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Thoughts Are Not Facts
Sunday Times, 06 July 2014
Thrive: The Power of Evidence-Based Psychological Therapies
by Richard Layard and David M. Clark
Depression shortens lives as effectively as smoking and is 50% more disabling than chronic physical conditions such as diabetes, asthma, angina or arthritis. Mentally ill people also get more physical ailments and respond worse to treatment.
This is not just a matter of indvidual suffering. More than 40% of lost work days are due to mental illness. If all mentally ill people could work, employment would rise 4%. Mental-health problems reduce our gross national product by the same amount — 4%. The mind is, in short, the location of the most damaging health problems that afflict humanity and the developed world spends only millions on treatment at the same time as its spends trillions on the body.
The reason is obvious. Until recently, there was almost nothing we could do. The talking cures — such as psycho-analysis — either didn’t work or took so long to work as to be completely impractical. Surgery — lobotomy, for example — was discredited following a succession of scandals. And the effectiveness of drugs was highly contentious, the Prozac paradise, among others, having turned out to be massively oversold.
All that, argue Richard Layard and David Clark, has now changed. Lord Layard is an economist, most famous for his book Happiness (2005), which advocated wellbeing rather than wealth as a political goal. Clark is a professor of experimental psychology at Oxford and an expert on cognitive behavioural therapy (CBT), the technique that seems to have resurrected the talking cure as the gold-standard treatment for the most common mental ailments.
The success of CBT — and its offshoot, mindfulness — is at the heart of this book’s case for increased spending on mental health. The most succinct summary of the method is “thoughts are not facts”. People suffering, typically, from anxiety or depression are trapped in thought processes that they have come to believe are truths about themselves and the world. The therapist identifies these thoughts, then provides techniques for reducing or eliminating their impact. It doesn’t take long — typically 12 sessions — and it has much higher success rates than any other treatment — about 50%. Mindfulness, meanwhile, is a meditation technique inspired by Buddhism that helps people to see thoughts as passing phenomena rather than traps.
CBT has been thoroughly tested — hence the phrase “evidence-based” in the subtitle — but its acceptance as a treatment at GP level remains problematic. The preconception that there is little that can be done about mental illness other than clobbering it with the right drug persists. Indeed, the authors remark that when they presented their findings to a seminar at Downing Street in 2005, many were amazed that psychological therapy had, finally, discovered a solid, scientific basis.
This book, first, celebrates the successes that flowed from that seminar. Britain now seems to be leading the world, thanks to our Improving Access to Psychological Therapies programme. Thousands of therapists have been trained to administer CBT and, gratifyingly, so far their results seem to be matching the 40%-50% success rate previously reported. Second, the book says we — and the countries that are now following us — must go much further. Millions are still suffering from debilitating condtions that could easily be treated.
We are also leaders in providing the evidence. The National Institute for Health and Care Excellence (NICE) seems to be the best body in the world for providing evidence of success or failure and for codifying best practice. There are fascinating tables in this book showing exactly what treatments are recommended for conditions such as bulimia, panic disorder, obsessive-compulsive disorder and so on. Most involve CBT. I was intrigued to learn that blood-injury phobia is unique in causing a drop in blood pressure — apparently, CBT can even cope with this.
Perhaps this all sounds too good to be true, and perhaps it is. There have been recent accusations that the flood of new therapists is resulting in a decline in quality and, as the book reports, bad therapists are worse than no therapists. Furthermore, previous “breakthroughs” in mental health, like the arrival of drugs such as Prozac, have proved more or less illusory. The difference here, however, is that the body of evidence is in the public realm. It is neither selectively concealed nor paid for by the giant pharmaceutical companies whose record in this area is abysmal. Nor is it in thrall to a master theorist. Freud was, indeed, a genius of the first order but psychoanalysis is no way to treat mental illness on a mass scale. The truth is that CBT and related therapies are really all that we have for the most common ailments. (The leading psychoses — schizophrenia, bipolar disorder — still need heavyweight drugs.)
I suspect that more contentious than mass availability of CBT will be some of the broader recommendations that appear at the end of the book. All schools, the authors say, should have the emotional wellbeing of their children as “an explicit objective” and society should become “less macho”, with more emphasis on collaboration and less on competition. Mindfulness should be taught in schools, and there should be a cabinet minister for mental health.
At this point, the mental-hygiene programme becomes a political project, an ideological statement of the way the world should be run. I am sympathetic. Somebody taught me mindfulness and, I can tell you, it works; also, macho culture is dull and eternal competitive striving is just another neurosis. But I fear Layard and Clark may have reduced the effectiveness of their case by the ambitions of their conclusion. There are plenty of macho competitive types in power who will be horrified by the suggestion that their virtues are, well, not virtues.
Nevertheless, the basic message is too important to be buried beneath political prejudice. If Layard and Clark are right, we seem at last to have found a gentle, non-disruptive and apparently risk-free way of dealing with the worst and most commonplace miseries of the mind. Let’s do it.
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12 July 2014 at 4:55 pm
CBT is indeed useful, but only if it’s a good fit with the particular patient at that time. Many patients are either in traumagenic circumstances that would require actual, external change for psychological improvement (poverty, violence, etc). In these cases to attempt to reframe realistic thoughts of “I am in danger” to “I will be OK” will merely create cognitive dissonance and more anxiety. Additionally, patients who are not psychologically and verbally sophisticated, and those who suffer from mental illnesses such as schizophrenia and bipolar disorder, which can impair cognition, are often not able to attain the witnessing of thought stance essential to CBT.