A yoke upon the necks of the poor?

26 November 2014

Everyone sings the praises of talking therapy these days. A myriad of therapies, each with their own logic and rationale and a technical sounding acronym, claim to cure an increasingly diverse range of problems including depression, obesity, poor parenting and cancer. Whether its CBT (cognitive behavioural therapy), or DBT (dialectic behavioural therapy) or plain counselling, or one of the newer forms of therapy like ACT (acceptance and commitment therapy), there's a group of experts somewhere claiming that this particular therapy is going to make you happier, healthier and better adjusted.

The UK government is so confident of the benefits of therapy, it is convinced that therapy is the solution to getting depressed people back to work. The Increasing Access to Psychological Therapies initiative (with the less than memorable acronym, IAPT), was set up with government funding and backing with the express aim of cutting the spiralling sickness benefits bill.

Surely all this therapy is a good thing? Surely there's nothing the matter with talking to a nice middle class professional who is paid to listen attentively and focus on you and your worries? Paul Moloney's well-argued, readable and passionate book suggests that there might be, and he makes a compelling case.

Moloney analyses therapy from three angles: the political, the philosophical and the empirical. On each count therapy is found wanting. From the political point of view, the over-riding problem with therapy is that it locates the problem within the individual, and optimistically leads people to believe that if only they can adjust their thinking, their problems will be solved. But there is extensive literature that demonstrates that being diagnosed with a mental disorder is strongly associated with living in conditions of social deprivation, poverty, or coming from a lower social class. Unemployment, insecure employment, poor housing, being a victim of crime, family breakdown, childhood abuse - all these factors make the incidence of mental disorder substantially more likely. Not only does therapy have no chance of addressing any of these, it allows society to look the other way, and present mental disorder as an individual weakness or vulnerability, rather than a more or less predictable result of living a marginalised existence in a society that increasingly celebrates extreme wealth and conspicuous consumption.

From the philosophical point of view Moloney argues that therapy is based on a misguided Cartesian separation between mind and person. There is no mental 'CEO' guiding and directing our actions, which can be coached into being more effective. He surveys research that demonstrates that we are not reliable reporters of our inner experience, and suggests the autonomous self of psychotherapy is an illusion. The self cannot be separated from its actions, which are responses to all its circumstances, past and present.

Moloney provides a detailed critique of the research on the effectiveness of psychotherapy, pointing out its major weaknesses, such as the difficulty of designing a 'placebo' or inactive therapy, and controlling for influences like the expectations of the therapist. The results are in any case disappointing, showing only small effects (like antidepressants). Moreover, all types of therapy appear to have about the same effects, and attempts to show that the specific ingredients of a particular therapy make a difference, such as the cognitive aspects of CBT, have failed (similarly, the effects of antidepressants are small, of doubtful clinical significance and despite being chemically diverse, there is no meaningful difference between agents).

Moloney reserves his harshest criticism, rightly, for the evaluation of the IAPT programme. This massive and expensive government-funded programme did not even bother to enlist a comparison group. The results of the evaluation are consequently completely worthless, even by the uncritical standards of psychotherapy research itself. The naïve belief that therapy could get people back to work and reduce the welfare bill illustrates the politically conservative purposes that Moloney argues are inherent in therapy: 'the therapeutic outlook allows the more prosperous sections of society to put the yoke of responsibility for social problems (like impoverishment) straight upon the necks of the poor.'

Moloney is not arguing for other types of interventions for mental health problems. He is just as critical of the mass prescription of psychotropic drugs like antidepressants and the whole project of constructing behavioural and emotional problems as medical diagnoses. And I don't think he is suggesting that mental health professionals should turn people away, or refuse to help the cases of individual misery they are confronted with daily. But he is reminding us that therapy, like drug treatment, encourages the idea that the individual is inadequate and in need of fixing, with expert therapeutic or pharmacological help. In this sense therapy provides a useful diversion from the social causes of discontent and undermines the impulse to agitate for a fairer and more equitable society, in which everyone can lead less blighted and more meaningful lives.

- Published by Pluto Press, 2013
Reviewed by Dr Joanna Moncrieff, who is a Senior Clinical Lecturer in the Division of Psychiatry at University College London. E-mail [email protected]