health services might apply a more stringent standard for what constitutes a mental disorder. Thus, we can hypothesize that this type of clinical judgment may often be more of a self-interest decision than one based purely on some objective criteria.

Stigma

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.

Violating the Respect of Service Users

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.

Not Emphasizing That These Concerns have the Potential to Serve an Adaptive Function

Many of the greatest achievements in human history were born out of strife. These experiences always have the potential to challenge us to seek a new way to live in harmony, and to generate creative ways to express our most challenging experiences. A loss of function in an area has the potential to lift one or more of the remaining functions to intriguing new heights.

An Alternative Way to Look at the Concerns that lead to a Psychiatric Diagnosis

In my opinion, there is a much better way to conceptualize the types of concerns currently addressed by mental health service providers than the one provided in the DSM-5.

The CSM: A Person Centered, Culturally Sensitive, Recovery Oriented Alternative to the DSM

The Classification and Statistical Manual of Mental Health Concerns (CSM) is a proposed alternative to the DSM. 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.” 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 stressful situation. The classification process of the proposed CSM respects the perspective of persons seeking services, recognizing that they have far more expertise about what is going on in their lives than any expert can have by interviewing them. 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 psychopathologizing jargon and emphasizing that they have the potential to serve an adaptive function. In contrast to the CSM, the DSM seeks to legitimize the privileging of the “expert.” We see this reflected in its classification systems when we find that it is the clinician that makes the “diagnosis.” This perspective hinders the empowering of mental health service users. It is argued that when compared to the DSM, the use of the CSM would increase the self-efficacy of individuals struggling with these concerns, improve their outcomes, be less stigmatizing, as well as more person centered, culturally sensitive, recovery oriented, and offer a new preferred option to both, mental health service users and their providers.

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.

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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 at no cost 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, ethics in mental health, ethics in psychiatry, mental disorders, mental illness, 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.

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 article titles, book titles and search engines.

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.

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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.

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

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Psychiatric Name Calling: What Do People Say About It?

Post author By Dr. Jeffrey Rubin
Post date May 10, 2015
13 Comments on Psychiatric Name Calling: What Do People Say About It?

In recent weeks, I have been providing a series of blog posts on psychiatric name calling (see here, here, here, and here). In these posts, I have expressed some negative opinions about the Diagnostic and Statistical Manual of Mental Disorders (DSM).

The DSM provides the names for the various mental health concerns that mental health service providers are often required to use if they want to be paid for their services or if they want to have their research published in professional journals.The language of the DSM places its terminology under the umbrella concepts of “mental illness,” “mental disorder,” and “psychopathology.” In my blog series, I have argued that the pathologizing of human experiences in this way does far more harm than good.

As part of my discussions on this topic, I quoted the opinions of some who agreed, and some who disagreed, with my opinions. The quotes that I used were selected from my own personal readings. Therefore, they may not have been characteristic of how a wider range of different people may think and feel about the DSM approach to labeling the various mental health concerns.

A few years ago, two teams of researchers have sought to obtain a broader range of views on this topic by carrying out surveys. 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). Lois Holzman and her team surveyed people in some New York City communities, and published her findings on the DxSummit.org website (A Report on Community Outreach: Lay Opinions on Emotional Distress and Diagnosis, http://dxsummit.org/archives/2249). Let’s take a look at their findings.

What the Psychologists Had to Say

Here’s a summary of the survey data by Jonathan D. Raskin and Michael C. Gayle:

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.

In the above summary, the number 5 after the letters DSM, refers to the fact that the DSM has undergone five major revisions. Since the 1980s, there have been three such revisions. Ideally, users of the DSM would see clear improvement for each revision.

When a survey was done in the early 1980s, psychologists were clearly skeptical of the DSM-2. As described by Raskin and Gayle,

More than 40% felt it (a) distorted clinician perceptions of clients, (b) applied medical labels to psychosocial problems, (c) was not reliable and valid, (d) emphasized diagnosis over treatment, (e) obscured individual differences, and (f) overemphasized pathology. Almost 60% were dissatisfied or somewhat dissatisfied with the DSM-2 with only 17% satisfied or somewhat satisfied.

When the DSM-3 came out in 1983, Smith and Kraft carried out an updated survey on this revision of the DSM-2. The findings indicated that psychologists at that time (a) preferred social–interpersonal diagnosis, nondiagnosis, and behavioral analysis over DSM-3—in that order; (b) felt that most conditions in DSM-3 were best seen as nonmedical problems in living; (c) believed too little had been done to develop scientific alternatives to the DSM; and (d) thought that client welfare and integrity would be better served by abandoning the medical model. Eighty-five percent disagreed that mental disorders are a subset of medical disorders.

In the latest survey that was carried out by Raskin and Gayle, 128 anonymous psychologists participated. Among the questions that were asked was, “How satisfied are you with the changes being proposed for DSM-5?” Their answers indicated that they were significantly more negative about it than neutral. The general attitude about the latest version of the DSM were very similar to what was found three decades ago, namely, that a significant number of psychologists are unhappy with the DSM.

What Community Folks Had to Say

In the community outreach survey of lay opinions on emotional distress and diagnosis carried out by Lois Holzman and her colleagues, people were asked questions at two annual NYC street fairs attended by millions of people. Conversations lasted from five to over ten minutes each. In all, 143 people participated in the survey in the first of these two surveys, which occurred in 2013. The second one had 149 people who participated, which occurred in 2014.

In the 2013 survey, the focus was on how psychiatric diagnosis affected kids. Forty percent felt that psychiatric diagnosis was not valuable. For the 60% that felt that psychiatric diagnoses can be valuable, 90% of them had reservations. That is, they said that it was only sometimes helpful, there was a danger of misdiagnosis, there was racism involved in diagnosis, and it leads to stigma and over-medication.

Ten percent were completely against diagnosis under any circumstance, some sharing their experiences pertaining to children. Examples of comments from this group follow:

“Medication makes you act out. My grandson was hyperactive, not ADHD and they wanted to put him on Ritalin – I told them no. Drugs at an early age can lead to hard core drugs later in life.”

“I worked with kids who had wrong diagnosis, and this is prevalent.”

“Kids get told in 1^st grade they’re crazy—then it becomes a self-fulfilling prophecy.”

In the 2014 survey, the researchers:

“tried to go a little deeper and see if we could help people explore the apparent conflict around diagnosis, i.e., its value and its dangers. We also wanted to learn what they thought about the necessity and mandate of diagnosis.

We all know people who have gotten very depressed when they’ve lost a loved one, or children who cannot sit still in school, lots of folks who are angry and demoralized about not finding a job. Do you think any of these people need to get a diagnosis in order to get help with their emotional pain?

(IF THEY SAY YES, ASK THE NEXT 2 QUESTIONS):

Do we need to relate to them as having brain disorders? Or chemical imbalances?

Right now, in most settings, if you want to get help with ANY kind of emotional pain from a mental health professional, they are required to give you a diagnosis. Do you agree with that?

Are there other ways to support people emotionally? What do you think could help them?

Like me, you probably know people in your family, church, or at work who have serious emotional problems, who may have been diagnosed with major depression, bipolar or schizophrenia. Obviously people deserve and need top quality mental health care including access to medication. Do you think that even in these situations a diagnosis can limit the person, label them, and stigmatize them? If so, how?

From our past surveys we have found that people are conflicted about diagnosis and labels. They find it relieving to get a diagnosis and at the same time feel like the diagnosis can stigmatize or label them. Why do you think that so many of us are conflicted about this, feel it can be both helpful and harmful?

Here’s a brief summary of the finding, as described by Dr. Holzman:

Diagnosis Needed: 60% of respondents said no, people did not need a diagnosis to get help with their emotional pain. The majority of the 40% who said diagnosis was needed told us that that was the only way to get to talk to someone.

Only those who said yes, diagnosis was needed (40%), were asked the next two questions.

1a. Biological Basis: 89% of those who said diagnosis was needed said we shouldn’t consider such people as having a brain disorder or chemical imbalance.

1b. Diagnosis Required: 75% of those who said diagnosis was needed did not agree that it should be required.

Other Ways to Support (alternative types of treatment):

Everyone offered an alternative, with most people suggesting more than one. The most frequent responses involved talking to people—therapy, counseling, group therapy being the most common (including, “A center they can go to without getting diagnosed”), followed by family, friends, self-help and support groups.

A wide variety of social activities and life style changes were recommended—volunteering, hobbies, music, dance, writing, meditation, exercise, yoga, diet, prayer and creating community (“Have events that bring people out, like this fair”).

& 4. Concerns about Diagnosis: 90% (including those who thought it was needed) expressed concerns about the stigma of diagnosis, the dangers of misdiagnosis, and/or the over-medication that too often accompanies a diagnosis.

Once you have that label it doesn’t stay at the clinic. You carry it with you for a long time.

People start calling you crazy. It can be a shame for the family.

I had to fight to get counseling for my kid. They just wanted to give him drugs.

Getting a diagnosis limits life experience, you’re treated differently, you feel like an outcast.

It’s helpful to the clinic but not in everyday life.

It’s good to know what’s wrong, but it might make them feel worse about themselves and put them in a box.

It pigeon-holes people and the diagnosis becomes all that I am.

It stagnates them. It keeps them on one path with only one destination.

They think something’s wrong with them.

There is too much use of medication. It is a quick fix to avoid a real understanding.

Against it – children are still growing. Against medication.

So there you have it, some views other than mine about psychiatric name calling. In interpreting these findings, I think it’s important to bear in mind that the views of the people surveyed developed in the context of a multibillion dollar advertisement campaign by the pharmaceutical companies over many years that is designed to convince them that emotional concerns are diagnosable illnesses requiring medication treatment. How might the views of those surveyed been different without this high finance selling of the illness model?

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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.

Tags DSM, mental disorders, mental illness, psychology

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Psychiatric Name Calling: Is There An Alternative?

Post author By Dr. Jeffrey Rubin
Post date February 24, 2015
5 Comments on Psychiatric Name Calling: Is There An Alternative?

The publishers of The Diagnostic and Statistical Manual of Mental Disorders (DSM) currently hold a monopoly for classifying the concerns that lead people to seek mental health services. Recently on this blog, in a series of articles, I have been pointing out numerous faults of the DSM. To check out some examples of these, see my posts titled Name Calling by Psychiatrists: Is it Time to Put a Stop to it? and Are “Mental Illnesses” Really Potentially Helpful Tools?

In these critical posts, I have touched upon what I believe would be a distinctly better alternative to the DSM and argued that its creation, in breaking up this monopoly, would stimulate through creative competition, improved mental health services. Today, let’s take a closer look at this.

The Classification and Statistical Manual of Mental Health Concerns (CSM)

I called this proposed alternative manual, the CSM, and you can find a much fuller description of it in a peer reviewed journal HERE. In brief, its first chapter would begin by stating that the developed 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.

The CSM begins from the perspective of the person seeking services. Because the expression of a mental health concern is a clearly observable event, 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, meaning of life, managing chronic pain, work, relationships, education, eating, cognition, sleep and challenging life situations.

Each of these topics would have separate major sections in the second chapter, and under each section would be a list of more specific concerns.

This second chapter would be devoted to listing all of the concerns that professionals tend to hear from those seeking their services. Each concern would be given a code that would be used for various administrative purposes such as insurance forms and computer filing systems. And then there would be, for each concern, a list of related search terms that can be used to assist people who want to utilize a search engine to find all the relevant literature regarding that particular concern.

The list of concerns would be identified by two types of surveys. First, a large sample of mental health service providers would be asked to list the various concerns that they are asked to address in their practice without couching them in pathological language and to stick as closely as possible to the language used by those seeking their services. So, a concern about feeling blue might simply be classified “feeling blue,” rather than the DSM’s “Major Depressive Disorder;” a concern about a child’s above average activity level might simply be classified as “above average activity level” rather than the DSM’s “Attention Deficit Hyperactivity Disorder.” The second type of survey that would be used to generate the list of concerns that would appear in the CSM, would ask the membership of mental health service user organizations to list the various concerns that led them to seek mental health services. They, too, would be asked to avoid pathological terminology. For a number of practical reasons, a maximum of four words would be used for classifying each expressed concern in this chapter.

The final chapter of the CSM would be devoted to describing good practice guidelines for the use of psychological formulation, which is an assessment approach that is consistent with the CSM’s philosophy of not pathologizing individuals. 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 relationships, social circumstances, 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?’

Unlike diagnosis, this type of psychological formulation is not about making an expert judgement, but about working closely with the individual to develop a shared understanding which will evolve over time. And, unlike diagnosis, it draws attention to the service user’s resources and strengths in surviving what are nearly always very challenging life situations.

Defending the CSM Approach

Now, some believe that the psychological formulation is all that is needed as an alternative to the DSM and that there is no need to join it with any classification manual such as the CSM. But keep in mind that currently the DSM is used by insurance companies and other third party payers such as Medicaid, Medicare, and Social Security. Insurance companies and these other third party payers 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 must 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 insurance companies 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 little 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” 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. Mental health consumers would be given the choice to go to pathologizing mental health service providers or those using the CSM approach.

That’s all the change that would be required in order to increase value for insurance customers as well as other third party payers. And a major goal that all third party payers have is to increase value for their customers. The cost and effort for these payers would be minimum and we would have numerous testimonials from customers that documents that this change would be viewed as a significant improvement.

A psychological formulation approach, which requires several paragraphs to be completed, would be far too cumbersome for these payers to incorporate into their bureaucratic system. Moreover, a short word or phrase that could replace terms like “Major Depressive Disorder” or “Attention Deficit Hyperactivity Disorder” is necessary for other practical forms of communication. For example, if I want to write a title for a research article, it would not be practical to insert into it several paragraphs. The psychological formulation approach would become far more widely used if it has some practical way of providing some short terms that are consistent with its non-pathologizing approach to conceptualizing an individual’s mental health concerns.

Some may argue that if everyone could go to a mental health professional merely to have their concerns addressed, then the system would soon be overloaded with clients and insurance policy costs would soar. Since insurance companies only cover people with more serious conditions known as “mental disorders,” so the argument goes, this limits the amount of people who can get to see a mental health professional.

Insurance and other third party payer executives are not stupid. They would readily understand, with a little explaining, that mental health service providers now using the current DSM do not turn anyone with a mental health insurance policy away who comes to their office expressing what I refer to as a mental health concern. Professionals are in the business of increasing their clients. Let’s be honest here; there are “close enough” matches throughout the DSM for anyone with mental health insurance coverage who currently wants mental health services to get it.

Here’s another reason why the CSM would improve the psychological formulation approach. In pretty much any of the advanced countries in the world, there is a rather large segment of the population that believes science has been an enormous help advancing our knowledge. The CSM, as already mentioned, is even more consistent with principles of science than the DSM because it solves the problem of reliability that has been a mess with the DSM. And for science minded people, each branch of science must have a system of classification that helps to organize concepts, to retrieve relevant research, and to be useful in formulating programs of research. In my view, the pairing of psychological formulation with the CSM’s list of brief descriptors of mental health concerns will fit well with this worldview.

And so, these are some of my arguments for uniting in the CSM proposal a classification system and the psychological formulation proposal. Together, both can clearly improve value for consumers of mental health services by providing a new choice, but only if consumers of mental health services role up their sleeves, organize, and effectively advocate for this type of change.

In summary then, the CSM is more consistent with principles of science. It is close enough to the worldview and administrative requirements of all of the stakeholders in the mental health field, thus reducing resistance that often comes with proposed changes. And the creation of the CSM would break up the DSM monopoly, thereby spurring creative approaches for understanding the nature of anguish, sadness and tears.

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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 and social intelligence. To begin at the very first post you can click HERE.

Tags CSM, DSM, mental disorders, mental health, mental health concerns, mental health service, mental health services, mental illness, name calling, negative criticism, psychiatry, The Classification and Statistical Manual of Mental Health Concerns

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The Myth of Ritalin’s Effectiveness

Post author By Dr. Jeffrey Rubin
Post date December 21, 2014
25 Comments on The Myth of Ritalin’s Effectiveness

In a recent post titled ADHD and Psychiatric Name Calling, I reviewed studies documenting how much is currently being spent annually on ADHD drug treatments. Here are some new numbers provided by Healthline: What are we getting for this? In this post I hope to clarify this issue. As you read it, you will see phrases in blue. By clicking on each, you will be taken to the actual research article that documents my statement.

For students placed on Ritalin or other stimulant drugs, in short term studies teachers and parents report some improvement in behavior. However, even in the short term, the vast majority of research indicates that there is no improvement on academic functioning. At the end of 14 months, drug treatment was not superior than no-drug treatment on the following measures: classroom observed behaviour, parent- and teacher-rated social skills, parent-rated parent–child relationships, peer sociometric ratings, and academic achievement. By the end of three years there was no significant effects of the drugs on any measure. stomach and head pain And yet, parents who undeniably care about their children, regularly expose their children to the side effects of these drugs, as well as potential long term risks. Why? Because they are convinced that the helpfulness of the drugs outweigh those negatives.

What is it about these drugs that create the myth that the drugs are really helping their children? To understand how this myth is created, it will help if we first take a quick look at how people come to believe smoking cigarettes helps them to deal with stress, and drinking caffeinated coffee helps them to be more productive.

The Myth that Cigarette Smoking Reduces Stress.

In a study published in the American Psychologist, researchers found the following:

Smokers often report that cigarettes help relieve feelings of stress. However, the stress levels of adult smokers are slightly higher than those of nonsmokers, adolescent smokers report increasing levels of stress as they develop regular patterns of smoking, and smoking cessation leads to reduced stress. Far from acting as an aid for mood control, nicotine dependency seems to exacerbate stress. This is confirmed in the daily mood patterns described by smokers, with normal moods during smoking and worsening moods between cigarettes. Thus, the apparent relaxant effect of smoking only reflects the reversal of the tension and irritability that develop during nicotine depletion. Dependent smokers need nicotine to remain feeling normal. The message that tobacco use does not alleviate stress but actually increases it needs to be far more widely known.

This paragraph just provides a summary of the research article that leads to its conclusion. In my view, the whole article lays out a very convincing argument that the relief from a drug withdrawal reaction that occurs each time a person ingests the drug can create the illusion that a drug is helpful. Moreover, I believe that this same argument can also be used to explain how a stimulant such as Ritalin can appear to be helpful even when it is not. Before we get to Ritalin, however, let’s first turn our attention to America’s favorite stimulant, caffeine.

My Personal Experience with Caffeine

When I was 18, I started college. My first class began at 8 a.m. Ugh! That meant waking up around 6 a.m. so I could wash up, have breakfast, and take the hour train ride.

Sitting down for breakfast, I decided to have my first cup of coffee. Both my parents drank coffee in the morning and throughout the day, too. I had heard that it gave you a boost when you were tired, and man, I was tired.

My first sip tasted rather bitter, so I dumped a couple of teaspoons of sugar in. Much better. Then came a little pleasant “up” sensation, but it was accompanied with a little stomach distress. Oh, well. Off I went and it wasn’t long after that I was drinking coffee regularly.

coffee3 As I entered into my twenties, I began to notice that in the morning before I got my first cup, I was irritable and struggling with sleepiness. With the first sips, ahhhh, relief.

In addition to my morning cups, I’d have a cup typically around 10 a.m., a cola with lunch, which has some caffeine in it, and a couple of cups after supper with dessert.

During my thirties, I began to develop headaches. I attributed them to stress.

coffee2 By the time I was forty, the headaches became so bad that I went to a physician who prescribed some pills. I don’t like taking pills, but the headaches were so bad that I thought maybe I should give them a try.

Before filling the prescription, I looked up information about it and found the prescribed pills were made entirely of caffeine. Then, I looked at the side effects and found that one of them was headaches. This surprised me.

Since I was already consuming caffeine throughout the day, and a side effect of caffeine was headaches, I thought maybe instead of taking the pills, the first thing I should try was to stop consuming caffeine.

Wow! Giving up coffee was not easy. For several days I went through a very rough period of headaches, feelings of depression, difficulty sleeping, and my brain seemed to be meandering through thick mud.

In retrospect, perhaps I should have tried tapering off coffee, reducing each week one cup at a time. But I did make it through the morass, and in a couple of weeks I was fine. And ever since, I no longer get any headaches.

More surprising is that when I wake up in the morning, by the time I wash up and sit down for breakfast, I’m every bit as awake as I used to become when I had finished my morning coffee. It is now clear to me that the exhausted, irritable feelings that I used to have before I gave up coffee was due to a caffeine withdrawal effect from going a whole night without having any. Throughout the day, I now find that I have a smoother ride and I am every bit as productive as I used to be when I was a coffee drinker.

The Myth of Ritalin’s Effectiveness

Ritalin, and most other drug treatments for “ADHD” are stimulants. And just as I came to mistakenly believe coffee helped me to be more productive, I think Ritalin’s effects lead to the same mistaken conclusion. And just like I didn’t attribute the side effects of caffeine to my coffee drinking, I think parents don’t realize how much of their child’s sleeping problems, headaches, late afternoon miseries are due to the drugs. And when parents try to withdraw their children from the drugs to see if it is really helping, as the withdrawal effects begin to become worse and worse, parents come to think that this is how their children naturally are when they don’t take the drugs.

Now, there is more to this story than I can reveal in a single post. For example, other factors that lead to parents thinking these drugs are more effective than they actually are is the clever advertisement of the drug companies. Moreover, in some cases, children, as they become older, typically mature at a certain pace. Thus, some children viewed as having ADHD problems completely grow out of these problems without any drug treatment. If this growth in maturity occurs shortly after a child begins to take the drugs, the improvement from natural maturity growth can be easily attributed to the effects of the drugs. When this happens, parents rave to their family members and friends that Ritalin saved their child, and they push other parents to do what they did–get their children on Ritalin.

And so, this is how I think the myth of Ritalin’s effectiveness is created. An initial improvement in behavior once the drug treatment begins; a slow tolerance develops to the drug so it becomes less and less effective, but this occurs over a period of time during which the child is naturally maturing. As a result, some parents don’t notice that the drug is becoming less effective. When parents do notice the decreased effectiveness of the drug, they often take the child to the doctor to get an increased dose. Again there is a boost in apparent improvement. As tolerance to the drug once again begins to occur, more time goes by, and of course there is more growth in the child’s natural maturity. This may lead to less attention problems, but the improvement is attributed to the drugs, rather than improved maturity. Whenever parents try to see if their child can do just as well without the drugs, the withdrawal reactions convince them that their child really needs the drug. Negative side effects of the drugs are attributed to other causes. Couple all of this with the clever advertisement campaign of drug companies, and we end up with a pretty impressive myth.

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Tags Adderall, ADHD, ADHD Treatment, caffeine's side effects, Coffee's side effects, drug treatment, DSM, mental illness, Myths, parenting, psychiatry, Ritalin

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ADHD or Attention Priority Difference?

Post author By Dr. Jeffrey Rubin
Post date December 8, 2014
14 Comments on ADHD or Attention Priority Difference?

A few years ago I worked as a school psychologist. One day the mother of a 12-year old boy, who we’ll call Pete, explained to me that upon the urging of one of his teachers, she took him to his pediatrician to be evaluated for ADHD. The pediatrician asked this mother a few questions, diagnosed Pete as having ADHD, and then wrote him a prescription for Ritalin. After reading the possible side effects of the drug, the mother became concerned and spoke to Pete’s father.

Pete’s father and mother were divorced. Pete lived with his father on weekends, and the rest of the time he lived with his mother. Upon hearing about the prescription for Ritalin, Pete’s father was very much opposed to his son taking any drug for treating this concern. And so, now the mother wanted to know what I thought should be done.

I explained that before I could make any recommendations, I would have to carry out an evaluation. As a student in the district that I served, there would be no cost to the family. Pete’s mother agreed to the evaluation.

First, I requested that the mother, father and each of Pete’s teachers fill out standardized questionnaires. The results indicated that Pete’s physical education teacher, art teacher and his father viewed his activity level and ability to pay attention as falling within the average range. Pete’s mother and academic class teachers generally saw him as having some problems paying attention. His math teacher, who had been the one to urge Pete’s mother to take him to the pediatrician, rated Pete’s ability to attend to his assignments as being way below average.

After looking at the results of the standardized questionnaire, I spoke to Pete’s father. He confirmed that it was his impression that Pete had no difficulty with either his activity level or paying attention.

“Do you mind describing a typical day that you have with your son?” I asked.

“Well, let’s see. Last Saturday, when we woke up, we went to play golf.”

“Do you walk the course, or ride in a cart?”

“We walk.”

“Pete doesn’t mind?”

“Not at all. He loves doing physical stuff like that.”

“After golf, then what did you do?”

“We went back to my place, I made some sandwiches, and then I read the newspaper while Pete worked on his drawing. He loves to draw, and he’s pretty good. Then we went in the backyard. I have a basketball hoop set up there and we shot around for a while. Then we started to get supper together.”

“Does Pete help you with that?”

“Yes.”

“Does he get distracted in any way when you two work on supper?”

“Not at all. He’s very helpful. Then we ate supper, went down to the basement and played ping pong for maybe an hour. Then we went upstairs and watched a movie.”

“When he watches a movie with you, does he appear to have difficulty sitting through it?”

“Not usually. Occasionally, the movie strikes him as boring. After the movie, he went to bed.”

“Does he have any trouble sleeping when he stays with you?”

“No. We do a lot of physical stuff that tuckers him out, and he ends up sleeping soundly.”

I then spoke with Pete’s mom. Consistent with how she filled out the standardized questionnaire, she confirmed that it was her impression that Pete did have difficulty paying attention.

“Do you mind describing a typical day that you have with your son?” I asked her.

“Well, yesterday, I got him up at 7 so he could catch the school bus on time. He complained the whole time he got ready. He hates the ride to school.”

“How long a ride is it?”

“An hour, and he says he doesn’t get along with the kids he rides with.”

“I see. He has to sit on the bus for an hour with kids he doesn’t like, then he’s in school sitting most of the time doing school work. Then he takes the bus home, sitting for another hour with kids he doesn’t like. For a boy his age who loves to do physical activity stuff, I could see how this could be hard for him.”

“Yeah, but other kids do it.”

“Most do. Please tell me what happened when he got home.”

“Well, I got home a little after he did. I started preparing supper, and that’s when I have him doing his homework. I sit him at the kitchen table where I can keep an eye on him while I prepare the meal. And he gets very distracted. He starts an assignment one minute, and I look over and I catch him doodling. Over and over again he gets distracted.”

“I see. After sitting most of the day, you have him sit and do his homework?”

“Yes. That’s when I can best keep my eyes on him.”

“How about the rest of the evening?”

“He’s fine then. Besides doing his homework, the only other time I have trouble with him is when I try to get him to clean up his room. He starts to do it, but when I look in a few minutes later, he has become distracted with something else.”

Next, I interviewed Pete. After some pleasant discussion I said, “Your math teacher says you have trouble paying attention in class. What’s up with that?”

“Aaaaa, he makes us fill out these worksheets doing the same problems over and over again. If I know how to do it, why do I have to keep doing 20 more of them? It’s so boring.”

“I see. Say, I hear that you like to draw. Would you mind drawing something for me.?”

Pete’s eyes light up. “Sure. What do you want me to draw?”

“Anything you like.”

Pete begins, and I notice he appears to become completely absorbed in the task. I start to try to distract him by making some extraneous sounds. He glances up to see what the commotion is all about, sees it’s nothing serious, and resumes work on his drawing.

A half hour later, he shows me what he has created. It’s an imaginative otherworldly drawing with spaceships and fascinating creatures. There is an excellent sense of shadowing. It’s far superior to anything I can create in the drawing department.

When I finished my evaluation, I informed the parents that in my opinion it is not in Pete’s best interest to view the concern that has been expressed about his attention as due to ADHD. A more apt description is to view Pete as having an “Attention Priority Difference.” School work was not a huge priority for him. He much preferred to draw and do more physically active tasks than is currently provided at school. These preferences may turn out to be his greatest values. He may someday find work that he truly loves in a field where his artistic interest and talent are crucial. And his interest in physical activity may keep him far more healthier than the many sedentary Americans who are at an increased risk of a number of real illnesses.

“Well,” said the mother, “will Ritalin help Pete with his Attention Priority Difference?”

To which I replied, “Consider an analogous situation. Suppose we identified a group of children who are not doing as well as most kids in physical education. Would it make sense to make up a pathological sounding term for these low-performing students, such as “Muscular Deficit Disorder” and then have doctors prescribe steroids for them?

“In my view, people have different interests and talents. This is a wonderful thing, not something that should be pathologized. We don’t just need every person in America sitting in ivory towers. We need, as well, artists, computer experts, magnificent athletes, hairdressers, and on and on.

“When I hear of a child placed on Ritalin, I become concerned about the child’s stomach, nerves, and brain. Drugs that have been said to be safe have turned out to be far more toxic than anyone ever dreamed of. I become concerned about the social misery that goes along with being singled out as a child that must take a pill to fix him. More than a few kids have told me that this became a dreaded experience.

“I believe that teaching children to turn to drugs when they are dissatisfied with their behavior or mood runs counter to a healthy lifestyle.

“I prefer to put forth a view that encourages us to teach our youth about the blessings of keeping our bodies in lifelong possession of its full youthful state by keeping their blood free of stimulants and narcotics. I wish to teach our kids that it is possible that the morning sun, air and dew can be sufficient powerful intoxicants. Doing something that puts a smile on the lips of a loved one, accomplishing a valued challenging task, providing assistance to another human being—these are the directions I wish we would point to when we guide a child toward a more fulfilling life.”

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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 and social intelligence. To begin at the very first post you can click HERE.

Tags ADHD, ADHD Treatment, Attention Priority Difference, attention problems, DSM, paying attention, pediatrician, Ritalin

conflict resolution crazy DSM The Diagnostic Manual of Mishegas

Crazy, Mentally Ill, and Meshuga

Post author By Dr. Jeffrey Rubin
Post date November 24, 2014
7 Comments on Crazy, Mentally Ill, and Meshuga

Followers of this blog seek to become experts in a branch of personal interactions referred to as name-calling. Among the words and phrases used in these interactions are “crazy,” “mentally ill,” and “meshuga.” In today’s post, I hope to weave a little narrative around their use in a manner that might take the sting out of them.

The Broad Use of These Words

These terms are often used so broadly that they mean the same thing as other words and phrases thrown at someone, such as “jerk,” “piece of trash,” “stupid idiot,” etc. When used like this, they all mean nothing more than the angry party strongly doesn’t like what the other party did. They serve as a type of exclamation point.

“I don’t like what you did,” is not as emotionally packed as, “Listen, you crazy idiot, I don’t like what you did!” Nor is it as emotionally packed as, “You must be mentally ill to do something like that, you jerk!” Nor is it as emotionally packed as, “Oy veh, you putz, you got to be meshuga to do something like that!!”

Of course, it is perfectly possible to convey emotionally packed exclamations without the use of these words. My mother was a master at this. Her abilities to clearly define what she objected to and to vary her tone of voice were all the tools she required to amply communicate to people where she stood on an issue.

The Special Similarities of Crazy, Mentally Ill, and Meshuga

Now, in addition to being used as general insults, “crazy,” “mentally ill,” and “meshuga” can also be viewed as falling into a group of ideas that have more similarities than most of the other insults that might be picked at random. That is, I would guess that “crazy” and “mentally ill” are viewed by most people as being more alike than “crazy” and “jerk,” even though each could be used as general insults.

It is important to note that there are people in our communities that have adopted a particular narrow use of the term “mentally ill.” To illustrate this, Margaret believes she has a mental illness and values that she has come to accept that about herself. For her, conflicts spring up when she hears someone use the term, “mentally ill” in its more broad, general insult manner. For example, let’s say Margaret is sitting in her backyard, and she hears that her neighbor, Tim, has gotten into a conflict with Ron. Suddenly she hears Tim shouting at Ron that he is a no good mentally ill idiot!!! Even though the conflict has, in a sense, nothing to do with Margaret, she becomes angry with Tim for using the term “mentally ill” in this broad, general insult manner. There is actually no law requiring that Tim adopt the narrower meaning that Margaret uses, but she is still outraged at him.

Who Should Get to Decide When it is Proper to use Terms Such as Crazy, Mentally Ill or Meshuga as a general Insult or in Some Particular Narrow Sense?

The actress, Marlene Dietrich, when asked if she believed in God, replied, “If there is a supreme being, he’s crazy.” In some religious communities, she would have been viewed as crazy for saying this. Meanwhile, Dr. Sigmund Freud, who is thought of by many as having been a great expert on mental illness, believed that all religious people suffer from a mental illness. Dr. Carl Jung, an equally great expert on the subject, disagreed with Freud, believing instead that religious people, even people today viewed as psychotic, may be in touch with deep and ancient truths.

When I was a young boy growing up in the Brooklyn neighborhood of Brighton Beach, I heard people from time to time being called a “meshugana,” which I was told means in Yiddish, “a crazy person.” What was unique about how the Yiddish term was used in Brighton Beach, is that as soon as someone was said to be a meshugana, it was very common to have someone stick up for that person with the words, “Hey, everyone has their own mishegas.” Loosely translated, this means that we all have a little craziness within us, so let’s not pretend to be so high and mighty by putting someone down like this.

Now, for people who want to know if they are really mentally ill, they can get the latest version of the DSM (Diagnostic and Statistical Manual of Mental Disorders), which was developed by the American Psychiatric Association. I happen to have a copy of it, and as I’ve been studying its pages, it has become apparent that with little imagination we can all be viewed as having some mental illness. That works out pretty good for psychiatrists because this way they never have to turn away any customers who come to their office seeking to become their patients.

But what if we really want to find out if we really, truly are crazy? Fortunately, there is now an alternative to the DSM, which can finally set us straight. It’s called the Diagnostic Manual of Mishegas (DMOM), and as the ad for it explains, the authors divide

all mental disorders into two realms: mishegas major and mishegas minor. And for each of the sub-categories it analyzes… yenta, kvetch, alter kocker, shnorrer, dementia-with-benefits, etc…THE DMOM will enable readers to transform ordinary tsuris and mishegas—the glooms, blues, angsts, and general chazzerie of their lives—into transcendent and easy-to-understand categories. It will turn kvetching into kvelling and guilt into gelt, so that readers will learn to live at peace with their inner mishegas and to treasure its precious and life-giving absurdities.

Well, I have nothing that can top that, so until we meet again, don’t let the insults get to you.

My Best,

Jeff

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Tags Carl Jung, crazy, DSM, mental illness, Mentally ill, Meshugana, Mishegas, sigmund freud, The Diagnostic Manual of Mishegas

conflict management conflict resolution DSM Name calling psychiatrists psychiatry The Diagnostic and Statistical Manual of Mental Disorders

Psychiatric Name Calling: Is it Helpful?

Post author By Dr. Jeffrey Rubin
Post date October 6, 2014
14 Comments on Psychiatric Name Calling: Is it Helpful?

Today I offer a follow-up to my earlier post titled “Name Calling by Psychiatrists: Is it Time to Put a Stop to it?” Among the points that I had tried to make is that psychiatrists falsely claim that the names they use to describe patients are “diagnoses.” In actuality, all that they do is convert someone’s expressed concerns into medical jargon.

I received a great deal of positive and negative comments about the post from readers, but my focus today is on the negative ones. Most of them argue that in contrast to my position, they had personally found their psychiatric diagnosis very helpful.

Those who Found the Psychiatric Pathologizing Helpful

I just finished an excellent book on this topic by Lucy Johnstone titled, A Straight Talking Introduction to Psychiatric Diagnosis. There we find several quotes from people who received a so-called diagnosis from psychiatrists and spoke of its positive personal impact. For example, some felt that it provided relief at knowing “what was wrong.”

I had something that I could firmly grasp, and, you know, I could find out more and try to resolve it…[I] felt relief that this whole jungle was going to be sorted out.

Another person wrote,

It gave me the comfort of explanation…. When I was told I was depressed it gave me a framework of understanding and a first grip on what was happening.

Some felt that it gave them hope for treatment and support.

Illness meant treatment and the possibility of cure.

Acceptance of my illness was a turning point…. By accepting treatment I could actively seek the right medication, access support, and turn my life around.

I think I prefer my illness having a name because it makes me feel less lonely, and I know that there are other people experiencing my kind of misery.

Then there were those who felt it provided them freedom from blame and guilt.

Diagnosis implied that this was an illness and not my fault—important for someone whose depression has always been riddled with guilt.

Commentary

Although there are many, many people who feel this way, Ms. Johnstone points out that the relief that these people experience is based on their assumption that the diagnosis itself is valid. If it isn’t, they are simply being offered a circular explanation—“Why are my moods so up and down?” “Because you have bipolar disorder.” “How do you know I have bipolar disorder?” “Because your moods are so up and down.”

Keep in mind, as well, that these people came to view their so-called diagnosis as helpful without ever having an opportunity to compare the pathologizing approach to any alternative approaches. For example, what would be the reactions of these same people whom I have just quoted if they were provided an option that avoided simplistic, misleading terminology, while professional mental health providers and peer support groups assisted the person to find their own stories and provided a choice of treatment options?

Moreover, finding freedom from blame and guilt by playing the blaming-the-brain game may not be anywhere as helpful as the pharmaceutical companies would have us believe. Many of us have learned that we all, from time to time, do things that violate our image of our ideal self and spend some time suffering the consequences. We come to realize that we not only violated the image of the ideal self in the past, but we’ll no doubt do so again and again in the future. The experience of suffering over these lapses is the spur that, after a period of difficult reflection, eventually gets us off our butts, learn new skills and seek out the type of support that moves us to make improvements. It can take time for this to happen. It can take more time than we in our modern pressure pot world may feel we have any right to take, and our loved ones may lose their patience. However, in the long run, drugging these feelings away have always produced more harm than good.

Those who Found the Psychiatric Pathologizing Unhelpful

In contrast to those who tell of some positive reactions to psychiatric name calling, there are other people who tell a dramatically different story.

For a number of years, I accepted the medical model as a framework of understanding…. But I gradually came to appreciate drawbacks to the framework. My reading suggested the model might not stand up scientifically…. By the time I was entering my second decade of service use, the medical model, which I had initially found reassuring, seemed increasingly unsatisfactory, without the capacity to encompass the complexity of my interior or exterior life and give it positive value. As a result, I began to actively explore frameworks that better met my needs.

I already knew something was wrong with me. Now I knew I was mad…. The diagnosis becomes a burden… you are an outcast in society…. It took me years to feel OK about myself again.

My diagnosis label promoted despair and threatened to become a self-fulfilling prophecy.

I have been diagnosed with dysthymic disorder since I was thirteen. One kind of harm I suffered from receiving a diagnosis, in and of itself, was that it seemed so final and despairing to receive as a teenager. For me, having a diagnosis seemed so final. Like it wasn’t just a tempory issue that I was having, adjustment or adolescence or something, but this disorder that I was going to have for the rest of my life no matter what I did.

But the worse part of this, which I have only been able to shake within the last year…is the defectiveness I felt. Just kind of in some core way. Like I’m totally different.

I was so offended. I was really offended. I thought well, ‘F*** you! You’re attacking my personality; you’re attacking me. You’re attacking the very soul of me, you know; who I am, and what I am, that’s a disorder.

I no longer identify with my previous role as a severely ill psychiatric patient but a human being that is experiencing and surviving life in my own unique way… just like every other human being on this planet.

Commentary

In her book, Ms. Johnstone summarizes what she has learned from these quotes:

It is understandable that service users, reaching desperately for an escape from anguish, confusion, guilt and blame, might see diagnosis (at least initially) as ‘salvation’. However, these benefits may be bought at the high price of taking on profoundly destructive messages of defect, dangerousness, damage and despair.

In my view, we can come up with a much better approach to the psychiatric pathologizing of people, an approach that doesn’t label anyone, but rather, classifies mental health concerns. For those who found the pathologizing approach helpful, this alternative approach would provide the professional and peer support that they value without misleading name calling. Psychiatric terms confuse questions of fact with questions of value, and superficially declare that a person’s experience is bad when it may have some pluses and minuses.

Undoubtedly, there are kind and decent folk who have a very different position than I on this subject. In no way do I mean to suggest that those who hold a different opinion are stupid, for I have met many who are as bright as a cloudless summer day. If they want to continue to use the DSM approach, it will continue to be available. All that I seek, all that I hope for, is that those who are uncomfortable with the DSM approach, can still assess mental health services using an alternative. All that I seek is that we all take some time to think more deeply about the nature of melancholy, sadness and tears.

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Tags A Straight Talking Guide to Psychiatric Diagnosis, conflict management, conflict resolution, criticism, dispute management, DSM, Lucy Johnstone, mental disorders, mental health, mental health concerns, mental illness