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Background: Cognitive Behavioural Therapy (CBT) aims to teach people skills to help them self-manage their depression. Trial evidence shows that CBT is an effective treatment for depression and individuals may experience benefits long-term. However, there is little research about individuals’ continued use of CBT skills once treatment has finished. Aims: To explore whether individuals who had attended at least 12 sessions of CBT continued to use and value the CBT skills they had learnt during therapy. Method: Semi-structured interviews were held with participants from the CoBalT trial who had received CBT, approximately 4 years earlier. Interviews were audio-recorded, transcribed and analysed thematically. Results: 20 participants were interviewed. Analysis of the interviews suggested that individuals who viewed CBT as a learning process, at the time of treatment, recalled and used specific skills to manage their depression once treatment had finished. In contrast, individuals who viewed CBT only as an opportunity to talk about their problems did not appear to utilize any of the CBT skills they had been taught and reported struggling to manage their depression once treatment had ended. Conclusions: Our findings suggest individuals may value and use CBT skills if they engage with CBT as a learning opportunity at the time of treatment. Our findings underline the importance of the educational model in CBT and the need to emphasize this to individuals receiving treatment.
Background: Cognitive behaviour therapy (CBT) for patients with treatment-resistant depression (TRD) aims to reframe underlying conditional beliefs that are thought to maintain depression. Aim: To systematically explore conditional beliefs expressed by primary-care based patients with TRD, defined as non-response to at least 6 weeks of antidepressants. Method: Conditional beliefs (stated in an “If. . .then. . .” format) were extracted from a random sample of 50 sets of therapist notes from the CoBalT trial, a large randomized controlled trial of CBT for TRD in primary care. The beliefs were separated into their two constituent parts; the demands (Ifs) and consequences (thens). An approach based on framework analysis provided a systematic way of organizing the data, and identifying key themes. Results: Four main themes emerged from the demand part of the conditional beliefs (Ifs): 1. High standards; 2. Putting others first/needing approval; 3. Coping; and 4. Hiding “true” self. Three main themes emerged from the consequence part of the conditional beliefs (thens): 1. Defectiveness; 2. Responses of others; 3. Control of emotions. Conclusions: Identifying common themes in the conditional beliefs of patients with TRD adds to our clinical understanding of this client group, providing useful information to facilitate the complex process of collaborative case conceptualization and working with conditional beliefs within CBT interventions.
Depression is expensive to treat, but providing ineffective treatment is more expensive. Such is the case for many patients who do not respond to antidepressant medication.
To assess the cost-effectiveness of cognitive–behavioural therapy (CBT) plus usual care for primary care patients with treatment-resistant depression compared with usual care alone.
Economic evaluation at 12 months alongside a randomised controlled trial. Cost-effectiveness assessed using a cost-consequences framework comparing cost to the health and social care provider, patients and society, with a range of outcomes. Cost-utility analysis comparing health and social care costs with quality-adjusted life-years (QALYs).
The mean cost of CBT per participant was £910. The difference in QALY gain between the groups was 0.057, equivalent to 21 days a year of good health. The incremental cost-effectiveness ratio was £14 911 (representing a 74% probability of the intervention being cost-effective at the National Institute of Health and Care Excellence threshold of £20 000 per QALY). Loss of earnings and productivity costs were substantial but there was no evidence of a difference between intervention and control groups.
The addition of CBT to usual care is cost-effective in patients who have not responded to antidepressants. Primary care physicians should therefore be encouraged to refer such individuals for CBT.
Some of the most pressing debates in development studies have concerned the relative merits of states and markets, or the means by which markets might be regulated by a range of public institutions from the local to the global scale. These debates have taken shape, most famously, in the contrasting cases of sub-Saharan Africa and East Asia, and they have an obvious and continuing relevance in countries as diverse as Brazil, Nigeria, India and China. Yet if debate on these issues continues to be fierce, there appears to be general agreement that ‘strong states’ or ‘free markets’ need to be kept in check by vibrant civil societies. Indeed, it is a common proposition in development studies that this hazy zone of ‘freedom’ between the family and the state is a source of unparalleled strength for ordinary men and women, and a source of development itself and even economic growth.
Robert Putman has made this claim as strongly as anyone. His suggestion that economic growth is promoted by a prior build-up of social capital – of people's engagements with a dense network of civic associations – has become a staple of World Bank thinking since the mid-1990s. Even where the causal propositions of Putnam are refused, it is clear that the virtues of civil society are widely admired. Arturo Escobar looks to civil society as a breeding ground for oppositional movements and experiments. It functions for him, and perhaps also for Ashis Nandy in India, as a potential zone of resistance to the dehumanizing claims of developmentalism.
The discipline of development studies does not have a good reputation among students of post-colonialism. Indeed, it is hard to think of two intellectual and political traditions that are further removed. Post-colonial scholars are deeply suspicious of the Eurocentric and depoliticizing instincts of development studies. This is a common thread in the work of Partha Chatterjee, Arturo Escobar and James Ferguson, however much they are divided on the possibility of development ‘itself’. Chatterjee and Ferguson do not fully share Escobar's pessimism about the past fifty years: the age of misdevelopment that supposedly brought about only famine, debts and immiseration. But they do insist that the ambitious plans of the development industry are repeatedly frustrated by structures of power and politics that are opposed to easy talk of citizenship, good governance and benign economic growth.
In the everyday worlds of ‘popular politics’, Chatterjee maintains, deals are struck by poorer people with those who mediate for them in exchanges with the state and governmental agencies. This is the dirty and sometimes dangerous world of political society. For Ferguson, meanwhile, the necessary and repeated failure of development projects to secure their stated aims is linked to the extension of state power over potentially rebellious populations. The development business, and the counterpart discipline of development studies, is neither ineffective nor especially insincere, but its power effects are often profoundly disempowering for poorer people.
Michel Foucault once told an interviewer that it was important to be humble in the face of apparent social irruptions. We should be properly alert, he said, to continuities of history and geography, and not constantly on the look out for markers of ‘the new’ or what today might be called ‘the post-’. This is surely good advice, and we need to bear it in mind when discussing issues like participation and good governance. The idea that states in the past have not been concerned with good government is clearly wrong. The emergence of biopolitics is one strong indicator of the responsibilities that governments are meant to have to their populations. Nevertheless, there is a strong perception in the development community that state failure and bad governance have become important issues since the 1970s, and this perception has been linked to a broader critique of rent-seeking behaviour, simple predation, and dirigiste development.
In the next part of the chapter we review some of the debates that have attended the rise of the good governance agenda. We shall also follow Adrian Leftwich and Rob Jenkins in drawing attention to the ways in which the agendas of good governance can be said to depoliticize accounts of development and rule. They do so, not least, by refusing to pay close attention to questions of state capabilities, and the incapacity of some regimes to secure control over their territories.
In recent years there has been a sea-change in the ways in which the state in India has sought to present itself to its poorest citizens. To listen to leading members of the National Democratic Alliance (NDA) government in 2004 one would think that the year 2000 (or even 2001 or 2002) was something like Ground Zero in this respect. Ministers from leading human development departments were in the habit of swatting away criticism of their ministries on the ground that everything was in flux. In a world of village education committees, citizen scorecards and newly vibrant panchayati raj institutions, not to mention a new era of public–private partnerships, it apparently made no sense to criticize ministers for faults that may or may not have dogged previous administrations.
This was nonsense, of course, for many of the innovations that were being trumpeted by the NDA were first given shape by the Congress and United Front governments of the 1990s, when village education committees and joint forest management were launched with appropriate pomp and fanfare. It would also be unwise to assume that new rhetoric about a kinder and more responsive system of government must correspond in any clear way to the perceptions of poorer or more vulnerable people. All democratic governments are tempted by the fruit of exaggeration, and Partha Chatterjee is right to insist that poorer people in ‘most of the world’ (2004: 3) are very often compelled to meet the state as members of social groups ‘that transgress the strict lines of legality in struggling to live and work’ (Chatterjee 2004: 40).
Special employment and poverty alleviation programmes
(a) Rural self-employment programmes
IRDP Integrated Rural Development Programme
50% centrally sponsored scheme with national coverage since 1980 (1976–80 pilot scheme in selected Blocks). Aims at providing self-employment through acquisition of productive assets and skills through provision of subsidy and bank credit. Targeted at rural BPL population, largely small and marginal farmers, agricultural labourers and rural artisans. Special safeguards for SC/STs, women, physically handicapped; priority to assignees of ceiling surplus land, Green Card holders under Family Welfare Programme and freed bonded labourers. Performance during Eighth Plan: total allocation (Centre and State) = Rs. 5,048 crores; 108 lakh families covered.
TRYSEM Training of Rural Youth for Self-Employment
50% centrally sponsored facilitating component of IRDP since 1979. Aims at providing basic technical and managerial skills through training. Targeted at rural BPL population between 18 and 35 years. Special safeguards for SC/STs and others, like IRDP. Performance during Eighth Plan: total allocation (Centre and State) = Rs. 370 crores; 15 lakh youth trained.
DWCRA Development of Women and Children in Rural Areas
Sub-scheme of IRDP started in 1982–3 on pilot basis, later extended to all Districts. Aims at improving living conditions of women and, thereby, of children by promoting women's income-generation activities through self-help groups and providing access to basic social services. Targeted at groups of 10 to 15 women among BPL families. 50% to SC/STs. Performance during Eighth Plan: total allocation (Centre and State) = Rs. 190 crores; 1.9 lakh groups formed; 30 lakh beneficiaries.
What follows is a report on the 1999 parliamentary election in Hajipur, Vaishali, that was written for the research team by our co-worker, Vishwaranjan Raju. Many of the themes that Vishwaranjan teases out here (gender issues, the relationship of local and national political figures, the temporary ‘stopping’ of the development state) are not specific to Hajipur. Several of them can be observed in elections in West Bengal, for example. Nor should we assume that the everyday qualities of political life in a District are captured in extremis by the events that occur at election time. This report should rather be read as a complementary piece to the accounts of political society in Vaishali that we built up in part II of the book.
For the record, the parliamentary seat of Hajipur was won in 1999 by Ram Vilas Paswan for the Janata Dal (United). The Janata Dal (United) was part of the BJP-led National Democratic Alliance which swept to power in New Delhi. Ram Vilas Paswan had won the seat in 1998 for the Janata Dal. At this point he was an ally of Laloo Yadav. The runner-up in the 1999 elections was Ramai Ram for the Rashtriya Janata Dal. Ramai Ram would have been required to resign his position as an MLA and State Minister in the government of Bihar had he won the parliamentary seat of Hajipur. Ram Sunder Das was placed third (in 1998 he took second place for the Samajwadi Janata Party (Rashtriya)).
We have said that one aim of this book is to consider how differently placed men and women see the state in rural India. Some of these individuals will be employees of the state, or external advisers to the Government of India and its constituent states and Union territories, although many more will be farmers or labourers. Some will be political fixers and members of the Backward Classes, while others will be farmers, Class IV government servants and adivasis at the same time. But what does it mean to talk about ‘seeing the state’?
We are used to the idea of the state seeing its population or citizenry. Visuality is at the heart of many theories of power and governmentality. Michel Foucault, most notably, has shown how the birth of modern forms of education and welfare provision corresponds to the emergence of biopolitics as a ‘form of politics entailing the administration of the processes of life of populations’ (Dean 1999: 98). Populations emerge when changes in working practices give rise to economic government and the discipline of political economy, and they get bounded by new exercises in mapping and measurement, including the production of censuses, cadastral surveys and expeditions. Biopolitics then refers to those government interventions that seek to improve the quality of a population as a whole, and these procedures produce that which we name the state as the effect of these interventions.