This blog seeks to empower its readers, many of whom are directly involved in the mental health arena or will become so in the future. Others are, or will become, involved indirectly because of someone they care about. Thus, it makes sense to spend some time learning how to effectively engage with mental health service providers.

One way to achieve this is to be aware of some of the arena’s major ethical challenges. Today, we will focus on four involving psychiatric diagnoses.

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

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

The Vague Line

The American Psychiatric Association provides a definition of a “mental disorder” in its most recent version of the Diagnosis and Statistical Manual of Mental Disorders (DSM-5). Let’s take a look at it:

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

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognitive, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities.  An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.  Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. (p.20) 

Notice how broad this definition is. It makes mention of a “disturbance” that reflects a “mental dysfunction in the individual.” We all run into some disturbances in our life. How can a professional reliably tell if the disturbance is due to a “mental dysfunction?” We are left in the dark about this. The process described in the DSM-5 for assessing the subjective notions of “clinical significance,” “disturbance” and “dysfunction in the individual” provides clinicians an opportunity to include anything that benefits their set of values.

Certain socially deviant behavior and conflicts are not mental disorders, although they may be. If the social deviance or conflict results from a “dysfunction in the individual,” then a mental disorder exists in the individual. Once again we are left in the dark about how this distinction is made. It is left to the subjective judgment of the clinician.

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

An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.

Let us try to apply this sentence to the following situation. A soldier in combat has his vehicle blown up. Although he survives, he suffers the loss of a leg and an arm. Moreover, in the attack, two of his closest team members had burned to death in front of his eyes. This soldier seeks psychological help. He tells his story with tears running down his face and his one hand that he has left is shaking. He reports having nightmares and difficulty functioning in social situations. The clinician is well aware that such stressful experiences are fairly common under the set of circumstances faced by this soldier. And yet can anyone imagine the clinician denying services to this soldier because his response to the stressor is expected and culturally approved? If the clinician does agree to provide services, he or she would have to provide some mental disorder “diagnosis” on an intake form.

In my view, clinicians routinely ignore the “expected or socially approved” clause. It might have sounded like a good idea to insert into the mental disorder definition for those who developed the DSM-5, but I think few people genuinely believe that in practice clinicians are turning away paying customers when someone seeks help after having experienced the death of a loved one, or any other common stressor. To see such clients, clinicians are required in most mental health settings to assign a mental disorder “diagnosis.”

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

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

Conflicts of Interest

Most clinicians have a financial interest in deciding whether or not those seeking their services have a “clinically significant” condition. When they judge that their clients’ conditions are indeed significant, they indicate this on the third party intake forms by assigning a mental disorder “diagnosis” and this allows them to continue to see these clients and to get paid for additional visits.

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

Stigma

Clinicians refer to mental health service users with “mental illness” and “mental disorder” terminology. These are the same terms that many people use as insults and the media regularly pairs with the most heinous crimes. The stigma associated with such terminology is well recognized. There would be some justifiable reasons to continue to use such terminology if it provided scientific precision to those who wish to communicate about those utilizing mental health services, but as we have seen, this is not the case.

Violating the Respect of Service Users     

The current psychiatric diagnoses approach focuses on the “dysfunctions” of individuals accessing mental health services rather than human strengths within a cultural context. Moreover, it seeks to legitimize the privileging of the “expert” who supposedly has access to the truth and who can see the truth of the truth. We see this reflected in the mental health arena when we find that it is the clinician that makes the so-called “diagnosis.” The expert is thus seen as always equipped with technical knowledge and jargons without which the truth of knowing would be imponderable. This perspective can paralyze the power of choices for mental health service users.

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

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

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

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

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

The Classification and Statistical Manual of Mental Health Concerns (CSM) is a proposed alternative to the DSM. It would begin with the following statement: “The developers of the CSM fully recognize that individuality outruns any classification system. It is for this reason that the CSM does not seek to classify anyone. Instead, it classifies the expressed concerns of individuals seeking to have their concerns addressed by a mental health service provider.” A mental health concern, as defined in this proposal, occurs when a person seeking mental health services expresses to a mental health service provider a concern about any of these topics: behavior, emotion, mood, meaning of life, death, dying, managing chronic pain, addiction, work, relationships, education, eating, cognition, sleep, and stressful situation. The classification process of the proposed CSM respects the perspective of persons seeking services, recognizing that they have far more expertise about what is going on in their lives than any expert can have by interviewing them. In addition to classifying mental health concerns, the CSM would describe a collaborative approach between the person expressing the concern and the mental health service provider for creating a psychological formulation narrative that eschews the DSM psychopathologizing jargon and emphasizing that they have the potential to serve an adaptive function. In contrast to the CSM, the DSM seeks to legitimize the privileging of the “expert.” We see this reflected in its classification systems when we find that it is the clinician that makes the “diagnosis.” This perspective hinders the empowering of mental health service users. It is argued that when compared to the DSM, the use of the CSM would increase the self-efficacy of individuals struggling with these concerns, improve their outcomes, be less stigmatizing, as well as more person centered, culturally sensitive, recovery oriented, and offer a new preferred option to both, mental health service users and their providers.

Although the CSM has not yet been fully developed, becoming familiar with its basic ideas are empowering. Combining these ideas with knowledge about the three psychiatric diagnoses ethical challenges–conflicts of interest, stigma, and violating the respect of mental health service users–can assist people to become far more effective in interacting with mental health service providers.

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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers at no cost to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional intelligence. To begin at the very first post you can click HERE.

CSMDSMethics in mental healthethics in psychiatrymental disordersmental illnessThe Classification and Statistical Manual of Mental Health Concerns