How Clinical Social Workers View and Utilize the Diagnostic Perspective of the DSM and the Person-In-Environment Perspective

Background and purpose: The purpose of this exploratory study was to understand how clinical social workers think about and work with two distinct worldviews: the diagnostic perspective of the DSM (focusing on the internal psyche) and the person-in-environment perspective (focusing on the individual in context). The former is a requirement for service and reimbursement in nearly every clinical setting; the latter is what has always distinguished social work from other helping professions. Since social workers now provide more therapeutic services than any other profession, study objectives included understanding the perceived merits and limitations of each approach, as well as ways clinicians have been able to integrate the two perspectives. Although there have been quantitative surveys of social workers' use of the DSM, this is the first qualitative study to examine the topic in depth. Method: Thematic analysis was utilized for the study because it is an inductive method that allows the researcher to begin from an orienting theoretical question to identify, analyze, and report patterns and themes within the data. A purposive, theoretical sample of 30 clinical social workers, recruited from local chapters of two professional social work organizations, took part in individual one-hour interviews. Follow-up interviews with one-third of the participants served as a member check to review preliminary findings for authenticity and trustworthiness; an additional peer review was conducted with a second group of clinicians similar to the sample. Interviews were coded using hyperRESEARCH, a qualitative software program, and analyzed thematically. An iterative approach was sustained throughout sampling, coding, and analysis. Results: Key findings indicate that participants found the DSM useful though not central, despite its many limitations and despite the significant ethical concerns and dilemmas it evoked. Most considered DSM diagnosis more useful for helping clients make sense of their experience and sustain realistic hope than as a direct guide for treatment choices, although this was moderated by both experience and severity of the disorder, and was more salient for certain diagnoses and in certain settings. While they viewed environmental information as essential, they did not consider environment to have the same “clinical weight” as diagnosis. Having made their peace with “the system,” participants utilized the two perspectives interactively and holistically, rather than viewing them as conflicting lenses. However, most viewed a third factor, the therapeutic relationship, as more essential to their practice than either perspective, alone or in combination. Overall, participants were most concerned with ethical dilemmas of balancing severity (“ramping up” in order to legitimize service) with potential stigma (“damping down” in order not to pathologize problems in living). Conclusions and implications: The richness and range of participants' responses point to important implications for social work education (developing a more integrated approach to teaching DSM assessment and human behavior in the social environment), policy (advocating to legitimize billing for V codes and Axis IV issues), and research (longitudinal studies of clinical social workers to better understand the impact of setting, population, and experience; and comparative studies of clinical social workers and other professionals).