In this interview, SJS speaks with avid SJS reader and facebook fan Lisa Zigler, of Canada. For the past 23 years Lisa has worked as a social worker in various settings, and describes herself as a professional informed and driven by her understanding of oppression, commitment to Social Justice issues, and her experiences with activism on various issues, such as feminism and LGBT issues. In 2004, she and her partner (now spouse) along with another lesbian couple successfully sued their Federal and Provincial Government to change the law allowing same-sex marriage in that jurisdiction.
Let’s see what Lisa has to say about her experiences, and her feelings on the new DSM 5. In addition, many of our readers have also asked for sources and references in regards to some of the comments made in past DSM interviews. So, at the bottom you will see that Lisa has provided several references to comments that she says.
Social Justice Solutions (SJS): SJS is excited to give a Canadian perspective to the new DSM, and we are delighted to be interviewing you today, so thank you very much! Let’s start by having you tell us a bit more about your social work experience.
Lisa: My practice has been varied and has included work with individuals living with mental health issues while living in Toronto; community work as the Executive Director of a women’s equality seeking organization in St. John’s, Newfoundland and Labrador, as well-being a course instructor at the School of Social Work at Memorial University in St. John’s.
My current position is with a large health authority here in Newfoundland and it involves overseeing a collaboration between the health, government and community sectors in order to improve the way our services are delivered to individuals with “complex needs.” Of course when we talk about complexity, it is really the systems themselves that are “complex” rather then individuals isn’t it? My MSW has given me opportunities to continue my work as a change agent.
SJS: Great! And how often would you say you use or have used the DSM in your practice?
Lisa: In my current position, I do not use the DSM on a regular basis. Rather, I am committed to educating a wide variety of people about the fact that we are all on a continuum of mental health; that we will all go through life experiences that may lead us to seek out mental health support. When I first started working in the health sector, my position was as a social worker in an Adult Psychiatry Unit of a Psychiatric Hospital here in St. John’s. I remember quite clearly my first experience of “clinical rounds.” Having just changed positions from my previous employment as the Director of a Women’s Centre, you can imagine my reaction when I sat in a room with mostly men who spoke about a “trauma survivor” as if she was somehow to blame for where she was in her life. I listened as the Psychiatrist had his medical students form an opinion of this individual based on the DSM 4 categories. Suddenly, this individual became a “borderline personality.”
When I could not stay silent anymore, I spoke of the impact of trauma and of the strong survivor skills this woman had developed. I challenged their view that this person had gone from being a unique individual to being a disorder in the first 10 minutes of the meeting. When I spoke about violence against women, poverty, and lack of choices, you could hear a pin drop in the room. They never asked me another question again. For the next several months I continued to speak out in order to give a voice to those who sometimes lose their own.
SJS: Wow, so great for you to advocate like that! What do you think is the biggest flaw with this new DSM 5?
Lisa: For me, the biggest flaw of the DSM 5 is that it continues to view aspects of the human experience as some kind of illness that needs to be treated. Although I fully understand that there are individuals with clinical mental health issues that seem to respond to pharmacological treatment, I fear that the DSM 5 will continue to result in many people being diagnosed with mental illnesses, when in fact they may be reacting to common stressors in our society.
As social workers, we need to be aware of the significant influence that Big Pharma has in the development of the DSM 5 and its previous editions and much of the research that is conducted in this area. As a profession with a commitment to social justice, social workers need to understand the impact of poverty, abuse and oppression upon groups and to be critical of the use of the DSM 5 as the primary tool to understand mental health issues.
SJS: And how will these changes influence the client population you work with specifically?
Lisa: I believe that the fact that “normal behavior” can lead to a psychiatric diagnosis will have a strong and I would suggest, a harmful impact on individuals with mental health issues. With this new edition, it seems to me that the focus has been on adding more “disorders” instead of asking the questions that need to be asked. As social workers, we are aware of the importance that the social determinants of health have on those with whom we work. To use the medical model and the DSM 5, which dictates how clinicians should understand and “treat” without factoring in structural issues such as oppression, will result in people not receiving the help they need. It is also important to keep in mind that having a psychiatric label carries with it a lot of stigma and can impact every facet of a person’s life.
Giving someone a range of medication without understanding that maybe the woman sitting in front of you is depressed because she knows that when she goes home after she sees you she will be beaten up. How does this help? Medication and a diagnosis of “battered women’s syndrome” for example, won’t get at the root causes of her feelings; it will only contribute to her core belief that she is doing something wrong.
SJS: And how do you believe these changes will influence the broader context of the mental health field and the social work profession?
Lisa: To be honest, I worry about the continued emphasis of the DSM and the significance it has for the psychiatric profession. I worry about the attitudes and practices of some professionals in the mental health field. I am especially worried about the messages that social workers are getting about the focus we need to have in our work. The prominence of the DSM 5 must be challenged. I am really pleased to see the critical dialogue that has resulted with the release of the DSM 5. The problem is that we continued to teach our future social workers; our employees; and our colleagues that the primary role of social work is to conform and accept that many of their “patients” will have some kind of biochemical disorder, this is troubling to me.
I have been concerned for some time about the direction that many schools of social work have taken around these issues. When I teach, I do cover the DSM, as students need to know what the manual is and what it is used for. I do however use a critical lens in discussing this clinical tool. I ensure that students are educated in the structural factors that impact their own lives and the lives of those who may seek out their support.
Unless social workers are getting this bigger picture, the use of the DSM 5 will continue to be used, sometimes exclusively, to make clinical judgments that may not be in the individual’s best interests. Social workers need to question this and be that all-important voice at the table.
SJS: Very good points, emphasis on diagnosis has such a broader impact than many think. So, what do you believe led the mental health professions to make such changes as those being suggested in the DMS 5?
Lisa: I believe one of the driving factors behind the DSM 5, as well as its earlier editions is without a doubt, the influence that Pharmaceutical companies have over the entire process. Lets keep in mind that these multinational companies make billions each year from selling medication. To be honest, I have no idea why we even needed a new version of the DSM. Although it seems to have added a few new “illnesses” here and here and it has taken out others, it makes no significant changes to the reliance that the mental health profession, psychiatry in particular, places on using this tool.
There has been a lot of good research about the link between drug companies and the “hold” they seem to have on many psychiatrists and family doctors. It is well-known and well documented that these companies spend significant amounts of money on convincing professionals to prescribe the “pill of the day” to individuals, some of whom may not even have a biochemical disorder.
For example, according to a study by Cosgrovea, Krimskyb, Vijayaraghavana and Schneidera (2006), on the financial connections that DSM 4 Panel Members, who decide what “disorder” is added and what is removed found:
“Of the 170 DSM panel members 95 (56%) had one or more financial associations with companies in the pharmaceutical industry. One hundred percent of the members of the panels on ‘Mood Disorders’ and ‘Schizophrenia and Other Psychotic Disorders’ had financial ties to drug companies. The leading categories of financial interest held by panel members were research funding (42%), consultancies (22%) and speakers bureau (16%).”
One only has to do a Google search on pharmaceutical companies and the DSM to understand the power and financial gain behind the development and use of this “diagnostic tool.”
SJS: Those are some frightening numbers, thank you for sharing the resource. Now, for the most part social workers have remained silent over the development and the release of the DSM 5, as with past DSMs and other major policies, standards and diagnostic changes that influence how we work with our clients. Why do you think this is?
Lisa: I think there are many reasons for the silence, including not receiving the kind of education that social workers need to develop a critical analysis, or perhaps not feeling as though they can ask the hard questions.
While there are many social workers that practice with great skill and awareness, I am very concerned that even after years of studying social work, there are some workers that don’t seem to get it. Our role is not to become complacent and it is certainly not to be a cog in a larger wheel. Rather it is to understand that diagnosing and “treating” is only one aspect of social work practice. I worry that our schools of social work have become far too mainstream, not encouraging students to find their voice. I think we need to take a step back and understand that this profession is about change, not silence. As long as members of a profession that by its very roots is about challenging injustice remain silent, the status quo will be maintained.
SJS: Okay, all very good possibilities as to why we might remain silent. To change track a little bit, where do you believe the mental health field will go from here?
Lisa: Good question. My fear is that if we continue to believe what we are told about the importance of diagnosing as opposed to understanding and respecting others, then we are in trouble. If we cannot see through the role of Big Pharma and the power behind psychiatry; if we start to believe all the advertisements suggesting that there is something wrong with us that a pill will fix, then we are in my opinion, part of the problem.
We have a responsibility to be ethical in the choices and decisions we make. Part of that for me is to view those with whom I work, holistically and understand that the personal really is political. On the other hand, if social workers find their collective voices, if they start to question, to challenge and to work for change, then we have a chance.
SJS: That’s a great call to action right there, and hopefully we can be part of the driving force behind moving in a new direction. To conclude, what can we as social workers do to ensure the most effective diagnosis and treatment of our clients?
Lisa: If you have an old version of the DSM, I would suggest that you pack that away somewhere. Instead of using your hard-earned money on purchasing the DSM 5, my advice would be to take that money and donate it to a worthwhile charity of your choice. Don’t worry if you actually need to use it, most of your colleagues will have a copy you can borrow.
If you are a student, become a world citizen. Become aware of world events. Don’t live your life on Facebook telling your friends what you are doing every five minutes. Rather use social media as a tool to become aware and educated.
If you are employed in an organization or hospital that uses the DSM 5 and the Medical Model to diagnose and treat, think back to why you became a social worker in the first place. If you are like me at all, it was to make a difference and to affect change.
Make that difference. Understand why individuals seek out our support and make a commitment not to judge, diagnose or treat. Instead, understand, listen, support and take action.
SJS: Wonderful advice for all walks of social workers! Thanks for interviewing with us Lisa.
Here are just a few resources/social media that have informed my thinking on these issues:
Caplan, P (1995) “They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal” De Capo Press, USA.
This book is still in print and is available online at a number of stores.
Dr. Paula Caplan on how psychiatrists decide who’s normal (video runs 25 minutes but is well worth a listen)
Cosgrove, Krimsky, Vijayaraghavan , Schneider. Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry. Psychother Psychosom 2006;75:154–160
Adam McGibbon Corporates cashing in on mental-health diagnosis, retrieved on June 12th 2013 on http://newint.org/blog/
Georgianna Dolan-Reilly, LMSW