A new approach to psychological therapies
Psychological therapy is a not a like-for-like replacement for medication. Part of the problems with the IAPT programme and with the widespread growth in the use of CBT is that we often talk as if 'CBT for depression' is conceptually the same as 'antidepressants for depression'. Unfortunately, too many psychologists are complicit with this idea. Our psychological well-being - our mental health - is dependent (at least in large part) on our framework of understanding about ourselves, other people, the world and the future. This framework of understanding does not represent some form of 'pathology' or 'thinking error', but rather the natural and understandable consequence of events and experiences in our lives together with our learned responses to those events. In that context, helping people to learn more resilient ways of responding to the challenges of the work can be useful. We need to talk to people and to try to understand their perspectives, the way they see the world, the messages that they have taken away from things that have happened to them, and how they approach the challenges in their lives. We need to work collaboratively with people to develop new ways of responding, and to examine the evidence for the conclusions they have drawn. When someone loses their job and concludes that there is no point in living, we should explore with them why they might have reached that conclusion ... and help them get a job. When an abused child comes to believe that she is responsible for the abuse, that she is unlovable and evil, we should challenge that conclusion ... but at the same time actively help protect children from abuse and bring abusers to justice. But we should not be under the misapprehension that these conversations, however helpful they might be, represent a set of 'treatments' for 'pathologies'. There is no such thing as 'abnormal psychology' just as there is no such thing as 'abnormal physics'.
And that means that all psychological therapies should all be based on intelligent integration of evidence about which approaches seem to be most helpful in general, and about how they impact on psychological processes (such as the tendency to interpret things in certain ways). Of course, all psychological therapies should be delivered by qualified, competent professionals. Decisions about what therapy or therapies should be offered to whom should be based their specific problems and on the best evidence is about what is likely to help with those problems, not on diagnosis. Individual formulations should be used to put together an individualised package of care suitable for addressing each person's unique set of problems. Since even clinical psychologists currently often follow a tacit disease model, using psychological therapies as part of a psychosocial, rather than biomedical, ethos would significantly change the way that clinical psychologists and others work.
With a starting point of a simple list of problems (as discussed in Chapter 2), the clinician and client should work together to come up with a shared understanding of the nature, causes and possible solutions for those problems - an individual case formulation. Each profession uses the term 'formulation', but each a little differently. It is common for psychiatrists, for example, to refer to a formulation developed after a diagnosis has been given - in other words, the client's problems will be assessed, the most appropriate diagnostic label agreed upon and then a more fulsome account of social and psychological aspects will be developed. Clearly, in the approach recommended here, such formulations should predominantly focus on the social and psychological contributors to a person's distress. Clinical psychologists, on the other hand, see formulations as alternatives to (rather than additions to) diagnosis. The formulations of clinical psychologists - with which I am, naturally, most familiar - usually consist of a list of problems together with hypotheses as to the possible origins of those problems. Good formulations should be based on a coherent 'psychobiosocial' model. That is, they should attempt to identify which of the almost infinite set of possible social, environmental and biological factors might be playing a role. We should attempt to identify factors in a person's childhood: parental absence or bereavement; emotional, physical or sexual abuse; bullying or abuse in childhood; the attachment relationships with parents; key life events ... the list is a long one. We should also attempt to identify those social factors known to lead to mental health problems in adulthood: marital difficulties, loneliness, unemployment and its mirror - unrewarding, insecure, stressful or bullying jobs - and financial difficulties. Again, the list is a long one. We should equally attempt to identify those very many biological factors that could influence a person's mental health - whether they be familial traits (of which I, personally, am highly sceptical, as they seem most highly likely to be family myths rather than real biological vulnerabilities and which may, in any case, represent learned patterns rather than biological pathologies) or physical ailments that understandably affect our psychological well-being. This is not intended to be a guide for conducting psychological therapy. This is not an extensive list of all the areas that need to be considered when assessing possible causal factors. It is merely intended to give an idea of those challenging events and circumstances that can lead to mental health problems and should be part of any assessment process.
Psychological accounts of mental health problems do not see people as mere corks, bobbed around by the waves of circumstance, neither do they see people as the product of biology alone. Instead, people make sense of their world, actively interpreting events and then responding to them. As well as assessing biological ('nature') and environmental ('nurture') factors in the development of mental health problems, psychologists quintessentially must explore the person's individual psychological response to events.19
It is an unfortunate concomitant of the growth in CBT over the past few years that appreciation of, and emphasis on our shared and normal psychological mechanisms seems to have shrunk rather than grown. This could be a consequence of the fact that, encouraged by the IAPT programme, many of the CBT therapists now practicing in the UK and abroad do not have a first degree in psychology. This makes their practice somewhat manual-based and naturally renders them less able to identify (or even recognise) key psychological mechanisms and their importance. In many descriptions of CBT for the public, emphasis is placed on the links between our thoughts and our mood, and reference is often made to 'negative automatic thoughts'. Psychological science is much richer than this. Again, an exhaustive list of psychological mechanisms and the ways in which quirks in the details of these mechanisms can affect our understanding of the world and interpretation of events would be much too long for this book. But psychologists can draw on knowledge of our perceptual system and the way that we make sense of the huge volume of visual and auditory information hitting our eyes and ears every second. We understand how people make sense of this information and how the brain stores information in memory. We understand basic principles of reward and punishment, and the details of how such technical issues as 'discriminant stimuli' and 'intermittent reinforcement' can make certain behaviours extremely difficult to change. Complex theoretical models such as the 'interacting cognitive subsystems' model20 can help to understand how the human mind transforms structural information about the world (the patterns of light and dark, edges and corners) into, first, factual information, then, progressively, information concerning objects, people, actions, relationships, and finally intentions and meaning, including emotional meaning. This touches on the striking phenomenon of 'change blindness', where people simply fail to notice significant changes in the real world.21 We have detailed (and constantly evolving) theoretical insights into the ways in which people understand their relationships with parents, with peers, partners and others. We study how people understand and explain events in the outside world: the 'causal attributions' we make about events seem to be particularly important not only for guiding our actions but also for our mental well-being - and how we identify and appraise our own internal physical states. There is a large and growing literature on how we understand our own thoughts - an area of research obviously closely linked to the idea of 'mindfulness'. Psychologists have studied a wide range of mental processes related to how we form and maintain beliefs, which is obviously pertinent to a wide range of serious mental health problems. Psychologists have studied - have won Nobel prizes for studying - 'heuristic reasoning', that is the mental 'short-cuts' that we use to make sense of and act towards a complex universe where much is possible and little is certain.22 We know a great deal about how people develop their sense of self, and how they maintain their self-esteem when things go wrong. Psychologists, especially from behavioural tradition, understand how people and animals respond in circumstances of unremitting punishment (so-called 'learned helplessness'). More recent 'cognitive' research (that is, research studying thinking processes) has explored our sense of self-efficacy (what we believe we can do, and why) and the negative cognitive schemas (sets of related thoughts) that accompany the depressed mood.
In a genuinely psychological approach, therapy should then proceed on the basis of these identified psychological processes (and this is, again, a very sketchy and inadequate illustrative list). In a genuinely 'psychobiosocial' model, we would see a genuine assessment of possible biological factors that could be playing a role, and the consideration of the possible role of medication. More pertinently in most cases, we would see a comprehensive assessment of the person's social circumstances and a practical, integrated, plan to address these real-world issues. For me, as a psychologist, we would also see a research-informed analysis of the possible role played by the way that the person is making sense of their world, and whether they are interested in exploring possibilities for change in that respect.
In practice, this rarely happens, even in the CBT of the IAPT programme. Despite the dominant role of psychiatry in the current mental health system, the basics of biomedicine are often neglected. People in the mental health system often have very poor physical health, sometimes exacerbated by poverty, loneliness, hopelessness, and the physically damaging effects of the medication. Those are surely matters for our medical colleagues. In passing, I believe that the failure of biomedical psychiatry to address these health issues is another very good reason to envision a much greater role for GPs. More specifically to mental health, it is currently the case that the very biomedical aspects of a case formulation that are argued to give our medical colleagues 'clinical primacy' in the care team are often neglected. Quite aside from the shameful failure to give all clients proper medical care, the biomedical aspects of clients' mental health issues are usually explored in a very cursory fashion. There is a good reason for this - MRI scans or blood tests are pretty much worthless in psychiatry; we (unsurprisingly, given my arguments so far) simply do not have biomarkers for mental health problems. As a consequence, in practice the role of the biomedical specialist defaults to making inaccurate, unreliable and invalid diagnoses and issuing prescriptions for psychiatric drugs which, as we saw in the previous chapter, bear little systematic relationship to the diagnosis, are in no real sense 'cures' and seem to cause nearly as many problems as they solve, at least in the long run.
Services commissioned through the IAPT programme may not meet the needs of our GP colleagues in their primary medical role either. Although I am no supporter of biomedical dominance, initiatives such as IAPT - indeed many initiatives involving secondary-care services to which GPs refer, rather than services within primary care - may make this neglect of physical health and genuine psychiatry even worse. Instead of community mental health and well-being teams with close links to primary care, as I would advocate, access to CBT and other psychological therapies too often relies on referral. The client is referred to an external service. While the GP (or another referrer) has determined that the person requires psychological therapy, the practical consequence is a referral to a service outside of the primary care system, in which - typically - a therapist engages in conventional CBT as a stand-alone intervention. Even if that therapist were medically trained (an extreme rarity), the nature of the service and the intent of the referral preclude any assessment of physical health. In practice, then, services such as the CBT provision commissioned under the IAPT programme often fail to consider physical health needs or any biological factors which may be playing a role in someone's mental health problems. Our system urgently needs reform.
The same considerations apply to the second major set of causal agents - social factors. In an ideal system, a comprehensive assessment of the client's social needs would contribute to the care plan, and assertive action would ensue. Theoretically, the major causal factors involved in someone's mental health problems should be identified, and careful, detailed and expert care taken to identify the pathways from external crisis - abuse, poverty, loneliness, unemployment, debt and so on - to understandable emotional distress. Practically, solutions should be developed that address these root causes. But instead of this, the referral to separate, secondary-care services such as those commissioned under the IAPT scheme can all too often effectively ignore such social factors. Public statements will refer to the ways in which local authority social services departments should work with mental health services to provide integrated care. In practice, these issues are quietly sidelined. The dominant biomedical model minimises (often, tacitly, by neglect) the role of social factors. CBT therapists are usually untrained in such social factors.
Instead of addressing the three aspects of a biopsychosocial or a psychobiosocial model in an integrated way, all too often 'psychological therapy' services provided through programmes such as IAPT merely offer clients a standardised, one-size-fits-all, manual-based, surface-level, sticking-plaster pseudo-solution. The therapists are trained and competent in delivering standard CBT. And that has its merits. But they are usually untrained in assessing and addressing biological, factors as part of a comprehensive formulation of a person's needs. They are usually equally untrained in assessing and addressing social factors. Perhaps most depressingly, they are often largely untrained in the final - psychological - element. There is a difference between understanding the complex psychological processes that pertain to an individual's circumstances and applying one of a limited number of standard CBT protocols (one for 'depression', one for 'generalised anxiety', one for 'panic disorder' and so on).