Are we truly 'guardians of the human psyche'?

It was with considerable interest that I read David Harper's article on "Beyond Individual Therapy" in the June 2016 issue of The Psychologist. I found it a pleasure to read his re-iteration, in such a succint form, of the arguments that have been put forward over the last 30 years or so about the nature of the work of psychologists. The identification of the lack of impact of individual therapy upon the "epidemic" as identified by David Clark and Richard Layard in their book "Thrive", and the comparisons with John Snow and the London epidemic in the 1850's with regard to efficacy, have all been made many times. The connection with the work of Wilson and Pickett and inequality is helpful as well.

Just to update Harper regarding antidepressant prescribing, 61 million such drugs were prescribed and dispensed outside of hospitals last year. This total was 31.6 million more than in 2005 and up 6.8% on 2014, according to a report from the Health and Social Care Information Centre (HSCIC). This also shows that individual therapy is hardly having the kind of impact that Clark and Layard originally claimed for their project. "The original justification for the IAPT programme was strongly based on the rationale that the service would pay for itself, and indeed make net gains in health spending and more broadly in relation to helping people stay or return to work"¹.

However, the analysis does not go anywhere far enough or include the work from different fields of research that also impact heavily upon the case Harper is trying to make. Psychology has become a siloed profession in the same way that many other professions have.

First of all, as Suskind and Suskind pointed out last year, "to what extent do we actually trust professionals to admit that their services could be delivered differently, or that some of their work could responsibly be passed along to non-professionals? If we leave it to professionals themselves to reinvent their workplace, are we asking the rabbits to guard the lettuce?"

This single statement encompasses a vast range of areas of that are left unquestioned by Harper's article. The implicit assumption Harper makes is that psychologists are the right people to redefine the nature of their work – is this so? The internet is changing the way people discover information and the view they take of "professional helpers". Many are now turning to internet chatrooms, unregulated private practitioners of psychological interventions, community groups and other sources of support such as third sector organisations. No longer does the role of a psychologist have the impact it might have done 30 years ago. Furthermore, the limited impact that services such as IAPT are having on the wellbeing of society is providing ammunition for the detractors of professionally guided therapies, Oliver Burkeman and Oliver James being two prominent examples. Michael Gove also recently dismissed expert knowledge and told the public they should not listen to them.

These attacks and the anecdotal stories frequently passed around among the recipients of IAPT and other psychological therapy providers are not helping the profession at all. Bearing in mind that, of the 1.3 million referred to IAPT in 2014-2015, only 189,152 reached "recovery", there are far more stories of a failed service than there are successes. Harper also alludes to the drastic cuts in funding by government and the movement called "Psychologists against Austerity" who are building a head of steam against such government austerity policies. However, there are also other organisations such as the "Mental Wealth Foundation" who are heading up a campaign against mandated use of psychological therapies in Jobcentre sites to get people into work, whose political agitating is primarily against psychologists and therapists who are working in these settings. (I make no moral judgment about this, as this is not part of my exposition at this time.)

All of this public activity is bringing into question the role of psychology and its impact upon the population as a whole. While individual psychologists are doing incredible work in every setting under the sun, the overall picture for the future of the profession is bleak. It has a fundamental problem. That problems lies in the difference between statistical studies, whether done in the laboratory or in vivo, and the experience of the individual. IAPT is a particularly spectacular example of how the trial has not translated into to the broader public arena. The Newham and Doncaster trials were well supported by all stakeholders, the people providing the therapy were highly experienced, the support staff had all had some input into this novel approach and were engaged with the process.

We see the same at the experiment in Canterbury with the Jobcentre pilot, all parties are thoroughly engaged with the process. However, when it comes to rolling out the projects, the rules are changed. IAPT became a payment by results, contracted to outside contractors whose priority was to make money, or at least stay afloat financially and achieve waiting times and throughput rather than quality interventions. Also, the priorities are different for the therapists and support staff who wish to keep their jobs (many will complain privately about conditions but few are prepared to speak out); as Harper points out, the survey in 2016 by the British Psychological Society suggests that there are high levels of discontent and distress among employees providing psychological input adds fuel to this particular fire.

Thus the "evidence" for an intervention comes under pressure when the environment and delivery method are altered. The "client experience" as a journey from first contact to goodbye is hardly considered by research programmes, yet other business and industry sectors see this as fundamental to the engagement of their customers and to a successful outcome. (Jobcentre employees are expected to see their clients as 'customers' as a nod to this experience).

The arcane approach of multiple assessments seems unnecessary, unproductive and unhelpful to me and another aspect of the professional's need to control the process. (I have written at length about the pointlessness of assessment elsewhere.) Furthermore, studies are now suggesting, at last, that risk assessment and care planning may be a misconstrued and misconducted activity (Littlechild & Hawley 2009) that is related more to the defensive needs of the organisation rather than the safety of the individuals being assessed.

The individual therapist endeavours to provide an environment in which trust, hope and collaboration between the engaged parties are developed and nurtured. However, these characteristics are developed in any transaction between parties regardless of whether or not it is a psychological intervention, buying a refrigerator or getting your car fixed. There is nothing special about the "therapeutic relationship" – it is a fictional construct that has evolved to meet the needs of the psychological practitioner. The nature of this personal engagement, however, is dependent upon a huge number of interpersonal factors that are impossible to control for (or even detect) in the therapy room. Such research as has been done has been based upon the construct of "therapeutic alliance" factors (e.g. Norcross, 2010). Has anyone done a controlled trial with another profession outside of health care to see if the same factors exist in those relationships and whether they are comparable? My guess is that other professions assume the "alliance" and get on with the job instead of agonising over how their clients perceive them. There is a further problem to explain for the "therapeutic alliance" group: how does that alliance work when 25% of all interventions in some therapies are one session (MacDonald 2007)?

This, then, is the major dichotomy for me. Alan Frances puts it very neatly when he says, "The limitation of almost all tests used by psychologists is that the distribution of their results follows our old friend – the bell shaped normal curve". The trouble is that this evidence no longer applies when two people walk into a room and sit down to try to work something out for the benefit of both parties (for it a transaction not a one-way process as implied by the use of the word "treatment"). Statistical evidence rarely translates reliably or effectively into one to one work in psychology.

Harper then goes on to make the observation that little investment is made in community strategies or even in prevention strategies as commissioners do not see this as a priority. I know that at least one commissioning group (Liverpool) is funding studies and intervention in this form and has been doing so for some time. My organisation is already taking interventions out into the community (see our "Conversations in Cafes©" work). There are many activities of this nature around the country run by small third sector organisations who are achieving considerable success in building communities that are safe havens for people suffering psychological distress. Making these activities successful and gaining useful data is a programme all of its own as often social value is incredibly difficult to quantify and not always amenable to simplistic medically based psychometric measures.

Psychology is currently trying to map complexity in its research, its interventions, interpretation and yet assumption remains the cornerstone of psychological activity. As Ionnadis points out, "Many of the features that make clinical research useful can be identified, including those relating to problem base, context placement, information gain, pragmatism, patient centeredness, value for money, feasibility, and transparency. Many studies, even in the major general medical journals, do not satisfy these features, and very few studies satisfy most or all of them. Most clinical research therefore fails to be useful not because of its findings but because of its design" (Ionnadis, 2016).

As observed earlier, most of psychology is based upon constructs that may be useful to describe particular aspects of human behaviour, but they are not facts. Yet, so much of human psychology is based upon these constructs. I made the observation earlier that the therapeutic relationship is a construct, to name just one: it has no scientific validity. The construct is simply a collection of concepts that appear to be relevant to the researcher, yet it is now being considered as an immutable fact of the process of psychotherapy.

But even this is not where I think psychologists should be intervening most intensely. All of the above, individual, group and community interventions are vital and highly effective in their own way, but there is a far more important and greater goal that psychology can highlight and act upon.

I want to begin my last observations with a quote from William Ophuls (2012),"the human mind is not well equipped for the cognitive demands of civilized life in general, and it is singularly ill equipped to deal with the implications of exponential growth in particular." In the last 30 years we have seen more change to technology and as a consequence, our societies, than in the whole of previous human history. Humans are attempting to adapt to innovation at an unprecedented rate. Curiously, the prefrontal cortex has evolved and produced exaptions at a phenomenal rate over the last few hundred thousand years. Yet it is clear that our society is not keeping up with the technology that this phenomenon of brain power is unleashing. This mismatch is producing results that Picket and Wilson describe eloquently through the data promoted in their website The Spirit Level of increasing inequality in the most technologically advanced and "WEIRD" nations (Western, Educated, Industrialised, Rich and Democratic: see Haidt, 2012). (And these nations are what most of psychological research is based upon!)

This inequality is leading to something that historians suggest is an inexorable slide into the fall of civilisation on a global scale. There are markers for the collapse of civil society in the demise of every civilisation in history and they are characterised as, "A cabal of insiders accrues wealth and power at the expense of the citizenry, fostering a fatal opposition of interests between haves and have-nots. Mental and physical illness proliferates. The majority lives for bread and circuses; worships celebrities instead of divinities; takes its bearings from below rather than above; throws off social and moral restraints, especially on sexuality; shirks duties but insists on entitlements; and so forth" (Tainter, 1988). Sound familiar?

It is time that the profession of psychology took itself seriously and stopped attending to the individual as the main object of its study and began to consider far more seriously the study of behaviours of communities and societies in order that broader policy influence can occur. It is time we began to consider the possibility that psychology has a role to play in producing leaders that can lead and create wealth with the best interests of society as a whole rather than electing leaders driven by ideology and broken promises. There is a movement toward this far more complex study of human behaviour with psychologists like Carolyn Kagan, Mark Burton, Paul Duckett, Rebecca Lawthom and Asiya Siddiquee (2012) leading the way. This new approach is in its infancy; it is so incredibly important that research in this area is not stifled by 'The one size fits all approach' of placing the problem firmly within the individual and individualist treatment that is currently being adopted by the most dominant members of the profession at this time.

NHS England in its 2015 report suggests that it wants to be part of this process by stating in its foreword that, "The NHS Five Year Forward View sets out how our health services need to change and argues for a new relationship with patients and communities. PHE's strategy, From Evidence into Action, calls for place-based approaches that develop local solutions, drawing on all the assets and resources of an area; integrating public services and also building resilience of communities in order to improve health and wellbeing for all and to reduce health inequalities". 

The irony of this statement seems to have been missed: the paternalistic approach of the words used still implies that the elite, whether it be strategists, managers or politicians know best what is right for communities. It remains a top down approach! If real change is going to occur, the approach from the top has to change and recognition that current leadership is as big a problem as the malaise of psychological distress that the whole world is facing. The "epidemic" is caused by who and what structures society and the environment we create for ourselves, not by some sort of construct that invades the individual mind and needs to be "treated" person by person.

Indeed, the people writing these reports fall into the same trap that has befallen so many societies in that, "… human beings cannot easily comprehend nonlinear systems with their linear minds, they repeatedly fall into a host of "systems traps" identified by Meadows – to wit, mistaking symptoms for causes, bounded rationality, the blame game, tugs of war, policy resistance, the tragedy of the commons, a drift to low performance, escalation, competitive exclusion, addiction, and rule beating." (Ophuls, 2012)

If psychologists and the profession as a whole want to have any real influence then it is time to begin questioning the very foundations that psychology is built upon, consider what kind of a world we want for ourselves and the totality of our species. Can we continue to use constructs and attempt to build models of certainty in an uncertain world? After all, do we, as psychologists, not consider ourselves to be the guardians of the human psyche and should we not recognise that the human psyche is evolving far faster than any modelling we can achieve?

I leave you with a parting thought from Ophuls who I think should be recommended reading for any psychologist who wishes to take their work seriously: 

"Species, people, firms, governments are all complex entities that must survive in dynamic environments that evolve over time. Their ability to understand such environments is inherently limited…. These limits are a fundamental feature of [all complex] systems [and] can no more be overcome by smarter analysis than we are able to break binding physical constraints… such as the speed of light." Self-organizing, nonlinear, feedback systems are inherently unpredictable. They are not controllable. They are understandable only in the most general way…. Our science itself, from quantum theory to the mathematics of chaos, leads us into irreducible uncertainty" (Ophuls, 2012)

- Steve Flatt is Director of The Psychological Therapies Unit, Liverpool.

References

Frances, Allen, M.D. (2013-05-14). Saving Normal: An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life (p. 12). HarperCollins. Kindle Edition.

Gould, S.J., and E.S. Vrba. 1982. Exaptation: A missing term in the science of form. Paleobiology 8(1):4–15.

Haidt, Jonathan. (2012) The Righteous Mind: Why Good People are Divided by Politics and Religion (p. 112). Penguin Books Ltd. Kindle Edition.

Improving Access to Psychological Therapies: IAPT three-year report: The first million patients, 2012

Ioannidis JPA (2016) Why Most Clinical Research Is Not Useful. PLoS Med 13(6): e1002049. doi:10.1371/journal.pmed.1002049

Kagan, Carolyn; Burton, Mark; Duckett, Paul; Lawthom, Rebecca; Siddiquee, Asiya (2012-12-10). Critical Community Psychology (BPS Textbooks in Psychology) (Kindle Locations 120-121). Wiley. Kindle Edition..

Littlechild, B. Hawley, C. (2009) "Risk assessments for mental health service users: Ethical, valid and reliable?", Journal of Social Work, first published online on August 4, as doi:10.1177/1468017309342191 , then in print April 2010, 10(2)

Macdonald, A (2007). Solution-Focused Therapy: Theory, Research & Practice (p. 33). Kindle Edition.

Norcross, J. eds. (2010) Evidence-Based Therapy Relationships, American Psychological Association

Ophuls, W. (2012) Immoderate Greatness: Why Civilizations Fail (p. 41). CreateSpace. Kindle Edition.

Pickett, K.   Wilson, R.  https://www.equalitytrust.org.uk/resources/the-spirit-level

Simpson et al. (2016) Recovery-focused care planning and coordination in England and Wales: a cross-national mixed methods comparative case study, BMC Psychiatry, 16:147.

Susskind, Daniel, susskind, R. (2015) The Future of the Professions: How Technology Will Transform the Work of Human Experts (p. 32). Oxford University Press. Kindle Edition.

Tainter, J. (1988) The Collapse of Complex Societies (Cambridge, England: Cambridge University Press, 1988), 214.