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Where are the ‘psycho-sceptics’?

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Where are the ‘psycho-sceptics’?

Those who advocate psychological therapies are good at being critical. Especially when it comes to medicine. But, argue  Huw Green and Leigh Emery psychology-types may need to be a bit more sceptical about what’s done in their name? 

When is a colouring book more than a colouring book? When it’s a mindfulness colouring book apparently. Last year’s hit Christmas gift was briefly talk of the Internet. Colouring-in is the latest form of mindful practice. An activity with which we are all familiar can evidently be a sophisticated spiritual and therapeutic exercise. It might make you wonder though: is colouring especially ‘mindful’? It’s possible to do almost anything, from washing up to walking the dog, mindfully. So, while the covers of the colouring books aren’t straightforwardly deceiving, they might be accused of being misleading. There’s something irksome about simply repackaging activity with which we are all familiar as a sophisticated spiritual or therapeutic exercise, and of creating an illusion that their book is more health giving than any other.

Perhaps this is a bit trivial, as no-one actually owns the term ‘mindfulness’ and authors can do what they like with it. But is it really OK just to pick up terminology and use it unchallenged for your own purposes? Moreover, do those of us who have the title of ‘psychologist’ have a responsibility to highlight inappropriate, opportunistic or just plain lazy uses of psychological concepts?

The explosion of mindfulness is a success story in terms of a psychological therapy gaining a place in public awareness. This process has been seen before: an idea emerges, has promise and acquires support. Eventually (especially if it’s heralded as a new hope), it becomes a label and breaks into the mainstream of public thought. However, while these developments may be positive (they raise the profile of psychological therapies and may make them more accessible), a raised profile also attracts people trying to cash in on the public enthusiasm.

Cognitive-behavioural therapy (CBT) is a good example of this process. Emerging from the work of a psychoanalyst (one who had come to think that a more proactive approach to changing his patients’ minds might be productive) the notion of ‘cognitive therapy’ could be clearly delineated as a new approach to psychotherapy. This approach gained popularity over the years as it represented something apparently more scientific than psychoanalysis. CBT has expanded dramatically over the years as its popularity has grown, and it now seems ubiquitous. It has been rolled out across the UK as part of the government’s IAPT programme, and can now be accessed over the telephone or online. It has become the subject of countless newspaper articles and popular self-help books. It’s has even been suggested as a means to help improve your poker game.

Similarly mindfulness, as well as cropping up in colouring books, has a government stamp of approval and gets offered to boost productivity and profits in the workplace. But when an idea gets stretched over such a large area is it really the same thing any more? This is an important question to ask, and again there is an important parallel with CBT. When a meta analysis found evidence that CBT might be losing its efficacy over time, one explanation posited was that key elements of the therapy process were getting lost. While the studies examined were delivering all the ingredients the manuals said they should, they may have deployed fewer of the common factors (things like building a relationship or encouraging risk-taking) which are known to contribute to all psychotherapy successes. Could it be that CBT delivered solely in terms of ‘the model’ (without any broader understanding of how to build a psychotherapy relationship) is a less potent way of helping people?

Complex ideas may actually be very difficult to package up and for wide consumption and the results can be questionable. One group who know this well are neuroscientists. Many have developed a lively online culture of debunking extravagant claims made for such concepts as mirror neurons, ‘brain training’ and ‘neuro-linguistic programming’. Twitter accounts like @neurobollocks and bloggers like Neuroskeptic make it clear that it is almost a point of honour among brain researchers to distance themselves from the making of money by adding superficial ‘neuro’ prefixes.

It seems strange, then, that clinical psychologists (and others who ply their trade in the world of psychological therapies) don’t seem to have developed their own version of this guild-scepticism. If anything, we seem to lean in the other direction. It is common for clinicians to think of themselves in terms of a particular theoretical model (e.g. as a psychodynamic practitioner, or an CBT practitioner) with plenty of brand allegiance. This recent article by Oliver Burkeman provides an example of how CBT and psychodynamic therapy both have brand advocates, too willing to carp at each other over territory. This territorial grandstanding feeds into a desire to defend your own at any cost, making (for example) a mindfulness-based therapist feel positively disposed toward mindfulness-friendly products, even if they are pretty wishy washy.

Perhaps another of the reasons clinical psychologists are less vocal in debunking dubious products is that the whole profession stands to benefit when a psychological model such as CBT or mindfulness explodes into the public consciousness. Psychological therapies (in the UK at least) struggle to get the attention (and funding) of commissioners. So when a particular therapy hits the mainstream, this can easily be heralded as a boon. But this comes at a price. Policy makers have an interest in the dilution and cheap dissemination of psychological products. Standardised therapies with clear end-points can be rolled out inexpensively by people with minimal training. This may be good for politicians (and good for branded therapies, at least to begin with), but it could prove disastrous for people who receive an ineffective, pared-back intervention on the strength of a brand alone.

Psychology has yielded many fruitful ideas, but also spawned endless opportunists seeking to cash in on them. The temptation is to see the mainstreaming of psychological ideas as all good, and avoid pointing out the ways it dilutes and degrades them. There is far more to psychotherapies than the technical mastery of isolated sets of principles. Clinical psychologists (and all other mental health professionals, for that matter) should aspire to be effective and comprehensive providers of excellent quality mental health care by influencing service cultures and delivery, not just peddling models. If we felt less tribally aligned to isolated models like CBT or mindfulness we might be in a position to advocate for more comprehensive and empirically informed psychological care.

We need to look beyond our allegiance to specific therapeutic modalities, and overcome our aversion to vocally debunking watered down brands and assorted flim-flam. Can we be brave enough?

 

You can follow the authors on Twitter @Huwtube (Huw) and @SafeUncertainty (Leigh)

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7 comments on “Where are the ‘psycho-sceptics’?

  1. “It seems strange, then, that clinical psychologists (and others who ply their trade in the world of psychological therapies) don’t seem to have developed their own version of this guild-scepticism.”

    Sorry, but where is your evidence to support this and the numerous other bold assertions in this piece? Ironic indeed, that you are criticising clinical psychologists for failing the scepticism test, when you base your argument on anecdote after anecdote after anecdote. Perhaps maligning an entire profession is not the best strategy for gaining the credibility you appear to seek.

    1. Thanks for your comment. Our piece is about what we perceive to be a broad cultural tendency in the profession. We based our observations on events which have unfolded on this very blog (see i.e. the debate that unfolded in the comments over CBT for psychosis here: http://discursiveoftunbridgewells.blogspot.com/2014/04/a-national-scandal-psychological.html) and on tendencies which have been historically documented in the work of e.g. Scott Lilienfeld, Robyn Dawes and Paul Meehl. While you are right to ask for evidence, it is unclear what sort of evidence should be brought to bear on the question of such a cultural/historical tendency. One strand might come from psychotherapy research into the allegiance bias (e.g. here—http://www.ncbi.nlm.nih.gov/pubmed/23500154) which is highly suggestive of the problematic tribal mentality we mention. The anecdotes we bring to bear, seem to us to speak to a surely undeniable desire for people to make money from models, and we suggest from our experience of social-media engagement that clinical psychology has produced far fewer skeptics about such money-making than, say, neuroscience. That this might be due to our professional self-interest is highly plausible. You might disagree, but to offer our conclusion on these grounds doesn’t feel so egregious to us. As for “maligning an entire profession” (one of which we are both a part), that seems far too strong a description of what we are doing.

  2. I honestly cannot believe you defend your weak arguments by citing, as supporting evidence, “comments on the internet” and your “experience of social-media engagement”.

    You, a clinical psychologist, then cite critical evidence produced by clinical psychologists to criticise clinical psychologists for not producing critical evidence. Before disappearing in a puff of self-refutation, you then claim that your “anecdotes” constitute “undeniable” evidence of a “desire” for people to make “money from models”. Notwithstanding this astonishing non sequitur, you go on to confound low social media engagement with lack of appropriate scepticism, while at the same time failing to acknowledge that the vocal neuroscientists you admire no doubt do rather well out of their celebrity status.
    You manifestly fail to consider alternative explanations for clinical psychologists being reluctant to enter the wild west of social media. You’ve reached your conclusion, informed as it is by the weighty evidence of comment-threads and newspaper articles.

    And yes, maligning an entire profession was exactly what you did in your frankly irritating article, which lacked nuance, caveats, consideration of alternative explanations – or indeed any evidential basis whatsoever. But then again, this is social media.

    1. Hello, thanks for your comments. I understand that our article has struck a nerve and that you don’t believe we are correct in our assertions. However, I’m less clear on what your position is on the issue and a a consequence, I’m unsure how best respond.

      Are you of the opinion that there IS a healthy culture of scepticism in our profession? Or that there ISN’T a tendency towards “brand allegiance”?

      Huw has outlined some of the bases for our argument on his comment above, but our article was ultimately an opinion piece based on our experience of working in the profession and our observations of trends in clinical psychology. I fully accept that not everyone will share our views, and no doubt your opinions differ from ours. I’d welcome having a discussion with you about it.

  3. Social media isn’t really a ‘wild west’. It’s far more regulated than your average street corner.
    In any case, there is ample evidence of a lack of skepticism in psychology. Take mindfulness and positive psychology as an example. When I explain the concept of ‘critical positivity ratio’ to laypeople, they generally laugh at the absurdity of it. It’s a confidence trick that would be beneath a used-car salesman. In psychology, however, it was taken seriously, and it is to the disgrace of the profession that it actually took a statistician to refute it. The same paradigm of mindfulness/positive psychology has been implicated in everything from torture at Guantanamo, workfare around the developed world, and is used as a tool to discipline those in the US military. Perhaps I’ve missed something, but these ethical and conceptual failings are almost totally absent from the scholarly literature, and so it doesn’t surprise me that a person relying on said literature, and self-excluding from social media, might believe (erroneously) that the profession is in good shape.

  4. I very much agree with David. When you read the ‘critical positivity ratio’ description again (I have to admit I skimmed it at the time) it sounds like an April Fool. I am broadly with the thrust of the piece in terms of how critical/questioning our profession is. It’s not absent but it is something that, the authors rightly point out, may be in conflict with a desire to have a promotional role. This was, for me at any rate, very much to the fore during the genesis of the Improving access to Psychological Therapies initiative in the UK. A very worthy desire to improve availability of psychological therapies did lead to a significant glossing of the shortcomings in the arguments and figures provides in the LSE Depression report. As far as I can see what we have now are therapies often delivered in a sub-clinical ‘dose’ and offering questionable value for money. There were some critical voices around a the time but the conflict outlined by the authors was very much present.

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