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.

IAPT’s Stepped Care approach

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?

The Dodo theory – named after the race in Alice in Wonderland in which ‘all shall have prizes’ – suggests that all therapies work equally well.

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…

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.

Like improvement?

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?

Peter Fonagy, managing the roll-out of IAPT in child services

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?

That’s correct.

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 -

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.

Philosophy for Life - official website of author Jules Evans -

IAPT is the biggest expansion of mental health services anywhere in the world, ever. It has already trained 4,000 new therapists in Cognitive Behavioural Therapy, and 2,000 more therapists are being trained. It’s doubled the NHS spend on mental health services (from 0.3% to 0.6% of the NHS annual budget), and is on course to treat 900,000 people for depression and anxiety in England every year, many of whom would never have had access to therapy in the private sector. The recovery rate for people requiring two or more sessions of treatment is approaching 45%, with others making improvements even if they remain depressed by clinical standards. That is a lot of human suffering healed, though still only 10-15% of those afflicted by depression and anxiety.

It is also, by the by, been five years since I started blogging.  Five years ago, I became fascinated by the direct link between Cognitive Behavioural Therapy and ancient Greek philosophy, and also by how governments were beginning to ‘roll out’ CBT on a mass scale, in the NHS, in schools, in the US Army and elsewhere. It seemed to me an interesting moment in the history of politics, philosophy and psychology. I started the blog, which back then was called The Politics of Well-Being, in February 2008, and I’ve really enjoyed it. For a prickly Stoic like me, it’s allowed me to be the master of my own fate, not dependent on the whims of commissioning editors, able to explore what interests me at the length I want.

I’m now researching a long article on the first five years of IAPT, which hopefully a magazine will publish. This week I interviewed David Clark, the CBT psychologist who masterminded IAPT, as well as several other therapists and service-users, and next week hopefully I’ll interview Richard Layard, the economist who made the economic case for IAPT to the Labour government in 2006. IAPT only arose, by the by, because Clark and Layard happened to meet when they were both made fellows of the British Academy in 2003. They met during the tea break, and Layard said he was writing a book on happiness and was interested in mental health. Clark told him a bit about CBT, and the rest, as they say, is history.

David Clark, left, having some more tea

Here are five interesting things I’ve learnt so far about IAPT:

1) IAPT is the prime example of psychotherapy in the age of big data

Back in the early 20th century, the evidence for psychotherapy consisted of therapists’ personal case histories, anecdotal evidence like Freud’s Anna O or Wolfman cases. These were interesting to read (who doesn’t love a good story) but they also turned out to be misleading and not very scientific (some of Freud’s patients didn’t recover, like he said they did). Today, psychotherapy is embracing the era of big data, and IAPT is the prime example of that. Service-users fill out feedback forms before each session, which are used to assess how well the treatment is working. These forms are then collated to assess how well the programme is working at the national level too.

So far, the data from IAPT has been fairly rudimentary, only really looking at recovery rates. But as of next month, the data sent through will be much richer, taking account of what conditions patients have, what treatment they received, what ethnicity and demographic they are, which region they’re in, and so on. All of this will be available to the public through the NHS’ information centre, which will which therapies have worked well for which conditions, and where the service is failing to reach people, in particular regions, demographics or ethnicities. There are already signs, for example, that IAPT is not sufficiently reaching the millions of people who suffer from social anxiety – so this group may need to be encouraged to self-refer for services.

2) IAPT needs improving

There is a risk that IAPT will suffer from ‘mission creep’ and end up being allocated serious cases it was not designed to treat. It’s designed for the treatment of common mental disorders like depression and anxiety. Unfortunately, in some local authorities, commissioning boards have cut funding for other types of psychotherapy which are used for more serious conditions, so IAPT services are now treating patients with, say, bipolar disorder or personality disorders. David Clark says that’s not happening at a national level, but may be happening in some regions (it is).

IAPT also remains controversial in so far as many psychotherapists in non-CBT traditions say it only really provides CBT. This is because the National Institute for Health and Clinical Excellence (NICE) mainly recommended CBT when it reviewed the evidence for psychotherapies for depression and anxiety (it also recommends Interpersonal Therapy, Couples Therapy, Counseling and Behaviour Activation Therapy). But psychodynamic and psychoanalytic therapists say NICE is wrong, and that in fact the evidence suggests all talking therapies work roughly as well as each other. They also suggest studies comparing CBT to other treatments are often biased because the researchers have an allegiance to CBT. And, finally, they insist randomised controlled trials aren’t necessarily the best assessment of how therapies work in practice.

These issues remain very contested within psychotherapy. This is unsurprising – IAPT must have arrived like a bomb into the world of private psychotherapeutic practice. Suddenly, there were 4000 new therapists providing therapy for free, many of them with only a year’s training. That was bound to annoy older therapists in the private sector.

Peter Fonagy

There are signs that other forms of therapy are beginning to embrace the IAPT methodology. Several prominent psychoanalysts from the Maudsley Clinic, including Peter Fonagy, are trialling Dynamic Interpersonal Therapy, which is a form of brief psychoanalytic therapy for depression. If the trial is approved by NICE, it might mark an interesting moment of mass Freudian therapy.

3) The NHS’ mental health services are about to become a free market

Just a few years after IAPT created a free national mental health service, the Coalition government’s NHS reforms are about to open it up to competition. Starting this year, Health and Well-Being Boards will be able to commission ‘any qualified provider’ to provide mental health services in their area. That might be the existing IAPT service, or it might be some new organisation competing for tenders.

Well-Being Boards will have to decide how to choose between competing organisations. They could decide to give money to the organisation with the best recovery rates. But that might create what David Clark calls “a skewed incentive” for organisations to only take on easy cases where recovery is much more likely, while turning away any harder cases. It also creates the risk of unscrupulous organisations simply faking their results in order to win NHS contracts. The Department of Health is considering how best to evaluate organisations at the moment – perhaps ‘progress made’ is better than recovery rates, in that it takes account of difficult cases who have made a lot of improvement even if they’re still clinically depressed. Some therapists think outcome measures should also assess actual changes people have made in their lives, rather than simply how they’re feeling.

4) IAPT is being expanded into new areas, and new countries

IAPT is now being rolled out for children and young people, though it appears to be happening on a smaller scale than the adult roll out. It’s also being expanded to treat patients with chronic physical health problems that may be co-morbid with emotional problems, like say cardiovascular disease or chronic pain; or for physical conditions that may be partly psychosomatic, like Irritable Bowel Syndrome. There are also trials underway of IAPT-style services for psychotic illnesses like Bipolar Disorder, Manic Depression and Personality Disorders, often using CBT but also Dialectical Behaviour Therapy. I would be interested to see if CBT might become one tool the NHS uses as it tries to reduce national obesity levels: there is some evidence it’s useful as part of a diet plan.

In terms of other countries, Scotland and Northern Ireland have still yet to put serious investment into mental health services, although their national mental health strategies have suggested they should. Canada’s new national mental health strategy also calls for greater provision of talking therapies. Norway has recently launched an IAPT-style pilot programme, with around 12 IAPT-style centres around the country.

Sweden already has a CBT programme to help people back to work, which hasn’t alas proved very successful. IAPT in the UK has more modest targets for helping people back to work, which so far it’s met – but a new article in the British Journal of Psychiatry suggests that Richard Layard’s original estimate of IAPT’s contribution to QALYs (Quality-adjusted Life Years) was “highly inflated” – so it may not be quite as good economic value as Layard originally argued.

5) There is a role for community arts organisations to work with IAPT services

IAPT services sometimes try to help patients beyond their course of therapy, so that they carry on their recovery and also meet other people working to get better. Sometimes, IAPT services will run post-treatment groups  – for example, some services run mindfulness-CBT groups for people with histories of depression. And sometimes they will connect with local community groups, such as MIND or Re-Think. That includes connecting with community arts groups – Lambeth’s IAPT service, for example, works with local sports organisations, a theatre group called Kindred Minds, an African culture group called Tree of Life, a debating club, even a circus-trapeze training group, as well as with several peer-led recovery groups. These groups have their own funding sources, by the way, they’re not funded by IAPT.

Some local authorities are also developing Recovery Colleges, which take a more educative approach to mental health recovery, treating people as students learning how to take care of themselves. I’m teaching a workshop in ancient philosophy at one such Recovery College next month, and I think there’s a lot of room for arts and humanities academics to connect with IAPT services or Recovery Colleges for their own expertise, whether that’s in art history, drama, history, literature, philosophy or other disciplines.

One therapist I interviewed, Nick McNulty from Lambeth’s IAPT centre, said he’d just met a client who was interested in Stoic philosophy, and wanted more of a values-based approach to mental health recovery. IAPT’s job is not to tell people what the good life is, it’s to help them through crises and to get them to a position where they can begin to seek the good life for themselves, according to their own definition of it. I think at that stage, after IAPT, there is potentially a role for practical philosophy, if it offered a broader ethical context for some of the CBT skills that people have recently learned. However, it would obviously need to avoid being dogmatic or preachy, helping people explore various different models of the good life without imposing one onto them.

In general, IAPT strikes me as an educational project as much as it is a health programme. A lot of what it provides is ‘psycho-education’, or ‘guided self-help’, trying to teach people to learn how to take care of themselves, as Socrates tried to do, and become ‘doctors to themselves’ as Cicero put it. NICE clearly sees the benefits of self-help, which is a big validation for people like me who believe that self-help isn’t a load of junk, although clearly the relationship with a therapist is very important for some people too. By providing a ‘stepped care’ approach, IAPT tries to help both people like me, who are interested in learning how to take care of ourselves, and other people who are really seeking a relationship of care.

We, as users of the service, need to learn how to ask for what we want – how to self-refer for talking therapy even if our GP wants us to take Prozac, how to ask to step up to a higher level of care if guided self-help isn’t enough, how to ask for specific types of therapy, and also how to ask how to change therapist if we don’t have a rapport with the one allocated to us. We need to learn how to take care of ourselves and each other, not entirely relying on the NHS to do the work for us. And, finally, we need to learn how to support the young service politically, if it’s something we think is worth keeping.

******

In other news:

The Atlantic magazine considers the ‘touch-screen generation’ - what impact will their immersion in digital technology have on children’s development?

The New Yorker reports on a new text-analysis study of the history of hip-hop, charting such nuggets as the first appearance of the word ‘bling’ and the number of uses of ‘Nike’ versus ‘Adidas’.

Are the French ‘taught to be gloomy’?

In the US, President Obama has launched an ambitious new project to make pre-school childcare universal, at the cost of $10 billion a year. This blog post looks at James Heckman, the psychologist whose work on childcare and early interventions has been an inspiration for Obama’s policy.

Polly Toynbee penned this excellent crie de couer over a new round of benefit cuts set to be introduced on Easter Monday, including slashing the budget for financial advice from the Citizens Advice Bureau from £22 million to £3 million.

Also in the Guardian, a report on the Care Quality Commission, which has found a fifth of hospitals fail to treat the elderly with the dignity they deserve.

In the London Review of Books, John Lanchester gets excited about fantasy fiction, and the new series of Game of Thrones (spoiler alert – he gives away some of the plot).

The BBC has a new 30-part series on the History of Noise, presented by David Hendy of the University of Sussex. The TLS, meanwhile, reviews a new book on the history of silence in Christianity.

Finally, I recently finished Alex Ross’s excellent history of 20th century classical music, The Rest is Noise. There was also a BBC TV series to accompany it, called The Sound and the Fury, which is available on BBC Four’s wonderful archive of TV on modern classical music. Here is a clip from it, of Messiaen’s Quartet for the End of Time, which he composed when a POW in Stalag VIII concentration camp. He and three other prisoners performed it in the camp, in the rain, on January 15, 1941.

See you next week,

Jules

Philosophy for Life - official website of author Jules Evans -

As one civil servant told us, ministers are extremely busy and rarely get time to read a newspaper article, let alone a research paper. They want any ‘action points’ to be clearly expressed in a two-page document. Tony Blair apparently said that if you can’t express your idea in two sentences, you don’t understand it. All of this was quite off-putting for some of the academics, trained as they are to appreciate subtlety, nuance and multiple readings. One academic was particularly horrified by the idea of using an infograph to get their ideas across.

On their side, some policy-makers expressed frustration at how little useful advice they were getting for all the money they were putting into academic research. For example, the government somewhat controversially set aside a pot of money for academic research into the ‘Big Society’, but apparently, few practical recommendations have arisen from all that research. I think that shows a mistake in timing – there is a lag between ‘government time’ and ‘academic time’, and academics can best influence policy in the quieter years before government, when politicians are formulating their broader policy visions, rather than during government when any academic contributions risk being seen as entirely expedient.

American academics might be better at mass communication

Another policy-maker noted that American academics seemed to be better at influencing British policy than domestic thinkers: think of the ‘Nudge unit’ inspired by Richard Thaler, Cass Sunstein and Daniel Kahneman; or the impact of Martin Seligman’s Positive Psychology on British policy. Why is the RSA’s schedule of public talks so full of visiting American intellectuals, with so few British intellectuals? Perhaps, one speaker speculated, American academics are better at selling themselves because they have a much bigger book market to sell into. That emphasis on mass communication makes them better able to deliver TED-style pitches to busy policy-makers.

However, it’s still the case in the US that arts and humanities scholars have little influence on public policy, with a few notable exceptions in history, law and ethics (Michael Sandel, Martha Nussbaum). English literature and cultural studies have little influence on policy, and perhaps that’s as it should be – novels and poetry thankfully resist the utilitarian bent of our times.

To be provocative: is it possible that the huge influence of critical theory, and particularly of Michel Foucault, on arts and humanities academics have, ironically, rendered them less capable of influencing power and changing the world? Doing an arts and humanities PhD sometimes reminds me of initiation into a cult – you go through a three-year period of social isolation, by the end of which you emerge fully inculcated in the radical doctrine of critical theory. This world-view puts you at odds not just with public policy, but also with mass society, including your friends, family and lovers. One academic told me that few relationships survive a humanities PhD, and that she herself had broken up with her boyfriend half-way through her studies (she’s now happily married to a Lacanian). The initiate in critical theory can end up so sceptical of power, they become incapable of influencing it. This limits their influence to the ‘in-culture’ of academia – a culture which is ironically very hierarchical.  I say this as an ‘outsider’ – someone without a PhD who came into academia through journalism (so perhaps I’m just insecure about my lack of qualifications!)

 Four ways that arts and humanities influence public policy

The bard has always played a central, if controversial, role in politics

Let me end on four positive ways that arts and humanities research can and do influence public policy. Firstly, through investigating stories and their impact on our emotions. The arts and humanities are right at the centre of public policy because political communication is to a large extent about stories, words, symbols and how they move us. The scop, the bard, the story-weaver, has always been an important part of court politics. The most obvious way that the arts and humanities could influence public policy, then, is through the exploration of rhetoric, narrative and its effect on the emotions. This exploration would include the recent work of social scientists and psychologists like Jonathan Haidt and George Lakoff into values and metaphor and how they move us.

At the moment, as far as I’m aware, there is only one centre for the study of rhetoric in the UK, which was opened in Royal Holloway’s classics department in 2010 – though I note that Philip Gould left money in his will for a ‘visiting professorship in rhetoric and the art of public persuasion’ at Oxford. There’s room for much more research in this area, and it would have the benefit of being very interesting and (dare I say it ) useful to politicians and their speech-writers. What are Shakespeare’s history plays if not explorations of the rhetoric, narratives and myths of political power? Winston Churchill was able to ‘mobilize the English language and put it to battle’ (as JFK put it) by studying rhetoric, by reading Shakespeare. Our political culture would be greatly improved if more politicians followed his example. Politicians improve or debase our political culture through their language.

Sir Adam Roberts

Secondly, history has an obvious role to play in public policy. We heard, for example, how the History and Policy project helped the policy-makers working on pension reform in the mid-noughties to unearth the history of the existing pension legislation and see how it had grown anachronistic. History helps us see how aspects of our culture that we might take as natural and eternal are in fact recent and constructed. It also gives us useful historical scenarios to think about where we are and where we’re going (think of Paul Kennedy’s work on imperial over-reach, for example, which might have been usefully read by the Bush government). Sir Adam Roberts is an example of a historian who has frequently contributed memoranda to parliamentary debates.

Thirdly, applied ethics has usefully engaged in public policy for several decades, from Baroness Warnock and others’ work on euthanasia, to the contribution of academic philosophers to the Leveson Inquiry’s debate on balancing press freedom with the right to privacy.

Amartya Sen and Martha Nussbaum: a good example of cooperation between the humanities and social sciences

Finally, arts and humanities scholars have a clear contribution to make to the politics of well-being. This new movement in politics has so far been dominated by economists and psychologists – the Office of National Statistics’ committee to define ‘national well-being’, for example, didn’t contain a single representative from the arts and humanities. Now, well-being economists and psychologists like Richard Layard and Amartya Sen are increasingly engaging with the humanities, particularly with philosophy. They are engaging with the history and plurality of philosophical definitions of well-being. This is good news, as it means well-being policy will become less top-down and dogmatic and more democratic. For example, I hope to work with Layard’s Action for Happiness to design a ‘well-being course’ for adults, which won’t try to shoe-horn everyone into one pre-fabricated definition of well-being, but will instead enable people to consider the scientific evidence, while also debating and forming their own idea of the good life.

At the moment, there are two main Centres for Well-Being in English academia – Richard Layard’s team at the LSE, which is mainly economists; and Felicia Huppert’s Well-Being Institute at Cambridge, which is mainly psychologists. Hopefully we can get the Well-Being Project at Queen Mary started up in earnest this year, to bring thinkers and practitioners from the arts and humanities more into the conversation.

******

In other news:

Jonathan Rowson of the RSA’s Social Brain project has published a thoughtful new report applying Iain McGilchrist’s thinking on neuroscience to public policy.

MPs will finally get access to therapy at the House of Commons. It would be great if they also received personal training on how to cope with becoming a minister – I was surprised to hear from the IFG that they are thrown into top positions without any training.

Disgraced science journalist Jonah Lehrer, who was exposed for plagiarism and fabricated quotes last year, broke his silence to give a speech to the Knight Foundation – for which he was paid $20,000. Cue much public indignation from other journalists, and this apology from the Knight Foundation.

You’ve spoken, we agree – it was a mistake for a #journalism foundation to pay @jonahlehrer for a speech kng.ht/XCPZb9 #infoneeds

— Knight Foundation (@knightfdn) February 14, 2013

The National Institute for Clinical Excellence (NICE) published its first recommendations for the treatment of psychosis in young people, deciding that anti-psychotics should only be used when absolutely necessary, and that CBT often works better. Another report highlighted that the popular association of psychosis with violence is not entirely a myth.

RIP Ronald Dworkin, the pre-eminent philosopher of law.

The London Philosophy Club is about to become the biggest philosophy club in the world! We’re poised to overtake our friends / rivals in New York. Join up and come see Clare Carlisle talk about Kierkegaard on the 27th, or Stephen Cave talk about immortality on March 13th.

Also, come to the free workshop on Epicurean philosophy and how we can use it in modern life, which I’m running this Tuesday evening at Queen Mary in London. Email me if you need details etc.

Finally, Alain de Botton, one philosopher not afraid of public engagement, declared in Metro newspaper that the Arts Council should be closed and arts engagement should focus on celebrities with millions of Twitter followers, like One Direction’s Harry Styles. Cue this tweet from Harry.

Socrates, born in Athens in the 5th century BCE, marks a watershed in Ancient Greek philosophy.

— Harry Styles (@Harry_Styles) February 13, 2013

47,000 re-tweets for Socrates. Impressive. Although not quite as many retweets as Harry’s previous tweet:

Deep Heat in my eye. GAAAHHHH

— Harry Styles (@Harry_Styles) February 12, 2013

See you next week,

Jules

Philosophy for Life - official website of author Jules Evans -

Philosophy is so utterly marginal to British culture, so threatened with irrelevance at school and university level – is it really helpful for prominent philosophers to use what little public space they get to criticise initiatives aimed at broadening the public awareness of philosophy?

The project at Exeter brings together classicists, philosophers and psychologists to engage in a dialogue about the relationship between Stoic philosophy and cognitive behavioural therapy (CBT). As regular readers of this blog will know, CBT was directly inspired by Greek philosophies (not just Stoicism, also Socrates, Plato, the Sceptics and Epicureans…but mainly the Stoics). CBT is now the most scientifically credible and popular form of therapy for many emotional disorders. To my mind it is fascinating that CBT has built up an evidence base to show that the Stoics’ ideas and techniques for transforming the emotions genuinely work. It is extraordinary that ideas about the emotions conceived two millennia ago should still be our best guide for healing the emotions today.

I have written about this connection between Stoicism and CBT for five years or so, and all that time I could not understand why more philosophers did not write about it and see it as something really positive and interesting. The exception is Martha Nussbaum, whose 2001 book ‘Upheavals of Thought: The Intelligence of the Emotions’, explores the scientific evidence for the Stoics’ cognitive theory of the emotions (although Nussbaum does not accept the Stoics’ normative position, and characterises her own position as ‘neo-Stoic’).

Now, thanks to the Exeter project and to a series of books in the last two years on the relationship between Stoicism and CBT (including my own book), there is a lot more interest in how ancient philosophies can really help people cope with difficult situations and transform their emotions.

There have always been philosophers who criticise the modern use of Stoicism as a form of practical therapy. When I published an interview with Albert Ellis (the pioneer of CBT) back in 2007, Mark Vernon criticised my article for mistakenly conflating Stoicism with CBT, and ignoring the differences between the two. CBT was, at best, ‘Stoicism lite’, he wrote. I disagreed at the time, but now I think he makes a fair point – CBT does leave out a lot of Stoicism, not least its cosmology, its theism, and its ethical value system. It instrumentalises it, turning it into a set of techniques rather than a comprehensive moral system.

You can understand why CBT did that. To become a scientifically credible therapy, it had to drop any talk of God or providence, or even of the meaning of life. It teaches people how to transform their emotions, how to steer the self, without telling them where to steer the self to. It leaves people to decide for themselves what the meaning or goal of life is. You could develop a Marxist CBT, or an Islamic, Buddhist, Epicurean, capitalist or Aristotelian CBT. All it teaches you is how to transform the self and its emotions, not what the ideal self looks like.

Many people who have been helped by CBT go on, as I did, to explore the Greek philosophies from which it evolved – they get into ‘Stoic CBT’ or ‘philosophical CBT’. We fill in the bits that CBT left out – about God, society and the meaning of life. That is for us to do, not cognitive therapists working in the NHS. My book shows the different ethical directions that the Greeks took the cognitive theory of emotions, and leaves the reader to make up their own mind.

Baggini, in this latest salvo, suggests that the Exeter project is part of a mass ‘therapisation’ of our culture. He writes:

Not so long ago, therapy was widely seen as something only for the seriously disturbed or neurotic, overeducated Americans. Now, all that is good is being turned into therapy. Rather than seeking help on Dr Freud’s couch, people are turning to Monty Don’s allotment or Jamie Oliver’s kitchen to soothe their troubled psyches. Ancient philosophy is also undergoing this process of therapisation.

I’m not sure about the first sentence. ‘Not long ago’…as in when? Therapy and self-help have been pretty central to western culture since at least the Sixties. And I don’t think that people see Jamie Oliver as a particularly therapeutic figure, do they? And if people do find that gardening or cooking makes them feel good, what is wrong with that? I hardly think that finding gardening soothing to soul is a decadent modern invention.

Baggini’s on even shakier ground when he suggests that we are distorting ancient philosophy by trying to turn it into a form of therapy. I’m sure he’s read the Stoics, Epicureans, Cynics, Sceptics and so on – so he’ll know that they themselves very explicitly saw their philosophy as a form of therapy, which heals people of emotional problems. The Greeks’ view of philosophy as a form of therapy is explored at length in my book; or Martha Nussbaum’s Therapy of Desire: Theory and Practice in Hellenistic Ethics; or Richard Sorabji’s Emotion and Peace of Mind: From Stoic Agitation to Christian Temptation, or the Royal Institute of Philosophy essay collection, Philosophy as Therapeia. The therapy of the emotions is there on every page of Hellenistic philosophy.

Baggini may not be into this Hellenistic tradition. He might think it’s all a load of sap. He might prefer, I don’t know, the modern analytic tradition, or continental philosophy, or British empiricism. That’s absolutely fine. But the Hellenistic tradition is very much concerned with the emotions and how to transform them. It’s very much concerned with therapy or the art of being doctor to yourself. We’re not distorting it.

Baggini writes:

The only good reason to embrace a philosophical position is that you are convinced it is true or at least makes sense of the world better than the alternatives. I’m not a stoic because I do not agree that we are all fragments of an all-pervading divine rationality which is providentially organising the world, or that Epictetus was right to say you should not be disturbed if your wife or child dies or that “my father is nothing to me, only the good”. To become a stoic is to endorse the truthfulness of its world view and accept its prescription for how you ought to live, not just to like how it makes you feel.

Aaron Beck, the founder of cognitive-behaviour therapy, and Albert Ellis, founder of rational-emotive behaviour therapy, both appropriated Stoic ideas for their own ends, as does the philosopher Richard Sorabji, who says of Stoicism: “I choose the bits which I find helpful and I don’t take the full theory.” Such cherry-picking is perfectly legitimate. What’s objectionable is praising the joys of scrumping as though it were on a par with the care, dedication and understanding of growing an orchard.

This is the ‘all or nothing’ argument that I have sometimes been presented with. Don’t talk about Stoicism unless you are going to be a 100% Stoic, accepting all their ideas (including belief in the Logos, indifference to all external things, and faith in the periodic conflagration of the universe). Otherwise you’re just ‘pick n’ mixing’, not really seriously committing to a particular ethical path.

My response to this is that the ancients themselves pick n’ mixed. Marcus Aurelius pick n’ mixed from the Epicureans and Neo-Platonists. Posidonius pick n’ mixed from Plato and the Stoics. Augustine pick n’ mixed from Christianity and Platonism. Cicero pick n’ mixed from every philosophy out there. Baggini took some ideas from Hume in his book The Ego Trick. Does he agree with 100% of Hume’s ideas? No? Well that’s just pick n’ mixing! That’s just scrumping!

We all, to some extent, construct our own philosophies. What is important is whether our life-philosophies fit with human nature and the needs of our society at this particular time, and whether we actually live by them.

Most of the people I know who are into Stoicism today are fairly heterodox. But they make an effort to understand what the ancient Stoics really meant. They read not just Seneca and Aurelius, but also AA Long, Nussbaum, Hadot, Annas, Sorabji. They are serious about their philosophy of life, even though they’re not academics. And I also know a lot of people who have never read AA Long or Sorabji, but who have still read some Epictetus or Seneca, and found it really helpful – even a life-saver. Are they ‘pick n’ mixing’? Are they ‘scrumping’? Who the hell cares. Thank God, they have been helped by the Stoics through life’s many difficulties. I don’t care if they are a ‘proper Stoic’ or not. I care if they are suffering, and if they find something that helps them to cope with the suffering.

I personally am not a proper Stoic. I do not think externals are indifferent. I believe in reincarnation. I believe some passions are appropriate. However, I think the Stoics were unrivalled in their understanding of how emotions arise and how we can change them. They were unrivalled in some of their practical ideas for how to stay resilient in chaotic conditions, such as Epictetus’ idea of knowing the difference between what you can control and what you can’t. These ideas saved my life, and got me through depression and anxiety. I still use these Stoic ideas and techniques today, despite not accepting the Stoics’ normative position. I don’t think this is illegitimate, nor do I think Ellis and Beck’s ‘appropriation’ of Stoic ideas and techniques is illegitimate: CBT has helped millions of people to overcome suffering, which is more than can be said for most contemporary philosophers.

Baggini wants to keep therapy and philosophy safely apart, he says. Therapy (like CBT) is a set of instrumental techniques for ‘coping, not treating the whole person’, while philosophy helps us develop ‘a comprehensive outlook on life, along with a set of values’. I agree that, if you have an acute emotional disorder, you need immediate coping strategies, not total moral systems. But for the Greeks and Romans, these two things were on a continuum – first the immediate coping with crisis, and then the searching out of a more comprehensive philosophy of life. How can you draw a firm line between CBT and the philosophies from which it emerged…and why would you want to?

Philosophy and psychotherapy: no talking allowed!

I think therapists are increasingly learning that it is difficult to avoid normative questions of value and of what we mean by ‘flourishing’ etc. And philosophers are learning that it’s important to ground ethics in proper working theories of human nature and the emotions. As I put it in my book, ethics without psychology is a brain in a vat, while psychology without ethics is a chicken without a head. So I don’t think we can or should draw a hard line between psychotherapy and philosophy  – and I think it’s strange that Baggini should want to, considering he writes a weekly column with his psychotherapist partner called ‘The Shrink and the Sage’.

Finally, Baggini criticises ‘Stoic Week’s use of well-being questionnaires. Well, look, I think he is taking too seriously what started off as a small and fun project for Exeter classics undergrads. I know Baggini hates ‘happiness measurements’ and the attempt to try and use them to draw moral prescriptions (I have some sympathy with him here), and perhaps he sees this as an invidious example of that positivist trend. Of course the Stoic ethos is not about personal happiness – although I think these questionnaires try to measure flourishing or resilience rather than happiness. I personally am taking part in the week without religiously filling in the questionnaires.

In general, Stoic Week was the idea of a young post-grad at Exeter called Patrick, who is part of the Exeter project, and who wanted to give his students a sense that Stoicism wasn’t just something to study, but something you could practice each day. That is a fantastic idea, and his students have posted some YouTube videos of their experiences. No one, especially not Patrick, expected Stoic Week to gain international attention, or to attract the criticisms of a prominent British philosopher in the Independent! In general, though, I’d suggest that if the next generation of academics have half as fresh, engaging and practical an attitude to philosophy as Patrick does, then the future looks bright.

As to the questionnaires, no one is saying this is a serious scientific study. But the reason CBT has succeeded in reaching and helping millions of people, is it created an empirical evidence base to show it really worked. Likewise, the reason mindfulness therapy is now accepted in the NHS is it built up an evidence base to show it helped people overcome depression etc. Keeping evidence is not so out of kilter with the ancients’ tradition – they would also keep track of their ethical progress in journals. You don’t have to measure your daily happiness. You could measure your success at not losing your temper, for example. Epictetus said ‘count the days on which you were not angry’. So keeping track of your progress can be a useful part of the philosophical life.

I look at the utter marginalisation of philosophy in our culture today, and I think it is a pity. I personally believe philosophy is an extraordinary thing, something that can transform and even save lives. I wish more people knew that. Philosophy needs all the help it can get right now, so why knock initiatives that succeed in getting people involved and showing them the wonderful riches within our philosophical tradition?

Let me end with my favourite quote from Seneca, an exhortation to all philosophers great and small: “There is no time for playing around. You have been retained as counsel for the unhappy. You have promised to bring help to the shipwrecked, the imprisoned the sick, the needy, to those whose heads are under the poised axe. Where are you deflecting your attention? What are you doing?”

Philosophy for Life - official website of author Jules Evans -