Thrive explores the new effective solutions to the misery and injustice caused by mental illness. It describes how successful psychological treatments have been developed and explains what works best for whom. It also urges us to do all we can to prevent these problems in the first place, through better schools and a better society. Marion Koob reviews, writing that this is a crucial and necessary book, especially for those who know little about mental illness

Koob, Marion

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23/06/2015Book Review: Thrive: The Power of Evidence-BasedPsychological Therapiesblogs.lse.ac.uk /lsereviewofbooks/2015/06/23/book-review-thrive-the-power-of-evidence-based-psychological-therapies/Thrive explores the new effective solutions to the misery and injustice caused by mental illness. Itdescribes how successful psychological treatments have been developed and explains what works best for whom. Italso urges us to do all we can to prevent these problems in the first place, through better schools and a bettersociety. Marion Koob reviews, writing that this is a crucial and necessary book, especially for those who know littleabout mental illness.Thrive: The Power of Evidence-Based Psychological Therapies.Richard Layard and David M. Clark. Penguin. 2014.Mental illness is a hidden blight. Neglected throughout the world, it isan endless source of discrimination. While the majority of its sufferersgo untreated, those that do ultimately get medical care receive it afteryear-long delays, or are handed inappropriate treatments.This is why Thrive, by Richard Layard and David M. Clark, is a crucialand necessary book. The authors give a chilling overview of the paucityof mental healthcare in the western world. Focusing on depression,anxiety disorders and conduct disorders in children, they seek topersuade their readers of their widespread extent, and of theeffectiveness of existing solutions.Layard is a prominent labour economist, member of the House Lords,and author of the book Happiness. Clark is Professor of Psychology atOxford, and is a world expert on Cognitive Behavioural Therapy.These ailments appear to be effectively treated with psychologicaltherapies. However, Layard and Clark argue that many are unaware ofthe the wide range of evidence-based therapy now available. Theauthors go on to demonstrate that improved provision of therapy is notonly a humanitarian imperative: it also makes economic sense. Thebook includes an evaluation of the United Kingdom’s Improved Access to Psychological Therapies (IAPT), whichbegan in 2008 (the authors lobbied for its implementation). Thrive concludes with suggestions as to which societalbehaviours and aspirations could prevent the prevalence of mental illness and be conducive to a happier population.Thrive is very much an advocacy book seeking to effect policy change. In this respect its release is timely; distantenough from IAPT’s beginnings to offer an evaluation, and published ahead of the 2015 UK General Elections. Theissue has generated some attention in the media, whether in the form of petitions or comment pieces. What’s more,the authors present new inroads into diseases which were previously difficult to treat.Compared to physical illnesses, mental disorders are woefully under-treated, principally thanks to the lack of suitablepsychological therapy. In Chapter 4, entitled Do they get help?, Layard and Clark note that while 90 per cent ofpeople with diabetes are supplied with healthcare, in the UK, US and continental Europe, less than a third of thosewith mental illness are treated. In low and middle income countries, this drops below 10 per cent. In the US, two-thirds of primary care physicians say they cannot get outpatient services for people with mental health problems,while in the UK, only 15 per cent of GPs who responded said that they could obtain the adult services they need.1/3Worse, in the US, people who do ultimately receive care for their mental health issues face incomprehensible delaysin accessing it. On average, this translates to a wait of sixteen years for social phobia; nine for generalised anxiety;and eight for depression. Only 28 per cent of suicides in Britain had been in contact with mental services during theprevious twelve months.Instead of therapy, individuals are offered pills. As medication is more readily available, and is used to treat otherdiseases, it is better understood. What’s more, medication is produced by drug companies, who are effectivelobbyists. In contrast, there is no forceful lobby for psychological therapy. Unlike most physical troubles, mentalillness is a subject of stigma. Victims and their families are more likely to be ashamed and thus less insistent that thedoctor find a solution. Misperceptions regarding available treatments contribute to this, as many people believe thatmental illness is untreatable. When the public believes there is no solution, Layard and Clark argue, issues tend tobe avoided, thus reinforcing the victims’ shame.Image Credit: TaxCredits.net, Flickr. CC-BY-2.0.Who then is to blame? Clark and Layard decry those who fund the provision of psychological therapy, that is to say,the commissioners of the National Health Service in the UK, or in the US and many other countries, the rules ofinsurers.In Chapter 11, Can we afford more therapy?, the authors go on to assert the cost efficiency of providing adequatetreatment. ‘Can we afford it?’, budget-anxious politicians and administrators alike will ask. With mental healthcare,investing in further provision would cost nothing. Yet, they remark that this question isn’t considered when it comesdown to physical illnesses.Investing in psychological therapies, would, the authors argue, generate large savings in welfare. Unlike physicalillness, mental illness is a problem of people in their working age. Treating sufferers on unemployment benefitscould give them the ability to successfully job search. According to modest estimates, which are backed up withexact numbers, providing such care would generate savings by putting people back in employment. There existsprevious evidence of this: in a randomised trial with a sample size of 300, 34 per cent of those who received a givenCBT treatment (over seven weeks, in three hour long sessions) were back in employment after four months. Out ofthose who had received generalised sessions of social support, only 13 per cent had found a job.The second source of savings would come from physical healthcare. Those with mental health problems generatemore costs in physical healthcare than those with comparable diseases. People with chronic physical illnessaccount for 70 per cent of all healthcare costs in Britain, and those of them who are mentally ill cost some 50 percent more than other patients with the same physical condition and at the same level of severity.2/3Here, evidence also suggests that these savings could be significant. In 1997, Britain’s national centre for angina, acoronary heart disease, introduced a short behavioural programme. It consisted of two 2-hour interviews eightweeks apart, with two consultants, plus stress-management advice, relaxation tapes, self-help manuals and gradedexercise. In the year after taking this programme, patients spent 33 per cent fewer days in hospital than the yearbefore, fewer of them died, and the total saving in cost per patient was £2,000. Layard and Clark underline thatsimilar results in savings to pay for treatments have since then occurred through the IAPT.Throughout the book, Layard and Clark posit an effective and well-backed case for the need of further psychologicaltherapy, and a change of mindset regarding mental health.However, the book suffers from a few minor flaws. While its economic argument is persuasive, it is a worryingreflection of our society that it should need to be made in the first place. If we aim to come to regard mental illnessas equally grave and deserving of attention as physical illness, does justifying on the basis of a low cost not riskbeing detrimental? Layard and Clark are responding to the realities of policy-making when arguing their case, but itseems like their humanitarian argument should have been at least as equally fleshed out as that of the economic.In addition, the book’s focus on building a case allows the authors to set aside unanswered questions. It would havebeen interesting, for instance, to hear their thoughts as to why the success rates of the best therapies are only 50-60per cent, or why provision of effective care has lagged so far behind the time of its initial discovery.Finally, Thrive also lets its readers down with the production of its graphics, most of which are either not labelledclearly or understandable. For a work seeking to persuade through force of evidence, it is rather frustrating to not beable to check the authors’ arguments against the tables which they reference.In the last chapters of the book, Layard and Clark maintain that a society focused on improving relationships andcreating happiness, rather than increasing GDP and income, would better thrive. It is a radical change from thecurrent mindset, and when reading the numbers one can’t help but think that they’re likely right. Their book is animportant work, and would be valuable for anyone to read, especially those who know little about mental health.__________________________________________________________________Marion Koob has a BSc in Government and Economics at the LSE and and MPhil in International Relations at theUniversity of Cambridge. She has worked in Polis, the LSE’s journalism think-tank, and is now at the British FilmInstitute.Authors David M. Clark and Richard Layard gave a public lecture about their book at the LSE; you can listen here .Copyright 2013 LSE Review of Books3/3

Book review: thrive: the power of evidence-based psychological therapies

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