Where Are the Social Workers?: One Social Worker’s
Road to Active Opposition to the New DSM
Jack Carney, DSW
The following is the fourth 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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Afterword: Part I (August 23, 2012)
So what’s happened in the interim?
For starters, immediately after the American Psychiatric Association’s annual meeting ended in Philadelphia in early May, 2012, where the new DSM was the major topic of discussion, John Gever, senior editor for Medpage Today, wrote a very thorough review of DSM-5’s post-APA status. Entitled “DSM-5: What’s In, What’s Out,” (Gever, 2012). Among the newly proposed diagnoses, all of which stirred some controversy, Gever noted that “Disruptive Mood Dysregulation Disorder,” aimed at “children [over 5 years of age] showing persistent foul temper punctuated by burst of rage,” had been retained in DSM-5 despite earlier criticism deriding it “as an attempt to medicalize ‘toddler tantrums’.”
On the other hand, “Attenuated Psychosis Syndrome,” to be applied to individuals “with low-level hallucinations and thinking disturbances,” was put on hold “because it might give patients who might never go on to more severe symptoms the ‘psychotic label” [and expose them to unnecessary] antipsychotic drug therapy.” Rather than being discarded, however, it along with several other proposed diagnoses – “body integrity disorder”; “hypersexual behavior”; “skin-picking syndrome”; “persistent complicated bereavement disorder” – were relegated to DSM-5’s “Section III with the hope of attracting more research.” It would appear that the DSM-5 Task Force is thinking ahead and already laying the groundwork for the DSM’s next revision.
Gever had little to say about the “Personality Disorders” section of the new DSM, which was proving so controversial that the Task Force was obliged to extend the public commentary period to July 15. To quote from the July 7 APA press release defending the Task Force’s work, the “diagnostic criteria [for personality disorders represent] a significant reformulation … [integrating] disorder types with personality disorder traits and … levels of impairment in what is known as ‘personality functioning’.” Critics such as Allen Frances debunked this assertion, contending, as Frances (2013b) does in his new book soon to be in press, that “the DSM-5 section on personality disorders is unusable” (Frances, 2013b) (see below). Much was also made of the resignation from the Personality Disorders Committee of its last two non-American members two months earlier, who had declared “We resigned from the DSM-5 … Personality Disorder Work Group … because the Work Group … has advanced a proposal that is seriously flawed.”
Fortunately for me, I’ve been able to continue to participate as a social worker in a public discussion dominated by psychiatrists and psychologists, thanks to several initiatives taken by my local, New York City, chapter of the NASW. First, in response to my queries re. social worker inaction on the APA/ACA Open Letter petition, the Chapter leadership invited me to write an article for Currents, the Chapter’s on-line newsletter,
which was published on the front page of its February edition. So far as I know, the article elicited little response from Chapter members. Next, the Chapter put me in touch with the person at NASW headquarters who had been charged with “monitoring” what was transpiring with DSM-5. She assured me that she was, that the NASW leadership was fully informed and that the NASW would maintain its “wait and see” stance. Zero for two, but still swinging.
Over the summer, the Chapter partnered with NYU’s Silver School of Social Work to co-sponsor a conference scheduled for October to discuss the new DSM and its implications for Social Work. The conference is titled “Evolution of the DSM and the Application of DSM-5 to Social Work Practice.” I’ve been invited to talk about “What changes mean for the profession,” which has been the occasion for developing the powerpoint presentation, “Where Are the Social Workers?’, which I’m offering to interested readers. (E-mail me for a copy). In it, I list my principal objections to the DSMs, which I’ve enumerated in section II of this article; remind conference participants that the public mental health system could well be entering a transitional stage, which will present social work with a unique identity to re-assert its essential role, reformulate its helping mission and champion the psychosocial as cause, consequence and solution (Gomory, Wong, Cohen & Lacasse, 2011). The presentation will conclude with the implications of my proposals for social work education and a listing of what I consider “essential readings.” While many audience participants – in the main, rank and file social workers – appeared interested, those in positions of authority – agency and program directors, were dismissive. Their concerns were centered on the changes – in computer software and billing practices – that the new DSM might occasion. Discussion with NASW NYC chapter leaders at the conference’s conclusion about follow-up actions were never resumed.
I followed the Conference’s keynoter, Dr. Jerome Wakefield, professor at the Silver School, whom I met online – how else? – at the instigation of Allen Frances. Dr. Frances, with whom I also have an online relationship – we read one another’s blog-posts – was determined to involve other professionals, particularly social workers, the single largest group of mental health practitioners in the country, in the struggle to stop or at least slow the new DSM. In addition to Dr. Wakefield, Dr. Frances introduced me to Dr. Joanne Cacciatore, an assistant professor of social work at Arizona State. Circles within circles. Dr. Frances prodded us to reach out to our social work networks, whose immediate negligible results might still have some longer term positive consequences. On a more personal level, Dr. Frances afforded me the opportunity to provide him with feedback re. the book he’s preparing for publication in the very near future, before the DSM-5 is published next May. It’s entitled The Essentials of Psychiatric Diagnosis and Coding, and it’s noteworthy, in my estimation, for its warm, welcoming tone. It will serve, as Dr. Frances intended, as an alternative to the DSM-5 that will help novice and experienced practitioners effectively engage and diagnose the persons they’re intending to help, as well as to develop a treatment plan to address the problems they uncovered. If I had my druthers, there would be no DSM and no alternative to it; but, as I indicated above, this is, at best, a time of transition, and practitioners will be besieged by the Centers for Medicare and Medicaid Services (CMS), other government agencies and insurance codes for diagnoses and codes. Dr. Francis doesn’t eschew the biomedical model; doesn’t include as key etiological factors trauma, racism or poverty; but he does emphasize the imperative for practitioners to do no harm. I have great respect for him and his endeavors.
As final reminders for readers, the APA/ACA Open Letter is still posted at http://www.ipetitions.com/petition/dsm5/ and should be read by all those who wish to inform themselves of the issues in question. It is comprehensive and clearly written and its accompany petition can still be signed by all who support the Open Letter’s message. Similarly, the DSM-5 Task Force’s website is also up and running – www.dsm5.org — and will contain periodic posts from the Task Force as the new DSM is finalized and nears publication. Finally, the struggle to change – and perhaps end – the public mental health system can only gather momentum as new actors, peer-survivors as practitioners, enter the field and the fray. Accordingly and despite DSM-5’s probable publication, don’t mourn, organize! Remember, we’re all “prisoners of hope.”
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Afterword: Part II (April 21 and July 30, 2013)
In late December, 2012, I decided to proceed and organize a boycott of the DSM-5. I recruited two individuals who were like-minded, Dr. Joanne Cacciatore, an assistant professor of Social Work at Arizona State University, and Dr. Dan Fisher, a psychiatrist and Executive Director of the National Coalition for Mental Health Recovery Cambridge, Massachusetts, and we set about organizing the Committee to Boycott the DSM-5. An account of the difficulties we experienced in launching the Boycott on February 6, 2013 is to be found in an article posted on Mad in America on February 26 and titled “The Politics of Systems Change: Lessons Learned from the Launch of the DSM-5 Boycott.” Another follow-up article, “Next Steps: More Lessons Learned From the DSM-5 Boycott,” was posted on Mad In America on May 24, four days after the official publication date of the DSM-5. Both describe, among other things, two unanticipated phenomena:
- The apparent indifference by most mental health professionals in the U.S. to the fundamental flaws uncovered in the DSM-5 and its predecessors. Less than 2000 persons have endorsed our Boycott statement in the more than three months it has been posted on our ipetitions website. (As of July 30, that number had risen to 2082.) Allen Frances has interpreted this to indicate that the “DSM-5 has a captive audience.” I prefer John Read’s earlier explanation, viz., that the biomedical model has succeeded in colonizing all others, including , so it seems, the critical thinking of most practitioners.
- The greater willingness on the part of European professionals, particularly psychologists and psychoanalysts, to refuse to purchase or use the new DSM and
to call for fundamental changes in existing public mental health systems. In part, it appears they resent what they consider the American cultural imperialism embodied in the DSM. In any event, it has taught us that opposition to the DSM is world-wide and that international collaboration is not only possible but, thanks to social media, practical.
In the end, despite our several setbacks, hope, like the Dude, abides, and our strategy to discredit the APA and the credibility of the DSM appears to have been on target.
On April 24, Dr. Thomas Insell, Director of the National Institute of Mental Health, announced that NIMH would no longer use DSM’s nosology or disease classifications in its research. Rather, NIMH will only fund investigations that utilize its own “research framework,” the “Research Domain Criteria (RDoC)”; which, wonder of wonders, is at least ten years away from being operational. To quote Insell, “… we cannot design a system based on biomarkers or cognitive performance because we lack the data … RDoC is a [research] framework for collecting the data needed for a new nosology … Not a clinical tool … a decade-long project that is just beginning…” (Insel, 2013).
The timing of Insell’s announcement could not have been worse for the APA – less than one month before the new DSM’s publication. And the rationale couldn’t have been more damning: the DSM’s continued poor construct validity – 20 years and still no biomarkers – and its worsening inter-rater reliability (see also Carney, 2013x). It’s not that NIMH was about to embark on a radically different course – it is still wedded to the biomedical model – and it would take, as per Insel’s estimate, a good ten years for its researchers to develop its own classification system. Yet, NIMH had dumped the DSM and set the stage for our next phase of action.
Come this Fall, we plan to launch our No-Diagnosis Campaign, asking practitioners committed to change to eschew the use of all DSM diagnoses with individuals who seek their services and to limit their utilization of ICD codes for billing purposes only. We will suggest as an alternative the “psychological formulation” methodology being promoted by Lucy Johnstone and colleagues in the U.K. – quite similar to the “collaborative formulation” pioneered by Paula Caplan twenty years ago, as well as to the psychosocial assessment which has historically been the bedrock of social work practice. Keep an eye peeled for the article I plan to post on MIA detailing the specifics of the campaign sometime in September and join us.
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Final Word (August 2, 2013)
One of this journal’s editors asked me to speculate as to why social workers have remained quiet about the new DSM, why they appear to have surrendered their allegiance to the psychosocial and succumbed to the biomedical.
Two thoughts on that. First, let me start with Tom Frank’s (2004) Whatever Happened to Kansas …? He theorized that Kansas voters abandoned the state’s traditional liberalism and went conservative, to the apparent detriment of their self-interest, as a consequence of their loyalty to fundamentalist religious principles. Social workers have done just the opposite, abandoning fundamental social work principles and, in the process, their commitment to change and social justice. Ironically, conservative Kansans and social workers, two presumably disparate groups, made apposite decisions by following the very same practice, i.e., by ignoring the facts. In the case of the Kansans, their self-identity was on the line and so creationism trumped evolution. Social workers, on the other hand, have surrendered who they are to a shell game promoted by hucksters who promise a magic pea, the biological origins of mental illness
Speculation #2. Ira Katznelson (2103), in Fear Itself: The New Deal and the Origins of Our Time, describes how the metaphor of “the market” has come to dominate the political as well as the economic spheres of American life, replacing bottom-up democracy and inter-group cooperation with competition between interest groups: those with the money and the power get what they want; ordinary Americans, with little of either and no large entity or institution to represent their interests, get growing income inequality and the promise of social marginalization.
American cultural and intellectual institutions have proceeded to adopt the market metaphor and its practices and now follow the money, regardless of the consequences for their constituencies or the larger society. Social work has not been immune to this phenomenology. Its leaders – academics; agency directors; policy planners — have accepted the hegemony of Psychiatry and its biomedical model with little inquiry into their validity, offering their constituency, rank-and-file social workers, no alternatives but to abandon social justice for social control and incarcerate their historical constituency, the poor and powerless, in an oppressive social welfare system. In short, following the money.
The facts are in. The biomedical model has no empirical foundation. Psychiatry is corrupt and bankrupt. The choices are clear. Remember Joe Hill’s plaintive reminder to us all as he faced a Utah firing squad — “Don’t mourn, organize!”
Written by Jack Carney, DSW
*Content published with the Author’s permission.
This is the fifth 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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