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The Politics of Science This web page will gather some material on the dialogue surrounding the ‘professionality’ of counselling and the politics that are embedded in that issue. The first item is a paper reviewing the politics masquerading as science behind the favouring of CBT over other therapies. The second piece is a response to an e mail enquirer on the professionalisation of counselling where the argument drifts into the political difference between physical health care and mental health care and other issues. Much of science is an ethical endeavour to find answers to ‘why’ questions. Certainly, its findings tend to be coloured by the values of the researchers. Michael Polanyi, in his book, Personal Knowledge, established that across all the sciences, even the physical sciences, as long ago as 1958. In the social sciences the effects of researcher allegiance are so familiar that they have even been quantified and can be corrected for (Luborsky et al., 1999). On occasions a subjective thread can become institutionalised to create an unreality not dissimilar to the emperor’s clothes. This is the politics of science where the truths reflect no more than the politics or prejudices of the day. When I was an undergraduate psychology student I was researching synaesthesia – how input into one sensory modality affects perception in another. For example, when we go to the cinema we hear the speech as coming out of people’s mouths, when in fact it is coming from the speakers in the hall. In the whole study of synaesthesia throughout the world there was agreement that the valued ‘skill’ was to be found in those who could accurately discriminate one stimulus from the other. It was no coincidence that men are much better than women at such discrimination. It was only after 50 years of research that some people began to ask whether the higher skill was not that of being able to integrate rather than discriminate stimuli! In the present day reporting of investigations purporting the superiority of cognitive behavioural therapy (CBT) over other more relational therapies such as person-centred therapy (PCT) and psychodynamic therapies (PDT) that engage the affective as well as the cognitive and the behavioural, we have a developed example of the politics of science. CBT fits nicely into the social control politics of the day, just as Leader (2007) suggests its use fitted the cultural revolution in China. This political preference is supported by a system for evaluating science that only considers one type of science as acceptable, namely the randomised controlled trial (RCT) whereby one heavily specified and standardised ‘treatment’ is uniformly administered and evaluated against another. This is indeed an appropriate methodology when evaluating pharmaceuticals but it is nonsense to apply it to relational therapies with people. The politics of preference is furthered by restricting the measure of effectiveness only to the current symptoms rather than whatever may be causing them. In other areas of medicine the physician does not solely set out to reduce the symptom but also endeavours to find out what the symptom is telling them and working on that. But the area of mental health and its patients are more feared – the aims of our society are not to delve deeper than the symptom and merely have the symptom go away – more to alleviate the discomfort of others than the patient. Of course CBT, unlike other therapies or counselling, is specifically targeted at the symptoms that are to be measured in the evaluation. Sounds crazy to compare two different endeavours on only the short term outcomes of one of them, but that is the current politics of science in this domain. An additional consideration that appears to have been totally ignored by the National Institute for Clinical Excellence (NICE) in their (only tentative) favouring of CBT is the extremely high proportion of CBT RCTs that have been done in-house (by CBT practitioners or within their organisations). Ironically, many of the RCTs that have investigated PCT have been done by CBT affiliates setting PCT up as the comparison condition against CBT, usually with therapists untrained in PCT. Robert Elliott investigated this disparity in respect of researcher allegiance, applied the aforementioned Luborsky corrections, and concluded that even on the RCT evidence (generally aimed only at symptom reduction), there was no superiority for CBT (Elliott et al. 2004). The politics is furthered by the discounting of what is called practice-based evidence. If the general public (or even the press) was aware of what this means, the politics might even be exposed. To a considerable extent this kind of social control politics relies on the collusion of the victims. So, it is acceptable to debate these issues within the defined and restricted scientific parameters, but there would be discomfort felt even by the victims in exposing it to the wider audience of service users. It feels safer to perpetuate the myth of the emperor’s clothes or only to contest it within the territory defined by the politics. If the public was made aware of the systematic rejection of practice evidence they would see that what is being ignored is the lived experience of many thousands of patients within the NHS. The results of these large scale studies consistently fail to show the assumed superiority of CBT over PCT and PDT. For example, the Stiles et al. (2006) study included the actual work done in primary health care counselling settings with 1,309 patients. I wonder if those patients know that their reports have been discounted in favour of the CBT in-house RCT studies? The same question applies to the 5,613 patients in the more recent Stiles et al (2007) study. This paper is published in Psychological Medicine along with a ‘commentary’ on it by Clark et al. (2007). It is interesting that the Journal felt that it was necessary to invite a commentary (which is really an attempted criticism) to accompany the publication of Stiles’ study. Recently Stiles (2008) has published a rejoinder to Clark and the debate has been furthered by press release from 'the four professors' (Cooper, Stiles, Bohart & Elliott) making the same kind of challenge as is offered in this paper. That press release spawned an array of articles including Laurance (2008). In September 2008 a key book on the research evidence is to be published (Cooper, 2008). This challenge to the politics of the ‘science’ underlying CBT is more about the suggestion that CBT should be the treatment of choice for a wide array of human distresses rather than about CBT itself or its practitioners. Indeed, the basic orientation of CBT is a part of all psychotherapies. There will often come a point in the client’s process in relation to their difficulties when they have substantially processed the underlying factors and the attending emotion. Yet, they may be left with what I call ‘ghosts’ that continue to represent the difficulties and impose themselves on the person’s life. For example, a client may have substantially worked through the emotion and the trauma relating to their earlier abuse, yet they are still troubled by historical symptoms – ghosts from the past that have little substance in the person they are now, but which continue to haunt them. Perhaps they still feel an initial tension on meeting some people who represent what they used to fear; perhaps they find themselves stereotyping individuals according to their previous experiences; or perhaps they still have difficulties with an eating disorder that had its roots in their previous distress. These are ‘ghosts’ in the sense that they no longer have the same substance – the same basis within their psychological make-up – but they still have an impact upon their daily living. In that context psychotherapists of any tradition would find themselves following their client to attend to these aspects of their daily living without expecting substantially to re-visit the previously worked upon underlying dynamics. Earlier in this paper I referred to counselling and psychotherapy (of all traditions) as working with the cognitive, the behavioural, and the affective. It is vital to be prepared to enter and appreciate the client’s affective world – to meet them in their distress – if we expect to have an impact upon the underlying experiences and dynamics. At the later stage described above we might find ourselves focusing more on the cognitive and the behavioural, but during the bulk of the work all three are important in counselling and psychotherapy. To ignore the fundamental work and dive straight to the final stages is like putting a fresh coat of paint on top of an old flaking surface – it looks good… for a while! It is a shame that the reputation of science should be so tarnished by politics. But it is important for us to remember that in our society the former is inevitably the slave to the latter. Nevertheless, true science still persists in the young researcher who is genuinely surprised and challenged by their novel discoveries when they have asked ‘why’ questions. References Clark, D.M., Fairburn, C.G. & Wessely, S. (2007). Psychological treatment outcomes in routine NHS services: a commentary on Stiles et al. (2007). Psychological Medicine, 37 Doi: 10.1017/ S0033291707001869. Cooper, M. (2008). Essential research findings in counselling and pyschotherapy. London: Sage (Publication date - September 18). Elliott, R., Greenberg, C.S. & Lietaer, R. (2004). Research on experiential psychotherapies. In M.J. Lambert (Ed.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change. 5th Edition, pp. 493-539. New York: Wiley. Laurnace, J. (2008). It's good to talk, or is it? The Independent. Tuesday, July 9. Leader, D. (2007). A dark age for mental health: A therapy last used on a mass scale in China’s cultural revolution is to be unleashed on the NHS. The Guardian, Saturday, October 13. Luborsky, L., Diguer, L., Seligman, D. A., Rosenthal, R., Krause, E.D., Johnson, S., Halperin, G., Bishop, M., Berman, J.S. & Schweizer, E. (1999). The researcher’s own therapy allegiances: A “wild card” in comparisons of treatment efficacy. Clinical Psychology: Science and Practice, 6, 95-106. Polanyi, M. (1958). Personal Knowledge. London: Routledge. Stiles, W. B. (2008). Letter to the editor. Routine psychological treatment and the Dodo verdict: A rejoinder to Clark et al. (2007). Pyschological Medicine, 38. doi:10.1017/S0033291708002717. Stiles, W.B., Barkham, M., Twigg, E., Mellor-Clark, J. & Cooper, M. (2006). Effectiveness of cognitive-behavioural, person-centred and psychodynamic therapies as practised in UK National Health Service settings. Psychological Medicine, 36, 555-566. Stiles, W.B.,
Barkham, M., Mellor-Clark, J. & Connell, J. (2007). Effectiveness of cognitive
behavioural, person-centred and psychodynamic therapies in UK primary-care
routine practice: replication in a larger sample. Psychological Medicine, 37,
(12 pages, as yet unassigned). Doi: 10.1017/S0033291707001511. Further to dialogue on the professionalisation of counselling and the politics/science involved, here is an e mail enquiry and my response. The response drifts somewhat, but perhaps into interesting areas. Sent: Wednesday, March 04, 2009 2:47 PM Subject: research for critique
Dear , I think that my view is as mixed as the arguments - 'much can be said on both sides'. I explore this kind of question in the paper: Mearns, D. (2003). ‘The agenda for Humanistic Psychology: Articulation.’ Journal of Humanistic Psychology, 43(3), 53-65. Generally, I strongly support the profession 'articulating' with the key institutions of Society, because that will be the only way for it to become widely available and free at the point of service. That requires a process of 'articulation' (see the paper). Articulation is dialogue rather than compromise and I have found it to be enormously productive in terms of winning large contracts to provide counselling services within primary care and education authorities. However, the danger is that, in its desire to be accepted, a profession may find that it prostitutes itself. That is a particular issue when we consider the place of psychological therapies in the Health Service. Counselling, as it is most commonly practised, should probably not be within mental health provision at all because its alignment with the potentiality model contrasts with the deficiency model that pervades mental health provision. I was always careful to position counselling within primary health care rather than secondary mental health care, because in primary care the GP will not solely be concerned with symptom reduction but will also be asking themselves what the symptom is telling them about the underlying condition of the patient. That is also the case in most approaches to counselling. But the paradigm within mental health care has always been more oriented to social control in the form of a sole attention to symptom reduction - that is all that is important, vis. symptom reduction is the only criterion used in efficacy research, and CBT, with its direct attention to symptom reduction, is seen as the treatment of choice despite the fact that independent research does not support that assertion. The fact that in mental health care there is no attention paid to what the symptoms are telling us about the underlying condition may partially be related to the ingrained and continuing discomfort felt within our culture about emotional distress and the support from the users' lobby to regard their distress as an illness unrelated to them, but I suspect that a larger factor is that it is an accident of history that mental health care is part of the medical portfolio. It stems from the time when so little was known about mental distress and so much was feared about it, that it was expedient to lock the worst perpetrators away under the pretence of offering them health care. So, psychological 'treatment' is within health care but human distress is not an illness (Pete Sanders writes well on this). It has to still be treated as an illness to justify its placement, but there is little hope of medicine being effective in affecting the underlying condition, so the attention does not go past the external symptoms. This is a clear and present danger when we consider the present disregard of scientific rigor in the comparative evaluation of psychological therapies (see the 'politics of science' paper on www.davemearns.com). So, it is important that this broader consideration is attended to as we question whether to align the whole profession closer to 'Health Professions'. Many years ago, in BACP, we had to make a choice as to whether to categorise the academic dimension of the profession under 'Education' or 'Professions Allied to Medicine' for the purpose of the 'Research Assessment Exercise' within the university sector. We chose the former, partly because more of our research was happening in Education Faculties, but also because 'Education' was politically less directed than mental health. It seems to me that this care within the profession to the politics of its alignment has been lost as a concern to BACP as its growth has led to its inevitable institutionalisation and rationalised pragmatism. They had every chance, early on, to point up the irrationality of the psychologists' advice to NICE on efficacy research, but they stayed quiet, justifying their cowardice and protection of their own jobs by suggesting that they should not exert a political voice. They had wanted to become 'the voice of counselling' but by the time they got large enough to be the voice they had been silenced by their own institutionalisation. Good luck with your critique. I'll put this up on my website (without naming you) so that it is within the public domain. That will make it less problematic for you to quote it in whole or in part. Best wishes, Dave Mearns.
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