There’s a big, hairy problem shadowing our field: what, exactly, is a mental disorder? Is using diagnostic language helping or hurting our clients? The way we describe suffering needs to be accurate, but I’m convinced we don’t get that from the DSM.
It’s been about a decade since I got my master’s in social work. In my undergrad years, I’d heard some buzz about different approaches to diagnosing, but I was so new to therapy that it hardly registered. My first job involved working in a charter school where we didn’t bill insurance, so I didn’t need to provide diagnoses. I could help kids and families just fine without them: I had a good sense of what was going on with them.
When my partner and I moved cities, I started working at a clinic affiliated with a hospital. Here, I had to provide a diagnosis, primarily for insurance purposes. And after a few years, I started to feel a kind of dissonance. Although diagnosing felt icky, there was a sense among my colleagues and clients that a diagnosis held weight. When I’d talk with clients about a diagnosis, I’d tell them my perspective: there’s a lot of controversy around these labels, and they don’t give the full story of who a person is. Instead of resorting to diagnostic language in my notes, I’d provide rich descriptions of my clients’ stories, using everyday language to describe what they’d been through. I’d write down quotes. I’d write about contributing factors, like abuse or bullying. I didn’t resort to labels like depression; instead, I’d say they were experiencing low moods, or feeling sad. This was general, nonmedicalized, nonpathologizing language. But it never quite made the ickiness go away—and it felt like in not issuing a diagnosis, I risked losing credibility.
Finally, my ambivalence reached a tipping point. I could either complain about the problems I experienced diagnosing, or I could do something about it. So recently, I decided to go back to school to get my PhD and take a deep dive into the research on diagnosing—and into developing practical alternatives to our current diagnostic frameworks.
I’m still in school and working on this creation, but the diagnostic alternative I’m envisioning pulls from a time-tested framework in social work. It consists of three levels: the micro level (which refers to the client), the mezzo level (which refers to their immediate environment—interpersonal relationships, home life, and community), and the macro level (which refers to the larger situations clients are embedded in, whether poverty, violence, or civil unrest). That’s the organizing framework. The other part involves simply describing people’s problems in nonpathologizing language similar to what I’ve done in my notes—not labeling them as “symptoms” or part of a “mental illness” or “disorder.” By overlaying these named problems onto the three-level framework, we’d have a fuller picture of the client’s emotional, behavioral, and psychological challenges.
As passionate as I am about this, sometimes forging a new path through so much entrenched thinking feels lonely. My sense is most clinicians are just practicing and diagnosing the way they were trained to. I know many are ambivalent about the DSM or have a positive view of it. Few seem to have outright disdain for it. I get it. When it comes to reimbursement, what other options do we have? As they say, these are the waters in which we swim. But since my career pivot, I’ve connected with people all over the world who are thinking outside the box, outside of the water they’ve been swimming in. And that inspires me.
I believe that any new framework that sticks will need to be codifiable and implementable into the U.S. healthcare system, like the DSM. This is going to take greater unity on our part as therapists. The loudest voices challenging the DSM are from different disciplines and professional groups, so we’re scattered, and that’s making it more difficult to find a framework we can all agree upon.
Effecting change is no easy task, but it is possible.
Arnoldo Cantú, LCSW, is a clinical social worker specializing in work with children, adolescents, and their families in school and community mental health settings. He’s a doctoral student at Colorado State University, with an interest in researching conceptual and practical alternatives to the DSM.
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