Where Are the Social Workers? One Social Worker’s
Road to Active Opposition to the New DSM
Jack Carney, DSW
The following is the third part of a serialized, four-part version of a larger article that has been accepted for publication in a peer-reviewed journal in 2014. The larger article is a compilation of three articles written in November, 2011, and in February and May, 2012, about the DSM-5 and its anticipated adverse impact on those in emotional distress who seek help from practitioners who utilize the DSM. In the series published here, the three articles are preceded by an Introduction, which constitutes Part I. They are subsequently followed by several Afterwords written in August, 2012, and April, July and August, 2013. The Afterwords comprise Part IV; references for all four parts will be found at the conclusion of Part IV.
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1984 & DSM-5 Revisited: Where Are the Social Workers (March 26, 2012)
Where are the social workers? Where are the NASW and its local and state-wide chapters? For that matter, where are the peer-run and-led advocacy and service organizations?
Over 12,000 individuals, mental health professionals and other stakeholders, have publicly declared their concern at the planned 2013 publication of the DSM-5 [14,000, as of August, 2012; 15,000 by July, 2013]. They’ve signed the petition launched six months ago by the Society for Humanistic Psychology and the American Counseling Association requesting that the DSM-5 Task Force delay finalization of the new DSM and allow a broader review of its work by professionals from disciplines other than psychiatry. Fifty-one professional organizations have also endorsed the petition … the National Association of Social Workers and its local affiliates, which represent 150,000 professional social workers, are not to be found among them.
So what’s going on with social workers? It’s almost like asking “What’s the matter with Kansas … ?” It seems like they and their professional organizations are voting against their own self-interest. Unquestioning acceptance of the DSM translates into unquestioning acceptance of the biological or medical model, which Read and colleagues have characterized as colonizing, i.e., diminishing, the psychosocial aspects of treatment — and, in the process, the relative importance of social workers (Lacasse, 2005). A 2008 article in the Archives of General Psychiatry describes the decline in the provision of office-based psychotherapy by psychiatrists, matched by a corresponding increase in psychopharmacology services – an apparent opportunity for social workers and psychologists, who comprise almost 90% of mental health professionals and provide the bulk of psychotherapy services nationwide. Offset, however, by the increasing proportion of outpatients who receive psychoactive medications without psychotherapy, as per the American Journal of Psychiatry (Druss, 2010).
Ultimately, however, most social workers, like most Kansas voters, are not motivated by self-interest but by core values and beliefs. Their acquiescence to the DSM-5 as currently composed signifies for me an abandonment of core principles – service to others; pursuit of social justice; respect for the worth of the persons being served; the importance of human relationships; and the salience of integrity and competence in social work practice (Code of Ethics @ www.socialworker.org) – and seriously undermines their fundamental mission of helping those who need it (see Lacasse, 2014).
The Open Letter which the Society for Humanistic Psychology and the American Counseling Association addressed to the American Psychiatric Association and which serves as the preface to their petition contains a pretty comprehensive review of the DSM-5 Task Force’s proposed revisions, most notorious of which include:
- lowering the threshold for mental illness, thereby increasing the likelihood of new and additional diagnoses;
- increasing the focus on children and adolescents via such novel diagnoses as Attenuated Psychosis Syndrome and Disruptive Mood Dysregulation Disorder, which appear to have little support in the clinical research literature and could well result in treatment with neuroleptic or other psychoactive medications;
- “fail[ing] to explicitly state that deviant behavior and primary conflicts between the individual and society are not mental disorders.”
- adding “grieving” that lasts for two weeks or longer to the list of criteria for Major Depressive Disorder.
To sum up the Letter’s principal concerns: “the proposal to lower diagnostic thresholds is scientifically premature and holds numerous risks … (that) increasing the number of people who qualify for a diagnosis may lead to excessive medicalization” and increased prescription of neuroleptic medications with all their attendant risks. To which I would add … “occupiers” beware, particularly when you “occupy” the APA Convention in Philadelphia on May 5 (2012); in addition — read Joanne Cacciatore’s blog-post entitled “DSM-5 and Ethical Relativism” that she posted on March 1 (2012) at (http://drjoanne.blogspot.com) and that has attracted widespread attention: she’s been grieving the loss of loved ones for more than two years and is still sad. How crazy is that!
Finally, be aware that the DSM-5 Task Force will soon announce its last public commentary period – check its website @ www.dsm5.org — after which it will begin to finalize the new edition. [That public commentary period ended in mid-June, 2012.] Accordingly, if you’re a social worker dismayed with a public mental health system in disarray, alarmed at the distortions resulting from the system’s sole reliance on the biomedical model, determined to re-commit to core social work values and promote change in a system that no longer works, here’s what you need to do:
- read the Open Letter and sign the petition … http://www.ipetitions.com/petition/dsm5/;
- e-mail the Board of Directors of NASW and ask them to endorse the petition … President@naswdc.org [still not too late to do so, as of August, 2012];
- Spread the word to your social work brothers and sisters. There’s still time to put a stop to the DSM.
- Don’t mourn, organize!!
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Boycott DSM-5? Why Not? (May 18, 2012)
Captain Boycott was the British land agent for Lord Erne of County Mayo who, in 1880, was ostracized from the local community as part of the Irish Land League’s campaign for agrarian tenants’ rights. Rather than harvest Lord Erne’s crops, his tenants let them rot in the fields, obliging the good captain to leave Ireland. Wittingly or not, he left behind his name, which was promptly applied to a protest tactic that has proved effective over the years.
I still don’t eat Iceberg lettuce or Thompson seedless grapes. And if grapes, why not the DSM?
The DSM-5 proved to be the center of conversation and contention at the American Psychiatric Association’s annual convention conducted in Philadelphia May 5 to 9. Even as the convention was concluding, a host of articles were published in the print and on-line press trumpeting the news that the DSM-5 Task Force had backed off including several proposed and controversial additions to the new DSM. Time magazine and Benedict Carey of The New York Times reported that two of the more controversial diagnoses, Attenuated Psychosis Syndrome and Mixed Anxiety Depressive Disorder, have been dropped because the field testing research undertaken by the Task Force did not provide sufficient supporting data. The “bereavement exception” to the diagnosis of Major Depression has also been re-inserted, if only as an explanatory footnote; and public commentary was re-opened on the DSM-5 website until June 15 although the projected publication date of May, 2013, remained unchanged (Frances, 2013a).
Medpage Today printed a comprehensive summary of all the changes in the draft DSM-5 to date, “DSM5: What’s In, What’s Out” (Gever, 2012); and Allen Frances, the editor of DSM IV and foremost critic of the new DSM, breathed a “Sigh of relief…” in his blog on Psychology Today. “… For the first time in its history,
DSM-5 has shown some … capacity to correct itself … the first step in a systematic program of reform … before DSM-5 can become a safe and scientifically sound document” (Frances, 2012a). He topped off his comments in an op-ed published in The Times May 11: “… Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists. They will also be an essential part of the mix but should no longer be permitted to call all the shots” (Frances, 2012b).
While I’m a great admirer of Dr. Frances, I don’t share his optimism regarding psychiatry’s ability to reform itself or the DSM-5 or psychiatrists’ willingness to share clinical decision-making or continued development of the DSM with other professional stakeholders. Those who have power don’t surrender it so quickly, unless under considerable duress. And I don’t believe the “public outrage” and the “uniformly negative press coverage” which Dr. Allen cites as instrumental in the APA Task Force’s modest turnaround, even if augmented, will prove sufficiently persuasive. Hence my idea for a boycott.
A recent article published in The New England Journal of Medicine (McHugh & Slavney, 2012),,“Mental Illness – Comprehensive Evaluation or Checklist?”, which expresses a point of view sharply if politely critical of the DSM-5, persuaded me that a boycott might not seem so far-fetched. The authors make three fundamental observations: first, the DSM task force has failed to answer the key question about the disorders that it presumes to categorize: “What are they?” In fact, the authors contend that the APA and its DSM task forces, dating from the DSM III, have failed to answer that question. Which is a polite way of re-stating Kirk and Kutchins’s and Bentall’s contentions that the DSM’s presumed disease entities, i.e., the mental illnesses it categorizes, have no construct validity, no data to support their existence. Accordingly, the DSM and its last four editions, III through IV TR, ignore the issue of causality – what’s behind these “illnesses” – and have substituted symptoms and their categorization in its stead. These same symptoms, the authors remind us, are common to a multitude of disorders and distinguishing between them as illness-specific is further confounded by continued poor inter-rater reliability. To bypass this problem, the DSMs have reduced presumed illnesses to symptom checklists which are expedient, cost-effective and serve more the interests of insurance companies and government monitors than those of clinicians and their patients. In practice, the checklists have replaced what the authors call the “bottom-up method of [assessment and] diagnosis … based on a detailed life history, painstaking examination of mental status and corroboration from third-party informants …”
The authors end with a biting admonition to psychiatrists: “ … [Only when psychiatrists address] psychiatric disorders in the same way that internists address physical disorders, explaining the clinical manifestations … by the causal processes and generative mechanisms known to provoke them … will psychiatry come of age as a medical discipline and a field guide cease to be its master work” (McHugh & Slavney, 2012, p. 1855)
Medical snobbery and one-upmanship aside, that statement tells me that psychiatry and its status within the medical profession hasn’t moved off the dime, that it’s still back where it was pre-DSM-III. As per Kirk and Kutchins (1992), one of the key motivating factors for the APA in assembling the DSM-III was to demonstrate to psychiatrists’ medical brethren that psychiatry had a solid scientific base and qualified as a medical discipline as valid as any other. The DSM-III and its subsequent iterations appeared to have secured professional legitimacy for psychiatry. Now it would seem that the brouhaha stirred by the DSM-5 has succeeded in blowing the smoke from the mirror, revealing anew the DSM’s original flaws – lack of construct validity and poor inter-rater reliability. Probably the best reason to not buy, to boycott the new DSM.
And what would be the consequences? For starters, the APA would lose a lot of money.
As Allen Frances has pointed out, the DSM, which has sold in the millions over the past thirty years, has been a “cash cow” for the APA (Frances, 2013a). More importantly, the thirty-year long momentum to label more and more individuals as mentally ill and to pathologize their behavior would be checked, even if not stopped entirely. Which would help to undermine the DSM as a tool of social control.
And what would clinicians use in its stead? Well, the DSM-IV-TR is still in circulation and could be used as a diagnostic checklist, its current principal function. Clinicians could also begin relying solely on the ICD (International Classification of Diseases) manual, which is itself a diagnostic checklist and must be used by providers, in accordance with U.S. law and international treaty, when submitting bills to CMS, the Center for Medicare & Medicaid Services, and to insurance companies. Coincidentally, the ICD-9 U.S.CM (clinical modification), which has been in use in this country for the past twenty years, was scheduled to be replaced by the ICD-10 in the Fall of next year. If you didn’t know already, the new ICD will contain 46,000 disease classifications, more than triple ICD-9’s current 14,000. Talk about bureaucracy. I guess the Feds and the insurance companies have been busy parsing every illness known to medical science. In that spirit, the DSM-5, now scheduled for release in May of next year, is being designed to contain a DSM à ICD 10 cross walk as an aid to clinicians.
In any event, Kathleen Sibelius, Secretary of Health and Human Services, the Federal agency that oversees the use of the ICD, recently announced postponement of the issuance of ICD 10 until 2014. Seems the necessary software programs are still being written. Something to look forward to! [There has also been speculation that the U.S. will bypass ICD 10 and proceed to issue ICD 11, which is scheduled to appear in 2015.]
It would be great to boycott use of the ICD as well; which would rattle the cage of the entire public mental health system; which serves to demonstrate how intertwined and intellectually bankrupt and financially fragile the whole mental health system is. A mirror image, so to speak, of our banking and financial systems. No, I would settle for a boycott of the DSM-5 to get things rolling. As I said earlier, I have no trust that continued pressure, even the threat of a boycott, would deter the APA from publishing #5.
At this point, the question I’d like answered is whether anyone reading this agrees that the idea of a DSM-5 boycott has some merit. Or is it just a crazy idea that would never fly? And if any one or more of you have any ideas about how to test the waters, how to get the word out to see if other folks, particularly the clinicians, who would be most likely to purchase copies, think a boycott could be mobilized.
Let me know what you think. Remember, don’t mourn, organize! Lots of work still to be done!
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Written by Jack Carney, DSW
*Content published with the Author’s permission.
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This is the fourth in a five-part DSM-5 boycott series that SJS will publish over the course of a month. For previous parts and to bookmark the entire series please visit http://www.socialjusticesolutions.org/social-work/dsm/dsm-series/.
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