Positive Health Online

Happiness, Richard Layard 2005; London: Penguin

The Depression Report: A New Deal for Anxiety and Depression Disorders 2006, Bell, S., Knapp, M., Layard, R., Meacher, Priebe, S., Thornicroft, G., Turnberg, Wright, B.; London: Mental Health Policy Group, Centre for Economic Performance, London School of Economics

Thrive: The Power of Evidence-Based Psychological Therapies 2014 Richard Layard & David Clark

On arriving at a conference on ‘Happiness’, we were greeted by a number of smiling people, each carrying a placard announcing “Get Free Hugs Here!”. Over two days we were repeatedly informed that there was now a Science of Happiness which had discovered what made people happy and that one could learn skills to do this. The scientific discovery behind the offer of a free hug was that happy people tend to have more physical contact than unhappy ones.

Dr Seligman and Learned Helplessness Experiment

Dr Seligman’s – Photo credit: D. Myles Cullen – learned helplessness experiments with dogs. Courtesy Wikipedia

The father of this new Science was Martin Seligman, onetime president of the powerful American Psychological Association. He gave electric shocks to dogs in situations that they were unable to escape from, until they gave up. These dogs were then shocked in situations that they could escape from, but they did not try to escape. They had now “learned helplessness”. Seligman went on to correlate learnt helplessness with Depression, which he characterized as the opposite of Happiness.

The Happiness ethos has found favour not only with those involved in the ‘Health’ industry, but also organizations globally. Journalists, universities, GPs and politicians all refer to it and its sister discipline – Cognitive Behavioural Therapy (CBT) – as established scientific fact.

What’s not to like about a movement that advocates that one’s happiness is at least, if not more, important than money?

This good news message was introduced into the UK about fifteen years ago by an economist who was a part of the inner circle of the Labour Party, Richard Layard (now a Lord) with the publication of his hugely successful book, Happiness. The following year Layard and a number of powerful patrons published The Depression Report: A New Deal for Anxiety and Depression Disorders which called on the Labour government of the day to change its social policy towards mental health. They succeeded to such an extraordinary degree that today, the psychotherapeutic landscape in the UK is almost unrecognizable from what it was.

To coincide with the tenth anniversary of this revolution, Layard with David Clark (one of the nine authors of The Depression Report) published a new book, Thrive: The Power of Evidence-Based Psychological Therapies, in which like victorious generals, they rehearse their rationales first put forward in Happiness and The Depression Report, and then look back at the successes of their campaign strategy called IAPT (Increasing Access to Psychological Therapies). Their intention had been to train 10,000 new practitioners of Cognitive Behavioural Therapy (CBT), and to convince mental health commissioners that this is the therapy that they should make available to the general public. In this, they have largely succeeded. Today, CBT is almost the only form of therapy available in the NHS.

Layard is an economist; he is neither psychologist nor moral philosopher. Despite this, his primary agenda for the nation has been a moral one, to increase the happiness levels of the nation; the moral theory that he grounds his reasoning in, is Bentham’s Utilitarianism. His secondary agenda is a psychological one, to promulgate the practice of CBT, as this is (allegedly) the scientifically proven psychological means to achieve the moral end of happiness.

Layard and Clark tell us that the feeling of happiness, which hitherto had languished in the mire of subjectivity, had recently been shown to have an objective reality by virtue of the fact that brain scans are able to show that the brain ‘lights up’ when people report feeling happy. Because of this, happiness is now ‘objective’, and so it becomes possible to study it scientifically. This requires that it be made measurable and quantifiable. This is managed by asking a person to state, on a scale of one to ten, how happy they feel. It is this numerical answer that transmutes the subjective experience of happiness into an apparently objective one.

Layard says: “for some people it seems impossible to be positive without some physical help. Until fifty years ago there was no effective treatment for mental illness” (Layard, 2005, p.9).

Almost all the difficulties with the Happiness/CBT theses are encapsulated in these two sentences. First is the implication that your primary state of mind ought to be mainly that of positivity; and if it is not, then there is something wrong with you. Second, what is wrong with you is that you are suffering from a mental illness. In other words, unhappiness is the symptom of a disease called mental illness.

The Depression Report claimed that one in six of the population will be diagnosed as having a mental disorder, and that “evidence-based psychological therapies” are capable of lifting at least half this number out of their suffering. ‘The most developed of these therapies is cognitive behaviour therapy’ (Bell et al, 2006, p.1). They tell us that “someone on Incapacity Benefit costs us £750 a month in extra benefits and lost taxes. If the person works just a month more as a result of the treatment, the treatment pays for itself….we…have a solution that can improve the lives of millions of families, and cost the taxpayer nothing” (Bell et al, 2006, p.1; italics added). They promised the exchequer even more – claiming that it would get in an additional twelve million pounds a year through taxes being paid by the newly employed as well as a reduction in ‘Benefits’ being paid out to the unemployed. It would receive this with an investment of just over half a billion a year to set up and run the service.

The ‘mental disorders’ referred to by Layard and Clark are a small handful drawn from the Diagnostic Statistical Manual. Layard and Clark make no mention of the fact that despite the authority invested in the DSM by mainstream psychiatry, its scientific credibility remains deeply problematic. It is still the case that when two psychiatrists are presented with the same individual, they are quite likely to end up with different diagnoses despite both of them sticking to the protocols in the DSM (Spiegel, 2005: 57).

Layard and Clark employ diagnostic categories as though there were no controversy over them. Instead they blandly assert that the science of CBT “is the same scientific model that is applied to solving any problem, be it social, psychological, biological or mechanical” (Layard & Clark, 2014, p.35).

Contra wise, many would argue that to apply the same scientific model to mechanical problems as well as the problems of human life, is to construe human problems in reductive mechanistic terms. Wittgenstein, and before him Kant, both cautioned against falling into this error by drawing attention to the distinction between cause and reason. Kant argued that it is acceptable to think that events in the inanimate world are determined by prior causes (the blue billiard ball has caused the red one to move by striking it). If we thought of human action in mechanical deterministic terms, then we would not have to take any responsibility for our actions, which would simply be the effects of some prior cause. To understand humans, we have to look to reasons, not causes. All of which is to say that humans are fundamentally unpredictable, because of their capacity to think. Humans live in world of meanings.

At first glance, Layard and Clark seem to advocate something very similar: “As the Stoics pointed out, what disturbs us is not what happens to us but how we react to it. Buddha said much the same thing. The aim is to achieve control over your thoughts, and in this way to achieve control over your life” (Layard & Clark, 2014, p.121).

But the ways of achieving control is not that of self-reflection (which would involve reason and meaning); rather it consists of learning a number of skills and techniques of thought-control through which it is possible to “directly address our bad feelings and replace them by positive feelings”  (Layard, 2005, p.188).

In line with the general ethos of CBT, Layard and Clark make it a point of virtue to insist that they are not interested in figuring out the reasons as to why you might be distressed or depressed, only in how the problem (your distress) is being maintained in the present. Depression and anxiety have no more meaning than malaria or cancer. It is not “necessary to know what caused the cancer – you cure it by cutting it out…Similarly, infections are often cured with antibiotics, without knowing their causes”  (Layard & Clark, 2014, p.109).

Mental Disorders are said to arise out of a mix of two causes – bad genes and thought malfunctions consisting of habituated errors of thinking. In order to deal with the organic side of things, Layard and Clark advocate psychiatric medication, which they also present as unproblematic and side effect free. The treatment for the psychological side of things is CBT. CBT begins with the insight that ‘our thoughts affect our feelings’. It follows then that you can change your feeling state by changing your thoughts about your perception about your situation; after all, “thoughts are not facts” Layard and Clark tell us. CBT consists of teaching a depressed person a set of skills through which they learn “to question their negative thoughts and to replace them with more realistic thoughts” (Layard & Clark, 2014, p.134). The result: “we can train ourselves in the skills of being happy” (Layard, 2005, p.189).

This involves taking control of our inner lives, in the same way that we have (apparently) already taken control of the material world: “Human beings have largely conquered nature, but they have still to conquer themselves” (Layard, 2005, p.9). The internal region to be conquered is where unhappiness holds sway: “By happiness I mean feeling good – enjoying life and wanting the feeling to be maintained. By unhappiness I mean feeling bad and wishing things were different” (Layard, 2005, p.12). The relationship between happiness and unhappiness turns out to be a simple binary either/or one: “Happiness is a single dimension of experience…it is not possible to be happy and unhappy at the same time” (Layard, 2005, p.21). Here, there is no room for ambiguity and ambivalence; and if it should be found to exist, then it must be due to ‘thought error’. You are either happy or unhappy. Apparently, you “cannot have positive and negative feelings at the same time” (Layard, 2005, p.189). The solution therefore is simple: learn techniques and skills that will enable you to click your mind from one state into another, because “happiness begins where unhappiness ends” (Layard, 2005, p.13).

Treatments consist of monitoring your thoughts closely, questioning the beliefs behind them, and discarding the thoughts that are found to be exaggerated and unrealistic.. Here are a couple of not unusual examples.

The press release for a paper published in four star journal The Lancet  (Wiles et al., 2013) claimed that “The findings demonstrate that CBT provided in addition to usual care including antidepressant medication is an effective treatment that reduces depressive symptoms, and improves the quality of life”. Note the use of the word “effective”. One does not have to look too closely at the figures to discover that just 23% the group receiving CBT did better than those who did not. Further, even the 23% were by no means cured of their depression; rather their symptoms of depression were reduced by about 50%. So the ‘results’ of the study actually ought to be announced in this way: “About two out of ten people came to feel somewhat better because of having received CBT; however, although better, they are still depressed, only less depressed. It is also the case that eight out of ten people will not be helped by this treatment”.

CBT has morphed over the years and currently is into its ‘third wave’ which include ‘softer’ notions such as Mindfulness and Compassion. Despite the softer notions, the treatment still consists of learning various forms of mind-control. In 2000 a highly regarded research paper purporting to demonstrate the efficacy of Mindfulness Based Cognitive Therapy (MBCT) was published (Teasdale et al, 2000). It was boldly entitled Prevention of Relapse/Recurrence in Major Depression by Mindfulness-Based Cognitive Therapy. ‘Prevention’ suggests that the treatment will halt the recurrence of major depression, which is exactly what the abstract proudly claims: “MBCT offers a promising cost-efficient psychological approach to preventing relapse/recurrence in recovered recurrently depressed patients” (p.615).

What they actually found after a year, was that 53 out of the 71 people (44%) in the MBCT group relapsed over the period of the study, and 38 out of 66 (58%) in the Treatment As Usual (TAU) group relapsed. But by cherry picking through the data they found that a group of people who had a) had depression on three previous occasions, and had b) had recovered from it each time, and c) were not currently depressed (of which there were 55), did much better than the rest. This is the figure they highlight and use in their statistical calculation, to say that there is “a 39% reduction in risk of relapse/recurrence in the MBCT condition”. A paragraph or two later this is amplified into: “for participants with three or more previous episodes of depression…MBCT almost halved relapse/recurrence rates”. On the MBCT website the claim is further inflated to half, that is 50%. Further, the 39% is the change relative to the starting condition, it is not the absolute change, which is in fact 25%. What this means is clarified by the situation in which one buys an additional lottery ticket. The chances of winning can be said to have increased by 100%, based on the starting condition of one ticket (the relative increase); in absolute terms the chances have improved from one out of fourteen million to two. Also note: in no way can the treatment be said to be a preventative. All the study has managed to demonstrate is that MBCT has reduced the likelihood of relapse of a quarter of those who had previously experienced and recovered from depression at least three times.

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A number of epidemiological studies, for example The Spirit Level, have demonstrated that the ills of a country (illness, crime, etc.) are directly correlated with the degree of inequality in the nation (the UK and USA being top of the list with Japan and the Nordic countries at the bottom). The solution to this you might think, would be to address the inequality and work towards a more egalitarian society. The CBT and Layardian solution is to adjust the individual’s experience of the inequality.

If happiness depends on the gap between your perceived reality and your prior aspiration, cognitive therapy deals mainly with the perception of reality.

(Layard, 2005, p.197; italics added)

The problem is not reality per se, but your perception of reality. The problem is relocated from that social inequality to our psychology: this being our unfortunate tendency to compare ourselves with others. This problem can be solved quite simply

We constantly distort our perception of reality by unhelpful comparisons. So one “secret of happiness” is to enjoy things as they are without comparing them with anything better.

(Layard, 2005, p.49)

Layard muses on the question: why it is that women continue to complain about their lot, even though their absolute situation in terms of status and salary has improved considerably over the last decades?

Women, whose pay and opportunities have improved considerably relative to men, but whose level of happiness has not…perhaps women now compare themselves more directly with the men than they used to and therefore focus more than before on the gaps that still exist.

(Layard, 2005, p.45)

If only women would stop focussing on the gap, they would surely be happier. The trouble though is that “People compare themselves…with people close to themselves…[their] ‘reference group’”. This is used by Layard to explain why the rich tend to be happier than the poor, and it is not because the rich have more resources to pursue and fulfil their desires.

The solution to the problem of inequality then, according to Layard, is that we should just stop comparing: “one ‘secret of happiness’ is to enjoy things are they are without comparing them with anything better” (Layard, 2005, p.53). And if you can't hold back from comparing, then you can fall back on another strategy “ignore the comparisons with people who are more successful that you are; always compare downward, not upwards” (Layard, 2005, p.47).

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The CBT model of mind as well as human life is not only linear; it is entirely rationalist. CBT stands and falls on the premise that it is possible to use thought to control one’s emotional life, and that it is reasonable to expect that a person ought to be able to do so. If you cannot control your emotional life, it is because you are suffering from a mental disorder. CBT will teach you how to control your thoughts as well as your emotions.

But by its own account, CBT is only able to be of benefit to about half of those it treats – but this figure is based on the afore mentioned relative change, not the absolute, which turns out to be in the region of 25%. But the actual figures are much worse, because as Teasdale himself says “Relapse and recurrence following successful treatment of major depressive disorder (MDD) is common and often carries massive social cost (Teasdale et al, 2000:615)”. We are in the land of double speak. Is the term ‘recover’ the appropriate one given that relapse is ‘common’?

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Given that Layard’s main ambition is in the moral sphere, how does it stand up to scrutiny?  Layard uses Utilitarian arithmetic to resolve any moral predicament he might find himself in. For example,

I…promised to attend my daughter’s play, but my mother is taken to hospital. How should I use my time?...  Obviously I should figure out whose feelings would be most hurt if I did not come. That is the Benthamite solution.

(Layard, 2005, p.116)

What of the possibility that the right moral decision might well be the more hurtful one? And how is one to calculate “whose feelings would be most hurt”.

In Layard’s universe all moral dilemmas are easily resolved by the arithmetic of happiness. On this basis he makes a number of moralistic assertions as though they were self-evident facts; for example:

There may be a conflict between the rules. If a Nazi Stormtrooper asks us where we think a Jew is hiding, we should surely invent a plausible lie.

(Layard, 2005, p.124; italics added)

Layard is able to be so ‘sure’ because he has positioned himself ‘outside the system’ and so is untouched by any consequences of his actions. If Layard were a German citizen at that time, would he have had the courage to protect the Jew by lying to the Stormtrooper? If the lie was found out, he and his loved ones would have found themselves delivered into one of the death camps, as was the case with many a German who stood against the Nazis. Would I have the courage? There is no ‘surely’ here for me.

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We are in the midst of another pandemic – that of medicalizing the difficulties of ordinary human life - calling them mental illnesses. Layard and Clark blithely talk about the increasing numbers of children being diagnosed with mental disorders like “Oppositional Defiant Disorder”, “Conduct Disorder” and “Attention Deficit Hyperactivity Disorder (ADHD)”. They do not ask any questions about why the ‘disorders’ are increasing (Whittaker, 2011). Nor are they troubled by the fact that these children are being medicated into passivity and submission – instead, they applaud medication as successful treatment. Surely being “oppositional” and “defiant” is part of the job description of being a child. I don’t doubt that many children are indeed troubled and are suffering. But there is a real question about whether this is because they are mentally ill or whether it is a response to the circumstances of their lives, or whether the trend is being driven by the pharmaceutical industry in collusion with sections of the psychiatric community (Goldacre 2012).

What Layard and Clark would have us do is to “inoculate … [children] with the capacity to resist mental illness throughout their lives” (Layard & Clark, 2014, p.224). Unsurprisingly the ‘inoculation’ consists of CBT treatment: “the best programmes are ‘manualized’ – there is a manual which gives detailed guidance to the teacher” (Layard & Clark, 2014, p.224). All the teacher needs to do is to follow instructions from the manual – and so they don’t need to go through onerous psychotherapy trainings.

Most worryingly, the UK government of the day has tried to make CBT compulsory for the unemployed, as a condition of receiving benefits. In pursuing this course, the government is merely pursuing the promise that was given in The Depression Report, that a course of CBT would cure the unemployed of the mental illness that prevented them from working.

Finally, let me return to the offer of free hugs that I touched on at the beginning of this piece. Happiness researchers have noticed that happy people have more physical contact than unhappy ones. They think that they can reverse engineer this correlation; they think that increased physical contact will lead to a state of happiness. This is akin to noticing that happy dogs wag their tails, and then presuming that teaching unhappy dogs to wag their tails will make them happy.

The offer of free hugs is born out of exactly this kind of error. A hug is no abstraction. I do not feel better for hugging anonymous strangers; when I hug, it is an expression of tenderness towards another; it is a form of giving. Instrumentalized hugs are in the service of making myself feel better, and so it is a form of taking.

CBT is not entirely without virtue, and in a sense the problem is not with CBT itself, but the hype that surrounds it and the use it is put to further specific ideological, professional and political agendas. In its original avatar, the scope of CBT was limited. Its technology was developed to help people recover from phobias, obsessive behaviours, and the like. In this it succeeds very well, and in these areas it is very often the ‘treatment of choice’. Problems became apparent when CBT’s ambitions expanded to colonize all forms of psychological suffering and its claim that it is the only answer to that suffering.

References and Further Reading

Spiegel, A. (2005). ‘The Dictionary of Disorder: How one man revolutionized Psychiatry’, The New Yorker , 3 January, available at www.newyorker.com/magazine/2005/01/03/ the-dictionary-of-disorder.

Wiles, N., Thomas, L., Ridgway, L., Turner, N., Campbell, J., Garland, A., Hollinghurst, S., Jerrom, B., Kessler, D., Kuyken, W., Morrison, J., Turner, K., Williams, C., Peters, T. and Lewis, G. (2013). ‘Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care-based patients with treatment resistant depression: results of the CoBalT randomised controlled trial’, The Lancet, 381: 375–84.

Teasdale, J.D., Williams, J.M.G., Soulsby, J.M., Segal, Z.V., Ridgeway, V.A., Lau, M.A. (2000). ‘Prevention of Relapse/Recurrence in Major Depression by Mindfulness-Based Cognitive Therapy’. Journal of Consulting and Clinical Psychology. Vol. 68, No. 4, 615-623.

Whittaker, R. (2011) Anatomy of an Epidemic  New York: Broadway Books.

Goldacre, B. (2102) Bad Pharma London: Fourth Estate.

Dalal Farhad. CBT: The Cognitive Behavioural Tsunami - Managerialism, Politics and the Corruptions of Science. Routledge. 2018.  ISBN 1782206647. Available from Amazon.co.uk and Amazon.com