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Psychotherapy in dissent Some of the objections to the rise and rise of CBT are not based on fact. Equally, CBT itself is changing in line with research that advances our understanding of what needs to be integrated within its approach

by David Veale

I have borrowed the title of defence of the profession Access to Psychological ‘There should be greater this article from the book when it was under heavy Therapies programme (IAPT) patient choice between Psychiatry in Dissent criticism, and argued which has been vilified in different types of therapies published in 1976 by passionately for an evidence- some quarters. I have tried to offered in the NHS’ Professor Anthony Clare, who based approach. I write in a extract the common themes The National Institute for sadly died last year. The book similar vein to correct some of from the various articles and Health and Clinical was very influential in the myths and letters that have been Excellence (NICE) is helping me to decide to train misunderstandings about published in therapy today responsible for guiding the as a psychiatrist. In it, cognitive-behavioural therapy and in the media, and NHS. Its remit is to Professor Clare came to the (CBT) and the Increasing respond. recommend treatments that

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are cost effective and the process and quality of life practitioners so that they therapy for severe minimise the burden for the for the many people with can collect and evaluate depression1,2. client. The guidelines it common mental disorders. data, participate in peer ■ CBT encourages produces are based upon the Being empirically review and be part of the integration. The most current best evidence grounded is a core value for scientific community. This important aspect of CBT is available – that is, a meta- cognitive-behavioural has been a major cultural the formulation of the analysis of hundreds of therapists and they have divide between CBT and processes that maintain a randomised controlled put an enormous other psychotherapies, but disorder, and so whatever is trials, cost-effectiveness investment in research over there are signs that this is the most effective way of studies and subsequent the past 40 years. Note that now improving. Referring breaking a cycle can be discussions with being empirically grounded agencies, commissioning legitimately used. An researchers, clinicians, and is not just about randomised agencies, health insurance example is the way that users. When there is controlled trials. What companies and clients will imagery techniques and evidence of cost clients tell us is the source increasingly seek empirical rescripting for aversive effectiveness, then the of inspiration in applying data rather than anecdote. memories, originally guiding principle in the empirical questions. There Of course, everyone described in Gestalt, has

‘Anecdotes and personal experience for a particular approach are for the media – not for making public policy decisions’

NHS is that of patient are of course many different supports greater patient been evaluated and choice. When given the designs to answer different choice. However, as far as incorporated into CBT, choice, clients commonly questions. They include: the NHS (and most health probably because these prefer an effective ■ experimental designs that insurance companies) is techniques offer a more psychological therapy over inform theory of why a concerned, the choice will be powerful way of evoking medication, yet many people symptom is maintained, between treatments that emotion than verbal who may potentially benefit which has led to specific have a good evidence base techniques do3. are either simply not models for different and are cost effective in the ■ Being data led informs referred because of the long disorders; long term. service delivery. An example waiting lists, or opt for the ■ case series with multiple It is worth stating that of the way data informs the private sector. The IAPT baselines or sequencing of CBT as it is currently delivery of therapy is programme aims to interventions prior to a practised will not exist in provided at my own unit. reconfigure services so that controlled trial; the future. It constantly Pilot data with post- they are more consistent ■ mediational studies to changes depending on new traumatic stress disorder with the NICE guidelines understand the processes research. Being data led (PTSD) or obsessive and can provide patients involved in improvement; with testable models has a compulsive disorder (OCD) with the choice of a ■ dissemination studies to number of exciting suggests that providing psychological therapy for determine whether a consequences: intensive therapy over one depression and anxiety treatment manual in a ■ It means no attachment to week (15 hours) leads to disorders. At this point, specialist centre can be any specific model or outcomes equivalent to evidence for the disseminated to primary technique. For example, in therapy once a week for 15 effectiveness of many care or real-life settings. 1979, Beck first published weeks. This is exciting psychological therapies The process for finding his manual for depression. because if it were to be other than CBT is lacking – evidence to disprove a The emphasis was on confirmed in controlled which is not the same as theory is slow and tedious challenging content of trials then it would provide evidence for the and requires a lot of thoughts and ‘control’ of greater patient choice. ineffectiveness of other investment over many symptoms – more recent Someone could take a week psychological therapies. We years. Anecdotes and practice is investigating off work; overcome his or all want good data that will personal experience for a Behavioural Activation, her problem and return to help us adapt and improve particular approach are for which helps clients to not work without having to turn the quality of life of our the media and not for engage in processes like up to a hallowed hour once HOICE SC clients. People who are making public policy ruminating, and helping a week. Other researchers ’ cynical of the process of decisions. The implications depressed patients to do the have looked into delivering NICE do not offer any are that all future things they are avoiding. CBT over the telephone4 or PHOTOGRAPHER alternative for making counsellors and This approach is exciting, as via webcam. This emphasis / decisions about public policy psychotherapists should be it may have advantages to on service delivery follows DEPCZYK C

or how they would improve trained as scientist standard Beck cognitive the values of placing the JA

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‘The most important aspect of CBT is the formulation of the processes that maintain a disorder, and so whatever is the most effective way of breaking a cycle can be legitimately used’

least burden on the client equal effect. These mild to moderate depression how a problem developed. A and securing maximum conclusions are drawn from in primary care but not for developmental formulation patient choice. large non-randomised phobias, PTSD or OCD. takes into account known (naturalistic) comparisons Sometimes, therapists factors that have led to the ‘It’s the relationship that of patients receiving advocate ‘deeper’ therapy current problems. Equally, heals, not the technique’ different therapies. The for more complex problems, there may be aspects of Many people in CBT over findings are very difficult to but CBT was reported to do temperament or biology that many years have been interpret because of the better than psychodynamic are not known. However, working hard to try to focus many selection biases8. They transference-based endlessly searching for the on key agents of change so note that in Stiles et al7 the psychotherapy in borderline root of the difficulties can that these can be delivered sample is less than 38 per personality disorder9. encourage processes such as in efficient, compassionate cent of the cases seen by the rumination that maintain and caring ways within a therapists who complete Outcomes largely depend the problem. Cognitive- supportive relationship. both pre and post outcome on the therapist’ behavioural therapists may Most scientists are not ratings and had been If there is a significant use imagery techniques to convinced that a therapeutic selected by the therapists. variation in CBT delivered, try to understand past relationship is a sufficient There are many different then this is usually because experiences, update their variable for change in most biases operating in those of poor supervision and meaning and prevent types of problems. It’s up cases selected. In inconsistent adherence to a avoidance of aversive to psychotherapies to randomised controlled trials treatment protocol. It is memories and action to test disprove this with a body of (RCTs), it is common for the important in CBT to audio out whether their beliefs are evidence to convince the last observation to be or video-tape sessions – one helpful in the here and now. scientific community that it carried forward for people copy is given to the patient is. There is, however, with missing data to to enhance learning and one ‘CBT ignores social evidence that therapies estimate post-treatment copy is used by the therapist context’ which offer more than a scores. If this were done, it for quality control in CBT does not ignore the good relationship do better would drop the overall supervision. Thus studies social context of mental for many problems. Equally, recovery rate from 58 per that demonstrate variance disorder. Competent therapeutic relationships cent to 22 per cent. Equally in therapist behaviour just therapists are aware of the are not ignored in CBT – significant in primary care mean that there was poor effects of, for example, what usually matters is a is natural recovery, which supervision and adherence poverty, continuing abuse or ‘good-enough’ relationship. may be anywhere between to protocol. Controlled trials the lack of social support, Cognitive-behavioural 40-60 per cent in have an adherence measure which interfere with therapists are not depression, so the added whereby sessions are rated progress. They take care to mechanistic or cold – benefit of a psychological by an independent observer facilitate the process by indeed, they are often rated therapy may be weak8. It is on a standardised scale, which the person becomes as amongst the warmest of not surprising, therefore, both to determine that the their own agent of change in therapists5. Equally, issues that a therapist (of therapy being delivered is a hostile environment, of ‘transference’ and whatever persuasion) feels following the protocol and to including interactions with ‘countertransference’ are not their approach works, as assess the quality of the relatives or friends who are ignored in complex most of their clients are relationship. Quality in critical or over-protective. problems, and Gilbert & getting better naturally and therapy is also improved by Practitioners address these Leahy6 discuss the not necessarily because of the therapists working in issues and work therapeutic relationship in what they do. teams specialising in a collaboratively on solutions CBT in more detail. To demonstrate that all particular disorder, or group that might be helpful in therapies are equal in effect, of disorders for supervision. overcoming these obstacles. ‘All therapies are equal we need more randomised in effect’ controlled trials with a ‘Clients need to discuss the ‘CBT is expert led, Stiles et al7 and many waiting list comparison – we root of the problem’ directive and makes people others suggest that all know that a number of CBT ignores neither the passive automatons’ psychotherapies have an approaches may improve context nor the history of Nothing could be further

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from the truth. Effective ‘CBT is not able to help barriers to training and Association of Behavioural CBT requires collaboration clients who cannot read or employment. and Cognitive Psychotherapies. and negotiation. Clients write or concentrate’ He is an Honorary Senior have a shared formulation CBT can be adapted for ‘CBT is being over-sold’ Lecturer at the Institute of that identifies the meaning people who cannot read or I am not sure who is over- Psychiatry, King’s College they attach to events or write and is used in child selling it. Scientists are London and a consultant internal experiences and and learning disability usually very cautious in psychiatrist in cognitive- the avoidance behaviours services. As noted above, discussing their results. behavioural therapy at the that are maintaining their sessions should be routinely CBT is not a universal South London and symptoms. audio-recorded to be panacea and cannot offer a Maudsley Trust and the Once a client has a good listened to again. Support quick fix. However, after Priory Hospital, North psychological material may be largely about 40 years of research, London. His research understanding of how s/he picture based and so on. it is doing reasonably well. interests are in treating is maintaining his or her The effect size and range of obsessive compulsive distress and handicap, then ‘CBT is too intellectual’ disorders it treats increases disorder, body dysmorphic during therapy they have CBT done poorly may with every new generation disorder, vomit phobia and the responsibility to change. appear this way. However, of researchers and I predict depression. Correspondence: They have agreed goals the emphasis in CBT is for it will continue to adapt and Centre for Anxiety Disorders that include a return to clients to act and to test out develop as new data is and Trauma, The Maudsley their valued directions in their beliefs or fears whilst collected. Hospital, 99 Denmark Hill, life, such as employment or experiencing emotion (so it’s London SE5 8AF. Email: social roles. They not done intellectually). David Veale is currently [email protected]; participate in the setting of President of the British website: www.veale.co.uk relevant homework between ‘The IAPT will be a cheap sessions, which is a crucial fix’ References component of CBT. This The Increasing Access to 1. Dimidjian S, Hollon SD, Dobson KS, Schmaling KB, might include testing out Psychological Therapies Kohlenberg RJ, Addis ME, Gallop R, McGlinchey JB, Markley whether a belief is true, programme is not only DK, Gollan JK, Atkins DC, Dunner DL, Jacobson NS. whether a cognitive process about providing Randomized trial of behavioral activation, cognitive therapy, (eg ruminating or self- psychological therapy but and antidepressant medication in the acute treatment of focused attention) is helpful also about improving the adults with major depression. Journal of Consulting and or whether behaviour such quality of therapy. This Clinical Psychology. 2006; 74(4):658-670. as avoidance maintains means that the therapists 2. Veale D, Willson R. Managing your mood. A self-help guide their symptoms in the will be accredited as using behavioural activation. London: Constable & Robinson; long term. reaching a minimum 2007. standard for training. They 3. Holmes EA, Arntz A, Smucker MR. Imagery rescripting in ‘CBT is just a “technical will follow empirically cognitive behaviour therapy: images, treatment techniques fix” or “sticking plaster”’ driven protocols derived and outcomes. Journal of Behavior Therapy and CBT is not a ‘technical fix’ from randomised controlled Experimental Psychiatry. 2007; 38(4):297-506. or series of techniques. CBT trials. Protocols are not 4. Lovell K, Cox D, Haddock G, Jones C, Garvey R Roberts C, is formulation driven and rigid and have to adapt to Hadley S. Telephone administered cognitive behaviour the model is derived from the context. Clients with therapy for treatment of obsessive compulsive disorder: research into cognitive more severe problems and randomised controlled non-inferiority trial. BMJ. 2006; processes and behaviours. co-morbidity can be routed 333:883. As described above, a to more experienced 5. Schaap C et al. The therapeutic relationship in behavioural formulation is shared with a therapists. Staff would psychotherapy. Chichester: Wiley; 1993. client. Once there is a road receive continuing 6. Gilbert P, Leahy R. The therapeutic relationship in the map, then various tasks professional development cognitive behavioural psychotherapies. Routledge; 2007. may be used to get from ‘A’ and attend workshops and 7. Stiles WB, Barkham M, Twigg E, Mellor-Clark J, Cooper to ‘B’. conferences to maintain M. Effectiveness of cognitive-behavioural, person-centred and Some routes are shorter their accreditation. They psychodynamic therapies as practised in UK National Health than others – therefore would use standardised Service settings. Psychological Medicine. 2006; 26:555-566. CBT tries to be a pragmatic outcome scales and 8. Clark DM, Fairburn CG, Wessely S. Psychological approach to help employment data that can treatment outcomes in routine NHS services: a commentary on individuals to return to be audited. If there is a high Stiles et al (2007). Psychological Medicine. 2008; their normal roles in life as completion rate of the rating doi:10.1017/S0033291707001869. quickly as possible. scales then the outcomes 9. Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Therapies that are longer can be audited against those Dirksen C; van Asselt T; Kremers I, Nadort M, Arntz A. need to demonstrate of a clinical trial. The IAPT Outpatient psychotherapy for borderline personality disorder: that they are more centres will be a one-stop randomised trial of schema-focused therapy vs transference- clinically or cost effective shop, so there will be access focused psychotherapy. Arch Gen Psychiatry. 2006; 63:649- than CBT on quality of life to employment advisers and 658. measures. help in overcoming the

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