The View from the Trenches
By 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. Of course, DSM-5’s critics don’t like this, and their objections, like the National Institute of Mental Health’s disavowal of the new edition, have received widespread media coverage. 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.
Overall, most of the participants in my workshops seem to feel that the diagnostic system in the DSM-IV was handy and working just fine for them. As clinicians in mostly nonacademic settings, they’ve been unpersuaded that the changes made in the new edition were necessary. They know the DSM-5 Task Force claims these changes were made to reflect new research in mental health care, but as one participant remarked, “It’s like the people on the Task Force have never sat in the room with a client. They’re up in an ivory tower somewhere, dictating how we should be diagnosing our clients, but the changes they’ve made don’t match up with what I see in my office with real people.”
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.
I share some of these concerns. The DSM-5 model of diagnosing leaves us with only a listing of the diagnoses, as opposed to the multiaxial system, which gave us a shorthand way to capture a fuller image of a client. Now, it seems it’ll be much more difficult to adhere to the wise adage that we should be more concerned with the person who has the condition than with the condition the person has. Of course, we need to make sure we’re always looking at conditions as part of a person’s experience, but we need to understand the person first.
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. One woman, in a fit of sarcasm, threw up her hands and said, “It’s a miracle! On the day we convert to DSM-5, everyone with Asperger’s will be cured!”
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. In addition, they’re concerned that people with a DSM-IV diagnosis of Asperger’s won’t continue to qualify for supportive services. The DSM-5 Task Force has said that most people with a well-established DSM-IV diagnosis of Asperger’s should meet the criteria for autism spectrum disorder in the DSM-5. If they don’t, clinicians are supposed to evaluate them for social (pragmatic) communication disorder. Of course, this response from the Task Force has done little to allay the concerns of people with Asperger’s and their advocates, and I’m sure this controversy will continue to gather force.
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.