Where are the Social Workers: Preparing for a Post-Psychiatry World?
In response to my own question, not yet, although a handful of us, including me and a few social work researchers that I’ll reference below, are attempting to push the profession in the U.S. in that direction. As for “post-psychiatry”, that’s a term that two Irish social workers, David Cameron and Patrick McGowan, are offering in lieu of “anti-psychiatry”. They consider – and I agree – “post-psychiatry” to be a “unifying” notion as well as indicative of the increasing demand by persons served by the public mental health system for services that lead to recovery and not mere maintenance. They also remind us – and social workers take note – that “Although recovery is very much in vogue and gaining momentum … if … generically defined by mental health professionals according to reductionist biomedical models of illness, it misses
the point. … recovery must be self-defined and self-directed by the … personalized narrative of each individual living the experience …” Cameron and McGowan then proceed to outline a unique position that social workers can take within the public mental health system to facilitate the recovery of those individuals they work with. More on this below.
Little more than a week ago, I participated in a panel discussion that focused on the implications of the DSM-5 for social work practice. It was part of a larger conference co-sponsored by the NYU School of Social Work and the New York City chapter of NASW. So far as I know, it was the first such social work conference that’s taken place in New York specifically assembled to review the new DSM. Social workers and their professional organizations have been notably quiet about the new DSM. I was invited at the instigance of the NYC Chapter, whose executive director, Bob Schachter, had been pressed by me since last year about NASW’s failure to sign the APA petition calling for wholesale revision of the more controversial additions of DSM-5. I had followed up several blog posts on this website that addressed that issue with an article that was published in February in Currents, the Chapter’s monthly on-line magazine. Interestingly, Schachter told me that relatively few of the Chapter’s several thousand members read the article; but its contents sufficiently impressed him and the Chapter’s president, Martha Sullivan, that they agreed to have the Chapter co-sponsor the NYU conference and nominated me as one of its principal presenters. It should be noted that I was the only one of the eight panelists who repudiated the biomedical model and called for a boycott of the DSM.
I found myself well received by conference attendees who, based on the questions directed to me, seemed genuinely interested in what I had to say. During the course of the less-than-thirty minutes I spoke, I made three basic points: that the increasing disrepute in which both psychiatry and the DSM were being viewed afforded social workers a window of opportunity to reclaim their psychosocial mission; that reliance on diagnoses that had no construct validity served to reduce individuals to symptom complexes virtually indistinguishable one from the other, as well as to block social workers from doing what they do best, viz., listen to the stories of the people who come to them for help and fashion assessments and plans based on those stories; and that the DSM itself could be totally disregarded in social work practice. With the elimination from the new DSM of the putative multi-dimensional Axes, particularly Axis IV, all pretense of interest in psychosocial correlates has been removed. Indeed the DSM-5 Task Force has claimed that all disorders listed in the DSM have biomarkers, i.e., are biologically-based. Not true, of course, but where does that leave social workers? Essentially de-valued and invalidated if they remain yoked to the DSM.
Not surprisingly, most folks seemed to struggle with what I was saying. One questioner contended I was putting her “between a rock and a hard place:” if she and her agency stopped using the DSM, how could they bill for their services? She was actually framing a perennial dilemma for social work – who or what comes first, person served or the agency? – whose usual resolution —agency on top — has undoubtedly contributed to social work’s failure to keep its focus on its psychosocial mission and its members’ loss of professional identity. More on this further down. In an effort to be helpful, I reminded my questioner and the entire audience that billing for services provided is carried out, in accordance with international treaty, via ICD-9 and not DSM diagnostic codes. The latter purposely conform to the ICD in order to promote continued reliance on the DSM.
Before I made my own presentation, I took the opportunity to ask questions of several of my fellow presenters. The one I recall most clearly is the one I asked regarding PTSD and trauma. It was more of a statement than a question and was prompted by some comments I heard John Judge make at the “Occupy APA in New York” rally in early October. I asked why trauma, which is an actual injury, is described in the DSM as a disorder and represented by a diagnosis, PTSD? (Not a novel concern, as Tom Insell, the Director of NIMH, recently acknowledged the “… ongoing debate about calling PTSD a disorder when it is unequivocally an injury …”) When applied to traumatized veterans, does this diagnosis allow the rest of us to distance from and disavow any responsibility for addressing the harm caused to persons sent to war with our tacit approval? In short, do we infer a characterological vulnerability or defect in the individuals whom we label with PTSD in order to ignore our collective role in sending them into harm’s way in the first place? No answer was forthcoming, and it appeared that no one present had ever considered the implications of the diagnosis for those so labeled. Thank you, John Judge!
A few days before the conference, on October 9, the New York Times published a front page article about ADHD, citing the correlation of an increase in diagnosing school kids with ADHD and prescribing stimulants to treat them with the decline in public funding for schools. The article’s author, Alan Schwarz, referenced a California school superintendant “who … noted that diagnosis rates of ADHD have risen sharply as school funding has declined.” He also quoted Dr. Ramesh Raghavan, “a child mental health services researcher and an expert in prescription drug use among low-income children. ‘We are effectively forcing local community psychiatrists to use the only tool at their disposal which is psychotropic medications.’ ” Another chicken vs. egg question: does the ADHD diagnosis represent an advance in treating a hitherto unacknowledged problem or rather the unacknowledged failure of our public schools and the larger society in funding the schools to effectively teach poor and often troubled kids? Or to ask the same question from another angle: was the sudden surge in learning disability and ADHD diagnoses twenty years after Brown v. Board of Education (1954) and the initiation of school desegregation mere coincidence or a direct consequence?
The editorial in the October issue of Ethical Human Psychology and Psychiatry written by Jim Tucker and entitled “Diagnosing Diagnosis,” also addresses the ethics of diagnoses and, ultimately, the function they play in the lives of persons who receive or give or support them. Dr. Tucker begins by noting that “A diagnosis may serve initially to support only a misguided bias, but it is likely to become a rationale for treatment unrelated to the issue involved.” He gives the example of “drapetomania,” a term introduced in 1851 and applied to “slaves who persisted in running away… An otherwise normal behavior (the honest effort to be free) that was outside the norms of society was considered to be evidence of a mental defect.” Tucker then proceeds to track the origins of the diagnoses of “learning disability” and ADHD, which began to be applied to children in the 1970’s and 80’s. Tucker asks whether these diagnoses “describe a set of conditions that had not existed previously? Or did the newly defined conditions provide a convenient category that allowed us to avoid potential responsibility for them? And when the conditions finally were discovered, did we tend to see them everywhere?” An article in the October issue of the Journal of the American Academy of Child and Adolescent Psychiatry, highlights the current prevalence rate in the U.S. of 5.5% for ADHD among all children and adolescents ages 4 to 17, and of 4.4% among adults 18 to 44. Tucker reminisces about a Nepalese graduate student who heard a description of the ADHD symptom complex “… and forcefully stated, ‘In Nepal, we call such children normal.’ ”
Finally, Tucker asks “… So why do we need three different words — [nonreader, illiterate, dyslexic] – to describe an individual who cannot read? … I submit that the reason has to do with our need to avoid responsibility for the condition. He concludes “… the history and current application of diagnosis says more about the ethical behavior of people in general than it does about specific professional application of symptoms that need to be addressed …”
What does it say, then, about the ethics of social workers who are taught from the moment they enter a school of social work to safeguard that most fundamental of all human rights, self-determination? Why such allegiance to reductionist diagnoses that don’t allow the individuals we’re presumably helping to tell us their stories? Are we so wedded to our social control responsibilities that we’re willing to forego our commitment to pursue social justice and social change, the only likely remedies to the problems I’ve described above?
In the aptly titled “The End of Neo-Kraepelinism”, also published in October’s issue of Ethical Human Psychology and Psychiatry, David Jacobs and David Cohen, clinical psychologist and social worker, respectively, also wonder at mental health practitioners’, including social workers’, continuing embrace of the DSM and its increasingly discredited bio-medical or neo-Kraepelinian model. They contend that the DSMs offer only abstract, unfalsifiable – hence, unverifiable – suppositions that interfere with the development of a therapeutic partnership between practitioners and those seeking their help. To quote at some length from the authors’ concluding paragraphs:
“In sum, the person’s psychiatric problem cannot be found outside of discourse and social interaction. Efforts to simplify and categorize what patients say about their personal difficulties distort these for the sake of standardization, quantification and statistical analysis. This is scientism [i.e., the reductionist belief that the only true knowledge is that which is measurable]. Neo-Kraepelinism [an ideology adopted with the publication of DSM-III in 1980] assumed biological discoveries that never materialized … [It] should be abandoned because it is based on the false premise that mental disorder (italics mine) could become the basis for an objective, scientific enterprise … it is a reified idea [i.e, an abstraction presumed to be real] … Clinicians may suspend their interest in social history and circumstances only when real medical disease explains, based on evidence, why persons behave in a manner that provokes concern that they ‘are mentally disordered’. Otherwise, no justification exists for adopting a framework of thought that simply assumes that clinically significant problems are idiopathic medical problems … Embracing neo-Kraepelinism commits one to losing sight of the patient’s personal history and environment, and the DSMs offer an extraordinarily sanitized, asocial view of the human condition. Unlike all other forms of life, people have their own ideas about their difficulties and can discuss them and act on them. Trying to minimize the difference between people and everything else because recognizing it is inconvenient for scientific study, is [as per above] scientism.”
To put this in a larger context and connect some dots, “scientism” is a cultural phenomenon that first earned close scrutiny when Karl Popper, among other philosophers and scientists, used the term to describe an unquestioning endorsement of scientific methodology. In our own field, Kirk and Kutchins, in The Selling of DSM: The Rhetoric of Science in Psychiatry (1992), their scathing critique of the DSM-III, accused the APA of creating a scientific smokescreen to gain prestige and status for psychiatry as well as for the DSM. I’ve just been reading some of Gore Vidal’s essays, in remembrance of his passing, and he writes about a similar controversy that ensued over the novel and its future in the 1960’s. It was sparked by the French philosophes – who else? – Nathalie Sarraute and Alain Robbe-Grillet, who advocated the re-invention of the novel via utilization of the scientific method. One of their intellectual opponents, Raymond Picard, another Frenchman, transcribed a fierce disagreement which reminded me of our own intramural dispute over the validity and meaning of the DSM. To quote:
“[Writers who pretend to be scientists] improperly apply to the literary domain methods which have proved fruitful elsewhere but which here lose their efficiency and vigor … What they’re after is its prestige: in other respects they are at opposite poles to the scientific spirit. Their statements generally sound more like oracles rather than useful hypotheses: categorical, unverifiable, unilluminating.”
So where does the foregoing leave social workers? In the same proverbial “between a rock and a hard place” that perplexed my questioner and sister social worker at the NYU conference. But we do have a choice. As I wrote in an earlier post (April, 2012), “social work has lost its identity. Reclamation of its sense of self will require more than a simple reprise of what it has customarily done for more than a century. The times have changed. Social work and its members will have to commit themselves to a mission that encompasses a program of liberation [for those they presume to help]; will have to remind themselves that their principal accountability is to their new-found partners [i.e., peer/survivors]; that their chief objective is to develop with them a post-psychiatry, post-authoritarian [helping] model …, collaborative in nature, that emphasizes psychosocial causation and remedies and has as its goal its participants’ reclamation of their community citizenship. What I refer to … as personal liberation [and others as full recovery]!”
Benjamin Carey, correspondent for The New York Times, has provided some leads as to how mental health practitioners, including social workers, can accomplish this. Over the past year and more, he has written a series of inspired articles about individuals diagnosed with presumed serious mental illnesses who have managed to achieve full recoveries. In an article published in The Times almost a year ago, on November 25, 2011, and entitled “Finding Purpose After Living With Delusion,” Carey tells the story of Milt Greek, then 49, married and a long-time computer programmer, who had received a diagnosis of schizophrenia in his early 20’s while a student at Ohio University.
He had been experiencing what his psychiatrists called grandiose religious delusions, specifically, the notion that he had a mission to create world peace. Later, when he found himself adrift, he experienced auditory hallucinations. Over the course of the next twenty years, he stumbled across several individuals, including his future wife, who essentially accepted him for the idiosyncratic person he is, gained his trust and enabled him to figure out what to do with his compassionate impulses.
And that’s what Carey’s story is essentially about: how one man, among an apparently increasing number of similarly-minded individuals, found acceptance, support and purpose for his life. Carey quotes Gail Hornstein, a clinical psychologist and author of Agnes’s Jacket: A Psychologist’s Search for the Meanings of Madness, and one of the persons he interviewed for this article: “It’s a thrilling time because people with lived experience are beginning to collaborate in large numbers … They are developing their own theories, their own language about what their experiences mean from the inside.” Greek himself, after interviewing a number of persons who have had presumed delusional experiences, divided the experiences into four “story lines: … the rescuer …; the self-loathing person …; the visionary …; and the messianic …”, into which last category he placed himself. “Each [of these distinct categories] grows out of a specific fear or trauma …”, much as his own did, the origins of which he has traced to a “very real childhood terror of being cast out, as … schoolyard boys [once] threatened [to do to him].” When Carey published his article, Mr. Greek was preparing his own “study for publication in a psychiatric journal …” He has also written a manual for families entitled
“Schizophrenia: A Blueprint for Recovery.” His own regimen to keep his recovery on track “combines [mindfulness] meditation, work [as a programmer in a nearby university] and drug treatment [an unspecified ‘antipsychotic’ medication] with occasional visits to a therapist and a steady diet of charitable acts. Some of these are meant to improve the community; others are for co-workers and friends, especially those dealing with [problems similar to his.]”
So where and how can social workers fit into the lives of persons like Milt Greek, whose personal story could well provide a blueprint not only for families but for a new and re-ordered public mental health system? Mr. Greek apparently continues to benefit from professional help when he feels stressed and stretched. I can’t say I’m happy with the help his therapist does provide, at least as described by Mr. Carey – diagnoses and anti-psychotics; no psychotherapy or skills building. But I assume they also have built a relationship and that Mr. Greek trusts his therapist. Social workers can certainly provide these services. They could also do what Cameron and McGowan, the two social work authors I referenced at the outset of this article, suggest in the article they just published in the October issue of the Journal of Social Work Practice, not usually noted for the promotion of innovation. Entitled “The Mental Health Social Worker as a Transitional Participant: Actively Listening to ‘Voices’ and Getting Into the Recovery Position,” the authors advocate that social workers adopt active if transitional roles in the recovery of the service users whom they seek to help. This will require that social workers learn to listen to all things their clients tell them, including those life experiences that social workers, by virtue of their training, would ordinarily consider delusional or hallucinatory. They can start by eliciting then listening to the content of the voices that many if not most of their clients hear, taking into account that voice-hearing has begun to be acknowledged as a human phenomenon experienced by millions of persons world-wide, the vast majority of whom never seek and don’t require mental health intervention. To quote the authors: “… Real learning and sustainable change can only take place when mental health social workers and service users feel safe enough to explore their respective world views …”
The authors proceed to adopt Winnicott’s view of social workers as “strategically … position[ed] in their [clients’] lives because [they are] in touch with a total situation representing a totality of experience.” They continue that “… the mental health social worker, therefore, is a ‘transitional participant’ … who can usefully bridge and integrate the disparate aspects of the reciprocally determined social (external) and subjective emotional (internal) environments of their clients … From this perspective, the mental health social worker is … ideally placed to establish a ‘real’ collaborative and emotionally life sustaining relationship which can promote real and meaningful recovery …” Of course, as I wrote at the very beginning of this article, this will require jettisoning the biomedical model of mental illness, which reduces those subjected to its application to unknown and unverifiable diagnoses and their putative biomarkers, and which is reported by an increasing number of its subjects as doing them more harm than good.
So again the question, where does that leave social workers and the professional organizations and schools that support them? Social work has paid a high price for its adoption of – one might say its colonization by – the biomedical model of mental illness. The latter provides a powerful and seductive explanation of human behavior in every circumstance as a function of neurobiology and epigenetics and eschews any possibility of treatment as a joint endeavor. Human experience is posited as a byproduct not a causative agent of human behavior, undermining the human right of self-determination and nullifying the metaphysical concept of free will, leaving the practitioner on her or his own, with no one to collaborate. It is no small wonder that social work lost its way. Let’s return to Ben Carey’s article for suggestions as to how social workers might get back on track.
Carey concludes his article by quoting Paris Williams: “By exploring a person’s anomalous beliefs and experiences, we are better able to understand the underlying feeling and needs that give fuel to these experiences.” It should be noted that Dr. Williams is “a psychologist who has struggled with psychosis… [He] recently published [Rethinking Madness, a book based on his] doctoral dissertation, [wherein] he analyzed the content of six people’s delusions, which has informed Mr. Greek’s work.” Anomalous beliefs and experiences for Williams are similar to what Bentall terms “complaints” and what psychiatrists and the great majority of mental health practitioners refer to as psychotic symptoms. From his own non-biological, existential perspective, however, Williams views the anomalous as intentional acts whose purpose is to help the person who experiences them protect her-/himself from perceived dangers in the environment. The therapist’s or helper’s role in these situations is to “find ways to make [the person] feel safe when they are being persecuted by malevolent forces, or find ways to help [the person] feel empowered when they experience demanding voices.” Moreover, it is crucial to the person undergoing the anomalous experiences that the helper/
practitioner support and not invalidate her/him and so allow the person to complete the experience unhindered so long as she/he and those around her/him are safe. This is invariably counter-intuitive for most mental health professionals, but to do otherwise will invariably result in a hospital incarceration and harm to the person’s sense of self.
To guide helper/practitioners and the persons they seek to help through this process, Williams proposes a non-biological paradigm, which he terms the Duality/Unity Integrative (DUI) Model of Recovery and which is informed by the work of Rank, Yalom, Rollo May and Beckel, as well as by several millennia of recorded mindfulness meditation practice by Buddhist monks. His model, he explains, is a compilation or integration of the self/other dialectic or duality, which represents the individual or person, as described by the four Western existentialists, and the dialectic or duality in which the self/other is involved with the monistic unity that represents the world. As in all meditation mindfulness, the objectives are to maintain a balance in the two dialectics – between self and other and between self/other and the world, as well as to accept one’s membership in the world. To lose balance in the latter dialectic exposes the individual to liminal or anomalous experiences which can overwhelm one’s capacity to understand or integrate the experiences with one’s paradigm of self and will result in psychosis. The helper’s task is to support the person to expand the cognitive constructs of her/his self paradigm and her/his Window of Tolerance (WOT) or comfort with these new anomalous experiences, which customarily take the form of what we now call delusions and hallucinations. Should the person succeed in integrating these new experiences, she/he will experience personal growth and an expanded capacity to deal with the vicissitudes of the world. Her/his recovery will proceed apace. Should she/he fail to do so, should her/his WOT be overwhelmed, she/he will suffer a setback, the gravity of which will be determined by the amount of support she/he did or did not receive while undergoing the experience and its aftermath.
I imagine this seems rather abstract, but please remember that Williams developed his non-biological DUI model after playing transitional psychologist and listening to the stories of six individuals who had travelled the long road to full recovery – early middle age; little or no meds; working; intimate relationships. Pretty much the same profile of the persons who attained full recovery in Harding’s Vermont Longitudinal Study. So it appears he’s on to something and it would be highly informative if his model could be tested in a variety of settings. It’s a natural for social workers, nurses and psychologists and, it goes almost without saying, peer specialists. If you’re interested, read his book. My next step is to try to get the ideas detailed in this article before the NASW or, perhaps more importantly, the Council on Social Work Education (CSWE).
One of the consequences of the NYU conference I wrote about at length above was the apparent commitment on the part of the leadership of the NYC Chapter of NASW to pursue further the issues I raised at the conference: the drawbacks for social work and its clients of the biomedical model; the disqualifying defects of the new DSM; and the need to develop effective strategies to address and resolve both. I’m waiting on a ‘phone call or e-mail from the Chapter President, Martha Sullivan, to invite me to a meeting of Chapter leaders to discuss next steps. I’m going to propose that we seek a meeting with the CSWE to discuss possible curricula revisions to promote a non-biomedical model understanding of recovery for persons who’ve been diagnosed as having a presumed serious mental illness – which will cover a wide range of issues, foremost among which is the profession’s unqualified support of psychoactive medications – and the role that social workers can take. I’m also intent on pushing for a boycott of the new DSM, a text that has absolutely no relevance for social work practice. We’ll see what happens. I’ll keep you informed. Your comments are most welcome.
I remain, as always, a prisoner of hope, and I intend, as always not to mourn but to organize!
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Cameron, D., McGowan, P., “The Mental Health Social Worker as a Transitional Participant: Actively Listening to Voices and Getting Into the Recovery Position,” Journal of Social Work Practice, October 5, 2012, pp. 1-12, http://www.tandf.co.uk/journals
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