Therapy Confronts the DSM-5

Therapists React to the Latest Diagnostic and Statistical Manual

Martha Teater

Since the release of DSM-5 in the spring of 2013, its critics have complained that the definitions in the new edition are now too broad, too inclusive (or not inclusive enough), too biological (or not biological enough), too vague, too quixotic, too unscientific, too much under the thumb of Big Pharma---the list goes on. However, since few people argue that mental health professionals can treat people or do research without some sort of diagnostic system, at this point—unless an unforeseen revolution upends the mental health field---we’ll have to make friends with DSM-5, particularly if we expect insurance companies to go on reimbursing us, or even if we simply want to maintain a decent sense of order in psychiatric diagnosis.

But how are ordinary clinicians across the country adapting to the specifics of the new manual? As someone who’s given dozens of workshops on DSM-5 and trained thousands of therapists in its use, I’ve had a front-row seat on how psychotherapists have reacted to the changes it means for their practice.

Not surprisingly, older clinicians are more resistant to the changes, and several have admitted to considering retirement rather than having to adapt to the new system. But even younger clinicians, who seem more open to the new system, have complained that the people involved in the development of DSM-5 are too academic, too institutional, and too removed from the experience of day-to-day client care. Almost universally, participants also worry that the involvement of too many psychiatrists has skewed the new manual in an overly medical direction. One psychologist expressed it like this: “My concern is helping the person sitting in front of me. Their priority seems to be related to the World Health Organization and the International Classification of Diseases system. I’m not dealing with abstract concepts. I’m dealing with real hurting people, people who struggle.”

Without a doubt, the subject that arouses the most passionate response in my workshops is when we talk about the loss of the multiaxial system, which used to split a diagnostic impression into five parts. Using the five axes, the evaluation of every patient documented clinical concerns leading to treatment; mental retardation and personality disorders; contributing psychosocial, environmental, and medical conditions; and a global assessment of functioning. Clinicians believe that losing the five axes means losing the ability to paint a more complete picture of what’s going on with the people they treat, which runs counter to our field’s new focus on integrating medical and behavioral health care. They complain that it feels like we’re being pushed into a more medical model.

Another change in the manual that consistently stirs up spirited disapproval is the loss of Asperger’s disorder as a diagnostic category. Now considered part of autism spectrum disorder, the term Asperger’s doesn’t even appear in the new manual. I have yet to have a single workshop participant praise this change.

People with Asperger’s, parents of children with Asperger’s, and autism and Asperger’s advocacy groups have all voiced their objections as well. They see Asperger’s as a different condition from autism, and they disagree with the decision to eliminate it as a separate disorder.

Where’s Sex Addiction?

Another issue that’s come up at every training I’ve done arises when people inevitably raise their hands as they flip through the handouts and say, “I don’t see where sexual addiction and pornography addiction are in the manual. Can you show me?” My answer is no, I can’t show them, because those conditions aren’t in the manual. When I say this, there’s usually a collective gasp of dismay, which only grows louder when I add that gambling is the only “behavioral addiction” listed. What’s more, sexual and pornography addictions aren’t even in the section on conditions needing further study, which is often where things go before they make the cut and become official diagnoses in some future revision.

Although people have clearly voiced criticisms of the new manual, one change that’s regularly viewed with great approval is the move from using the old Global Assessment of Functioning scale to new severity scales that are specific to different diagnoses. Clinicians applaud the idea of having separate and unique severity scales for anorexia, bulimia, substance-use disorders, oppositional defiant disorder, and other conditions.

The Impact on Therapy

As the authors of DSM-5 remind us again and again, the new manual is nothing if not scientifically up to date: putting it together, they’ve drawn on nearly 20 years of international research into mental disorders since the publication of the previous manual. And except for a surprisingly modest number of genuinely significant changes, including the newly introduced dimensional scales, DSM-5 is still clearly the offspring of DSM-IV. Despite the howls of fear and outrage from its critics, it’s most definitely not a radical departure for psychiatric diagnosis, much less a revolution.

The changes in the manual won’t be critical for doing therapy; most therapists seek to understand how and why clients are troubled before they try to pin them to DSM diagnoses anyway. But the new manual will make a big difference procedurally and bureaucratically. To get paid, therapists will need to rethink how they define and document their clients’ problems according to the template DSM-5 has set before them. Further, there will be rumblings throughout the pharmaceutical companies, since changes in diagnostic practice notoriously tend to precede an increase in the sale of drugs to newly diagnosed populations.

On the whole, DSM-5 isn’t really all that bad. Think of it as a way to help us organize and think about complex, labile, hard-to-understand phenomena in our clients’ lives. It might be difficult to acquire the regular habit of just using the new thing, but as most therapists know, it’s possible to practice new habits---even DSM coding---until they become second nature.

This blog is excerpted from “Shedding Light on DSM-5". Read the full article here. >>

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Topic: Professional Development | Anxiety/Depression

Tags: add | addiction | addictions | anorexia | asperger's syndrome | autism | depression | Diagnostic and Statistical Manual | DSM | dsm-5 | psychotherapy | sex addiction | therapist | therapy | magazine | networker | manual | changes | clinician

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1 Comment

Saturday, August 29, 2015 6:31:50 PM | posted by Kathie Taylor
Having read this article I am still left with the question of how to code "Sexual Addiction". How are other therapists dealing with it?