Invited commentary on … Proposals for massive expansion of psychological therapies would be counterproductive across society

Summary

Will an expansion of access to cognitive-behavioural therapy lead to greater happiness? Summerfield and Veale debate this question by focusing on the nature of mental distress and the best evidence for ameliorating it. Stimulating though it is, their debate left me wondering about the wider philosophical and ethical implications behind our rush to therapy.

As I read this debate an image came to mind of two boxers in the ring back-to-back, flailing punches in the air but not engaging. Although at face value the motion concerns the validity of our concepts of mental illness and whether mass cognitive–behavioural therapy (CBT) in Layard centres could be counterproductive across society, it has much wider implications. The real issues at play here are the public role of therapy, its place in society and the implications of making it into a mass marketable commodity. ¹

Summerfield opens in fine rhetorical form arguing that a focus on symptoms in the absence of context is misplaced and will increase the likelihood that people will regard themselves as ill rather than victims of life's vicissitudes. He claims that stress has become a catch-all justification for work absence but attributes this unwelcome trend at least in part to a (originally Thatcherite) political endeavour to massage the joblessness totals by moving people off the unemployment register and onto disability benefits. He argues that medicalising distress undermines age-old ways in which we understand and cope with the brutality of daily living and its perceived meaninglessness. However, he is not explicit about how this is done. Veale counters his arguments with a clarion call to evidence, particularly that found in published research. He thumps the diagnostic table with claims that shore up the validity of the English national morbidity surveys (of which I have been on the organising end) and the evidence base for talking therapies. He quite correctly places CBT in its context, namely the patient, their beliefs and their world.

All this is eminently sensible but I felt it failed to come to grips with the dilemmas at the heart of the debate. First, what is the right relationship of publicly available psychotherapy to law, politics, ethics and religion? Second, do psychiatric diagnoses and CBT divert us from a fuller grasp of what it is to live a life that for many has little meaning, is frequently unjust and ends in death? Throughout history people have traditionally used spiritual or religious belief to steer them through such existential mysteries. Even early Enlightenment figures did not ditch God in their rush to rationality. However, our current crop of proselytising atheists (e.g. Richard Dawkins) completely misses the point about religion by condemning as plain silly its explanations for the world in which we live. Probably all except the most fundamentally religious agree with that. Religion is about much more than explanation; rather it concerns the sacred and a sense of meaning that goes beyond our current perception and understanding. Where does this fit in to the secular world of CBT? How will mass therapy, which is deeply and inextricably ethical in character, function in that complex mix of culture, ethnicity, religion and morals which is British society?

The empiricist focus rides unchallenged in Layard's proposals and there is little surprise in that. However, as Veale also stresses, CBT is far more than a treatment of symptoms in that it grapples with how one regards oneself in the world of relationships, work and leisure. Summerfield appears to argue that CBT is some kind of technical innovation in a brave new world. In fact, it has a history reaching back in one form or other to Buddhist texts, the Hebrew Scriptures (particularly Proverbs) and Enlightenment thought. The Scottish Enlightenment philosophers Francis Hutcheson and Adam Smith stressed the natural links between inner impulses (virtuous or otherwise), behaviour, rationality and happiness. ² Smith in particular wrote about the ‘impartial spectator’ as one half of an internalised divided self that approved or condemned the conduct and character of the whole. ³ This natural moral psychology was a forerunner to Beck's ‘distancing’ from thoughts or the current fashion for a mindful approach to cognition. Thus, there is little that is new in modern CBT, apart from its call for evidence of efficacy. However, debate over the public role of psychotherapy is very new; what is argued here is its application as a fix for the (distressed) masses.

I enjoyed Summerfield's style; after all, few would disagree that we have become far too comfortable with those symptom collections that we call diagnoses. However, like Veale, I was uneasy with what he might propose instead of Layard. Very little, as far as I could see, apart from the tiring business of keeping one's upper lip stiff. Nor was I convinced that Layard's vision for CBT will make the British population into a mass of work-shy, complaining layabouts who cannot cope. Such a view patronises the British psyche.

As I said at the outset, I believe this debate leaves untouched many of the conundrums inherent in greatly expanding access to CBT in Britain. After all, who says psychotherapy is inherently a good? Despite the science, CBT like all psychotherapy is a value-laden, social construction that has most meaning in Western societies. How do we decide whether a behaviour is right, a personality characteristic worthy, a therapist virtuous or a goal of therapy good? ⁴ Could depression be a sign of something inherently awry with a person's place in the world rather than faulty thinking? And on what basis is someone's thinking faulty in the first place? Recourse to impressive treatment protocols of the sort Veale describes often shelters us from the ethics and values that are inevitably part and parcel of expanding access to psychotherapy so dramatically. This I think is what bothers Summerfield but not Veale. And so, what lies at the heart of this debate is the balance between the extreme individualism seen in the expansion of CBT on this scale and broader ideas about citizenship that take a more complex approach to the place of individual happiness in the world. ⁵ Will Layard's vision be counterproductive across society? Clearly we shall have to wait and see.