Stuart A. Kirk (Ed.), Mental Disorders in the Social Environment: Critical Perspectives.

Stuart A. Kirk (Ed.), Mental Disorders in the Social Environment: Critical Perspectives. New York: Columbia University Press, 2005, $69.50 hardcover, $34.50 papercover.

Kirk sets out to provide a "counterpoint to conventional wisdom" (p. 17) about mental health practice in general and mental disorders in particular. To do so, he has gathered an impressive cadre of mostly male colleagues and invited them to author chapters which would "selectively raise critical questions" (p.17) on the topic. He introduces the reader to the text by summarizing what will be the arguments of many, but not all, of the 30 authors whose comments will follow his: namely, that social work's ties to psychiatry are intensely problematic, that we have been co-opted and thus are blind to market forces that shape mental health practice, and, along that line, we lack a sufficiently critical perspective on mental health practice today. The book is a good read, infuriating at times with its own ignorance of a critical perspective, but also at times educational, useful, entertaining and thought-provoking. I may very well adopt it in my mental health courses.

However, perhaps predictably with such a text, neither the tone nor the content of the chapters is consistent. Yes, the book includes Wakefield's confrontation of the social worker's role in using the deeply flawed DSM and in "treating mental disorders," as well as Epstein's articulate and destructive words about our ignorance of the "plausibility of ineffectiveness and pernicious harm" (p.323), and Gambrill's angry, albeit well-organized, indictment of, well, just about everything not related to evidence-based practice (her version of it, that is). Gomory reprises his scathing, some might say, mean-spirited, attack on the published ACT intervention research, even stooping to implicate blame for the ACT program's failure to prevent suicide in some clients. His important call to examine coercion in this, and presumably all, mental health intervention is almost lost. Saleeby also opens his chapter with strong words, specifically referring to the "medical-psychiatric/pharmaceutical/insurance cartel" (p. 23), but ends with an important plea to shift our ideas about professional authority and put hope at the center of practice. He encourages us not to be blind to the truly radical nature of the strengths perspective. Likewise, Corcoran and colleagues open with "managed care is a mess" (p. 430) but offer a candid and useful update on where managed care has been and is today. As I have suggested elsewhere, Cohen mixes solid criticisms of psychiatric medication that need to be heard, with seemingly dismissal of the positive real life experiences of thousands of consumers of medication. I am surprised that someone who is known for his banishment of clinical research in psychopharmacology relies heavily one recent study of placebo effects to make his case. Such a quirky incongruence seemed evident in the Moses and Kirk chapter. While reminding us of absolutely vital things like publication bias in research about medication and the need to pay attention to the meaning of medication, it uses phrases like "resistant" and "refuse," words long abandoned by client-centered practice advocates in favor of words like "reluctant" or "decline."

When the book is good, it brings a fresh and scholarly perspective to contemporary issues in mental health. Bola and Pitts provide both a helpful summary of the field's rejection of schizophrenia as one thing, and a well-written reminder on how to avoid "biological thinking" errors. They may be the only authors that directly and empathetically speak of the suffering of people with mental disorders, even in the face of their rejection of schizophrenia as a "valid hypothetical construct" (p. 33). Mattaini's unique and engaging chapter looks at the advantages and disadvantages of assessment strategies through the lens of social justice. Offering up one of the book's few new ideas, he suggests movement toward target/goal taxonomies rather than the disorder/problem centered systems. However, to me, the most important chapter in the book is La Pan and Platt's indictment of the profession with respect to the eugenics movement last century. In meticulous fashion, the authors demonstrate how our professional arrogance and past notions of the "best interest" of others led us to be powerful instruments of social control over women, people in poverty, and people with mental and physical disabilities. This reminder that our all-too-frequent self-congratulatory accolades about the social justice aspects of our mission can be misguided in the light of historical analysis. Thyer, too, reminds us that social workers don't always "get it right." He uses excerpts from social work authors to argue that behavioral theory and practice has been misunderstood, indeed seriously distorted, by the profession.

I should mention that in a book filled with provocation-some much-needed, some worn-out--several chapters are brief and straightforward: Dickson's summary of laws about involuntary medication with inmates, Segal's piece on self-help groups, Reamer's rather generic chapter on ethical practice, Reid and Colvin's (amazingly non-defensive) discussion of evidence-based practice and transportability, and Rosenfeld and Pottick's brief but terrific discussion of gender, power and "self-salience" in mental health. The implications of men externalizing problems while women internalize them is not new, but this chapter by Rosenfeld and Pottick is somehow fresh and approachable. Rose recounts his wonderful, almost inspiring, argument for values-based practice centered in empowerment, action and dialogue. Howard and colleagues, in perhaps the most genuinely helpful chapter in the book, offer a review of "guideline development as a growth industry" (p. 271). Like others, Hsieh and Kirk warn against mindless application of the DSM by practitioners, but also seem to recognize that social worker's training may position them best to avoid that. Who would have thought it, but Nugent presents a look at probability theory's relevance to assessment and diagnosis, coming to the same negative conclusion that others in the book do; Nugent's specific words connect diagnostic inference to roulette and black jack. If you can avoid getting lost in the technicality and get past the tendency to reify mental disorder (the chapter is built around whether one "'has a mental disorder"), the chapter appeals to the fanatic in logic.

The call for a more critical perspective on mental disorders and mental health practice within social work has been appropriately loud and persistent for many years. The book continues that effort and often succeeds, as I have detailed above. It fails when criticisms of existing research read like methodological murder, with the ignorance of the continuum of research rigor and the fact that confidence in an intervention's effectiveness is related to an analysis of plausible threats to internal and external validity as well as to logic and replication over time. It fails when a few underemphasize social work's biopsychosocial lens and overstate its allegiance to a biological reductionism, now itself on the way out. It fails when a few convey an "us-them" mentality, when straw person arguments are set up, and when evidence of true change within the mental health and social work fields, are ignored. I look forward to the continuing conversation.

Kia J. Bentley

Virginia Commonwealth University