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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.
Eight ring-ditches and several stretches of pit alignment have been excavated between 1981 and 1985, as part of the investigation of an extensive cropmark complex on a gravel terrace in the Upper Severn valley at Four Crosses, northern Powys. Excavation of the ring-ditches, which form part of a more scattered barrow cemetery, has revealed a long and complex pattern of development of barrow types and burial forms in the period between the Middle Neolithic and the Middle Bronze Age. This is compared with the recently published sequence from the neighbouring upland barrow cemetery at Trelystan, and subdivided into four hypothetical phases. There is evidence of activity in the vicinity of some of the sites in the Iron Age, Romano-British, and possibly the early post-Roman period.
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.
James Ferguson ends his account of The Anti-Politics Machine with a useful and very honest Epilogue which addresses the question ‘What is to be done?’ In the course of his discussion he makes a number of points that we find helpful. In particular, he warns against a form of romanticism that would turn the fieldworker into a hero or social activist. The truth is that most of us should not expect to make a difference. Social change is most often made slowly and in a non-linear fashion by the men and women who become the subjects of social science. Ferguson quotes Foucault to bolster this argument. ‘As Foucault remarked of the prisons, when the system is transformed, “it won't be because a plan of reform has found its way into the heads of the social workers; it will be when those who have to do with that … reality, all those people, have come into collision with each other and with themselves, run into dead-ends, problems and impossibilities, been through conflicts and confrontations; when critique has been played out in the real, not when reformers have realized their ideas”’ (Foucault 1981: 13, quoted in Ferguson 1990: 281). This view is largely consistent with the arguments we have developed here, although we would want to signal more clearly than Foucault the role that directed change can make, particularly when it is being pressed by the wealthy and the powerful.
The idea that ordinary people should have a say in the ways in which government programmes in the United Kingdom are run on their behalf is so well established that it has become a commonplace. Parents there have long been afforded some of the rights of scrutiny and decision-making which are now being extended to parents in rural Bihar through Village Education Committees. In principle, too, they are able to exercise some control over local planning and budgetary decisions through their participation in local government elections – again, just as in India. We know, however, from the UK and other richer countries, that turnout rates in local elections are often quite dismal, and that the democratic process can be undermined by backdoor deals with commercial interests, including property developers. It would be odd, then, if we didn't expect similar patterns of disinterest, subversion, and/or elite capture to hold in rural India. And yet even a cursory reading of some of the more ebullient texts of the Government of India, or of development agencies like DFID or the World Bank, suggests that such recognition is often played down or is simply missing. ‘Participation’, according to Bill Cooke and Uma Kothari, is threatening to become a ‘new tyranny’. It is a discourse that wishes away conflicts of interest and power, and which promises the poor not just direct sightings of the state but powers of oversight as well.
In this part of the book we draw on fieldwork in Bihar, Jharkhand and West Bengal to comment in more detail on how different actors come to see and engage the state in eastern India. chapters 4–6 offer different and yet complementary takes on what is necessarily an interlocking set of issues. In chapter 4 we consider why and how (and if) people participate in a range of ‘development’ schemes, including the Employment Assurance Scheme and Village Education Committees. These schemes make important assumptions about the construction of citizenship and civil society in rural India. In chapter 5 we direct our attention to the career paths of various government servants, and to the ways in which they construct working lives and practices that may or may not agree with the agendas of good governance now being promoted by New Delhi and the international development institutions. In chapter 6 we focus on the ways in which poorer people's encounters with the state are structured with close regard for the conventions of the political societies that operate in our study areas. We also take up the question of corruption here, as we do in chapter 5.
In this chapter we want to say something about the livelihoods and social networks of poorer people in our study areas. We will introduce some of the individuals (for example, brokers and ‘local uppers’) who become key figures in the stories we tell in chapters 4, 5 and 6, and we shall comment on the ways in which poorer men and women use their non-state social networks to access the state or keep it at a distance.
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.
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.