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Psychotherapy in Dissent Some of the Objections to the Rise and Rise of CBT Are Not Based on Fact

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Psychotherapy in Dissent Some of the Objections to the Rise and Rise of CBT Are Not Based on Fact DavidVealeFINAL.qxd 31/1/08 1:16 pm Page 1 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 4 therapy today February 2008 DavidVealeFINAL.qxd 31/1/08 1:16 pm Page 2 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 therapy today February 2008 5 DavidVealeFINAL.qxd 31/1/08 1:16 pm Page 3 ‘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.
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