Letters, September 2008

Teaching us how to American dream?

Cognitive behavioural therapy (CBT) is a form of psychotherapy, born from American culture and its intrinsic individualistic values – the American dream. It teaches patients to manage their own symptoms, based on the fundamental ancient idea that 'Men are disturbed not by things, but by the view which they take of them (Epictetus in The Enchiridion, 2nd century ad). Both the American dream and CBT cast individuals as culpable for their own condition and destiny, and in particular in the latter, their own feelings.

In recent years, CBT has quickly become a panacea for most of our mental health ills. Hailed as the evidence-based talking therapy par excellence the approach is regarded as a 'one size fits all', manualisable and quick-fix cure for the masses. In the NHS, Layard's recommendations and the subsequent Improving Access to Psychological Therapies strategy is currently spawning an industry of nouveau CBT therapists armed to the teeth with manuals on how to do it and blank thought diaries for their patients to complete and discover just how distorted and irrational their thinking really is. There are a number of reasons why we should be perhaps a little cautious, if not wholly cynical, about this apparently benevolent eulogising of CBT. Here are just two.

Firstly, despite numerous papers showing the efficacy of CBT in the short term, there appears little in the way good longitudinal research. Furthermore, equally plausible alternative therapies remain underresearched, and there is a surprising paucity of convincing evidence that links CBT to the cognitive theory of depression it purports to be based on. Astonishingly of course, this means that the rationale for cognitive interventions (that changes in cognition mediate therapeutic change in CBT) currently lacks empirical support!

Secondly, and perhaps somewhat more worrying, is that CBT has the potential to render both therapist and patient blind to the social inequalities, power dynamics, and institutional systems which profoundly shape human consciousness, experience and life-chances. In CBT these factors are simply masked in attempting to enlighten individuals to their cognitive distortions. There is a very grave risk of inadvertently conveying the message to patients undergoing CBT that it is not government policy and social inequity that is the root cause of their depression, not the reality of their miserable hostile and lawless environment and relationships that lead to the experience of anxiety or whatever, but rather something fundamentally wrong with their perspective on things.

For the disillusioned in society, for those whose faith in the British-American Dream is waning or for those merely making a fairly accurate cognitive appraisal of the environment around them, CBT becomes no more than selling a pseudoscientific version of the Monty Python song 'Always look on the bright side of life'. For the state it provides a relatively cheap way of demonstrating tokenistic commitment to mental health care provision, whilst simultaneously absolving it of any role in societal mental ill health.

Whilst these criticisms are not entirely new, they are perhaps worthy of some further reflection as (in the name of improving access to psychological therapies for all) a huge CBT sausage machine is at this very moment being assembled in our midst. Well-meaning, but novice, therapists with little training are being set up to deliver the therapy in order to help people to recognise their error-laden, illogical thoughts so that they may perhaps 'American dream' once more. Potential patients for CBT would do well both to carefully examine the qualification and experience of their potential CBT therapists, and to consider whether to accept the proposition that their unhappiness is a product of being mentally unwell rather than the consequence of a much more accurate cognitive appraisal of the socio-political environment they find themselves in and feel powerless to change.
John Kelly
Consultant Clinical Psychologist/Gerontologist
Harrogate

 

Pitfalls of secondary sources

Ceri Parsons, of the Society's Press Committee, believes that it is acceptable to copy out other peoples' descriptions of 'famous experiments' because of something called 'intertextuality' ('Costs and benefits', Media page, August, 2008).

The most famous experiments are precisely those which are most vulnerable to misrepresentation, and it is particularly important to get the details right, if one wants to quote them. I was fortunate to be taught by Peter McKellar, who was fond of quoting the example of Little Albert, who was subjected to a conditioning procedure by J.B. Watson, so that he developed a phobia of rabbits and other small furry animals. In many accounts of this (some in well-respected textbooks), Watson is then described as having deconditioned the boy, using the technique of desensitisation. While Watson did do experiments on desensitisation, they did not involve Little Albert, who presumably grew up with his phobia. McKellar used this example to illustrate the sorts of transformations first described by Frederick Bartlett, in his book, Remembering, but it also illustrates the pitfalls of working from secondary sources.

Quoting erroneous accounts of famous experiments is a trap that one might fall into with realising it, but attributing the account would at least lay the blame where it belongs. If we all went round copying things out we'd never know what was going on.
Jacob Empson
Department of Clinical Psychology
Hull University
Editor's note: See p.756 for more on Albert

 

Shifting how we think about big issues

I am directing a new project for the Royal Society for the encouragement of Arts, Manufactures and Commerce (RSA) to ask how insights from cognitive and behavioural sciences can help us respond to pressing social challenges. I would like to seek the input of readers of The Psychologist.

The project is based on the belief that major social change occurs when profound challenges are matched by the emergence of powerful new solutions. Thus the industrial age challenge of urban squalor, disease and ignorance was met by the rise of municipalism, the public health movement and the welfare state. In the face of many of today's social challenges – how we cope with complexity and information overload, how we respond to the massive growth in the mentally frail elderly, how we foster local and global solidarity in the face of diversity and individualism, how we live contented lives – a new set of solutions are required.

The core hypothesis of the new RSA initiative is that emerging knowledge about how we think may help us to respond to these challenges. To this end, we are seeking to bring together insights from a range of disciplines, including but not limited to cognitive neuroscience, behavioural economics, anthropology
and both cognitive and social psychology. Emerging from all these different areas over the last couple of decades is an emphasis on the process as well as the content of our thinking and a recognition that our conscious mind is only one part of a broader picture in which a variety of factors determine our cognitive processes.

In the first instance the project will ask what it would be like if our thinking about contemporary public policy challenges, such as ageing populations, inequality, learning or well-being, was really informed by our best scientific understanding. But it will also be asking whether a cross-disciplinary approach to these subjects can enable the emergence of profound shifts in how we think about big issues such as collective agency, social solidarity or our relationship to the natural world.

We are keen to get input from psychologists of all sorts. This project can only hope to succeed if it is able to generate a genuinely inter-disciplinary dialogue that engages both experts, practitioners and a broader public. The project will begin in the autumn with a series of public policy workshops. We are looking for cognitive and social psychologists to participate in these workshops and in the broader public dialogue around them. To learn more about the project and how you can get involved please contact me or visit www.rsacognition.wordpress.com.
Jonathan Carr-West
The Royal Society for the encouragement
of Arts, Manufactures and Commerce
[email protected]

 

Qualifying in health psychology – A correction

'Careers' piece in the August issue, 'Caledonian road to health', carried the byline 'Dougie Marks discusses a new Scottish route to qualification in health psychology'. This is misleading – it simply isn't a new route, and it isn't Scottish, per se. It's just that Scottish health boards have funded those places. It could happen elsewhere, it just hasn't yet. It's a way to get a job that gives people chance to come onto the BPS qualification. That's an important distinction.

Furthermore, Dougie Marks claims that 'until recently, the career path to qualification in health psychology in Scotland was not always clear. To become fully trained, prospective candidates had to fulfil competency requirements while working in other full-time jobs'. They still do, unequivocally. The training routes are the same all over the UK, overseen by the Society. The government-funded posts Dougie speaks of still require trainees to submit plans to be approved by the Board of Assessors in Health Psychology, and the assessment process and regulations are the same as those of any other trainee, because they are all enrolled on the same qualification.

We constantly strive to communicate clearly to trainees and potential trainees what the official routes to chartership are, arguably this could undermine that.
Mark Forshaw
Centre for Health Psychology
Staffordshire University

 

Look at the causes

Whilst it was of interest to read Mark Turner's piece 'Robots, mirror neurons, virtual reality and autism' (August 2008), I was concerned that the solution
to the increase in the growing numbers of children diagnosed with autism was perceived to be to put our faith in technological help for those affected, rather than a focused study of the undoubtedly environmental factors which are creating the rise. Prevention is always better than 'cure'.

There is now little doubt that most new cases of autism are the result of environmental rather than purely genetic causes, and until we dedicate far more research resources towards highlighting these factors we will not prevent more and more children from becoming autistic. The reason for the increase is by far the most pertinent of the issues facing autism research but has yet to be adequately addressed.

Unfortunately, most professionals still erroneously view autism, as a 'genetic problem' although the increase in numbers is far greater than would be expected if this were the case. Perhaps it is a more comfortable option to play with technology than to ask the difficult question 'What are we doing in our society/environment to create autism in our children?'
Jennifer Poole
Nemeton Foundation
Romsey, Hampshire
www.nemetonfoundation.org.uk

 

Evolution – fact and theory

This letter is in response to the 'Budongo trail shows the way' news item (July 2008). I read the article with some interest. It is vital that we provide animals living in captivity with surroundings that mirror their natural habitat. It is also important to enable researchers and the general public to increase their understanding of their behaviour in order to educate and thus encourage individuals to take a more active interest in the world around them.

Reading further into the article however, especially towards the end, I became rather saddened and shocked at the writer's presentation of theory as fact. It is a fact that a theory is just that. It does not include suppositions that are irrefutable – this fact seems to have been ignored here. I have found that it is commonly the case that when discussion turns to evolution, relating information is often presented as fact. I am surprised at the unquestioning conviction with which pro-evolutionary theorists put forward their assertions.

I have yet to find unequivocal evidence that suggests that the human race does in fact have primate lineage. I would challenge all readers to present evidence to support such an assertion.
Sarah James
Trainee counselling psychologist
Regent's College

 

Compromising test materials

As a peer supervision group of clinical neuropsychologists, we write to express our concern about the recent exposure of standardised test materials on television. Television programmes command large audiences, and unnecessary exposure has the potential to invalidate tests, which may have important clinical consequences for diagnosis and treatment.

Tests are time-consuming and expensive to develop, so are not easily replaced. Television companies cannot be expected to understand why such exposure is unacceptable, so it is incumbent upon test users to ensure that unnecessary public exposure does not occur; indeed registered psychologists have an ethical obligation in this regard. Whilst there are some situations in which it maybe difficult to prevent tests falling into the public domain (such as exposure in a court of law), it is unlikely that television companies would be able to film tests being administered without the assistance of a psychologist. We therefore urge colleagues to exercise extreme caution when discussing and presenting test material in the media.
Michael Oddy, Camilla Herbert, Veronica Bradley, Stuart Anderson, Michael Tossell, Sarah McCrimmon, Sally Stapleton