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All Watched Over by Behaviourists of Cognitive Grace


Posted by Dr No on 08 July 2014

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Last week, as yet more errors were piled on the statin comedy, and antibiotics got it in the neck from Red Dave, another it’s time we put-it-in/took-it-out of the water story caught Dr No’s eye. An economist – economists seem to get all the top health slots these days – and a psychologist – he was on the Today programme, sounding worryingly like Peter Cook’s classic amiable psychiatrist - want Cognitive Behavioural Therapy (CBT) to be much more widely available to treat mental health problems. It is what airheads call a no-brainer. As Bush Lite might have said, CBT is where wings take dream (it works), and it makes the pie higher (it more than pays for itself: lower healthcare costs and folks back at work). Yet not just folks but our government have misunderestimated the power of CBT. NHS provision has increased in recent years, but from a very low base, and still only one patient in eight who might benefit gets the therapy. That’s one helluva misunderprovision for something that has if not wings then legs.

CBT works by evaluating and retraining the patient’s thought patterns. The central tenet is that what we think (cognition) affect what we feel and do (behaviour). It has a great advantage over pills: given a little ongoing practice, the new thought patterns can be used indefinitely at no extra cost - the main reason why it is so cost-effective. The patient doesn’t have to keep taking the medicine, just keep up with practice. This way, a depressed patient – a condition in which CBT is often effective - becomes ‘psychologically immunised’ against depression. Another advantage over pills is the lack of side effects; yet another is the absence of drug withdrawal syndromes. Although no magic bullet – nothing is – by and large, CBT is safe, effective and affordable. What’s, as they say, not to like? Or, as Siobhan Sharpe might say, let’s juice this lemon.

Which leads Dr No, via a typically deranged knight’s move thought, to the question: could CBT turn out to be another sort of lemon, not in the way of zest, but in being a dud? Others certainly think so, notably in the Guardian, which has from time to time aired views that – to summarise - CBT is at best patronising junk, at worst a con, a sort of cognitive lobotomy that tricks patients into thinking they are better when they are nothing of the sort. Life is still shit, but the CBT victim is now moronically happy in their pile of shit. Such moral cynicism must surely exist, but then equally we could reply we are all in the gutter, and is it not better that we look at the stars, rather than circle the drains?

So, by and large, Dr No remains in favour of CBT for patients. Where he gets uneasy is when he hears talk of wider use. The unnamed economist in the first paragraph is in fact none other than the one time Happiness Tsar, the Leader of the Dream Team, one Richard Layard, and Layard is On a Happiness Mission. The recent media activity arose from the publication of the alarmingly up-beat-or-else titled book ‘Thrive’, co-written by Layard and his soothing psychology buddy David Clark. It makes a compelling case that CBT works, is cost-effective, and must be more widely available, yah-da-dah. So far, so good.

But – and here we see the outline of a fly in the happiness ointment – Layard is an economist, not a doctor. Proper doctors (public health doctors, who we all know are nuts, tend to be the exception) concern themselves with ill health in individuals. Being an economist, Layard sees things in economic terms, on an economic scale, only his particular fancy leans more towards the Gross Happiness Quotient instead of the more usual GDP. While most economists focus on wealth, Layard zooms in on health. Instead of wanting us to be wealthier, he wants us all to be healthier, in short, to be Happier.

At this point, some realists are wont to put paper bags over their heads, to save time reaching for one when the time comes to throw up. Dr No doesn’t necessarily have his paper bag on yet, but his here-we-go-again detector is certainly crackling away. He sees clear potential for diagnostic and so therapeutic creep. Flown by the Happiness Tsar, the more CBT airbus loaded with extra therapists has, like one of those NASA airplanes with piggy-backed shuttle, another payload, a payload that on this occasion could threatens us all. If CBT improves clinical depression, then why shouldn’t it help ordinary unhappiness? Discontents and malcontents alike could be cognitively lobotomised to a condition of moronic delusional happiness. It would certainly be what the Incredible Dement once called, as he watched Smedley can himself, ‘a result’. Indeed, it would be more than that, ‘a result’ on a mass scale, a populace of happy morons all watched over by behaviourists of cognitive grace.

At which point, Dr No’s paper bag went pop.

Note: the title and some of the ideas in this post are derived from the 2011 BBC2 TV Series ‘All Watched Over by Machines of Loving Grace’ (a title itself taken from a poem by Richard Brautigan), an excellent look at another Dream Team’s doomed attempt to liberate humanity from itself. Well worth seeing if it is broadcast again.

3 comments:

I too have been impressed by CBT and have advocated its use for those unfortunate people who find themselves depressed and cared for in the community. Unfortunately some of the organisations that provide care in community homes have little interest in “curing” their residents as they are the source of their income. (I wonder whether CBT can help my cynicism?)

That aside, CBT can of course be classified as an “enhancement” (enhancement being eugenics that as has been rebranded so as to dump all that inconvenient history). There are some, many of whom purport to be philosophers, that would add CBT to the other enhancements like psychotropic drugs that increase intelligence, morality and happiness, transcranial direct current stimulation, microprocessor brain implants, behavioural gene engineering, technologies that greatly increase human life expectancy, mind uploads into computers (immortality), the Volcan mind probe and other sci-fi nonsense. That said, there is one major drawback with CBT that might make them reject it, which again all comes down to money. Most of the enhancements that excite today’s eugenicists require a lot of R and D and much rational thinking and decision making by experts in the theory and science of enhancement. In other words, there are jobs and money in this enhancement stuff for self-appointed rational experts. With the exception of providing therapists with an income, CBT does not have all the lucrative links today’s market orientated eugenicists like to promote, so it is unlikely to be championed as a universal happiness maximiser.

But even if it was provided free for all by the government I would still object to it being used to reduce the population to, as you put it, a condition of moronic delusional happiness. Of course I am not a rational expert and my resistance to this therapy and other enhancements must, according to the rational experts, be irrational. This, many rational experts claim, gives them and the state the right to make enhancement compulsory because irrationality must be eradicated for the good of all living and yet unborn humans.

It’s all very depressing. Perhaps I do need some CBT.

CBT behavioural experiments are worth investigating.

I think (and am only an amateur in this) that they are not quite the same thing as behavioural exposure because one has to pin one's colours to the mast by very precisely in advance by defining in advance what one expects to happen, then go into the situation and observe, write it down, and then compare what happened with what was written down. It has the effect of unblinding and is humbling I think is the right word. It is very interesting.

There are four very good explanations of how to do behavioural experiments. They are:

Melanie Fennel's Overcoming Low Self Esteem - the end of Chapter 4 "Checking out anxious predictions in practice" see p86-91 of 1999 paperback (Constable & Robinson 1999)

Gillian Butler's Overcoming Social Anxiety and Shyness Chapter 8 "Doing things differently" and Chapter 10 "Building up confidence" particularly the Counter-belief worksheet on p. 181-2 of the 1999 edition (Constable and Robinson)

Melanie Fennell's "Boost Your Confidence" - far more upbeat version of Overcoming Low Self Esteem has bits on how to design experiments.

Chapter 2 of the Oxford Guide to Behavioural Experiments in Cognitive Therapy by James Bennett-Levy, Gillian Butler, Melanie Fennell, Ann Hackman, Martina Mueller and the late David Westbook. (Oxford 2004)

Gillian Butler's Counter Belief worksheet and Kate Goes Shopping in Melanie Fennell's OLSE are very clear and simple explanations with no jargon.

MF and GB both say you need to back up reasoning with experience.

Hope that this does not get forgotten about in the rush for mindfulness.

A further note: CBT behavioural experiments are interesting because they use the scientific method to attempt to unblind oneself rather than adopting any strategic policy.

Popper says (All Life Is Problem Solving. Routledge 1999) that all organisms are making testing movements:

1. the old problem
2. formation of tentative theories
3. attempts at elimination through critical discussion including experimental testing (can lead to demise of organism)
4. the new problems that arise from the critical discussion of our theories (if organism survived (3)

NB (4) can only happen if we survive (3) - as one of the potential outcomes of (3) is that the organism would be eliminated if the theory were proved to be wrong.


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