The Classification and Statistical Manual of Mental Health Concerns: An Alternative to the DSM that is Practical and Consistent with the Principles of Science
I have been enjoying reading the various posts at the International Diagnostic Summit (DxSummit.org). There, readers can examine well-articulated descriptions of the numerous faults of the DSM. At the same time, there is an understanding that criticism is far more useful when, in addition to pointing out the faults of something, it is combined with a clear vision of an alternative that would have fewer faults. In the case of the DSM, without that vision, those supporting its use can simply state that even with all of its faults it’s the best that can be currently conceived.
With this in mind, the Summit has begun to go beyond just describing faults of the DSM. Peter Kinderman, for example, is calling for a problem-based, case formulation alternative to the DSM. Although I readily agree that his approach has merit and would indeed be an improvement over the DSM, here I would like to suggest another alternative for consideration of Summit participants. In fashioning this alternative, I have aimed for it to be practical while not violating principles of science.
A Mental Health Concerns Classification System
I currently have a problem with the term “mental health” because it implies that if someone is not mentally healthy they are mentally ill. I have laid out my objections to this term in an earlier publication (Rubin, 2000). William James, in his 1896 Lowell Lectures on Exceptional Mental States, which were reconstructed by Eugene Taylor (1984), perhaps best briefly summarizes my position.
At the very beginning of the lectures, James argues that experiences that are commonly viewed as unhealthy or morbid are really “an essential part of every character” (Taylor,1984, p. 15), and give life “a truer sense of values” (p. 15). To support his contention, James first provides three examples of famous individuals who suffered from melancholy, a term that corresponds closely with what the DSM refers to as “major depressive disorder.” St. Paul, the religious figure of the New Testament, Cesare Lombrosa, a late 19th-century Italian criminologist, and Immanual Kant, the 18th-century German philosopher, became, according to James, better as a result of their grappling with their troubling experiences.
James went on from there to note that medical writers tend to
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. Moreover we are all instruments for social use, and if sensibilities, obsessions and other psychopathic peculiarities can so combine with the rest of our constitution as to make us the more useful to our kind, why, then, we should not call them in that context points of unhealthiness, but rather the reverse . . . 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? (pp. 163-165)
Despite the many concerns that I have with the “mental health” concept as it has been used for over one hundred years, any alternative to the DSM must deal realistically with our present situation. People have a hard time dealing with ideas that strike them as too radical. To have some promise to be adopted, an alternative must put forth a vision that is distinctly better, but is still respectful of what has come before.
Currently we have such enormous organizations as the National Mental Health Association and its state and regional affiliates, the NIMH, 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, “A Mental Health Concerns Classification System” maintains the concept of “mental health,” but within its system it defines its use in a way that is just enough different so it can be comfortably and realistically accommodated into the many large organizations currently using it.
The Meaning of “Mental Health Concerns” within the “Mental Health Concerns Classification System”
“Mental Health Concerns,” in this classification system, refers to any concern that is directly expressed to a professional counselor, psychologist, psychiatrist, or social worker on the following ten topics: behavior, emotion, mood, meaning of life, work, relationships, education, eating, cognition, and sleep. I use the mnemonic, BEMMWREECS, which I pronounce “bem reeks,” to help me to recall them all. The word “mental” in “Mental Health Concerns” refers to the ten topics of concerns. The words “mental health” in “Mental Health Concerns” explicitly rejects the idea that the opposite of mental health is mental illness. Rather, the word “health” in this mental health classification system is designed to indicate 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 fall under the ten mental health concern topics have been identified in scientific studies as “physical health risk” factors. For example, people who express a concern about drinking far more alcohol than average are at an increased risk of developing sclerosis of the liver. Others who express concerns about eating more than average may be at greater risk of diabetes and heart disease. Poor relations, lack of sleep, depression with thoughts of suicide and various other concerns or clusters of concerns can be studied for the degree of risk that they pose. The degree to which this assertion is true can be studied using currently available epidemiological methodology that comports with principles of science.
A major goal of mental health providers under this classification system is to turn physical health risk factors into “physical health protective” factors. To the degree that this is successful can also be studied using currently available methodologies. It is in this very specific sense that the ten 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, I hope to avoid most of the negative baggage that comes with this type of terminology.
Some Clarifications about the Mental Health Concerns Classification System
No individuals are labeled in this system, rather, it is the expressed concern that is.
Unlike the DSM, the concern system makes no pretense to make so called mental disorder diagnoses. During counseling, both client and mental health practitioner are free to provide hypotheses about the “cause” or “causes” that led to the concern. Case notes can summarize these hypotheses.
There are two major classes of expressed mental health concerns:
- The client expresses a concern about him or herself.
- The client expresses a concern about another person.
An example of the first class is John Doe expresses his concern to a counselor about being depressed. An example of the second class is Mary Smith expresses a concern about her son not paying attention at school.
The goal of Mental Health professionals is not necessarily to eliminate a concern, though this may, and frequently occurs. Rather, it is to address the concern. Here is one of the clear distinctions that can be made between the mental health concern classification system, and the type of problem-based, case formulation that Peter Kinderman is calling for.
When people express concerns to mental health professionals, one way the professionals address the concern is to display empathy and, from time to time, to validate the concern. That is, suppose someone says to me that she is depressed because her lover left her. I could summarize in a caring way what she said and perhaps mention how I’ve lost a love of my own in the past and, wow, it was pretty rough. Then I could continue to listen in a caring way. Even if I don’t solve any of her problems, her concern has still been addressed.
A problem-based model misses this point. In my own counseling practice over the years, on numerous occasions people thanked me for being a good listener even when I couldn’t make their problems go away.
Why is this Proposed System more Scientific Than the DSM?
I’m pretty certain that if you asked a thousand people in the USA, randomly chosen, if there are people in our society who go to mental health professionals and express concerns to them, all of them would agree that this indeed occurs. This is not some vague hypothetical construct; it is a known sociological fact. As soon as we go from a mental health concern as defined in this system to a higher abstract level such as a mental disorder, disagreements begin to swirl around.
A scientific classification system is designed to help people who are interested in a topic find relevant information about a topic. For example, if I want to find out about any scientific studies that looked at different ways that addressed concerns about depression, in Google Scholar I can now simply put in the search engine, “depression, treatments.” Without adding the words “major” and “disorder” in the search engine, I can currently get numerous relevant hits. If the new concern classification system was adopted, soon the term “addressing concerns” would be receiving the same number of relevant hits that I now get by using the search term “treatment.” Thus, this scientific requirement would be amply fulfilled without using the search terms of “major depressive disorder” and “treatment.”
From my reading of the literature, scientific studies rarely define a group of subjects by their DSM classification. Reliable and valid measures, such as the Beck Depression Inventory or the Hamilton Depression Inventory, are used to better define the degree of concern. This would also be done in scientific studies if a mental health concern classification system came into use.
The Practicality of a Mental Health Concerns Classification System
None of the current major organizations and certifying programs would need to change their names if this classification was adopted as an alternative to the DSM. Clients could be given a choice as to how they want their visit to a professional be labeled, either to have it be described as a treatment for a mental disorder, or to have a mental health concern addressed.
Some may argue that if everyone could go to a mental health professional merely to have their concern addressed, then the system would soon be overloaded with clients and insurance policy costs would soar. Since insurance companies only cover people with more serious conditions known as “mental disorders,” so the argument goes, this limits the amount of people who go to see a mental health professional.
Well, insurance executives need their heads examined if they really believe that mental health professionals now using the current DSM turn anyone with a mental health insurance policy away who comes to their office expressing what I refer to as a mental health concern. Professionals are in the business of increasing their clients. Let’s be honest here, there are “close enough” matches throughout the DSM for anyone with mental health insurance coverage who currently wants mental health services to get it.
As for how disability services would be affected by this concern model, I’ll just point out for now that currently having a doctor say you have a mental disorder does not automatically lead to a person getting a disability check. Something more must be provided in this type of determination. Peter Kinderman refers to a “case formulation” process. This type of process will be necessary as well for a concern model.
Well, there you have it—a brief overview of the mental health concern classification system that I am proposing. It differs from Kinderman’s fine proposal in that it more clearly describes the topics that fall under its umbrella, and provides a mnemonic to recall them–BEMMWREECS. While maintaining “mental health” as a descriptor, it modifies its meaning so it avoids the numerous objections launched at it for over a century. It replaces its basic concept of “problem” with “mental health concern.” And, finally, while it includes the concept of “solving problems,” it adds the idea of “addressing concerns.”
Rubin, J. (2000). William James and the pathologizing of human experience. Journal of Humanistic Psychology, 40(2), 176-226.
Taylor, E. (1984). William James on exceptional mental states: The 1896 Lowell Lectures. Amherst: The University of Massachusetts Press.