Marketising the Mental Health Crisis: How the CBT Empire-Builders Colonised the NHS

Andy

Andy

Senior Member (Voting rights)
Just before the general election, a colleague and I met shadow health secretary Jonathan Ashworth’s team to make the case for scrapping the government’s flagship talking therapy service, Improving Access to Psychological Therapies (IAPT).

It would have been a long, hard sell, even to a left Labour government. Politicians, NHS bosses and the media have been singing the praises of short term cognitive behavioural therapy (CBT) for years. And, for Labour, after all, IAPT is one of its own, launched in 2008 by Tony Blair’s ‘happiness tsar’ Lord Richard Layard, and trumpeted around the world as a sort of miracle cure for common mental health conditions.

Under the Tories, scrapping IAPT will be a lot harder.

IAPT is designed to provide psychological therapies at primary care level for the NHS throughout England. It was rolled out during the financial crash, and amid all the austerity cuts and empty promises for mental health services, its funding has quadrupled to nearly £400m a year over the last decade. It rapidly replaced most other counselling and psychotherapy provided by GP practices and the third sector – closing hundreds of locally based services and forcing others to convert to its short-term, number-crunching regime. IAPT, inevitably, is increasingly an outsourced provision populated by private companies.
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https://novaramedia.com/2020/02/17/...ow-the-cbt-empire-builders-colonised-the-nhs/
 
Very clear-eyed article. Literally the minimum level of wisdom that can be qualified as "more than complete foolishness" made it very blatant this was a pie-in-the-sky delusion, especially that it would lead to any cost-savings.

And this very important point given the MUS movement:
At the same time, IAPT services are rejecting an increasing number of people as ‘unsuitable for treatment’ – with symptoms too complex, too severe or too enduring to help them meet their target recovery rates.
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Mental health services are barely capable of helping people with genuine mental health needs as it is. At best it's a crapshoot and at worst it's basically the same kind of "benefit" that a bartender has for millennia: just someone who listened (although the without judgment part is lacking here). They are completely unequipped to deal with illness and as such people with complex long-term conditions are essentially booted out of medical practice and onto services that then refuse them because if they did take them it would completely obliterate their mandated targets for "recovery".

There is a clear obsession with working the numbers, whose only purpose is to allow the service to continue. This is blatant in the 50% recovery target, as pie-in-the-sky as cost-savings are. Those numbers simply cannot be achieved while meeting the pretend goals of the program. This means IAPT-style services will ALWAYS refuse, bury, reject or otherwise select those patients out of even their own stats.

They literally have no choice. If they take LTC patients their numbers will tank, as will morale. So this shift towards IAPT for LTCs literally cannot happen, the services will simply weed them out at triage simply for having to maintain the fiction of 50% "recovery", which has been allowed to be redefined as those users who complete the service. By having those patients not complete the service, they do not harm the target numbers. So the patients essentially disappear while the service continues marketing 50% "recovery", which they assure by cheating.
 
We never have got to the bottom of how David and Wessely - I discount the initial role of Chalder and Butler on the basis of their qualifications, not their sex- came up with the idea of CBT and GET in 1989, or before that, as the paper was published in 1989. Clearly the idea of anxiety and depression must have come from Goldberg, and that of CBT and GET from Gelder but the means of transmission has not, so far as I know, been identified.

Presumably SW must have been part of a team subject to oversight by a consultant, but I have never seen a reference as to whom that might have been.
 
Interesting that this sort of critique is only coming from people even further into the psychotherapy scam. This guy seems to be a born-again Jungian into all sorts of magic. He is threatened by IAPT because it is 'too medical'.

Still, civil war amongst psychosocialists may not be a bad thing.
 
Jonathan Edwards said:
This guy seems to be a born-again Jungian into all sorts of magic.
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I agree that he finds IAPT threatens longer-term psychotherapeutic relationships, and he is identified as a Jungian. Are the "scam" and "born-again Jungian into all sorts of magic" observations something you got from the text, or just what you think of Jungians and the purported benefits of psychoanalysis or long-term psychodynamic therapy?
 
I don't know about the author or what sort of evidence their is for any therapy that they'd prefer, but the piece seemed worthwhile, and it's good to have these sorts of concerns being aired to different audiences. There are therapists from a range of background who think that they should take a cautious approach to claims about efficacy, and instead just offer themselves as independent people who can be used to talk problems through with - some people will want to be able to access something like that, even if it's more a form of social support than any sort of treatment. (Having said that, I just looked up Jungian therapy as I always get those old schools confused: it's one of the ones that seems heavy on the loopiness).

I looked at the website of the organisation he's linked to, and found this from Millions Missing: https://freepsychotherapynetwork.co...sing-campaign-may-12th-2018-me-awareness-day/

There seemed to be quite a bit of good stuff on there imo.

The Novara piece links to this critical review of Layard's book in the Guardian that makes some fair points... I'd missed that and thought that the Guardian was still consistently chowing down on that BS:

Layard says that we can trust people’s statements about their mental state because there is a “good correlation” between what they say, and “objective measurements taken from the brain”. This, the footnote suggests, refers to a 1990 neuroscientific experiment by Richard Davidson: test subjects were shown short emotional films and the electrical activity in their brains measured. Yet this concerns not the background “life satisfaction” that Layard is trying to assess, but transitory emotional responses to a stimulus. It doesn’t back up Layard’s methodology. It just invokes, as the book often does, the irresistible authority of brain science. Layard is no less slapdash in drawing his inferences. Where he finds a correlation, he immediately infers causation. Findings show that a child’s happiness is strongly correlated with which primary and secondary school she attends. The author concludes that teachers and classroom methods are the main drivers of childhood happiness. He does not entertain the alternative hypothesis that attendance at a specific school is correlated with other social factors giving rise to emotional problems, such as poverty. This approach becomes jarringly recursive.
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https://www.theguardian.com/books/2...appier-richard-layard-review?CMP=share_btn_tw
 
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dave30th said:
Are the "scam" and "born-again Jungian into all sorts of magic" observations something you got from the text, or just what you think of Jungians and the purported benefits of psychoanalysis or long-term psychodynamic therapy?
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Some of the arguments in the text about medical models allow the magic bullshit to show through but I admit that I have already formulated a view on people who call themselves Jungians. One of my best friend's mother was a Jungian psychotherapist and the devastation wreaked by the mumbo jumbo played out over a period of fifty years. For me being a psychotherapist is itself one of the more egregious forms of psychopathology in everyday life.

But I am not disagreeing with the fact that this is a useful critique. One of the things that intrigues me about metaphysics (the philosophy of reality, which I dabble in) is that religious people often critique the foundations of intuitive beliefs more thoroughly than atheists. It is as if having an unshakeable belief makes you less hesitant to explore because you know you have right on your side. Jungian beliefs are untouchable because they are 'known' to be based on archetypes embedded in prior reality. I actually think there is some truth in the archetype idea, but not its usage by Jung.
 
Funny personal story: I went to therapy early on in my illness when I accepted the idea proposed by family members that it was a psychological problem (I was young and naive). I now recognize that the psychiatrist had a psychoanalytical orientation and the therapy sessions involved her waiting for me to say something. To avoid awkward silence, I told her what I thought she wanted to hear because I didn't actually have any real psychological difficulties, but that only meant having to dig deep to search for them, right? The therapy did nothing whatsoever, but the therapist was convinced it was working very well and that I should have continued. It was a total scam.

This is one reason why I find the lightning process so concerning. Another is that youg people might actually seriously believe that they ought to be able to control the illness with their mind (and either live a lie or feel like they are failing terribly for not being able achieve this supernatural power).
 
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At the same time, IAPT services are rejecting an increasing number of people as ‘unsuitable for treatment’ – with symptoms too complex, too severe or too enduring to help them meet their target recovery rates.
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Well its quite obvious that if you make mental health mean anything you want you can be selective in a cohort to meet a 50% recovery rate target.

All you need is people like Prince Harry banging on about mental health 3 times a day in the news and you can convince almost everyone that everything they experience every single emotion, every difficulty in their lives is a mental illness.

Round them all up for a course of behavioural therapy to tell them they have to report feeling different to feel better and then at the end of a three session interaction with a computer screen you collect the "feedback" and declare them better or still mentally ill if they are still experiencing stuff in their lives.

Meanwhile people who have real needs continue to have the same needs whatever they may be.
 
I think this paragraph gives away the muddled thinking behind the author's stance:


Insisting on a medical model of diagnosis, with an ‘expert-imposed’ treatment plan, may work well most of the time for physical health care. But it is often a disaster for mental health, where you need the client to actively understand what is happening and for them to be able to relate to the practitioner, for any real, beneficial change to take root.

Getting a patient to understand what is happening has nothing to do with whether or not you have an expert-imposed protocol. Patients need to know whatever the situation. Same for relating to a practitioner. The second sentence has nothing to do with the first.

And what an 'expert-imposed' plan really means is a plan that has been authorised by people who have scrutinised some decent evidence. So the author is really arguing the opposite - that you should not follow evidence of efficacy. Which of course is a bit strange in the context of the rest of the article that is all about the evidence being dodgy.

In essence the author wants to believe that the best treatment is what the therapist feels is going to be best, drawing on 'experience'. But this is exactly the argument put up by psychotherapists to counter the absence of evidence in PACE. Moreover, PACE shows that the effect is so small that experience would not be able to pick it out.
 
Jonathan Edwards said:
In essence the author wants to believe that the best treatment is what the therapist feels is going to be best, drawing on 'experience'.
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Yes, I agree that is squishy. But that is essentially what all psychotherapists do, in whatever modality they're working in. Since I've benefited--or believe I've benefited, or experience myself as if I've benefited--from psychotherapy, I can't come down hard on all such approaches. But it certainly doesn't seem like the various practices are backed by legitimate or robust research.
 
dave30th said:
Since I've benefited--or believe I've benefited, or experience myself as if I've benefited--from psychotherapy, I can't come down hard on all such approaches.
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I strongly suspect that some counsellors or therapists put people's lives back together and do real good. On the other hand I know of cases where lifelong harm has been done. In general the harm seems to stem from theory-based approaches rather than just pragmatic help.

So it may well be that the do what you think best pragmatic approach is right and trials are a waste of time but this guy seems to wanting to argue both ways, to a degree.

Maybe standard trial formats are just no use for quality control for counselling. But some sort of quality control is needed if harm is going on.

I think what one should come down hard on is the sort of thing in the IAPT training objectives about how trainees should finish knowing how to apply theoretical knowledge to the individual case. This is pure pseudoscience. It might be better if the objective was that trainees should finish realising the depth of our ignorance about what is best.
 
I have no expertise and maybe wading in where I don't belong but it seems to me that people who have legitimately experienced benefits from psychotherapy do so despite the various theoretical constructs the therapist has learned and uses in practice.

IMO it depends more on the kind of person the therapist is and their maturity and experience along with openness to new information and flexibility in how things move forward.

Too many therapists rely too heavily on taught constructions of reality without questioning their validity.
 
I did eventually benefit from psychotherapy in a certain sense because years later, a different therapist said something to my family (I don't know what exactly) and they treated me better from there on. I don't think I actually benefitted from the therapy itself.

In my view a problem is that therapists are erroneously convinced that unexplained illness is something they can treat and understand. That view makes it harder to help people with unexplained illness.
 
Snowdrop said:
I have no expertise and maybe wading in where I don't belong but it seems to me that people who have legitimately experienced benefits from psychotherapy do so despite the various theoretical constructs the therapist has learned and uses in practice.
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I don't think any of us have expertise! So we are all wading up to our midriffs.

I agree.

The problem is how do you recruit trainees and at the end of the MA course say - 'sorry Mr Doogooder but you are the wrong sort of chap for this, you won't do anyone any good'. And who decides? Maybe Professor Bloocardy with all the funny theories decides.
 
Jonathan Edwards said:
I don't think any of us have expertise! So we are all wading up to our midriffs.

I agree.

The problem is how do you recruit trainees and at the end of the MA course say - 'sorry Mr Doogooder but you are the wrong sort of chap for this, you won't do anyone any good'. And who decides? Maybe Professor Bloocardy with all the funny theories decides.
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Yes, admittedly there are no easy answers.

I do think it might be useful at the teaching level to admit to rather more limitations of treatment than presently. But that doesn't solve much either.
 
Not sure how to frame this, but isn't there a large amount of contradiction/hypocrisy going on.

The campaign to get people to talk about their mental health issues started long before the pandemic and now is beginning to reach pandemic levels in itself (certainly here in the UK). Everyone seems to want to talk about their mental health and are being encouraged and praised for doing so.

And yet, the same crowd promoting this campaign relentlessly criticise those with physical illnesses for 'obsessing' about their symptoms or having 'unhelpful illness beliefs'.
 
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