Tag: mental health

The Rolling Stones On Going Insane

Post author By Dr. Jeffrey Rubin
Post date July 1, 2024
2 Comments on The Rolling Stones On Going Insane

Welcome to From Insults to Respect.

Those who experience what is sometimes referred to as a nervous breakdown can receive a great many insults as their behavior begins to annoy. The Rolling Stones’s hit “19th Nervous Breakdown” insightfully explores this issue.

The lyrics begin,

You’re the kind of person you meet at certain dismal, dull affairs
Center of a crowd, talking much too loud, running up and down the stairs
Well, it seems to me that you have seen too much in too few years
And though you’ve tried you just can’t hide your eyes are edged with tears

You better stop, look around
Here it comes, here it comes, here it comes, here it comes
Here comes your nineteenth nervous breakdown

The song tells us about someone who frequently, nineteen times so far, experiences what the vocalist, Mick Jagger, refers to as a nervous breakdown. I get the sense the “talking way too loud” is annoying. Mick hazards a guess in this first stanza as to what’s causing these breakdowns–seeing too much in too few years. The character in this tale is overwhelmed.

Mick, in the next verse, provides some additional theorizing.

When you were a child you were treated kind but you were never brought up right
You were always spoiled with a thousand toys but still you cried all night
Your mother who neglected you owes a million dollars tax
And your father’s still perfecting ways of making sealing wax

Early childhood experiences, such as being spoiled, a lack of motherly attention, and family financial difficulties can be significant stresses leading to a variety of emotional concerns. Supporting this line of thinking is an abundance of research evidence (see HERE, HERE, and HERE).

Meanwhile, the pharmaceutical industry, along with psychiatrists who sold out to it, promotes the theory that these emotional concerns are due to a chemical imbalance. The right pill prescription, they claim, is the first line of treatment.

Because doctors in the physical health arena have become so respected because of many amazingly successful treatments dealing with physical health problems, doctors in the mental health arena find it easy to convince their patients to take a variety of pills. This financially rewording model continues despite years of negative research findings (see HERE). Hans S. Schroder, clinician and researcher at the Harvard Department of Psychiatry along with his colleagues, recently wrote:

“Our findings are in line with accumulating evidence that some biogenetic beliefs, like the chemical imbalance belief, are linked with poorer expectations for improvement, especially among those with the most troubling symptoms.”

As the Rolling Stones song continues, it begins to express the exasperation that can occur when trying to help someone going through emotionally challenging experiences:

Oh, who’s to blame
That girl’s just insane
Well, nothing I do don’t seem to work
It only seems to make the matters worse
Oh, please

You were still in school when you had that fool who really messed your mind
And after that you turned your back on treating people kind
On our first trip I tried so hard to rearrange your mind
But after awhile I realized you were disarranging mine

It’s understandable how people can lose their patience with someone viewed as insane. That’s one of the reasons some people are super quick to encourage the quick fix of psychiatric drugs. However, in another hit by the Rolling Stones, “Mother’s Little Helper,” Mick doesn’t seem too comfortable with this. The song’s lyrics deal with the popularity of prescribed drugs and the potential hazards of overdose or addiction. The early part of the song tells us,

What a drag it is getting old,

“Kids are different today”
I hear every mother say
Mother needs something today
To calm her down
And though she’s not really ill
There’s a little yellow pill

She goes running for the shelter
Of her mother’s little helper
And it helps her on her way
Gets her through her busy day

We are indeed getting older, and having anxiety about this is a common useful experience, not an illness. Anxiety, when handled skillfully, motivates us to come to mature understandings about how we can live a life worth living (see HERE for a fuller understanding regarding the nature of anxiety). But when a mother goes to a doctor and expresses concerns about her anxiety, there’s an excellent chance she will have her expressed concerns translated into mental disorder language and she will leave the office with a drug prescription. That’s how the doctors make their money. How does this sit with Mick?

“Things are different today”
I hear every mother say
Cooking fresh food for her husband’s just a drag
So she buys an instant cake
And she burns a frozen steak

And goes running for the shelter
Of her mother’s little helper
And two help her on her way
Get her through her busy day

“Doctor, please
Some more of these”
Outside the door
She took four more
What a drag it is getting old

Life has its periods of frustration. If you were brought up in a home where feeling down was viewed as something is wrong with you, it’s easy to move from that view to pathologizing such experiences. The pharmaceutical industry promotes this way of thinking with ads that depict someone feeling down, and then, following a prescription for a pill, the sun is now shining, and everyone is all smiles. There is a serious downside that comes with this approach, as the song’s next lines begin to bring into focus.

“Men just aren’t the same today”
I hear every mother say
“They just don’t appreciate that you get tired”
They’re so hard to satisfy
You can tranquilize your mind

So go running for the shelter
Of a mother’s little helper
And four help you through the night
Help to minimize your plight

“Doctor, please
Some more of these”
Outside the door
She took four more
What a drag it is getting old

Notice that two pills are no longer sufficient for these mothers. The process of addiction is underway. In the scientific literature, this process is called “down regulation” or “tolerance.” To understand this process, let’s take the example of tobacco smokers. We see evidence of tolerance to tobacco in studies that indicate fewer responses than do non-smokers to the same amount of nicotine (Perkins et al. 2001b). More specifically, we see a reduction on measures of subjective stimulation that may be viewed as pleasurable, such as arousal, vigor, and a subjective experience often referred to as “head rush” or “buzz.”

The relief that smokers feel each time they give themselves another dose of nicotine creates the powerful illusion that cigarettes help them to deal with stress. Thus, 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. Moreover, adolescent smokers report increasing levels of stress as they develop regular patterns of smoking. For those who quit the smoking habit their stress levels are reduced. Far from acting as an aid for mood control, nicotine dependency exacerbates stress. This is confirmed in the daily mood patterns described by smokers, with above average levels of stress 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 occurring between nonsmoking intervals.

drug withdrwal 1 This is largely the reason why people become addicted to other substances, such as alcohol, caffeine, illegal drugs, and the drugs that psychiatrists prescribe. They all have the potential of creating for addicted people the illusion that they are functioning better than they did before they started consuming the addictive drug. During the interval when they do not take the drug they begin to experience an uncomfortable withdrawal reaction. They don’t attribute the discomfort to a withdrawal reaction, but instead, to falsely believing it is due to the return of how they would feel if they had never taken the drug.

Another part of the addiction process is that the addictive substance often is used as part of a ceremony creating a very pleasant experience. Here’s what that process is like.

Many people, when they have more than a small dose of the drug, they begin to feel sick. This keeps their intake of the drug at moderate levels. Even at these moderate levels, regular consuming of the drug tends to increase moderately the risk of negative health consequences. Nevertheless, once tolerance has been established the relief that comes from the easing of the negative withdrawal effects each time they take the drug is perceived as pleasant. Moreover, there is pleasantness from the rest of the ceremony that often involves marking the end of the work day, putting on music they love, and joining together with friends in a pleasant shared experience. In this way, people end up feeling the resulting pleasant feelings that come with this combination–the easing of the drug withdrawal process and the ceremony– is worth the minor risk of negative health consequences from the moderate use of the drug or drugs.

Although this can be an acceptable decision for many, for others, hoping they can remain moderate users of one or more of these types of drugs is disastrous, which is brought out in the last few lines of “Mother’s Little Helper.”

“Life’s just much too hard today”
I hear every mother say
The pursuit of happiness
Just seems a bore
And if you take more of those
You will get an overdose

No more running for the shelter
Of a mother’s little helper
They just helped you on your way
Through your busy, dying day

Although Mick is singing about the kinds of pills being prescribed by doctors, within the crowd of musicians he hung out with, he was witnessing some awful consequences of addiction to street drugs.

There are a variety of skillful ways to deal in a healthy manner with anxiety and its sister experiences, depression and melancholy. There are ways to make friends with these experiences.

Meditating once or twice a day provides an opportunity to spend time addressing concerns with little distractions. Although as we enter into meditation, we don’t do so with the intent to address concerns, they naturally bubble up from the relatively peaceful state, and our minds spend time working through our various concerns in a natural healthy manner before we become overwhelmed. Taking a walk, particularly in a place filled with nature, journal writing about concerns, and speaking to a counselor are other healthy examples.

Well, there you have it, some of my thoughts for this week provoked by two wonderful songs of The Rolling Stones.

My Best,
Jeff

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

Tags Anxiety, Insanity, mental health, Psychiatric Drugs, The Rolling Stone

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

My 2016 APA Speech On Psychiatric Diagnoses

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

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

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

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

My 2016 APA Speech

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

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

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

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

Chapter 1: The CSM Basics

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

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

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

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

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

Chapter 2: Classification of Mental Health Concerns and Codes

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

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

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

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

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

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

Chapter 3: The CSM Approach to Psychological Formulation

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

Defending the CSM

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

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

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

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

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

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

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

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

Conclusion

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

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

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

My APA Speech On An Alternative to Psychiatric Jargon

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

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

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

My Speech

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

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

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

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

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

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

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

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

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

Chapter 1

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

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

After this statement, the CSM would clearly define its main construct:

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

So, those are the basic ingredients of Chapter 1.

Chapter 2

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

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

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

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

Moving on to Chapter 3

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

Defending the CSM

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

When I was doing my practicum at the University of Minnesota’s Counseling Center, I worked there for a whole year and we had no need to use the “mental disorder” jargon of the DSM to communicate. When my advisor asked me to quickly tell him about my morning cases, I would reply with words like, “My 9:00 a.m. case is concerned about feeling depressed, my 10:00 case is concerned about his failing grades, my 11:00 case is concerned about how anxious she is in social situations. If my advisor wanted to know more about a case, we went into the psychological formulation type of information. Communication flowed easily. This is how the CSM would work in practice.

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

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

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

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

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

Conclusion

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

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

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

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

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

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

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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

Bad Mood conflict resolution fear mental disorders Mental Illness psychiatry psychological maturity psychopathology William James wisdom

William James’s Personal Bout with a “Mental Disorder”

Post author By Dr. Jeffrey Rubin
Post date March 8, 2015
5 Comments on William James’s Personal Bout with a “Mental Disorder”

William James, psychologist and philosopher, passed away over a century ago. Nevertheless, his remarkable body of work remains as fresh as fruit plucked from its tree but moments ago.

His views about his personal bout with a challenging experience developed over many years. Today I think it will be instructive if we spent a little time reviewing what he learned.

A Glimpse at James’s Early Views on Mental Disorders

We begin in April of 1867. James is 25-years old. Suddenly, he interrupts his medical education and flees to Europe.

Later, on describing the feelings that led to his departure, James wrote “it was as if something hitherto solid within my breast gave way entirely, and I became a mass of quivering fear. . . . I awoke morning after morning with a horrible dread in the pit of my stomach.”

William and Henry James's Father, with Young Henry on the right — William and Henry James’s Father, with Young Henry on the right

Several years went by and then, gradually, James’s spirits lifted. His father, noticing the difference in him, asked about it, and then relayed the news by letter to another son, Henry, in March, 1873:

He came in here the other afternoon when I was sitting alone, and after walking the floor in an animated way for a moment, exclaimed “Dear me! What a difference there is between me now and me last spring this time: then so hypochondriacal” (he used that word, though perhaps in substantive form) “and now feeling my mind so cleared up and restored to sanity. It is the difference between life and death.” He had a great effusion. I was afraid of interfering with it, or possibly checking it, but I ventured to ask what especially in his opinion had promoted the change. He said several things: the reading of Renouvier (specially his vindication of the freedom of the will) and Wordsworth, whom he has been feeding on now for a good while; but especially his having given up the notion that all mental disorder is required to have a physical basis. This had become perfectly untrue to him. He saw that the mind did act irrespectively of material coercion, and could be dealt with therefore at first-hand, and this was health to his bones.

We see in the above that at this time James viewed his experience that led to his departure from medical school as a “mental disorder.” Moreover, his conceptualization of it had begun to develop from a physiological pathology model to one that gives at least some freedom to the will. In time, his views begin to develop even further.

Letter to Henry James, 1885

The two brothers. Henry is on the left and Professor William James is on the right

William James and his younger brother, Henry, shared an especially close fraternal bond. Historians have greatly benefited from this because the letters that the two brilliant men shared reveal insights about their deepest concerns.

In 1885, now a medical school graduate and teacher at Harvard, James writes to Henry:

To suggest personal will and effort to one “all sicklied o’er” with the sense of weakness, of helpless failure, and of fear, is to suggest the most horrible of things to him. What he craves is to be consoled in his very impotence, to feel the Powers of the Universe recognize and secure him, all passive and failing as he is.

In James’s letter to his brother, we see he has discovered that in marked contrast to his own favorable reaction to suggestions about the effectiveness of will and effort, some people react with horror. Such people view themselves as helpless, weak, passive, and failing. Rather than looking to a creative force within themselves, they look for the Powers of the Universe to fix them.

The Mature James

Toward the end of James’s career, he adds a new way of viewing the types of concerns that affected him so profoundly when he was young. We begin to see this new way when James discusses individuals who view themselves as “healthy-minded.” These individuals believe that those who worry are “morbid-minded” and “diseased.”

James responds to this name calling by stating that those referred to as morbid-minded have argued that “the world’s meaning most comes home to us when we lay them most to heart.”

After describing the argument between the so-called “healthy-minded” and the “morbid-minded,” James then states:

In our attitude, not yet abandoned, of impartial onlookers, what are we to say of this quarrel? It seems to me that we are bound to say that morbid-mindedness ranges over the wider scale of experience, and that its survey is the one that overlaps. The method of averting one’s attention from evil, and living in the light of good is splendid as long as it will work. It will work with many persons; it will work far more generally than most of us are ready to suppose; and within the sphere of its successful operation there is nothing to be said against it as a religious solution. But it breaks down importantly as soon as melancholy comes; and even though one be quite free from melancholy one’s self, there is no doubt that healthy-mindedness is inadequate as a philosophical doctrine, because the evil facts which it refuses positively to account for are a genuine portion of reality; and may after all be the best key to life’s significance, and possibly the only openers of our eyes to the deepest levels of truth.

To James, people confront events daily that create feelings of helplessness, pain, sadness, horror, and dread. James argued that the feelings that go along with these kinds of events can lead toward truth. Thus, he counteracts any tendency to assume that those referred to as morbid-minded are automatically inferior to those referred to as “mentally healthy.”

The Development of James’s Views About Mental Health Concerns

And so, starting from James’s own bout with a challenging experience, we see that his views develop over the years. Initially, mental health concerns are “mental disorders” which require a physical basis. He then changes his mind, coming to believe these experiences are not completely controlled by one’s physiology, and therefore they could be dealt with through philosophical and poetic means.

It then occurs to him that in contrast to the benefits that his new perspective had for him, others prefer, even crave, to believe they are helpless in the face of these types of experiences. Finally, James comes to believe that some people can derive benefits from the kinds of challenging experiences that, to many, are properly viewed as symptoms of a diseased mind.

Like James, I have undergone a similar developmental trajectory. As I have dealt with my own challenging experiences, I have, over a good many years, learned to greet them as old friends who have valuable messages to share with me. Sometimes they stay a little longer than I would like, and I may find it frustrating that they don’t always come right out and tell me what these messages are. But my patience, through meditation and the maturity that sometimes comes in the course of passing years, has been steadily improving.

Well, I hope this discussion has deepened the reader’s views of the nature of experiences that lead to people expressing concerns to mental health professionals. Until next time, may all of your concerns be addressed with wisdom, love, and kindness.

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Tags challenge, Henry James, mental disorders, mental health, name calling, William James, wisdom

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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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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

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Psychiatric Name Calling: Is Science to Blame?

Post author By Dr. Jeffrey Rubin
Post date September 22, 2014
14 Comments on Psychiatric Name Calling: Is Science to Blame?

A couple of weeks ago I raised the question, “Name Calling by Psychiatrists: Is it Time to Put a Stop to it?” In response, some blamed the insurance companies and other third party payers for the name calling. Because it is true that these payers do require the pathologizing of people seeking mental health services, in last week’s article, I took a close look at that issue.

Others responding to my question argued that diagnosing mental illness is based on the principles of science. So, let’s look at this line of thought.

The Nature of Science

Science enquires what is the nature of something? what is its constitution, origin, and history? Human beings also make enquires of a different sort, What is the object’s importance, meaning, significance, or value now that it is once here? Neither judgment can be deduced immediately from the other. They proceed from diverse intellectual preoccupations, and the mind combines them only by making them first separately and then adding them together.

As Steven Jay Gould, professor of zoology and geology at Harvard University, explains it:

“The net of science covers the empirical realm: what is the universe made of (fact) and why does it work this way (theory). The net of religion extends over questions of moral meaning and value. These two magisteria do not overlap, nor do they encompass all inquiry (consider, for starters, the magisterium of art and the meaning of beauty). To cite the usual clichés, we get the age of rocks, and religion retains the rock of ages; we study how the heavens go, and they determine how to go to heaven.”

In the natural sciences there is a branch called pathology that classifies tumors, lesions, bone fractures, tissue tears, toxic reaction to a chemical, blockage of blood flow within the circulation system, blockage within or to an organ, and microbe infections. Pathologists have reliable ways of identifying and categorizing these naturally occurring entities. When we take a science view of each of these entities of interest to pathologists, it is not a value judgment if they exist or not. If ten pathologists look at a tumor, they can all see it, describe its color, density, weight and what each of the tumor’s cells look like under a microscope.

Pathologists, as scientists, have been studying these entities and sometimes they found that some of them are associated with certain physical complaints. For example, some people complain about headaches and vision problems. When they died, autopsies were carried out and often a tumor was present that was pressing against the optic nerve.

This finding led to a theory that for people who expressed this type of physical complaint, if an operation was carried out while the patients were still alive and this type of tumor was indeed pressing on the optic nerve, perhaps removing it would alleviate the complaint. Studies were carried out and it led eventually to a valued treatment.

The connections between the research findings of pathologists gave doctors some understanding of what was causing some of the physical complaints of their patients. But often doctors could not find evidence that any of the entities of interest to pathologists were the cause of the complaint. When this occurred, most doctors merely changed the expressed complaint into some medical jargon that sounded somewhat like those concerns that had been shown to be due to a pathological condition. In such cases, they offered some treatment that was often based more on the commercial art of medicine rather than science.

These doctors usually called both types of physical complaints (those with pathological findings and those without) “illnesses” or “disorders.” By doing so, the science of medicine and the art of medicine became blurred. And then, business interests became wrapped up in the various treatment options and principles of science began to become more and more murky when applied to the medical world.

Disorders and Psychiatry

In a book titled Psychiatric Persuasion by Elizabeth Lunbeck, there is considerable documentation that back at the turn of the 20th century when the main job of psychiatrists was running insane asylums their professional organization decided to expand their market by doing two things. 1. Persuade the public that more and more normal behaviors are pathologies that require psychiatric treatment, and 2. Develop a category system that converts all psychological concerns that a person might want to get help for into a language that sounds like a pathological condition. This would legitimize the treatment of anyone who came to their office, thus the argument that the current psychiatric “diagnosis” system has become a business tool while being promoted as science.

Now, it is certainly possible to create a categorical system consistent with science for the problems that come to the attention of psychiatrists and other mental health service providers that don’t confuse conditions that are associated with pathological findings and those that are not. Such a system would classify “mental health concerns,” rather than calling people names. A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern about any of the following topics: behavior, emotion, mood, meaning of life, managing chronic pain, work, relationships, education, eating, cognition and sleep. Two classes of mental health concerns are concerns expressed about oneself and concerns expressed about someone else.

One benefit of classifying “mental health concerns” rather than “mental disorders” has to do with inter-rater reliability. Consider being in a room with 100 psychologists, or even 100 average Joes and Jills, and a person in front of the room says she has been feeling depressed. A questioner asks the client, “Are you concerned about feeling depressed?” and the person says, “Yes.” If you asked for a survey of how many people in the room thinks the person has expressed a concern about being depressed, you would get, I believe, 100 percent agreement. Expressing a mental health concern is a specific action that people do, and therefore it is clearly observable.

Research on the inter-rater reliability of the mental disorders classification system has demonstrated that its inter-rater reliability is very problematic.

Science is Not to Blame

It is not science that is to blame for psychiatric name calling; it is the psychiatric business tool that is cleverly designed to capitalize on the public’s respect for science.

When we begin to use a classification system that does not clearly separate principles of science from values involved in business interests, other values start to slip into the classification process as well. Early on when the pathologizing of human experience was just getting underway, William James made a number of relevant comments about this.

James argued that experiences that are commonly viewed as unhealthy or morbid are really “an essential part of every character” and give life “a truer sense of values.” To support his contention, James first provided three examples of famous individuals who expressed concerns about melancholy. Such experiences today, if expressed to a psychiatrist, would probably be converted into a so-called “diagnosis” of “major depressive disorder.” St. Paul, the religious figure of the New Testament, Cesare Lombrosa, a late 19th-century Italian criminologist, and Immanual Kant, the 18th-century German philosopher, became, according to their biographies, better as a result of their troubling experiences.

Although hallucinations can mean madness to some, James presented the case of Socrates who “once stood motionless for many hours in the cold and spoke of having a guiding demon.” Attempting to counter the association between pathologies and hallucinations, James stated, “Even if this demon [of Socrates] were really meant hallucinations of hearing, we know now that one in eight or ten of the population has had such an experience and that for insanity we must resort to other tests than these.”

James stated that there is no end to the possible types of obsessions that we see all around us. What benefit can such experiences have? James wrote about Henry Borg, founder of the American Society for the Prevention of Cruelty to Animals in 1866; Charles Henry Parkhurst, a Presbyterian clergyman and reformer who held a New York City pastorate from 1880 to 1918 and who launched a furious attack on organized crime in state government that led to an official investigation; Dorothea Dix, a mid-19th-century humanitarian who visited the insane asylums and successfully advocated for legislation to improve the care for those labeled mentally ill.

Later, James stated, “Individuals are types of themselves and enslavement to conventional names and their associations is only too apt to blind the student to the facts before him.”

James concluded that,

“Any peculiarity that is of use to a man is a point of soundness in him, and what makes a man sound for one function may make him unsound for another. Moreover we are all instruments for social use, and if sensibilities, obsessions and other… peculiarities can so combine with the rest of our constitution as to make us the more useful to our kind, why, then, we should not call them in that context points of unhealthiness, but rather the reverse . . . The trouble is that such writers [pathologizers]. . . use the descriptive names of symptoms merely as an artifice for giving objective authority to their personal dislikes. The medical terms become mere appreciative clubs to knock a man down with. . . . The only sort of being, in fact, who can remain as the typical normal man, after all the individuals with degenerative symptoms have been rejected, must be a perfect nullity… Who shall absolutely say that the morbid has no revelations about the meaning of life? That the healthy minded view so-called is all?”

To illustrate what James means here, consider an article in the American Journal of Psychiatry (May, 2004), titled “Virginia Woolf (1882-1941).” Although she is described by psychiatrists as having bipolar disorder, her diaries and letters, document movingly, her emotional extremes and her capacity to savor the “ordinary rhythms of life.” At times Woolf railed against her distressing emotional experiences, felt frustrated and impeded by them, and at other times she felt it was essential to her. In diaries and letters, she returned to the question repeatedly without reaching a resolution: were her emotional experiences a terrible obstacle to her art, or were they the necessary condition for it?

For those trying to sell psychiatric drugs, a simplistic answer to this question is eagerly promoted. Science has not provided a definitive answer to this question as far as I am concerned, and throwing around phrases such as “the brain is malfunctioning in depression,” or “the brain has a chemical imbalance in depression” goes way beyond the available evidence.

Psychiatric labels are like masks held on by rubberband straps. They hide some of the characteristics of an individual. Wearing such masks may serve some purposes, but after a while they start to get uncomfortable for many, particularly around the ears. Let those who want to wear these masks be free to do so. But let those who want to meet us face to face, also be free to do so.

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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 disrespectful, DSM, free social intelligence and emotional intelligence curriculum, insults, mental disorders, mental health, mental health concerns, mental health services, mental illness, name calling, psychiatry, science, Steven Jay Gould, William James

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Psychiatric Name Calling: Are the Insurance Companies to Blame?

Post author By Dr. Jeffrey Rubin
Post date September 16, 2014
5 Comments on Psychiatric Name Calling: Are the Insurance Companies to Blame?

Last week, I posted an article titled “Name Calling by Psychiatrists: Is it Time to Put a Stop to it?” It created quite a stir and it’s currently challenging my two previous most popular posts—“Teaching Children How to to Deal with Criticism” and “Is it Wise to be Assertive?”—for the number one spot.

The article points out that by using the term “diagnosis” in psychiatric terminology it misleads people in a variety of ways. For example, when psychiatrists provide their patients a so-called diagnosis many people believe there is now a valid explanation for why they are struggling with their personal difficulties. Instead, all that has really happened is that the psychiatrist has converted the expressed concern of the patient into pathologizing language.

The manual that psychiatrists use when deciding which words to use when converting concerns to “diagnoses” is called The Diagnostic and Statistical Manual of Mental Disorders (DSM). Of course as this manual was developed there was a huge financial interest to utilize language that encourages the perception that an expressed concern is a very, very serious life-long condition that requires medical treatment for a lifetime. Consequently, when patients express a concern about being depressed, the psychiatrist informs them that they have “major depressive disorder,” and often couple this with statements such as, “This is a serious lifetime condition that must be managed for a lifetime.” Any language that suggests that there is substantial evidence that most people recover even without treatment runs counter to the psychiatric business plan.

Among the many comments that I received about the name calling article are those that point out that most of the doctors who are using the psychiatric terminology provided in the DSM are not psychiatrists. Pediatricians, general practitioners, internists, psychologists, and neurologists daily call people these names. Other comments present the argument that it is the pharmaceutical companies that promote the pathologizing of human concerns in order to convince people to ingest their drugs.

I’ll be exploring these issues in coming weeks. But today, let’s focus in on the argument that the real group of people at fault for this type of name-calling is the third party payers such as insurance companies, Medicaid, Medicare, and Social Security. After all, by far, the DSM terms are used most by these types of entities.

The DSM and Third Party Payers

Most people in the United States who seek mental health services don’t directly pay for them. Instead, they have insurance policies that cover some, or all, of the fees; or they qualify for Medicaid, Medicare, or Social Security benefits. Insurance companies and these other agencies are called third party payers.

Third party payers currently have a form that must be filled out whenever someone seeks mental health services under their plan. That form has boxes for the name of the person seeking services, his or her contact information, policy number, some information about who is being asked to provide services, and then, imbedded in all of this, is a little box that currently says, “Diagnosis.” In that box, mental health professionals must fill in the DSM code that corresponds to their “diagnosis” of the person seeking services.

Third party payers initially developed their form for people who were seeking medical services for physical complaints. Physicians would fill in the diagnosis box with a code that corresponded to a list of diagnoses in their pathology manuals based on a visual inspection of a tissue tear, the results of x-rays, blood test, or a pathologist examining a tissue sample of a tumor under a microscope. Sometimes it was based on a report from a toxicologist because it was theorized that the patient had been exposed to some toxic substance. In each of these cases, the diagnosis that was provided actually did provide some understanding for why patients were struggling with their expressed physical complaints.

However, I hasten to point out that in many cases physicians were unable to uncover the reason for the physical complaint. At such times they often did pretty much what psychiatrists do today—they converted the physical complaint into medical jargon, typically using Latin derived syllables, and then stuck them into the third party payer’s “diagnosis” box on the third party payer forms, prescribed some treatment, and low and behold, third party payers paid the doctors just like they did when a real diagnosis was provided.

A physician once confided in me that for the majority of his cases he was unable to identify the reason for the physical complaint but he nevertheless provided some diagnosis and a prescription for a pill. “If I didn’t,” he said, “my patients would feel that they wasted their money by coming to see me.” I then asked him how he felt about misleading his patients in this way. “Well,” he replied, “if my patients feel that I have made a real diagnosis and prescribed some pills, they feel a sense of being reassured and the pills can have a placebo effect which may be very curative in its own way.”

“The pills that you prescribe,” I replied, “are not simply substances with no physical effects beside the placebo effect, they have a number of real serious side effects associated with their use. Is that really ethical?”

“Well, the physical side effects often help the placebo effect because the patient feels something is really physically happening. It is part of what reassures them that what was prescribed has a powerful effect. When weighing the risk of serious side effects versus the minor side effects that can be helpful, I make my decisions on what to prescribe.”

And so, that’s a little of my understanding of the reasoning behind this type of misleading name-calling and prescribing practices of physicians dealing with physical complaints. I prefer honesty. However, for those who prefer this fatherly treatment that is mixed with huge financial interests, I’m advocating that they continue to get what they want.

Now, once third party payers began to provide coverage for mental health services, their administrative forms didn’t have to be changed. There was already a precedent for placing in the “diagnosis” box on the form fake diagnoses, and psychiatrists seeing that this business model was a source of a great deal of money created the DSM.

What would be a Reasonable Alternative to the DSM?

For those who prefer to be treated honestly, can an alternative to the DSM be developed?

The alternative I’ve been working on is called The Classification and Statistical Manual of Mental Health Concerns, or, for short, the CSM. With this approach, no individuals would be classified, only their expressed concerns.

With the CSM proposal, all that we would be asking insurance companies to do differently in order to add value to their customers, is to slightly change that little box that currently requires a diagnosis or a word pretending to be a diagnosis. Instead of just saying “Diagnosis” as it currently says, that box would just 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.

The cost and efforts for insurance companies would be minimal, and we would have numerous testimonials from customers that documents that this change would be viewed as a significant improvement.

Now, some of the insurance company executives might pause and say, “Wait a minute. You’re asking us to permit the use of the CSM as an alternative to the DSM. Just wait a minute. The DSM has been developed by mental health experts and is backed by a major mental health professional organization—the American Psychiatric Association. Does the CSM have that type of authority to back it up?”

If we prepared for this, we will be able to answer that the CSM was also developed by mental health experts and does have several mental health professional organizations backing up its use as an alternative to the DSM. I believe this can be achieved. We have in our alternatives group several people who would qualify as mental health experts, and I think we can get some more involved as well. And when the latest edition of the DSM was released several professional organizations expressed a strong desire that an alternative to the DSM be developed. I think it’s reasonable to assume that at least some of them would agree to back this alternative, especially if we involve them in its development.

In short, the creation of the CSM would permit us to present to insurance company executives and other third party payer administrators a real alternative to the DSM. It would be virtually cost free for them to permit its use, it would have the authority of being developed by experts in the mental health field, the backing of mental health professional organizations, and it adds value for a significant number of their customers.

The CSM Would also Help Mental Health Service Providers

Now, besides the insurance companies and other third party payers, the other big group of people in America that is currently using the DSM is mental health services providers. How would they react to being given the choice to replace the DSM code with the CSM code on third party payer forms when they felt in their professional judgment that it was appropriate? Well, we get a little sense of what their reaction would be from a survey Paula Caplan tells us about in her book, They Say You’re Crazy. According to this survey, over 70 percent of those practitioners who responded to the survey said that the only way they use the DSM is to fill out the insurance form. Other than that, it doesn’t help them at all.

To those who believe that the use of the current DSM terminology helps to enhance the placebo effect of treatment, keep in mind that this is a testable theory. We can arrange for studies that compare the outcomes of service providers that utilize the DSM coding system with service providers that employ the CSM coding system. But that would be an approach that employs basic principles of science, rather than unsupported claims backed by enormous financial interests.

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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 disrespectful, DSM, insults, insurance companies, mental disorders, mental health, mental health services, mental illness, name calling, psychiatric disorders, psychiatry