Alternatives to Psychiatric Diagnoses
An Update On The Most Recent Published Discussions
Welcome to From Insults to Respect.
Dr. Jeffrey Rubin
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,
Dr. Jonathan D. Raskin
“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.
If I’m not mistaken, I once already commented in this venue on your CSM approach and, certainly in comparison with the DSM / ICD approach, was in favor of it. So again: Applause.
I wrote many times on mental health/illness/disorders myself, and came to the conclusion it’s an ingroup/outgroup thing. I quote myself:
“Like race, mental health and mental illness is fiction, made up, to give to people yet another foul reason to feel superior, righteous, healthy, and safe, and make others feel inferior, on the wrong path, sick, and suicidal.”
“The DSM (no matter its version), as well as other instruments to box in people, only exists because the majority of humans in the Western industrialized nations are afraid of people who make them feel uncomfortable, and because of the professionals in the field supporting this fear.
Yes, I know, it’s a bit extreme, but so is the person sitting in front of a screen, legally sending explosives to the other end of the planet to kill scores of people, and not declared severely suffering from a mental disorder by the DSM.”
“Diagnosing? Finding out what is going on? The cause of it “all”? Why? How? And in case you think you’ve found it, how can you be sure you’re correct? What if you’re wrong? The odds are mostly not in your favor, you know? It’s not a plumbing job, so to speak.
Try this instead: Ask the person(s) sitting with you, what he/she/they want, where she/he/they want to go, and see if you could be of any assistance. Yes I know, this isn’t working either sometimes, but at least the generalizing, the labeling, and stigmatizing are out.”
Note: Seems mainstream acceptance of your proposal would greatly depend on money, which confirms my ingroup/outgroup conclusion. Yet another example of the pathology of normalcy in my book.
It’s nice to communicate with someone who is so aligned with my own views on this topic. Thanks for your kind words, and I love your writing style.
Dr. Rubin,
Thanks for this very helpful blog! As it stands now the mental health system is doing far more harm than good. I was given a cancer diagnosis and totally took it in stride because my intuition along with the facts of the pathology etc, told me it was not a threat to my health. While in cancer treatment I began to experience insomnia from the 3 toxic drugs and steroids you must take to try mitigate some of the damage the drugs do. I was then sent to see a psychiatrist under the guise the visit was for “help with sleep meds”. I did not meet the criteria for even one psychiatric “disorder” aka label, but would later discover the psychiatrist hastily published 4 major psych disorders to my electronic records. Not only that but I was shocked to read the many false statements and outright lies she wrote to try support the psych labels. These labels have caused me to continue to be treated horribly by all other health care providers and repeatedly be dismissed and denied needed health care services. The psychiatrist refuses to correct my records even though I provided overwhelming proof and evidence showing these diagnoses are totally erroneous and in fact outrageous. (support letters from many who know me well, including 2 doctors, my spouse, sister, friends and psychologists I later saw for help dealing with these harmful labels) For example, she labelled the well known toxic side effects of carboplatin (one of the 3 chemo drugs) as a “Somatization Disorder”.
Many people are being severely harmed by the bogus labels of the DSM so your activism and writing is greatly needed. Thanks again!
Hi Rosalee,
Thanks for sharing your very upsetting experience. Although it takes courage to speak up, I applaud your efforts. I believe it is crucial that people hear about such goings on. You are not alone in having to deal with such injustices. Although speaking out about these injustices don’t always change them, by keeping silent about them, will certainly leave the status quo where it currently sits.
My Best,
Jeff
I am grateful for the fact that we are looking for different and better ways to address people that are having “problems with living” and thus negating the DSM/ICD approach.
However, I do have some reservation with the terminology used by the CSM approach. Namely the fact that these problems with living are compartmentalized into “Mental Health Concerns”.
What does it have anything to do with “mental health”?
We are, again, submitting to the medical model that there is something wrong with ones mental state, and not just that, but the state of their health as well.
When these problems can be directly attributed to ones environment. For instance “Environmental Concerns” or concerns within ones family or community.
Again, we are saying that there is a problem with the person, and taking for granted that the situation one is in is perfectly perfect and it is the individual themselves that has a ‘problem’. The world and society are far from perfect. Although this seems to be beyond the scope of this blog.
Not only that, but I am not pleased with sticking to the model that it is a “mental health” concern.
Great that you are looking for alternatives, Dr. Rubin, and it is a step forward, but far from something that needs to be implemented.
This does not seem to be satisfactory and does not do someone like Thomas Szasz justice.
Hi Lui Bliss,Thank for your thoughtful comment, and, like you, I have concerns about the phase “mental health concerns.” I address these concerns in my Journal of Humanistic Psychology article which you can see for free by clicking on the link provided in the article.
I originally suggested using the term “psychological concern” but social workers and counselors made the case that a broader term should be employed so that all of the mental health service providers would be able to easily utilize the alternative system. I suppose you would would prefer Dr. Szasz’s term, “problems in living.” Here is how I explain the choice of that term and mental health concerns:
Keep in mind that a concern only becomes a mental health concern when someone voluntarily seeks a mental health service provider to help address his or her concern.
Szasz (1961) believed that the types of experiences that are typically referred to as mental disorders or mental illnesses are more aptly construed as problems in living. But not all such experiences are easily described as a problem. For example, consider the case of John Smith who has just heard he has 6 months to live. He knows that he cannot solve the problem that he is terminally ill. Still, he seeks out Dr. Doe to help address the feelings he has been experiencing. Dr. Doe can indeed address John Smiths concern about these feelings by listening in a caring way and validating that it is understandable that he is experiencing anguish, sadness, and tears.
In contrast, there are some instances where mental health service providers can easily frame a presenting concern as a problem. However, as soon as they begin to classify their clients’ problems, we find variations due to theoretical backgrounds. On seeing a client who feels depressed, a psychodynamic therapist can define the problem as “How do I help this person stop repressing infantile wishes?” A biological psychiatrist, meeting the same client, can construe the problem as “How do I convince this client to take an antidepressant?” A cognitive-oriented service provider can describe the problem still differently, and so on. Because people seeking mental health services express their concerns before their mental health service provider defines their problem, there is a window of time at the start of the mental health service process when there is general agreement about what the service user’s expressed concern was. This period of enhanced general agreement makes classifying expressed concerns far more practical and objectively descriptive than classifying problems for the full range of providers with varying theoretical backgrounds.
Also, many problems in living are clearly distinguishable from the type of concerns that a person seeks assistance from a mental health service provider. If a person is having problems dealing with their wealth, a wealth advisor is the person he or she would want to speak with. If a person living in a two floor home loses the ability to walk, the problem of how to go traverse the two floors might better be handled by a building contractor.
The CSM Is also practical because it maintains the concept of “mental health.” What I mean by this is currently, we have such enormous organizations as Mental Health America and its state and regional affiliates, the National Institute of Mental Health, university and college programs offering degrees in mental health counseling, and states offering certifications in this field. Psychologists, social workers, counselors, and psychiatrists regularly refer to themselves as providing services under the umbrella of “mental health service providers.” For these reasons, the CSM would maintain the concept of “mental health” so it can be comfortably and realistically accommodated into the many large organizations currently using it.
However, the CSM would use the term “mental health” in a way that is different from what is implied in the DSM and the ICD. The CSM would explicitly reject the idea that the opposite of mental health is mental illness. Rather, the word “health” in the CSM’s “mental health” would be phrased in a manner that indicates that professionals dealing with mental health concerns are part of the allied health professions. The reason for thinking of these professionals as health providers follows.
Many of the concerns that would fall under the CSM’s list of related topics (behavior, emotion, mood, addictions, meaning of life, death, dying, managing chronic pain, work, relationships, education, eating, cognition, sleep, and challenging life situations) have been identified in scientific studies as “physical health risk” factors. For example, people who express a concern about being addicted to alcohol are at increased risk of developing sclerosis of the liver (O’Shea, Dasarathy, & McCullough, 2010). Those who express concerns about eating more than average may be at greater risk of diabetes and heart disease (Mokdad et al., 2003). Quality of interpersonal relations, lack of sleep, depression with thoughts of suicide, and various other concerns or clusters of concerns can be studied for the degree of physical health risk that they pose.
A major goal of mental health providers under the proposed CSM system is to turn “physical health risk” factors into “physical health protective” factors. The degree to which this is successful can be studied using currently available methodologies. It is in this very specific sense that the mental health concern topics are viewed not merely as mental concerns but also mental health concerns. By being explicit about this change in conceptualizing mental health, we have good reason to believe that the CSM proposal holds promise for avoiding most of the negative baggage that comes with this type of terminology.
Does this explanation for the choice of utilizing the term “mental health concerns” address your concerns?
My Best,
Jeff
Re: “Does this explanation…….” It does to me 😉
Re: “In contrast, there are some instances……….” This part of your answer appears twice.
Hi Roald Michel,
Thanks for catching my error in repeating a part of my answer. I have now removed that error. Please feel free to let me know if you catch any other mistakes that I make in any of my posts. Your feedback is always welcome.