“Walking the Tightrope:” Clinical Social Workers’ Use of Diagnostic and Environmental Perspectives

The purpose of this study was to understand how clinical social workers think about and utilize two distinct worldviews: the
psychiatric perspective of DSM diagnosis (Diagnostic and Statistical Manual of Mental Disorders) and the contextual person-in
environment perspective. The former is a requirement for service and reimbursement in nearly every clinical setting, while
the latter has always been the hallmark of a distinctively “social work” approach. Although there have been quantitative surveys
of social workers’ use of the DSM, this is the first qualitative study to examine how social workers actually navigate these
two worldviews. Thirty clinical social workers took part in individual interviews, and their responses were analyzed thematically
using HyperRESEARCH, a qualitative data management program. Findings reveal an array of ethical and practical issues, including
the central “tightrope” of balancing the need to “ramp up” problem formulation in order to access service with the desire
to “damp down” in order to minimize stigma and avoid pathologizing problems in living. Implications are addressed for social
work practice, policy, and education.