Philosophy for Life - official website of author Jules Evans -]]>
I’m impressed by Cummings’ cognitive surplus, and the sheer range of his references, from Mendel to Kahnemann, from Thucydides to Nate Silver. The memo covers everything from Big Data to darknets, from ABMs to RCTs, and sometimes reads like the sort of breathless brain-dump of someone who’s stayed up all night watching TED talks on Red Bull.
The memo has grabbed headlines for its criticism of teachers – most of whom are ‘inevitably’ mediocre, according to Cummings, though I think by ‘mediocre’ he just means ‘average’, which is statistically true. It must be annoying for teachers to be constantly criticised by non-teachers like Cummings, but his criticisms are more structural than personal. And he may have a point that our system is being blighted by an acceptance of low standards – we’re now 21st out of 24 OECD countries for literacy and numeracy, and the only country where standards have stalled in the last 40 years.
Beneath the noise, Cumming’s broader suggestion is that we need to develop what he calls ‘Odyssean education’, a term coined by Nobel-prize-winning physicist Murray Gell-Mann to mean a synthesis of the Apollonian skill of rationality with the Dionysian skill of intuition. An Odyssean education would, Cummings says, combine the natural sciences, the social sciences, and the arts and humanities.
This all sounds good to me – I’ve also argued that our education system needs to be broader, needs to specialize less early (I’d prefer the International Baccelaureate to A Levels for this reason) and, at degree level, it needs to be closer to the Scottish or American liberal arts model, perhaps with science majors expected also to take courses in the humanities, and vice versa. I also love the idea of finding a synthesis between the Apollonian and the Dionysian – in a way, that’s what I’m trying to do, having written one book on cognitive therapy and Socratic philosophy (the Apollonian) I’m now researching another on ecstatic experiences (the Dionysian).
My problem with Dominic’s vision, however, is that it’s entirely Apollonian. It’s entirely scientific, rationalistic and technocratic in its focus, without any Dionysiac sense of the value of the arts or religion, or indeed of emotions, beliefs, values, narratives, myths and meaning.
Look, for example, at the seven bold goals that he thinks the education system should fix:
1. Maths and complexity. Solve the Millennium Problems, better prediction of complex networks.2. Energy and space. Ubiquitous cheap energy and opening space for science and commerce.3. Physics and computation. Exploration beyond the Standard Model of particle physics, better materials and computers, digital fabrication, and quantum computation.4. Biological engineering. Understanding the biological basis of personality and cognition, personalised medicine, and computational and synthetic biology.5. Mind and machine. Quantitative models of the mind and machine intelligence applications.6. The scientific method, education, training and decisions. Nielsen’s vision of decentralised coordination of expertise and data-driven intelligence (‘a scientific social web that directs scientists’ attention where it is most valuable’); more ambitious and scientifically tested personalised education; training and tools that measurably improve decisions (e.g. ABMs).7. Political economy, philosophy, and avoiding catastrophes. Replacements for failed economic ideas and traditional political philosophies; new institutions (e.g. new civil service systems and international institutions, a UK DARPA and TALPIOT (non-military), decentralised health services).
Noble aims all of them, but these are all technocratic problems that would be best solved by a super-computer. Indeed, after reading Dominic’s paper, with its 100 pages of complex systems analysis, one imagines the ideal product of his education system would also be a computer, without any messy human emotions clouding its rational analysis.
There is no sense of the value of emotions as motivators for learning, as there is in education theorists like, say, Aristotle or John Stuart Mill. What is an education system without the emotions of wonder, play, tragedy and joy? Nor is there a sense of the need for meanings, myths, and narratives as motivators of human beings – which happens to be the arts and humanities’ strong point.
There is a great deal of genuflecting to American technologists and social scientists (this is typical of our political class, which tends to keel over in awe at any American idea, no matter how faddish) and no mention of our world-leading strength in theatre, movies, art, music, literature, design and computer graphics. We hear a lot about foreign science academies, but there is no mention of the BRIT school, for example, which has managed to produce several of the top-selling artists worldwide in the last decade. The omission suggests this government really doesn’t get the value of English and Welsh arts – neither their value to our economy, nor to our spiritual health as a society, nor for engaging young people and making learning fun.
More fundamentally, there is a yawning meaning-gap at the heart of his vision. It’s a Weberian, technocratic vision of education, dedicated to the smooth and efficient running of the machine, without any clear articulation of what the machine is for, what education is for, what indeed life is for.
Cummings might say that asking what the system is for is teleological thinking, and therefore bad. Plato and Aristotle were guilty of this sort of primitive teleology, he says. The great leap forward into modernity is to abandon teleology, and embrace Darwinian evolutionary thinking. But at least Plato and Aristotle had a clear idea of what the moral goal of their education should be, and what sort of character values it should produce in young people.
Cummings, by contrast, puts his entire faith in scientific thinking. Science and the market have disenchanted the world, led us out from superstitious belief-systems like religion and into godless complex market technocracies. Yet, crucially, he admits that science has ‘not produced ‘a rational basis for morality’.’ So we find ourselves in a complex machine without a morality. We find yourself in what Weber described as a ‘polar night of icy darkness’ – without God, without myths, without meanings or values, even without emotions – simply a machine running on without a driver.
Clearly there is a meanings gap in this vision of education and life. It is an entirely Apollonian system – a system of rational technocratic control or, in neurobollocks terminology, a system dominated by left-brain-hemisphere thinking. To become a truly Odyssean system, it would need to bring in the right-brain hemisphere, the domain of intuition, emotion, the arts, narrative and myth. Cummings has half the system right – he’s just missed out the other half.
Look back to Periclean Athens – it had both the Apollonian rationality of Thucydides, Hippocrates and Socrates, and also the Dionsyiac insight of Sophocles, Aeschylus, Agathon, Pindar, and the cults of Eleusis and Dionysus. Athens managed to find a fragile Odyssean balance between the Apollonian and the Dionysian, or between the sciences and the arts and humanities. Perhaps we can too.
Philosophy for Life - official website of author Jules Evans -]]>
Philosophy for Life - official website of author Jules Evans -]]>
Dumfries is a a squat concrete slab, circled with barbed wire and slits for windows. I was dropped off, buzzed in, and told to leave my bag, wallet, mobile and any valuables at the reception. Then the head of prison education came to meet me, he seemed a nice sort. I followed him through a locked door. And another. And another. He unlocked and then locked about ten doors in the space of 20 metres as we sank into the bowels of the building.
And then, abruptly, I was in a small room with some paintings and drawings on the walls. Inside were about ten men, all wearing orange and brown prison clothes. They were mainly white, English and Scottish, from their early 20s to 50s, with two youngish Pakistanis sitting together at the back, and a black guy with dreads on the right. I said hello, introduced myself, and they all did too. Then I launched into it, about how philosophy had helped me through depression, how it had inspired Albert Ellis to invent cognitive therapy, the Stoics’ idea that our emotions come from our beliefs or perspectives.
I asked, as I often do in these talks, for someone to suggest a moment recently that had upset them, so we could consider what beliefs or perspectives had led to the upset. Complete silence. Maybe it’s not something you admit publicly in prison – what gets to you. So one of the teachers jumped in and talked about how her brother wound her up.
Then I got onto the idea of focusing on what you can control rather than what you can’t. I told the story of Rhonda Cornum, how she had used Stoic techniques to cope with being a prisoner-of-war. ‘When you’re a prisoner, your guards control everything about your life, everything external anyway, except your thoughts and beliefs.’ That got their attention. Stoicism, after all, is very much a philosophy of finding inner freedom in external imprisonment – that’s why it’s inspired various inmates, from James Stockdale to Nelson Mandela.
By the end of the workshop, the front five people were sitting forward and engaged, and I’d got about half of the back row into it too, with two people apparently completely unphased by it all. It emerged that four of them had read my book, and they brought me copies to sign. The black guy told me he’d been about to begin a philosophy degree when he got arrested. He said to me, ‘I like what you’re doing, taking philosophy outside of academia’. I replied ‘if you can practice philosophy when life gives you a serious set-back, and you manage to cope, then you’re practicing at a much higher level than an academic writing in a journal’. I signed his book and wrote ‘Keep going’ in it.
We all shook hands. I was genuinely moved that ancient philosophy seemed to resonate in here, perhaps even more than in academia. I thanked them all for their contribution. ‘Well’, said one old fella, ‘you had a captive audience’. The rest of the class groaned – clearly an old joke. They asked what philosophy book I’d recommend for the library. I thought about suggesting Gramsci’s Prison Notebooks, but decided on Boethius’ Consolations of Philosophy, written while he was on death-row for a false accusation of treason.
Afterwards, I met Nikki Cameron, a teacher in Low Moss prison, near Glasgow. She’s set up a philosophy club in the prison, and she says it’s been hugely popular – it’s running every week now, twice on Fridays, and they get ten or so people sitting round discussing everything from happiness to nothingness to the nature of evil.
Her boss at Motherwell College (which runs further education courses in western Scottish prisons) had given her a copy of my book, and she was excited about the possibility of developing a course on ‘living the good life’, which teaches some CBT self-management tips within more ethical and reflective context of philosophy. ‘Inmates are often conspiracy theorists, and they’re very wary of anything that sounds like a behaviour-change programme’, she says. ‘But philosophy piques their interest and gets them thinking and asking questions.’
Nikki didn’t know of any other philosophy clubs in British prisons. Nor did I, but apparently there is at least one – Alan Smith has been teaching a philosophy class in prisons for 12 years, and has actually just brought out a book about it, called Her Majesty’s Prisoners. The Reader Organisation has also run reading groups in prisons, similar to the Changing Lives Through Literature programme in Texas. There is also something called The Epictetus Club run by Jeff Traylor in the Ohio Penitentiary. I know AA Long has taught classes on Stoic philosophy in San Quentin prison too (in many ways, he’s the Johnny Cash of Hellenistic ethics).
I asked if the Alpha course ran in Dumfries and Low Moss. Carol, one of the teachers at Dumfries, said: ‘Religion is often quite divisive in Scottish prisons. The first question people get asked is, ‘which football club do you support?’, which really means, ‘are you Protestant or Catholic?’ And your answer will decide whether they think of you as one of them or as the enemy. ‘It’s incredibly tribal in here’, Nikki adds. ‘That’s why philosophy brings something new – it gets people thinking for themselves, not just governed by tribal loyalties.’
Religious prison-courses have one advantage, however, which is that they can perhaps offer a form of community to inmates when they go back outside. Carol says: ‘We see a lot of people re-offending in November, so they can be inside over Christmas. This used to surprise me, and I once said ‘what could be worse than being in prison over Christmas?’ An inmate said to me, quick as a flash, ‘there are a lot worse places to be over Christmas than prison, like sitting on your own in a bed-sit.’
For some people, it seems, prison is the closest thing they have to a caring community, and it can be a less chaotic, dangerous and lonely place than the outside world. Could philosophy provide community for them? Perhaps prisons could link up with recovery colleges and other community charities, so that inmates have somewhere to go, socialise, feel listened to, and feed their minds. Perhaps universities could also link up to such colleges, so that there is a steady stream of volunteers prepared to share their knowledge.
I also wondered if philosophy / CBT helps with the really deep stuff, of helping people cope with their guilt or their sense of being unlovable. ‘I think it can’, said Nikki. ‘CBT teaches us that guilt is a destructive habit of thinking.’ But is it always? What if you’ve done something really bad?
I asked what sort of a prison Dumfries is, assuming it was a low-security prison for short sentences. ‘No, it’s a high security prison’, I was told. ‘The class was basically made up of [people who had committed serious crimes, I'm not allowed to tell you what]. They’re people that couldn’t safely be allowed in with the other prisoners.’
This was quite a shock to me. I’d shaken all their hands, even written ‘keep going’ in the front of one of their copies of my book. They had done that? And they were all deeply in denial, keeping the memories of their crimes locked up in the back of their mind, just as the abused often bury their memories out of their consciousness. Could philosophy really help people to confront what they had done? Could it shift their psyches at such a profound level?
And why should we help people who’d done something so awful, so damaging to other people’s lives? It’s not an easy question. I think one can do it for various reasons. One can do it because it seems a bit racy, a philosophy class in prison, with violent criminals, wow! I imagine that wears thin fairly quickly. One can do it because you believe philosophy can change people, even people with deeply-ingrained habits of destructive behaviour. Maybe.
Or you can do it because you believe they have souls too, that it’s worth a shot, and sometimes God can speak to people even through layers and layers of denial, abuse, addiction and sin, and liberate them. Is that possible? Or just another self-serving delusion?
I’m completely new to the whole prison education thing, and I’m sure some of you have a lot more experience, so feel free to share your stories and ideas in the comments.
In other news:
Two pieces in the Guardian about sex trafficking really hit me this week – this one by a lady who was sold into sex slavery by her parents, who now campaigns to help the victims of sex trafficking; and this one, about the Mumbai sex slave economy.
This interesting neuroscience study suggests it has found neural correlates for unconscious thinking.
One of my non-fiction heroes interviewed another this week – Jon Ronson did a profile of Malcolm Gladwell on the Culture Show to discuss his new book, David and Goliath. Fascinating stuff. Ronson also has a story on this week’s episode of This American Life. I’m in awe of his work ethic and how he makes it all seem so shambling and relaxed…like Boris Johnson!
While Ronson and Gladwell have helped to create a golden age of non-fiction, it’s worth remembering what fiction can do for us – according to this study in Science, it improves our empathy and social intelligence, by leaving more up to our imagination. That’s the danger of our increasingly unimaginative and fact-based era.
OFSTED slammed English schools for how badly they teach Religious Education (and PSHE, and basically anything to do with ethics).Teachers don’t get much training in how to teach it. We don’t know how to teach ethics in our schools. This is a serious problem!
One possible approach – teach some practical ethics and wisdom, rather than focusing entirely on theory. Give young people some ideas they can take away and use in their life – like Stoic philosophy! That’s what John Lloyd, the creator of shows including Blackadder and QI, suggests in this interview I did with him, where he talks about how Stoicism (and other philosophies) helped him through five years of depression.
Jonathan Rowson of the RSA discusses the usefulness of the term ‘spirituality’ in this blogpost. I’ve started talking about ‘spiritual experiences’ in some of my talks, and asking the audience if they’ve ever had any. Lots of them have, it turns out – it’s really a hidden world out of there of profound spiritual experiences that people are having, often outside of traditional religious structures. One sane-looking man, at a small talk I gave in Wigtown last week, told us ‘I often have out-of-body experiences, and am increasingly able to steer them’. Crikey! Honestly, once you start asking about these things, in an open-minded way, you hear some amazing stories.
Some upcoming events: I’m talking in Epsom library tomorrow evening, and on Saturday afternoon the Philosophical Society of England has a free event on Albert Camus at Conway Hall in London. And my book is coming out next week in America, without any apparent publicity campaign. Here’s the US edition on Amazon.com. Some kind souls have given it some reviews – thanks for that.
Finally, I really recommend you go see an exhibition at Nottingham University, called Art in the Asylum. It has an amazing collection of outsider art from asylums including Kingsley Hall, Lausanne and Dumfries, including this remarkable drawing by William Bartholomew, an inmate at Dumfries asylum. See you next week, Jules
Philosophy for Life - official website of author Jules Evans -]]>
Philosophy for Life - official website of author Jules Evans -]]>
The question was revisited this week by a moving Panorama documentary called Broken by Battle, made by Sunday Times journalist Toby Harnden, who won the 2012 Orwell Prize for his book Dead Men Risen, about his time with the Welsh Guards in Afghanistan. The programme traced a sharp rise in the number of suicides among troops who served in Afghanistan, and suggested the Ministry of Defence is not doing enough to help soldiers coming home with PTSD.
Toby tells me:
While I was in Helmand, I’d see instances of ‘battle shock’, where soldiers would freeze in battle, curl up into the foetal position, and be helicoptered away. I’d wonder what would happen to them. I’d heard a bit about PTSD, but I wondered if it was real or some slightly nebulous condition like Gulf War Syndrome. But out in Helmand I got to know staff sergeant Dan Collins, who developed PTSD and subsequently killed himself.
The Panorama programme explores how Dan was sectioned in an NHS mental care facility, and what a blow that was to his pride as a brave soldier (the Army used to have its own psychiatric facility but closed it). We are then shown Dan’s last words, recorded on his phone when he had left his wife and retreated to the hills, self-exiled from human society. We see him, desperately alone, wearing his military kit and the bandana he wore in Afghanistan. He apologises to his mum for being ‘a bit selfish’ in killing himself, and asks for a full military funeral. We’re told that, shortly afterwards, he hung himself from a tree.
After writing Dead Men Risen, I moved to the US, and saw the staggering statistics of PTSD and veteran suicide in the US armed forces. They had clearly identified a huge problem there, while in the UK armed forces, the attitude seemed to be ‘nothing to see here’.
So why the dramatic difference in PTSD rates among US and UK veterans? This is where it gets controversial. UK military psychiatrists like Simon Wessely, director of the King’s Centre for Military Health Research, suggests it’s because the British army is older, has more officers and fewer reservists, and shorter tours of duty – all of which implies that if the US did things differently, it would have a much lower level of PTSD among its veterans. US military psychiatrists bristle at such suggestions, and point out that US soldiers were in much heavier fighting in Iraq – only 32% of UK soldiers reported coming under small arms fire, compared with more than 90% of US soldiers.
US psychiatrists also suggest that cultural differences play a role, and that the British ‘stiff upper lip’ means that (in the words of a New Yorker blog) British veterans are ‘less likely to be told they have PTSD. They are more likely, in turn, to end up abusing alcohol or to be given the less controversial diagnosis of clinical depression, according to William Nash, a retired U.S. Navy psychiatrist and co-editor of an influential cross-cultural anthology on PTSD, ‘Combat Stress Injury: Theory, Research and Management.’
Harnden’s view, meanwhile, is that the Ministry of Defence wants to limit its financial liability for PTSD, so it is deliberately underplaying the scale of the problem. His documentary explored how the MoD don’t keep track of PTSD levels among discharged soldiers, nor of suicide statistics once soldiers have left the Army (although a report will be published on that next year). He also showed how veterans often fall between the cracks of the MoD and the NHS. We have a minister for veterans, Mark Francois, but apparently he doesn’t have responsibility for veterans’ healthcare (so what does he do?). The US has a Department for Veterans and the Pentagon spends a huge amount trialling new therapies for PTSD, both in treatment and in prevention.
Harnden also points out that the Kings Centre for Military Health, our main source for PTSD incidence in British soldiers and veterans, is mainly funded by the MoD. The head of that Centre, Simon Wessely, retorts that the Panorama programme was one-sided in its exploration of the issue, and that its ‘shock horror’ statistic that more veterans committed suicide last year than were killed in Helmand is sensationalist rather than statistically meaningful. Simon also suggests that the reason PTSD incidence appears to be going up in UK troops could be because stigma about it is slowly being reduced – which is a good thing.
Both, ultimately, want to help British soldiers, and if PTSD is rising among our troops, that may be because of the intense fighting in Afghanistan in the last few years. So how could the MoD do more for our soldiers and veterans? The families of soldiers who committed suicide have drawn up a petition, which has seven demands:
1) Medical notes should be automatically passed onto GPs after a soldier is discharged. (This is to try to get the MoD and NHS to link up better).
2) The Army should carry out mandatory welfare checks on soldiers every six months after being discharged as per the recommendations of the ‘Fighting Fit’ mental health policy paper drawn up by Dr Andrew Murrison MP.
3) There should be residential units to treat all serving soldiers and veterans suffering with PTSD.
4) Serving soldiers should be able to access NHS services.
5) To reduce waiting lists for veterans seeking help for mental health related issues. Waiting lists are currently too long and it should not be left to charities to deal with this problem.
6) Soldiers should be able to ask for help with mental health issues without it going on their permanent Army records.
7) Soldiers’ families should be informed about the symptoms of Post Traumatic Stress Disorder(PTSD) and other mental health related illnesses.
You can sign the petition here.
Permission to be hurt
If there is still a ‘stiff upper lip’ in the British military, then I’d suggest that the military (and all of us) need to broaden our conception of male strength, to incorporate the Stoic idea that being strong means knowing how to take care of yourself, rather than taking out your problems on yourself and those around you. That definition of ‘Stoic’ is not the same as denying or bottling up your feelings, which is how some people misinterpret stoicism.
Personally, I was diagnosed with PTSD when I was 20, and I bottled it up for years out of a sense of shame at my weakness and foolishness (there was nothing heroic about my wound – I’d done too many drugs). Funnily enough, one of the things that helped me come to terms with my woundedness was a book about shell-shock by my great-grandfather, Lord Moran, called Anatomy of Courage.
My great-grandfather was a doctor serving in the trenches during the Somme. I was particularly touched by one passage where he admitted his own fear and woundedness. He wrote of how, during the Somme, the man next to him was obliterated by a German shell: “I had a feeling as if I was physically hurt though I was not touched, the will to do the right thing was for a moment stunned…The war had never been the same since, something in the will had snapped…At the time I do not think I was much frightened, I was too stunned to think. But it took its toll later. I was to go through it many times in my sleep…Even when the war had begun to fade out of men’s minds I used to hear all at once the sound of a shell coming.”
My great-grandad went on to do great things – he was Churchill’s doctor during the War – but what touched me was that brave moment of vulnerability and candour in his writing. Even though there is a vast difference between him getting shell-shock in the trenches, and me traumatizing myself with LSD, it still seemed to give me a sort of permission to be wounded.
In other news:
Talking of the stiff upper lip, this excellent short essay by GK Chesterton argues that the stiff upper lip was invented by decadent aristocrats in the Edwardian era and that actually manly Brits are fine with sobbing like babies.
Cary Cooper, guru of well-being at work at Lancaster University, has published a massive book called Well-Being: A Complete Reference Guide. So that’s that sorted then.
Here’s an interesting initiative: http://www.philosophydinners.org/
City AM, of all places, looks at the revival of the liberal trivium in education and business.
Daniel Dennett gives an interesting interview on religion, why Jesus is a good role model and why we need secular places that make us feel special and loved.
This week I’ve been pondering whether and how ecstatic / revelatory experiences can be ‘tested out’.
Danny Fox of Frieze considers pretentiousness with reference to Eno and Paris is Burning.
The Stoned Age: were cavemen on drugs? Would the Bronze Age have happened quicker if they weren’t?
Finally, the LA Review of Books reviews an interesting-sounding book by Dutch philosopher Peter Sloterdijk, arguing for a spirituality based on the idea of practice, with the goal of saving humanity from itself. Interesting – although the Nietzchean / Foucaultian idea of spirituality as care of the self, which Sloterdijk draws on, is highly individualistic and ignores the idea of religion as relational – as a relationship not just with your self but with your community and God. It also, perhaps, ignores ecstatic experience and the idea of people feeling a connection with God.
However, the title of the book, You Must Change Your Life, hints at the idea of hearing a divine voice – it comes from a brilliant poem by Rilke, where he stands in front of a headless statue of Apollo, god of prophecy (on the right), and seems to hear a voice telling him ‘you must change your life’. Is that his own projection, or the God speaking to him from the ruins of antiquity? Here’s the poem, ‘Archaic Torso of Apollo’ in translation:
We cannot know his legendary head
with eyes like ripening fruit. And yet his torso
is still suffused with brilliance from inside,
like a lamp, in which his gaze, now turned to low,
gleams in all its power. Otherwise
the curved breast could not dazzle you so, nor could
a smile run through the placid hips and thighs
to that dark center where procreation flared.
Otherwise this stone would seem defaced
beneath the translucent cascade of the shoulders
and would not glisten like a wild beast’s fur:
would not, from all the borders of itself,
burst like a star: for here there is no place
that does not see you. You must change your life.
See you next week,
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 -]]>
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 -]]>