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The Power of Evidence Based Psychological Therapies
Richard Layard and David Clark
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Nearly everyone who is physically injured gets treatment, but two out of three with mental illness are not. If your bone is broken you are treated automatically, but if your spirit is broken, you are not.
The treatments pay for themselves -fewer people on welfare, fewer people locked up for crimes or antisocial behaviour. Mental illness accounts for half the people on disability.
The last 50 years have seen less poverty, better physical health, more education and better housing. Yet there is just as much misery as there was 50 years ago. In US, more people die by suicide than by road accidents.
Cognitive Behaviour Therapy grew out of the observation that many mental patients constantly and automatically circulated negative thoughts through their mind.
The brains of depressed people different to normal. Their amygdala (where our fight or flight response) is lot more active, and pre-frontal cortex (whichregualtes emotions and reactions) is less reactive than normal. Anti-depressants affect the amygdala, but not PFC. And when stop taking them, they stop affecting the amygdala. But CRT returns both amygdala and PFC to normal, and continues to work even after treatment stops.
One in six adults in Britain suffer from depression or severe anxiety disorder. Both are potentially life-threatening illnesses, yet two-thirds of sufferers won't get treated. It is a national scandal that leaves so many people with mental health problems without professional help. In Thrive, Richard Layard and David Clark set out to show how urgently we need to improve mental health provision, and what a false economy it is to try to save money by cutting back on, and refusing to fund, enough services for the mentally ill. In the days of New Labour, Layard was known as the government's "happiness tsar". In fact, he is an economist with an evangelical mission to deal with the immense and massively ignored problem of mental health in Britain. Numbers are important to him, and his numbers are alarming. He makes the case that mental illness is no less debilitating than physical illness, using statistics that show depression to be on average 50% more disabling than angina, asthma, arthritis or diabetes. Yet, he says, although 90% of those who take their own lives have mental health issues, only a minority are receiving treatment, while 100% of those with heart disease will get medical attention.
These figures from surveys and censuses are fairly straightforward and shocking, and with them, the authors make an urgent case for increased spending on the issue. More problematical are the definitions and solutions that Layard and Clark – a psychologist – offer. In an attempt to show that "mental illness also has a major effect on your physical health", they reveal "an extraordinary fact" by quoting from a survey that took a sample of British people over the age of 50 and measured their degree of happiness with "a few simple questions". When the researchers returned nine years later, they found that those who had been judged least happy "were 50% more likely to die each year than people in the happiest group". The authors are clearly equating unhappiness with mental illness.
In 2003, Layard defined happiness and unhappiness. "By happiness I mean feeling good – enjoying life and feeling it is wonderful. And by unhappiness I mean feeling bad and wishing things were different." It is not just simplistic, but actually alarming that, by his own definition, unhappiness – "feeling bad and wishing things were different" – stands as a description of the mentally ill. The authors hope to increase happiness through treating the mentally ill and eradicating the wish for things to be different; they set out to achieve a placid, self-satisfied society, which is quite content with things as they are. A politician's dream, but hardly a healthy state to be in as we increasingly discover so many aspects of government and policy that require the oversight of a critical public. In all areas of life, critical thinking may not make you perfectly happy, but you might want to question whether perfect happiness is quite as desirable as it seems to be for Layard and Clark, and whether you want to be considered mentally ill if you don't achieve a state of bland satisfaction. The desire for everyone to be happy might seem kindly, but it can lead to various destinations, including Huxley's Brave New World and cloud cuckooland.
In Thrive, Layard and Clark set out their plan to improve mental health resources. The first thing to do, they say, is to measure the mental health of the populace using what they call the "new science of happiness". The results should then be used by government – which only exists "to promote happiness, and especially … to reduce misery" – to improve the sense of well-being of the nation by increasing mental health services. The authors cite research that suggests mental health is top of a list of factors on which people say their happiness depends, echoing King Lear ("O let me not be mad, not mad, sweet heaven!"). If government isn't convinced that the people's happiness is its main raison d'etre, the authors provide other figures to show that by getting people better and back to work as fast as possible, the Treasury could claw back the 4% of GNP that is lost by the combined effects of mental illness; that is, lost working days, sickness benefit, lost tax and the cost of the physical illness that also attends depression and anxiety disorders.
What form these improved mental services should take is very clearly defined, even in the book's subtitle: The Power of Evidence-Based Psychological Therapies. The joy of simple measurement is the heart of Thrive. If it can't be or hasn't been measured, it's no use. The phrase "evidence-based therapy" is used repeatedly, and at a single stroke it dismisses most person-centred talk therapy, in particular psychoanalysis and long-term psychotherapy, which are lengthy, expensive and not amenable to simple measurement. In their place, the authors would put cognitive behavioural therapy in its various forms. For Layard, the economist, and Clark, one of the world's leading experts on cognitive behavioural therapy, the provision of CBT to all patients with mental health problems is a simple, economic and effective answer. CBT fulfils the authors' admirable desire for an improvement in mental health provision. It takes at most 20 sessions, often far fewer; it is so standardised that therapists can be trained very quickly, and use a manual (they talk of manualised conversations) to conduct their sessions. It is so standardised that patients can be treated by phone, online or with self-help books. It is cheap, and has as good a recovery rate, we are told, as medication. CBT deems patients who are depressed and anxious to be having wrong thoughts. These thoughts are examined in the sessions and found to be negative. Repetitive negative thoughts are called rumination and patients are trained to alter their thinking to be positive. If I claimed, say, to be depressed about the fact I will die sooner rather than later, perhaps I would be told to focus on the fact that I'm not dead today. This is true, but doesn't alter the inevitable, which it might be useful for me to think about and come to terms with. Exercises and homework are given that are said to reprogramme the mind, put a stop to brooding, and replace negative thoughts with positive ones. It is, they claim, as simple as that. And the results are measurable, patient improvement is quantified after every session and at the end of each course. There is no need to dig into the past, to look for trauma. The mind, as if it were a material entity, can simply be changed by some outside process without reference to causes. Thoughts, we are told, are not facts. It brings us back, once again, to behaviourism: at least one of the discoverers of CBT looked to Pavlov's experiments. Thrive quotes Aristotle's belief that "the key to a good character is good habits" and tells us the aim is to replace those negative thoughts with "realistic ones". Just change those bad habits. And if they return, get a CBT top-up. Person-centred psychotherapy and analysis guide the patient to investigate herself, her past and her complex behaviour to discover the reasons for her symptoms. It makes understanding the goal, and assumes, along with Socrates, that the unexamined life is not worth living.
CBT has certainly worked for many people who, in six weeks or so, have learned to amend and reverse their negative thinking and feel better. It suggests to governments that they will get what they most want: value for money and a tranquil population. It is the chosen method of the National Institute of Health and Care Excellence and already almost the only kind of therapy offered by the NHS other than medication. The authors are clearly compassionate people who want to abolish the misery of mental illness, and CBT, so appealing to economists with its manualised conversations, standardised questionnaires and worksheets, and in tune with contemporary culture's desire for measurable fast outcomes, is the pragmatists' holy grail. CBT aims to get the patient symptom-free, back to work and paying her taxes. In generations to come, if we can ward off the return of the repressed, people will be looking back at 20th-century literature and philosophy and wondering what on earth they were on about with their incomprehensible talk of the unconscious, their tales of guilt, sublimation, drives and dreamwork. Because, by then, the mysteries of the human heart will have been abolished and all the world will be transparent and symptom-free.
Economist Richard Layard and psychologist David Clark champion evidence-based therapies for depression and anxiety. They tell how their mission has just begun.
Your book is about the mental health initiative you two fought to start. Who is the book for?
Richard Layard: Everyone. We hope it will be a bestseller. David Clark: We want people to realise where science has got us to: people whose lives might otherwise be ruined by long-term mental health problems can benefit from the latest psychological treatments, and many can have their lives transformed. If you get treatment in your 20s and 30s, that means you've got 50 years of a very different life.
How big a problem is the undertreatment of mental illness?
RL: In rich countries one in five people suffer a mental illness, mostly depression or anxiety disorders. Mental illness accounts for 38 per cent of all illness and even more for people of working age. Yet in most rich countries it gets under 10 per cent of healthcare expenditure.
Coming from outside psychology, as an economist, I was shocked. Throughout the rich world, less than one-third of people with common mental disorders are in treatment; for common physical illnesses like diabetes or cardiovascular problems, it's over 90 per cent. This difference is an outrage. There are people who have problems, here and now, who could be treated and are not being treated.
Why don't people get treatment?
DC: Part of it is because health authorities and doctors still do not realise how powerful and cost-effective the treatments are. There's also a lot of stigma about mental health, which makes people with mental illness less likely to seek treatment. That is probably made even worse because many don't know that there are effective treatments waiting for them. These are problems we set out to address with the UK initiative we proposed, Improving Access to Psychological Therapies (IAPT). In the last 30 years there have been major advancements in psychological treatment, but they largely have not been acted on in clinical practice.
Why has clinical practice lagged behind?
DC: There are lots of reasons. Among them, there's this very unfortunate term "talking therapies". Everyone hears that and thinks: "Oh, it's just like having a chat with someone who's nice." People think it would be a nice thing to have, but that it can't be very effective.
Of course, these therapies aren't like that. They are based on science, they are tailored to and differ between conditions, and they have evolved enormously on the basis of research about the underlying psychological processes.
What are the consequences of undertreatment?
RL: Among people who are least satisfied with their lives, the biggest cause is poor mental health. These problems affect people in every social class and have huge costs. They also cause low effectiveness at work, family break-up, crime and a host of other problems.
The programme started in England in 2008. Six years on, has it made a difference?
DC: Last year more than 700,000 people were seen through IAPT services, most of whom would not otherwise get any psychological therapy. In services with experienced staff, about two-thirds of people who receive a course of treatment show reliable improvement and close to 50 per cent recover.
What treatment strategies work well?
DC: Initially the focus of the IAPT programme was cognitive behavioural therapy. CBT is recommended for depression and all anxiety disorders by the UK's National Institute for Health and Care Excellence (NICE). For mild to moderate depression, NICE also recommends treatments such as counselling and couples therapy, so those are offered as well. This is all about evidence-based treatment. CBT is backed by the most evidence, but it's not the only show in town.
What makes CBT so effective?
DC: There is emphasis on having an empathic, supportive therapist. But it's called CBT because it focuses on thoughts (cognitions) and behaviours. The key idea is that when people have emotional problems, negative patterns of thinking – and the way these influence behaviour – are what keep the problems going.
How would you use it to treat social anxiety, say?
DC: People with this condition have distorted mental images of how they appear to others. One way CBT might deal with this is to video their interactions, then have them compare the video with their images of themselves.
Your behaviour also changes if you're frightened of talking to people. If I'm worried you might think what I say is stupid, chances are, while we're talking, I'd be lost in my head memorising things I've said. So what I'm doing to manage my anxiety actually gives the impression that I'm not interested in you. In therapy you help people discover that such mental strategies can make things worse, and encourage them to drop those strategies.
How do you know if it's working?
RL: Each time someone is seen, they complete a simple measure of anxiety and depression DC: Prior to this initiative, you couldn't go to any mental health service and ask: "If I came to you to treat my anxiety or depression, what is my chance of recovery?" They didn't have complete enough data to answer the question. In just the last three months, about 85,000 people completed a course of treatment with IAPT, and there is pre and post-treatment outcome data on 98 per cent of them.
This has never happened anywhere in the world. It is a revolution. Now those who commission mental healthcare are realising you can set goals based on outcomes – not for reduced waiting times or more people coming in, but for whether people actually get better.
How long does it take to make a difference for one person – and how much does it cost?
RL: For depression and anxiety disorders, NICE guidelines suggest that about half of people will recover within 10 sessions. So far for IAPT, the average cost is about £650 per person. This is not expensive treatment. Moreover, it can prevent public spending on the disability that mental illness can lead to. Our case is that these treatments would actually cost the UK nothing if they were provided more widely.
How much does mental illness cost societies?
RL: For any advanced country, it's about 8 per cent of GDP. In the UK, the estimate is nearly £130 billion. There are now laws here and in the US that require equal esteem for mental and physical health, but we're still nowhere near truly equal access to treatment.
In the UK's National Health Service, treatments are still not provided to NICE guidelines. In the US, health insurers often offer just six sessions of psychological therapy – then you have to reapply if you need more. That's like saying if a surgical operation takes over an hour, please reapply to continue.
It seems you still have a battle ahead. Why are things moving so slowly?
RL: The problem is that there's no constituency. It's less a matter of opposition than not enough people making the proposition, largely because of stigma associated with mental illness. People will fight for more resources for cancer or heart disease. But when it comes to mental illness, there's no effective lobby.
What could change this?
RL: It requires an uprising by the general public. If ill people themselves are not able to protest by virtue of their illness, we need to hear much more from their relatives, friends and colleagues. Where healthcare is provided in a democracy, politicians respond to the number of letters that make the point.
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