The Great Divide: A Growing Disconnect (Response to the DSM-5)
by SaraKay Smullens, MSW, LCSW, CGP, CFLE, BCD
In your work, you may be encountering an unfortunate reality of the social work profession and of the psychological professions in general: researchers and clinicians have not usually walked hand in hand, consulting and collaborating, complimenting each other’s efforts. In fact, it too often has seemed as if the two orientations exist in a universe unrelated to the other.
In the field of psychiatry, research-oriented psychiatrists and academics often have little awareness of the solid, time tested body of knowledge that is the essence of social work education. Our emphasis on mutual respect and lack of condescension toward those we are privileged to work with, as well as the deep respect we hold for the innate capacities of all individuals to grow, heal, and change, is often overlooked by researchers in favor of an emphasis on biomedical, genetic, and neurological factors.
This divide has intensified in recent decades as psychiatry has become dominated by a growing attempt to categorize psychological reactions in the same way medical science categorizes physical illnesses. Normal conditions are classified as disorders, while at the same time, many of our clients with serious psychiatric illnesses who can be accurately and clearly diagnosed and treated are being neglected.
In brief, those who “talk this talk,” even those with patient contact, usually have little understanding or appreciation of the real lives and struggles of our clients or the body of time tested knowledge and skill we call on as we “walk the walk” with them. The recent changes in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) reflect this unfortunate and widening schism. According to one of the nation’s preeminent professors of social work, Dr. Jerome Wakefield, “The DSM-5 Task Force would claim that (these) changes are based on scientific evidence; however, when the evidence is closely examined, this claim turns out to be extremely exaggerated. It depends very much on the specific change. Some changes are based on reasonable evidence; others are based on flimsy or questionable evidence, and still others are based on virtually no evidence at all” (personal communication, 2013).
The “brain disease” model that currently dominates in psychiatry largely ignores the complexity of emotional problems and their frequent anchoring in real environmental circumstances. It encourages the development of new drugs to treat what is often normal emotional distress in an already over-medicated population. It is based on a mindset that disregards or minimizes respect for individual complexity and difference, marking a dangerous individual, familial, and societal direction. We, as social workers, as well as all clinicians who are dependent on insurance companies for reimbursement, know that these reimbursements will depend on strict adherence to the DSM-5. We also know that fewer available sessions will mean greater dependency on drugs for a society that is already far too drug dependent.
Consider these facts: 94% of all individuals in the United States who consult a mental health professional will visit with a mental health and substance abuse social worker, a clinical and counseling psychologist, a marriage and family therapist, or other mental health or substance abuse counselors (Grohol, 2011). Yet, for example, not a single individual with a social work background was on the committee that made the final decisions regarding diagnostic evaluations.
It is ironic that although the majority of mental health patients in the United States have clinicians as their health care professionals, researchers have come up with many dangerous and seemingly arbitrary changes to the newest edition of the DSM that have no chance of standing the test of time (Frances, 2012). What we find reflected in the recent DSM is an emphasis on unnecessary diagnostic labeling and a reliance on either unnecessary or prolonged medication and hospitalization. What is missing is emphasis on working through conflicts and the clinical support and alternative healing strategies, including a combined tincture of time and talk, that provide solace, lessen pain, and lead to insight and clarity of thought.
I am in no way saying that medication is all bad, or not to be used in the short term to feel better and cope, and when indicated for longer periods. What I am saying is that drugs are not always necessary, and long-term medication should be a very clearly thought out option, not a first and easy one.
We are learning more and more about serious brain disorders and how to treat them. The growing science of the mind concludes that our mind and our brain are inseparable—that our brain is the complex organ that controls the mind. This is an extraordinary, burgeoning achievement, one that researchers, academics and clinicians can, should, must use in concert for the well being of those our professions serve. For serious illness, some respond better to meds, some to psychotherapy, and some a combination. My mentor—the late psychoanalyst Eli Marcovitz—and Aaron Beck—who pioneered cognitive therapy—have each insisted that their respective fields, psychoanalysis and cognitive therapy, can be studied empirically. This means that serious psychiatric illnesses can be better treated than ever before. That said, becoming unsettled by tragic life events or to the insensitivity and cruelties of others are not brain disorders.
I am reminded here of a wedding I went to a few years ago. I was seated next to a psychiatrist/researcher several years younger than I. His wife sat across the table, staring into space. Pointing to her as if she were an inanimate object, the psychiatrist and father of three explained that his wife was medicated and then described his marital frustrations to our small table: “From the beginning of our marriage, my wife complained and complained and nagged, telling me I was not home enough. She just did not understand the demands of my work and that it was her job to care for our home and kids.”
A few at the table offered polite comments, attempting to change the focus of the conversation. But the psychiatrist persisted: “Then five years ago, out of the blue, she spent thousands of dollars on a piano that she does not know how to play, and a piece of art, featuring of all things, a man and a woman having sex. I immediately knew I had been overlooking that my wife is bipolar. A couple of weeks in the hospital and her meds have made our life manageable.”
I quietly responded to my dinner companion that perhaps these purchases were his wife’s plea for someone to hear her music—someone to talk to and connect with. His response was a smirk, as he turned to someone sitting on his other side to converse with, keeping his back to me for the rest of the evening. Later in the evening when I had the opportunity to introduce myself to his wife, I sat down next to her. What she told me was bone-chilling: “I am no longer here, you know.”
Now the newly published DSM-5 has taken this growing “take a pill and fix it” approach to even more dangerous ends. Normal sadness after the loss of a beloved partner falls under the heading of clinical depression. (Isn’t deep, persistent sadness following this kind of trauma a continued love letter to a beloved?) Angry outbursts fall unto the category of an intermittent explosive disorder. (Who, I would also like to know, takes into account that certain ways one may be treated can lead to such explosions? Or in the words of one of my former professors at the University of Pennsylvania, Dr. Richard Lodge, “Every house has a chimney, and people need them too!”) Further, there is a dire lack of research on the impact of drugs readily prescribed for the long term. (Think of what research revealed about long-term use of hormone replacement therapy.)
How do we distinguish, then, between what is illness, requiring medication, and what is a manifestation of life faced by the “worried well,” which does not?
Wakefield (2013) presents this conceptual framework: There is a difference between mental disorder and normal range problems of living. Mental disorders are not merely problematic or harmful; they are ‘‘harmful dysfunctions,” in which the harm can be any negative or undesirable condition according to social values, and the dysfunction that causes the harm is the failure of some internal psychological process or mechanism to function as it was biologically designed to function. There is impressive agreement by clinicians and lay people on many judgments of which problems represent disorders and which are part of normal distress and problems of living, suggesting that the concept of disorder is widely shared, even if inherently fuzzy. However, nothing in the concept of disorder determines that every psychological dysfunction— that is, every failure of mental processes to operate as they were biologically designed to do—must be a brain dysfunction rather than a problem strictly at the level of the interaction of thoughts, emotions, and other meanings.
And, Wakefield adds, most emotional problems are not due to genuine psychological dysfunctions at all, but to normal psychological processes that yield suffering that is problematic but not disordered, but may fall under expansive DSM definitions nonetheless.
Using Wakefield’s distinction, how do we recognize the “normal range problems of living”? When I was in graduate school, I was taught by professors I deeply respected that the best way to understand psychic pain (and the human condition) was to study literature, the classics, theatre, and art. I was also taught that to label people, rather than to understand how they got to be who they are, and why, and recognize the individuality and worth of every person, was disrespectful and hostile. The gifted and wise psychiatrist, Eli Marcovitz, MD, once shared with me, as we discussed one of the cases I presented to him for discussion and consultation, “Everyone has some psychological frailty that another could label ‘sickness.’ But to label a human being, rather than offer solid help, always thwarts true healing.”
The head of residency training when I was a young social worker at Philadelphia Psychiatric Hospital in Philadelphia, Morris Brody, MD, put it another way: “Each member of humankind has some degree of crazy within. Mental health is working to understand this about yourself, so that you can love and be loved. Always remember that we each live in glass houses.”
Many of the normal range problems exist on a gradation—meaning anyone in certain circumstances can be pulled back from the edge or pushed off of it. And yet, most medical academics today exhibit a dearth of understanding of or appreciation for the complexities, contradictions, and frailties of the human condition; the impact of individual longing for connection, so often thwarted; and the clinical necessity of hearing and understanding with heart, as well as mind, in order for individual potential and fulfillment to be reached.
What can you and I do to positively address this unfortunate reality? We can write about this disconnect, educating others about both the art and science of healing, while strengthening our own positioning and belief in the clarity of thought in our profession and its value system. The leadership of our graduate schools can insist that social workers also have a seat at the table of the decision makers who play such an important part in the futures of our clients.
Another important step is to recognize that it is both possible and necessary to combine research and a clinical approach in our work, a union that strengthens our positions about what our clients are going through and the time and support they need.
For instance, after a several year effort, I was able to publish a codification of five invisible, largely ignored, and dangerous cycles of emotional abuse that, without intervention, pass from generation to generation (Smullens, 2003, 2010). It is my deepest hope that research will eventually validate what I have consistently seen anecdotally: Without intervention, these cycles morph into physical and sexual violence.
The Clinical Social Work Journal, founded in 1973, devotes itself to this quality of relevant, contemporary, innovative practice and evidence-based clinical research. It is heartening to see that more schools of social work are offering clinical DSW degrees as part of their curricula, something that I repeatedly urged during the nine years I served on the Overseer Board of my alma mater, the University of Pennsylvania School of Social Work (now the School of Social Policy and Practice). The Penn DSW clinical doctorate, shepherded by Professor Ram Cnaan, was introduced in 2007, producing what the Dean of Students and program director, Dr. Lina Hartocollis, aptly describes as “scholar-clinicians.”
We can also lobby our elected officials about this situation. In a compelling letter to the editor in The New York Times, Allen Frances (2013) says: “We badly need a conversation about a diagnostic system that is far too loose, a drug industry that is far too unregulated, and a mental health system that is badly broken.” Frances calls for a congressional investigation.
I see the social work profession, one committed to necessary social action, as a leader in this call. We can organize within our local chapters of the NASW so that all social workers have a voice and that as further editions of the DSM evolve, those voices will be heard and valued.
Together, you and I can continuously emphasize the urgency of this necessary approach to therapy and healing—one that recognizes the complexities of each life and reflects deep respect for the innate capacities and potential of each human being to live a full, fulfilling, and meaningful life.
References
Frances, A. (2012). DSM5 in distress: The DSM’s impact on mental health and practice. Psychology Today. Retrieved from http://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes.
Frances, A. (2013, March 24). Letter to the editor. The New York Times.
Grohol, J. M. (2011). Mental health professionals: U.S. statistics. Psych Central. Retrieved from http://psychcentral.com/lib/2011/mental-health-professionals-us-statistics/
Smullens, S. K. (2003, Fall). Developing an emotional sense of direction: A therapeutic model for the treatment of emotional abuse. Annals of the American Psychotherapy Association, 6 (3), 17-21.
Smullens, S. K. (2010). The codification and treatment of emotional abuse in structured group therapy. International Journal of Group Psychotherapy, 60 (1), 111-130.
Wakefield, J. C. (2013). DSM-5 and clinical social work: Mental disorder and psychological justice as goals of clinical intervention. Clinical Social Work Journal, 43, 131-138.
Wakefield, J. C. (2013, September). Private communication, with appreciation from the author.
SaraKay Smullens, MSW, LCSW, CGP, CFLE, BCD, whose private and pro bono clinical social work practice is in Philadelphia, is a certified group psychotherapist and family life educator. She is a recipient of a Lifetime Achievement Award from the Pennsylvania chapter of NASW, and the 2013 NASW Media Award for Best Article. SaraKay is the best-selling author of Whoever Said Life Is Fair and Setting YourSelf Free.