Impact in Qualitative Research: Mikkel Kenni Bruun on the unintended effects of ‘evidence-based’ practice in NHS Talking Therapies

two women sitting across from each other with hands folded in their laps

Dr Mikkel Kenni Bruun is a social anthropologist working on various aspects of mental healthcare in the UK. He has conducted long-term ethnographic research on NHS Talking Therapies and evidence-based psychotherapy. He is part of the SAMCOM project at King’s College London which examines surveillance practices in Europe. Bruun’s most recent research looks at how people engage in different forms of self-monitoring in everyday contexts of care, from fitness to mindfulness.

As an anthropologist, I approach mental health practices in Britain as I would approach other healing practices encountered elsewhere in the world – practices that might appear ‘strange’ or ‘alternative’ from the perspective of European medicine and psychology. Our therapeutic practices and ideas about bodies and minds are ‘strange’ in their own ways – what anthropologists call ethnographically interesting – compared to other, more culturally distant, notions of what it means to be human. However, by deliberately rendering our theories and practices strange, I do not mean to imply a lack of commitment to their scientific salience and persuasiveness. This is just a general anthropological approach through which we can examine some of the ambitions and problems that have shaped ‘talking therapies’, including notions of mental health more broadly (Bruun 2023a).

‘Evidence’ is a matter of concern in many healthcare systems. The rise of evidence-based medicine (EBM) in the 1990s had a profound influence on understandings of evidence-making. EBM has been described as a methodological framework for assessing the effectiveness of interventions, with the randomised control trial (RCT) as the hallmark of evidence in biomedicine (Timmermans and Berg, 2003; Lambert, 2006). But when we move into the world of psychotherapy, what is deemed evidence-based, and why, are questions that are not at all self-evident.

Psychotherapy has not always found it easy to comply with a positivist formulation of evidence-making. More recently, however, NHS Talking Therapies (formerly IAPT/Improving Access to Psychological Therapies) has helped establish a field of psychotherapeutics amenable to the scientific conventions of EBM. In particular, Cognitive Behavioural Therapy (CBT) and Mindfulness-Based Cognitive Therapy (MBCT or Mindfulness) have become the benchmark for evidence-based talking therapy due to the highly standardised, manualised, and quantifiable frameworks within which these interventions are delivered. CBT and Mindfulness have received broad scientific recognition as a result, which has been quite an achievement.

Where are we now?

Evidence is still an important but not unproblematic category that has taken on new life in the NHS and beyond (Goldenberg, 2006). I have argued elsewhere that IAPT has effected an elision of notions of evidence with practices of monitoring (Bruun 2023b). Therapists have situated evidence-based practice in the ambitions – and constraints – of a ‘medical model’ of treatment. Many now feel that they are working within a ‘factory of therapy’ where care is recast in the service of outcome measures:

IAPT was trying to counter the imbalance of all the resources that were being ploughed into physical healthcare and the neglect of mental healthcare in the NHS. In that sense, the initiative of IAPT is good. But IAPT is becoming more about monitoring a service than providing therapeutic care. (Therapist ‘Alex’, in Bruun 2023b)

Some of the excitement that an evidence-based approach to psychotherapy has generated, can seem uncritically accepting of the principles of EBM. It is not always clear what exactly counts as evidence – and how it counts – when it comes to psychotherapeutic care and relations (see e.g. Chambless and Ollendick, 2001; Berg and Slaattelid, 2017).

Evidence-based psychotherapy has often been presented as a case of simply applying to psychological therapies the measures and methods of testing drawn from EBM. Psychotherapy, it is argued, needs to be on an equal empirical footing with biomedicine (cf. Layard and Clark 2014). It is an appealing and reasonable aim. But the anthropologist might want to point out that rendering psychotherapy into a quantifiable object as if it was a test drug (RCTs were designed to test medication, not therapeutic relations), is very much part of the problem. The scientific persuasions of NHS Talking Therapies have made psychotherapy conceivable and workable in particular ways. However, the service has also made practitioners flounder in the face of obvious tension between the drive for measurable outcomes and psychotherapeutic efforts to care for people:

 [NHS Talking Therapies] doesn’t leave a lot of space for people to be human: to be contradictory and complex beings.
(Therapist ‘Paola’, in Bruun 2023b)

The language of evidence-based therapy is powerful and important. But its scientific securities are not always self-evident and a sanctimonious reliance on EBM might leave us less empirically grounded. An anthropological perspective on evidence-based therapy is therefore not one that criticises NHS Talking Therapies for its concern for ‘evidence’ nor one that eschews scientific rigour. On the contrary, it suggests that evidence-based conventions are neither rigorous enough nor as empirical as they might believe.