|Post Qualification Training in Selective Ignorance: a report from two recent national conferences for therapeutic psychologists
The Midlands Psychology Group * The proceedings of two recent national conferences for therapeutic psychologists suggest that in this supposedly scientific field, science in fact comes a long way behind professional interest.
What keeps ignorance alive or allows it to be used as a political instrument? These are the questions posed by the sociologist Robert Proctor, in his discussion of ‘agnotology’ – a new academic field which asks how selective ignorance is maintained in the world of culture, politics and science and who benefits from this state of affairs (Proctor, 2008). This paper describes two recent conferences in the UK psychotherapy world as case studies in this field.
The first such conference, ‘Against and For CBT: Towards a Constructive Dialogue’, took place at the University of Roehampton in November 2008. This was billed as a constructive dialogue between advocates of CBT and those who are sceptical about the theory and practice of this approach - and particularly about the way in which it is being promoted throughout the NHS and indeed the English speaking world as the most evidence-based and effective of all psychological treatments. It was no accident that this conference coincided with the UK government’s promise to invest in the Improving Access to Psychological Therapies (IAPT) initiative. This is a 650 million pound per year programme designed to make ‘psychological therapy’ (in fact largely CBT) readily available to anyone in the general population of England and Wales, and officially the programme has two key aims. These are first, to halve the reported levels of depression and anxiety and their associated medical treatment bills and second, to move 25,000 distressed people away from Incapacity Benefit and back into work by 2011 – thus paying for the cost of the IAPT programme itself and saving the Dept of Works and Pensions many millions of pounds into the bargain (Layard,2006). The IAPT scheme therefore marks the first attempt to render psychological treatment an instrument of public policy-making, and for the British New Labour government, it is the money-saving aim that is likely to be paramount (see for instance, Pollock, 2009). The IAPT development therefore also marks the transformation of psychological therapists
* John Cromby, Bob Diamond, Paul Kelly, Paul Moloney, Penny Priest, David Smail and Janine Soffe-Caswell
into overt servants of political power – into DSS operatives, charged with the task of reducing the length of the queues for government sickness payments. According to current plans, by 2012 we will see ten legions (10,000) of IAPT therapists spread across 250 teams throughout England and Wales, all of whom will be using a highly standardised manual to treat nearly a million patients during the first three years of the project alone (National Mental Health Development Unit, 2009). This is therapy on an industrial scale.
After many years of lobbying by clinical psychologists at the Institute of Psychiatry and at Oxford and UCL, CBT has achieved market dominance. For the many therapists and clinical psychologists who work in the public sector and who do not describe themselves as CBT practitioners, the IAPT initiative is a threat in both professional and economic terms. It has rekindled longstanding (and unresolved) debates about the aims of therapies, how they are said to ‘work’ and how their effects should be measured and understood. It was these questions that ran throughout the entire conference, together with a more fundamental issue that, as we shall see, was not raised once by any of the assorted counsellors, psychologists and psychotherapists in attendance.
The first speaker arguing ‘For’ CBT, Professor Windy Dryden, described how his own clinical experience had shown that the approach was easy for people to understand and to apply in their daily lives – a practical form of personal problem solving. He also described research that claims to show that clients who get the most out of CBT are those who attribute change to themselves, rather than to their therapist - showing that CBT offers powerful techniques for personal development, which place the client in the driving seat of their own treatment.
The second ‘for CBT’ speaker, Isobel Clarke, continued with the themes of user friendliness, pragmatism and flexibility - sketching how she had learned to shape CBT to the exigencies of an inner city psychiatric service in which many clients had long been struggling with deep-seated anguish and despair. For many such individuals, psychological therapy had marked the first time that a mental health professional had bothered to enquire about the substance of their distressing experiences - hitherto dismissed as the meaningless symptoms of their faulty neurochemistry. These so-called psychotic experiences spoke directly of the troubled individual’s history, fears, aspirations and deepest emotional and spiritual needs. Indeed, she outlined how for many clients, it had been possible to fruitfully combine cognitive behavioural techniques with the spiritual practices of East and West - including Buddhist mindfulness meditation.
This concern with the subjective experience of the individual must surely be an advance upon the indifference of a biomedical psychiatry, in which the idea of listening to patients’ accounts of their distressing experiences was long held to be anathema. As a psychological therapy, however, there seemed to be little to distinguish this version of CBT from those that elide into that vague entity known as ‘integrative therapy’: a melange of empathic support, relaxation techniques and collaborative enquiry combined with selective advising and challenging of the patient’s more dysfunctional thinking styles (Beutler, Consoli and Lane, 2005; Norcross, 2005). Furthermore, it seemed unlikely that clients who were beside themselves with loneliness, fear or despair would find the kinds of supportive relationship described by Dr Clarke to be unhelpful, at least in the short term. There is a large body of evidence to suggest that people who are perceived as warm and concerned are likely to have a positive impact upon the people that they work with. However, this is a long way from saying that the techniques of CBT are responsible for any changes in the client’s mental state, or indeed that paid-for affection of this kind is likely to resonate beyond the period of clinical contact - as both of these speakers seemed to assume (see, for example, Epstein, 2006).
The first speaker against CBT, Professor Andrew Samuels - took up the theme of evidence from a psychodynamic perspective – challenging the field’s longstanding reliance upon rigid quantitative outcome measures, few of which captured the fluidity and subtlety of the therapeutic encounter or left much room for the client to express their own views. This speaker also highlighted how CBT could sometimes serve, unwittingly, as a vehicle for falsely encouraging people to believe that their distress was an entirely individual matter, isolated from what was happening in the wider social and political world around them.
Samuels did not question the assumption – shared by the two ‘pro’ CBT speakers – that this approach represents a lucid treatment framework, founded upon a solid body of theory and research. And yet, as the second speaker arguing against CBT, Professor David Pilgrim outlined, these taken-for-granted notions cannot withstand the briefest historical scrutiny. Instead, he showed that when this approach is examined from a historical perspective, it is revealed as a self-contradictory mishmash of psychiatric ideas, behavioural techniques, crude clinical pragmatism and post hoc justifications from the academic discipline of ‘cognitive psychology’ – or at least those bits of it that can be made to fit with the claims of the therapists. In other words, CBT is a ‘tradition’ rather than a distinct modality, owing most of its success to its appeal to a superficial rationalism and to the promise of delivering ‘cheerful efficiency’: the theme tunes of government, of work and of personal life in the post-modern era.
Rather than leading to the intense debate that might have been expected, however, these views were met with a mild acknowledgement of what seemed to be both sides of the argument. Perhaps therapeutic psychologists simply suspend their critical faculties when faced with awkward questions.
In the Q and A session the audience had more opportunity to ask questions and to debate key themes. Predictably, a split opened up between those who advocated the flexible use of psychological techniques aimed at restructuring thinking and behaviour and those who placed more emphasis upon therapy as a supportive relationship, in which the therapist made use of their intuitive understandings to help the client to arrive at their own insights. As the discussion progressed, however, this division seemed to be papered over into a consensus that all reflective therapists seek to cultivate a strong alliance with their clients as either a platform or medium for change, and that thoughtful practitioners will differ only in the weight that they give to this relationship. This outcome was as disappointing as it was inevitable. It seemed virtually certain that this group of well meaning speakers would arrive at a rough concordat of this kind - the orthodoxy of the bulk of the early 21st century counselling world. What this conference lacked was any hardcore CBT protagonist, willing to defend their approach as the self-evident champion amongst unequals.
A further sign of this polite avoidance of real debate was the way in which occasional critical observations were met with a flat and uncomfortable silence, to be rapidly and nervously filled with a more congenial topic. Rather in the way that some families avoid talking about embarrassing subjects at the dinner table. An example of this occurred where one audience member asked the panel for their thoughts on the solid research evidence which shows that professional therapists are no more effective than untrained paraprofessionals. Now this is indeed a weighty issue, which cuts to the heart of the many arguments about the professionalisation of psychotherapy and claims for its ability to ‘cure’ (Howard, 2005). What resulted, however, was a muted response from one of the panellists on the need for psychotherapy research to more actively investigate the potency of ‘non-specific effects’. Any further awkward questions were quickly avoided, as some of the discussants turned with apparent relief toward the possibilities offered by non-Western or ‘new paradigm’ healing practices. Long ignored or dismissed by positivist psychology, these potent therapies based upon a combination of counselling, therapeutic touch and massage could be highly effective – owing to quantum mechanical ‘non local interactions’, ‘action-at-a-distance’ and ‘non linear causation’ derived from ‘chaos theory’. These extraordinary claims were met not with incredulity, but with a round of enthusiastic applause, though even Dr Who might have demurred.
There were more reflective and even amusing observations. For instance, one speaker noted how history shows that most therapies are enthusiastically adopted when they are new (‘as the latest thing’) but then gradually become the focus of disillusionment as their limitations become more apparent. This was likened to the end of the honeymoon stage in a romance, when we start to realise that our adored one is merely human after all – encapsulated by the moment when they fart loudly in our presence for the first time. For some of us, this speaker observed - though perhaps with questionable accuracy - CBT had not yet farted. Welcome though it was, this dose of humour only helped to avoid discussion of the most fundamental question: whether any form of therapy could be shown to be effective at all.
The second conference was the annual event organized by the BPS’s Division of Clinical Psychology, which took place in London in December of 2008. The billed highlight was a presentation of the main findings and future plans for the government’s IAPT initiative. In keeping with the odorous theme, this conference could be described as redolent of a more upmarket aftershave. Something to complement (or perhaps conceal) the self-consciously corporate and ‘on-message’ air of the whole event, which seemed to take place in an over-lit and determinedly optimistic world, located somewhere between a party political presentation and a car salesperson’s convention. In the midst of the tasteful functionality of the conference suite at the national TUC headquarters, half a dozen of the main researchers and promoters for the IAPT programme assembled together upon the podium to hold forth on the ‘business case’ for the ‘national rolling out’ of their project. The audience was treated to a series of slick PowerPoint presentations in which a rapid succession of brightly coloured tables, photographs and flow charts flicked by - as in a train ride at the fun-fair: all the while portraying the heady intricacies of ‘stepped treatment’, ‘low versus high intensity therapy’ and ‘clinical outcome’. If all of this sounds more like advertising than science then that’s because it was. We were seeing the marketing of the profession of clinical psychology and of its latest product.
There was no mention of the many serious conceptual and methodological flaws that lie at the heart of the IAPT programme. At the broadest level, when Layard accurately identifies the wider social environment – especially inequalities in wealth and the effects of unbridled consumer capitalism – as the key causes of distress, why have the government and the clinical psychology profession chosen to focus so intently upon individual psychological therapy as a major key to these problems? This is particularly puzzling, because there is so much evidence that progressive social policy in regard to taxation, housing, work and family life would have a far greater impact upon the wellbeing of the population than could ever be achieved through the piecemeal provision of individual therapy (Wilkinson and Pickett, 2009). There was no mention of the fact that the IAPT outcome measures themselves are based upon psychiatric diagnoses such as depression, which - according to many academic researchers and current NICE guidelines – are unsatisfactory because they lack both coherence and validity (NICE, 2004). Indeed, the more recent editions of these guidelines have downgraded the value of this specific diagnostic category, on the grounds that it offers few useful clues as to the nature, causes or treatment of misery (NICE, 2009). Furthermore, as the description of the previous conference has made clear, there are deep questions as to whether the psychological therapies, including CBT, amount to proven technologies of personal change in the way that Layard and his supporters from within IAPT clearly assume.
In the brief Q and A session that followed with a participant audience of perhaps sixty people, only two delegates seemed willing to put these points to the panel. Instead of answering these questions, however, one professor simply asserted the proven effectiveness of CBT and then denied that there was any evidence to suggest that redistributive social and economic policies might offer the best tools for tackling widespread unhappiness. Likewise, the panel refused to address the issue of diagnosis-driven treatment, restating their unshakable faith that the therapies on offer would be of proven effectiveness and that that, quite simply, was that. For anyone who was hoping for informed debate this was not a satisfactory response. And yet if others in the audience harboured similar doubts they did not declare them. Rather, the attentive and respectful silence of the participants suggested that many - perhaps most - of the delegates were impressed, or perhaps too browbeaten to dissent from the official line on IAPT. It was only after the close of the session that one psychologist privately confided that she and many of her colleagues had many misgivings about the clinical and ethical value of the IAPT programme. While this expression of doubt was reassuring, what does it say about the scope for openness and debate within a profession that is supposedly based upon a respect for evidence and for truth?
Both of these conferences illuminate the connections between manufactured ignorance and professional interest, which ensure that certain fundamental difficulties are never addressed. In the first example, the proliferation of ever more convoluted debates successfully obscured any hint of the main issue. This had the effect, in the end, of lulling everyone into a polite consensus that was as insipid as it was self-congratulatory. In the second conference, ignorance was maintained through the construction of a huge edifice of spurious certainty, backed up by institutional and political power. These kinds of practices are not the exclusive preserve of psychology and can be found in many other fields of scientific endeavour – including dietary health promotion (Taubes, 2004), global warming (Oreskes and Conway, 2008) and environmental toxicity (Michaels, 2008). When it comes to self-interest, being a psychologist makes us no more immune from self-deception than any other group – professional or otherwise. Perhaps we should spend less time elaborating and defending complex theories of psychological change which have little basis in demonstrable reality. Instead, to paraphrase Robert Proctor, we should focus more of our energies upon thinking about the conscious, unconscious, and structural production of ignorance, its diverse causes and conformations, whether brought about by neglect, forgetfulness, myopia, extinction, secrecy, or suppression (Proctor, 2008.p.17). Now that would make an interesting topic for a conference.
Beutler, L. E., Consoli, A. J. & Lane, G. (2005). Systematic treatment selection and prescriptive psychotherapy: An integrative eclectic approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of Psychotherapy Integration (2nd ed., pp. 121-143). New York: Oxford.
Epstein, W. (2006) The Civil Divine: Psychotherapy as Religion in America. University of Nevada Press.
Howard, A (2005) Counselling and Identity. London. MacMillan.
Layard, R. (2006) The Depression Report: A New Deal for Depression and Anxiety Disorders. The Centre for Economic Performance’s Mental Health Policy Group. London. London School of Economics.
Michaels, D. (2008) Doubt is their product: How industry's assault on science threatens your health. London. Oxford University Press.
National Institute of Clinical Excellence (2009) CG90 Depression in Adults: Full Guidance – interim proof copy. http://www.guidance.nice.org.uk/CG90/pdf/English Retrieved 12th November 2009.
National Institute of Clinical Excellence (2004) CG23 Depression: management of depression in primary and secondary care. http://www.guidance.nice.org.uk/CG23/pdf/English Retrieved 23rd December 2004.
National Mental Health Development Unit (2009) IAPT Programme Responds to the Observer Article (4 October). http://www.nmhdu.org.uk/news/iapt-programme-responds-to-the-observer-article-4-october/ Retrieved 12th November 2009
Norcross, J. C. (2005). A primer on psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 3-23). New York: Oxford.
Oreskes, N. and Conway, E. M. (2008) Challenging Knowledge: How Climate Science Became a Victim of the Cold War. In, Proctor, R. and Schiebinger, L. (Editors) Agnotology: the making and unmaking of ignorance. Stanford, California. Stanford University Press.
Pollock, A. (2009) NHS Plc: The Privatisation of Our Health Care. (Second Edition) London. Verso.
Proctor, R. (2008) Agnotology: a missing term to describe the cultural production of ignorance (and its study). In, Proctor, R. and Schiebinger, L. (Editors) Agnotology: the making and unmaking of ignorance. Stanford, California. Stanford University Press.
Taubes, G. (2004) The Diet Delusion: Challenging Conventional Wisdom on Diet, Weight Loss, and Disease. London. Vermillion.
Wilkinson, R. and Pickett, K. (2009) The Spirit Level: Why More Equal Societies Almost Always Do Better. Harmondsworth. Penguin.
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