The majority of psychologists are dissatisfied with the DSM, unaware of the alternatives

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The Diagnostic and Statistical Manual of Mental Disorders (DSM), developed by the American Psychiatric Association (APA), is used worldwide as a diagnostic system for mental health problems. Still, psychologists’ attitudes toward the DSM are unclear, and the limited available research suggests a lack of enthusiasm for this diagnostic tool.

Given the lack of research in this area, in a new study, accepted by Professional psychology: research and practice, the researchers set out to assess psychologists’ perceptions of the manual. They found that although the DSM has been revised and updated over the past four decades, the majority of psychologists are dissatisfied with the DSM and are interested in alternatives, although there is a lack of familiarity with it. the alternatives available.

A review of existing and limited research on psychologists’ attitudes toward the DSM revealed dissatisfaction and a desire for alternatives. This dissatisfaction has been expressed since the first research in the 1980s. The authors, led by psychologist Jonathan Raskin, write:

“. . . 90.6% of respondents used the DSM-II, but more than 40% were concerned that it distorts the way clinicians view clients, medicalizes psychosocial issues, has reliability and validity issues, emphasizes diagnosis at detrimental to treatment, masks individual differences and over-pathologizes people. . . Nevertheless, 90.2% of respondents planned to use the DSM-III, although only 19.1% thought it would be beneficial for psychology. »

Later research in the 1980s and most recently in 2016 by the current authors came to similar conclusions – psychologists had more negative than neutral feelings about the DSM, expressed concerns about its reliance on medical understandings of mental health issues and desired alternatives, but conceded to continue using DSM due to lack of other options.

Although there are alternatives to the DSM, clinicians are largely unaware of them, aside from the International Classification of Diseases (ICD), which is very similar to the DSM in terms of categorizing mental health problems and may not look any different at all to some clinicians. It has also caught the attention of the American Psychological Association, which has published materials to educate psychologists about it. Additionally, ICD diagnostic codes, borrowed by DSM, are used for billing purposes by US clinicians.

Other alternatives include the Psychodynamic diagnostic manual (PDM), which takes a psychodynamic approach, the Hierarchical Taxonomy of Psychopathology (HiTOP), which uses a dimensional system, and the Power Threat Meaning Framework (PTMF), which is the most radical of the alternatives, and advocates for the understanding of mental health problems as social problems, rather than as localized disorders in individuals.

In the current study, Raskin and colleagues surveyed 703 licensed psychologists from all disciplines and theoretical backgrounds about their perceptions of the DSM.

The authors write of their findings:

“This study has revealed something remarkable – that psychologists’ attitudes toward the DSM today are largely the same as they were when DSM-III debuted in the early 1980s. The manual has undergone five revisions to refine and improve it. However, during this time, psychologists have remained largely unenthusiastic. As was the case over 40 years ago, psychologists as a group are more dissatisfied than satisfied with the DSM, and they don’t think the manual has had much effect on them or on the diagnosis.”

Looking more closely at their findings, the researchers found differences in opinion about the DSM among psychologists with different theoretical orientations. For example, psychologists with a background in cognitive-behavioral therapy (CBT) generally had a positive view of the DSM, while psychodynamic and humanistic/constructivist/systemic psychologists tended to have a negative view of the DSM. Psychologists with eclectic or integrative backgrounds have remained largely neutral in their perceptions of the DSM.

Despite overall negative opinions of the DSM, with concerns expressed about the diagnostic categories included and its medicalization of psychosocial issues, at least 88% of psychologists surveyed use the DSM at least once a month, primarily for billing convenience. .

Psychologists of all theoretical orientations agreed that little effort had been made to create alternatives to the DSM and supported the development of alternatives. Most were aware of ICD (89.74%), and CBT psychologists and integrative/eclectic backgrounds were supportive of its use.

Overall, psychologists were unfamiliar with other alternatives, including PDM, HiTOP, and PTMF – aside from a vague familiarity with PDM on the part of psychodynamic psychologists. The researchers hypothesize that lack of familiarity with available alternatives, along with other factors, such as lack of diagnostic codes and categories, may have contributed to a lack of enthusiasm for alternatives other than CIM.

Another major criticism of the DSM was its reliance on understanding the medical model of mental illness. The only group that did not agree with concerns about the medical model were the CBT psychologists. Despite this, most psychologists surveyed agreed that mental health issues are not a subgroup of medical disorders. However, most were not in favor of doing away with the medical model altogether – the only group that did was the humanistic/constructivist/systemic psychologists.

Since most psychologists view mental health issues as non-medical, Raskin and colleagues suggest that greater familiarity with alternatives such as PDM and HiTOP, which understand mental health issues not as medical issues , but rather through the prism of personality assessment and psychodynamic theory, would lead to greater support for these methods by psychologists.

Additionally, they advocate moving away from a standardized approach to diagnosis and towards a diversity of diagnostic options, highlighting how different theoretical orientations would likely be attracted to different alternatives, such as psychodynamic psychologists at PDM.

They wonder :

“The diversity of diagnostic options is not something psychologists are used to given the long dominance of the DSM, but it could prove beneficial for clients and practitioners alike. After all, if different types of psychotherapy are equally effective, can’t different diagnostic systems also be? »

The researchers suggest that greater familiarity with the alternatives be cultivated through continuing education and training workshops on the alternatives, as well as the inclusion of alternatives to the DSM in APA-accredited programs.

A limitation of this study is the exclusion of data from participants who did not complete at least 75% of the non-demographic items, the use of surveys, and recruitment to APA divisions, as opposed to members of the ABS as a whole. Future research should also address how factors such as years of practice, or psychologists working primarily with adults versus children, may have affected their perceptions of the DSM.

Raskin and his colleagues conclude by highlighting the challenges that alternatives face in gaining widespread adoption:

“Successful alternatives must not only gain familiarity and theoretically appeal to one or more niche groups of psychologists, but must also offer the same practical advantages as the DSM – or find a practical way to co-exist with the DSM on the reimbursement front while by offering something that clinicians find useful. Until the alternatives overcome these obstacles, it is doubtful that psychologists will adopt them, regardless of their good scientific faith. Even if they overcome them, it will be necessary to complete research and development through education and training initiatives.In the meantime, we expect psychologists to continue to use the DSM despite their lack of enthusiasm for it.

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Raskin, JD, Maynard, D. and Gayle, MC (2022). Attitudes of psychologists towards the DSM-5 and its alternatives. Professional psychology: research and practice. (Link)

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