THE NEW COCA-COLA?
No architect troubled to design houses that suited people who were to live in them, because that would have meant building a whole range of different houses. It was far cheaper and, above all, timesaving to make them identical.
- Michael Ende, Momo, 1973
A desolate-looking man approached me recently, and introduced himself as a psychotherapist looking for work. He had spoken to a number of NHS fundholders in London but had hit a brick wall - there just weren't any opportunities for experienced psychotherapists to provide therapy to people who were clinically in need but unable to pay the going rate. I had to confess - his chances of practicing in Camden were slim, unless he chose to go private.
This is a strange situation. Alan Johnson recently announced an injection of funding to the tune of £170m over three years, which would help lots more people to access psychological therapies on the NHS. You'd have thought people like my friend the psychotherapist would be jumping for joy. But unfortunately, he is unlikely to gain from the Secretary of State’s announcement, and it is doubtful whether patients will either.
The government's idea of effective psychological therapies is limited to say the least. Firstly, it says that ideally they should be short-term. Although you will hear some politicians and NHS managers claiming that this is to prevent people becoming dependent, most will admit that the advantages of short-term therapies are purely financial. In fact, evidence suggests that short-term therapies provide little long-term benefits to people with more profound illness.
Secondly, the government says talking therapies should have a body of evidence to back them up. No holder of public funds could possibly have a problem with this, except that the methodology used by policy-makers to demonstrate the effectiveness of talking therapies is pharmacologically-based. Empirical evidence suggests the government’s preferred form of therapy – cognitive behavioural therapy – is not the panacea it is made out to be. Indeed, the Institute of Psychiatry recently held a conference entitled: "CBT is the New Coca-Cola: This house believes that cognitive behavioural therapy is superficially appealing but over-marketed and has few beneficial ingredients."
The methodology used to demonstrate the effectiveness of CBT is the randomised-controlled trial (RCT), used to test the efficacy of pharmaceuticals. The irony is, the controlled nature of the methodology leads to gross inconsistencies in the evidence-base of psychological therapies.
An RCT will take two groups of randomly-selected people, and administer one group with the treatment under trial, the other with the current, standard treatment, and evaluate the results. In order to compare the two groups, each must be as uniform as possible to avoid the influence of mitigating factors. So, people with two or more diagnoses will be ineligible for the RCT because the secondary diagnosis might have some bearing on the treatment of the first. Next, each person in the first group must be given an identical treatment, otherwise they will not be comparable. Finally, the deliverer of the therapy must be identical – which either means one person acting as therapists for everybody in the group or, more likely, the therapy being manualised. So you see, we have identical patients being given identical treatments by identical therapists.
Psychoanalytic and psychodynamic therapies have a philosophy of different patients being given different treatments by different therapists, according to the needs of the patient and the nature of the therapy. Their course is unpredictable, because they are determined by the relationship between therapist and patient, and are sufficiently flexible and amorphous to allow unforeseen material to be uncovered. In fact, practitioners of nearly all psychological therapies will admit that actual clinical practice never follows the book word-for-word. Testing any such therapy via an RCT will therefore be futile.
If you want something which fits the RCT model, Cognitive Behavioural Therapy has to be your premium choice, because of its highly structured approach. It is one of the few therapies approved by the National Institute for Clinical Excellence, and is the favourite therapy of Richard Layard, the so-called “happiness guru” (an economist with little experience of clinical psychology or psychiatry) who advises the Government on mental health and social inclusion policy. CBT does not care to delve into any childhood factors which may have caused the symptoms to occur, but instead uses a by-rote approach to alter aspects of behaviour which the patient finds traumatic. Although symptoms will differ from person to person, the delivery of CBT will remain consistent, which means it adheres perfectly to the exigencies of the RCT methodology.
The conclusion drawn from all this is not that the evidence mechanism needs to be more flexible, but that psychotherapies are ineffective. Ministers and managers have accepted the dictums that (a) CBT is evidence-based, and (b) there is little or no evidence to suggest that long-term therapies work. This dictum is highly misleading since, as we have seen, its evidence-base is generated by RCTs which only use those rare (non-existent?) patients with a discrete diagnosis and no extenuating factors. For the moment, it is the CBT industry which will gain most from the Secretary of State’s funding. But it is up to psychotherapists to devise a methodology which is sufficiently objective, and which demonstrates positive outcomes for patients, and good rates of sustainable recovery (the extent to which CBT provides lasting psychological improvements is unproven). They may well have a fight on their aims, for CBT is emblematic of the rather blinkered and reactionary view our society has towards psychological health.
Cognitive Behavioural Therapy is the one so-called talking therapy (or talking cure) which chimes with the pharmacological approach to psychology, in that it takes an objective approach to human psychic activity, and proceeds by a method which is uniform from patient to patient. Pharmacologists and mainstream psychiatrists use the infamous Diagnostic and Statistical Manual (DSM) of Mental Disorders. Its diagnoses claim to be empirically founded, but in fact they are constructs based on what is considered socially normal and abnormal. Yet paradoxically, any claim that a disorder might have social as well as biological causes is dismissed as unscientific and unverifiable. The fact that diagnoses correlate with perceived social abnormality means that treatments favoured by the pharmacological community will aim to normalise a person, rather than to treat them holistically. Once again. we find that Cognitive Behavioural Therapy fits the bill perfectly.
The renaissance of the pharmacological approach – “blaming the brain,” in Elliot S Valenstein’s words – roughly coincides with the rise of neoliberal capitalism, and it is not difficult to see the association. Defining mental health in purely biological terms helps social and economic structures off the hook. Those diagnosed as having a disorder can be treated, via drugs, neurological interventions or standardised psychological therapies, so that they can become normal, productive members of society. This normalising approach can be dangerous: many authoritarian states have managed dissent by treating it as deviant, psychologically abnormal behaviour, and we can read about British care homes which administer medication to older people with dementia or challenging behaviour in order to sedate them.
Therapies which treat a person’s symptoms in the context of his or her circumstances (both historic and socio-economic) are liable to be more challenging to society. Their assumptions are also borne out rather more convincingly than the assumptions (which focus on genes and neurological make-up, rather than material factors) of the pure pharmacologists.
The World Health Organisation and the European Commission have studied the prevalence of mental illness in a sample of countries throughout the world, and their results suggest that genetic make-up is of far less consequence than the society in which one lives. Countries such as the US and the UK , whose economies are predominantly neoliberal have much higher incidence of depression and other neurotic illnesses than those with other economic systems. We know that, under the post-1979 New Right administrations of Thatcher, Major, Blair and Brown, 1% of British earners doubled their share of the national income (from 6.5% to 13%), and that top chief execs now earn 133 times more than the average wage (in 1980, FTSE 100 execs earned 20 times more than the average). The Scandinavian model of capitalism, while still faulty, has curbed the gap in economic inequality.
The EU’s Outcome of Depression International Network found that 17.1% of people in Liverpool suffered from a depressive disorder, compared to 8.8% in Oslo and 5.9% in Turku , Finland . This cannot be explained by genes, and studies show that when people migrate from one place to another, their physical and mental health will change. In other words, those Finns would be nearly three times more likely to suffer from depression if they lived in the UK .
Why is this? Oliver James suggests that economic inequality does not merely create higher levels of misery – it also thrives on it. “Selfish capitalism stokes up relative materialism: unrealistic aspirations and the expectation that they can be fulfilled. It does so to stimulate consumerism in order to increase profits and promote short-term economic growth. Indeed, I maintain that high levels of mental illness are essential to selfish capitalism, because needy, miserable people make greedy consumers and can be more easily suckered into perfectionist, competitive workaholism.” Despite the disparity in incomes and access to cash which has grown steadily under Gordon Brown’s stewardship as Chancellor and Prime Minister, and despite the chances of upwards social mobility which have shrunk under the Tories and New Labour, still we reach further for the stars.
An end to this selfish capitalism would do a lot more for Britain’s mental health than £170m worth of CBT.