Philosophy for Life - official website of author Jules Evans -]]>
There have been exceptions to this emotional illiteracy in liberal philosophers, says Nussbaum. Rousseau imagined a ‘civil religion’, which would fuse the people together in ecstatic worship of the state (his ideas bore fruit during the French Revolution in the bizarre Cult of Reason.) The social scientist Auguste Comte also developed his own eccentric ‘Positivist religion’ which he planned to impose on the citizenry in his ideal state.
But Nussbaum finds these solutions unsatisfactory. Any sort of imposed religion – theistic, civil or positivistic – is illiberal and probably doomed to failure. Following Rawls, Nussbaum believes the state should not impose any ‘comprehensive theory of the good’ onto its populace. Nonetheless, she thinks it proper for a liberal state to encourage certain pro-social emotions as a psychological foundation for political stability. Rational utilitarianism isn’t enough – we need a more full-blooded ‘enthusiastic liberalism’.
Nussbaum is not alone in this desire for a more emotional politics. There has been a revival in the last two decades of Aristotle’s contention that it is the proper role of the state to encourage eudaimonia, or flourishing, in the citizenry. One finds this idea in a spate of books and articles on the politics of happiness, well-being and virtue over the last 20 years, by the likes of Richard Layard, Geoff Mulgan, Jeffrey Sachs, Derek Bok, Robert and Ed Skidelsky and others.
There has also been a growing interest in ‘political theology’, or the role of religion (whether theist or atheist) as an important cultivator of political emotions, in thinkers as diverse as Ronald Dworkin, Roberto Unger, Alasdair MacIntyre, Maurice Glasman, Jonathan Haidt, John Gray and Simon Critchley. The philosopher Alain de Botton has even started his own ‘religion for atheists’, while Lord Layard has launched a grassroots movement called Action for Happiness. There is a growing sense that liberal societies need more than rational skepticism, that we either need to return to religion (see the current popularity of the Pope and Archbishop Welby among political reformers) or to find some secular alternative.
Let’s say we accept the proposition that liberal societies are failing to promote the proper emotions, and this is threatening their long-term survival (this is a big claim, and Nussbaum does not do enough to back it up). Let’s say we accept her list of ‘good’ emotions and ‘bad emotions’ (are shame and envy necessarily bad for the polis? Protagoras and Adam Smith might disagree). The question remains: how can governments promote emotions in their citizens, without becoming cultish and totalitarian? What policy levers are available to the budding political psychologist, keen to promote certain emotional states in the citizenry?
Nussbaum rightly recognizes that if politicians really want to reach into the souls of their citizens and stir their emotions, they need the arts and humanities: symbols, metaphor, gesture, rhetoric, poetry, music, dance, monuments, architecture, festivals, pageantry, all the cultural apparatus that the Church wielded so expertly before the Reformation and Enlightenment tore it down as so much superfluous bunting.
With her usual critical acuity, she provides close readings of various works of art – the patriotic poetry of Whitman, the songs and dances of Rabindranath Tagore, Mozart’s Marriage of Figaro – to show how deftly they cultivate pro-social emotions in the audience while never becoming fanatical. However, none of these works of art were ‘ordered’ by politicians. They arose spontaneously from the genius of their authors. Artistic genius is unpredictable, the muses tend to resist clumsy advances by politicians. So how can policy-makers directly work with the arts to try and cultivate political emotions? Don’t they have to leave artists alone to experiment?
Politicians can at least recognise that the arts play an important role – not just in earning money for the ‘creative economy’, but more profoundly in making us who we are, in shaping our emotions and national identity. Politicians can create conditions in which artistic talent is more likely to arise, and help to educate a populace to a level where it’s capable of responding to great art.
They can do this by encouraging the teaching of arts and humanities in schools and adult education, and by supporting artistic institutions and allowing them to take risks. Nussbaum looks to John Stuart Mill’s inaugural address to the University of St Andrews, in 1867, in which Mill highlights the importance of ‘aesthetic education’ in schools and universities as the foundation for a sympathetic, liberal ‘religion of humanity’. Nussbaum would also include dance classes in her ideal education, as they were in the Tagore school where her friend Amartya Sen grew up. I completely agree – Plato argued that dance has a central role in our emotional education, and it’s sad that schools give so little space to dance (or indeed, to sport).
A second policy tool available to the budding political psychologist is rhetoric. Nussbaum analyses the speeches of Martin Luther King, Churchill, Lincoln and Franklin D. Roosevelt to show how cleverly they cultivated the political emotions appropriate to the crises their countries faced. Today, by contrast, politicians speak in tweet-like soundbites. There’s a lot to be said for trying to raise the bar of political rhetoric in our time, although the presidency of Barack Obama show that rhetorical prowess is no guarantee of successful government.
A third policy lever available to the political psychologist is urban planning (as another new book, Happy City, explores). Nussbaum provides clever readings of emotionally literate public spaces, such as Chicago’s Millennium Park and the Lincoln Memorial. However, the rising cost of living space (in London, particularly) arguably has a much bigger impact on people’s well-being than any park or monument.
Despite these examples, my abiding impression of Nussbaum’s book is of the disconnect between academic philosophy and the emotional lives of ordinary people, even with an unusually ‘public’ philosopher like Nussbaum. Her close readings of the Marriage of Figaro or the tragedies of Sophocles are interesting, but alas our citizenry is not as culturally sophisticated as the citizenry of fifth century Athens (we don’t have the luxury of a large slave population to support our leisure), and while there is a mass audience for high culture, it is still a minority. Today, the main aesthetic cultivators of the public’s emotions are pop music, cinema and television. Yet these are strangely absent from Nussbaum’s cultural analysis (she doesn’t listen to pop and probably doesn’t watch television).
Some philosophers have considered the cultural and emotional impact of pop culture – Roger Scruton in Modern Culture (2007), Carson Colloway in All Shook Up: Music, Passion and Politics (2001), Allan Bloom in his 1987 book, The Closing of the American Mind. But these philosophers cast the most cursory of glances at pop culture before dismissing it with a Platonic sneer as barbaric and infantile. This is a pity. The two most successful recent examples of art shaping our political emotions in this country were the Queen’s Diamond Jubilee Concert in 2012 and the Olympic Opening Ceremony the same year. In both of them, pop music played a key role. For good or ill, TV has also profoundly shaped our national psyche, far more than any opera or monument.
Another strange absence from her book is any discussion of psychotherapy and psychiatry – two policy levers by which governments can influence their citizens’ emotions. Aldous Huxley imagined a state where the citizens were pacified through soma. Today, the NHS spends $2 billion annually on mood-altering chemicals, including 50 million prescriptions for anti-depressants. The government has also spent over half a billion pounds on talking therapy, particularly Cognitive Behavioural Therapy, to try and reduce levels of depression and anxiety disorders in the population. CBT, as I’ve explored, was directly inspired by the Hellenistic philosophies that Nussbaum has done so much to revive, and is a way for many ordinary people to discover ancient philosophy.
Oddly, Nussbaum has never discussed CBT in her books, and has been very dismissive of Positive Psychology. She has made valid criticisms of Positive Psychology – it’s overly fixated on optimism, and can be illiberal and dogmatic when politicians try to impose it on their citizens without their consent. And yet for all their flaws, CBT and Positive Psychology have brought the ideas of Socratic philosophy to millions of people, which is more than can be said for any academic philosopher.
Nussbaum neglects to consider at any length the importance of religions to political emotions (again, for good and ill). She is rightly wary of governments imposing any particular religion onto its citizenry. Yet policy makers can still try to work with faith groups, as say the anti-slavery campaign and the Jubilee debt campaign did so successfully. As Jonathan Haidt has explored, if you really want to generate ‘enthusiasm’ in the populace, you will probably need to tap into areas of the mind usually reached by religion. It’s notable how many of the figures she celebrates are, in one way or another, religious: Whitman, Tagore, Gandhi, Luther King. We are moved by the sacred, which is a tricky thing for a secular liberal philosopher like Nussbaum.
Political Emotions is an important contribution to an already impressive body of work. Nussbaum has transformed modern philosophy, helping to re-connect it to the emotions, to psychology, to the arts, and to public policy. She has been a defining influence in the rise of the Neo-Aristotelian idea that philosophy, including political philosophy, can and should transform our emotions.
And yet Political Emotions is curiously unemotional, dense, and unlikely to get the pulse racing. It opens the way for ‘further research’ (that phrase beloved of academics) and for no doubt interesting papers, seminars, conferences and books by other academics on the political emotions. But can philosophers not merely discuss the public emotions, but actually affect them? Maybe so – but to do so, they will need to venture further beyond the safety of the Ivory Tower and into politics and popular culture.
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.
Philosophy for Life - official website of author Jules Evans -]]>
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.
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.
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,
Philosophy for Life - official website of author Jules Evans -]]>
Philosophy for Life - official website of author Jules Evans -]]>
It seems our country is increasingly weight-obsessed. Every day, a newspaper article waggles its finger in our face, telling us that 22% of Brits are obese. It’s not just the UK – globally, over-eating is now killing three times as many people as malnutrition, according to a report published in The Lancet in December. We need a new kind of charity fundraiser: Don’t Feed The World, or Enough with the World-Feeding Already, where the developing world audience will be shown moving video montages of over-weight westerners. ‘This is Homer. Homer hasn’t seen his toes for five years. For just £1, you can help us swap Homer’s doughnuts for celery.’
Humans have always worried about their diet. The Greek philosophers thought what you ate was a key part of the good life, and therefore of ethical philosophy. In fact, diatia means ‘a way of life’, suggesting the Greeks thought a wise diet has to be part of a whole ethical framework. ‘Eat to live, don’t live to eat’, said Socrates, he of the pot-belly.
Over-eating and corpulence has long been a problem, but it tended to mainly affect the upper classes, simply because everyone else had to work so hard. Over-eating particularly affected French kings, like William the Conqueror, who became so fat in his 40s that he set himself a diet of only drinking booze (it didn’t work), or his son, Henry I of England, who died from eating too many eels.
While the upper classes got fat, the lower classes struggled with the threat of starvation, and this threat lasted in western countries well into the 19th century, when Thomas Malthus wrote his Essay on Human Population, in which he speculated that famine and pestilence would always keep our numbers in check:
The power of population is so superior to the power of the earth to produce subsistence for man, that premature death must in some shape or other visit the human race. The vices of mankind are active and able ministers of depopulation. They are the precursors in the great army of destruction, and often finish the dreadful work themselves. But should they fail in this war of extermination, sickly seasons, epidemics, pestilence, and plague advance in terrific array, and sweep off their thousands and tens of thousands. Should success be still incomplete, gigantic inevitable famine stalks in the rear, and with one mighty blow levels the population with the food of the world.
He was a cheery old soul, Malthus.
Even in the 20th century, a large proportion of our population faced constant hunger and malnutrition. My distant ancestor, Seebohm Rowntree, researched how many calories a day a worker needed in order to stave off malnutrition. He then discovered that many workers in Britain were not paid enough to acquire that basic diet, and that over a quarter of people in his native York lived below the calorie-poverty line. He used that evidence, gathered in his great work Poverty, to campaign for the introduction of a minimum wage and the eventual introduction of unemployment benefits and other state protections.
From austerity to affluence, and back again
Yet in the post-war boom, within a dizzying period of 15 years, western countries went from staving off the threat of starvation, to trying to cope with the new problems of affluence: anxiety, addiction, consumerism and consumer debt, body-image disorders and over-eating. It was in the second half of the 20th century that dieting became big business – Weight Watchers was set up in 1963 by a Brooklyn housewife called Jean Nidetch before eventually becoming a global conglomerate with $1.5 billion in annual sales. Gyms also became big business in the 1960s, like Gold’s Gym, founded in 1965.
The post-war neo-liberal individual tried to discipline themselves, manage themselves, govern themselves in the age of affluence. But all too often, the age of affluence won, we simply couldn’t resist all the high-fat, high-sugar, high-sodium products waved before our noses. And our bellies got bigger and bigger.
In the last 20 years, obesity has become a political issue. It’s an issue right at the heart of the politics of well-being, a politics which in some ways challenges neo-liberalism and suggests that governments have a greater and more interventionist role to play in guiding us towards the good life. Obesity, from one perspective, represents a failure of liberalism: a failure of individuals to be the rational governors of their selves. Edmund Burke said: ‘Men are qualified for liberty in exact proportion to their disposition to put moral chains upon their own appetites.’ If we are incapable of controlling our appetites, does the state have to step in to control them for us?
The issue is particularly salient in European countries where there is some form of nationalised health service – because in that instance, obesity is the result of people’s personal life-choices, but the economic consequences of those life-choices are socialized. And now we’re in the age of austerity, we’re wondering if we can afford to pay for the ills of affluence. The Department of Health estimates that obesity costs the NHS £5.1 billion a year. That’s half of what we spend on higher education annually. Rather than paying for young people’s education, we’re paying for obese people’s diet.
What could be done? One possibility is introducing ‘fat taxes’ on junk food, or ‘soda taxes’ on fizzy drinks. At the moment, higher calorie foods are cheaper than healthy foods, but a tax would change that and could lead to a change in public consumer habits, much as higher taxes have led to a steep decline in smoking. Fat taxes have proved very controversial, however. Attempts to introduce them in the US have so far failed (two cities in California were the latest to reject a city-wide ‘soda tax’ in November last year, after an intense lobbying campaign by Coke, Pepsi and others), while Denmark introduced a ‘fat tax’ in 2011, only to abolish it a year later.
Then there are more direct methods governments can take – Mayor Bloomberg of New York has introduced a ban on extra-large containers for fizzy drinks, which comes into effect in March. Others in the US have called for food benefits to only be usable for healthy foods. In the UK, David Cameron has considered introducing a junk food tax, while Labour’s shadow health secretary Andy Burnham called this weekend for statutory controls on the amount of sugar, fat and sodium in foods, including children’s cereal.
And a new report published by Westminster Council this week suggested that benefits could be tied to the amount of exercise people took. It writes: “the increasing use of smart cards for access to leisure facilities…provides councils with a significant amount of data on usage patterns. Where an exercise package is prescribed to a resident, housing or council tax benefit payments could be varied to reward or incentivize residents.’ Yes, the next time you go to pick up your benefits, they’ll say ‘I’m sorry sir, the computer says you only spent ten minutes on the jogging machine this week.’ Run, man! Think of the kids!
Such efforts are controversial partly because they often, as in Jamie Oliver’s ‘food revolution’, involve middle-class people telling working-class people to buck up their ideas and get a grip. As satirical website the Daily Mash put it:
From April all benefit claimants will be fitted with a headset so they can be controlled by a middle class person who is trained to know what is best for everyone. The headset will be attached with stainless steel screws and a probe will enter the brain via the ear. Electronic pulses delivered via a Department for Work and Pensions satellite will then be used to control every aspect of the poor person’s lifestyle. A spokesman said: “You can’t stay fat if your brain is being controlled by someone who went to university.
There is some truth to this satire. Obesity is to some extent correlated with income and poverty, perhaps because high calorie foods are cheaper than health foods, because state schools have worse sports facilities than private schools (they often no longer have any facilities at all), and because if you’re depressed or unemployed you’re more likely to be overweight, and the strongest predictor of depression is poverty. However, obesity is also rising among middle and upper income populations.
Some claim that the ‘war on obesity’ has been manufactured, like other wars before it, to give political elites an excuse to intervene in others’ lives, as the Thinifers invade the Fattypuffs in the children’s book. It’s a politics of superiority and revulsion at an imagined fat other, who should be punished for their lassitude. Some suggest that public health officials are being alarmist, and that in fact there is no strong link between Body-Mass Index or BMI, and mortality risk. In fact, the statistics suggest that if you are slightly overweight, you are likely to live longer. So should doctors be telling the fit to grow slightly fat?
Others suggest that the obsession with dieting and body-image is making us all miserable. James Watson, discoverer of DNA and one of our greatest living scientists, thinks the plump may be happier and even better in bed, because their higher-fat diets produce more of a hormone called MSH. Watson became interested in MSH after hearing of a scientist who injected himself with it to try and get a tan, and who instead got an eight-and-a-half-hour erection. ‘I now look at fat couples in a totally different way’ says Watson. ‘When you see two thin people together you know they’ve got problems.’
It is a strange situation we’re in. The fatter America gets in reality, the more its media sells America a thin fantasy for the populace to gaze at. It’s the same in the UK, to some extent – my friend, a newsreader, was told to shed the pounds to go on CNN, and in my local gym, I am constantly flanked by the BBC’s Gavin Esler, toiling away to preserve our thin national persoa. Go Gavin go!
Fighting this supposed body-fascism is an American organization called NAAFA, the National Association for the Acceptance of Fat Americans, which organises conventions, summer camps and fashion shows. Their events attract a certain amount of thin men who, er, like their girls big. There are also several dating websites for the overweight and ‘chubby chasers’, called things like Cuddly Free and Single.
I do think NAAFA have a point, and that our society sells us an image of thinness, then various high calorie consolations for not meeting that image. Still, I wonder what history will make of our era, in 50 years, when the world is warmer, arable land is shrinking, and we are wondering how to feed the nine billion. Anyway, in the meantime, I’m going to stick to my exercise plan for a few more weeks, not out of any Puritanical sense of self-loathing, just because exercise makes me feel good, whatever Watson says. Besides, my diet plan is not particularly spartan. It comes from the first-ever published guide to battling obesity, from 1864:
For breakfast I take four or five ounces of beef, a cup of tea, a biscuit and dried toast.
For dinner, five or six ounces of fish or meat, and two or three glasses of good claret.
For tea, fruit.
For supper, three or four ounces of meat, with a glass or two of claret.
For nightcap, a tumbler of grip, or a glass or two of claret.
This plan leads to an excellent night’s rest.
Time for another claret I think…
In other news:
Here is an NYT write-up of a great study in Science magazine by Harvard’s Dan Gilbert and others, showing to what extent we underestimate how much we will change in the next ten years – a fallacy Gilbert calls ‘the End of History illusion’.
Here’s an interesting critique of the Skidelskys’ book, ‘How Much is Enough?’, from a philosophy professor at Notre-Dame. He thinks the Skidelskys have not quite found the right balance between liberal autonomy and the Greeks’ idea of the good life, and have missed out the crucial role of liberal education. It is education that teaches us to govern ourselves and find happiness in the wisest ways (an important issue in the battle against obesity). In which case, the question becomes how best to provide quality education to everyone, not just until they are 21, but afterwards. Why is adult education so far down the policy radar at the moment!
Anyway, British universities have launched their own MOOC platform (MOOC stands for Massive Open Online Course) called FutureLearn. The CEO is the person who set up the BBC’s iPlayer. Exciting development – I’ll try and get an interview with him for this blog.
Here is a good TED talk by Rene Gude, a leading Dutch philosopher, who is battling cancer and who recently had a leg amputated. TED without the bullshit.
Here’s an interview with Nassim Nicholas Taleb being typically crotchety:
I’ve enjoyed Melvyn Bragg’s latest series on Radio 4, called The Value of Culture, which explores the idea of culture from Matthew Arnold to Raymond Williams to Roger Scruton (although no women discussed, as a friend pointed out). It’s available on iTunes if you’re outside the UK.
Well, that’s it for this week. Welcome to the new subscribers, and thank you to people who have bought my book. It just came out in Croatia. Keep spreading the word in 2013.
Philosophy for Life - official website of author Jules Evans -]]>