Victim of Circumstance

Published in the Spring 2010 issue of SSA Magazine

When does context mitigate a mental disorder?

Clinicians lack a clear understanding of the significance of social context in diagnosing a mental disorder, according to a study published in the June 2009 Social Service Review. The article, "Do Perceptions of Dysfunction and Normality Mediate Clinicians' Judgments of Adolescent Antisocial Behavior?" also points to limitations in the Diagnostic and Statistical Manual of Mental Disorders (DSM), according to authors Stuart Kirk, professor of social welfare at UCLA, and Derek Hsieh of the Los Angeles County Department of Mental Health.

On mental disorders in children, the DSM requires at least three of a list of 15 problematic behaviors, including bullying, lying and running away from home. The DSM cautions, however, that the clinician must also determine that the behaviors are "symptomatic of an underlying dysfunction within the individual and not simply a reaction to the immediate social context."

For their study, Kirk and Hsieh sent out three vignettes to some 3,000 social workers, psychologists and psychiatrists around the country describing a fictional youth's anti-social behavior. The first vignette described behavior that clearly fit the DSM's definition of "conduct disorder." The second added details suggesting that the youth's behavior was a normal or expected reaction to his social circumstances—the youth's school was described as often plagued by gang violence, for example. The third vignette, by contrast, suggested an absence of mitigating circumstances and implied that the boy's behavior—his bursts of temper, for example—came from some problem within him.

Each clinician received one of the three versions and was asked whether the youth suffered from a mental disorder. Most who received the third agreed that the implication of internal dysfunction justified a diagnosis of conduct disorder. But those who received the second disagreed on the significance of social context, and many concluded that the youth suffered from a conduct disorder, even though the DSM explicitly excludes such a diagnosis if the behavior seems a normal reaction to circumstances. Interestingly, social workers were more likely to see social context as a mitigating factor than psychologists and psychiatrists. "We're trained to pay attention to social environment in a way other professions are not," Kirk says.

Kirk has been studying the DSM and its use for 25 years. He argues that the current study suggests the need for greater agreement among both researchers and clinicians on the meaning of central concepts like mental disorder and inner dysfunction. And although the DSM is currently going through a major revision, Kirk doesn't expect the rewritten guide will address his fundamental issues with it.

"The question is, do we want to continue down the road of viewing more and more behaviors and emotional problems as medical entities, rather thinking about a way of funding services to people just because people need help?" he says.
Kirk, Stuart A., and Derek K. Hsieh. 2009. "Do Perceptions of Dysfunction and Normality Mediate Clinicians' Judgments of Adolescent Antisocial Behavior?" Social Service Review 83 (2): 245-66.