Psychologist Attitudes Toward DSM-5 and Its Alternatives

Raskin, J. D., Maynard, D., & Gayle, M. C. (2022). Psychologist attitudes toward DSM-5 and its alternatives. Professional Psychology: Research and Practice, 53(6), 553–563. https://doi.org/10.1037/pro0000480

Key Points

• The study found that almost 90% of psychologists regularly consult DSM-5, despite overall dissatisfaction with it.
• Opinions varied significantly by theoretical orientation, with cognitive-behavioral psychologists holding positive attitudes about DSM-5, while psychodynamic and humanistic/constructivist/systems psychologists were negatively inclined toward it.
• Diagnostic codes and identifying pathology were seen as DSM-5’s biggest advantages, while medicalization of psychosocial problems and obscuring individual differences were viewed as its biggest disadvantages.
• Psychologists supported developing alternatives to DSM-5, but were generally unfamiliar with specific alternatives except for the International Classification of Diseases (ICD).
• Although not wishing to abandon the medical model entirely, psychologists (except cognitive-behaviorists) felt DSM-5 relies too heavily on medical semantics and questioned whether mental disorders should be considered a subset of medical disorders.
• Psychologists use DSM-5 primarily for practical reasons like diagnostic categories and codes rather than scientific ones like validity and reliability.
• The study reveals that despite ongoing revisions to DSM over four decades, psychologists remain lukewarm toward it and strongly interested in alternatives. However, until alternatives are better known and provide necessary practical advantages, psychologists will likely continue using DSM despite mixed feelings.

Rationale

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been the predominant diagnostic system for mental health issues worldwide for decades.

However, psychologists’ current attitudes toward the DSM-5, published in 2013, remained unclear. Previous research suggested that psychologists viewed the manual with suspicion and used it primarily to secure third-party payments (Miller et al., 1981; Smith & Kraft, 1983).

This study aimed to examine psychologist attitudes toward DSM-5 and several alternatives to it, including the International Classification of Diseases (ICD), Research Domain Criteria (RDoC), Psychodynamic Diagnostic Manual-2 (PDM), Operationalized Psychodynamic Diagnosis (OPD), Hierarchical Taxonomy of Psychopathology (HiTOP), and Power Threat Meaning Framework (PTMF).

The researchers sought to determine if psychologists’ attitudes have changed since DSM-5 appeared and to assess familiarity with and support for alternative diagnostic systems.

Understanding psychologists’ perspectives on diagnostic systems is crucial for informing future developments in the field and identifying potential gaps in knowledge or training.

This research builds on previous studies by exploring attitudes toward specific alternatives to DSM-5 and examining how theoretical orientations influence these attitudes.

Method

The study employed a 49-item online survey using Qualtrics. The survey contained various question types, including fill-in responses, forced choice, multiple response, and visual analogue scale (VAS) items.

Participants were asked about their use of DSM-5, attitudes toward it, familiarity with alternatives, and general views on diagnosis.

Sample

The final sample consisted of 703 participants who had completed a doctoral degree (PhD, PsyD, or EdD), were licensed psychologists, and had completed at least 75% of the non-demographic survey items. The sample included 538 clinical psychologists, 93 counseling psychologists, 25 school psychologists, and 45 who selected “other.”

Measures

The survey covered various aspects of DSM-5 use and attitudes, including frequency of use, reasons for use, perceived advantages and disadvantages, satisfaction with DSM-5, views on its impact, familiarity with alternatives, support for alternatives, and general attitudes about diagnosis and DSM.

Statistical measures

Analyses included one-sample t-tests to compare group means to the neutral point on 15-point scales, and comparisons across theoretical orientations (cognitive-behavioral therapy, psychodynamic, humanistic/constructivist/systems, and integrative/eclectic).

Due to the large number of tests, the significance level was set at α = .001.

Results

1. Use of DSM-5: 88.1% of participants reported using DSM-5 directly or indirectly at least once a month.
2. Reasons for use: The top two reasons were “required by third-party payers” (62.32%) and “to help make a differential diagnosis” (59.46%).
3. Overall satisfaction: Psychologists were generally dissatisfied with DSM-5, though attitudes varied by theoretical orientation.
4. Perceived advantages and disadvantages: The main advantage was diagnostic codes (54.71%), while main disadvantages included applying medical labels to psychosocial problems (55.21%) and obscuring individual differences (53.74%).
5. Effects on diagnosis and psychologists: Overall, psychologists felt DSM-5 had not significantly affected diagnosis or benefited/harmed their profession, though views varied by theoretical orientation.
6. Support for alternatives: Psychologists supported developing alternatives to DSM-5 but were mostly unfamiliar with specific alternatives except for ICD.
7. General attitudes: Psychologists felt DSM-5 relies too heavily on medical semantics and disagreed that mental disorders are a subset of medical disorders.

Insight

This study reveals that psychologists’ attitudes toward DSM-5 remain largely consistent with views expressed about earlier versions of the manual dating back to the 1980s.

Despite multiple revisions aimed at improving the DSM, psychologists continue to express mixed feelings about it, particularly those from psychodynamic and humanistic/constructivist/systems orientations.

The research highlights a paradox in the field: while psychologists are generally dissatisfied with DSM-5, they continue to use it widely, primarily for practical reasons such as insurance reimbursement.

Attitudes toward DSM-5 and the medical model varied significantly based on theoretical orientation. Cognitive-behavioral therapists (CBT) generally viewed DSM-5 positively, aligning with its symptom-focused approach. 

In contrast, psychodynamic and humanistic/constructivist/systems psychologists were more critical, likely due to their emphasis on underlying psychological processes and holistic views of individuals. 

These orientations often clash with DSM-5's categorical approach to diagnosis. Integrative/eclectic psychologists occupied a middle ground, reflecting their incorporation of multiple theoretical perspectives. 

This divergence in attitudes highlights the ongoing debate within psychology about the nature of mental health and the most appropriate ways to conceptualize and diagnose psychological issues.

This finding suggests that the DSM’s utility in clinical practice is driven more by systemic requirements than by its perceived scientific validity or reliability.

The study also uncovered a strong interest in alternatives to DSM-5 among psychologists, but a lack of familiarity with most existing alternatives.

This gap between interest and knowledge points to a need for increased education and training on alternative diagnostic systems in psychology curricula and continuing education programs.

The varying attitudes across theoretical orientations suggest that a one-size-fits-all approach to diagnosis may not be ideal for the field of psychology.

Future research could explore the potential benefits of multiple diagnostic systems tailored to different theoretical approaches or clinical needs.

Strengths

1. Large sample size (703 participants) providing robust data.
2. Inclusion of psychologists from various theoretical orientations, allowing for comparison across different approaches.
3. Comprehensive survey covering multiple aspects of DSM-5 use and attitudes.
4. Examination of attitudes toward specific alternative diagnostic systems, providing nuanced insights.
5. Use of validated statistical methods and conservative significance levels to ensure reliable results.

Limitations

1. The study only included members of specific American Psychological Association divisions, potentially limiting generalizability to the broader population of psychologists.
2. Self-report data may be subject to recall bias or social desirability effects.
3. The study did not explore how factors such as years of practice, practice setting, or client population might influence attitudes toward diagnostic systems.
4. The research was conducted before the release of DSM-5-TR, so attitudes may have shifted slightly since the study was completed.

Clinical Implications

The findings have significant implications for clinical psychology practice and education:

1. Training programs should consider incorporating more comprehensive education on alternative diagnostic systems to address the gap between interest and knowledge.
2. Professional organizations might need to advocate for changes in insurance reimbursement practices to allow for greater flexibility in diagnostic approaches.
3. The development of diagnostic systems might benefit from considering the needs and perspectives of psychologists from different theoretical orientations.
4. Continuing education programs could focus on helping practicing psychologists stay informed about emerging alternative diagnostic systems.
5. The paradox of dissatisfaction with but continued use of DSM-5 suggests a need for broader discussions within the field about the role of diagnosis in clinical practice.
6. The findings may encourage more research into the practical applications and outcomes associated with alternative diagnostic systems.

References

Primary reference

Raskin, J. D., Maynard, D., & Gayle, M. C. (2022). Psychologist attitudes toward DSM-5 and its alternatives. Professional Psychology: Research and Practice, 53(6), 553. https://doi.org/10.1037/pro0000480

Other references

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Miller, L. S., Bergstrom, D. A., Cross, H. J., & Grube, J. W. (1981). Opinions and use of the DSM system by practicing psychologists. Professional Psychology, 12(3), 385–390. https://doi.org/10.1037/0735-7028.12.3.385

Smith, D., & Kraft, W. A. (1983). DSM-III: Do psychologists really want an alternative? American Psychologist, 38(7), 777–785. https://doi.org/10.1037/0003-066X.38.7.777

Keep Learning

1. How might the continued use of DSM-5 despite dissatisfaction impact the quality of mental health care?
2. What are the potential benefits and drawbacks of having multiple diagnostic systems tailored to different theoretical orientations?
3. How can the field of psychology balance the practical needs (e.g., insurance reimbursement) with the desire for more nuanced or theoretically aligned diagnostic approaches?
4. What role should client perspectives play in the development and use of diagnostic systems in mental health?
5. How might increased education on alternative diagnostic systems influence the future practice of clinical psychology?
6. In what ways could the development of alternative diagnostic systems challenge or reinforce the medicalization of mental health issues?
7. How might cultural factors influence attitudes toward different diagnostic systems, and how can these be addressed in future research and practice?