Philosophy for Life - official website of author Jules Evans -]]>
Talking to him, I was struck, paradoxically, by the power of ideas and beliefs to alter people’s lives, and to harm them. This smart young chap – call him Eric – happened to go to university now, in the high point of Scientistic Materialism, which meant he happened to have read Sam Harris, and to accept the hardcore materialist line that free will is an illusion. He accepted that idea, absorbed it into his organism, and it led to real-world consequences for him – he now can’t do an MA in anthropology, as he planned, and is stuck in something of an existential crisis.
Eric might say to me that what his situation really proves is that he had no choice. As I’ve just said, he happened to be at university during the high-point of Scientistic Materialism, he happened to be exposed to Sam Harris, and hence this situation. Yet I – like the good Stoic I am – would say that he did have a choice, whether to accept the hardcore materialist theory or not. He swallowed it, then he chose to act on it. And here’s where he ended up.
Nonetheless, his story does illustrate the power of culture – by which I mean the amniotic fluid of ideas that we find ourselves absorbing and feeding off. We may have some choice what we believe, but our range of choice is limited by the ideas we find in our culture at any one moment. And that is what worries me about the popularity of hardcore materialism in our culture – I think the theory that we have no free will is a toxic idea, which has serious real world implications for those unfortunate enough to swallow it, because it attacks and dissolves their sense of meaning, purpose and autonomy.
I don’t think the main battle line in our culture is between theists and atheists. The main dividing line, for me, is between those who believe in free will, and those who don’t. It’s between those who think we can use our conscious reason – however weak it is – to choose new beliefs and new directions in our life; and those who think we are entirely automatic machines, without the capacity to choose.
Hardcore materialists insist we don’t have free will, we don’t have the capacity to choose a path in life, because free will seems too ‘spooky’ and doesn’t fit with their strict material determinism. Where I see a universe brimming with consciousness, they see just a mass of matter, like a vast rubbish dump, a tiny portion of which suffers from the delusion of choice.
I think this is bad science, ignoring our everyday experience of being conscious and making choices. It’s bad psychology, ignoring humans’ capacity to change themselves and get out of even chronic problems like alcoholism or depression (without medication…not that there’s anything wrong with medication). And it’s bad ethics, because it empties our lives of meaning and autonomy, and leads to people like Eric wondering what’s the point of doing anything.
The hardcore materialist position also leads to the rise and rise of pharmaceutical solutions to life’s problems – people think their emotions have no meaning or connection to their own beliefs and choices, they are simply malfunctioning machines, so the only solution is to put chemicals into the machine (despite the fact that 90% or so of the effect of anti-depressants is placebo, ie it comes from our own beliefs and expectations).
This is not strictly an argument against atheism, only one variant of it. It’s also an argument against a particular variant of religion. There are religious believers who seem to have little or no belief in free will or our power to make conscious, reasonable choices in our life. We are entirely at the mercy of God’s will, and our only option is to beg God to intervene in our lives.
In Christianity, for example, there is a strong tradition going back through Calvinism and Augustine all the way to St Paul, which suggests humans have no real choice or control over whether they are ‘saved’ or not. It’s all down to God’s choice, and that choice was made before we were born.
This is why ecstatic experiences for, say, Methodists were quite so ecstatic – they felt the Holy Spirit and thought I’m saved! God had chosen me! I’m not going to Hell for eternity! Thank fuck for that! It’s like suddenly winning the lottery for eternity. As for the other 90% of humanity who aren’t chosen by God, well, sucks to be you, we’re off to Vegas, I mean, heaven!
The hardcore Calvinist belief in predestination isn’t that ubiquitous anymore, thankfully, but I still meet a lot of charismatic Christians who seem to think God has complete control over their life and they should surrender their own reason and choices entirely to God and wait for His directions. God will reveal what to do. God will show the way. God? Hello? God?!?
This also seems to me a bit of a recipe for feeling helpless and morose. The Stoic in me feels like saying, look mate, God has given you reason, and the capacity to choose your own path in life. Stop waiting for the Divine Hand to pick you out of the gutter and instead try to change those parts of your self and your life that you can (while also praying to God for help in that process).
That might sound a bit DIY – the self-help myth of the self-made man, pulling themselves up by their bootstraps. I recognize the limits of that myth. I recognize that most of my decisions are automatic, unconscious, and determined by the past and the culture I happen to be floating in, and it’s the same for others too. We don’t choose to be destructive bastards, it just sort of happens. More positively, I also recognize that there are moments of grace, moments where something beyond our rational consciousness picks us up and carries us. I am fascinated by such moments, and have been hugely helped by them in my own life.
But we can’t rely entirely on such rare moments of grace to guide us every day of our life. At least, I don’t think you can (maybe that makes me a bad Christian or a Pelagian heretic). I think part of the meaning and value of our lives comes from using our God-given free will and discernment to try and make wise decisions and to try to come closer to the reality of God. Of course, we can sometimes choose to surrender, just as the Stoics choose to surrender their external lives to the Logos. Such surrender is still, paradoxically, a choice.
You may not believe in God or the immortality of the soul. You may not believe our free will is God-given or that the proper end of it is to return to God. Still, if you believe in trying to liberate beings from suffering, and you believe we can use our reason and free will in the effort to do that, then I am on broadly on the same side as you (although of course we have some big differences). If, on the other hand, you think we have no free will and no choice, if you either think we’re entirely automatic machines or are completely at the mercy of God’s will, then to me those are two sides of the same toxic fatalism.
In other news:
The Harvard philosopher Roberto Unger is in London. I’ve only recently (as in…this morning) read some of his ideas. Interesting stuff – reminds me of continental philosophy like Heidegger or Badiou but the mysticism is not too pretentious and is democratic as opposed to Maoist. Read this lecture, the inspiration for his upcoming book ‘The Religion of the Future’.
Leading neuroscientist Christoph Koch explains why he believes in panpsychism – which for him means the theory that consciousness is the product of highly integrated systems, and therefore the potential for consciousness is in all matter (so the internet could become conscious, for example).
My friends at Aeon have launched Aeon Films, showcasing short, beautiful films like this one about the last days of Philip Gould, which rather undid me.
Also from Aeon, cognitive scientist of religion Jesse Bering discusses the $5 million ‘Immortality Project‘, which tries to find empirical evidence both for immortality, and our belief in immortality.
This week I spoke at a well-being at work conference to lots of Human Resources people. Weird! But interesting too – with talks from Paul Farmer of MIND about overcoming the stigma of mental illness at work; a presentation from an online CBT company called Big White Wall,and an inspiring talk by the Free Help Guy, who for six months decided to offer free anonymous help for whatever people suggested, via GumTree. This week, another anonymous person gave him £100,000 to carry on his work!
Here’s a TEDX talk I did! If you’ve seen me talk about Philosophy for Life, you’ll have heard it before. Would be great if people shared, retweeted etc.
Philosophy for Life needs all the help it can get in the US, where the publishers are struggling to get any publicity for it. Even a review on Amazon.com would help, if you feel like it.
The Nation lays into a swathe of new happiness books, declaring them ‘neoliberal’, and suggesting we should really find happiness via Keynesian economics. Which to me is another form of toxic fatalism – the only solution to our emotional problems is collectivist economics. Keynesian institutional reforms might be some of the answer but it’s not all of it – we can also take care of our own souls (and help others learn how to do that).
Finally, this week’s Start the Week had Sir John Tavener, Jeanette Winterson, and the head of All Souls College discussing prayer, faith and culture in a post-religious age. I felt like Andrew Marr was seeking to explore how his stroke had changed him and made him more interested in the life of the spirit…but there was a nervousness about doing that on primetime BBC. Interesting though, and poignant, as Tavener died the following day.
That’s all. Next week I’m in Durham doing various talks, including one on ecstatic experiences at the Centre for the Medical Humanities on Wednesday the 20th. I’m also doing a talk at St Cuths on the 19th, at 4pm.
Oh, and thanks to the platinum members who contributed to the blog! Your names will echo for eternity! If you want to donate £10 or more for your annual enjoyment of the blog (it costs $30 a month to run the newsletter, not including my own time, so it’s very much a loss-making venture!), click on the link below.
Philosophy for Life - official website of author Jules Evans -]]>
Philosophy for Life - official website of author Jules Evans -]]>
This is a consequence of the splitting off of psychology from philosophy at the beginning of the 20th century. Philosophy lost touch with the central and immensely practical question of how to live well, and that ethical vacuum was filled by psychology, and even more by pharmacology.
Ironically, the most evidence-based talking therapy – Cognitive Behavioural Therapy – was directly inspired by ancient Greek philosophy, and uses many of its ideas and techniques. CBT picked up the baton which modern philosophy dropped, of trying to help ordinary people live happier lives. But it lacks the ethics, values and meaning dimension that ancient philosophy had.
Philosophy and psychology need each other. Philosophy without psychology is a brain in a vat, artificially cut off from emotions and actions and the habits of life. Psychology without ethics is a chicken without a head, focused entirely on evidence without any clear sense of the goal. Practical philosophy is a bridge between the evidence-based techniques of psychology, and the Socratic questioning of philosophy.
I wish that, when I was suffering from social anxiety and depression at school, someone had told me about Stoic philosophy, and explained their idea that my emotions are connected to my beliefs and attitudes, and we can transform our feelings by changing our beliefs. They might also have explained how CBT picked up the Stoics’ ideas and tested them out. Instead I had to find all this out for myself, and it took me several rather unhappy years. When I did finally come across ancient philosophy, it helped me enormously.
And I’m not alone in this. John Lloyd, the creator of Blackadder and QI, was a very bright boy at school, but never learned to reflect on the good life or how his thoughts create his subjective reality. He had to learn that himself, coming to philosophy after a five-year breakdown in his thirties. He now says: ‘I think every child should learn Stoic philosophy.’ Making Stoicism part of the national curriculum is quite a big ask. But wouldn’t it be great if there was at least some practical philosophy, some indication that philosophy can practically improve students’ lives?
Eight Key Ideas To Get Across
Stoicism for Everyday Life is a project bringing together philosophers, psychotherapists and classicists, who are fascinated by the links between Stoic philosophy and Cognitive Behavioural Therapy, and committed to raising public awareness of Stoicism as a life-improving resource. We’re organising Live Like A Stoic Week (Nov 25 – Dec 1), and trying to get people involved in Stoic events all over the world. We’re preparing a handbook for Stoic Week, with a different Stoic idea and exercise for every day, and we’re inviting people to follow the Handbook for the week, then reporting back to us via a brief questionnaire. It will be released in November.
We’d love it if students at schools and universities got involved too. Last year, several schools around the world got involved for the Week, and some undergrads posted YouTube videos describing how they found the practical exercises. If you’re a teacher, and you want to do a class or philosophy club on Stoicism, here are eight key ideas that, speaking personally, I wish I’d come across at school:
1) It’s not events that cause us suffering, but our opinion about events.
People often think ‘Stoic’ means ‘suppressing your emotions behind a stiff upper lip’. This is not what ancient Stoicism meant. The Stoics thought we could transform emotions by understanding how they’re connected to our beliefs and attitudes. The quote above, from the philosopher Epictetus, is so powerful and useful – and it was the main inspiration for CBT. Often what causes us suffering is not a particular adverse event, but our opinion about it. We can make a difficult situation much worse by the attitude we bring to it. This doesn’t mean relentlessly ‘thinking positively’ – it simply means being more mindful of how our attitudes and beliefs create our emotional reality. We don’t realise that often we are the ones causing ourselves suffering through our thoughts. Have you noticed how people react very differently to exactly the same event, how some sink rapidly into despondency while others shrug it off? Perhaps we can learn to be more resilient and intelligent in how we react to events.
2) Our opinions are often unconscious, but we can bring them to consciousness by asking ourselves questions
Socrates said we sleepwalk through life, unaware of how we live and never asking ourselves if our opinions about life are correct or wise. CBT, likewise, suggests we have many cognitive biases – many of our deepest beliefs about ourselves and the world might be destructive and wrong. Yet we assume automatically they’re true. The way to bring unconscious beliefs into consciousness is simply to ask yourself questions. Why am I feeling this strong emotional reaction? What interpretation or belief is leading to it? Is that belief definitely true? Where is the evidence for it? We can get into the practice of asking ourselves questions and examining our automatic interpretations. The Stoics used journals to keep track of their automatic responses and to examine them. CBT uses a similar technique. Maybe your students could keep a Stoic journal for a week.
3) We can’t control everything that happens to us, but we can control how we react
This is another very simple and powerful idea from the Stoics, best presented by Epictetus, the slave-philosopher, who divided all human experience into two domains: things we control, things we don’t. We don’t control other people, the weather, the economy, our bodies and health, our reputation, or things in the past and future. We can influence these things, but not entirely control them. The only thing we have complete control over is our beliefs – if we choose to exercise this control. But we often try to exert complete control over something external, and then feel insecure and angry when we fail. Or we fail to take responsibility for our own thoughts and beliefs, and use the outside world as an alibi. Focusing on what you control is a powerful way to reduce anxiety and assert autonomy in chaotic situations – you could use the stories of Rhonda Cornum, Viktor Frankel, James Stockdale or Sam Sullivan to illustrate this idea – they all faced profound adversity but managed to find a sense of autonomy in their response to it. The Serenity Prayer is also a nice encapsulation of this idea.
4) Choosing your perspective wisely
Every moment of the day, we can choose the perspective we take on life, like a film-director choosing the angle of a shot. What are you going to focus on? What’s your angle on life?
A lot of the wisdom of Stoicism comes down to choosing your perspective wisely. One of the exercises the Stoics practiced was called the View From Above – if you’re feeling stressed by some niggling annoyances, project your imagination into space and imagine the vastness of the universe. From that cosmic perspective, the annoyance doesn’t seem that important anymore – you’ve made a molehill out of a mountain. Watch this video interview with the astronaut Edgar Mitchell about ‘seeing the Big Picture’. Another technique the Stoics used (along with Buddhists and Epicureans) was bringing their attention back to the present moment, if they felt they were worrying too much about the future or ruminating over the past. Seneca told a friend: ‘What’s the point of dragging up sufferings that are over, of being miserable now because you were miserable then?’
5) The power of habits
One thing the Stoics got, which a lot of modern philosophy (and Religious Studies) misses with its focus on theory, is the importance of practice, training, repetition and, in a word, habits. It doesn’t matter what theory you profess in the classroom if you don’t embody it in your habits of thinking and acting. Because we’re such forgetful creatures, we need to repeat ideas over and over until they become ingrained habits. It might be useful to talk about the Stoic technique of the maxim, how they’d encapsulate their ideas into brief memorisable phrases or proverbs (like ‘Everything in moderation’ or ‘The best revenge is not to be like that’), which they would repeat to themselves when needed. Stoics also carried around little handbooks with some of their favourite maxims in. What sayings do you find inspirational? Where could you put them up to remind yourself of them throughout the day?
Another thing the Stoics got, which modern philosophy often misses, is the idea of fieldwork. One of my favourite quotes from Epictetus is: ‘We might be fluent in the classroom but drag us out into practice and we’re miserably shipwrecked’. Philosophy can’t just be theory, it can’t just be talk, it also has to be askesis, or practice. If you’re trying to improve your temper, practice not losing it. If you’re trying to rely less on comfort eating, practice eating less junk food. Seneca said: ‘The Stoic sees all adversity as training’. I love the bit in Fight Club where students from Tyler Durden’s school get sent out to do homework in the streets (even if the homework is a little, er, inappropriate, like intentionally losing a fight). Imagine if philosophy also gave us street homework, tailor-made for the habits we’re trying to weaken or strengthen, like practicing asking a girl out, or practicing not gossiping about friends, or practicing being kind to someone every day. Imagine if people didn’t think philosophy was ‘just talking’. Diogenes the Cynic took askesis to the extreme of living in a barrel to prove how little we need to be happy – students tend to like stories about him.
7) Virtue is sufficient for happiness
All the previous main points are quite instrumental and value-neutral – that’s why CBT has taken them up and turned them into a scientific therapy. But Stoicism wasn’t just a feel-good therapy, it was an ethics, with a specific definition of the good life: the aim of life for Stoics was living in accordance with virtue. They believed if you found the good life not in externals like wealth or power but in doing the right thing, then you’d always be happy, because doing the right thing is always in your power and never subject to the whims of fortune. A demanding philosophy, and yet also in some ways true – doing the right thing is always in our power. So what are we worried about?
At this point your students might want to consider what they thing is good or bad about this particular definition of the good life. Is it too focused on the inner life? Are there external things we also think are necessary for the good life, such as friends or a free society? Can we live a good life even in those moments when we’re not free, or we don’t have many friends? What do your students think are the most important goods in life?
8) Our ethical obligations to our community
The Stoics pioneered the theory of cosmopolitanism – the idea that we have ethical obligations not just to our friends and family, but to our wider community, and even to the community of humanity. Sometimes our obligations might clash – between our friends and our country, or between our government and our conscience (for example, would we resist the Nazis if we grew up in 1930s Germany?) Do we really have moral obligations to people on the other side of the world? What about other species, or future generations? A useful exercise here, as Martha Nussbaum has suggested, is the Stoic exercise of the ‘widening circles’, imagining all the different wider communities that we’re a part of.
Those are just some ideas I’ve found useful, and which I’ve found people of all ages respond to in workshops (including teenagers). Feel free to suggest other things I’ve missed out in the comments. If you’re a student or teacher who wants to take part in Stoic Week, or who wants to help get more practical philosophy into schools, get in touch.
In other news this week:
This week I got to take part in a fascinating workshop on spirituality, part of Jonathan Rowson’s spirituality project there. One of the participants was Pippa Evans of the Sunday Assembly – the ‘atheist church’ who are in the process of trying to crowd-fund £500,000 to help launch other Sunday Assemblies around the world.
Another cool initiative: Unbound, the crowd-funded publisher set up by John Mitchinson (the other brain behind QI), has raised £1.2 million to expand.
Scary article: Vice magazine on how hackers hack into people’s computer-cameras, video then when they’re…er…indisposed and then blackmail them!
Everyone’s discussing Russell Brand’s call for revolution in the New Statesman. Persuaded? Sounds incredibly half-baked to me, although the problems he addresses are real enough. And I like his support for meditation. I just find his attack on democracy a bit depressing.
Next week I get to be on a panel with Sir Gus O’Donnell! GOD himself. That’s at the launch of the Legatum Institute’s Prosperity Index. Here’s an article he wrote on improving government, including how to use well-being data more successfully. Talking of which, the ONS published the latest happiness data, showing not much change, and no one paid much attention.
Two philosophers (Jerry Coyne and Eric MacDonald) got in a bun-fight about whether materialism precludes free will, and what it all means for the appreciation of poetry. I think MacDonald has a point – most poets believe in the Platonic theory of the arts (the idea that the best artists get their inspiration from spirits / God) – so materialism is anti-poetry (though for different reasons than he argues).
Tomorrow I’m off to Gateshead for the Radio 3 Free Thinking Festival, where the theme is ‘Who’s In Control?’ and I’m talking a talk on ecstatic experiences. Looking forward to it.
Have a good weekend – oh, and if you enjoy the blog, I’d welcome donations – it takes up a day a week, and costs me to run the site and newsletter, so if readers could give £1 a month or £10 a year, that’d be great! Alternately, if you want to advertise your company or product and think there’s a good match with my blog, get in touch.
Philosophy for Life - official website of author Jules Evans -]]>
Philosophy for Life - official website of author Jules Evans -]]>
Dumfries is a a squat concrete slab, circled with barbed wire and slits for windows. I was dropped off, buzzed in, and told to leave my bag, wallet, mobile and any valuables at the reception. Then the head of prison education came to meet me, he seemed a nice sort. I followed him through a locked door. And another. And another. He unlocked and then locked about ten doors in the space of 20 metres as we sank into the bowels of the building.
And then, abruptly, I was in a small room with some paintings and drawings on the walls. Inside were about ten men, all wearing orange and brown prison clothes. They were mainly white, English and Scottish, from their early 20s to 50s, with two youngish Pakistanis sitting together at the back, and a black guy with dreads on the right. I said hello, introduced myself, and they all did too. Then I launched into it, about how philosophy had helped me through depression, how it had inspired Albert Ellis to invent cognitive therapy, the Stoics’ idea that our emotions come from our beliefs or perspectives.
I asked, as I often do in these talks, for someone to suggest a moment recently that had upset them, so we could consider what beliefs or perspectives had led to the upset. Complete silence. Maybe it’s not something you admit publicly in prison – what gets to you. So one of the teachers jumped in and talked about how her brother wound her up.
Then I got onto the idea of focusing on what you can control rather than what you can’t. I told the story of Rhonda Cornum, how she had used Stoic techniques to cope with being a prisoner-of-war. ‘When you’re a prisoner, your guards control everything about your life, everything external anyway, except your thoughts and beliefs.’ That got their attention. Stoicism, after all, is very much a philosophy of finding inner freedom in external imprisonment – that’s why it’s inspired various inmates, from James Stockdale to Nelson Mandela.
By the end of the workshop, the front five people were sitting forward and engaged, and I’d got about half of the back row into it too, with two people apparently completely unphased by it all. It emerged that four of them had read my book, and they brought me copies to sign. The black guy told me he’d been about to begin a philosophy degree when he got arrested. He said to me, ‘I like what you’re doing, taking philosophy outside of academia’. I replied ‘if you can practice philosophy when life gives you a serious set-back, and you manage to cope, then you’re practicing at a much higher level than an academic writing in a journal’. I signed his book and wrote ‘Keep going’ in it.
We all shook hands. I was genuinely moved that ancient philosophy seemed to resonate in here, perhaps even more than in academia. I thanked them all for their contribution. ‘Well’, said one old fella, ‘you had a captive audience’. The rest of the class groaned – clearly an old joke. They asked what philosophy book I’d recommend for the library. I thought about suggesting Gramsci’s Prison Notebooks, but decided on Boethius’ Consolations of Philosophy, written while he was on death-row for a false accusation of treason.
Afterwards, I met Nikki Cameron, a teacher in Low Moss prison, near Glasgow. She’s set up a philosophy club in the prison, and she says it’s been hugely popular – it’s running every week now, twice on Fridays, and they get ten or so people sitting round discussing everything from happiness to nothingness to the nature of evil.
Her boss at Motherwell College (which runs further education courses in western Scottish prisons) had given her a copy of my book, and she was excited about the possibility of developing a course on ‘living the good life’, which teaches some CBT self-management tips within more ethical and reflective context of philosophy. ‘Inmates are often conspiracy theorists, and they’re very wary of anything that sounds like a behaviour-change programme’, she says. ‘But philosophy piques their interest and gets them thinking and asking questions.’
Nikki didn’t know of any other philosophy clubs in British prisons. Nor did I, but apparently there is at least one – Alan Smith has been teaching a philosophy class in prisons for 12 years, and has actually just brought out a book about it, called Her Majesty’s Prisoners. The Reader Organisation has also run reading groups in prisons, similar to the Changing Lives Through Literature programme in Texas. There is also something called The Epictetus Club run by Jeff Traylor in the Ohio Penitentiary. I know AA Long has taught classes on Stoic philosophy in San Quentin prison too (in many ways, he’s the Johnny Cash of Hellenistic ethics).
I asked if the Alpha course ran in Dumfries and Low Moss. Carol, one of the teachers at Dumfries, said: ‘Religion is often quite divisive in Scottish prisons. The first question people get asked is, ‘which football club do you support?’, which really means, ‘are you Protestant or Catholic?’ And your answer will decide whether they think of you as one of them or as the enemy. ‘It’s incredibly tribal in here’, Nikki adds. ‘That’s why philosophy brings something new – it gets people thinking for themselves, not just governed by tribal loyalties.’
Religious prison-courses have one advantage, however, which is that they can perhaps offer a form of community to inmates when they go back outside. Carol says: ‘We see a lot of people re-offending in November, so they can be inside over Christmas. This used to surprise me, and I once said ‘what could be worse than being in prison over Christmas?’ An inmate said to me, quick as a flash, ‘there are a lot worse places to be over Christmas than prison, like sitting on your own in a bed-sit.’
For some people, it seems, prison is the closest thing they have to a caring community, and it can be a less chaotic, dangerous and lonely place than the outside world. Could philosophy provide community for them? Perhaps prisons could link up with recovery colleges and other community charities, so that inmates have somewhere to go, socialise, feel listened to, and feed their minds. Perhaps universities could also link up to such colleges, so that there is a steady stream of volunteers prepared to share their knowledge.
I also wondered if philosophy / CBT helps with the really deep stuff, of helping people cope with their guilt or their sense of being unlovable. ‘I think it can’, said Nikki. ‘CBT teaches us that guilt is a destructive habit of thinking.’ But is it always? What if you’ve done something really bad?
I asked what sort of a prison Dumfries is, assuming it was a low-security prison for short sentences. ‘No, it’s a high security prison’, I was told. ‘The class was basically made up of [people who had committed serious crimes, I'm not allowed to tell you what]. They’re people that couldn’t safely be allowed in with the other prisoners.’
This was quite a shock to me. I’d shaken all their hands, even written ‘keep going’ in the front of one of their copies of my book. They had done that? And they were all deeply in denial, keeping the memories of their crimes locked up in the back of their mind, just as the abused often bury their memories out of their consciousness. Could philosophy really help people to confront what they had done? Could it shift their psyches at such a profound level?
And why should we help people who’d done something so awful, so damaging to other people’s lives? It’s not an easy question. I think one can do it for various reasons. One can do it because it seems a bit racy, a philosophy class in prison, with violent criminals, wow! I imagine that wears thin fairly quickly. One can do it because you believe philosophy can change people, even people with deeply-ingrained habits of destructive behaviour. Maybe.
Or you can do it because you believe they have souls too, that it’s worth a shot, and sometimes God can speak to people even through layers and layers of denial, abuse, addiction and sin, and liberate them. Is that possible? Or just another self-serving delusion?
I’m completely new to the whole prison education thing, and I’m sure some of you have a lot more experience, so feel free to share your stories and ideas in the comments.
In other news:
Two pieces in the Guardian about sex trafficking really hit me this week – this one by a lady who was sold into sex slavery by her parents, who now campaigns to help the victims of sex trafficking; and this one, about the Mumbai sex slave economy.
This interesting neuroscience study suggests it has found neural correlates for unconscious thinking.
One of my non-fiction heroes interviewed another this week – Jon Ronson did a profile of Malcolm Gladwell on the Culture Show to discuss his new book, David and Goliath. Fascinating stuff. Ronson also has a story on this week’s episode of This American Life. I’m in awe of his work ethic and how he makes it all seem so shambling and relaxed…like Boris Johnson!
While Ronson and Gladwell have helped to create a golden age of non-fiction, it’s worth remembering what fiction can do for us – according to this study in Science, it improves our empathy and social intelligence, by leaving more up to our imagination. That’s the danger of our increasingly unimaginative and fact-based era.
OFSTED slammed English schools for how badly they teach Religious Education (and PSHE, and basically anything to do with ethics).Teachers don’t get much training in how to teach it. We don’t know how to teach ethics in our schools. This is a serious problem!
One possible approach – teach some practical ethics and wisdom, rather than focusing entirely on theory. Give young people some ideas they can take away and use in their life – like Stoic philosophy! That’s what John Lloyd, the creator of shows including Blackadder and QI, suggests in this interview I did with him, where he talks about how Stoicism (and other philosophies) helped him through five years of depression.
Jonathan Rowson of the RSA discusses the usefulness of the term ‘spirituality’ in this blogpost. I’ve started talking about ‘spiritual experiences’ in some of my talks, and asking the audience if they’ve ever had any. Lots of them have, it turns out – it’s really a hidden world out of there of profound spiritual experiences that people are having, often outside of traditional religious structures. One sane-looking man, at a small talk I gave in Wigtown last week, told us ‘I often have out-of-body experiences, and am increasingly able to steer them’. Crikey! Honestly, once you start asking about these things, in an open-minded way, you hear some amazing stories.
Some upcoming events: I’m talking in Epsom library tomorrow evening, and on Saturday afternoon the Philosophical Society of England has a free event on Albert Camus at Conway Hall in London. And my book is coming out next week in America, without any apparent publicity campaign. Here’s the US edition on Amazon.com. Some kind souls have given it some reviews – thanks for that.
Finally, I really recommend you go see an exhibition at Nottingham University, called Art in the Asylum. It has an amazing collection of outsider art from asylums including Kingsley Hall, Lausanne and Dumfries, including this remarkable drawing by William Bartholomew, an inmate at Dumfries asylum. See you next week, Jules
Philosophy for Life - official website of author Jules Evans -]]>
Philosophy for Life - official website of author Jules Evans -]]>
How did IAPT come about?
I think the first thing is NICE in 2004 starting publishing guidelines on the treatment of different mental health problems, and pointing out that for anxiety and depression there was good evidence for some therapies being effective. And then a number of people noted that the British public wasn’t getting much access to these treatments. Richard Layard and I met at around that time. And we formed a partnership to try and put forward an argument, based on the fact that most people weren’t getting access to the NICE-recommended evidence-based psychological therapies, and that if they did get access to them, and they were properly implemented, then this would be a programme that would not only provide people with treatments that were helpful, but it would also be economically viable. Richard’s ability to put a cost-effectiveness to the argument was very helpful.
How did you and Richard Layard meet?
Completely by chance. We were both being elected fellows of the British Academy one day. We were standing next to each other having a cup of tea, and we introduced ourselves. Richard explained he was an economist but writing a book on happiness, and was writing a chapter on mental health, and did I know anything about mental health, and I said, well, I’ve spent most of my life developing psychological treatments, so we had a lot to talk about.
We put together a paper which went to the government, an internal briefing paper, laying out the case for what became IAPT. The Cabinet Office organised the seminar. Richard laid out the broad case and I had to cover the evidence base for psychological therapies. That, alongside other arguments at the time, led to the 2005 Labour election manifesto commitment to increasing access to NICE-recommended psychological treatments.
To what extent was IAPT a step forward?
The exact way IAPT framed came about from lots of discussion after the election between lots of people. The Department of Health set up an expert reference group to map it out. But it has a lot of pretty radical elements to it. The first is the very high level of outcome monitoring. Prior to IAPT, I dont think there was a single service anywhere in the country, where you could go long, if you were suffering from anxiety or depression, and say ‘if I go to you, what’s my chance of recovery?’
There were quite a lot of services that were doing their best to collect outcome data, but they might give a questionnaire at the beginning of the treatment, and then maybe at the end, but there would be a lot of variability on when people ended their treatment, so there was a lot of missing data. On average, those services trying to monitor outcomes would get data on 30% of their patients. IAPT has changed that by adopting a session-by-session monitoring system, so that if someone finishes therapy a bit earlier than you anticipated, you still have data on how they’ve done, up to that session.
That was based on something we developed in Northern Ireland, following the Omagh bomb in 1998. They set up a walk-in community service, and of course you didn’t know if people would be coming for lots of sessions or not, so we developed a system for measuring outcomes each time. That turned out to be very helpful because it meant we could show the Northern Ireland office the results of the first 100 or so people that we saw. And they did very well. They improved as much as in randomised controlled trials in universities, although this was a community service that helped everyone. That led to the government of the day funding a treatment centre called the Northern Ireland Centre for Trauma and Transformation, which then made these treatments available to victims of other terrorist attacks.
So we built on that, and thought we should be able to adopt the same principles, and get data on most people. That has been really crucial in several ways. The first is, it allows for continued political support in the programme, because the government knows what it is getting for its money. Prior to that we didn’t really know. You might reduce waiting lists but we didn’t know: are people getting better, and are more people getting better? Now we know.
It also has produced extraordinary transparency in mental health. We’ve been very keen that the results are published every quarter – the outcome data from every IAPT service in the country. This sort of information has never been available to users of mental health services. And I think going forward it’s likely to be a real driver for quality improvements, because it allows services to bench-mark themselves against other services. There is variability of course, but once you know about it, you can ask, how do we move the services that are not doing so well closer to those that are – just as Bruce Keogh did for cardio-vascular surgery.
I see this as one of the big achievements. There were a lot of professionals who were against this sort of outcome-monitoring. They thought it was too much of a hassle for patients, and maybe they wouldn’t like it. But our experience has been, that actually patients really love it, and they find it really helpful.
To what extent was IAPT an expansion of services?
The obvious problem was we didn’t have enough therapists. So the heart of the programme was training new therapists in evidence-based therapies. Then the big decision point was, obviously you can only train people at a certain rate. Train some people one year and another cohort the next year. Should we take the first year of trainees and distribute them in small numbers to existing services? In which case there’s a good chance they’ll just get lost in the system. Or should we try and create a small number of new services more or less at full capacity, and get them to open their doors and properly function. We decided that’s the way we’ll go, because the training is more rigorous in terms of following evidence-based protocol, everyone in the services would do outcome monitoring, and not everyone in routine services was doing that. And we needed for everyone to have good supervision in the services. So we thought we’d create new services, small numbers in the first year, and then spread them around.
Why do you think there was the political will suddenly to substantially increase government resources into mental health services?
The economic argument was very influential. We argued that the programme would largely pay for itself. When people are less depressed and anxious they’re more productive at work. They’re more likely to get into work. They also cost the NHS quite a lot less in terms of unnecessary physical investigations. So someone with panic disorder will get lots of physical investigations, they worry about their heart or whatever. I think the government was persuaded by the argument that this is really an invest to save programme, it’s not a costing. It’s also having the benefit that a lot of people are getting better. That was the argument that worked. It probably wouldn’t have got off the ground if it wasn’t a coalition between three different groups: obviously academic clinicians like myself, who are arguing that these are effective treatments which people should be able to access; secondly the economists, above all Richard Layard; and then many voluntary sector groups like MIND and Re:Think, who were very aware that lots of patients were complaining that all they got was drugs, and a lot of them would like psychological therapy.
Five years on, how successful has IAPT been?
Nationally, it’s more or less on track. We had targets for the number of people seen and the clinical outcomes at this stage. And we’re more or less on those targets. We’ve now got an outcome monitoring system in place. And commissioners are realising that you commission services for whether or not they get better, rather than just waiting lists. That has changed the way commissioners think of mental health, and that will have an enduring impact not just on IAPT but throughout mental health.
But we’re not finished, in terms of the number of people who are meant to be seen. We’re aiming for 15% of those with depression and anxiety, and we’re operating at 10% at the moment, so there’s a big step up to be done there. We’ve only got about two thirds of the people trained so far. The other thing is this is all happening in the context of reforms and changes to the health service. And some of those changes slow things down, because people who might be commissioning a service are different from one week to the next. So there’s a lot of uncertainty.
And the data that’s publicly reported at the moment is fairly simplistic – it’s just some index about whether people have dropped below some clinical cut-off for recovery. We collect much more sophisticated information about how much people have improved, across a lot of different domains, and also what sort of people they are, ethnic groups, disabilities and things. We want to make all of that information available, which will happen soon. When that happens, people will discover lots of things they would like to improve. I suspect some services are much better than others at giving different parts of the community access to the services. And also with a more detailed data we’ll get a much better idea of who benefits and who doesn’t. And that information all needs to be fed back into the services. I see the service as a continued improvement initiative. They’re up and running, but there’s a lot more that needs to be done.
Does the data show the recovery rates of different disorders?
It will do, in about three months time. Up until recently, we’ve relied on the commissioners of the services sending headline figures – the number of people recovered, the number of people seen. But about eight months ago, we shifted to a system where individual patient level information goes to the NHS information centre. It becomes anonymous, but all the data – ethnicity, disability, what type of problem they had, what kind of treatment they had, how much they improved – all that flows now, nationally. In about three months time you’ll get very detailed reports. Nowhere in the world is that kind of detail available.
So the data at the moment shows recovery rates of about 40%?
The current rate is 46%.
Is that for people who complete the course of therapy?
It’s for people who’ve been seen at least twice. In psychotherapy research there was a period where people would record ‘completer analysis’, on people who had got through a full course of therapy, and rather ignore the people who dropped out, and that’s completely wrong. You don’t get a fair idea of how a service is doing unless you basically take more or less everyone, which is what you call an ‘intention to treat’. And in IAPT we say, if you’ve come along for at least two treatments, then you’ve engaged with the treatment and we should be reporting the outcome. Now a lot of the therapists might say, the course of the treatment might be eight sessions and they only came for three, they dropped out. But in our national reporting we ignore that, we still give their data. Wherever they finished is where they got to.
How reliable is the data? If patients are filling it out and handing it in to the therapist, they might not want to offend the therapist. Does that create a bias in the data?
There are risks of that sort. They probably operate at different levels. If you take the high intensity therapy – face-to-face CBT – the patient fills out the forms in the waiting room, not in front of the therapist. It’s rather like what you do in a randomised controlled trial. And we know, there’s a large literature from those trials, when people fill in measures that way, but they’re also seen by an independent assessor, who doesn’t know what treatment they’ve had, and you seem to get similar results, from independent non-biased assessment as from patients’ self-reported assessment collected that way. So I feel reasonably confident that the self-report data that you get from traditional high intensity therapy is pretty valid.
But we also have low intensity work, where people are having guided self-help, and quite a lot of that is done on the phone. And at the moment the therapist asks the outcome measurement questions on the phone and the patient answers. It seems to me there is more potential for a demand effect there. And it’s not an ideal situation. We should be moving to a more automated situation which goes automatically into the IT system. It also frees up more therapy time.
To what extent are referrals and applications for therapy going up?
It’s continuing to increase. A key feature for IAPT, another revolution I suppose, is self-referral. When the NHS was created in the 1940s, everyone was concerned about the cost. And so partly for that reason, we created a universal GP system. So the GP is the gate-keeper for the costs, so you don’t normally get specialist treatment unless your GP refers you. That was certainly true of specialist treatments for anxiety and depression.
But when we did two pilot projects for IAPT, in Newham and Doncaster, we discussed with the Department of Health that it’s possible in mental health that the GP referral only system is excluding systematically people that really need help. That could be for reasons of stigma, they may be unhappy about talking to their GP about the problem, if they know the GP isn’t going to do the treatment; and some groups may be more averse to coming along to primary care than others. So we asked, will you let us experiment with self-referral. And some people thought, this is a dangerous way to go, because you’ll be flooded by very mild cases who perhaps don’t need so much attention.
But what we found was really the opposite. If you compare the self-referrers and the GP-referred, the self-referrers were as severe, but tended to have the problem longer, and were more representative of the community in general. This was particularly clear in Newham, which is a very ethnically diverse borough. We found that the rate at which different ethnic groups came into the service pretty much tracked their prevalence in the community in the self-referred route, but in the GP route, people from black and ethnic groups were seriously under-represented.
Does that mean they were more likely to be prescribed chemical treatments?
It might be, we don’t know. That led Alan Johnson, when he announced the IAPT initiative, to be really radical in NHS terms, and say, this new initiative will be open to self-referral everywhere. I think that’s helped and improved fairness of access. Interestingly, if you look at the data, those people who self-refer are just as likely to recover as GP-referrals, which is good, but they recover with less therapy sessions. We think that’s probably because, if you go through the process of self-referral you might look at the website of a service, and see a description of the problems that they treat, and you think through ‘is this right for me?’. You’re almost socialised into the process when you come along.
Has IAPT had any impact on anti-depressant prescriptions?
We don’t have in the same database anti-depressant prescriptions so we don’t know. What we have looked at is people who were on anti-depressants at the start of the treatment and what happened to them, and you had more people coming off than staying on. But we don’t have a large connected up database.
What about relapse rates, can we know?
This is a weakness of the current IAPT system, and one we’d like to see changing. Most IAPT services will not do a systematic follow-up. Commissioners have been very keen that services see a large number of people and haven’t been particularly keen to pay for follow up. And I think that’s a false economy, particularly because some of the treatments like CBT provide good evidence that they provide durable effect, but they have built in to the treatments relapse prevention programmes that you do for the last couple of sessions. Really what you’d want to do is see if they’re working for everyone, and quite a lot of these relapse prevention programmes have things like, if you’re noticing a bit of a set back, look at your notes, and then ring up your therapist and come in for a booster session. At the moment only a few services do that, so as things move forward we’d like that to happen. Research-wise, in the Newham and Doncaster pilot sites, we did a nine month follow up. What we found was in Newham people were as well after nine months as they were at the end of treatment. In Doncaster, there was a small but significant drop back but they were still a lot better than when they started.
It seems that the drop out rate is quite high.
Well, if you say that people finish treatment in less time than was expected, that’s true. But that’s not what is taken into account in the outcomes. So people who dropped out are still reported in the outcomes.
But is there concern that a lot of people are just dropping out and deciding this treatment is not for them?
I don’t think so. Where the issue of uncertainty is is somewhere different. In the original model, there was the idea that some people would actually benefit a lot from having a good assessment, helping see what their problem is, and getting some sort of simpler advice, and maybe being sign-posted to somewhere else, like debt counselling for example. So they might only have one session, but it might be very satisfactory. And then there were other people where they definitely need psychological treatment, so they’d come in for regular therapy. The weakness of the system at the moment, in terms of national reporting, is we only have outcome reporting for people who come in for therapy. We have a lot of people who have this one session – it’s about 40%. There is no reporting of whether than one session was a satisfactory one or an unsatisfactory one. There might be people who have that one session, who are offered therapy and decide they don’t want it, because they don’t like this service, which is a bad outcome.
Or maybe not been offered therapy, and needed it.
Yeah. So I think it’s been a serious weakness of the reporting so far, that we just don’t know and can’t distinguish between those possibilities. We need to know exactly what happened. And it’s probably very variable between different services. The Department of Health has recently agreed a coding for these one-off sessions which would allow people to be classified as ‘reasonable outcome’ or not. Were they discharged after mutual consent with advice and sign posting, or were they offered therapy, because they thought they needed it, and they said ‘piss off, I’m not interested’. That’s what we need to get the numbers on.
OK. In IAPT, a lot of the ‘guided self-help’ work is done by PWPs (Psychological Well-Being Practitioners). I’ve spoken to some PWPs, and they express some concern that sometimes they’re seeing cases they’re not trained to handle, after a year’s training. And of course, there’s quite a lot of stress, big workload, and they didn’t always feel the promotion avenues are that open. Is that a concern?
These are all serious concerns. The PWP role is the most novel bit from a clinical viewpoint. It exists because there were a reasonable number of trials supporting guided self-help. But creating a workforce that delivers it and that operates within its capabilities, and with reasonable career progression is a completely new beast. And a lot of learning is coming out of where we have go to so far. And there’s no doubt that in services, PWPs are seeing cases that are more complicated than would be appropriate for the training they have.
In terms of career progression, it’s true there isn’t much career progression. But some services are working hard at that, in terms of creating a new position of senior PWPs, and some people going into training PWPs as well as doing senior clinical work and supervising other PWPs. But the turnover of people in PWP posts is much higher than in high intensity posts. And that raises questions about IAPT. If the turnover is high because they’re staying in IAPT but going to work in a neighbouring service which gives them a senior role rather than a junior role, that’s good. If however they are being lost to the system or they’re all doing high intensity training, then our estimate of how much that workforce costs are wrong, because we’re having to do constant training of new PWPs. Obviously the big argument for PWP work is its an economic way of providing treatment for mild to moderate cases, but if it turns out it costs twice as much as we think, because of the training costs, then that part of the argument might not hold up. One would have to re-think the whole role.
The original idea was that IAPT pays for itself. Has it done that?
If you look at the number of people who move from being unemployed to employed or part-employed, the number is in line with the projections in Richard’s analysis.
Is there a risk that CBT could become overhyped, and seen as a silver bullet by politicians?
IAPT isn’t just about CBT, it’s about implementing NICE guidence. We are actually supporting four other non-CBT therapies in IAPT, and a third of the IAPT workforce can deliver these non-CBT therapies. Interpersonal Psychotherapy, Couples Therapy, Counselling, and Behavioural Activation (though I suppose that’s also CBT), and Brief Psychodynamic Therapy. The view we’ve taken is, if NICE recommends several therapies for a condition, then patient choice should operate, because people are more likely to get better from something they’ve chosen. If NICE only recommends one treatment for a disorder, then that’s all we’ll provide in the service. The idea is the offer will change as NICE guidance changes. In depression, the offer is already beyond CBT.
Do you think there will be more choice in IAPT as we go forward?
I think so yes, for a lot of reasons. One is because as it matures we’re able to put more emphasis on training people in other therapies. The other thing is, a crucial message has gone out to the therapy community, which is: if you record outcomes and results, there’s going to be investment. They’ve never known that before. Previously, you do your best to argue with commissioners, that we need some more therapy because a lot of people are handicapped, but if you’re not presenting outcome data, commissioners have been hesitant to invest. Now we’ve seen that you can get real investment, if you can show that patients get better with measurements that people are happy with. That’s meant there’s been a big increase in interest in people doing controlled evaluations of a whole range of psychological therapies. There’s now much more outcome research being done now. The consequence of that is we’re going to learn a lot more about a range of therapies that work. So we will be able to support more therapies as time goes on, because of the sea change in attitudes to evaluation that has come from the IAPT programme.
I was helped by CBT in my early twenties, but I do also see studies which suggest the Dodo theory – lots of other therapies do just as well. Could be the therapeutic alliance or perhaps we don’t know. What do you think of the Dodo theory?
It’s not a false theory but it also doesn’t quite say what it seems to. NICE doesn’t endorse the Dodo theory. There aren’t NICE guidelines saying ‘just do any psychological therapy’, which is what you’d think from the Dodo account. And the reason is no NICE guidelines say that is, if you look at specific conditions and you look at all the randomised controlled trials, you get strong support for some therapies, less strong for others, and also evidence that some don’t work. So that is the position within conditions. But of course in these RCTs, you’re almost always using highly trained therapists. But in the databases that are used for the Dodo account, you might just use anyone who is giving therapy in large services, and ask ‘what therapies are you giving?’, and then you get less marked differences, but you also don’t quite know what therapies they’re giving. If you take a large service of therapists, some of whom are not highly trained, then some of these differences wash out. But if you’re dealing with highly trained therapists, then there’s clear evidence that certain ways of doing therapy work better than others.
Now regarding the allegiance bias, it’s a perfectly reasonable hypothesis. But most of the data advanced to support it is post-hoc. So the argument is advanced is this: if you’re involved in developing a treatment, you’re going to be very enthusiastic about it. You’re going to give a really good go to your treatment, but be a bit half-hearted about the rival treatment. A lot of the evidence for the allegiance bias comes from researchers looking back at trials, and saying, looking at the address of those authors, I think they were in favour of IPT, or in favour of CBT, and then let’s code them that way, and then let’s look at the data and whether it fits with allegiance. But that is very post-hoc, and it’s non-blind rating by people who have a view – they believe in allegiance. What you need to do is prospective experimental test. The classic way to do that is to take two therapy centres, use them both in a trial, and use one of them because it’s expert in one therapy, and the other because it’s an expert in the other therapy, then you train therapists in both centres in both treatments. Now you have a proper design and you can distinguish between the allegiance hypothesis versus the procedures. This has been done many times, and the answers is, it’s not the allegiance. Unfortunately people who advocate the allegiance hypothesis forget to mention these studies.
IAPT focuses people very much on training people up to the standard you’d expect in trials, using national curricula, with an emphasis very much on quality.
Some psychodynamic therapists say their services are being cut while IAPT funding is being protected. And IAPT therapists say they’re seeing patients with things like bipolar disorder etc, which is putting a strain on them as well. Is that happening?
This is a very serious issue. If that’s generally true that’s a big problem, as the whole point of IAPT is additionality – it’s not meant to be removing existing services, it’s meant to be creating a whole new set of services which create additional capacity and improved access. If instead commissioners are saying ‘we have IAPT so we’ll close down the other stuff’, that’s undermining the whole point. Because of this worry, the Department of Health asked all PCTs last year to return information on how much they were spending on talking therapies that were not IAPT and on IAPT. They have this data going back to 2004. The spend on non-IAPT services nationally has held up – there’s not a reduction. As a consequence, before IAPT, the NHS was spending 3% of total mental health budget on talking therapies. It’s now 6.6%. The national picture is this isn’t happening. That doesn’t mean that in some areas there are services that have been going for some time, which commissioners have now chosen to decommission, which people feel aggrieved about.
Are some people being squeezed into IAPT services with problems that IAPT people haven’t been trained to treat?
That may be happening, and it shouldn’t be.
A broader criticism of CBT is that it focuses too much on individual thinking errors and not enough what might be genuine environmental adversities. Are we trying to treat cognitively things that might be economic or environmental?
IAPT was never envisaged to be solely a psychological treatment initiative. Right from the start we built into all the services employment advisors and debt counsellors, because depression and anxiety occurs in a social context and there are some things that the services can do to help that. That’s why right from the start we said it isn’t just CBT or any other therapy, it’s also some help with social problems. The other thing is that, yes, it’s true that on an actuarial basis you get higher rates of mental health problems in more deprived areas. But it’s also true that if you equip people to be more robust in the face of adversity, they’re less likely to suffer in a protracted way. So it’s not an either / or. Try and help as much as you can with the social adversity, and also equip people with the mental skills to manage that adversity.
Another critique of CBT is that it’s too individualistic, very much focused on the social. But it seems there is more group CBT beginning to be able in IAPT. Is that the case?
Yes quite a lot of the services have groups run. And NICE recommends group CBT for depression. I think one of the things which is a misunderstanding of CBT is to say ‘CBT is CBT is CBT’. It isn’t. When done properly it focuses on your particular concerns, your social circumstances, your behaviours. While there are broad themes covered, it should feel very different for different patients. It’s not like giving a drug, you don’t do the same thing with everyone.
Yes, it can feel quite cookie-cutter – you go to see a PWP and come away with a list of thinking errors to watch out for.
Yes, though what you’re describing is more psycho-education than face-to-face CBT, which would look very different. The idea in the IAPT services is if people don’t find psycho-education helpful, they should step up to face-to-face therapy. Step up rates vary – we did a study from the pilot schemes, and we found several features of services that predicted better overall outcomes. And one of them was having a high step-up rate. So if you are a service where if someone doesn’t recover at low intensity, you are very likely to step them up to high intensity, then your service is likely to have higher recovery rates. There were some services with a very low step up rate, and those services had much poorer outcomes.
The risk is the PWP might see it as a failure if they have’t cured the person.
That could happen, but obviously that’s not the model.
At the end of the 10 weeks…
Isn’t that how long the treatment is typically?
It varies from service to service. Some are much more flexible in the number of sessions. And one of the other predictors of overall success is a higher average number of sessions per patient. NICE doesn’t just recommend treatments, it says there’s a dose of them. For depression it’s nearer 20 sessions. So we would say if you’re fully NICE compliant you should offer up to those numbers.
What are the options for a service user after that course, if they want to keep practicing? Are there options in community groups etc?
There are some IAPT services that run continuing groups. As services mature they need to focus more on this longer-term monitoring and follow up and continuation.
Is mindfulness CBT a growing part of IAPT?
NICE recommends mindfulness CBT for prevention of depression recurrence. So the evidence for it is restricted to those who have had at least three episodes of depression. They are at a much higher risk of recurrence. There are two therapies NICE recommend to reduce that risk. Drugs don’t reduce it, but high intensity CBT and mindfulness CBT both have good evidence that they halve that risk. We are encouraging IAPT services to offer one or other of these treatments. Mindfulness CBT is offered when people are recovered – it’s like a class people go to.
Can you tell me about Any Qualified Provider and what it means for mental health.
It’s just starting, so we don’t quite know how it will pan out. The idea is that the government would like to open up the provision of a lot of healthcare to groups that are suitably qualified and produce a more competitive market. In IAPT we do already have a multitude of providers. For example, in some IAPT services, low intensity help is managed by a voluntary group like MIND or Re:Think. There are many examples of that working very well and being reasonably economical.
But as the market opens up more, there are big risks, and the risk is people use too simplistic a method for organising payment. AQP could mean just payment by result. If you say ‘we’re going to pay you if someone reaches clinical recovery’, which could be a temptation for a commissioner, then you’d be providing a perverse incentive to services to only see mild cases, because they’re closer to the cut off so you don’t need to improve so much to get the money. It would be a travesty if we started commissioning services that way.
Or to duke the figures.
Yes. These are all risks. So if the benefits of competition are not to be outweighed by the perverse incentives, you do need a much more sophisticated way of assessing outcomes, so you can avoid these perverse incentives.
Yes. On the IAPT website there is a document on AQP on perverse incentives, and it explains these issues. The DH has got 20 pilots running which are collecting data for payment by results system, to work out what would be a fair system. It’s certainly not just going to recovery, it’s also improvement, fairness of access, and delivering NICE recommended treatments, so people don’t end up skimping, and patients suffering.
How do you see IAPT developing and what other countries are doing?
In terms of how it’s developing in England, the coalition has made several commitments to expand it. The first one, which is really important, is to develop a children and young person’s IAPT. It’s based in CAMHS. What IAPT does is train up new people, and this time place them in CAMHS. It brings in universal outcome monitoring. And it also brings in some general service improvement initiatives. So try to bring everyone in the services to bring in evidence-based practice and monitoring outcomes.
Will that be a culture clash as child psychology is more psychoanalytic?
It seems to be going well, the child IAPT, perhaps because people have seen the adult IAPT. The national advisor is Peter Fonagy, the Freud memorial professor of psychoanalysis. It’s not just CBT, it’s a range of therapies.
Will it mean more money?
Yes, but it’s started small. It’s more like proof of concept at the moment. Just like the adult one, new training has been developed with national curricula linked to agreed competencies.
The other things happening in England is focusing on people with long-term physical disease and mental health problems, like cardiovascular illness and depression. And these people tend not to have been seen so much in traditional therapy services in the past, which is a shame because actually if you can help them with depression, it’s much easier to manage their other conditions. There’s also a start of looking at IAPT-like services for psychosis and personality disorders. What that isn’t, is saying ‘let’s get all the people with psychosis treated in existing IAPT services’. It’s not that at all. What it is, is trying to build some of the ideas of IAPT into these secondary services, like the outcome monitoring, and training people in evidence-based protocols. And there are a number of pilot sites doing that around the country. We want a joined-up system where, whatever your illness and wherever you’re seen, there are some basic standards: the people who treat you will be fully trained, services look at how they’re doing and adjust their behaviour.
IAPT is an English initiative. The Scots are increasing access to psychological therapies, but not on the same scale. In Northern Ireland they are looking at implementing clinical guidelines. Outside of the UK, IAPT has been watched very closely. The Norwegians have opened up 14 IAPT-like services, which are very closely modeled on UK example, and they’ve been using the material that you can download from the IAPT website, and they’re using our outcome monitoring level. And there’s discussion about using IAPT-type services throughout Norway’s mental health services. That’s interesting, as Norway in a sense have more funding for this than we have, but still aren’t sure what they’re buying. So they want to move towards more evidence-based therapies.
What about Sweden?
I’ve just come back from Sweden, and they haven’t really moved into any national programme. The government is interested in evidence-based interventions. They’ve made some investment into back-to-work programmes….
Which haven’t worked that well?
Is that a concern for IAPT?
Well, IAPT is not just a back-to-work programme.
What about the US and Canada?
It’s difficult to do it in the US. The Canadians have a health commission, but haven’t progressed as far as the IAPT system.
Is there a meaning gap to CBT?
CBT doesn’t really focus on meaning. If people wanted to explore that, then other therapies would be more suitable. But if that’s a limitation on the outcomes people get, that’s an empirical question. CBT doesn’t work for everyone. In an ideal world, perhaps we could judge who would be likely to respond to different approaches, but we haven’t got there yet.
Is the future bleak for existential and psychoanalytic therapies?
I certainly don’t think so, quite the opposite. We’re supporting training for brief psychoanalytic therapy for depression, and the people involved in that have agreed to do a randomised-controlled trial for that. People are doing evaluations of more psychoanalytic work. The psychoanalytic treatments are changing, and becoming more focused and differentiated for different conditions, which is good.
Are the days of dream analysis gone?
It doesn’t figure very prominently.
Have we lost something there?
There’s not a lot of evidence that it helps people get better to do it.
Here’s the transcript of the interview I did with Richard Layard for the Aeon piece.
Philosophy for Life - official website of author Jules Evans -]]>
Philosophy for Life - official website of author Jules Evans -]]>
In the piece, I tell the story of how IAPT occurred because of a chance meeting at a British Academy tea party:
In 2003, Lord Richard Layard was made a fellow of the British Academy. He’d made his reputation as an unemployment economist at the London School of Economics, but he’d always had an interest in depression and happiness. He inherited this interest, perhaps, from his father, the anthropologist John Layard, who suffered from depression, shot himself in the head, survived, was analysed by Carl Jung, and then re-trained as a Jungian psychologist. Layard junior was more interested in hard data than the collective unconscious, but he’d become interested in a new field in economics that tried to measure individuals’ happiness, and use the data to guide public policy. Layard wondered: what if governments started to take happiness data as seriously as they took unemployment or inflation? He tells me: ‘The most obvious policy implication was for mental health services.’
At the British Academy tea party, Layard struck up a conversation with the man standing next to him, who was called David Clark. ‘It was a fortuitous meeting’, Layard tells me. Synchronicity, his father might have said. Layard asked Clark if he happened to know anything about mental health. Clark replied that he did. He was, in fact, the leading British practitioner of CBT. He had helped to set up a trauma centre in Omagh after the Provisional IRA bombing of that town in 1998. The centre treated Omagh citizens for post-traumatic stress disorder, and kept careful measurements of the outcomes. The data showed that front-line provision of CBT in the field showed comparable recovery results as in clinical trials: roughly 50% of people recovered. Clark explained to Layard that trials of CBT showed similar results for depression, anxiety and other emotional disorders. He also explained that there was very little CBT (or any other talking therapy) available on the NHS for common problems like depression. Layard, who is nothing if not a doer, decided he wanted to ‘get something done about mental health’. So, at the age of 70, that is what he did.
With Clark’s help, Layard assembled a powerful argument for the British government to increase its spending on CBT. Depression and anxiety affect one in six of the population. Besides causing a lot of human suffering, this costs the economy around £4 billion a year in lost productivity and incapacity benefits. This problem has a solution, Layard argued: CBT. The government’s own National Institute for Health and Care Excellence (NICE), which evaluates evidence to guide NHS spending, recommended CBT for depression and anxiety in 2004. Yet for some reason, the NHS just £80 million a year on talking therapies, out of a total NHS annual budget of £100 billion. Layard and Clark recommended doubling the budget, so that 15% of adults with depression and anxiety would get access to psychological therapy. Some of them would get off incapacity benefits in the process, it was argued, so the service would pay for itself.
Layard and Clark presented their recommendations at a seminar at 10 Downing Street in January 2005. They managed to get IAPT into New Labour’s manifesto for the 2005 election, and were then faced with the task of turning it into a reality following Labour’s election victory. Clark designed the service. Firstly, and radically for the NHS, it allowed for self-referrals. Secondly, the service would have a ‘stepped-care’ approach: for mild cases of depression and anxiety, people would be treated by ‘Psychological Well-Being Practitioners’, who had a year’s training in CBT, and who provide ‘psycho-education’ and guided self-help, often over the phone. If that wasn’t adequate, people were encouraged to ‘step up’ to more intensive face-to-face therapy for a longer period of time, with a fully-trained therapist. Thirdly, IAPT would only offer NICE-recommended evidence-based therapies, which meant mainly CBT. Finally, IAPT centres would measure outcomes at every therapy session, and make this data available online, so both patients and politicians could see the results.
The reason Layard and Clark convinced politicians to put serious money into talking therapies is that CBT had built up a big evidence base to show it worked. I look at the origins of this evidence – the invention of the ‘Beck Depression Inventory’:
Beck developed Cognitive Behavioural Therapy in the early 1960s. He tells me: “I was also influenced by the Stoics, who stated that it was the meaning of events rather than the events themselves that affected people. When this was articulated by Ellis, everything clicked into place.” While Ellis was content to be a free-wheeling rebel, Beck was more of an institution man. He wanted to transform clinical psychotherapy from within, by building up an empirical evidence base for cognitive therapy.
Before Beck, evidence for psychotherapy mainly consisted of therapists’ case studies. The reputation of psychoanalysis, for example, was built on a handful of canonical case studies written by Sigmund Freud, like ‘the Wolf-man’, ‘Dora’, and ‘Anna O’. The problem with that approach was the evidence was anecdotal, non-replicable, and relied strongly on the therapist’s own account of a patient’s progress. The therapist might exaggerate the success of a treatment, as Freud arguably did in the foundational case of Anna O.
Beck’s radical innovation was to develop a questionnaire which asked patients how they felt on a four-point scale. In 1961, he created the Beck Depression Inventory, a 21-question survey which measured a person’s beliefs and emotional state through questions like:
0 I do not feel like a failure.
1 I feel I have failed more than the average person.
2 As I look back on my life, all I can see is a lot of failures.
3 I feel I am a complete failure as a person.
By measuring the intensity of a person’s negative beliefs and feelings, Beck discovered a way to quantify emotions and turn them into data. Using the BDI, he could quantify how a person felt before a course of CBT, and after it. According to the BDI, after 10-20 weeks of CBT, around 50% of people with depression no longer met the diagnostic criteria for major depressive disorder. And, crucially, this result was replicable in randomised controlled trials by other therapists. CBT showed similar recovery rates for anxiety disorders like social anxiety and post-traumatic stress disorder.
Beck launched the era of ‘evidence-based therapy’. In doing so, however, he made some drastic alterations to the ancient philosophy that inspired him. He pruned out anything that was not scientifically measurable – including any mention of God or the Logos, virtue or vice, the good society, or our ethical obligations to other people. I once asked Beck if he agreed with Plato that certain forms of society encouraged particular emotional disorders. He replied: ‘I am loath to toss out an opinion that is not based on empirical evidence.’ There is much about which CBT is silent. It teaches you how to steer the self, but does not tell you where you should steer it to, nor what form of society might encourage us to flourish.
I wax lyrical about the place of IAPT in the history of ideas:
IAPT is an interesting moment not just in the history of psychotherapy, but in the history of philosophy. It is an attempt to teach Stoic – or ‘Stoic-lite’ – self-governance techniques to millions of people, an exercise in adult education as much as healthcare. The scale of it is beyond the dreams of the ancient Stoics, teaching on the street corners of Athens. Although the early Stoics wrote political works, they were all lost in antiquity, and later Roman Stoics viewed Stoicism more as a sort of individual self-help for the elite. Marcus Aurelius, the Stoic emperor of Rome, was in a position to spread Stoicism to the entire empire if he so wished, but he had a pessimistic sense of the limit of politics. ‘I must not expect Plato’s commonwealth’, he told himself. ‘[For] who can hope to alter men’s convictions, and without change of conviction what can there be but grudging subjection and feigned assent’.
Stoicism’s therapy of the emotions remained popular with intellectuals, but few believed it could be taught by the state to the masses. David Hume wrote that the majority of humanity is ‘effectually excluded from all pretensions of philosophy, and the medicine of the mind, so much boasted…The empire of philosophy extends over a few, and with regard to these, too, her authority is very weak and limited.’
The early results of IAPT have been better than Hume might have predicted, with recovery rates of 44.4%. IAPT is now being rolled out into child services, into the treatment of chronic physical conditions which have an emotional toll, and into the treatment of unexplained conditions like Chronic Fatigue Syndrome. An IAPT-style programme is also being piloted in Norway.
And finally I consider whether the state has any business providing therapy for our emotions. My position is basically that I’m all for the provision of CBT because it doesn’t try to tell people what ‘flourishing’ or the meaning of life is. But I’m wary of state support for Positive Psychology precisely because it does try to tell people what flourishing ‘is’. In place of Positive Psychology, I’d like to see something else – call it Positive Philosophy – which is more open-ended and Socratic when it comes to discussing the good life.
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