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Lord Layard

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.

CBT, lost in the Moral Maze

Radio 4’s Moral Maze this week looked at the government’s expansion of Cognitive Behavioural Therapy (CBT), and at a new report from Lord Richard Layard of the LSE (the principal arranger of the government’s embrace of CBT), which warns that local and national governments are failing to honour the spending commitments they made to CBT.

I personally think that the expansion of CBT is one of the major achievements of the last five years (God knows there haven’t been that many national achievements during that time). Finally, we’re taking mental health seriously. Finally, we’ve found a therapy which works for the most common emotional disorders. And finally we’re putting in place the people and resources to enable the suffering to get help quickly. But, like most big steps forward, it’s been almost entirely un-celebrated by our media – unnoticed even – except by a few angry psychoanalysts who are indignant that CBT should have got so much funding and their own therapy so little.

So I’m disconcerted that, on one of the rare occasions that the government’s support for CBT was discussed, not one of the panellists (Michael Portillo, Matthew Taylor, Claire Fox and Melanie Phillips) should have felt the need to support it. Not one of them saw the need to defend that Service, and to try and protect its funding. What a missed opportunity. Rather than unpicking it, they should have applauded it.

Instead, the need for a National Mental Health Service was criticised from both right and left. On the right, Michael Portillo thought Richard Layard had massively over-emphasised the number of people who are affected by depression in the UK (6 million, according to David M. Clark, the psychotherapist who is the chief architect of the national CBT strategy). Portillo accused Layard of confusing depression, which is serious and nasty, with unhappiness. Lots of people are unhappy, for lots of reasons – calling it ‘depression’ just serves various ‘powerful lobbies’ (i.e. Big Pharma and the CBT industry), and gives scroungers a free ticket to benefits. If extended into the criminal justice system, it also lets people off the hook for bad deeds. Psychology becomes ‘excuseology’.

On the left, Matthew Taylor of the RSA thought Layard was medicalising unhappiness, and suggested that people might have very good social, economic and political reasons for being unhappy. CBT focuses too much on the ‘inner man’, and not enough on the outer conditions. It puts the blame for any dissatisfaction we might feel firmly on our own shoulders, which is a convenient move for government and the rich.

These concerns and confusions come about partly as a result of CBT’s origins in Greek philosophy, and I think we can clear them up if we replace CBT in its original context.

CBT emerged from Socratic and Stoic ethics, which developed as a form of ‘therapy for the soul’, which everyone could use to take care of themselves and transform their negative emotions. The idea was that you practice philosophy your whole life, both in periods of emotional turmoil (what we might call depression today) and when things are going well. The Greeks, lacking the Diagnostic Statistical Manual (DSM), did not divide emotional disorders into endless categories. They simply recognised emotional suffering – those moments when we become the passive victim of our passions, when they block us from enjoying a ‘good flow of life’. And they offered a way for students to get out of such situations, by learning how to examine their unconscious beliefs and values, and to change them.

CBT emerged from Socratic ethics, which taught people to 'take care of their souls'

As for  the ‘medicalisation’ of ethics and emotions, that goes all the way back to the Greeks too. They called negative emotions ‘passions’, from the Greek pathe, meaning suffering or sickness. They often compared the philosopher to the physician, and called philosophy a ‘medical art for the soul’ (as Cicero put it). So the idea that the unhappy are also unwell is a very old one. So is the idea that the morally bad are, in fact, deluded and sick – that’s what Seneca, Plato, Marcus Aurelius and others argued. It is no easy thing to separate these categories, as the Anders Breivik case shows. Of course Breivik should be held accountable. But of course, he is also fucked up – shooting 65 teenagers is fairly strong proof of being mentally ill, to my mind.

When we go back to the ancient Greek roots of CBT, it clears up various issues.

First, the question of how much to concentrate on the inner man versus the outer conditions. We see that CBT emerged particularly from Stoic philosophy, which focuses entirely on the inner man rather than outer conditions. The philosopher, according to the Stoics, is so mentally resilient that they can be happy in any situation, even while being tortured. They make their soul an ‘inner citadel’ against their culture’s toxic values. CBT inherits this same highly individualistic focus – change your self and make it an inner citadel against the fucked-up-ness of your society.

We can (and should) disagree with this intense focus on the inner man, and point to the strong influence of environmental factors like poverty on mental health. At the same time, the Stoics were right that all humans have some capacity to control our emotions, and helping people develop this capacity gives them the strength and autonomy to change their environment and change their society.

So Stoicism / CBT doesn’t have to be some sort of neo-liberal atomised self-help. If you look at Aristotelian philosophy, for example, it shares the Socratic principles of Stoicism / CBT (i.e. the idea we can use our reason to change ourselves and achieve flourishing) but it also recognises that our society and culture plays a big part in our well-being, and that as citizens we should take care of both ourselves and our society. We should balance the inner work of CBT with the outer work of changing our society. I think Layard recognises that. He’s not saying we should focus entirely on the inner man, only that we have ignored that factor for far too long in western politics. That’s a wise realisation for a Fabian in his 70s to reach.

Secondly, the question of personal responsibility.  Does CBT excuse people from their moral behaviour? Or does it put too much responsibility on our frail shoulders? Again, going back to the Greeks helps. They didn’t argue that we are all born free, rational, sovereign agents. But they argued that the vast majority of us can become slightly more free, slightly more self-aware, slightly more self-controlled, if we practice philosophy for several years. Autonomy is an exercise, and like other forms of exercise, we become better at it through practice.

But the first step is to take responsibility for our own beliefs and actions – not blame them on our environment, on our parents or friends or the economy or the weather. The economy may be terrible, and you being unemployed will almost certainly affect your mood. That’s not your fault. But how you think about your situation is going to affect your feelings. You can make that shitty situation a lot worse, if you want, or you can cope with it in a wiser and more effective way – not beating yourself up, while also looking for opportunities to get out of the situation.

Since my book has come out, I’m often asked by worried parents if their offspring’s mental / emotional problems are their fault. They are often relieved to hear about CBT, as an alternative to the old Freudian line that ‘they fuck you up your mum and dad’. Well, actually, you might very well have been fucked up by your mum and dad. They might very well have indoctrinated you in the thoughts and habits that are making you miserable today. However, these are now your thoughts and habits. Your mother and father aren’t standing over you forcing you to harm yourself. You’re doing it to yourself. As the great Bill Knaus says in my book, what happens to us is not necessarily our fault. But how we think about it is our responsibility. Don’t be a masochist. Don’t beat yourself up and then blame it on someone else.

Of course, some people are born into much harder situations than others. Some people grow up in environments that are constantly pushing them to depression or vice. Others grow up in environments that are constantly pushing them to flourish. That’s unfair, and we should do what we can to correct that. Part of that is giving people the tools to be resilient to their environment, to resist its bad influences and find the good influences.

Finally, the question of the division between Depression and unhappiness. Are we medicalising the entire society and pathologising perfectly normal things like unhappiness, shyness or anxiety? Again, let’s go back to the Greeks. Without the benefit of the Diagnostic Statistical Manual (DSM), the Greeks didn’t recognise particular emotional disorders, nor did they try to ghettoise them from ‘normal human experience’. Instead, they saw emotional suffering as on a continuum, from the very distressed to the quite distressed to the well to the flourishing. And they recognised that philosophy could and should help people all along this continuum.

Today, most people still don’t seek help for emotional problems, because they’re worried about ‘making a fuss’, or about admitting that they’re somehow officially broken or sick. Might it appear on their permanent NHS record? What if their employer found out, or their friends, or their family? Would they lose respect, authority or even their freedom as a result? And besides, isn’t it narcissistic to worry about their feelings? Who the hell is happy in this world anyway? And so most people do nothing to take care of themselves. They carry on veering through life, like a car with a flat tyre.

Philosophy, as Socrates insisted, helps us learn how to take care of ourselves. That isn’t selfish. It’s responsible. If we’re not taking care of ourselves, we’re probably affecting the people around us, and we’re also probably not engaging as effectively with our society as we could be. CBT is a form of therapeutic philosophy for people in serious distress – that could mean a particularly stressful period of your life, or a bout of depression, or panic attacks, and so on. Such moments affect many of us – perhaps 25%, perhaps as much as 50% – so go get some help, either from a GP, or from a CBT book, or from my book! Learn how to take care of yourself, how to steer yourself.

The Greeks thought philosophy should be available for everyone. I agree. I think everyone should be introduced to it, to learn how to take care of themselves. However, there is a difference to helping people in a serious emotional crisis, as CBT does, and helping people not in a serious crisis, as Positive Psychology tries to do. The latter group should not be told how to be happy. They can be taught some of the basics – how emotions arise, how we can change them – while also being encouraged to explore the different ethical visions of the good life that we can use these basics for.

One of the panellists, Michael Portillo, was particularly scornful of the fact we diagnose people with depression by asking them how they feel. People could lie, he pointed out. Well, that’s true, and no doubt many people do. But how else can we diagnose depression? How can we know how someone is feeling, except by asking them?

Aaron Beck, the pioneer of CBT, took ideas and techniques from ancient philosophy, and then married them to scientific empiricism. He invented the Beck Depression Inventory, which measures how depressed a person is by asking them, for example, how often they think about killing themselves. Now of course that sort of diagnostic technique can be fiddled by the unscrupulous. And of course, it is a bit simplistic. But it’s also a useful way of discovering if a therapy is really having any obvious effect. If a person, at the beginning of a therapy, says they’re extremely unhappy and think about killing themselves often, and at the end of the therapy they say they’re fairly happy and don’t think about killing themselves ever, then that’s a measurable success, isn’t it? And crucially, it’s only through such measurements that governments have been persuaded to support CBT. If it wasn’t for such measurements, far fewer people would be reached or helped by CBT.

I, like Portillo, am wary of the power of Big Pharma, and of a world where we have defined the entire population as in need of chemical interventions. But I do, actually, think that, in the words of Albert Ellis, 99% of the world is out of their fucking minds. Including me. We’re all on a continuum of mental health, and I certainly don’t think I am ‘flourishing’. I’m pretty well, but I’m self-aware enough to recognise I have a long way to go yet. Philosophy, no doubt, will help me on my journey.

Anyway, this is all a rather roundabout way of saying I think it is a very good thing that we now have a National Mental Health service, and that CBT has become available to ordinary people, rather than just the rich. So many of my friends have suffered from mental health problems at one time or another – most of them in quiet desperation. A lot of them could be really helped by some therapy, whether through the NHS, or through DIY therapy like reading a CBT book. That’s not narcissistic. It’s responsible. It helps them contribute to their society. Please can policy makers and opinion-influencers celebrate our new National Mental Health Service, rather than attacking it?