The most basic critique of the DSM-5 is the same critique that has been levied against psychiatry for decades: that it does nothing more than medicalize or pathologize normal behavior. So is it ever ok to say that someone isn’t normal? Are there ever situations where giving a diagnosis is good? As it turns out, yes. And I’m not just talking about diagnosis as a means to finance treatment. Yes, third party reimbursement hinges on diagnosis. But I’m talking about something less institutional and more personal. There are people who like labels, who find comfort in being able to name or label what is wrong. The label draws a boundary around an experience. Labels can even draw up boundaries around a group of people. According to psychologist Gary Greenberg, “[the label] Asperger’s syndrome gave people whose primary symptom was isolation a way to belong and provided resources to those who were diagnosed” (Reese, 2013).
Download MP3 [37:19]
So, I know what you are wondering - is DSM diagnosis good or bad? Well, today’s episode won’t be the definitive answer to that question. But, it will give you cause to pause when you think about the role of DSM-5 in the professional life of social workers and the people we serve. My guest is social work faculty member from Florida State University, Jeffrey Lacasse, Ph.D. Dr. Lacasse has published several critiques of the changes in DSM-5. In today's episode, Dr. Lacasse critiques the definition of mental illness, the empirical support for and reliability of most diagnoses, the politics associated with the DSM and the implications for social workers who represent the single largest group of professionals who provide DSM diagnoses.
Kudos to @socworkpodcast & @JeffreyLacasse for their critiques of #DSM5. "Normal is a social construct." https://t.co/KxG2eH1fBt #Socialwork
— Elaine Eisenbaum (@eeisenbaum) January 26, 2016
Download MP3 [37:19]
Bio
Education
- Ph.D., 2008, Florida State University; Social Work
- M.S.W., 2000, Florida State University; Clinical Social Work
- B.A, 1997, St. Leo College; Liberal Arts and Psychology
Research Interests
- Mental Health, Psychiatric Medications
Transcript
Introduction
Jonathan Singer: Today's episode of the Social Work Podcast is a critique of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5.
"The two years leading up to the publication of the DSM-5 (American Psychiatric Association, 2013) in May, 2013 have been described as a “war… that has shaken psychiatry to its core” (Greenberg, 2013, p. 3). The chair of the DSM-IV task force, Allen Frances, publicly denounced the process used by the DSM-5 task force and cautioned that the changes in DSM-5 would “turn our current diagnostic inflation into hyperinflation by converting millions of ‘normal’ people into ‘mental patients’” (Frances, 2013, p. 3). The value of the DSM-5 as a “bible” for mental health practitioners was further questioned in 2013 when Thomas Insel, then the director of the US National Institute of Mental Health (NIMH) published a blog post in which he said, “[Mental health research] cannot succeed if we use DSM categories as the gold standard. ...That is why NIMH will be reorienting its research away from DSM categories” (Insel, 2013). By the time the DSM-5 was published in May 2013, it seemed quite possible that the addition of 15 new diagnoses, removal of the multi-axial system, and the reorganization of the text itself, would lead to a disaster of epic proportions" (Alvior, Drake, Kim, Lee & Singer, 2014, p. 2).
So, have the dire predictions come true, or, were these predictions, to quote Shakespeare, “… full of sound and fury, signifying nothing” (Shakespeare, 2002, p. 179)?" Well, I’m recording this in January 2016 and it is still a little early to tell. The DSM-5 didn’t go into effect for most social workers until 2015. What we do know is that the critiques of DSM-5 haven’t let up.
The most basic critique of the DSM-5 is the same critique that has been levied against psychiatry for decades: that it does nothing more than medicalize or pathologize normal behavior. Let’s play a game. I’ll describe something and you tell me if it is normal or not normal (because that’s basically what a DSM diagnosis is supposed to represent): Having a conversation with God. The desire to escape slavery. Falling in love. Debilitating sadness over the death of a loved one. Forgetfulness in old age. Believing that you are invincible. If you answered “normal” to all of those, then you’d be right. But if you answered not normal to all of those, then you’d also be right. And if you answered “normal” to some and not others then you’d still be right.
So, how can this be? In a nutshell, “normal” is a social construction. One of the vocal critics of the moral and scientific foundations of psychiatry, Thomas Szasz who was, himself, a psychiatrist, wrote about the social construction of schizophrenia in this way: "If you talk to God, you are praying; If God talks to you, you have schizophrenia. If the dead talk to you, you are a spiritualist; If you talk to the dead, you are a schizophrenic" (Szasz, 1973, p. 85). That was in 1973. Today if I hear someone talking out loud but I can’t see who they are talking to, I’m much more likely to assume there’s a Bluetooth headset in their ear as I am to assume schizophrenia.
So, what about that question of escaping slavery? Again, it is an issue of social construction. In 1850, Samuel Cartwright, a doctor and slave owner invented a diagnosis called "drapetomania" which basically said that enslaved Africans who tried to escape were suffering from a mental disease (Reese, 2013). See - it wasn’t the conditions of slavery that would make someone want to run away – it was a diseased mind. If you accept this premise, then the corollary would have to hold true – that not trying to escape was proof of good mental health. Fast forward 120 years and we find that same-sex romantic or sexual attraction is a psychiatric illness. And then in 1973, the DSM committee voted to eliminate “homosexuality” from the DSM. That’s right. Committee vote and survey says, Homosexuality is no longer a psychiatric illness. Millions of people, not crazy. The best report about this historic decision is an episode of This American Life, called 81 Words. Look it up. It is amazing.
Fast forward another 40 years to 2013 and Allen Frances, a psychiatrist and the chair of the DSM-IV committee that I mentioned earlier is warning people that DSM-5 will medicalize normal behavior. Is this starting to sound familiar? He even wrote about it in a 2014 editorial in Research on Social Work Practice. “DSM-5 exacerbates the medicalization of normal behavior by relabeling as mental disorder the sadness of grief, the temper tantrums of children, the normal forgetfulness of old age, the everyday distractibility of adult life, the worries of the medically ill, and the temptations of binge eating” (Frances & Jones, 2014, p. 12). Now, if you’re still in the mood for games you can try and name the diagnoses Dr. Frances is referring to.
So is it ever ok to say that someone isn’t normal? Are there ever situations where giving a diagnosis is good? As it turns out, yes. And I’m not just talking about diagnosis as a means to finance treatment. Yes, third party reimbursement hinges on diagnosis. But I’m talking about something less institutional and more personal. There are people who like labels, who find comfort in being able to name or label what is wrong. The label draws a boundary around an experience. One of the most effective psychotherapies for the treatment of depression, Interpersonal Psychotherapy, which I talked about in episode 10 – uses labeling as a key intervention. In IPT the therapist gives people the “sick role.” It goes something like this (imagine I’m the therapist and you’re the client. You meet criteria for major depressive disorder. I might say something like this: “The reason why you’ve been having difficulty is because you have an illness called depression. It is a treatable illness, but like all illnesses, it makes it difficult to do some things.” In the case of IPT, the sick role draws a boundary around the experience of depression and says “it is reasonable to do this and not reasonable to that, until your depressive symptoms decrease.”
Labels can even draw up boundaries around a group of people. When you put up boundaries, you separate. When separation systematically oppresses people we call that boundary segregation. But, when labels group people together, it can also create community. Psychologist Gary Greenberg has suggested that one of the best examples of the power of a diagnosis to build community is the diagnosis of Asperger’s Syndrome (which was established in DSM-IV and subsumed under Autistic Spectrum Disorder in DSM-5). According to Greenberg, “Asperger’s syndrome gave people whose primary symptom was isolation a way to belong and provided resources to those who were diagnosed” (Reese, 2013).
So, I know what you are wondering - is DSM diagnosis good or bad? Well, today’s episode won’t be the definitive answer to that question. But, it will give you cause to pause when you think about the role of DSM-5 in the professional life of social workers and the people we serve. My guest is social work faculty member from Florida State University, Jeffrey Lacasse, Ph.D. Dr. Lacasse is an expert in psychiatric medications and has published several critiques of the changes in DSM-5. In today's episode, Dr. Lacasse critiques the definition of mental illness, the empirical support for and reliability of DSM-5 diagnoses, the politics associated with the creation and publishing of the DSM, and what it means for social workers to be the single largest group of professionals who diagnose people with psychiatric disorders based on the DSM.
One quick note about the interview: I spoke with Jeff in January 2016 at the 20th annual Society for Social Work and Research conference in Washington DC. We did the interview in his hotel room and at one point you can hear music and children in the background. It’s not really distracting, but since we’re talking about mental disorders, I thought it was only fair to let you know that you’re not hearing things.
And now, without further ado, on to episode 101 of the Social Work Podcast: Critiques of the DSM-5: Interview with Jeffrey Lacasse, Ph.D.
Interview
[10:55]
Jonathan Singer: Jeff, thanks so much for being here on the podcast and talking with us about DSM 5.
[10:59]
Jeffrey Lacasse: Thanks for having me Jonathan!
[11:02]
Jonathan Singer: So one of the things that the DSM 5 was advertised as being was a significant improvement over the highly criticized DSM-IV. But you don’t really see it as an improvement, do you?
[11:14]
Jeffrey Lacasse: I do not see it as an improvement. And I think that is what the data would show. I think one thing that we have to remember, especially as social workers, is that the DSM 5 is a product of a private guild, who makes a profit by selling it. And it’s actually a very interesting thing if you think about it, that a private guild gets to decide who is mentally ill and who is not, in our society. And as social workers, from a social justice stand point, that is an awful, interesting, and very kind of American sort of thing for us to think about, given the relationships between drug companies and psychiatrists, and especially those who are influential in something like the DSM 5. To be fair, I think there’s plenty of academic psychiatrists out there that would say that the DSM 5 is not an improvement. And, NIMH voted with their feet, saying that they do not want to be involved with the DSM 5.
[12:05]
Jonathan Singer: They said that they wanted to do the RDOCs.
[12:06]
Jeffrey Lacasse: And yeah, they wanted to do the RDOC criteria. And I mean that’s a really complicated separate issue. But obviously the utility of DSM 5 is going to be in clinical practice. That’s why social workers need to be familiar with it for reimbursement purposes, etc. But as far as DSM 5 being an expression of you know, improved science, I do not think that it true. And I think that is remarkable actually, if you think about it. Because DSM-IV is 1994, DSM-IV-TR is 2000 and then 15 years later it would be reasonable to say okay so we have improved this system right? We got a little better. Actually some of the numbers for DSM 5 are worse than the tests for DSM-III in 1980. And…
[12:50]
Jonathan Singer: What do you mean by that? What numbers?
[12:51]
Jeffrey Lacasse: Yeah… Just to give you one example the Kappa value, the test-retest reliability for diagnoses is the primary variable used to measure accuracy. Which is somewhat primitive but it has some utility. So that means if a client goes to see two separate clinicians, and around the same time period, what percentage of the time do they agree that the client has, let’s say, depression.
[13:12]
Jonathan Singer: So if they went to see me and they went to see you.
[13:15]
Jeffrey Lacasse: Exactly. And so if you know there’s 100% agreement that’s great, but that does not exist in medicine. There is always diagnostic ambiguity, but I was stunned at the level of inaccuracy of the DSM 5. And that is why I am at this conference with you and presenting a paper on this issue. It was 28% for major depression. It was 20% for generalized anxiety disorder.
And the interesting thing was the American Psychiatric Association, their work group, they were really trying to spin these results in the scientific journals. And you know as researchers were used to that, the average consumer of research results just think these are scientists, this is going to be objective research. It is anything but. They spun these as, if not an improvement, at least as very positive results. They said, “We got good results. The DSM is pretty reliable.” 20% and 28%? I mean, I am just going to cut to the chase. Those are abysmal results. And those are two of the most, as you know, two of the most common disorders diagnosed. And let me be a little more specific. If there’s 100 clients, the way the study worked, if there’s 100 clients who had previously been diagnosed with generalized anxiety disorder under DSM-IV-TR or very prominent symptoms of it, and you and I got trained specifically on how to share diagnostic patterns. And then we used instruments that are contained in the DSM 5 which are often not used in the community. And if we did this study in a place that has a lot of people who have generalized anxiety disorder, the prevalence is quite high and then the number at the end of the study is 20%. It leads to questions, you know, that’s just reliability by the way, that’s not validity which is a whole separate discussion.
But DSM 5, the whole idea that the modern DSM system, the reason why you have checklists is to make diagnosis at least reliable. And validity we can’t really get to but reliable we can get to, we can get to…Reliable status is supposed to be the point. 20-28%? Schizophrenia was 46%? Alcohol use disorder was 40%? But I have to say, it would be unrealistic to expect numbers in the 90s or maybe even the 80s. You know autism I think was 69% for example and that’s something that because of the eye contact and how young it happens it’s probably easier to diagnose. ADHD was fairly high, but some of these very commonly diagnosed mental disorders in this bell jar of an experiment where they’re trying very hard, had numbers of like 20%. And of course, the American Psychiatric Association defined what a good value was for this and they said unacceptable is 20% or lower, implying that anything above 20% was okay, or at least acceptable if not good or excellent, etc. And it was interesting because, people may not be aware, but two of the primary critic of the DSM 5 were Bob Spitzer, the editor of DSM-III and DSM-III-R who wrote a letter in saying, certainly you're going to get Kappa values as good as we got in 1980. I mean he really threw that on, it was very interesting. And then Allan Frances comes in saying, you are trying to redefine accuracy so we look silly to the rest of medicine.
[16:21]
Jonathan Singer: Allen Frances, head of the DSM-IV task force.
[16:24]
Jeffrey Lacasse: Yes, DSM-IV and DSM-IV-TR, who has made a public apology for the DSM-IV and DSM-IV-TR. He came out of retirement to fight against the, you know the rhetoric around the DSM 5. So, I think it’s an important issue when it comes to informed consent and some of the things you could argue from an ethical stand point. There’s a way that, as far as what clinicians would get out of something like this. There is a way to talk to a client about diagnosis, and there is pragmatic issues about reimbursement and all that sort of stuff. But do clients know that. Imagine someone just got out of a divorce or bad relationship or had some other kind of loss and they’re diagnosed after three months of chronic symptoms with depression. That’s a dilemma for clinicians. You have to make judgment calls, there’s the bereavement stuff, in the DSM there is a note to clinicians. But does the client who is being diagnosed know - look if you saw someone else, on average 20% of the time those two people would agree that you are indeed depressed. Now the people could be, I mean I think it’s really important to say, this doesn’t mean we don’t identify people who are distressed or disturbed or have lots of symptoms that are in this DSM checklist. But for social workers and social work academics like us, the dilemma that is an unpleasant dilemma to raise, is we have pushed all in on this this idea of evidence based and evidence informed practice, that treatment guides are organized around these clusters, around these diagnoses. And in this recent tutorial, I said hold on a second, if the diagnosis isn’t reliable, how do you even proceed beyond that? And I think it’s frustrating to people because I don’t have a good answer to that question at all. But that’s a really important question and it’s very convenient to skip that question I think, but I don’t think anyone has good answers to that question yet.
[18:09]
Jonathan Singer: That’s such a great point because for years, and as for as long as I, you know I went to school in the mid-1990s for MSW. And for years the mantra has been that treatment follows assessment and diagnosis. And your right. If I am saying, “oh this is definitely major depressive disorder” and I am not saying “you know, you could get a second opinion and they could totally disagree.” Like there’s, then the person is not providing informed consent to this and, furthermore, my treatment plan could very well be wrong, because I diagnosed it, does not necessarily mean I am right.
[18:42]
Jeffrey Lacasse: Well luckily a lot of what we do is non-specific. And luckily a lot of the common factor stuff would say maybe it doesn’t matter whether you have “generalized anxiety disorder” or its “depression with anxious features”. And through the therapeutic relationship, a lot of that stuff is going to work regardless of the diagnosis. I study psychiatric medications as my primary thing, and those are labeled by DSM category for what they’re approved for, that’s a little different. And I think and there is some non-specific stuff about the way drugs works too obviously. But it’s called an anti-depressant because it’s used for depression, and they’re also used for anxiety disorders and they are pretty effective for, just as effective for that as they are for depression, maybe even more so. To the degree that they are effective at all. I think as a field, and this was in an editorial, I said we have to start rethinking this a little bit. Because it actually opens up new avenues of research and new ways of looking at things. And also, we’re not psychiatrists. I mean we have a 100-year history of cooperating very closely with psychiatrists but we’re theoretically, more holistic, more committed social justice, the macro, the meso, the effects of things like depression and things that are related to depression that we don’t think of as biological. And I think when you diagnose using the manual written by psychiatrists, I understand it has to be done in practice, I don’t have great answers for that either. But, what I’d like to see is to see an agency, a state, an area, experiment working without diagnoses. I teach psychopathology and I would actually be curious to hear your opinion on this issue. In all the text books it says that diagnoses are essential for good clinical communication. So that clinicians can communicate to each other. Just as an example. So I could write down that John has major depression of a severe nature. I just don’t understand, and I’m not trying to be facetious here, but I don’t understand how that is more helpful, than me telling you ‘Hey Jonathan, John just got divorced. He is chronically sad and suicidal. It’s been going on for twelve weeks, and he is not doing well at all, and he needs some help.” That took an extra five seconds to say that. I don’t understand, I literally don’t understand. I get the reimbursement issues. I get the medication issues. But in terms of clinical communication, if you and I are working in an agency together, I think the latter description is much more descriptive and I did it at an 8th grade level of education, you know, but it sounds less medical. There is a lot of, so that’s something that I think we all should think about. All the textbooks say this is essential for clinical communication and I don’t know that it is.
[21:16]
Jonathan Singer: Well, and what happens is that when I am saying, “Oh yeah. John has major depressive disorder,” historically it becomes more problematic when I am like, “Oh yeah, John, borderline personality disorder.” Right? I am not talking about, “yeah, so there is some real issues with emotion regulation – he’s got some issues around self-harm, he’s got this, there’s some trauma background. All that stuff is really important clinical information. But, I’m like, “yeah, borderline,” and you’re sitting there like “yeah, I don’t want to work with this guy.” And I think that is a great example of how a diagnosis is terrible clinical communication.
[21:50]
Jeffrey Lacasse: Now I would agree. And we kind of talked out of both sides of our mouth out of necessity in that we teach students to do in depth psycho socials and that is really good clinical communication. But the diagnosis is supposed to be like the summary statement. That whole borderline issue though is very interesting, it is a fairly sexist diagnosis. And rather than saying so-and-so was sexually traumatized as a child and has these acting out behaviors, etc., we collapsed it into borderline. What is interesting is that there was a study done where they looked at how many different types of borderlines you can build using the checklist in the DSM 5, and you create hundreds of clients - some of whom look nothing like each other. And we still call them all borderline because that is the disorder. That’s the name of the disorder. So even that idea that it communicates something, that you can build different looking depressive symptoms too.
[22:35]
Jonathan Singer: And it’s really different by age.
[22:38]
Jeffrey Lacasse: Absolutely. I think this is the other thing about the DSM that we might want to think about as far as the degree to which its scientific, is it was like a medical textbook, you know. And it looks very authoritative, and it’s from the American Psychiatric Association, which is you know we have respect for that profession and so on and so forth. So what happened is a bunch of people got around a table and decided this is a mental disorder and here are the and there are books written about this. Paula Caplan wrote a book about the, I don’t want to say the invention, but the creation of premenstrual dysphoric disorder or PMDD. She resigned from it in disgust because she was so offended by the process because it was so subjective. But when you get that book in the mail or when you get the online book on Amazon or whatever and you look at it, you forget like a bunch of people just decided this. Now they may have used research to do that and it depends on which disorder were talking about, how well validated it is, how reliable it is. But Paula makes the point that she wrote an entire book about how human and troubling she found the process. Speaking of DSM 5, we end up with new disorders like binge eating disorder, like minor neurocognitive disorder, which some people say is medicalizing being in your 50s and early 60s you know. And there was just a drug approved by the FDA for phemo hypoactive sexual dysfunction, which you know it’s easy to critique that disorder on the basis, that it’s medicalizing what is a very relational issue. So if these things can be reliable, if these kappa values could be really high for all these entities, it’d be a different debate. They’re just really poor and I don’t, it’s not like I don’t understand what American Psychiatric Association would say no these are good values, this was a rigorous test because they are selling their book with science. And there are competitors we could switch to ICD the International Classification of Diseases. It’s on the web for free. But I think people forget that they are buying, this is a product that they marketed and you have to wonder if there will be a DSM 6. I mean I’m sure you remember all the furor on the Huffington Post. I mean lay people in the supermarket are familiar with the debates around the DSM 5, bereavement issues, and you know ADHD being over diagnosed, all this kind of stuff. So, I don’t know if there will be a DSM 6. It’s the most common question I get at the end of my psychopathology class, do you think there will be a DSM 6? I mean I have no idea, but from a PR stand point, it might be better to not have a DSM 6, it really might.
[25:07]
Jonathan Singer: Yea or I could imagine them doing a DSM 5.1, .2. Like not saying were going to completely re-haul again, were just going to some updates.
[25:18]
Jeffrey Lacasse: Yea and just to give a little, this is a little bit in reverse order but you know, DSM 5 took so long to come out because they were incredibly optimistic, I think it was the year 2000 or 2001 when the white paper on DSM 5 comes out. And they said look DSM 5 is going to integrate neuroscience and categorical diagnosis. And it was interesting because I was in my PhD program at that time and I’m studying the limits of what we know about the brain, how complicated the brain is, what we know about, and lesions underlying a mental disorder, and I was puzzled at the time, because I couldn’t imagine in ten years that we would be able to, you know do that. But they were incredibly optimistic and none of that materialized. I mean zero new science materialized that allowed them to map disorders onto the brain. You do wonder at what point do you say look this is not an endeavor that is going to bear fruit to the clinician, and the research studies are different. I mean they provide data that would be useful to other scientists, but as far as for the clinician? I mean a lot of times my students are under the impression at any time, some of these disorders, that we could discover the cause. And what is interesting is that happened between DSM-IV and 5 with one specific disorder that’s pretty rare called Rett's disorder, which is a sub type, it was classified under Autism I believe. They found the genomic problem that causes Rett's disorder. The etiology of these disorders is discussed in the chapters, right, for each disorder. They removed it from the book. They said no DSM 5 is a book of behavioral disorders, mental disorders, that means we don’t know the cause of them. Alzheimer’s is always in there, dementia is always in there, as these weird ones kind of in between, but my students are usually flabbergasted when I’ll say “wait a second that got taken out of the book cause we figured out what caused it so now it’s a known medical disease, not a confusing mental disorder that takes all kinds of clinical judgment to sort out”. So that’s a fascinating example of, I think, what the DSM 5 actually is.
[27:15]
Jonathan Singer: That is amazing, I didn’t know that. I didn’t know that they took out Rett’s because they figured out what caused it, that’s bizarre.
[27:23]
Jeffrey Lacasse: Well what’s interesting is I think that, the fascinating thing about being a clinician or researcher regarding mental disorder is that it’s very mysterious, it’s very confusing, it takes great clinical skills, and it’s a detective story to some degree. I mean you’ve worked with people, you know what I am talking about. Often it gets presented to the public as this is very simple. “We know what depression is, depression is a chemical imbalance in your brain.” That’s gets, and that’s just by the way the DSM does not say that. But so the DSM should be a book of things that are poorly understood, difficult to assess for, and maybe will always have poor reliability due to how hard those studies are to do. And that people’s clinical presentation change, or people lives change, and the drugs they are taking change. So we could reach a place, I think, where we say well this is going to be kind of a, I don’t want to say a disaster, but it’s always going to be a very troubling, from a scientific standpoint, sort of book. So what’s the purpose of this book? It’s financial, it’s for reimbursement, it’s for bureaucratic coding, cool. But you see it held up as a piece of shining science – yeah, that’s really difficult to support. And I think Allen Frances coming out of the woodwork, who is as conventional a psychiatric guy as you will find. I mean he was involved with the TMAP project which was a Texas medication algorithm project, which was a very well-critiqued, conventional kind of project. Chair of psychiatry at Duke, I believe, or high up at Duke. For him to come out of retirement to rail against this, I think was really an important sort of thing. So rather than people thinking wow these social workers surely, “they sure critique the DSM a lot, and, those wacky hippy social workers…” It’s more like if you listen to the psychiatrists very closely and look at their own internal debates, they’d beat up on the DSM 5 pretty bad too, but who’s using it mostly? Well we outnumber psychiatrists, it’s got to be close to 10 to 1 in terms of mental health clinicians in the United States. But I, if you go to the back of the DSM 5 and try to find, not who participated in the field trials but the scientific advisors that created the disorders and all that sort of thing, look for social workers. There are a few, but there is not very many. So interesting that we do an awful a lot of the work and then as far as our representation, our voice, in the actual creation of the manual, not really there. And that’s of course assuming that our voice would be different than their voice, I don’t know if that is true.
[29:49]
Jonathan Singer: So those are some great critiques of the reliability of the disorder, about the internal fighting in psychiatry, the role of social workers in sort of perpetuating diagnosis as this thing we should do because we are the ones that are primarily doing… I mean if we look just in terms of numbers, we’re doing it. Are there other critiques that social workers should be aware of?
[30:15]
Jeffrey Lacasse: Well yeah, there definitely are and some of them are a little more conceptual in nature. But they’re important. And there pretty social worky, so to speak. I mean one of them would be that the definition of mental disorder has changed yet again for DSM 5. It’s pretty inadequate scientifically. First of all it’s interesting that over the years the definition of something like a mental disorder has changed, which just shows you how fuzzy this is and how it hard it is to pin down. Allen Frances said in an article in Wired by the journalist Gary Greenberg, who has written some good stuff on DSM 5... he says you can’t define it, you just can’t define it. [transcript note: the actual Greenberg quote is: "Al Frances... has broken off his exercise routine to declare that 'there is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it.'"] So you’re starting with something that the people who are engaged in this are saying that you can’t define it, where is that boundary between normality and disorder. So that’s a, that’s a problem. The other thing would be, this is a thought experiment. Couldn’t you talk about mental disorder without assuming that these are medical problems? You could talk about behavior. You could talk about a social, a sociological or deviance kind of approach. There’s a lot of different ways you could look at these problems. But as they’re sorted in the book, these are medical - sometimes they use the word disease, sometimes they use syndrome, sometimes they use mental disorder. They use those terms sort of interchangeably. Those are actually very different things if we’re going to be technical about it. I just use mental disorder to refer to something that’s in the DSM. But even that concept, as I just said, it’s a confusing concept. Now, DSM-IV had some really interesting limitations noted in the book.
[31:43]
There was a whole section called the “limitations of categorical diagnosis.” That was removed for DSM 5. So that is something important for clinicians to know. It’s just my opinion, but I think its important. The DSM 5 was a much more political document than the DSM-IV to me. Because I teach this class, because I am, I might be the only person who sat down and read DSM 5 cover to cover to see what was new - that’s a bizarre thing to do I understand that. But, I did that. And as I did that I noticed some changes that I thought were kind of disturbing. First of all, they deleted that section on the limitations of categorical diagnosis. DSM-IV-TR mentioned that the brain changes seen as schizophrenia may be related to treatment with anti-psychotic medication. That’s gone now. It just has a statement about - I believe it says that - it just to refers to the fact that there is brain changes. That kind of suggest its due to the schizophrenia. So there is a debate in the literature about that. But the DSM-IV said it might be the drugs, DSM 5 says it hey the brain shrink over time, and it is a heavily medicated population. I don’t think it nailed every single one of them. There’s also stuff about, you know, some effects of meds like akathisia. Where it looks to me more like a book written by people who diagnosis and primarily medicate. And it’s political and almost promotional about how they present things. And DSM-IV certainly had components of things like that. If you were someone who really knew the literature deeply and read it you would say there was some politics here, there’s some spin here and there. But I think DSM 5 is worse objectively on these issues. See, this puts the idea that this is supposed to be a valuable resource for clinicians. Because my students are usually very upset about this- by the way, I show them on power points “this is what the DSM-IV said and here is what the DSM 5 said. Do you think this is a better cause they removed that information or removed that limitation?” And my students are like “wow, why was that taken out?” Again, it is also possible no one reads this information besides the billing codes and it doesn’t matter, so I want to be realistic about it. But I do think that’s an issue.
[33:50]
Jonathan Singer: So, given all of these critiques - which I think are really important for social workers to keep in mind, and you know, what you said earlier about social workers doing psycho social assessments… In DSM-IV, those really mapped onto the Axis IV the environmental stressors and those sorts of things. Social workers have to use the DSM 5 in certain situations, and since they do, and since Axis IV is gone, how should social workers be using this responsibly?
[34:24]
Jeffrey Lacasse: Yes, that’s a great question Jonathan. So two-part answer to that. First of all, the removal of axis four we should be more offended by that than I think we are. Barbra Probst wrote an excellent piece of Research on Social Work Practice, which I guest edited, about the demise of Axis IV. That was, you know, often called the social workers axis. And as far as we can tell, it just kind of disappeared without them asking an entire profession about that. So your right. When I worked at a psychiatric hospice I spent a lot of time writing things like “homelessness” on Axis IV. And that might be a way that the full five axis DSM-IV diagnosis might have provided some good clinical communication in that you get a good idea of the client’s presenting problems pretty fast. You get a GAF score, that kind of thing. So, GAS/GAF is gone. Axis IV is gone. We have Z codes now instead of the previous V codes. And the Z codes list almost every conceivable social worker problem you could think of. So, one suggestions, and I teach my student to do this, is to note the Z codes to give a more complete picture of the client. You know if someone has a diagnosis of major depression, as we have been discussing, and that’s the only thing on their chart, I think they become a depressive. You know, I think we sort of pathologize it etcetera etcetera. And there is a list of ten Z codes that list just what they are facing in their life, that, I think, can paint a different picture. So I think that can be important. As far as what we do in macro level its a very simple suggestion and I don’t know how you would implement it easily, and probably impossible, but if you could reimburse for z codes, I’d like to see how many people would, given the choice: I can diagnose you with this disorder, or I could just list these life problems your having. Which would you prefer? That’s an interesting though experiment at least. And Paula Caplan, one of her edited books - I think it was on a little rural health clinical - they stopped using the diagnosis as an act of rebellion. And what they said was that nothing happened. As far as I know, the impact of it - as far as they could tell - it didn’t change their practice very much. But those Z codes - I think students, I hope they get taught in DSM class cause I certainly teach them and you know those have some utility. And in actual practice when people take the time to fill those out. I hope so. I don’t know.
[36:38]
Jonathan Singer: Well Jeff, thank you so much for talking about DSM 5 critiques, things that social workers should be thinking about this new document.
[36:46]
Jeffrey Lacasse: Thank you for having me Jonathan. I really appreciate it.
Interview
[10:55]
Jonathan Singer: Jeff, thanks so much for being here on the podcast and talking with us about DSM 5.
[10:59]
Jeffrey Lacasse: Thanks for having me Jonathan!
[11:02]
Jonathan Singer: So one of the things that the DSM 5 was advertised as being was a significant improvement over the highly criticized DSM-IV. But you don’t really see it as an improvement, do you?
[11:14]
Jeffrey Lacasse: I do not see it as an improvement. And I think that is what the data would show. I think one thing that we have to remember, especially as social workers, is that the DSM 5 is a product of a private guild, who makes a profit by selling it. And it’s actually a very interesting thing if you think about it, that a private guild gets to decide who is mentally ill and who is not, in our society. And as social workers, from a social justice stand point, that is an awful, interesting, and very kind of American sort of thing for us to think about, given the relationships between drug companies and psychiatrists, and especially those who are influential in something like the DSM 5. To be fair, I think there’s plenty of academic psychiatrists out there that would say that the DSM 5 is not an improvement. And, NIMH voted with their feet, saying that they do not want to be involved with the DSM 5.
[12:05]
Jonathan Singer: They said that they wanted to do the RDOCs.
[12:06]
Jeffrey Lacasse: And yeah, they wanted to do the RDOC criteria. And I mean that’s a really complicated separate issue. But obviously the utility of DSM 5 is going to be in clinical practice. That’s why social workers need to be familiar with it for reimbursement purposes, etc. But as far as DSM 5 being an expression of you know, improved science, I do not think that it true. And I think that is remarkable actually, if you think about it. Because DSM-IV is 1994, DSM-IV-TR is 2000 and then 15 years later it would be reasonable to say okay so we have improved this system right? We got a little better. Actually some of the numbers for DSM 5 are worse than the tests for DSM-III in 1980. And…
[12:50]
Jonathan Singer: What do you mean by that? What numbers?
[12:51]
Jeffrey Lacasse: Yeah… Just to give you one example the Kappa value, the test-retest reliability for diagnoses is the primary variable used to measure accuracy. Which is somewhat primitive but it has some utility. So that means if a client goes to see two separate clinicians, and around the same time period, what percentage of the time do they agree that the client has, let’s say, depression.
[13:12]
Jonathan Singer: So if they went to see me and they went to see you.
[13:15]
Jeffrey Lacasse: Exactly. And so if you know there’s 100% agreement that’s great, but that does not exist in medicine. There is always diagnostic ambiguity, but I was stunned at the level of inaccuracy of the DSM 5. And that is why I am at this conference with you and presenting a paper on this issue. It was 28% for major depression. It was 20% for generalized anxiety disorder.
And the interesting thing was the American Psychiatric Association, their work group, they were really trying to spin these results in the scientific journals. And you know as researchers were used to that, the average consumer of research results just think these are scientists, this is going to be objective research. It is anything but. They spun these as, if not an improvement, at least as very positive results. They said, “We got good results. The DSM is pretty reliable.” 20% and 28%? I mean, I am just going to cut to the chase. Those are abysmal results. And those are two of the most, as you know, two of the most common disorders diagnosed. And let me be a little more specific. If there’s 100 clients, the way the study worked, if there’s 100 clients who had previously been diagnosed with generalized anxiety disorder under DSM-IV-TR or very prominent symptoms of it, and you and I got trained specifically on how to share diagnostic patterns. And then we used instruments that are contained in the DSM 5 which are often not used in the community. And if we did this study in a place that has a lot of people who have generalized anxiety disorder, the prevalence is quite high and then the number at the end of the study is 20%. It leads to questions, you know, that’s just reliability by the way, that’s not validity which is a whole separate discussion.
But DSM 5, the whole idea that the modern DSM system, the reason why you have checklists is to make diagnosis at least reliable. And validity we can’t really get to but reliable we can get to, we can get to…Reliable status is supposed to be the point. 20-28%? Schizophrenia was 46%? Alcohol use disorder was 40%? But I have to say, it would be unrealistic to expect numbers in the 90s or maybe even the 80s. You know autism I think was 69% for example and that’s something that because of the eye contact and how young it happens it’s probably easier to diagnose. ADHD was fairly high, but some of these very commonly diagnosed mental disorders in this bell jar of an experiment where they’re trying very hard, had numbers of like 20%. And of course, the American Psychiatric Association defined what a good value was for this and they said unacceptable is 20% or lower, implying that anything above 20% was okay, or at least acceptable if not good or excellent, etc. And it was interesting because, people may not be aware, but two of the primary critic of the DSM 5 were Bob Spitzer, the editor of DSM-III and DSM-III-R who wrote a letter in saying, certainly you're going to get Kappa values as good as we got in 1980. I mean he really threw that on, it was very interesting. And then Allan Frances comes in saying, you are trying to redefine accuracy so we look silly to the rest of medicine.
[16:21]
Jonathan Singer: Allen Frances, head of the DSM-IV task force.
[16:24]
Jeffrey Lacasse: Yes, DSM-IV and DSM-IV-TR, who has made a public apology for the DSM-IV and DSM-IV-TR. He came out of retirement to fight against the, you know the rhetoric around the DSM 5. So, I think it’s an important issue when it comes to informed consent and some of the things you could argue from an ethical stand point. There’s a way that, as far as what clinicians would get out of something like this. There is a way to talk to a client about diagnosis, and there is pragmatic issues about reimbursement and all that sort of stuff. But do clients know that. Imagine someone just got out of a divorce or bad relationship or had some other kind of loss and they’re diagnosed after three months of chronic symptoms with depression. That’s a dilemma for clinicians. You have to make judgment calls, there’s the bereavement stuff, in the DSM there is a note to clinicians. But does the client who is being diagnosed know - look if you saw someone else, on average 20% of the time those two people would agree that you are indeed depressed. Now the people could be, I mean I think it’s really important to say, this doesn’t mean we don’t identify people who are distressed or disturbed or have lots of symptoms that are in this DSM checklist. But for social workers and social work academics like us, the dilemma that is an unpleasant dilemma to raise, is we have pushed all in on this this idea of evidence based and evidence informed practice, that treatment guides are organized around these clusters, around these diagnoses. And in this recent tutorial, I said hold on a second, if the diagnosis isn’t reliable, how do you even proceed beyond that? And I think it’s frustrating to people because I don’t have a good answer to that question at all. But that’s a really important question and it’s very convenient to skip that question I think, but I don’t think anyone has good answers to that question yet.
[18:09]
Jonathan Singer: That’s such a great point because for years, and as for as long as I, you know I went to school in the mid-1990s for MSW. And for years the mantra has been that treatment follows assessment and diagnosis. And your right. If I am saying, “oh this is definitely major depressive disorder” and I am not saying “you know, you could get a second opinion and they could totally disagree.” Like there’s, then the person is not providing informed consent to this and, furthermore, my treatment plan could very well be wrong, because I diagnosed it, does not necessarily mean I am right.
[18:42]
Jeffrey Lacasse: Well luckily a lot of what we do is non-specific. And luckily a lot of the common factor stuff would say maybe it doesn’t matter whether you have “generalized anxiety disorder” or its “depression with anxious features”. And through the therapeutic relationship, a lot of that stuff is going to work regardless of the diagnosis. I study psychiatric medications as my primary thing, and those are labeled by DSM category for what they’re approved for, that’s a little different. And I think and there is some non-specific stuff about the way drugs works too obviously. But it’s called an anti-depressant because it’s used for depression, and they’re also used for anxiety disorders and they are pretty effective for, just as effective for that as they are for depression, maybe even more so. To the degree that they are effective at all. I think as a field, and this was in an editorial, I said we have to start rethinking this a little bit. Because it actually opens up new avenues of research and new ways of looking at things. And also, we’re not psychiatrists. I mean we have a 100-year history of cooperating very closely with psychiatrists but we’re theoretically, more holistic, more committed social justice, the macro, the meso, the effects of things like depression and things that are related to depression that we don’t think of as biological. And I think when you diagnose using the manual written by psychiatrists, I understand it has to be done in practice, I don’t have great answers for that either. But, what I’d like to see is to see an agency, a state, an area, experiment working without diagnoses. I teach psychopathology and I would actually be curious to hear your opinion on this issue. In all the text books it says that diagnoses are essential for good clinical communication. So that clinicians can communicate to each other. Just as an example. So I could write down that John has major depression of a severe nature. I just don’t understand, and I’m not trying to be facetious here, but I don’t understand how that is more helpful, than me telling you ‘Hey Jonathan, John just got divorced. He is chronically sad and suicidal. It’s been going on for twelve weeks, and he is not doing well at all, and he needs some help.” That took an extra five seconds to say that. I don’t understand, I literally don’t understand. I get the reimbursement issues. I get the medication issues. But in terms of clinical communication, if you and I are working in an agency together, I think the latter description is much more descriptive and I did it at an 8th grade level of education, you know, but it sounds less medical. There is a lot of, so that’s something that I think we all should think about. All the textbooks say this is essential for clinical communication and I don’t know that it is.
[21:16]
Jonathan Singer: Well, and what happens is that when I am saying, “Oh yeah. John has major depressive disorder,” historically it becomes more problematic when I am like, “Oh yeah, John, borderline personality disorder.” Right? I am not talking about, “yeah, so there is some real issues with emotion regulation – he’s got some issues around self-harm, he’s got this, there’s some trauma background. All that stuff is really important clinical information. But, I’m like, “yeah, borderline,” and you’re sitting there like “yeah, I don’t want to work with this guy.” And I think that is a great example of how a diagnosis is terrible clinical communication.
[21:50]
Jeffrey Lacasse: Now I would agree. And we kind of talked out of both sides of our mouth out of necessity in that we teach students to do in depth psycho socials and that is really good clinical communication. But the diagnosis is supposed to be like the summary statement. That whole borderline issue though is very interesting, it is a fairly sexist diagnosis. And rather than saying so-and-so was sexually traumatized as a child and has these acting out behaviors, etc., we collapsed it into borderline. What is interesting is that there was a study done where they looked at how many different types of borderlines you can build using the checklist in the DSM 5, and you create hundreds of clients - some of whom look nothing like each other. And we still call them all borderline because that is the disorder. That’s the name of the disorder. So even that idea that it communicates something, that you can build different looking depressive symptoms too.
[22:35]
Jonathan Singer: And it’s really different by age.
[22:38]
Jeffrey Lacasse: Absolutely. I think this is the other thing about the DSM that we might want to think about as far as the degree to which its scientific, is it was like a medical textbook, you know. And it looks very authoritative, and it’s from the American Psychiatric Association, which is you know we have respect for that profession and so on and so forth. So what happened is a bunch of people got around a table and decided this is a mental disorder and here are the and there are books written about this. Paula Caplan wrote a book about the, I don’t want to say the invention, but the creation of premenstrual dysphoric disorder or PMDD. She resigned from it in disgust because she was so offended by the process because it was so subjective. But when you get that book in the mail or when you get the online book on Amazon or whatever and you look at it, you forget like a bunch of people just decided this. Now they may have used research to do that and it depends on which disorder were talking about, how well validated it is, how reliable it is. But Paula makes the point that she wrote an entire book about how human and troubling she found the process. Speaking of DSM 5, we end up with new disorders like binge eating disorder, like minor neurocognitive disorder, which some people say is medicalizing being in your 50s and early 60s you know. And there was just a drug approved by the FDA for phemo hypoactive sexual dysfunction, which you know it’s easy to critique that disorder on the basis, that it’s medicalizing what is a very relational issue. So if these things can be reliable, if these kappa values could be really high for all these entities, it’d be a different debate. They’re just really poor and I don’t, it’s not like I don’t understand what American Psychiatric Association would say no these are good values, this was a rigorous test because they are selling their book with science. And there are competitors we could switch to ICD the International Classification of Diseases. It’s on the web for free. But I think people forget that they are buying, this is a product that they marketed and you have to wonder if there will be a DSM 6. I mean I’m sure you remember all the furor on the Huffington Post. I mean lay people in the supermarket are familiar with the debates around the DSM 5, bereavement issues, and you know ADHD being over diagnosed, all this kind of stuff. So, I don’t know if there will be a DSM 6. It’s the most common question I get at the end of my psychopathology class, do you think there will be a DSM 6? I mean I have no idea, but from a PR stand point, it might be better to not have a DSM 6, it really might.
[25:07]
Jonathan Singer: Yea or I could imagine them doing a DSM 5.1, .2. Like not saying were going to completely re-haul again, were just going to some updates.
[25:18]
Jeffrey Lacasse: Yea and just to give a little, this is a little bit in reverse order but you know, DSM 5 took so long to come out because they were incredibly optimistic, I think it was the year 2000 or 2001 when the white paper on DSM 5 comes out. And they said look DSM 5 is going to integrate neuroscience and categorical diagnosis. And it was interesting because I was in my PhD program at that time and I’m studying the limits of what we know about the brain, how complicated the brain is, what we know about, and lesions underlying a mental disorder, and I was puzzled at the time, because I couldn’t imagine in ten years that we would be able to, you know do that. But they were incredibly optimistic and none of that materialized. I mean zero new science materialized that allowed them to map disorders onto the brain. You do wonder at what point do you say look this is not an endeavor that is going to bear fruit to the clinician, and the research studies are different. I mean they provide data that would be useful to other scientists, but as far as for the clinician? I mean a lot of times my students are under the impression at any time, some of these disorders, that we could discover the cause. And what is interesting is that happened between DSM-IV and 5 with one specific disorder that’s pretty rare called Rett's disorder, which is a sub type, it was classified under Autism I believe. They found the genomic problem that causes Rett's disorder. The etiology of these disorders is discussed in the chapters, right, for each disorder. They removed it from the book. They said no DSM 5 is a book of behavioral disorders, mental disorders, that means we don’t know the cause of them. Alzheimer’s is always in there, dementia is always in there, as these weird ones kind of in between, but my students are usually flabbergasted when I’ll say “wait a second that got taken out of the book cause we figured out what caused it so now it’s a known medical disease, not a confusing mental disorder that takes all kinds of clinical judgment to sort out”. So that’s a fascinating example of, I think, what the DSM 5 actually is.
[27:15]
Jonathan Singer: That is amazing, I didn’t know that. I didn’t know that they took out Rett’s because they figured out what caused it, that’s bizarre.
[27:23]
Jeffrey Lacasse: Well what’s interesting is I think that, the fascinating thing about being a clinician or researcher regarding mental disorder is that it’s very mysterious, it’s very confusing, it takes great clinical skills, and it’s a detective story to some degree. I mean you’ve worked with people, you know what I am talking about. Often it gets presented to the public as this is very simple. “We know what depression is, depression is a chemical imbalance in your brain.” That’s gets, and that’s just by the way the DSM does not say that. But so the DSM should be a book of things that are poorly understood, difficult to assess for, and maybe will always have poor reliability due to how hard those studies are to do. And that people’s clinical presentation change, or people lives change, and the drugs they are taking change. So we could reach a place, I think, where we say well this is going to be kind of a, I don’t want to say a disaster, but it’s always going to be a very troubling, from a scientific standpoint, sort of book. So what’s the purpose of this book? It’s financial, it’s for reimbursement, it’s for bureaucratic coding, cool. But you see it held up as a piece of shining science – yeah, that’s really difficult to support. And I think Allen Frances coming out of the woodwork, who is as conventional a psychiatric guy as you will find. I mean he was involved with the TMAP project which was a Texas medication algorithm project, which was a very well-critiqued, conventional kind of project. Chair of psychiatry at Duke, I believe, or high up at Duke. For him to come out of retirement to rail against this, I think was really an important sort of thing. So rather than people thinking wow these social workers surely, “they sure critique the DSM a lot, and, those wacky hippy social workers…” It’s more like if you listen to the psychiatrists very closely and look at their own internal debates, they’d beat up on the DSM 5 pretty bad too, but who’s using it mostly? Well we outnumber psychiatrists, it’s got to be close to 10 to 1 in terms of mental health clinicians in the United States. But I, if you go to the back of the DSM 5 and try to find, not who participated in the field trials but the scientific advisors that created the disorders and all that sort of thing, look for social workers. There are a few, but there is not very many. So interesting that we do an awful a lot of the work and then as far as our representation, our voice, in the actual creation of the manual, not really there. And that’s of course assuming that our voice would be different than their voice, I don’t know if that is true.
[29:49]
Jonathan Singer: So those are some great critiques of the reliability of the disorder, about the internal fighting in psychiatry, the role of social workers in sort of perpetuating diagnosis as this thing we should do because we are the ones that are primarily doing… I mean if we look just in terms of numbers, we’re doing it. Are there other critiques that social workers should be aware of?
[30:15]
Jeffrey Lacasse: Well yeah, there definitely are and some of them are a little more conceptual in nature. But they’re important. And there pretty social worky, so to speak. I mean one of them would be that the definition of mental disorder has changed yet again for DSM 5. It’s pretty inadequate scientifically. First of all it’s interesting that over the years the definition of something like a mental disorder has changed, which just shows you how fuzzy this is and how it hard it is to pin down. Allen Frances said in an article in Wired by the journalist Gary Greenberg, who has written some good stuff on DSM 5... he says you can’t define it, you just can’t define it. [transcript note: the actual Greenberg quote is: "Al Frances... has broken off his exercise routine to declare that 'there is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it.'"] So you’re starting with something that the people who are engaged in this are saying that you can’t define it, where is that boundary between normality and disorder. So that’s a, that’s a problem. The other thing would be, this is a thought experiment. Couldn’t you talk about mental disorder without assuming that these are medical problems? You could talk about behavior. You could talk about a social, a sociological or deviance kind of approach. There’s a lot of different ways you could look at these problems. But as they’re sorted in the book, these are medical - sometimes they use the word disease, sometimes they use syndrome, sometimes they use mental disorder. They use those terms sort of interchangeably. Those are actually very different things if we’re going to be technical about it. I just use mental disorder to refer to something that’s in the DSM. But even that concept, as I just said, it’s a confusing concept. Now, DSM-IV had some really interesting limitations noted in the book.
[31:43]
There was a whole section called the “limitations of categorical diagnosis.” That was removed for DSM 5. So that is something important for clinicians to know. It’s just my opinion, but I think its important. The DSM 5 was a much more political document than the DSM-IV to me. Because I teach this class, because I am, I might be the only person who sat down and read DSM 5 cover to cover to see what was new - that’s a bizarre thing to do I understand that. But, I did that. And as I did that I noticed some changes that I thought were kind of disturbing. First of all, they deleted that section on the limitations of categorical diagnosis. DSM-IV-TR mentioned that the brain changes seen as schizophrenia may be related to treatment with anti-psychotic medication. That’s gone now. It just has a statement about - I believe it says that - it just to refers to the fact that there is brain changes. That kind of suggest its due to the schizophrenia. So there is a debate in the literature about that. But the DSM-IV said it might be the drugs, DSM 5 says it hey the brain shrink over time, and it is a heavily medicated population. I don’t think it nailed every single one of them. There’s also stuff about, you know, some effects of meds like akathisia. Where it looks to me more like a book written by people who diagnosis and primarily medicate. And it’s political and almost promotional about how they present things. And DSM-IV certainly had components of things like that. If you were someone who really knew the literature deeply and read it you would say there was some politics here, there’s some spin here and there. But I think DSM 5 is worse objectively on these issues. See, this puts the idea that this is supposed to be a valuable resource for clinicians. Because my students are usually very upset about this- by the way, I show them on power points “this is what the DSM-IV said and here is what the DSM 5 said. Do you think this is a better cause they removed that information or removed that limitation?” And my students are like “wow, why was that taken out?” Again, it is also possible no one reads this information besides the billing codes and it doesn’t matter, so I want to be realistic about it. But I do think that’s an issue.
[33:50]
Jonathan Singer: So, given all of these critiques - which I think are really important for social workers to keep in mind, and you know, what you said earlier about social workers doing psycho social assessments… In DSM-IV, those really mapped onto the Axis IV the environmental stressors and those sorts of things. Social workers have to use the DSM 5 in certain situations, and since they do, and since Axis IV is gone, how should social workers be using this responsibly?
[34:24]
Jeffrey Lacasse: Yes, that’s a great question Jonathan. So two-part answer to that. First of all, the removal of axis four we should be more offended by that than I think we are. Barbra Probst wrote an excellent piece of Research on Social Work Practice, which I guest edited, about the demise of Axis IV. That was, you know, often called the social workers axis. And as far as we can tell, it just kind of disappeared without them asking an entire profession about that. So your right. When I worked at a psychiatric hospice I spent a lot of time writing things like “homelessness” on Axis IV. And that might be a way that the full five axis DSM-IV diagnosis might have provided some good clinical communication in that you get a good idea of the client’s presenting problems pretty fast. You get a GAF score, that kind of thing. So, GAS/GAF is gone. Axis IV is gone. We have Z codes now instead of the previous V codes. And the Z codes list almost every conceivable social worker problem you could think of. So, one suggestions, and I teach my student to do this, is to note the Z codes to give a more complete picture of the client. You know if someone has a diagnosis of major depression, as we have been discussing, and that’s the only thing on their chart, I think they become a depressive. You know, I think we sort of pathologize it etcetera etcetera. And there is a list of ten Z codes that list just what they are facing in their life, that, I think, can paint a different picture. So I think that can be important. As far as what we do in macro level its a very simple suggestion and I don’t know how you would implement it easily, and probably impossible, but if you could reimburse for z codes, I’d like to see how many people would, given the choice: I can diagnose you with this disorder, or I could just list these life problems your having. Which would you prefer? That’s an interesting though experiment at least. And Paula Caplan, one of her edited books - I think it was on a little rural health clinical - they stopped using the diagnosis as an act of rebellion. And what they said was that nothing happened. As far as I know, the impact of it - as far as they could tell - it didn’t change their practice very much. But those Z codes - I think students, I hope they get taught in DSM class cause I certainly teach them and you know those have some utility. And in actual practice when people take the time to fill those out. I hope so. I don’t know.
[36:38]
Jonathan Singer: Well Jeff, thank you so much for talking about DSM 5 critiques, things that social workers should be thinking about this new document.
[36:46]
Jeffrey Lacasse: Thank you for having me Jonathan. I really appreciate it.
END
References and Resources
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed). Washington, D.C: American Psychiatric Association.
- Alvior, M. E., Drake, A., Kim, J., Lee, M. Y., & Singer, J. B. (2014). Transitioning to DSM-5: Practical Considerations. NASW CAYA Newsletter, Spring/Summer, 2-4.
- Author. (2016, January 14). "Thomas Szasz" In Wikipedia, the free encyclopedia. Retrieved from https://en.wikipedia.org/w/index.php?title=Thomas_Szasz&oldid=699766282
- Caplan, P. (1996). They say you're crazy: How the world's most powerful psychiatrists decide who's normal. Da Capo Press
- Frances, A. (2013). Essentials of Psychiatric Diagnosis, Revised Edition: Responding to the Challenge of DSM-5®: Guilford Publications.
- Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, Big Pharma, and the medicalization of ordinary life. New York: William Morrow.
- Frances, A., & Jones, K. D. (2014). Should Social Workers Use Diagnostic and Statistical Manual of Mental Disorders-5? Research on Social Work Practice, 24(1), 11–12. http://doi.org/10.1177/1049731513507981 [FREE]
- Gomory, T., Wong, S.E., Cohen, D., & Lacasse, J.R. (2011). Clinical social work and the biomedicalindustrial complex. Journal of Sociology and Social Welfare. 38(4), 135-165.
- Greenberg, G. (2013). The book of woe: The DSM and the unmaking of psychiatry. New York: Blue Rider Press.
- Greenberg, G. (2013). DSM-5: How the emperor got his clothes. http://www.madinamerica.com/2013/02/dsm-5-how-the-emperr-got-his-clothes/
- Greenberg, G. (2010). Inside the battle to define mental illness. Wired. http://www.wired.com/2010/12/ff_dsmv/
- Insel, T. (2013, April 29). Transforming Diagnosis. Retrieved from http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml
- Kirk, S.A., Gomory, T., & Cohen, D. (2013). Mad science: Psychiatric coercion, diagnosis, and drugs. Transaction Publishers
- Lacasse, J. R. (2014). After DSM-5: A Critical Mental Health Research Agenda for the 21st Century. Research on Social Work Practice, 24(1), 5–10. http://doi.org/10.1177/1049731513510048 [FREE]
- Probst, B. (2014). The Life and Death of Axis IV: Caught in the Quest for a Theory of Mental Disorder. Research on Social Work Practice, 24(1), 123-131. http://doi.org/10.1177/1049731513491326
- Reese, H. (2013, May 2). The Real Problems With Psychiatry. The Atlantic. Retrieved from http://www.theatlantic.com/health/archive/2013/05/the-real-problems-with-psychiatry/275371/
- Shakespeare, W. (2002). The tragedy of Macbeth (B.A. Mowat & P. Werstine, Eds.) (Folger Shakespeare Library). New York: Washington Square Press.
- Singer, J. B. (Producer). (2007, February 26). #10 - Interpersonal psychotherapy (IPT) [Episode 10]. Social Work Podcast [Audio podcast]. Retrieved from http://www.socialworkpodcast.com/2007/02/interpersonal-psychotherapy-ipt.html
- Szasz, T. (1973). The Second Sin (1st ed.). Garden City, N.Y: Anchor Press.
- Washburn, M. (2013). Five Things Social Workers Should Know about the DSM-5. Social Work, 58(4), 373-376. http://doi.org/10.1093/sw/swt030
- WHO | International Classification of Diseases (ICD). (n.d.). Retrieved January 25, 2016, from http://www.who.int/classifications/icd/en/
APA (6th ed) citation for this podcast:
Singer, J. B. (Producer). (2016, January 25). #101 - Critiques of the DSM-5: Interview with Jeffrey Lacasse, Ph.D. [Audio Podcast]. Social Work Podcast. Retrieved from http://www.socialworkpodcast.com/2016/01/DSM5critique.html
1 comment:
Hi, does this episode have transcript?
Post a Comment