Introduction, Part 2

Adult Psychopathology, Second Edition
by Francis J. Turner, Ph.D.

(Page 2 of 2)

The essential point for all of us is to avoid dichotomizations of those aspects of our clients' realities in which we become involved. Rather we must view various facets of clients' situations as continua. Having a clear perception of both ends of a continuum in regard to particular presenting situations helps us to assess severity and to decide whether we can help or not as well as the intensity of the help required. It also helps us to recognize when change is taking place in either direction. Mary Woods's chapter on Personality Disorders (chapter 16) is particularly helpful in understanding this concept of continuum. As social workers, in addition to a focused interest in our clients' mental functioning we bring a commitment to view this from a very broad base of interacting systems, few if any of which can be correctly seen as yes/no situations. Hence the utility of an understanding of continua.

Our responsibility as social workers is to be aware that many persons we meet have a myriad of problems originating from a plethora of interinfluencing causes that interfere with their mental health, which in turn influences their ability to function in many life roles. We need to understand all persons as individuals of course, but also as individuals manifesting similar situations, as do other groups of persons — which similarities help me to understand them and in turn to help them. In seeking to understand it is equally important that we learn to assess the myriad of strengths and resources a person possesses in his or her biopsychosocial realities, not only the nature and intensity of problems. Our diagnostic question is always, how is this person in his or her profile of strengths and limitation like no other person I have met, and as well how is he or she like some others I have met? Following from this is the further challenge that says, "Based on this understanding of who they are, what do I bring of knowledge, skills and resources that can be of help to them or what do others bring that are not within my competence?"

Our present situation, in North America at least, is that, unlike in earlier days, fewer people are institutionalized for any forms of mental illness or psychopathological behaviors, apart for very brief periods. Hence, to an increasing extent, community-based social workers in all practice settings will come into regular and frequent contact either directly or indirectly with the entire gamut of types and severities of psychopathologies. Thus, to respond responsibly and effectively, with understanding, wisdom, and competence we must be knowledgeable about this range of human problems.

This responsibility implies the ability to accurately diagnose, as mentioned earlier. Here of course we are talking of diagnosis from a social work perspective. We do not, nor must not, assume the responsibility of formulating our diagnoses from the perspective of other professions. That is for them to do. Social workers do not make medical diagnoses; we make social work diagnoses. Social workers do not make psychological diagnoses; that is for psychologists to do. Similarly, physicians nor nurses nor psychologists do not make social work diagnoses; they make medical or nursing or psychological diagnoses. Understandably and appropriately and to an increasing extent, there will be elements of commonalities across professions. Hence the richness of transdisciplinary practices discussed by David Millard in the next chapter. Certainly in an era of close interprofessional team practice it will and should happen that at times many aspects of our diagnostic formulations will be similar to those formulated by colleagues in other disciplines. So be it! It is a social work diagnosis that we must make based on the spectra of judgments we make, and for which we must be prepared to be held responsible. This in turn requires that we have the requisite knowledge to do so, to ensure that our responses to clients are as appropriate, ethical, and helpful as possible.

In our days a new reality has emerged as a part of social work practice: the question of practitioner safety. This is a topic rarely, if ever, mentioned in the standard textbooks on social work practice until very recently and then only on occasion. As well, it is a topic rarely considered in practice except in those specialized areas where there is a known high probability of violence.

Unfortunately it is now a factor that needs to be considered by all practitioners. We know all too well that there are people whose mental state is such that they are frequently a high risk danger to us, to themselves, or to others. Fortunately we know something of the patterns of mental upset or illness of those persons who are high risk. I consider it totally unethical for practitioners or teachers of practice to tell our beginning colleagues that diagnosis and use of labels are of no value and instead one must learn only to trust one's "gut reaction." An accurate and skillful understanding of the process of diagnosis and the sensitive use of diagnostic categories as a part of this process can alert us to high risk situations and lead us to take appropriate steps for our own and others' security. Failure to do so can result in death. Let us not forget this!

We cannot help everyone we meet in our practice. Hence an essential and conscious determination we need to make in all situations is: Is this is a situation for which I am prepared to take professional responsibility, or is it one that should best be handled by some other profession, or is it one that requires a multidiscipline approach, or is it one I or others do not understand sufficiently well and thus we must seek further input? We, or any profession, just do not have enough knowledge to help everyone. I do emphasize, however, that turning our backs on the knowledge that is available out of a distorted misunderstanding of the accurate meaning of diagnosis is unethical, irresponsible, and in relation to this point dangerous. I am not suggesting that mastering the content of this volume or the material of DSM will ensure that there be no risk to our practice. But it certainly will help us to be more responsive.

We have just mentioned DSM, a volume now in its fifth revision. This is a project that reflects an ongoing search for more precision and common usage of concepts across professions. Certainly all of us in social work are aware of the major contribution this work has made to broaden our view of psychopathology and to help other professions to broaden theirs. DSM has helped to ensure that psychopathology needs to be multiaxially understood, to foster an ongoing search for increased precision, to open the doors of richer interprofessional cooperation, mutual understanding, and multidiscipline practice and to foster the need to understand categories of pathology from a multifaceted perspective. It was because of the importance and influence of this work on social work practice, especially in North America, that we invited Dr. Marcia Brubeck to write a chapter for this volume on DSM, a topic not specifically addressed in the first edition. This she has done in a highly useful and objective way.

Although strongly influenced by DSM this volume does not want to, nor pretend to, nor attempt to cover all that it contains. Rather what we have done is to identify those situations most frequently met in front-line social work practice that require a more detailed knowledge of particular forms of presenting situations of pathology in various forms of intensity

In addition to new topics, in this edition there are several new themes that emerge across the spectrum of chapters. First there is a growing emphasis on the concept of multicausality and interinfluencing factors in psychopathology, which in turn require a multifaceted knowledge base. Implied in this is the renewed emphasis on the need for social workers to be much better informed about the neurological and physiological aspects of many presenting situations — not of course that we attempt to be neurologists, but that we have sufficient knowledge and appreciation of the importance of being appropriately sensitive and responsive to this critical area of understanding.

In a similar way there is the need for social workers to be much more understanding of, and thus responsive to, the role of pharmacology in assisting various types and intensities of pathology in the varying levels on which we meet it. Again not that we attempt to be pharmacists; but to a much greater extent than we have heretofore, we must also be more sensitive and responsive to our need to see our colleagues in pharmacy as resources of considerable import in our practice. Failure to do so can result in our misunderstanding of many aspects of clients' functioning, or a failure to be aware of pharmaceutical resources for clients that can be of considerable assistance to them and in turn to their significant others. Both of these latter topics receive much more attention by the various authors in this edition than in the first.

As well, there can be noted two very mature additional trends. The first is the comfort that there are limitations in our knowledge, and thus the extent of our ability to help in many situations. That is, we do not have to pretend to ourselves or to society that we have a level of effectiveness that does not exist. But we must never cease our efforts to expand our levels of competence. Thus the second trend reflects a corresponding readiness to identify areas where social work-based research is needed to advance our ability to improve our effectiveness with particular types of situations from a multimethod and multitheory perspective. As we become more comfortable in our awareness of limitations in knowledge we also grow more confident in what we do know. We have much to contribute to the multidiscipline team. Our current literature strongly reflects this, as seen in the greatly increased amount and quality of strong research writing. There is as well as an expanded confidence in using this knowledge. One of the challenges faced by each author was that of condensing into single chapters material which could easily fill a book. As knowledge grows about each topic, the task of presenting it in a manner that makes it succinct enough for front-line workers is formidable.

However, as befits good social work practice two further themes emerged loudly and clearly from this group of colleagues. The first was the need to individualize each situation with which we are confronted. As mentioned earlier, categories and subtypes and classificatory labels are very useful tools to help us to understand both strengths and limitations and areas of vulnerability and to assess risk — but, as we have said, they must only be tools to be used skillfully, compassionately, carefully, rarely, and partially. But they cannot be ignored.

A second theme critical in the content of these chapters is to remind ourselves of that dictum we were all taught in Casework I for some of us many years ago: "We must start where the client is." Often a client only wants and needs something to eat and nothing more. Recognizing that such a person is manifesting some psychopathological symptoms does not mean necessarily that these will be the focus of our interventions. Such recognition may and should help us to develop a sensitive base from which to respond to where individual clients are and what they want. That is, understanding that a client is manifesting a high degree or range of symptoms of behavior that attend a specific form of pathology can help us to help him or her and help others to find a needed resource not necessarily related to his or her pathology in a manner that is sensitive, helpful, nonthreatening, and sustaining. To not recognize and identify and respond appropriately to these aspects of our clients' profiles can result in hurt, rejection, misunderstanding, and failure to help.

We have come far in social work in learning to respond helpfully to clients and families and communities who are involved with or in touch with or touched by some aspect of human psychopathology. We have come far in our comfort with both a multitheoretical and multimethod perspective. We have yet far to go. But this need not daunt us. What must drive us is the need to be as knowledgeable, responsive, and accountable as possible to all whom we dare to serve.

Copyright © 1984 by The Free Press
Copyright © 1999 by Francis J. Turner

About the Author

Francis J. Turner, Ph.D., is Professor Emeritus at Wilfrid Laurier University in Toronto. He is the editor of several Free Press books, including Social Work Treatment, Fourth Edition, and Differential Diagnosis and Treatment in Social Work. He is also Editor in Chief of International Social Work. He lives in Toronto, Ontario.