POWER, AUTHORITY and VALIDITY ?
The IAPT/CBT Nexus
GUEST EDITORIAL Janet Low PhD
Dr David Veale, president of the British Association for Cognitive Behaviour Therapy, parades an army of 6,000 people in response to Andrew Samuel's letters to the national press (Oct 12, Guardian, Oct 21 Observer). He draws attention to Andrew's human weakness and then calls on another large and powerful institution (NICE) as an ally against this one man. Finally, Veale copies his letter to more groupings within Royal Colleges and Departments of Health to situate himself safely within the walls of the establishment ready to take on a Professor of Psychoanalysis!
What was it that Andrew Samuels said that provoked such a formidable response? He dared to question the essence of the ideology that underpins recent Government announcements (10 Oct) to put CBT at the forefront of NHS quick fix mental health policy.
Let's look at the ideology. Richard Layard, the Government, and David Veale all appeal to the ultimate authority of NICE, which in turn depends on an idea of Evidence Based Research. NICE presents itself as an institution that aims to create an ideal equality where no-one is privileged, no one is cleverer than anyone else, and no-one has the right to tell anyone else what to do.
Paradoxically, in this brave new world, NICE turns out to be: more equal than anyone else, in a privileged position, and treated as if it were cleverer than everyone else. In spite of its best intentions it finds itself in the position of the one who must tell everyone else what to do.
Max Weber, a founding father of sociology, wrote about bureaucracy and the paradox of unintended consequences. He is well remembered today for the link he revealed between the protestant work ethic and the spirit of capitalism. Although Weber is neither New nor Modern, and his work would not be considered as Evidence in the NICE political climate, his ideas are still fresh and insightful and offer considerable explanatory power.
The unintended consequence of contemporary politics is a massive move towards a totalizing, impersonal, invisible field of knowledge where solutions emerge from a bureaucratic machine hidden by a single signifier: NICE. All signs of human foibles are concealed from the field and leave the impression that things come direct and undistorted straight from ... well, from some kind of god.
Systematic Reviews, Cochrane Reviews, Evidence Based Medicine, Randomized Controlled Trials, Effectiveness and Efficiency are all words put to work to guarantee the impartiality of the new NICE agency. But in fact they are all words that are easily attributable to a real, flawed, character who would be amazed to discover he had become deified and removed from the scene.
Archie Cochrane first published his little book Effectiveness & Efficiency in 1972. In it, he set out his personal position, his political aspirations, and his agnostic point of view. His book is full of caveats, reservations, contradictions and is refreshing for its open acknowledgement of his many human biases. He would be appalled to see how his random reflections have been turned into a regimented ideological machine.
Archie Cochrane died in 1988 and cannot be held responsible in any obvious way for the rise and rise of the ideology that has culminated in the current state of affairs (Shapiro (1995) suggests that if he could see how his ideas have been put to use today, he would certainly be spinning in his grave). But it is instructive to return to his book and do the honourable thing. Read it. All of it. It's only 100 pages long. On page 24 of the 2004 reprint you will discover that Evidence Based Medicine has an unexpected affinity with Protestantism.
"If some such index as the number of RCTs per 1,000 doctors per year for all countries were worked out and a map of the world shaded according to the level of the index (black being the highest), one would see the UK in black, and scattered black patches in Scandinavia, the USA, and a few other countries; the rest would be nearly white. It appears in general it is Catholicism, Communism, and underdevelopment that appear to be against RCTs." (Cochrane, 1999 p24)
Cochrane goes on in his light-hearted way to make a joke at the expense of communists and Catholics and touchingly reveals his prejudice. We don't need to be frightened of that (we know that he fought on the side of the communists against the fascists in the Spanish Civil War) - but we would indeed become something to be frightened of if we pretended that people aren't human, that differences should be removed, or that evidence alone gives good ground for action. Evidence is always situated in a scheme of thought. Always.
All thoughtful endeavour depends on thinkers responding ably to phenomena they encounter. Trying to insist that one method answers all questions, and that all we then need is an army of administrators is absolutely shocking.
Andrew Samuels has already replied to David Veale (letter dated Nov 5), and has promised another letter to follow up. In this next missive he wants to display his own army: of peer-reviewed research that shows that CBT is not demonstrably more effective across the board than other therapies. Unfortunately, most of the references that have volunteered to serve in this army are themselves subject to the ideology of false objectivity. This should be a lesson for us all – it is very easy to lose one’s way in this mess. Nevertheless we have some strong points of navigation: it is an ideology that is the problem, and one that has become so widespread that it is practically invisible. By drawing attention to it and revealing its characteristics we can each do something, one by one, which will ultimately save much more than money.
Janet Low 9 Nov 2007
AL Cochrane, 1999, Effectiveness and Efficiency: random reflections on health services, London Royal Society of Medicine Press
S Shapiro, 1995, Book Review, Journal of American Medical Association v274 p668
