SWM-007: Social Work and the DSM-5, with Michael First and Janet Williams (2/2)

March 25, 2014 @ 7:56 pm

Social Work Matters podcast coverWhen the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, abbreviated as DSM-5, was released last year by the American Psychiatric Association, mental health professionals had to get used to a new set of diagnostic criteria for the first time in 19 years. The clinical faculty in the Columbia School of Social Work hosted a day-long conference on the DSM-5 this past December targeted at social workers in the mental health field: which of the new criteria will have the most impact on their interactions with clients? This is the second podcast in a two-part series featuring keynote speakers Dr. Michael First, a professor of clinical psychiatry at the Columbia University Medical Center and a research psychiatrist at the New York State Psychiatric Institute, and Dr. Janet Williams (MS’74, PhD’81), professor emerita of Clinical Psychiatric Social Work at the Columbia University College of Physicians and Surgeons, both of whom have played key roles in developing DSM contents over the years. Also on this podcast is second-year student David Forman (MS’14), who is specializing in advanced clinical practice. He poses some questions from a social work perspective.

SEE ALSO: SWM-006: Social Work and the DSM-5, with Michael First and Janet Williams (1/2).



  • Michael First was involved in the research planning of DSM-5 and was one of the co-authors of the research agenda. He was called in as a coding and editorial consultant in the final phases before publication.
  • Janet Williams, an alumna of the School of Social Work, was the text editor of DSM-III and –IIIR.
  • Dr. Williams asks: “Were there any social workers involved in the DSM-5?” Dr. First: “They claim there were; I don’t know…not as many as there should have been… I’m almost a hundred percent sure there’s at least one… But again, it’s clearly peripheral compared to the importance of social workers in the practice and delivery of mental health care.”
  • What does the decision to remove the DSM-4’s multi-axial system signify? (Notably, Axis IV consisted of the “psychosocial and environmental factors contributing to the disorder”—which tend to be of concern to social workers.) According to First, this section was not being used, so the editors thought it would be more effective to discuss environmental factors within the text itself (they are listed as one of the “risk and prognostic factors”)—a significant development. Of further (though somewhat less) significance was the decision to expand the V codes (a series of codes used to describe encounters with circumstances other than disease or injury) to include more psychosocial and environmental problems.
  • All of that said, it’s worth noting that no one consulted the community of mental health practitioners on whether they wanted to keep the multi-axial system; rather, the decision was made in a vacuum. (Williams & First) First suggests that anyone who is dissatisfied with the revisions should provide feedback on the DSM-5 site in hopes of influencing the contents of the DSM-5.1 (the first in a series of incremental updates until a new edition is required).
  • Williams reports that she asked NASW to constitute a group for keeping an eye out for opportunities for input to the DSM-5 but “didn’t receive a welcoming hug.” She concedes it is hard to know the amount of influence social workers can have over a document that is owned by the American Psychiatric Association. “Psychiatry is a branch of medicine, and the APA is unlikely to do anything to give the impression that DSM-5 not a medical document.” That said, there are always people who say they like it when the DSM moves away from the medical model, suggesting there is “some wiggle room, some room for input.” (Williams)
  • First is now working on the Structured Clinical Interview (SCID) for the DSM-5, a process that is “plunging us into the weeds to an unbelievable degree”—where the “lack of clarity in criteria becomes more apparent.” The first SCID, which is expected this spring, “will be our best guess,” he says.
  • Can First and Williams offer any guidance or advice for social work clinicians beginning to use DSM-5? First says that while the top audience for the SCID is the research community, they will also be developing a clinician version. He uses the SCID all the time when seeing patients and advises other mental health clinicians todo the same: “There’s lots of educational value in the SCID even though it’s primarily intended as research tool.” Williams recommends that social work clinicians invest in one of the learning companions for the DSM-5—e.g., Michael First’s Handbook of Differential Diagnosis. First says he designed the handbook to be used in the field for coming up with diagnoses: changes to the manual are embedded in the book’s tables and decision trees.
  • The discussion moves to a couple of points made by the social work professors in their break-out sessions. For instance, one of them said she feels that the DSM-5’s treatment of post-traumatic stress disorder (PTSD) is an advance. First responds that while someone in the field might feel that way—more people will qualify as PTSD sufferers under DSM-5 than DSM-4, meaning that more can be covered for treatment—others may worry that expanding the numbers will lead to too many false positives. Also, PTSD is used by lawyers more than any other mental health disorder to prove disability. This, too, argues against making it too easy to get a diagnosis.
  • Another social work professor had expressed approval of the expansion of the V codes to reflect a more holistic, textured view to mental health, in line with social work values. Williams says the only problem is, the codes won’t be used. “You don’t get paid for them, that’s the problem,” she explains. First concurs: “Unfortunately, this is the society we live in. You get healthcare insurance coverage for illness.”
  • First is also working on the WHO’s International Classification of Diseases (ICD)-11. The idea of harmonizing the DSM with the ICD was a big part of DSM-4, but there are still significant differences, he says. For example, the European classification of PTSD requires flashbacks, but this is not the case here. Also, the United States still uses ICD-9—and is only just now switching over to ICD-10 to enable more accurate comparisons of healthcare data with other countries. (First)
  • The DSM is not really designed for use by social work researchers who are interested in exploring the effects of poverty on mental health. There’s a V code for poverty but little else, First says, and it is important to remember that “the DSM doesn’t do everything.”
  • Fifty years from now, what will researchers think of the DSM-5? First thinks that over time, more of the groupings will reflect genetic and biological discoveries. For instance, he suspects that schizophrenia and bipolar disorder will be a lot closer. In addition, the document tends to reflect social advances. For instance, homosexuality used to be thought of as a pathology but is now seen as a normal variant. In that same vein, gender identity disorder (GID), which the DSM-5 renamed to “gender dysphoria,” is now an issue. DSM-5 decided to include because you need a diagnosis for insurance companies to cover some of the expenses of sex reassignment therapy. However, GID will be kicked out altogether from the mental disorders chapter of ICD-11 and placed in a new, non-psychiatric chapter entitled “Certain conditions related to sexual health.” As First puts it: “The science is the science, but lots of social considerations play a role.”