Tag Archives: DSM-5

What’s new with the DSM-5-TR?

By Aaron L. Norton September 29, 2022

Diagnostic and Statistical Manual of Mental Disorders, image via Flickr

Image via Flickr http://bit.ly/2lfWuka

Traditionally, our holistic emphasis on a wellness model as opposed to a medical model has been touted as a unique aspect of our professional identity as counselors. Many counselors feel more comfortable with humanistic, existentialist and postmodern theories that seem to clash with the medical model. The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), is one of the most salient symbols of that model, so why should we care about it?

The ability to diagnose using a medical model is integral to much of what we want for our profession, such as Medicare parity, licensure portability, fair and equal access to psychological tests, and integrated care. For this reason, counseling associations have advocated relentlessly for state legislators to include the diagnosis of mental disorders in the scope of practice of licensed counselors.

According to the National Conference of State Legislature’s Scope of Practice Policy website, 36 states and U.S. territories specifically include diagnosis in behavioral health providers’ scope of practice, and an additional 19 states and U.S. territories neither empower nor prohibit counselors from diagnosis.

This diagnostic power conferred by the state comes with great responsibility, and the 2014 ACA Code of Ethics calls on counselors to diagnose properly (see Standard E.5.a.). The DSM is the most widely recognized diagnostic system for mental disorders. Although the DSM is imperfect and flawed, and there are alternative ways of conceptualizing mental health, it is nonetheless important for counselors to have a working knowledge of it.

In the following sections, I explore some common questions counselors have about the latest edition, the DSM-5-TR, which was published in May.


Why DSM-5-TR? Why not DSM-6?

The “TR” stands for “text revision.” Essentially, this means that APA intended to update the research components of the text and clarify some of the diagnostic criteria, but there were not enough advances in the field to support the need for the creation, revision and elimination of multiple disorders. The DSM-5 was published in 2013, and the research and statistical data contained in the manual are now outdated. The DSM-5-TR provides updated data consistent with research published since 2013.

How was DSM-5-TR developed? Were any counselors involved?

The DSM-5-TR revision started in the spring of 2019, and the final version was published in March. The DSM-5-TR specifically includes counselors in a list of professionals the text was written for, but were any counselors involved in the revision itself?

Over 200 multidisciplinary subject matter experts were involved in the revision — 64% psychiatrists, 30% psychologists and just 6% “other health professionals.” The text states that “many professional and educational groups were involved in this development and testing of DSM-5, including physicians, psychologists, social workers, nurses, counselors, epidemiologists, statisticians, neuroscientists, and neuropsychologists.” It is unclear how many counselors were involved in the revision, but it does not appear that many were.

Three primary groups were involved in the revision, including the DSM-5 Task Force, DSM Steering Committee and Revision Subcommittee. Experts were divided into 20 disorder review groups, each headed by a section editor. Four cross-cutting review groups (culture, sex and gender, suicide, and forensic) recommended updates throughout the text. Revisions were approved by the APA Board of Trustees, and public feedback was solicited and considered.

Are there any new disorders in DSM-5-TR?

There is only one new disorder in the DSM-5-TR: prolonged grief disorder. It is an updated version of a disorder that we saw in Section III of the DSM-5 (i.e., the section that describes conditions being considered for future editions of the DSM) called persistent complex bereavement disorder. It can now be found in Section II of the DSM-5-TR in the “Trauma and Stressor-Related Disorders” chapter because it is considered a reaction to a trauma or stressor.

The diagnosis of prolonged grief disorder is conceptualized as an intense longing or yearning, often with intense sorrow and emotional pain, for a deceased person close to the bereaved client, accompanied by preoccupation with thoughts or memories of the deceased person. It can only be applied if:

  • the deceased person died more than 12 months ago (for adults) or 6 months ago (for children and adolescents);
  • the client has a persistent grief response present on most days “to a clinically significant degree” (e.g., intense longing/yearning for the deceased, preoccupation with thoughts and memories of the deceased);
  • at least three of eight specified symptoms (i.e., identity disruption, marked sense of disbelief about the death, avoidance of reminders about the death, intense emotional pain, difficulty reintegrating into relationships and activities, emotional numbness, feeling that life is meaningless, and intense loneliness) have been present most days to a clinically significant degree;
  • symptoms cause clinically significant impairment or distress;
  • duration and severity of bereavement clearly exceed social, cultural or religious norms; and
  • the disturbance is not better explained by another disorder or the effects of one or more substances.

Its prevalence is unknown, but the DSM-5-TR references a rate of 9.8% with little clarity about that statistic (i.e., whether it is cross-sectional or a lifetime or perhaps 12-month prevalence rate).

Critics of the new disorder voice concerns that grief is being pathologized. Proponents, however, point out that only a small percentage of bereaved clients would meet the diagnostic criteria, the criteria clearly represent an unusual response to grief, individuals who meet criteria respond to specialized therapeutic approaches (i.e., prolonged grief disorder therapy) while their peers with uncomplicated bereavement require less intervention, and those individuals need professional help that might be difficult to access without the construct of a diagnosis.

What about racism, discrimination and cultural considerations? Anything new?

A cross-cutting review committee on cultural issues consisting of 19 U.S. and international-based experts in cultural psychiatry, psychology, and anthropology and an ethnoracial equity and inclusion work group of 10 mental health practitioners from diverse ethnic and racialized backgrounds with expertise in disparity-reduction practices were involved in the development of the DSM-5-TR. Because of their work, several semantic changes were made to the text, including the following:

  • The terms “race” and “racial” were replaced by “racialized” to highlight the socially constructed nature of race.
  • The term “ethnoracial” was used to denote U.S. Census Bureau categories Hispanic, white, or African American that combine ethnic and racialized identifiers.
  • The terms “minority” and “non-white” were avoided, as these terms infer that white is hierarchical to other racial identities, thus perpetuating social hierarchies.
  • The term “Latinx” replaced Latino/Latina in an effort to be sensitive to individuals who do not identify with binary gender markers. This revision may be lauded by transgender advocates but could also be frustrating to many Hispanic Americans who view the term Latinx as a form of colonialist intrusion into their language. Polling data from the Pew Research Center in December 2019 revealed that 76% of Hispanic adults had never heard of the term Latinx, 20% had heard it but didn’t use it, and only 3% used the term. According to an article published in Politico in December 2021, nearly half of Hispanic Americans view the term Latinx as offensive, so the two largest Spanish-speaking television networks in the country opted to replace Latinx with Latino and Latina. In an article published in The Conversation in September, Melissa Ochoa, an assistant professor of women’s and gender studies, reported that the governments of Argentina and Spain released public statements banning use of the term Latinx in July, and the term “Latine” has emerged as a more suitable gender-neutral term to replace the terms Latino and Latina because it does not violate rules of the Spanish language. It will be interesting to see whether Latinx or Latine becomes more widely accepted with time.
  • The term “Caucasian” was replaced with “non-Latinx white.”
  • Throughout the DSM-5-TR, prevalence data on specific ethnoracial groups has been included when possible.

What other disorder-related changes were made?

Some relatively minor changes (most of which are semantic) were made for a few other disorders. In my opinion, one of the most important changes involves the creation of diagnostic codes for suicidal behavior and nonsuicidal self-injury, which will allow for more effective tracking of these conditions. Other changes include the following:

  • The DSM-5 contained two sets of codes next to each disorder: the International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes. Because all U.S. health care providers regulated by the Health Insurance Portability and Accountability Act were supposed to transition to ICD-10 codes on Oct. 1, 2015, the ICD-9 codes have all been removed from the text.
  • The Criterion A phrase “as manifested by the following” for autism spectrum disorder was replaced with “as manifested by all of the following” to maintain high diagnostic threshold.
  • Disruptive mood dysregulation disorder was clarified as diagnosable between ages 6 and 18.
  • The note “witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures” in Criterion A2 of posttraumatic stress disorder was removed for children 6 years and younger due to redundancy.
  • The phrase “with relatively intact reality testing” was removed from attenuated psychosis syndrome, and symptoms were described more accurately.
  • A new set of severity descriptors was added to bipolar disorder.
  • The phrase “reduced orientation to the environment” for delirium was replaced with “accompanied by reduced awareness of the environment.”
  • Conversion disorder was renamed as functional neurological symptom disorder.
  • Several terms related to gender dysphoria were altered. Specifically, “desired gender” was replaced with “experienced gender,” “cross-sex medical procedure” was replaced with “gender affirming medical procedure,” “cross-sex hormone treatment” was replaced with “gender affirming hormone treatment,” “natal male” was replaced with “individual assigned male at birth,” “natal female” was replaced with “individual assigned female at birth,” and “differences in sex development” was noted as an alternative term for “disorders of sex development.”
  • For intellectual disorder, renamed intellectual developmental disorder, clarification was provided that although one should not be bound narrowly to the 65-75 IQ score range, the diagnosis would not be appropriate for those with substantially higher IQ scores.
  • For major depressive disorder, the Criterion D phrasing “The occurrence of the major depressive episode is not better explained by schizoaf­fective disorder” was changed to “At least one major depressive episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia.”
  • Narcolepsy subtypes were revised to harmonize with the third edition of the International Classification of Sleep Disorders and ICD-11.
  • Olfactory reference disorder (olfactory reference syndrome), which the DSM-5 referred to as “Jikoshu-kyofu,” replaced other specified obsessive-compulsive and related disorder to dispel the misunderstanding that the disorder only occurs in Japan.
  • In the third example of other specified bipolar and related disorder, the line “if this occurs in an individual with an established diagnosis of persistent depressive disorder (dysthymia), both diagnoses can be concurrently applied during the periods when the full criteria for a hypomanic episode are met” was deleted because of a conflict with Criterion E for persistent depressive disorder, which states in part that “there has never been a manic episode or a hypomanic episode.”
  • Manic episode superimposed on a psychotic disorder was added as the fifth example of other specified bipolar and related disorder with the intention of being used when other psychotic disorders from the exclusion criterion for Bipolar I and Bipolar II disorders (i.e., schizophrenia, delusional disorder, psychotic disorder not otherwise specified) do not have mood episodes as part of their diagnostic criteria, leaving no way for the mood episodes to be accounted for by the diagnosis.
  • The DSM-5 example of “attenuated delirium syndrome” under other specified delirium was replaced with “subsyndromal delirium.”
  • “Major depressive episode superimposed” was added as a fourth example of other specified depressive disorder for use when a major depressive episode occurs concurrent with a psychotic disorder that does not have mood episodes as part of its diagnostic criteria.
  • The sentence “individuals with atypical anorexia nervosa may experience many of the physiological complications associated with anorexia nervosa” was added to the description of the atypical anorexia nervosa example of other specified feeding or eating disorder to clarify that the presence of physiological consequences during presentation does not mean that the diagnosis is the (typical) anorexia nervosa.
  • In the fourth example of other specified schizophrenia spectrum and other psychotic disorder, the phrase “delusional symptoms in partner of individual with delusional disorder” was changed to “delusional symptoms in the context of relationship with an individual with prominent delusions” to clarify that (a) the “inducer” does not need to have a romantic relationship with the patient and (b) the “inducer” does not necessarily need to have a delusional disorder.
  • For persistent depressive disorder, the parenthetical “dysthymia” was removed to avoid confusion with DSM-IV-TR diagnosis of dysthymic disorder, which could not be diagnosed if the individual had ever met criteria for a major depressive disorder. Additionally, all specifiers were removed except anxious distress and atypical features.
  • The parenthetical “social phobia” in social anxiety disorder was removed.
  • For substance/medication-induced bipolar and related disorder, the DSM-5 Criterion A terminology “prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by elevated, expansive, or irritable mood, with or without depressed mood” was changed to “prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy.” Additionally, the DSM-5 Criterion B1 phrase “developed during or soon after substance intoxication or withdrawal or after exposure to a medication” was changed to “developed during or soon after substance intoxication or withdrawal or after exposure to or withdrawal from a medication.”

What changes were made to Section III in DSM-5-TR?

Section III of the DSM-5-TR contains emerging measures and models relevant to the diagnosis and conceptualization of mental disorders. Specifically, it contains several free assessment measures that counselors can use in clinical practice, additional information on cultural considerations for diagnosis, an alternative model for personality disorders, and conditions that are being considered for adoption in future revisions of the DSM. Changes made to Section III include the following:

  • Male and female checkboxes were removed from all assessment measures in a shift away from binary gender identification.
  • Instructions in the Clinician-Rated Dimensions of Psychosis Symptom Severity measure were edited to mirror new severity specifiers for psychotic disorders added to Section II.
  • Scoring instructions for the World Health Organization Disability Assessment Schedule 2.0 were clarified.
  • Terms such as “culture,” “race” and “ethnicity” were revised in the Cultural Formulation Interview. 

If I already own the DSM-5, do I need to purchase the DSM-5-TR?

Given that the DSM-5-TR contains a new diagnosis and updated research, I recommend obtaining a new copy. However, if you are not concerned with prolonged grief disorder and you do not use the statistical information in the DSM, then you may not have a sense of urgency to purchase the new edition.

Where can I go to learn more?

Here are some resources where you can learn more about the DSM-5-TR:



Aaron L. NortonAaron L. Norton is the executive director of the National Board of Forensic Evaluators, a visiting instructor at the University of South Florida’s Department of Mental Health Law & Policy, and the southern regional director for the American Mental Health Counselors Association.





Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

APA accepting feedback for DSM revision

By Bethany Bray February 6, 2017

The American Psychiatric Association has created an online portal for the public to submit suggested changes to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Launched this winter, the portal allows clinicians, scholars and members of the public to submit suggested additions, deletions or modifications to the DSM.

Often called the “psychiatric bible,” the DSM-5 is a go-to resource for many practitioners when it comes to the classification and diagnosis of mental disorders. APA released this most recent version of the DSM in May 2013, after more than a decade of planning, research and review.

The online portal creates a way to keep the DSM updated in a more timely manner and make changes incrementally, as new information and research is available, according to the APA website.

This new medium offers an important and much-needed chance to have counselors voices considered in what has traditionally been an arena dominated by psychiatrists, says Stephanie Dailey, who was involved with the American Counseling Association’s DSM-5 Task Force and co-author of the ACA-published book DSM-5 Learning Companion for Counselors.

However, Dailey, a licensed professional counselor and associate professor and director of counseling training programs at Argosy University, Washington, D.C., expresses some skepticism about which submissions might actually be considered for changes to the DSM. She contributed some thoughts, via email, to Counseling Today:


“The Diagnostic and Statistical Manual of Mental Disorders (DSM) has long been criticized, amongst other things, for poor utility; inadequate psychometric evidence for diagnostic categories and specifiers; comorbidity issues; overutilization of ‘catch all’ diagnoses (e.g., not otherwise specific [NOS] and generalized anxiety disorder [GAD]); and underutilization of emergent genetic, neuroscientific and behavioral research.

While APA’s DSM-5 Task Force attempted to rectify many of these issues, there are still considerable challenges in regard to validity, reliability and clinical utility within the DSM-5. Clarification of diagnostic descriptions, criteria, subtypes and specifiers is needed and there is a significant dearth of information regarding sociocultural, gender and familial patterns for diagnostic classifications. There is also a lack of rigorous psychometric validation for suggested dimensional and cross-cutting assessments (introduced in the DSM-5) and no consensus was made during the last revision to the DSM in terms of modifications needed for the personality disorders category. Thus, this diagnostic category has remained unchanged and clinicians (and clients) are facing the same challenges as they did 20 years ago when the DSM-IV was released.

In terms of the new portal, it is important for individuals to understand the revision process of previous iterations of the DSM to really appreciate the magnitude of an ‘open’ call for revisions. The revision process of the DSM-IV to DSM-5 was a 14-year process, beginning in 1999, which originated with a research agenda primarily developed by the American Psychiatric Association

Image via Flickr http://bit.ly/2lfWuka

(APA), the National Institute of Mental Health (NIMH) and the World Health Organization (WHO). In 2007, APA officially commissioned a DSM-5 Task Force which formed 13 work groups on specific disorders and/or diagnostic categories. While the scope was broad, the intent of the workgroups was to improve clinical utility, address comorbidity, eradicate the use of not otherwise specified (NOS), do away with functional impairments as necessary components of diagnostic criteria and use current research to further validate diagnostic classes and specifiers. Having released the draft proposed changes, three rounds of public comment and field trials were conducted between 2010 and 2012. During this time, numerous professional organizations, including ACA, voiced significant concerns (See ACA’s 2011 letter to APA: bit.ly/2kxJBVY).

Despite attempts to become involved, at no time has any professional counselor ever served on APA’s DSM Task Force. In regards to the new portal, our time to have a foothold in changes to current diagnostic classifications is now.

In looking at the portal which lists specific kinds of revisions sought, one can easily see that APA is looking to remedy the long-term critiques of the manual, specifically validity, reliability, utility and the need to capture emerging research.

However, what proposals (and by whom) that are selected for inclusion remains to be seen. While the portal allows anyone to submit a proposal, there is a long history of bias in the type of research which is deemed appropriate for consideration by APA. While there is no dispute in terms of the need for rigorous research designs and large scale studies to validate criterion, these studies are not likely going to be conducted by anyone outside of APA, NIMH, WHO and other large scale ‘think tanks.’

The problem, particularly for counselors, is both philosophical and practical. First, the psychiatric profession as a whole is trained in the medical model, while counselors tend to operate on a more humanistic, holistic perspective. Next, while Paul Appelbaum, chair of the DSM Steering Committee, stated that acceptance thresholds will be high, reports from Appelbaum and others have ensured scrutiny for submissions which don’t provide ‘clear evidence.’ This is not only vague, but likely slanted towards the psychiatric community.

No one is disputing the need for the best available scientific evidence or the ability of the counseling profession to produce substantive outcome research for the mental health community. The American Counseling Association has members who have significant, scientific-based expertise in areas relevant to the DSM and strong research agendas which can support evidence-based changes. However, our seat at the table in these discussions has been scant.

Thus, counselors are strongly urged to contribute to the revision process by submitting proposals and working towards serving as unique contributors to the next edition. This is particularly relevant to counselors whose focus is on marginalized populations and underserved groups. Outcome-based research is needed, specifically that which has been repeatedly shown to improve treatment outcomes.

This is the time for counselors to become involved and make our experience known, and more importantly, our clients’ voices heard.”




Find out more


Visit APA’s DSM portal at https://psychiatry.org/psychiatrists/practice/dsm/submit-proposals


See Counseling Today’s Q+A with Dailey: “Behind the Book: DSM-5 Learning Companion for Counselors





Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.






Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Behind the Book: DSM-5 Learning Companion for Counselors

By Bethany Bray November 10, 2014

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 DSM5Companion 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.”


Q+A: DSM-5 Learning Companion for Counselors

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:

  1. 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/)
  2. 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).
  3. 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.
  4. 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.
  5. 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.




78087The 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 bbray@counseling.org


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday


Counselors and the clinical staging model

By Allen E. Ivey and Mary Bradford Ivey February 28, 2014

sad-teenCounseling is a preventive profession, typically working with issues and challenges that our clients face daily. However, client concerns often exist at deeper levels, and counseling process often shades into therapy. As counselors, you regularly encounter children and youth who may be at risk. Whether with a medicated child who has been deemed as having attention-deficit/hyperactivity disorder or a depressed teenager whose family is unable to afford private treatment, counselors often end up being the key mental health resource. Of necessity, we often work with clients who have no other realistic source of treatment. For example, a teenager may return to high school after a stay in a psychiatric or drug treatment facility. A child or adult may need specialized care, but no referral sources are available.

The impact and effect of your work is vital not only with the “normal” issues that young people face, but also with the issues posed by potentially more disturbed youth. The National Institute of Mental Health estimates that 26 percent of the U.S. population ages 18 and older has a diagnosable mental disorder during any given year, while 6 percent face diagnosis of serious mental illness. Sixty-five percent of serious mental conditions such as anxiety and affective disorders appear before age 21, thus emphasizing the importance of early counseling intervention. Children and adolescents are increasingly being diagnosed with mental disorders and prescribed medications that can sometimes be dangerous. In 2012, the website ScienceDaily reported a 62 percent increase in the use of antipsychotic drugs with publicly insured children, with two-thirds of these potentially dangerous drugs being off-label prescriptions. In 2010, the Archives of General Psychiatry reported evidence that these medications shrink the amount of gray matter in children.

Professor Patrick McGorry, an Australian psychiatrist and world expert on young people at risk for psychosis, is challenging the very concept of diagnosis for conditions such as borderline personality disorder, major depression and schizophrenia. He asserts that the diagnostic categories in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are “endpoints” with little or no attention paid to etiology and developmental issues. For example, subclinical youth may show signs of decreased functioning. Although we may see affective dysregulation and other signs, clear diagnosis is usually impossible. “Persistence and severity are key dimensions setting the bar for care, irrespective of the specific set of features,” McGorry has said. He speaks of a “soft entry” to treatment rather than arbitrary categories that all too often lead to overmedication and overtreatment.

McGorry Clinical Staging Table

Table adapted from “Early intervention, clinical staging in youth mental health” as presented by Patrick McGorry (see youtube.com/watch?v=gYTX7lQU_Ag for a full presentation of the model in its most current form).

CLICK HERE TO VIEW PDF IN FULL SIZE: McGorry Clinical Staging Table


McGorry makes it clear that all “disorders” have early clinical features or prodromes — early symptoms that might indicate the onset of a disease. Prodrome is the term ascribed to at-risk youth whose functioning is decreasing significantly. It has been found that one-third or more of these youth will become psychotic within three years. However, it is important to separate those youth who have a true prodrome from those who may be suffering from grief or trauma, the major effects of which pass over time.

The research appendix of the DSM-5 names the prodrome as attenuated psychosis syndrome. There is evidence that preventive treatment programs can significantly reduce later reversion to psychosis. Rather than one-third of these youth becoming psychotic, a 2012 review written by McGorry and colleagues in the journal Clinical Practice found that early intervention preventive programs reduce that figure to 5 to 10 percent. Even if psychosis does not appear, however, those considered at risk continue to have significant life challenges, often requiring some form of counseling throughout the life span.

This is an important issue, and the question remains — how can we work effectively to prevent psychosis in young people? In hopes of finding the answer, we visited Australia to meet McGorry. There we saw programs in operation that make a significant difference in preventing serious disturbance in youth. Rather than applying the potentially damaging label of attenuated psychosis syndrome to these youth, McGorry uses the terms high risk and ultra high risk. His program focuses on early prevention and avoids medication as much as possible. He worries that the attenuated psychosis syndrome label being used in the United States will lead to overuse of unnecessary medications because psychiatry does not give much attention to prevention or early intervention. If the attenuated psychosis syndrome diagnosis as formulated in the DSM-5 is accepted in isolation, we can expect preventive research to be ignored, while seeing a vast increase in potentially dangerous medications for youth.

A practical framework 

Counselors often are the first professionals to observe when a young person’s behaviors indicate high risk of continuing and future major behavioral and emotional issues. Thankfully, effective counseling and systematic programs can make a difference, and the need for further help, or even institutionalization, may be prevented.

Diagnostic risk factors include, first of all, a noticeable decrease in functioning. The endpoint features of attenuated psychosis syndrome in the DSM-5 include symptoms that may appear only occasionally; most of the time, these youth will function normally in society. The attenuated psychosis syndrome diagnosis looks for odd beliefs or magical thinking, perceptual disturbance or some paranoid ideation, along with occasional disconnections from reality. Depression, anxiety or explosive outbursts may increase. The youth’s appearance may change in terms of clothing, self-care or significant gain/loss of weight.

McGorry’s clinical staging model is designed to work for patients, clinicians, families and researchers. It is rooted in the model of normalization and prevention. Clinical staging is the method used in McGorry’s Early Psychosis Prevention and Intervention Centre (EPPIC), which focuses on youth at risk with specific recommendations for treatment at each clinical level (see the accompanying table). The diagnosis is for level of need and treatment, not for a specific category.

Clients are first placed in two general categories — those who appear to be working with “normal” difficulties and those who may be at risk, high risk or even ultra high risk for becoming constantly depressed, bipolar or schizophrenic. Typically, the first group represents Clinical Stages 0 and 1. This group is treated using concepts that are well known and integral to the counseling movement. It is here that we see the counseling profession overlapping with in-depth psychiatry. Furthermore, it is obvious that counselors have an important role in working with at-risk youth. While traditional diagnostic endpoints do not lead to treatment recommendations, clinical staging does. The scaling and normalization of youth concerns leads to a newly integrated form of counseling and therapy.

McGorry’s original research has been replicated in many settings, internationally and in the United States. There is clear short- and long-term evidence that the clinical staging framework (or variations on that theme) reduces the chances of youth reverting to psychosis. Those youth who may never revert to psychosis receive the benefit of quality treatment without being labeled as suffering from attenuated psychosis syndrome.

Why are counselors so important in this process? Take a look at the mental health workforce in the United States. The Occupational Outlook Handbook shows more than 1 million helping professionals but lists only 24,210 psychiatrists, although other estimates range as high as 36,000. Even if we take the larger figure, psychiatry represents approximately 3.6 percent of professionals able to meet the mental health needs of the nation. From these data, it is patently clear that members of the American Counseling Association will continue to play a major role. The primary and secondary treatment options listed in the accompanying table have long been considered major roles. Not only are counselors needed, but they have the skills and experience to work with these youth.

Coordination of mental health services is key to the EPPIC model — infants, children, adolescents and adults in individual, family, group, school and community contexts. Furthermore, all mental health issues, from typical daily concerns to serious issues such as autism and schizophrenia, fall within this framework. McGorry seeks to avoid the use of medications with clients as much as possible, while focusing on psychoeducation and cognitive behavior therapy. The model includes typical counseling interventions such as stress management, anger management, family counseling and job placement with support, all with an extensive emphasis on relapse prevention.

The clinical staging model in a high school 

The counseling and guidance program at Massachusetts Wellesley High School illustrates how the clinical staging model is related to counseling practice. Under the leadership of principal Andrew Keough, Wellesley High School states that “schools are more like families than like business, and every member needs a voice.” To build that family community, students have brief daily meetings and a half-hour meeting once per month in advisory groups of eight to 10 members. This ensures that every teen has personal contact with a teacher, counselor or administrator. Groups are randomly chosen to enlarge the students’ circle of acquaintance in the large school. There is a daily check-in, typically followed by short discussions on topics such as “what was the highlight of the weekend” or a school issue. There is often enough time for brief trivia contests or discussion of personal issues as well.

Additional student contact is made twice weekly through small group guidance seminars taught by counseling staff. The small groups are limited to 12 to 15 students and take place for all four years of the students’ high school experience. Groups in the first year cover study skills and school adjustment issues. In ensuing years, the groups tackle decision-making skills, positive mental health and symptoms of anxiety and depression. These programs make it possible to know all of the school’s students, and they also encourage self-referrals to counseling staff. They are important components of the first two clinical stages of McGorry’s model. Counseling, of course, covers the full range of academic and personal issues, including the ability to support students who are more challenged.

A student support team meets weekly to discuss student issues, with special attention paid to Stages 2 and 3, but always with awareness of Stage 1. For students at Clinical Stage 3 who are more distressed and may have been released from a hospital or drug treatment program, small groups ranging from three to five people provide support, while the leader often works in concert with the treatment facility. These groups also serve as transition teams to gradually return these students to their regular classrooms.

Another preventive effort designed to further community is an after-school enrichment/recreation program that caters primarily (but not exclusively) to students who are not involved in the many formal school groups or athletic teams. Students are encouraged to define their own desires for a group experience, supported by an interested teacher. Examples include time in the gym or on the athletic field for those who did not make school teams, a computer group that is taught how to develop apps, karate and boxing groups, clay and art workshops, and many others.

Somewhat parallel to the Wellesley program, McGorry has originated the Headspace program, which seeks to work with youth when “things are not quite right.” These centers offer similar services to those provided by Wellesley, but in a separate setting. There are currently 45 Headspace centers throughout Australia, with 90 planned by 2015. They function as combination community centers with a counseling focus for young people. Supportive counseling is available, and a major effort is made to get parents involved. Headspace emphasizes positive mental health and therapeutic lifestyle changes such as exercise, socialization skills, meditation and relaxation, drug prevention, adequate sleep and nutrition as personally and multiculturally appropriate. Headspace also includes access to medical and psychotherapy services and interface with crisis teams (24/7 mental health teams). The central function of these programs is to enable at-risk youth to stay in the community, to prevent more serious issues and to provide counseling support as appropriate.


Visit the EPPIC website at eppic.org.au or the Orygen Youth Health website at oyh.org.au for additional information, including the outpatient programs where methods, systems and practices can be downloaded. We also recommend EPPIC’s 2010 Cognitive-Behavioural Case Management in Early Psychosis: A Handbook (oyh.org.au/online-store/cognitive-behavioural-case-management-early-psychosis-handbook). Extensive information on Headspace can be found by conducting a Google search. In addition, many useful videos are available, often presenting real clients and counselors discussing matters such as bullying, depression and gay/lesbian issues. These can be found on youtube.com/playlist?list=PL8C639D508E0A4B3C  or by searching Headspace Ambassadors on YouTube. Information on Wellesley High School is available at wellesley.k12.ma.us/wellesley-high-school.



Allen E. Ivey is distinguished university professor emeritus at the University of Massachusetts, Amherst and courtesy professor at the University of South Florida. Contact him at allenivey@gmail.com.


Mary Bradford Ivey is a courtesy professor at the University of South Florida. Contact her at mary.b.ivey6@gmail.com.


Letters to the editor: ct@counseling.org


Facing a rising tide of personality disorders

Sebastian Montes November 1, 2013

CoverTwenty years ago, the preponderance of Elaine Beckwith’s most troubling cases tended to center on substance abuse and the outpouring of near-psychotic clients cast into the general population after the onset of deinstitutionalization.

The past few years have brought a new pattern to the fore, one as pronounced as it is problematic. More and more, the Florida-based counselor is seeing signs of personality disorders running rampant among the clientele in her private practice. It seems now as if she’s dealing with 50 percent more personality disorders than at any time in her 30-year career.

“It almost feels like every time we turn around it’s, ‘Well, there’s another borderline mother,’” says Beckwith, an American Counseling Association member who is also adjunct faculty in the Palm Beach State College Psychology Department.

Though not yet quantified in appreciable detail, personality disorders appear to have surfaced at an alarming rate in counselors’ offices and on college campuses, by some accounts in unprecedented proportion.

The surge comes as the counseling profession recalibrates its approach to defining personality disorders, thanks in large part to the alternative diagnostic landscape laid out in updates to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Those two forces combined are compelling practitioners to confront a confounding yet essential dilemma: Are counselors seeing the pervasive, persistent traits of true personality disorder, or are they applying outdated norms and expectations?

“The problem is, I think we’re trying to say that these things [personality disorders] are acceptable because we’re seeing them in everybody, and there doesn’t seem to be a choice because it’s in such alarming numbers,” says Morgan Brooks, an ACA member who is an associate professor and director of the clinical mental health program at Niagara University. “It’s one of the things that confounds this issue. Should we be excluding this [behavior] as a disorder, or should we be accepting [that] this might be the normal behavior now?”

If the trend has been obvious, its causes have proved harder to pin down. Prevailing wisdom gives the apparent surge in personality disorders a generational genesis — a seeming groundswell of millennials disproportionately beset by narcissistic, histrionic and borderline tendencies.

A fact sheet from the American Psychiatric Association (APA) describes personality disorders this way: “Personality disorders are associated with ways of thinking and felling about oneself and others that significantly and adversely affect how an individual functions in many aspects of life. They fall within 10 distinct types: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, antisocial personality disorder, borderline personality disorder, histrionic personality disorder, narcissistic personality disorder, avoidant personality disorder, dependent personality disorder and obsessive-compulsive personality disorder.”

Counselors may come across any of these disorders in their work with clients, but certain personality disorders seem more commonplace. For example, individuals with narcissistic personality disorder are obsessed with overblown notions of self-worth. Those with histrionic tendencies display impulsive and emotive behavior that seeks to attract attention. Clients with borderline personality disorder lack a sense of self and engage in intense but unstable relationships. They often have a history of sexual abuse or other childhood trauma.

The professional literature remains relatively scant regarding the surge, leaving academics and mental health practitioners to construe anecdotal accounts as to how and why so many signs of personality disorder are flooding their offices and classrooms.

“We all have theories about why this is happening,” Brooks says, “but it’s a lot harder to test those theories because there aren’t really assessments [available]. You have to really create surveys and somehow validate them.”

Millennials maligned

A popular school of thought hinges on the millennial generation’s endemic sense of entitlement that, taken to an extreme, burgeons into full-fledged traits of a personality disorder.

The advent and explosion of social media — Facebook, Twitter and the like — has also drawn scorn for its impact on the way children and teens invest their formative years online, often at the expense of engaging in genuine, real-world relationships.

Some trace the personality disorders phenomenon to a generation of parents who heaped excessive and disproportionate praise on their children — leading to deluded notions of grandeur and self-worth — and “helicopter parents” who hover over their children’s lives well into early adulthood, exerting an undue influence that stifles maturation.

Much of that line of thought builds off of the “emerging adulthood” theory that Jeffrey Arnett laid out a decade ago, in which people in their late teens and early 20s languish through a period of frequent career changes, extended education and nonmarital cohabitation. It is a period, Arnett explains, defined by instability, identity exploration and being self-focused.

The theory has gained wide acceptance among mental health professionals of every ilk, some of whom see emerging adulthood as a foundation from which personality disorders too easily spring forth.

Arnett warns that such reasoning can be overblown, citing research that shows a marked decrease in depressive symptoms and increase in self-esteem over the span from late teens to mid-20s. But he does acknowledge that emerging adulthood is a particularly vulnerable time that can pose serious developmental challenges.

Whatever their root, personality disorders are being repeatedly, and tragically, brought into the public eye as laypeople and media pundits speculate (or, conversely, refute speculation) about the purported mental health of the perpetrators of some of our nation’s worst mass shootings: Virginia Tech, Sandy Hook Elementary School, Fort Hood, Aurora, Colo., and, most recently, at the Washington Navy Yard.

Gap in the data

Brooks and four colleagues at Niagara University have tried to give shape to the nebulous phenomenon in a study of a random sampling of students, the results of which were published earlier this year. Brooks expected to see a high prevalence of personality disorders, but what the study exposed, she says, was “absolutely staggering.”

During her graduate school internship in the late 1990s, the issues Brooks counseled college students on typically amounted to little more than dorm-room disputes, homesickness or a need for career advice. Only on rare occasions did she see full-blown, clinical-level instances of personality disorder.

That all changed around the middle of the first decade of the new millennium, when Brooks was working in Niagara University’s counseling center.

“It was incredible. It was all of a sudden. It was just a marked shift,” she says. “There was nobody coming in and saying they were homesick. There was nobody who just had a roommate problem. Nearly everyone — I would say nearly 90 percent of people — walked in already suspecting they had a disorder, or already having a name for a disorder that they’d been given by a previous therapist, or were continuing therapy from high school, if not further back than that.”

The surge of students on medication was so pronounced, she says, that the university hired a psychiatric nurse practitioner to keep up with the demand.

“They were coming to campus with these issues already, with the diagnoses, on the medications,” Brooks says. “There were real and serious issues going on.”

To quantify the explosion of personality disorders, Brooks and her Niagara colleagues screened 351 voluntary participants at the 2,700-student school.

With a 1 percent to 3 percent threshold thought to be the norm, the study unearthed an “unprecedented prevalence” for the 10 kinds of Axis II diagnoses laid out in the DSM-IV, with the most striking figures coming for histrionic personality disorder and narcissistic personality disorder, at 29.6 percent and 21.1 percent, respectively.

Even more distressing, the study — published in the International Journal of Education and Culture — found no significant statistical difference in the prevalence of eight of the Axis II disorders between clinical participants and those who had never been in a therapeutic setting. The data offer a startling indication, Brooks and her co-authors write, that personality disorders may be vastly more widespread among college populations than previously suspected.

“We’re seeing this across the board,” Brooks says. “If you’re on a college campus, you hear this stuff from everybody. We are all seeing these things and all wondering, ‘How are these people going to succeed in life?’ So it surprises me that more people aren’t looking at this, to be honest.”

A mother’s legacy

The 13-year-old girl who sat in Beckwith’s Palm Beach office that day in 2009 bore all the hallmarks of borderline personality disorder: A childhood defined by a tumultuous home life. Arguments, screaming, name-calling, a litany of self-destructive behavior and emotions that would get the best of her. Promiscuity, self-mutilation and declarations of a desire to kill herself. An inability to maintain friendships and a constant craving for a boyfriend to make herself whole. On top of that, Beckwith suspected the girl had been exposed to domestic violence.

The client’s careening behavior reached its breaking point when her parents caught her in bed with an 18-year-old and decided to bring her in for counseling.

Those borderline traits, as well as a history of depressive episodes, revealed themselves before the first session was complete. And over three ensuing years of counseling sessions and therapy, the case emerged as perhaps the most extreme instance of borderline personality disorder Beckwith has ever seen. “It was right out of the textbook,” she says. “Every symptom was there.”

The cause traced quickly and clearly to the girl’s mother, who from one moment to the next vacillated between smothering affection and “annihilating rage,” Beckwith says, while also showing jealousy over the daughter’s relationship with her father. The mother would insist that the daughter get help, then would turn around and undermine Beckwith’s efforts to provide that help.

“Mom would tell her, ‘I would have been better off without you. I want you out of my life.’ And the next minute she’d be hugging her and crying, ‘Oh, I love you,’” Beckwith says. “The daughter was totally, totally abandoned emotionally. She was rebellious and would constantly seek attention and love from just about anybody else. You could see how much the daughter was just trying to get mom’s love and support, and how much mom just could not come out of her own needs.”

Beckwith turned to the 2002 book Understanding the Borderline Mother by Christine Ann Lawson and conducted weekly sessions of trauma outcome process therapy with the girl. Sessions focused on the girl’s hypersensitivity and the cascading physical reactions — quickening heart rate, anger-induced blackouts and various anxieties — that were triggered anytime her mother flew into a rage. As a result of those episodes, the girl’s emotions would get mixed up, conflated and confounded into a sort of numbness and sense of disassociation, Beckwith says.

Much of Beckwith’s work was aimed at helping the girl empathize, understand boundaries, socialize better and grasp societal norms, and forge and maintain healthy relationships. Beckwith provided her with a sampling of psychoeducational literature to take home, which the girl had to make copies of and sneak into her backpack to conceal from her undermining mother.

“What was amazing is, I sat down with [the girl], I took it right out of the DSM and explained to her what a borderline personality is,” Beckwith says. “And when I pointed it out, it’s like a light went off in the daughter’s head, and it started making sense to her.”

Over time, the girl’s appearance started to soften. Her wardrobe featured more pastels. She grew more relaxed, centered and self-assured. She was coming into her own, emotionally, academically and socially, Beckwith says. She cultivated positive friendships and even started dating in what Beckwith saw was a healthy way. She was flourishing as an artist and began looking to apply to colleges.

More than two years into therapy, as the girl neared her 16th birthday, she started talking about seeking emancipation to free herself from the toxic relationship with her mother. She showed Beckwith an intricate budget laying out the income from her two jobs and the cost of rent, food and expenses. Beckwith knew the girl was no longer simply acting out; she was becoming stronger and who she needed to be.

“I was afraid to say to myself, ‘Could she be getting better? Could she actually be getting healthier?’” Beckwith says. “But things really were falling into place.”

It was, for Beckwith, one of the most personally rewarding cases of her career. The success she experienced is in stark contrast to what many counselors face when working with clients who have personality disorders — particularly borderline personality disorder. This population of clients can be notoriously difficult to treat. “They just suck your emotions dry,” Beckwith says.

Not  ‘doomed forever’ 

Counselor burnout was part of why Marsha Linehan devised dialectical behavior therapy (DBT) 30 years ago, a landmark shift that made headway in treating some of the most intransigent disorders and dysfunctions. With its central tenet of a perpetual exchange between acceptance and change, DBT has become the standard-bearer for treating borderline personality disorder.

The technique proved particularly apt for Cheryl Hamilton’s work at a community mental health agency in Columbus, Ohio, and in her counseling of juvenile clients in the local county court system. Over the course of six years — until Hamilton went on maternity leave this past spring — more than half of her client caseload showed traits or had a full diagnosis of borderline personality disorder.

Hamilton’s tact adhered as closely as possible to the archetypical DBT model, with its specific targets, hierarchy and modes of service delivery: individual psychotherapy, group skills training, phone consultations and a team consultation.

The community mental health center where Hamilton worked asked clients to commit to DBT therapy for a year. Therapeutic work in the initial stages included group sessions to develop the client’s skills in mindfulness, emotional regulation, distress tolerance and interpersonal effectiveness.

What makes DBT effective, for both client and counselor, is its explicit structure, says Hamilton, a member of ACA. “I found that when other counselors referred clients to me, the clients felt like they had been in so much chaos in their [previous] therapy if they weren’t using a structured model,” she says. “With DBT, you know what the target is. There are no surprises. I knew where we were going [and] they knew where we were going. It kept us moving instead of being stuck. Compared with not using DBT, it always felt like there was movement and progress and a goal. What it does is get them to apply those skills so they can decrease their emotional suffering and all that chaos.”

Many of Hamilton’s clients would come directly from a hospital after a suicide attempt or some other self-destructive behavior. Originally developed to treat clients with a history of parasuicide attempts, DBT is one of the few treatments empirically proved to achieve significant improvement.

“Unfortunately, I’ve had a lot of clients who would meet criteria [even] after treatment for borderline,” Hamilton says. “But I’ve also had a lot of clients who wouldn’t. Some of the traits of that personality might still be there — some of that vulnerability, some of that emotional intensity — but not necessarily meeting diagnostic criteria. So, I definitely think there’s hope that someone isn’t doomed forever to have the disorder.”

In his work with students at Hiram College, a liberal arts school outside Cleveland, Kevin Feisthamel has developed a style that folds in elements of DBT with a handful of other techniques. The director of counseling, health and disability services at Hiram, Feisthamel places emphasis on having clients improve their situational self-awareness and mindfulness of all their senses. Sometimes, he asks clients to keep a journal detailing specific behaviors. He also integrates elements of positive psychology and motivational interviewing techniques along the lines of the Stage of Change model conceived by James Prochaska and Carlo DiClemente.

Meditative therapies have been of particular interest lately to Feisthamel, a member of ACA. “I know it’s relatively new here in the Western world, but all the research I’ve seen regarding meditation has been very positive, even with personality disorders,” he says.

Millennials struggling with personality disorders tend to lack any deep emotional attachment, Feisthamel says, but because of their relative youth, they are also generally less entrenched in their disorder and thus more able to internalize and implement change.

“Those habits can be changed, which is important for students to hear, because so often they don’t think there’s any change that can come,” Feisthamel says. “It’s about making them aware of, ‘Now you’re not 10 years old anymore. You had no choice when you were 10, but now you’re a grown adult, and here are some choices you can make for yourself.’ With the young kids of today, having them feel comfortable and safe — to be able to talk about specific issues in their life and how to function better on a daily basis — a huge part of that is working on it with them together. That client-counselor relationship is the No. 1 predictor of change in all the research, and forming that relationship is huge.”

A line in the sand

Beckwith sets the case of her teenage client with borderline personality disorder squarely within the context of the unsettling rise of personality dysfunction she is seeing both as a counselor and as an adjunct professor. She says her classrooms are rife with students who feel disproportionately privileged and who think that because they’ve paid tuition, they are owed an easy A and deferential treatment. “So many young people these days, they feel so entitled that when they don’t get what they need, they simply cannot handle it,” Beckwith says.

The seeming deluge of personality disorders has called their very definition into question, prompting leaders in the field to reevaluate how mental health professionals face the issue. During development of the DSM-5, proposals were made to eliminate several categories of personality disorder. This proposal was ultimately voted down, and the same 10 personality disorders from the DSM-IV were retained. However, an alternative hybrid dimensional-categorical model for diagnosis is included in Section III of the DSM-5.

As detailed in a personality disorders fact sheet published by APA, “The [Personality Disorders] Work Group’s first revision represented a significantly different approach to diagnosis. It attempted to break down the concise models of personality disorders, which sometimes are too rigid to fit patients’ symptoms, and replaced them with a trait-specific method. Using this model, clinicians would have determined if their patients had a personality disorder by looking at the traits suggested by their symptoms and ranking each trait by severity.

“As evidenced by the field’s reaction, this new model was too complex for clinical practice. … The result was reflected in a second proposal, a hybrid model that included evaluation of impairments in personality functioning (how an individual typically experiences himself or herself as well as others) plus five broad areas of pathological personality traits. Although this hybrid proposal was not accepted for DSM-5’s main manual, it is included in Section III for further study. … APA hopes that inclusion of the new methodology … will encourage research that might support this model in the diagnosis and care of patients, as well as contribute to greater understanding of the causes and treatments of personality disorders.”

Ideally, that hybrid alternative will push mental health professionals to think of personality disorder less in black-and-white terms and more in nuanced shades of gray, says Feisthamel, who presented a standing-room-only session on understanding personality disorders in the DSM-5 at the ACA Conference in Cincinnati this past March.

Having had time now to delve into the since-published DSM-5 and consider its approach to personality disorders in greater depth, Feisthamel has found merit in some of its suggestions. Perhaps the greatest positive, he says, is that the alternative model in the DSM-5 suggests breaking out the characteristics of personality disorder so that practitioners can document a collection of traits “instead of giving that full-blown diagnosis of personality disorder.” And instead of the “not otherwise specified” designation that Feisthamel says too easily became a catchall under the DSM-IV, the “Trait Specified” diagnosis encourages practitioners to pick and choose facets of disorder.

It’s a framework that jibes well with Feisthamel’s approach to counseling undergraduates and in teaching future mental health professionals to be more guarded and judicious before doling out a diagnosis. “We’re always very cautious of assigning the [old] Axis II disorders — especially the personality disorders — because it is a lifelong punishment,” he says. “Those are labels for life.”

The prevalence of personality disorders at Hiram doesn’t seem as dire to Feisthamel as the reports he hears from some of his peers on other college campuses. He has seen the surge of personality disorders firsthand, however, especially when he worked in community mental health centers earlier in his career, where he says prevalence rates were as high as 85 or 90 percent.

“It’s a big change in the culture of our country,” he says. “I do think there is a change in people’s behaviors and individuals being raised where you do have those people feeling entitled. There are a lot more people in need and who need that access [to counseling].”

Feisthamel believes some of the apparent increase is due to the public’s growing comfort with talking about mental health issues. He points to Hiram’s chapter of Active Minds, a student-run nonprofit that advocates for mental health awareness. The organization focuses its efforts on establishing a more open dialogue that educates students and encourages them to seek help when needed. Since incorporating 10 years ago at the University of Pennsylvania, Active Minds has spread to more than 400 schools nationwide.

“I think we’re doing a good job of decreasing the stigma,” Feisthamel says. “I find myself being on a college campus where individuals are more knowledgeable about seeking services, which I think is excellent. So maybe it’s that more people are aware of the signs and symptoms and they are getting in for treatment at that moment.”

Just as understanding of the autism spectrum has evolved within the mental health fields and the public at large, Feisthamel says, counselors need to adapt their definition of “personality disorders” to keep pace with shifting cultural norms.

But at some point, Brooks says, mental health practitioners must be mindful to stand their ground about what constitutes a willingness to be flexible versus what constitutes clearly delineated personality disorders.

“These are not adaptive skills,” she says. “No matter what generation you’re in, or what time, if you can’t have a face-to-face conversation, if you can’t sit down for an interview without rolling your eyes or crossing your legs or looking bored, or you can’t get to class on time — or you don’t bother to come at all — no matter who you are and whoever your boss is, I can’t imagine anybody is going to be able to keep a job or a healthy relationship. Maybe we will all adapt to that, but that to me would be a very sad world. What would happen to us if everybody just didn’t show up to work, to school, or know how to function in a relationship? We’d completely fall apart. And I think we’re moving more and more in that direction.”




To contact the individuals interviewed for this article, email:




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