Approximately a week ago, I wrote an article asking Will Clinical Social Workers Embrace the New DSM 5 in light of the National Institute of Mental Health withdrawing its support for the publication. Then, Dr. Allen Francis wrote an article making a case for social workers not to embrace the DSM 5.
Responses by social workers on different social media outlets varied, but one unifying question remained….Why now? Historically, social workers have not been included in the developmental process of the DSM by the American Psychiatric Association (M.D.’s) despite being the largest provider of mental health services. I decided to email Dr. Frances and asked if he was available to answer some follow-up questions about his article on social workers.
He responded, “Sure…Let’s have a telephone call today. The week is very busy”. Dr. Frances spoke with me for almost a hour in order to help me relay the likely long term implications of the DSM V and why social workers being the largest stakeholders should be concerned too. This article is packed with resources because I independently verified every statement made by Dr. Frances in order for you to make your own assessment.
Before I dive into the interview with Dr. Frances, I would like to bring you up to speed with some background information on this not so new controversy.
What makes Dr. Allen Frances an authority on the DSM?
Dr. Allen Frances was chair for the DSM IV task force and the Department of Psychiatry at the Duke University School of Medicine, and he is currently a professor emeritus at Duke University. In late 2010, Dr. Frances did an in depth interview with Wired Magazine who had unlimited access to him as he reflected on almost two decades in the past when he authored the DSM IV. Here is an excerpt from Wired Magazine:
In its first official response to Frances, the APA diagnosed him with “pride of authorship” and pointed out that his royalty payments would end once the new edition was published—a fact that “should be considered when evaluating his critique and its timing.”
Frances, who claims he doesn’t care about the royalties (which amount, he says, to just 10 grand a year), also claims not to mind if the APA cites his faults. He just wishes they’d go after the right ones—the serious errors in the DSM-IV. “We made mistakes that had terrible consequences,” he says. Diagnoses of autism, attention-deficit hyperactivity disorder, and bipolar disorder skyrocketed, and Frances thinks his manual inadvertently facilitated these epidemics—and, in the bargain, fostered an increasing tendency to chalk up life’s difficulties to mental illness and then treat them with psychiatric drugs. Read Full Article
The article in Wired Magazine was indeed an eye opener. It discusses how an influential advocate for diagnosing children with bipolar disorder failed to disclose money received from the makers of the bipolar drug Resperdal. When viewed with a wider lens, it not really all that surprising considering the recent revelations on Attention Deficit Disorder as discussed in the New York Times.
History of Social Work Involvement with DSM
Back to the interview with Dr. Allen Frances, the first order of business was to gain some insight on the sudden outreach to the social work profession, and I didn’t anticipate learning something new. However, this was not the case.
Dr. Frances went on to tell me about Social Worker Janet B. Williams who was the text editor on the DSM III. Additionally, he also notes that she has been the only social worker ever to be included in the DSM development process. Currently, Janet Williams is the Vice President of Global Science at MedAvante. As stated in a 2011 PRNewswire Press Release, “MedAvante solutions help sponsors achieve enhanced assay sensitivity for increased drug effect and reduced trial failure rates, enabling them to bring better drugs to market faster.”
Dr. Frances acknowledged that social workers have not been represented in the development process despite being the largest provider of mental health services. However, he did state, “Social Workers have a huge stake in improving care for the really sick and should not be distracted by the expansions of the DSM V.”
DSM 5 Impact on Consumers
Dr. Frances expressed concerns for military service men and women being overly diagnosed with PTSD in lieu of allowing time for transitional services. Dr. Frances gives another example of how unemployment causes depression which is the result of environmental factors and not a mental illness.
Once someone regains employment and the situational stressors have abated, should this individual retain the label of a psychiatric disorder for seeking counseling as a coping mechanism? Do practitioners really want to label someone as a major depressive because they are unemployed or have been diagnosed with Cancer? Here is a video where Dr. Frances goes more in depth on the potential problems this will cause:
Unintended Consequences of DSM V
Dr. Frances stated one of the major issues with the DSM series is that its primary authors are research academics who are making suggestions and recommendations based on controlled research studies conducted in University clinics which are not helpful in everyday practice. By expanding the DSM 5 to cover challenges of everyday living, it will mislabel medical illness as a psychiatric disorder.
Dr. Frances also stated it will continue to foster an environment that diverts attention and resources away from the severely mentally ill and uninsured. As an example, Dr. Frances referenced the 1 million inmates in prison as a result of an undiagnosed and untreated mental health disorders due to poor resources and health care. Apparently, the Bureau of Justice Statistics agrees with him, and you can view their report here.
Dr. Frances quotes President Obama when he stated, “It’s easier to get a gun than an outpatient appointment.” Although gun control was not apart of our discussion, it should be noted that the National Rifle Association (NRA) is using its powerful lobbying efforts to change mental health thresholds and reporting laws in all 50 states.
Couple this type of legislation with over diagnosis by mental health professionals, the outcomes for children and families could be devastating. The New York Times does a great job of summarizing the presenting issues with current NRA proposals in an article entitled, The Focus on Mental Health Laws to Curb Violence is Unfair, Some Say. You can also view this video of Dr. Allen Frances speaking on the over diagnosis of mental illness:
Common Misconceptions About the DSM V
The interview with Dr. Allen Frances gave me an opportunity to ask him for clarification on some of the concerns expressed by social workers and their reasons for embracing the anticipated DSM 5. I made of a list of the main key points that he wanted Social Workers to know:
- The DSM is a copyrighted manual by the APA with no official authority with public or private health insurers.
- The ICD Codes are the only required codes necessary for billing mental health services. He states these codes are free of charge from the government with accompany resources and guides available. Here is the link found on CMS.Gov.
- The APA is motivated by earnings for publishing a new manual to cover budgetary shortfalls.
- Unless your institution demands use of the DSM V, Don’t buy it, don’t use it, and don’t teach it.
“The ICD is the global standard in diagnostic classification for health reporting and clinical applications for all medical diagnoses, including mental health and behavioral disorders. The United States will be one of the last industrialized countries to adopt the ICD-10, even though it was published in 1990.
Every member state of the World Health Assembly is expected to report morbidity and mortality statistics to the World Health Organization (WHO) using the ICD codes, but countries are allowed to modify the ICD for use within their own country.” ~Practice Central
Dr. Frances provided his twitter feed where he disseminates information on his current projects. He also stated to tweet your questions, comments, and concerns to @AllenFrancesMD as seen above.
Dr. Frances states that he believes there should be a government arm similar to the FDA to help regulate, provide guidance for mental health providers, and make recommendations for public policy. He believes it should be comprised of an interdisciplinary team of psychiatry, social workers, and public health in order to create a holistic approach to treatment and diagnoses. Dr. Frances stated the APA should no longer have a monopoly on mental health especially with increasing influence from drug companies manifesting in their policies.
Self Help Tips and Advice For Social Workers
There is no denying the positive impact social workers have on hundreds of families and individuals throughout their career. They will tell you about the rewarding experiences they have helping others in need. Unfortunately, for every success, there is at least one case in which they could not help. Social workers see the best and the worst of society every day, and even the strongest among us can crack under the pressure. That is why self-care is so important. Being mindfully aware of your needs as well as the needs of those around you can keep you healthy and able to be there when you’re needed.
What is Self Care and How Can You Do It Every day?
Self-care is a practice that becomes a lifestyle. Understand and commit to the idea that it is not something you do once, it is something you do every day. The key is to be mindful and aware.
It is important to be mindful of where you are and what you are doing as you go about your day. Whether you are in a meeting or at the grocery store, notice how you are feeling in the moment. This can range from listening to your body and noticing your state of health to recognizing an emotional situation in your life.
Become aware of your breathing. When we are feeling stressed, emotional, or run down, we forget how to breathe. Our breath can become fast and shallow which deprives our bodies of the oxygen it needs. Pay attention to your breathing and focus on slowing it down. Allow the air to fill your abdomen, not just your lungs. You will find that mindful breathing exercises calms your thoughts, allows for greater clarity, and lessens your anxiety.
Now That You Are Aware, How Do You Improve?
It’s one thing to be mindful and aware of how you are feeling, but doing something about it is another matter. Improving your physical and emotional state requires some life changes as well.
Many social workers have the stress relieving habit of smoking or grabbing an unhealthy snack from the vending machine. It makes us feel like we’re taking a moment for ourselves. Instead of grabbing a cigarette or a bag of chips, try an e-cigarette starter kit or grab a granola bar. This gives you a moment away while making healthier choices through controlling the nicotine and sugar you intake. The idea is not to deprive yourself but to make small changes that will make you feel better over time.
Changing the way you approach daily tasks is another life change that will give you some added peace of mind. For decades we have been taught to multitask but all we’ve learned is how to start tasks but not finish them in a timely manner. By focusing on one task at a time you’ll allow yourself to finish a job before moving onto something else. This creates a sense of accomplishment and boosts your confidence at the job you are doing.
Maintaining Your New Found Awareness
Creating a support system is important when attempting to care for yourself. By relying on your friends and family you are willingly accepting love and nurturing that you simply cannot give to yourself. When meditating on an issue in your life doesn’t result in answers, one of the best things we can do is turn to our support system for help. It’s not necessary to face every challenge alone and often times, they can see from a perspective that you cannot. You may also find that the more willing you are to receive care from others, the easier it becomes for you to provide care for the people you’re working to help.
Self-care is difficult for those who spend their lives taking care of others. By allowing yourself the care you need you will find that it not only feeds your soul but it will improve your ability to care for the people around you.
National Survey Reveals the Scope of Behavioral Health Across the Nation
The Substance Abuse and Mental Health Services Administration’s (SAMHSA) latest National Survey on Drug Use and Health (NSDUH) report provides the latest estimates on substance use and mental health in the nation, including the misuse of opioids across the nation. Opioids include heroin use and pain reliever misuse. In 2016, there were 11.8 million people aged 12 or older who misused opioids in the past year and the majority of that use is pain reliever misuse rather than heroin use—there were 11.5 million pain reliever misusers and 948,000 heroin users.
“Gathering, analyzing, and sharing data is one of the key roles the federal government can play in addressing two of the Department of Health and Human Services’ top clinical priorities: serious mental illness and the opioid crisis,” said HHS Secretary Tom Price, M.D. “This year’s survey underscores the challenges we face on both fronts and why the Trump Administration is committed to empowering those on the frontlines of the battle against substance abuse and mental illness.”
Nationally, nearly a quarter (21.1percent) of persons 12 years or older with an opioid use disorder received treatment for their illicit drug use at a specialty facility in the past year. Receipt of treatment for illicit drug use at a specialty facility was higher among people with a heroin use disorder (37.5 percent) than among those with a prescription pain reliever use disorder (17.5 percent).
The report also reveals that in 2016 while adolescents have stable levels of the initiation of marijuana, adults aged 18 to 25 have higher rates of initiation compared to 2002-2008, but the rates have been stable since 2008. In contrast, adults aged 26 and older have higher rates of marijuana initiation than prior years. In 2016, an estimated 21.0 million people aged 12 or older needed substance use treatment and of these 21.0 million people, about 2.2 million people received substance use treatment at a specialty facility in the past year.
Rates of serious mental illness among age groups 26 and older have remained constant since 2008. However, the prevalence of serious mental illness, depression and suicidal thoughts has increased among young adults over recent years. Among adults aged 18 or older who had serious mental illness (SMI) in the past year, the percentage receiving treatment for mental health services in 2016 (64.8 percent) was similar to the estimates in all previous years.
“Although progress has been made in some areas, especially among young people, there are many challenges we need to meet in addressing the behavioral health issues facing our nation,” said Dr. Elinore McCance-Katz, Assistant Secretary for Mental Health and Substance Use. “Fortunately there is effective action being taken by the Administration and U.S. Department of Health and Human Services with initiatives to reduce prescription opioid and heroin related overdose, death, and dependence as well as many evidence-based early intervention programs to increase access to treatment and recovery for people with serious mental illness. We need to do everything possible to assure that those in need of treatment and recovery services can access them and we look forward to continuing work with federal and state partners on this goal.”
“Addiction does not have to be a death sentence – recovery is possible for most people when the right services and supports in place, including treatment, housing, employment, and peer recovery support,” said Richard Baum, Acting Director Office of National Drug Control Policy. “The truth is that there’s no one path to recovery because everyone is different. And frankly, it doesn’t matter how someone gets to recovery. It just matters that they have every tool available to them, including peer recovery support and evidence-based treatment options like medication-assisted treatment for opioid addiction.”
NSDUH is a scientific annual survey of approximately 67,500 people throughout the country, aged 12 and older. NSDUH is a primary source of information on the scope and nature of many substance use and mental health issues affecting the nation.
SAMHSA is issuing its 2016 NSDUH report on key substance use and mental health indicators as part of the 28th annual observance of National Recovery Month which began on September 1st. Recovery Month expands public awareness that behavioral health is essential to health, prevention works, treatment for substance use and mental disorders is effective, and people can and do recover from these disorders.
Anxiety in Children: How Can You Help?
Mental health issues amongst children are becoming more and more common, and this is a trend that doesn’t show any signs of slowing down. If you’re a parent or caregiver, it’s a good idea to become familiar with signs of mental ill-health, and think about how you might be able to help.
The first step is to recognize the symptoms. While small experiences of anxiety are a natural part of life, it’s important to recognize when it’s becoming more prevalent, and when it’s having a negative impact on a child. Symptoms might include an irrational and ongoing sense of worry, an inability to relax, general uneasiness and irritability, as well as difficulty sleeping, difficulty concentrating or sudden, unprovoked feelings of panic. Anxiety and depression are not always obvious in children and symptoms can vary significantly depending on the child. Because of this, it’s really important to involve professional medical help if you’re worried about someone in your care.
The second step is to work out if and how to talk about it. Simply letting them know you care can make a big difference. You might like to share a story about times you’ve experienced anxiety. This can be an avenue into a discussion around anxiety, and can provide an opportunity to ask if they have similar worries.
If you’re going to try to help a child with anxiety, there are a few key things to avoid as they can end up being accidentally unhelpful. Avoid phrases like ‘just relax’, or ‘calm down’ as they can escalate the feelings of anxiety and make the child feel like they are doing something wrong. Also consider and be aware of situations that might exacerbate your child’s anxiousness, for example being in loud, crowded places could evoke feelings of uneasiness or panic. It’s important that you can find the balance between understanding and supporting what your child might be going through and acting as a self-assigned counsellor – don’t be afraid to seek professional help if you need to.
The next thing you can think about is how to empower your child to deal with particular triggers. For example, if your child is feeling anxious about a certain event – an exam, public speaking at school, or an upcoming sports game, you may be able to talk with them about whether you can help them to practice or prepare in a way that they might find helpful.
Perhaps practicing a speech in front of you could help them to pinpoint what it is about the experience that’s making them feel anxious. You can’t promise that they’ll ace their presentation or win their sports day, but you can help them practice what they’re concerned about and provide them with tools to manage the anxiety they may feel in these situations. You don’t want to create further anxiety-inducing situations though, so make sure your child is happy to try this out, and mix it up with fun activities too. Revisiting things that they are familiar with and good at can help to develop a sense of capability and foster self-esteem.
When dealing with anxiety, this three-step breathing exercise can be used as a tool to interrupt anxiety as it builds, and it is something you can practice together.
- Step 1: When you feel tension and anxiety building, stop and close your eyes and take a slow, deep breath in through your nose for 6 seconds.
- Step 2: Hold it for 2 seconds, then slowly breathe out through your mouth for 4 seconds.
- Step 3: Repeat this as many times as necessary, gently bringing your focus back to the breath.
If you’re worried about your child, or someone close to you, it’s important to get the advice of a qualified healthcare professional. Anxiety and depression are illnesses that often benefit from a range of treatment options, and often professional support is key to management and recovery.
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