A Kinder Approach to Mental Health
by Jeffrey Rubin, PhD
Can psychologists come up with a kinder, more respectful, healthier approach for dealing with the types of concerns people seek mental health services?Concerns about the Medical Model
William James
“Individuality outruns all classification, yet we insist on classifying everyone we meet under some general head. As these heads usually suggest prejudicial associations to some hearer or other, the life of philosophy largely consists of resentments at the classing, and complaints of being misunderstood.”
The various “mental disorders,” falls under the head of “diseases” in the WHO’s International Classification of Diseases. Not everyone feels at home with this. Here is one service user expressing her discomfort:
“By the time I was entering my second decade of service use, the medical model, which I had initially found reassuring, seemed increasingly unsatisfactory, without the capacity to encompass the complexity of my interior or exterior life and give it positive value. As a result, I began to actively explore frameworks that better met my needs.”
Note that she was looking for a framework that would give her complex life positive value. We shall return to this issue shortly. But first, I think it would be helpful if I share my own concerns about the medical model.
My Experience: My original exposure to the pathologizing medical model occurred when I took a course in Abnormal Psychology as an undergraduate at Brooklyn College. Shortly afterwards, I found that my classmates began to use the new terms that they learned in the course as insults whenever someone did something they didn’t like. One person was called a narcissist, another–a manic depressive, another–psychotic, and on and on.
This insulting behavior didn’t sit well with me. As an undergraduate I had, at various times, the typical troubling emotional experiences of teenagers that could easily be framed as various mental disorders. The stigmatizing mental disorder labels being used as insults could readily be applied to me.
Then, as a PhD graduate student, I was required to take a course titled, “Descriptive Psychopathology.” There I learned that because of a vote, mental health professionals had first declared that being what they termed “homosexuality” was a mental disorder, but recently they voted to no longer view it as a disorder. Although I’m not gay and happily married to a wonderful woman, I was glad to hear this, for I had since met some gay folks and felt the psychopathologizing of them didn’t seem right. I also thought that classifying people as having a disease based on a vote, rather than on some objective evidence of an infection, tumor, organ blockage, or tissue tear also wasn’t quite right.
Then I began to read books by William James. He had advocated that mental health service providers should not take their terminology too seriously, referring to it as superficial medical talk. This viewpoint of James began as early as 1896. In his Lowell Lectures on Exceptional Mental States (which were reconstructed by Eugene Taylor in 1984 from James’s notes), the good professor stated that experiences that are commonly viewed as unhealthy or morbid are really “an essential part of every character” and give life “a truer sense of values.” He went on from there to note that,
“medical writers represent the line of mental health as a very narrow crack, which one must tread with bated breath, between foul friends on the one side and gulfs of despair on the other…. There is no purely objective standard of sound health. Any peculiarity that is of use to a man is a point of soundness in him, and what makes a man sound for one function may make him unsound for another…. The trouble is that such writers use the descriptive names of symptoms merely as an artifice for giving objective authority to their personal dislikes. The medical terms become mere appreciative clubs to knock a man down with…. The only sort of being, in fact, who can remain as the typical normal man, after all the individuals with degenerative symptoms have been rejected, must be a perfect nullity. Who shall absolutely say that the morbid has no revelations about the meaning of life? That the healthy minded view so-called is all?
Upon graduating and serving in various roles as a psychologist, I learned about the various shortcomings of the pathologizing approach:
- It is stigmatizing to mental health service users.
- It privileges the clinician’s perspective over that of the mental health service user.
- It has serious reliability and validity problems.
- By focusing on what’s wrong with the individual it tends to miss their strengths, the complex relational context they find themselves in, and malfunctioning social structures.
- By pathologizing psychological concerns, it promotes the use of psychiatric drugs that in many situations worsen outcomes.
Regarding this last shortcoming, I became aware that the pharmaceutical industry has had a huge financial interest in promoting the idea that psychological concerns are real “illnesses” that require drug treatments just like physical illnesses. Cosgrove, and her team of researchers have made a compelling case that this can be seen by how the industry has been exerting a great deal of influence on psychiatric research and practice, resulting in publications and news reports that exaggerate claims of its drug treatments’ effectiveness while minimizing harms. For example, the “Clinical Practice Guidelines (CPG)” for mental health services provides the “standard of care” for health care providers. The confidence in the benefits of these drug treatments, if it were free of industry influence, would be more convincing but Cosgrove’s team found,
“Ninety percent of the authors of 3 major guidelines in psychiatry had financial ties to companies that manufacture drugs which were explicitly or implicitly identified in the guidelines as recommended therapies for the respective mental illnesses. None of the financial associations of the authors were disclosed in the CPG”.
Now, I know millions of people like taking drugs, whether they be prescribed by doctors or not. So, any alternative to the medical model that interferes with this desire is going to meet with a tsunami of resistance. So, the medical model as an option to service users is likely to continue. The best we might hope for, is that third party payers that now require a mental disorder “diagnosis” also cover services under a more kinder, respectful framework.
A Proposed Alternative
For people who have come to believe the medical model is too stigmatizing, and drugging problems away is not for them, what might a more acceptable alternative look like? One idea comes from a recent study by Schroder, et al. (2023).
“We describe the historical development of popular messages about depression and draw from the fields of evolutionary psychiatry and social cognition to describe the alternative framework that depression is a “signal” that serves a purpose.
We then present data from a pre-registered, online randomized-controlled study in which participants with self-reported depression histories viewed a series of videos that explained depression as a “disease like any other” with known biopsychosocial risk factors (BPS condition), or as a signal that serves an adaptive function (Signal condition) …. The Signal condition led to less self-stigma, greater offset efficacy, and more adaptive beliefs about depression.”
As we have discussed above, the medical model conceptualization of the types of concerns that is classified under the disease heading often fails to motivate active coping beyond taking a pill. Moreover, it fails to honor the labeled person’s perspective. The above study suggests that framing these concerns as a potentially healthy functional signal can lead to less self-stigma, and perhaps greater self-efficacy in making healthy life-style improvements.
Dr. Jeff Rubin
Consistent with this suggestion, in several of my earlier posts, I provide numerous examples of people who found various experiences typically labeled as “mental disorders” as helpful. For example, Joshua Wolf Shenk in his biography of Abraham Lincoln, makes the case that his depression fueled his greatness. Similarly, the music legend, Joni Mitchell, upon discussing her frequent bouts of depression observed,
Joni Mitchell
“Depression can be the sand that makes the pearl. Most of my best work came out of it. If you get rid of the demons and the disturbing things, then the angels fly off, too. There is the possibility, in that mire, of an epiphany.”
In a paper I published in the Journal of Humanistic Psychology, I describe in detail one proposed alternative that is consistent with this way of thinking. This alternative involves creating a manual for a classification system that replaces the disease overarching concept of mental disorders with mental health concerns that potentially serve an adaptive function. Those seeking mental health services would be given a choice to have their concerns addressed utilizing the pathologizing approach or the mental health concern approach. Both types of services would be equally covered by third party payers. 
I argued that, in contrast to the pathologizing approach, this alternative would increase the self-efficacy of individuals struggling with these concerns. Additionally, it would be kinder, more respectful, improve outcomes, provide a new choice, stimulate fresh perspectives, and open new avenues of research.
The first chapter of the manual would explain that the mental health concern approach begins from the perspective of the person seeking services. It does not classify anyone. Instead, each person is viewed as a unique individual. What is classified is the concern expressed to a mental health service provider. Then, the manual would clearly define its main overarching construct:
“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, addictions, meaning of life, death, dying, managing chronic pain, work, relationships, education, eating, cognition, sleep, and challenging life situations.”
This is an observable event that occurs at a specific time and place, and therefore avoids the reliability and validity problems of the vague definitions provided in both the APA and WHO mental disorder manuals.
Two types of data sources would be utilized to identify the list of concerns that would appear in this alternative manual. The first would come from a large sample of mental health service providers that ask them to list the various concerns that they have been asked to address in their practice in the past year without couching them in psychopathological language and to stick as closely as possible to the language used by those seeking their services. The second source would come from another survey that would ask the membership of mental health service user organizations to list the various concerns that led them to seek mental health services. They, too, would be asked to avoid psychopathological terminology.
Some have argued that there is no need to have any classification system. According to this argument, a “psychological formula” approach consisting of a few paragraphs describing the case without pathological labels is sufficient to replace the medical model. But note that the vast majority of current third-party payer systems do use the mental disorder codes. The codes are used in the following manner. Third party payer systems utilize forms that must be filled out whenever someone seeks mental health services under their plan. These forms typically have a little box that reads, “Diagnosis.” In that box, mental health professionals must fill in a short code that corresponds to some specific “mental disorder.”
Utilizing just the psychological formulation approach, which involves the creation of several paragraphs as an alternative to these codes, would be far too cumbersome. The concern approach, like the medical model approach, provides a short descriptive phrase coupled with a code and is therefore far more workable.
With the concern proposal, all that third-party payer institutions would need to do differently to add value for their customers is to slightly change that little “Diagnosis” box. Instead of just reading “Diagnosis,” that box would add two simple words, so it would read, “Diagnosis or Concern.” Then, when mental health professionals fill in the box, they would be given the choice to either write in the letters “D” and the code number that corresponds to the so-called diagnosis, or they would write the letters “C” and the code number that corresponds to the specific concern. 
Mental health consumers would be given the choice to go to pathologizing mental health service providers or those using the concern approach. This is all the change that would be required to increase value for a significant number of mental health service users. The cost and effort for third party payers to make both the pathologizing and concern approaches available would be minimal.
Moreover, a short word or phrase that could replace terms like “major depressive disorder” or “attention deficit hyperactivity disorder” is necessary for other practical means of communication. For example, if I want to write a title for a research article, it would not be practical to insert several of the formulation paragraphs into the title. The psychological formulation approach would be far more widely used if it had some practical way of providing some standard short terms for conceptualizing an individual’s mental health concerns arranged in a valid scientific classification manual.
Some may argue that the mental health concern approach is not practical because if everyone could go to a mental health professional merely to have their concerns addressed, then the system would soon be overloaded with clients, and third-party payers’ costs would soar. Because third party payers made up of insurance companies and national health services only cover people with more serious conditions known as mental disorders, so the argument goes, this limits the number of people who can get to see a mental health professional. However, how do mental health service professionals honestly determine if a person has a serious enough condition to warrant “treatment?”
The process with the pathologizing approach is suppose to be as follows. When someone who expresses a concern (which is referred to as a “symptom”) to the mental health professional, the professional is to decide if the symptom arises to the vague level of “clinical significance.” Only if it does is the symptom considered serious enough to warrant a “mental disorder diagnosis.”
I have been a PhD level psychologist for over forty years. Not once have I heard of an occasion in which an individual who made an appointment for mental health services and then showed up for it, leave the appointment without a mental disorder diagnosis. This intuitively makes perfect sense because mental health professionals are in the business of increasing the number of their clients. Given that they have over 300 vaguely described “mental disorders” to choose from, and the only way they will get paid for their services is to declare that the person seeking services has a “clinically significant” disturbance, who can doubt that no one is turned away.
The professional status of the service provider leads the public to think something more serious has been established when a diagnosis is declared. Although it is true that some expressed concerns are more serious than others, a mental disorder diagnosis is not indicative of this.
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 intelligence. To begin at the very first post you can click HERE.
Love this post Jeff. It expresses every concern I’ve had about diagnosing clients (not patients)
Much thanks for this comment, Linda.
Jeff
Dear Dr Rubin,
Your article is about psychologists and “mental health”.
You evoke the “medical model”. Is this the medical model of disability, which is supposed to be replaced by the social model, based on human rights?
In my country France, as an advocate of persons with psycho-social disability, I have to face governmental deny of the gross human rights violations perpetrated by psychiatry. One difficulty is the flawed semantics. Nobody teaches medicalization or pathologization or the UN CRPD’s human rights and the social model of disability to medical practitioners. What about psychologists?
Here are examples of these flawed semantics, in French Law, by the French Health Authority, and the French Government:
“Psychiatry” = no definition except circular, but it is the mandatory medicalization of psycho-social complaints.
“Care without consent” = forced psychiatry.
“Care program” = forced psychiatry in the community.
“Care” = are called care, some forms of psychiatric torture, like isolation, restraints, and neuroleptic drug torture.
“Mental health” = psychiatry. Do not be fooled by the term, it is the old psychiatric dystopia rebranded. Big Pharma is behind all the push to include “mental health” in sustainable development goals. Perspectives of profits are simply, huge.
“Mental health practitioner” = psychiatrist. (That one is in French Law)
“Mental health prevention” = psychiatric child abuse: profiling, indoctrination, labeling, poisoning, lifelong stigmatization.
“Therapeutic alliance” = forced confession of illness and conversion to the psychiatric sect, by means of chemically-induced brainwashing, indoctrination, bullying and threats of forced psychiatric hospitalization (this one by the Health Authority).
“Treatment” = psychiatric procedures.
“Inability to consent” = rejection of the proposed psychiatric procedures.
“Anosognosia” = rejection of psychiatric labeling.
“Patient” = any person complaining, or a person somebody is complaining about.
“Psychotic” = any patient not cooperating. For example, a victim of forced psychiatry, like a psychiatric inmate or a psychiatric slave in the community. Any patient who has confessed and converted to the psychiatric sect and cooperates is said to be “in remission” (but never “cured”).
“Disorder” = psycho-social complaint.
“Diagnosis” = pathologization of a psychiatric inmate or slave. Pathologization of thoughts, inner experiences, feelings, behavior, personality.
“Informed consent” = lies and/or bullying.
It’s all about posturing: This is what psychiatrists would say: “I am a medical man, you are a patient. I know and you know not. There is a complaint, hence you are suffering from a disorder, I diagnose you, I treat you. I make the bet that your brain is unhealthy, and as a physician I have obligation of means, if not of results. If I don’t treat you, I would have failed my professional obligations. If you disagree with this, know that my drugs are stronger than you, and I can assure you that you will agree with me, in time. I serve society first, and I fulfill my role as a social control institution, before I serve you. Say thank you, please.”
My point is that the fulfillment of the person’s human rights, UN CRPD style, should come before any psychological or medical proposal. This includes security, which means that psychiatric coercion must completely stop and complete reparations be offered, UN-like, as the CRPD Committee’s Guidelines on deinstitutionalization explain (CRPD/C/5).
Hi Luc Thibaud,
Thanks for letting your views be known here at From Insults to Respect. I fully agree with you regarding involuntary “treatment.”
To your question, you say I evoke the medical model. I do more than evoke it, I present in my post the leading criticisms of that model. The model that I support, in contrast, is indeed social, though many voluntarily seeking the services I’m most familiar with don’t have a disability as I understand the term, and some have what I refer to as having different abilities than what some view as average or above average abilities. I actually view each person as a unique individual and avoid labeling him or her.
There are people who voluntarily seek out services from psychologists, counselors, other mental health professionals, and these professionals voluntarily address the expressed concerns of those seeking services as best that they can. I think that my proposal, as an alternative to the medical model, is a significant improvement for the voluntary addressing of these types of concerns.
Always enjoy hearing your comments, Luc.
My Best,
Jeff