Monday, May 9, 2016

The Political Beliefs of Mental Health Counselors

On more than a few occasions, I've heard clients and prospective clients talk about avoiding counseling because they expected the counselor to impose a biased worldview.  This has been particularly notable among politically or religiously conservative clients.  Apparently, some of them have been exposed to the same stereotypes about counselors that those of us who work in the profession have been exposed to; the image of a liberal intellectual--perhaps formerly a hippie--who is vaguely spiritual but clearly opposed to organized religion, espousing a worldview of moral relativism.  

But is there any truth to these stereotypes?  If so, is there any evidence that they impact the quality or nature of the therapeutic relationship between counselor and client?

To find out, I started by looking for research published in peer-reviewed professional journals that might shed light on the political beliefs of mental health professionals.  I discovered that in previous studies the majority of social workers, clinical and counseling psychologists, school counselors, and professional counselors and counselor educators identified as politically liberal, which wasn't very surprising.

What I was surprised to discover is how little research I could find on the implications of this correlation.  How does the dominance of liberal political ideology impact the field of mental health counseling?  How does it affect interactions between counselor and client?  How does it manifest in the classrooms of counseling students?  How does it influence what and how counseling researchers explore?

I decided these might be some interesting questions to explore, so I designed the first in what may be a series of studies designed to at least partially answer these questions.  I started with exploring the question of how political ideology might influence counseling sessions.  I wanted to see if there was any connection between the political beliefs of Licensed Mental Health Counselors and their preferred counseling theories.

Basically, counseling theories are beliefs and assumptions about people and their problems, and more specifically how to help people accomplish their goals.  For readers who are not already familiar with them, let me offer a brief summary of theses approaches:

  • Cognitive-Behavioral: Teach people strategies to identify unhealthy thoughts and behaviors and replace them with healthier alternatives.
  • Experiential: Provide people with therapeutic experiences that help them to resolve emotional problems.
  • Humanistic, Existential, and Constructivist: Help people tap into their internal resources by finding meaning or purpose, identifying what they really want or need, and/or adopting strategies or stories that help them accomplish their goals.
  • Mindfulness-Based: Teach people to be aware in the present moment of their thoughts and emotions without judging them.
  • Psychodynamic: Help people develop insight into the developmental experiences and subconscious processes that contribute to their present suffering so that those patterns can be interrupted.
  • Systems: Help people to understand the role each member of a system (e.g., family or relationship) plays in the functioning of that system as a whole and interrupt processes that negatively affect the system.

To date, I have found only one study that examined the relationship between the political beliefs of mental health professionals and their preferred counseling theories, but the study was conducted with psychologists rather than counselors, the sample size was too small to carry a strong effect size, and I also didn't like that the study used a unidimensional approach to categorizing political ideology ranging from liberal to conservative.  I prefer a bi-dimensional approach that includes labels for political ideologies that mix conservative and liberal beliefs (e.g., libertarianism).  For example, on the traditional unidimensional spectrum ranging from conservative on one of the spectrum to liberal on the other, a libertarian who is economically conservative but socially liberal falsely appears moderate or centrist, when in fact he or she tends to take extreme positions depending on the whether the issue is social or economic in nature. A bidimensional approach eliminates this type of illusion.  Finally, I wanted to know more about some of the more specific political beliefs of counselors than the previous study explored.  

For my study, I surveyed 490 Licensed Mental Health Counselors in Florida, asking them how they identified their political ideology (conservative, liberal, moderate, libertarian, communist, etc.), how much they believed their political beliefs influenced their counseling theories, and which political party they last registered with.  I then asked them to rank-order the six counseling theories above from least to most preferred.  Lastly, I asked them to rate how much they agreed or disagreed with 14 political statements related to social and economic freedom on an individual level.  

I developed five hypotheses about what I would find and reported on whether or not the data collected supported those hypotheses.  I created a manuscript of my findings and submitted it to the Journal of Mental Health Counseling in hopes that it would be published.  As of this writing, I'm still awaiting a response.

Hypothesis 1: Mental health counselors are more likely to identify as liberals than as conservatives.

This hypothesis was supported by the data.  Nearly 52% of counselors described themselves as liberal, and only 20% of the sample described themselves as conservative.  Also, 54% of counselors reported that they were registered Democrats, whereas 23% were registered as Republicans.

Hypothesis #2: A majority of mental health counselors will report a perception that their political ideology influences their counseling theory.

Only about 30% of mental health counselors reported that they don't think their political ideology influences their counseling theory at all.  The remaining 70% believe that their political beliefs at least partially influence their counseling theory.

Hypotheses 3 and 4: Liberal mental health counselors will be more likely to prefer humanistic and experiential counseling theories, and conservative counselors will be more likely to prefer cognitive behavioral theory.

The first thing I learned when I explored preferred counseling theories is that cognitive behavioral theory was the most preferred counseling theory among the six options I gave counselors.  The bar graph you see below provides the average rating given by counselors in my sample on a scale of 1 to 6.  As you can see, cognitive behavioral theory was most popular, followed by humanistic/existentialist/constructivist, mindfulness-based, systemic, psychodynamic, and experiential theories in that order.

Next, I used statistical procedure called a chi square test for independence to try and determine whether or not there was any statistically significant relationship between political ideology and each counseling theory.  This test demonstrated a significant relationship with only two of the counseling theories; cognitive-behavioral and mindfulness-based.  As a rule of thumb, in the social sciences we consider a relationship between two variables to be significant if we can obtain a Pearson chi-square value of 0.05 or less, which literally means that the probability that two variables are unrelated is 5% of less.  The value I obtained for cognitive behavioral theory and political ideology was 0.00, meaning that there is approximately a 0% likelihood that the two variables are not related.  The value I obtained for mindfulness-based theory and political ideology was 0.009, meaning that the probability that the two variables are unrelated is less than 1%.

To find out exactly what that relationship was, I had to dig a little deeper and look at ratios.  I discovered that of the 232 counselors who describe themselves as liberal, 159 (68.5%) selected cognitive behavioral theory as their first or second most preferred counseling theory compared to 81 of 89 (91%) conservative counselors.  Twenty (8.6%) liberal counselors and three (3.37%) conservative counselors least preferred cognitive behavioral theory.  In other words, although cognitive behavioral theory was the most popular theory among both conservatives and liberals, conservatives preferred it much more than liberals on average.

I also discovered that 34 of the 232 (14.66%) liberal counselors most preferred mindfulness-based counseling theories, compared to 3 of the 89 (3.37%) conservative counselors.  Four of the 232 (1.72%) liberal counselors least preferred mindfulness-based counseling theories, compared to 3 of 89 (3.37%) conservative counselors.  In other words, liberal counselors tended to prefer mindfulness-based counseling theories more than conservative counselors.

When I examined the relationship between political party affiliation and cognitive behavioral theory, I found similar results.  The probability that the two were unrelated was approximately 0%.  Eighty-seven of the 102 (85.29%) counselors who reported that they were registered Republicans selected cognitive behavioral theory as their first or second preferred theory, compared to 176 of 241 (73.03%) counselors who were registered Democrats.  Six of the 102 (5.88%) Republican counselors least preferred cognitive behavioral theory, compared to 16 of the 241 (6.64%) Democrat counselors.  In other words, although both Democrats and Republicans favored cognitive behavioral theory, Republicans favored it much more than Democrats.

Surprisingly, I did not find that Democrats were any more likely to prefer mindfulness-based counseling theories than Republicans, despite that liberal counselors were more likely than conservative counselors to prefer it.

I did not find any significant relationship between any other counseling theory and political ideology nor party affiliation (i.e., humanistic/existentialist/constructivist, psychodynamic, experiential, and systemic theories).

Hypothesis #5: Mental health counselors will be more likely to support political statements reflective of high levels of individual social freedom than those reflective of high levels of individual economic freedom.

I asked counselors to rate how much they agree with 14 political statements on a scale of 1 to 5.  Seven of those statements were designed to support high levels of individual economic freedom, and the other seven were designed to support high levels of individual social freedom.  These statements are similar to items in The Political Compass and The World's Smallest Political Quiz.  Below, you'll see the average rating counselors gave each item on that scale from 1 to 5.

As I anticipated, counselors were more likely to endorse items supporting social freedom (freedom to make lifestyle choices without government interference) than economic freedom (freedom to make choices about how to spend one's income).

I used the data obtained from these 14 items to create a Nolan Chart, which is essentially a scatter plot providing a graphical representation of where each counselor stands on a bi-dimensional spectrum that separates counselors into four quadrants based on endorsement of beliefs supportive of freedom on an individual level.

(1) Communitarian Quadrant: low social freedom and low economic freedom;

(2) Liberal Quadrant: high social freedom and low economic freedom;
(3) Conservative Quadrant: low social freedom and high economic freedom;
(4) Libertarian Quadrant: high social freedom and high economic freedom.

When I grouped all of those data points into just one point on the same chart that represented the average counselor's position, I came up with the chart below, which depicts the average counselors as a moderate liberal:

Limitations and Flaws of the Study

My study has several limitations and flaws.  First, any study that relies on email responses to a survey runs the risk of sampling bias and volunteer bias.  Basically, any counselor who doesn't have access to email or who did not report his or her email address to the licensing board did not receive the invitation to participate.  What if those counselors, few as they may be, would have made a difference in my results?  Also, what if the counselors who chose not to participate in the study are substantially different from those who took the time to participate?  What if, for example, the counselors who participated are more passionate about politics (and possibly less moderate)?  

Second, this study tells us nothing about causation, it only tells us about correlation.  In other words, we don't know if conservative political ideology causes a stronger preference for cognitive behavioral counseling theories; We only know the two variables are strongly related somehow.  Personally, I suspect that both counseling theory and political ideology are subsets of a broader concept of worldview--a person's overall philosophies of life, or beliefs in how and what people and the world are or should be like.

Third, it's possible that counselors aren't very accurate in applying labels that describe their political beliefs.  What if, for example, the counseling profession tends to attract people who are less politically-informed or politically neutral, and such individuals don't know enough to accurately self-report on their political beliefs?  Personally, I strongly doubt this possibility is true, as counselors tend to be educated individuals who care a lot about society, but I can't say that I know for certain that this is the case.

Lastly, it could be argued that the 14 items I selected and the model I employed to divide counselors into four quadrants is flawed, irrelevant, or perhaps biased.  I think this is a valid perspective in the sense that by definition models are ways of conceptualizing phenomena that are often rooted in preference and are therefore at least partially subjective in nature.  Also, the Nolan Chart that I used to illustrate responses was created by the founder of the Libertarian Party, and as such could raise questions as to whether the model is biased to favor libertarians.

That being said, I certainly uncovered a great deal of evidence that many in the political science field support bidimensional models like the model I used over the traditional unidimensional model that rates political ideology on one spectrum from liberal to conservative (e.g., Feldman & Johnston, 2014; Treier & Hillygus, 2009), and my reasoning for avoiding this reductionist approach seems sound and reasonable (see paragraph 8).  Also, my experience thus far is that at first glance most people who pay a great deal of attention to politics look at the 14 items I selected and consider them to be relevant in terms of understanding an individual's political ideology, and the items were based on items in popular political surveys, suggesting face validity.  And at the very least, these 14 items tell us something about the political beliefs of counselors.

What Might These Findings Say About the Counseling Profession?

I have several theories bout why most of my hypotheses were supported by the data, and what they mean.  First, several researchers have asserted that conservatives may be more attuned to threat than liberals and may prefer order and structure as a means of countering chaos, whereas liberals may have a greater preference for openness and novelty-seeking.  

If these findings are accurate, then one might expect conservatives to be attracted to the structured, orderly, and methodical approach of cognitive behavioral therapy, in which cognitive distortions, irrational thoughts, and maladaptive behaviors can be identified, targeted, extracted, countered, and/or replaced.  Conversely, liberals may be somewhat more likely to spread their preferences out over a variety of counseling theories with less regimented approaches.  They may be attracted to the idea of acknowledging and accepting unpleasant thoughts and feelings with a nonjudgmental stance, as mindfulness-based approaches emphasize.

Also, because cognitive behavioral therapy is so well-researched and popular in counselor education programs, conservative counselors may view it as a "safe bet" of sorts, preferring it to other approaches with less empirical support.

Are there benefits to liberal bias in the counseling profession?  Do liberals tend to make better counselors somehow?  Why does the profession attract more liberals than conservatives?  These are interesting questions to explore, although they may also feel threatening to conservative counselors, counseling students, and counselor educators.  But even if there were advantages to the liberal lean in the counseling profession, there may also be several drawbacks.  

A popular team of researchers on moral reasoning recently published a position paper asserting that the field of social psychological science has progressively become less politically diverse (i.e., more politically liberal) over time, and that this lack of political diversity contributes to bias that sometimes harms the profession.   

Could the same be true for the counseling profession?  I believe that the following research questions related to political homogeneity may be useful in exploring this further: 

  1. (How might the relationship between counseling theory and political ideology manifest in the therapy room (e.g., whether or not clients tend to have better outcomes when matched with a counselor with a similar political ideology or worldview, differences in decision-making or case conceptualization by counselors with varying political ideologies); 
  2. Does the lack of political diversity in our field negatively impact research in mental health counseling (e.g., biased questionnaires or experimental research, lack of research in areas more likely to be appealing to conservative counselors and researchers, confirmation bias, etc.)? 
  3. How might this lack of political diversity impact counselor education (e.g., intentional or unintentional gate-keeping by liberal educators, fear of genuine disclosure by counseling students with a minority political belief system, biased education on topics with a strong connection to political issues)?
  4. How might political homogeneity impact the actions and positions of counseling associations?

To illustrate this fourth question, when the Affordable Care Act was passed into legislation, the American Counseling Association (ACA), the largest professional association representing counselors, released a statement to its members entitled The Affordable Care Act: What Counselors Should Know.  The flyer described several ways the legislation would benefit counselors and clients. Concurrently, several news stories, briefs, articles, and books were published with information on how the legislation could also adversely impact mental health counselors, especially those working in private practice (e.g., Hixson, 2013; Nordal, 2012; Rasmussen, 2013; Rodriguez, 2014; Varney, 2013).  Given that private practice was the second most prevalent work setting among the ACA’s membership in 2011, it is reasonable to question why the ACA did not inform its members of the potential drawbacks of the legislation and whether this intentional or unintentional omission may be related to political bias resulting from the lack of political diversity in the profession.  

Don't counselors deserve for their professional associations to give them objective and balanced information about issues that face them?  If counseling associations fail to do so, will legislators begin to view them as biased mouthpieces of political parties?  If they lose credibility, do they lose influence on important issues of professional advocacy?  These are important questions to explore in a profession that lacks political diversity.

As I mentioned earlier, I anticipate that I will be conducting a few more studies to explore some of the questions I posed above.  I'm also hoping that others will design similar studies so that we can learn more about benefits and drawbacks of political diversity in the counseling profession.  If you're interested in this line of research, stay tuned. 

Update 8/19/16

My manuscript was not selected for publication by the Journal of Mental Health Counseling, primarily because they did not think I had gone far enough in my statistical analysis.  I resubmitted the manuscript to Counseling Values, which may be a more appropriate fit in terms of content and am still awaiting a response.

In an attempt to increase the validity of my findings, I performed some additional analysis on the 14 political statements that I asked counselors to respond to. A one-way analysis of variance was conducted to evaluate the relationship between scores on the economic freedom and social freedom scales of the political beliefs questionnaire and the reported political ideology of participants. The independent variable, the reported political ideology of the participants, included six categories: communist, socialist, liberal, moderate, conservative, and libertarian. The dependent variables include the scores on the economic freedom and social freedom scales. The ANOVA was significant, F (5, 394) = 4.79, p =0.00. This result indicated that the economic freedom and social freedom scores among these six political groups were different.  In other words, counselors who report different political ideologies were likely to respond differently on the 14 items I selected.

Update 10/9/18

I partnered with Dr. Tony Tan at the University of South Florida to improve the statistical analyses of this study, and our manuscript has since been published in the American Journal of Orthopsychiatry.  We are helpful that it will be useful in furthering discussion and research in this are of inquiry.  

Wednesday, September 17, 2014

September Letter from the President

Reposted from Suncoast Mental Health Counselors Association (SMHCA) 

Greetings, SMHCA members!

Last month, I had the pleasure of attending a FMHCA planning retreat in Orlando, which really helped me to organize some of my goals and objectives for 2014-2015 as the incoming President.  Based on feedback I've collected from members of both FMHCA and SMHCA, I've developed a list of seven objectives I have for the upcoming year.  I'd like to share them with you and invite you to be part of the dialogue.  I'd love to hear any ideas, recommendations, suggestions, or criticism that members would like to share as we go forward into what I am confident will be another productive and meaningful year for our chapter.

(1) Expand training and professional development opportunities.  I love working in a profession in which one can never say, "I've learned it all."  SMHCA already offers our members quality continuing education with dynamic, informed presenters.  In addition to the three CEUs offered at every monthly meeting, we have sponsored or co-sponsored a number of special events for continuing eduction, such as the Spring Symposium, the 5th Annual Institute on Counseling the Military, Families, and Children, and the four-hour DSM-5 training we offered at the University of South Florida as a service to students and alumni.  I'd also love to see SMHCA provide live-streaming cyber training and webinars "on demand" for our members who can't travel to our training events. 

(2) Increase, inspire, and invigorate chapter membership.  There is power in numbers.  There are 2,076 LMHCs and an additional 1,991 registered mental health counselor interns in the five counties served by SMHCA.  If even a third of those professionals were members of SMHCA, our membership would expand by 1,200  professionals, and that's not including the unknown number of counseling students in our coverage area!  I'm not just interested in expanding membership; I'd also like to increase membership participation.  I know that our members have creative potential, and I'd like to see that energy in action.

(3) Foster a stronger relationship with the local Veterans Affairs (VA) programs.  LMHCs are the newest behavioral health professionals to be included in the VA's mental health treatment family.  I want to educate the VA on the many benefits of hiring LMHCs and maintain a direct line of communication between the VA hiring personnel and SMHCA members who are interested in joining the VA's workforce.  I also envision a symbiotic referral relationship between the VA and LMHCs in agency and private practice settings.

(4) Increase the public's familiarity with the specialty of clinical mental health counseling.  Understandably, the average client in need of mental health treatment is confused about the difference between LMHCs and other allied therapeutic professionals, such as LCSWs, LMFTs, psychologists, psychiatrists, and psychiatric ARNPs.  Frankly speaking, many healthcare professionals know very little about LMHCs, our scope of practice, and how our services play an integral role in the healthcare industry.  I'd love for every LMHC to be able to articulate a reasonable explanation of what LMHCs bring to the table.  Last year, Past President Mary Lutzo and other SMHCA members distributed brochures they designed to facilitate this dialogue, making them available to our membership.  I'd like SMHCA to provide local LMHCs with additional tools to promote our profession.

(5) Promote and expand the Colleague Collaboration program.  Peer supervision and collaboration is a tremendous benefit, especially for our members who work in private practices that can sometimes be very isolating.  It seems as though this opportunity is under-utilized by our membership, and I'd love to see more participation.

(6) Foster a stronger relationship between SMHCA and its state and national affiliates, FMHCA and AMHCA.  The efforts of our state and federal affiliates trickle down to local practitioners.  There are tremendous disparities and threats to our profession that need to be addressed on those levels in order for us to secure our place at the table in the national healthcare industry.  LMHCs should be able to bill Medicare just as LCSWs and psychologists do.  We are dramatically under-represented in the VA system, and many branches of the armed services, such as the U.S. Air Force, hire psychologists, psychiatrists, social workers, and nurse practitioners as medical officers while excluding licensed professional counselors.  Psychologists have made several unsuccessful attempts to prevent LMHCs from administering tests that measure personality and pathology constructs despite our training in assessment and evaluation.  As FMHCA's "chapter of the year" for two consecutive years, I'd love to see our members take a more active role in FMHCA activities, and I'd love to increase dual membership.

(7) Revise and update chapter By-Laws.  A subcommittee consisting of Mary Lutzo, Past President Misty Fenton, Jay Schrader, and Cristina Gonzalez was formed last spring and has been working hard over the summer to develop a list of recommended changes to our by-laws.  I anticipate that we will be examining their recommendations during our September meeting.

I don'w know about you, but I'm looking forward to SMHCA being named FMHCA's "Chapter of the Year" for the third year running.  Feel free to contact me with your ideas on how to make that happen.  Cheers!

Friday, December 27, 2013

Exploring New Terrain: DSM-5 and Substance Use Disorders

Explore DSM-5 at the 2014 FMHCA Annual Conference
by Aaron Norton, LMHC, CAP, CRC    

It's been six months since the release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and counselors are gradually shifting towards full implementation of the new criteria. For many, this task is overwhelming and perhaps unwelcome.

After all, human beings are in many ways creatures of habit, and counselors are no exception. It takes a great deal of time and effort to re-educate ourselves every time the "bible of psychiatry" written in dry, academic prose gets tampered with, and if you're like me, you're pretty busy and can think of much more interesting things to do with your limited spare time. Personally, the best way I could think of to force myself to learn about the DSM-5 was to register for a number of trainings and start scheduling my own presentations on the topic, paying homage to the old saying, "We teach what we need to learn" (or is it, "Those who can't, teach?").

Still, this nearly 1,000 page snoozer offers us far more utility than bibliotherapeutic treatment of insomnia via bedtime reading, filling an empty space on our office bookshelves, or serving effectively as an expensive paper weight. The DSM-5, as imperfect as it may be, is the "gold standard" of diagnosis and case formulation here in the U.S. It helps us organize our thoughts, identify effective treatments, and measure clinical progress. Knowledge of its contents is required of counseling students in CACREP-accredited programs, interns sitting for their licensure exams, and clinicians who work with third party payers who want to ensure that we're submitting claims for treatment of a disorder vs. preventative care. In this professional climate, updating ourselves on DSM revisions is a matter of necessity, not luxury.

FMHCA is doing its part in helping counselors accomplish this daunting task by providing a two-day conference this February dedicated to updating counselors on a variety of changes impacting our field. By my count, the conference includes nearly nine hours of DSM-5 update training, including my three hour workshop on using the DSM-5 and the newly released 2013 American Society of Addiction Medicine (ASAM) treatment criteria to conduct quality substance abuse assessment and evaluation. I'm hoping to make the DSM-5 update easier by focusing on the paradigm shift in the new edition and connecting each change to that shift.

What do I mean by "paradigm shift?" Let's start with a brief glimpse of the history of the DSM. The first edition, published in 1952, was dramatically brief in comparison to the heavy volume we're now so familiar with. It consisted of brief, psychodynamic-oriented descriptions of disorders. The next paradigm shift of the DSM came with the third edition published in 1980, which implemented a medical model with very specific criteria for disorders and a litany of statistical data supporting each. Not surprisingly, the DSM expanded dramatically in length with that edition.

The DSM-5 was intended to establish a new paradigm shift within the context of the existing medical model of diagnosis. As I see it, the six most salient examples of this shift include efforts to:

  1.  Reduce the dichotomous nature of diagnosis (i.e. "You either have the disorder, or you don't") by shifting towards a spectrum approach to classifying disorders with more specific information attached to the diagnosis (e.g. more specifiers available for each diagnosis, including extra scales of severity);
  2. Streamline and simplify diagnosis by combing similar disorders and then providing more options within the diagnosis in the form of new specifiers. (You'll be happy to know, by the way, that for the first time in DSM history, the volume actually decreased in size.);
  3. De-pathologize "different" by more clearly delineating between abnormal and disordered human experience;
  4.  Reduce the frequency of inaccurate or generic diagnosis;
  5. Enhance consideration of cultural and developmental factors in the diagnostic process; and
  6. Eliminate the phenomenon of "mind-body dualism" inherent in previous editions. It's official; the large group of psychiatric professionals tasked with developing the new edition have decided that our brains are, in fact, part of our bodies. Consequentially, it no longer makes sense to separate the physical aspects of human wellness from the mental aspects of wellness as though the two are entirely separate realms with no overlap.
Changes made to substance use and related disorders provide an excellent example of all of these paradigm shifts:
  1. Streamline and simplify diagnosis and reduce the dichotomous nature of diagnosis: Because the DSM-IV diagnoses of Substance Abuse and Substance Dependence differed primarily in severity, the two disorders have been collapsed into one substance use disorder with an added spectrum of severity in the form of mild, moderate, and severe specifiers based on the number of symptoms the client meets. This measure also solves the problem of "diagnostic orphans," a concept a little too complex to address in this article (although it will be covered at FMHCA's annual conference). It also eliminates the DSM-IV problem of the absence of a diagnosis for Nicotine Abuse. Previously, only Nicotine Dependence could be diagnosed, but in the DSM-5 a milder tobacco use disorder is available. The symptoms have also been reordered into groups that may make more sense to the clinican.
  2. De-pathologize: The more loaded terms "abuse and dependence" have been replaced with the more neutral phrase "substance use disorder." Also, the threshold for the number of symptoms needed for a diagnosis has increased from one to two to strengthen the legitimacy of the diagnosis.
  3.  Reduce the phenomenon of inaccurate or generic diagnosis: The diagnosis Polysubstance Dependence has been deleted, because it was so frequently inaccurately applied by clinicians. For the first time, craving (a strong desire or urge to use) has been added to the diagnostic criteria;
  4. Increase cultural and developmental sensitivity in the diagnostic process: The symptom for recurrent problems with law enforcement was eliminated "because of cultural considerations that make the criteria difficult to apply internationally" and many of the statistics on substance use disorders provide detail on differences among age groups;
  5. Eliminate mind-body dualism: The specifiers "with physiological dependence" and "without physiological dependence" have been removed. Frankly speaking, the delineation between physical and psychological addiction is silly. Cannabis Withdrawal has been added as a diagnosis based on decades of consistent research and case history of a clear withdrawal syndrome experienced by many chronic, daily marijuana users. This addition contradicts the popular societal myth that marijuana isn't physically addictive; it's just psychologically addictive. Caffeine Withdrawal has also been added, although Caffeine Use Disorder exists only in Section III of the DSM-5 to be considered for future revisions.

As helpful as I view some of these changes, the new criteria raise a few interesting dilemmas for counselors to ponder.

For example, the Americans with Disabilities Act and the Rehabilitation Act acknowledge that Alcoholism and drug addiction (or "chemical dependency" as some government programs label it) can be protected disabilities, provided that other requirements for a disorder to be considered a disability are met and the individual is no longer using the substance. Traditionally, a DSM-IV diagnosis of Substance Abuse was not sufficient to be considered a disability, whereas Substance Dependence may be. Moreover, Substance Abuse could be considered a temporary diagnosis, whereas Substance Dependence was considered a chronic disorder, regardless of whether or not it was in remission. How will rehabilitation counselors, diagnosticians employed by social programs, and others involved in social program eligibility now delineate between abuse and dependence?

And now that the criterion for "recurrent substance-related legal problems" has been removed, how will diagnosticians be able to determine if a defensive client with a significant history of substance-related arrests still meets criteria for a substance use disorder based on the remaining criteria?

And now that the DSM criteria for substance use disorders has changed, what will change with ASAM treatment criteria?

As much as I want to be helpful with this article, I'm not going to give away the farm, folks. I'll be happy to answer explore these issues in detail at FMHCA's annual conference in February. I hope to see you there!

Sunday, June 2, 2013

Reflections on DSM-5: Strengths and Controversies

The DSM-5 is a tool used by mental health professionals for case conseputalization
A couple weeks ago, the American Psychiatric Association (APA) unveiled the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), triggering headlines such as "DSM-5 is here: What the controversial new changes mean for mental health care" and "Controversial update to psychiatry manual, DSM-5, arrives."

Aaron Norton, LMHC, presents on DSM-5
The buzz word, of course, is "controversy."  And why not?  Few, if any, areas of modern medicine are more controversial than Psychiatry.  Mental illness remains, in many respects, stigmatized by society-at-large.  Many struggle to accept mental disorders as legitimate medical conditions.  Throw in the fact that although the DSM was created to aid trained mental health professionals with case conceptualization for treatment planning, others use it to build a case for or against someone in criminal and civil case proceedings, disability determination, and eligibility for a number of social programs. 

The stakes are high and the implications are vast, so any changes in the way mental health professionals categorize, label, or conceptualize mental disorders are bound to be met with some degree of skepticism or criticism both within and outside the field.  I think that's just par for the course.

But what are the hot button issues with this revision?  What are critics alleging?  I'll briefly explore two of the most commonly discussed controversies:

1) The creation of new disorders pathologizes normal human behaviors and experiences.  Disruptive Mood Dysregulation Disorder, Premenstrual Dysphoric Disorder, Mild Neurocognitive Disorder, and Binge Eating Disorder are among the most controversial additions, and the removal of the Bereavement exclusion from the criteria for a Major Depressive episode has triggered criticism that normal human grief has been unnecessarily labeled a disorder.  I think this is a valid concern in the sense that I am attuned to the risk of medicalizing unpleasant or abnormal human experience.  But when I read the criteria for these new disorders, it seemed obvious to me that the new edition isn't targeting common temper tantrums, the occasional fast food drive thru experience, mild absentmindedness, or the typical mood fluctuation that many women experience during "that time of the month."  I think the criteria paint a fairly clear picture of a severe symptom presentation causing a clinically significant degree of impairment or distress that often warrants treatment.  And because I recognize that the neurobiology of a clinically depressed person isn't different if that individual is grieving the loss of a loved one, removal of the Bereavement exclusion makes logical sense to me.  Moreover, there are several examples in the DSM-5 of the de-stigmatization of abnormal human experiences.  Changes in the category of Paraphilic Disorders and the re-classification of Gender Dysphoria are, I think, great examples.  Of course, the DSM is essentially the brainchild of the APA, an association that exclusively represents psychiatrists vs. mental health professionals who treat mental illness without prescribing medication (e.g. counselors, therapists, psychologists, clinical social workers), so some are concerned that the APA is in bed with "Big Pharma," and therefore benefits from classifying relatively benign human experiences as a form of mental illness.  Meanwhile, while some believe that the DSM-5 revisions will cause an increase in the number of Americans who are deemed "mentally ill," others are concerned that revisions will squeeze some Americans out of diagnostic labels.  For example, some critics of the merger of Aperger's Disorder into Autism Spectrum Disorder fear that some individuals currently diagnosed with Asperger's won't meet the new diagnostic criteria despite the APA's findings to the contrary.

2) The classification system is arbitrary and/or not organized based on the neurobiological characteristics of the disorder.  Just prior to the release of the DSM-5, Dr. Thomas Insel, the Director of the National Institutes of Mental Health, alleged that "the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure," opining that "patients with mental disorders deserve better."  I certainly agree
Thomas Insel, MD
that the DSM's classification system is not ideal, but I also believe that mental health is a complex subject area; it can't necessarily be reduced to a set of data points extrapolated from a routine lab test.  As we continue to develop new technologies for study of the human brain, I imagine the way we classify mental disorders will continue to evolve.  Indeed, there are several examples of changes in the DSM-5 that stem from advancements in the field of Neuroscience.  Gambling Disorder shifted into the new Substance Use and Addictive Disorders chapter due to commonalities in the underlying neurobiology of both addictive experiences.  Asperger's Disorder was merged in with Autism and two other developmental disorders based on evidence that the four disorders were, on a biological level, varying degrees of severity of the same disorder.  The DSM-IVTR chapter entitled "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" was eliminated, and disorders previously listed in that chapter were reorganized into chapters of disorders with similar underlying neurobiological processes.  Lastly, I'm not certain that any critics of the current classification system have any better ideas at the present.  Two weeks after posting his criticisms of the DSM-5, Insel co-wrote a press release conceding that "Today, the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), along with the International Classification of Diseases (ICD) represents the best information currently available for clinical diagnosis of mental disorders."

So what do I like about the DSM-5?  I like that several revisions reinforce the notion that the distinction between the body and brain are, essentially, more myth than fact.  People often think of mental health as a distinctively separate realm from physical health, as though the two were entirely disconnected spheres of the human experience.  But what are mental disorders if not biological?  They involve genetics, neurotransmitters and hormone levels, brain structures, electrical impulses that travel through the body, encoding of information into short-term and long-term memory, organization of various mental constructs imprinted through life experience, and the intriguing interface between environmental exposure and internal biology (e.g. epigenetics).  Even "non-medical" treatments such as psychotherapy are, in essence, biological interventions in the sense that they involve refined integration of the brain and trigger neurological processes such as neuroplasticity and neurogenesis.  The field of psychoneuroimmunology is bursting with findings substantiating the connection between Mind and Body.  Consequentially, I'm pleased with subtle verbiage changes such as scrapping the phrase "due to a general medical condition" for a more accurate word choice of "due to another medical condition."  And I'm thrilled that somatic disorders can now be diagnosed even if an individual has a known, legitimate, diagnosed medical condition.

I also like that the classification system is less dichotomous.  Several disorders have been merged together and conceptualized as varying points on a spectrum.  The truth is that two people with the same diagnosis can experience dramatically different levels of severity and functioning.  

Finally, the DSM-5 is overall a somewhat more simplified and streamlined product than the DSM-IVTR.  Its shorter in length with several examples of less convoluted wording.  Some old diagnostic labels that have become pejorative labels have been renamed (e.g. "Mental Retardation" became "Intellectual Disability").

All in all, I think the DSM-5 is an improved product in comparison to the DSM-IVTR. Its imperfect and flawed, like any organizational system, but it's probably the best that we have for now.  We'll see what changes with future revisions.

Highlights of Changes from DSM-IVTR to DSM-5
APA's DSM-5 website

Want to learn more about DSM-5 revisions?  If your agency or practice would benefit from an-service training, ask me about my presentation on DSM-5.  I'm available for workshops, conferences, and in-service training in the Tampa Bay area.

Aaron Norton, LMHC provides training on DSM-5