Chapter One: Introduction
Francis J. Turner
The term psychiatric social work, a term once highly status laden, is now rarely seen or heard in the profession's lexicon. In its heyday the concept was seen as denoting some form of higher-level position and practice than "just" social work. This attitude prevailed partially because social workers with this designation appeared to have a close connection to other human-service colleagues in the mental health field, a connection that was thought to give some degree of status. The designation also implied possession of a specialized body of knowledge relating to the then identified types and forms of mental illness. These two factors in combination were seen as putting the title and those possessing it above colleagues without it. This term was prevalent at a time when in most countries there was in fact a very clear division between general social work practice and that encompassed by the term mental health services. This segregation of services, only one of many that existed, further added to the perception of a differential role in the profession.
In practice this identification of social work in the mental health field as a separate specialty was never as definitive as the terminology indicated and in recent years has blurred. Experienced social work practitioners in all direct service roles understood all too well that over a period of time, regardless of practice setting, one met the entire gamut of human psychopathology. Hence knowledge about it and skills in responding to it were necessary for all practitioners. As well, even if one did not meet such clients on a face-to-face basis, it has always been necessary that social workers understand these patterns of problematic mental functioning to ensure that policies and services meet the specific needs of clients.
Thankfully the blurring of this artificial division of the profession has continued at a rapid pace, facilitated by changed community attitudes, great advances in pharmacology, and of course the broad impact of deinstitutionalization. These factors have both increased the nature of social workers' involvement with the mentally ill and, as well, expanded the extent of this involvement. Today all social workers are in reality in the mental health field and all must have an enriched knowledge of psychopathology. Hence the need for volumes such as this.
As with the first edition, this volume starts from the premise that accurate diagnosis is the essence of contemporary, skilled, and responsible social work practice. This statement immediately opens up another question of terminology. If one uses as a reference point most of the current social work practice texts in North America, the current "politically correct" position appears to be that diagnosis is itself a somewhat pejorative term and thus one to be avoided. This for a long list of supposed negative connotations of the concept. Instead the term assessment is to be substituted. Here is not the place to continue this debate, apart from stating my own position. It is my strong conviction that we underserve our clients, weaken our relationship with our coprofessionals, and avoid the discipline inherent in the term diagnosis if we fail to include it in our conceptual purview and professional vocabulary.
As I have studied this issue I remain increasingly convinced that for a variety of sociological, political, historical and turf issues we have "misdiagnosed" what is meant by diagnosis, made it a scapegoat onto which we have loaded all the failings of the misuse of labels and categories, and attempted to drive it out of our practice lexicon. But for me, and clearly for my fellow contributors to this volume, and to an ever increasing number of senior colleagues, it is still a critical term that needs to stand, as it once was, at the heart of our clinical responsibility.
This discussion, as with many that need to take place around the misuse of designated categories of behavior, relates of course to the question of "labeling." Thankfully, the antilabeling movement, itself a label, seems to have greatly diminished in intensity in professional circles since the first edition. To a welcomed increasing extent, we have come to understand that our concern about labels is correctly one about their misuse; we can, if not most careful, make them all-inclusive, overgeneralized, depersonalized, and disempowering.
But we need a precise vocabulary. We cannot practice without an accepted terminology to convey large bodies of essential information to each other about individuals and groups by means of a single word, phrase or sentence. However, all of us who have practiced have seen how destructive and limiting can be the misuse of such labels and hence the awesome responsibility to use them carefully. We need to ensure they work for us and not we for them.
Clearly the basic structure of this volume is built on a commitment to the skilled and effective use of a common nomenclature within and between human-service professions. This presumes that over the centuries we have learned much about the myriad ways in which the human person can develop patterns of behavior that reflect some internal dysfunction of the mental apparatus, or some responses to complex interpersonal or societal realities that also cause dysfunctions or intensify the internal condition. As well, we have learned much about the complex ways in which the biopsychosocial spheres are interconnected. (It is hoped that we soon can add to this multifaceted understanding the spiritual dimensions of human existence as well.)
We have learned that these responses are not random; they can be understood and classified and in so doing, to an increasing extent, they can be managed and modified in a manner that brings comfort and enhanced autonomy and empowerment to persons.
But to make use of this accumulated wisdom we need to understand the degree of precision or lack thereof that we possess in each category and the extent to which we, as a profession on our own or in conjoint activity with other professions, have or lack strategies of intervention that can assist in particular ways. We, especially social workers, also need to understand the extent to which many of our perceptions of, and responses to, various patterns of behavior can often reflect more of society's views and attitudes to them than signs of internal suffering or dysfunction. In a related way we need to be aware that differential perceptions of and reactions to similar behaviors exist in different cultures. This latter becomes of increasing importance in the highly culturally diverse practice context of many parts of the world.
Certainly as our knowledge expands so too does our awareness of the need to alter vocabulary through deletions, additions, regrouping, or modifications of categories. The fact that our vocabulary changes, at times rapidly, is a humbling declaration to each other, and to the world, that our knowledge is far from perfect, that our categories do not -- and must not -- stand as unchangeable, that today's apparent convictions must be ready to yield to new insights and understandings. We also know that a term that today is viewed as useful and neutral can later become loaded with socially generated negative connotations and thus be more harm producing than helpful. But the process of knowledge development only takes place through the proper use of categorizations based upon a commitment to precision in the development of concepts-which in turn are subject to empirical reification.
Hence this process of knowledge building must be carried on in a manner that keeps constantly before us the risks and potential harm of the misuse of the vocabulary by which we communicate with each other. An especially relevant facet of this discussion relates to the title of this book, Adult Psychopathology. To date no one has challenged me on the use of the label "Adult," but it had been suggested that the label "Psychopathology" is no longer acceptable. Indeed one of the participants suggested that combining the subtitle Social Work with the title Psychopathology was an "oxymoron." Psychopathology for him is a medical term only. Obviously we disagree, but these different perceptions about appropriate vocabulary remind us that we need be very sensitive to terminology and how it is differentially used and perceived both within our profession and by other professions.
It is my position that no profession owns any words or labels. It is how we understand, interpret, and make use of such words in our practice that creates differences between disciplines. Hence for some the word psychopathology is to be eschewed. It is viewed by such persons as being out of date, overmedicalized, and reflecting a too narrow view of mental disorders. Whether in a future edition we may change the title remains to be seen. I think not!
However as with the term diagnosis, I view the word psychopathology as a most useful term that stands clearly as one of the anchoring points on the health-nonhealth continuum. If we accept that "healthy" is a legitimate concept, a much-to-be-sought-after state of existence for all of us, then we need to have a term that conveys states of nonhealth, or less health, which is exactly what the term psychopathology does.
The essential point for all of us is to avoid dichotomizations of those aspects of our clients' realities in which we become involved. Rather we must view various facets of clients' situations as continua. Having a clear perception of both ends of a continuum in regard to particular presenting situations helps us to assess severity and to decide whether we can help or not as well as the intensity of the help required. It also helps us to recognize when change is taking place in either direction. Mary Woods's chapter on Personality Disorders (chapter 16) is particularly helpful in understanding this concept of continuum. As social workers, in addition to a focused interest in our clients' mental functioning we bring a commitment to view this from a very broad base of interacting systems, few if any of which can be correctly seen as yes/no situations. Hence the utility of an understanding of continua.
Our responsibility as social workers is to be aware that many persons we meet have a myriad of problems originating from a plethora of interinfluencing causes that interfere with their mental health, which in turn influences their ability to function in many life roles. We need to understand all persons as individuals of course, but also as individuals manifesting similar situations, as do other groups of persons -- which similarities help me to understand them and in turn to help them. In seeking to understand it is equally important that we learn to assess the myriad of strengths and resources a person possesses in his or her biopsychosocial realities, not only the nature and intensity of problems. Our diagnostic question is always, how is this person in his or her profile of strengths and limitation like no other person I have met, and as well how is he or she like some others I have met? Following from this is the further challenge that says, "Based on this understanding of who they are, what do I bring of knowledge, skills and resources that can be of help to them or what do others bring that are not within my competence?"
Our present situation, in North America at least, is that, unlike in earlier days, fewer people are institutionalized for any forms of mental illness or psychopathological behaviors, apart for very brief periods. Hence, to an increasing extent, community-based social workers in all practice settings will come into regular and frequent contact either directly or indirectly with the entire gamut of types and severities of psychopathologies. Thus, to respond responsibly and effectively, with understanding, wisdom, and competence we must be knowledgeable about this range of human problems.
This responsibility implies the ability to accurately diagnose, as mentioned earlier. Here of course we are talking of diagnosis from a social work perspective. We do not, nor must not, assume the responsibility of formulating our diagnoses from the perspective of other professions. That is for them to do. Social workers do not make medical diagnoses; we make social work diagnoses. Social workers do not make psychological diagnoses; that is for psychologists to do. Similarly, physicians nor nurses nor psychologists do not make social work diagnoses; they make medical or nursing or psychological diagnoses. Understandably and appropriately and to an increasing extent, there will be elements of commonalities across professions. Hence the richness of transdisciplinary practices discussed by David Millard in the next chapter. Certainly in an era of close interprofessional team practice it will and should happen that at times many aspects of our diagnostic formulations will be similar to those formulated by colleagues in other disciplines. So be it! It is a social work diagnosis that we must make based on the spectra of judgments we make, and for which we must be prepared to be held responsible. This in turn requires that we have the requisite knowledge to do so, to ensure that our responses to clients are as appropriate, ethical, and helpful as possible.
In our days a new reality has emerged as a part of social work practice: the question of practitioner safety. This is a topic rarely, if ever, mentioned in the standard textbooks on social work practice until very recently and then only on occasion. As well, it is a topic rarely considered in practice except in those specialized areas where there is a known high probability of violence.
Unfortunately it is now a factor that needs to be considered by all practitioners. We know all too well that there are people whose mental state is such that they are frequently a high risk danger to us, to themselves, or to others. Fortunately we know something of the patterns of mental upset or illness of those persons who are high risk. I consider it totally unethical for practitioners or teachers of practice to tell our beginning colleagues that diagnosis and use of labels are of no value and instead one must learn only to trust one's "gut reaction." An accurate and skillful understanding of the process of diagnosis and the sensitive use of diagnostic categories as a part of this process can alert us to high risk situations and lead us to take appropriate steps for our own and others' security. Failure to do so can result in death. Let us not forget this!
We cannot help everyone we meet in our practice. Hence an essential and conscious determination we need to make in all situations is: Is this is a situation for which I am prepared to take professional responsibility, or is it one that should best be handled by some other profession, or is it one that requires a multidiscipline approach, or is it one I or others do not understand sufficiently well and thus we must seek further input? We, or any profession, just do not have enough knowledge to help everyone. I do emphasize, however, that turning our backs on the knowledge that is available out of a distorted misunderstanding of the accurate meaning of diagnosis is unethical, irresponsible, and in relation to this point dangerous. I am not suggesting that mastering the content of this volume or the material of DSM will ensure that there be no risk to our practice. But it certainly will help us to be more responsive.
We have just mentioned DSM, a volume now in its fifth revision. This is a project that reflects an ongoing search for more precision and common usage of concepts across professions. Certainly all of us in social work are aware of the major contribution this work has made to broaden our view of psychopathology and to help other professions to broaden theirs. DSM has helped to ensure that psychopathology needs to be multiaxially understood, to foster an ongoing search for increased precision, to open the doors of richer interprofessional cooperation, mutual understanding, and multidiscipline practice and to foster the need to understand categories of pathology from a multifaceted perspective. It was because of the importance and influence of this work on social work practice, especially in North America, that we invited Dr. Marcia Brubeck to write a chapter for this volume on DSM, a topic not specifically addressed in the first edition. This she has done in a highly useful and objective way.
Although strongly influenced by DSM this volume does not want to, nor pretend to, nor attempt to cover all that it contains. Rather what we have done is to identify those situations most frequently met in front-line social work practice that require a more detailed knowledge of particular forms of presenting situations of pathology in various forms of intensity
In addition to new topics, in this edition there are several new themes that emerge across the spectrum of chapters. First there is a growing emphasis on the concept of multicausality and interinfluencing factors in psychopathology, which in turn require a multifaceted knowledge base. Implied in this is the renewed emphasis on the need for social workers to be much better informed about the neurological and physiological aspects of many presenting situations -- not of course that we attempt to be neurologists, but that we have sufficient knowledge and appreciation of the importance of being appropriately sensitive and responsive to this critical area of understanding.
In a similar way there is the need for social workers to be much more understanding of, and thus responsive to, the role of pharmacology in assisting various types and intensities of pathology in the varying levels on which we meet it. Again not that we attempt to be pharmacists; but to a much greater extent than we have heretofore, we must also be more sensitive and responsive to our need to see our colleagues in pharmacy as resources of considerable import in our practice. Failure to do so can result in our misunderstanding of many aspects of clients' functioning, or a failure to be aware of pharmaceutical resources for clients that can be of considerable assistance to them and in turn to their significant others. Both of these latter topics receive much more attention by the various authors in this edition than in the first.
As well, there can be noted two very mature additional trends. The first is the comfort that there are limitations in our knowledge, and thus the extent of our ability to help in many situations. That is, we do not have to pretend to ourselves or to society that we have a level of effectiveness that does not exist. But we must never cease our efforts to expand our levels of competence. Thus the second trend reflects a corresponding readiness to identify areas where social work-based research is needed to advance our ability to improve our effectiveness with particular types of situations from a multimethod and multitheory perspective. As we become more comfortable in our awareness of limitations in knowledge we also grow more confident in what we do know. We have much to contribute to the multidiscipline team. Our current literature strongly reflects this, as seen in the greatly increased amount and quality of strong research writing. There is as well as an expanded confidence in using this knowledge. One of the challenges faced by each author was that of condensing into single chapters material which could easily fill a book. As knowledge grows about each topic, the task of presenting it in a manner that makes it succinct enough for front-line workers is formidable.
However, as befits good social work practice two further themes emerged loudly and clearly from this group of colleagues. The first was the need to individualize each situation with which we are confronted. As mentioned earlier, categories and subtypes and classificatory labels are very useful tools to help us to understand both strengths and limitations and areas of vulnerability and to assess risk -- but, as we have said, they must only be tools to be used skillfully, compassionately, carefully, rarely, and partially. But they cannot be ignored.
A second theme critical in the content of these chapters is to remind ourselves of that dictum we were all taught in Casework I for some of us many years ago: "We must start where the client is." Often a client only wants and needs something to eat and nothing more. Recognizing that such a person is manifesting some psychopathological symptoms does not mean necessarily that these will be the focus of our interventions. Such recognition may and should help us to develop a sensitive base from which to respond to where individual clients are and what they want. That is, understanding that a client is manifesting a high degree or range of symptoms of behavior that attend a specific form of pathology can help us to help him or her and help others to find a needed resource not necessarily related to his or her pathology in a manner that is sensitive, helpful, nonthreatening, and sustaining. To not recognize and identify and respond appropriately to these aspects of our clients' profiles can result in hurt, rejection, misunderstanding, and failure to help.
We have come far in social work in learning to respond helpfully to clients and families and communities who are involved with or in touch with or touched by some aspect of human psychopathology. We have come far in our comfort with both a multitheoretical and multimethod perspective. We have yet far to go. But this need not daunt us. What must drive us is the need to be as knowledgeable, responsive, and accountable as possible to all whom we dare to serve.
Copyright © 1984 by The Free Press
Copyright © 1999 by Francis J. Turner