In Saturday’s Grauniad there was a debate on the topic of “Should workplaces have on-site psychiatrists?” Personally I think it would make more sense for workplaces to have on-site counsellors and mental health first aiders than psychiatrists, but that’s not really the point of this post. I’ve been irritated by the condescension of Oliver James, one of the debate participants.
The debate was between Oliver James and Alistair Campbell, the former Downing Street spin doctor who has spoken publicly about his recovery from depression and alcoholism. James is a psychologist (though he doesn’t appear to be registered with the Health and Care Professions Council as a practitioner psychologist), and author of books such as Affluenza and They F*** You Up.
In the debate, James states,
Psychiatrists mostly offer pills and other sticking plasters, like cognitive behavioural therapy (CBT). For the commonest problems, depression and anxiety, neither really work. The major part of the effect of antidepressants is placebo; the patient might as well swallow coloured chalk. Meta-analyses show that 18 months after undergoing CBT, there is no difference between people who had it and those who did not.
I have benefited both from the expertise of psychiatrists and from medication.
To which James replies,
If the medics have done the business for you, great. But the evidence suggests you are very much the exception. I suppose I do concede a small part of the stigma could be reduced by the wheeze. However, my core point is that the Human Genome Project is rapidly proving that genes play little part in causing mental illness: the huge differences in prevalence between different countries strongly suggests politico-economic and cultural factors are vital.
There’s a couple of unsourced claims in there – that CBT has no benefit after 18 months, and that the Human Genome Project is disproving genetic theories of mental illness. I’ve been trawling through Google Scholar looking for papers to back up the latter claim and drawing something of a blank.
But what’s really annoying me is James’ assertion that antidepressants are as therapeutic as swallowing chalk, and when Campbell suggests they’ve worked for him, James just dismisses this experience as some sort of anomaly.
Don’t get me wrong. I do think antidepressants are over-prescribed, and often in inappropriate ways. We can all think of examples of this. Somebody is sinking into a reactive depression because he’s lost his job and can’t find another one. He goes to the GP. What he really needs is a new job, but the GP doesn’t have one of those to give, so he gets a packet of fluoxetine instead.
I’m a nurse therapist in CAMHS. Much of my job involves psychological therapies with young people who are low in mood. CBT has its uses, but it’s certainly not a cure-all panacea. I find that systemic and family approaches can often have good effects, as can just good old-fashioned problem-solving and relationship-building. So in that sense I’m partly with James on the limitations of antidepressants and CBT.
But…there are also those times when a young person has sunk so low that the therapy isn’t helping. Often, they can’t even engage with it. Meanwhile their school attendance and grades are going through the floor, they can’t sleep, they can’t eat, they can’t concentrate. At this point one could be slavish to “medication bad, therapy good” and leave the kid to carry on suffering. Or you could offer a trial of a low dose of fluoxetine.
And what happens when we take the latter path? More often than not, they get better, and they get better quickly. As for James’ assertion that antidepressants only offer placebo, and Alistair Campbell is some sort of one-in-a-million exception, I see evidence to the contrary on a regular basis.
It’s the fundamentalism of James’ approach that annoys me. Sure, people with depression often need to make life changes in order to recover, but sometimes they need that chemical boost just to have the energy to do it. Sometimes they need the lift just for therapy to make sense, which leads me to another bugbear I have about “medication vs therapy” arguments. They ignore the fact that the two can sometimes complement each other.
So, what are James’ alternatives to antidepressants and CBT? Mostly he seems to be arguing for structural changes in society to reduce materialism and inequality, and more focus on the wellbeing of children in their early years. I’m fine with both of those, though I doubt that doing so is likely to eradicate mental illness altogether.
And what is he proposing for those adults who still experience mental health problems even after the established of the Glorious Peoples Republic of Oliver James? From his background I’m guessing psychodynamic therapy. While that’s a type of therapy that some people find helpful, it’s arduous, takes a long time and costs a hell of a lot of money for something that by no means guarantees a helpful outcome.
And that’s even before we get into the sheer number of outright quacks working as psychodynamic therapists, particularly in the private sector. Take a look at what happened with this therapist. Does it sound like (a) he was doing a good job of helping people or (b) that the UK Council for Psychotherapy are doing a good job of regulating people like him?
If we really want to say what helps in mental health, there’s a straightforward mantra and it goes like this:
“Some people find medication helpful. Some people find therapy helpful. Some people find medication and therapy helpful. Some people don’t find either helpful.”
Why is that so difficult to understand?
Courtesy of Zarathustra via The World of Mentalists