The DSM and Clinical Social Work: Widespread Diagnosing of 'Mental Illness' Is Not Working

Viewpoints

By Arnoldo Cantú, LCSW

In an ideal world, seeking mental health services would not be predicted on being diagnosed with a mental disorder or mental illness. Instead, it would be like entering the office of an accountant or lawyer in which you’d be able to obtain help without being labeled as “ill.“

However, there are no alternatives to diagnostic labels for use as clinicians within mental health. You are pigeonholed into “diagnosing” heaps of clients with controversial mental disorders that have long been questioned as medical conditions. Put differently, current standard practice is to erroneously repackage comprehensible human difficulties into medical ones to allow the suffering person access to services.

When individuals in the U.S. enter the office of a mental health provider and plan to use health care insurance, they will most likely walk out of the first appointment deemed “mentally ill” with a psychiatric diagnosis stamped into their medical record or psychotherapy notes. (“Psychiatric diagnosis” is used interchangeably with “mental disorder” and “mental illness.”) Social workers—by virtue of making up the largest segment of the mental health workforce in the U.S.—are the professionals individuals will presumably encounter in time of need and the most likely to dole out these kinds of labels, given their ample presence in the field.

Ordinarily, receiving a medical diagnosis provides relief. It usually indicates that a medical provider has obtained some sort of objective evidence—for example, through laboratory results, bloodwork, scans, and so forth—resulting in the cause of the person’s symptoms and illness having been identified. However, at the juncture of “objectivity” is where psychiatric diagnoses greatly diverge.

As a mental health provider, you may regularly rely on the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM).

This book is the ever-growing compendium described to be the “bible of psychiatry,” containing hundreds of identified mental disorders, purportedly discovered through decades of rigorous scientific research.

You were likely taught how to use this book in graduate school, considering that codes paired with DSM diagnoses are used for most third-party insurance payments. This is due to regulations set forth by the Department of Health and Human Services’ Centers for Medicare and Medicaid Services (CMS): A service needs to be deemed medically necessary; the documentation of a diagnosis is required in the client’s medical records; and the use of the codes found within the DSM are “mandated” by CMS for reimbursement purposes. The way teachings of the DSM are parroted to social work students, however, are usually one-sided.

You may have been taught that the DSM contains indisputable medical diagnoses said to exist in reality—mental disorders residing in the diseased brains of individuals. After all, mental faculties, emotions and behaviors are said to be byproducts of the wrinkly organ between our ears. Nothing could be further from the truth. The “discovery” of most mental disorders found in the DSM likely occurred through voting by members within the APA—not via scientific processes. A notable example occurred in 1973 when the APA voted to remove homosexuality from the DSM in response to activist protests, declassifying it as a mental illness in one fell swoop.

Psychiatrists have decreed the DSM and its collection of diagnoses to be “deeply flawed,” “discredited and scientifically unsound,” and merely reflecting the opinions of its creators. Even the psychiatrist who helped define “mental disorder” in DSM-IV—a definition whose vestiges remain in the current DSM-5-TR’s definition—has proclaimed that not only is the term “mental disorder” unhelpful in identifying what should or shouldn’t be considered a mental disorder, but the term itself is … undefinable.

Mental disorders suffer from low “reliability,” meaning the likelihood is poor that two clinicians will agree on a diagnosis when presented with the same person. Mental disorders also suffer from a lack of validity, meaning they do not necessarily reflect reality or identifiable disease processes in the body. As a result, mental disorders are “diagnosed” subjectively. One can speculate this might be a reason why billions of dollars and decades spent in research to identify biological causes of mental disorders has come up empty. It’s also telling when the former director of the largest funding source of mental health research in the world—Thomas Insel of the National Institute of Mental Health—pointedly stated in 2013 that the NIMH would no longer fund research predicated on DSM diagnoses due to their lack of validity, among other issues.

It’s imperative to reiterate that this is the current tool forcibly handed to you in school and upon entering the profession. This occurs by both the lack of alternatives available and the regulations set in place necessitating the DSM’s use. Perhaps this is where we, as social workers, can collectively enact change. It’s possible for researchers and practitioners supported by NASW and other professional organizations to develop an alternative manual without medical jargon and pseudoscientific diagnoses to eventually take the DSM’s place—or live alongside it, if formally endorsed by CMS.

As an interim goal, it’s also possible for us—pulling from our profession’s rich history of engaging in advocacy—to advocate for regulations to be modified to allow the health care coverage of psychosocial problems. In the back of the DSM, a section contains a multitude of codified environmental, circumstantial, and interpersonal problems—for example, disruption of family by divorce, physical abuse and homelessness—that social workers can select. Currently, however, the use of these problems as a “primary diagnosis” in lieu of a psychiatric diagnosis is typically not covered by insurance. The DSM can be seen as a runaway freight train having successfully barged its way into society, language, and numerous systems such as schools, courts, and social services.

However, we social workers can—and should—collectively push back on it given the adverse effects it facilitates—like deception, increased stigma, and despair to name a few. With the vast number of clinical social workers—and new generations entering the field every year—it is crucial we find a way out of being pigeonholed into the unethical practice of widespread diagnosing of “mental illness,” lest we remain complicit in perpetuating harm onto the vulnerable people with whom we work.