Letter from the American Counseling Association Questioning DSM - 5:

[Guest guest]

November 8, 2011

Oldham, MDPresident, American Psychiatric Association1000 Boulevard, Suite 1825Arlington, VA 22209â€3901

Dear Dr. Oldham:

I am sending this letter on behalf of the American Counseling Association (ACA), the world’s largest association forprofessional counselors. There are 120,000 licensed professional counselors in the United States; as such, werepresent the second largest group that routinely uses the DSM.ACA appreciates the efforts of the American Psychiatric Association (APA) and the DSMâ€5 Task Force to update themanual according to new scientific evidence. However, professional counselors have voiced several concerns aboutthe DSMâ€5 development process and they have reservations about many of the proposed revisions. We believeresolving these issues are critical to counselors’ continued confidence in the DSM as a tool for competent andethical diagnosis of psychopathology. Our concerns focus on empirical evidence, dimensional and crossâ€cuttingassessments, field trials, the definition of mental disorder, and transparency.Empirical Evidence. While we appreciate APA’s commitment to quality research, counselors are concerned that anumber of the DSMâ€5 proposals have little basis in empirical studies. A systematic and independent review of theresearch base is critical when revising diagnostic criteria. Unfortunately, guidelines for conducting evidenceâ€basedreviews (e.g., Kendler et al., 2009) were not provided to work groups until approximately 18 months afterrevisions had begun. The rationales posted on the DSMâ€5 website provide either incomplete or insufficientempirical evidence to support many of the proposed revisions. Reportedly in response to this, the DSMâ€5 TaskForce appointed a Scientific Review Committee (SRC) charged with reviewing the empirical evidence supportingthe proposed revisions. While we strongly applaud this decision, we would like more information as to how theSRC will conduct their review so that those outside the process can be assured of the solidity of the empiricalevidence behind the proposals.Dimensional and Crossâ€Cutting Assessments. ACA members were initially supportive of the idea of usingdimensional and crossâ€cutting assessments, but our review of the proposed assessments on the DSMâ€5 websitecauses us considerable worry. Little information regarding scale development has been provided and, according tothe field trial protocols, there is no evaluation using external validators. Furthermore, more than half thedisorders—including important disorders such as attentionâ€deficit/hyperactivity disorder and conduct disorder—have no assessments posted on the website, so we cannot effectively evaluate all of the measures being proposed.Field Trials. Evaluating diagnostic validity using “a variety of external criteria†is essential in developing or revisingdiagnostic criteria (Kraemer, 2007, p. S9). Yet, the DSMâ€5 field trial protocols focus exclusively on reliability,feasibility, and user acceptability. There is an absence of external validators (i.e., evaluation of validity usingexternal criterion measures); thus, there is no way of determining whether any of the proposed changes improvethe validity of the DSM. Furthermore, since the DSMâ€IV and DSMâ€5 criteria are not being simultaneously applied tothe same clients, there is no way to assess the impact of changes on prevalence rates of the various mentaldisorders.5999 son Avenue, andria, Virginia 22304 ph / fx web www.counseling.orgAmerican Counseling Association is committed to equal opportunityDefinition of Mental Disorder. The DSMâ€5 Task Force has proposed a new definition of mental disorder whichincludes, “A behavioral or psychological syndrome or pattern that occurs in an individual that reflects anunderlying psychobiological dysfunction†(APA, 2011). Using the term psychobiological implies that all mentaldisorders have an underlying biological component. Although advances in neuroscience have greatly enhanced ourunderstanding of psychopathology, the current science does not fully support a biological connection for all mentaldisorders. We therefore request that the definition of mental disorder be amended to indicate that mentaldisorders may not have a biological component.Transparency. Although the DSMâ€5 Task Force has described its development process as “open, transparent andfree of bias†(Kupfer & Regier, 2009, p. 40), all work group members were required to sign confidentialityagreements that prohibit them from divulging information about the DSMâ€5 process, even after it is published.Most problematic, the reports of the DSMâ€5 SRC are not available for public inspection, which is a violation of oneof the most basic and vital tenets of science—open access to data and/or processes for independent evaluation andcritique. Without full transparency and openness, counselors may have difficulty having confidence in and trustingthe DSMâ€5.In conclusion, based on these issues, professional counselors have expressed uncertainty about the quality andcredibility of the DSMâ€5. Therefore, to ensure continued trust and confidence in the DSMâ€5, we ask that the APAcarry out the following recommendations:1. Make public all empirical evidence submitted to the DSMâ€5 Scientific Review Work Group, as well as thegroup’s evaluations and recommendations.2. Submit all evidence and data (from work groups and field trials) for review by an external, independent groupof experts in evidencedâ€based decisionâ€making and make the results of this review public.3. Remove any DSMâ€5 proposed revisions deemed to lack strong empirical evidence by external, independentreview, or add them to the Appendix for Criteria Sets Provided for Further Study.4. Eliminate any dimensional or crossâ€cutting assessments that lack supportive reliability and validity evidence,limited feasibility and poor clinical utility.

We appreciate and value the work APA has done in developing a diagnostic classification system that is used byover half a million nonâ€psychiatric mental health professionals in the United States. However, to produce a crediblediagnostic manual, it is essential that the DSMâ€5 be based on research that involves rigorous, systematic, andobjective procedures; an open process; and independent, objective scientific review.

Sincerely,Don W. LockeACA President

cc: Dilip V. Jeste, MD, APA President–Elect Peele, MD, APA Secretary Fassler, MD, APA TreasurerCarol A. Bernstein, MD, APA Past PresidentAlan F. Schatzberg, MD, APA Past PresidentNada L. Stotland, MD, MPH, APA Past PresidentJoyce A. Spurgeon, MD, APA ECP Trusteeâ€atâ€LargeFrederick J. Stoddard Jr, MD, APA Area 1 Trustee E. Nininger, MD, APA Area 2 Trustee Crowley, MD, APA Area 3 Trustee J. Wernert, III, MD, APA Area 4 Trustee A. Greene, MD, APA Area 5 TrusteeMarc Graff, MD, APA Area 6 Trustee M. Womack, MD, APA Area 7 Trustee

5999 son Avenue, andria, Virginia 22304 ph / fx web www.counseling.orgAmerican Counseling Association is committed to equal opportunity

Ann Marie T. Sullivan, MD, APA SpeakerR. Benson, MD, APA Speakerâ€Elect B. , MD, APA Memberâ€inâ€Training TrusteeAlik S. Widge, MD, PhD, APA Memberâ€inâ€Training Trusteeâ€Elect Hurley, MD, APA/Public Psychiatry Fellow Gordon, MD, APA/SAMHSA Fellow Fayad, MD, American Psychiatric Leadership Fellow H. Scully Jr, MD, Medical Director & CEOReferencesAmerican Psychiatric Association (APA). (2011). Deinition of mental disorder. Retrieved fromhttp://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=465Kendler, K., Kupfer, D., Narrow, W., , K., & Fawcett, J. (2009). Guidelines for making changes to DSMâ€V.Retrieved from http://www.dsm5.org/ProgressReports/Documents/Guidelinesâ€forâ€Makingâ€Changesâ€toâ€DSM_1.pdfKraemer, H. C. (2007). DSM categories and dimensions in clinical and research contexts. International Journal ofMethods in Psychiatric Research, 16(S1), S8–S15.Kupfer, D. J., & Regier, D. A. (2009). Counterpoint: Toward credible conflict of interest policies in clinical psychiatry.Psychiatric Times, 26(1), 40

Thanks,

Mitch Silvers.

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