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anxiety, crisis reactions and so on), that the original idea, that it specifically treats depression, seems totally outdated.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).