Seeking to Reform the Psychiatric Diagnosis System

Welcome to From Insults To Respect. As several of my earlier blog posts have indicated, many professionals, mental health service users, involuntary patients, and the general public have little, to no respect, for the American Psychiatric Association’s most recent version of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Just before the DSM-5 was published, early drafts were made available, and in 2011 the British Psychological Society (BPS) and the American Psychological Association’s Society for Humanistic Psychology expressed concern that:

…clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation…

Additionally, many researchers have pointed out that psychiatric diagnoses are plagued by problems of reliability, validity, and prognostic value.

These concerns, among others, appeared in an Open Letter to the DSM-5 developers that was endorsed by over 15,000 mental health professionals and other individuals, as well as by over 50 professional organizations, including 15 additional divisions of the American Psychological Association. These concerns were largely ignored by the DSM-5 developers.

Since then, we have seen the development of a few proposals for alternative frameworks. Most of them continue to pathologize those seeking mental health services.

In contrast, there is now my own proposed alternative, the Classification and Statistical Manual of Mental Health Concerns (CSM) which I presented at the American Psychological Association’s Annual Convention, and published in a peer reviewed psychology journal (see HERE). The CSM approach recognizes mental health professionals require some classification system for providing a common language for them to communicate about those utilizing their services. These terms must, for practical purposes, be short phrases that are convenient for placing them into titles and search engines, and for efficient/streamlined communication in the often hectic environments of many hospitals and clinics.

However, unlike the CSM, other frameworks being proposed use the term “diagnosis,” which implies that the mental health professional, once providing the diagnosis, now knows the cause of the concerns being expressed by the person seeking services, which is simply not true. Instead, they may have some tentative theory for the cause or be completely puzzled. Nevertheless, to access services, the misleading diagnosis is provided. Moreover, the “diagnostic” terms used identify and locate problems within individuals and labels the individual as having a mental disorder, which is often stigmatizing.

In contrast, the CSM does not seek to label anyone. Instead, it classifies the expressed concerns of those seeking mental health services, using the typical non-jargon phrases employed by them. These phrases would become the short phrases that would be used by mental health professionals for titles and search engines, and for efficient/streamlined communication.

Beyond creating this practical classification system, the CSM then relies on a psychological formulation approach that opens the door to finding causes for these types of concerns in the circumstances of the service seeker’s lives. Locating problems within only individuals, as the DSM-5 does, misses the relational context and undeniable social and structural influences on many of these concerns.

I developed the CSM approach while working with the Task Force on Diagnostic Alternatives of the American Psychological Association’s Division 32 (Society of Humanistic Psychology). That group has not officially supported, as of yet, any single alternative. Instead, it has wisely decided that its next step is to send out a new open letter hoping to garner support for starting a process that will involve all of the mental health stakeholders including former and current mental health service users, individuals who experienced involuntary treatment, their family members, and mental health professionals.

Why bother to create a new open letter to those who are in positions that can really make meaningful changes since the last one was largely ignored? It is because of a deep understanding of how meaningful positive changes do occur. Advocates for change are, at first, largely ignored. Then, through continued advocacy, some meaningful discussions do get underway. And finally, positive changes occur. The process by which women obtained the right to vote is one notable example of this.

So, this letter was created with the flame of hope still flickering within the hearts of many of us.

The letter is addressed to:

Co-Chairs of the World Health Organization Joint Task Force (JTF) on the ICD-11 for Mortality and Morbidity Statistics, 

Stefanie Weber, MD
Head, Medical Vocabularies
German Institute for Medical Documentation and Information (DIMDI)
Waisenhausgasse 36-38A
50676 Cologne, Germany

James Harrison
Director, Research Centre for Injury Studies
Flinders University, Adelaide Australia
GPO Box 2100 Adelaide SA 5001 Australia

Chair, DSM Steering Committee:

Paul S. Appelbaum, MD
Elizabeth K Dollard Professor of Psychiatry, Medicine & Law
New York State Psychiatric Institute
1051 Riverside Drive, #122
New York, NY 10032

Coordinator, RDoC:

Bruce N. Cuthbert, PhD
National Institute of Mental Health
NSC BG RM 6200
6001 Executive Boulevard
Rockville MD 20852

I was one of the consultants that helped to craft the letter. Among the main points that it seeks to make are:

In practice, diagnoses are not conferred in a contextual vacuum. The criteria are not culture or value-free but instead reflect current normative social expectations. At the same time, psychiatric diagnoses have substantial impact on the social and occupational lives of those to whom they are applied. And reductionist biomedical diagnoses obscure the social determinants of our distress. This is important: as the United Nations Special Rapporteur concluded in 2017, we are under an international obligation to ensure that mental healthcare adequately addresses social contexts and relationships.

The letter concludes:

As a next step to address these concerns, we request an online, telephone or in-person meeting to discuss these issues in more depth. We look forward to your response.

Readers of this blog are invited to read this letter HERE. 

My Best,

Jeff  

Alternative to the DSM and ICDCSMDSMICDPsychiatric Diagnosis