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social anxiety

PoW: Mutual aid in public health: back to the 19th century?

There’s a new spirit of self-help and mutual improvement blowing through public health policy. I first felt its breeze in Scotland’s national mental health strategy, which was published in August, and which made much of its ‘person-centred approach’ to mental health in Scotland. One of the main themes of the strategy is “embedding more peer-to-peer work and support”,  for example via a network called the Scottish Recovery Network, which trains people who’ve recovered from mental illness so they can help other people recover. Seems a good idea. Scotland’s strategy also emphasised the role of self-help in mental health services:

NHS 24 has developed, piloted and now delivers the Living Life Guided Self Help Service, under which self-help coaches guide individuals over the phone through a series of self-help workbooks to help them understand some of the reasons why they are feeling low, depressed or anxiousNHS Health Scotland managed the Steps for Stress resources which contain practical ways for people to start to deal with stress.

A similar approach is evident in the Welsh government’s Together For Mental Health strategy, published this month, which includes self-help provisions like the Book Prescription Service  (bibliotherapy as national policy!). And the self-help / mutual aid spirit is front-and-centre in a new report from the Centre for Mental Health, called Implementing Recovery through Organisational Change. The report looks at how the Coalition government’s healthcare reform is giving a lot more power to Health and Well-Being Boards (HWBs) at the local government level, and how HWBs are increasingly looking to work with user-led community organisations:

This might include peer support groups, advocacy, tenancy support, adult education and training opportunities, sources of information and advice, eg on welfare rights or employment, as well as resources that support overall wellbeing and quality of life…From walking groups to literacy and numeracy classes, from learning English to managing debt, finding out about sources of low cost credit, tenancy maintenance, cookery classes and gardening projects, access to natural spaces and places to ‘stop and chat’…

Dance you monkeys! Keep dancing until the minister leaves!

No doubt for some of you the words ‘self-help’ and ‘mutual aid’ set off alarm bells, because it sounds like an excuse for slashing public service budgets, rolling back the barriers of the state and returning to the 19th century, when we didn’t have an NHS and if poor people needed support they had to sing for their supper at the Salvation Army. These are valid concerns.  According to a Young Minds survey, 52% of councils said they planned to reduce their budget for children’s mental health services next year, sometimes by up to 30%. David Clark, the pioneer of Improved Access for Psychotherapies, the government’s flagship therapy policy, warned recently that budgets for IAPT were also being cut, sometimes by 30%. Even the best self-help book is not a replacement for trained counselors.

Some of you may also think that ‘self-help and mutual aid’ smacks of a neo-liberal approach – pull yourself together and get on with it, and don’t rely on the state to help you. The Norman Tebbit approach to personal growth. A lot of self-help can certainly be a bit like that. But self-help / mutual aid doesn’t have to be neo-liberal, individualist or laissez faire capitalist. The Centre for Mental Health report says that the recovery approach “means an emphasis not only on personal development, but also on the need for collective support and reciprocity to allow people to build decent lives and for their communities to flourish.”

The report highlights the work of a group called the Personalisation Forum Group, a ‘user-led organisation’ in Doncaster, which helps people with mental health issues to help each other, and also work collectively to represent themselves and campaign for better mental health services and personalised mental health budgets in their local community. Sounds awesome – though, to be a tiny bit cynical, how ‘user-led’ is the PFG really? It was set up by a social worker, Kelly Hicks, and seems to be very politically tuned-in and publicity savvy for a new organisation supposedly run by people with mental health problems. It’s already won multiple awards (‘social worker of the year’ for Kelly!), has secured Ed Miliband’s support, and set its sights on the total reform of the national mental health system to make it more user-based and personalised.  I’m not sure that people with mental health issues would call their self-run support group the ‘Personalisation Forum Group’? That sounds like academic policy-wonk speak. And I notice Kelly is also CEO of a company called Personalisation Plus, offering councils advice on personalised mental health budgets. So who is the PFG serving? Its users or the mental health professionals who set it up and promote it? (Perhaps the answer is both).

Ben Franklin's Junto: a mutual improvement club that met every Friday in Philadelphia

Anyway, I’m a firm believer in mutual aid, ever since I was helped to overcome social anxiety by a support group over a decade ago. I love the tradition of mutual aid – the Quakers, Samuel Smiles, the coop movement, Benjamin Franklin’s Junto, Peter Kropotkin, Alcoholics Anonymous, tenant boards. And I see the potential for grassroots philosophy clubs to play a role in local mental health policy, by working with Health and Well-Being Boards, with NHS well-being centres, with community colleges, to expand the provision of practical philosophy for ordinary people.

But there would be real risks to this engagement of grassroots philosophy clubs with local or national mental health policy, as my fellow community organizers warned me, at a recent seminar. There’s the risk of being co-opted into political goals, being forced to meet bureaucratic box-ticked well-being targets.  There’s the risk of a confusion of public and private interests, and of financial mismanagement – look at the example of A4E, the welfare-to-work organisation currently being investigated for massive fraud (and check out the incredibly bad interview its CEO, Emma Harrison, gave on Channel 4 this week).There’s the risk that community organisations become PR vehicles for personal and professional self-aggrandizement and publicity rather than genuine mutual improvement. Perhaps the greatest risk is that social enterprises or charities get more focused on winning funding than on helping people. They can end up more worried about sustaining their own existence rather than supporting their users. And political bureaucracy can be deadening to the community spirit: I look at the alphabet soup of formal adult education – NIACE and the BIS supporting the WEA through SDIs or whatever – and think, that’s all just dead bureaucrac-ese and nothing to do with real, intimate human relations.

Those are the risks that community organisations have to consider before getting involved with local or national government – and I know many informal philosophy groups want to steer well clear of politics. Then again, for all the achievements of community philosophy, it could still be a lot bigger than it is. We’re still in a country where most people don’t see any relevance or usefulness in philosophy. If you want to change that, as many of us do, then is working through public policy a necessary evil?

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Here are some good links from the last week:

Here’s two interviews I did with pioneers of grassroots philosophy – first, one with Roman Krznaric, a founding faculty member of the School of Life, and another with Paul Doran, co-founder of Philosophy In Pubs. And here’s an article about Christopher Phillips, founder of the Socrates Cafe movement in the US.

Here’s a Radio 4 obituary of Paul Kurtz, philosopher and founder of the modern Skeptic movement (it’s 14 minutes into the show). I was invited onto the show as an interviewee, and they also interviewed James ‘the Amazing’ Randi. I talk about how, in his last years, Kurtz fell out with the institutions he founded – particularly the Center for Inquiry – because he thought they had become too ‘new Atheist’ and aggressive in their ridiculing of religion. So they kicked him off the board!

That story reminded me of what happened to Albert Ellis, the pioneer of cognitive therapy, who was also kicked off the board of the Albert Ellis Institute in the last years of his life. The AEI then employed someone called Jeffrey Bernstein to be their CEO. This week, Bernstein was convicted of grand larceny for stealing millions from the AEI. Good going AEI. Top recruitment there.

Here’s a scary Times Educational Supplement story by a teacher about internet porn and its effect on teenagers today – the first generation to grow up with constant access to hardcore porn. Some shocking stories in there.

Derren Brown’s new show, Apocalypse, involved him purportedly hypnotising someone into believing civilisation has collapsed and the survivors have turned into zombies. Brown has said the show is inspired by his reading of the Stoics, and their exercise of imagining the worst to appreciate what you have (I don’t think Seneca had zombies in mind!) Was the show an elaborate hoax? People on the net are suggesting the experiment subject – supposedly a 21-year-old ne’er-do-well – is actually an aspiring actor, and my friend the hypnotherapist Donald Robertson says he doesn’t think Brown would have got a license to hypnotise someone for entertainment if there was a risk of distress. Wouldn’t be the first time Brown has hoaxed the public – the Stoics would be shocked!

Here’s Sir Isaiah Berlin on Desert Island Discs, which includes a very funny story of how Churchill mistakenly invited Irving Berlin, the song-writer, for dinner at Number 10 during WWII, when Isaiah Berlin was a diplomat in Washington. ‘Do you think Roosevelt will win the next election?’ Churchill asked Irving. ‘Well, I voted for him last time and might vote for him next time’ Irving replied, much to Churchill’s confusion.

If you’re in London, there’s a great two weeks of events starting today on the 365th anniversary of the Putney Debates – a wonderful moment in grassroots radical philosophy during the Civil War. Details here.

And if you’re in Holland, I’ll be there all of next week, doing talks and workshops, including one on Monday evening on Stoicism. Email or tweet me for further details.

Finally, some publishing stuff. News emerged that Penguin may be sold to Random House. The new company is provisionally called Penguin House, with the new logo unveiled this week (on the right), although ‘Random Penguin’ is still garnering votes. Meanwhile Penguin’s hottest signing, Pippa Middleton, failed to sparkle at the launch for her book on party-organising. The event was held with some 6-year-olds, who it was hoped would not ask difficult questions. Unfortunately one of them, after being told by Pippa she would love pink princesses when she was older, declared ‘I hate princesses…I like vampires!’ Well, you know, they’re kind of the same thing…

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.