Critical Approaches to the DSM

Transcript:

Olivia Baker (00:00):

Yeah. I think that you only need to look at past DSMs and see that there was the inclusion of homosexuality.

Cassie (00:05):

Yeah

Olivia Baker (00:07):

as a mental illness in the DSM as well as recently I was looking over the, I think the DSM one and there was something called insufficient personality disorder. So kind of our understanding has shifted. So I think that that’s important to think about in this case of the DSM five.

Cassie (00:28):

Hello, I’m Cassie Gillespie, and you’re listening to the Social Work Lens. The Social Work Lens is a podcast produced by the University of Vermont’s Child Welfare Training Partnership and the State of Vermont. Today, though, we’re bringing you something completely different. This is our first student driven episode, and we’re welcoming special guests, Olivia Baker and Danielle Jatlow. Here to have a conversation about critical approaches to the DSM. This conversation is based off Olivia’s work in her senior independent study in the Bachelor’s of Social Work Program. So let me welcome you both and would you mind taking a minute to introduce yourself?

Danielle Jatlow (01:09):

Sure. Hi, I’m Danielle Jatlow. I use she her pronouns. I am currently the BSW coordinator and lecturer in the Department of Social work at the University of Vermont. But I’ve also been a clinical social worker and a social worker in San Francisco and New York City, and now up here in Burlington, Vermont. And I’ve worked with adolescents and families in a variety of contexts.

Cassie (01:34):

Awesome. We’re so happy to have you, Danielle.

Danielle Jatlow (01:36):

Thank You.

Cassie (01:38):

And Olivia, how about you?

Olivia Baker (01:40):

Hi, my name is Olivia Baker. I use she her pronouns. I in 10 days as we’re recording this, we’ll have my BSW.

Cassie (01:48):

woo-hoo. Yay

Olivia Baker (01:50):

<Laugh>. And I did my internship at a hospital diversion program working with Youth Experiencing crisis, as well as doing this independent study, as Cassie mentioned on the DSM.

Cassie (02:05):

That’s great. And we’re really grateful that you were willing to come in and chat with us about it, and that we’re able to offer a different type of conversation between student and advisor and faculty member about some of the rich kind of concepts we can unpack in the social work department. Okay. So let’s maybe start at the beginning. What drew you to this topic, Olivia?

Olivia Baker (02:25):

Yeah. I think that this is a story that I share often, but when I was probably seven or eight years old, I have a very distinct memory of sitting on the floor in my kitchen reading the DSM.

Cassie (02:39):

<laugh>.

Olivia Baker (02:39):

with my mom and being like, what’s flat affect and just going through it and being fascinated by it of this like way of categorizing life. And so I think that that was kind of my start to the interest of DSM.

Cassie (02:52):

Yeah.

Olivia Baker (02:53):

And then that kind of continued throughout my life and was really highlighted by my work at the Hospital diversion program as it in crisis, there’s a lot of diagnosis that is happening and understanding. So that’s kind of what drew me to this topic.

Cassie (03:10):

Thank you. And I’m realizing we should probably maybe pause even right now, I don’t know that we plan to do this, but we’ll catch ourselves as we go. What is the DSM? I don’t know, Danielle, do you wanna tackle that one? Or Olivia, where should we start?

Danielle Jatlow (03:23):

You wanna, you wanna take it?

Olivia Baker (03:24):

Yeah, I can start and then people can add. Yeah. The DSM stands for the Diagnostic Statistical Manual, and it is right now we’re on the fifth iteration, so the DSM five, it is a way of categorizing and diagnosing folks with different mental illnesses. It is the manual that therapists and other providers use in order to diagnose, and it has a lot of ties to insurance as well as like the everyday folks understanding what is happening.

Cassie (03:57):

Yeah. Great. Perfect. And is it the only book I, I’m doing that thing where I’m asking a question I kind of know the answer to, but there are other manuals out there to diagnose mental health disorders. Yes. Yes.

Danielle Jatlow (04:08):

There’s the ICD and I think, you know, there’s a range, and I should also say there’s a range of assessment tools and practices that aren’t necessarily connected to the DSM, but there certainly are a wide range of ways to engage in assessment.

Cassie (04:25):

Perfect. And so the reason I was sort of fishing around for that is I wonder if it makes sense to, to kind of share why the DSM in particular, because there are a couple different frameworks out there that people can use.

Olivia Baker (04:37):

Yeah. I think the DSM in particular, kind of in the most practical reason, it is what is used most broadly in the United States and has overarching kind of implications in and beyond the United States. I’ll get to some of this more research later, but as I was doing the reading, a lot of them mentioned kind of the wide breadth that it has in the way of understanding mental illness as a whole, both, like I said, in and outside of the United States.

Cassie (05:02):

Perfect. So, okay. Would both of you be willing to share a little bit about this independent study, the project that led to this conversation and maybe how it was set up or, or how you took it forward?

Olivia Baker (05:13):

Yeah. I, so I started with do meeting with Danielle and kind of planning it out and then doing a bunch of reading and making a annotated bibliography of sorts. So basically just getting the source and writing a small piece about it. And then Danielle and I discussed that it felt important to have a creative aspect to this as well as a sharing aspect to this. So together we created an event where we invited a bunch of folks and discussed this information while creating a creative piece. So there was a big piece of paper with artwork around it, and it was a discussion with peers and with faculty Danielle, about the DSM and about kind of all the research that I had. I organized it into a list of probably 30 to 40 different main takeaways from all the different research projects or research papers that I read. And had a, a long, like hour, hour and a half discussion about it. While creating a piece of art. Very

Cassie (06:14):

Cool.

Danielle Jatlow (06:15):

Yeah, and I’ll just add that, you know, Olivia came to me and I think just, you know, just to share Olivia’s intellectually curious and a critical thinker and is just authentically engaged with the topic as she identified. And so it just felt like a really good fit since I’m also really interested in kind of looking critically at the ways in which we engage in service provision in the mental health field.

Cassie (06:42):

Yeah. ’cause you have a long, long history of working as a mental health provider, Don’t you?

Danielle Jatlow (06:46):

Yes, yes, yes. And I, I think, you know, in some positions that I’ve held, we haven’t used the DSM and in some positions I’ve held, it’s been an important part of our billing process as, as Olivia mentioned. And so I’ve had kind of opportunities to also work really closely with young people and families on their own perspectives about diagnosis as well.

Cassie (07:06):

Awesome. So, you know, I think we’ve sort of done the stage setting there, and I just wanna offer to you listeners, you know, we wanted to be really clear about who we are and how we’re entering into this conversation, but this book, the DSM, you know, if you have any, if you carry any mental health diagnoses, receive treatment for them, it’s highly likely that this book is, is sort of in the background of your medical record. And so at this point we wanna kind of delve into the project and start hearing about it. And I just wanted to offer that context if you’re listening along, going, okay, well that’s great. You know, we someone read papers, you know, how does this connect to me? We’re all really impacted by this, by this book, so, alright. How about where should we start? Limitations?

Olivia Baker (07:50):

Yeah, that sounds good. Okay. Pulling up limitations. The first limitation that I found in the research was the DSM serves to medicalize distress in a way that is purposely benefiting the pharmaceutical industry and the care industry as a whole. So the committee that formed the DSM five, which is, like I said, the current iteration contained major conflicts of interest including financial backing by the pharmaceutical industry. So 56% of the members of the panels that made the DSM had financial ties to pharmaceutical companies as well as a hundred percent of the members on the panels of mood disorders and schizophrenia had financial ties to pharmaceutical companies.

Cassie (08:39):

Yeah, I think that’s a really striking statistic that isn’t terribly well known. I was certainly surprised.

Olivia Baker (08:44):

Same.

Danielle Jatlow (08:45):

Yeah, and I think, I mean, something I have been thinking a lot about is kind of wherever you go, there you are. And I think, you know, we, there is this kind of economic or kind of neoliberal or economic part of our service system that I don’t think we look at very often. So I was really glad that Olivia had done some reading and incorporated that into the conversation.

Cassie (09:07):

Yeah, It’s powerful. And is there the answer to this can totally be no, but is there more you wanna say about that point? Like is it a standalone statistic or does that create a piece of context or is there an inference there you want us to kind of unpack?

Olivia Baker (09:21):

Yeah, I think it feels important because the DSM is used so broadly to like, understand treatment and next steps for mental health. And so if there is, and the people that are forming it, this tie to pharmaceutical companies, I think as Danielle was saying, like under a neoliberal context, it makes it so that there could be like backing or a motivation to further medicalize distress. So to further create a reason for kind of the heightened use of pharmaceutical intervention, which is not at all to say that pharmaceutical intervention is bad, lots of folks feel really helped by pharmaceutical intervention, but by making it like the main point it can serve to create harm, especially within marginalized communities, which I will continue to talk about.

Cassie (10:12):

Yeah. And we’ll also set aside some time today to talk about all the wonderful things about the DSM and the strengths and the ways it’s helpful to people. So I appreciate you kind of bringing that in right from the get go. But it is helpful to have some eyes open information about the origin and the genesis of, of the processes on this. Okay. What else did you kind of uncover in your, in your deep dive here that kind of fall into the limitations category?

Olivia Baker (10:37):

Yeah. Another big kind of category or another big thing was the DSM ignores environmental factors, thus pathologizing in quotes, natural responses to in quotes natural circumstances. And I think it’s important to say, I wish I had said this earlier, but this is not all stuff that I like stand behind with my whole chest. Most of it is a amalgamation of research. So it’s like presenting facts. There are things that I agree with, there are things that I challenge.

Cassie (11:06):

Sure.

Olivia Baker (11:07):

but especially as someone who does not have a lot of direct experience with using the DSM as someone who does not have their MSW or licensure it felt important for me to take a a research based stance.

Cassie (11:22):

Yeah.

Olivia Baker (11:24):

But when considering the environmental factors, we can think of it as under this system of capitalism, under the system of white supremacy of harm that is happening. A way of viewing it could be that like the responses of distress or kind of a response to these circumstances that we’re not as humans, like made to live under. So feelings of like, feeling really down or feeling really anxious, our responses to kind of the world feeling unmanageable or feeling really distressing.

Cassie (11:58):

Yeah. And so maybe not like an organic neurobiological or sort of physiological individual defect, but a really reasonable response to a collective structure or stressor.

Danielle Jatlow (12:10):

I also wanna add, I I, yeah, I am glad that you wrote that in that, you know, social and structural determinants of health impact health, right. And so we have all these non-medical factors that impact health like poverty, unequal access to healthcare stigma, racism and structural, you know, kind of governmental processes economic and social policies that impact working conditions, housing, education, access to reproductive healthcare, gender affirming care. And so these types of determinants of health are not factored in, but we know, you know, all of the literature points to how important these are in terms of healthcare access, healthcare utilization, and then ultimately healthcare equity or inequity.

Cassie (12:56):

Yeah. Yeah. I’m really glad you brought it in. Thank you. So let’s see. Are there more? Oh, it looks like, yeah, there’s a couple more that we’ve uncovered. So, or you’ve uncovered Olivia, go ahead. Where to next?

Olivia Baker (13:09):

Yeah, I think the next is the DSM serves as a political, economic and social tool to control in quotations deviant behavior. So in understanding this, like, one way that this can manifest is an individual is reduced to their diagnosis, and thus when they express distress, their distress is deemed as part of the sort of pathologized illness and thus not worthy of serious consideration. So when folks are like pushing back against structures of inequality in the service systems that they’re seen as, oh, this is part of your depression or your anxiety or your psychosis, rather than like, this is a serious consideration.

Cassie (13:52):

Yeah.

Olivia Baker (13:52):

And a serious thing. And so kind of this argument points to the way that both the service field and the government as a whole has used kind of the DSM and the diagnosis process in general to kind of undermine people’s political and kind of dissent or political disagreement

Cassie (14:14):

Yeah. Or personal autonomy.

Olivia Baker (14:15):

Yeah.

Cassie (14:16):

Well, actually, let me ask a question about that. Is this where you would place the personal autonomy piece? Like where folks are maybe involuntarily admitted to treatment programs? Is, is that sort of in this piece of the conversation for you?

Olivia Baker (14:29):

Yeah, definitely. I think that the DSM is a huge part in kind of the, like the words that you use, like the, a voluntary placement of people.

Cassie (14:40):

Yeah. I teach the intro class at UVM and the social work department, and we spend a bunch of time, you know, arguing but arguing effectively, like good arguing for good reason, <laugh> about where is the line to compel someone to get treatment or compel someone to take medication. And how those rules and policies and regulations are a little bit different state to state. And you know, it doesn’t take long to get everyone pretty sure that there’s no good answer about that and that it’s really, really tricky.

Danielle Jatlow (15:09):

And Olivia, didn’t we talk about that in class as well? Actually after listening to this podcast,

Cassie (15:15):

oh, <laugh>.

Danielle Jatlow (15:16):

about thinking about suicide and suicide assessment and suicide risk. And I know that those can be hard topics to think about and talk about, but in class we did talk a little bit about kind of self-determination and safety and kind of how you kind of navigate that during trickier complicated situations with folks.

Cassie (15:38):

Yeah.

Danielle Jatlow (15:38):

We didn’t solve that problem <laugh>. That was, that was a conversation we had. And I thought, I thought the students, I don;t know if you remember that Olivia, that that everyone had some really good points and I think are really connected to the topic based on all a wide range of different experiences, the identities that they hold, the lived experiences that they have, the values or beliefs that they are carrying with them. So it was an important conversation

Cassie (16:05):

And I think that’s so connected to this idea that there’s a right and a wrong answer for these deep complicated questions. You know, and that might walk us right into the next limitation around social construction.

Olivia Baker (16:17):

Yeah, I was about to say that this is related to kind of the understanding that the DSM assumes that language is only descriptive and not also performative. Kind of thus ignoring or not being inclusive of a social constructionist framing. We talked about this a lot in the creative piece in the meeting about this, but to kind of break down ’cause I know when I was doing the research, I was confused by this idea of like, what is descriptive versus performative mean?

Cassie (16:45):

Yeah, Yeah. Help us understand.

Olivia Baker (16:47):

Yeah. so I think the example that I used in the meeting was that of a table to look at, a descriptive understanding of a table is to be like, this is a table. And that’s because we say it is versus kind of thinking of it in a performative way would be that all of us in this room have a shared understanding that this like square thing with four legs is a table. That there’s nothing about the item of a table directly that makes it a table. But that we have decided together that it is a table. And then moving beyond just tables <laugh> into the topic of the DSM, kind of a descriptive look at the DSM would be that this person is presenting in this way, thus they have depression. And that is like what it is. Versus a performative would be that we as a society have decided that this

Cassie (17:39):

Depression looks this way.

Olivia Baker (17:40):

Yeah. Amalgamation of symptoms or behavior is depression, but that there is nothing inherent about that person that is depressed. It is just that we have described it as so.

Cassie (17:51):

Oh, interesting.

Olivia Baker (17:52):

And the kind of DSM, which I think is part of what happens when you put things into writing. Like that’s not only the fault of the DSM, but kind of ignores that understanding and makes it seem like this is so,

Cassie (18:04):

Yeah. Yeah.

Danielle Jatlow (18:05):

I guess I also just wanna add that then our systems also kind of take that on. And so our service systems then can tend to kind of categorize like we see people who present in this way and we don’t see people who present in this way. And so it can be a way of kind of excluding or not being as inclusive or expansive as we might want our service systems to be. I also think in my work with adolescents, you know, there’s like a very, very wide range of ways that people can present in, you know, even from one minute to the next or for one hour to the next adolescents is a stage of development characterized by a lot of change in transition. And so, you know, a lot’s going on and so to kind of label without, you know, with kind of it, it can be helpful and it can be it might not be as accurate kind of over the long term and people kind of have all different experiences, maybe even with the same diagnosis.

Cassie (19:07):

Yeah. I think about working with older youth in the child welfare system or even parents at times, and you may look in their file and they have this sort of laundry list of diagnoses that were given at different times. Each one treated at the time that it was diagnosed as, this is the thing we know it is true, it describes what’s happening for this person. And then, you know, you have this list that kind of follows people around where when you look at it in totality, it’s like, how can you have all these things at the same time? Or, you know, how exactly does that work? They never seem to get crossed off, ruled out. It, it becomes a little harder, I think, to, to see the DSM like working in the way it was intended when you, when you see someone sort of medical file, you know, following them in that way.

Danielle Jatlow (19:51):

Yeah. And I think certain diagnoses maybe Olivia will touch on this you know, have different levels of stigma. And so some people feel really connected to certain diagnoses and maybe they are even kind of diagnoses that have less like weight than others. And so there’s certain categories like personality,

Cassie (20:13):

Give an example, what are you saying?

Danielle Jatlow (20:14):

Sorry. Like, you know, I think maybe like in the personality disorders or I know in our classroom the other day we were talking a little bit about a program in the community who uses like oppositional defiant disorder. Where I, I might tend to come at that from a more trauma informed place that maybe something has happened to this young person or, you know, if something is happening continuing to happen with this young person as opposed to labeling their communication of distress through kind of externalizing behaviors. So that’s, you know, one example, I dunno if you have another Olivia, or

Olivia Baker (20:52):

Yeah. I was just gonna say that I think this relates to another point that was found out of like the idea that the DSM functions under an assumption that the diagnosis listed capture completely and discreetly the range of human suffering. And that is kind of shown through the checklist function of.

Cassie (21:09):

Yeah.

Olivia Baker (21:09):

For folks that don’t know the chest checklist function of the DSM is like a list of symptoms often separated into different categories, and you have to meet like three out of five of these symptoms. Which is kind of an interesting way of understanding people. Like, it feels like you’re going and you’re like checking boxes of something that is like so wide and.

Cassie (21:32):

Yeah.

Olivia Baker (21:33):

Kind of big in a person’s life. And I think that that the idea of different diagnosis and the weight, that different diagnosis have often many something could be presented as different things and there are factors of like institutional factors that make it so that certain folks get diagnosed with one thing over the other. For example ADHD and oppositional defiant disorder have both been disproportionately diagnosed to young boys of color, in particular young black boys.

Cassie (22:07):

Yeah. And if we were presenting with that same sort of consolation of symptoms but didn’t fall into that demographic or identity-based category, you, you may end up with a different diagnosis or no diagnosis at all.

Olivia Baker (22:17):

Yeah. either like kind of understanding it more through the lens of trauma.

Cassie (22:23):

Mm-Hmm. <Affirmative>.

Olivia Baker (22:23):

or like you said, not pathologizing it at all. And I also think that the conversation of personality disorders, I know borderline personality disorder is disproportionately given to women.

Cassie (22:35):

Yeah.

Olivia Baker (22:35):

And is something that can be very stigmatized within the mental health field.

Cassie (22:42):

Yeah. And I’m just struck listening how, you know, like I said, we will talk about strengths because it isn’t all bad and, you know, diagnosis in general and the DSM in particular can really provide really helpful organization and structure for folks. But I, I am struck with this belief I had growing up that, that these things were finite, that they were evidence-based, that people really knew, you know? And so from that brain point, I can imagine listening saying, well, we do see a higher instance of borderline personality disorder in female presenting individuals <laugh>, you know, and like, it’s just so complicated to kind of pull those threads apart. Do you wanna talk a little bit about the evidence-based component?

Olivia Baker (23:21):

Yeah. So in a lot of the articles that I was reading, there was kind of this statement of, despite its claims, the DSM does not provide information that is backed by any meaningful evidence. So as Cassie was mentioning, there’s kind of this challenge to this idea that kind of thinking of the DSM as research based and research based as the arbiter of truth.

Cassie (23:45):

Mm-Hmm. <Affirmative>.

Olivia Baker (23:46):

like if something is based by research, that means it has to be true.

Cassie (23:49):

We know from the research.

Olivia Baker (23:50):

Yeah. <laugh>,

Cassie (23:51):

Full disclosure, I actually say that phrase all the time when I teach and present. So it’s so insidious.

Olivia Baker (23:57):

And I mean, my whole presentation is based on research. so..

Cassie (23:59):

You know, from your research Go ahead. Anyway, I cut you off. So you were saying

Olivia Baker (24:04):

That was kind of the, the main point of it. But, but yeah, so I think that there’s a challenge to this idea both that a lot of research has been done and of the legitimacy of research, especially when considering a non-Western or a non kind of dominant culture population.

Cassie (24:26):

Yeah.

Danielle Jatlow (24:26):

And I think we have to also, to piggyback on that which I, I agree with is to think about whose voices are being centered within the research, who are the participants. I also wanna highlight that the DSM is, is iterative. And so, you know, we’re on DSM five, we’ve had previous versions. I think that’s just a really important part of thinking about what we know now is what is not what we will know in the future. And I hold that in my practice work all the time when we talk about the evidence-based, both really important to be practicing with great intention and to have some research backing and also to make sure that we are always thinking about what we used to do is not what we do now and what we’ll do in the future is not what we are doing now. So that’s, that’s something I think about a lot.

Cassie (25:15):

Yeah. And I, I wanna underscore that because when you look at the physical copies, like the hard copies of the DSM, they’re all different sizes. You know, the way DSM three and DSM four, you know, they grow and they shrink. And something that we were certain is a pathology and has this criteria, you know, can completely not be included in the next edition. And, and that should be ’cause we’re out, you know, learning like that’s a strength. That is a strength, but also I think that it’s hard to hold that hold that reality in this moment like as you’re talking to someone about their current diagnosis.

Olivia Baker (25:49):

Yeah. I think that you only need to look at past DSMs and see that there was the inclusion of homosexuality.

Cassie (25:56):

Yeah.

Olivia Baker (25:56):

As a mental illness. In the DSM as well as recently I was looking over the, I think the DSM one and there was something called insufficient personality disorder <laugh>. So kind of our understanding has shifted. So I think that that’s important to think about in this case of the DSM five. And I think that’s a very, like you were saying, I think that’s a strength and a very beautiful thing.

Cassie (26:20):

Yeah. Yeah.

Olivia Baker (26:20):

Of our understanding that we’re gonna look back and be horrified by some things in the DSM five. I think that that shows like growth and change

Cassie (26:27):

For sure.

Danielle Jatlow (26:27):

Absolutely.

Cassie (26:28):

Yeah. Yeah. So I know there’s a lot of other strengths we wanna talk about. Before we kind of pivot, are there other limitations that you wanted to highlight before we switch gears?

Olivia Baker (26:39):

I think two kind of quick important ones are one that the, the DSM kind of forces people into this westernized pathology. So impacting those with marginalized identities and kind of thinking, as I mentioned about homosexuality being in the previous DSM being there is a way that the DSM can also be seen as pathologizing trans, and I use that with an asterisk to include non-binary folks as well.

Cassie (27:08):

Yeah.

Olivia Baker (27:08):

As with the inclusion of gender dysphoria.

Cassie (27:11):

Yeah. That feels, that feels really important to call out. Thank you. So should we switch a little bit and, and make sure we share some information about what works well about the DCM or the DSM? What are some of its strengths?

Olivia Baker (27:24):

Yeah, definitely. I think that one big one especially for folks that are interact with the DSM in like a consumer way or in a patient way is the, the DSM can serve to normalize and validate experiences as well as creating a sense of community and belonging. So getting a diagnosis can feel normalizing of like, this is not a character flaw.

Cassie (27:53):

Yeah.

Olivia Baker (27:54):

This is not something that I’m doing badly. This is something where there is other people that act this way and there’s a reason. And then this can be especially important to those whose distress is seen as exaggeration or hysterical.

Cassie (28:08):

Oh, yeah.

Olivia Baker (28:08):

So one article talked about the introduction of premenstrual dysphoric disorder and how that could be seen for people who menstruate as kind of normalizing this feeling of like, it’s not just me being in quotations crazy.

Cassie (28:25):

Right.

Olivia Baker (28:26):

but that there is a reason that I’m acting this way.

Cassie (28:29):

Yeah, yeah. Yeah. Isolation is so harmful. So any, any opportunity Right. Structural or otherwise to, to feel seen and connected can be really powerful and healing.

Danielle Jatlow (28:38):

I also think, again, from the provider perspective, you know, a lot of people come into care really looking for what do I have? What’s going on with me?

Cassie (28:46):

Tell me what’s wrong with me.

Danielle Jatlow (28:47):

Tell me, tell me what’s going on and not from a place of maybe like, tell me what’s wrong with, but maybe like I’m, I’m having these experiences or these feelings and they, some folks who I’ve worked with feel a sense of relief once they know that there’s a name for this. There’s support and help and therapeutic modalities that we can engage in that will you know, hopefully alleviate some of the difficult feelings you’re having. So that can be a positive.

Cassie (29:15):

Yeah. That makes sense. Are there other, I’m sure there were other positives that came out in the research.

Olivia Baker (29:20):

Yeah. Another big one is the idea that there are professional benefits.

Cassie (29:25):

Oh, that makes sense.

Olivia Baker (29:26):

To the DSM. So both having a standardization for communication so that multiple providers can talk and kind of be on the same page funding for treatment and research to further understand these patterns of distress as well as insurance is a huge part of our care systems and billing insurance often requires a DSM diagnosis and then can also be a map for potential next steps. So kind of a way of understanding where to go next.

Cassie (30:00):

Yeah.

Olivia Baker (30:01):

And what to do for treatment. And then finally it provides a legitimization of the mental health field.

Cassie (30:07):

Yeah.

Olivia Baker (30:07):

So way of being like, this is real, this is serious. Kind of in the same way that doctors have books and understanding of diagnosing physical conditions, a way of kind of providing that same.

Cassie (30:18):

Yeah.

Olivia Baker (30:19):

List for mental health conditions.

Cassie (30:21):

That makes sense.

Danielle Jatlow (30:22):

And I think yeah, I agree with all of those. Thanks for, for weaving those in. Olivia, thanks for bringing those in. I think in social work too, I don’t know, I know we’re talking about strengths. I don’t know that if, if we there’s so many roles and so many contexts and locations that social workers where they practice.

Cassie (30:44):

Yeah.

Danielle Jatlow (30:45):

And so not all of those places and spaces use the DSM as I was mentioning before, I’ve had many jobs where I didn’t use the DSMI would do home visits up in the Bronx for families impacted by HIV and aids. I would sit in families’ homes because they were unable to come to the office and we had different funding mechanisms in place so that we didn’t have to use the DSM or you know, bill kind of in a fee for service model.

Cassie (31:11):

Yeah.

Danielle Jatlow (31:11):

The way that insurance companies would like us to. But that does take some creativity on the part of agencies. I do think it puts the onus on agencies to find other funding mechanisms to do different kinds of work.

Cassie (31:24):

Yeah.

Danielle Jatlow (31:24):

Work that doesn’t just look like clinical practice with individuals.

Cassie (31:28):

So I guess that might bring us to like, how should we think about this? What are some ideas about how to go forward with it? Because, Danielle, you’re offering, you know, one model, which is to kind of think outside the box and build different systems. Are are there other ideas or other thoughts that you wanna include?

Olivia Baker (31:43):

Yeah, I think one, and we kind of touched on this throughout the conversation, but is being very considerate of which diagnosis is given and kind of considering a multitude of factors including longevity, like how long the diagnosis will be seen for or kind of think of last for, so something like a personality disorder.

Cassie (32:06):

Right.

Olivia Baker (32:07):

Has broader implications than something like

Cassie (32:10):

An adjustment disorder.

Olivia Baker (32:11):

An adjustment disorder was the word I was thinking of. And as well as like cultural factors. So back to the example of young kids of color being overdiagnosed with ADHD and oppositional defined disorder. Thinking under that context of like, maybe it is not the most appropriate to diagnose a young kid of color with oppositional defiant disorder because of the historic and cultural implications of that. I know that the agency that I worked at really shied away or kind of distanced itself from oppositional defined disorder.

Cassie (32:44):

Yeah. And it sounds like has some reflection points about how like systems of oppression and then your own bias might also come in, I’m guessing, but

Olivia Baker (32:53):

Yeah. As well as how people receive that diagnosis. So kind of understanding if someone is reading the file of someone, how they understand the difference between a trauma based disorder and opposition defiant.

Cassie (33:07):

Yeah. Yeah.

Olivia Baker (33:07):

And that has very real implications in terms of how the youth is then treated, which is then obviously compounded by other marginalized identities.

Cassie (33:16):

I’m glad you unpack that.

Danielle Jatlow (33:17):

I think I also wanna just give a nod to kind of our quick fix culture, which is all about identifying a problem and fixing it Versus honoring the complexities and really having time and space and presence to hold just a complex variety of factors. For example, instead of diagnosis, might we look at the ways in which our systems, like you just mentioned, you know, kind of the oppressive systems, like the ways in which school systems work for some and not for others.

Cassie (33:49):

Yeah.

Danielle Jatlow (33:49):

Or healthcare systems, you know, feel more comfortable for some and feel more exclusive to some. And we have data to back that up. And so I know I’m a little broken record around like looking at systemic and structural changes that we can make, but I think it will require a kind of multi-systemic approach to focusing on health and wellness for all people if we wanna look at, you know, health equity and equity across multiple systems.

Olivia Baker (34:16):

And then the other big piece that I think is kind of exemplified here is a big call that the research had was to have conversations among students with professionals in the field who have experience using the DSM through a social justice or a social constructionist or et cetera, et cetera lens.

Cassie (34:38):

Yeah.

Olivia Baker (34:38):

And having these conversations. So that change can be made kind of through a, not necessarily a cross generational but cross experience lens.

Cassie (34:48):

Yeah. Very cool.

Danielle Jatlow (34:49):

Right? Like all the key stakeholders should be involved and should have a voice in kind of the co-creation or their co-development of tools that are gonna impact so many.

Olivia Baker (34:58):

Yeah. and I know that that’s a major tenet of the disability movement of like, no decision about us without us.

Cassie (35:06):

Yeah.

Olivia Baker (35:07):

So as well as the conversation being among student and more experienced, the conversation should also include those who have direct experience with the DSM in both positive and in challenging ways.

Cassie (35:20):

Yeah. Hey, well that was really rich and lots to think about. We’re, we’re wrapping up. So I always ask this question at the end for each of you, if there’s, is there one primary thing you wanna highlight for our listeners to, to take away to kind of like summarize and wrap it up?

Olivia Baker (35:37):

Yeah, I think one major takeaway for me is kind of the importance of holding onto the DSM loosely. So the DSM is here and informs a lot of treatment decisions. And it is not inevitable, but in many ways is like deeply entrenched into our society. It’s not something that’s going away in the next 5, 10, 15 years.

Danielle Jatlow (35:56):

No <laugh> <laugh>. No it’s not.

Olivia Baker (35:59):

So it is important to kind of understand that and there are so many strengths of it. And it is important to also hold kind of the limitations and change that is gonna be, need to be made, both on an individual level and a society level.

Cassie (36:12):

Yeah. Thank you Danielle.

Danielle Jatlow (36:14):

I agree. I agree. And you know, all my students have heard me say this, but strengths and limitations to all tools and practices. And I think also just remembering that it’s really important to center the person in front of you. And I think about, you know, how might we consider moving away from categorical and towards expansiveness.

Cassie (36:35):

Very cool. Alright. I can’t thank you enough for coming in. It’s been a busy week for all three of us. I know. So thank you so much. It was such a pleasure to have you. And thanks for coming.

Danielle Jatlow (36:46):

Thank you, Cassie. Thank you. And thank you Olivia. What an awesome project. Thank

Olivia Baker (36:50):

You, Danielle, for guiding me through it.

Cassie (36:55):

The Social Work Lens is produced by the University of Vermont’s Child Welfare Training Partnership and the State of Vermont. Our theme music is composed and performed by local band Brick Drop, and our sound production and engineering has been brought to you by Egan Media Productions. We’d also like to give a special thank you to our in-House administrative production assistant Emma Baird for the social work lens. I’m Cassie Gillespie, and we’ll see you next time.