My Upcoming APA Speech on Psychiatric Diagnosis
An Invitation to Critique My Position
Last year at the American Psychological Association Convention, I presented a paper on a proposal for an alternative to the current psychiatric diagnosis system, which can be read HERE. It provoked supportive comments, suggestions for making some improvements, and an invitation to write up my approach for an article in the Journal of Humanistic Psychology.
Now I have been invited to present an update to my proposal at this year’s APA convention in Denver. My remarks will be part of a three hour symposium titled, “The Future of Diagnosis: Ethics, Social Justice, and Alternative Paradigms.”
I am currently in the midst of preparing the final touches on my presentation. As I do so, I’m hoping to get some feedback from my blog readers. To that end, below you will find a summary of what I plan to say. Please look it over, and I’m inviting all of you to let me know what you think about it. Feel free to raise questions, to present as much negative criticism as you wish, and of course positive comments are also welcomed.
Title of 2016 APA Convention Paper: The CSM: A Person-Centered, Culturally Sensitive, Recovery-Oriented Alternative to the DSM and ICD
Presenter: Jeffrey Rubin, PhD
Paper Summary
The Classification and Statistical Manual of Mental Health Concerns (CSM) is a proposed alternative to the American Psychiatric Association’s DSM and the mental disorders section of the International Classification of Diseases (ICD). Both the DSM and ICD seek to legitimize the privileging of the “expert” by having the clinician making a mental disorder diagnosis. It is argued that that perspective hinders the empowering of mental health service users. The CSM, in contrast, would respect the perspective of persons seeking services by beginning with the following statement: “The developers of the CSM fully recognize that persons seeking mental health services have far more expertise about what is going on in their lives than any mental health service provider. Moreover, individuality outruns any classification system. It is for this reason that the CSM does not classify anyone. Instead, it classifies the expressed concerns of individuals seeking to have their concerns addressed by a mental health service provider.” A mental health concern, as defined in this proposal, occurs when a person seeking mental health services expresses to a mental health service provider a concern about any of these topics: behavior, emotion, mood, meaning of life, death, dying, managing chronic pain, addiction, work, relationships, education, eating, cognition, sleep, and challenging life situation. In addition to classifying mental health concerns, the CSM would describe a collaborative approach between the person expressing the concern and the mental health service provider for creating a psychological formulation narrative that eschews the DSM and ICD psychopathologizing jargon. It is argued that when compared to the DSM and ICD, the use of the CSM would be less stigmatizing, as well as more scientific, person-centered, culturally sensitive and recovery-oriented.
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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional and social intelligence. To begin at the very first post you can click HERE.
I find this interesting but I’m left wanting more information. When will you be completing your article? An alternative to DSM has been a long time coming.
Hi Valerie,
Much thanks for your interest. My article has been accepted for publication and should be available in a few months.
My Best,
Jeff
It will be too hard. It means that each person has to be assessed on their merits and that would take time. Time is money, and how would they bill the person? Does feeling sad cost more or less than feeling worried? Is a delusion worth more or less than obsessing about the locks? We’re talking about people who have been trained for many years to be DOCTORS, and DOCTORS treat SYMPTOMS. That’s what they learned in med school, and that’s what they have to do or they will suffer so much anxiety that they will be useless. Anyway, that sort of airy fairy stuff is what psychologists do, and if they’d wanted to be psychologists they wouldn’t have invested all those years becoming doctors so that they could be much more IMPORTANT and SCIENTIFIC than that kind of person. We’re looking at a group of people who are living in a collective delusional state of denial, whose belief set is that of a religion brooking no denial and whose potential for very distressing cognitive dissonance cannot allow them to take you or anyone else who questions them seriously. Sadly I think you run the risk of being ridiculed, Jeffrey, but I commend your courage and insight.
Hi Deidre,
Much thanks for your thoughtful comment. And you are correct in that throughout my quest, there have indeed been some who have ridiculed me. On the other hand, there have been many, many people, like you, who have been very supportive. Those who advocated against slavery knew that they would face strong opposition, but they persisted. I aim to do likewise.
Warm Regards,
Jeff
Dear Jeffrey, I came across this article from your post on an FB group.
Its a really interesting read and a novel, less-thought approach to mental illnesses. Your approach to clients is very humanistic and objective. In fact, many people (experts) may criticize your ideas about lack of objective consensus on what classifies as a mental health concern, since client’s words may have diverse meanings and interpretations. But over that, I feel that this approach or any other similar alternative is going to bring more objectivity into clinical practice as the focus is on client.
CBT and many other evidence-based therapies fail on many grounds to provide adequate mental health care to clients. One of the reasons for their failings is symptom/illness based manualized approach where strict guidelines have to be followed to achieve success in therapy. However, ground realities are very different. When approaching a client through the lens of an illness, several personal concerns of the patient are ignored or unaddressed due to many practical aspects.
I agree with Deirdre’s suggestions that CSM approach would be very time consuming and distressing for the clients since they won’t be getting timely remedies. However, rather than suggesting CSM as an alternative approach, I believe that new paradigms may function in adjunct to popular DSM and ICD. Replacing DSM or ICD with a client-centered perspective may not be fruitful at this time, however, a supplement (and a necessary one) MUST be formalized to be applicable and utilized in clinical settings. This may still be feasible as it would not put practitioners in jeopardy.
Deirdre rightly said that DOCTORS trained to use classical DSMs and ICDs may not like or accept your idea and may ridicule your approach to the core. Putting someone’s professional authority in danger would reduce your chances of getting heard. In fact, it may have an impact of total alienation of your ideas. So, I believe that instead of an alternative, a supplement manual should be proposed. That would be Psychiatrist friendly as well as Clinical Psychologist friendly too.
As with Tarun Vera above ~ I think somehow that your concept (and potential process) might best be used in conjunction with DSM especially when it comes to some diagnoses that involve resistant patients.
A couple of things. First, your speech describes the function of the two systems, but doesn’t evaluate the strengths/weaknesses of each. Do you have a very short time limit? If not, I’d like to see comparative lists outlining (PPT?) what each system has to offer. Also, a list of effects of the new system would be good — why is it better? How will patients benefit, in concrete terms? Finally, I’d put in a good example — Patient X is diagnosed in this way by Method 1, this way by Method 2. Maybe do this before you go into benefits. I just don’t see how describing the two systems is really offering a real-life alternative to psychiatrists.
Oh — and one last point — how much new learning will this require for doctors? They aren’t going to want to have to study that much.
I’m not sure that you, Tarun Verma, might have missed my point about the time consuming element. I meant that the DOCTOR might find it distressing, not the patient. Most patients would appreciate extra time beyond the 10-20 minute checklist diagnosis and med check that passes for treatment under the present regime. And as for placing DOCTORS in jeopardy because they might be expected to revise their training and orientation from their own gratification to consideration of their patient’s needs, I suggest that is their problem. If these people are so resistant to new ideas, they are doomed anyway, because the move towards patient centred treatment is growing exponentially in practice, though perhaps not among psychiatrists, the bulk of whom are no longer trained in any psychotherapy techniques. The `what happened to you’ is taking over from the `what’s wrong with you’ at a grass roots level and psychiatrists ignore this at their peril. Needless to say, it would require some new learning, which many will resist, but the Australian Medical Board and I presume the medical profession generally clearly states that DOCTORS have an OBLIGATION to continue their professional development. E.g.
Development of your knowledge, skills and professional behaviour must continue throughout your working life.
Good medical practice involves:
7.2.1 Keeping your knowledge and skills up to date.
7.2.2 Participating regularly in activities that maintain and further develop your knowledge, skills and performance.
7.2.5 Ensuring that your personal continuing professional development program includes self-directed and practice-based learning.”
So just sitting on one’s well upholstered butt saying,`it’s always been this way and that’s how I like it’ and `changing is too hard’, though widespread, especially at the top, is not good enough.
Katherine Ballensky – can you explain what you mean about `resistant’ patients? Are these the ones who object to being diagnosed with stigmatising, invalid (Thomas Insell 2012) labels? Are they the people who don’t believe they are `ill’ (Thomas Szasz, R.D. Laing et al), and can you please enlighten me how keeping the DSM can deal with this problem?
What is your core idea, or core intuition?
Not clear from the above descritption.
Jeff,
Take a look at the feminist psychology body of work on this topic if you haven’t already. My own first book, Engendered Lives from 1992 deals extensively with this issue and can be downloaded online for no charge. Brooklyn-me too.
Hello Jeffrey, I can’t speak for the American system of diagnosis, but I can from the British system, which is beset with problems from the onset. misdiagnosis is very oft the case, and together with that, the (un)necessary meds to go with it. which merely replaced one disassociated place with another. I worked on the “other” end, if you will, of people that had gone through the system, many times, and during the course, picked up a multitude of other “problems” along the way. My, “system” if I had one, was to “humanize” the poor sod first, they would come to “our” unit, when pretty much every other avenue failed. there would follow lengthy sessions, over a period of time, and depending on the level of damage, that could take up to 2 years, I am all for empowering, I saw it as my job to help the “client” see what he already knew, with the right therapy, people can overcome these problems, a “state of being” may only be a temporary one, and I believe, very often is, but is dealt with as a permanent condition by the current system. I know I’ve just took a “left” on the topic but I feel your system is probably far more effective than the current one, so good luck squire..
Great pioneering effort, Jeffrey. An arduous task ahead of you (and all of us) but one most definitely worth taking on. You have chosen to push psychology in a direction of evolution that it probably has feared to some extent. Struggle, Adapt, Learn, and Evolve.