by Allan Barsky, J.D., MSW, Ph.D.
The Diagnostic and Statistical Manual of the American Psychiatric Association, Fifth Edition (DSM 5) is known as the primary method of classification used by American mental health clinicians to diagnose patients with mental illnesses and conditions (http://www.dsm5.org). Diagnosis refers to a process of gathering information to understand a client’s condition, linking that information with knowledge about various cognitive, emotional, and behavioral conditions. The DSM is commonly referenced by social workers, particularly by clinical social workers practicing in the field of mental health.
At their best, DSM diagnoses help social workers and other mental health professionals understand clients, guiding their interventions from an evidence-based perspective. Diagnosis helps professionals with goal setting, treatment planning, and determining a client’s prognosis. Having a common nomenclature for diagnoses also facilitates research. Despite the widespread use of the DSM, social workers should be cognizant of the ethical issues that may arise in the context of using this diagnostic tool.
This article explores the DSM in relation to ethical concerns such as demonstrating respect for the dignity and worth of all people, empowering clients, practicing within one’s professional competence, and owing a primary duty of care to one’s clients. This article also provides suggestions for addressing these ethical concerns, allowing social workers to promote social work values and ethics even when using the DSM poses certain risks.
The social work value of “respect for the dignity and worth of all people” (in the National Association of Social Workers Code of Ethics) can be translated into ethical guidelines such as being nonjudgmental and building on client strengths. Diagnosing mental illnesses, however, is essentially an exercise in judging clients and focusing on their pathologies or weaknesses. When a social worker diagnoses a client with schizophrenia, for instance, the worker is highlighting problematic factors such as hallucinations, delusions, and paranoia. Conditions such as depression, borderline personality disorder, and autism spectrum disorders also label clients with undesirable client traits. So, does this mean that using the DSM to diagnose clients runs contrary to social work ethics?
Although some professionals might argue that DSM diagnoses violate the principles of nonjudgmentalism and strengths-based practice, others might argue that such diagnoses are ethically justifiable under the principle of beneficence, doing good. As noted earlier, providing diagnoses serves clients by providing a framework for selecting appropriate, effective interventions. Diagnoses may also serve clients by providing them with medical labels rather than moral labels. In the field of addictions, for instance, being labeled as an alcoholic or addict may lead to moral judgments, implying frailties such as laziness, lack of willpower, moral weakness, or irresponsibility. Having a DSM diagnosis such as “substance use disorder” suggests that the person has a medical condition rather than a moral weakness.
Thus, in terms of respect, social workers who use diagnoses should avoid language that reduces the person to a diagnosis—for example, “He is a borderline personality,” or “She is a schizophrenic.” Rather, they should use language that separates the person from the problem—for example, “He is a person with borderline personality disorder,” or “She is coping with schizophrenia.”
Social workers should also ensure that they provide holistic assessments, not just focusing on problems or psychopathologies. A holistic assessment highlights client strengths and considers clients in the context of their social environments, including their family, friends, co-workers, neighbors, and other social support systems. A holistic assessment includes psychological functioning and problems, but also includes social functioning, spirituality, physical health, and coping abilities.
“Empowerment” refers to providing clients with time, space, support, and other conditions that allow them to have greater control over their lives. Empowerment demonstrates respect for the dignity and worth of clients by treating clients as autonomous individuals with the right to make choices and decisions throughout the helping process (NASW Code of Ethics, Standard 1.02).
When using the DSM to diagnose, social workers assume the role of expert, taking responsibility for determining which mental conditions clients have, rather than involving clients as full partners in the decision-making process. For instance, a social worker informs a client that he has depression rather than inviting the client to jointly explore whether he has concerns regarding depression.
Although providing DSM diagnoses can disempower clients, social workers can mitigate this concern by the manner in which they conduct their diagnoses. Consider a social worker who educates a client about the diagnostic process, allowing the client to be a more equal partner in determining what conditions the client may be experiencing. The worker could provide the client with information about depression, including the possible indicators of depression and what tools can be used to help determine whether the client is clinically depressed.
Ideally, the worker and client agree upon the process for diagnosis, as well as the determination. In situations in which the worker and client disagree about the diagnosis, the worker could document both the worker’s and the client’s conclusions. “The client scored 38 on Beck’s Depression Inventory, indicating a severe form of depression. The client says she does not think she is depressed because she does not feel suicidal.” Workers should explore why the client is denying a particular condition. The client may have cultural or personal concerns, such as taboos or negative implications of particular diagnoses (e.g., “If I am diagnosed with depression, I’ll be shunned and nobody will want to marry me.”).
The client may also have questions about the validity of the DSM. The DSM-5 has omitted a number of diagnostic categories used in its previous editions, because they lacked validity and research support. Who is to say that the current diagnostic categories are valid? In many situations, clients require a DSM diagnosis for services to be covered by Medicare, Medicaid, or private insurance. Workers should explain the purposes of diagnosis, including the possible benefits and risks of having a diagnosis. Explaining the purpose and implications of diagnosis provides the client with an opportunity to provide truly informed consent (NASW Code of Ethics, Standard 1.03). If a client does not want to be diagnosed, the worker could discuss alternatives, for instance, referring the client for services where a DSM diagnosis is not required.
In terms of professional competence (NASW Code of Ethics, Standard 1.04), workers should not diagnose clients unless they have the appropriate training, supervision, knowledge, and skills—as well as licensing. If social workers lack such competence or accreditation, they should avoid language that suggests they have diagnosed a client. Stating that a client has depression, for instance, indicates the worker has made a diagnosis. If the worker lacks competence to provide a diagnosis, the worker could document indicators of depression, but should not draw the conclusion that the client has depression. If the client needs a formal diagnosis, then the worker should refer the client to a properly qualified mental health professional.
Duty of Care
Social workers owe their primary duty of care to the clients they are serving. Thus, when determining whether to diagnose a client, they should consider whether the diagnosis is truly in the client’s best interests. A social worker might argue that providing a client with a clinical diagnosis ensures the client has access to services, as well as ensuring that treatments or services meet the needs of the client given the client’s diagnosis. Still, the worker should consider whether a diagnosis is truly in the client’s best interests. What if having a diagnosis serves the agency or practitioner’s needs, but not the client’s? What if providing a client with a diagnosis causes the client more stress, anxiety, guilt, or shame than help? What if diagnosing a client might cost the client a job, or the ability to obtain future employment? Having a history of mental illness may be used as grounds for denying employment or even professional licensure. Although the Americans with Disabilities Act (ADA) prohibits discrimination on the basis of disabilities (including mental illnesses), discrimination may arise and it may be difficult for clients to enforce their rights under the ADA.
Providing clients with a DSM diagnosis could cause harm, so it is incumbent for workers to consider both the possible benefits and risks of providing a DSM diagnosis. In many settings, providing diagnoses is such an integral part of the agency’s processes that workers hardly give a thought to the possible harms that clients may incur.
Some workers and supervisors may say that providing a diagnosis is required and that there is no alternative. Although diagnosis may be required for agency or insurance reimbursement purposes, there are alternatives. As noted earlier, other agencies may be able to provide services without a diagnosis. Alternatively, a client may decide to reject services rather than receive a psychiatric diagnosis.
Some critics have argued that the DSM is too complex, incoherent, and inconsistent with the research. Social workers will need to be particularly cautious with some of the more controversial diagnostic categories. For instance, some mental health scholars argue that “disruptive mood regulation disorder” will turn temper tantrums into a mental disorder. Likewise, normal grief experiences could be diagnosed as “major depressive disorder.” Periodic excessive eating could lead to a diagnosis of “binge eating disorder.” Many diagnostic categories allow diagnosticians to rate disorders as mild, medium, or severe. Diagnosticians should be careful about diagnosing people with mild disorders, as there may be a thin line separating normal functioning and the mild form of a particular diagnostic category. If a substance use disorder, for example, is very mild, then does it warrant a diagnosis that will stay on the client’s records for the rest of his or her life?
Remember that the DSM is not the only tool for diagnosing clients. Social workers may find other instruments more helpful for gathering information and developing a better understanding of their clients. In some instances, using the DSM in conjunction with other tools may be helpful for the worker and the client.
Yes, in many contexts of practice, DSM diagnosis is a fact of life. Regardless of the context of practice, social workers should mitigate the risks of DSM diagnoses. We can do so by respecting the dignity and worth of clients, empowering clients, putting client interests first, and, if diagnosis is required, ensuring that the diagnostic process is conducted by a professional with appropriate knowledge and skill.
Dr. Allan Barsky is Professor of Social Work at Florida Atlantic University and former Chair of the National Ethics Committee of the National Association of Social Workers. He is the author of Ethics and Values in Social Work (Oxford University Press), Conflict Resolution for the Helping Professions (Oxford University Press), and Clinicians in Court (Guilford Press). The views expressed in this article do not necessarily reflect the views of any of the organizations with which Dr. Barsky is affiliated.