Are You Ready for the October 1 Deadline?

Whether the DSM-5® is a book you love to hate or hate to love, one thing is certain: beginning Oct. 1, 2105 you need to put your feelings for the DSM-5 aside and learn to live with change. Read more for some DSM-5 resources.

Whether the DSM-5® is a book you love to hate or hate to love, one thing is certain: beginning Oct. 1, 2015 you need to put your feelings for the DSM-5 aside and learn to live with change.

Why now?

When the DSM-5 was released in 2013, it was done under the guide that the ICD-10 would be adopted by the United States health care system that same year. The two books act as companions, both helping to categorize and communicate patient diagnoses into codes for the purpose of insurance reimbursement. As the ICD-10 implementation continued to be delayed, it meant that the ICD-9 codes provided in the DSM-IV would still allow clinicians to receive reimbursement for their care.

As ICD-10 goes live, the codes provided in the DSM-IV will officially retire. For mental health providers it means one thing: The change to DSM-5 has become inevitable. Make the switch, or simply lose your reimbursement.

What do you NEED to know about coding changes?

One major change is the numbering system; the ICD-10 has switched to an alpha-numeric system. ICD-10 diagnosis codes have between 3 and 7 characters and always begin with an alpha digit. All mental health codes will begin with the alpha digit ‘F’.


How DSM-5 and ICD-10 Are Combined in Diagnosis


For all the abuse the poor old DSM has taken, it brings a much needed sense of order and logic to what’s otherwise a raw, chaotic mess of mental and behavioral phenomena. Undoubtedly, many a therapist, even perhaps some of those loudest in condemning DSM, has consulted it, not just to figure out the most reimbursable diagnosis, but to get some handle on the maddening complexity that clients bring to sessions. If we didn’t have the DSM, would we be reduced to consulting clairvoyants?

Need more info on the changes to the DSM-5® and ICD-10 before the Oct. 1 deadline? We’ve got you covered.

Marilee Fini: Nurturing the Mind, Body and Soul of Those Who Stutter

Marilee Fini sheds a unique light on the subject of stuttering since she has spent most of her life dealing with her own stuttering. Throughout her journey, she has faced many situations which she deemed as “IMPOSSIBLE” but was able to overcome them through hard work, dedication and faith.

I began to stutter at 4 years old. As a child, it was something I hated and found deeply embarrassing. Throughout elementary school and high school, I had a lot of therapy focused on fluency. And while addressing the physical aspect of my stuttering was important, no one seemed to understand or recognize the need to also address the emotional aspect of my disorder.

While everyone was concerned about “my speech” and how it sounded, I felt like I was dying inside. I was so embarrassed and shameful about the way I talked that I avoided speaking at times, especially at school.

As an adult, I decided to pursue a career in speech pathology because I wanted to make a difference for others dealing with communication disorders. I wanted to help others find ways to feel “good” about communication—regardless of how their words came out. I wanted them to know their spoken words had value, because as a child who stuttered, I didn’t know this.

When pursuing my Master’s Degree in Speech Pathology, I joined the National Stuttering Association.  I didn’t know it at the time, but this decision would truly change the trajectory of my career. Being part of the NSA taught me that I was more than my stuttering, and it helped me to deal with feelings of shame and embarrassment related to my stuttering. I began realizing that anything was possible in terms of speaking. For the first time in my life, I had opportunities to practice public speaking, and I felt good about communicating with others!

When I started my private practice 15 years ago, I decided to do some public speaking to help educate my community about communication disorders. Even though I had presented through the NSA, in the back of my mind I kept thinking, “this is silly, I will stutter a lot, and no one will ever come to me for help.”

My first presentations were hard, and a lot of sweat and tears were involved. Then something happened; public speaking became my passion! As my confidence surrounding public speaking grew, so did the length of my presentations. Short presentations turned into half day workshops, and today I present whole day workshops and keynote addresses.

When I stand in front of others to do public speaking, something magical happens.  I let out that “voice” that was held back as a child, and I rejoice in my freedom to express myself!

If you work with clients who stutter, I encourage you to not only work on the physical symptoms, but to also take care of the emotional feelings and attitudes that are part of these disorders. It’s critical to remember that a person who stutters is more than just a mouth, they are a mind, body, and soul, and we have to nurture every aspect of their person in order for them to thrive.

This post has been brought to life by PESI speaker Marilee Fini, MA, CCC-SLP.

You Can Heal Your Heart After Grief: Honoring Pet Loss

Pet loss is grief that is often not talked about. But the grief is real because the love is real. Grief and loss expert David Kessler invites you to take a moment to learn how you can heal your heart after a pet loss.

Pet loss is grief that is often not talked about. But the grief is real because the love is real.

Grief is a natural reflection of life and exists in any relationship where we have feelings and attachments. In that context, it seems unlikely to think that we wouldn’t grieve for the animals in our life that we are indeed very much attached to. After all, grief is about love, and our animal companions often show us some of the most unconditional love we could ever experience.

There is a unique difficulty with the loss of pets as opposed to that of human loved ones. Like children, we take care of them, keep them safe, feed them, and tend to their well-being. This makes it easy to turn grief into guilt, believing that their death was our fault. The reality is that despite our best efforts to do everything for our pets, they will still die someday.

Grief from pet loss in not as easily fixed as some would have us believe, and it’s hard to live in grief that’s judged as unworthy. If you or someone you love has recently lost a pet, take a moment to learn how you can heal your heart after a pet loss.

This blog has been brought to life by PESI speaker and renowned grief and loss expert David Kessler. It features passages from his book You Can Heal Your Heart, co-authored by Louise L. Hay.

Suicide Risk Assessment: A must for clients reporting TBI and Depression

Former Detroit Lions quarterback, Erik Kramer, attempted suicide by way of gunshot wound to the head. PESI speaker Meagan Houston, Ph.D., SAP, discusses how traumatic brain injury and major depressive disorder are connected and the importance of conducting a suicide risk assessment with a patient who reports a mild or severe form of TBI.

A recent news report sadly revealed that former Detroit Lions quarterback, Erik Kramer, attempted suicide by way of gunshot wound to the head. His former wife attributes this suicide attempt to Major Depressive Disorder (MDD), a disorder that may have been caused by football related head trauma or traumatic brain injury (TBI).

Research has indicated that Major Depressive Disorder (MDD) is one of the most common conditions that patients encounter following a TBI. Some TBI patients report symptoms of MDD at least once in the first year after their injury. These patients may also report suicidal ideation—a symptom of mild to severe MDD— or even actual suicide attempts.

There are several factors that may lead to the development of depression following a TBI, and these factors vary greatly among those diagnosed with the condition. Depression symptoms could be related to organic, physical changes in the brain as a result of injury to areas that control and regulate emotion and mood, or they could be caused by changes in the levels of certain natural chemicals (neurotransmitters) in the brain.

It shouldn’t be surprising that some patients with TBI are suffering from symptoms of MDD. The effect of TBI on both the family and the injured person can be devastating. Loss of memory, mood swings, headache, difficulty thinking, and frustration are common in mild TBI injuries. For those suffering from severe TBI, symptoms can include limited function of their limbs, loss of thinking ability and emotional problems. As TBI patients adjust to temporary or enduring changes in their physical and cognitive abilities, it can lead to major role changes within the family and society.

It is imperative that, we, as mental health professionals, recognize this correlation between TBI and depression and conduct a brief or, if warranted, a more extensive suicide risk assessment with a patient who reports mild or more severe forms of TBI. Litigation becomes an issue when we fail to conduct these assessments appropriately and when we do not make reasonable and prudent efforts to accurately assess, diagnose and address patient concerns.

Here are a few questions I pose to audience members attending my Suicide and Self-Destructive Behaviors seminar, when discussing suicide risk assessment and legal implications. You may find these questions helpful when determining a course of treatment with your clients.

Were You Negligent?

  1. Was the clinician aware or should have been aware of the risk?
  2. Was the clinician thorough in assessment of the client’s suicide risk?
  3. Did the clinician make “reasonable and prudent efforts” to collect sufficient and necessary data to assess risk?
  4. Was the assessment data misused, thus leading to a misdiagnosis where the same data would have resulted in appropriate diagnosis by another mental health professional?
  5. Did the clinician mismanage the case, being either “unavailable or unresponsive to the client’s emergency situation?”

Awareness, continuing education, candid conversation and consultation are key elements to engaging in best practice with our clients.  Through these mechanisms we are able to provide more preventive, well-informed and effective mental health services.

This post was contributed by PESI speaker Meagan Houston, Ph.D., SAP. Learn more about suicide and para-suicidal behaviors.

Better-But-Believable Thoughts: An alternative to cognitive therapy

If you have a client with chronic worry, you’ve likely tried cognitive therapy. But cognitive therapy is time-consuming and complex. For a simple, quick way to nip worry in the bud, Jennifer Abel, Ph.D., suggests B3s.

For most of us, a small amount of worry can spur us into action and help us solve a problem. But for others, worrying can become a problem. For those that are pre-occupied with worry, it can take an extensive toll on their body.

If you have a client with chronic worry, you’ve likely tried cognitive therapy on some level. Collaborating with the client to identify thought styles, such as catastrophizing, filtering, shoulds, and mind-reading, and replacing these with alternative positive thoughts has been proven effective for generalized anxiety disorder and panic disorder. However, these methods are time-consuming and complex.

First, the client is expected to identify the thought style they are experiencing. Next, the client must construct a new thought based on a list of suggestions. It’s a laborious process that is also flawed when the commonly used suggestion to “think positive” is added in.

According to Jennifer Abel, Ph.D., the bottom line is that if the person doesn’t really believe that the thought is true, it’s going to be useless. Abel has created a new, simpler strategy to try with your clients: Better-but-Believable thoughts, or B3s.

Check out this clip from 101 Practical Strategies for the Treatment of GAD, Panic, OCD, Social Anxiety Disorder, Phobias and Insomnia to see B3s in action. In this example, you’ll learn how to stop a mother’s worry about her son riding his bike using Better-but-Believable thoughts.

We want to know… What do you think about Better-but-Believable thoughts?
Tell us in the comments below!


This blog is based on the seminar 101 Practical Strategies for the Treatment of GAD, Panic, OCD, Social Anxiety Disorder, Phobias and Insomnia presented by Jennifer Abel, Ph.D.

The Lazy River: An Exercise in Mindfulness

We all have a steady stream of thoughts and feelings. Use the simple guided imagery handout with your clients to help them learn to notice and dismiss thoughts without engaging in them.

The following is an excerpt from Mindfulness Skills for Kids & Teens by PESI author Debra Burdick, LCSWR, BCN.

We all have a steady stream of thoughts and feelings. One of the basic skills in mindfulness is noticing thoughts, feelings, or sensations, dismissing them without engaging in them, and bringing our attention back to our intended target of attention. This tool provides an effective way to practice dismissing them and noticing the next ones that come along.

Use the simple guided imagery handout with your clients to help them learn to notice and dismiss thoughts without engaging in them. Explain that you are going to pretend that thoughts, feelings, and bodily sensations are riding in rafts or boats on a lazy river. The goal is to notice them, but to just let them float by without getting in the boat or raft (engaging with them). They can picture words written on the side of the boat or raft if they like. One of my clients used this skill to stop obsessing about a mean classmate. She imagined her classmate’s name written on the side of a raft and just watched it float by without “getting in the raft.” She was able to allow thoughts about the classmate to go without getting into all the feelings of anger she had been experiencing. Using this process, the client was able to very quickly stop the obsessive thoughts.

After clients have practiced this imagery you might add a step where they find a boat or raft with something positive written on it. When they see the positive one come by they can imagine that they get in that boat or raft and float with the positive thoughts or feelings that go with it. For example, they let the boats or rafts that have something in them that upsets them go by, but they can get in a boat or raft that is associated with something that feels good. In other words, let the “anger” boats go by, but get in the “happy” boat.

Help clients reflect on what this exercise was like for them:

  • Were they able to imagine the lazy river?
  • Did they imagine boats or rafts or both?
  • Did they notice any thoughts or feelings or bodily sensations riding in the rafts or boats?
  • What came up for them while they did this exercise?
  • Did any of the rafts or boats have words written on them and, if so, what were they?
  • Were they able to let the rafts and boats float by?
  • Did they get in any of the rafts or boats and, if so, which one(s)?

This exercise can be a great doorway to a discussion of what the client is holding onto that may need to go.

Download: Guided Imagery Handout—The Lazy River

Want more mindfulness skills for everyday use? Visit Debra Burdick’s website: The Brain Lady.

Shedding Light on the DSM-5®: The View from the Trenches

While the polemical debates over the new DSM have received widespread coverage, the reactions of ordinary clinicians have yet to receive much scrutiny.

Since the release of DSM-5® in the spring of 2013, its critics have complained that the definitions in the new edition are now too broad, too inclusive (or not inclusive enough), too biological (or not biological enough), too vague, too quixotic, too unscientific, too much under the thumb of Big Pharma—the list goes on. However, we’ll have to make friends with DSM-5, particularly if we expect insurance companies to go on reimbursing us. But how are ordinary clinicians across the country adapting to the specifics of the new manual? As someone who’s given dozens of workshops on DSM-5 and trained thousands of therapists in its use, I’ve had a front-row seat on how psychotherapists have reacted to the changes it means for their practice.

Overall, most of the participants in my workshops seem to feel that the diagnostic system in the DSM-IV was handy and working just fine for them. They know the DSM-5 Task Force claims changes were made to reflect new research in mental health care, but as one participant remarked, “It’s like the people on the Task Force have never sat in the room with a client. They’re up in an ivory tower somewhere, dictating how we should be diagnosing our clients, but the changes they’ve made don’t match up with what I see in my office with real people.”

Another psychologist expressed it like this: “My concern is helping the person sitting in front of me. Their priority seems to be related to the World Health Organization and the International Classification of Diseases system. I’m not dealing with abstract concepts. I’m dealing with real hurting people, people who struggle.”

Without a doubt, the subject that arouses the most passionate response in my workshops is when we talk about the loss of the multiaxial system, which used to split a diagnostic impression into five parts. Using the five axes, the evaluation of every patient documented clinical concerns leading to treatment; mental retardation and personality disorders; contributing psychosocial, environmental, and medical conditions; and a global assessment of functioning.

Clinicians believe that losing the five axes means losing the ability to paint a more complete picture of what’s going on with the people they treat, which runs counter to our field’s new focus on integrating medical and behavioral health care.

I share some of these concerns. The DSM-5 model of diagnosing leaves us with only a listing of the diagnoses, as opposed to the multiaxial system, which gave us a shorthand way to capture a fuller image of a client. Now, it seems it’ll be much more difficult to adhere to the wise adage that we should be more concerned with the person who has the condition than with the condition the person has.

Another change in the manual that consistently stirs up spirited disapproval is the loss of Asperger’s disorder as a diagnostic category. Now considered part of autism spectrum disorder, the term Asperger’s doesn’t even appear in the new manual. I have yet to have a single workshop participant praise this change.

People with Asperger’s, parents of children with Asperger’s, and autism and Asperger’s advocacy groups have all voiced their objections as well. They see Asperger’s as a different condition from autism, and they disagree with the decision to eliminate it as a separate disorder. In addition, they’re concerned that people with a DSM-IV diagnosis of Asperger’s won’t continue to qualify for supportive services. The DSM-5 Task Force has said that most people with a well-established DSM-IV diagnosis of Asperger’s should meet the criteria for autism spectrum disorder in the DSM-5. If they don’t, clinicians are supposed to evaluate them for social (pragmatic) communication disorder. Of course, this response from the Task Force has done little to allay the concerns of people with Asperger’s and their advocates, and I’m sure this controversy will continue to gather force.

Where’s Sex Addiction?

People inevitably raise their hands as they flip through the handouts and say, “I don’t see where sexual addiction and pornography addiction are in the manual. Can you show me?” My answer is no, because those conditions aren’t in the manual. When I say this, there’s usually a collective gasp of dismay, which only grows louder when I add that gambling is the only “behavioral addiction” listed. What’s more, sexual and pornography addictions aren’t even in the section on conditions needing further study, which is often where things go before they make the cut and become official diagnoses in some future revision.

Although people have clearly voiced criticisms of the new manual, one change that’s regularly viewed with great approval is the move from using the old Global Assessment of Functioning scale to new severity scales that are specific to different diagnoses. Clinicians applaud the idea of having separate and unique severity scales for anorexia, bulimia, substance-use disorders, oppositional defiant disorder, and other conditions.

They also approve of the new symptom cluster for post-traumatic stress disorder (PTSD). This new symptom cluster, which comprises negative alterations in mood and cognitions, was added to the original three clusters from DSM-IV: reexperiencing, avoidance, and increased arousal. Some of the new features of the negative cognitions include persistent, distorted self-blame, persistent negative emotional state, feeling detached and estranged, and persistent inability to experience positive emotions. Clinicians feel that the emphasis on these cognitive changes better reflect ways that people with PTSD often feel most affected by their trauma exposure.

Changes in the language of gender dysphoria also seem to reflect positive movement toward a more open, inclusive point of view. The current wording in DSM-5—“some alternative gender”—indicates that we’re now thinking of gender as falling along a continuum, rather than being divided between two qualitatively different sexes. This change reflects major social and cultural shifts in the United States.

The Impact on Therapy

Except for a surprisingly modest number of genuinely significant changes, including the newly introduced dimensional scales, DSM-5 is still clearly the offspring of DSM-IV. It’s most definitely not a radical departure for psychiatric diagnosis, much less a revolution.

The changes in the manual won’t be critical for doing therapy; most therapists seek to understand how and why clients are troubled before they try to pin them to DSM diagnoses anyway. But the new manual will make a big difference procedurally and bureaucratically.

To get paid, therapists will need to rethink how they define and document their clients’ problems according to the template DSM-5 has set before them.

Further, there will be rumblings throughout the pharmaceutical companies, since changes in diagnostic practice notoriously tend to precede an increase in the sale of drugs to newly diagnosed populations.

Certainly, DSM is the book we love to hate. And yet, what else is there? Until we have some huge breakthroughs in neurophysiological research explaining what happens neuron-by-neuron to cause mental disorders, our lumbering mental health enterprise needs a common system of diagnostic categories simply so we can talk coherently to each other about our clients. That being the case, DSM-5 isn’t really all that bad.

Using the DSM-5 and ICD-10

Earn CE and review in detail the changes to the DSM-5.

Identify the major revisions in the DSM-5 to substance, mood, anxiery, and other common categories of mental disorders. Describe five changes in the organization of mental disorder categories in the DSM-5. Discuss the diagnostic criteria for six or more diagnoses in the DSM-5 and more.

Learn more about Using the DSM-5® and ICD-10: The Changing Diagnosis of Mental Disorders.

This post is based on an article originally brought to life by our partner, Psychotherapy Networker.

The full article, “Shedding Light on the DSM-5,” written by Martha Teater, appeared in the March/April 2014 issue of Psychotherapy Networker magazine.

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