In This Issue
A brief overview of the DSM-5 reform effort
By David N. Elkins
In the spring of 2011, the British Psychological Society (BPS) provided a critique of the proposed DSM-5, raising serious concerns about numerous proposals by the DSM-5 Task Force. When I became president of Division 32, Society for Humanistic Psychology, American Psychological Association, in August, 2011, I asked the Division 32 Executive Committee to support my recommendation that Division 32 follow BPS's example and raise concerns of our own about the proposed DSM-5. The recommendation was unanimously approved by the 14-member Executive Committee. I then appointed Brent Dean Robbins, secretary of Division 32, and Sarah R. Kamens, student representative to Division 32 and doctoral candidate in clinical psychology at Fordham University, to join me as members of a three-person committee which we named the "Division 32 Open Letter Committee." The committee prepared an "Open Letter to the DSM-5 Task Force and the American Psychiatric Association." Kamens, who had been studying the DSM-5 development process for two years, drafted the letter and Robbins and I, along with Kevin Keenan (another member of the Division 32 Executive Committee), edited the letter. The letter was then submitted to the Division 32 Executive Committee for their final approval. Read the open letter that provided a scholarly critique of several problematic portions of the proposed DSM-5.
In early October 2011, I sent the Open Letter by email attachment to APA divisions, inviting them to sign. Two divisions — Division 27 ( Society for Community Research and Action: Division of Community Psychology) and Division 49 (Group Psychology and Group Psychotherapy) were the first divisions to sign. Presidents of those two early signers contacted me by email to say they wished to endorse the open letter. On Oct. 22, 2011, the open letter was quietly posted at a petition website without publicity or fanfare, inviting professionals to read the letter and, if they agreed with it, to sign the petition. The results were unexpected and overwhelming. Within a few days more than 1,500 psychologists and other mental health professionals had signed the letter, along with several mental health organizations. Allen Frances, MD, who chaired the DSM-IV Committee and who had been raising concerns about the DSM-5 effort for some time, assisted us greatly by publishing our open letter and petition website link in his blogs. In addition, news agencies picked up the story and it is now estimated that more than 100 media outlets around the world have covered the DSM-5 reform effort. These include USA Today, ABC News, the New York Times, the Washington Post, the San Francisco Chronicle, Fox News, the Chicago Tribune, the Huffington Post, the Wall Street Journal, Nature, The Scientific American, Psychology Today, and dozens of other news media in Canada, Europe, South America, Australia and other places. The Division 32 Open Letter Committee also produced a short video that called attention to the social justice concerns related to the proposed DSM-5, particularly those having to do with vulnerable populations such as young children, adolescents, and the elderly.
At the time of this writing (August, 2012), the number of endorsers of the open letter has now grown to almost 14,000 individual signatories and more than 50 endorsing groups and mental health organizations, including the British Psychological Society (50,000 members), several divisions of the American Counseling Association, and a total of 15 divisions of the APA (including all the clinically-oriented divisions). For the names of all the individuals and organizations that have signed, please see the Open letter/Petition website.
As detailed in our open letter, which is the Division 32 Open Letter Committee's official scholarly statement of concerns about the proposed DSM-5, the following is a summary of our central concerns: (a) the lack of adequate empirical support for some of the new DSM-5 diagnoses; (b) the lowering of diagnostic thresholds in several categories, raising the specter that hundreds of thousands of young children, adolescents, the elderly, and others who experience normative distress might be labeled with a mental disorder and treated with psychiatric drugs that can have dangerous side effects; and (c) the introduction of new disorder categories that may result in harm, especially to vulnerable populations, exacerbating the current national problem of overzealous and inappropriate prescribing of psychiatric drugs.
The DSM-5 Task Force and the American Psychiatric Association responded to the open letter, thanking us for the letter and assuring us that they would consider the concerns that had been raised. See their see the letter (PDF, 86KB).
In January, 2012, the Division 32 Open Letter Committee sent a second letter to the DSM-5 Task Force and the American Psychiatric Association requesting that the controversial proposals in DSM-5 be submitted for an outside, independent review by scientists and scholars who had no associations with the DSM-5 Task Force or the American Psychiatric Association. See our letter requesting an independent review. In their response, the DSM-5 Task Force and the APA refused the request for an independent review, stating that there was no outside group of scholars and scientists that was qualified to evaluate the DSM-5 proposals.
Early in 2012, during the public comment period on the DSM-5, the Open Letter Committee expressed appreciation for the relegation of Attenuated Psychosis Syndrome and Mixed Anxiety-Depression, two proposed disorders with insufficient empirical support, to the appendix and for the modification of the earlier definition of mental disorder so that the phrase "underlying psychobiological dysfunction" was eliminated. At the same time, the Open Letter Committee also expressed continuing concern about the following:
- The proposal to include new disorders with relatively little empirical support and/or research literature that is relatively recent (e.g., Disruptive Mood Dysregulation Disorder)
- The lowering of diagnostic thresholds, which may result in diagnostic expansion and various iatrogenic hazards, such as inappropriate treatment and stigmatization of normative life processes. Examples include the newly proposed Minor Neurocognitive Disorder, as well as proposed changes to Generalized Anxiety Disorder, Attention Deficit/Hyperactivity Disorder, Pedophilia, and the new behavioral addictions.
- The perplexing Personality Disorders overhaul, which is an unnecessarily complex and idiosyncratic system that is likely to have little clinical utility in everyday practice.
- The development of novel scales (e.g., severity scales) with little psychometric testing rather than utilizing established standards.
In addition, the Open Letter Committee expressed concerned about the development process of the manual:
- Continuing delays, particularly in the drafting and field testing of the proposals.
- The substandard results of the first set of field trials, which revealed kappas below accepted reliability standards.
- The cancelation of the second set of field trials.
- The lack of formal forensic review.
- Ad hominem responses to critics.
- The hiring of a PR firm to influence the interpretation and dissemination of information about DSM-5, which is not standard scientific practice.
Finally, we requested, for the second time, that the controversial proposals in the DSM-5 be submitted for an outside, independent review.
At the time of this writing (September, 2012), the DSM-5 Task Force still has made only a few changes to the proposed DSM-5, despite the concerns that have been raised by thousands of mental health professionals and dozens of mental health organizations around the world. Although it is still possible that the calls for reform could result in changes to the remaining problematic proposals in DSM-5, we are not very hopeful at this point. Despite the fact that clinical trials conducted in 2012 revealed poor reliability and thus poor validity of numerous diagnostic categories, it appears that the American Psychiatric Association remains on track to publish the controversial manual in May, 2013.
At the APA Annual Convention in Orlando, Fla. (August 2-5, 2012), Division 32 sponsored a two-hour symposium, along with conversations hours, on the DSM-5 reform effort. The symposium, which attracted more than 400 people, was chaired by Brent Robbins of Point Park University (who also presented) and had the following other participants: Dayle Jones of the University of Central Florida and major architect of the American Counseling Association's response to the DSM-5 Task Force, Sarah Kamens, doctoral candidate in clinical psychology at Fordham University, Lisa Cosgrove of the University of Massachusetts, Douglas Bremner, a psychiatrist from Emory University, and David Elkins of Pepperdine University. The audience was enthusiastic and clearly committed to the DSM-5 reform effort. At a conversation hour on Saturday at the convention, the speakers included Melba Vasquez, immediate past president of the APA, Frank Farley, past president of both Division 32 and the APA, Peter Kinderman, primary architect of the British Psychological Society's response to the DSM, Donna Rockwell of Michigan School of Professional Psychology and a former CNN reporter, Jonathan Raskin of State University of New York at New Paltz and an influential constructivist psychologist, and several presidents or appointees of APA divisions who gave brief comments on why their divisions endorsed the open letter and joined the DSM-5 reform effort. During the audience participation portion of the conversation hour, members of the audience made insightful and passionate comments in favor of the reform effort. In short, the symposium and conversation hours at the APA convention in Orlando were memorable in terms of attendance, passion, and commitment of both the speakers and the audience.
In regard to the future, Jonathan Raskin and Frank Farley, members of the Division 32 Open Letter Committee, will chair an international summit in 2013 of representatives from major mental health associations to explore the feasibility of developing an alternative and perhaps parallel diagnostic system that would give appropriate emphasis to psychosocial factors in the causation of psychological difficulties and provide an empirically based foundation for psychotherapeutic interventions that, while recognizing the importance of biological models and treatments, would give much-needed attention to psychosocial and psychotherapeutic approaches. One of the long-standing problems is that the DSM is produced by the American Psychiatric Association which is composed of about 38,000 psychiatrists. The international summit that we are planning would provide an egalitarian platform that would include all clinically-oriented professions such as clinical psychologists, counseling psychologists, marriage and family therapists, licensed clinical social workers, pastoral counselors and others, along with major representatives from various psychology organizations such as the British Psychological Society, the American Counseling Association, and various divisions of the American Psychological Association. We believe it is problematic that a relatively small association of 38,000 psychiatrists produce the DSM which must then be used by hundreds of thousands of other mental health professionals, many of whom do not share the assumptions of the American Psychiatric Association and the DSM about psychological problems and how best to assist clients who are suffering from those problems. Thus, we envision the possible development of an alternative conceptualization of emotional distress and perhaps even, in time, an alternative classification system produced by an egalitarian effort of scholars and scientists in the various mental health professions. We are not naive about the formidable challenges such a revolutionary and egalitarian effort would pose but we believe the time has come for at least discussing this possibility with our colleagues across the various therapeutic professions.
I thank the 14-member Division 32 Executive Committee for their unanimous support for this effort. I especially thank the members of the Division 32 Open Letter Committee, Donna Rockwell, Brent Robbins, Frank Farley, Jonathan Raskin, and Sarah Kamens (consultant member), for their passion and commitment to the DSM-5 reform effort. I also thank Jason McCarty who donated many hours to developing the Coalition for DSM-5 Reform website and posting information on a timely basis. Special thanks also to Melba Vasquez, immediate past president of the APA for joining our conversation hour at the 2012 APA Convention in Orlando, the 15 divisions of APA that endorsed our open letter, Peter Kinderman of the British Psychological Society and major architect of the British Psychological Society's response to the DSM-5 (who gave up a vacation in South France to fly to the U.S. and speak), Dayle Jones of the University of Central Florida and primary architect of the American Counseling Association's response to the DSM-5, Lisa Cosgrove of the University of Massachusetts who has investigated the associations of DSM-5 Task Force members with the pharmaceutical industry, Douglas Bremner, MD, a psychiatrist from Emory University, Allen Frances (Chair of the DSM-IV Task Force) and Suzy Chapman who have steadfastly called attention to the problems with DSM-5, the division presidents and/or appointees who spoke at our conversation hour at the APA convention, Anthony J. Isacco of Chatham University and Division 51 that donated an hour of their convention time to our effort. Anthony was named co-chair of that conversation hour but, due to other commitments, Division 51 asked Sarah Kamens to co-chair that session in Anthony's place. Finally, I thank the news media who realized this was an important story and the thousands of professionals in the U.S., Canada, South America, Europe, Australia and other places around the world who joined the DSM-5 reform effort.
The past year has been historical in terms of the how the tide has turned against the DSM-5 and I believe we have the passion, momentum, and commitment to make the international summit in 2013 a landmark event in the history of therapeutic psychology. More information about this event will be available soon on the Division 32 website and other electronic venues.