TPC-Journal-V4-Issue3

The Professional Counselor \Volume 4, Issue 3 197 Counselors can address, consider and convey contextual factors through use of V Codes and Z Codes , and by including attention to contextual factors within the treatment record and conceptualization process (Kress, Paylo, Adamson, & Baltrinic, in press). In the DSM-5 , the APA greatly expanded the list of codes to provide a means for documenting “other conditions and problems that may be a focus of clinical attention or that may otherwise affect the diagnosis, course, prognosis, or treatment of a patient’s mental disorder” (2013, p. 715). These are included alongside mental disorders and medical conditions on the nonaxial diagnosis discussed previously. Examples of V/Z Codes in the DSM-5 include the following: difficulties rooted in interpersonal issues (e.g., parent–child, sibling, partner distress), issues with abuse and neglect (e.g., partner abuse, child abuse, maltreatment), education or occupational difficulties, problems with housing and finances, difficulties within their social environment (e.g., phase of life, acculturation, target of discrimination), legal issues and other personal circumstances (e.g., obesity, nonadherence to treatment, borderline intellectual functioning). For example, a client who presents with major depressive disorder and reports a recent marital separation that has resulted in homelessness might receive a diagnosis of: 296.22 (F32.1) major depressive disorder, single episode, moderate; V61.03 (Z63.5) disruption of family by separation ; and V60.0 (Z59.0) homelessness . The move toward eliminating the multiaxial system emphasizes the idea that mental disorders do not occur apart from physical considerations and contextual struggles. In some ways, this change is consistent with a professional counseling philosophy. However, because there is no longer an infrastructure to cue consideration of contextual concerns, counselors must be ever more vigilant in identifying systematic ways to assess this information and integrate it into treatment plans in meaningful ways. How counselors convey this information may vary across providers and contribute to some confusion in communicating this information. Thus, the elimination of this axis may provide more flexibility at the expense of clear communication. Functioning and Disability (Axis V) Initially developed as the Health-Sickness Rating Scale, the GAF was introduced as Axis V of the DSM-III and DSM-IV (Aas, 2011). The scale called for clinicians to “consider psychological, social, and occupational functioning on a hypothetical continuum of mental health–illness. Do not include impairment in functioning due to physical (or environmental) limitations” (APA, 2000, p. 34). Over time, this single number scale came to be used to assist in payers’ determinations of medical necessity for treatment and in determining eligibility for disability compensation (Kress & Paylo, 2014). The APA discontinued use of the GAF in the DSM-5 , and now suggests that clinicians use the World Health Organization Disability Assessment Schedule (WHODAS 2.0) as a measure of disability. The GAF scale was removed from the DSM-5 because of perceived lack of reliability and poor clinical utility (APA, 2013). In a comprehensive review of literature regarding the GAF, Aas (2010, 2011) concluded insufficient reliability in clinical settings, lack of precision, inability to detect change and limited evidence of concurrent and predictive ability. One additional concern is the way in which the GAF combined attention to symptom severity and impairment. Hilsenroth et al. (2000) noted concern regarding overlap between previous Axis I and II diagnoses and GAF ratings, as evidenced by the APA’s continuing work to develop alternate measures of functioning such as the Global Assessment of Relational Functioning and the Social and Occupational Assessment Scale. Empirical evidence suggested that GAF scores relate to client and clinician perceptions of concerns (Bacon, Collins, & Plake, 2002; Hilsenroth et al., 2000) more so than with social adjustment or interpersonal problems (Hilsenroth et al., 2000). Others have expressed concern regarding the limits of use of the GAF with children (Schorre & Vandvik, 2004). Ro and Clark (2009) argued that the construct of functioning is complex and multidimensional in a way that simple GAF ratings regarding symptom severity and impairment cannot capture. They stated that the World Health Organization’s (WHO) conceptualization of functioning as a component of health, and disability