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Set the controls for the heart of happiness

The eagle-eyed among you will have noticed there was no newsletter last weekend. Apologies. The reason for this is I have journeyed deep into the warm, pulsating heart of the happiness movement. Last Thursday I took part in a conference on Positive Psychology at Wellington College (the pioneer of well-being classes), and then I went down to Dartington, in Totnes, Devon, to take part in an Action for Happiness two-day happiness festival.  I left Dartington, I kid you not, while a choir stood on the misty lawn singing ‘happy, happy, happy clappy!’ I felt like a rehab patient leaving the Priory.

Anyway, abandoning my usual dour demeanour, I admit that both events were great fun, and encouraging. My sense is that the Positive Psychology / happiness movement is becoming less positivistic (in other words, less dogmatic in its claims to objectivity and scientific truth) and more responsive to the role of philosophy and ethical reasoning in the search for the good life. (On that point, it’s sad that Christopher Peterson, one of the more philosophical voices within Positive Psychology, died this week. Here’s his beautiful last blog post).

I organised a philosophy discussion circle at Dartington – the first time I’ve facilitated one – and I think everyone involved really felt the benefit of that sort of open Socratic inquiry into what the good life means for us. As the Quakers well knew, there’s something very egalitarian and democratic about a discussion circle – there’s no expert or priest or higher authority ‘up there’ while the masses kneel beneath them. Everyone is equally at the front or at the centre. And facilitating a circle discussion seemed to involve letting go of control and letting silences happen – both quite difficult for me!

I also came away from the events hopeful that the Positive Psychology / happiness movement is aware of the risk that, in deifying certain emotional states or personality types as ideal, you pathologise their opposites. If you say that happiness is ideal, there’s a risk that sadness becomes an unacceptable failure. If extroversion is absolutely good, then introversion could be deemed absolutely bad. If optimism is always healthy, then pessimism becomes toxic. That sort of thinking is far too black-and-white, and I believe it actually causes suffering rather than mitigating it, by making introverts or pessimists feel worse about themselves. After all, introverts and pessimists have important social roles to play too, particularly in chronically optimistic short-term societies like ours.

We have many different moods and dispositions, and sometimes the best way to transform the difficult ones is to accept them rather than demonise them. In the words of Rumi, in what I think might be my favourite poem:

Learn the alchemy true human beings know: the moment you accept what troubles you’ve been given, the door opens.
Welcome difficulty as a familiar comrade.
Joke with torment brought by a Friend.
Sorrows are the rags of old clothes and jackets that serve to cover, and then are taken off.
That undressing, and the beautiful naked body underneath, is the sweetness that comes after grief.

I’ve given a lot of talks in the last month or so on the relationship between ancient philosophy and CBT,  and often someone in the audience criticises CBT for being shallow, simplistic, mechanistic, capitalist and ‘not dealing with root causes’. Usually such critics are therapists or counsellors in other traditions, annoyed that they didn’t get any public money. My answer is typically that I expect other forms of therapy to get public funding in the future – it’s already happening for approaches like mindfulness therapy – but you can’t expect to get any government funding without a convincing evidence base. Anecdotal case studies by psychologists simply won’t cut it anymore. As Freud proved, they’re too easy to fake.

It is also clear to me, however, that CBT is not for everyone and the research still has a long way to go to work out how to help more people. But what saddens me is that some therapists fail to find anything to celebrate in the government’s new support for talking therapies. Nor do many lay-people see the young national mental health service as something to fight for. The Improved Access for Psychotherapies (IAPT) policy is still very young, and vulnerable (as Paul Burstow MP, former minister for care services, recently emphasised). We shouldn’t assume it will stay in existence without our protection.

Richard Layard, the economist who more than anyone helped get IAPT funding, warned at Dartington that not all allocated funding is coming through and that as much as half of all children’s therapy services are being closed (I’ve asked him for stats to back up that claim). It is a very recent phenomenon for government to take mental illnesses like depression and anxiety seriously. If you believe in talking therapies, not just CBT but any talking therapies, then please support IAPT. I am all for expanding the range of therapies available on the NHS, as long as they are evidence-based.

Idealistic champions of adult education like RH Tawney are long gone.

Meanwhile, one thing that struck me as we discussed various ‘happiness policies’ at Dartington, was how little anyone spoke of adult education. Likewise, not one political party mentioned adult education at their conference. Schools, academies, universities – they’re all in the news constantly. But adult education is completely off the political radar at the moment. Adult education was a central part of the socialist vision for thinkers like RH Tawney. But no one in parliament cares about it now, none think it worth fighting for. At least Action for Happiness is trying to do something for adult education, albeit in a rather informal and unstructured way. It is a noble attempt to spread ideas about the good life and the good society – inspired, I believe, by Richard Layard’s experience of attending a Quaker reading group for many years.

The Octagon Room at Queen Mary, University of London

Talking of reviving adult education, we had a seminar at Queen Mary, University of London yesterday evening, in the beautiful Octagon Room, which was once a library for East End workers back in the 19th century when Queen Mary was known as the People’s Palace. We had a great group of participants come and talk about their work – including Philosophy Now, Philosophy In the Pub, Skeptics In the Pub, Pub Psychology, Sapere (a charity that does a lot of work with Philosophy 4 Children), Niki Barbery Bleyleben (good name!) who runs discussion groups for mums, and many others. We videoed the presentations and will put them up soon, along with the report I’m writing on philosophy clubs, and the website, thephilosophyhub.com, which will finally launch next week, I promise!

One of the things I suggest in the report is that the contemporary grassroots philosophy movement is in part a product of the 1960s, and that decade’s radical reformation of academia and demand that it ‘look beyond the campus’ (in the words of the Port Huron Statement). In that spirit, here is a 2008 BBC Radio 4 documentary by Nick Fraser on ‘1968: Philosophy in the streets’, with contributions from philosophers including Simon Critchley and Alain Badiou.

One of the participants at our seminar was Paul Hains, who together with his wife Brigid recently launched the excellent online magazine Aeon. I’m not just saying that because he occasionally sponsors our philosophy club events – the essays it publishes are really very good. Check out this one by Ross Andersen (whose Atlantic articles on philosophy are typically excellent) on dendrochronology and the threats facing the oldest trees in the world

Here, from the Futility Closet blog, is some advice from 1820 on how to fight ‘low spirits’, in a letter from Sidney Smith to Lady Georgiana Morpeth:

Dear Lady Georgiana,

Nobody has suffered more from low spirits than I have done — so I feel for you. 1st. Live as well as you dare. 2nd. Go into the shower-bath with a small quantity of water at a temperature low enough to give you a slight sensation of cold, 75° or 80°. 3rd. Amusing books. 4th. Short views of human life — not further than dinner or tea. 5th. Be as busy as you can. 6th. See as much as you can of those friends who respect and like you. 7th. And of those acquaintances who amuse you. 8th. Make no secret of low spirits to your friends, but talk of them freely — they are always worse for dignified concealment. 9th. Attend to the effects tea and coffee produce upon you. 10th. Compare your lot with that of other people. 11th. Don’t expect too much from human life — a sorry business at the best. 12th. Avoid poetry, dramatic representations (except comedy), music, serious novels, melancholy, sentimental people, and everything likely to excite feeling or emotion, not ending in active benevolence. 13th. Do good, and endeavour to please everybody of every degree. 14th. Be as much as you can in the open air without fatigue. 15th. Make the room where you commonly sit, gay and pleasant. 16th. Struggle by little and little against idleness. 17th. Don’t be too severe upon yourself, or underrate yourself, but do yourself justice. 18th. Keep good blazing fires. 19th. Be firm and constant in the exercise of rational religion. 20th. Believe me, dear Lady Georgiana,

Very truly yours,

Sydney Smith

Did you see the BBC 2 series on the history of the stiff upper lip? It was excellent, and managed to get the history of emotions onto mainstream TV. Well done to my supervisor, Thomas Dixon, for contributing to the programme (he’s now a leading historian of public crying, or a ‘sobbing guru’ as someone put it on Twitter). Check out the blog posts he wrote about the research behind the show.

Talking of stiff upper lips, a fortnight ago I participated in an excellent seminar on Stoicism and CBT at Exeter University. Here’s a blog on Stoicism and its uses today that came out of it – expect some very good posts in the future from some of the seminar participants.

I admire Jenny Hartley and Sarah Turvey of the University of Roehampton for their pioneering work over the last decade on reading groups and book clubs. Their latest project is taking reading groups into prisons. They have expanded the number of such groups from 4 to 30. Great work.

Here’s a BBC radio programme about the fast-developing science of hallucinations.

From 3 Quarks Daily, here’s communitarian philosopher Charles Taylor in an hour-long discussion with Confucian philosopher Tu Weiming, asking if we’re leaving the secular age.

And here’s an essay with Tu Weiming explains why he thinks we’re moving beyond the Enlightenment and philosophy is taking a ‘spiritual turn’.

I’ve had some wonderful emails from people who have read the book over the last fortnight – thank you very much. It means a huge amount to me and makes me feel the hard work is worth it. You can help me in my work by buying the book for yourself or others, spreading the word, or writing a review on Amazon or Good Reads. We finally got an offer from the US (hooray! thanks for your support on that). There’s still a lot of work to be done, so your help in promoting the book is hugely appreciated.

In the meantime, here is a photo of the nominees for this year’s Booker Prize, with Will Self at the back showing how to do book promotion.

See you next week,

Jules

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.