Tuesday, 11 February 2014

Agendas and Anxieties: CBT for Psychosis

I have been watching discussion about the latest CBTp trial with interest and some weariness. If you haven't kept up, at least 3 expert blogs have painstakingly critiqued the results and reporting of a new study in the Lancet. Their work may have led the BBC to water down initially highly enthusiastic but inaccurate coverage:

Before and after: The BBC's shifting versions of the same study

I remain a fairly novice methodologist so I have nothing of value to add to this dispute. However, one striking and familiar pattern has emerged, apparently driven by particular anxieties upon which it is interesting to speculate.

Defenders of CBTp have emerged in the comments of these blogs angrily seeking to discredit its critics without providing much substantive defence of the data. Among the more striking things about these comments is their tone; irritable and impatient, levelling accusations of personal agendas and talk of "cabals". Perhaps for the most part, this can be attributed to the familiar fact of modality-affiliation-bias on the part of defenders. People want CBT to be effective for psychosis because they have invested time and energy in it as a cause. The same bias of course motivates overly-enthusiastic defences of any treatment. 

I think there is another anxiety present too however, one which, however misguided, is perhaps more noble. This other anxiety arises out of the current topography of the mental health debate, which appears to pit "medical"/"evidence-based" interventions against "intangiable"/"humanistic" interventions. With these binary goggles on it can look as though CBT is just about the only "humanistic" intervention that has any chance of passing the stringent hi-tech tests of an atomistic neoliberal psychiatry. Discrediting CBT is not just about one intervention; it entails a further discrediting of any provision of psychological care in this field. 

This reasoning doesn't follow, and I am not trying to motivate a case in favour of CBTp of the back of it. Why then have I said it is "noble"? Well, whatever the evidence for different specific interventions in psychosis, we would seem to want to provide in addition to them  "old-fashioned" "holistic" "person-centred" (call it what you will) care. Care, as it were, in the straightforward "folk" sense of the word rather than in the jargony bureaucratic sense. One person I interact with on Twitter has suggested calling it "psychiatric palliative care". Although I can anticipate some protests at this idea ("palliative" implies pessimism; a degenerative, fatal trajectory) I understand where she is coming from and think it's a neat coinage. Care is about a sort of ethical responsibility and it draws on a certain instinctual sense that people ought to look after and love one other. It is the sort of care which Jenni Diski recently eulogised in the LRB, sad to realise that the loss of Victorian asylums (good riddance) had also entailed the loss of "asylum" in contemporary society's treatment of mental health.

It would be misguided to rally to a therapy that cannot substantiate its claims to efficacy. We should be advocating treatments that really help people, and it is a strange thing when we don't. We need to understand why we get into such ruts if the debate is to progress. At least some of the problem is an unspoken fear: that if we see all of our caring efforts simply as testable technologies, we might lose them altogether. 

1 comment:

  1. Thank you for your thoughtful, balanced and thought-provoking commentary!
    Reading it, I thought on your "noble mistake" theme that it is strange how many people believe that "evidence-based" must imply medical and medicalised. This simply isn't through, as its most clearly set out by Bruce Wampold in his The great psychotherapy debate, that very much focuses on this question. And Duncan et al (2010) The heart and soul of change give the same message in an even more easily readable way.

    Care is vital, but care is effective, and because it is effective it's easy to prove that it works.

    The problem reminds me a bit about the many people who are so very anti-medicalisation and anti-DSM etc., but who secretly are afraid that purely "mental" problems, as long as no physiological basis has been proven, remain somehow inferior to the bodily / biologically based ones.....

    Care, the mental, intangibles, are as real as the physical, that's my motto!