Sep 1, 2014 | Article, Volume 1 - Issue 2
Brandon Hunt, Genevieve Weber Gilmore
In an effort to ensure the efficacy of preparing emerging counselors in the field, CACREP standards require that by 2013 all core faculty at accredited universities have a doctorate in Counselor Education and Supervision. However, literature suggests that a disparity may exist in the preparation of counselor educators and the actual responsibilities of faculty members. As such, the present study investigated CACREP-accredited doctoral programs’ preparation of students to teach from the perspective of both students and program coordinators. Results support a didactic course in teaching and a co-teaching internship to help doctoral students learn to develop course materials, manage classroom behavior, and develop a teaching style and philosophy. Recommendations for effective counselor education training practices are provided.
Keywords: counselor education, faculty, CACREP, doctoral students, teaching
The field of counselor education continues to grow and with the rise in counseling programs there is an increased need for doctoral level counselor educators. In support of this need, the 2009 Council on Accreditation of Counseling and Related Educational Programs (CACREP) standards require that by 2013 all new core faculty have a doctorate in Counselor Education and Supervision (CES), since they are trained to teach, conduct research, and contribute service to the counseling profession (Sears & Davis, 2003). The training mission of CACREP-accredited CES doctoral programs meets the growing interest in reform for graduate education and the needs of a changing academy (Austin & Wulff, 2004).
An examination of the literature raises curiosity about the consistency between graduate preparation and the roles and responsibilities of faculty members. For example, faculty members spend more than half their time on teaching (Davis, Levitt, McGlothlin, & Hill, 2006; Golde & Dore, 2001), yet research is often the dominant focus of doctoral-level training. This leaves graduates better prepared for the role of researcher and less prepared for the role of teacher (Golde & Dore, 2001; Heppner & Johnston, 1994; Orr, Hall, & Hulse-Killacky, 2008). For example, Rogers, Gill-Wigal, Harrigan, and Abbey-Hines (1998) found that counseling faculty ranked experience in the area of teaching higher than publication experience in the faculty selection process. The focus on research in doctoral preparation appears contrary to what programs want in faculty—that is, well-rounded faculty who are prepared to teach, conduct research, and provide service to their institution, profession, and community.
According to Burke (2001), doctoral programs typically prepare students for careers at research institutions, and in doing so offer graduate fellowships, assistantships, and other training opportunities in research. This traditional model emphasizes research preparation while paying little attention to other faculty responsibilities like teaching (Rogers et al., 1998; Wulff, Austin, Nyquist, & Sprague, 2004). Consequently, many new faculty members lack didactic and hands-on training in teaching. Heppner (1994) supports this notion and found few graduate programs had systematic curricular experiences designed to prepare graduate students to teach, and those that did typically involved two to three days of seminar-based instruction that emphasized topics like grading and academic dishonesty. Without formal curricular experiences designed to train teachers, doctoral students who plan to enter a career in academia are too often not receiving training in the basic aspects of how to teach. As a result, new faculty are learning to teach during their first year while simultaneously adapting to a new professional environment, and in some cases developing a research agenda (Berberet, 2008; Burke, 2001).
A few studies that examined early experiences of new assistant professors have been identified in the literature. In a qualitative study by Magnuson, Black, and Lahman (2006), new assistant professors in counselor education were interviewed about their first three years as academicians. One participant described feeling “competent clinically,” but “completely ill prepared” for the role of counselor educator (p. 176). Wulff et al. (2004) investigated how graduate students’ experiences contributed to their development as educators and the types of training that most effectively prepared them for the professoriate. Their findings underscored a lack of “systematic feedback and mentoring” (Wulff et al., p. 62) in graduate students’ development as educators. Students reported their departments did not prepare them for the role of educator or provide feedback on their teaching skills. For students who did receive feedback, it was not “thorough or carefully designed to help them grow as teachers” (Wulff et al., p. 62). Consequently, participants relied on formal and informal feedback from students as well as their students’ grades to identify their most effective teaching strategies (Wulff et al.).
Doctoral students sometimes gain experience as teaching assistants (TA), yet these experiences may not adequately prepare them for the activities necessary for successful faculty careers. Although TA opportunities can help graduate students learn how to deliver a lecture and evaluate student work, these assistantships often serve as “mechanisms for financial aid and provide a labor pool of junior instructors for the university” (Golde & Dore, 2001, p. 25). According to Fagen and Suedkamp Wells (2004), “Teaching assistants are thrown into teaching environments in a sink-or-swim manner. No advice, preparation, or supervision is given” (p. 84). Therefore, one cannot assume that teaching assistantships are the answer to preparing doctoral students for the professoriate.
Without formal curriculum designed to train teachers, students who plan to enter a career in academia lack training in important aspects of teaching such as developing a teaching philosophy, incorporating information technology into the classroom, and creating inclusive classroom environments (Golde & Dore, 2001). This lack of training prevents aspiring faculty from truly understanding the art of teaching; that is, guiding students to new levels of understanding rather than standing in front of the room and lecturing (Wulff et al., 2004).
Researchers suggest that graduate students who experience progressively challenging teaching roles with faculty supervision benefit most from their graduate teaching experiences (Wulff et al., 2004), yet less than 50% of graduate students receive appropriate training before they enter the academy and they lack appropriate supervision to help enhance their teaching skills (Fagen & Suedkamp Wells, 2004). Accordingly, recommendations to graduate programs to provide greater opportunities for students to develop teaching skills have been proposed. One such opportunity is the teaching internship, which can help broaden the program emphasis beyond that of research to better prepare students for jobs in academia (Nerad, Aanerud, & Cerny, 2004).
According to Burke (2001), requiring a teaching internship for doctoral students can lead to a powerful climate change in academe that benefits graduate students, their doctoral programs, their institutions, and higher education as a whole. Burke contends that adding an elective or a required course in teaching is not enough. Rather, doctoral programs should provide students with varied teaching opportunities that become increasingly more demanding, require more responsibility, and allow for activities including but not limited to advisement and the development of a teaching philosophy (Wulff & Austin, 2004). It is important to note that adding a teaching internship is not intended to deemphasize the importance of research; rather, doctoral training for the professoriate should be strengthened to include emphasis on the most time-consuming activity of a professor—teaching.
Rationale for the Study
CACREP-accredited doctoral programs have responded to the growing interest in reform in graduate education by increasing their emphasis on training the next generation of faculty to teach. Zimpfer et al. (1997) reported that counselor education doctoral programs rated instructional and co-teaching activities as highly important student activities, yet a description of such teaching activities and an investigation of their effectiveness was not provided. According to CACREP Doctoral Standard III.B,
Doctoral students are required to complete doctoral-level counseling internships that total a minimum of 600 clock hours. The 600 hours include supervised experiences in counselor education and supervision (e.g., clinical practice, research, teaching). The internship includes most of the activities of a regularly employed professional in the setting. The 600 hours may be allocated at the discretion of the doctoral advisor and the student on the basis of experience and training. (CACREP, 2009, p. 54; emphasis added)
This standard, however, does not specifically describe or offer suggestions on how doctoral programs should train their students to teach or how a teaching internship should be developed and implemented. CACREP Standard II.B.2 also mandates students should be provided with opportunities to “develop collaborative relationships with program faculty in teaching, supervision, research, professional writing, and service to the profession and the public” (CACREP, 2009, p. 53l; emphasis added). Finally, as stated in the “Doctoral Learning Outcomes” section of the 2009 CACREP Standards, graduates should be knowledgeable about theory and methods related to teaching and they should have developed their own philosophy of teaching.
Our interest in this topic grew out of our experiences learning to teach at the graduate level. The first author learned to teach by co-teaching with a faculty member when she was a doctoral student, even though her program did not have a formal teaching internship. The faculty member then required doctoral advisees to complete a formal teaching internship until the time her program made the decision that all counselor education doctoral students were required to complete a didactic course on teaching as well as complete a teaching internship. The second author completed a didactic course as part of her doctoral program, and did her teaching internship with the first author. Our basic assumption going into the study was that completing a teaching internship is important in helping doctoral students become competent teachers. We discussed our assumptions and thoughts about the teaching experiences of CES students before and during the current study.
A review of the counseling literature uncovered no research related to how doctoral students in counselor education are being trained to teach in accordance with CACREP standards. Thus, CES students who plan to spend a significant portion of their academic careers teaching are not able to access information that describes how CES graduates are best prepared to teach, specifically what works and what does not work from the perspectives of faculty and other students. To address this gap in the literature, we conducted a preliminary study to answer the following research questions: (a) How are doctoral programs in counselor education training their CES students to teach? And, (b) What are the experiences of CES students who have completed a teaching internship?
Methodology
We used both quantitative and qualitative questions to answer the research questions. We collected descriptive data to investigate how counselor education programs are training CES students to teach and used general qualitative inquiry to learn about the teaching internship experiences of CES students. Our study was conducted in two phases. In Phase 1, we surveyed CES professors who were doctoral coordinators about the training their programs provide to doctoral students with regard to teaching. In Phase 2 we surveyed CES students who were completing or had recently completed their teaching internship. We could not find an appropriate survey for our study, so we developed questions for both phases of the study based on our review of the literature on teaching at the collegiate level.
For Phase 1 of the study, we sent email surveys to the doctoral coordinators for all CACREP-accredited CES programs. The survey, which included the language from CACREP (2009) Doctoral Standard III.B, consisted of the following questions: (a) How many doctoral students are accepted into your program each year? (b) What is the main focus of your program (i.e., train faculty, train researchers, train supervisors and practitioners)? (c) How does your program meet CACREP Doctoral Standard II.B? (d) Does your program offer or require a didactic teaching course? (e) Does your program offer or require a teaching internship? And, (f) What other opportunities does your program offer that allow doctoral students to gain teaching experience? At the time we collected data there were 44 CACREP accredited doctoral programs, and despite repeated contacts with program coordinators encouraging their participation, we received responses from only 16 doctoral coordinators (36% response rate).
For Phase 2, we sent email surveys containing open-ended questions to the ten doctoral coordinators who responded that their programs offered a teaching internship—not all programs offered a teaching internship—asking them to forward the survey to students currently completing or who had completed their teaching internship. Fourteen students responded and all questions were answered. The student survey noted we were looking specifically at the teaching internship experience, not teaching assistant experiences, and asked questions about (a) teaching experiences prior to the doctoral teaching internship, (b) what students appreciated most about the teaching internship, (c) what they found most and least helpful about the teaching internship, (d) if they had a separate didactic course related to teaching, what was most and least helpful about the course, (e) what would they have liked to have known before they started the teaching internship/co-teaching experience, and (f) how prepared they felt to teach independently after completing the teaching internship?
Results
CES program coordinators provided commentary on the status of the teaching internship at their institution (Phase 1), and doctoral students on their experiences with the teaching internship (Phase 2).
Phase 1: Program Coordinator Responses
Coordinators for the 16 programs noted they typically accepted six CES students a year. With regard to the main focus of the program (i.e., train faculty, train supervisors and practitioners, train researchers), 10 coordinators noted their program focused on training counselor education faculty, one program emphasized training of counselor education faculty as well as training of supervisors and practitioners, one program focused exclusively on training supervisors and practitioners, and four programs had an equal balance between all three areas.
With regard to how programs met the CACREP standard regarding teaching, the responses were varied with 15 of 16 participants responding to this question. Three coordinators noted their programs required no teaching experience as part of doctoral training. Of these, two noted that while their programs did not require a teaching experience most CES students co-taught a course with a faculty member. Nine coordinators said their students must complete a formal teaching internship, which typically entailed teaching a master’s level lecture course with a program faculty member. Of the programs that required a teaching internship, eight also required that students complete a didactic course on college teaching. Four coordinators noted they offered the course on teaching in their department, and four participants noted the required teaching course was offered outside of their department. When asked what other opportunities their programs offered for CES students to gain additional teaching experience, eight coordinators responded that their students had the opportunity to teach an undergraduate course independently, three programs provided opportunities for students to lead workshops, and two programs provided opportunities for CES students to teach master’s level courses independently.
Phase 2: Experiences of CES Student Respondents Who Completed the Teaching Internship
As noted, 14 doctoral students responded to Phase 2 of the study. They were asked to answer questions about their experiences prior to, during, and following their teaching internship. Eight respondents reported they had some level of teaching experience prior to their doctoral programs, which included teaching at the K–12, undergraduate, and master’s level. Following the principles of the constant comparative method of analysis (Lincoln & Guba, 1985), we reviewed and coded the responses to the remaining eight questions independently and placed them in categories. Then we met to discuss our independent categories until we came to consensus about the categories’ titles and meanings.
We took several steps to verify our findings. First, we used multiple participants as a form of data triangulation (Creswell, 2007; Patton 2002). Second, we analyzed the data independently and then together, which is a form of investigator triangulation (Lincoln & Guba, 1985; Patton, 2002). We also revisited participant responses when necessary throughout the analysis process, which provided us with opportunities to remain aware of potential research biases as well as to support or refute our categories. Finally, we used “thick description” (i.e., quotes) from the participants to add detail to their experiences (Lincoln & Guba, 1985).
Based on our analysis, responses emerged in the following four categories: (a) most and least helpful aspects of the teaching internship, (b) most and least helpful aspects of the didactic course on teaching, (c) what students should know before starting their teaching internship, and (d) how prepared students felt to teach independently. Responses will be described in detail, including exemplary quotes from the participants.
Most and least helpful aspects of the teaching internship. According to one respondent, the teaching internship is an opportunity for doctoral students to observe, model, and collaborate with “trusted and experienced” professors in preparation for their careers as counselor educators. Of the 14 doctoral students who responded, only one person wrote that the teaching experience was not helpful. The remaining respondents appreciated the support and guidance provided by the professors with whom they taught, which according to one respondent helped guide the student through “the rough spots” and improved his/her teaching skills. One respondent wrote, “I appreciated working closely with my supervisor to ensure that I had the support necessary to do the job right.” Another respondent shared that support and guidance were received through “bouncing ideas and feelings off” professors and collaboration on curriculum development and leading class discussions.
Respondents also appreciated the autonomy fostered by co-instruction opportunities, which allowed them to “have control over what assignments were being given.” One respondent underscored the importance of co-creating course syllabi and being involved with “in-class demonstrations and mini-lectures.” The flexibility and freedom to generate course curriculum and relevant materials encouraged the development of teaching philosophies and styles, both of which are essential to effective pedagogy. Another respondent stated, “My professor allowed me to choose half of the lectures and create my own materials for the class. I felt a sense of independence and empowerment as a co-instructor.”
Weekly teaching internship meetings where doctoral students and a professor met either individually or in a group to discuss ideas and concerns related to the teaching internship were described as beneficial. Respondents appreciated sharing ideas and hearing “strengths and areas of improvement” with regard to their teaching competencies. One respondent noted “meeting with the instructor of record to co-plan for [class]… helped me to deal with different problems that arose…[as well as] having trust and confidence placed in my abilities and me.”
Having a sense of being supervised too closely by the faculty co-instructor, however, was described by a few respondents as unhelpful, as the presence of the professor “made it hard to establish rapport and authority with students.” Feelings of frustration arose for one respondent when students would bypass the doctoral student and go directly to the faculty member of record “when it came to issues of grades, or syllabus-dictated course requirements.”
Additionally, although the majority of respondents viewed professors as experienced and excellent role models, several observed faculty who “did not model successful teaching strategies” or did not have a mastery of the material. One respondent stated, “Having to meet in a tiered supervision group with a professor who did not understand the unique aspects of the school counseling setting was not helpful.”
The “hands-on” training approach of the teaching internship was described as a valuable component of the experience as it promoted doctoral students’ observation and participation in realistic roles and responsibilities of professors. One respondent indicated, “I really got to experience how much prep work goes into teaching.” Others noted the opportunity “to teach a variety of courses” and “interact with different students” helped strengthen their abilities to reach and teach “all types of thinkers.” Some participants reported, however, that they felt unprepared for the “hands-on” approach, and found a number of characteristics of the teaching internship unhelpful. For example, one respondent noted, “prior knowledge of the level of preparation needed to teach a subject would have been helpful.” Another respondent struggled with “not knowing the level of competence of the students ahead of time,” and a third respondent found it “challenging to teach some students who were very unengaged in the course.”
Most and least helpful aspects of the didactic teaching course. Most graduate student respondents found their didactic course on teaching helpful in preparing them to teach. In particular, the didactic course provided opportunities for doctoral students to develop syllabi, exams, and grading rubrics, as well as receive feedback from professors and classmates. One respondent wrote,
Every assignment and class meeting was valuable. Assignments included writing a syllabus from start to finish and revising it after receiving feedback, keeping a journal on relevant topics (philosophy of teaching and learning, dealing with problems from students or other situations, our own biases), writing a sample test utilizing different types of test items, sharing and critiquing a video of us teaching, and creating a teaching portfolio that includes our philosophy of teaching, the things we created, and how we would evaluate students and ourselves.
Another respondent stated that the course on teaching required that respondents read the text they would be teaching the semester prior to teaching. This assignment, as described by the respondent, was “helpful in developing and receiving feedback on a tentative syllabus and lesson plans.” Respondents also indicated they enjoyed the opportunity to interact with other doctoral students, allowing for the comparison of “experiences” and acquisition of “new ideas.” Overall, these didactic experiences increased respondents’ knowledge of the course content, and furthered the development of their basic teaching skills and overall teaching philosophies.
Although many respondents found the didactic component of the teaching internship helpful, a few respondents shared that the course overemphasized the development of lesson plans. One respondent noted, “it was least helpful to develop individual lesson plans when we would be co-teaching.” The respondent continued with this recommendation: “it would have been more useful to develop lesson plans with our co-instructor, instead of having to merge and blend them together the first day of class.” One respondent shared his dislike for the course’s lack of emphasis on actual teaching. Two other respondents described the quality of course materials and the course curriculum as not beneficial. One respondent noted, “…a lot of the course was review, and for the parts that were new, I think I could have just written a paper based on the book,” and a second respondent identified her readings for the course as unhelpful.
What students should know before starting their teaching internship. Respondents provided various suggestions to future students with regard to what they should know before beginning the teaching internship. Mentorship was described as an important area of support for graduate students in counselor education. For those students who can choose the professor with whom they will teach, one respondent underscored the importance of “choosing a professor whose style you value” rather than choosing a particular course only based on interest. Furthermore, it is beneficial to consider “which ‘profs’ were the best teachers” and to “try to incorporate the successful strategies employed by your favorite teachers.” This comment speaks to the importance of faculty modeling effective teaching strategies to teaching interns. Another respondent provided a suggestion that emphasized the value of supervision:
Use your mentor as a sounding board, especially if you have never taught before. Rarely will you be presented with an issue in your class with which your supervisor has not had prior experience. Pay attention to the way effective professors do business.
Structured supervision also was indicated as an important area of interest. For graduate students who might not have a formal teaching supervision experience in place, one respondent advised, “Find out with whom they can consult formally or informally. Do not try to teach in a vacuum, especially if they are new to teaching…form an informal peer supervision group or seek outside supervision from another knowledgeable source.”
In addition, classroom management also was identified as a practical area that graduate students should know before beginning their teaching internship. Responses included dealing with “student issues,” “classroom dynamics,” and engaging “the difficult-to-engage student.” A few respondents commented on the importance of understanding and using effective ways to interact with students. For example, one respondent stated, “make sure you pay attention to how people react to being challenged…or how people go about disagreeing…[since] not everyone responds to criticism or being challenged in the same way.” Another respondent underscored the value of having structure in the classroom, noting: “It is easier to be ruthlessly rigid and demanding at first and then loosen the reigns toward the end of the semester than it is to be lax in enforcing grading or class rules and then try to put the hammer down at the end of the semester.” This respondent also recommended that teaching interns “set the tone from the start” of the course.
Finally, a few respondents recommended doctoral students understand the time, dedication, and competence required to develop course materials and integrate technology into the curriculum. For example, one respondent suggested doctoral students should know the “most professional issues relevant to the course; how to develop a syllabus; and how to create assignments that truly measure knowledge gained by students.” One respondent proposed that doctoral students plan “to double their estimated time of preparation and to try to gain competence in the use of technology like ANGEL and WEBCT,” which are computerized course management systems.
How prepared students felt to teach independently. Overall, respondents described the teaching internship as an essential component in preparing them to teach independently. Emphasis was placed on the importance of didactic training and the co-teaching experience in addition to teaching assistantship opportunities. One respondent noted, “The teaching internship is so essential for counselor educators…and this means a structured course or practicum beyond just being a teaching assistant!” Co-teaching experiences allowed students to gain knowledge of course material as well as skills to manage the classroom, both of which were invaluable to their training. One respondent noted the value of having a didactic course and teaching internship as part of his training: “I believe that my internship alone did not 100% prepare me to teach independently. I think that internship, the class on college teaching and other co-teaching experiences TOGETHER have helped me feel prepared to teach.” After completing the teaching internship, one person indicated she was hired by her department as an instructor for a master’s level course, which helped her gain additional experience and earn extra income during her doctoral studies.
Discussion
Findings from Phase 1 of the study show the majority of faculty respondents, all from CACREP-accredited CES programs, focused on training doctoral students to become faculty with particular emphasis on teaching, research, and service. Given that the master’s degree is the professional-level degree in counselor education, it seems appropriate that doctoral programs focus on training future faculty to teach. The majority of participants noted they were providing some level of teaching opportunities to CES students even if it was not offered in a formalized and systematic way. Doctoral coordinators for three programs did not respond to this question, and three noted they did not require students to complete any kind of teaching experience despite teaching being noted as an important element of doctoral training in the CACREP standards. Nine programs required students to complete a formal teaching internship, typically co-teaching a master’s-level counseling course with a counselor education faculty member, and of those programs eight required students to complete a didactic course on teaching. Additional training experiences offered to CES students included teaching undergraduate or graduate courses independently and leading workshops.
As noted earlier, results from our analysis of the student responses (Phase 2 of the study) provided information on the most and least helpful aspects of the teaching internship and the didactic teaching course, as well as what students should know before starting their teaching internship. Mentorship, support and guidance from faculty and peers, and weekly supervision were helpful aspects of the teaching internship. Teaching supervision that was too intensive and working with weak role models of quality teaching were unhelpful aspects of the teaching internship. Although most respondents found the didactic teaching course to be helpful, a few respondents expressed concern over the heavy focus on developing lesson plans (when they were not teaching a course yet) and the lack of actual teaching experience in the course. As a result, respondents recommended that other students be selective about with whom students complete their teaching internship, focusing on the instructor rather than the course content; make full use of the supervision provided by the faculty mentor as well as peer support; learn good classroom management skills; and be aware of the amount of time and energy required to develop and teach a course. All these recommendations are made possible through a didactic teaching course coupled with hands-on teaching experience.
Students respondents also described how prepared they felt to teach independently. Overall, the teaching internship, beyond being a teaching assistant, was very important in helping them feel prepared to teach independently since respondents learned both how to present content and manage the classroom elements of teaching.
Findings from our study are contrary to Wulff et al. (2004) and Fagan and Suedkamp Wells (2004), who found that doctoral students who wanted to become faculty reported they did not receive adequate orientation, preparation, or training to enter the classroom as teachers. Although the comparative research examined experiences across many disciplines and was not primarily focused on counselors, it is the only literature that could be located relevant to the current topic. It appears that students enrolled in CES programs that include a teaching internship requirement, if not requiring both a didactic course and the internship, felt supported as they learned to teach and believed they were well prepared to teach independently. Wulff et al. also suggested that students engage in teaching experiences that are progressively more challenging, moving from some level of teaching observation or a didactic course to then co-teaching with faculty, and then teaching independently, which happened for a number of the doctoral participants in our CES study.
Our findings support Heppner’s (1994) assertion that providing graduate students (five psychology students in this case) with the opportunity to engage in a teaching practicum or internship experience significantly increased their knowledge about teaching as well as teaching self-efficacy. Participants in Heppner’s study stated that receiving feedback from faculty co-instructors and peers as well as sharing ideas with their peers was particularly helpful, which is similar to our findings.
Limitations and Implications
As with all research, this study has limitations. Because of the preliminary nature of the study and the relatively low response rate for Phase 1, it is not possible to generalize the findings to all CACREP-accredited CES programs or to all counselor education doctoral programs. In addition, our findings reflect research institutions that train counselor education doctoral students. Therefore, caution should be used in interpreting our findings. Limitations for Phase 2 could include some degree of researcher bias since the authors initially had a student-professor relationship and worked together in a teaching internship, but we took the steps described above to ensure trustworthiness and attend to potential biases.
Despite these limitations, there are several implications that arise from our findings. First, CES programs would benefit from developing a systematic process for training doctoral students to teach. Having a required process is not only important in terms of meeting the CACREP standards, but also has an important influence on how we train future generations of master’s-level counselors. This process could include having students complete a didactic course on teaching, preferably offered within the department, and either simultaneously and sequentially completing a co-teaching internship with a faculty member.
Based on the research and our findings, it seems most effective to have doctoral students select the faculty member with whom they want to co-teach and that they receive consistent supervision. Burke (2001) takes the process even further, recommending that doctoral students complete a year long teaching internship that would include teaching two courses a semester and being involved in departmental meetings where curricular issues are discussed, as well as advising students. For specifics on a model designed to meet the CACREP standards for training counselor education doctoral students on how to teach, see Orr et al. (2008), who developed the collaborative teaching teams (CTT) model to help CES students gain experience and increase their sense of competence in teaching.
During the teaching internship students should be provided with formal opportunities to interact with other doctoral students completing their teaching internship, preferably in a weekly group setting. Again, our findings and existing research support the idea that peer support and critique is as important, if not more important, to doctoral students as they learn to become effective and confident teachers. Respondents benefitted from seeing what their colleagues did in similar teaching situations and imagining how they might handle a challenge that a doctoral peer was facing.
Lastly, counselor education programs can help doctoral students broaden their definition of teaching to include community and conference presentations, workshops, and other public speaking opportunities where CES students can use their counseling and teaching skills to educate others. Teacher training also should include specific content about how to assess and handle classroom situations where students may have committed academic misconduct or may be impaired in some way and what campus resources exist to help faculty and students navigate these challenging situations, including how codes of ethics and university policies and procedures apply in the classroom.
As Heppner and Johnston (1994) stated, “the development of excellent teaching skills involves continuous learning, a lifelong process…Given the complexity of the skills required for outstanding teaching, it is surprising that most faculty members have not had formal training in teaching” (p. 492). By providing the same level of focus and attention to teaching in CES programs that we do to research, we can help future CES faculty increase their level of competence and self-efficacy as counselor educators, thus effecting positive change in the classrooms of counselor education master’s programs across the country where our graduates are hired to teach. Our provision of quality and comprehensive doctoral-level education also responds to the call for reform for graduate education, particularly in preparing future faculty members to meet the needs of a changing academy.
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Brandon Hunt, NCC, is a Professor at Counselor Education, Counseling Psychology, and Rehabilitation Services at Penn State University. Genevieve Weber Gilmore is an Assistant Professor of Counseling at Hofstra University. Correspondence can be addressed to Brandon Hunt, Penn State University, University Park, PA, 16802, bbh2@psu.edu.
Sep 1, 2014 | Article, Volume 1 - Issue 1
Joel F. Diambra, Melinda M. Gibbons, Jeff L. Cochran, Shawn Spurgeon, Whitney L. Jarnagin, Porche’ Wynn
To inform and guide their practices, counselor educators would benefit from having a clearer picture of how the research literature and professional standards of the field correspond and contrast. To elucidate this relationship, researchers analyzed 538 Journal of Counseling and Development articles published from 1997–2006 for fit with the 2001 and 2009 eight core areas of Council for Accreditation of Counseling and Related Educational Programs (CACREP). The articles fell into three tiers delineated by year and based on the number of articles assigned to each core area. Human Growth and Development and Helping Relationships are the two core areas most frequently represented across the 10 year time span examined.
Keywords: professional standards, research literature, CACREP, NBCC, ACA, Human growth and development, helping relationships
There is an inherent symbiotic relationship that exists among related professional organizations. Within the counseling profession, there are a number of organizations or entities that coexist, support one another, encourage and challenge one another, disseminate information, and act as gatekeepers. These major counseling entities include the American Counseling Association (ACA), the National Board of Certified Counselors (NBCC), the Council for Accreditation of Counseling and Related Educational Programs (CACREP) and the Journal of Counseling and Development (JCD). These entities mutually influence each other by acting and reacting to needs, changes and research findings within the counseling profession.
Given the new CACREP 2009 standards, it is now time for counselor educators to review and possibly revamp their training programs to better reflect the current issues faced by those in the counseling field. Counselor educators will benefit from having a clearer picture of how our research literature and professional standards correspond and contrast to inform and guide our practices.
As the respective flagship journal and primary accrediting standards of the counseling field, the JCD and the CACREP standards are predominant guiding resources that reflect, communicate, and shape the values, interests, and work of counselor educators. As JCD is the journal for ACA, and as the National Counselor Examination is based on CACREP requirements, an obvious extension to include these entities occurs as well. These entities also influence each other. JCD and CACREP can be seen as leaders of an input loop in the counseling profession. JCD, as the flagship journal for the American Counseling Association (ACA), shapes counselors’, stakeholders’ and counselor educators’ views of the counseling field. Continuing the loop, every seven years CACREP engages in a review of its standards for counseling programs. This review includes invitations for input from all counselors and stakeholders (Bobby & Kandor, 1995). As the revised standards are enacted in CACREP and CACREP-modeled programs, the standards influence the education and licensing of counselors, which then influences the work, research, writing, and submissions to JCD from the counseling field over time; JCD article topics, content, and methodology loop again to inform counseling practitioners, students, and educators.
While the 2009 CACREP standards revisions are implemented into counseling programs, it seems an important time for counselor educators to reflect on and explore the profession’s flagship journal articles in relation to future CACREP standards and to discuss future counseling literature that will shape and inform directions for counselor educators and the counseling field. Calls for a strong professional counselor identity (CACREP, 2009; Gale & Austin, 2003; Goodyear, 1984; Hansen, 2003) and professional unity from a recent ACA President (Canfield, 2007) would also seem to indicate the need to reflect on and gain perspective from the trends and foci of our professional literature. The current study provides an analysis and discussion of the fit of JCD articles from 1997–2006 with the eight core areas in both the 2001 and adopted 2009 CACREP standards. We selected this 10-year span because the research project began in late 2007 and 2006 represented the last complete year of JCD articles at that time. We hope such an analysis will help illuminate areas for potential change in counselor education programs.
Professional Organizations and Publications in Counseling
American Counseling Association
With its roots as far back as 1952, ACA is the world’s largest association focused exclusively on representing professional counselors. As reflected on their website, “The ACA is dedicated to the growth and development of the counseling profession and those who are served” (ACA, 2010). Its mission is to enhance the quality of life in society and promote the development of professional counselors, advance the counseling profession, and use the profession and practice of counseling to promote respect for human dignity and diversity (ACA). ACA has 56 chartered branches in the U.S., Latin America and Europe and currently boasts 42,594 members. To communicate to its membership and inform the profession of contemporary issues and treatment modalities, ACA publishes an online website, numerous textbooks, Counseling Today (its monthly magazine) and JCD (its official journal).
Journal of Counseling and Development
In addition to being ACA’s primary journal, JCD appears to have grown to a significant readership, and this is particularly interesting considering that at least two-thirds of ACA members receive JCD as their only ACA journal. According to ACA (personal communication, Rae Ann Sites, December 20, 2007), the JCD Winter 2008 issue had a total print run circulation of 43,500 journals. Approximately 1,000 of these subscribers are institutional subscribers (i.e., college/university libraries). Therefore, it seems logical to assume the majority of subscribers are individual ACA members.
Members also have the option to join one or more of 17 divisions within ACA and many of these divisions publish their own journals. As of December 20, 2007, the cumulative membership in these 17 divisions was 16,279. At most, division membership could represent 37% of ACA members, but it is important to note that some ACA members join multiple divisions, thus exaggerating the 37% figure. Following ACA’s 1997 decision to allow ACA membership exclusive of a division membership and the 2004 decision to permit division separation from ACA, the American Mental Health Counseling Association (AMHCA) and American School Counseling Association (ASCA) announced independence from ACA and are no longer included in these 17 divisions. ACA data available from June 30, 2007, indicate 2,182 (approximately 5%) of ACA members who also were AMHCA members and 2,648 (approximately 6%) who also were ASCA members (personal communication, Jennifer Bauk, December 3, 2007). When compared to the total membership figures of these two professional counseling organizations (AMHCA, 5,860 [personal communication, Mark Hamilton, November 27, 2007]; ASCA, 23,021 [personal communication, Jennifer Bauk, December 3, 2007]), the percentage of AMHCA members who joined ACA was 37% and ASCA members 16%. From these data, it is apparent that JCD is circulated to a wide and diverse counselor audience. Therefore, we can assume that many graduates of our training programs will read only JCD as their professional journal to inform them of current issues and important research.
Council for Accreditation of Counseling and Related Educational Programs
CACREP has evolved to be a significant influence on the counseling field. A brief recap highlights CACREP’s growing influence. Bobby and Kandor (1992) reported that 44 programs housed within 16 institutions were granted approval by CACREP’s Board of Directors at the Council’s first meeting in 1981. In 1992, 195 programs had gained accreditation (Bobby & Kandor); and in 2004, that number had risen to 434 (McGlothlin & Davis, 2004). Currently, CACREP has accredited 505 programs housed within 210 institutions across 48 states, the District of Columbia, and Canada. In addition, 117 programs are currently being considered for CACREP accreditation. This is evidence of CACREP becoming more wide spread and ingrained within the counseling profession (CACREP, 2007).
National Board for Certified Counselors
Developed in 1982, NBCC conducts a national certification program for professional counselors; it is one of two leading certification organizations for the counseling profession, the other being the Commission on Rehabilitation Counselor Certification (CRCC). Although initially created by ACA, NBCC operates as an independent body without direct connection to ACA. Currently, over 46,000 counselors hold the National Certified Counselor (NCC) credential (NBCC, n. d.). In 41 states (82%), NBCC’s National Counselor Examination (NCE) is used as part of the licensure process.
The NCE contains eight content and five work behavior areas. The eight content areas mirror those in CACREP’s core curriculum and include human growth and development, social and cultural foundations, helping relationships, group work, career and lifestyle development, appraisal, research and program evaluation, and professional orientation and ethics. The five work behavior areas include fundamentals of counseling, assessment and career, group, programmatic and clinical intervention, and professional practice (NBCC, n. d.). Given this consistent overlap in core components and the growing use of the NCE for state licensure requirements, it is apparent that NBCC, ACA, JCD, and CACREP are linked in their view of what effective counselors need to know.
Support for Professional Organizations in Counseling
CACREP, JCD and NBCC have been the focus of several empirical studies. Over the past 10 years, researchers have examined issues pertaining to CACREP standards including supervision (LaFountain & Baer, 1999), spirituality and religion (Burke, Hackney, Hudson, Maranti, Watts, & Epp, 1999), community counseling (Hershenson & Berger, 1999), and school counseling (Holcomb-McCoy, Bryan, & Rahill, 2002). Haight (1992) investigated the CACREP standards, focusing on the quality of the standards. In addition, researchers have explored CACREP standards’ relevance to counselor preparation (Vacc, 1992) and their perceived benefit for practitioners (McGlothlin & Davis, 2004). Although some researchers have challenged the standards, most reviews and discussions related to CACREP have been favorable (Schmidt, 1999).
Vacc (1992) investigated counselor educator perceptions of the 1988 standards relevance to the preparation of counselors. He found that respondents judged each of the eight CACREP core areas as crucial or important to counselor preparation. Percentages of perceived importance ranged from 91% to 100%, with Social and Cultural Competence perceived as least relevant and Group Development, Dynamics, and Counseling Theories perceived as most relevant. Based on these findings, Vacc concluded that the data provided evidence to support the validity of the standards.
McGlothlin and Davis (2004) investigated perceived benefits of the CACREP standards. They surveyed counselors to determine perceptions of the benefits of the 2001 core curriculum standards. The core curriculum standards were perceived as being beneficial overall. Ranked in order of perceived benefit (highest to lowest) were: Helping Relationships, Human Growth and Development, Social and Cultural Diversity, Group Work, Professional Identity, Assessment, Career Development, and Research and Program Evaluation. Both studies established credibility for CACREP’s eight core standards.
As noted earlier, NBCC provides the examination used for professional licensure in the U.S. (NBCC, n. d.). Support exists for NBCC due to its oversight of the NCE. Adams (2006) compared NBCC National Counselor Exam scores across CACREP and non-accredited programs. She found that graduates of CACREP-accredited programs scored significantly higher than those from non-accredited programs. Pistole and Roberts (2002) encourage licensure as a primary way to secure professional identity. Similarly, Calley and Hawley (2008) identified professional certification and licensure, along with membership in professional organizations such as ACA, as ways counselor educators help promote a professional counseling identity. Support for both NBCC and the NCE is evident and furthers counselor professional identity.
JCD publications can be seen as shaped by a number of forces and as evolving over time. For example, Weinrach (1987) argued that JCD had been fashioned by contributors’ articles and editors’ aims. Twelve years later Williams and Buboltz (1999) asserted that JCD publications were influenced by changes within society, evolving counselor and student needs, the teaching aims of professors, and most importantly by the research and practical topics that are popular during a historical period.
The content analysis by Williams and Buboltz (1999) of volumes 67–74 most closely resembles the aims of the current study. Their article analysis covered a nine-year span and cross-classified articles into 11 categories (e.g., Counselor Selection, Training and Evaluation, Personal Development and Adjustment, Technology and Media, and Special Groups) and sub-grouped articles by editorship. The purpose of their study was to identify possible topic changes and trends over time and JCD editors. Overall ranking of topics pertinent to the 8 core areas identified by CACREP included Individual, Group Counseling, and Consultation ranked first, Special Groups third, Vocational Development and Adjustment/ Career Counseling seventh, and Technology and Media tenth.
In this study, ACA is assumed to be represented by its flagship journal, JCD, while NBCC is represented by CACREP, as the NCE is based on CACREP accreditation standards. To date, no study has analyzed JCD article content by CACREP core areas. In addition, no study could be found that focused on the similarities and differences between what is required for appropriate training and licensure of counselors and what is represented in the flagship journal of the counseling profession. Therefore, the purpose of the current study is to provide that analysis and discussion for the consideration of counselor educators and the counseling field.
Method
Procedure
Using first the 2001 standards and later the 2009 revisions, two researchers used a qualitative content analysis method to sort articles into the eight CACREP core areas. The eight CACREP core areas included Professional Orientation and Ethical Practice; Social and Cultural Diversity; Human Growth and Development; Career Development; Helping Relationships; Group Work; Assessment; and Research and Program Evaluation. Researchers independently analyzed content by sorting articles by CACREP core area. As per classic content analysis procedures described by Ryan and Bernard (2000), researchers assumed that the eight 2001 CACREP core curricular experience areas were the pre-defined codes of interest. Because of the time span from which articles were analyzed (i.e., 1997–2006), the researchers determined that both an analysis of the 2001 and 2009 standards was appropriate given that the 2001 standards were adopted during this time period and analysis of the 2009 standards would provide insight as to how previous articles would fit into the future standards.
First, researchers independently analyzed the JCD articles using the 2001 standards. After independent analysis, the two researchers compared findings, identified matching results and noted findings on which they differed. A list was established identifying the articles on which the two researchers disagreed. The same two researchers independently reanalyzed these articles and then met to compare findings again. No comparisons were made between the first and second attempts in order to maintain the independence of the second analysis. After this second attempt, the researchers obtained a cross-rater reliability of .93 for the 2001 data. Of the remaining articles for which coding differed, 20 differed in coding for CACREP core area. These articles were equally distributed throughout the 10 years of JCD being analyzed and were not representative of a single time period or editor. These remaining articles were coded by a third researcher, once again independent of the first two analyses. The three coders then reviewed each article together and, through consensus, determined the best placement for each.
After completing analysis using the 2001 CACREP standards, the two researchers addressed the data using the 2009 CACREP standards. The researchers noted that the eight core CACREP area titles remained constant between 2001 and 2009. However, differences between the 2001 and 2009 standards included changes within the eight core areas. Changes typically included additions of specific counseling related practices into core areas. Within the Professional Orientation and Ethical Practice core, additions were made related to crisis management and counselor self-care. Under Social Cultural Diversity, counselor self-awareness, social justice, and cultural skill development were added. In the Human Growth and Development core, additions included the effects of crises on individuals and theories of resiliency. The Career Development core remained relatively unchanged. Helping Relationships added crisis response and wellness orientation. Group Work and Assessment core areas remained substantively unchanged while Research and Program Evaluation incorporated evaluative measures and ethics related to research (CACREP, 2009). One overall change appeared to be that culturally inclusive language was more represented across most of the core areas. With these changes in mind, the two researchers independently re-reviewed titles and abstracts of all articles for 2009 CACREP core area best fit.
Analysis
The total number of articles in the JCD 1997–2006 issues was 538, excluding minutes from ethics committees and calls for editorial board members. Researchers examined 479 out of the 538 possible articles. Fifty-nine articles (11%) were eliminated from coding including interviews of well-known counselors and reviews of other articles (typically found in the Trends section). These articles did not fit into the predetermined coding categories. In all cases, an attempt was made to select only one option per area. Coding was based on the core area which was most representative of describing the article. For the 2001 Standards, approximately 7% of the cases (35 of 479 articles), were impossible to fit into only one area, so two areas were selected for coding. Three additional articles needed two areas after being reanalyzed with the 2009 Standards. For example, some articles were equally about a client issue and how counselors could effectively address the issue. These articles were coded as representative of both the Human Growth and Development and Helping Relationships core areas. In the two cases that no CACREP core area was found to match the article, an ‘Other’ category was selected. This category was used only when both researchers found it impossible to connect the article to a CACREP area.
When analyzing JCD articles using the 2009 CACREP core areas, researchers identified 97 articles that required reanalysis. These 97 articles were fully analyzed again. Fifty-nine of the 97 articles remained unchanged from the original assigned coding. Three articles were changed from representing two core areas to just one core area. Six articles were changed from representing one core area to two core areas (included originally coded CACREP core area plus one additional CACREP core area). Twenty-nine articles were recoded to a new core area.
Results
Due to the fact that only 29 (6%) of the 479 articles differed across core areas coding from the 2001 to 2009 CACREP standards, and because the proportional ranks remain the same, researchers are providing the 2009 CACREP Standards results, as 2009 is the current standard. CACREP core area results are presented in Table 1. The core area with the most articles was Human Growth and Development, followed by Helping Relationships and Social and Cultural Diversity. Group Work, Research and Program Evaluation, and Career Development were the least represented core areas. Thirty-eight of the articles were coded in two core areas, and all of the core areas were represented at least twice in a two-coded article. Seventeen of the two-coded articles involved Social and Cultural Diversity, 15 involved Helping Relationships, and 14 involved Human Growth and Development.
Table 1
Rankings of core areas by percentage of articles tended to be stable throughout the 10-year focus period of this study. Human Growth and Development and Helping Relationships had the top two highest percentages of articles in the 10-year average and maintained consistently high percentages across the years, having been the first or second largest article category each year, except one. Within our analysis, these core areas formed the highest tier. Social and Cultural Diversity and Professional Orientation had the third and fourth highest percentages of articles and were ranked third or fourth each year (except one year for Professional Orientation and two years for Social and Cultural Diversity, affected by a special issue focused on that topic in 1999). Within our analysis, these core areas formed the middle tier. Assessment, Career Development, Research and Program Evaluation, and Group Work consistently varied from fourth to eighth in article percentages and formed the lowest tier of the rankings. These core areas not only occupied the lowest tier, but the percentages of articles representing them were noticeably lower than those representing the four leading core areas.
Table 2
Results by CACREP Core Areas across the ten year span are presented in Table 2. Over the 10-year period, most CACREP core areas are equivalently represented with minor fluctuations between years. Human Growth and Development and Helping Relationships are the two core areas most frequently represented and are reasonably consistent in percentage of articles representation from year to year across the 10 years. Human Growth and Development core area articles ranged in frequency from 8 to 19 across the years with a mean of 13.6 articles per year. Helping Relationships articles ranged from 6 to 16 with a mean of 12.1 articles published per year. Professional Orientation is the most consistent core area from year to year (range of 4 to 9 articles) with a moderate number (mean = 6.7) of articles published per year. Social and Cultural Diversity fluctuates substantially from year to year with a low of 2 articles published in 1997, a high of 30 articles in 1999 and a mean of 10.2 for all ten years. Assessment articles are relatively steady from year to year, yet low in number with a range from 0 to 7 articles each year and a mean of 2.9 articles per year. Research and Program Evaluation is similar to Assessment in low but steady frequency across the years with a range from 0 to 5 articles and a mean of 2.1 per year. Notably, Research and Program Evaluation articles increased slightly in the latter five years. Career Development is low in frequency, but less steady across the years with a range from 0 to 6 and mean of 2.8 articles per year. Notably, only 3 articles were published in this core area in the last three years of this study (i.e., 2004–2006), one article each year. Lastly, Group Work article frequency ranged from 0 to 3 and the lowest average frequency at .9 per year. In the last three years no articles were published in the Group Work core area.
Discussion
Having established the symbiotic relationship between four central counselor entities (i.e., CACREP, ACA, NBCC and JCD), the researchers focused their review on the overlap between the required CACREP training core and the topics represented in the counseling profession’s flagship journal, JCD. We were primarily interested in relating the content of articles from 1997–2006 to the eight CACREP core areas. When we began our study, we made the assumption that JCD and CACREP served as informative tools for its members and that CACREP standards were an appropriate measure of adequate counselor training. JCD purports “to publish articles that inform practicing professional counselors with diverse populations in a variety of settings and that address issues related to counselor education and supervision, as represented by the membership of the American Counseling Association” (JCD, n.d.). Whereas many specialty journals highlight one specific aspect or one core area, JCD attempts to provide relevant information that cuts across all CACREP core areas. Additionally, CACREP reports being “dedicated to (1) encouraging and promoting the continuing development and improvement of preparation programs, and (2) preparing counseling and related professionals to provide service consistent with the ideal of optimal human development” (CACREP, n.d.). In the counseling flagship journal and accrediting body, a goal exists to prepare, train, and provide counselors with information necessary to good clinical practice. As stated earlier, JCD is the journal representing ACA, and NBCC bases the NCE on current CACREP standards.
The results highlight an overlap between the missions and goals of JCD and CACREP with a weighted emphasis in key CACREP core areas. Results in Table 1 indicate that almost 70% of the articles published during this time period fall under three CACREP areas: Human Growth and Development, Helping Relationships, and Social and Cultural Diversity. It seems sensible and fitting to us that JCD articles would emphasize these areas. Remley and Herlihy (2007) stated that one of the essential beliefs in the counseling profession is that problems individuals face in life are developmental in nature. JCD’s emphasis on Human Growth and Development aligns with CACREP’s view that counseling helps clients work toward optimal human development. Additionally, the focus on Helping Relationships in JCD seems appropriate given the preponderance of research and literature across time that support relationship variables as most important in predicting outcome in counseling (e.g., Bergin & Lambert, 1978; Cochran & Cochran, 2006, Krumboltz, Becker-Haver, & Burnett, 1979; Lambert & Okiishi; 1997; Lubersky et al.,1986; Norcross, 2002; & Wampold, 2001). Finally, the 2009 CACREP standards support both a broad definition of Social and Cultural Diversity as a core area and the more specific recommendation of incorporating this concept into every course. This change relates to the current belief that cultural issues are not separate from other aspects of counseling, but rather integrated into all counseling activities.
Results indicated subtle yet notable shifts in the literature focus from those in previous research studies. For example, when Vacc (1992) investigated counselor educator perceptions of the CACREP standards relevance to the preparation of counselors, he found Social and Cultural Competence perceived as least relevant while results of the current study indicate Social and Cultural Diversity as in the middle tier of topic occurrence in JCD from 1996–2007. This seems to reflect the increased emphasis given to Social and Cultural Diversity within the counseling field in the last 20 years. Additionally, Vacc found Group Development and Dynamics was perceived as one of the core areas considered most relevant by counselor educators. The current study indicates that JCD articles focused on Group Work ranked in the lowest tier of frequency of occurrence. This could indicate a shift in importance over time or incongruence between counselor educator perceived importance and the number of JCD articles published in core areas. Finally, whereas group counseling and vocational development were covered extensively in JCD in the mid-1980s and early 1990s (William & Buboltz, 1999), our findings demonstrated considerably less focus on these areas over the last 10 years. Clearly, some important shifts in the literature have occurred over the past 25 years.
We find it important to also note the match between the ranked frequencies of JCD articles within the CACREP core areas and the results of McGlothlin and Davis’ (2004) study of the core areas perceived benefits. McGlothlin and Davis’ survey results ranked counselors’ perceptions of the importance of the core areas in nearly the exact rank of article frequency in JCD by core area. This suggests an overall match between publication patterns of JCD and the valuing of CACREP core areas among counselors.
Implications for Counselor Educators and Practitioners
It is clear that the articles published in JCD follow many of the trends suggested by CACREP as training requirements for counselors. If, however, as the earlier statistics suggest, JCD is the only professional journal received by the majority of ACA members, it is important for practitioners to recognize that they may not regularly be receiving as much ongoing information in these core areas compared to others, especially if they are only receiving JCD. Career development is viewed as a central factor in the lives of most people (Betz & Corning, 1993). For counselors working with children and adolescents, career development is influenced by a multitude of factors, including perceived barriers and supports (Kenny, Blustein, Chaves, Grossman, & Gallagher, 2003), family background (Eccles, Vida, & Barber, 2004), and self-efficacy beliefs (Pinquart, Juang, & Silbereisan, 2003). In adults, career-related concerns are linked with traumatic experiences (Strauser, Lustig, Cogdal, & Uruk, 2006), relationship problems (Risch, Riley, & Lawler, 2003), and overall stress (Pinquart et al.). Clearly, most counselors will encounter a need to discuss career-related issues with their clients, yet findings suggest that counselors may not receive a robust and ongoing supply of contemporary theoretical or research-based treatment approaches on this topic in JCD.
In addition, many counselors have the opportunity to facilitate groups as a part of their work. Vacc’s (1992) finding that counselor educators perceived Group Development and Dynamics as one of the most relevant core areas to the preparation of counselors and McGlothlin and Davis’ (2004) finding that Group Work ranked fourth in perceived benefit of the CACREP standards suggests that Group Work may be of importance to current working counselors, even though it is not well represented in JCD. Continuing education through professional journals can be a way to keep counselors-in-training, practicing counselors, supervisors and counselor educators abreast of new research and ideas regarding career and groups. Counselor educators, as well as clinical supervisors and counseling practitioners, would benefit by realizing that supplemental journals are needed to ensure adequate information on group dynamics is reaching their students and supervisee’s or informing their counseling practice.
Research and Program Evaluation and Assessment also received less representation in JCD. Counselors-in-training often struggle with these subjects or report disliking the bland content of these courses (Stockton & Toth, 1997). In fact, Bauman (2004) surveyed school counselors and found only 49% agreed or strongly agreed that they felt prepared to critique research, and only 43% agreed or strongly agreed that they had the skills needed to complete a research project on their own. Currently, a call in the profession exists promoting practitioners to conduct research in the field (Kaffenberger, 2009; Niles, 2003; Whiston, 1996), but with these feelings about research and assessment, it is unlikely that many will do so. Practitioners need to look beyond JCD for professional development on becoming competent and self-assured researchers. Knowing that a single journal is not the best option for gaining research self-efficacy might push practitioners to seek help elsewhere, rather than simply continuing on without furthering their knowledge.
Counselor educators and students can benefit in general from the findings of this study. For example, when conducting literature reviews or submitting research manuscripts for review, results provide guidance as to which counseling-related topics are more frequently or less frequently addressed in JCD. Results help to inform counselor educators when to best use and recommend JCD as an initial resource or different journal when they or their students are investigating specific topics within CACREP core areas. Additionally, one could argue that results suggest a reason to join multiple professional counseling organizations such as ASCA or AMHCA, or join the smaller sub-interest groups (e.g., National Career Development Association and Association of Specialists in Group Work) when first joining ACA or renewing their ACA membership. Overall, having more information available on major sources of training and continuing education can only assist practitioners and educators in their roles.
Implications for Future Research
Although this study provides an analysis of JCD articles over a 10-year period, with CACREP guidelines, additional research in this area is needed. Several ideas for future research foci are provided as preliminary courses of action. Researchers could help to identify students’, counselor educators’ and working counselors’ perceptions as to the importance of some of the lesser represented areas, such as Career and Group. Additionally, perceptions from these same constituents on how JCD, ACA, NBCC, and/or CACREP shape their views of the counseling field seems to be worthy of investigation. More research focused on specific CACREP areas and articles from other journals (e.g., the types of articles that represent each CACREP area and the impact on continuing education and training of future counselors) would further illuminate the relationship between the accrediting body and the counseling journals in general. Regardless of the exact focus of future research, it is clear that there is a link between the counseling accrediting body and the flagship journal. Further research is needed into how JCD and other counseling journals, along with CACREP and NBCC, may have or will influence each other over time.
Conclusion
It is our hope that the findings of the present study will be included in the perpetual input loop linking ACA, NBCC, JCD, CACREP and the counseling profession. With CACREP’s 2009 accreditation standards being implemented, we believe now is a good time for the counseling profession to re-examine the roles of the major counseling entities’ relationships to each other. Continuing this discussion, especially focusing on CACREP and ACA, may help strengthen the unity of our profession and further cement our identity as professional counselors.
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Joel F. Diambra, NCC, Melinda M. Gibbons, NCC, Jeff L. Cochran, NCC, and Shawn Spurgeon, ACS, teach Counselor Education at the University of Tennessee at Knoxville. Whitney L. Jarnagin, NCC, teaches at Walters State Community College. Porche’ Wynn is a counselor education doctoral candidate at the University of Tennessee. Correspondence can be addressed to Joel F. Diambra, University of Tennessee at Knoxville, 449 Claxton Complex, 1122 Volunteer Blvd. Knoxville, TN, 37996-3452, jdiambra@utk.edu.
Jul 11, 2014 | Article, Volume 4 - Issue 3
Matthew R. Buckley
It is a pleasure to introduce this special DSM-5 edition of The Professional Counselor, which provides a solid primer regarding changes in the DSM-5 diagnosis process and how these changes will likely impact mental health professionals. Changes within the DSM-5 have prompted counselors to revisit the basics of diagnosis and consider the cessation of certain conventions (e.g., the multiaxial system) and what these changes mean to counselors as they perform their vital work for the benefit of clients. The unprecedented inclusion of various mental health professionals in the development of the DSM-5 is an inherent recognition of how this tool is being used across a wide range of professional disciplines that focus on psychopathology. I hope these articles not only inform, but encourage further research into the practical use of the DSM-5, “stimulate new clinical perspectives” in mental illness (American Psychiatric Association [APA], 2013, p. 10), and inspire continued professional dialogue around DSM nosology and the diagnostic processes.
Keywords: DSM-5, diagnosis, psychopathology, mental illness, multiaxial system
The fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) is an update of a major diagnostic tool (APA, 2013). The manual was originally designed to help mental health professionals within a wide variety of disciplines assess and conceptualize cases in which people were suffering from mental distress. This conceptualization is important in that it facilitates an understanding in a common language toward the development of treatment planning to address complex and entrenched symptomology. The DSM has undergone numerous iterations and represents the current knowledge of mental health professionals about mental illness (APA, 2013). One of the primary aims of the DSM-5 workgroups was to align the manual with the current version of the International Classification of Diseases (ICD-9). In addition, political, social, legal and cultural dynamics influenced the development of the DSM-5—and not without controversy (Greenberg, 2013; Locke, 2011; Linde, 2010; Pomeroy & Anderson, 2013). As with any tool, concerns have emerged about the potential of misuse. It is the professional responsibility of skilled and ethical mental health counselors and other professionals to prevent misapplication of the manual (American Counseling Association [ACA], 2014, E.1.b, E.5.a–d). Walsh (2007) succinctly noted that “the primary goal of the DSM is to enhance the care of individuals with psychiatric disorders” (p. S3).
The introduction of the DSM-IV-TR states that the DSM has been used by numerous mental health practitioners (APA, 2000), with no mention of their investment as legitimate stakeholders in the process of DSM development. Well before the final revision of the DSM-5, various mental health professionals, organizations and other relevant collaborators helped formulate the manual in unprecedented capacities. In the introduction to the DSM-5 (APA, 2013) the authors intentionally state that numerous stakeholders were involved in DSM-5 development including counselors and “patients, families, lawyers, consumer organizations, and advocacy groups” (p. 6). Of particular note was the inclusion of national organizations such as the ACA in the form of a DSM-5 task force, which submitted position statements and recommendations to the APA. Various mental health professionals participated directly in the formulation of the DSM-5, primarily in field trials which “supplied valuable information about how proposed revisions performed in everyday clinical settings” (p. 8). Much of the data supports the use of more than 60 cross-cutting and severity symptom measures (see http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures).
Clinical Utility
First (2010) reported that utilizing broad and diverse populations of mental health professionals provides rigor for clinical utility. Achieving clinical utility within the DSM diagnostic processes meets the following four objectives:
to help clinicians communicate clinical information to other practitioners, to patients and their families, and to health care systems administrators;
to help clinicians implement effective interventions in order to improve clinical outcomes;
to help clinicians predict the future in terms of clinical management needs and likely outcomes; and
to help clinicians differentiate disorder from non-disorder for the purpose of determining who might benefit from disorder-based treatments. (First, 2010, p. 466)
Any changes to the DSM were framed within the context of how they might be utilized by all mental health professionals, including revisions to definitions of diagnoses and symptoms, proposed diagnostic categories, dimensional assessment (including cross-cutting), and a renewed emphasis on severity specifiers. Ultimately, the consideration was whether the revised manual would be accepted and utilized by the practitioners it proposed to serve (APA, 2013; First, 2010). First (2010) noted that no mandate exists requiring the use of the DSM by any professional, and that other tools used to arrive at an ICD diagnosis exist or are in development (e.g., the NIMH Research Domain Criteria initiative; APA, 2013; Nussbaum, 2013). The DSM-5 workgroups were challenged to revise the manual in order to make it user-friendly and maintain its relevance among mental health professionals. Even though the manual is an imperfect resource, the goal was to enhance clinical utility.
Determining a Differential Diagnosis
In his primer on diagnostic assessment focused on the DSM-5, Nussbaum (2013) offers six considerations in determining a differential diagnosis that serve as an important basis for practice. These considerations or steps include the following:
to what extent signs and symptoms may be intentionally produced;
to what extent signs and symptoms are related to substances;
to what extent signs and symptoms are related to another medical condition;
to what extent signs and symptoms are related to a developmental conflict or stage;
to what extent signs and symptoms are related to a mental disorder; and
whether no mental disorder is present.
Each of these process steps serves as important reminders for getting back to the basics of rendering diagnoses that help inform treatment. When working with clients, these steps function as points of reference to rule out potential factors influencing misdiagnosis. Additionally, client cultural factors are essential at capturing comprehensive context for assessment and diagnosis.
Consider to what extent signs and symptoms may be intentionally produced. Signs and symptoms may be purposely feigned on the part of a client for secondary gain (e.g., financial benefits, drug seeking, disability status, attention from others, reinforcement of an identity of pathology, avoiding incarceration). Counselors must recognize the context in which signs and symptoms occur and pay attention when something does not “fit” with how a client presents for treatment. Assessing prior mental health treatment (including outcomes), cultural factors and potential motives to fake an illness can assist counselors in making an accurate differential diagnosis.
Consider to what extent signs and symptoms are related to substances. A wise and influential professor and mentor during my graduate training said, “Always assess for substance use!” Clients can present with a variety of conditions that are induced by prescription or over-the-counter drugs, illicit substance, or herbal supplements (Nussbaum, 2013). An important emphasis within the DSM-5 is substance-use and substance-induced disorders, which are included in many relevant diagnostic criteria (APA, 2013). Counselors are well-advised to make this determination in the initial assessment and continue to assess throughout the course of treatment.
Consider to what extent signs and symptoms are related to another medical condition. Clients present with signs and symptoms that may be caused by or coincident with another medical condition in a variety of ways. Nussbaum (2013) defined possible manifestations including (a) medical conditions that directly or indirectly alter signs and symptoms, (b) treatments for medical conditions that alter signs or symptoms, (c) mental disorders and/or treatments that may cause or exacerbate medical conditions, or (d) both a mental disorder and a medical condition that are not causally related. Counselors should gather medical information from the client and appropriately follow up with medical personnel as needed to ensure proper and accurate diagnosis, which will lead to more targeted and effective treatment.
Consider to what extent signs and symptoms are related to a developmental conflict or stage. A primary strength of counseling professional identity is the focus on human development as a key factor in client distress and resiliency. The counseling practice of “meeting clients where they are” includes where they are developmentally. Counselors must recognize where incongruence exists between what clients present and the expected behaviors or characteristics of their particular developmental stage. Nussbaum (2013) stresses the importance of gathering a comprehensive psychosocial history to determine expected developmental milestones. Being on the lookout for developmental delays, regressive behaviors of an earlier developmental period, primal defense mechanisms, or signs of “a developmental conflict in a particular relationship” (p. 201) will help ensure that all essential contextual factors are addressed when making a diagnosis.
Consider to what extent signs and symptoms are related to a mental disorder. The definition of mental disorder has not changed significantly from previous versions of the DSM: a mental disorder is “a syndrome characterized by clinically significant disturbance in…cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes…[and] usually associated with significant distress or disability in social, occupational, or other important activities” (APA, 2013, p. 20). Identifying mental disorders, or the process of diagnosis, involves more than clear-cut observations and often includes the consideration of complex factors involving comorbidity, symptom clusters “that may be part of a more complex and unified syndrome that has been artificially split in the diagnostic system” (Nussbaum, 2013, p. 202), overlap between diagnostic criteria, genetic predisposition, and the mutual influence of two or more conditions. Counselors must be careful to consider the presence of these factors, consult when necessary, and take into account differential diagnosis to determine the most appropriate diagnosis given the verbal and observable data available.
Consider whether no mental disorder is present. Sometimes a client may present with symptoms that do not meet the full diagnostic criteria for a mental disorder, despite significant distress in social, occupational or other areas of functioning. In these cases, utilizing the not otherwise specified or unspecified diagnoses may be warranted in order to provide opportunities for deeper inquiry. For example, the symptoms of a disorder may be a secondary reaction to an identifiable social stressor that may justify a diagnosis of an adjustment disorder. The possibility exists that there may not be a diagnosis present (Nussbaum, 2013), and in these cases, counselors and other mental health professionals are challenged to make that decision in the face of pressures to diagnose.
Cultural Implications
It is imperative that counselors take their clients’ social and cultural influences into account when assessing and diagnosing. Culture impacts all aspects of diagnosis and treatment, including how and when treatment is sought; power differentials between clients and mental health professionals; the age, gender, ethnicity, race, religion, sexual orientation, and socioeconomic status of both clients and mental health professionals; how illness is defined by both; and how problems are conceptualized and addressed within the context of culture (Lewis-Fernández et al., 2014; Tomlinson-Clarke & Georges, 2014).
Two decades of experience using the Outline for Cultural Formulation (OCR), which was introduced in the DSM-IV (APA, 1994), evolved into the Cultural Formulation Interview (CFI) now contained in the DSM-5, comprised of 16 semi-structured questions designed to collect data in a more consistent and efficient manner. Like other dimensional, cross-cutting and severity measures developed specifically for the DSM-5, the CFI was field tested at 12 sites representing several countries to determine feasibility and usefulness (Lewis-Fernández et al., 2014). For the first time, culture in its varied manifestations has been intentionally incorporated into the DSM nosology through a specific assessment instrument. “The CFI follows a person-centered approach to cultural assessment…designed to avoid stereotyping, in that each individual’s cultural knowledge affects how he or she interprets illness experience and guides how he or she seeks help” (APA, 2013, p. 751). Counselors are encouraged to utilize the CFI as a way to understand their clients more meaningfully and to aid in clinical utility.
The TPC Special Issue: Counseling and the DSM-5
Because the DSM-5 is a tool for mental health professionals to utilize in their conceptualization of client distress, understanding how to use the DSM effectively is at the heart of this special issue published by The Professional Counselor (TPC). Readers will find a variety of articles that will assist mental health professionals by providing important context for most of the salient changes within the DSM-5 (APA, 2013) from the perspective of professional counseling. Inherent in each of these contributions is the theme of getting back to the basics in not only understanding the DSM-5 conceptually, but also providing ideas for putting concepts into practice.
An essential element in understanding and using the DSM-5 effectively is exploring the foundational and historical roots of this complex nosology. Dailey, Gill, Karl, and Barrio Minton (2014); Gintner (2014); and Kress, Barrio Minton, Adamson, Paylo and Pope (2014) offer excellent overviews of salient changes within the DSM-5 that impact clinical practice, including how the DSM has evolved over time. While there is necessary redundancy on key points (e.g., elimination of the multiaxial format, implementation of cross-cutting symptom measures, closer alignment with the ICD coding system), each article provides an important and unique perspective. Dailey et al. (2014) offer important perceptions on changes within the DSM-5 including how changes evolved historically and the philosophical foundations behind those changes, especially those that clash with the philosophical underpinnings of counseling. The authors review the implications of such changes for professional counselors. Gintner (2014) provides an excellent context regarding the harmonization of the DSM-5 with the ICD, the inclusion of cross-cutting symptom measures and dimensional assessment, and how the manual is organized. The article focuses on how counselors might respond to these changes. Kress et al. (2014) offer an important perspective on the removal of the multiaxial convention used by mental health professionals for over three decades and the implications for counselors in the practice of assessment and diagnosis. These authors provide an important context for the decision to terminate the multiaxial system including advantages and disadvantages of DSM-5 changes.
King (2014) describes the practical application of diagnostic criteria and the use of cross-cutting dimensional assessments. This perspective offers a backdrop on which to compare current practice and how it may alter with use of the DSM-5. This article focuses on clinical utility and ensuring that the DSM-5 remains a guide to assessment, diagnosis and treatment. Schmit and Balkin (2014) give a comprehensive review of the cross-cutting, dimensional and severity measures from the perspective of psychometric instrumentation, including the practical application of validity and reliability. These authors underscore DSM-5 assessments as soft measures and provide important cautions to counselors using these instruments in their work with clients, including the importance of developing multiple data points.
Understanding specific diagnostic categories is essential to good clinical practice. Welfare and Cook (2014); Kenny, Ward-Lichterman and Abdelmonem (2014); and Jones and Cureton (2014) provide solid descriptions of specific diagnostic criteria and emphasize areas essential to our understanding of developmental and demographic strata. Welfare and Cook (2014) tackle chronic and persistent mental illness manifested in diagnoses within the following categories: schizophrenia spectrum and other psychotic disorders, bipolar and related disorders, and depressive disorders. Clinical examples help contextualize the process of assessing and diagnosing these disorders and provide a detailed example of effectively utilizing each step of the diagnostic process. Kenny et al. (2014) provide a cogent overview of the changes made to the “Feeding and Eating Disorders” chapter, including the addition of binge eating and avoidant/restrictive food intake disorders, severity criteria for anorexia nervosa based on body mass indexes, and how the diagnosis of eating disorder not otherwise specified (EDNOS) has changed as a result. Jones and Cureton (2014) offer important perspectives on significant changes to the “Trauma- and Stressor-Related Disorders” chapter and how these changes may impact clinical practice. The authors discuss how diagnostic criteria have been developed for both children and adults and how cross-cutting symptoms (e.g., panic and dissociation) manifest in a range of disorders. Another significant change to this category is the acknowledgement of sexual abuse as a traumatic event; this takes post-traumatic stress disorder (PTSD) out of the often associated realm of combat veterans and into more common and insidious manifestations of trauma.
Counselors should consider the aforementioned changes to the DSM-5 in the context of their counselor identity. Maintaining professional identity and promoting a wellness- and strength-based perspective continues to be an important concern for the counseling profession and the training of counselors. Tomlinson-Clarke and Georges (2014) provide an overview of maintaining professional identity in the process of assessment and diagnosis within a system representing the medical model. A particular strength is the inclusion of how multicultural competency is crucial in using the DSM-5 effectively, which is an essential basic foundation to sound practice. Implications for counselor preparation also are a focus. Finally, Frances (2014) provides a critical commentary of how the DSM has been used by pharmaceutical companies to leverage significant profits at the cost to consumers of mental health services and our economy. As the former chair of the DSM-IV task force, Frances reminds counselors and other mental health professionals of their essential place within treatment and cautions counselors to use the DSM in a balanced manner. His comments are consistent with advocacy inherent in our profession for treatments that promote client resilience, and address psychosocial and environmental factors that impact client functioning.
Conclusions
This special TPC issue on counseling and the DSM-5 provides a compilation of articles covering the history of the DSM, structural and categorical changes, the process of diagnosis, implications for practice, and cautions and criticisms. These articles validate the unique and important perspective counselors bring to their work, and challenge all mental health professionals to use the DSM-5 accurately. The DSM continues to evolve, and its advocates have made significant strides in reaching out to a variety of professionals; one manifestation of this outreach is the development of the DSM-5 website (see http://www.psychiatry.org/practice/dsm/dsm5). Counselors have the opportunity to use the DSM-5, provide feedback directly to the APA, and help shape and influence future editions of this diagnostic tool. This is an important way counselors can advocate for their clients as well as their profession, and shape how the DSM is used to help treat those suffering from mental and emotional distress.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest or funding contributions for the development of this manuscript.
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Matthew R. Buckley, NCC, is a faculty member in the Mental Health Counseling program at Walden University, Minneapolis, MN. Correspondence can be addressed to Matthew R. Buckley, Walden University, 100 Washington Avenue South, Suite 900, Minneapolis, MN 55401-2511, matthew.buckley@waldenu.edu.
Jul 10, 2014 | Article, Volume 4 - Issue 3
Stephanie F. Dailey, Carman S. Gill, Shannon L. Karl, Casey A. Barrio Minton
Regardless of theoretical orientation or work setting, professional counselors should have a thorough understanding of the American Psychiatric Association’s (APA) fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This article includes an overview of the most recent revision process and identification of key structural and philosophical changes in the DSM-5. The authors conclude with a summary of practice implications for counselors, including specific guidance for recording diagnoses, using diagnostic specifiers and incorporating emerging assessment measures.
Keywords: DSM-5, diagnosis, diagnosis specifiers, assessment, American Psychiatric Association
By definition, counseling is a professional relationship between client and counselor based on empowerment, rooted in diversity, and committed to accomplishing mental health, wellness, education and career goals of individuals, families and groups (Kaplan, Tarvydas, & Gladding, in press). To accomplish these goals, counselors often include diagnosis as an essential component of the counseling process. Even counselors who work in settings where they are not traditionally responsible for diagnostic assessment must possess a comprehensive understanding of diagnostic nosology and nomenclature. Such an understanding helps providers recognize diagnostic concerns and participate in interdisciplinary discussions and treatment decisions regarding consumers who experience distress or disability. Despite competitors such as the ICD-10 Classification of Mental and Behavioural Disorders (World Health Organization [WHO], 1992), the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) is the world’s standard reference for evaluation and diagnosis of mental disorders (Eriksen & Kress, 2006; Hinkle, 1999; Zalaquett, Fuerth, Stein, Ivey, & Ivey, 2008).
The purpose of this article is to present major structural and philosophical changes within the DSM-5 (APA, 2013) in order to make those changes more accessible to counselors. We, the authors, describe how these changes translate to current counseling practice and how they will help counselors utilize the revised nomenclature system. To better understand these changes, we believe it is important to first review development of the DSM and the most recent revision process.
History of the DSM
The original DSM was psychiatry’s first attempt to standardize mental illness classification. Published in 1952 by the APA, the DSM represented an alternative to the WHO’s sixth edition of the ICD that included a section on mental disorders for the first time (APA, 2000). Focused on clinical utility, the first DSM was grounded in psychodynamic formulations of mental disorders (Sanders, 2011). Emphasizing Adolf Meyer’s psychobiological view, this version of the manual claimed that mental illness represented “reactions” of the personality to psychological, social or biological aspects of client functioning (APA, 2000). A particularly noteworthy characteristic of the DSM’s first edition is that of the 106 conditions it included, only one diagnosis—adjustment reaction of childhood/adolescence—was relevant to youth (Sanders, 2011).
The APA published the next iteration, the DSM-II, in 1968. This version included 11 diagnostic categories and 182 disorders (APA, 1968). Reflecting significant changes in theoretical ideology, the focus of the manual shifted from psychopathology (i.e., reactions) to psychoanalysis (i.e., neuroses and psychophysiological disorders; Sanders, 2011). Authors of the DSM-II maintained a narrative focus when describing disorders.
APA began working on the DSM-III in 1974 and published it in 1980. This iteration differed significantly from previous editions and represented a dramatic shift to a more medically focused model (APA, 1980; Wilson, 1993). Authors of the DSM-III stressed use of empirical evidence to develop diagnoses and claimed theoretical neutrality, signaling a clear attempt to separate the DSM from its psychoanalytic origins (Maser, Kaelber, & Weise, 1991). A new multiaxial system included attention to biopsychosocial conceptualization. For the first time, the DSM-III contained descriptive diagnoses with a focus on positivistic, operationally defined and explicit diagnostic criteria (Wilson, 1993); narrative text also included information such as familial patterns, cultural considerations and gender (Sanders, 2011). The age of empirically based treatments had arrived, and widespread use of the DSM-III became commonplace.
Intended at first only to include minor changes, the APA published substantial modifications to text and diagnostic criteria within the DSM-III-R (1987); as a result, a number of scholars criticized the document intensely (APA, 2000; Blashfield, 1998; Scotti & Morris, 2000). Expanding to 297 diagnoses, Axis I descriptions nearly exceeded 300 pages, while attention to Axes IV and V remained limited to just a few pages. Many scholars continued to question the multiaxial system and validity of field trials (Rogler, 1997).
Heavy critique of the DSM-III and the DSM-III-R led to relatively mild changes to the DSM-IV, published in 1994 (APA, 2000). At nearly seven times the length of the original DSM, this version totaled 365 diagnoses in 886 pages. A text revision (DSM-IV-TR) published in 2000 included wording modifications to ensure nonstigmatizing, person-first language (Scotti & Morris, 2000). The APA also included empirically based information for each diagnosis and diagnostic code modifications to maintain consistency with the ICD-9 (APA, 2000). Like its predecessors, the DSM-IV-TR was heavily critiqued by scholars due to a heavy emphasis on a medical model and rigid classification systems (Eriksen & Kress, 2006; Ivey & Ivey, 1998; Scotti & Morris, 2000). Issues of comorbidity, questionable reliability, controversial diagnoses and excessive use of not otherwise specified (NOS) diagnoses were hot topics among critics (Beutler & Malik, 2002). APA identified these issues as driving forces for structural and philosophical changes in the DSM-5 (APA, 2013).
The DSM-5 Revision Process
Beginning in 1999, one year before the APA published the DSM-IV-TR, the APA began working on a new edition, which would be more scientifically based, increase clinical utility and maintain continuity with previous editions (APA, 2014a). APA released an initial research agenda focused on nomenclature, neuroscience, developmental science, personality disorders, and the relationship between culture and psychiatric diagnoses (APA, 2000; Kupfer, First, & Regier, 2002). The APA, the National Institute of Mental Health (NIMH), and the WHO held 13 conferences between 2004 and 2008 in which stakeholders discussed relevant diagnostic questions and solicited feedback regarding potential changes in nosology. Resulting themes facilitated the research base and fueled the agenda of the DSM-5 working groups (see Kupfer et al., 2002 for the full DSM-5 research agenda).
In 2007, the APA officially commissioned the DSM-5 Task Force, made up of 29 members including David J. Kupfer, M.D., Chair; and Darrel A. Regier, M.D., M.P.H., Vice-Chair (APA, 2014a). Kupfer and Regier provided clear direction to eradicate the use of NOS diagnoses, eliminate functional impairment as necessary components of diagnostic criteria, and use empirically based evidence to justify diagnostic revisions (Gever, 2012; Reiger, Narrow, Kuhl, & Kupfer, 2009). With these marching orders, each working group proposed draft criteria and justification for changes.
Between April 2010 and June 2012, the DSM-5 Task Force facilitated three rounds of public comment and two field trials (Clarke et al., 2013; Jones, 2012a; Narrow et al., 2013; Regier et al., 2013). The APA Board of Trustees reviewed final revisions in December 2012 and published the DSM-5 in May 2013. Although no professional counselors were invited to serve on the DSM-5 Task Force, several professional counseling associations served as important advocates during the revision process (Dailey, Gill, Karl, & Barrio Minton, 2014).
Major Structural Changes
The general format of the DSM-5 (APA, 2013) is quite different from that of the DSM-IV-TR (APA, 2000). Although roughly the same number of disorders is included in both editions, structural similarities end here. The DSM-5 (APA, 2013) includes three major sections, revised chapter organization, cross-cutting symptom and severity measures, adoption of a nonaxial system and enhanced coverage of cultural considerations (Dailey et al., 2014). As with previous versions, the text includes a number of appendices related to terminology and coding.
Section I: DSM-5 Basics
Section I of the new manual includes an introduction to the DSM-5 (APA, 2013) and general instructions on how to use the updated manual, including attention to nonaxial diagnosis and coding considerations. Counselors who diagnose in accordance with the DSM-IV-TR (2000) may be surprised to see that the APA eliminated both the multiaxial classification system and the Global Assessment of Functioning (GAF) scale. Never required for diagnosis, the APA removed the multiaxial system on the premise that it may lead to inaccurate, oversimplified conceptualization regarding complexities of physical, biological and emotional concerns. Furthermore, removal of the GAF was due to claims of insufficient clinical utility and reliability.
Less radical structural changes discussed in Section I include harmonization of language with the forthcoming ICD-11. The DSM-5 (APA, 2013) incorporates two sets of ICD codes: ICD-9 codes (for immediate use, presented in black print) alongside ICD-10 codes (for use upon nationwide conversion to ICD-10-CM coding expected October 1, 2015, presented in parentheses and in gray print). In addition, authors address consideration for implementing new other specified and unspecified disorder criteria, which present more specific alternatives to previous NOS diagnoses.
Section II: Diagnostic Criteria and Codes
Section II includes 20 diagnostic classifications or chapters, four more than the DSM-IV-TR (2000), and a significantly revised organization with attention to development and etiology in hopes of enhancing clinical utility (Brown & Barlow, 2005; Kupfer et al., 2002). For example, classifications more frequently diagnosed in childhood and believed to have similar root causes, such as neurodevelopmental disorders (most of which were formerly known as disorders usually diagnosed in infancy, childhood or adolescence), appear first. Diagnostic classifications more commonly seen in older adults and believed to have similar root causes, such as neurocognitive disorders (most of which were formerly known as delirium, dementia, and amnestic and other cognitive disorders), appear much later in the text.
The DSM-5 Task Force reorganized disorders into new chapters based on research regarding etiology as well as similarity in symptom experience or manifestation. For example, anxiety disorders, which were previously grouped together, now appear in three distinct chapters: “Anxiety Disorders,” “Obsessive-Compulsive and Related Disorders,” and “Trauma- and Stressor-Related Disorders.” Extrication of trauma- and stressor-related disorders allows diagnoses that result from traumatic external events or triggers to be grouped together in a more meaningful way (APA, 2013). Because they are diagnostically unique yet often triggered by traumatic events, the chapter “Dissociative Disorders” immediately follows the chapter “Trauma- and Stressor-Related Disorders.”
The DSM-5 Task Force also attended to etiology and development when choosing the order of diagnoses within chapters. This represents a shift from presenting more highly specified disorders first in previous editions of the manual. For example, the chapter “Feeding and Eating Disorders” opens with diagnostic criteria for pica, rumination disorder and avoidant/restrictive food intake disorder (previously classified as disorders usually first diagnosed in infancy, childhood and adolescence) before covering disorders more classically associated with adolescence and adulthood (e.g., anorexia nervosa, bulimia nervosa, binge-eating disorder).
Section III: Emerging Measures and Models
Counselors should not overlook the third and final section of the DSM-5 (Dailey et al., 2014). Section III includes a variety of measures and models in development, including assessment measures, cultural formulation tools, a proposed personality disorders model and conditions for further study (e.g., Internet gaming disorder, nonsuicidal self-injury). Section III does not represent formal changes in nosology or diagnostic processes; rather, most elements are included to enhance clinical use by clinicians and fuel investigations by researchers.
Proposed assessment measures comprise a major component of Section III. Level 1 cross-cutting symptom measures are tools designed to screen for a broad range of presenting concerns in adults (13 domains) and children (12 domains). In turn, Level 2 cross-cutting symptom measures facilitate more focused assessment of Level 1 domains flagged as concerning. The print version of the DSM-5 also includes a sample dimensional assessment related to psychosis and a reprinting of the WHODAS 2.0, a tool to assess disability and impairment. Most proposed assessment measures are not included in the print version of the DSM-5. For example, the DSM-5 website currently includes many Level 2 cross-cutting symptom measures and disorder-specific severity measures intended to be used as dimensional assessments for some of the most frequently diagnosed concerns. Counselors can find more information about these tools and additional dimensional assessment tools not included in the print version of the DSM-5 by viewing Online Assessment Measures (APA, 2014b) and reading resources provided by Jones (2012b) and Narrow et al. (2013).
Finally, authors of the DSM-5 (APA, 2013) devoted special attention to diverse ways in which individuals experience and describe distress. This fosters accurate communication so that counselors may better differentiate pathology from nonpathology when working with diverse clients (Dailey et al., 2014). As we will discuss below, counselors may use the cultural formulation interview to talk with clients about symptoms, cultural understanding of concerns and implications for treatment. The DSM-5 Appendix also includes a glossary of cultural concepts of distress.
Major Philosophical Changes
Two major philosophical changes will modify the ways in which counselors approach diagnosis, assessment and communication with other professionals when using the DSM-5 (Dailey et al., 2014). The first is movement away from a purely descriptive diagnostic model (i.e., a traditional medical perspective) toward a neurobiological model. This approach is grounded in client functioning as opposed to strict pathology, and includes research in genetics, neuroimaging, cognitive science and pathophysiology (Kupfer et al., 2002). The second philosophical change is a shift away from a strictly categorical classification system toward a more dimensional approach to nosology (Dailey et al., 2014).
A Neurobiological Perspective
The first major philosophical change involves a shift in focus from phenomenological interpretations toward identifiable pathophysiological origins (Dailey et al., 2014; Kupfer et al., 2002). Simply stated, the traditional medical model focuses on treating the problem, and the newer functional model focuses on treating and better understanding the problem. Diagnostic assessment has shifted from what to what and why. Previous iterations of the DSM based disorders purely on symptom identification and behavioral observations. As mentioned previously, APA reordered this iteration of the manual to align more clearly with a pathophysiological model that includes attention to etiology, neuroscientific evidence and functional changes associated with or resulting from disease or injury. This shift is consistent with national priorities for deeper understanding of mental illness (Kupfer & Reiger, 2011).
The DSM-5 Task Force incorporated text regarding neurobiology throughout the document, including standing descriptions of genetic and physiological risk factors, prognostic indicators and biological markers that may impact one’s experience with disorder. As noted previously, the lack of clear differentiation between mental and physical disorders served as a major reason for removal of the multiaxial system. The DSM-5 also includes several semantic changes that are philosophical, and possibly strategic, in nature. Whereas the DSM-IV-TR included reference to general medical conditions, the DSM-5 references disorders due to another medical condition. This implies that mental health concerns are, in essence, medical concerns. These seemingly innocuous philosophical shifts send a powerful message regarding the nature of a disorder and, in turn, assumptions about treatment.
As noted in the section regarding structural changes, some diagnostic classifications that were combined previously due to analogous symptomology now stand alone because of research regarding disorder etiology. Aside from the previously mentioned division of anxiety disorders into three separate classifications, mood disorders have been divided into two distinct chapters: “Bipolar and Related Disorders” and “Depressive Disorders.” This philosophical and in some cases structural modification is intended to reflect an emphasis on improved clinical utility and to “encourage further study of underlying pathophysiological processes that give rise to diagnostic comorbidity and symptom heterogeneity” (APA, 2013, p. 13). An example of “underlying pathophysiological processes” is the previous placement of attention-deficit/hyperactivity disorder (ADHD) as a disruptive behavior disorder within the first chapter of the DSM-IV-TR. Given abundant genetic links to ADHD (Rowland, Lesesne, & Abramowitz, 2002), it did not make sense for ADHD to continue as a disruptive disorder alongside oppositional defiant disorder and conduct disorder. ADHD is now classified within the neurodevelopmental disorders chapter of the DSM-5.
In accordance with a neurobiological perspective, the DSM-5 Task Force eliminated the chapter “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” and replaced it with a neurodevelopmental disorders chapter. Disorders not considered neurodevelopmental in nature are no longer included in this chapter. For example, reactive attachment disorder, which originates from gross pathological care during infancy, is now located within the chapter “Trauma- and Stressor-Related Disorders.” There also were other reasons for removing the chapter on disorders usually first diagnosed in infancy, childhood, or adolescence, such as the erroneous insinuation that these disorders manifest only in early development (Dailey et al., 2014).
Despite these changes, the impact of this shift was not as significant as neurobiologists would have hoped (Dailey et al., 2014). The DSM-5 Task Force did not fully accept or incorporate the biological perspective, and critics claimed that clinicans might dismiss important sociocultural variations, especially given the elimination of the multiaxial assessment (Mannarino, Loughran, & Hamilton, 2007).
Dimensional Versus Categorical Nomenclature
The second major philosophical change involves attention to dimensional assessment and documentation as opposed to strictly categorical diagnosis. Categorical assessment is based on the assumption that diagnostic criteria represent independent, discrete phenomena (First, 2010; Jones, 2012b). In reality, client symptoms occur on a continuum rather than as part of a dichotomy (Dailey et al., 2014).
As noted previously, dimensional assessment scales are designed to assess frequency, duration, severity or other characteristics of a specific diagnosis (Jones, 2012b). Near the beginning of the revision process, the DSM-5 Task Force proposed dimensional assessment measures for nearly every disorder in the manual. Following widespread concern regarding questionable psychometric data, the APA included only one dimensional assessment tool, clinician-rated dimensions of psychosis symptom severity, in the print version of the DSM-5 (APA, 2013). The APA, however, has provided supplemental assessment tools online (APA, 2014b).
Like the neurobiological perspective, the shift toward dimensional conceptualization was neither universal nor complete. The DSM-5 (APA, 2013) included new severity specifiers for most disorders, and it shifted forward dimensional conceptualization for several key diagnostic classifications. For example, in the DSM-5, DSM-IV-TR substance abuse and substance dependence disorders were collapsed into one new substance use disorder with severity indicators ranging from mild to severe based on the number of criteria presented by the client. Counselors are to diagnose clients who meet two or three criteria as having a mild disorder, those who meet four or five criteria as moderate, and those who have six or more criteria as severe. Counselors will find similar conceptualizations throughout the DSM-5, including in the newly conceptualized persistent depressive disorder, which combines dsythymia and chronic instances of major depressive disorder and includes 18 possible specifiers.
A more radical reflection of the dimensional approach in the DSM-5 is the presentation of spectrum disorders rather than distinct disorders. One umbrella diagnosis—autism spectrum disorder—replaced DSM-IV-TR (APA, 2000) disorders of autism, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder. Autism spectrum disorder includes severity specifiers based on whether a client meets operationalized criteria for “requiring very substantial support, requiring substantial support, or requiring support” in social communication and restricted, repetitive behaviors domains (APA, 2013, p. 52). Similarly, the new chapter “Schizophrenia Spectrum and Other Psychotic Disorders” retains discrete diagnoses, but introduces the probability that brief psychotic disorder, schizophreniform disorder, and schizophrenia exist on a continuum. The APA (2013) claimed that the purpose of this change is to improve diagnostic efficacy, accuracy and consistency; however, critics conceptualized this as more of a philosophical shift (Dailey et al., 2014).
The APA has indicated intent to continue incorporating dimensional approaches in to future iterations of the DSM. For example, Section III includes a framework for diagnosing personality disorders using a hybrid categorical and dimensional model (APA, 2013). This model is based on the premise that personality dysfunction is a range of trait variations “with normal personality functioning on one end and abnormal personality functioning on the other” (Dailey et al., 2014, p. 309). Individuals who adopt the alternative model for clinical or research purposes will conceptualize clients as presenting impairment related to identity, self-direction, empathy and intimacy as they relate to five trait domains (i.e., negative affectivity, detachment, antagonism, disinhibition, psychoticism) and 25 more specific trait facets (APA, 2013). It is unclear whether the more complex dimensional model will be adopted fully in the next iteration of the DSM (Dailey et al., 2014).
Practice Implications for Counselors
Although many voiced concerns that the DSM-5 would lead to drastic shifts in counselors’ conceptualization of mental disorders, assessment procedures and diagnostic thresholds, this version of the “psychiatric bible” (Kutchins & Kirk, 1997, p. 1) looks remarkably similar to other iterations (Dailey et al., 2014). Despite similarities, the DSM-5 (APA, 2013) provides groundwork for future iterations to more closely represent neurobiological and dimensional conceptualizations of mental illness. Given the professional identity of counselors, and a scope of practice that “serves to promote wellness across the lifespan . . . [including] preventing and treating mental disorders” (Kraus, 2013, p. 1), strictly neurobiological interpretations may lead consumers to ignore essential interactions between individuals and their environments. Counselors who operate from strength-based wellness approaches will likely reject the notion that all mental illness has biological foundations (Dailey et al., 2014), especially as it is a short leap from assuming biological foundations to assuming that one must treat all disorders biologically. Counselors recognize that a biological orientation could lead to erroneous diagnosis, unwarranted medications and the selection of inappropriate treatment approaches. Although one cannot deny that life experiences have powerful impacts on neurobiological systems (e.g., Badenoch, 2008; Cozolino, 2010), there is concern that too heavy a focus on neurobiology may detract from the humanistic roots of counseling (Montes, 2013).
Certainly, counselors will continue to explore ways in which these philosophical shifts will affect the practice. In the following pages, we provide concrete recommendations for rendering diagnoses consistent with the DSM-5. These include recommendations for using other specified and unspecified disorders, procedures for recording diagnoses, insurance transitions and possibilities for incorporating attention to assessment tools.
Other Specified and Unspecified Disorders
A primary goal of the DSM-5 Task Force was the removal of NOS diagnoses from the DSM (Gever, 2012; Regier et al., 2009). This removal was based on perceived overuse of NOS by clinicians, especially when clients did not meet clear diagnostic criteria for more specific disorders (Jones, 2012b). Critics claimed that NOS diagnoses were a result of heavy reliance on “psychodynamic, a priori hypotheses” rather than “external, empirical indicators” (Kupfer & Regier, 2011, p. 672). By turning attention to more flexible dimensional diagnoses, creators of the DSM-5 hope to provide avenues for more flexible, yet more accurate labeling of mental disorders.
Counselors now have two options when working with individuals who do not meet full criteria for a specific diagnosis: other specified and unspecified. Use of other specified allows counselors to indicate, by using either specifiers assigned to that particular diagnosis or a descriptive narrative, the specific reason a client does not meet criteria for a more specific mental disorder (APA, 2013). When more specific information is not available or counselors do not feel comfortable providing additional detail, they may select an unspecified disorder. Each chapter of the DSM-5 includes at least one set of these disorders (e.g., other specified elimination disorder, unspecified elimination disorder).
Some diagnostic categories, such as bipolar and related disorders and depressive disorders, include specific examples of other specified disorders. For example, a client who meets all the criteria for a major depressive disorder except the time requirement may be diagnosed with 311 other specified depressive disorder, short-duration depressive episode. Counselors are not limited to using only these examples, as other reasons may warrant an other specified diagnosis (Dailey et al., 2014).
Recording Procedures
Nonaxial recording. Technically, DSM-IV-TR consumers were never required to present diagnoses using a multiaxial format (APA, 2013). Those who are used to the multiaxial system will simply combine previous Axis I (mental disorders and other conditions that may be a focus of treatment), Axis II (personality disorders and mental retardation), and Axis III (general medical conditions) diagnoses into one nonaxial diagnosis. Counselors also might note psychosocial stressors, environmental concerns, and impairments or disability as a brief narrative explanation relevant to the client’s mental health diagnoses if these are not (a) already indicated by the diagnosis, (b) included as a diagnostic subtype or (c) indicated by a unique specifier or severity indicator for the disorder. Counselors may list V codes or 900 codes (conditions associated with neglect or sexual, physical, and psychological abuse) as stand-alone diagnoses or alongside other diagnoses as long as these are relevant to clients’ presenting concerns and course of treatment. Although the DSM-5 does not include directions for formatting, counselors should keep explanations brief and use terminology appropriate for multidisciplinary communication (Dailey et al., 2014).
Counselors who see dual-diagnosis clients, individuals with medical conditions, and those who have psychosocial and environmental concerns may be overwhelmed by how to prioritize diagnoses. One solution is to list diagnoses in order of priority and scope of the presenting problem (APA, 2013; Dailey et al., 2014). When these are different, such as an adult referred for bereavement but found to have suicidal ideation and meet criteria for major depressive disorder, the APA (2013) advised users to include a parenthetical notation differentiating between the diagnosis and reason for visit. An example diagnosis might be 296.23 major depressive disorder, single episode, severe (principal diagnosis) and V62.82 uncomplicated bereavement (reason for visit).
Counselors also may need to prioritize presentation of diagnoses when clients have relevant medical diagnoses in addition to mental health concerns. For example, a client who experiences a manic episode, uses alcohol excessively and is not able to control a preexisting thyroid disorder because of the disturbance may receive a diagnosis of: F31.13 bipolar disorder I, current episode manic, severe; F10.10 alcohol use disorder, mild; and E06 chronic lymphocytic thyroiditis. We chose to list alcohol use disorder second because the client appears to be most impaired by the severe manic episode, and we suspect that a pattern of alcohol use and difficulty managing chronic medical conditions are both related to the bipolar disorder.
The second example raises an important consideration regarding counselors’ scope of practice. Diagnosis of medical conditions alongside mental health disorders makes sense for psychiatrists who are qualified to diagnose and treat both conditions and for mental health professionals who work in interdisciplinary settings where medical diagnoses are a matter of record (Dailey et al., 2014). Given that counselors are not qualified to diagnose medical conditions, it may be wise to refrain from including diagnostic mention of specific medical conditions unless information is gathered via official medical record or consultation. Counselors may consider including mention of client-reported medical conditions elsewhere on the clinical record or qualify medical conditions as self-reported.
ICD coding. Since publication of the DSM-III, ICD-9 codes have appeared next to each diagnostic classification (APA, 1980). Originally created for statistical tracking of diseases, not reimbursement, most medical systems within the United States use these codes for billing purposes. These codes are also required for use by medical insurance organizations by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In the DSM-5 (APA, 2013), ICD-9 codes are in black print, appear first, and typically include three digits or begin with V. In contrast, ICD-10 codes are gray in print, appear in parentheses, and generally begin with the letter F or, if representing psychosocial or environmental factors, with the letter Z. The reason for including both coding sets in the DSM-5 is that all practitioners must align with HIPAA, which requires use of ICD-10-CM (clinical modification) codes no later than October 1, 2015. Complete ICD-9 and ICD-10 codes can be found in the Appendix of the DSM-5, listed alphabetically and numerically.
The implication of this modification is relatively minor for counselors. Counselors should be aware that the initial printing of the DSM-5 contained several coding errors, and not all terminology used within the DSM-5 matches ICD-10 exactly. Counselors can obtain a printable desk reference with coding updates by visiting the DSM-5 coding update section on the website (APA, n.d.).
Specifiers and subtypes. In keeping with a dimensional philosophy, the DSM-5 (APA, 2013) contains an expanded listing of specifiers and subtypes for disorders listed throughout the manual. As noted previously, this update may include a greatly expanded number of options to denote experience within a diagnosis. For example, counselors may now add the specifier with panic attacks to any diagnosis within the DSM-5. Other important changes include an expanded listing of specifiers for bipolar and related disorders and depressive disorders, such as with catatonia, with anxious distress, and with mixed features. These specifiers are intended to account for experiences that are often present in both types of disorders, such as elements of anxiety, but may not be part of the general criteria for the disorders (APA, 2013).
Counselors should note all relevant specifiers for each diagnosis. For more information regarding specifiers and subtypes, professional counselors can refer to the DSM-5 for specific coding instructions and examples (APA, 2013). Despite these changes, most situations will require counselors to use the same diagnostic codes regardless of subtypes and specifiers assigned (APA, 2013; Dailey et al., 2014). There are some exceptions, however, such as when recording substance-related disorders.
Insurance Transitions
The APA (2013) noted that the DSM-5 was “developed to facilitate a seamless transition into immediate use by clinicians and insurers to maintain a continuity of care” (p. 1). Counselors may begin using diagnostic criteria as soon as they are ready to do so. Insurance companies, other third-party payers and mental health agencies, however, may take additional time to adjust their reporting systems from ICD-9 to ICD-10. This is especially true for the transition from a multiaxial to a nonaxial format (Dailey et al., 2014).
Although many counselors used the multiaxial system for diagnostic decisions, conversations and reimbursement, elimination of this system should not impact treatment decisions or reimbursement. Many third-party billing systems and government agencies collected data regarding a specific diagnosis only (previously Axis I, II and III); therefore, with the transition they should simply be reporting the same type of information.
Some insurance panels and reimbursement systems may have previously required more information, such as a GAF score, when determining eligibility for services. Given the expansion of severity indicators and specifiers contained throughout the DSM-5, functional impairments or specific disabilities may be noted within the nonaxial diagnosis. If this is not the case, as mentioned previously, counselors may use narrative notations alongside diagnostic labels. To the extent that functional impairment or disabilities are not listed and would previously have been indicated in the multiaxial system, counselors will need to work closely with associated parties to identify revised reporting requirements (Dailey et al., 2014). Counselors also can use the WHODAS 2.0, found in Section III of the DSM-5 or at www.psychiatry.org/dsm5, to more clearly indicate an individual’s level of functioning (APA, 2013).
The APA initially predicted that the insurance industry would transition to DSM-5 by December 31, 2013. This estimate was overly optimistic, however, as most third-party billing systems and government agencies have been slow to switch over to the DSM-5 and likely will not do so until the nationwide mandate for the use of ICD-10 codes goes into effect on October 1, 2015. Counselors can check with their employers and third-party payers to ensure a smooth transition to the DSM-5 in a manner consistent with local administrative procedures. The APA also is making implementation and transition updates available via their website.
Emerging Assessment Measures
As discussed previously, the DSM-5 includes a variety of cross-cutting assessment measures, disorder-specific severity measures and interview tools for clinicians. The APA (2013) qualified all print and online assessments, including the WHODAS 2.0 and Personality Inventories, as “emerging measures” intended for further research and exploration in clinical practice. Counselors may do well to integrate attention to screening of cross-cutting symptoms and monitoring of diagnostic severity in practice.
In most cases, the tools provided by the APA are clear, direct and ready to use; however, these online assessments vary widely in format, quality and rigor of psychometric validation (Jones, 2012b). For example, the severity measure for depression is the Patient Health Questionnaire–9 (APA, 2014b; Kroenke, Spitzer, & Williams, 2001). This well-developed instrument is in the public domain, and psychometric data are easy to access and indicate a strong degree of psychometric integrity. On the other hand, the Severity Measure for Panic Disorder–Adult (Shear et al., 2001) has limited validation and few publicly available references regarding development procedures and psychometric considerations (Keough et al., 2012). From an ethical perspective, counselors who use these measures are responsible for ensuring that they do so in a manner that is within their scope of practice and includes appropriate attention to instrument validity and administration procedures. Professional counselors must adhere to ethical standards (American Counseling Association [ACA], 2014; National Board for Certified Counselors [NBCC], 2012) and best practice guidelines (Association for Assessment in Counseling, 2003) when administering and interpreting diagnostic assessments.
A potentially useful tool to enhance clinical understanding of a client’s cultural worldview, the cultural formulation interview (CFI) is the APA’s attempt to address critics’ claims that the DSM has not historically included culture as part of diagnostic assessment (Dailey et al., 2014). Whereas the DSM-IV-TR (2000) included some cultural characteristics within its diagnostic classifications, it was clear that consumers needed more attention to psychosocial and environmental factors (Smart & Smart, 1997). The DSM-5 has continued this trend by updating diagnostic classification to include culture-related diagnostic issues for most disorders, supplemental information about cultural concepts and inclusion of the CFI.
The CFI is a 15–20 minute semi-structured interview consisting of 16 key questions (APA, 2013). With its coverage of numerous topics related to cultural perceptions of the presenting problem, the CFI helps counselors facilitate conversations about domains such as etiological origin, specific circumstances, interpersonal support systems, and coping and help-seeking behavior. Twelve additional modules, to be used as supplements to the CFI or independent of the CFI, are provided by the APA. These modules address topics or specific populations, such as immigrants and refugees; coping and help seeking; and spiritual, religious, or moral traditions. These modules can provide a firm foundation for culturally sensitive counselors to build competence and better understand a client’s worldview from a diagnostic perspective. Even if counselors simply find the CFI a helpful tool for facilitating conversations about culture, the inclusion of the CFI in the DSM-5 is an important step forward in helping professionals improve their understanding of cultural competence as essential to diagnostic assessment.
Perhaps most importantly, counselors do not have to use assessment measures or interview tools associated with the DSM-5 unless those assessment measures are integrated into standard operating procedures with insurance panels or agency policies. We encourage counselors to be selective and discerning as they incorporate emerging tools into practice. Because we expect the APA to continue to release new dimensional assessment and supplemental practice tools on a rolling basis, counselors may wish to visit the DSM-5 website and continue to assess the degree to which the recommended tools may enhance their practice.
Conclusion
Professional counselors comprise one of the largest bodies of DSM consumers (Frances, 2011). Regardless of background, training or theoretical orientation, counselors are responsible for understanding diagnostic practices and using them responsibly (ACA, 2014; NBCC, 2012). Counselors who are aware of recent modifications to the DSM position themselves for continued advancement of care systems that support “diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals” (Kaplan et al., in press). In this article, we attended to higher-level philosophical and structural changes within the DSM so that counselors may deepen their understanding regarding underlying foundations and motivations for DSM-5 revisions, even as they adopt more concrete diagnostic practices. We hope this historical and philosophical context helps counselors better advocate for a seat at the table in future DSM revision processes. In the meantime, counselors may use this information to make informed decisions about whether and how they will use the DSM-5.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest or funding contributions for the development of this manuscript.
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Jul 9, 2014 | Article, Volume 4 - Issue 3
Gary G. Gintner
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) includes numerous alterations to specific disorders, as well as fundamental conceptual and organizational changes. The purpose of this article is to review three fundamental conceptual changes in DSM-5: the harmonization of the manual with the International Statistical Classification of Diseases and Related Health Problems, the introduction of spectrum disorders and dimensional ratings, and the new organization of the manual. For each change, potential benefits and shortcomings are discussed in terms of innovation, limitations and clinical implications.
Keywords: DSM-5, ICD-10, classification, diagnosis, spectrum disorders
The DSM is probably one of the most widely referenced texts in the mental health field. Considering this scope of influence, the release of its latest edition, DSM-5 (American Psychiatric Association [APA], 2013), has garnered considerable interest among professionals, patient advocacy groups and the public alike (Paris, 2013). Reactions have ranged from enthusiastic support (McCarron, 2013) to concern (Welch, Klassen, Borisova, & Clothier, 2013) and even calls to reject the manual’s use outright (Frances, 2013; Frances & Widiger; 2012). The strength of this reaction—both positive and negative—reflects the scope of change. DSM-5 attempts to integrate almost 20 years of burgeoning research in psychopathology, classification and treatment outcomes that have emerged since the publication of DSM-IV (APA, 1994), the last major revision of the manual’s criteria sets. While DSM-5 has made numerous alterations to specific disorders, fundamental conceptual and organizational changes have had the most substantial impact on reshaping the manual (APA, 2013; Regier, Kuhl, & Kupfer, 2013).
The purpose of this article is to review three of these fundamental conceptual changes: the harmonization of the manual with the ICD, the introduction of spectrum disorders and dimensional ratings, and the new organization of the manual. For each of these innovations, three questions will be addressed. First, what was the basis for introducing the change as an innovation to the manual? Here the rationale and potential contribution of the change will be discussed. Special attention will be paid to issues such as enhanced diagnostic accuracy, coverage and clinical utility. Second, does the innovation have any potential drawbacks or limitations? For example, to what extent could the innovation contribute to over or underdiagnosis, limit access to treatment, or pose some harm like increased stigmatization? Third, what are the practical consequences of the innovation relative to how clinical mental health counselors provide care for their clients? This section considers the impact on day-to-day practice and how the diagnostic process itself may be transformed. The conclusion section ties these three threads of innovations together and discusses implications for mental health practice in the 21st century.
DSM and ICD Harmony
There are two major classification systems for mental disorders: the DSM, used primarily in North America, and the ICD, used worldwide under the auspices of the World Health Organization (WHO). The ICD is a much broader classification encompassing causes of death, illness, injury and related health issues with one chapter dedicated to mental and behavioral disorders (Stein, Lund, & Nesse, 2013). As part of the United Nations Charter, countries around the world have agreed to use the ICD codes to report mortality, morbidity and other health information so that uniform statistics can be compiled. In the United States, the ICD codes are the official codes approved by the Health Insurance Portability and Accountability Act (HIPAA), which are used by insurance companies, Medicare, Medicaid and other health-related agencies (Goodheart, 2014). The code numbers that the DSM has always used are derived from whatever the official version of ICD is at that time. Currently, the ninth revision of the ICD (ICD-9; WHO, 1979) is the official coding system in the United States. The 10th revision of the ICD (ICD-10; WHO, 1992/2010) is scheduled to go into effect on October 1, 2015.
The DSM and ICD classifications of mental disorders have a number of similarities, but also have important differences. Both are descriptive classifications that categorize mental disorders based upon a constellation or syndrome of symptoms and signs. Symptoms are the client’s reports of personal experiences such as feeling sad, anxious or worried. Signs, on the other hand, are observable client behaviors such as crying, rapid speech, and flat affect. Structurally, both manuals group related mental disorders into either chapters (DSM) or diagnostic blocks (ICD). The names and diagnostic descriptions for many of the mental disorders in the ICD are similar to those in the DSM, a consequence of collaboration over the years and a shared empirical pool from which both have drawn.
Despite these similarities, there are significant disparities. First, DSM criteria are very specific and detailed, while the ICD relies more on prototype descriptions with less detailed criteria and minimal background information to guide the diagnostic process (First, 2009; Paris, 2013; Stein et al., 2013; WHO, 1992). Second, since DSM-III (APA, 1980), the DSM has used a multiaxial system that notes not only relevant mental and medical disorders, but also other diagnostic information such as environmental factors (Axis IV) and level of functioning (Axis V). The ICD, on the other hand, has always employed a nonaxial system that simply lists medical disorders, mental disorders, and other health conditions. These differences in complexity reflect the constituencies that each manual is designed to serve: The DSM is primarily used by licensed mental health professionals with advanced degrees, while the ICD needs to be accessible to a range of health care professionals worldwide with a broad range of educational backgrounds (Kupfer, Kuhl, & Wulsin, 2013; WHO, 1992).
A third discrepancy is that the names and descriptions for many disorders differ, which at times reflects marked conceptual differences (First, 2009). For example, in ICD-10 (WHO, 1992) bulimia nervosa has to be characterized by a “morbid dread of fatness” (p. 179), a concept akin to anorexia, while DSM-IV-TR (Text Revision; APA, 2000) requires that self-evaluation be “influenced” (p. 549) by only body shape or weight. As another example, the definition of the type of trauma that qualifies for post-traumatic stress disorder (PTSD) is much broader in ICD-10 (allowing for events that are exceptionally threatening or catastrophic) than in DSM-IV-TR (requiring that the event must be associated with actual or threatened death, serious injury, or threat to the physical integrity). These ICD-DSM disparities have led to difficulties comparing research results, collecting health statistics, communicating diagnostic information and reaching similar diagnostic decisions (APA, 2013; First, 2009; Widiger, 2005). Like conversing in two different languages, the diagnosis has often been lost in translation.
Innovation
From the outset of the DSM-5 development process there was a concerted effort to address these disparities. Joint meetings of representatives from APA and WHO met regularly throughout the process in an effort to make the manuals more compatible (APA, 2013; Regier et al., 2013). The goal was to find ways of harmonizing structural, conceptual and disorder-specific differences. The results of this process have had immediate effects on the look of DSM-5 and will have long-term effects on the harmonization of DSM-5 with the upcoming ICD-11, expected to be released in 2017 (APA, 2013; Goodheart, 2014).
The most significant impact of the harmonizing effort is the discontinuation of the multiaxial system in DSM-5. Axes I–III, the diagnostic axes (APA, 2000), are now collapsed into a nonaxial system, consistent with the ICD format. Psychosocial and environmental problems (formerly Axis IV) can be noted using ICD-10’s codes for problems and situations that influence health status or reasons for seeking care. These are usually referred to as Z codes and were formerly termed V codes in DSM-IV-TR. Axis V’s Global Assessment of Functioning (GAF) has been removed and replaced by an ICD measure for disability, the World Health Organization Disability Assessment Schedule (WHODAS) 2.0 (APA, 2013). Unlike the GAF, however, this rating is not required and serves only as an ancillary tool.
The following is an example of how a DSM-5 diagnosis might be listed using ICD-9’s nonaxial system in ICD-9:
296.42 Bipolar I disorder, current episode manic, moderate severity, with mixed features
307.83 Borderline personality disorder
V62.29 Other problem related to employment
The order of diagnoses would indicate that the bipolar disorder was the principal diagnosis and either the focus of treatment or reason for visit. In this example, borderline personality disorder is a secondary diagnosis. The V code is noted because it is an important area to target in the treatment plan.
There were three major reasons for abandoning the multiaxial system. First, health professionals in general medicine found it difficult to use because it was so different from the ICD format (Kupfer et al., 2013). Second, the multiaxial system contributed to the idea that mental disorders were qualitatively different from medical disorders, a dated dualistic distinction between mind and body (APA, 2013; Kupfer et al., 2013; Lilienfeld, Smith, & Watts, 2013). Third, research had shown that distinctions between Axes I and II were artificial and did not reflect that these axes actually overlapped considerably (Lilienfeld et al., 2013). Thus, the multiaxial system seemed to create artificial distinctions that did not seem valid (Lilienfeld et al., 2013). The ICD, on the other hand, offered a more simplified system that allowed a diverse group of health professionals to code disorders using a similar format.
Substantial harmonization of the manuals, however, will happen in the future. Not much could be done with harmonizing ICD-10 (WHO, 1992), a manual of the DSM-IV (APA, 1994) era, the organization and conceptual framework of which were well established (APA, 2013; Goodheart, 2014). The forthcoming ICD-11 will adopt much of DSM-5’s organizational restructuring (discussed below) and include a number of the new DSM-5 disorders (APA, 2013; Goodheart, 2014).
Limitations
Despite the potential contribution of this harmonization, there are three major drawbacks to consider. First, the loss of the multiaxial system may compromise the richness of the diagnostic assessment. In a sense, the multiaxial system was holistic in that it provided a way of noting prominent psychiatric conditions, maladaptive personality functioning, medical conditions, relevant stressors and environmental problems, and overall functioning. What will prompt clinicians to consider these important domains remains unclear. Noting V codes and assessing disability using the WHODAS 2.0 may be an alternative. However, these tasks are not required in the diagnostic workup and, if history is any guide, will probably be underutilized.
A second consideration is that consilience with the ICD clearly makes the DSM-5 a “medical classification” (APA, 2013, p. 10) and as David Kupfer, the Task Force Chair of DSM-5, has put it, “psychiatric disorders are medical disorders” (Kupfer et al., 2013, p. 388). The DSM espouses that it is atheoretical (APA, 2013; Lilienfeld et al., 2013), but the momentum is clearly swinging toward the central role of biological factors. This risks a reductionistic conceptualization of mind as simply brain. Alternative perspectives that recognize the importance of contextual, psychological, developmental and cultural factors, fundamental to the mental health counseling tradition (Gintner & Mears, 2009), may suffer as a result. The picture is more ominous considering the National Institute of Mental Health’s initiative, Research Domain Criteria (RDoC), designed to develop the next generation of psychiatric classification based upon underlying etiology of “brain disorders” (p. 749) and the identification of biomarkers (e.g., laboratory tests) to direct treatment selection (Insel et al., 2010). The direction in which the diagnostic train is heading is clear. The question is whether the track can be altered to one that is more balanced and biopsychosocial.
A third concern is that efforts to harmonize the manuals do not address many of the disparities between DSM-5 and ICD-9 or ICD-10. This is particularly true of the new disorders that DSM-5 has added, which lack clear ICD-9 or ICD-10 counterparts. The ICD codes that have been selected often do not map well onto these disorders. For example, the code for DSM-5’s hoarding disorder translates to ICD-9’s and ICD-10’s obsessive-compulsive disorder (OCD). Ironically, hoarding disorder was added because research showed that 80% of the time individuals with this condition did not meet criteria for OCD. As another example, binge eating disorder was added to DSM-5 to recognize individuals who had a pattern of maladaptive bingeing episodes, but did not have the compensatory behaviors (e.g., purging) characteristic of bulimia nervosa. The ICD code selected for this disorder was, nevertheless, bulimia nervosa. Because ICD is updated annually, it may be that more appropriate codes will be made available in future years. Thus, while ICD-DSM consilience has occurred, at least to this point, it has been superficial and restricted to the nonaxial formatting of the diagnosis. Clearly, it may enhance the curb appeal of DSM-5 to the medical community, but the real interior renovation is yet to occur, awaiting ICD-11.
Clinical Implications
The demise of the multiaxial system means that mental health counselors must be more intentionally biopsychosocial in their diagnostic assessments. More meat can be put on the bare-bones nonaxial system by systematically assessing these biological, psychological and sociocultural factors. This can be accomplished by always assessing whether any important contextual factors can be noted using the V codes, which will be termed Z codes when ICD-10 goes into effect. The WHODAS 2.0, the retired GAF, and other functioning measures can be recruited to assess impairment. While these measures are not part of the formal diagnosis, they can be noted in the chart and inform treatment planning.
Many insurance companies require a multiaxial diagnosis. The GAF score was often used to justify level of care. At the time of this writing, it is not clear what insurance companies will do with these modifications. The decision here will be important. What insurance companies require, for better or worse, often has profound impact on what clinicians do and the kind of clinical care they deliver.
Spectrum Disorders and Dimensionality
Both the DSM and ICD classify mental disorders into discrete categories. Clinicians make a yes-no decision about whether or not an individual has a disorder, based upon the particular criteria. But it has long been known that this categorical approach is fraught with problems (First & Westen, 2007; Widiger, 2005). First, comorbidity is common and there is some question as to whether comorbid conditions such as depression and anxiety are distinct or are really different expressions of some shared underlying dysfunction (Lilienfeld et al., 2013). Second, clinicians have used the not otherwise specified (NOS) category 30–50% of the time, indicating that a sizable proportion of phenomena have a varied presentation that existing categories do not capture (Widiger, 2005). This is problematic because NOS is not particularly informative in terms of describing the condition or making decisions about treatments. Finally, a categorical system assumes that each disorder is homogenous and that disorder occurs at the particular cut point. There is no recognition of subthreshold symptoms, and there is the assumption that those who do fulfill the criteria are qualitatively similar. This view is at odds with data showing that symptoms vary considerably in terms of severity and accompanying features (First & Tasman, 2004). In this sense, categorical assignment loses potentially useful clinical information about the condition and about what treatment strategies might be indicated.
Innovation
DSM-5 attempts to address this issue by introducing dimensionality to supplement the categorical approach (APA, 2013). While categories indicate differences in kind, dimensions describe variations in degree (Lilienfeld et al., 2013). From this perspective, mental disorders are considered to lie on a continuum, like blood pressure. Theoretically, the spectrum can run from optimal functioning to significant impairment. Markers of morbidity or adverse outcome determine where on the spectrum the cut point for disorder is drawn. In the case of blood pressure, for example, it is 140/90. This dimensionality allows for more fine-grained determination of not only severity or impairment, but also improvement or deterioration. Over the past 30 years, research has shown that many mental disorders appear to be more dimensional and heterogeneous than suggested by ICD’s or DSM’s purely categorical system (First & Westen, 2007; Helzer, 2011; Paris, 2013).
Dimensionality is incorporated into DSM-5 in three general ways. First, DSM-5 has added several formal spectrum disorders, which combine highly related disorders. Autism spectrum disorder merges together DSM-IV-TR’s autism disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder NOS. Research has shown that these four conditions share many common symptoms, and the differences are more a matter of degree (APA, 2013; Tsai & Ghaziuddin, 2014). Another spectrum disorder is substance use disorder, which blends the former categories of abuse and dependence. The somatic spectrum is captured by somatic symptoms disorder, which merges what was formerly somatization disorder, pain disorder and undifferentiated somatoform disorder. For each of these spectrum disorders, DSM-5 provides a severity rating as well as other specifiers to note degree of impairment and complicating features.
A second way that dimensionality is infused into DSM-5 is that severity ratings and an expanded list of specifiers have been placed within the existing categories. In a sense, DSM-5 tries to dimensionalize the category. While this was done to some extent in previous editions, DSM-5 broadens this effort throughout the manual. For example, a number of new specifiers were added to describe mood episodes such as anxious distress (presence of comorbid anxiety), mixed features (presence of symptoms from the opposite mood pole), and peripartum onset (onset of symptoms sometime during pregnancy through one month post-delivery). The addition of these notations can be helpful in making treatment-planning decisions (First & Tasman, 2004). For example, severity ratings are an important consideration in deciding whether to use psychotherapy or medication for the treatment of major depressive disorder (APA, 2010). Feature specifiers like anxious distress and mixed features have been shown to increase suicide risk and portend a more complicated treatment regime (APA, 2013; Vieta & Valentí, 2013).
A third way that dimensionality is being promoted in DSM-5 is through the availability of a variety of online assessment measures (APA, 2014). These are rating scales that fall into three general categories. First, there are disorder-specific measures that correspond closely to the diagnostic criteria. These measures could be used to buttress the more clinical assessment that relies on the diagnostic criteria. They could also provide a means of assessing the client’s baseline and response to treatment over time. Measures are available for a range of disorders including depression, many of the anxiety disorders, PTSD, acute stress disorder and dissociative symptoms. Versions are available for adults as well as children aged 11–17. Most of these are self-completed but some are clinician-rated. A second type of measure is the WHODAS 2.0, discussed earlier, which assesses domains of disability in adults 18 and older. A third type of measure is referred to as cross-cutting symptom measures (CCSM). Similar to a broadband assessment of bodily systems in medicine, these measures assess common psychiatric symptoms that may present across diagnostic boundaries and may be clinically significant to note in the overall treatment plan. Level 1 CCSM is a brief survey of 13 domains of symptoms (e.g., depression, anxiety, psychosis, obsessions, mania). A more in-depth Level 2 assessment measure is available for a domain that indicates a significantly high rating. These measures can be reproduced and used freely by researchers and clinicians and can be downloaded at http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures. Use of these types of measure is hoped to add surplus information that can aid diagnosis, case monitoring and treatment planning.
Limitations
Dimensions are not only intuitively appealing, but also seem to be a better reflection of nature (Lilienfeld et al., 2013). Notwithstanding, serious concerns have been raised. First, determining the appropriate cut point on these dimensions is critical in terms of determining true psychopathology. If the bar is set too low, there is a danger of pathologizing normal behavior. If set too high, those who need treatment may be excluded and denied services. At this point, data suggest that at least for autism spectrum disorder and substance use disorder, the bar might be set too high. For both, DSM-5 criteria tend to miss people on the more benign end of the spectrum. For example, those who formerly might have been diagnosed with mild to moderate Asperger’s, pervasive developmental disorder NOS, or substance abuse may no longer qualify for a diagnosis (Beighley et al., 2013; Mayes, Black, & Tierney, 2013; Peer et al., 2013; Proctor, Kopak, & Hoffmann, 2013). On the other hand, Frances (2013) has suggested that the threshold for somatic symptoms disorder is set too low, pathologizing many with normal worry about their medical illnesses.
A second concern is that lumping mild and more severe disorders into a unitary spectrum disorder can have unintended social effects, especially for people on the more benign end of the spectrum. For example, those who formerly were diagnosed with Asperger’s disorder will now be labeled with autism spectrum disorder. A college student who was diagnosed with alcohol abuse using DSM-IV-TR criteria will now carry the same diagnosis as someone who is considered an alcoholic and dependent (Frances, 2013). One unanswered question is the impact of these types of name changes on perceived stigma and consequent help seeking.
A final concern is that the dimensional measures were released prematurely without adequate testing and without sufficient guidelines for their use (Jones, 2012; Paris, 2013). While some of the measures are well established (e.g., Patient Health Questionnaire [PHQ]-9; APA, 2014), others have little to no psychometric support (e.g., Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders). Scoring guidelines are made available, but information about the measure’s psychometric properties and norming are lacking. There also is no information on who is qualified to use these measures and what type of training they should have. Thus, while dimensionality may be an important innovation in the development of the DSM classification system, there are significant challenges ahead in calibrating these dimensions, refining the measures and considering social consequences.
Clinical Implications
Will dimensionality help or hinder the diagnostic process? On one level, the additional information about the condition may shift counselors’ fundamental way of thinking about treatment from “curing” clients (dichotomous) to helping them move toward more optimal points on the spectrum (dimensional). The availability of dimensional measures has the potential of improving diagnostic accuracy and providing a measure of treatment outcome (Segal & Coolidge, 2007). It may open the door to more measurement-based care, in which these ratings can be used to assess more precisely the need for care and the extent to which clients are profiting from treatment. This process may be more feasible to administer, score and record if these measures can be stored on tablets or mobile applications.
In terms of using these dimensional measures, however, the unanswered question is—at what cost? Clinicians are already busy, and anything that encumbers that process even more will be resisted (Paris, 2013). Criteria sets are now a bit more complex to navigate because of the added severity rating and feature specifiers. It will take considerable time to learn and master the range of measures that have been posted online, much less research their psychometric appropriateness for the situations in which they will be used. The wild card is whether managed care will require these types of measures as a way of documenting need for treatment and response to provided services. At this point, clinicians would be best served to proceed cautiously, ensuring that the measures they use are reliable and valid for the client population intended.
The New Organization of DSM-5
How was it decided in previous editions of the DSM which chapters to include and which disorders to place in each of them? While some research guided this process, tradition and clinical consensus were the primary sources that informed the organization of these earlier manuals (First & Tasman, 2004; Regier et al., 2013; Widiger, 2005). DSM-5 took a radically different approach, drawing upon research that examined how disorders actually cluster together. In this section, the new framework is examined and potential benefits and costs discussed.
Innovation
The DSM-5 manual is divided into three major sections. Section I provides an introduction, a discussion of key concepts such as the definition of a mental disorder, and guidelines for recording a diagnosis. Section II is the meat of the manual and contains all the mental disorders and other conditions that can be coded with their diagnostic criteria and background information. Section III includes tools for enhancing the diagnostic process, such as some of the dimensional measures discussed earlier, the WHODAS 2.0, and a Cultural Formulation Interview designed to assess the impact of culture on the clinical presentation. This section also includes a list of proposed mental disorders that require further study (e.g., Internet gaming disorder) and an alternative system for diagnosing personality disorders.
Table 1 lists DSM-5’s major categories (chapters) of mental disorders. Two general principles determined the sequence of chapters and the placement of disorders within chapters. First, disorders were grouped into similar clusters based upon shared underlying vulnerabilities, risk factors, symptoms presentation, course and response to treatment (APA, 2013). Groups that are positioned next to each other share more commonalities than those placed further apart. For example, bipolar disorder follows schizophrenia spectrum because they share a number of vulnerability factors (APA, 2013). Next to bipolar disorder is the chapter on depressive disorders. However, the sequence of chapters indicates that depressive disorders are more distantly related to schizophrenia spectrum. Next, internalizing disorders characterized by depression, anxiety and somatic symptoms are listed in adjacent chapters because of common risk factors, treatment response and comorbidity (APA, 2013). Externalizing disorders, noted by their impulsivity, acting out and substance use, are placed in the latter part of the manual.
Table 1
DSM-5 Classification
|
Sequence of Chapters in Section II
|
| Neurodevelopmental DisordersSchizophrenia Spectrum and Other Psychotic DisordersBipolar and Related DisordersDepressive DisordersAnxiety Disorders
Obsessive-Compulsive and Related Disorders
Trauma- and Stressor-Related Disorders
Dissociative Disorders
Somatic Symptom and Related Disorders
Feeding and Eating Disorders
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse Control, and Conduct Disorders
Substance-Related and Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
Other Mental Disorders
Medication-Induced Movement Disorders and Other Adverse Effects of Medication
Other Conditions That May Be a Focus of Clinical Attention |
This shared commonality principle is also evident in the placement of disorders within chapters. As a result, a number of disorders have been transferred to different chapters. For example, DSM-IV-TR’s chapter on sexual and gender identity disorders contained sexual dysfunctions (e.g., premature ejaculation), paraphilias (e.g., exhibitionism) and gender identity disorder. Research showed that these three were not highly related, so they have been moved into different chapters, each of which is more proximally located to related disorders (APA, 2013). As another example, DSM-IV-TR’s anxiety disorders chapter has been divided into three separate chapters: anxiety disorders that are more fear-based (e.g. phobias); obsessive-compulsive and related disorders, which are characterized by preoccupations and repetitive behaviors (e.g., body dysmorphic disorder); and trauma- and stressor-related disorders. The latter is akin to a stress-response spectrum that ranges from severe reactions like PTSD to milder reactions characteristic of an adjustment disorder. It is hoped that these organizational changes will help clinicians locate disorders as well as identify related comorbidities (APA, 2013).
A second organizational principle is that the DSM-5 framework reflects a life-span perspective, both across and within chapters. Neurodevelopmental disorders (e.g., autism spectrum disorder, attention-deficit/ hyperactivity disorder [ADHD]) are listed first because they typically emerge early in life. Schizophrenia spectrum disorders also frequently have antecedents that manifest themselves in childhood (APA, 2013). Next are disorders that usually appear in adolescence and early adulthood, such as bipolar disorders, depressive disorders and anxiety disorders. In the middle and back of the manual are disorders that emerge in adulthood or late adulthood, such as personality disorders and neurocognitive disorders (e.g., dementia related to Alzheimer’s disease).
A developmental perspective also is infused into the organization of each chapter. DSM-IV-TR’s chapter on disorders of infancy, childhood and adolescence has been eliminated, and these disorders have been redistributed throughout the manual into relevant chapters. Each chapter is developmentally organized with disorders that emerge in childhood listed first, followed by those that appear in adolescence and adulthood. For example, oppositional defiant disorder and conduct disorder have been moved to the beginning of the chapter on disruptive, impulse control and conduct disorders. In addition, the criteria sets now include developmental manifestations of symptoms. For example, the ADHD criteria set includes both child and adult examples of the various symptoms. There also is an expanded section on development and course for each of the disorders, which explains how symptoms typically unfold over the life span. It is hoped that these types of changes will help clinicians recognize age-related manifestations of symptomatology (Kupfer et al., 2013; Pine et al., 2011).
The intent of the DSM-5 initiative was to develop a more valid organizational structure grounded in research. In the end it also may help to uncover common etiological factors—the holy grail of classification efforts (Insel et al., 2010; Stein et al., 2013). Certainly, these changes will help with differential diagnosis. The organization provides a better map of the relationship between disorders and how the diagnostic landscape may change over the life span.
Limitations
The new organization of the DSM-5 has been generally well received (Stein et al., 2013). One major concern that has been raised, however, is the decision to dismantle the chapter on child and adolescent disorders (Pine et al., 2011). Now there is not one place where the range of childhood disorders is listed. The neurodevelopment disorders—the remnant of the former child and adolescent chapter—is largely limited to disorders that manifest with early developmental delays and problems with language, learning, motor behavior, thinking or attention. Missing, however, are a broader range of behavior problems and anxiety disorders that the former chapter included. The problem is that many of these disorders can co-occur. For example, about 30–50% of children with conduct disorder have a specific learning disorder (Gintner, 2000). The wide separation of conditions such as these in the manual may interfere with accurate detection, especially among those who are not familiar with child and adolescent disorders.
Clinical Implications
Mental health counselors have a new organization to master. Anecdotally, probably one of the most common comments I hear about the new manual is, “Where do I find X now?” Understanding the new organization of the manual will require more than simply looking over the new structure. It will be critical to read the manual to understand why disorders were grouped in a particular chapter. Chapters that are either newly introduced in the manual or that were significantly altered will certainly need to be carefully reviewed. These include the chapters on neurodevelopmental disorders, obsessive-compulsive and related disorders, trauma- and stressor-related disorders, substance-related and addictive disorders, and neurocognitive disorders.
Importantly, the new DSM-5 message is that the structure is designed to indicate relationships within chapters and between chapters. This is a different way of thinking diagnostically. For example, in considering possible diagnostic alternatives, the clinician can first ask this broad question: Is this on the internalizing or externalizing spectrum? If the condition seems more internalizing, then the possible chapters have been winnowed down, and progressively more specific questions can be asked to locate the disorder in the particular chapter. The organization also alerts the diagnostician that adjacent chapters may hold comorbid conditions or even unexplained subthreshold symptoms. To take advantage of this diagnostic aid, however, it will be critical for mental health counselors to learn their way around this new framework.
Conclusions
These conceptual changes define the new look of DSM-5. ICD’s consilience, dimensionality and the organizational restructuring have fundamentally transformed DSM-5 into a 21st-century document that reflects the current state of knowledge in the mental health profession. The good news is that these changes may make the manual a better reflection of nature (i.e., research has shown it to be more valid) compared to previous editions. As a result, the way counselors diagnose and how they think about mental disorders is changing. Hopefully, such change will not only result in better care, but will also help researchers identify the deeper etiological substrates of mental disorders.
In science, progress also can have a dark side. While the DSM-5 incorporates the latest research, the entire development process and critical review highlight the primitive state of knowledge in the profession. While the spectrums and dimensions will no doubt transform the way mental health professionals diagnose, at this point they are crude and may help certain client populations, but hurt others. Harmonization with the ICD will probably take the DSM-5 to a broader audience of health providers. But it also further medicalizes the DSM-5 and will steer it perilously close to a biologically-based classification system. It will be up to mental health counselors and allied mental health professionals to help correct the course and find the middle way exemplified in the biopsychosocial model. Until then, DSM-5’s advances will be tempered by these potential limitations.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest or funding contributions for the development of this manuscript.
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Jul 8, 2014 | Article, Volume 4 - Issue 3
Victoria E. Kress, Casey A. Barrio Minton, Nicole A. Adamson, Matthew J. Paylo, Verl Pope
With the advent of the DSM-5 in 2013, the American Psychiatric Association eliminated the longstanding multiaxial system for mental disorders. The removal of the multiaxial system has implications for counselors’ diagnostic practices. In this article, the removal of the multiaxial system in the DSM-5 is discussed, and counselor practice suggestions related to each of the five Axes are provided. Additionally, ways in which counselors can sustain their current diagnostic skills while developing updated practices that align with the new streamlined system will be discussed.
Keywords: DSM-5, multiaxial system, diagnostic skills, mental disorders
The American Psychiatric Association (APA) developed the original Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 to create a uniform way to define mental health disorders. At the time, the manual contained narrative, psychodynamic descriptions regarding psychiatric disorders. Fueled by criticism regarding questionable foundations and lack of discrete diagnostic criteria, APA engaged in a comprehensive overhaul of the diagnostic system in preparation for the third edition of the manual (First, 2010). In 1980, the APA released the radically different DSM-III, a categorical nosological system with presumably atheoretical foundations and a multiaxial assessment system that ensured attention to biological, psychological and social elements related to mental disorders.
Although paradigm shifts were not as comprehensive as some might have hoped (First, 2010; Kupfer & Reiger, 2011), the most recent revision process resulted in the DSM-5 (APA, 2013) and the first major structural changes to diagnostic classifications and procedures since the DSM-III (APA, 1980). Key DSM-5 changes included reorganization of disorders into new categories on the basis of presumed etiological characteristics, movement toward dimensional conceptualization of disorders and discontinuation of the multiaxial system (Dailey, Gill, Karl, & Barrio Minton, 2014). Some revisions, such as a trend toward lower diagnostic thresholds (Frances, 2013; Miller & Prosek, 2013) and incorporation of complex, unvalidated assessment tools (First, 2010; Jones, 2012) received a great deal of public attention and comment. In contrast, removal of the multiaxial system happened quietly and with very little scholarly or public comment (Probst, 2014).
In this article, the title DSM will be used to refer to historic versions of the Diagnostic and Statistical Manual of Mental Disorders. References to specific editions will be clearly indicated with numerals or numbers in addition to the title. First, we provide a brief overview of the DSM and its use by counselors. Next, we describe the longstanding multiaxial system and discuss arguments in favor of and against removal of the multiaxial system. Throughout, we discuss implications for counselor diagnosis and practice.
Counselors’ Use of the DSM
In order to understand the implications of the elimination of the multiaxial system, professional counselors must possess a preliminary understanding of the complex relationship between professional counseling and the DSM. Over time, the more general DSM system has come under critical review, especially by counselors who question how the diagnostic process fits with our professional identity and ethical obligations (Eriksen & Kress, 2006; Kress, Hoffman, & Eriksen, 2010; Zalaquett, Fuerth, Stein, Ivey, & Ivey, 2008). Eriksen and Kress (2005) detailed commonly cited limitations of the DSM and how it is used:
- Historically, some diagnostic labels have marginalized, stigmatized and harmed those who are different from the mainstream (e.g., homosexuality was once a DSM diagnosis).
- There is limited evidence of cross-cultural validity in diagnostic conceptualizations.
- Counselors who focus narrowly on diagnosis may only look for behaviors that fit within a medical or biological understanding of the person’s struggles (i.e., becoming reductionistic).
- The DSM system does not include sufficient emphasis on contextual factors (e.g., developmental struggles and transitions, culture, gender), strengths, resources, and uniqueness that may better explain the roots of client struggles and treatment implications.
- The DSM system cannot predict treatment outcomes or point to the etiology of mental disorders.
- Some people may use diagnosis to accept a self-fulfilling prophecy that their situation is hopeless and that they are sick.
- Diagnosing may preclude a focus on the client’s unique construction of his or her experience.
- There are flaws in the science behind DSM diagnoses; what is and is not classified as a mental disorder is often rooted in a political agenda and historical influences.
Limitations of the DSM require that counselors use it carefully, and thoughtfully consider challenges related to its use. Although Eriksen and Kress (2005) wrote in reference to the DSM-IV-TR, underlying assumptions and broad-based diagnostic processes have not changed in the DSM-5 (APA, 2013). We expect that these limitations will continue to be relevant to counselors.
In contrast to the reductionistic, medically oriented diagnostic model inherent within the DSM system (Eriksen & Kress, 2005), counselors emphasize strength-based and developmentally, culturally and contextually sensitive approaches (Kress & Paylo, 2014). Despite the best efforts of many counselors to establish and promote a professional identity that is distinct from other mental health professions, market demands frequently dictate aspects of clinical practice (Eriksen & Kress, 2006). Counselors are licensure-eligible in all 50 states and regularly recognized on insurance panels; as such, there is an expectation that mental health counselors will use the DSM for third-party reimbursement (Kress & Paylo, 2014). Thus, counselors may find themselves working to balance unique professional identities with realities of a diagnostic system created by and for physicians who have a primary focus on pathology.
Despite its limitations, the DSM system is useful in a number of ways (APA, 2013; Dailey et al., 2014; Eriksen & Kress, 2005, 2006; Kress & Paylo, 2014). Primarily, it serves as a way of communicating about client problems and struggles. Assuming that all client-related information is considered, it offers a vehicle for reducing complex information into a manageable form (Kress & Paylo, 2014). Through the categorization of psychological symptoms into disorders, the DSM system provides a means for counselors to select evidence-based treatments that correspond to said disorder. Some clients may benefit from receiving a diagnosis as it may help them to normalize and understand their experiences, sometimes even helping them to reduce the shame and self-blame that often relate to symptoms (Eriksen & Kress, 2005). Finally, categorization and identification of disorders allows researchers to study the etiology and treatment of various mental disorders. Such a process lends itself well to the development of prevention, early intervention and effective treatment measures that have very real impacts on clients’ lives (APA, 2013). The DSM-5 (APA, 2013) also provides systematic information about diagnostic features, associated features supporting diagnosis, subtypes and/or specifiers, prevalence, development and course, risk and prognostic factors, diagnostic measures, functional consequences, culture-related diagnostic issues of each diagnosis; this information may be helpful to counselors who are struggling to fully understand their clients’ experiences.
An understanding of clients’ contextual experience is essential for conceptualizing client concerns and planning counseling strategies that are relevant to clients and have a strong probability of success (Kress & Paylo, 2014). In the past, those who engaged in multiaxial diagnosis were cued to at least consider biopsychosocial elements of clients’ concerns, including mental disorders, medical conditions, psychosocial and environmental stressors, and overall functioning. In the following section, we attend to the rise and fall of the multiaxial system.
Rise and Fall of the Multiaxial System
The APA first introduced the multiaxial system in the DSM-III (1980). A radical departure from the previous version of the document, the DSM-III introduced categorical, symptom-based diagnosis (First, 2010). In attempts to ensure clinical utility of information reported, the authors suggested, but did not require, that clinicians report diagnostic information on five distinct Axes. This tradition continued with only modest changes in the DSM-IV (APA, 1994) and DSM-IV-TR (APA, 2000).
The DSM-IV-TR (APA, 2000) multiaxial system involved documentation of diagnosis on five Axes. Axis I listed the primary or principal diagnoses that needed immediate attention; this included recording of clinical disorders as well as “Other Conditions That May Be a Focus of Clinical Attention” (e.g., life stressors, impairments in functioning; APA, 2000, p. 27). Axis II contained pervasive psychological issues such as personality disorders, personality traits and mental retardation (now intellectual disability disorder) that shaped responses to Axis I disorders. Axis III was intended to cue reporting of medical or neurological problems that were relevant to the individual’s current or past psychiatric problems. Axis IV required clinicians to indicate which of nine categories of psychosocial or environmental stressors influenced client conceptualization or care (e.g., recent divorce, death of partner, job loss). Finally, Axis V included the opportunity to provide a Global Assessment of Functioning (GAF) rating, a number between 0 and 100 intended to indicate overall level of distress or impairment.
Introduction of the multiaxial system was never without controversy or difficulty (Probst, 2014). Specific concerns included the degree to which Axes I and II were mutually exclusive and distinct (Røysamb et al., 2011), lack of clear boundaries between medical and mental health disorders (APA, 2013), inconsistent use of Axis IV for clinical and research purposes (Probst, 2014), and poor psychometric properties and clinical utility of the GAF (Aas, 2010; APA, 2013). Those most closely associated with APA noted concern that the multiaxial system was rarely used to its full potential and lacked clinical utility (APA, 2013; First, 2010). In 2004, APA first entertained a motion to explore elimination of the multiaxial system unless evidence was presented to suggest that the system enhanced patient care (First, 2010; Probst, 2014). Upon reviewing the literature, a 2005 committee recommended maintaining the system in the next iteration of the DSM and suggested that APA provide resources to support more widespread and consistent use (Probst, 2014). Nearly eight years later, the APA discontinued use of the multiaxial system, seemingly without public discussion or comment. Indeed, APA included just three paragraphs regarding this shift in the DSM-5, noting that “despite widespread use and its adoption by certain insurance and governmental agencies, the multiaxial system in DSM-IV was not required to make a mental disorder diagnosis” (2013, p. 16).
From Multiaxial to Nonaxial Assessment
Clinicians who are accustomed to documenting diagnosis using a multiaxial system may wonder what DSM-5 assessment and diagnosis will look like. APA provided little concrete guidance, stating, “DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axes I, II and III), with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V)” (2013, p. 16). In the following sections, we explore evidence related to the shift and identify implications for counselors.
Medical and Mental Health Conditions (Axes I, II and III)
Axes I, II and III have been eliminated in the DSM-5 (APA, 2013). Clinicians can simply list any disorders or conditions previously coded on these three Axes together and in order of clinical priority or focus (APA, 2013). Because many billing systems already used this system, this may not result in meaningful changes in terms of third-party billing.
This change removes the distinction of previous clinical disorders, personality disorders and intellectual disability disorder. Over time, clinicians have questioned whether Axis II personality disorders were qualitatively different from or any more stable than Axis I clinical disorders (Røysamb et al., 2011); one might also argue that certain developmental disorders (e.g., autism spectrum disorder, previously coded on Axis I) are just as longstanding and pervasive as intellectual disability disorder. Although there is some evidence that personality disorders are distinct from other clinical disorders, emerging evidence indicates that mental disorders do not factor cleanly into these classifications (Røysamb et al., 2011). It is possible that this subtle shift in coding may decrease the stigma often associated with personality disorders.
At the same time, this change in coding suggests that there is no differentiation between medical conditions and mental health disorders. Initially, APA released a definition in which it conceptualized mental disorders as “a behavioral or psychological syndrome or pattern that occurs in an individual” and “reflects an underlying psychobiological dysfunction [emphasis added]” (APA, 2012). The resulting controversy and dialogue regarding lack of evidence for the claim led to a more balanced definition of mental disorder as involving “a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (APA, 2013, p. 20). Still, clinicians will find that the previous DSM-IV-TR phrase “general medical condition” has been replaced with “another medical condition” throughout the DSM-5 (e.g., APA, 2013, p. 161). Together, these reinforce an assumption that mental disorders are rooted in biological causes.
Some have suggested that an increased emphasis on mental disorders as organic implies that environmental factors are less important, and this could reduce the stigma that many people with mental disorders feel (Yang, Wonpat-Borja, Opler, & Corcoran, 2010). Certainly, the DSM-5 (APA, 2013) includes evidence that some mental disorders have considerable genetic and neurological links, even if scientists have yet to identify clear laboratory markers for any DSM diagnosis (First, 2010). However, others have suggested that this approach could reinforce the notion that those with mental disorders are biologically flawed as opposed to being complex beings who traverse many complicated contextual factors that impact their functioning (Ben-Zeev, Young, & Corrigan, 2010).
This shift toward viewing mental disorders from a neurobiologically based perspective may result in increased use of psychopharmacotherapy, or medication therapy (Frances, 2013). Although many clients may benefit from or require psychotropic medications to function effectively, others with mental disorders do not require this type of intervention. The use of medications can invite serious side effects and financial costs and preclude participation in psychosocial therapies demonstrated to be successful in long-term management of many mental disorders. Counselors should be mindful of these changes as they advocate at the community, state and national levels to ensure clients are educated about medication options, understand effectiveness of psychosocial and counseling treatments, and have access to appropriate care (Dailey et al., 2014).
Even if somewhat arbitrary, removing the distinction between mental disorders and medical disorders has the potential of creating confusion within the helping professions as to the nature of the treatment provided. Counselors may struggle regarding their role in recording medical diagnoses that they are not qualified to diagnose, and should collaborate with medical professionals to offer a holistic treatment conceptualization. Counselors would do well to consider the body of evidence regarding etiology of mental disorders and evaluate ways in which they may make unique contributions to client change.
Psychosocial and Contextual Factors (Axis IV)
Clinicians previously listed psychosocial and contextual factors that affect clients and are relevant to conceptualization on Axis IV:
Originally conceived in the third edition of the diagnostic manual as a way to rate and rank the severity of particular stressors, axis IV was simplified for the fourth edition because of the difficulty in reliably quantifying the etiologic contribution of specific stressors to mental disorder; instead, clinicians were asked to simply note salient environmental factors. (Probst, 2014, p. 123)
This included notation regarding concerns in nine key areas: primary support group, social environment, education, occupation, housing, economic, access to health care, legal system/crime and other (APA, 2000).
Although information listed on Axis IV was intended to supplement diagnoses on the first two Axes, clients who attended counseling for only an Axis IV diagnosis were not eligible to receive mental health coverage from insurance companies (APA, 2013). In fact, Probst (2014) provided evidence that APA was intentional in ensuring that Axis IV was not codable and optional for billing purposes in efforts to preserve a degree of client confidentiality. As such, the new nonaxial coding system might actually increase accessibility of services depending upon insurance companies’ individual responses (APA, 2013). Beginning with the DSM-5, clinicians are advised to make a separate notation regarding contextual information, rather than including it in axial notation. However, the APA (2013) did not provide guidance regarding how or where to do so.
Although there is no longer an Axis for contextual factors, it is imperative that counselors maintain a holistic focus that aligns with our unique identity (Hansen, 2009). Along with a humanistic, strength- and competency-based perspective, counselors are sensitive to contextual and cultural considerations. Context refers to the interrelated conditions in which clients’ experiences occur, or any factors that surround their experience and illuminate their situation. As previously discussed, many traditional understandings of mental disorders highlight a pathology- and deficit-based perspective. When considering clients’ situations from a contextual perspective, counselors are responsible for incorporating attention to culture, gender and various developmental factors. “Eliminating axis IV does not eliminate the need to consider context—unless it can be shown that genetic and neurochemical factors alone account for the emergence, variation, and trajectory of mental and emotional disorder” (Probst, 2014, p. 129). Thus, counselors are challenged to find new ways to communicate information previously provided in the multiaxial system.
A firm understanding of clients’ context may lead to a more compassionate and holistic conceptualization of symptoms that could be better explained by contextual factors or environmental stressors (Eriksen & Kress, 2005; Kress & Paylo, 2014). In addition, epidemiological research suggests that psychosocial and environmental problems have moderate predictive value for understanding prognosis of major depression, suicidality, anxiety disorders and substance use disorders (Gilman et al., 2013). Additionally, contextually sensitive counselors define some mental disorders as being a person’s functional attempts to adapt to or cope with a dysfunctional context (Ivey & Ivey, 1999). It is important that any diagnostic discussions integrate a focus on these contextual factors.
Culture is an exceptionally important contextual consideration; through culture, clients define, express and interpret their beliefs, values, customs and gender role expectations (Bhugra & Kalra, 2010). Multicultural considerations should enlighten counselors’ diagnostic decisions and ultimately the treatment process. Although it still has room for development, the DSM-5 (2013) includes systematic information regarding gender and culture for each diagnostic category. In some cases, this is limited to a simple accounting of the prevalence of disorders within certain groups; in other cases, APA provided information regarding the diverse presentation or understanding of disorders. Further, the American Counseling Association’s (ACA) Code of Ethics (2014) emphasizes that culture influences manifestation and understanding of problems; thus, counselors must consider culture throughout the counseling and treatment process.
Counselors can use formal or informal assessment to explore and understand clients’ context. The DSM-5 includes a Cultural Formulation Interview (CFI) that counselors can use to help them understand clients’ context and its impact on their experiences and symptoms. The CFI may help counselors obtain the most clinically useful information, develop a relational connection with clients and ultimately make accurate diagnoses. The CFI is included in Section III of the DSM-5 and is a semi-structured interview composed of 16 questions that address both individual experience and social context. The text is divided into two columns, with counselor-generated questions on the right and instructions for application on the left. Two versions of the interview are available, one for the individual and one for an informant (e.g., a caregiver or a parent). The interviews also are available online at the APA’s (2014) DSM-5 website. The CFI also includes 12 Supplementary Modules, which provide additional questions used to assess domains of the 16-item CFI (e.g., cultural identity) as well as questions that counselors can ask during the cultural assessment of particular groups (e.g., children and adolescents, older adults, immigrants and refugees, and caregivers).
Should counselors elect not to use this more formal interview format to assess culture, there are multiple additional formal and informal cultural assessments as well as assessment guidelines that they can apply. For example, Castillo (1997) provided the following guidelines for culturally sensitive diagnosis: (a) assess the client’s cultural identity; (b) identify sources of cultural information relevant to the client; (c) assess the cultural meaning of a client’s problem and symptoms; (d) consider the impacts and effects of family, work and community on the complaint, including stigma and discrimination that may be associated with mental illness in the client’s culture; (e) assess for counselor personal biases; and (f) plan treatment collaboratively. Castillo’s guidelines offer a comprehensive assessment that may inform diagnostic practices.
The ACA’s Code of Ethics (2014) also indicates that counselors should recognize social prejudices that lead to misdiagnosis and overpathologizing of certain populations. It is impossible to understand clients’ unique situations and how to best help them if cultural considerations are not addressed. An understanding of clients’ culture in relation to diagnosis includes understanding cultural explanations of their experiences, their help-seeking behavior, the cultural framework of clients’ identity, cultural meanings of healthy functioning and cultural aspects that relate to the counselor–client relationship (Eriksen & Kress, 2005).
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 as impairment in functioning, was particularly helpful. Perhaps more importantly, Ro and Clark presented empirical evidence that functioning includes four key factors: well-being (including satisfaction, quality of life and personal growth), basic functioning in life demands, self-mastery, and interpersonal and social relationships. Certainly, this conceptualization fits well with an understanding of counseling as a profession dedicated to maximizing human development (Hansen, 2009).
Historically, payers approved the nature and extent of services based upon GAF scores, diagnosis, severity of symptoms, danger to self or others, and disability across life contexts. With the elimination of the multiaxial system, counselors will no longer note a GAF score, and will not have an assessment of functioning built into the documentation process. In the absence of GAF scores, the APA (2013) suggested that practitioners use alternative ways to note and quantify distress and disability in functioning. The APA also suggested that practitioners continue to assess for suicide and homicide risk and use available standardized assessments to assess for symptom severity and disability (APA, 2013).
The APA (2013) recommended the WHODAS 2.0 as a preferred measure for use in assessing clients’ functioning. The WHODAS 2.0 can be used with clients who have a mental or physical condition or disorder. The WHODAS 2.0 is a free assessment instrument that is provided in the DSM-5, included on the WHO’s website and available through the DSM-5 online assessment measures website (www.psychiatry.org/dsm5). A manual (Ustün, Kostanjsek, Chatteriji, & Rehm, 2010) also is available free of charge.
The WHODAS 2.0 is a 36-item measure that assesses disability in people 18 years and older. It assesses for disability across six different domains: self-care, getting around, understanding and communicating, getting along with people, life activities (e.g., work and/or school activities), and participation in one’s community/society. When completing the form, clients rate the six areas based on their functioning over the past 30 days. Respondents are asked to respond as follows: none (1 point), mild (2 points), moderate (3 points), severe (4 points), and extreme or cannot do (5 points). Scoring of the assessment measure involves either simple scoring (i.e., the scores are added up based on the items endorsed with a maximum possible score suggesting extreme disability as 180) or complex scoring (i.e., different items are weighted differently). The computer program that provides complex scoring can be found on the WHO’s website. The WHODAS 2.0 can be used to track changes in the client’s level of disability over time. It can be administered at specified intervals that are most relevant to the clients’ and counselors’ needs.
The WHODAS 2.0 has been decades in development, involving more than 65,000 participants in hundreds of studies conducted across 19 countries. Ustün et al. (2010) summarized psychometric evidence in support of the WHODAS as follows:
The WHODAS 2.0 was found to have high internal consistency (Cronbach’s alpha, α: 0.86), a stable factor structure; high test-retest reliability (intraclass correlation coefficient: 0.98); good concurrent validity in patient classification when compared with other recognized disability measurement instruments; conformity to Rasch scaling properties across populations, and good responsiveness (i.e., sensitivity to change). Effect sizes ranged from 0.44 to 1.38 for different health interventions targeting various health conditions. (p. 815)
The authors concluded that the instrument is robust and easy to use. Likewise, the assessment tool was tested in the DSM-5 field trials, and researchers suggested that it was sound and reliable in routine clinical evaluations (APA, 2013). Despite strong validity evidence, Kulnik and Nikoletou (2014) cautioned that the instrument seems to connect most cleanly to medical or physical elements of disability, sometimes at the expense of social aspects of disability. Similarly, the WHODAS 2.0 only assesses one of four areas of functioning identified by Ro and Clark (2009). Although counselors may find the WHODAS 2.0 helpful for understanding some elements of disability, they may do well to consider additional holistic and comprehensive opportunities to assess client functioning and strengths.
Discussion
Counselors should be aware that the act of rendering a DSM diagnosis is only one part of a comprehensive assessment. What one reports in terms of diagnosis is just a snapshot of the client. It does not capture the totality of one’s understanding regarding client strengths and limitations, nor does it indicate how counselors go about constructing that understanding. Any thorough assessment must take into account an understanding of all relevant factors. These include, but are not limited to, psychosocial factors such as psychological symptoms, family interactions, developmental factors, contextual factors, functional abilities and longitudinal-historical information.
Given elimination of the multiaxial system, we advise counselors to be especially alert to listing V or Z Codes as part of the diagnosis in order to maintain consideration for client context in addition to biology and symptomology. As with prior editions of the DSM, counselors can still use V or Z Codes as sole diagnoses or to augment other diagnoses. Counselors also should document contextual information in their records so that this information can be conveyed to others as appropriate and used to support clients’ treatment.
There are a number of models that can be used to guide counselors’ diagnostic, case conceptualization and treatment practices. One such model is the I CAN START model (Kress & Paylo, 2014), which follows:
- I (Individual) represents the individual counselor and his or her unique experiences, competencies, limitations and other personal factors;
- C (Context) relates to an understanding of the client’s unique context (e.g., culture, gender, sexual orientation, developmental level, religion/spirituality);
- A (Assessment and Diagnosis) represents the assessment of the client and his or her symptoms and the accompanying DSM-5 diagnosis;
- N (Necessary level of care) refers to the client’s required level of care (e.g., residential treatment, hospitalization, outpatient treatment, individual counseling, family therapy);
- S (Strengths) signifies the client’s strengths, resources, and capacities, which can be used in treatment to help him or her overcome his or her problems and thrive;
- T (Treatment) represents the utilization of an evidence-based treatment in addressing the presenting disorders or problems;
- A (Aims and objectives of treatment) denotes the development of clearly defined problems, with measurable goals and clear behavioral counseling objectives;
- R (Research-based interventions) refers to the use of counseling techniques that are based on research; and
- T (Therapeutic support services) involves the use of support services that may complement counseling interventions and treatments (e.g., case management, medication management, nutrition counseling, a physical exercise program, parent training, yoga, meditation).
The loss of the multiaxial system in the DSM-5 provides both opportunities and challenges to counselors. The exact outcome of how the new process will be implemented is not yet known, and only time will show the extent of its impact. With the loss of the multiaxial system, some of the structure associated with its use is also lost. Moving forward, counselors should continue to develop methods for assessing and documenting aspects of the multiaxial system that have been eliminated. With this change comes an opportunity to reaffirm holistic and integrated views of clients and to provide leadership for other mental health professions and professionals regarding how to incorporate this perspective into diagnostic practices.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest or funding contributions for the development of this manuscript.
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Victoria Kress, NCC, is a Professor at Youngstown State University. Casey A. Barrio Minton, NCC, is an Associate Professor and Counseling Program Coordinator at the University of North Texas. Nicole A. Adamson, NCC, is an Assistant Professor at the University of North Carolina at Pembroke. Matthew J. Paylo is an Associate Professor at Youngstown State University. Verl T. Pope, NCC, is Chair and Professor of Counseling at Northern Kentucky University. Correspondence can be addressed to Victoria Kress, 1 University Plaza, Youngstown, OH, 44555, victoriaekress@gmail.com.
