If you’re working in the mental healthcare profession, including addiction rehabilitation – or if you’re in recovery and treatment for addiction – chances are good that you’ve heard of the DSM-V (often referred to as the DSM-5).
The Diagnostic and Statistical Manual of Mental Disorders has been around since the 1950s, helping guide healthcare decision-making by doctors and other mental health professionals in North America and worldwide.
It’s not the only tool doctors use to help diagnose mental disorders like addictions, but it is a commonly used resource. And despite the criticism against it, and some of the challenges of using it in everyday practice, the DSM is a valuable tool healthcare professionals need to know about.
What is the DSM-V?
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a handbook used by healthcare professionals to guide diagnosis of mental disorders. The DSM-5 (or DSM-V) is the latest edition of this handbook, published in 2013 by the American Psychiatric Association.
The DSM is constantly under review and revision by the Association as research and understanding of mental health increases and improves; further editions are expected if and when updates need to be made.
What makes the DSM so useful is its comprehensive catalogue of descriptions, symptoms, and other criteria for diagnosing mental disorders. It provides a common language for doctors to use when talking to each other, and to patients and their families, helping ensure consistent and reliable diagnoses as well as usable data for research.
Addiction in the latest DSM
The DSM is commonly used in addiction and rehabilitation to help diagnose and treat people’s addictions and other mental health issues.
Importantly, the DSM-5 defines addictions to alcohol and drugs as psychiatric disorders. By including addiction in the DSM as an aspect of mental health, the psychiatric profession has reinforced what we know from research and rehabilitation: that addiction is a brain disease.
The major change regarding addiction in the DSM-5 edition is that it combines together the categories of substance dependence (addiction marked by a pattern of compulsive use or loss of control) and substance abuse disorders (using in a manner that causes problems but does not have a pattern of compulsive use) under one broad category called “substance-related disorders”.
Substance-Related Disorders and the DSM
Specifically, the DSM-5 recognizes substance-related disorders resulting from the use of 10 separate classes of drugs:
Plus, the DSM-5 lists two distinct groups of substance-related disorders: substance use disorders and substance-induced disorders. Both groups are important in the diagnosis, treatment, and research of drug and alcohol use and addiction.
Challenges to Using the DSM
The DSM is not the only reference out there to diagnose addiction or any other mental health condition. The World Health Organization publishes the International Classification of Disease, which is often used side-by-side with the DSM as a compatible tool for diagnosis and monitoring.
Some, like the National Institutes of Health, have criticized the DSM for focusing too much on superficial symptoms and a lack of measurable, scientific signs of mental health disorders. Others, like Alcoholics Anonymous, prefer to use models outside such clinical classification systems.
However, here at Renascent we recognize that the DSM does contain the most up-to-date criteria currently used for diagnosing mental disorders like addiction, and that despite its challenges, it is routinely and widely used.
So begins “The Road Less Travelled,” a wisdom book about living well by Scott Peck. Talk about keeping it simple! We hear the same awareness time and again in the rooms of recovery: “Just because I’m sober doesn’t mean my life is easy.”
I had no idea what Peck was talking about when I first opened his book back in the mid-1980s — probably because I was neck deep in my addiction and desperate to believe that everything in my life would just work out. Magically.
Now I get it — probably because I’ve been clean and sober for a while and I’m paying attention. Today I’m free to say “Yes” to life, and most days I choose to face life on its terms, not mine, as best I can.
Unfortunately for me, however, I don’t always have answers for life’s challenges. The next right action isn’t always clear to me. In fact, living sober sometimes leaves me feeling as rudderless, scared, and discouraged as I felt when I was using.
Life is difficult. And I don’t mind admitting I need a power other than King “I” to help me live sober — just as I needed that same power to help me get sober.
Enter Step Eleven, my favourite Step.
Something about this Step grabbed me — I can’t quite say what. I jumped right into it the day after l graduated from “The House.” I still try my best to greet each new day with a time of prayerful and meditative quiet.
At first this was new and it was hard. And I definitely still need discipline to keep it up. I do keep it up because I’ve grown to like how the still, deep quiet feeds my spirit. I need that. And I love the results.
Step Eleven is my anchor. Working this Step keeps me grounded in my relationship with the higher power I committed to in Step Three, and then some — it takes that relationship to a deeper place. I tap into courage when scared; strength when worn out; comfort when hurt or lonely; determination when discouraged. Step Eleven keeps me trudging along.
Over time, I’ve learned what works best for me. If I want solid results, I need a solid morning routine with built-in quality time for practicing the Step. A rush job doesn’t cut it. For me, that’s 20 minutes minimum — I prefer at least a half hour, if not longer. And of course that dictates when I set the alarm!
I’m better at the conscious part of “conscious contact” if I start by taking what time I need to calm my thoughts, relax my body, and settle into a true quiet. Sometimes that takes a few minutes and sometimes, on bad days, longer. And I’m more open — less easily distracted — if I do my Step work first thing in the morning, before the rush of getting ready for work.
Step Eleven is also my rudder. I can’t describe how that works for me any better than the Step itself does:
“In thinking about our day we may face indecision. We may not be able to determine which course to take. Here we ask God for inspiration, an intuitive thought or a decision. We relax and take it easy. We don’t struggle. We are often surprised how the right answers come …”
~ “The Big Book,” Step 11, page 86
“Ask.” I don’t always know what to do. When I was new and inexperienced with this Step I’d pray for direction, then immediately look to the elders in recovery for advice. I still do.
“Relax and take it easy.” “Don’t struggle.” If I’m anxious and impatient, then I’m fighting the Step. That blocks the power in the process from doing its work.
And then, “Surprise!” A burden lifted; a door opened; a next step; a new direction.
Practicing this Step over time has given me a more open heart, one with a greater capacity to listen. It’s more natural for me to sit and wait with patience. Best of all, I can better recognize the inspiration, or intuition, that actually does come from my deepest, truest self, from my wise child, from my God. And to trust it!
All in all, Step Eleven gives me an unshakeable foundation for life — just as it promised me.
Practicing this Step over time has given me a more open heart, one with a greater capacity to listen. Best of all, I can better recognize the inspiration, or intuition, that actually does come from my deepest, truest self, from my wise child, from my God.
Some 10 years ago, I started to practice Buddhist meditation and study Buddhism in depth.
With 14 years sobriety and having gone through the steps 14 times, I felt I needed to be able to look at myself through a different lens. For me, this was the spiritual path that fit.
This is how my practice of the Four Noble Truths and the Eightfold Path of Buddhism works with my practice of the 12 Steps:
The First and Second of the Noble Truths can be aligned with Step One.
Step One: We are powerless over _____ and our lives are unmanageable.
The First Noble Truth: Suffering
Human beings are subject to desires and cravings, but even when we are able to satisfy these desires, the satisfaction is only temporary. Pleasure does not last; or if it does, it becomes monotonous. Even when we are not suffering from outward causes like illness or bereavement, we are unfulfilled, unsatisfied. This is the truth of suffering.
The Second Noble Truth: The truth of the cause of suffering
The Buddha taught that the root of all suffering is desire, tanhā. This comes in three forms: greed and desire; ignorance or delusion; hatred and destructive urges.
In the First Noble Truth I can see how drinking worked for a time, how it eliminated my internal suffering (restless, irritable, discontent). In the Second Noble Truth I can see that suffering brings back the desire (obsession) to use or drink, so I can fix the malady; that delusion can be twofold: 1) I don’t have a problem and believe deeply that I don’t; 2) This substance is doing something to relieve the malady; and, of course, that Greed is the selfishness in me.
The Third Noble Truth can be seen within Step Two.
Step Two: Came to believe that a power greater than ourselves could restore us to sanity.
The Third Noble Truth: Cessation of suffering
The Buddha taught that the way to extinguish desire, which causes suffering, is to liberate oneself from attachment. This is the third Noble Truth – the possibility of liberation.
To liberate oneself from attachment is to understand that lack of power is my dilemma and come to believe that on my own I am unable to relieve my addiction. So, there will need to be something greater than self.
The Fourth Noble Truth works with Step Three.
Step Three: Made a decision to turn our will and our lives over to the care of God as we understood Him.
The Fourth Noble Truth: Path to the cessation of suffering
This is the Buddha’s prescription for the end of suffering: a set of principles called the Eightfold Path. The Eightfold Path is also called the Middle Way: it avoids both indulgence and severe asceticism, neither of which the Buddha found helpful in his search for enlightenment.
The step says as we understood him, not as others understand him. Here I am going to find my truth. But I need to remember it’s not me. Also, the decision in this step is just to move forward to find my truth and to follow the Eightfold Path.
The Eightfold Path
The eight stages are not to be taken in order, but rather support and reinforce each other:
Right Understanding: Accepting Buddhist teachings. (The Buddha never intended his followers to believe his teachings blindly, but to practise them and judge for themselves whether they were true.)
Right Intention: A commitment to cultivate the right attitudes.
Right Speech: Speaking truthfully, avoiding slander, gossip and abusive speech.
Right Action: Behaving peacefully and harmoniously; refraining from stealing, killing and overindulgence in sensual pleasure.
Right Livelihood: Avoiding making a living in ways that cause harm, such as exploiting people or killing animals, or trading in intoxicants or weapons.
Right Effort: Cultivating positive states of mind; freeing oneself from evil and unwholesome states and preventing them arising in future.
Right Mindfulness: Developing awareness of the body, sensations, feelings and states of mind.
Right Concentration: Developing the mental focus necessary for this awareness.
Steps Four, Five, Six and Seven are essential to get to the practice of the Eightfold Path. Steps Four and Five assist me in finding where I was wrong in all eight areas of my life. I no longer do a column inventory, but inventory by putting my life against the Four Noble Truths and the Eightfold Path. Step Six is being willing to make the changes required for contented sobriety. Step Seven is being willing to let go of self, so these changes can take place.
I have to make the Step Eight list in order to be able to follow the path, and need to make my Step Nine amends because freedom is essential for my recovery.
Steps Ten and Eleven are strict disciplines and I must use them the way they were written. I am still human and make mistakes, and must rectify them promptly if I am to follow the path. At least morning and night I go to the mat for meditation and prayer. (In Tibetan the word OM or AUM is used to start and end prayer.) At night I also do daily review. Without meditation and daily review, I can return to the unconscious state where ego rebuilds, and it can take me out of the path I have chosen to follow.
This leads to the Twelfth Step. Carrying the message is essential to my sobriety, and the practice of the principles are the principles of the Eightfold Path. As for the spiritual awakening, there is a Zen saying: “Before enlightenment, chop wood and carry water. After enlightenment, chop wood and carry water.” It tells me that no matter what, I must practice daily.