The Controversy of Diagnosis in the Social Work Profession

Introduction

The historical evolution of the field of social work has lent itself to an assortment of different views as to how the practice of diagnosis fits into the social work profession. I will discuss and analyze the debate within the social work field regarding the controversy of diagnosis and labeling and how it fits within the strengths based empowerment perspective. I will do this by critiquing the various perspectives and then outlining the pros and cons of diagnoses and it’s correlation to the strengths perspective.

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Diagnoses and Labeling

As social workers in a profession that fights against biases one must find a way to increase awareness of bias in the mental health arena. Social workers and practitioners do this through research and ongoing discussions about the history and controversies that surround many DSM diagnoses. “Thinking critically about the conceptual underpinnings that inform human science, research often reveals hidden class, ethnic/race, and gender biases in psychiatric taxonomy because many diagnoses reflect stereotypes.” (Gilson, 1998) The article continues by stating that many individuals and families feel stigmatized by the labels given to them by members within their cultural surroundings and society as a whole. With the new stereotype and stigma, comes a sense of hopelessness and self loathing. “We must start from the assumption that research hypotheses and diagnostic labels must be neutral and free of bias.” Cosgrove continues, “Avoiding bias in psychiatric diagnosis requires critical thinking, a willingness to reflect on one’s assumptions and values, and as noted above, and the ability to critically evaluate mental health research.” (Cosgrove, 2005)

Labeling a client can be dibiliating, especially since there is a bias/ stigma amongst mental health labels. Diagnostic labels are meant to locate the causes of the problem within the individual; but by no means do these labels state the individual is the problem. (Cosgrove, 2005) For example, Cosgrove stated that researchers, “Long ago addressed the oppressive implications of psychiatric labeling and the ways in which such labeling may reinforce gender, class, and race bias.” Learning how to critique research and discover how to avoid bias when assigning diagnoses to individuals are the “necessary preconditions for respecting individual and cultural differences, as is consistent with CACREP (2001) standards,” (Cosgrove, 2005) and in turn work through the empowrement and strengths perspective by acknowledging the person rather than the label and their own cultural values and stigmas associated with being labeled with a mental health affliction.

Conceptualization of the stigmatization process

Many studies have come to the conclusion that there is a correlation between the experience of stigma and the well-being of the stigmatized individuals and their families. In the arena of mental health there has been debate surrounding the degree and the extent of the effects of labeling and stigma. One of the arguments in the articles believes that what has been used to downplay the importance of these factors is the “substantial body of evidence suggesting that labeling leads to positive effects through mental health treatment. However, labeling can simultaneously induce both positive consequences through treatment and negative consequences through stigma.” (Link, 2009) Seeking treatment for mental health afflictions can help the stigmatized individuals find a new sense of self and self worth through the therapeutic process. This inturn helps them process the stigma of being labeled with other labeled individuals and build on their strengths, i.e. seeking treatment, being proactive in their treatment, overcoming the stigma and obstacles associated with stigma and the label. As recently stated, research has demonstrated a strong connection between the experience of stigma and the well-being of the stigmatized. Studies and experiments reveal that stigma affects social interactions. “Stigmatization is an obvious possibility along these lines because, as Rosenfield (forthcoming) points out, official labeling can simultaneously lead to positive treatment effects and negative stigma effects.” (Link, 2009)

Link stated in his article that the conceptualization of the stigma process starts with defining stigma. He and his co workers defined stigma in two parts, “as a “mark” that (1) sets a person apart from others and (2) links the marked person to undesirable characteristics.” When the stigmatized people are linked to over generalized undesirable characteristics, a third facet of stigma comes into play and that is rejection and the unintended or intended isolation of the stigmatized peoples. This two can lead to the negative parallel between stigma and diagnoses in the field of social work. Stigma is therefore seen as a matter of degree. Link continues by saying that stigma can be seen as the mark or label that sets the individuals apart “and can vary in the extent to which it sets a person apart; the marked person can be strongly or weakly linked to a variety of undesirable characteristics; and the rejecting response can be more or less strenuous.” So the role of the social worker is to be aware of the stigmatization process and assist the stigmatized individuals in redefining themselves through positive interactions with other labeled peoples and interactions with in their “unlabeled” communities, as well as educate the community regarding mental illness and the labeling process.

“With respect to mental illness, a clear example of stigma would exist if a person were hospitalized for mental illness (a mark or label) and then assumed to be so dangerous, incompetent, and untrustworthy that avoidance and social isolation ensue. Thus, the concept of stigma as we define it includes both cognitive and behavioral components. It includes cognitive processes in which people -stigmatizers or the stigmatized-use labels to infer that a marked person possesses undesirable characteristics. It also includes the behavioral sequelae of such cognitive processes in which stigmatizers reject the stigmatized or the stigmatized engage in “secondary deviance,” such as secrecy or withdrawal, as a means of “defense, attack, or adaptation.” (Link , 2009)

According to Link et al, culturally stimulated expectations emerge in the following manner; through socialization people tend to develop the concept of what it means to be identified as a mentally ill person. They question, “Will others think less of me; reject me, because now I am a person identified as having a mental illness (or being addicted to drugs)?” In this way, labeling triggers expectations of rejection that in turn bring down confidence levels, disrupt social interaction though isolation, and impair social skills. (Link, 2009)

Diagnoses as a stereotype

Stereotypes through the labeling process is one way in which people unaware, or for a lack of better words, uneducated concerning mental illness, identify and pigeonhole stigmatized groups. Mental health professionals use diagnosis to classify people into certain treatment groups. Yet these classifications vary trough the individuals. You might group individuals labeled bipolar together but that classification has sublevels to it. You can be bipolar depressive or bipolar manic or bipolar combination mania and depression. Yet, as outlined in systems such as the DSM, diagnosis is fundamentally a classification enterprise. (Ben-Zeev, 2010) “Classification is not the only approach to diagnosis; continuous dimensions, which are discussed more fully later, provide an alternative paradigm that is less prone to the stigma associated with categorization. Thus, diagnosis assumes that all members of a group are homogeneous and that all groups are distinguished by definable boundaries.” (Corrigan, 2007)

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Diagnostic classifications serve several purposes. It helps social workers maintain large amounts of information pertaining to the groups under classification. It provides clinicians and therapists with a well-organized description of classified patients, not only the symptoms of said patients but also the expected treatment and diagnosis. Yet this is where one must be careful not to over generalize the population one is working with. And lay claim to biases and stereotypes that may come up when working with classified individuals.

Strengths Perspective and Labeling

Mental health professionals have developed a view called the strengths perspective. As Dennis Saleebey stated, practicing from a strengths perspective means that everything you do as a helper will be based on facilitating the discovery and embellishment, exploration, and use of clients’ strengths and resources in the service of helping them achieve their goals and realize their dreams. The strengths model has been used in helping adults with severe and persistent mental illness.

“Students and professionals no longer have to make an either/or choice: either validate their clients’ experiences and accept the idea that a diagnostic label reveals a real mental illness or challenge the label and undermine the legitimacy of their clients’ distress. Such dichotomous thinking can be avoided by recognizing that DSM categories are constructs that reflect implicit values, beliefs, interests, and ideologies. In other words, how distress is understood and conceptualized is a function of the language/labels that are dominant in a particular culture at a particular time.” (Cosgrove, 2005)

As outlined and mentioned throughout this paper one can use the strengths and empowerement perspective when working with individuals stigmatized through a mental health label. All you have to remember is that every individual, family, and community has strengths. You must use and acknowledge those strengths to help the individuals empower themselves. Social workers and mental health professionals’ best serve their patients and clients by collaborating with them instead of for them. When we approach clients as a helper; we work with clients rather than on their cases because it is assumed that is what we were meant to do. In the Strengths Perspective, clients’ voices are heard and valued at all levels of intervention and their treatment is contingent on the client’s strengths. (Walsh, 2010)

Pros and Cons of Diagnoses

Psychiatric diagnosis and the DSM provide a framework within which to understand mental illness. It allows the mental health practitioner to maintain large amounts of information pertaining to the groups under classification. It provides clinicians and therapists with a well-organized description of classified patients, and helps in the decision making process regarding treatment. When patients are given diagnoses; it can validate their experiences by letting them know that others have had similar experiences. Yet, as history and experience dictates patients having clusters of symptoms known as diagnoses if used appropriately can be used to inform treatment. This however is a con because a patient’s diagnosis more often than not dictates their treatment without the patient’s input. Also diagnosis sometimes becomes a stereotype. In contrast to the positivist assumption that diagnoses accurately describe preexisting illnesses. . . That is, psychiatric labels create certain realities and marginalize others and in the process, may inadvertently sustain unjust social relations. (Ishibashi, 22005)

Conclusion

When working with diagnosis and classification a mental health practitioner must be aware of the stigma and stereotypes associated with such classification. As a social worker one must work to help individuals empower themselves regardless of labels thrust upon them. We can do this by focusing on our own biasis and prejudices. Also, by working through a strengths and empowerment perspective and allowing the client to dictate their treatment. Above all we must work to educate the communities about mental illness and help them view clients as people and not labels. This paper spoke to the pros and cons of diagnoses. Unfortunatley as Ben-Zeev(2010) stated “as outlined in systems such as the DSM, diagnosis is fundamentally a classification enterprise.