When I read the response to the criticisms offered by Dr. Darrel A. Regier, vice-chair of the DSM-5 task force that the DSM is “a set of scientific hypotheses that are intended to be tested” I became deeply concerned. My first thought was: “When I go to my physician, I don’t want her to have a hypothesized diagnosis that she is going to test on me, I want her to know what is wrong and how to fix it!” And while Dr. Regier’s comment (and a subsequent one that he “hoped” that there would be regular updates to DSM 5, like software) might have been meant to ameliorate the criticism against DSM-5, the reality is that once it is published they will go from being “editable hypotheses” to “diagnostic canon” that insurance companies, government agencies, and courts will all hold clinicians to (to say nothing of the pharmaceutical industry), which will have serious consequences for the entire field. The problem is that the process and its proposed remedy fails to take into consideration the criticisms against it: namely, that it has been based on VERY shaky science (if any at all).
This should concern us all.
As a clinician and counselor educator, I recognize the power and responsibility behind diagnosing clients. Because of this, I want a diagnostic classification system that is rigorous, clinically accurate, and scientifically valid. I fear this is not happening with DSM-5. So what are we to do about it?
Personally, as a counselor, I think that this affords us a unique opportunity as a discipline. In fact, I think that our finest hour may be upon us. Certainly, we are witnessing “history in the making” as psychiatry—once the vanguards of mental illness treatment—is waning (evidenced in their diminishing numbers). Now their influence is weakening (as evidenced by this “revolt” around the DSM-5). But for us counselors, this might be the beginning of something new. For years, we have sought “legitimacy” from the other professions in the form of recognition (for licensure), access to insurance panels, Medicare, Medicaid and Tricare, etc. This has given birth to the efforts for establishing counselor identity (culminating in efforts like licensure in all 50 states, CACREP standards for training, and the VISTAS 20/20 Task Force of ACA), which are all tied to legitimacy. Now, I think that we have the opportunity to assert our legitimacy (rather than wait for it to come from others) in this debate over DSM-5. I think that we can claim another title in our identity: scientists. In addition to being helper, healers, and advocates, we are also scientists. For years, a criticism of counseling has been that we were not rigorous enough in our own work. However, over the last 15 (or more) years, our discipline has taken great strides to apply scientific rigor to our evidence-based practices, our outcome informed learning, and our peer-reviewed empirical articles. Today, we can claim to be full-fledged scientists of counseling regardless of whether one is enamored by the nuances of statistical procedures, or if one never intends to publish a single article. And as such, we have the right—and the obligation—to call into question any process or procedure (as well as its output) that does not submit to the fundamental rigors of scientific research.
All counselors should expect that whatever results from the DSM-5, it should be rigorous, transparent, predictive, replicable, and falsifiable. These are the most basic and important principles of science. If it does not conform to this, as scientists, we have the right to critique and decide for ourselves how to respond to the current DSM process. By doing so, counseling science will come into its own, and counseling will see its finest hour dawn. What we do, and how we respond will determine a good portion of our future for the next few decades. It behooves us all to pay attention to this, and join in the call for a diagnostic system that is scientifically rigorous and appropriate for counseling practice. Hopefully the DSM-5 task force will respond appropriately, otherwise more changes will come, and counselors may see themselves asserting their legitimacy as scientists and leading the call for wider change in the field.
Paul R. Peluso is a counselor and Associate Professor in the
Department of Counselor Education at Florida Atlantic University