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[Clinical Psychology Forum, 2006, no. 168, 17-20.]


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[Clinical Psychology Forum, 2006, no. 168, 17-20.]



Is Clinical Psychology Selling its Soul (Again)?

David Smail

Trailing along for most of its career as a minor profession in the shadow of medicine, clinical psychology has often been tempted to sacrifice integrity to expediency.

In the days before almost anyone can remember, when the greatest confirmation of professional status was to be permitted to lunch in the “doctors’ dining room” of the old Victorian psychiatric institutions, it was our dream to be able to talk to and try to help patients without first having to get medical consent. That breakthrough was achieved at the cost of espousing and promulgating a clearly inadequate ideology of ‘behaviour therapy’, and gradually easing our way out of a ‘scientific’ role, as advocated in the ‘Zuckerman Report’ (Zuckerman 1968), into a ‘professional’ one, as advocated in the ‘Trethowan Report’ (Department of Health 1977).

There can be no doubt that these moves brought us money and – to a degree – status beyond the wildest dreams of those early psychiatric helots. But they also ended up tying us to a model of clinical psychology as being essentially about ‘treatment’, with the more accommodating ideology of CBT replacing that of ‘pure’ behaviour therapy. Since we cannot afford to discover that such treatment doesn’t work, critical thought, genuine empirical enquiry and (in the best sense) scientific detachment have become encumbrances to the smooth advance of professional influence and no longer figure seriously in our discourse.

However, the course of true self-interest never runs that smoothly, and having pretty successfully ducked out of the medical yoke, we found ourselves, following the Thatcherite counter-revolution, facing new masters. These were no longer themselves clinicians, but business people looking to set up health services as profitable enterprises in which clinical activities are strictly supervised and controlled to conform to managerial aims.

It is thus not surprising that many clinical psychologists should be tempted to overlook the questionability—even contradictoriness—of such notions as ‘evidence-based practice’ (in fact there is no reliable evidence base for much of what we do - see Moloney, 2006) when a chance to jump on the new bandwagon offers. Given that basking in the approval of the powerful is a rare experience for us, it is even less surprising that many of us should react with excitement to the advice of Lord Richard Layard that clinical psychologist numbers should be dramatically increased in order to help deliver ‘therapy for all on the NHS’. Layard’s view was, after all, conceived within the Prime Minister’s Strategy Unit, and published in two main documents (Layard, 2004; 2005) which have been received with interest (to put it mildly) in clinical circles (e.g. Roth & Stirling, 2005; Turpin, 2006; Independent on Sunday, 2006). Indeed, Layard’s proposals appear to have set a bandwagon rolling which has found eager passengers in the form of credulous journalists (e.g. Toynbee, 2006) and compliant academics (see for example London School of Economics, 2006).

Richard Layard, we should remember, is an academic economist as well as New Labour peer, and acknowledged in his 2005 talk that ‘I probably know less about mental health than anyone’ in his audience. But then mental health is only indirectly his concern – much more important is reducing the number of those claiming state benefits:-

Mental illness is one of the biggest causes of misery in our society – as I shall

show, it is at least as important as poverty. It also imposes heavy costs on the

economy (some 2% of GDP) and on the Exchequer (again some 2% of GDP). There are now more mentally ill people drawing incapacity benefits than there are unemployed people on Jobseeker’s Allowance. (Layard 2004, p2, emphasis in original).

Again:-

…we desperately need a better NHS, delivering more help and understanding to patients. But for many patients, work is also a major route to recovery. And as taxpayers who pay for Invalidity Benefits, we can all say amen to this. (Layard 2005, p5)


Layard seems to have dispelled any doubts his ignorance of mental health matters may have caused him by placing his reliance on the productions of the National Institute for Health and Clinical Excellence (NICE): their guidelines on such matters as “OCD and ‘body dysmorphic disorder’”, ‘the management of anxiety’, etc., are downloadable from their website (NICE 2006), as is their more recent advice on ‘computerized cognitive behaviour therapy for depression and anxiety’.

Layard concludes from his self-confessedly untutored examination of the NICE guidelines that the number of clinical psychologists should be doubled, operating from, and leading, psychological treatment centres set up country-wide on a ‘hub-and-spoke basis’.

The staff would operate under clear NICE guidelines relating to number of sessions, and patient progress would be monitored using a standard national system of recording completed at the beginning of each session ( Layard 2005, p4).

There is no doubt that the NICE guidelines come down heavily on the side of CBT (though leaving plenty of room for drug treatments also to prosper), and, as a clinical psychologist, one would have to be phenomenally incorruptible not to experience just a tiny frisson of interest at contemplating such inducements as those dangled by Layard before one’s eyes. But Mephistopheles turns up in unlikely disguises: for Faust he was a poodle, for us a Labour peer.

For the kind of bureaucratized ‘science’ peddled by NICE is exactly the kind of thing a healthy and independent clinical psychology, in charge of its own soul, would criticize, not endorse. In many ways the guidelines make fascinating, if somewhat numbing, reading, since they appear to wipe out almost everything the copious research into psychotherapy in the twentieth century seemed to establish about the complexity and uncertainty of the therapeutic enterprise. In their way they’re masterpieces of pseudo-scientific bureaucracy, taking the Taylorization of intellectual endeavour and clinical practice to an extreme one wouldn’t really have thought possible. Their method is to proceed via a kind of algorithm of treatment recommendations for the various DSM categories under consideration, with the recommendations in turn being scrupulously backed up by recitation of the ‘evidence base’ that has been identified for them.

It is impossible in the space available to attempt a detailed critique of this ‘evidence base’, though relevant critiques do exist (I think in particular of the chapter on CBT in a forthcoming book by William Epstein (2006, in press). What is striking about the evidence base is its near total reliance on rationalized/mechanized research methodology together with an equally near total indifference to the actual content of the research (this is demonstrated in the reliance placed on review articles and meta-analyses, for a trenchant critique of which see Charlton, 2000). A kind of unholy alliance is built up involving the DSM IV, the Cochrane Library and various limiting methodological requirements concerning control groups, double-blind trials, etc., which results in the virtually automatic churning out of ‘results’ that, on the principle that the emergence only of garbage can follow from its input, inevitably support the relative superiority of CBT.

None of the factors that one had always taken research in psychological therapies to point up as being important receive any real consideration or influence the NICE evaluation of the so-called evidence. Very little attention is paid to who ‘delivers’ the treatments or what their theoretical allegiances are or what the characteristics, personal or demographic, of clients are beyond their age and diagnosis. Nothing about the quality of relationship between treaters and treated. Huge reliance is placed on DSM IV and on self-report questionnaires to indicate improvement or otherwise. Reflecting a total faith in mechanization, ‘measurement’ is everywhere and meaning nowhere; questions concerning reliability are mostly taken for granted while validity is on the whole simply not considered. There is no indication of what practitioners actually do beyond the ascription of an orientation (mostly variants of behavioural and cognitive approaches).

This is in fact a strangely unhinged, make-believe world in which entirely hypothetical constructs—mere words—are taken as necessarily pointing to valid entities in the real world (the DSM productions are of course prototypical in this respect). The combination of an almost metaphysical set of beliefs about the potency of ‘cognitions’ and the nature of ‘disorder’ with obsessively detailed procedures of ‘measurement’ and statistical analysis is in fact uncannily reminiscent of the procedures of 17th century astrologers as recounted by Keith Thomas (Thomas 1973): interestingly, astrologers pointed to the complex methodology and mathematical intricacy of horoscope production as an argument for its scientific validity.

What emerges from all this is that CBT appears to be either mildly ‘effective’ or at least not harmful in about two thirds of cases; this is what we already knew to be the case with pretty well all therapies, talking or otherwise. The apparent triumph of CBT is thus a kind of sleight of hand performed, so to speak, on a darkened stage where the world beyond its rationalist/mechanist limits is simply hidden from view.

The NICE version of things may not be valid or remotely true in any significant sense, but it is certainly useful in enabling the central control and direction of professional activity, whether in research or practice. As you can imagine, it’s also not uninteresting to those practitioners who stand to gain from its undisputed rule.

Roth and Stirling, for example, although they feel that Layard may be a bit too enthusiastic about what CBT can achieve (‘…there is a real risk that the efficacy of CBT is being over-sold.’), are nevertheless quite clear about which side their bread’s buttered:

The government will only be persuaded to move on these proposals on the basis of hard-headed arguments, especially because this is—at the end of the day—an exercise in transfer of costs between departments, justified by a projection that this will be a cost-neutral exercise with major social benefit. It is for this reason that the rationale of offering evidence-based treatments of known efficacy is pragmatic, even if not completely consonant with clinical opinion. The case for the profession pulling together on this is clear. (Roth & Stirling 2005, p 48, my italics).


Graham Turpin, is also just a little nervous that Layard’s proposals could mean jobs for only some of the boys and girls, but feels nevertheless that:

Whereas the evidence for the efficacy of CBT interventions exists, the contribution of other evidence-based psychotherapeutic approaches could also be factored within the design of psychotherapy services to ensure that clients have a real choice of talking therapies on offer by the NHS. ( Turpin, 2006, p 12)


Turpin proposes therefore that the Society should formulate a response ‘as to how psychologists can help drive this agenda forward’.

What all this amounts to is that we have lost any semblance—indeed any pretence—of pursuing scientific inquiry, what is the case, what is true. Just look again at those sentences of Roth and Stirling: ‘…the rationale of offering evidence-based treatments of known efficacy is pragmatic, even if not completely consonant with clinical opinion. The case for the profession pulling together on this is clear.’ This is almost classic in its near-phobic avoidance of considering anything that could possibly be construed as speaking the truth about the world. What we deal with, rather, are rationales, pragmatics and opinions. What is not disputed, of course, is that these latter constitute what one might call a clear interest-base for professional action.

Despite its eagerness to sell its soul over the years, clinical psychology somehow managed to retain a critical edge which permitted those so inclined to question their discipline and to test the official line through empirical investigation, and many clinical psychologists were wary also of playing too compliant a role in a political orthodoxy having an interest in individualizing distress. Given the oppressive conventionality of most training courses, a large part of the successful guardianship of our scientific (in the best sense) soul can be put down to Clinical Psychology Forum (CPF) and its editorial collective under the leadership of Craig Newnes. Though a commendably unpretentious publication, CPF has a large readership in Britain for a journal of its kind and there can be few clinical psychologists who are unaware of its content. Under Craig’s stewardship it has somehow managed to achieve a critical social awareness while at the same time satisfying the need to reflect and inform on conventional professional issues. This kind of balancing act is very hard to achieve: CPF could so easily have become just another boring outlet for received views and professional self-congratulation, or, less likely of course, a strident hectoring of the professional establishment ignoring the everyday concerns of readers.

With Craig’s departure and a change of editorial structure one’s fear is that CPF might take the former of these two possible routes. If that should happen, only Mephistopheles will gain.



References

Charlton, B. G. (2000). The new management of scientific knowledge: a change in direction with profound implications. In M. Hampton and B. Hurwitz (eds), NICE, GHI and the NHS reforms: enabling excellence or imposing control?. London, Aesculapius Medical Press: 13 - 32.


Department of Health (1977) The Role of Psychologists in the Health Service (The

Trethowan Report). London: HMSO

Epstein, William (2006, in press). Psychotherapy as Religion: The Civil Divine in America, to be published by the University of Nevada Press

Independent on Sunday (2006). Professor David Clark: ‘We are a bit therapy-averse in this country’. 16th April.


Layard, Richard. 2004. Mental Health: Britain’s Biggest Social Problem?

http://www.strategy.gov.uk/downloads/files/mh_layard.pdf
Layard, Richard. 2005. Therapy for all on the NHS. http://www.scmh.org.uk/
London School of Economics, The Centre for Economic Performance’s

Mental Health Policy Group. 2006. The Depression Report. A New Deal for Depression and Anxiety Disorders.


Moloney, Paul. 2006. The trouble with psychotherapy. Clinical Psychology Forum, No 162, June. Pp 29-33.
NICE (2006). Follow links from http://www.nice.org.uk/
Roth, T. & Stirling, P. 2005. Expanding the availability of psychological therapy. Clinical

Psychology Forum, no.155 (November), 47-50.
Thomas, Keith.1973. Religion and the Decline of Magic. Penguin Books.
Toynbee, Polly. 2006. It is not fanciful to make the pursuit of happiness a political imperative. The Guardian, Friday 16th June.
Turpin, G. 2006. Responding to Lord Layard. The Psychologist, 19, no. 1 (January), 12.
Zuckerman Report. Hospital scientific and technical services London: HMSO, 1968




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