Truth, Politics and Psychological
Therapy – May The Lord Delivers Us from Professional Uncertainty
I feel quite diffident about airing my views in public
these days. Having retired from NHS
clinical psychology nearly eight years ago, and from voluntary clinical
practice about three years ago, I find it surprising how quickly things seem to
change, and how almost dizzyingly out of touch one can get in what seems no
time at all. However, I’m not going to
let that stop me holding forth this evening, in the hope that what a pensioner
such as myself lacks in currency may to some extent be compensated for by length
of perspective.
I had
thought until recently that I could fairly safely, even if tentatively, draw a
few conclusions from nearly forty years’ experience of thinking and reading
about, as well as practising and writing about psychological therapy.
In many ways what seemed to me the most
important of these conclusions followed from my observation from clinical
psychological practice—my own and others—that the various theories put forward
to underpin psychological therapies of pretty well all persuasions were not
supported by what actually happened to patients/clients.
I can
best sum up my observations with the help of a reasonably simple table:-
|
Theory suggests |
Clinical experience teaches |
|
Insight leads to change |
We are not in control of our conduct; therapeutic change is not demonstrable |
|
People may ‘assume responsibility’ |
There is no such thing as ‘will power’ |
|
Thought (‘cognitions’) leads to action (‘behaviour’) |
The causes of our conduct are frequently mysterious, and rationally unalterable |
|
Characteristics/actions (real or imagined) of the therapist are central to change (e.g. ‘transference’; ‘warmth, empathy and genuineness’; behavioural and/or cognitive manipulations, etc.) |
Patients’ conduct is controlled by more potent influences in their social environment |
If in fact one wants to understand why
people behave as they do and why also they so often find it very difficult or
impossible to change—even when they desperately want to and bravely try to—it
seemed to me very obvious that one would need to take into account the world
they live in. People don’t just exist in
a consulting room with their therapist, they live in a highly complex web of relations, personal and
impersonal, within a society that is structured by powerful influences over
many of which they have no control at all.
In this kind of situation ‘choice’ is not always, or even often, the
option it seems to be.
Now this does really seem, does it not,
pretty obvious. So why on earth would
the creators and theorists of so many therapeutic approaches overlook or ignore
the importance of the social world in the formation of individual conduct? Why not, for example, let experience shape
theory, rather like this, perhaps?:-
|
Clinical experience teaches |
Theoretical requirements |
|
We are not in control of our conduct; significant therapeutic change is not demonstrable |
Need to identify the causes of conduct beyond personal agency. These likely to be biological as well as social |
|
There is no such thing as ‘will power’ |
Need to establish the limits of ‘responsibility’; factors that make free action possible |
|
The causes of our conduct are frequently mysterious, and rationally unalterable |
Rationalist explanations insufficient; need to account for the disjunction between conduct and the accounts we give of it |
|
Patients’ conduct is controlled by more potent influences in their social environment |
Need to develop a multi-layered understanding of influence (including therapeutic influence), its modes of operation and the reasons for the permanence/impermanence of its effects |
Well, I think the answer to this is fairly
obvious as well, and that is that it is not in the interest of practitioners of psychological therapies to do so. In order to justify making a living by
holding out the promise or expectation of curing or alleviating clients’
distress, one has to individualize its causes as well as the mechanics of its
cure: they just must be put down to
what can be identified in the consulting room and what goes on between its
occupants. To admit the primary
importance of social influences and the environmental conditions of people’s
lives takes the whole question of ‘cure’ out of the hands of psychologists,
counsellors and others, and identifies it as an essentially political
issue. In most important respects we do
not choose to be who we are—the world
(including biology) makes us such.
Now, up until a few weeks ago I was fairly
happy with this broad conclusion. It’s
not that the vast literature that had grown since the mid-twentieth century was
completely barren, by any means: there was plenty to show that most therapeutic
approaches led to modest improvement for clients, as did drug treatments come
to that. It was just that such therapies
tended to be nowhere near as potent as their practitioners would have wished,
were on the whole pretty impermanent, and depended for their effectiveness not
on the technical practices through which they were delivered, but on the
quality of the human relationship between therapist and client.
It seemed to me that the possible benefits
of therapy could be summed up as clarification, comfort and encouragement. You didn’t necessarily need trained professionals
to provide these—and indeed there is a fair amount of evidence to suggest that
they can be equally well if not better dispensed by lay people (ideally, of
course, they should be woven as permanent features into the social fabric). It
seemed, in fact, that roughly two-thirds of clients improved somewhat under
pretty well any therapeutic regimen, while the other third stayed the same or
got worse. While not exactly disastrous
for the practice of psychological therapies, this didn’t seem anything much to
shout about either.
Now
in view of the extent to which their interests are challenged by what was the
research evidence, it didn’t exactly surprise
me that professional psychological therapists and counsellors should
simply carry on regardless, and this is certainly true of my own profession of
clinical psychology, which has continued to develop and promulgate the virtues
of ‘cognitive behavioural therapy’ (CBT) undeterred by any scientific scruples
about the lack of really significant evidence for its effectiveness. What I personally hadn’t reckoned on,
however, and which has only recently
dawned on me, was the extent to which clinical psychology’s interests would
flow together with other ideological and political interests to set up what
threatens to become a kind of scientistic hegemony in the general field of
talking therapies and mental health.
There seem to be a number of strands to
this, the central engine of which is the drive towards the establishment of a
market in health care that diverts public funds into private pockets (cf
Pollock, 2005). In order to achieve
this, you need political, legislative power and a managerial bureaucracy to
control both professional activity and the production of knowledge itself.
Rather amazingly, in view of its heretofore
relative insignificance, clinical psychology now finds itself at the centre of
a situation where all these elements are pretty well in place. This has been revealed particularly clearly,
I think, by the coming of the lord—in this case Lord Richard Layard, professor
of economics at the LSE and (?former) adviser within the Prime Minister’s
Strategy Unit, which, so it says, is a management unit of the Cabinet Office.
Lord Layard has produced two documents in particular
that have caused great excitement among clinical psychologists. The first is a Strategy Unit production
entitled Mental Health:
Now it’s pretty clear what Layard’s agenda is, indeed
he sets it out in the first paragraph of Mental
Health:
Mental
illness is one of the biggest causes of misery in our society – as I shall
show,
it is at least as important as poverty. It also imposes heavy costs on the
economy
(some 2% of GDP) and on the Exchequer (again some 2% of GDP).
There
are now more mentally ill people drawing incapacity benefits than
there are unemployed people on
Jobseeker’s Allowance. [My italics]
Scattered here and there in both documents
are almost lachrymose references to, e.g., ‘the torment of mental illness’ (Layard
2005, p2), but its obvious that Layard’s focus is the money, not the
misery. This is implied in the
introduction to his Sainsbury talk.
Meant perhaps to be disarming, it seems to me almost menacingly disingenuous:-
I am honoured to be asked to give this
lecture, especially as I probably know less about mental health than any one
here.
Most revealing, though, is in my view a
passage from the Sainsbury lecture introducing the section ‘Pathways to Work’:
So we desperately need a better NHS,
delivering more help and understanding to patients. But for many patients, work
is also a major route to recovery. And
as taxpayers who pay for Invalidity Benefits, we can all say amen to this.
Luckily, especially for clinical
psychologists, Layard has identified exactly what’s needed to deliver help and
understanding, as well of course as get people off benefits and back to work,
and that is CBT, delivered by teams headed by clinical psychologists located in
treatment centres set up on a ‘hub and spoke’ pattern throughout the country.
To realize Layard’s vision, the number of
psychologists would need to be doubled, and recruitment of psychiatrists would
also need to be drastically stepped up.
So pretty well everybody is likely to be cheered by these proposals.
The key to all this, of course, is the
pre-eminent effectiveness of CBT, of which Layard has become convinced largely
through the good offices of our, in my view, absurdly named National Institute
of Clinical Excellence (NICE).
Now it’s with NICE that we come down from
the political stratum to the managerial bureaucracy that’s needed to realize
political aims.
Despite his self-confessed ignorance of
such matters, Layard doesn’t hesitate to prescribe what his proposed
therapeutic professionals would do. For
example:-
The staff would operate under clear NICE guidelines relating to number of sessions, and patient progress would be
monitored using a standard national system of recording completed at the beginning
of each session. (p4)
Since
NICE guidelines are bandied about—not only by Layard—as almost infallible
indicators of so-called ‘best practice’, I thought I’d better steel myself to
reading some, so I had a look at the recent guideline on “OCD and ‘body
dysmorphic disorder’” (that caused a brief flurry of excitement in the media a
few weeks ago), containing 53 pages of recommendations, and the slightly
earlier full, 165 page guideline on the ‘management of anxiety’.
In
many ways these make fascinating, if somewhat numbing, reading, since they
appear to wipe out almost everything I thought I knew about psychological
therapies. In their way they’re
masterpieces of pseudo-scientific bureaucracy, taking the Taylorization of
intellectual endeavour and clinical practice to an extreme I wouldn’t really
have thought possible.
They do indeed assert that CBT is the
treatment of choice for the ‘disorders’ in question, though it is noticeable
that ample room is left for drug treatments.
There is a kind of algorithm of recommendations for the various DSM
categories under consideration, and the recommendations are scrupulously backed
up by recitation of the ‘evidence base’ that has been identified for them.
I
simply haven’t got the heart or the spirit to attempt a detailed critique of
this ‘evidence base’, though relevant critiques do exist (I think in particular
of the chapter on CBT in a forthcoming book by William Epstein (in press). What’s striking about it—the evidence base,
that is—is its near total reliance on rationalized/mechanized research
methodology together with an equally near total indifference to the actual
content of the research (this is demonstrated in reliance placed on review
articles and meta-analyses). A kind of
unholy alliance is built up involving the DSM IV, the Cochrane Library and
various limiting methodological requirements concerning control groups,
double-blind trials, etc., which results in the virtually automatic churning
out of ‘results’ that with a kind of deadening inevitability support the
relative superiority of CBT. Let me just
give you a taste of this – we haven’t got time for a measured critical analysis
(see appendix – there are 151 references in the guideline, most of them
described in this format).
None of the factors that I had always taken
research in psychological therapies to point up as being important receive any
real consideration or influence the NICE evaluation of the so-called evidence.
Very little attention is paid to who ‘delivers’ the treatments or what their
theoretical allegiances are or what the characteristics, personal or
demographic, of clients are beyond their age and diagnosis. Nothing about the
quality of relationship between treaters and clients. Huge reliance is placed on DSM IV and on
self-report questionnaires to indicate improvement or otherwise. Reflecting a total faith in mechanization,
‘measurement’ is everywhere and meaning nowhere; questions concerning
reliability are taken for granted while validity is on the whole simply not
considered. There is no indication of what practitioners actually do beyond the
ascription of an orientation (mostly variants of behavioural and cognitive
approaches).
This is in fact a strangely unhinged,
make-believe world in which entirely hypothetical constructs—mere words—are
taken as necessarily pointing to valid entities in the real world (the DSM
productions are of course prototypical in this respect). The combination of an almost metaphysical set
of beliefs about the potency of ‘cognitions’ and the nature of ‘disorder’
with obsessively detailed procedures of
‘measurement’ and statistical analysis is in fact uncannily reminiscent of the
procedures of 17th century astrologers as recounted by Keith Thomas
in his Religion and the Decline of Magic:
interestingly, astrologers pointed to the complex methodology and mathematical
intricacy of horoscope production as an argument for its scientific validity.
What emerges at the end of all this,
anyway, is that CBT appears to be ‘effective’ in about two thirds of cases, which,
as I said earlier, is what we already knew to be the case with pretty well all
therapies, talking or otherwise. The
apparent triumph of CBT is thus a kind of sleight of hand performed, so to
speak, on a darkened stage where the world beyond its rationalist/mechanist
limits is simply not visible.
The NICE version of things may not be valid
or remotely true in any significant sense, but it is certainly useful in maintaining
an individualized model of ‘disorder’ as well as enabling the central control
and direction of professional activity, whether in research or practice. As you can imagine, it’s also not
uninteresting to those practitioners who stand to gain from its undisputed
rule.
Prominent
clinical psychologists Tony Roth and Pam Stirling, for example, writing in the
clinical psychology house journal Clinical
Psychology Forum (November 2005), though they feel that Layard may be a bit
too enthusiastic about what CBT can achieve (‘…there is a real risk that the
efficacy of CBT is being over-sold.’), are nevertheless quite clear about which
side their bread’s buttered:
The government will only be persuaded to move on these proposals on the basis
of hard-headed arguments, especially because this is—at the end of the day—an
exercise in transfer of costs between departments, justified by a projection
that this will be a cost-neutral exercise with major social benefit. It is
for this reason that the rationale of offering evidence-based treatments of
known efficacy is pragmatic, even if not completely consonant with clinical
opinion. The case for the profession
pulling together on this is clear.
(p 48, my italics).
In a piece in The Psychologist (January 2006) entitled ‘Responding to Lord
Layard’, the Chair of the BPsS Division of Clinical Psychology, Graham Turpin,
is also just a little nervous that Layard’s proposals could mean jobs for only
some of the boys and girls, but feels nevertheless that:
Whereas the evidence for the efficacy of CBT interventions exists, the
contribution of other evidence-based psychotherapeutic approaches could also be
factored within the design of psychotherapy services to ensure that clients
have a real choice of talking therapies on offer by the NHS. (p 12)
Turpin proposes therefore that the Society should
formulate a response ‘as to how psychologists can help drive this agenda
forward’.
What
all this amounts to is that we have lost any semblance—indeed any pretence—of pursuing
scientific inquiry, what is the case, what is true. Just listen again to those sentences of Roth and
The
reluctant conclusion that I find myself forced to contemplate is that truth
plays only a very minor role in shaping the conduct of human beings, and one
should not be puzzled by the observation that no one seems to take much notice
of it.
That human behaviour is best understood as
the upshot of practical and ethical choices based on reasoned consideration of
reality, is, I suggest, a kind of myth that inhabits the very core not only of
our everyday thinking—what has been called popular psychology—but also of
almost all formal, psychological theories, including broadly clinical ones
(including indeed, despite appearances to the contrary, psychoanalysis). If, as it has professed to do, psychology has
pursued the ‘prediction and control of behaviour’, this essentially
rationalist/cognitivist model has got it precisely nowhere. Control
of behaviour seems to me a vain as well as a disreputable aim, but, in my view,
anything like a valid understanding
of human conduct—maybe even with a bit of accurate prediction thrown in—will
not be possible without the recognition that what most of us do most of the
time is react to the almost blind
operation of power and interest within an inescapably social framework. The
‘almost’ here is very important however, as in certain unusual and protected
circumstances the pursuit of truth, as well as of justice, may indeed be
possible. Such circumstances are unusual
because they require an extremely artificial control of the operation of power
and interest, whereby certain kinds
of interest are suppressed (e.g. financial gain or personal glory) and certain
others maximized (e.g. technical, practical or emancipatory interests of
the kind that Habermas wrote about in Knowledge
and Human Interests).
As far as
everyday life is concerned Niccolo Machiavelli and Karl Marx probably make much
more convincing psychologists than do Sigmund Freud, B.F. Skinner or, God help
us, Aaron Beck.
If I was nominating people for best 20th
century psychologist, theoretical and applied, I certainly wouldn’t think of
anyone who emphasized cognitivist rationality in their scheme of things. For ‘best theoretical psychologist’, I
think I’d nominate Mandy
Rice-Davies. Not everyone here, I imagine
will remember or even have heard of her, though most will know the
pronouncement she was famous for. She
was a kind of up-market prostitute who gave evidence in the court case that
arose out of the infamous Profumo scandal in 1963. When prosecuting counsel pointed out to her
that the then Lord Astor denied having had an affair with her, as she claimed, or
even having met her, she replied ‘Well, he would, wouldn’t he’. That demonstates to me a more profound
understanding of human motivation than just about any ‘official’ theory I can
think of.
My nominee for
best applied psychologist goes to someone everybody knows: Margaret Thatcher, who demonstrated within
weeks of coming to office that
one can change the behaviour of virtually a whole population by the ruthless
application of power. Thatcherism, in
fact, introduced a world, now firmly established, in which the operation of
crude economic interest plays the fundamental, almost the only, role. The social and cultural, not to say psychological/emotional
devastation this causes is maintained by a web of nearly impenetrable institutional
power/interest relations and obscured by a haze of Business gobbledegook,
academic claptrap, and psychobabble.
God
knows how we begin to get a grip on all this. I’d have thought that, to start
with, and even if we have to maintain an element of secrecy about it, the best
policy might be honesty.
References
Habermas, J.
1968. Knowledge and Human Interests.
Heinemann.
Epstein, William Psychotherapy as Religion: The Civil
Divine in America, to
be published by
the
Layard, Richard. 2004. Mental Health:
http://www.strategy.gov.uk/downloads/files/mh_layard.pdf
Layard, Richard. 2005. Therapy for all on the NHS. http://www.scmh.org.uk/
Pollock, Allyson. 2005. NHS plc.Verso.
Roth, T. & Stirling, P. 2005.
Expanding the availability of psychological therapy. Clinical
Psychology Forum, no.155 (November), 47-50.
Thomas, Keith.1973. Religion and the Decline of Magic.
Penguin Books.
Turpin, G.
2006. Responding to Lord
Layard. The Psychologist, 19,
no. 1 (January), 12.
NICE Guideline on Anxiety, pp132-3
CBT versus supportive counseling
Barrowclough et al 2001
This randomised controlled
trial sought to measure the effectiveness of cognitive behavioural
therapy in older adults with a range of anxiety disorders. Patients were aged
over 55 years and
had a diagnosis of an anxiety disorder according to DSM IV including GAD, panic
disorder with or without agoraphobia, social phobia and anxiety disorder not
otherwise specified. Patients on medication had to maintain constant dosage
through the study. Randomised patients entered a 6 week baseline phase in which
no treatment was administered before being randomised to between 8 and 12 1
hour sessions of either CBT or Supportive Counselling. Each patient completed
a credibility questionnaire to assess treatment credibility at sessions 2,
at the end of treatment and then at 3, 6, and 12 month follow-up. Of 225 referrals,
55 fulfilled the inclusion criteria. After baseline, 9 dropped out before therapy
and a further 3 became seriously ill and 3 dropped out by the 4th therapy session.
Thirty nine patients were available for 3 and 6 month follow up and 40 for
12 month follow-up. 51% of patients had Panic Disorder and 19% had GAD. The
primary outcome measures concerned Global anxiety and included three self-report
questionnaires (the Beck Anxiety Inventory, The Spielberg, State Trait Anxiety
Inventory, Trait version and a 20 item measure of anxiety). The Hamilton Anxiety
Rating Scale was also used. Depressive Symptomatology was measured but is not
reported here. The study design did not employ an intention to treat analysis.
Results were tested for skewness and parametric and nonparametric tests were
applied as appropriate. ANCOVAs were performed using pretreatment scores as
the covariate. There was no significant difference between groups on treatment
credibility. CBT had a significantly better outcome than the SC group on the
BAI (F(1,42)=5.29, p<.05 and the Geriatric Depression Scale. There was a
significant improvement within treatment on all measures apart from depression
which did not improve. On all the measures, CBT, showed a significantly better
outcome than the SC group with CBT also demonstrating a significant time by
treatment interaction (F(3, 105)=2.39, p<.08).
To assess clinical significance, 2 measures of treatment response or magnitude
of change were
taken as being meaningful. This with endstate functioning being within the
normal range. The
20% reduction was found to be a meaningful cut-off in earlier documented research
(Stanley et al 1997).
Seventy one per cent of CBT and 39% of SC patients met the criteria for responders
for anxiety at 12 month follow-up. More patients in the CBT group showed clinically
significant response (?2 (1, N=40) = 3.88 P<0.05). There was no significant
difference between groups in proportion of responders on depression symptoms.
Neither was there any significant differences in endstate functioning between
groups on either anxiety or depression. 41% of the CBT and 26% of the SC group
had high endstate functioning at 12 month follow-up. The authors state that
results from this study show that CBT treatment may be effective when delivered
in a format of a mean of 10 sessions with a primary emphasis on cognitive techniques.
David Smail
Nottingham March 2006
Unpublished Talks
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