Counselors for Social Justice Position Statement on the Development of the Diagnostic and Statistical Manual of Mental Disorders-5th

ed. (DSM-5) and Proposed Draft Revisions to DSM Disorders and Criteria Submitted by Counselors for Social Justice (CSJ) A Division of the American Counseling Association (ACA) On behalf of the CSJ Committee on DSM-5 Chair: Julie R. Ancis Members: Michael DAndrea, Rhonda Bryant, Cheree Hammond, Susan Riser, and Shemya Vaughn Approved by the CSJ Board on August 26, 2011 The following statement represents the position of Counselors for Social Justice (CSJ) regarding the draft of the Diagnostic and Statistical Manual of Mental Disorders 5th ed. (DSM-5) and the process by which this draft has been developed. As a professional organization committed to fostering healthy human development by promoting social justice in our society, CSJ outlines numerous concerns and recommendations for corrective actions related to the current draft revisions of DSM disorders and criteria in the following sections of this position statement. I. Importance of Empirical Basis

The APA (2010a) website on DSM-5 Development indicates the following as one of the principles guiding the revision of the DSM: that all recommendations should be guided by research evidence. Similarly, David Kupfer, Chair of the DSM-5 Task Force, asserted that the APA is committed to developing a manual based on the best science available and that the manual is clinically useful (APA, 2010b). Based on these assertions, CSJ expects that all of the disorders included in the new edition of the DSM will be based on solid, empirical research.

Recognizing the importance of supporting the development of diagnostic categories that consist of research-based mental disorders, CSJ is concerned about the lack of an empirical basis for many of the proposed changes. This includes newly proposed mental disorders such as behavioral addiction and obsessive-compulsive spectrum disorder (Storch, Abramowitz, & Goodman, 2008). CSJ is also concerned that some of the proposed diagnoses, such as internet addiction, are under-researched, explored with weak methodologies, and consequently not yet fully understood from an empirical perspective (Albrecht, Kirschner, & Grsser, 2007; Grohol, 2009). II. Social and Political Implications

The implications of new diagnoses and lower thresholds, as pointed out by Allen Frances (2010), former chair of the DSM-4 committee, may include artificial inflation of the rates of mental disorders. The creation of new categories for subthreshold and prodromal syndromes, again without a sound empirical basis, will predictably result in many falsepositive diagnoses and an increasing medicalization of everyday mental health problems and not fully realized disorders. The APA (2010a) website on DSM-5 Development clearly states: when considering whether to add a mental/psychiatric condition to the DSM nomenclature, or delete a mental/psychiatric condition from the nomenclature, potential benefits (for example, provide better patient care, stimulate new research) should outweigh potential harms (for example, harm to particular individuals, misuse). Some areas under consideration for the fifth edition of the DSM not only have very limited empirical support, but are potentially harmful. For example, the newly proposed diagnosis paraphilic coercive disorder, appears to describe little more than a propensity for rape. There are substantial social and legal implications of diagnosing those who rape as having a mental illness. Inclusion of paraphilic coercive disorder in the DSM5 ignores the sociocultural context that contributes to rape

and sexual assault and may excuse rape under the guise of medical legitimization. In addition, inclusion may lead some professionals and the general public to underestimate the adverse impact of various forms of violence (physical, psychological, emotional violence) on survivors. Although unintentional, such outcomes would violate the spirit and principles upon which the American Psychiatric Associations code of ethics are based. CSJ is concerned about the recommended inclusion of what is referred to as premenstrual dysphoric disorder in the new edition of the DSM. Inclusion of this proposed mental disorder represents another example of the mental health professions continued pathologizing of womens natural biological processes. The lack of empirical evidence to support its inclusion contradicts APAs commitment to only include new categories that are clearly substantiated by extensive and consistent evidence supporting them as mental disorders. CSJ also asserts that the recommendation to include gender identity disorder as a mental disorder without substantial and consistent empirical support, represents an example of pathologizing alternative expressions of gender. In essence, the construct of gender identity disorder represents a culturally and socially biased view of human development that not only pathologizes an alternative identity developmental process experienced by many persons, but does so without substantial empirical documentation of this identity as a disorder. The above noted points are equally relevant for the newly proposed sexual arousal/interest disorder in women. III. Cultural Considerations

CSJ supports efforts to describe cultural influences in the expression of mental health difficulties. However, the inclusion of Culture-Bound Syndromes (CBS) in the Appendix of the DSMIV-TR suggests that the DSM as currently structured is primarily comprised of conceptual constructions of mental disorders that are mainly relevant for clients of European descent while the

Appendix describing CBS is reserved for People of Color. Moreover, it is unclear whether the CBS Appendix actually reflects cultural idioms of distress or represents fully realized and legitimized mental disorders in appropriate cultural contexts (Ancis, Chen, & Shultz, 2004; Hughes, 1988). More to the point, CSJ observes that diagnostic criteria that are culturally based and relevant have been relatively absent in all of the DSM editions. Thus, it is strongly suggested that the inclusion of descriptions of culturally influenced expressions of common mental disorders, based on substantial empirical evidence, such as culturally-specific manifestations of depression and anxiety, are important and necessary considerations for the new edition of the DSM. Similarly, the proposed revisions to DSM fail to acknowledge the impact of cultural bias, particularly along the lines of race, gender, and sexual orientation. Moreover, the proposed revisions fail to fully consider the importance of social inequities and differentials in socioeconomic power dynamics that can result in lack of access to preventive and quality mental health services. Thus, some of the proposed diagnoses are inherently discriminatory as they diagnose conditions that could be human reactions to poverty, discrimination, and societal marginalization. IV. DSM Multiaxial Diagnosis System

The purpose of the multiaxial system of diagnosis is to bring greater clarity to the whole of a clients mental functioning and, in doing so, to convey more clearly and accurately client difficulties. CSJ recognizes and supports an integrative and holistic approach to understanding mental disorders and diagnostic processes. For this reason, CSJ is concerned about the possible collapsing of Axes I, II and III and eradication of Axis IV as suggested by the DSM5 Task Force. CSJ asserts that client symptoms result from internal as well as from external experiences; the latter includes but is not limited to racism, homophobia, sexual orientation, discrimination, classism, sexism and other forms of social injustice and cultural oppression. The diagnostic system, as it

currently stands, provides clinicians an opportunity to acknowledge contextually-based stressors that contribute to client distress. Addressing concerns about the possible collapsing of Axes I, II and III and eradication of Axis IV would continue to support the DSMs purview in understanding the multidimensional nature of mental disorders. Consolidation or elimination of any aspect of the current multiaxial format may lead clinicians away from a holistic diagnostic process and result in a reductionist perspective that does not account for systemic issues as they impact mental disorders. CSJ recommends that the DSM5 Task Force explicitly support the importance of having mental health professionals embrace a holistic approach to diagnoses with particular attention aimed at understanding the role of systemic/contextual/environmental factors in the development of mental disorders. CSJ urges the DSM-5 Task Force to include sections in the DSM5 that emphasize the importance of understanding and including considerations of social, cultural, environmental, and political factors when making diagnoses. Such considerations have been absent from or marginally addressed in past versions of the DSM as well as the in the draft of the new edition of the DSM put forth by the DSM-5 Task Force. By overemphasizing biological and medical factors in diagnostic criteria and excluding or minimizing social, cultural, environmental, and political factors known to exacerbate mental disorders, two problems typically ensue. First, failure to operate from a holistic perspective results in a reductionist perspective characterized by incomplete inclusion of relevant diagnostic variables. Second, incomplete diagnostic assessments lead to inaccurate and unreliable diagnoses. There are many negative consequences that predictably result from inaccurately diagnosing clients mental disposition. This includes but is not limited to overemphasis on a disease model, often resulting in limited understanding of the patients condition, simplification of its causes, and overmedication. Continued dominance of a medical model denies the legitimacy of holistic diagnosis

and treatment of mental illness and discourages consideration of the effects of social, cultural, environmental, and political factors on mental disorders. Failing to recognize the role these factors play in the development of mental disorders leads many mental health professionals to disregard the need for treatment that addresses them. V. Secretiveness and Nondisclosure

CSJ is concerned about the manner in which the current DSM revision process has been undertaken, particularly the apparent secrecy involved. Non-disclosure statements and confidentiality agreements signed by members of the DSM-5 Task Force indicate a level of secrecy that is disconcerting and counterproductive to a profession that requires open dialogue and critique for its advancement. Some task force members appear to have relationships with pharmaceutical companies and related industries that could lead to conflicts of interest for those individuals. Those who have such formal or informal relationships with these entities could potentially benefit from the increased medicalization of mental disorders. It is further acknowledged that while income and ownership interests are limited during the time task force members work on the revised DSM, they still receive benefits including those from unrestricted research grants. VI. Ethical Concerns

We reviewed the 2009 Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, developed by the American Psychiatric Association. We were disappointed to find that there are no ethical principles that explicitly address diagnostic issues in general or the implementation of the DSM in particular. However, CSJ recognizes that Section 5 of the 2009 Ethical Principles states that A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law (p. 2).

Given the lack of attention that the American Psychiatric Association directs to issues related to psychiatric diagnoses and the ethical responsibility physicians (and particularly psychiatrists) have in respecting the rights of other health professions, Counselors for Social Justice has concerns about the recent draft from the perspective of the ethical rights and responsibilities under which professional counselors are bound to practice, according to the 2005 Ethical Standards of the American Counseling Association (ACA). CSJ is concerned that professional counselors would potentially violate their own code of ethics in following the proposed diagnostic criteria. The specific ethical standards in question are found in Section E.5 of the ACA Ethical Standards under the heading of Diagnoses of Mental Disorders. What follows are specific ethical subsections representing our concerns, followed by brief explanations of the basis of such ethical concerns: Section E.5.a - Proper Diagnosis Counselors take special care to provide proper diagnosis of mental disorders. Assessment techniques (including personal interview) used to determine client care (e.g., locus of treatment, type of treatment, or recommended follow-up) are carefully selected and appropriately used (ACA, p. 12). The lack of empirical support for a number of newly proposed diagnoses leads us to question their inclusion in the DSM-5. Counselors are required to diagnose responsibly and carefully. This is difficult, if not impossible, to do without empirical data supporting a diagnosis. Section E.5.b - Cultural Sensitivity Counselors recognize that culture affects the manner in which clients problems are defined. Clients socioeconomic and cultural experiences are considered when diagnosing mental disorders (ACA, p. 12). Counselors are required to include cultural factors in defining clients problems, thus making a holistic diagnosis. Medicalization without consideration of cultural and contextual factors can lead to pathologizing of persons.

E.5.c - Historical and Social Prejudices in the Diagnosis of Pathology Counselors recognize historical and social prejudices in the misdiagnosis and pathologizing of certain individuals and groups and the role of mental health professionals in perpetuating these prejudices through diagnosis and treatment (ACA, p. 12). CSJ is concerned that several of the proposed diagnoses, as described in this position statement, will result in pathologizing alternative developmental processes, such as in the case of gender identity disorder; pathologizing womens natural biological processes, such as in the case of premenstrual dysphoric disorder; and excusing the behavior of others, such as in the case of paraphilic coercive disorder. E.5.d Refraining from Diagnosis Counselors may refrain from making and/or reporting a diagnosis if they believe it would cause harm to the client or others (ACA, p. 12). All of the sections listed above allude to various ways that that the current draft of the DSM5 may cause harm to clients. VII. Conclusions

CSJ does not support the inclusion or creation of unsubstantiated, empirically lacking diagnostic disorders that may result in unnecessary, harmful, and preventable stigmatization of persons in marginalized and devalued groups in our society. CSJ does not support the creation of unsubstantiated, empirically lacking diagnostic disorders for the purposes of benefitting pharmaceutical companies. Pharmaceutical companies and related entities have a vested interest in advancing a medical approach to psychiatric diagnoses and mental health-care services. CSJ endorses a DSM revision process that results in the development of diagnostic categories that represent empirically validated mental disorders across cultural, societal, and environmental contexts.

CSJ supports an open and collaborative process in the development of the DSM-5 and any revisions that would follow. It is hoped that the DSM-5 Task Force will consider and address the above noted issues in ways that will strengthen the overall relevance, comprehensiveness, cultural responsiveness, and description of those contextual factors that contribute to mental disorders in the DSM-5 References Albrecht, U., Kirschner, N. E., & Grsser, S. M. (2007). Diagnostic instruments for behavioural addiction: An overview. GMS Psycho-Social-Medicine, 4, 1-11. Retrieved from http://www.egms.de/dynamic/en/journals/psm/index.htm American Counseling Association. (2005). American Counseling Association (ACA) Code of Ethics. Retrieved from www.counseling.org American Psychiatric Association. (2009). The Principles of Medical Ethics: With annotations especially applicable to psychiatry. Retrieved from http://www.psych.org/mainmenu/psychiatricpractice/ethics/resourcesstandards/principles ofmedicalethics.aspx American Psychiatric Association. (2010a). DSM-5: The future of psychiatric diagnosis. Retrieved from http://www.dsm5.org/Pages/Default.aspx American Psychiatric Association (2010b, February 10). New proposed changes posted for leading manual of mental disorders: Draft diagnostic criteria for DSM-5. Science Daily. Retrieved November 23, 2010, from http://www.sciencedaily.com /releases/2010/02/100210001247.htm Ancis, J. R., Chen, Y., & Schultz, D. (2004). Diagnostic challenges: The so-called

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