Friday, 27 September 2013

Return to baseline: Behavioural therapies and the DSM5 debate

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

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.

It also has to be said that in some ways, the cognitive “revolution” in psychology has reinforced the focus on diagnosis. I’m forever seeing research and increasingly focused treatment models that are sold as “CBT for depression”, “CBT for Obsessive Compulsive Disorder” and the like. Some responsibility needs to be taken for the fact that perhaps an unintended consequence of the cognitive revolution has been the strengthening of diagnosis-based approaches. So, let’s have a return to behavioural psychology: a Return to Baseline!