Understanding the DSM for Social Workers
To paraphrase Cochran and Walsh, The DSM tends to look at clients in a vacuum and separates the disorder from the person and the events in their lives that caused it. In general, it does not emphasize the roles that systems play in the emergence of problems (Corcoran & Walsh, 2020). Social workers traditionally take a holistic approach to a diagnosis, while the DSM relies on descriptive rather than etiology-based categories, with disorders defined primarily at the symptom level rather than in terms of deeper processes, which may include unconscious processes (Wakefield, 2013). It is these differences that bring about tensions and ethical issues related to the diagnosis of patients.
It is easy to diagnosis a person with a mental disorder using the DSM, it is a game of matching symptoms together. Corcoran and Walsh contend that two different people can have the exact same diagnosis, but have totally different symptoms. The underserved and underprivileged seem to be more likely to have a mental illness diagnosis from the DSM, while their struggle may in fact be related to an environmental factor. By discarding factors such as economic status, employment issues, society biases such as stigmas related to homelessness, poverty, and race in order for a billing code, undermines the entire therapeutic process.
A DSM diagnosis may suggest that a client has severe depression, because they are upset due to not being able to find employment. Then the client is referred to a medical professional for medication to treat their depression, while the root problem still exists. In cases such as this helping the client find gainful employment may be the solution to the issue to begin with. It is for this reason we need to put our biases aside.
Unconscious bias is something that we all have and should be aware of. As a result, becoming conscious of my own prejudices would be my first line of defense against the perpetuation of stereotypes about the underserved and underprivileged.
I possess another weapon in my armory, namely prayer. I am currently in daily contact with underprivileged and underserved adolescents. Perhaps not in an official therapeutic context, but in a manner in which they are able to open up to me. If I know I will be meeting with Billy at 1 p.m. to discuss his treatment work, I will pray at 12:40 p.m. asking God to direct me and provide me with Billy’s viewpoint and understanding. Being mindful that the adolescents I serve will often have a different world view than myself is key to being able to look past my own biases.
I’ve been working with young people who have substance abuse difficulties for six years, and throughout that time I’ve had to put myself in their shoes on a number of occasions. I have had the good fortune (and the misfortune) to have experienced many of the same challenges that my students do. Poverty, homelessness, drug addiction, and violence are just a handful of the issues that exist. I would want to believe that I am free of prejudices, yet I frequently catch myself harboring them, and the bulk of those prejudices are motivated by dishonesty. I have a tendency to view all of my pupils as dishonest individuals, despite the fact that this is not always the case. I have to remind myself to keep my emotions under control on a regular basis.
Even with our biases in check, there still is the ethical issues of diagnosis in the first place, which seems to be a bigger issue. An issue that I would imagine could help perpetuate our own biases even more without even realizing it.
Rather than finding that the client had no “true” illness, they “played the game” and “danced the dance” to find a DSM category that suited well enough to justify services and compensation. They were willing to “extend the severity” of a client’s condition if necessary, but not to the point that they felt ethically compromised, according to the literature on clinical decision-making (e.g., Reamer 1997; Wolfson 1999 as cited in (Probst, 2013).
This seems to break so many ethical principles of the NASW code of ethics. We can first look at service, which states “Social worker’s elevate service to others above self-interest” (Reamer, 2018). I cannot think of any way that “playing the game” would not be doing something for self-interest. If you are doing it for your employer, then the self-interest is potentially your job, or if private practice, the self-interest would be for financial gain. Regardless the only reason to “dance the dance” is for financial reward in the end.
This plays right into the value of integrity. “Social workers are continually aware of the profession’s mission, values, ethical principles, and ethical standards and practice in a manner consistent with them” (Reamer, 2018). No further exploration on this value is really need it, as it sums it all up by practicing in a manner of consistent with the ethical standards and principles.
The ethical value of “Dignity and Worth of the Person” (Reamer, 2018) relates directly to the use of the DSM-5. This section of the NASW code of ethics continues by stating “social workers treat each person in a caring and respectful fashion”. If we are “extending the severity” of client’s condition, are we then treating our clients in a caring and respectful manner? Labeling someone with a mis-diagnosis can often cause them to be looked down upon, hurt them in a career search, this is all due to the false stigma that is placed on mental health disorders.
In closing I want to paraphrase Micki Washburn. Regardless of one’s own feelings regarding the DSM and the diagnostic procedure it promotes, social workers must be aware of the changes in the DSM-5 and their potential implications for clients. If social workers want to deliver the greatest possible assistance to their clients, correct diagnosis is the first and most important step. However, as social workers, we must be acutely aware of what we are diagnosing, the strength of the evidence foundation for the diagnostic criteria we are employing, and the ramifications of these diagnoses for our clients. (Washburn, 2013)
Corcoran, J., & Walsh, J. (2020). Mental health in social work: A casebook on diagnosis and strengths-based assessment (Third edition). Pearson Education, Inc.
Probst, B. (2013). “Walking the Tightrope:” Clinical Social Workers’ Use of Diagnostic and Environmental Perspectives. Clinical Social Work Journal, 41(2), 184–191. https://doi.org/10.1007/s10615-012-0394-1
Reamer, F. G. (2018). Ethical standards in social work: A review of the nasw code of ethics (3rd edition). NASW Press.
Wakefield, J. C. (2013). DSM-5 and Clinical Social Work: Mental Disorder and Psychological Justice as Goals of Clinical Intervention. Clinical Social Work Journal, 41(2), 131–138. https://doi.org/10.1007/s10615-013-0446-1
Washburn, M. (2013). Five Things Social Workers Should Know about the DSM-5. Social Work, 58(4), 373–376. https://doi.org/10.1093/sw/swt030
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