By:
SOPHIA F.
DZIEGIELEWSKI
The publisher of the DSM is the American Psychiatric Association, a professional organization in the field of psychiatry. Nevertheless, individuals who are not psychiatrists buy and use the majority of copies. Early in the introductory pages of the book, the authors remind the reader that the book is designed to be utilized by professionals in all areas of mental health, including psychiatrists, physicians, psychiatric nurses, psychologists, social workers, and other mental health professionals (APA, 2013).
Since there is a need for a system that accurately
identifies and classifies biopsychosocial symptoms
and for using this classification scheme as a
basis for assessing mental health problems, it is no surprise that this book
continues to maintain its popularity.
Of the documented
650,500 jobs held by
social workers in the
United States, more than 57% are in the area of
health, mental health, substance abuse, medical social work, and public health, where many are
directly involved in the diagnostic process (Bureau of Labor Statistics,
U.S. Department of
Labor, 2012). When compared with psychiatrists, psychologists, and psychiatric
nurses, social workers are the largest group of mental health providers
with a significant effect on
diagnostic impressions related to the current and continued mental health of
all clients served.
Mental health
practitioners (also referred to
as clinicians), such as
social workers, are active in clinical assessment and intervention planning.
Back as far as 1988,
Kutchins and Kirk reported that when they surveyed clinical social workers
in the area of mental
health, the DSM was the
publication used most
often.
Furthermore,
since all states in the United
States and the District of Columbia require some form of licensing, certification, or registration to
engage in professional
practice as a social
worker (Bureau of Labor Statistics, U.S. Department of Labor, 2012), a
thorough knowledge of
the DSM
is
considered essential for competent
clinical practice.
Because all
professionals working in the area
of mental health need to
be capable of service reimbursement and to be
proficient in diagnostic assessment and treatment planning, it is not surprising that the
majority of mental health professionals support the use of this manual (Dziegielewski, 2013;
Dziegielewski, Johnson, & Webb, 2002). Nevertheless, historically some
professionals such as
Carlton (1989), a social worker, questioned this choice. Carlton believed
that all health and
mental health intervention needed to go beyond the traditional bounds of
simply diagnosing a
client’s mental health condition.
From this
perspective, social, situational,
and environmental
factors were considered key ingredients for
addressing client problems. To remain consistent with the person-in-situation stance, utilizing the DSM as the path of least resistance might lead to a largely successful fight—yet would it win the war?
Carlton, along with other professionals of
his time, feared that the battle was being fought on the wrong battlefield and advocated a more
comprehensive system of reimbursement that took into account environmental aspects.
Questions raised include:
How is the DSM used?
Is it actually
used to direct clinical interventions in
clinical practice?Or
Is the focus and use of the manual primarily limited
To ensuring
third-party reimbursements, qualifying for agency service, or avoiding a
diagnostic label? Psychiatrists and
psychologists also questioned how the DSM serves clients in terms of clinical utility (First & Westen, 2007; Hoffer,
2008).
Concerns evolved
that clients were not
always given diagnoses
based on diagnostic criteria and that the diagnostic labels assigned were
connected to unrelated
factors, such as individual clinical judgment or
simply to secure reimbursement. These concerns related directly to professional
misconduct caused ethical and legal dilemmas that affected billable and nonbillable
conditions that had
intended and unintended consequences for clients.
To complicate the situation further, to provide the most relevant
and affordable services,
many health care insurers require a diagnostic code. This can be problematic,
from a social work perspective, when the assistance needed to improve mental health functioning
may rest primarily in providing family support or working to increase support systems
within the environment.
The DSM
is
primarily descriptive, with little if
any attempt to look at underlying causes (Sommers-Flanagan &
Sommers-Flanagan,2007).
Therefore, some
mental health professionals
are pressured to pick
the most severe diagnosis so their clients could qualify for agency services or
insurance reimbursement.
This is further complicated by just the opposite trend, assigning the least
severe diagnosis to
avoid stigmatizing and labeling (Feisthamel & Schwartz, 2009).
According to Braun and Cox (2005), serious ethical violations
can be included, such as
asking a client to collude with the assigning ofmental disorders diagnosis for
services. A client agreeing
to this type of practice may be completely unaware of the long-term
consequences this
misdiagnosis can have regarding present, continued, and future employment,
as well as health,
mental health, life, and other insurance services or premiums.
Regardless of the
reasoning or intent, erroneous diagnoses can harm the clients we serve as well as the
professionals who serve them (Feisthamel & Schwartz, 2009). How can
professionals be trusted, if this type of behavior is engaged in? It is easy to see
how such practices can raise issues related to the ethical and legal aspects
that come with
intentional misdiagnosing. These practices violate various aspects of the principles of
ethical practice in the
mental health profession.
Although use of
the DSM is clearly evident in mental health practice, some professionals continue to question
whether it is being utilized properly. For some, such as social workers, the
controversy over using
this system for diagnostic assessments remains. Regardless of the controversy in
mental health practice and application, the continued popularity of the DSM makes it the most frequently used publication in the field of mental health. One consistent theme in using
this manual with which
most professionals agree is that no single diagnostic system is completely
acceptable to all. Some skepticism and questioning of the appropriateness of the function of the
DSM is useful.
This, along with
recognizing and questioning the changes
and the updates needed, makes the DSM a vibrant and emerging
document reflective of the times. One point
most professionals can agree on is
that an accurate, well-defined, and relevant diagnostic label needs to reach beyond ensuring service reimbursement.
Knowledge of how
to properly use the manual is
needed. In addition, to
discourage abuse, there must also be knowledge, concern, and continued
professional debate
about the appropriateness and the utility of certain diagnostic categories.
References
SOPHIA F.
DZIEGIELEWSK, 2015, DSM-5TM
in Action, by John Wiley & Sons, Inc.
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