Why is CBT still being promoted as a cure-all?

As a psychotherapist I continue to come across the ad nauseam promotion of CBT – Cognitive Behavioural Therapy – 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 locations like the NHS.

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 evidence allegedly supporting it have since proven unfounded, with countless CBT therapists hired on the back of them.  CBT is now embedded in the public mind and insurance company approval lists with little to substantiate it’s effectiveness 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: something insurance companies and economists love in their efforts to save money by any possible means. 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 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.  In response to this I include some information and references below to help individuals gain a more balanced and realistic view of CBT 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.  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.

As an M.E. patient myself I have been offered CBT over the years as a first-line treatment when government quangos like NICE were 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 ineffective for them, and the emerging literature on the subject, which increasingly sheds doubts on the initial glory days’ hyperbolic claims being pumped through every consulting room doorway.  I worked alongside clinicians studying for clinical doctorates in CBT(!) with an inferred level of complexity, 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 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

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“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

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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’

The Guardian: Why CBT is falling out of favour

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

 

Photo credit: pexels.com

12 Comments Add yours

  1. Leni says:

    Good article and totally agree. It would be good to hear what you think is a solid, verifiable solution for survivors of abuse, whose shame based identity, negative thinking and maladaptive behaviour can be rooted in programming from abusers and as a “normal” occurrence of being abused.

    Liked by 1 person

  2. Stephen says:

    Hi Leni, thanks for your comment. ‘Solid and verifiable’: I’m not aware of a therapy that can deliver this. That was the problem with CBT – it still makes such claims. the other problem is that the psyche doesn’t conform nicely to the medical/ psychiatric model, and so attempts to standardise ‘treatment’ tend to fail. Some patients say EMDR has worked for them, others say it hasn’t. I suspect time will tell whether it claims more than it delivers.

    If we go back to the kind of mistreatment and abuse you’ve described, and look at it as an expression of evil (it is my firm belief that it is), then our starting point for healing and relationship has to be good: love, truth and kindness that is genuine, not used as a ‘technique’. That attitude is what I would call a therapeutic starting point for healing the psyche. My approach to abuse of various forms is to then build a detailed picture of the individual and their unique needs, difficulties and history, and any risk that needs to be addressed. The next step is discussing with the patient what I see happening, how it seems to operate and the functions it has in meeting or failing to meet needs, and then looking at what she/ he might expect from psychotherapy. I use a broad variety of creative approaches to helping survivors recover themselves at their own particular pace and depending upon what their aims are. It can take a long time and much of that time is about building a trustworthy relationship. But I’ve had good results, which is not to say that every future attempt would be solid and verifiable in any scientific sense, which is not my area of interest. Sadly, there are no guarantees with any kind of work. CBT has stood out simply because of the claims it has made suggesting it is solid and verifiable, when it isn’t. As I say, taking a mechanistic or technological approach to the psyche is to treat the patient like a thing, not a person. It is the person who is suffering, and being treated as a thing, an object to be manipulated, is the approach abusers take. I would suggest survivors don’t need more of that approach to heal them.

    It would be good to hear of your experience of all this, and of CBT if you feel comfortable enough sharing your opinions.

    Liked by 1 person

  3. Stephen says:

    PS A significant part of any abuse scenario is a confusion that happens with identity. Separating out that confusion is a core aspect of therapy. It happens with abuse of children at a prodound level, and with adults who are abused to a lesser, but nevertheless, powerful degree. It’s why, as survivors, we treat ourselves like crap.

    Like

  4. This is really interesting. I’ve heard a lot of good things about CBT and few bad things, so this perspective is definitely worthwhile to know.

    I have actually had bad experiences with CBT myself, but I assumed I was an outlier because of how confident my therapists were that changing my thoughts would work. I actually felt very suicidal after my second session with a therapist promoting CBT. She said that behind every negative emotion was a negative thought (or something like that). She made me feel like I was at fault for having these emotions and not stopping my negative thoughts. As I’ve learned since, many of my negative emotions arise when I am reminded of trauma memories — something that happens unconsciously and is not a conscious thought I can control! The psychology today article you linked to seems to agree with me here.

    I wonder what you think of DBT? I have been doing DBT therapy for the past few months and have found it very helpful, much more that CBT. It is my understanding that DBT developed out of CBT and added in a lot of mindfulness. DBT has the distress tolerance skills for when emotional arousal is too high for conscious thinking, and it has self validation and radical acceptance and observe, describe, etc. that seem to get at more of the causes of the emotions and deal with the root problems.

    Liked by 1 person

    1. Stephen says:

      Hi, thanks for posting and for sharing your experiences. I’m glad you’ve found a therapy that works for you. I’m aware of DBT and how it operates at a theoretical level (like many therapies it is a derivative of other therapies, CBT being one of them). I haven’t had experience of it as a practitioner or patient, so I can’t really comment.

      What I would say is that people tend to find that a therapy is helpful when the therapy fits with them in terms of their understanding and worldview. A lot of people don’t like, for example, the way they feel treated by CBT because it takes quite a mechanistic view of the human being. Some people like it because this is the way they relate to themselves. Conversely, other people get more out of psychotherapies that are about building a trusting honest relationship in which they feel seen for who they are. My personal preference is what drives my own work, which is about building a respectful, trusting, honest relationship whilst having enough skills and methods to help individuals cope with their experiences, as you’ve described. Hope that makes sense.

      Liked by 1 person

      1. That does make sense, thank you for replying. I guess DBT fits well with me! 🙂

        Liked by 1 person

  5. Totally agree. I think, more importantly, psychotherapy needs to be deprofessionalized and delicensed. Why whould the state have anything to do with peoples minds? We now have seperation of church and state (at least in America), I think we also need a seperation between mind and state. Let people practice and pay for whatever type of therapy they want.

    Liked by 1 person

    1. Stephen says:

      We’ve allowed our ‘elected representatives’ to rule us rather than be the public servants that they are supposed to be. The over-reach into our lives is so pervasive now (the US seems to be worse than anywhere else on the whole licensing idea) as to have become the bars of an ‘invisible’ cage. Only the majority seem quite happy with the arrangement (or are they just silent?), even to the extent that many will ask the government to take control of their profession! This happened a few years ago in the UK when counsellors and psychotherapists were demanding that the government regulate the field! As one piece of graffitti reads: “Slaves need masters”. Thankfully, in a rare moment of insight or disinterest, the government decided to say ‘no’. But the self-infantilising phenomenon of ‘enslave me, please enslave me!’ continues amongst many in the therapy field here. There’s an excellent book out by Richard Mowbray which you can read here, giving a systematic response against the regulation argument: http://www.transmarginalpress.co.uk/Resources/The%20Case….pdf

      Liked by 1 person

  6. Breakthrough Veil says:

    In the words of Dr. Amen, forerunner on brain scans, behavior modification can actually be cruel to those whose disease or trauma (TBI) have damaged the areas of the brain this type of therapy aims to change. Some military have damage so severe they can’t even articulate thoughts, much less change them. Although I’m not educated enough on this yet to really have an opinion lol!

    Liked by 1 person

    1. Stephen says:

      I think CBT is a symptom of our society’s shift in focus away from the value of relationships to help heal our emotional troubles. In fact CBT views emotions as a problem to be solved. People have learned to view themselves more and more as objects to be ‘fixed’ rather than as beings. CBT and other technique-heavy approaches reinforce the mechanistic view of the person, so it’s ideal for people who understand themselves and the world that way.

      Like

      1. Breakthrough Veil says:

        Thanks! Very thoughtful answer, lots to learn!

        Liked by 1 person

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