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.
Gay, Bisexual, Sexually Abused Male Inmates More Fearful of Prison Rape, More Open to Therapy
There is nowhere to escape in what often is referred to as a “sexual jungle,” especially for the most vulnerable. However, “Zero tolerance” toward prison rape is now national policy thanks to the Prison Rape Elimination Act passed by the United States Congress in 2003. Although this law changed how Americans think about prison rape, few studies have examined how inmates perceive rape and if they feel safe in prison. Even less is known about how their perceptions influence whether or not they ask for mental health treatment while incarcerated.
The most recent National Inmate Survey of 2011-12 of 92,449 inmates age 18 or older shows that among non-heterosexual prison inmates, more than 12 percent reported sexual victimization by another inmate and almost 5.5 percent were victimized by a prison staff member within the past 12 months. In comparison, 1.2 percent of heterosexual prisoners were sexually victimized by an inmate and 2.1 percent were victimized by a prison staff member. These rates are even higher for those with mental illness. About one in 12 inmates with a mental disorder report at least one incident of sexual victimization by another inmate over a six-month period, compared to one in 33 male inmates without a mental disorder.
Using data from more than 400 male inmates housed in 23 maximum-security prisons across the U.S., researchers from Florida Atlantic University conducted a novel study to examine the factors related to fear of rape in prison and the likelihood of male inmates requesting mental health treatment while incarcerated. They focused specifically on prisoners at risk of being sexually victimized in prison: gay or bisexual inmates and those with a history of childhood sexual abuse.
A key finding from the study, published in the Journal of Interpersonal Violence, is that sexual orientation and a history of childhood sexual abuse are significant predictors of male inmates fearing rape as a big threat in prison and voluntarily requesting mental health treatment. Findings from the study reveal that nearly 38 percent of gay and bisexual inmates and 37 percent of inmates with childhood sexual abuse fear rape as a big threat.
Compared with straight inmates, gay and bisexual inmates are approximately two times more likely to perceive rape as a threat and three times more likely to voluntarily request mental health treatment in prison. Inmates with a history of childhood sexual abuse are more than twice as likely to perceive rape as a threat and almost four times more likely to request mental health treatment than inmates who did not report a history of childhood sexual abuse. Notably, this finding is inconsistent with previous research that has shown that there is no significant relationship between childhood sexual abuse and feelings of safety among male inmates.
“The consequences of perceiving rape to be a threat in prison are vast and could contribute to violence among inmates as well as negative mental health ramifications such as increased fear, psychological distress, chronic anxiety, depression and thoughts of suicide,” said Cassandra A. Atkin-Plunk, Ph.D., co-author and an assistant professor in the School of Criminology and Criminal Justice within FAU’s College for Design and Social Inquiry.
Inmates incarcerated for two to five years are nearly three times more likely to perceive that rape is a big threat compared with inmates incarcerated for less than two years. Inmates in prison longer than 18 years are nearly four times more likely to voluntarily request mental health treatment in prison. The researchers also found that Black inmates are twice as likely to seek mental health treatment in prison compared to White inmates.
“Knowing that gay and bisexual inmates and inmates with a history of childhood sexual abuse are more likely to fear rape and seek mental health treatment, prison staff can target outreach and treatment efforts for this vulnerable sub-population,” said Mina Ratkalkar, LCSW, MS, lead author and a licensed clinical social worker pursuing a Ph.D. who conducted the study while she was a graduate student at FAU. “Our study shows that these sub-groups of inmates are receptive to treatment, and our findings have implications for both practice and policy in the United States.”
The sample consisted of a nearly equal number of men in their 20s, 30s and 40s. Black inmates made up about half of the sample, with White inmates comprising about one-third of the sample. Nearly one-third of the sample had previously been in juvenile detention and about one-quarter were incarcerated for the first time in the adult criminal justice system at age 18 or younger.
About 16.4 percent of the sample identified as gay or bisexual. About one-fifth of the men (73) reported a history of childhood sexual abuse, and about one-third of the men reported having received mental health treatment outside of prison.
How to Recognize and Help an Addict
It’s devastating to know a friend or a loved one suffers from an addiction. Before people get help, they often go down a long road of addiction prior to anyone, including themselves, noticing a problem. Consider the information and advice below if you know or suspect someone is an addict.
Addicts are excellent liars. It can seem disheartening to hear that you shouldn’t take them at face-value. However, listen to your gut. Your gut is telling you that something is wrong. Do not ignore this. They will tell you all the right things you’d like to hear. They will go into detail about where they were, why they did something and more. Everything will sound right to your mind. The very fact that you feel something isn’t right means more than likely something truly isn’t. Listen to what they say, and take notes because if they are addicts, they will slip up eventually. Don’t be the big-bad wolf that’s out to get them, but don’t be an enabler either. Enablers help them to stay stuck in their addiction by making excuses for them.
Addicts especially high-functioning addicts think that if they’re able to go to work, bring money home, do housework and other normal day-to-day life they do not have a problem with addiction. An addict is not just the junkie on the corner. Most addicts are high-functioning, which means they go under the radar for what passes as an addict to society. Because of this, and for reasons such as not wanting to face themselves, addicts will lie to themselves and the world. This is why most addicts are in denial. They might also reason that they don’t drink “enough” to be an addict. Make no mistake that alcoholism isn’t about the quantity of alcohol ingested. It’s about the mental obsession and physical craving of alcohol that makes someone an alcoholic. People who don’t drink for three of four months and suddenly “binge” can be alcoholics.
Things Don’t Add Up
It is often said that addicts lead double lives. This is true for anyone living in dysfunction. To the outside world, they have it together. Underneath that façade is a broken human being who uses alcohol, substances or anything else to get by. To make matters worse, this outward appearance can be further covered up, or justified, with a prescription medication. Abuse of a prescription medication is a serious concern. People often overdose on their pills or makeup excuses for why they need them even though they don’t have a legitimate need for them. This is why centers offer painkiller addiction treatment because it is a common phenomenon. It is also a growing phenomenon.
To the addict, you’re “mean,” “unreasonable,” and a few choice words when you confront them. Expect this upfront. It’s not a reflection of who you are as a person despite their best attempts to assassinate your character. What they say about you has everything to do with their dysfunction. More often than not, they will choose their addiction over you. Real help and real love mean saying, “I’m going to tell you the truth,” “I need to love myself before I can love you,” or “I don’t accept your excuse. You’re responsible for your behavior, and I refuse to be a part of your life until you take responsibility for yourself.”
You can’t force someone to get help, but you can stop enabling them. Don’t make excuses for their behaviors or addiction. Addicts have to want to get help before they do. Once you know there is a problem, stand your ground. Speak truthfully to the addict. Above all, love yourself because this has been and will continue to be incredibly hard on you. Understand that they have to learn to love themselves too.
Veterans: Take This Survey!
Learning about military-to-civilian reintegration requires asking the right questions of the right people. A novel, new study is seeking military veteran respondents to learn more about the way service impacts health, civic engagement, and socio-economic outcomes for military-connected men and women. The data collected through this survey are expected to help us answer questions such as:
• Do veterans feel welcome and interested in institutional service groups like the VA and informal groups like VSOs? Do those organizations serve their needs? How are prospective members welcomed and served?
• How does military service impact community involvement and political engagement?
• How does military service impact experiences on the job market (and is this effect conditioned by demographic factors?
• Does military service break the glass ceiling for service women?
The project was developed by an interdisciplinary research team with experience, training, and connections to the military community. Dr. Kyleanne Hunter is a Marine Corps Cobra pilot and political science researcher. Dr. Rebecca Best is an experienced security studies researcher with a focus on service women. Dr. Kate Hendricks Thomas is a public health researcher and Marine Corps veteran. Each has specific training in community-based, participatory research and is invested in filling current gaps in what we think we know about the transition from service member to civilian.
Access the survey online here: https://udenver.qualtrics.com/jfe/form/SV_572AiK5P3P75KQt
Is Counseling For You
Have you been in counseling or therapy? If not, have you ever hesitated in seeing a counselor, or wondered why you felt so wary? Studies show about 20-35% of Americans having attended some form of counseling and psychotherapy compared to approximately 80% of mental health professionals.
Believing that counseling and psychotherapy could be helpful for anyone in alleviating problems, improving relationships, and developing a more positive outlook toward life, a Journal for Human Services research study explores why some people attend counseling or therapy while others do not.
Researchers, Ed Neukrug, Mike Kalkbrenner, and Sandy Griffith wondered why it was that some people seemed readily to attend counseling while others hesitate or who don’t attend often to their own detriment. Their research on attendance in counseling of helping professionals and their upcoming research on attendance in counseling of the public in general offers a thoughtful analysis which will hopefully shed some light on this important concern.
After an exhaustive review of the literature, researchers independently looked at over 60 potential barriers to attendance in counseling and eventually reduced this number down to 32 specific items. Their research found three broad areas or reasons likely to affect individuals who tend to avoid counseling and therapy. They identified these areas as “Fit,” “Stigma,” and “Value” to reflect the areas they represent.
Factor 1: Fit
Fit has to do with one’s sense of comfort with being in counseling and whether one has the ability to trust the process of counseling will be beneficial. Some typical fit questions were related to whether a potential client believed a counselor would feel comfortable with the potential client’s sexuality, disability, or other aspects of the client’s identity. Other questions in this area assessed whether a potential client believed a counselor could understand him or her, was competent enough to deal with the client’s problem and could keep the client’s concerns confidential. In addition, other “fit” questions queried whether potential clients had a bad experience with a counselor in the past and if they thought they could find a counselor near to where they lived
Factor 2: Stigma
Stigma is the feeling of shame or embarrassment some people experience when they consider entering a counseling relationship. Some of the stigma questions highlighted whether a potential client believed their friends, family, peers, colleagues, or supervisors might view them negatively if they knew the individual was in counseling. Other questions focused on how some potential clients might consider themselves weak, embarrassed, or unstable if they were in counseling. Often, those with high scores on stigma believed others would judge them, and thus, they would feel badly if they were to enter counseling.
Factor 3: Value
Value is the perceived benefit or worth one believes he or she is receiving from attendance in counseling. Potential clients who would score high in this area often believed the financial cost of counseling was not worth its benefits. Participants in this category simply could not afford counseling or they didn’t have time for it. Many participants in this category believed counseling wasn’t necessary because problems usually resolve on their own, or that counseling was simply not an effective use of their time. These individuals simply did not embrace the counseling process because the financial costs in their mind are hard to justify over meeting basic needs and/or having to take time off from work.
Although some individuals cannot find a counselor to their liking, participants worried whether counseling would be worthwhile, or they were ashamed or embarrassed about going to counseling. Most people believe that when faced with difficult life problems, counseling could be helpful.
It is hoped through research like this, people can better understand why they might be hesitant to seek a counselor and maybe overcome some of their fears. Additionally, this research can help national organizations, in the helping fields, find ways to help clients overcome these barriers.
Turnkey: A Co-Housing Experience in an Italian Public Service for Addiction
Turnkey is a term used in the economic field, but it also fits well in a social rehab project. The idea comes from the need to give some answers to the problem of those patients that experienced a long term therapy in an addiction rehab center for 3 or 4 years.
In the Italian welfare system, the outpatient service team -work (doctor, psychologist, educator, nurse and social worker), operating in the addiction recovery can schedule long term treatment in the residential rehab centers. In some cases, this long time permanence is something obliged, because of the serious addiction and also for the lack of different life perspectives after the recovery.
These kinds of patients need more therapeutic help in order to return to civil society in order to find meaningful social membership. Usually, these clients have no meaningful familiar connections, no job, and no significant friendship.
In the last years, our social services system has become more careful about the use of public money. They noticed social workers more equipped to provide therapeutic interventions using a holistic approach in order to spare economic resources. Social workers are more capable to assist patients in reaching a better life condition by using their abilities toward social integration.
Five years ago, the program’s director asked for the professional team to think about a solution for the rehabilitation of the” long term patients”.
I started wondering about the meaning of poverty which is not only economics but it also the satisfaction of primary needs. It’s the lack of healthy relational bonds which weakness a lot the patients coming out of the drug addiction recovery programs.
I also noticed that this relational deficiency is a modern human condition; in the weakest social situations the loneliness is something that “destroys the mind “.
So I got an idea: I proposed to my director to start thinking about a possible apartment for a temporary co-housing for at least two patients.
He liked the project and submitted the plan to the municipalities which have the competence in the social side of rehabilitation. The municipalities agreed to the project and financed it.
For the patients in long term recovery, the rent was paid through the financing with the municipalities (an average of 6.000 Euro a year for 4 years, renewable), whereas the utilities and the others cost of the house has been in charge to the occupants.
The management of activities like the admission of the patients, the guaranteed respect of the therapeutic contract, the check of daily life and the help in the money administration, are some of my specific competences as a social worker.
In my job role, I had a significant part into find fitting persons for the project who were able to live together. I also contributed to choosing the people eligible to live in that specific therapeutic situation.
I helped the patients to organize their new life and to establish minimum rules of mutual life in the apartment. The project is strictly tied to the learning of the skills required to come back to live a regular life.
– living together is an opportunity for the patients to learn mutual respect
-cleaning the home and paying the utilities is a way to come back to daily responsibility and autonomy.
– having a good neighborhood relationship is a way to learn again to have good relationships without drug addiction to interfered an apartment, next to the main social and sanitary services of the town.
Since 2011, we housed 11 clients in the apartment with an average of one year placement. We should consider that one year in a residential rehab center cost 30.000 euro each person.
Eight of them returned was able to manage a regular social life, their addiction, a job, maintain social relationships which helped them to achieve a dignified lifestyle.
Two persons are still in the co-housing situation, one of them has a regular job, and he is searching for an own house. Only one person abandoned the treatment.
This intervention is a daily challenge for our team; it gave us good results in the recovery outcomes like independence, citizenship, struggle against the stigma and improvement of personal resources.
We also have spared a significant amount of public money while offering to our clients a higher quality of life.
The creativity and the professional skills mixed together with the help of other colleagues in the multidisciplinary teamwork made this project an effective strategy to help patients overcome their circumstances.
So, I can call myself a responsible social worker, because I help to improve the personal resources in my client’s life. I was mostly inspired from the basic professional principle “start from where the client is”.
Will Veteran Suicide and Mental Illness Rate Improve?
It was about 9 years ago. I decided to put down the rifle and pick up the DSM. You see, I was an infantryman since I was age 17. That means, since I was a child, I was literally trained to kill people. Looking back at it, that sounds like a profound concept.
I am proud of my time in the military. I am proud of my brothers and sisters who have ever answered the call. But… I am also worried.
As I said, 9 years ago, I decided to change my path. I didn’t realize where that path would lead. I seen multiple traumas and death happen to my fellow comrades. I went through some trauma myself, but I still worried about others more than myself. So, I decided to become a Mental Health Specialist in the military.
It’s been a long road going from Infantryman to Social Worker. There are a lot of learned attitudes and behaviors I had to change. Can you believe it? I literally had to learn empathy. And that took a long time.
Just about anyone in the military knows that drinking alcohol is a part of the lifestyle. Everyone I looked up to drank and considered me a p**sy if I didn’t. So… when I was sent to Germany back in the early 2000’s as a 19 year old kid, you better believe I drank. It was legal!
Looking back at my adventures between then and now, I don’t regret a thing. Yes, there were many embarrassing moments, and I have lost many friends along the way. I also met some great people. My alcohol use made my path rockier than anything else.
Many others have had this experience as well. Between 1998 and 2008, binge drinking went from 35% to 47% of veterans, and 27% of that 47% experienced combat.
Between 2002 and 2008, misuse of opiate prescriptions went from 2 percent to 11 percent in the military. These prescriptions were mostly due to injuries sustained in combat, as well as the strain of carrying heavy equipment.
This concerns me. When I was young, I had a good time. Looking back, maybe it wasn’t.This might not be every veteran’s experience, but the culture encouraged substance use and discouraged getting help. There are others that would agree with me.
This could explain why 20 veterans a day on average commit suicide. This is actually down from 22 a day before the 2014 study from the VA. However, it is a 32% increase since 2001. In 2014, veteran suicides accounted for 8.5% of U.S.’s adult suicides, and the rates were especially high among 19-29 year old compared to the older generation.
Let’s not forget about the infamy of PTSD. Up to twenty percent of veterans have suffered from this. Of course, those who suffer are more likely to admit their distress to a computer program than a battle buddy or their superior. This, again, goes with the constant culture that causes our military to fear judgment.
These wars have been a constant the last two decades, and have cost all U.S. citizens a pretty penny. According to one report, the VA spends $59 billion a year on health care. This number is 3 times as much as it was since before 2002.
And let’s not forget the cost this country has incurred for being in war for this long. Well, we don’t really know an exact number. The cost is estimated by many to be in the billions or even trillions. This isn’t including the interest from borrowed money.
So, after looking at all these figures, I am overwhelmed. How can I even make a dent in helping our nation’s veterans? The current administration is planning on increasing our presence in war zones. I am expecting the rate of PTSD and suicide to increase once again. Also, our country will continue to spend. It seems to me that we are all participating in a death and mental illness factory. The thing is, I didn’t even get to the physical injuries many of our combatants have suffered from.
I love our nation’s military. I want every one of them to know that I am here to support them. But most of all, we all need to be here to support each other.
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