“The fact remains that the construct of psychiatric diagnosis and the construct of a psychological model aligning itself to it are both divorced from the actual, more complex and individuated realities of the particular patient and the individual practitioner. The technocratic relationship of the first denies the non-mechanistic, much more complex organic nature of the latter.” (this article)
As a psychotherapist I continue to come across the ad nauseam promotion of CBT – Cognitive Behavioural Therapy – and its derivatives, both within the NHS and outside of it for what seems to be any and every ailment known to man, woman and child. This is partly due to the lasting momentum of a politically-motivated campaign of CBT promotion that has been underway in the UK and elsewhere for at least the past two decades, and its uptake by many NHS psychologists practicing with an eclectic toolbag approach to psychological interventions. It is also largely driven by self-promoters of the therapy and moreso by those with economic agendas to sell, since CBT is low-cost in terms of the relatively short duration of time it takes to train practitioners and the brevity of its delivery in publicly funded medical locations like the NHS. Being a medical service, the NHS also has a vested interest in maintaining the view that human distress is essentially psychiatric, and its ready acceptance of CBT as a set of techniques created to specifically ‘treat’ psychiatric conditions appears to sit neatly with this biomedical paradigm of mental distress.
“A preoccupation with the symptoms of mental illness, rather than their social causes, is because there’s no “big drug lobby behind prevention”, Harper says. Treatments such as CBT have proved a cost-effective cattle prod for herding the mentally ill off welfare benefits. As chancellor, George Osborne introduced the therapy for 40,000 recipients of Jobseeker’s Allowance as part of a back-to-work agenda.”
Layard and Clark in the UK also managed to whip up something of a feeding frenzy with the associated government funding during their now infamous IAPT campaign, and there are still the lasting effects of this even though many of their claims about CBT and the data allegedly supporting it have since proven unfounded, with countless CBT therapists hired by the NHS on the back of them. CBT is now embedded in the public mind and insurance company approval lists with little to substantiate it’s advantages over any other form of therapy. What it does have behind it is a litany of randomised control trials laying claim to ‘scientific’ evidence of effectiveness, with a limited number of sessions for virtually everything listed in the DSM psychiatric manual and more: something insurance companies and economists love in their efforts to save money by any possible means. With Psychiatry’s credibility and reliance upon a biomedical model of mental disorders under serious attack (see reference below), we must also question those symptom- and diagnosis-focussed techniques like CBT that were created specifically to interface with psychiatric diagnoses. Add to this the time-lag involved in updated research filtering through to academic course providers of medical, pharmacy and psychology training, and we still feel the ripples today of a marketing hype that started over twenty years ago.
Sooner or later there was going to be a backlash.
However, apart from anything else I also believe it irresponsible to continue to promote CBT, or any treatment, with the implication that it is a cure for anything, as many seem to be suggesting, particularly specific psychiatric disorders that CBT claims to treat that have no firm scientific validity as discreet mental conditions. The fact remains that the construct of psychiatric diagnosis and the construct of a psychological model aligning itself to it are both divorced from the actual, more complex and individuated realities of the particular patient and the individual practitioner. The technocratic relationship of the first denies the non-mechanistic, much more complex organic nature of the latter.
In response to these and other anomalies I include some information and references below to help individuals gain a more balanced and realistic view of models like CBT and its derivatives in a climate that would have us all believe the quasi-religious fervour that seems to have created the CBT mythology. No one therapy can do everything, and sometimes they do nothing. Indeed psychotherapies of any description certainly aren’t for everyone, even those that require years of training and their trainees to be in continual analysis themselves, unlike the requirements of CBT training, which permits trainees to qualify without ver having had an hour’s therapy themselves.
Whilst CBT can help some patients and some conditions, it fails to help others and is certainly not the universal cure claimed by many, particularly but not exclusively related to illnesses such as M.E. and Chronic Fatigue Syndrome, depression and anxiety, and schizophrenia, for example. Ubiquitous claims to effectiveness also seem to ignore the fact that CBT or any helping method (including car mechanics, plumbing and interior decoration) is only as effective as the practitioner’s ability to implement it with skill and good judgement, both of which vary from one practitioner to the next.
“We have concluded that GET [Graded Exercise Therapy] should be withdrawn with immediate effect as a primary intervention for everyone with ME/CFS.
“CBT courses, based on the model that abnormal beliefs and behaviours are responsible for maintaining the illness, have no role to play in the management of ME/CFS and increase the risk of symptoms becoming worse.”
As an M.E. patient myself I have been offered CBT and its derivative GET over the years as a first-line treatment when government quangos like NICE are still handing down their ‘guidelines’ (read ‘commandments’) on the matter against the counter-force of common sense and anecdotal evidence from patients themselves. Apart from balking at any mechanistic or reductionistic approach to the human condition, I knew long before the PACE trial was concluded that CBT would do nothing for me as a sufferer of this illness. This was based on my own knowledge and study of CBT at Masters Degree level and its reliance on ‘changing negative thoughts’ as its acclaimed mechanism for domino-effect changes in feelings and behaviours. Add to this my experience as an NHS psychotherapist with many years behind me of listening to patients’ accounts of CBT having been wholly ineffective for them over a wide range of mental health problems, and the emerging literature on the subject, which increasingly sheds doubts on the initial glory days’ hyperbolic claims emanating from every NHS manager’s doorway. I worked alongside clinicians studying for clinical doctorates in CBT(!) with an inferred level of complexity that CBT simply does not have, when at the same time the CBT promoters were pushing CBT’s super-simplistic methodology via self-help books and computer programs. Like some 1970s TV commercial for a new Miracle Cleaner, CBT seemed to be good for everything if you believed the salesmanship. And like any hyped product, the big claims have turned out not to stand the test of real world application.
Below are several papers, links and articles that prospective patients and clients may find useful in coming to a decision about whether CBT could be of benefit to them or whether other forms of therapy, help or support might be better suited to their needs, personality, psychological make-up, temperament and physical and mental constitution, all of which are factors in determining what path to take in healing oneself. CBT is very structured and easy to understand, which I would suggest is its main appeal for many. But its premise that your negative thoughts are responsible for your woes, as most rational people will know, is fine if you’re frightened of spiders (at least those that you know are not poisonous!). Not so fine if your ‘cognitions’ are a completely accurate and sane response to abusive, toxic or unhealthy circumstances, a troubled or traumatic personal history, and the wide variety of very real, very unpleasant challenges brought to us by a corrupted world to which CBT as a social band-aid would simply have us adapt ourselves against the better wisdom of our ‘negative’ thinking.
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“CBT/GET is a non-evidenced based therapy and even potentially harmful for many ME/CFS patients”
British Medical Journal article HERE
“So, it comes as no surprise to find that a very careful re-analysis of some of the PACE trial data by Carolyn Wilshire and colleagues has concluded that impressive claims for recovery following CBT and GET are not statistically reliable.
“It is also very concerning to note that this data was only released through use of the Freedom of Information Act and a very costly Tribunal – which ordered the release of data…”
“The claim that patients can recover as a result of CBT and GET is not justified by the data, and is highly misleading to clinicians and patients considering these treatments.”
“The widespread adoption of [CBT in Sweden] has had no effect whatsoever on the outcome of people disabled by depression and anxiety. Moreover, a significant number of people who were not disabled at the time they were treated with CBT became disabled, costing the government an additional one billion Swedish crowns. Finally, nearly a quarter of those who started treatment, dropped out, costing an additional 340 million!”
Scott Miller article HERE
Is the NHS’s therapy for depression a total waste of time?
by Oliver James
A quarter of us suffer from a mental illness at any one time, mostly anxiety or depression. The cost to our economy is enormous – £105 billion a year, never mind the personal anguish – and for too long the only treatment was pills.
What a tragedy, then, that the first attempt to provide talking therapy to patients nationwide is using the wrong kind: cognitive behavioural therapy (CBT).
The theory behind CBT is that your thoughts control your feelings. Change your thoughts, and you change how you feel. If you keep getting anxious for no reason, perhaps worrying that something awful will happen or that you will make a fool of yourself, CBT teaches you to think the opposite.
‘Cognitive behavioural therapy is all about marketing – it is a cheap, quick fix’
In just six to 16 sessions, cognitive behavioural therapy claims to be able to convert you from depressed or anxious, to ‘recovered’.
The scheme introducing CBT nationwide – snappily named the Improving Access to Psychological Therapies (IAPT) programme – was created in 2009 by Professors Richard Layard, an economist, and David Clark, a clinical psychologist at Oxford University.
They sold it to the New Labour government as a way to help at least half of sufferers from anxiety or depression to recover.
And at first sight, the claims for its success seem quite impressive, with ‘recovery’ in around 40 per cent of cases who complete the treatment.
Closer inspection reveals a much less rosy picture. Cognitive behavioural therapy is all about marketing – it is a cheap, quick fix.
Even before the IAPT scheme was introduced, there was extensive evidence to show that two years after treatment, depressed or anxious people who had CBT were no more likely to have recovered than those who had no treatment.
(It’s worth noting that Layard and Clark make no mention of this in their new book, Thrive, a polemic on the failure to treat mental illness which continues their relentless promotion of CBT.)
Many other researchers have since shown that two-thirds of those treated for depression with CBT and who had apparently ‘recovered’, relapsed or sought further help within two years.
Furthermore, around 30 per cent don’t even complete the course.
The fact is, if given no treatment, most people with depression or anxiety drift in and out of it. After two years, those given CBT have no better mental health than ones who have been untreated.
Working as a psychotherapist, I rarely encounter patients who haven’t been subjected to CBT, which failed to help them.
The problem with CBT is that no attempt is made to understand the causes of depression and anxiety. Proper therapy – such as psychodynamic therapy, which looks at why we behave as we do – can treat the causes.
The causes themselves are one of the best-kept secrets of modern science. They do not include your genes. The latest evidence strongly suggests that mental illness is not genetic.
Indeed, in a remarkable recent admission, Robert Plomin, Britain’s top gene psychologist, stated that: ‘I’ve been looking for these genes [for mental illness] for 15 years and I don’t have any.’ Off the record, many experts will admit that no genes are going to be found; that the difference in psychology between us – including even siblings – has little or nothing to do with DNA.
By contrast, the evidence for the critical role of childhood experience is becoming overwhelming.
The best study, by Professor Alan Sroufe in Minnesota, shows that 90 per cent of people who suffered childhood maltreatment have a mental illness at age 18.
Another study – by Robert Anda, of America’s National Centre for Chronic Disease Prevention – shows that adults who suffered five or more childhood adversities (such as abuse or neglect) are 193 times more likely to be mentally ill than people who suffered none.
Virtually all studies show that the more childhood adversity, the greater the risk of mental illness.
Given the strength of this evidence, it is bizarre that practitioners of CBT are explicitly required to steer patients away from their childhood.
A few anxieties, such as panic, are changed by CBT, but for the great majority, when the gloss wears off, the distress returns. The CBT theory ignores causes, teaching practitioners to concentrate only on how thoughts are causing symptoms. Major reviews of the evidence, such as that by American psychologist Jonathan Shedler, show that therapies which explore childhood causes and focus on the relationship with the therapist truly work in the long term. If only the IAPT programme had really been evidence-based, it would have used those therapies.
Knowing Richard Layard to be a well-intentioned man and an economist, not a psychologist, I can forgive him. But David Clark is an Oxford University psychology professor.
Clark strongly stresses that CBT is the evidence-based, scientific treatment – yet fails to mention that this evidence proves it does not work in the long term.
A few anxieties, such as panic, are changed by CBT, but for the great majority, when the gloss wears off, the distress returns.
Yet thanks to Clark and Layard, CBT is now largely the only therapy it is possible to obtain from either the NHS or from private health insurance companies.
Of course these two aren’t exclusively to blame – CBT appeals to politicians and the National Institute for Health and Care Excellence because it is quick and cheap. The therapies proven to work long term, such as psychodynamic therapy, would not be so cheap because they require more sessions than six to 16.
It is no coincidence that it was under New Labour that the IAPT scheme was introduced.
Just as CBT is all about salesmanship, selling an idea of yourself to yourself regardless of your inner emotional truth, so Blair’s government put the spinning of policies ahead of what was actually true.
CBT does have some virtues. It encourages practical steps proven to improve wellbeing, such as taking exercise, meditation and yoga.
Professor Clark is a highly skilled clinician and I do know people who claim to have been helped by CBT to reduce their depression.
But all of them had done it for many years and the relationship with the therapist was what helped, not the change in thinking patterns. Studies prove this: insofar as CBT works, it’s if there is a good relationship with the therapist. But that is not what CBT is about – it discourages the emotional attachment to the therapist.
There is growing fury in the mental health field at the way David Clark has hijacked so much attention and resources for CBT.
In early November, leading figures, such as Jonathan Shedler, will gather at Dartington in Devon to discuss the overselling of the evidence for CBT’s effectiveness.
In the meantime, for the vast majority, CBT will continue to be virtually all that is on offer.
In its stead we urgently need therapies for everyone – not just those who can afford the alternatives – that treat the childhood causes of depression and anxiety through the relationship with the therapist.
Full article credit: Oliver James
Related articles and papers:
‘Researchers have found that CBT is roughly half as effective in treating depression as it used to be’
PACE Trial Conclusions on CBT and GET for M.E./ CFS
“These findings raise serious concerns about the robustness of the claims made about the efficacy of CBT and GET. The modest treatment effects obtained on self-report measures in the PACE trial do not exceed what could be reasonably accounted for by participant reporting biases.”
Full article HERE
- Selling Bad Therapy to Trauma Victims
- ME Awareness: The PACE Trial
- Study casts doubt on evidence of ‘gold standard’ psychological treatments
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