05/15/2013 05:51 pm ET Updated Jul 15, 2013

After the DSM, What?

I have been arguing for many years in books like Rethinking Depression that the DSM ought to be repudiated. In recent months this idea has been gaining tremendous momentum and just recently the National Institute of Mental Health essentially repudiated the DSM.

This is great news and perhaps the beginning of a movement in the direction of a smarter, truer understanding of human distress. But where should we go next in this movement? Below are some thoughts on what a "new agenda for mental health" might look like.

1. If we want to start fresh conceptualizing "mental health" and "mental disorders" so as to provide more help to sufferers, what sort of research agenda might we set?

2. How might we conceptualize the task of rethinking mental health? How, for example, could we research the nature of the complete or original endowment with which each individual arrives in the world? What are the alternatives to scientific research and by what criteria would we want to judge the reliability or usefulness of each alternative approach?

3. What various definitions of "mental health" might be proposed? If a given definition of mental health rested on some other construct like "good coping skills," "resilience," "high functioning in society," or "self-report of contentment," what is our rationale for choosing that underlying construct rather than a competing one?

4. What are the current psychological models, how do we judge their strengths and weaknesses, and how do we tease out what we want a service provider to know about these models? As a corollary idea, what constructs or concepts within a given psychological model are the strongest, truest, or most sensible?

5. To what extent do we currently rely on self-reports to "diagnose mental disorders" and if that reliance is very high, on what else might we rely? What do we rely on in medicine to make diagnoses and to what extent is any of that apparatus applicable when it comes to "mental distress" or "mental disorder"?

6. How might we conceptualize an individual's contribution to the maintenance of his or her emotional distress? If, for example, an individual agrees that she would be happier if she did x but is reluctant to do x, how might we conceptualize that reluctance?

7. What do we take "behavior" to stand for? What sort of marker is bed-wetting, "excessive" hand-washing, "alcoholic" drinking, or a suicide gesture? What are the arguments for linking any given behavior to a construct called a "mental disorder" or a "mental disease"?

8. How should we conceptualize the differences between a behavior and an inner state? Tossing a book aside is an "observable behavior" but what it means is known only in its human context. How can we conceptualize the task of relating observable behavior to the "causes" or "sources" of that behavior?

9. How do we retain the sense that a human being is involved? How might a human being's "individuality and instrumentality" be conceptualized and should we act "as if" the individual is a person, a collection of dynamic forces, a symptom generator, or something else?

10. What shall we call a person who walks into the office of a "mental health service provider"? If we shouldn't call that person a "patient," shall we call that person a "client"? Are there still better words to use and what are the arguments for those better words?

11. What will a "new mental health service provider" provide? If it is wise to repudiate the DSM "shopping catalogue" approach and its pseudo-medical model, what will a person currently called a "psychotherapist" be doing or providing?

12. If it turns out that the "wise counsel" model is the most appropriate model for service provision, how do we train "wise counsels," how do we change curricula to reflect our new understanding of courses like "introduction to abnormal psychology" or "understanding the DSM," and how do we distinguish between "coaching" and "psychotherapy"?

13. Whether or not we ever understand "what is really going on in the mind," we nevertheless want to be of service to people seeking help with their "emotional problems." Given that, what helps? How shall we research the "best treatment methods" given that we may well not be talking about organic problems but reactions to life challenges?

14. What might be the rationale for employing a given helping strategy or tactic? Can we perhaps employ strategies without knowing their rationale or without granting the legitimacy of that rationale if individuals report that the strategy has helped them? Would it even matter if it were "only" a placebo effect?

15. What is cause and what is effect? When, for example, we see a certain pattern in a brain scan, how should we go about deciding whether the individual's sadness caused that brain look or whether the brain look is telling us anything about the cause of his or her sadness?

16. What do we mean by "reducing emotional distress" or "improving our mental health"? Is "feeling better" always the highest good or can the side effects or consequences of "feeling better" outweigh the so-to-speak undeniable benefit of not experiencing certain emotional distress? How can these matters be conceptualized?

17. How do we "step back" and seize this moment as an opportunity to "change the game"? Given the variety of stakeholders and the fact that the welfare and emotional health of hundreds of millions of human beings worldwide will be affected by any changes, how should we handle this moment and who handles this moment?

Maybe this is a moment for a "blue ribbon panel," but let us pray that not only the usual players are on it! If they are, it is unlikely that we will be able to seize this opportunity to rethink mental health.

Eric Maisel, Ph.D., is the author of more than 40 books, among them Rethinking Depression and The Van Gogh Blues. You can visit Dr. Maisel at or contact him at

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