Thursday, 2 August 2018

What the world can learn about equality from the Nordic model

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Geoffrey M Hodgson, University of Hertfordshire
Rising inequality is one of the biggest social and economic issues of our time. It is linked to poorer economic growth and fosters social discontent and unrest. So, given that the five Nordic countries – Denmark, Finland, Iceland, Norway and Sweden – are some of the world’s most equal on a number of measures, it makes sense to look to them for lessons in how to build a more equal society.
The Nordic countries are all social-democratic countries with mixed economies. They are not socialist in the classical sense – they are driven by financial markets rather than by central plans, although the state does play a strategic role in the economy. They have systems of law that protect personal and corporate property and help to enforce contracts. They are democracies with checks, balances and countervailing powers.
Nordic countries show that major egalitarian reforms and substantial welfare states are possible within prosperous capitalist countries that are highly engaged in global markets. But their success undermines the view that the most ideal capitalist economy is one where markets are unrestrained. They also suggest that humane and equal outcomes are possible within capitalism, while full-blooded socialism has always, in practice, led to disaster.
The Nordic countries are among the most equal in terms of distribution of income. Using the Gini coefficient measure of income inequality (where 1 represents complete inequality and 0 represents complete equality) OECD data gives the US a score of 0.39 and the UK a slightly more equal score of 0.35 – both above the OECD average of 0.31. The five Nordic countries, meanwhile, ranged from 0.25 (Iceland – the most equal) to 0.28 (Sweden).

The relative standing of the Nordic countries in terms of their distributions of wealth is not so egalitarian, however. Data show that Sweden has higher wealth inequality than France, Germany, Japan and the UK, but lower wealth inequality than the US. Norway is more equal, with wealth inequality exceeding Japan but lower than France, Germany, UK and US.
Nonetheless, the Nordic countries score very highly in terms of major welfare and development indicators. Norway and Denmark rank first and fifth in the United Nations Human Development Index. Denmark, Finland, Norway and Sweden have been among the six least corrupt countries in the world, according to the corruption perceptions index produced by Transparency International. By the same measure, the UK ranks tenth, Iceland 14th and the US 18th.
The four largest Nordic countries have taken up the top four positions in global indices of press freedom. Iceland, Norway and Finland took the top three positions in a global index of gender equality, with Sweden in fifth place, Denmark in 14th place and the US in 49th.
Suicide rates in Denmark and Norway are lower than the world average. In Denmark, Iceland and Norway the suicide rates are lower than in the US, France and Japan. The suicide rate in Sweden is about the same as in the US, but in Finland it is higher. Norway was ranked as the happiest country in the world in 2017, followed immediately by Denmark and Iceland. By the same happiness index, Finland ranks sixth, Sweden tenth and the US 15th.
In terms of economic output (GDP) per capita, Norway is 3% above the US, while Iceland, Denmark, Sweden and Finland are respectively 11%, 14%, 14% and 25% below the US. This is a mixed, but still impressive, performance. Every Nordic country’s per capita GDP is higher than the UK, France and Japan.

Special conditions?

Clearly, the Nordic countries have achieved very high levels of welfare and wellbeing, alongside levels of economic output that compare well with other highly developed countries. They result from relatively high levels of social solidarity and taxation, alongside a political and economic system that preserves enterprise, economic autonomy and aspiration.
Yet the Nordic countries are small and more ethnically and culturally homogeneous than most developed countries. These special conditions have facilitated high levels of nationwide trust and cooperation – and consequently a willingness to pay higher-than-average levels of tax.
As a result, Nordic policies and institutions cannot be easily exported to other countries. Large developed countries, such as the US, UK, France and Germany, are more diverse in terms of cultures and ethnicities. Exporting the Nordic model would create major challenges of assimilation, integration, trust-enhancement, consensus-building and institution-formation. Nonetheless, it is still important to learn from it and to experiment.
The ConversationDespite a prevailing global ideology in favour of markets, privatisation and macro-economic austerity, there is considerable enduring variety among capitalist countries. Furthermore some countries continue to perform much better than others on indicators of welfare and economic equality. We can learn from the Nordic mixed economies with their strong welfare provision that does not diminish the role of business. They show a way forward that is different from both statist socialism and unrestrained markets.
Geoffrey M Hodgson, Research Professor, Hertfordshire Business School, University of Hertfordshire
This article was originally published on The Conversation. Read the original article.

Why CBT should stop being offered to people with schizophrenia

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Keith Laws, University of Hertfordshire
Cognitive behavioural therapy, or CBT, has in the past decade become a standard tool for helping people with schizophrenia deal with their symptoms. Recent developments, however, raise serious questions about how effective this talking therapy really is for this illness.
Despite strongly advocating that all people with schizophrenia should be offered CBT, the National Institute for Health and Care Excellence (NICE) – the organisation that evaluates treatments for the NHS – has inexplicably neglected to update its evidence base since 2008. In the intervening years the number of randomised controlled trials – the gold standard for clinical research – assessing symptom reduction through CBT has doubled, and many of them cast doubt on the institute’s recommendations.
Very few trials had reported on the impact of CBT on social and professional functionality, or quality of life, so with this in mind we recently published the first meta-analysis assessing the impact of CBT on these aspects.
The results were not positive. While we found that CBT initially improved the ability of patients to function, the benefit was shortlived. CBT failed to alleviate the distress associated with the symptoms of psychosis. CBT also failed to improve quality of life, as measured in a patient’s sense of self, hope, well-being, relationships and so on. Indeed, not one CBT trial has ever reported a rise in quality of life for people diagnosed with schizophrenia.

A growing weight of evidence

This was just the latest study to raise question marks, and a 2014 meta-analysis by our research group had already concluded that claims that CBT alleviates classic symptoms such as delusions are “no longer tenable”.

CBT helps with a great many things. But perhaps not schizophrenia. Shutterstock

A 2014 meta-analysis from the Netherlands found that almost none of the latest studies reported reductions in schizophrenia symptoms, such as social withdrawal, apathy, or “emotional blunting” (having no positive or negative emotions). The authors concluded: “CBT studies focused on psychotic symptoms might not work as well in reducing negative symptoms as previously thought.”

Furthermore, a Cochrane review, an authoritative voice on evidence-based healthcare, concluded that CBT showed “no clear and convincing advantage” over other, sometimes much less sophisticated, therapies, or even simple, non-technical approaches such as befriending. This involves talking with the patient about neutral topics of interest, such as music, sport, books, pets and so on.
A smaller amount and lower quality of evidence was required to establish CBT as an intervention, than now exists for it to be rejected. Earlier trials of CBT for schizophrenia – such as those reported by NICE – were much less rigorous than their modern counterparts. For example, many early researchers did not use blind outcome assessment – that is to say, they knew which of their subjects had received CBT and which had not, potentially leading to confirmation bias. These earlier trials spuriously inflated the apparent benefits of CBT five or six times over.

Risk and reward

One of the main factors that can lead to the withdrawal of an intervention is if harm is seen to outweigh benefit. Psychological interventions such as CBT are often assumed to cause no harm, but a recent study urged caution. It warned: “The measurement and reporting of adverse effects in trials of psychological interventions for psychosis (and other conditions), is extremely poor.”

There is a question mark over whether patients actually want CBT in the first place. Shutterstock

The fact that harm is not routinely assessed, or is poorly assessed in psychotherapy trials should raise a red flag over recent calls for CBT to be an alternative to antipsychotic medication. The single recent, relevant study comparing the two treatments showed that adding CBT to antipsychotic medication gave no significant additional benefit, while adding antipsychotic medication to CBT produced significant improvement in symptoms.
But even setting aside efficacy and potential harm, do the patients themselves actually want CBT? Evidence suggests not – according to the 2014 National Audit of Schizophrenia published by the Royal College of Psychiatrists, more than half of those offered CBT decline it.

The evidence used by NICE is low quality and outdated, and their endorsement of CBT is in dire need of reconsideration. There are serious doubts as to whether CBT actually reduces schizophrenia symptoms, and now also whether it improves key outcomes such as functionality, quality of life and symptom-related distress. If we want psychological interventions to evolve, then new research to be directed at developing and assessing alternative treatments.

The ConversationAnd if we want an accessible, cost-effective and equally potent alternative in the meantime, why not listen to the Cochrane group. We might do just as well with befriending.
Keith Laws, Professor of Cognitive Neuropsychology, University of Hertfordshire
This article was originally published on The Conversation. Read the original article.