The Many Roads to Ordinary Happiness
by Jane McChrystal
Concerned about government mental health proposals to favour a single method of counselling and psychotherapy, Dr. Jane McChrystal makes the argument for diversity in the means to pursue ordinary happiness
Regular readers of the British newspaper, the Observer, may well be aware of the New Deal for depression and anxiety disorders proposed by Lord Layard, an economist, who this year, 2008, heads the Well-being Programme at the London School of Economics. First heralded in a leader of June 2006 as a policy to “alleviate misery for many”, the New Deal has been adopted enthusiastically by the government, particularly as a means of ending long-term unemployment amongst those suffering from mental health problems and getting them off incapacity benefit. In October 2007 Alan Johnson, Secretary of State for Health, announced the release of £170 million to implement Layard’s proposal for the launch of an army of 10,000 psychological therapists into England’s GP practices, workplaces, job centres and voluntary organisations. The therapists will be trained in the delivery of a brief course of cognitive behavioural therapy (CBT) designed to help their patients with depression and anxiety disorders.
A policy which proposes to make talking therapies available to people who would usually be offered medication or nothing at all, surely this can only be a good thing? (*)
First, I must declare an interest. What follows is written from my perspective as a psychotherapeutic counsellor with sixteen years’ experience of helping people who come to me from their GP with a diagnosis of anxiety and/or depression. This position has given me some insight into the wide variety of difficulties faced by people who consult with their GP for mental health problems, and the different ways in which they can be helped.
The insistence on CBT as the treatment of choice for all originates from the Depression Report’s reliance on NICE guidelines. The National Institute for Clinical Excellence is the body set up to recommend which treatments should be delivered within the health service on the grounds of scientific evidence for their effectiveness. NICE proposes that talking therapies can be just as effective as a course of medication. The use of CBT with its focus on attaining practical goals and obtaining symptom relief, has produced the kind of evidence which NICE is prepared to regard as reliable. The therapeutic effects of CBT can be most easily converted into numerical terms and subject to statistical analysis, for example counting and comparing symptoms of depression before and after treatment.
While it is entirely reasonable to fund talking therapies from tax payers’ money which have an evidence base, lack of scientific proof for therapies other than CBT might be a sign of a lack of research findings rather than their ineffectiveness. It is true that adherents of other therapeutic models, especially in Britain, have dragged their heels over producing evidence for their effectiveness. However the CORE (www.coreims.co.uk) system has gathered good evidence for the effectiveness of a range of therapies, including CBT, delivered in health and other settings to 33,000 people. There are many highly qualified, experienced psychological therapists providing a wide variety of treatment options, many of them already working in the health service. Why, then, should future government funding be concentrated on the provision of one form of therapy provided by fairly inexperienced therapists, when it could be used to enhance existing therapy services?
At this point I can imagine the reader assuming that I am merely indulging in a bit of special pleading based on professional interest, but there is more at stake here. I believe it would be a grievous error to direct public money available for the talking therapies towards the creation of a psychotherapeutic monoculture. CBT has an evidence base and is highly acceptable to anyone who wishes to reduce symptoms of anxiety and depression. It is rooted in the idea that emotional distress is the result of distorted beliefs about the self and the surrounding world, which cause disturbing feelings with adverse effects on the individual’s behaviour. The practitioner of CBT works on identifying and revising those beliefs in order to attenuate troubling feelings and enable the individual to achieve positive behavioural change.
However, unhappiness, and how we view it, takes many forms. It seems reasonable, then, that professional responses to it should be as varied. Some of us feel overwhelmed by feelings such as fear, sadness, anger and shame which must be given their due before we can even start to think about practical goals. Some of us are troubled by past experiences, which feel impossible to leave behind without some means of making sense of them. Some feel driven to repeat patterns of destructive behaviour for unknown reasons. Some are disturbed by the unease stirred up by philosophical questions about the purpose of our existence. Many of us are distressed by relationships that don’t work.
Most of us are unlikely to respond to a therapy which is inconsistent with our view of our unhappiness. Humanistic therapies, with their emphasis on the here and now, might suit those troubled by overpowering feelings. Psychodynamic therapies can help those struggling with impulses originating from the past, which are not held in the conscious awareness. The more philosophically inclined might benefit from an existential approach. Each of these therapeutic approaches will enable people to work on relationships in a way which is meaningful to them.
Aside from the argument that it would be a grave mistake to direct all future efforts in the development of the public provision of psychological therapy to CBT, I would also like to return to the idea that a brief intervention provided in accordance with Layard’s proposals will provide a panacea for the mental health problems of the long-term unemployed. I believe this may turn out to be a vain hope, as the kind of mental health difficulties associated with long-term unemployment are usually too complex and deeply embedded to respond to the ten sessions proposed in Layard’s plan.
Layard’s proposal forms the foundation of the government’s Increasing Access to Psychological Therapy (IAPT) initiative. If we are going to see the development of a national psychotherapeutic service which is truly accessible by virtue of its diversity and sensitivity to individual need, it will demand a more flexible response from those who commission and practise talking therapies. Commissioners need to be aware that arguments about the supremacy of one psychological therapy have long been superseded in the wider world by studies of what makes effective therapists and how good therapeutic relationships develop. Practitioners of therapies other than CBT need to participate actively in the kinds of research likely to demonstrate their strength and enter the political arena prepared to talk in a language which is understood there.
If the professionals can open up to new ways of thinking, anybody who approaches Mental Health Services in future can be assured that there will be a therapy that works for them, rather than the provision of a ready-made solution suitable for some.
* What is CBT?
Cognitive Behavioural Therapy is based on the idea that we are not troubled by the world we live in but rather by the way we see it. In other words it is our beliefs about self, others, and our environment that cause disturbing feelings and trigger dysfunctional patterns of behaviour. The individual who seeks help from the Cognitive Behavioural Therapist can expect a collaborative, educational approach. Initially therapist and client will work to identify those beliefs which cause negative thoughts and feelings, and hold them up for examination. Are they accurate? Are there any alternative views? Some time will be spent on identifying the origins of mistaken beliefs but most of the work focuses on the present. Once the distorted beliefs are out in the open the clients are expected to do homework between sessions. They will monitor beliefs and how they affect thoughts, feelings and behaviour using worksheets and diaries. They are expected try out new ways of viewing problematic situations and initiating new adaptive behaviours learnt at a later stage in therapy. For example a client with panic attacks will learn that a racing heart or breathlessness is a physiological reaction to stress not a sign of imminent death. S/he may then learn from the therapist how to control anxious feelings through breathing exercises. This should lessen the need to resort to maladaptive reactions to anxiety such as avoiding the situations which usually activate symptoms of panic. The goal of the therapy is to equip the client with a new set of skills which s/he will be able to take into the world independent of the therapist. CBT does not aim to bring about fundamental shifts in the individual’s personality but to extinguish symptoms, mitigate overwhelming feelings and set in motion new adaptive behaviours. It is time-limited and of relatively short duration depending on symptom severity. Practitioners claim to be able to treat everything from depression to schizophrenia.
©Dr. Jane McChrystal, February 2008
Jane McChrystal is a London-based psychotherapeutic counsellor and her particular research interests are in attachment difficulties and their effects on mental health. She is currently involved in the development of a primary care-based brief psychotherapy service in north London.