Steven Hayes: Scrap the DSM

The day before yesterday I went to hear the creator of Acceptance and commitment therapy (ACT), Steven Hayes, talk at Stockholm University. He talked about the future of psychiatry and psychotherapy and I felt he had many clever and interesting things to say.

I have written before about the problems with psychiatric diagnosis and Hayes seemed to share those views. His prediction is that in the future there will be much less interest in psychiatric diagnosis and in diagnostic manuals. He had two arguments for this. First, after several decades and lots of research, the diagnostic system doesn’t really add any meaningful understanding of people and how to help them. I understand this argument like this: There is evidence that ADHD is simply an extreme of a continuum. Some people are less active, some are more, and some are hyperactive, sort of. And with depression, there is a cutoff point, meaning that if you are sad and down for less than two weeks, this is considered ”normal” sadness and not included in the DSM, whereas if you are sad for more than two weeks, you have some sort of disease and should be diagnosed.  And of course it is good that we try to understand why some people have problems with prolonged periods of sadness, but the action of trying to delineate clear boundaries between normal and abnormal adds little in this search for knowledge. I can’t think of any DSM-diagnosis where there is a clearcut and non-negotiable way of distinguishing ”sick” from ”healthy”, they all seem to exist on a continuum where many ”normal” people share those traits included in the DSM.

Hayes second argument was that despite extensive research, there is remarkably little progress in linking specific treatments to DSM-diagnoses. For instance SSRI-medication is now used for such a broad range of problems (sleeping problems, depression, GAD, PMS, social anxiety, crisis reactions and so on), that the original idea, that it specifically treats depression, seems totally outdated. The therapy concept that Hayes is working with, ACT, uses a concept called psychological flexibility, that seems to be a factor in many different forms of psychological suffering. Hayes argued that the scientific evidence that links psychological flexibility to mental health and unhealth, is much more solid than any of the research regarding reasons and treatment of DSM-diagnosis. He felt that if you can prove that a particular treatment or therapy has a good influence on psychological flexibility, it should be regarded as evidence-based.

Hayes presented the idea that it would be much more fruitful to search for broader themes in psychological suffering than putting resources in producing diagnostic manuals with ever more detailed diagnosis. Problems with social interaction and social network is a common theme creating a lot of psychological suffering. Social issues, like poverty and workplace stress, is another very important cause of suffering. Instead of manuals like DSM, we should create a more flexible and fluid system, that really helps people and clinicians to think about different factors in mental health.

Hayes gave 20 points that he think (hope) will be trends in the future development of psychotherapy. He also mentioned an increased role for the peer-support movement, that is the end-users of psychiatric services, and another thing that I and many have talked about; that the long-term effects of psychiatric medication seems to be negative, and that it is time to start acting on that knowledge (see for instance Robert Whitakers books)

Here’s a link to my original post about diagnosis and the idea of psychiatric diseases (translated with google translate).

I got a letter… about sleeping methods

I got a letter from a parent concerning their use of a Swedish “sleeping method” called the ”Good-Night’s-Sleep Cure” developed by Anna Wahlgren. For English speaking readers who haven’t heard of this method, I would say it is quite similar to the so-called “cry it out” approaches in the Anglo-saxon world. The letter is translated here into English. It includes some references to specific features of the method such as singing a rhyme or “jingle”. These terms, as well as the reference to being “cured”, come directly from Wahlgren. Basically, singing a short song, rhyme or jingle is supposed to “give security” or act as a sleep trigger. It is a little bit difficult for me to explain the method to an international audience here, but I hope you get the idea. More about Wahlgren below the letter.
I send my deepest gratitude to Jane Blackwell for her kind help with the English translation.

Dear Daniel,

I have followed your blog since the beginning of this year. I have also read older posts and was struck when Anna Wahlgrens’ Good-Night’s-Sleep Cure (GNS) was mentioned. For us, that method was quite wonderful. Our younger girl was “cured” at the age of 8 months, and it went really well. After two nights, she slept 11 hours without awakening, and if she did wake up we would sing the jingle softly from our bed so that she heard it from her cot behind the curtain, two meters away, and then she would once again sleep, so sweet, so sweet. If the bedtime ritual went awry at any time, we just sang the jingle cheerfully on and off from the sink, so that we got the last word in. And then she slept. How wonderful. Her older sisters also needed some time before bedtime, so it was very practical that the youngest should be asleep by seven o’clock. This continued for one and a half years, and then their younger brother came along, and the bedtime rituals started getting more difficult. Screams and noise behind the curtain, and angry protests. A “bump in the road”, as it is called on Anna’s forums.

Bump in the road? This is a cunning way to rephrase a form of abuse perpetuated against our child, who tried in all possible ways to reach us through our loud singing, corrections and brief good-nights, uttered as we walked out of the room, turning away from her – she who was left alone in the total darkness behind the dark blackout curtains.

You write that there is a lack of research into the long-term consequences of this sort of sleep-method, and this is a pity. I have myself struggled for six months to mend the gigantesque wounds that our behaviour caused in our daughter. The attachment process has had to start all over again, and whether it will ever be complete remains to be seen, but it is improving. She is going to be three years old in one month, and nowadays she always falls asleep together with mom or dad in her bed. She also chooses herself to hold my hand, something that has taken a long time for her to be able to accept.

I suppose one might say that I woke up one day and started wondering what the heck we were doing. How would I feel if my spouse totally ignored my attempts at communicating, responding only with inconsequential answers repeated four times, sometimes six, from the other end of the house? I am really ashamed over this.

It is possible that other GNS practitioners succeed better that we do. That their kids happily jump into bed to sleep well, like they have been taught, and keep on with that throughout the years. Maybe we didn’t follow all the details of the method, but just wanted to take the yummy parts of a long uninterrupted sleep and minimal hassle when the child sometimes woke up at night? In other words: I cannot say that the method is damaging, but I KNOW that it trivialises and reduces the child into something that is barely human. At night you sleep. Period. If you don’t fall asleep quickly and easily, mom and dad haven’t been clear enough in their “message”. What drivel.

Now, this is something which I, a mature person over 40, with an extremely orderly situation in my worklife, my wallet and my life in general, have done against my child. My heart is bleeding when thinking of this.

I don’t think that this would have left such traces if we just hadn’t tried to correct that “bump in the road” that appeared when she was around two. Before that she really fell asleep one minute after the good-night. She never cried at night, just grumbled a little and got to hear a gentle voice repeating the well-known words. The damage appeared when the bedtime routine DID NOT work and we chose to continue to apply the tools of the GNS method to make the girl go to sleep by herself. 30-40 minutes was not uncommon. There it certainly went very wrong.

One night last summer I apologized to her. We had read a story together, and as usual she was angry and aggressive towards me. Tired and angry. The pillow flew against me numerous times and the hands hit me. Again. No contact. It had been like that the whole summer. She didn’t feel present, but would glide into a weird facial expression with an underbite and a stiff gaze and then these scratching hands that wrangled away mine when I tried to embrace her back to calm her. This happened regardless of how gently I touched her.

Oh, yes, the apology. I often felt empty and sad inside in these situations. What was I going to do? How were we going to correct what we felt had gone wrong? She would not accept to be close except when playing and roughhousing, and above all not at bedtime. This evening I just started talking. I talked about how sad I was that she had had to be all alone in her bed, and that I understood how alone she must have felt. That she must have been very afraid, and that mom and dad had done wrong when they hadn’t come and consoled her then. In all possible ways I describe what I felt she must have experienced, and at the same time I stroke her chin. What happens during these minutes is forever etched into my memory and my heart. Little Elin starts to cry, not in the way of a child, but in a very tormented and restrained way. Like if she struggled to control herself. She lays on her back in her bed, and I sit beside her. Her gaze is on the ceiling and her underlip is trembling. Her chest almost cramps from her breathing that has fallen out of rhythm. She tries to say something but it only gurgles, and she vomits right into the air. I don’t have time to move before she literally throws herself into my bosom and clenches her arms hard around me. She can’t really talk but vomits more, and we wipe it up with the bed-sheet. I continue to talk; poor little Elin who has been so afraid and lonely. So afraid and lonely and mom didn’t come. I am so sad Elin, I am so sorry. I will never do it like that again. It was wrong. I am really so sorry. And I repeat this until she stops crying. Then she starts talking. She says that I was frightening then. That she was superfrightened then. She tells me this over and over again.

The next day we have a different girl here in our home. She sits close. I get to hug her gently. At bedtime, she interrupts the story and asks me to tell her about when she was alone and afraid. I tell her and say that I’m sorry. She falls asleep easily. After this it has only got better and better, but anyway, it is not complete yet. Difficult to explain, but evident for me as a mother.

Sorry, this became a long letter after all. I just wanted to relate our story that gives a glimpse into what this method has caused in our little family. The younger brother who is now ten months will never experience the same thing. If you have questions I will be glad to respond.

Best regards,

The mother of Elin [names changed for confidentiality]

– – – –

Comment from Daniel:

Anna Wahlgren’s method is based on the idea that all children are “afraid of the wolf”, and if we stay close to our children at bedtime, we as parents validate this fear, but if we stay at a distance and act calmly, the child would believe that there is no wolf to fear. I don’t know if there is any research supporting this idea. On the contrary, from an evolutionary point of view, it would be natural for children to have a deep fear of beasts for many years, a fear that cannot be eliminated by any “method”.

Wahlgren’s books has touched generations of Swedish parents. And much of her advice is quite sane from a humanistic point of view, like for instance being the best friend of your child. The most problematic and controversial part seems to be her sleep advice. My understanding is that she has some issue against body-touch; she manages to put forth many smart-sounding reasons to avoid touching your baby, and I really don’t understand why she is so negative about touch.

You can see videos of her questionable methods here.

Wahlgren has nine children, and in 2012 one of her daughters, Felicia Feldt, wrote a book that really made the Swedish public question her status as a parenting guru. Feldt described a quite horrible childhood, including Anna Wahlgren allowing her new partners to sexually abuse her teenage daughters.

For more about alternatives to “sleeping-methods”, I recommend Aware Parenting.

New study: does the LCHF-diet lead to stroke and cardiovascular disease?

Today the tabloids in Sweden announced that a new study has found that LCHF (Low Carb, High Fat diet, Atkins, paleo diet etc) can increase risk of stroke. There has been lots of debates about these diets recently, so this was on the news bills. I took the time to read the original scientific paper and found several problems with the news reports:

The connection LCHF-stroke

Even the heading of the original paper mentions high-protein/low carb-diet, but what the researchers actually did was to send a questionnaire to women in a part of Sweden in 1991-92 and then measure the ”outcome” in terms of cardiovascular diseases. They found which of the women that had any such diseases, and used statistical methods to measure if there was any relationship between the variables diet and subsequent disease.

As far as I know there were no talk about Atkins or LCHF at that time in Sweden, I would estimate that approximately 0 % of the women in the sample followed any diet similar to LCHF.

This makes the conclusions dubious at best. As far as my understanding goes the study cannot say very much about the consequences of LCHF or similar diets.

The link high protein-stroke

But, you might say, there was after all a strong statistic correlation between eating little carbohydrates and lots of protein and cardiovascular disease. The problem is that this correlation might be a sign of another confounding variable. To illustrate this in a simple way, let’s say that there is a big ”normal” cluster of women in the sample eating some sort of average food, and then a smaller ”vegetarian” cluster, eating less protein and more vegetables, and then a ”hedonistic” cluster eating more fat, meat, sauces with cream in etc. Then, with my knowledge of the situation in Sweden at that time, I would guess that the ”vegetarian” cluster was most ambitious with exercise and drank the least alcohol and smoke less. And then ”hedonistic” women probably behaved the opposite, smoked more, drank more and exercised less, on average. (I should stress here that they have used a statistical method to standardise the ratios of carbohydrates/fat/protein, so it makes sense to assume that these clusters will really be visible in the study)

The study mentions taking some account for this, looking at smoking and alcohol use. But it does this with variables that are very coarse, dividing the sample into only three groups concerning alcohol intake. And they don’t take exercising into account at all.

This makes it quite possible that what they are really measuring is a correlation between protein/carbohydrate intake and general lifestyle variables like smoking and exercise.

What does this has to do with the themes of this blog?

This subject is not really related to the themes of this blog: psychology, parenting and psychotherapy. But I think it shows how scientific reports in both reputed journals and in mainstream media can be flawed and biased.

Another more important reason that these things might be of interest to the readers of this blog is that as I wrote when reviewing the Paleo-diet-site Marks Daily Apple (MDA), there are new and very interesting research coming about a connection between inflammatory processes in the body and at the same time there are signs that paleo-diet (a diet with similarities to LCHF) can decrease those inflammatory processes. And on MDA there are actually quite interesting reports about depressed people recovering using that diet. There are also other reports saying that a ketogenic diet (with little carbohydrates) can be helpful for depression. I absolutely don’t want to claim that there is any sort of scientific clarity on this, I just want to say that we should keep our eyes open and curious towards this area, and look at different hypotheses with an open mind.

Note 1: For clarity I would like to stress that I do not mix dieting advice into my practice as a psychologist, rather I very much urge people with eating issues to first look at the psychological aspect of their eating.

Note 2: The study is: Low carbohydrate-high protein diet and incidence of cardiovascular diseases in Swedish women: prospective cohort study by Lagiou, Sandin, Lof (Löf), Trichopoulos, Adami, Weiderpass in British Medical Journal.

Review of Mark’s Daily Apple

For the September issue of the magazine YourLife, I was interviewed by a journalist about my views of the recent trend with exercise forms that are both hard and integrate the whole body, like cross-fit and military training. It was quite flattering for me, who was always very ordinary in sports, to get to talk about exercise alongside the fitness icon Dolph Lundgren…

I gave a rather dull psychologist-answer: that these forms of exercise look really impressing, but for the majority of people the big challenge is to start exercising at all. Since then I have been following occasionally the blog Mark’s Daily Apple, and in spite of my misgivings, I do find it quite fascinating. I have even tried a couple of the concepts of the blog, like barefoot running, and I like it a lot.

Mark’s Daily Apple is the blog of former triathlet Mark sisson about ”grok-living” or ”following the primal blueprint”. The idea is that since the human race have spent most of its days as hunterers-gatherers, our genes are programmed to certain forms of diet and exercising, and if we obey the rules of our genes, we’ll be much more healthy and happy. The diet is very similar to what we in Sweden call LCHF – but with a lot of vegetables and somewhat more carbohydrates. The exercise is a combination of barefoot running, heavy lifting, sprints etc.


These are the strong points that I find in the concepts of Sisson:

* For a person who wants to stay healthy in our modern society, there are many temptations. Where I live they have recently placed an automatic vending machine for candy, so we can basically get it any time of the day, like if you return tired from work at 10 pm. Here it can be a great help to work together with other people to keep on a healthy track, like I see people doing at MDA. See for example this video.

* The exercise ideas seem quite sane to me, Sisson carefully stresses that it is important not to exercise too much. Training two to four times per week is encouraged.

* As ways of losing weight, LCHF and paleo might have some advantages. Swedish speaking readers can find good reviews of the research on this on träningslä

* Sisson also have some very interesting posts on IBS and depression – in short there are some very preliminary evidence that this diet might be helpful with these and some other nasty conditions. I would be very interested in seeing more research about this.

* There is something in the general ambiance of this site that I like a lot. Some sort of warm enthusiasm that is caring about Mother Nature.

The flip-side of the coin

I also see weaker spots:

The concept of primal living

The big components of the primal lifestyle seem to be diet and exercise. The more you read the blog, the more this lifestyle seems attractive and self-evident. But in fact there is no real logic that one need to package together paleo-diet with particular forms of exercise. The ”primal” people do not seem so interested in paleolitic dancing or caveman worship, for instance. Living ”Grok” is a nice and cosy idea that may appear really authentic, but in fact, it is very much a concept that is adapted to the modern 21-century rich world (Grok is the imagined forefather that you want to imitate in this lifestyle).

Some people seem to feel that Primal/Grok lifestyle resonates perfectly with how they want to live their lives, and for them of course this is a way to a more healthy and fulfilled life. But for the many of us who are struggling with keeping an exercise regime at all, it might be too difficult a task to try and model both our exercising and our diet according to these concepts. The threshold might be too big.

My suspicion that this is not so much a concept for ordinary couch-potatoes, is supported by the fact that most of the people featured on the blog seem to have been fitness nerds already before they started with the ”primal” lifestyle.

I see a larger problem of public health here. Around 50 % of the population in the western world are chronic couch potatoes, and don’t even take walks regularly. This is a huge public health problem. They are at risk for all sorts of serious diseases like cancer, heart disease, diabetes and other. I think many of these people have negative views of themselves and negative views of exercising that makes it more difficult for them to stick with some exercise habits. They might think that exercising is not for them, or that exercising are for ”nuts” (hurtbuns, we say in Swedish…). These views might be reinforced by looking that sites like MDA.

If you look at magazines, newspapers or on the internet, there are tons of information geared towards people who are already into exercising, but very scarce material for all those people who need help to get started with some simple exercising and to learn to stick with it.

So this critique does not concern only MDA, but I really think it might be helpful it if was more sincere about targeting people who already have healthy lifestyles.

What life does this really lead to?

While I find the general ambiance on the blog quite nice and relaxed, in the forums I see signs that many people maybe take this lifestyle a little bit too seriously. In this thread for instance people seriously debate if one ought have some sugar after exercising. Of course, there might be some way of scientifically answer this issue, but I can’t help but thinking: aren’t there more exciting things to do in life than debating this? The other day I saw a Zumba clip on YouTube. They use the word ”party” in every sentence, and when compared to some things on MDA, Zumba seems a much more vibrant and fun way of spending your leisure time if you want to become fit.

Too much focus on ”looking gourgeous”

I get quite a mixed picture here. Often I get the impression that this is a concept where you want to turn your back to many of the things of contemporary life, like TV, cars and big cities, and live closer to nature and the basics of existence. But at the same time, there is a lot of focus on how the primal lifestyle makes you look good in a conventional 21-century way.

As far as my understanding goes, the paleolitic man didn’t have the resources to worry about how (s)he was looking – they didn’t even have mirrors. And if they wanted to change their bodies in some way, I believe their primary dream would be to be more fat.

An example is the recently published story about a woman who is around 50 and she starts out with a body quite normal for her age, not at all overweight or obese. She then does an ambitious ”primal” plan and in the end there are photos where she smiles and has a body of a traditional ”skinny model”. And then there are dozens of comments where people praise her work with words like ”you look gourgeous”. This is the type ot text that I would absolutely not want any insecure teenage girl to read. It really supplies a recipy for eating disorders complete with diet and exercise tips, and literally promises that losing a lot of weight will give you appreciation and love.


So in the end my review is quite mixed. The concept of following the primal blueprint might have a lot offer to some people but I would strongly encourage Sisson and his friends to take a closer look on their attitude to ”looking great”.

Notes: Mark Sissons book on Adlibris, Bokus.
Swedish text
on ”primal” exercise.

The pink hot dog and the angry child

I saw this clip on the tv-show ”Doctors”. Dr Sears acts in a small scene where he is taking his 6-year old nephew out to eat hot dogs. The boy sees a pink hot dog on the roof on the hot-dog-place, demands to have a pink hot dog and then becomes more and more agitated, and we can sense that a tantrum is coming up. In the TV-show, we then are back to the studio, and the audience is asked to ”vote” between different alternatives, like ”discipline him in the line” or just carrying the boy away. The latter alternative, to leave, won and was also endorsed by the doctors.

I live in Sweden, and for us the Americans seems a little bit obsessed with ”discipline” and maybe this clip should be seen from that perspective, maybe the show wants to present more humane and long-term alternatives to ”discipline”. When I see this, though, I get the following thoughts:

When the boy demands a pink hot dog – why not just go to the counter and ask for that? Maybe the boy knows that when an adult really wants something, they go to the counter and talk to the attendant, and sometimes even strange requests can be met. In that case the child’s frustration would be quite understandable; the adult does not do to the kid what he might do with himself.

If I would be in such a situation I would just pick up the boy with my arms and go and ask politely: ”Excuse me, we have a small emergency here; Do you by any chance have pink hot dogs?”. Of course I am not sure about how people would react in the United States, but in Sweden, most people would smile and at least try to think of a solution. And if they say no, I might ask some supplementary questions like ”if we come back here later, would you then be able to make us a pink hot dog?” or ”do you know where we can get one?”

This way of acting has several advantages to the solution proposed by the ”Doctors”:

  • One: it teaches the child an important skill in life – to ask for help from a person behind a counter. This might be a life saving skill ten years later, when he is travelling alone for the first time in his life, and it can also help in building a trustful view of the world; the message is something like: In a crisis, there might be people out there ready to help you.
  • Two: it would show that the adult is on the child’s side against the world. If there aren’t any pink hot dogs to get, at least he’s doing what he can to help.

And I would even like to suggest that if they don’t offer to make any pink hot dogs, one might ask the child: Do you REALLY want to have a pink hot dog? Do you want us to go to a supermarket and ask if they can help us make one ourselves?

To make a pink hot dog should not be impossible. Maybe you can make a pink sauce to dip it in. Or you might find some sort of colouring to boil it in. This is the sort of adventure that could be perfect for a day with an uncle. It also would teach the boy a number of important things: To plan a sequence of actions to get to a desired goal. That problems that seem impossible might be solved with cooperation and creativity. And it might also be a terrific bonding-exercise for the two.

And there is also another twist to this story:

Maybe there is a real obstacle here, for instance, say that the doctor really do think that pink hot dogs are a health hazard and couldn’t think of exposing the boy to that. In that case, of course, it would be helpful if he had explained that. But even more importantly, the child might still cry and rage, and there’s a lot of research that shows that this venting of feelings might be very beneficial for the child. There are so many frustrations of this kind in the life of a child, and crying and raging helps children to get back into balance. Of course it is a difficult challenge when other people dislikes your child’s emotional expression, but this also raises the question: on who’s side are you? In my mind it would be very possible to let the child have a tantrum there on the spot, it can’t be illegal, can it? And if the child goes into a tantrum the uncle/doctor should not, as is suggested in the program, ignore it, but stay close and supportive towards the child.

In sum: It think this clip shows very well that by implementing a ”the adult knows best”-approach, you might miss out on an awful lot of opportunities for learning, creativity and connection.

Note: This posting is inspired by parenting philosophies Playful Parenting and Aware Parenting.

A story of courage, hope and recovery

Today I publish an account by a friend of her journey from an abusive childhood to healing and a normal life. Janet suffered from serious troubles with social relations, mood, and dissociation and was a patient in the psychiatric system for several years, until she found recovery with help from the works of Alice Miller, Konrad Stettbacher and Jean Jenson.

I recommend Janets account to anybody touched by issues with childhood abuse and psychological suffering. I feel that by focusing on just telling what happened to her, she very well captures the everyday drama that happens to children all over the world.

A brief background on these therapy koncepts: Alice Miller published her first book, The Drama of the Gifted Child. in 1979. In the eighties she wrote several books that were increasingly critical towards the Freudian tradition in psychotherapy. She became quite famous and her books sold in tens of thousands in many languages all over the world. She became sort of a spokesperson for suffering children and childhood. People started writing to her to request how they could find therapy in accordance with her books. She didn’t know of any such therapy, so she choose to recommend the books of Stettbacher and Jenson as basis for self-therapy. She has later taken back these endorsements, as is discussed in Janets text.

Today Janet suffers from a serious cancer. This is extremely sad. You are very welcome to comment on her story, or send her your greetings below in the comment field.

Link to pdf: I want to live by Janet.

Update 19 september 2011: new version of the story published.
Update 23 March 2014: New totally reworked version published (this version was also published in print in Dutch)