There are indications in the press, on social media and in the journals that the psychological professions see a great need for an increase in therapists and expert therapeutic intervention, particularly as a consequence of the pandemic. While there is some recognition that politics play a part in the health and well-being of our society the professional psychological and psychotherapeutic organisations appear to be playing largely lip service to the significance of community and political interventions.
I want to consider some alternative possibilities to the threat of still more psychological therapy for individuals or small groups, I also want to consider some of the reasons why the professionals continue to maintain this professional, expert and rather individualistic role.
One doesn’t need to look very far on social media to see the turf wars that are being fought between psychiatry and psychology and within both professions. These battles for the soul of the client, to my mind, are almost entirely pointless but are indicative of the meritocracy in which they are being conducted.
There are a number of areas that I wish to cover, the common good, meritocracy, scaling/impact and commodification. I do not intend to provide all, or perhaps any of the answers, but to begin to ask questions about how each of these impinges on the nature of the delivery of services at the current time and try to get people to consider alternative interventions that may be worthwhile exploring and perhaps more effective.
Improving Access to Psychological Therapies (IAPT) has now been running for more than a decade and has no doubt helped, probably, millions of people. After all, we know that somewhere between 10 and 20 million people have accessed the service during the time it has been in existence. However, while it may have made a difference to individual lives there is absolutely no evidence to suggest it has improved the well-being of the nation in anyway whatsoever.
Indeed, I would be surprised in the current climate if any individualistically based intervention would impact upon the current neoliberal political ideology that holds sway. Rather than focus upon the real or perceived shortcomings of the IAPT service I wish to take a more helicopter view all the difficulties we face as a nation and consider how we might be more effective as a body of knowledgeable individuals who for the most part wish to make a difference to the quality of life of those around us.
Some of the issues that I consider may not appear to be immediately relevant but please try to stick with the narrative and I will attempt to explain why I am considering them.
I think the place to start is with the idea of meritocracy. The evidence for the increase of inequality of income and opportunity over the last 40 years or so is unequivocal. It has been driven by a careful shift of emphasis by global politicians from the idea of sharing common goals, space and resources to the idea that we are each responsible for our own success. Michael Sandel (2020) puts it very well,
“It encourages people to think of themselves as responsible for their fate, not as victims of forces beyond their control. But it also has a dark side. The more we view ourselves as self-made and self-sufficient, the less likely we are to care for the fate of those less fortunate than ourselves. If my success is my own doing, their failure must be their fault. This logic makes meritocracy corrosive of commonality.”
I can’t help looking at the race for qualifications and expertise within the psychological professions that provides clear water, academically speaking, between the therapist and their client. Indeed, I could argue that cognitive behaviour therapy is particularly responsible for this; how its language is inherently paternalistic, for example describing someone’s beliefs as irrational is profoundly disrespectful in today’s climate. Just to make the point, I consider that the degree of success attributed to this particular form of psychological intervention is overblown and often due to researcher allegiance and that proponents of the intervention have an ideological adherence to the model that is irrational. I have little doubt that there are those who are now bridling at my statement and would suggest that I am the irrational one!
Cognitive behaviour therapy was a product of an era, that era has now passed in much the same way as, for the vast majority of people, psychoanalysis is also past its sell by date. The human psyche is a constant and dynamic process, changing as the environment changes and in the 30 years since CBT became popular as a form of psychological therapy the world has changed considerably, economically, socially and spiritually. The idea that an expert therapist can understand the mind of the individual sat in front of them to the extent that they can make judgments as to whether their thoughts and beliefs are rational or otherwise has long since passed. I would also make the point that therapy is in a position to be able to prepare people for work and should be encouraging people back into work is a value judgement that is not part of the therapeutic process.
Wilkinson and Pickett (2014, Kindle Locations 960-965) observe that it may be that greater public spending on mental health services reduced the burden of mental health difficulties. However,
“A study was specifically designed to test this using data on over 35,000 people from 30 European countries. It found no support for explanations involving public spending, but did find support for what the author called the ‘psychosocial hypothesis’: more equal countries seemed to have better mental health at least partly because their populations are less anxious about status and are more involved in social networks that involve reciprocity, trust and co-operation. A similar study that sought to see if lower public expenditure contributed to the relationship between higher inequality and higher levels of violence reached the same negative conclusions”.
The development of an explicit meritocracy in the last few years has created huge inequality and has begun to explicitly blame those less fortunate for their misfortunes. This has been exploited by politicians in the West unmercifully. This meritocracy is clearly displayed in a single set of statistics from Kate Raworth (2017 Kindle Locations 869-872),
“Thanks to the scale of global income inequality, responsibility for global greenhouse gas emissions is highly skewed: the top 10% of emitters – think of them as the global carbonistas (The wealthy elite) living on every continent – generate around 45% of global emissions, while the bottom 50% of people contribute only 13%.”
I consider that this growth of meritocracy is actually part of what enabled Improving Access to Psychological Therapies to come into existence. It is based upon the expertise and idealism of the meritocratic professional.
This brings me neatly to my second point which may not be immediately obvious. Over the centuries there has been a steady erosion of the entitlement of the common person to those things which have been held in common for all. It began in earnest with the enclosure acts in England and by 1844 a third of all the tillable land in England and Wales had been enclosed by private landlords. Hundreds of thousands of small farmers were reduced to beggary (Rocker, 1989). The coming of the industrial revolution produced overcrowding and reduced sanitary conditions for millions.
“The commons – a vehicle for meeting everyone’s basic needs in a roughly equitable way – is being annexed and disassembled to serve a global a market machine which treats nature as a brute commodity. Commoners become isolated individuals. Communities of commoners are splintered and reconstituted as armies of consumers and employees. The “unowned” resources of the commons are converted into the raw fodder for market production and sale (Bollier & Helfrich (eds) 2012).
This erosion of the Commons has continued to this day. “Private control over living beings is now reaching into the deepest levels of people, plants and animals, i.e., their DNA. The same impulse to implant “code for control” is also being implemented deep inside the new digital commons” (Crosnier 2012 found in Bollier & Helfrich eds, Kindle Locations 4834-4836).
Crosnier goes on to say,
“Similarly, the commons of world scientific research may also be contaminated by fraud, which erodes collective confidence in the research while boosting the careers of deceitful researchers. Deceptions may at times lead the scientific community to pursue dead-end lines of research and ignore more promising research priorities”.
Crosnier also observes that, “the threats to the commons are also threats to communities, their existence and their ways of life. The dispersion of communities, generally due to violence, is the main form of attacks on the commons.” However, there are many more much more subtle attacks on communities through the commodification of services to communities.
Wilkinson and Pickett, Kindle Locations 470-471) make the point that,
“Over the last thirty or forty years, a large number of studies have shown that having a network of close friends, good relationships and involvement with others is extraordinarily beneficial to health”.
The determination of the psychological professionals to become the assessors, advisors, diagnosticians and treaters of misery is part of that disablement of people to manage their own difficulties and distress within their communities. If professionals really want to get on board with psychological distress, then they need to be part of and firmly embedded in their community and help people to recognise their inherent skills and develop those skills to help themselves and not treat the skills of the expert as a commodity to be sold into a community.
Russel (2020) reminds us that,
“The first invisible threat results from living in a culture of consumerism. In this kind of culture, the members believe that they can buy everything they need for a good life. The only thing they can’t buy is community, and community is the essential producer of a good life. He reveals the second threat as the world of professionalism. In that world, the message is “you will be better because I know better.” Cormac reminds us that a community is made up of people who know best how to create the future that will kindle a good life. The third threat Cormac makes visible is governments and institutions that claim they want to help. Their help most often creates a benign dependency” (Kindle Locations 136-142).
This quote provides more than just a nod to that aspect of meritocracy outlined above where professionals assume that they know better than the person living and working in a particular environment which frequently has never been experienced or is even understood by the expert.
The final frontier Of the Commons is that of our minds, which are not very subtly being invaded by nudge units, psychologists and psychotherapists. One could argue that this invasion of the mind began with Descartes who disentangled mind from body and suggested that the body was simply deterministic matter and the mind was a rational principle detached and standing above that raw clay. In today’s world we know that body, emotions, mind and beliefs are intimately tied to one another in a daily dance where each has their turn at ascendancy while we struggle with the paradox of trying to be a human being.
To then try to struggle with ‘new principles and new ideas’ of yet another supposed expert when we are distressed seems utterly bizarre to me. But, more importantly, this is yet another invasion and a reduction of our common rights as a human being.
As (Kilty & Dej (2018) Put it so eloquently,
“Psycho-centrism refers to the dominant view that pathologies are intrinsic to the person, promoting a hyper-individualistic perspective at the expense of understanding social, political, economic, historical, and cultural forces that shape human experience. Psycho-centrism is itself a form of social injustice that promotes individual reformation rather than social and economic justice.”
Finally, there is an unwarranted assumption that research in human psychology provides final answers. it is common knowledge that psychological research is hard to replicate (Amir & Sharon 1990, Galak, LeBoeuf, Nelson & Simmons 2012, Earp & Trafimow, 2015, Ingre & Nilsonne 2018), But what is even more uncertain is the idea that small scale research in one specially designed and controlled environment can be scaled up to national and international scale interventions that are going to be effective.
As McLean, Gargani & Lomofsky (2020) observe,
We don’t know what works, what might work depends on context, and context is complex. This is why research and innovation are critical. And why the common wisdom about scaling typically falls short. Unlike in the private sector, and as attractive as it may seem to donors and social enterprise, when it comes to development outcomes, faster, bigger and more is not necessarily better. Instead, we need to shift our focus toward achieving positive impact at optimal scale.”
Right at the beginning of this essay I observed that while IAPT has had impact for individuals across the decade of its existence it has had absolutely no impact upon the well-being of our society and despite being set up with trying to get people back to work in mind (Indeed, it was this premise that suggested the service would be cost neutral by returning people into work and that this was part of its political attraction) has palpably failed in this goal.
The argument is only just beginning about how we move forward post pandemic and, more importantly, when the primitive hunter-gatherer economy that we continue to rely upon finally breaks down entirely. There is considerable research (for example, Wilkinson and Pickett, Kate Raworth) suggesting alternative modes of existence for human beings but these alternatives are much less oriented towards the meritocratic winners and losers approach that we have at the moment and illustrate clearly the efficacy of community and cooperation instead of competition. This is not a plea for socialism or any other sort of ‘ISM’ it is a plea for people to start thinking about what kind of a world they would like their children and their children’s children to live in, rather than considering more and more ways of attempting to climb the greasy pole of meritocracy and expertise at the expense of others who have just as much right to live and have access to the commons as those blessed by being born into more fortunate circumstances.
References:
Amir, Y., & Sharon, I. (1990). Replication research: A “must” for the scientific advancement of psychology. Journal of Social Behavior and Personality, Special Issue, 5, 51-69.
Baker, M. (2015), Over half of psychology studies fail reproducibility test. https://www.nature.com/news/over-half-of-psychology-studies-fail-reproducibility-test-1.18248
Bollier, D. Helfrich, S. (eds) (2012) The Wealth of the Commons: A World Beyond Market and State (Kindle Location 22). Levellers Press. Kindle Edition.
Earp, B., Trafimow, D. (2015) Replication, falsification, and the crisis of confidence in social psychology. Frontiers in psychology 6, 621, 2015
Galak, J., LeBoeuf, R. A., Nelson, L. D., & Simmons, J. P. (2012). Correcting the Past: Failures to Replicate Psi. Journal of Personality and Social Psychology.
Ingre M, Nilsonne G. (2018) Estimating statistical power, posterior probability and publication bias of psychological research using the observed replication rate. R. Soc. Open sci. 5: 181190.http://dx.doi.org/10.1098/rsos.181190
Kilty, J. Dej, E, (eds.), (2018) Containing Madness, https://doi.org/10.1007/978-3-319-89749-3_2
McLean, R. Gargani, J. Lomofsky, D., (2020), Scaling what works doesn’t work: we need to scale impact instead, September 7th. https://blogs.lse.ac.uk/impactofsocialsciences/2020/09/07/scaling-what-works-doesnt-work-we-need-to-scale-impact-instead/
Raworth, Kate. (2017) Doughnut Economics, Random House. Kindle Edition.
Rocker, R. (1989) Anarcho-syndicalism, Pluto Press 345 Archway Road, London N6 5AA. https://libcom.org/files/Rocker%20-%20Anarcho-Syndicalism%20Theory%20and%20Practice.pdf
Russell, C. (2020) Rekindling Democracy: A Professional’s Guide to Working in Citizen Space, Kindle edition.
Sandel, Michael J. (2020) The Tyranny of Merit, Penguin Books Ltd. Kindle Edition.
Wilkinson, R. Pickett, K. (2014) The Inner Level: How More Equal Societies Reduce Stress, Restore Sanity and Improve Everyone’s Wellbeing. Penguin Books Ltd. Kindle Edition.
