| November 11 2007 | LEGAL | ARCHIVE | IPN | CONTACT | HOME | CONTENTS........ | ||||||||
|
||||||||
|
||||||||
Correspondence
In recent correspondence in the national press Professor Andrew Samuels, UKCP Fellow, challenged the wisdom of the UK government's IAPT initiative and its capture by CBT. This and a pained response to his letters by David Veale, President of the BABCP, plus Samuels' replies, are posted here. In support of his challenge, Professor Samuels has made a collection of research documents questioning CBT dominance.
The confrontation that Andrew Samuels makes with CBT dominance and the NICE guidelines that power it is very welcome but eIpnosis was very disappointed by the BABCP response and Andrew Samuels' 'evidence'.
Don't these academics know that it is possible to do research with people? Are they unaware of the discourses of action research, cooperative and participative enquiry theory and practice?1. Decades old, this research tradition has patiently and diligently demolished the credibility of research on passive human subjects:
While a positivist, realist worldview still holds the loyalty of the medical research community, and tends to dominate the culture of the Western academy its assumptions have been almost universally discredited. As Lincoln and Guba put it, "positivism is passé" as the dominant paradigm of our times (1985:24).2
And yet in Dr Veale's letters and across most of Andrew Samuels references collection, validity and authority are seen deriving from positivist research on people.
I exaggerate to make the point but the correspondence looks like a faction fight for territory (and protection of business opportunities). Samuels, Fellow, and spokesperson of UKCP, voices serious doubts about the IAPT/CBT nexus, BABCP loads its RCT/EBP ammunition and backed up by the NICE guideline howitzers, fires off a four page defensive barrage in the direction of Samuels. But then Samuels, having brought up reinforcements, replies using the same weaponry of alienated quantitative 'mensura', RCT/EBP/Systematic review research on people, on patients.
Aside from the Andrew Samuels jousting with David Veale, public debate around the IAPT/CBT nexus has been low key to the point of inaudibility. Apparently, according to Andrew Samuels, some practitioners find these developments very disturbing, but not perhaps disturbing enough to jeopardize the promise of employment in the cascade of patronage set to shape the new world of NICE/CBT/IAPT/HPC stepped care.
Monoculture
Ipnosis looked in vain for any recognition that NICE, IAPT, CBT and the HPC, four psycholodeons stitched together by the promised state regulation of the psychological therapies, comprise a damaging monoculture. Through seeking to eliminate or suppress diversity of psychological practice such a monoculture not only doesn't protect clients, it harms the client experience.
How so?
Monocultures favour the global over the local.3 NICE claims that the pharma-style global knowledge4 of CBT/RCT/EBP/Systematic Review is intrinsically superior to the diverse local knowledge of the hundreds of viable ways of working with the human condition. By making these assertions of exclusive virtue, NICE/CBT deny clients access to this rich psychopractice ecology of skills and psychic preference. Not only that but as part of their dominance, such monocultures actively seek to demean and invalidate competing alternatives.5 This prepares the ground for corporate colonization of the kind illustrated by the name of this Brussels polyclinique.
Debate
Andrew Samuels wants a debate about CBT and IAPT and presumably the ubiquitous NICE. But isn't such a debate already billed and over-subscribed in the shape of the forthcoming Savoy Conference6?
Our objective is to help shape the intellectual climate in which a national strategy for psychological therapies can develop. We wish, in short, to foster a new, open and forward thinking dialogue around evidence based practice. (eIpnosis emphasis)
A 'debate' that, judging by the composition of the platform requires us to be signed up to the CBT monoculture (and a full-time clinical psychology/academic job). The promised 'debate' will also have to contend with, and accommodate the marketing of appetizing IAPT training opportunities. Might the latter account for why this conference was sold out months ago?
We were led to expect at the recent Reference Group meeting that there will be a 'Savoy Declaration'7 at the Savoy conference, presumably a mission statement for the psychological therapies (a brother to the EAP Strasbourg declaration?8 The text for this monument to our ethically challenged occupations has been in private development between the Big Five mainstream accrediting bodies for some weeks and according to the published programme, will be announced at the Savoy event. eIpnosis has tried several times to gain access to the conversation. No luck. So much for debate.
The RCT/EBP/Systematic Review Paradigm
This conference apart, how would any debate within this charmed world of the DoH, HPC, IAPT, NICE, BPS and CBT and the mainstream accrediting bodies not be hopelessly contaminated by a priori commitment to, and membership of, the RCT/EBP/Systematic review paradigm?
The latter, as even a cursory look at the material that challenges CBT in Professor Samuels collection of papers shows, takes hierarchical control of human variables and research agendas for granted and pursues them through the narrow lens of intellect.
There is a strong scientific and research base to support the effectiveness of "therapist delivered" cognitive behaviour therapy (CBT), in the management of people with depression, anxiety disorders, obsessive compulsive disorder, schizophrenia and bi-polar disorder. There is also a strong research base to support the use of "therapist delivered" CBT in the management of a number of long-term conditions such as chronic obstructive pulmonary disease and diabetes.(Ipnosis emphasis)
As an alternative to "therapist delivered" CBT, the recent NICE technology appraisal (TA097) assessed the evidence for clinical and cost effectiveness of computerised CBT (cCBT) in the treatment of a number of different clinical mental health conditions and has made recommendations for its implementation. Improving access to psychological therapies (IAPT) programme Computerised cognitive behavioural therapy (cCBT) implementation guidance March 2007
''...The purpose of this article is to provide a brief review of the history, development, and current status of the concepts of clinical significance (CS) and the reliable change index (RCI). I address issues regarding the development, criticisms, and applications of CS and RCI. I review the use of normative data, cutoff points, formula adjustments, and the comparative validity of various RCI methods. An examination of the convergence of multiple domains and multiple measures demonstrates ways to further develop the concepts of reliable change and CS...''
Edward A. Wise JOURNAL OF PERSONALITY ASSESSMENT, 82(1), 50-59
Such refraction of human life recapitulates unreconstructed patriarchal agendas of dominion and naturalizes them, making them seem inevitable and beyond question.
The methodology of psychology as a discipline has reinforced the mistaken idea that it is only what can be directly observed and measured that counts. The turn to 'evidence' in 'treatment' tightens the circuits of social control and closes down spaces for those who want to find new ways of living, new ways of being. p111
There is no such thing as disinterested research that simply uncovers the 'facts' about human psychology, and there is no such thing as knowledge about psychology without political effects9 p208
For eIpnosis, key elements of the IAPT/CBT nexus include a tendency to authoritarian decision-making and a preference for hierarchical organization epitomized by the necessary background condition of marriage to the state. These continue the slow poisoning of psychopractice.
In a closely related perspective, eIpnosis is inclined to see the grouping of IAPT/NICE/HPC/BPS and their master of ceremonies CBT, as paid up members of the cultures of dominance10 that are threaded through our daily life. These celebrate coercion and the use of force and install a disconnect between such human relations and their consequences. A diet that continues to poison human relations.
We learn to both fear and tolerate violence.
This violence not only deforms my high street, it deforms research. The discourse of RCT evidence-based practice, statistically significant ratings of outcome values etc that flowed into Andrew Samuels' mailbox when he asked for help, does violence to subjectivity and human relating.
'...The "psychic structure" axis of the OPD is one of four axes of a diagnostic system that defines clinically relevant psychodynamic constructs as much as possible close to observation and independent of any particular meta-psychological school in order to complement purely phenomenological diagnostics and descriptive systems like ICD or DSM. The axis, which has been in use under clinical everyday conditions in different settings as well as in research projects for more than 10 years, provides precise guidelines for the assessment of a patient's level of mental functioning and personal integration on the basis of his mental capacities and vulnerabilities...'
To hide this violence from ourselves we learn to tolerate a narrowing of focus. This disables discrimination and induces a hypnotic trance. In this trance we can believe in and support institutions such as NICE and CBT based on propositions about life and love that are in direct denial of our deepest recurrent personal and practitioner experience.
We fail to notice that a key characteristic of CBT is that it is a successful brand, the McDo of psychopractice11. Social insanity. We fail to notice UKCP, BACP and psychoanalytic practitioners practising institutional dominance through, embracing state control of psychopractice, while being committed to eliminating it in the practitioner/client relationship. Again social insanity.
And there are local deformities, for example in this footnote from the DoH guidance on implementing cCBT in the NHS
Self-referrals for cCBT were more compliant and improved more than did referrals for cCBT from mental health professionals (Mataix et al 2006, Compreh Psychiat, 2006, 47, 241-245). It was also found that a substantial number of self-referrals, including a disproportionately high number of NHS staff, would like to have access to cCBT without having to be referred by a clinician, and their severity is comparable to that of referrals by GPs. They improve appreciably with cCBT when offered a pathway to use NICE-approved cCBT confidentially without stigma (Marks et al 2003 & 2007). (Ipnosis emphasis)
Any pretence that IAPT/CBT/NICE/HPC are primarily about protecting clients has currently disappeared from view. Privately many practitioners know that this culture will institutionalize a subtle and durable form of harm. Not because of what it does, CBT is a viable therapy, and the HPC is run by well-intentioned people, but because of what has to be excluded to prove efficacy, to enforce regulation.
What then falls between the fingers is everything that really matters, pre- and perinatal attachment, love, embodiment, emotionality, intuition and the transpersonal. And if and when, through the HPC, the state becomes the proprietor of the psychological therapies, we can expect challenges to power, authority and validity in our occupations to become even more muted.
Survival Options
Staying sane while the psychopractice occupations to which we belong fall into social lunacy12 can be a very challenging life task. What can you do?
You could capitulate. Opt for cynicism. Book into a conversion course in CBT. Prepare yourself intellectually and emotionally for false compliance, saying one thing, doing another.
Or you could prepare for PNC Principled Non Compliance. Work out how to avoid registering with the HPC. Adopt a new practice title out of their range. Encourage your accrediting body to stop talking to the government. Get and read copies of the HPC regulatory documentation.13 Study and actively contradict the culture of state regulation for which you are headed.
Better still you could do research. Research is an antidote to this psychosocial craziness. Research with people. Research that includes jouissance, embodiment, intuition, discrimination and gesture, that embraces subjectivity, community and love.
There is a deep, world-wide, tradition of such research, some of it very refined and intentional, some naïve.14 The Independent Practitioners Network [IPN] is a thriving example of both. IPN features action research rooted in the subjectivities of continuing face to face enquiry. It values 'research outcomes' such as sustained civic accountability of practitioners, that embody what we know about our psychic capacities and group tendencies, i.e. research that lives in and through us. Find out more about IPN.
References
'...Research is usually thought of as something done by people in universities and research institutes. There is a researcher who has all the ideas, and who then studies other people by observing them, asking them questions, or by designing experiments. The trouble with this kind of way of doing research is that there is often very little connection between the researcher's thinking and the concerns and experiences of the people who are actually involved. People are treated as passive subjects rather than as active agents. We believe that good research is research conducted with people rather than on people. We believe that ordinary people are quite capable of developing their own ideas and can work together in a co-operative inquiry group to see if these ideas make sense of their world and work in practice...'
Chapter 16 of P. Reason & H. Bradbury (Eds.), Handbook of Action Research: Participative Inquiry and Practice (pp. 179-188). London: Sage 2001
2. Reason, P. (1998). Co-operative Inquiry as a Discipline of Professional Practice. Journal of Interprofessional Care., 12(4), 419-436. .
...monocultures of the mind generate models of production which destroy diversity and legitimise that destruction as progress, growth and improvement....[this leads to] impoverished systems both qualitatively and quantitatively. They are also highly unstable and non-sustainable systems not because they produce more, but because they control more The expansion of monocultures has more to do with politics and power than with enriching and enhancing systems..
Monocultures identify themselves through their attitude to the distribution of power.
Uniformity goes hand in hand with centralisation, while diversity demands de-centered control.
'When local knowledge does appear in the field of the globalising vision, it is made to disappear by denying it the status of a systematic knowledge, and assigning it the adjectives 'primitive' and 'unscientific'.'
Shiva, V. (1993) Monocultures of the Mind: Perspectives on Biodiversity and Biotechnology Zed Books, quoted in Postle.,D. The Alchemist's Nightmare: Gold into Lead - the annexation of psychotherapy in the UK
4. Pharma - the collective interests of the pharmaceutical industry
5. A former chair of the UKCP, Emmy van Deurzen, kick-started eIpnosis resistance to the professionalisation of psychotherapy and counselling back in 1997 when while talking about the regulation of psychopractice she outlined her view of us as weeds to be uprooted.
'...When a garden has been very fertile and has been left to itself for a long period of time it is overgrown. Sprawling plants obscure each other's light and deprive each other of nutrients. It is then necessary to cut the plants back, quite drastically' and carefully select the ones that one wishes to encourage and make room for, at the same time as uprooting those plants considered to be weeds...'
6. Savoy Conference The Psychological Therapies in the NHS: Science, Practice and Policy
7. The Savoy location has a rich history of such declarations. A Savoy conference was held in 1661 at the Savoy Palace, London, attended by 12 Anglican bishops and 12 Puritan ministers, with nine assistants from each side, in order to decide on revisions for The Book of Common Prayer; it resulted in the majority of Puritans defecting from the Church of England.
An earlier 'Savoy Declaration of Faith and Order 1658' was 'a modification of the Westminster Confession to suit the Congregational polity'.
8. The Strasbourg declaration of the European Association for Psychotherapy includes the following view of psychotherapy as 'scientific':
1. is an independent scientific discipline...
2. Training in psychotherapy takes place at an advanced, qualified and scientific level
International Journal of Psychotherapy Vol2 No1 May 1997
9. Parker, I. Revolution in Psychology Alienation to Emancipation Pluto Press p111
10. The notion of cultures of domination is best accessed through the images that adorn our media and high streets.
11. Branding employs the phenomenon of trance induction to sell us a product. Through exposing us to a generic evocation of human aspiration, 'blue sky' 'fresh air', 'happiness', or 'well-bring' a seductive ambiance is created that disallows discrimination.
12. Alan Johnson Secretary of State for Health announces funding for Increasing Access to Psychological Therapies
We can announce today-which is, of course, world mental health day-that we will build a groundbreaking psychological therapy service in England. Backed by new investment rising to £170 million by 2010-11, the service will be capable of treating 900,000 additional patients suffering from depression and anxiety over the next three years. Around half are likely to be completely cured. (eIpnosis emphasis) Hansard
13. see eIpnosis
CRITICAL REVIEW: The Health Professions Council: Creeds and Commandments of a Technocratic Religion
14. the following is a brief listing of action research/cooperative enquiry resources
The Centre for Action Research in Professional Practice (CARPP), established in 1993, is a major centre for work on the theory and practice of action research. It has been instrumental in establishing Action Research, an international journal, which has helped bring CARPP's work firmly onto the world stage.
'...our interest and concern is with approaches to action research which integrate action and reflection, so that the knowledge gained in the inquiry is directly relevant to the issues being studied; and in which there is increased collaboration between all those involved in the inquiry project. Our work aims at helping the individual practitioner develop skills of reflective practice and to help organizational members develop communities of inquiry, as well as contribute to wider understanding of the place of inquiry in the development of professional practice...'
The Practice of Co-operative Inquiry: Research with rather than on people John Heron Chapter 16 of P. Reason & H. Bradbury (Eds.), Handbook of Action Research: Participative Inquiry and Practice (pp. 179-188). London: Sage 2001
'...Research is usually thought of as something done by people in universities and research institutes. There is a researcher who has all the ideas, and who then studies other people by observing them, asking them questions, or by designing experiments. The trouble with this kind of way of doing research is that there is often very little connection between the researcher's thinking and the concerns and experiences of the people who are actually involved. People are treated as passive subjects rather than as active agents. We believe that good research is research conducted with people rather than on people. We believe that ordinary people are quite capable of developing their own ideas and can work together in a co-operative inquiry group to see if these ideas make sense of their world and work in practice...'
Doing Cooperative inquiry Handbook of Action research Participative Inquiry and practice Peter Reason and Hilary Bradbury Sage 2005
A PARTICIPATORY INQUIRY PARADIGM
Heron, J., & Reason, P. (1997). A Participatory Inquiry Paradigm. Qualitative Inquiry, 3(3), 274-294.
What Do We Measure and Why? Questions About The Uses of Measurement
Journal for Strategic Performance Measurement, June 1999
Margaret Wheatley and Myron Kellner-Rogers
Handbook of Action Research Participative Inquiry and Practice
Peter Reason Hilary Bradbury editors Sage Publications
Introduction:Inquiry & participation in search of a world worthy of human aspiration
Reason, P. (1998). Co-operative Inquiry as a Discipline of Professional Practice. Journal of Interprofessional Care., Journal of Interprofessional Care12(4), 419-436.