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Jason H. King, PhD, DCMHS , CCMHC, ACS Core Faculty – Walden University MHC Program

Using the DSM-5 to Develop the Professional Identity and Clinical Competence of Mental Health Counselors UMHCA 2013 Annual Conference. Jason H. King, PhD, DCMHS , CCMHC, ACS Core Faculty – Walden University MHC Program. Goals. 1. Explore professional identity

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Jason H. King, PhD, DCMHS , CCMHC, ACS Core Faculty – Walden University MHC Program

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  1. Using the DSM-5 to Develop the Professional Identity and Clinical Competence of Mental Health CounselorsUMHCA 2013 Annual Conference Jason H. King, PhD, DCMHS, CCMHC, ACS Core Faculty – Walden University MHC Program

  2. Goals • 1. Explore professional identity • 2. Understand clinical competence • 3. Preview the DSM 5 DSM 5 - Jason H. King, PhD, DCMHS, ACS

  3. Professional Identity DSM 5 - Jason H. King, PhD, DCMHS, ACS

  4. What is Professional Identity? • “The unique characteristics of one’s selected profession that differentiates it from other professions” (Weinrach, Thomas, & Chan, 2001, p. 168). DSM 5 - Jason H. King, PhD, DCMHS, ACS

  5. What is Professional Identity? (Chreim, Williams, & Hinings, 2007; Cohen-Scali, 2003) DSM 5 - Jason H. King, PhD, DCMHS, ACS

  6. What is Professional Identity? • CACREP (2009) • PROFESSIONAL ORIENTATION AND ETHICAL PRACTICE • SOCIAL AND CULTURAL DIVERSITY • HUMAN GROWTH AND DEVELOPMENT • CAREER DEVELOPMENT • CACREP (2009) • HELPING RELATIONSHIPS • GROUP WORK • ASSESSMENT • RESEARCH AND PROGRAM EVALUATION DSM 5 - Jason H. King, PhD, DCMHS, ACS

  7. Questions About Professional Identity • “As counselors, one of the major questions of our times is ‘Who are we’” (Hendricks, 2008, p. 259)? • “What is the difference between being a mental health counselor and a social worker or marriage and family therapist?” (Gerig, 2007, p. 6) • “What type of clientele should we serve? • What counseling methodologies should be employed by the counselor? • What is the goal of the profession of counseling” (Palmo, 2006, p. 52)? DSM 5 - Jason H. King, PhD, DCMHS, ACS

  8. Questions About Professional Identity • Myers, Sweeney, and White (2002, p. 399) • How does our identity converge with and diverge from that of other mental health professionals? • Where is our niche, and how can this niche be emphasized and marketed to various public sectors? • How are our specialty areas defined, and how do they relate to professional counseling in general? DSM 5 - Jason H. King, PhD, DCMHS, ACS

  9. Clinical Competence DSM 5 - Jason H. King, PhD, DCMHS, ACS

  10. Clinical Competence • What is Clinical Mental Health Counseling? • UMHCA (2011) • "Clinical mental health counseling promotes optimal wellness for individuals, couples, families, and groups throughout the lifespan. • Those educated and trained as clinical mental health counselors treat as well as prevent mental, emotional, and behavioral disorders through mental health assessments, diagnosis, prevention and treatment plans, and psychotherapeutic counseling interventions.“ • AMHCA (2011) Standards for the Practice of Clinical Mental Health Counseling DSM 5 - Jason H. King, PhD, DCMHS, ACS

  11. Clinical Competence • Vocational Rehabilitation September 30, 2011: • “USOR has determined that when we are paying for psychological testing, evaluation, assessment, and other activities leading to a DSM diagnosis, we will do so with the highest level of professional credential, education, and training. Our standard is a licensed Ph.D. level psychologist, or licensed medical doctor. • I have reviewed the most current mental health licensing laws on DOPL. I find that the law does not allow LPC's, LCSW's, or Substance Abuse Counselors to conduct psychological testing, evaluation, leading to DSM diagnosis. • If the profession, as a profession, has information otherwise, I would be happy to sit down with their professional organization and discuss and reconsider. Until then our standard is our standard.” DSM 5 - Jason H. King, PhD, DCMHS, ACS

  12. Clinical Competence • Mental Health Professional Practice Act • Scope of practice – Limitations – PAGE 16 • (1) A licensed clinical mental health counselor may engage in all acts and practices defined as the practice of professional counseling without supervision, in private and independent practice, or as an employee of another person, limited only by the licensee's education, training, and competence. • Clinical Mental Health Counselor Licensing Act Rule • (H) a minimum of two semester or three quarter hours in psychometric test and measurement theory; • (I) a minimum of four semester or six quarter hours in assessment of mental status including the appraisal of DSM maladaptive and psychopathological behavior DSM 5 - Jason H. King, PhD, DCMHS, ACS

  13. Clinical Competence • NCE • Psychometric statistics – types of assessment scores, measures of central tendency, indices of variability, standard errors, and correlations • NCMHCE • Evaluation & Assessment • Diagnosis & Treatment Planning • AMHCA 2011 Code of Ethics • Mental health counselors utilize tests (herein references educational, psychological, and career assessment instruments), interviews, and other assessment techniques and diagnostic tools in the counseling process for the purpose of determining the client’s particular needs in the context of his/her situation. DSM 5 - Jason H. King, PhD, DCMHS, ACS

  14. Clinical Competence • ACA 2005 Code of Ethics • Section E: Evaluation, Assessment, and Interpretation • Introduction • Counselors use assessment instruments as one component of the counseling process, taking into account the client personal and cultural context. Counselors promote the well-being of individual clients or groups of clients by developing and using appropriate educational, psychological, and career assessment instruments. • E.1.a. Assessment • The primary purpose of educational, psychological, and career assessment is to provide measurements that are valid and reliable in either comparative or absolute terms. These include, but are not limited to, measurements of ability, personality, interest, intelligence, achievement, and performance. • E. 5. Diagnosis of Mental Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS

  15. Clinical Competence • ACA 2014 Code of Ethics • “When possible use multiple forms of assessment, data, and/or instruments in forming conclusions, diagnoses or recommendations” • CACREP (2009) • “…Diagnostic interviews, mental status examinations, symptom inventories, and psychoeducational and personality assessments.” • “…Psychological testing and behavioral observations.” • “…Diagnostic process, including differential diagnosis, and the use of current diagnostic tools, such as the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)” • CACREP (2016) • “Use of informal assessments for diagnostic purposes” • “Use of symptom checklists, personality, and psychological testing” • “Use of assessment results to effectively diagnose developmental, behavioral, and mental disorders” DSM 5 - Jason H. King, PhD, DCMHS, ACS

  16. Clinical Competence • King (2012) • HOW ETHICAL CODES DEFINE COUNSELOR PROFESSIONAL IDENTITY DSM 5 - Jason H. King, PhD, DCMHS, ACS

  17. Clinical Competence • "The specific diagnostic criteria included in the DSM-IV are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion" (p. xxxii) DSM 5 - Jason H. King, PhD, DCMHS, ACS

  18. DSM 5 DSM 5 - Jason H. King, PhD, DCMHS, ACS

  19. DSM-IV-TR • Why diagnose? • Most common diagnostic myth? • “A common misconception is that a classification of mental disorders classifies people, when actually what are being classified are disorders that people have. • For this reason, the text of the DSM-IV (as did the text of DSM-III-R) avoids the use of expressions such as “a schizophrenic” or “an alcoholic” and instead uses the more accurate, but admittedly more cumbersome, “an individual with Schizophrenia” or “an individual with Alcohol Dependence.” (DSM-IV-TR, 2000, p. xxxi) DSM 5 - Jason H. King, PhD, DCMHS, ACS

  20. DSM 5 • Backlash • The National Institute for Mental Health has launched a plan to replace the DSM-5 with a new “Research Domain Criteria (RDoC)” project • incorporating genetics, imaging, cognitive science, and other levels of information • Stating that the DSM is little more than a dictionary, that the DSM criteria are unreliable, and that those diagnosed with mental disorders “deserve better,” NIMH Director Dr. Thomas Insel made the announcement this past week • With its 1.5 billion dollar budget, NIMH is the major source of mental health research in the United States DSM 5 - Jason H. King, PhD, DCMHS, ACS

  21. DSM 5 • Dimensional assessments • Better recognizes the complexity of the interface between psychiatry and medicine • Defines disorders on the basis of positive symptoms • distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms • Organizational Changes • The proposed framework for DSM-5 re-orders the current manual’s 16 chapters based on underlying vulnerabilities as well as symptom characteristics • The chapters are arranged by general categories such as neurodevelopmental, emotional and somatic to reflect the potential commonalities in etiology within larger disorder groups • Such changes are aimed at facilitating more comprehensive diagnosis and treatment approaches and encourage research across diagnostic criteria DSM 5 - Jason H. King, PhD, DCMHS, ACS

  22. DSM 5 • Work Groups • Clarify the boundaries between mental disorders to reduce confusion of disorders with each other and  to help guide effective treatment • Consider “cross-cutting” symptoms (symptoms that commonly occur across different diagnoses) • Demonstrate the strength of research for the recommendations on as many evidence levels as possible • Clarify the boundaries between specific mental disorders and normal psychological functioning DSM 5 - Jason H. King, PhD, DCMHS, ACS

  23. DSM 5 • What is the most significant change? • Roman numerals have been attached to DSM since the second edition of the manual was published more than four decades ago • But in the 21st century, when technology allows immediate electronic dissemination of information worldwide, Roman numerals are especially limiting DSM 5 - Jason H. King, PhD, DCMHS, ACS

  24. DSM 5 • New definition of mental disorder • A behavioral or psychological syndrome or pattern that occurs in an individual • That reflects an underlying psychobiological dysfunction • The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning • Must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals)That is not primarily a result of social deviance or conflicts with society • DSM IV-TR definition of mental disorder • Mental Disorder unfortunately implies a distinction between 'mental' disorders and 'physical disorders' that is a reductionistic anachronism of mind/body dualism. • A compelling literature documents that there is much 'physical' in 'mental disorders' and much 'mental' in 'physical' disorders • Mental Disorders can generally be categorized as a clinically significant behavior or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom DSM 5 - Jason H. King, PhD, DCMHS, ACS

  25. DSM 5 • Chapter Layout • Neurodevelopmental Disorders • Schizophrenia Spectrum and Other Psychotic Disorders • Bipolar and Related Disorders • Depressive Disorders • Anxiety Disorders • Obsessive-Compulsive and Related Disorders • Trauma and Stressor-Related Disorders • Dissociative Disorders • Chapter Layout • Somatic Symptom and Related Disorders • Feeding and Eating Disorders • Sleep-Wake Disorders • Sexual Dysfunctions • Gender Dysphoria • Disruptive, Impulse-Control, and Conduct Disorders • Substance-Related and Addictive Disorders • Neurocognitive Disorders • Personality Disorders • Paraphilic Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS

  26. Neurodevelopmental Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS

  27. Neurodevelopmental Disorders • Intellectual Developmental Disorder • Assessment of both cognitive capacity (IQ) and adaptive functioning – severity • Communication Disorders • Language disorder (which combines DSM-IV expressive and mixed receptive-expressive language disorders) • Speech sound disorder (a new name for phonological disorder) • Childhood-onset fluency disorder (a new name for stuttering) • Social (pragmatic) communication disorder • a new condition for persistent difficulties in the social uses of verbal and nonverbal communication DSM 5 - Jason H. King, PhD, DCMHS, ACS

  28. Neurodevelopmental Disorders • Autism Spectrum Disorders • Merger of the following from DSM-IV: • Autistic Disorder • Asperger’s Disorder • Childhood Disintegrative Disorder, • Pervasive Developmental Disorder Not Otherwise Specified • ASD is characterized by 1) deficits in social communication and social interaction and 2) restricted repetitive behaviors, interests, and activities (RRBs) • Because both components are required for diagnosis of ASD, Social Communication Disorder is diagnosed if no RRBs are present • DSM-IV was skewing Autism diagnoses towards children with social and communication difficulties • As the APA puts it "delays in language are not unique nor universal in ASD" • Lifting age requirement of 3 years • Including sensory processing issues • 1-3 Severity Rating (support, substantial, very substantial) DSM 5 - Jason H. King, PhD, DCMHS, ACS

  29. Neurodevelopmental Disorders • ADHD • Still 18 symptoms, cross-situational requirement strengthened to “several” symptoms in each setting • Examples added to the criterion to facilitate application across the life span • Age of onset: “Several noticeable inattentive or hyperactive-impulsive symptoms were present by age 12” • “Presentations” instead of “Subtypes” • Comorbid diagnosis with ASD is now allowed • Symptom threshold change for adults • reflects their substantial evidence of clinically significant ADHD impairment • with the cutoff for ADHD of five symptoms, instead of six required for younger persons, both for inattention and for hyperactivity and impulsivity DSM 5 - Jason H. King, PhD, DCMHS, ACS

  30. Neurodevelopmental Disorders • Specific Learning Disorder • Combines the DSM-IV diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified • Coded specifiers • Motor Disorders • Developmental coordination disorder, stereotypic movement disorder, Tourette’s disorder, persistent (chronic) motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder DSM 5 - Jason H. King, PhD, DCMHS, ACS

  31. Schizophrenia Spectrum and Other Psychotic Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS

  32. Schizophrenia Spectrum and Other Psychotic Disorders • New Chapter Organization • Schizotypal Personality Disorder • Psychotic Disorder Associated with Medical Condition, Substance or Catatonia • Changes • Dropped subtypes • Elimination of the special attribution of bizarre delusions and “Schneiderian” first-rank auditory hallucinations (e.g., two or more voices conversing) • Addition of a requirement in Criterion A that the individual must have at least one of these three symptoms: delusions, hallucinations, and disorganized speech • Clarification of negative symptoms • Avolition • Expressive deficits DSM 5 - Jason H. King, PhD, DCMHS, ACS

  33. Bipolar and Related Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS

  34. Bipolar and Related Disorders • Overview • Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood • “With mixed features” • Categorization for individuals with a past history of a major depressive disorder who meet all criteria for hypomania except the duration criterion (i.e., at least 4 consecutive days) • Too few symptoms of hypomania are present to meet criteria for the full Bipolar II syndrome, although the duration is sufficient at 4 or more days • Anxious Distress Specifier • Intended to identify patients with anxiety symptoms that are not part of the bipolar diagnostic criteria DSM 5 - Jason H. King, PhD, DCMHS, ACS

  35. Depressive Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS

  36. Depressive Disorders • Disruptive Mood Dysregulation Disorder • Underserved children who are often misdiagnosed as having Pediatric Bipolar NOS • They do not show the same characteristics of individuals with classic bipolar disorder (ex: episodic grandiosity/elevated mood/manic episodes) • Have developmentally inappropriate and significant difficulties • Ages 6-18 • 3+ times per week for 12 months of verbal rages or physical aggression • Premenstrual Dysphoric Disorder • Major Depressive Disorder • Chronic Depressive Disorder – the new Dysthymic Disorder • Bereavement Exclusion • 2 months versus 1-2 years DSM 5 - Jason H. King, PhD, DCMHS, ACS

  37. Anxiety Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS

  38. Anxiety Disorders • Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social Phobia) • Deletion of the requirement that individuals over age 18 years recognize that their anxiety is excessive or unreasonable • This change is based on evidence that individuals with such disorders often overestimate the danger in “phobic” situations and that older individuals often misattribute “phobic” fears to aging • Instead, the anxiety must be out of proportion to the actual danger or threat in the situation, after taking cultural contextual factors into account • 6-month duration, which was limited to individuals under age 18 in DSM-IV, is now extended to all ages • Intended to minimize overdiagnosis of transient fears • Panic Disorder • Situationallybound/cued, situationally predisposed, and unexpected/uncuedis replaced with unexpectedand expected panic attacks DSM 5 - Jason H. King, PhD, DCMHS, ACS

  39. Anxiety Disorders • Agoraphobia • This change recognizes that a substantial number of individuals with agoraphobia do not experience panic symptoms • Endorsement of fears from two or more agoraphobia situations is now required, because this is a robust means for distinguishing agoraphobia from specific phobias • Criteria for agoraphobia are extended to be consistent with criteria sets for other anxiety disorders (e.g., clinician judgment of the fears as being out of proportion to the actual danger in the situation, with a typical duration of 6 months or more) • Social Anxiety Disorder (Social Phobia) • “Generalized” specifier replaced with a “performance only” specifier • problematic in that “fears include most social situations” was difficult to operationalize • distinct subset of social anxiety disorder in terms of etiology, age at onset, physiological response, and treatment response DSM 5 - Jason H. King, PhD, DCMHS, ACS

  40. Anxiety Disorders • Separation Anxiety Disorder • Core features remain mostly unchanged • Wording of the criteria has been modified to more adequately represent the expression of separation anxiety symptoms in adulthood • For example, attachment figures may include the children of adults with separation anxiety disorder, and avoidance behaviors may occur in the workplace as well as at school • Diagnostic criteria no longer specify that age at onset must be before 18 years, because a substantial number of adults report onset of separation anxiety after age 18 • Selective Mutism DSM 5 - Jason H. King, PhD, DCMHS, ACS

  41. Obsessive Compulsive and Related Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS

  42. Obsessive Compulsive and Related Disorders • Clinical utility of grouping these disorders in the same chapter • Reflects the increasing evidence that these disorders are related to one another in terms of a range of diagnostic validators • “With poor insight” specifier refined to allow a distinction between individuals with good or fair insight, poor insight, and “absent insight/delusional” obsessive-compulsive disorder beliefs • “Tic-related” specifier • New disorders • Hoarding disorder • Excoriation (skin-picking) disorder • Substance-/medication-induced obsessive-compulsive and related disorder • Obsessive-compulsive and related disorder due to another medical condition DSM 5 - Jason H. King, PhD, DCMHS, ACS

  43. Obsessive Compulsive and Related Disorders • Body Dysmorphic Disorder • Diagnostic criterion describing repetitive behaviors or mental acts in response to preoccupations with perceived defects or flaws in physical appearance added • consistent with data indicating the prevalence and importance of this symptom • A “with muscle dysmorphia” specifier added • reflects growing literature on the diagnostic validity and clinical utility of making this distinction in individuals with body dysmorphic disorder • The delusional variant of body dysmorphic disorder no longer coded as both delusional disorder, somatic type, and body dysmorphic disorder DSM 5 - Jason H. King, PhD, DCMHS, ACS

  44. Obsessive Compulsive and Related Disorders • Hoarding Disorder • Available data do not indicate that hoarding is a variant of obsessive-compulsive disorder or another mental disorder • evidence for the diagnostic validity and clinical utility of a separate diagnosis of hoarding disorder • which reflects persistent difficulty discarding or parting with possessions due to a perceived need to save the items and distress associated with discarding them • Hoarding disorder may have unique neurobiological correlates • associated with significant impairment • Excoriation (Skin-Picking) Disorder • AKA: Dermatillomania, neurotic excoriation, pathologic skin picking compulsive skin picking, or psychogenic excoriation • “Repetitive and compulsive picking of skin which results in tissue damage” DSM 5 - Jason H. King, PhD, DCMHS, ACS

  45. Obsessive Compulsive and Related Disorders • Trichotillomania is now termed Trichotillomania (hair-pulling disorder) • Other Specified and Unspecified Obsessive-Compulsive and Related Disorders • Body-focused repetitive behavior disorder • Characterized by recurrent behaviors other than hair pulling and skin picking (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors • Obsessional jealousy • Characterized by nondelusional preoccupation with a partner’s perceived infidelity • Unspecified obsessive-compulsive and related disorder DSM 5 - Jason H. King, PhD, DCMHS, ACS

  46. Trauma and Stressor-Related Disorders DSM 5 - Jason H. King, PhD, DCMHS, ACS

  47. Trauma and Stressor-Related Disorders • AMHCA (2011) Standards for the Practice of CMHC • Trauma training standards • CACREP (2009) and (2016) • PROFESSIONAL ORIENTATION AND ETHICAL PRACTICE • c. counselors’ roles and responsibilities as members of an interdisciplinary emergency management response team during a local, regional, or national crisis, disaster or other trauma-causing event • HUMAN GROWTH AND DEVELOPMENT • c. effects of crises, disasters, and other trauma-causing events on persons of all ages • APA-CoA (2007) • Nothing • COAMFTE (2005) • Nothing • CSWE (2008) • Nothing DSM 5 - Jason H. King, PhD, DCMHS, ACS

  48. Trauma and Stressor-Related Disorders • Acute Stress Disorder • Stressor criterion (Criterion A) changed • requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly • Criterion A2 regarding the subjective reaction to the traumatic event (e.g., “the person’s response involved intense fear, helplessness, or horror”) eliminated • evidence that acute posttraumatic reactions are very heterogeneous • DSM-IV’s emphasis on dissociative symptoms is overly restrictive • Exhibit any 9 of 14 listed symptoms in these categories: • intrusion, negative mood, dissociation, avoidance, and arousal • Adjustment Disorders • Reconceptualizedas a heterogeneous array of stress-response syndromes that occur after exposure to a distressing event • Subtypes unchanged DSM 5 - Jason H. King, PhD, DCMHS, ACS

  49. Trauma and Stressor-Related Disorders • Posttraumatic Stress Disorder • Stressor criterion (Criterion A) is more explicit • Criterion A2 (subjective reaction) eliminated • Diagnostic thresholds lowered for children and adolescents • separate criteria for children age 6 years or younger • Now four symptom clusters in DSM-5 • 1. Reexperiencing • 2. Avoidance • Now with persistent negative alterations in cognitions and mood • 3. Numbing • includes new or reconceptualizedsymptoms & persistent negative emotional states • 4. Arousal and reactivity • includes irritable or aggressive behavior and reckless or self-destructive behavior DSM 5 - Jason H. King, PhD, DCMHS, ACS

  50. Trauma and Stressor-Related Disorders • Reactive Attachment Disorder • DSM-IV subtypes emotionally withdrawn/inhibited and indiscriminately social/disinhibited is now two DSM-5 distinct disorders • result of social neglect or other situations that limit a young child’s opportunity to form selective attachments • 1. Reactive Attachment Disorder • dampened positive affect • more closely resembles internalizing disorders • essentially equivalent to a lack of or incompletely formed preferred attachments to caregiving adults • 2. Disinhibited Social Engagement disorder • more closely resembles ADHD • may occur in children who do not necessarily lack attachments and may have established or even secure attachments DSM 5 - Jason H. King, PhD, DCMHS, ACS

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