One in six adults in Britain suffer from depression or severe anxiety disorder. Both are potentially life-threatening illnesses, yet two-thirds of sufferers won't get treated. It is a national scandal that leaves so many people with mental health problems without professional help. In Thrive, Richard Layard and David Clark set out to show how urgently we need to improve mental health provision, and what a false economy it is to try to save money by cutting back on, and refusing to fund, enough services for the mentally ill. In the days of New Labour, Layard was known as the government's "happiness tsar". In fact, he is an economist with an evangelical mission to deal with the immense and massively ignored problem of mental health in Britain. Numbers are important to him, and his numbers are alarming. He makes the case that mental illness is no less debilitating than physical illness, using statistics that show depression to be on average 50% more disabling than angina, asthma, arthritis or diabetes. Yet, he says, although 90% of those who take their own lives have mental health issues, only a minority are receiving treatment, while 100% of those with heart disease will get medical attention.
These figures from surveys and censuses are fairly straightforward and shocking, and with them, the authors make an urgent case for increased spending on the issue. More problematical are the definitions and solutions that Layard and Clark – a psychologist – offer. In an attempt to show that "mental illness also has a major effect on your physical health", they reveal "an extraordinary fact" by quoting from a survey that took a sample of British people over the age of 50 and measured their degree of happiness with "a few simple questions". When the researchers returned nine years later, they found that those who had been judged least happy "were 50% more likely to die each year than people in the happiest group". The authors are clearly equating unhappiness with mental illness.
In 2003, Layard defined happiness and unhappiness. "By happiness I mean feeling good – enjoying life and feeling it is wonderful. And by unhappiness I mean feeling bad and wishing things were different." It is not just simplistic, but actually alarming that, by his own definition, unhappiness – "feeling bad and wishing things were different" – stands as a description of the mentally ill. The authors hope to increase happiness through treating the mentally ill and eradicating the wish for things to be different; they set out to achieve a placid, self-satisfied society, which is quite content with things as they are. A politician's dream, but hardly a healthy state to be in as we increasingly discover so many aspects of government and policy that require the oversight of a critical public. In all areas of life, critical thinking may not make you perfectly happy, but you might want to question whether perfect happiness is quite as desirable as it seems to be for Layard and Clark, and whether you want to be considered mentally ill if you don't achieve a state of bland satisfaction. The desire for everyone to be happy might seem kindly, but it can lead to various destinations, including Huxley's Brave New World and cloud cuckooland.
In Thrive, Layard and Clark set out their plan to improve mental health resources. The first thing to do, they say, is to measure the mental health of the populace using what they call the "new science of happiness". The results should then be used by government – which only exists "to promote happiness, and especially … to reduce misery" – to improve the sense of well-being of the nation by increasing mental health services. The authors cite research that suggests mental health is top of a list of factors on which people say their happiness depends, echoing King Lear ("O let me not be mad, not mad, sweet heaven!"). If government isn't convinced that the people's happiness is its main raison d'etre, the authors provide other figures to show that by getting people better and back to work as fast as possible, the Treasury could claw back the 4% of GNP that is lost by the combined effects of mental illness; that is, lost working days, sickness benefit, lost tax and the cost of the physical illness that also attends depression and anxiety disorders.
What form these improved mental services should take is very clearly defined, even in the book's subtitle: The Power of Evidence-Based Psychological Therapies. The joy of simple measurement is the heart of Thrive. If it can't be or hasn't been measured, it's no use. The phrase "evidence-based therapy" is used repeatedly, and at a single stroke it dismisses most person-centred talk therapy, in particular psychoanalysis and long-term psychotherapy, which are lengthy, expensive and not amenable to simple measurement. In their place, the authors would put cognitive behavioural therapy in its various forms. For Layard, the economist, and Clark, one of the world's leading experts on cognitive behavioural therapy, the provision of CBT to all patients with mental health problems is a simple, economic and effective answer. CBT fulfils the authors' admirable desire for an improvement in mental health provision. It takes at most 20 sessions, often far fewer; it is so standardised that therapists can be trained very quickly, and use a manual (they talk of manualised conversations) to conduct their sessions. It is so standardised that patients can be treated by phone, online or with self-help books. It is cheap, and has as good a recovery rate, we are told, as medication. CBT deems patients who are depressed and anxious to be having wrong thoughts. These thoughts are examined in the sessions and found to be negative. Repetitive negative thoughts are called rumination and patients are trained to alter their thinking to be positive. If I claimed, say, to be depressed about the fact I will die sooner rather than later, perhaps I would be told to focus on the fact that I'm not dead today. This is true, but doesn't alter the inevitable, which it might be useful for me to think about and come to terms with. Exercises and homework are given that are said to reprogramme the mind, put a stop to brooding, and replace negative thoughts with positive ones. It is, they claim, as simple as that. And the results are measurable, patient improvement is quantified after every session and at the end of each course. There is no need to dig into the past, to look for trauma. The mind, as if it were a material entity, can simply be changed by some outside process without reference to causes. Thoughts, we are told, are not facts. It brings us back, once again, to behaviourism: at least one of the discoverers of CBT looked to Pavlov's experiments. Thrive quotes Aristotle's belief that "the key to a good character is good habits" and tells us the aim is to replace those negative thoughts with "realistic ones". Just change those bad habits. And if they return, get a CBT top-up. Person-centred psychotherapy and analysis guide the patient to investigate herself, her past and her complex behaviour to discover the reasons for her symptoms. It makes understanding the goal, and assumes, along with Socrates, that the unexamined life is not worth living.
CBT has certainly worked for many people who, in six weeks or so, have learned to amend and reverse their negative thinking and feel better. It suggests to governments that they will get what they most want: value for money and a tranquil population. It is the chosen method of the National Institute of Health and Care Excellence and already almost the only kind of therapy offered by the NHS other than medication. The authors are clearly compassionate people who want to abolish the misery of mental illness, and CBT, so appealing to economists with its manualised conversations, standardised questionnaires and worksheets, and in tune with contemporary culture's desire for measurable fast outcomes, is the pragmatists' holy grail. CBT aims to get the patient symptom-free, back to work and paying her taxes. In generations to come, if we can ward off the return of the repressed, people will be looking back at 20th-century literature and philosophy and wondering what on earth they were on about with their incomprehensible talk of the unconscious, their tales of guilt, sublimation, drives and dreamwork. Because, by then, the mysteries of the human heart will have been abolished and all the world will be transparent and symptom-free.
• Jenny Diski's books include Skating to Antarctica and What I Don't Know About Animals. To order Thrive for £14.49 with free UK p&p call Guardian book service on 0330 333 6846 or go to guardianbookshop.co.uk.
