The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), often referred to as the “psychiatric bible,” occupies a mandatory spot on the bookshelves of many counselors.
The American Psychiatric Association released this most recent version of the DSM in May 2013, after more than 12 years of planning, research and review.
The ability to confidently navigate the DSM-5’s nearly 1,000 pages of material is of the utmost importance to counselors of all types, says Stephanie Dailey, co-author of DSM-5 Learning Companion for Counselors, newly published by the American Counseling Association.
Dailey and co-authors Carman Gill, Shannon Karl and Casey Barrio Minton collaborated on the book to bring counselors up to speed on the new manual and highlight how it applies to their day-to-day work.
Their goal, says Dailey, was to make the DSM-5 accessible to counselors.
“Even professionals who are not traditionally responsible for diagnosis as a part of their counseling services, such as school or career counselors, should understand the DSM so they can recognize diagnostic problems or complaints and participate in discussions and treatment regarding these issues,” the authors write in the book’s introduction.
“Despite widespread guidance encouraging counselors to be familiar with the DSM, utilization of the manual is not without challenges and controversy. … As counselors are only too aware, clients cannot be encapsulated into fixed categories. Each client comes to counseling with numerous sociocultural issues that the counselor must consider prior to making a diagnosis and putting together an approach for treatment.”
Responses from co-author Stephanie Dailey
At 947 pages, you and your co-authors had a lot of ground to cover. Please explain the thought process that went into the way you broke the DSM-5’s subject matter up in your book.
We wrote this Learning Companion to make the DSM-5 accessible to professional counselors. Given the huge implications of changes to diagnostic nomenclature, our primary goal was to break down the changes and additions found within the revised manual. We used language that was applicable to the work that counselors do and, after reviewing major philosophical and structural changes, organized the book by disorders counselors most frequently diagnose. The learning companion is divided into four parts grouped by diagnostic similarity and relevance to the counseling profession. In each of the four parts, we provide a basic description of the diagnostic classification and an overview of the specific disorders covered, highlighting essential features as they relate to the counseling profession. We also provide a comprehensive review of specific changes, when applicable, from the DSM-IV-TR to the DSM-5. When specific or significant changes to a diagnostic category or diagnosis have not been made, we provide a general review of either the category or the diagnosis, but we refrain from providing the reader with too much detail because the purpose of this Learning Companion is to focus on changes from the DSM-IV-TR to the DSM-5.
Having spent so much time delving into the DSM-5, what are some key takeaways you would want counselors to know about it?
This is a tough question because of the multiple roles that counselors play. However, if I had to choose five “must know” takeaways, I would select the following:
- Removal of the multiaxial system, including the Global Assessment of Functioning (GAF): When writing up disorders, counselors should combine Axes I, II and III and include Axis IV with clinical disorders, either as a notation or as a V Code. The WHODAS 2.0 has replaced the GAF (see int/classifications/icf/whodasii/en/)
- Emerging measures: The American Psychiatric Association has published on its website measures which counselors can use, provided they are knowledgeable about the measure and can ethically incorporate them into their work. There are two different types of measures — cross-cutting and disorder specific. Measures are not required for diagnosis, but some counselors may find them useful (see org/practice/dsm/dsm5/online-assessment-measures).
- Other specified and unspecified diagnoses: To reduce overreliance on NOS (not otherwise specified) diagnoses, clinicians who work with individuals who do not meet full criteria for more specific disorders within the DSM-5 now have two options: “other specified” and “unspecified” diagnoses. Clinicians will use other specified diagnosis to record a concern within a specific diagnostic category and a reason why a more specific diagnosis is not provided. Clinicians will use unspecified diagnoses when they are certain about the category of diagnosis but unable or unwilling to provide additional details.
- Start using the DSM-5 now (or when it makes sense to do so): Counselors may begin using the updated manual and diagnostic criteria as soon as they are ready to do so. However, insurance companies, other third-party payers and community agencies may need time to adjust reporting systems from multiaxial to nonaxial formats. At the time the DSM-5 was published, the American Psychiatric Association predicted that the insurance industry would transition to DSM-5 by December 31, 2013. However, this estimate was optimistic, as most third-party billing systems and government agencies are unlikely to formally switch over to the DSM-5 until October 1, 2015, when a nationwide mandate for the use of ICD (International Classification of Diseases)-10-CM codes goes into effect.
- Coding changes and specifiers: The DSM-5 includes ICD-9-CM codes for current billing use as well as ICD-10-CM codes for use after the October 1, 2015, nationwide conversion to ICD-10 In the DSM-5, ICD-9-CM codes appear first, are in black print and generally include three digits or begin with V. In contrast, ICD-10-CM codes appear in parenthesis, are in gray print and generally begin with a letter. Psychosocial and environmental factors often begin with Z. There are more specifiers in this edition, many of which indicate symptom severity, than any other DSM to date. Counselors should pay particular attention to these when recording diagnoses.
Although ACA advocated for counselors throughout the DSM-5 revision process, no professional counselors served on its task force. Is one of the goals of your book to provide a counseling “translation” of a volume written for and by psychiatrists?
One of the major frustrations of mine is that counselors have yet to be included in the development process of any iteration of the DSM. That said, ACA served as an important advocate for professional counselors during the revision process. Through advocacy efforts of ACA’s Professional Affairs Office and the ACA DSM-5 Revision Task Force, two ACA presidents sent letters to the American Psychiatric Association indicating concern over proposed changes. The first was sent by Lynn Linde, ACA 2009–2010 president, to David Kupfer, [American Psychiatric Association] DSM-5 Task Force chair. The letter indicated that ACA members had concerns regarding five areas of particular importance to professional counselors. The second letter was sent by Don Locke, ACA 2011–2012 president, informing John Oldham, American Psychiatric Association president, that licensed professional counselors were the second largest group to routinely use the DSM-IV-TR. He noted uncertainty among professional counselors about the quality and credibility of the DSM-5 and included a prioritized list of concerns the American Psychiatric Association should consider before publishing the DSM-5.
So, yes, it was our goal to help counselors transition to the new manual but, more importantly, we also believe it is imperative that counselors have a place at the table when future iterations of the manual are developed. By pointing out strengths and weaknesses of the DSM-5 as they pertain to the work that counselors do, we hope this book will help facilitate future advocacy efforts.
Do you feel counselors refer to the DSM-5 too often or not enough (or neither)?
The DSM-5 is simply a part of the work that counselors do, its use specific to the role that each professional plays. Professional counselors who provide services in mental health centers, psychiatric hospitals, employee assistance programs, detention centers, private practice or other community settings must be well versed in client conceptualization and diagnostic assessment. For those in private practice, agencies and hospitals, a diagnosis using DSM criteria is necessary for third-party payments and for certain types of record keeping and reporting. Even professionals who are not traditionally responsible for diagnosis as a part of their counseling services, such as school or career counselors, should understand the DSM so they can recognize diagnostic problems or complaints and participate in discussions and treatment regarding these issues.
Do you think the DSM-5 is something counselors sometimes feel overwhelmed or frustrated by? If so, how?
No, counselors should not feel overwhelmed. Although many advocates voiced concerns that the DSM-5 would lead to a rather drastic shift in conceptualization of mental disorders, assessment procedures and diagnostic thresholds, this version of the psychiatric bible looks remarkably like its predecessor.
What inspired you and your co-authors to collaborate and write this book?
We wrote this Learning Companion to make the DSM-5 accessible to professional counselors by breaking down the complexity of the changes and additions found within the revised manual. Because the CACREP 2009 Standards require that programs “provide an understanding of the nature and needs of persons at all developmental levels and in multicultural contexts … including an understanding of psychopathology and situational and environmental factors that affect both normal and abnormal behavior,” we believe it is essential that new and seasoned professional counselors, counselor educators and counseling students have easily accessible and accurate information regarding the DSM-5 and implications of changes for current counseling practice.
What do you hope counselors take away from the book?
The ability to navigate and use the DSM-5 so they can recognize diagnostic problems or complaints and participate in discussions, treatment and research regarding these issues. Most importantly, we wanted to describe how these changes translate to current counseling practices.
The DSM-5 Learning Companion for Counselors is available from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222
About the authors
- Stephanie Dailey is a licensed professional counselor and assistant professor of counseling at Argosy University in Washington, D.C.
- Carman Gill is a licensed professional counselor and associate professor and chair of the counselor education program at Argosy University. She served on ACA’s DSM-5 Revision Task Force.
- Shannon Karl is a licensed mental health counselor and associate professor with the Center for Psychological Studies at Nova Southeastern University in Florida. She was a member of ACA’s DSM-5 Revision Task Force from 2011 to 2013.
- Casey Barrio Minton is an associate professor and counseling program coordinator at the University of North Texas.
Bethany Bray is a staff writer for Counseling Today. Contact her at firstname.lastname@example.org