Paternalism has always worried me, especially when it is exercised with the power of the state. An example came to mind when a long term friend of mine expressed concern about the imposition of Cognitive Behaviour Therapy for treatment for psychic distress in the UK. We are talking about NICE clinical guidelines being imposed de facto on the NHS here: incidentally how can anyone let anything end up with an abbreviation like NICE. Now I should emphasise that this is not an argument against CBT per se. CBT after all is a technique with an evidence base in practice and theory. It is an argument against selection of a single approach, in particular one which is focused on creating wellbeing and happiness, words which sound good but have a poor history in use by government agencies. The fact that the technique can be self administered by way of CBT is even more scary. Warning bells should start to ring if we ever plan for uniformity. A similar theme, in a different context, is picked up by Kim in Thinking Shift, on the danger of standing out from the crowd, of being different in any way.
We need difference, we cannot afford in an area such as psychology (or any major area of policy) to embed a particular theory or practice and thus prevent evolution of both. To be honest this seems to be another example of inappropriate industrial practices (in this case best practice) being imposed in the public sector to its detriment. There is far too much of this at the moment, and management-speak seems to reign, to make another Orwellian reference. So let those better qualified than I speak on this subject:
Julia (my friend) posted her concerns in a comment to Willem Buiter blog, the particular posting concerned displays a savage satirical streak in respect of utilitarianism
A utilitarian paternalistic government would know what to do in this situation. It would rewrite the intergenerational social contract to include mandatory involuntary euthanasia at age 87 for men and at age 89 for women. The week before my 87th birthday, I would receive a note informing me that in a week's time I have to turn up at my local NHS hospital to be humanely executed by lethal injection. Those who have served in the armed forces could opt instead to be executed by firing squad. The penalty for failing to turn up would (of course) be death
so there, put that in your pipe and smoke it! To Julia's well expressed concern. I repeat her comment in full:
Julia's comment
My name is Julia Evans. I am a Lacanian (Jacques Lacan) psychoanalyst who has been closely following the government’s progress on the regulation and registration of the talking therapies.
I agree with your position in Propositions 1 to 7 and give a brief summary of points which expand on your Proposition 4 and onwards.
In this clip from the World At One (October 10th), Lord Layard and the Minister of State for Health, Alan Johnston, outline their plans for “Happiness Centres”. recording This is called I.A.P.T.: Improved Access to Psychological Therapies. It is driven by economic assumptions.
The technology which provides the end-result of happiness is prescribed by the government in the NICE (National Institute for Clinical Excellence)’s 1994 clinical guidance for the treatment of ‘Anxiety’ and ‘Depression’. All clinical guidance for psychic distress end with an operative performing cbt (cognitive behaviour therapy) as it is the ‘evidence-based’ solution. There are many references disputing the government’s clinical judgment (See Professor Andrew Samuels, Centre for Psychoanalytic Studies, University of Essex, Letters, Friday October 12, 2007 The Guardian) but the government and Lord Layard knows best in the clinic of the distressed.
Further control processes are being put in place under the Health Professions Order 2001. This is part of the Privy Council so there is no parliamentary challenge possible. The legislation promises to ‘safeguard the health and well-being’ of all users. Thus, the government guarantees safety from criminal and negligent acts in all situations. The Donaldson report likens risk in the ‘health industry’ to the Alpha Piper Disaster, Chernobyl and aircraft crashes. This is explored in ‘Wellbeing and happiness as used by the UK government’ by Julia Evans. The Psychoanalytical Notebooks. Issue 16 Regulation and Evaluation. 2007. A review of the London Society of the New Lacanian School.
In order to provide the “Happiness Centres” and ensure protection from charlatans (those not registered with the Health Professions’ Council), the government has persuaded the British Psychological Society to give the HPC responsibility for registration and regulation of their members’ training, practice, professional development, complaints, etc. ( Google: bps & statutory regulation – 18th October) The HPC are drawing up standards in these areas which, when the Privy Council has agreed them, will regulate how psychologists work. For a more detailed account of some of the issues involved in this area please consult eIpnosis web-site.
This happy collaboration between the bps and the government means that the “Happiness Centres” can be supervised by government-controlled psychologists, overseeing the hastily-trained cbt operatives. This scheme will be launched at a prestigious conference entitled (also a web-link) 'Psychological therapies in the NHS: science, practice, and policy', Lord Layard and the Minister of State for Health, Alan Johnston, will appear on the podium to explain the government’s approved procedures for the production of happiness in cases of psychical distress to Nuremberg-Rally-style-cheers and general rejoicing.
Julia Evans
Julia@julia-evans-psychoanayst.org.uk
www.psychoanalysislondon.org.uk
Comments (4)
Hello,
The NICE clinical guidelines for Anxiety and Depression were published in December 2004 not 1994 as stated. I think I was muddling it with 1984... Sorry. Julia
Posted by Julia Evans | November 12, 2007 2:11 PM
Posted on November 12, 2007 14:11
There seems to be a similar paternalistic streak in the treatment of school leavers, who, if Jim Knight has anything to do with it, will be required to 'do something useful' from the age of 16, or face some form of sanction. This of course runs in tandem with his wish to photograph and fingerprint every school child in the country.
Posted by John Howard | November 12, 2007 2:44 PM
Posted on November 12, 2007 14:44
Dave
You're right about difference. The description of "Evidence Based" in quote marks referring to Cognitive Based Therapy bothers me a little.
I don't trust policy makers to appreciate the richness and subtlety of the human condition. In fact they might not even like diversity. So a rich view is important. That should be compatible with some degree of evidence. Different medicines affect people in different ways but no one would suggest that efficacy and evidence for efficacy isn't important
If anyone is interested in a rich view I'd suggest reading Madness Explained by Richard Benthall which takes issues with the DSM IV definitions and illustrates the history of and treatment of madness including depression and schizophrenia. It has a cognitive bent. I'd also suggest that people read Andrew Solomans "The Noonday Demon" or view Sherwin Nuland personal experience of Electro Shock Therapy on TED (http://www.ted.com/index.php/talks/view/id/189)
No single grand theory. All about evidence and steps in the right direction
Dermot
Posted by Dermot | November 13, 2007 10:15 AM
Posted on November 13, 2007 10:15
Originated: 13/11/2007 18.16 Revised 15/11/2007
Hello,
I think the letter from Lesley Murdin, wpf, is an important departure so I reproduce it here. Andrew Samuels’, ( Centre for Psychoanalytic Studies, University of Essex), letter to The Observer also follows. This follows Professor Samuels’ letter to the Guardian. (Our national heritage is not a luxury. Friday October 12, 2007 Web-Link:The Guardian )
My reasons:
Both Andrew Samuels' and Lesley Murdin's letters argue for inclusion of talking therapies beyond cbt in IAPT Centres (the government’s ‘Happiness Centres’ set up on advice from Lord Layard).
Assumptions the writers seem to make:
Both want control of the patient’s choice
Lesley Murdin puts a 'trained practitioner' in place to protect the subject from making their own decision. This is an extension of the government’s promise to safeguard (Health Professions Order 2001) It seems to me that even a skilled assessor will not have as much information after a half-hour slot as the subject possesses after a lifetime. The trust relationship which should be formed during this slot will then be broken because the ‘trained practitioner’ knows best. Really?
Andrew Samuels challenges Lord Layard’s (a distinguished economist) use of the government’s NICE clinical guidelines. By implication he, quite rightly I think, also challenges the government’s clinical judgment. Cbt (Cognitive Behavioural Therapy) has limits – it is not the unary panacea the government thinks it is prescribing. Andrew Samuels asks that other therapists use ‘their much more extensive trainings in these areas alongside the new CBT approaches’. So Happiness Centres which carry the government’s guarantee of ‘safeguarding health and well-being’ (HPO2001) by using the ‘evidence-based’ best practice, cbt, now have different approaches working from behind the screen of government approved, cbt. The attendee, referred for cbt (NICE clinical guidelines) could end up with something else. Of course, with their ‘much more extensive trainings ‘ the counterfeit cbt therapists will be doing a much better job so the Centre’s attendees need not worry – they will be safeguarded. This sounds deceitful to me and I am not comfortable with it.
I have a new subject who, having emerged from 4 years of cbt,, has landed on me via a friend’s referral after trying two other therapists. She is not making her decision on which flavour is my training, but whether she feels comfortable in the relationship.
What's the problem with this?
Why can't subjects choose for themselves?
Julia Evans
Julia@julia-evans-psychoanalyst.org.uk
www.psychoanalysislondon.org.uk
Your letters
Sunday October 21, 2007
Web-link): The Observer
CBT is not the only therapy
A government commitment to provide more counsellors is indeed a landmark, as Richard Layard suggests ('And now for the good news about therapy', Comment, last week).
Cognitive behavioural therapy (CBT) is a valid and effective treatment for many people - but not for all. That is why we are calling for an initial assessment consultation with a trained practitioner that will determine the approach most appropriate: CBT, ongoing counselling, group analytic therapy, psychotherapy or other interventions including medication.
Lesley Murdin Chief executive, wpf Counselling and Psychotherapy, London W8
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Professor Lord Layard knows full well that there's a lot wrong with Cognitive Behavioural Therapy. He has allowed himself to get caught up in a web of prejudice against more subtle and profound forms of psychotherapy. If the government's plans are not challenged, we are headed for another public health disaster. Most of the counsellors he expects to become 'psychological therapists' will already have specialisms, mostly in psychodynamic or integrative psychotherapy. Let them use their much more extensive trainings in these areas alongside the new CBT approaches.
Andrew Samuels Centre for Psychoanalytic Studies, University of Essex
Posted by Julia Evans | November 15, 2007 8:53 PM
Posted on November 15, 2007 20:53