In mid-April, American Counseling Association President Lynn Linde sent a letter to the American Psychiatric Association regarding the proposed draft revisions to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). On behalf of the 43,000 members of ACA, Linde detailed feedback on five areas of particular importance to professional counselors: applicability across all mental health professions, gender and culture, organization of the DSM-5 multiaxial system, lowering of diagnostic thresholds and combining diagnoses, and dimensional assessments.
After the American Psychiatric Association released proposed draft revisions in February, ACA solicited member feedback both online and through a town hall meeting at the ACA Annual Conference & Exposition in Pittsburgh. After this comment period ended, an ACA task force convened to boil down the ideas and suggestions.
"Professional counselors have a master’s or doctoral degree in counseling and utilize the DSM as an integral part of our work," Linde wrote in the introduction of the letter to David J. Kupfer, chair of the American Psychiatric Association’s DSM-5 Task Force. "As such, ACA appreciates the opportunity to provide feedback on the proposed draft revisions to DSM disorders and criteria."
Linde then detailed six recommendations from ACA.
1) The DSM-5 should focus on clinical utility across mental health disciplines.
Although ACA welcomed the openness of the DSM revision process and the opportunity to comment, Linde expressed concern about the minimal attention given to clinical utility for clinicians who are not psychiatrists. According to literature, components of clinical utility include appropriateness, accessibility, practicability and acceptability, as well as reliability, predictive value and specific clinical implications. Although some empirical work had been done on these components, the ACA letter noted that "users" were limited to psychiatrists and medical interns, leaving studies with non-medical mental health professionals undone. "It is assumed that when diagnostic criteria are user-friendly, the likelihood and accuracy of usage are increased, clinical decision making is improved and clients are better served," ACA’s letter stated. "Therefore, the American Counseling Association strongly suggests that the task force examine usage patterns of clinicians across educational levels and across disciplines."
2) The DSM-5 should integrate gender and cultural issues across disorders and criteria.
Although culture and gender play important roles in mental health, the mention of those topics, from ACA’s perspective, is too insignificant in the proposed draft DSM revisions. ACA members expressed concern that the mental health issues of African, Latin, Asian and Indigenous Americans, as well as recent immigrants, LGBT individuals, the aging population, individuals with disabilities and other marginalized populations would continue to be misdiagnosed, underdiagnosed or ignored through the proposed classification system. The ACA letter offered the example of a female client who had experienced repeated sexual harassment at work and then presents with symptoms of depression, anxiety or other disorders. "The etiology of the symptoms is sociopolitical/cultural and/or historical, yet the client will be diagnosed with pathology," Linde wrote.
3) The DSM-5 Task Force should provide specific information about the multiaxial system reorganization and allow for further comment after this information is provided.
One of the proposed draft revisions for the DSM-5 is to combine Axes I, II and III. That action, which would essentially commingle physical and mental conditions, could potentially result in dilution of the focus of each type of disorder and confusion over comorbid conditions. The ACA letter advised that treatment focus could be diminished with an undisciplined compilation of disorders, and knowledge gained from state (Axis I) and trait (Axis II) characteristics would be lost. Combining the Axes risks medicalizing mental health rather than underscoring the uniqueness of each mental health problem.
4) The DSM-5 Task Force should clarify the boundaries between specific mental disorders and normal psychological functioning, and efforts to combine diagnoses should not result in increased difficulty in determining specialized accommodations.
The proposed draft revisions lean toward lowering diagnostic thresholds and combining diagnoses, Linde wrote in the letter. "Although ACA is encouraged that this may add some clarity and an ability to categorize some symptoms that have otherwise fallen under the NOS (Not Otherwise Specified) category or caused clinicians to use adult diagnoses in identification of symptoms in children, we recommend more clarity of the boundaries between specific mental disorders and normal psychological functioning. We are concerned that without this clarification, the lowering of diagnostic thresholds may increase false positives or provide questionable indicators of future diagnoses." Among the examples ACA used to support this point: Diagnosis of substance use disorders would require only two symptoms to meet the criteria, major depressive disorder would no longer exclude bereavement, and the autism spectrum disorder would include pervasive developmental disorder and Asperger’s disorder.
6) Dimensional assessments should have utility across mental health disciplines, integrate with existing categorical diagnoses and provide strong psychometric properties.
Part of the proposed draft DSM revisions address dimensional assessments, which are slated for inclusion within the existing categorical system. The purpose is to provide clinicians with additional help in assessment, treatment planning and treatment monitoring. But ACA points out that professional counselors have long known about the limitations of a purely categorical approach. The letter from ACA emphasized support for efforts to improve the quality of diagnosis through dimensional assessments but also suggested that dimensional assessments have clinical utility to all mental health practitioners, that the system integrate existing categorical diagnoses and that dimensional measures be "thoroughly tested and show strong psychometric properties."
In closing, Linde reflected on the American Psychiatric Association’s stated goal of an open and inclusive process in revising the DSM. She noted the process has been less inclusive of mental health disciplines outside of the psychiatric community. "The American Counseling Association has expressed a willingness to participate in the development of the DSM-5," Linde wrote. "However, we have been excluded from this process repeatedly without explanation. It is essential to involve us in this process because we provide a unique perspective. Because of the frequency and duration of counseling appointments, clients/patients may share information with a counselor that is essential to diagnosis and assessment that they do not share with their psychiatrist. As such, ACA requests that we be included in both the field-testing process and the dissemination of information to be adequately prepared for the final feedback opportunity in 2011."
To read the letter in full, go to counseling.org/counselors/ACA-DSM-response.pdf.
ACA Chief Professional Officer David Kaplan said special credit should be given to the ACA DSM Task Force appointed by Linde to review the proposed draft revisions, solicit feedback from ACA members and incorporate those comments into the recommendations that ACA ultimately submitted to the American Psychiatric Association.
The following members served on the ACA DSM Task Force:
- Charles Pemberton (chair)
- Camille Clay
- Rebecca Daniel-Burke
- Karyn Dayle Jones
- Monica Kintigh
- Jacqueline Swank
Letters to the editor: firstname.lastname@example.org.