Welcome to From Insults to Respect.
From time to time I have written about the growing lack of respect for the current manner in which people seeking to obtain mental health services are treated. Particularly upsetting to many is the requirement that they be labeled as having a mental disorder.
This labeling process relies on descriptions provided in the Diagnostic and Statistical Manual of Mental Disorders–Fifth edition (DSM) and the International Classification of Diseases–Tenth edition (ICD). Both are manuals that are conceptually similar, utilizing as their core concept, mental disorders, and both share the same “diagnostic” codes. Because of their similarities, I will simply refer to them as the DSM/ICD approach.
Many professionals defending the use of this approach explain that it provides a common language for mental health professionals to communicate about those utilizing their services; its various classification terms, such as major depressive disorder, anxiety disorder, and so on, are short phrases that are convenient for placing into titles and search engines, and for efficient/streamlined communication in high-speed hospitals and clinics; third-party payers of mental health services have found that their coding system works well as part of a practical method for their record keeping; with the aid of these codes, people manage to access mental health services, mental health service providers manage to get paid, and for-profit health companies tend to make a profit.
Unfortunately, there are a number of serious weaknesses with this approach. 
It tends to be stigmatizing to mental health service users. The lack of reliability and validity of the various so called diagnoses violate basic principles of science. The process of coming up with a psychiatric label privileges the clinician’s perspective over that of the mental health service user. It ignores the fact that many people who have been labeled with these stigmatizing psychiatric terms come to realize that the experiences which led to their seeking services, rather than being an indication of a pathological condition, are really an essential element to their creative development. Many have also expressed concerns about the “mental illness” terminology which medicalizes mental health concerns, thus leading to an incredible number of people being prescribed psychiatric drugs, the use of which leads to numerous serious side effects.
Just as I was writing this post, major news outlets began to report that researchers found nearly a 50% increased odds of dementia for those taking the most popular drugs for treating depression and other mental health concerns. Although the study could not prove conclusively that these drugs caused the increased risk of developing dementia, because these same drugs had already been linked to confusion or memory issues, the new evidence is deeply troubling. The researchers expressed concerns that if this association is causal, it “would equate, for example, to around 20,000 of the 209,600 new cases of dementia per year in the United Kingdom.” With the population of the US being 6 times larger, this could mean that over 100,000 cases of dementia may be attributed to these drugs every year here in my own country.
Adding fuel to these types of concerns about negative effects of ingesting these drugs are the recent findings indicating that despite the fact that more Americans than ever are being prescribed so called antidepressants, the rate of suicide has climbed to an all-time high. Is the increased use of antidepressants causing this increased rate of suicide? Although definitive evidence is not yet available, it is a well known research finding that these drugs do increase the risk of suicidal thinking in many patients.
Meanwhile, the DSM/ICD approach has created a monolithically wealthy pharmaceutical industry, with all of the drawbacks associated with such institutions.
Given these problems, an international effort has been seeking to come up with some reasonable alternative that could provide all of the perceived practical benefits of the DSM/ICD approach, while having significantly fewer shortcomings. 
As part of this effort, I have come up with one alternative proposal which I discuss most extensively in a peer reviewed article published in a 2018 volume of the Journal of Humanistic Psychology (see HERE). Today, I shall summarize my approach, and then we’ll look at some of the published discussions on this topic that have come out after my article first appeared.
A Summary of My Approach
My proposed alternative to the DSM/ICD approach calls for the development of The Classification and Statistical Manual of Mental Health Concerns (CSM). In contrast to the DSM/ICD approach’s overarching concept of “mental disorders,” the CSM’s overarching concept is “mental health concerns.”
The CSM approach begins with a full recognition that individuality outruns any classification system. It is for this reason that the CSM does not classify anyone. Instead, it classifies the expressed concerns of individuals seeking to have their concerns addressed by a mental health service provider. A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern about any of these topics: behavior, emotion, mood, meaning of life, death, dying, managing chronic pain, addiction, work, relationships, education, eating, cognition, sleep, and challenging life situations.
Classifying the expressed concern would provide mental health service providers a common language that is helpful when communicating among other professionals. So, a professional might say to a colleague something like, “My 9:00 a.m. case is concerned about feeling depressed, my 10:00 case is concerned about his failing grades, my 11:00 case is concerned about how anxious she is in social situations.” Such communications are straightforward and easy to understand, not only for professionals, but for the general public as well.
Each expressed concern listed in the CSM would be a sufficiently short phrase so that it can be conveniently used in titles and search engines to retrieve valued relevant information. Along with each classified expressed concern, there would be a numerical code that would be convenient for third-party payer bureaucratic record keeping.
The CSM, in addition to coming up with a brief label for the expressed concern and a code for third party payers, describes a collaborative approach between the person expressing the concern and the mental health service provider for creating a psychological formulation narrative of a few paragraphs that eschews the DSM/ICD pathologizing jargon. 
This process involves a mental health service user and a mental health service provider co-constructing a hypothesis or “best guess” about the origins of the mental health service user’s concerns in the context of his or her relationships, social circumstances, cultural heritage, life events, and the sense that he or she has made of them. Once it has been established what the concerns are, the immediate next question is, “How do we jointly understand these experiences, why they arose, and how we might be able to address them?” This formulation is not something that is shared with third party payers of mental health services, but is utilized exclusively by the mental health service user and service provider.
With the CSM approach, no one is viewed as mentally ill, having a mental disorder, or having some psychopathological condition. Instead, it highlights that the progress of society is due to the fact that individuals naturally vary from the human average in all sorts of directions, that the originality is often useful, while, at the same time, being different can create a variety of concerns. Moreover, some people become concerned about how they are handling enormously stressful and traumatic experiences. Still others are living in unhealthy ways, such as making unhealthy choices in what they consume, or getting insufficient exercise. Mental health professionals, with the CSM approach, are viewed as seeking to address these types of concerns that arise from these conditions in a supportive setting while relying on a variety of wisdom traditions. Central to this approach, is an honoring of what Ralph Waldo Emerson referred to as the grand sweep of humanity.
Compared with the DSM/ICD approach, the use of the CSM would be less stigmatizing, more respectful to those seeking services, and more practical because of the ease of understanding the words and phrases that it utilizes. Moreover, it would be more consistent with principles of science because instead of using as its core concept the vaguely defined “mental disorders,” the CSM uses as its core concept “mental health concerns,” which is a clearly recognized event that occurs at a specific time and place. Finally, the CSM approach would provide a new choice to both mental health service users and providers, challenge old ideas, stimulate fresh perspectives, and open new avenues of research.
The Latest Discussions
Since my article on the CSM was published, the Journal of Humanistic Psychology (JHP), in its May 2019 issue, has several articles that discuss my approach as well as a few others. Let’s take a look at some of what was said, and as we do so, I’ll share a few thoughts about my reaction.
In an article titled, “What Might an Alternative to the DSM Suitable for Psychotherapists Look Like?” Jonathan D. Raskin notes that recent surveys of psychologists and counselors indicate they are dissatisfied with the DSM/ICD approach and are interested in coming up with alternatives better suited to their professions. Nevertheless, more that 90% said they will use the DSM/ICD; after all, that is how they get paid by third party payers.
What would be a better alternative for psychotherapists and counselors than the DSM/ICD approach? According to Dr. Raskin, it would have to be a system that allows them to contextualize psychosocial and biological aspects of human suffering in a more nuanced manner. And then he writes,
“Jeffrey Rubin (2018) has proposed that we classify concerns that clients bring to therapy, not disorders they have. Identifying concerns is very different from identifying disorders. Concerns are things such as feeling anxious about one’s job, unhappy about one’s marriage, emotionally distraught about past abuse, or unable to move past what one witnessed while fighting in a war. The current diagnosis system encourages clinicians to translate these concerns–which are clearly contextual and not reducible to biology alone–into disorders that afflict people. But therapists and counselors do not actually treat disorders. Instead, they talk to people about their concerns–some of which are quite serious and lead to extremely challenging and intransigent difficulties.”
To Dr. Raskin, any alternative to the DSM/ICD approach must be a better fit with what therapists and counselors actually do. The CSM approach admirably achieves this.
In a commentary on Dr. Raskin’s article that appears in the same JHP issue, Rachel Cooper, a senior lecturer in philosophy at the United Kingdom’s University of Lancaster, and author of Diagnosing the Diagnostic and Statistical Manual of Mental Disorders, puts in some of her own thoughts on this topic.
She begins by agreeing with Dr. Raskin that most psychologists and counselors would be keen for an alternative classification to be developed. She then reviewed research indicating that social workers should be included among the professionals unhappy with having to use the DSM/ICD approach. In surveys, most indicated they would not use it if it was not required for insurance purposes.
Despite this finding, Dr. Cooper expresses pessimism about any alternative becoming accepted for funding psychotherapy via health care insurance. Among the factors that make it particularly challenging is the marketing of psychopharmaceuticals, which heavily promotes the idea that certain drugs treat the specific conditions listed in the DSM and ICD. The sum of money being acquired with this approach, she points out, makes producing a competitor classification far beyond the reach of most organizations.
She then refers to my CSM approach, stating that I suggest that insurance companies could be persuaded to pay for “Mental Health Concerns,” as they would readily come to understand, with a little explaining, that mental health service providers now using the current DSM/ICD approach do not turn anyone away who has mental health insurance coverage and comes to their office expressing what the CSM refers to as a mental health concern. She then writes,
“I think that Rubin’s optimism is misplaced. The fact that some (but by no means all) therapists currently get away with recording DSM diagnoses to facilitate payment even in cases where a diagnostic criteria may not be met will not be news to insurance companies. It is a practice that insurers have long known about and usually try to prevent. I think it unlikely that insurers would easily agree to cover Rubin’s ‘Mental Health Concerns.'”
First of all, when Dr. Cooper says insurance companies usually try to prevent mental health providers from recording diagnoses to facilitate payment even in cases where a diagnosis criteria is not met, I strongly disagree with her. I’ve never in my entire career heard of an insurance company questioning a diagnosis, and on what basis could they possibly do so? Insurance funders are not present in the room when a so called diagnosis is made. All that they get as documentation for a given diagnosis is a code indicating the diagnosis.
Moreover, the ICD actually encourages mental health professionals to come up with a diagnosis when criteria are not met. Thus, it states, “When the requirements are only partially fulfilled, it is nevertheless useful to record a diagnosis for most purposes” (WHO, 1992, p. 8).
I do agree, however, with Dr. Cooper when she says that getting the change that I have been advocating for is not going to be easy. Nevertheless, I believe we–professionals, service users, and service users’ relatives and neighbors–have a responsibility to try. Moreover, I have been encouraged by the steady increase in the influence of mental health service user advocacy groups who are becoming more and more vocal about the need for their members to be treated respectfully. And whenever I am invited to speak to professional organizations about the CSM approach, the rousing applause that I receive at the end of my presentation, along with the positive comments from audience members afterwards, keep my hope alive.
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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.
Your insurance company requires that I must place a diagnosis on your health insurance form for you to access that service. I hear, so far, that you are concerned about….”
“Well, I wish we didn’t have to get into this labelling issue. Personally, I think it’s best to treat each person that I provide counseling to as an individual. It is understandable that many people don’t want to be placed in a diagnosis box, especially one known to be stigmatizing. But the insurance companies do require a diagnosis.”
In my journal article, I go on to propose a practical, more scientific alternative to the DSM. I call this alternative, the Classification and Statistical Manual of Mental Health Concerns (CSM). The first words in the CSM would be: “The developers of the CSM fully recognize that individuality outruns any classification system. It is for this reason that the CSM does not seek to classify anyone. Instead, it classifies the expressed concerns of individuals seeking to have their concerns addressed by a mental health service provider.”
On the other hand, some resisted the CSM approach. As I began to question them, seeking to figure out where exactly the disconnect was, I discovered that for some, it had to do with their belief that the DSM is a classification system based on solid principles of science and nothing could possibly be better. As I questioned them further, I discovered that their understanding of what a scientific classification system is designed to do was a bit incomplete. So, in today’s post, I explain in an easy to understand manner the nature of scientific classification systems, beginning with a description of a classification system with which we are all so very familiar–birds. This will enable us to see clearly why the bird classification system is useful as a scientific instrument. We will then look at the DSM classification system in light of what we learned about the bird system, and this will reveal the DSM‘s serious scientific shortcomings. Finally, we will compare and contrast the DSM system with the proposed CSM system in a manner that can make the superior scientific merits of the latter crystal clear.
As it turns out, there are some people very interested in birds.
Once scientists carefully define their general topic of interest, they describe different types of what they are interested in. So in our bird example, the scientist interested in them came up with a taxonomy that lists bluejays, pigeon, sparrow, and so forth as subtypes of the general category of birds, describing each subtype in a precise manner that can reliably distinguish each from the others on their list. Why bother to do this?
The main reason is that when they discuss their findings with others, they want to make sure they are using words that mean the same thing, and it is a great time saver. For example, let’s say John is a bird scientist and he says to Judy, another scientist, “I saw a bird the other day and I didn’t know what type it was; can you help me figure out what it is?” Notice that since both of these scientists know the meaning of a bird, it saves John quite a few words. Just imagine if instead every time John uses the word bird he had to say, “I saw something that had an endothermic vertebrae, characterized by feathers, toothless beaked jaws, the laying of hard-shelled eggs, a high metabolic rate, a four-chambered heart, and a strong yet lightweight skeleton.” That’s quite a mouthful to have to say each and every time you refer to a bird. In this example, just saying bird saves a scientist about 30 words each time the word bird is used.
And let’s say John, the scientist, wants to find in a library some information about a particular type of bird. He would have to waste time looking at every single book in his library until he found one that seemed to be talking about what he was interested in.
This would result in John having to unnecessarily wade through numerous books on flying insects, of which there are hundreds of thousands of types, bats, and some fish that sort of can fly. With the current bird classification system, anyone can go to a library and quickly find the specific section that houses information on just birds. Similarly, placing the word “bird” in a search engine enables John to more quickly retrieve relevant information than would a less explicit definition.
“In the DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significant increase risk of suffering death, pain, disability, or an important loss of freedom.”
The latest edition of the DSM (DSM-5) is just as vague. It begins, “Although no definition can capture all aspects of all disorders in the range contained in the DSM-5, the following elements are required.” Although it says the following elements are required, it then makes it clear that the elements that it lists are not required. As I provide the rest of the definition, notice the use of the word “or” and “usually.”
“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognitive, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.” 
This is about as vague a descriptor as one can possibly conjure up. How about the descriptor “dysfunction?” This, too, is left to the subjective opinion of mental health providers who often have financial interests in declaring that someone has a mental disorder.
I, for one, am interested in a phenomenon that I, and others, call mental health concerns. Obviously there is wide interest in this. After all, there are numerous educational institutions that provide training to people so they can become credentialed to address mental health concerns. Numerous people actually voluntarily go to these educational institutions, devoting considerable time and expense. Once completing the credentialing requirements, they apply to their state credentialing board, pay a fee, and then after the board checks to see if all of its requirements have been fulfilled, it grants a license permitting the person to legally provide mental health services. That person then sets up a practice that offers mental health services. People wishing to access these services first devote some time to decide where to go. They then make an appointment, show up for the appointment, and then express their mental health concern to the mental health service provider. Aspects of all of this occur each and everyday and involves tens of thousands of people working in a coordinated fashion to have mental health concerns addressed in a professional manner.
This definition of a mental health concern requires all of the following items for a mental health concern to exist:
Also notice that no one doubts that each of the 4 listed items that, taken together, make up the mental health concern concept exists. Everyone agrees that there are people who seek mental health services in our society. Everyone agrees there are people licensed to provide mental health services. If you go further down the list, there is no question whatsoever, that these other conditions also exist. So the definition, I contend, meets the scientific standard that it describes the something of interest (mental health concern) in a clear and detailed manner, leaving no room for confusion or doubt. Once the CSM classification system comes to be fully developed, people would be able to use the term “mental health concern” as a short way to indicate a phenomenon that contains all four of its defining characteristics.
With regards to the various types of concerns that mental health service providers are asked to address by those seeking their services, two major types would be, 1. concerns expressed about oneself, and 2. concerns expressed about someone else. Under the headings of each of these two major types would be concerns regarding behavior, emotion, mood, meaning of life, death, dying, managing chronic pain, addiction, work, relationships, education, eating, cognition, sleep, hearing voices others don’t hear, and challenging life situations. This, of course, is just a preliminary list of types, and through survey data that ask psychologists and mental health advocacy groups about the various mental health concerns that they are asked to address, the list would become more fully developed.
The above explanation was designed to clarify just one of the reasons why the proposed CSM’s mental health concern concept provides a far more solid scientific foundation on which to build a classification system than the DSM‘s mental disorder concept. Despite the fact that many people have become convinced that the DSM‘s classification system is a sound scientific instrument, its definition is far more vague than how I propose defining a mental health concern.
Well, in thinking about this, I hasten to mention that Thomas Kuhn’s (1972) classic book, The Structure of Scientific Revolutions, rightly points out, for real change to occur in a branch of science, it is not enough to point out the weaknesses of a paradigm. There needs, as well, a new approach that is a distinct improvement over the old paradigm.
Welcome to “From Insults to Respect.” Regular readers know that I have some serious objections to how mental health service providers treat those seeking their services. As things stand now, unless you can afford to completely pay for such services without any insurance coverage, to access services you are very likely to be required to be labelled as having a mental disorder.
This blog seeks to empower its readers, many of whom are directly involved in the mental health arena or will become so in the future. Others are, or will become, involved indirectly because of someone they care about. Thus, it makes sense to spend some time learning how to effectively engage with mental health service providers.
One way to achieve this is to be aware of some of the arena’s major ethical challenges. Today, we will focus on four involving psychiatric diagnoses.
The American Psychiatric Association provides a definition of a “mental disorder” in its most recent version of the Diagnosis and Statistical Manual of Mental Disorders (DSM-5). Let’s take a look at it:
Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. (p.20) 
Notice how broad this definition is. It makes mention of a “disturbance” that reflects a “mental dysfunction in the individual.” We all run into some disturbances in our life. How can a professional reliably tell if the disturbance is due to a “mental dysfunction?” We are left in the dark about this. The process described in the DSM-5 for assessing the subjective notions of “clinical significance,” “disturbance” and “dysfunction in the individual” provides clinicians an opportunity to include anything that benefits their set of values.
If the social deviance or conflict results from a “dysfunction in the individual,” then a mental disorder exists in the individual. Once again we are left in the dark about how this distinction is made. It is left to the subjective judgment of the clinician.
An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.
Although he survives, he suffers the loss of a leg and an arm. Moreover, in the attack, two of his closest team members had burned to death in front of his eyes. This soldier seeks psychological help. He tells his story with tears running down his face and his one hand that he has left is shaking. He reports having nightmares and difficulty functioning in social situations. The clinician is well aware that such stressful experiences are fairly common under the set of circumstances faced by this soldier. And yet can anyone imagine the clinician denying services to this soldier because his response to the stressor is expected and culturally approved? If the clinician does agree to provide services, he or she would have to provide some mental disorder “diagnosis” on an intake form.
In my view, clinicians routinely ignore the “expected or socially approved” clause. It might have sounded like a good idea to insert into the mental disorder definition for those who developed the DSM-5, but I think few people genuinely believe that in practice clinicians are turning away paying customers when someone seeks help after having experienced the death of a loved one, or any other common stressor. To see such clients, clinicians are required in most mental health settings to assign a mental disorder “diagnosis.”
Most clinicians have a financial interest in deciding whether or not those seeking their services have a “clinically significant” condition. When they judge that their clients’ conditions are indeed significant, they indicate this on the third party intake forms by assigning a mental disorder “diagnosis” and this allows them to continue to see these clients and to get paid for additional visits.
Clinicians refer to mental health service users with “mental illness” and “mental disorder” terminology. These are the same terms that many people use as insults and the media regularly pairs with the most heinous crimes. The stigma associated with such terminology is well recognized. There would be some justifiable reasons to continue to use such terminology if it provided scientific precision to those who wish to communicate about those utilizing mental health services, but as we have seen, this is not the case.
The current psychiatric diagnoses approach focuses on the “dysfunctions” of individuals accessing mental health services rather than human strengths within a cultural context. Moreover, it seeks to legitimize the privileging of the “expert” who supposedly has access to the truth and who can see the truth of the truth. We see this reflected in the mental health arena when we find that it is the clinician that makes the so-called “diagnosis.” The expert is thus seen as always equipped with technical knowledge and jargons without which the truth of knowing would be imponderable. This perspective can paralyze the power of choices for mental health service users.
Although the CSM has not yet been fully developed, becoming familiar with its basic ideas are empowering. Combining these ideas with knowledge about the three psychiatric diagnoses ethical challenges–conflicts of interest, stigma, and violating the respect of mental health service users–can assist people to become far more effective in interacting with mental health service providers.
Third party payer systems have a form that must be filled out whenever someone seeks mental health services under their plan. This form has a little box that currently says, “Diagnosis.” In that box, mental health professionals are required to fill in the DSM code that corresponds to their so-called diagnosis of the person seeking services.
