I have been intrigued recently by online
debates, blogs, and presentations at conferences and other events raging
against the new DSM5 diagnostic criteria for psychiatric disorders. A core theme
of the anti-DSM5 camp is that we would do better to focus not on diagnostic
labels but on the core problems most distressing to individuals. Psychological
treatment should focus on core behaviours (“symptoms”) as opposed to treating
the “disorders” that are at the heart of DSM5.
These ideas are sometimes presented as if
they were new or radical. Oftentimes, I have been surprised by the lack of
historical perspective on these issues. In particular, there is a branch of
psychology that has never signed up to the notion of psychiatric disorders, has
always been uncomfortable using disorder labels, and should have a focus on
core behaviours that need to be changed. This branch of psychology is
behavioural psychology, most significantly aligned with the science of the
application of learning theory to the resolution of problems of social
significance (Applied Behavioural Analysis [ABA] – see my blog http://profhastings.blogspot.com/2012/12/autism-evidence-3-what-is-aba-for.html).
In the early days of psychological therapy
(after the origins of psychological therapy in psychodynamic approaches), it
was all about the application of behavioural theory to psychological problems.
However, we were consistently told that these approaches failed to consider
language and emotions and so a cognitive revolution was needed. This reflected
a broader alleged paradigm shift in psychology towards cognitive psychology.
Recent debates around DSM5 seem to suggest that it was a mistake to throw out
the behavioural baby with the bathwater. Anti-DSM5 folks also seem to have
forgotten that behavioural baby. But the baby survived, carried on growing up,
and is still around.
Misperceptions abound about the inability
of behavioural psychology to consider the experiences and behaviours we call
emotions and thoughts. B. F. Skinner himself clearly recognized that these
experiences and behaviours had to be understood and that intervention approaches
built on behavioural theory had to be able to address them. Over the decades,
many researchers and clinicians working from a behavioural perspective have
continued to develop Skinner’s early ideas and to establish new behavioural
therapies that include powerful change processes focused on thoughts and
emotions. These new behavioural therapies are gradually gathering an evidence
base and receiving recommendations in guidelines for the treatment of mental
health problems.
Two good examples of the new behavioural
therapies are Acceptance and Commitment Therapy (ACT) and Dialectical Behaviour
Therapy (DBT). The developers of ACT explicitly combined traditional
behavioural therapy concepts such as behavioural activation (broadly conceived
here) with recent ABA models of language. ACT has been applied to address
numerous problems, including evaluation in several Randomised Controlled Trial
designs. Because ACT is a broad behavioural intervention approach, it is
applicable probably to pretty much all human psychological distress. And this
is how it has been evaluated – not really specifically for any particular
“disorder” (although you will see, for example, research papers about ACT for
people with Psychosis). DBT is a meld of ABA and mindfulness-based approaches
that directly address significant problems of emotional regulation. In the
world of the UK National Institute for Health and Care Excellence (NICE), DBT
has been recommended for the treatment of Borderline Personality Disorder and
also for Self-Harming Behaviours. Note that NICE works on a medical model
(compatible with DSM) in that it reviews evidence for medical disorders by
their label – including psychological problems.
So, what was my point in writing this blog?
First, I am making a plea that everyone especially in the anti-DSM5 camps takes
a look back at some history and recognizes the value of the behavioural
psychology approach focused on the amelioration of specific behaviours that are
distressing for individuals. Second, there needs to be some recognition that
behavioural psychology never went away but continued to develop. Now,
behavioural psychology is perhaps ahead of the game. People should inform
themselves about how behavioural psychology has developed and look to the new
behavioural therapies as examples. Third, there could be a strong alliance
between the anti-DSM5 movement and the field of behavioural psychology.
