Abstract
This article examines problems in the clinical utility of the diagnosis of schizophrenia including reliance on questionable data, arbitrary criteria and categorization, inadequate precision for assessment and treatment evaluation, and omission of information on causal current and historical environmental factors. Some alternatives to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) are briefly considered including continuous recording of individual client’s specific problems and goals, and functional assessments and functional analyses. The article discusses how biomedical assumptions implicit in the DSM-5 diverts mental health workers’ attention from social adversity factors contributing to the development of psychotic behavior and available psychosocial interventions for this disorder, thereby perpetuating biomedical dominance of mental health services.
Keywords
Schizophrenia is a term that conjures up the belief of a condition existing in reality, more exactly, a physical disease occurring in people. However, schizophrenia is actually a diagnostic construct inferred from behaviors performed or symptoms reported by clients. Even psychiatric experts principally responsible for constructing and revising the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses will concede that these categories are actually hypothetical constructs (Andreasen, 1994; Brauser, 2011; Frances & Widiger, 2012). Like other DSM diagnoses, the definition of schizophrenia has shifted over the decades, and revisions in the DSM–fifth edition (DSM-5) are only the most recent evidence of this malleability. Readers with a deep interest in this enigmatic term are encouraged to read Mary Boyle’s (2002) book, Schizophrenia: A Scientific Delusion?, for a penetrating and exhaustive deconstruction of the psychiatric diagnosis. Boyle painstakingly reviews the history of the diagnosis, including the original work of Kraepelin, Bleuler, and Schneider; problems in the conceptualization and correspondence rules for the construct; methodological and interpretive flaws in genetic research attempting to establish its biological etiology; and professional and broader social forces supporting the use of this term in mental health services. The present article has a more modest goal befitting its length and discusses contradictions and troublesome aspects of this label from a clinician’s viewpoint.
Although this special issue of Research on Social Work Practice focuses on DSM-5 diagnoses, this article will not emphasize the new DSM-5 definition of schizophrenia, as it has not changed significantly from the previous version. Furthermore, it could be argued that preoccupation with details of the latest revision of the DSM and its supposed improvements keeps researchers and clinicians from examining more fundamental defects in the nosology and professional and service systems utilizing these labels. This article will also not discuss the dubious reliability and validity of DSM diagnoses—although these are critical shortcomings for a clinical assessment tool—because these subjects have been covered in depth in other sources (Bola & Pitts, 2005; Boyle, 2002; Kirk & Kutchins, 1992, 1994; Kutchins & Kirk, 1997).
This article will examine several aspects of the diagnosis of schizophrenia that make the label problematic or unhelpful for clinicians working with clients who have this diagnosis. This discussion will include logical contradictions and imprecision in the category, including reliance on questionable data, use of arbitrary criteria and categorizations, and limited clinical utility due to poor quantification. The article will also consider the diagnosis’ failure to take into account current and historical environmental events that precipitate and maintain psychotic behavior as well as its tendency to ignore and devalue information relevant to psychosocial prevention and treatment. We will then consider some alternatives to the DSM’s ostensibly atheoretical assessment scheme and how its implicit medical model draws mental health workers’ attention away from social adversity factors contributing to the development of psychotic behavior. Finally, this article will briefly discuss the elephant in the room, or why social workers and other nonmedical mental health professionals are wedded to this medical nosology, in addition to reasons to reevaluate this union.
Logical Contradictions and Imprecision
Veracity of the Data
The first issue we will examine is the accuracy or credibility of the information upon which the diagnosis of schizophrenia is based. The first paragraph of the “Diagnostic criteria for schizophrenia” in the DSM-5 lists the following key features as Criterion A of the disorder:
A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms. (i.e., diminished emotional expression or avolition; American Psychiatric Association [APA], 2013, p. 99)
Hallucinations are the second key feature listed. According to the DSM, hallucinations are “…perception-like experiences that occur without an external stimulus”(APA, 2013, p. 87). Hallucinations “may occur in any sensory modality…,” however, “…auditory hallucinations are the most common…” and are “…usually experienced as voices…distinct from the individual’s own thoughts” (APA, 2013, p. 87). There is an epistemological problem, however, in using hallucinations as a primary criterion for a mental disorder. Hallucinations are “private events” (Moore, 1980; Skinner, 1945) or sensations known only to the person experiencing the hallucination. We cannot verify another person’s hallucinations in the same way that we can observable, external events. Hallucinations are a particularly indeterminate type of private event, because they are not associated with a physical condition that can be used to corroborate them (unlike pain, for instance, that can be substantiated by finding tissue damage or a record of prior injury). Information on hallucinations is usually obtained through self-report or clients giving verbal accounts of the sensations they claim to have experienced. (In some instances, clients might be assumed to being experiencing hallucinations because of their overt motor or verbal behavior [e.g., gesturing or talking to empty space]. In these situations, however, all that can be said with certainty is that the client was gesturing or talking to no one in particular. What the client actually saw or heard at that moment can only be inferred.)
The problem with relying on self-reports of hallucinations is that there is no way to independently verify the presence or form of the purported hallucinations. This contrasts with standards within social and behavioral sciences that require reliability checks or other safeguards to confirm the credibility and objectivity of obtained data (Bloom, Fischer, & Orme, 2009; Cooper, Heron, & Heward, 2007). The problem is further compounded when we use self-report of hallucinations taken from a client who also exhibits delusions, the key feature discussed earlier. The same informant who is relied upon to provide accurate information about his private events might at another point in the interview show himself to be a source of erroneous information. So, with our previous client, we accept as accurate the self-report of hallucinations from the same person who only moments before said that he is Julius Caesar. Similar difficulties emerge if we consider the third key feature in Criterion A, disorganized speech. Self-report of hallucinations may also be taken at face value, even if they come from a client who exhibits loose associations or incoherent speech. Basing a psychiatric diagnosis on self-report taken from clients who are exhibiting psychotic verbal behavior must be one of the few professional or ostensibly scientific measures that use data obtained from a source known to be inaccurate.
While unverifiable, private sensory experiences of clients are central to the diagnosis of schizophrenia, more obvious factors relating to clients’ motives and experience with mental health services that could influence their responses in a clinical interview are often overlooked. In particular, clients’ motives for gaining or regaining entry into the mental health system (to obtain disability payments, housing, medical care, and personal attention) and the clients’ familiarity with the psychiatric interviewing process—in particular, knowledge of what must be said in order to receive a DSM diagnosis and get those needed resources—is given little weight. Although there are brief cautions about the possibility of malingering and factitious disorders (APA, 2013, p. 96), there is no protocol given for assessing this possibility and, by and large, a client’s verbal content is accepted as factual. Minimal consideration is given to the client’s current needs, living situation, and history within mental health systems that might induce him to make those key verbal responses.
The preceding paragraphs are not meant to suggest that people do not experience hallucinations, or that some people diagnosed with schizophrenia have given false self-reports about this experience. On the contrary, this section points out it cannot be determined with any confidence that person has or has not hallucinated recently or in the past. At the same time, it is not difficult to claim one has had this experience and there often are powerful incentives to do so. This discussion highlights the dubious verbal evidence that is often accepted and the relevant contextual information that is typically ignored when giving the diagnosis of schizophrenia.
Arbitrary Criteria and Categorizations
The DSM-5 is organized in the form of separate diagnostic categories with the goal of assigning clients to one or more of these categories. Much of the DSM-5 text is devoted to establishing and dividing the categories, and various qualitative and quantitative criteria set boundaries for the categories. Schizophrenia is located within a spectrum of disorders, including schizophrenia, schizophreniform disorder, and brief psychotic disorder, among others. Of the many seemingly arbitrary cutoff points in the DSM-5 diagnosis are the criteria dividing schizophrenia from schizophreniform disorder (both of which must meet Diagnostic Criteria A, given earlier).
One of the distinguishing criteria for schizophrenia is that the key features are present for a significant portion of time during a 1-month period, and continuous signs of disturbance persist for at least 6 months (APA, 2013, p. 99), whereas for schizophreniform disorder the key features are present for a significant portion of time during a 1-month period, but less than 6 months (APA, 2013, pp. 96–97). Why the DSM-5 differentiates between 6 months of exhibiting key diagnostic features versus some shorter or longer time period is not explained. The social and clinical significance of exhibiting these behaviors for 6 months versus 5 months and 29 days would appear to be trivial and nonexistent. The DSM-5 also presents no epidemiological data or other evidence to show that this 6-month dividing line separates clients into groups with different clinical profiles, different responses to treatments, or other meaningful variations. The only other diagnostic criterion distinguishing between schizophrenia and schizophreniform disorder is that the former involves a marked decline in level of functioning in one or more areas (e.g., work, interpersonal relations, and self-care) following onset of the disorder (APA, 2013, p. 99), whereas the latter does not involve such decline (APA, 2013, pp. 96–98).
The dismal, post hoc assessment leading to a diagnosis of schizophrenia rather than schizophreniform disorder requires minimal time and effort to make; but, unfortunately, it also provides minimal applicable information. This is because it only describes a different clinical outcome (i.e., longer duration of symptoms and greater functional impairment), without giving information on important factors that might have contributed to that outcome (e.g., client’s personal living situation, absence of family supports or stressors, and lack of assistive or adverse working conditions). In keeping with a disease model of mental illness, the DSM-5 emphasizes client pathology which is located entirely within the individual without taking into account external causal or contributory factors. Yet, it is exactly those factors that therapists should want to identify and change in order to mitigate clients’ disturbances and to improve their functioning. Rather than being preoccupied with the DSM-5’s arbitrary distinction between schizophrenia and the schizophreniform disorder, progressive clinicians would be engaged in identifying and manipulating variables so as to prevent clients diagnosed as schizophreniform from becoming schizophrenic, and to help clients diagnosed as schizophrenic to become more schizophreniform.
Finally, the existence of these diagnoses as discrete syndromes (real clusters) warrants skepticism because of the frequent overlap of symptoms displayed by actual clients. Case in point, schizophrenia is highly correlated with substance abuse with about half of the persons qualifying for the former diagnosis also qualifying for the latter (Blanchard, Brown, Horan, & Sherwood, 2000; Buckley, 1998). The writers of the DSM-5 manage this complication with the notion of “comorbidity” or the assignment of two or more diagnoses. Yet, with a classification system relying on such weak criteria and arbitrary cutoff points, the combining of categories when individual categories fail to correspond with actual client characteristics seems yet another attempt to preserve the illusion of a distinct cluster of schizophrenic behaviors (Boyle, 2002) despite recurring deviations from that hypothetical grouping.
Inexact Categories Versus Precise Continuous Measurement
The diagnosis of schizophrenia does not indicate which particular symptoms from the list of schizophrenic symptoms are actually exhibited by an individual client, and so the DSM diagnosis only provides a rough starting point for interventions for that client. (An individualized assessment of the client’s unique set of behavioral excesses and deficits would be more helpful in guiding treatment planning. Such an assessment identifies the problematic behaviors that need to be reduced [e.g., tangential comments] and performance deficits that need to be remediated [e.g., self-care behaviors] [Wong, Wilder, Schock, & Clay, 2004]. Individualized assessments focus clinicians’ attention on areas requiring interventions, and keep energy from being expended on areas that do not require professional attention.) Although starting point DSM diagnoses are roughly categorical in nature, the symptoms defining these categories are behaviors that vary along a continuum. For example, a delusion (e.g., erroneous claims that one’s coworkers are plotting against oneself) could be exhibited with frequencies ranging from once per month to several times per day. The frequency or rate of the behavior is a crucial dimension for determining the magnitude or severity of the diagnosed disorder.
When applying an empirically supported behavioral program, cognitive behavioral therapy, or another type of rehabilitation with a client diagnosed with schizophrenia the emphasis quickly shifts from categorical to continuous monitoring. The objective is now to move the client along a continuum toward more normative frequencies or rates of the various targeted behaviors. For example, social skills training (Kurtz & Mueser, 2008)—consisting of verbal instructions, modeling, behavioral rehearsal, corrective feedback, and positive reinforcement—has been utilized to increase the frequency of conversational skills up from zero to multiple occurrences of the skills in each social encounter (Wong & Woolsey, 1989; Wong et al., 1993). A similar set of educative procedures combined with tangible reinforcement has been used to raise self-care and grooming skills from a near zero level to a daily performance or more frequent basis (Nelson & Cone, 1979; Wong et al., 1988). Recreational activities have been introduced to reduce bizarre vocal and motor behavior (Corrigan, Liberman, & Wong, 1993; Wong et al., 1987; Wong, Wright, Terranova, Bowen, & Zarate, 1988) and increase appropriate leisure behavior (Wong et al., 1988) in psychiatric patients of varied diagnoses including schizophrenia. In an analogous fashion, Bradshaw (2000) and Bradshaw and Roseborough (2004) employed cognitive–behavioral procedures of progressive relaxation and exercise, thought-stopping and self-distraction, cognitive restructuring, and positive self-appraisal to progressively lower ratings of global pathology and to raise ratings of adaptive role functioning.
When clinicians apply effective therapies to gradually increase socially appropriate behavior or to decrease schizophrenic symptoms, this brings up some interesting dilemmas for the diagnostic category. First, as key features or problem behaviors that initially met the criterion for schizophrenia are gradually attenuated or removed, the individual’s original diagnosis of “schizophrenia” begins to disappear. The DSM-5 does not provide any guidelines on how to adjust psychosocial treatment procedures to correspond with this vanishing diagnosis, although logically such adjustments would seem to be in order. Second, if treating and monitoring a client’s individual problem behaviors is a reasonable and systematic approach for remediating specific concerns of schizophrenia, then it is not clear what clinical utility the broader classification of “schizophrenia” itself has above and beyond the inexact list of problematic client behaviors. In clinical practice, the list of sometimes-absent, sometimes-present symptoms (and, when present, of varying frequency and intensity) is of nominal benefit to the formulation and evaluation of nondrug treatments.
Narrow and Inaccurate Biomedical Characterization of Behavioral Disorders
This topic brings us back to delusions, a key feature of schizophrenia discussed earlier. As noted at the beginning of this article, the DSM-5 defines delusions as “…fixed beliefs that are not amenable to change in light of conflicting evidence” (APA, 2013, p. 87). The definition portrays delusions as relatively immutable and impervious to external stimuli. This characterization is paradoxical, because it begs the question as to where the general form and particular details of clients’ delusional beliefs came from in the first place. Delusions are not spontaneous or random thoughts, but rather distortions of reality. For example, jealous delusions usually involve attraction to another person the client has met or has seen in the media, grandiose delusions about oneself being a famous person require some knowledge of history or living celebrities. Clients’ sensory and symbolic input (e.g., through conversation, TV, and readings of the Bible or the Koran) coming from the diverse and ever-changing world provide the raw material for their “fixed” delusions. This psychiatric definition also ignores decades of clinical research showing that delusional beliefs are not fixed and can be modified by presenting conflicting evidence as part of a cognitive restructuring strategy (Bouchard, Vallières, Roy, & Maziade, 1996).
Watts, Powell, and Austin (1973) originally proposed and validated a behavioral strategy for modifying delusions and replacing them with more normative and rational beliefs. Their psychosocial intervention consisted of (1) minimizing resistance by beginning work with the least strongly held belief and gradually moving to more strongly held beliefs; (2) avoiding direct confrontation and asking clients to only consider and entertain alternatives to their unusual beliefs; (3) not asking clients to abandon their delusional beliefs but only to examine evidence contrary to their beliefs; and (4) encouraging clients to voice arguments opposing their own beliefs. Using this strategy and additional techniques, independent researchers in the United Kingdom (e.g., Chadwick & Lowe, 1990; Chadwick, Lowe, Horne, & Higson, 1994; Kingdon & Turkington, 1991; Watts et al., 1973) and the United States (e.g., Alford, 1986; Alford, Fleece, Rothblum, 1982; Himadi & Kaiser, 1992; Himadi, Osteen, Kaiser, & Daniel, 1991) have significantly reduced or eliminated long-standing delusional beliefs in persons diagnosed with schizophrenia. Not all clients treated with this technique improved and results at follow-up assessments differed across individuals, but this series of largely successful studies has been totally disregarded by the writers of the DSM-5. We can only speculate as to the reasons for overlooking these clinical breakthroughs, but implications of these studies are obvious—they contradict the DSM-5’s definition of “delusions” because they show them to be malleable rather than fixed, they demonstrate the importance of the manner in which verbal and physical stimuli are presented to and verbal responses are evoked from clients, and they reveal that establishing collaborative therapeutic relationships with clients can be the first step in making delusional beliefs more pliable. This strategy has repeatedly proven effective in changing deeply rooted delusions in persons with long histories of schizophrenia (Bouchard et al., 1996); however, this verbal psychotherapy is not part of the psychiatric franchise and acknowledging its contribution to the understanding and deconstruction of delusions challenges psychiatric expertise and its sovereign authority over thought disorders.
Lack of Information on Current and Historical Environmental Events That Contribute to the Development and Maintenance of Psychotic Behavior
The DSM is presented as a classification system for mental disorders to be used by psychiatrists and other mental health professionals from different orientations including psychologists, social workers, psychiatric nurses, occupational therapists, rehabilitation therapists, and others. The DSM is offered to these other professional groups as a nosology without a presumed, or at least without an explicitly stated, theory, etiology, or recommended treatment approach for the identified disorders. Yet, there are inconsistencies in portraying DSM-5 diagnoses in this manner. First, the term “diagnosis” is defined as “…the art or act of identifying a disease from its signs and symptoms” ( Merriam-Webster, 2013; italics mine). Characterizing the many emotional, behavioral, functional, and social concerns listed in the manual as physical “diseases” is a theoretical and ideological assertion. And, even though this assertion is repeated endlessly in professional and commercial media, the claim rests on faulty definitions, logical fallacies, and weak empirical evidence (Boyle, 2002; Moncrieff, 2008; Read, Mosher, & Bentall, 2004; Valenstein, 1998).
Second, another meaning of diagnosis is the “investigation or analysis of the cause or nature of a condition, situation, or problem” ( Merriam-Webster, 2013). However, the DSM purports not to present analyses or causes for the named mental disorders. This is an anomaly for medical diagnoses, which, whenever possible, identify known or likely causes of diseases (e.g., the World Health Organization’s [2013] International Classification of Diseases names probable determinants such as infection, autoimmune response, injury, or other potential causes). This is also a major defect in an assessment framework applied by mental health professionals, who usually want to determine probable causes of disorders they are working with so they can design suitable interventions to mitigate or eliminate the problem. These two inconsistencies have a puzzling if not disingenuous quality and seem intended to make DSM diagnoses more palatable to nonmedical professionals and to persons objecting to the medicalization of these societal concerns.
Some Alternatives to Diagnostic Categorization: Functional Assessments and Functional Analyses
In contrast to the DSM’s lack of explicit hypothesized causes, clinical assessments are available to guide social workers and other mental health professionals who want to provide effective psychosocial or rehabilitative interventions for severe behavioral disorders. For instance, functional assessments and functional analyses are empirically validated procedures that identify environmental contingencies that motivate problem behavior. Data obtained through interviews and informal observations in a functional assessment, or through observations with controlled experimental manipulation of conditions in a functional analysis, are used to pinpoint consequences that serve as reinforcement for and thereby maintain problem behavior. Information from functional assessments or functional analyses is employed to design a program that simultaneously removes reinforcement for aberrant behavior while providing reinforcement for appropriate alternative behavior.
Schock, Clay, and Cipani (1998) reported several cases in which functional assessments lead to successful interventions for bizarre behavior in clients diagnosed with schizophrenia. One case involved a 42-year-old man diagnosed with paranoid schizophrenia who had been in a locked facility for 12 consecutive years. This client refused to bathe because he claimed he was made of dirt and would melt. The standard institutional approach to dealing with this problem would have been to simply medicate the client and physically guide him through the shower despite his objections. Relying on the functional assessment, however, the client’s delusional statements were assumed to be a form of avoidance behavior (which might have developed after extensive shoulder surgery and experiencing unsteadiness standing in the shower). The intervention in this case involved scheduling baths instead of showers and providing extra positive reinforcement (additional program points) for completing showers. As the client responded to this procedure, the extra reinforcement was gradually withdrawn and bathing was maintained with social praise for good hygiene.
A functional analysis (Beavers, Iwata, & Lerman, 2013; Iwata, Dorsey, Slifer, Bauman, & Richman, 1982) is an empirical assessment that identifies reinforcement contingencies maintaining a problem behavior by presenting a series of brief (5–15 min) sessions during which various contingencies are simulated and in which the client’s behavior is recorded. Sessions with different reinforcement contingencies are presented in random order and the amount of problem behavior occurring during each type of session is then compared. Wilder, Masuda, O’Conner, and Baham (2001) assessed contingencies that were maintaining delusional speech in a middle-aged man with schizophrenia by presenting alternating conditions of the following four types: (1) escape from demand (the therapist asked the client to work on a task, e.g., a simple household chore, until the client made a bizarre statement, after which the therapist allowed the client to take a 30-s break from the task); (2) attention (the therapist pretended to be preoccupied and ignored the client until the client made a bizarre statement, after which the therapist made eye contact and told the client that he “shouldn’t talk” like that); (3) alone (the client was left alone in the room and observed to see if the bizarre statements would occur without any social consequences and thus were self-stimulatory or self-reinforcing); and (4) control (the therapist interacted with the client until he made a bizarre statement, after which the therapist broke off eye contact and terminated all conversation for 10 s).
Results of the functional analysis by Wilder et al. (2001) were that bizarre speech occurred in a substantially greater percentage of the scored intervals with attention (mean = 26%) as compared to escape from demand (mean = 2%), alone (mean = 0%), or control (mean = 5%) conditions. Utilizing this information, an intervention consisting of differential reinforcement of alternative speech (attention for appropriate verbalizations) plus extinction for bizarre speech (planned ignoring) was designed. When this intervention was applied and evaluated within a reversal design, it nearly eliminated the client’s psychotic speech. Findings of this study were later replicated with a female client also diagnosed with schizophrenia who displayed bizarre verbalizations in the form of tangential remarks (Wilder, White, & Yu, 2003).
Few social workers know how to conduct functional assessments and functional analysis to identify conditions that motivate clients’ problem behavior (for a notable exception, see Filter & Alvarez, 2012), and fewer still can apply this technique with schizophrenic behaviors. Nevertheless, the previous studies illustrate how such alternative assessments can lead to a greater understanding of social and environmental stimuli that influence problematic responses and to practical psychosocial interventions to alleviate these problems. Equipped with the knowledge of these and other therapeutic techniques, social workers can take a more active role in the design and implementation of effective psychosocial interventions, rather than being handmaidens of psychiatrists and relying on the finite benefits of their pharmacological treatments (Cohen, 1997; Harrow & Jobe, 2007; Hegarty, Baldessarini, Tohen, Waternaux, & Oepen, 1994; Whitaker, 2010).
Biomedical Distraction From Social Adversity Factors Contributing to the Development of Psychotic Disorders
The professed atheoretical and unbiased nature of DSM-5 diagnoses clashes with the primary function they serve within the current infrastructure of biomedically dominated mental health systems. Transforming a client’s mental, emotional, behavioral, and interpersonal concerns into a psychiatric diagnosis of schizophrenia is the first of many professional and institutional operations that place the client’s complaints, and complaints about the client, firmly within the jurisdiction of medical practice (Conrad, 1992; Cooksey & Brown, 1998; Kutchins & Kirk, 1997). Beginning with this formal definition of the problem in psychiatric terms, the clients’ treatment and care is overseen by medical practitioners, is administered within clinics and hospitals, and almost inevitably leads to prescription of one or more psychotropic drugs. Within these medical systems, psychosocial treatments and efforts to improve clients’ physical and social environments are at best secondary or ancillary interventions and often merely an afterthought.
While current mental health services focus primarily on treating unconfirmed biological or neurological diseases (Gomory, Wong, Cohen, & Lacasse, 2011; Kingdon & Young, 2007; Whitaker, 2010), social workers and other mental health professionals should not confine themselves to this narrow, reductionist perspective and should be sensitive to other factors contributing to severe mental and behavioral disturbances. Social workers trained in person-in-the-environment perspectives should recognize how adverse conditions such economic deprivation, social isolation, trauma, and predatory relationships can bring about personal distress, behavioral disturbances, and impaired role performance. There is abundant research on environmental and social adversity factors contributing to the development of schizophrenic symptoms and psychosis to guide our practice in social advocacy, prevention, and treatment of mental and behavioral disorders.
Research has revealed a host of environmental and social adversity factors increasing the risk of psychosis that social workers should be keenly sensitive to, beginning with poverty and low socioeconomic status (Cohen, 1993; Hudson, 1988, 2005; Wicks, Hjern, & Dalman, 2010; Wicks, Hjern, Gunnell, Lewis, & Dalman, 2005). When disadvantaged socioeconomic status is combined with genetic liability (a biological parent receiving inpatient care for psychosis), the risk increases substantially (Wicks et al., 2010). Greater risk of developing schizophrenic and psychotic symptoms is also associated with being born from an unwanted pregnancy (Myhrman, Rantakallio, Isohanni, Jones, & Partanen, 1996), psychological trauma (Scott, Chant, Andrews, Martin, & McGrath, 2007; Spauwen, Krabbendam, Lieb, Wittchen, & van Os, 2006), childhood physical abuse (Arseneault et al., 2011; Fisher et al., 2009; Heins et al., 2011; Kelleher et al., 2008, 2013; Shevlin, Dorahy, & Adamson, 2007), childhood maltreatment and domestic violence (Arseneault et al., 2011; Kaslow & Thompson, 2008; Kelleher et al., 2008), sexual victimization or rape (Elklit & Shevlin, 2011; Fisher et al., 2009; Shevlin et al., 2007), and bullying by peers (Arseneault et al., 2011; Kelleher et al., 2013; Mackie, Castellanos-Ryan, & Conrad, 2011; Schreier et al., 2009). Some of the previous studies incorporated prospective or longitudinal designs, showing the emergence of psychotic symptoms in nonclinical participants (Arseneault et al., 2011; Kelleher et al., 2013; Schreier et al., 2009; Spauwen et al., 2006), other studies cited found a dose–response relationship where increases in the number, type, or severity of traumatic events raised the risk of psychotic symptoms (Kelleher et al., 2013; Schreier et al., 2009; Scott et al., 2007; Wicks et al., 2005); both of these methodologies indicated that traumatic events were causal and not coincidental to schizophrenic and psychotic symptoms.
This research has implications for social workers’ obligations, as called for by our training and Code of Ethics (National Association of Social Workers, 2008), to prevent and intervene with social problems, such as severe mental and behavioral disorders, by providing for basic human needs, protecting vulnerable and oppressed persons, and promoting social justice. These obligations will not be met or substituted for by work in medical institutions that only deals with after effects of deprivation, trauma, and other harmful experiences and mainly through administration of psychotropic drugs.
Elephant in the Room
The biggest question is, given the many conceptual, scientific, and technical shortcomings of the diagnosis of schizophrenia, and of DSM diagnoses in general, why are social workers, psychologists, and other mental health professionals so dutiful in their use of the DSM and not more outspoken in their criticism of these psychiatric labels? One likely reason is that social workers and other mental health professionals have been indoctrinated within the prevailing biomedical model (Cohen, 2002; Gambrill, 2013) and are unaware of the flaws and biases within psychiatric diagnoses (Lacasse & Gomory, 2003). Another more formidable reason is that the biomedical model dominates mental health services, its verbiage permeates legal, governmental, and financial systems that support mental health services (Frazer, Westhuis, Daley, & Phillips, 2009), and questioning its ideas and approach puts one at odds with one’s employer and adds unwanted complications to one’s job and future career. However, simply acquiescing to this medical ideology also has dire consequences for individual clinicians and their professions. For social workers, it means putting aside our person-in-the-environment approach, our appreciation of how life experiences and living conditions shape peoples’ thoughts and actions, and our professional independence. Furthermore, this issue goes beyond professional subordination to medical doctors and intellectual submission to a reductionist biological ideology, it is also means abandoning our ethical mandate to be well informed, critical thinkers and to advocate for our clients. Discerning eyes would see the poor outcomes associated with pharmacological treatments for persons diagnosed with schizophrenia are undeserving of their monopolistic hold over mental health services (Cohen, 1997; Harrow & Jobe, 2007; Hegarty et al., 1994; Whitaker, 2010), and they would recognize that this situation calls us to act for social justice. Our clients need a wider range of effective services, programs aimed at improving their quality of life and developing their adaptive potential, and interventions that prevent rather than merely treat mental, emotional, and behavioral disturbances. Such assistance is not and probably never will be provided by the existing monolithic, medically and pharmaceutically driven institutions, and therefore it is our responsibility to fight for more humane and effective approaches to these problems.
Discussion and Applications to Social Work
This article examined a number of significant conceptual and technical weaknesses in the diagnosis of schizophrenia that greatly limit its utility for nonmedical professionals working in the prevention and treatment of severe mental and behavioral disturbances. These deep flaws in a DSM diagnosis—which social workers use regularly, but which they did not write and into whose form and content they had little input—should be a serious concern to our field. It would appear that, much like how a practical definition of mental illness has been elusive for the DSM (Frances & Widiger, 2012), a practical definition for schizophrenia, if this syndrome exists at all (Boyle, 2002), has eluded the diagnostic manual. The weightiest problem of this diagnosis, however, will not be resolved by more refined definitions, new criteria, or field trials conducted for the DSM, sixth edition, the DSM, tenth edition, or the some later iteration of the DSM. The greatest concern is that of social workers, who constitute the largest number of mental health professionals, succumbing to the flood of institutional propaganda about so-called mental disorders (Gambrill, 2013). Intellectual surrender to this propaganda can take the form of uncritical acceptance of schizophrenia and other psychiatric diagnoses, thereby adopting biomedical models based on negligible scientific evidence that replace broader person-in-the-environment perspectives and that stifle alternative and potentially more effective assessment, prevention, and intervention approaches (Gomory et al., 2011; Wong, 2006).
When social workers recognize DSM diagnoses as formal mechanisms by which medicine and pharmaceutical industries maintain hegemonic control over mental health services, they can take steps to counteract this influence. To start, social workers and other mental health professionals can confine their work with DSM diagnoses to situations where institutions and bureaucracies demand their use. This will compartmentalize the diagnoses and limit their influence on our professional thought and action. Social workers should also be cautioned against indoctrination in and blind allegiance to psychiatric diagnoses, which reifies these labels while obscuring their defects and function in upholding hierarchical relationships between helping professions. When DSM diagnoses are taught, coverage should be critical and contextual, including controversies surrounding the biomedical model of mental illness; problems in the conceptualization, reliability, and validity of DSM diagnoses; psychiatry’s long history of mutating diagnoses, somatic (now primarily drug) treatments, and unfulfilled promises of cures; and how psychiatric diagnoses shape the beliefs and actions of subordinate mental health professions, such as social work.
Social workers and other mental health professionals interested in and needing classification systems or more refined assessment instruments should develop and utilize their own tools suited to their specialized practice. These groups could also exercise and advance their professional independence by making critical analyses of DSM diagnoses and the development of alternatives regular topics at professional conferences and in research publications. Open criticism and resistance to the DSM would be a fitting starting point for organizing and opposing medical dominance and the biomedical hegemony over mental health services, and thereby better assisting members of our society with mental, emotional, and behavioral disturbances.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.