Thursday, June 02, 2011

Dr. Allen Frances - Who Needs DSM 5? A Strong Warning From Professional Counselors

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From the very beginning of the process, there has been a LOT of controversy around the development of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Revision - otherwise known as the DSM-5. Certainly, a major issue has been that this book is created by psychiatrists - medical doctors - 75% of whom do not actually do therapy with their clients anymore. They want to medicalize the field of psychology and mental illness, with the end result (unstated, of course) being that all diagnoses will eventually be treatable with pharmaceuticals.

Obviously, this does not sit well with a lot of people, including Dr. Allen Frances, who has been one of the loudest and most coherent voices in opposition. I've been very appreciative of his efforts and supportive of many of criticisms.

The American Counseling Association (ACA), the organization that represents professional counselors (LPCs) - such as my future self - set up their own task force to monitor the DSM-5 process and advocate on behalf of counselors, who (along with social workers [MSWs], Ph.D. psychologists (APA), and marriage and family therapists [MFTs]) do the majority of mental health counseling in this country. Let's just say that counselors are not pleased with the direction the DSM committees have moved with their medical model agenda.

Dr. Frances recently received an email from Dr. Dayle Jones who chairs the DSM 5 Task Force of the American Counseling Association (ACA). He posted about it on the ACA blog.

As Dr. Jones mentions, the revision of the ICD-10-CM codes (International Statistical Classification of Diseases and Related Health Problems, 10th revision) will become official (October, 2013) about the same time that the DSM-5 is released - and the IDC meets all insurer-mandated and HIPAA coding requirements and will be free on the internet. I would personally favor the switch to the ICD-10-CM.

Who Needs DSM 5? A Strong Warning From Professional Counselors

Allen Frances, M.D.

I just received a very important email from Dr. Dayle Jones who chairs the DSM 5 Task Force of the American Counseling Association (ACA). Counselors provide a wide range of therapy, rehabilitation, and support services in very varied settings (like colleges, community mental health centers, psychiatric hospitals, substance treatment agencies, and private practice). There are more than 115,000 licensed professional counselors in the United States (far outnumbering the 40,000 psychiatrists as users of DSM). They (along with the 93,000 psychologists, 53,000 marriage and family therapists, and 198,000 social workers) have a deep interest in how DSM 5 will affect daily work with clients.

An ACA Task Force on DSM 5 was appointed to provide feedback to the American Psychiatric Association on proposed revisions. It has become extremely well-informed about DSM 5 and has developed an insightful analysis of the possible detrimental impacts. The ACA Task Force critique should carry great weight and cries out for a serious response (so far unreceived) from the DSM 5 leadership.

The following are direct quotes from Dr Jones’ email expressing the ACA concerns about the proposed revisions for DSM 5:

• Lowering of diagnostic thresholds - this constitutes pathologizing or medicalizing normal behavior, which goes against the philosophical orientation underlying the counseling profession with its emphasis on individual uniqueness, wellness and development. Examples include removing the grief exclusion criterion from major depressive episode; combining substance abuse and dependence into one disorder that requires only 2 of 11 symptoms; reducing the number and duration of symptoms in generalized anxiety disorder; reducing the number of symptoms required for adults to obtain an ADHD diagnosis; and many more.

• Consequences of the proposed revisions - counselors are concerned that the DSM 5 Task Force has failed to consider the risks of the proposed revisions. These include stigma, unnecessary treatments (including needless psychiatric drugs), or even overdiagnosis to the point of creating false epidemics.

• Excessive complexity of the dimensional assessments - counselors are first and foremost practitioners. A typical day involves conducting assessments; treating clients in individual, group, couples, and/or family counseling; completing case work such as diagnosis, treatment plans, and progress notes; and much more. As such, the process of diagnosis must be manageable and uncomplicated. Professional counselors already have intense time demands placed on them. Dimensional assessments that are complex and burdensome are likely to fail.

• Quality of proposed scales - the DSM 5 Task Force has allowed work groups to develop their own new assessments rather than choosing from among the many hundreds of well-established rating scales that cover almost every aspect of psychopathology. Counselors are concerned about the type and quality of scale development procedures (which is not documented on the DSM 5 website) and whether the scales are psychometrically sound. Ethical standards direct counselors (and really all mental health professionals) to use assessment methods that are reliable, valid, and appropriate to the individual, particularly when the results inform important decisions about whether or not the person has a particular mental disorder.

• Even though they are one of the largest constituencies meant to use DSM 5, counselors have been excluded from its development process. Not a single professional counselor was selected to be on the DSM 5 Task Force and counselors were initially not even listed as one of the professional groups that could apply for the “routine clinical practice field trials.” Counselors certainly feel left out, not recognized by psychiatrists as worthy of contributing to the diagnostic manual.

• Finally, we get to the crucial (and still open) question whether counselors should, and need to, use DSM 5? We have followed the DSM lead for the past 30 years. But the poor product and closed process of DSM 5 make us wonder whether to continue. DSM is not mandatory for most clinicians unless specifically required by their institutional settings. Should the DSM become so complicated, or if the development process is viewed as too questionable and controversial, counselors could choose to reject DSM 5 altogether and simply use the ICD-10-CM codes that will become official around the same time DSM 5 will be published in 2013. The ICD-10-CM codes meet all insurer-mandated and HIPAA coding requirements and will be free on the internet.

Dr Jones’ powerful email will hopefully stimulate a prompt (if belated) response from the DSM 5 leadership. The ACA has provided a much needed wake-up call for the American Psychiatric Association. Its projected future budgets are heavily dependent on expected publishing profits from DSM 5. Book sales are likely to be much reduced if the opinions of clinicians and the needs of patients continue to be ignored.


Allen Frances, M.D., was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke.


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