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Monthly Archives: March 2013

Five years of IAPT (Improving Access for Psychological Therapies)

It’s been five years since the launch of the government’s flagship mental health programme, Improving Access for Psychological Therapies (IAPT).

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.

David Clark, left, having some more tea

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.

Peter Fonagy

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,


The Shining: Kubrick’s unheimliche manoeuvre

How do you…fill your days?’
My editor was looking at me with a hint of concern, in a cafe on Portland Street. She was worried I was losing my edge. It had been almost a year since my first book had come out, and still I hadn’t started working on another. Well, I thought to myself. Kubrick didn’t rush his projects. 12 years between his penultimate and final movie. Besides, how could I explain to her or anyone that I’d spent the last four days somewhere else entirely, perhaps in another dimension, also known as the Overlook Hotel.

But I’m getting ahead of myself. It all started on Tuesday.

On Tuesday evening, I watched a film called Room 237. It introduces us to some of the online obsessives who, in the last few years, have put forward complex and often very sophisticated readings of Kubrick’s horror-masterpiece of 1980, The Shining. We hear from six critics, each putting forward a different master-theory of the film: that it’s about the Indian genocide, or the Jewish holocaust, or the faking of the moon landing. Some of the theories are more credible than others, but the film certainly convinces you that Kubrick is playing some strange semantic games.

There’s the question, for example, of whether the ghosts in the hotel are real or just a reflection of Jack’s inner demons. He only ever sees the ghosts when there are mirrors around. Who is the management of the hotel, the higher powers driving him to kill his wife and child? There’s also the weird ending, with the photo of Jack from a party at the hotel in 1921. He is told that he’s ‘always’ been the caretaker. Has he been reincarnated? And who in damnation is that guy in the bear suit?

Then there are the little details that have driven online theorists crazy with speculation. The film is full of continuity errors – furniture appearing then disappearing, photos on the wall changing arrangements. The first scene in the hotel takes place in a room which appears to have an impossible window (see the map below) – as if the hotel’s architecture doesn’t make sense, like a building in a dream. These hints of hidden meanings and codes have driven people to construct theories bringing together every single detail in the film, from typos on the pages Jack writes (‘all work and no play makes Jack a dull boy’) to the cartoon figures on Danny’s bedroom door. Everything becomes soaked with hidden significance.

Re-activating Animism

One way to understand the film is as an exploration of how we have an emotional need to find hidden meanings, as Sigmund Freud discussed in his essay, Das Unheimliche, or The Uncanny. Kubrick and his co-writer Diane Johnson repeatedly read and discussed this essay while writing the script for The Shining.

In his essay, Freud begins by exploring the etymology of the German word unheimliche, the opposite of heimliche which means ‘homely’ or ‘familiar’. He suggests that the uncanny is the fear we feel when the homely is made strange and frightening to us. Freud then explores some of the plot-devices with which Gothic writers produce this feeling in us  – ghosts, dopplegangers, telepathy, curses, apparitions in mirrors, inanimate objects coming to life, events from the past repeated, numbers repeated, symbols and patterns repeated, all of which produce the over-riding sense of “something fateful and unescapable”. Freud suggests that these Gothic plot-devices work on us emotionally because they reconnect us to our pre-modern animist beliefs. The uncanny, he writes, connects us to

the old animistic conception of the universe, which was characterized by the idea that the world was peopled by the spirits of human beings, and by the narcissistic over-estimation of subjective mental processes (such as the belief in the omnipotence of thoughts…the carefully proportioned distribution of magical powers)…It would seem as though each one of us has been through a phase of individual development corresponding to that animistic stage of primitive man, that none of us has traversed it without preserving certain traces which can be re-activated.

Romantic literature attempted to keep alive this old animist paradigm within the scientific-industrial age, and succeeded for a while, but gradually such beliefs came to seem more and more childish to us, and were pushed to the margins of our culture, into nursery rhymes and fairy tales, and then into the ‘low art’ of fantasy, horror, science fiction and comic book culture. Modern men and women duck into the low dives of ‘trash culture’ to re-activate their primitive belief in the spirit-world.

Kubrick recognised this cultural-religious function in sci-fi (he explored animist-religious ideas in 2001: Space Odyssey) and in horror-fantasy. He rang up Stephen King at 7am one morning, in their first conversation, and launched in with ‘I think stories of the supernatural are always optimistic, don’t you?’ King, perplexed, asked ‘why do you think that?’ ‘Because supernatural stories all posit the basic suggestion that we survive death.’ They appeal, he later said, to our ‘longing for immortality’. They also posit the suggestion that there is some higher pattern, some secret dimension, to our banal material existence, which is also perhaps an optimistic idea, even if the secret dimension turns out to be Evil.

Engineering the Uncanny

What Kubrick does in The Shining, and what David Lynch does in his works, is masterfully re-activate these animistic traces and engineer a sense of the uncanny. (Kubrick made the crew watch Lynch’s Eraserhead before making The Shining to give a sense of the mood he wanted to evoke, while Lynch’s Twin Peaks is clearly influenced in turn by The Shining). Take Kubrick’s repetition of certain numbers. Freud noted:

we of course attach no importance to the event when we give up a coat and get a cloakroom ticket with the number, say, 62; or when we find that our cabin on board ship is numbered 62. But the impression is altered…if we come across the number 62 several times in a single day, or if we begin to notice that everything which has a number – addresses, hotel-rooms, compartments in railway-trains – always has the same one, or one which at least contains the same figures. We do feel this to be ‘uncanny’, and unless a man is utterly hardened and proof against the lure of superstition he will be tempted to ascribe a secret meaning to this obstinate recurrence of a number…

Kubrick seized on this idea for The Shining. The cover of his edition of Stephen King’s novel is covered with scrawls of him trying to work out ways to use the number 217, which in King’s novel is the hotel-room where Danny and Jack see a witch (it’s changed to the number 237 in the film).

Kubrick’s copy of Stephen King’s The Shining

Kubrick repeats the number 42 throughout the film – on Danny’s shirt, on the number-plate of Hallorann’s car. When Danny and his mum are watching TV, it’s showing a film called The Summer of 42. The numbers 2, 3 and 7 when multiplied together make 42. The stools in the bar where Jack meets the ghostly barman are arranged in a group of four and a group of two. And so on.

Kubrick also plays with mirrors, twins, dopplegangers and doubling to suggest hidden connections between figures – Danny is connected by telepathy to Hallorann, Jack is haunted by the ghost of the previous caretaker Grady, or maybe he is the previous caretaker. David Lynch did the same sort of thing in Twin Peaks – Laura is doubled with her evil doppleganger from the Red Room, and also with her cousin Maddy. Her father Leland is also Bob, who appears when he looks in mirrors. In the Red Room, the giant is doubled with the dwarf, who speaks in reverse in a sort of mirror-language, just as Danny does when he chants Red Rum. Both Kubrick and Lynch also use garish carpet patterns to suggest hidden patterns in reality (they should have opened a store together: Uncanny Carpets).






The Uncertainty of the Uncanny

At the heart of the uncanny is a confusion of the self and its boundaries. The philosopher Charles Taylor suggests that in the modern secular age we all have ‘buffered selves’ that are walled off from nature and from each other. In the animistic age, we had ‘porous selves’, selves without firm boundaries, invisibly connected to each other by thoughts, energies, elective affinities, and also connected to the spirit-world, capable of being invaded by  benevolent or malevolent spirits. In the modern world, we are autonomous agents trying to figure out what to do in an indifferent universe. In the animist world, we are the creatures of the Fates, threads in some cosmic pattern of Good and Evil.

The uncanny is a particularly modern emotion, however, because it rests on an ambiguity and uncertainty about whether there is a natural or a supernatural explanation for the eeriness of the atmosphere. The Bible is not an uncanny work because it is very clear that all the supernatural events are the work of God or the Devil. There is no ambiguity. The Shining is an uncanny work because there is this uncertainty. This is what initially drew Kubrick to King’s novel. The ghosts appear at the corner of our eye, at the margins of our modern rational consciousness.  The events in the Overlook Hotel could be explained in secular Freudian terms as fantasies emanating from the hidden violence in the Torrance family – Jack’s murderous anger and Danny’s Oedipal rage. The Shining could simply be a story of male domestic violence against women and children. Likewise, Twin Peaks could simply be a drama about an incestuous family.

Kubrick complicates matters further by introducing a political level of significance. The violence in the film could also point to the historical violence of white Americans against Indians (the hotel is on an Indian burial-ground and there are Indian symbols around the hotel) or African slaves, or the Nazis against the Jews (42 was the year Hitler began the Genocide). Or the film could simply be a story of how the political elite (the hotel management and its powerful guests) use stooges like Jack for their state-sponsored mass murders – look, in the final photo, how Jack’s hand seems to be held up by the rich people around him. He is their  puppet, their errand-boy.

Can we escape the past?

Is The Shining really an optimistic film, as Kubrick suggested all horror stories are? On one reading, the film could suggest humans are trapped in cycles of violence, frozen in sin like Jack at the end of the film,  doomed to repeat our crimes over and over. On the other hand, Danny and his mother escape the Overlook Hotel. Danny is not lost in the maze – he retraces his steps and gets out. Perhaps we too can escape history.

Perhaps the film suggests that we’re at risk when we overlook things, when we forget the crimes of the past – like Dilbert Grady apparently forgetting that he killed his wife and children. Art holds a mirror up and show us our dark side, reminding us to take care, showing us a way out of the maze like Ariadne’s thread or Perseus’ mirror-shield.  Kubrick said: “There’s something inherently wrong with the human personality. There’s an evil side to it. One of the things that horror stories can do is to show us the archetypes of the unconscious: we can see the dark side without having to confront it directly.”

Or perhaps that is too neat and utilitarian an explanation of art’s power, and art is in fact more dangerous than that. The uncanny, after all, is a dangerous emotion. Once activated, how can we be sure it will stay within the bounds of art and not spill out into reality? How can we be sure we will not ourselves be possessed by the old belief-system and find ourselves back in the demon-haunted world we thought we had left behind?

Kubrick wrote: “Freud said that the uncanny is the only feeling which is more powerfully experienced in art than in life. If [horror] required any justification, I should think this alone would serve as its credentials.”  For better or for worse, we crave the uncanny. We have a deep emotional need for patterns of meaning and intimations of immortality. Freud would say that was the vestige of our primitive self, Jung would say it was our true self seeking its Maker.

Either way, modern life does not that satisfy this emotional need for the uncanny, so we turn to art, and to The Shining. We try to decipher Kubrick’s intentions as if he was God, and every detail of His creation is a clue to His meaning. Like lost souls, the acolytes haunt the Kubrick archives at the University of Arts London, which I imagine as a vast warehouse containing an almost infinite number of crates. And in one of those crates, perhaps, lies the key.


In other news:

John Gray is our next guest at the London Philosophy Club, on April 9. You can sign up here.

How useful would randomised controlled trials be in public policy, in areas like education for example? The debate rages on the internet, as Michael Gove dismisses ‘bad academics’ for blocking evidence-based policies, while some academics suggesting there are risks to thinking everything can be quickly solved by an RCT. Rebekah Higgit summaries the debate and provides lots of useful links here, while Evgeny Morozov warns of the risk of ‘solutionism’ in public policy, in his new book reviewed here.

Teenagers used to define themselves by whether they liked Blur or Oasis. Now they define themselves by whether they own Mac or Samsung, argues this piece. And, to prove how chic geekdom has become, Owen Wilson and Vince Vaughn’s new film sees them become hapless interns at Google. Sounds…pretty dire!

I’m working on an article looking at five years of Improved Access for Psychological Therapies (IAPT), the British government’s flagship mental health policy which has brought CBT to the masses. Here is a good blog by a therapist looking at the data coming out of IAPT. And here’s a good new article in Philosophy, Psychiatry and Psychology looking at the limits of evidence-based medicine in psychiatry (behind a pay wall alas).

A philosopher and psychologist debated whether psychology was a science or an art on Radio 3’s Nightwaves this week. The debate then rumbled on for days on Twitter…for all I know it’s still going. The discussion is 34 minutes in here.

Some new books. My friend Tom Chatfield from the School of Life has a new book out called Netymology, a dictionary for tech language. Another friend, Tom Butler-Bowden, has a new book out called 50 Philosophy Classics – I’ll publish an interview with him soon. I’m still reading David Esterly’s book about wood-carving and philosophy  – it’s really brilliant. I admire David a great deal.

Finally, here’s a Tumblr that made me laugh a lot this week – a collection of lousy book covers from the world of fantasy fiction. Enjoy, and see you next week.