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Mental Health

Should Social Workers Use the DSM-5

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Among the 500,000 mental health professionals in the US who will use the DSM 5, the 250,000 social workers (Center for Health Workforce Studies, 2006) comprise by far the largest group, followed by 120,000 mental health counselors (American Counseling Association, 2011), 93,000 psychologists (American Psychological Association, 2011), and 38,000 psychiatrists (American Psychiatric Association, 2011).

For many social workers, DSM is a daily companion having a dramatic impact on how they assess patients, make a diagnosis, and plan treatment. The American Psychiatric Association (APA) is the sole group that revises the DSM, despite the fact that psychiatrists account for only 7% of all mental health professionals and only 10% of all physicians who prescribe psychotropic medications.

dsm-5In the past, social workers and other mental health professionals have relied on APA and the DSM for guidance in the diagnosis process. And while previous DSMs have failed to achieve universal admiration, none has failed to achieve universal acceptance.

Certainly, there have been numerous controversies about the overall reliability of the system; its seeming tilt toward a biological approach; the relative lack of participation of professional groups other than psychiatry; and the inclusion and/or definition of particular mental disorders.  But no one questioned whether DSM should be used at all or suggested that there was an alternative way forward.

DSM-5 has changed the landscape by being so closed in its process, flawed in its execution, unrealistically ambitious in its hopes, and dangerous in its product that many mental health professionals may choose not to use it.

The work on DSM-5 has been secretive, geared less to protecting the public trust than to generating publishing profits for the American Psychiatric Association (APA). Participants were forced to sign confidentiality agreements, the scientific review has been conducted behind closed doors, and APA rebuffed a petition endorsed by fifty-one professional organizations for an open and independent review of its suggestions.

Everything about DSM 5 was done in a disorganized way: constant missing deadlines, inconsistent methods for conducting literature reviews, poor research design for the field trials, and finally the cancellation of the crucial quality control step because time was running out (Frances, 2010, 2012; Jones, 2012). This process has not inspired confidence.

The DSM-5 product is frightening in its over-inclusiveness- with lowered diagnostic thresholds across a number of disorders and the addition of many new “subthreshold” disorders.  The changes blur the boundaries between pathology and normal behavior, resulting in increased overall prevalence rates of mental disorders and many new false epidemics.  Millions of normal people will be mislabeled as mentally ill and subjected to stigma and to unnecessary treatment and testing.

This will exacerbate what is already a serious problem in the United States – the medicalization of normal behavior. We are already in the midst of a national glut of excessive medication use causing harmful and unnecessary side effects and complications. What can social workers do if they don’t like the DSM-5 final product?  Ignore it.

There is nothing official about DSM 5. There are no DSM 5 codes- all codes used for reimbursement are ICD-9-CM codes which are available for free on the internet. You can bypass DSM-5 altogether and instead use the readily available diagnostic codes of the International Classification of Diseases (ICD). You can also continue to use DSM-IV diagnostic codes until oct 2014 when they will be replaced by ICD-10-CM which will also be available for free.

DSM is not mandatory for clinicians unless specifically required by their institutional settings (First, 2010).  In fact, the ICD is the only classification system approved by HIPAA (Department of Health and Human Services, 2009) – not the DSM classification.  As such, ICD codes meet all insurer-mandated and HIPAA coding requirements.

My advice- don’t buy DSM 5, don’t use it, don’t teach it.

References
American Counseling Association (ACA). (2011). 2011 statistics on mental health professions. Alexandria, VA: Author.
American Psychiatric Association (APA). (2011). American Psychiatric Association. Retrieved from http://www.psych.org/
American Psychological Association (APA). (2012). Support center: How many practicing psychologists are there in the United States?  Retrieved fromhttp://www.apa.org/support/about/psych/numbers-us.aspx#answer
Center for Health Workforce Studies School of Public Health University at Albany. (2006). Licensed social workers in the United States, 2004. Available at http://workforce.socialworkers.org
Department of Health and Human Services. (2009). HIPAA administrative simplification: Modifications to medical data code set standards to adopt ICD-10-CM and ICD-10-PCS. 45 CFR Part 162. Federal Register 74, no. 11 3328-62. Available at http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf
First, M. B. (2010). Clinical utility in the revision of the diagnostic and statistical manual of mental disorders (DSM). Professional Psychology: Research and Practice, 41, 465-473.
Frances, A. J. (2012, November 13).  You can’t turn a sow’s ear into a silk purse. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/blog/frances/content/article/10168/2099456#
Jones, K. D. (2012). A critique of the DSM-5 field trials. Journal of Nervous and Mental Disease, 200, 517-519.
Regier, D. (2012, April). DSM-5 Field Trials: Reliability of the Categorical Diagnoses. Presentation at the Annual Meeting of the American Psychiatric Association, Philadelphia, PA.

Also View:
Can Congress Cure the Disorder in Mental Health 

Allen Frances, M.D., was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke.

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Mental Health

APA Offers Resources for Coping with Mass Shootings, Understanding Gun Violence

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Constant news reports about the shooting in Las Vegas can cause stress and anxiety for people, leaving them with questions about the causes of and solutions to gun violence. Resources on the American Psychological Association’s website can help people with both issues.

One APA resource offers tips for managing feelings of distress in the aftermath of a shooting. “You may be struggling to understand how a shooting could occur and why such a terrible thing would happen. There may never be satisfactory answers to these questions,” it says. “Meanwhile, you may wonder how to go on living your daily life. You can strengthen your resilience – the ability to adapt well in the face of adversity – in the days and weeks ahead.”

Talking to children about the shooting isn’t easy but parents or teachers shouldn’t completely shield them from violence or tragedies. APA offers a series of tips to parents and other caregivers on how to guide the conversation in a proactive and supportive way. “The conversation may not seem easy, but taking a proactive stance, discussing difficult events in age-appropriate language can help a child feel safer and more secure,” according to the resource available in the APA Help Center.

Parents should also watch for signs of stress, fear or anxiety.

For those who feel too overwhelmed to use the tips provided, APA suggests consulting a psychologist or other mental health professional.

“Turning to someone for guidance may help you strengthen your resilience and persevere through difficult times,” it says.

There is no single personality profile that can reliably predict who will use a gun in a violent act, according to a report issued by the APA in December 2013 entitled Gun Violence: Prediction, Prevention, and Policy. There is, however, psychological research that has helped develop evidence-based programs that can prevent violence through primary and secondary interventions.

Written by a task force composed of psychologists and other researchers, the report synthesized the available science on the complex underpinnings of gun violence, from gender and culture to gun policies and prevention strategies.

“The skills and knowledge of psychologists are needed to develop and evaluate programs and settings in schools, workplaces, prisons, neighborhoods, clinics, and other relevant contexts that aim to change gendered expectations for males that emphasize self-sufficiency, toughness and violence, including gun violence,” according to the report.

Gun violence is estimated to cost hundreds of billions of dollars a year in medical, legal and other expenses, not to mention the psychological toll. That is why the government needs to approach it as a public health problem, according to APA acting Executive Director for Public Interest Clinton Anderson, PhD, writing in a blog post entitled No Silver Bullet: Why We Need Research on Gun Violence Prevention.

“Some have argued that we need to focus on policies that prosecute criminals and prevent those individuals who have been found to be a danger to themselves or others from obtaining a firearm,” wrote Anderson. “While these policies have merit, they are clearly not fully effective, and do not address the roots of violence in our society.”

No one policy will prevent gun violence, writes Anderson. “It will take a multi-faceted approach. Funding research that explores these horrific, impulsive acts can help us all inform and adapt our policy approach.”

In another blog post, clinical psychologist Joel Dvoskin, PhD, warned against unfairly stigmatizing the mentally ill by immediately jumping to the conclusion that most shooters have a mental illness.

“Too often, even the most well-intentioned among us believe that most mass shootings are carried out by those with untreated mental illness,” he wrote. “What the perpetrators seem to have in common is the experience of extreme situational crisis.”

Additional resources:

Talking to Kids When They Need Help

7 Ways to Talk to Children and Youth about the Shootings in Orlando

Helping Children Manage Distress in the Aftermath of a Shooting

How Much News Coverage is OK for Children?

Gun Violence Prevention

APA Initiatives to Prevent Gun Violence

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Emergency Management

Rescue to Recovery Stages in a Red Cross Disaster Deployment

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Roy was my partner for most of our deployment with Red Cross on the Disaster Mental Health Team in Texas. We spent many hours on the road mostly on our own, with the exception of “ride to the office” or “back to the shelter” caravans, which could be quite crowded as there were few available cars to ferry us all from the staff shelter to Headquarters for the day.

Conversations stayed rooted mostly in the present, even with kids occasionally Face-timing us in the car when a signal would pop up. I know that he’s been a social worker since 1970 and that he has been married nearly as long. Getting to know each other on a disaster mental health deployment is a different way of knowing someone, but knowing them well regardless. Similar relationships are built with the people you sleep a couple of feet from in the staff shelter.

Roy: “Wasn’t there a band people used to like called the Dead Heads? People liked them but I think they’re dead.”

Roy, In response to a question about breakfast: “Right I’ll give you another rotten orange in the morning.

Kristie: “No thank you; that coffee was sufficient.”

Roy, just go ahead and get in the wrong lane again for this right turn.” (Texas “turnarounds” can be a nightmare).

There was the normalcy of the city center recovering, demonstrated through open shops and Home Depot’s parking lot was nearly at capacity. Starbucks opened, there was a carafe in HQ for one of the lucky teams.

Vulnerability and exploitation were visible not far from the city center. Compounding issues plague those who struggled prior to the disaster. Living paycheck to paycheck when there is suddenly no paycheck creates a domino effect of financial disaster. You can only call the companies to beg for mercy if your phone works, if there are enough bars available to connect you. The smell is rising in neighborhoods, and the question, “What is that smell?” was more frequent today. Mold grows rapidly, and you can smell it from the street.  Weeks have passed since the initial disaster, but it is just beginning to unfold for many people do not have flood insurance.

I ended up making a call to the Attorney General’s office regarding landlords who are refusing to remediate damage and demanding rent from those who cannot pay (or live in their home), with the threat of their things being sent to the dumpster. The police were empathetic but said that it’s a civil issue and in a disaster needs to go to the AGs office. So the wet carpet stays with children living inside, and they lack healthy food- maintaining on what looks like a vending machine diet.

There are contractor company scams that further exploit the exploited, and many workers are being brought in from surrounding areas without protective gear (notable lack of face masks) and clearly without reasonable hours or meal contracts.

On the other end of helplessness and anger, I felt in awe of all of the volunteers and what they do. They respond at the crack of dawn to Headquarters to work with a team using colored post it’s on the wall to map progress and hot spots for the day. Knowing that it’s likely that at the end of the day, they will have gotten sidetracked from the need that was directly in front of them, feeling regret for not making it back to the places they know are in desperate need but are now blocked by factors beyond their control.

Headquarters experienced an evacuation- someone screamed, “Get out! Get out of the building!” It turned out to be some off-gassing cones, but everyone went right back to work outside while standing outside the building waiting for clearance entirely unfazed.

Volunteers will talk it out with each other back at the shelter late at night, eating cold leftovers from the ERV (feeding) vehicles. Informal meetings run from their cots which will make a difference the next day in how resources are allocated because drivers are sleeping next to mental health, nurses, and those doing communications assessments. If you end up both eating and securing a space in line at the shower trailer behind the civic center before it’s too late, it’s something of a miracle. With a lot of contamination and illness going around, it’s best to just throw away the shoes on your way out.

As for the people we served, we realized the depth of desperation that is held for those in areas without good water. Your clothes were washed away or were contaminated, and even if you could wash them, you can’t because your washer and dryer is flooded (one family had some kind of snakes in theirs) as is the laundry mat down the road.

We brought restaurant workers wearing their last items of clothing and shoes serving people in the only community restaurant to open back up in Port Arthur in a certain radius, knowing that those clothes too, would soon be dirty. So what then? How long will this all take? While you may see signs of recovery in the city center, it’s clear that this is going to take so much longer for others, and the rural areas are barely touched by “helpers”.

The depth of this disaster isn’t something that we are used to covering, Katrina taught us a few things that are applicable, but each disaster is its own, and this scale is unimaginable. Puerto Rico is now unfolding as we watch on our screens, in some sort of mass denial of scale.

Most of us can sit comfortably behind our devices and all caps “GET TRUCK DRIVERS!” and while I can personally imagine the barriers that they have in distribution as we just experienced them in Harvey, you just can’t know unless you’re there and are using all of your five senses.

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Employment

Abusive Bosses Experience Short-Lived Benefits

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Being a jerk to your employees may actually improve your well-being, but only for a short while, suggests new research on abusive bosses co-authored by a Michigan State University business scholar.

Bullying and belittling employees starts to take its toll on a supervisor’s mental state after about a week, according to the study, which is published in the Academy of Management Journal.

“The moral of the story is that although abuse may be helpful and even mentally restorative for supervisors in the short-term, over the long haul it will come back to haunt them,” said Russell Johnson, MSU associate professor of management and an expert on workplace psychology.

While numerous studies have documented the negative effects of abusive supervision, some bosses nevertheless still act like jerks, meaning there must be some sort of benefit or reinforcement for them, Johnson said.

Indeed, the researchers found that supervisors who were abusive felt a sense of recovery because their boorish behavior helped replenish their mental energy and resources. Johnson said it requires mental effort to suppress abusive behavior – which can lead to mental fatigue – but supervisors who act on that impulse “save” the mental energy that would otherwise have been depleted by refraining from abuse.

Johnson and colleagues conducted multiple field and experiments on abusive bosses in the United States and China, verifying the results were not culture-specific. They collected daily survey data over a four-week period and studied workers and supervisors in a variety of industries including manufacturing, service and education.

The benefits of abusive supervision appeared to be short-lived, lasting a week or less. After that, abusive supervisors started to experience decreased trust, support and productivity from employees – and these are critical resources for the bosses’ recovery and engagement.

According to the study, although workers may not immediately confront their bosses following abusive behavior, over time they react in negative ways, such as engaging in counterproductive and aggressive behaviors and even quitting.

To prevent abusive behavior, the researchers suggest supervisors take well-timed breaks, reduce their workloads and communicate more with their employees. Communicating with workers may help supervisors by releasing negative emotions through sharing, receiving social support and gaining relational energy from their coworkers.

Co-authors are Xin Qin from Sun Yat-sen University, Mingpeng Huang from the University of International Business and Economics, Qiongjing Hu from Peking University and Dong Ju from Communication University of China.

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