Sunday, 17 June 2012

Has CBT killed the human spirit?

Much as psychoanalysis set the cultural tone for our understanding and conduct of relationships for most of the twentieth century, cognitive behavioural therapy (CBT) has been leading us into a much less forgiving place for the last twenty years or so.  

In the world of psychotherapy, CBT has numerous siblings and cousins: most with three letter abbreviations to make a multiflavoured soup of ‘alphabetti spaghetti therapies’. Two flavours of the month are Dialectical Behaviour Therapy (DBT)  and Menatlisation Based Therapy (MBT). DBT, with its trendy 'mindfulness' plus new age and hippy edge, give its authoritarianism a warm fuzzy feeling; mentalisation has considerable weight of respectability afforded to it by years of attachment research in the experimental psychology departments of prominent universities – and charismatic professors with superstar status to market it. There are many other manualised and packaged 'new therapies', easily findable with your favourite search engine. But my overwhelming feeling is that they are all missing the point, and engaged in a pointless horse race with celebrity status prizes for the academics who reduce the interventions to dumbed-down therapy cookbooks, and then make sure everybody is following the recipes with multivariate statistical analyses backed up by powerful regulators like NICE. To me, this all seems like a very elaborate, somewhat sinister and ruthlessly inexorable way of taking the essential human qualities of the therapeutic relationship out of the picture.

It feels like these ways of working are all fashions of the moment – holding onto the coat tails of …of what? That is the big puzzle. All sorts of vaguely pejorative words and phrases get bandied about by malcontents like myself – without understanding the precise definitions – such as reductionism, materialism, biogenic dogmatism, logical positivism, determinism, behaviourism, scientism, alienating modernity, market managerialism. The best one I’ve seen lately is instrumental rationality:   "A specific form of rationality focusing on the most efficient or cost-effective means to achieve a specific end, but not in itself reflecting on the value of that end"

At its root, at least from where I stand at the moment, seems to be the need for certainty – and the fear of chaos that would ensue were we not able to measure, predict and control everything in our working lives. It is interesting indeed that complexity – what we have to deal with on multiple levels in our work every day – is only a step away from chaos, and indeed ‘creative chaos’ is an important ingredient of therapeutic communities, and perhaps all group therapies. Along with ‘therapeutic ordinariness’ and Keats’ Negative Capability (being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason) we seem to be in the world of the romantic poets, postmodernists, and idealists – dealing with moral philosophy, semiotics and  aesthetics. Truth and love and beauty, maybe, rather than rigour and technique and effectiveness.

 I would maintain anywhere that we need all of both sets of values in the world of the complex and often chaotic systems that determine human development, and we confront daily in psychotherapeutic work. We need multivariate regressions, p-values and confidence intervals for instrumental reasons – but they should be our tools rather than our purpose. Perhaps complexity and chaos theories could provide a conceptual, and even mathematical, bridge between these two worlds.

After an ill-tempered social meeting with two senior colleagues, and months of fighting the ‘corporate machine’ in my day job I think these considerations have wider relevance – in academia, public policy and health service management. What links them may be the impossibility of allowing any human being working in these systems to trust another – an no longer allowing people to hold that uncertainty, rather than algorithms and risk registers.

Universities are now run by financial considerations where the security of grant income subordinates everything else: they have to ‘play it safe’. We end up with students mounting legal challenges when they do not agree with the results when their work is marked, and researchers who produce numerous programmes, projects and papers with very little real value – and only need to show that their strategy does not cause any risk to the projected income stream.

In public policy, it is utterly unacceptable for anybody in the civil service to admit any failing – however small – that might reflect ill on their political masters. When we have a colossal failing  – such as the absence of anything that is genuinely psychotherapeutic in the statutory structures of the whole of a country’s mental health system – then the conspiracy of silence is utterly deafening…

In the corporate world of NHS Foundation Trusts, a similarly sanitised version of reality is all that is allowed to be released for public consumption. When everybody knows that real cuts are being made, it cannot be spoken – even in letters to medical colleagues. Presumably it would be a ‘reputation risk’ for the truth to be acknowledged.

But this ugly truth – of the way we are so often not allowed to relate to each other as human beings any more – might even go to the core of the current global malaise. I met an economics undergraduate the other day, and he was explaining to me the depth of mathematical and statistical techniques that he is struggling to learn. The bursting of ‘debt bubble’, from which we are all now suffering, was built on sophisticated algorithms which allowed financial risk to be packaged and sold at lightning speed, with no intervening human thought about sustainability, or feeling that something morally wrong was being done. Is it not this chicanery, and the political systems which underpin it, that need to be exposed and dismantled?

The answer, I hope, is in the philosophy of greencare. Not particularly in the details of therapeutic horticulture, animal assisted interventions or care farming, but in the better use of land, air, soil, water, sunshine and each other for our mental health; the realisation that we need to live sustainably in a finite world; that mental health care is not scalable like an industrial process; and that it’s only relationships between each other that really matter.

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