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On English melancholy

An academic got in touch with me last week, inviting me to a seminar on Stoicism, which was nice of him. On the seminar programme, he described me as ‘an author of books on happiness’. Alas I’ve only written one book (one that was published anyway), and it’s strange to have it described as ‘on happiness’. My friends, when they’re introducing me, also often say something like ‘he writes about well-being’, or ‘he writes about happiness’. And at the philosophy festival, How The Light Gets In, I was actually described as a ‘happiness guru’, which sounds pretty horrific – I think if I ever encountered a ‘happiness guru’ I would shoot them on sight, then mount their head on my living room wall.

I suppose I did have a blog called The Politics of Well-Being, and I do run something at Queen Mary called The Well-Being Project, and I have written quite a lot about the fad for measuring happiness (though usually from a sceptical point of view). It’s strange, anyway, to be thought of as a writer on happiness, as I’d say I naturally have quite a melancholic disposition – and I’m OK with that, and feel no need to try and dispel the occasional mists of melancholy so the sun shines unremittingly.

I believe there is a fine English tradition of melancholy. You see it particularly in English music – many of our greatest pop musicians are deeply melancholic. Think of Damon Albarn, who has described himself as ‘an English melancholic’, and songs of his like The Universal or End of the Century (or the wonderful album title ‘Modern Life is Rubbish’). Albarn even wrote a song called Melancholy Hill (Oasis, by contrast, don’t seem a melancholic band at all).

Pulp’s Jarvis Cocker also has a wonderful melancholy streak in him, so does Pulp guitarist and mournful crooner Richard Hawley, so does Badly Drawn Boy. Further back, Morrissey discovered a rich vein of poetry in English melancholy – and also discovered the humour in it, the reveling in the downbeat (‘I was looking for a job and then I found a job, and heaven knows I’m miserable now’). Paul Weller, Elvis Costello, even Sting all tap into that melancholy vein. Pink Floyd had it in spades – particularly the song Time, which, if you think about it, is an incredibly downbeat song for a rock band at the height of their popularity:

Every year is getting shorter
Never seem to find the time
Plans that either come to naught
Or half a page of scribbled lines
Hanging on in quiet desperation
Is the English way
The time is gone
The song is over
Thought I’d something more to say

Alison Goldfrapp, mistress of melancholy

The uber-melancholist of the 1960s would have to be Ray Davies of the Kinks – I wonder if English melancholy in pop was in some ways a rebellion against US culture? The Beatles could tap into it too, particularly John Lennon, though Paul McCartney’s For No One is sublimely melancholic, as is Eleanor Rigby of course. The Stones seem much less in tune with that mood. Nick Drake is a perfect embodiment of the melancholic bard.

And then there are all those melancholic minstrelettes: Amy Winehouse, Adele, Alison Goldfrapp, Laura Marling – compare them to, say, Rihanna, Avril Lavigne, Lady Gaga, or Katy Perry. Their American counterparts don’t do melancholic. Lana Del Rey tries but comes across as mawkish. OK, some contemporary American female singers are masters of melancholy, like Cat Power. But they tend to be at the margin of American pop these days. In British pop, they’re still front-and-centre.

'Always Dowland, always miserable'

English song-writers have themselves traced this melancholic vein in English pop back to the Elizabethan era. Damon Albarn, for example, looks back to Dr John Dee, and the link between Saturnian melancholy and creative power. Sting has performed a concert of the songs of John Dowland, the famous melancholic bard of the Elizabethan era, whose motto was ‘Semper Dowland, semper dolens’, or ‘always Dowland, always miserable’.

Why does this strain exist in our culture and temperament? It could be connected to the weather, to the seasons, and particularly to this time of year, when summer changes into autumn (‘it is November when the English begin to hang themselves’ was apparently a common saying on the continent in the 18th century). Robert Hooke, one of the founders of the Royal Society, believed he could plot his melancholy by tracking it against weather patterns.

But there are melancholy strains in other cultures too – think of German Romanticism and The Sorrows of Young Werther, the ennui of Baudelaire, the Jewish tradition of kvetching, the strain of Japanese melancholy found in the novels of Haruki Murakami, the Russian melancholy of Chekhov and Lermontov, the blues of African-American music.

Anton Chekhov: 'A fine day to hang oneself'.

Really, then, melancholy is a sort of patchwork global construction, and English melancholy has certainly drawn on these other national variations (English pop drew heavily on American rhythm and blues, English comedy has drawn on Jewish kvetching, and English literature has drawn on Russian and German melancholics like Chekhov and WG Sebald).

While Nietzsche famously declared that ‘humanity does not strive for happiness, only the English do that’, I’d suggest English melancholy is much older and more prevalent than the Benthamite cult of happiness to which Nietzsche was referring. And I like the melancholy strain in our national character. I like the poetry it has led to, the humour, the mysticism. I like the scepticism of melancholia – the wise sense of human limits, human fallibility. The melancholy awareness of death and impermanence make life more beautiful, more poignant. I don’t think we should try and drive it out of our national psyche, like St Patrick driving out the snakes from Ireland.

At the same time, of course, you can indulge in too much melancholy and it turns into the sort of crippling depression that hit Coleridge, for example, and disabled his creative powers. Melancholy’s a bit like drugs – a little bit of it appears to be good for creativity but indulge too much and you incapacitate yourself (or even kill yourself). I think one can celebrate English melancholy, and also celebrate therapy. I don’t see Cognitive Behavioural Therapy as some sort of American invasion, some attempt to transform our national psyche and turn it into one big smiley face. After all, CBT came from Stoicism which is, let’s face it, a fairly melancholic philosophy. That’s probably why melancholy English thinkers like Matthew Arnold are so fond of it.

CBT prevents the mists of melancholy from turning into the storm-clouds of violent depression, when our negative beliefs turn into prisons, and (in the words of Thomas Gray in 1742), our mind “believes, nay, is sure of everything that is unlikely, so it be but frightful; and on the other hand excludes and shuts its eyes to the most possible hopes, and everything that is pleasurable; from this the Lord deliver us!” Amen to that.

Anyway, here is a Spotify playlist I have made of English melancholy pop. What have I missed out?

Since I wrote this, I heard about a new book called This Will End In Tears: A Miserabilist Guide to Music. Sounds brilliant! Here’s a video interview with the author:

Sweden opens up CBT monopoly, gives nod to psychodynamic therapies

Psychodynamic therapists of the world, rejoice! After years of complaining that CBT sucks up all the public funding, it seems that psychodynamic therapists may be about to get a break – in Sweden at least.

For the last four years or so, Sweden’s government has put substantial funds (around £200 million according to one source) into CBT provision and CBT training. Now, it looks like the government’s National Board of Health and Welfare, Socialstyrelsen, has accepted that psychodynamic therapies are as effective as CBT at treating depression – which experts say is likely to lead to the introduction of government support for psychodynamic therapies.

This is significant for UK mental health policy, as our government has also put substantial funds into CBT, and is facing a similar dispute from psychodynamic therapists who claim that practice-based research shows that all therapies work equally well in the field – therefore they should all get funding, not just CBT.

Rolf Holmqvist

The shift in Swedish policy is in part due to the work of Rolf Holmqvist, professor of clinical psychology at Linköping University, whose research suggests that just about every form of talking therapy is equally effective when used in the field. He’s written an article in the new issue of Socionomen, the journal for social workers in Sweden, in which he presents his latest research. Rolf agreed to be interviewed to explain his findings and their implications. I should say at the beginning that I’m a big supporter of CBT and the UK government’s funding for it, but don’t want to be blindly defending my own preferences.

JE: Sweden’s government is a big supporter of CBT, isn’t it?

RH: Yes, it’s a pretty similar situation to the UK. In Sweden, the government has put a lot of money into training therapists to do CBT.

JE: I read it has spent 2 billion kronor (£200 million) on it in the last four years or so.

RH: I’m not sure of the exact figures, but it’s a lot of money. Several hundred therapists and social workers have been trained in CBT. Unfortunately, at some places therapists do not really do CBT, they just call it that to get public money. The government sponsors CBT treatments for depression and anxiety, up to around £1,000 per person.

JE: So therapists must ‘convert’ to CBT?

RH: They’re not obliged to. But if they want government funding, they must either provide CBT or Interpersonal Psychotherapy (IPT)

JE: So tell me about the new issue of Socionomen, and how Swedish mental health policy is changing.

RH: In our study we used the CORE-OM system for rating therapy outcomes [as opposed to the Beck Depression Index, designed by Aaron Beck, who’s also the founder of Cognitive Behavioural Therapy]. We started by examining outcomes in primary care centres. In Sweden, there is perhaps one such centre for every 10,000 people. And at every centre, there is one or two people providing psychological treatment. We asked therapists to ask their patients to rate their state on the CORE-OM outcome measure, so we could follow the progress of their treatment, which was typically rather short – on the average six sessions. We compared a number of things, particularly how different treatment orientations succeeded – particularly CBT and psychodynamic,. We found exactly the same results, for both depression and anxiety. They all got good results, with about half of patients recovering. Even supportive therapy, which is the Cinderella of therapies because it seems too simple, got quite good results.

Effect Size for All Treatments

  CORE-OM   Function   Symptoms   N
Supportive .68 .56 .68 108
Dynamic 1.04 .82 1.0 84
CBT 1.05 .85 1.09 99
Cognitive 1.72 1.43 1.67 41
Crisis intervention 1.18 .85 1.34 49
Behavioral .91 .73 .81 21
Relational 1.25 .95 1.57 12
Client-centered .48 .35 .27 10
Systemic  .64 .48 .66 17
Counselling 1.0 .53 .85 10
Directive  1.16 .97 1.14 173
Reflective 1.07 .85 1.06 99

 

JE: Can you briefly describe the difference between CBT and psychodynamic therapies?

RH: CBT is directive. It’s educational, and it helps people to train themselves to get better. Psychodynamic therapy is reflective. It helps people reflect on their feelings.

'Everybody has won, and all must have prizes.'

JE: So does the research show the famous Dodo effect – all talking therapies seem to have the same impact.

RH: Yes, on many psychiatric states. And we also found that, in practice, therapists don’t always follow only one therapeutic approach. In practice, therapists and patients together tend to negotiate and find a treatment that works for the patient. By the way, there was a parallel study in the UK recently that found exactly the same results: Stiles at al (2008) [for a response from David M. Clark, the chief champion of the government’s support for CBT, to Stiles at al, see this paper].

JE: So your study found that all these different therapies showed some beneficial results? Because I saw a write-up of the Socionomen report which suggested it says the government’s CBT programme has had no impact whatsoever, or even a negative impact.

RH: That was another report by professors in health economy from the Karolinska Institute. They were looking at whether CBT was helping people to get off benefits and go back to work. In that respect, they couldn’t see any effect of CBT treatment. But I wouldn’t say there was no effect – we were able to show a good effect.

JE: So is it true the Swedish government is changing its approach and broadening the range of therapies that it might support?

RH: It’s true that the National Board of Health and Welfare, Socialstyrelsen, said a few months ago that it feels as if psychodynamic therapies are as good as CBT for depression. It still insists CBT is the best for anxiety, although our practice-based findings suggest psychodynamic therapies are also just as good for anxiety.

JE: Is that likely to mean a broadening of financial support for training in and provision of other therapies?

RH: Yes, it’s likely.

JE: What are the other implications of your research?

RH: I think the main implication is to recognise that there are two types of valid research paradigms: firstly, randomised controlled trials (RCTs), where you compare clearly defined treatments. Secondly, practice-based studies, where you don’t compare narrowly-defined treatments for selected patients, but instead look at how therapies are provided within real settings. The problem with RCTs is they are not as clean as they claim to be – a lot of noise gets in to them, through researchers’ allegiance and therapists’ expectations and so on. When governments in Sweden and the UK looked at which therapies to support, they decided there must be accountability. So they looked at the field of therapies, and they found lots of RCT studies for CBT, and few for psychodynamic therapies. But practice-based studies better show the successful outcomes for psychodynamic therapies. Practice-based studies are becoming more accepted now. For example, in the new edition of the Handbook of Psychotherapy and Behavioural Change, there will be a new chapter on practice-based studies.

JE: What I don’t understand about the Dodo effect is that these different therapies often have very different and conflicting conceptual underpinnings. Different theories about what emotions are and how to change them, for example. So they can’t all be right, can they? I mean, either emotions are connected to beliefs, and you can change them by changing your beliefs, or they’re not.

RH: Well, what you often find is what therapists say is the mechanism of change is usually not. So in cognitive therapy, for example, Aaron Beck thought that cognitive restructuring of beliefs is the way to change people’s mood. In fact, some research suggests that the depression changes first, then the thinking. [It also seems that, with anxiety disorders, the behavioural component of CBT is as important or more important in recovery than cognitive restructuring – see Clark et al (2008)]

We’ve lived now for some decades with this big debate between psychodynamic therapy and CBT. And in 15 years, there will be other kinds of division between them. Even now, people use lots of combinations of the two.But, in general, it seems that talking therapies, when they work, enhance the possibility to stand and accept strong emotions. They help people explore affects and try to stand them.

I can think of critiques to Rolf’s findings – if, by his own admission, therapists in the field are using a jumble of all kinds of different therapies (while often calling it CBT), then how can he compare the outcomes for CBT to psychodynamic therapies? The Dodo effect also has worrying implications for government support for mental health policy. If all therapies work the same (and I’m not sure they do, for specific conditions like social anxiety for example), then should government finance everything from maracas-shaking shamans to aromatherapists?  There is also, clearly, a difference between passing episodes of stress, which might naturally clear up on their own no matter what therapy a person receives, and more chronic conditions – a point made in Clark’s rebuttal to Stiles et al, which is linked to above. I will discuss these issues, and the problem of the Dodo effect, further in my newsletter tomorrow. In the meantime, feel free to leave comments below.