Why This Book Is Needed
A conceptual introduction sets forth the book’s aim: to guide clinical social work students (and practicing clinicians) to explore assessment from a range of theoretical frameworks, each with its own emphasis, limitations, and form of evidence, and to think critically about what each perspective has to offer, takes for granted, omits, and counts as knowledge. It begins by exploring the meaning of the key terms “critical thinking,” “diagnosis,” and “assessment” and draws on both theory and research to trace how these concepts have been addressed in social work education and practice. Following an overview of the book’s structure and content, including introduction to the case of Ray (a case that will be used throughout the chapters and analyzed from each clinical perspective), the introduction concludes with specific suggestions for educators about ways to use the book to develop complex, reflexive, and critical thinking in their students.
The Prognosis for Social Work Diagnosis
SOCIAL WORK DISTINGUISHES itself as a profession in part through its approach to the assessment of clients and their problems. Members of the profession, however, have been ambivalent about the development and use of formal classification systems because of their concern about the negative effects of labeling clients and the limited usefulness of classification systems for treatment planning. On the other hand, social work’s heavy involvement in the field of mental health has compelled workers to use the classification systems of the American Psychiatric Association, particularly its most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R).1 Despite the widespread use of DSM by social workers, little attention has been given to its implications for social work. One difficulty social workers have in describing their work is their lack of an accepted, defined vocabulary for defining the problems of their clients.2 Because mental health has become the most common field of social work practice and because DSM is so widely used in mental health practice, the American Psychiatric Association’s system of naming and classifying mental disorders has unofficially and by default had significant effects on diagnosis in clinical social work. For example, a recent survey found that for the vast majority of clinical social workers, DSM has become the most frequently consulted reference book in the profession.3 Another survey found that information about DSM is incorporated into many courses in graduate schools of social work.4 The present article reviews the evolution of the profession’s distinctive conception of clinical social work diagnosis and suggests why, despite past efforts to formulate one, it lacks a comprehensive, well-formulated diagnostic system. It then considers some of the limitations of the DSM-111-R and how it affects social work assessment. Finally, recent developments in social work diagnosis are assessed.
The diagnostic strengths manual?.
As influential as it is, the DSM-IV (the DSM-IV-TR has just been published and has approximately 100 additional pages of text on disorders--primarily because of the increased enumeration of criteria and specifiers) of the American Psychiatric Association (1994) poses some dilemmas and tensions for practitioners and, therefore, for clients and patients who are diagnosed under its protocols and schematics. Volleys of criticism of DSM-III, -III-R, and -IV have come from many fronts, based on a variety of concerns: that the DSM fails to provide convincing evidence for the reliability and validity of diagnostic criteria and standards that other medical specialties ostensibly require (Kutchins & Kirk, 1997), and that it provides an insufficient and hard-to-operationalize conceptualization of mental disorder (Wakefield, 1992). In addition, this lack of a clear definition permits an ever-widening net of definition of disorder so that all manner of common human foibles, annoying traits, and bad habits are captured as mental disorders (Wolin & Wolin, 1993); it has an extensive white male bias and a history of developing diagnostic categories that are inimical to some racial groups and to women (Tavris, 1992); and through its numeric system of taxonomy and the numerical anonymity of the patients who appear in the "casebook," the DSM subtly encourages objectification of individuals with mental disorders (Cutler, 1991). Whatever its weaknesses and whatever the character of its construction of human frailties and foibles, the DSM is enormously popular, and its influence would be hard to understate. It is the lingua franca of mental health professions. Insurance companies and the enormously powerful pharmaceutical industry rely on it heavily for very different reasons. (Goleman, 1994; Kutchins & Kirk, 1997) Finally, the social, medical, scientific, and political processes that have nourished the development of an influential document like DSM reflect an evolving social norm (and its attendant practices) and cultural dynamic of "progressive infirmity." Such a norm decrees that an expanding range of behaviors, internal emotional and mental states, and human conditions come to be labeled as deficiencies requiring medication, sequestering, treatment and, in some cases, imprisonment. This has the cumulative effect of producing a rapidly developing social hierarchy in which a growing number of individuals and professions, employing the lexicon of deficit, have the power to evaluate and act on those who are identified as not measuring up, weakening more communal understandings and melioration of human trials, troubles, and tribulations; and "enfeebling" the sense of self of those who fail under the terms of the new normative lexicon (Gergen, 1994). Obviously, the DSM has a host of individual, disciplinary, professional, and institutional supporters. Its intent to create, like Emil Kraepelin 70 years before (Andreasen, 1984), an encyclopedic, descriptive manual that clearly distinguishes a given disorder, through specific and behavioral criteria, from every other disorder reflects the intent of medicine generally. It must be pointed out, however, that other branches of medicine are interested as well in underlying pathology (causality) because locating and understanding that particular cellular, physiological, or biochemical dynamic is a key to effective treatment, cure, or prevention (Walker, 1996). The framers of DSM seem curiously uninterested in cause. There are two particular problems with DSM-IV that I think are especially disturbing, and both have profound and too often adverse effects on people who seek the help of mental health professionals. It's All in Your Head! Many, if not most physical illnesses, serious and slight, often yield cognitive, emotional, and behavioral changes as part of the symptom picture. In some of these illnesses, the emotional and cognitive changes are the first thing that might be observed by family members or a psychiatrist. …