Dear Jane
As requested.
Best wishes,
Mark

                                                19th October 2007
 

 
 
Dear Editor,
 
Changing politicians' minds about changing our minds?
 
We write in response to the Health Secretary's recent announcement that £170m is to be made available by 2010 to increase the availability of low intensity, high volume, psychological interventions. At present Cognitive Behaviour Therapy (CBT) is the preferred approach, to be delivered at primary care level to adults of working age, by people who have some basic training.
 
While we welcome the belated recognition of widespread emotional distress in our community, and applaud the government's willingness to spend public money on it, we have a number of serious reservations about the approach adopted. Briefly, the scale of socially caused distress is so vast, and growing so rapidly, that it is impossible to 'treat it better', let alone 'cure' it, as Mr Johnson and Lord Layard have suggested, by training more therapists. It is, simply, not feasible to treat all of those in distress, one at a time, with any therapeutic technique.
 
Even if we could train enough practitioners, there is good reason to believe that one-to-one talking treatments administered by professionals are mostly only marginally effective. While it is certainly the case that a wealth of evidence exists to suggest that professionally-delivered therapy, in the hands of some practitioners, for some people, may be of some benefit, effect sizes tend to be small. However, and the widely cited NICE Guidelines overlook this, the research base is also clear that not only may lay people be as effective as professionals in delivering help through talking and listening, but also that all talking therapies are effectively equivalent, and equivalently limited, especially for those in the most difficult living circumstances.  This is so even when delivery is organised through the stepped care model that runs from use of self help guides to full therapeutic interventions.
 
That is to say, not only is the effectiveness of CBT and kindred interventions - in any hands - widely exaggerated, but they are impossible to apply in many 'real world' situations and with many people. Indeed the widely reported 'cure' rates in the studies relied on by the government and its advisers are, actually, quite likely an artefact of the highly controlled nature of the randomised controlled trials (RCTs) which purport to demonstrate their effectiveness. As with all such clinical trials, RCTs by their very design can not, and do not, reflect the 'real world' where treatment is actually applied. As such, framing policy via reliance on their artificially-inflated success rates is either scientifically naive or politically expedient, or both.
 
Moreover CBT, and all like treatments, individualise social problems, draw attention away from the more important social, economic and material causes of distress and propose individual cognitive dysfunction as both the cause of people's problems and as the most appropriate site for intervention. We note that a compelling account of the factors which have produced the present, and remarkably recent, 'epidemic' of individual cognitive dysfunction seems to be absent from the analyses that government has offered to date. We also note that the relentless focus on the individual, and their supposed cognitive deficits, illicitly employs a medicalised metaphor of 'illness' to describe human misery and thus distracts attention away from the noxious effects on persons of structural poverty, unemployment, job insecurity, violence, abuse, racism, sexism, inequality and consumerism (among others) which are the root causes of human distress. It is, surely, bad enough to be depressed because of difficult living circumstances or to be anxious because you are subjected to regular domestic violence, without currently popular theory suggesting your depression or anxiety are caused by your own irrational thinking. Blaming the victim like this simply proffers therapeutic ritual as a cure for societal oppression, whilst at the same time placing responsibility for distress and its' resolution onto the individual.
 
The approach announced is, we argue, not only conceptually misguided, but also likely to be socially and economically wasteful of scarce resources. Even assuming therapeutic success, when 'treated' many or most distressed people will return to the same psychologically toxic environments that produce distress and will be subjected to the same causes of distress all over again. If they do not go back into immediately toxic contexts, there will still be a flood of newly damaged people as a result of the persistence of the social causes of distress ignored under present mental health policy settings. CBT and associated approaches are thus comprehensively problematic. Primary prevention of distress at a society-wide level - not the 'cure' of individuals - is the only way to substantially reduce socially, economically and materially caused misery.
 
To be effective, primary prevention necessitates social not cognitive change. Contemporary research shows that reducing income inequality in our society would be just one of the most effective ways to reduce psychological distress and physical ill health - not just for the disadvantaged - but across society in general.
 
Signatories
 

Julia Bird, Jan Bostock, Mark Burton, Julie Chase, Deborah Chinn, Paul Cotterill, John Cromby, Dawn Darlaston-Jones, Bob Diamond, Paul Duckett, Suzanne Elliott , Michael Göpfert, Dave Harper, Carl Harris, Carolyn Kagan, Valeska Matziol, Steve Melluish, Annie Mitchell, Paul Moloney, Moira O'Connor, Penny Priest, Mark Rapley, David Smail, Janine Soffe-Caswell and Carl Walker on behalf of the UK Community Psychology Network, a group which includes academics, campaigners, mental health service users and survivors, health and social services managers, clinical psychologists, students and volunteer workers.
 
Mark Rapley, PhD,
Professor of Clinical Psychology,
Programme Director - Doctoral Degree in Clinical Psychology,
School of Psychology,
University of East London,
London, E15 4LZ,
U.K.

Tel:   +44 (0)208 223 6392 (Direct)
Tel:   +44 (0)208 223 4567 (Messages)
Tel:   +44 (0)7951 908409  (Mobile)


On 19/10/2007, [log in to unmask] <[log in to unmask] > wrote:

Please could you resend this letter as an email; we are unable to accept attachments.
Jane Campbell
Letters

Dear Editor,
I attach a letter for publication from the UK Community Psychology Network.
With best wishes,
Yours sincerely,
Mark Rapley

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http://www.independent.co.uk/
http://www.nla.co.uk/
Please consider your environmental responsibility before printing this email.
_______________________________________________________________________________________________________________________

This email and any attached files are confidential and may be privileged or otherwise protected from disclosure. If you are not the intended recipient, please notify the sender immediately and delete this email and any attachments from your system, and do not store, copy or disseminate them or disclose their contents to any other person. Views and opinions expressed in this email or attachments are those of the author and are not necessarily agreed or authorised by Independent News and Media Limited or its associated companies (together 'INM'). INM may monitor emails sent or received for operational or business reasons as permitted by law. INM does not accept any liability for any virus that may be introduced by this email or attachments and you should employ virus-checking software. Use of this or any other email system of INM signifies consent to any interception we might lawfully carry out to prevent abuse of these facilities or for any other lawful purpose.
Independent News and Media Limited is a company in the Independent News & Media group, registered in England and Wales under company number 1908967, whose registered office is at Independent House, 191 Marsh Wall, London E14 9RS, UK. VAT number GB 248 1845 43
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