Thursday, 24 October 2013

The Sale of Certainty

This morning I heard health expert Dame Prof Sally Davis, on BBC radio 4, talking about the health of UK children. (It seems that cases of rickets are on the rise. She suggested the introduction of vitamin supplements for all kids).
During the interview (which you can listen to here, at approx 2h 39min), she was also called upon to comment on mental health issues in family life, and their treatment.
How disappointing it was to hear the same old line trotting out once again, like a soundbite, or one of those management-speak buzzwords that seems to be infectious in the meeting-room spreading from one employee to another. It goes something like this:
 (a lot of mental health problems) "will respond to.... Cognitive Behavioural Therapy... talking therapies..... "

The words used here are telling. They show a lack of understanding about the therapy world; its different modalities, and their potential use in the wide range of mental health issues. The words also show a willingness to endorse, publicly, a particular form of treatment.

I have previously drawn attention to this advertising of the CBT 'brand' here.

Dame Sally makes it very clear to us exactly why she wears this logo on her T-shirt. She says "I believe that we should only offer treatments that are evidence-based."
What she's saying, then, is that she only values treatments (and that includes therapies) which offer a statistical probability of "success" based on "outcome measures", and perhaps therapies which lend themselves to a widely-accessible "treatment protocol".
(For a deliciously sarcastic take on this kind of approach, see my friend Jason Mihalko's blog here).

Dame Sally is, of course, coming from her own training and heritage. She is steeped in the politics of medicine; a world of ever-increasing tension between public treatment needs and public costs. She values 'evidence-based' therapies, because, perhaps rightly, it would be hard to advocate the spending of public cash on therapies that aren't shown to be 'cost-effective'. The taxpayer deserves value for money, of course.

Evidence-based treatments are useful because, in the medical world, they offer the best assurance that a certain drug/intervention will work. The science tells us that in (n) cases, (x) show a measurable improvement compared to a control group who haven't been given this intervention. Therefore, the chances of your symptoms improving with this treatment are predictable to a certain level of probability.
Evidence-based treatments are also seductive, because they offer us a sense of safety and hope for a particular outcome that we are invested in.
We invest psychologically as patients, because we all want our symptoms to improve.
We also - as Dame Sally illustrates - invest financially. This, on a political level, has huge consequences, because government will clearly be much happier to offer therapy that offers clear, predictable outcomes.

Easy, then, to be fooled into thinking that therapies offering statistically-supported outcomes are the 'best'.
Sure, if you have the type of problem that fits neatly into the standardized diagnostic boxes that NICE and the APA prefer. But the problems of our life and our world are, to my mind, mostly in a different category than this.

How many times, for instance, have you lost a night's sleep because of a meeting, interview, or other event the next day that you are uncertain about?
We have all become stressed and irritable, maybe felt depressed, because of an ongoing issue in life that we can't control or predict.
Maybe you have thought about making a major decision in your life but have been held back for some time, because of the fear of the unknown. "If I knew I could get more work over there, I'd leave this job for good. But how do I know...?"

If only there were an assured, statistically-supported outcome, that you could be certain of....!

I don't believe I'm in the business of offering people assured or certain outcomes. Because in lots of ways, I don't believe there are many to be found. However, the selling of empirically-supported therapy is popular because it fits with an economic and medicalized model of human suffering. The natural human needs for self-exploration, mutual discovery and understanding, and psycho-spiritual development, are not necessarily part of the 'treatment plan'.....



  1. First off, how can I arrange to have the title Dame? Would that then make me known as Dame Doctor Mihalko? That has a nice ring to it--and I'd imagine that it would come with some sort of special costume. Is there someone I can call?

    Secondly, I think we therapists need to do a better job advocating for ourselves. The books, television interviews, and newspaper articles that are available for the average person to read have all worked together to brand therapy to be a thing that is equated is empirically supported cognitive behavioral interventions. As therapists, we've not put ourself in the public square talking about what we do, why we do it, and why it's important. We've not effectively used the trappings of our profession (research, journals, conferences -- and the pop psychology book market) to brand therapy as something that is a thing other than cognitive behavioral therapy.

    Many new patients show up to my office and ask for CBT. They've learned this script, and it gives new comers a sense of safety. They have an idea of what they expect. In practice they might actually be looking for a few skills, but at the end of treatment they are looking for change and only know how to ask for CBT because that's all that we've taught people to ask for.

    So before I say the same thing I different way -- I'm going to go start changing my stationary to Dame Dr. Mihalko, purveyor of hand crafted relational and cognitive interventions.


  2. Thank you Doctor Dame Mihalko, for reading & commenting!

    I really like your new title. I will email Ede & Ravenscroft and ask if they have any robes that would suit you!

    I also love your description "purveyor of hand crafted" interventions. I'm sure if we were able to convey this image to the public, it would help them understand the value of relational working.

    With kind wishes as always, Ian