|
Comment
Cognitive
behavioural therapy - no more than another Labour quick fix
October
9, 2008
The government
has started recruiting
thousands of more cognitive behavioural therapy-trained therapists
in a bid to "cure" 450,000 people with depression and
anxiety in England and Wales. But cognitive behavioural therapy
is based on a desperate simplification of what lies at the heart
of distress, argues Dorothy Rowe
.....
In
mental distress the real problem always arises from some kind of
threat or insult to the sense of being a person. This can be hard
to uncover, and difficult to ameliorate. It is never amenable to
a quick fix.
New
Labour
has always favoured the quick fix. Children can’t read and
write? Set a national curriculum and test them. Methicillin-resistant
Staphylococcus aureus (MRSA) a problem in hospitals? Deep-clean
them. The fact that weighing piglets doesn’t fatten them,
and that it’s people, not walls and floors, that pass on infections
is irrelevant.
The
next problem was that people who are depressed are unlikely to be
good workers. Anti-depressants are expensive and inefficient, so
let’s use the simplest of all the therapies, train people
quickly and cheaply as therapists, and get these depressed people
back to work.
If only life were that simple! Many
experienced CBT (cognitive behavioural therapy) therapists have
found that it isn’t. About ten years ago, they discovered
that they needed to take into account how the client saw the therapist,
something that Freud had called it ‘counter-transference’.
Next, some CBT therapists concluded that doing prescribed homework
wasn’t enough to change those pesky dysfunctional cognitions.
What was needed was mindfulness, something that the Buddha mentioned.
Now what’s important is compassion, something that features
in all religions. Although it’s possible now to do a Master’s
degree in mindfulness, and to write academic papers on compassion,
it’s not easy to put mindfulness and compassion into a CBT
formulation.
Mindfulness is concerned with how
we experience our individual existence. I try to write about this,
but I always find that there’s a dearth of words in English
to describe these powerful experiences. Compassion concerns those
other powerful experiences when, in some extraordinary way, we’re
able to make a connection with another person, even though each
of us is trapped in our own world of meaning. Again, our language
lacks the words with which to talk about these experiences.
All my work has been concerned with
how we experience our sense of existence and our connections to
other people, and how we make sense of our world. My first article
on this was published in 1971, and I’m still writing about
it because I can never come to the end of understanding what it
is to be a human being. I continually see something new, or something
that I’ve seen before, but now from a different angle. No
one can ever be a trained therapist. You can acquire a certain amount
of experience with which you might be let loose to engage in a conversation
with a trouble person, but you never come to the end of discovering
what you need to know.
CBT is a dishonest therapy in that
it fails to acknowledge the basis on which it has been built. The
use of the categories as set out in the DSM in the curriculum of
the IAPT (Improving Access
to Psychological Therapies) implies that the dysfunctional cognitions
in depression are caused by that disorder. Many CBT therapists don’t
acknowledge, or perhaps don’t know, that CBT is actually based
on the proposition that what determines our behaviour isn’t
what happens to us, but how we interpret what happens to us. This
proposition has a secure base in what neuroscientists have discovered
about how our brain operates. Neuropsychologist Chris Frith wrote,
"Even if all our senses are intact and our brain is functioning
normally, we do not have direct access to the real world. It may
feel as if we have direct access, but this is an illusion created
by our brain." He also wrote, "Another of the many illusions
which my brain creates is my sense of self. I experience myself
as an island of stability in an ever-changing world." [i]
What we experience isn’t the
real world but the guesses which our brain has constructed about
the world, using the interpretations of our past experience which
our brain has stored. Since no two people ever have exactly the
same experience, no two people ever see anything in exactly the
same way. Our constant stream of interpretations in the form of
thoughts, feelings or images develops a kind of whirlpool which
we call our self or our sense of being a person. Whirlpools aren’t
stable. Our self, the most important part of our existence, is made
up of guesses that can be proved wrong by events. When this happens,
we feel that our sense of being a person will vanish like a wisp
of smoke in the wind, and we are terrified. We create all kinds
of defences to prevent our self being annihilated. Some of these
defences are what CBT therapists call dysfunctional cognitions.
When I was training as an educational
psychologist in 1961, one of my teachers, Bess Kemp, told me the
one thing that is always found in therapy. She said, "the presenting
problem is never the real problem." In mental distress the
real problem always arises from some kind of threat or insult to
the sense of being a person. This can be hard to uncover, and difficult
to ameliorate. It is never amenable to a quick fix.
Ref: [i]
Making Up the Mind Blackwell Publishing, Oxford, 2007, p.40, p.169.
*
Dorothy
Rowe is a clinical psychologist and author
of 15 books, including Depression:
The Way Out of Your Prison and Beyond
Fear. Her latest book, What
Should I Believe? considers beliefs about death. Dr
Rowe
is Emeritus Associate of the Royal College of Psychiatrists
.....
Giving CBT
a bad name
From:
Ingrid Wolpert, psychotherapist (CBT-trained), Brussels, Belgium
Date:
October 10, 2008
The author seems to contradict herself. On the one hand, she presents
CBT as a quick fix which is bound to fail and even "dishonest",
then she moves on to argue that better therapy is about understanding
the threat to our real sense of self, our "person". Our
sense of self is based on our interpreation of events, other people
and ourselves - indeed! That is what CBT is about - trying to challenge
a construction of a "reality" that may, in fact, be inaccruate,
by different means - changing the way you think, but also, very
importantly, modifying your behaviour. Well-trained CBT therapists
know this and it is a shame that some therapists trained in other
schools misunderstand CBT and try to give it a bad name.
.....
Mindfulness
research
From:
Shamash Alidina, MBSR
and MBCT teacher, Hampton, Middlesex
Date:
October
15, 2008
Interesting that Dorothy mentions mindfulness. Mindfulness has been
combined with CBT to create MBCT which is particularly effective
at reducing depression in those with more than three major relapses
into depression.
This
research has been repeated and found to hold true. In the US, mindfulness
based stress reduction, very similar to MBCT, has also been found
to reduce blood pressure, pain perception and much more. See www.learnmindfulness.co.uk/research.html
for research in this area.
.....
Disorder
or not?
From
Roger Kostick, private practice counsellor, Aberdeen, Scotland
Date:
October
15, 2008
In reference to the "Giving CBT a bad name" comment, the
use of the categories as set out in the DSM in the curriculum of
the IAPT (Improving Access to Psychological Therapies) implies that
the dysfunctional cognitions in depression are caused by that "disorder"
ie
the "disorder" causes the dysfunction. That is not my
"interpretation" of what causes distress... so I see no
contradiction.
.....
More to psychological
support than CBT
From:
Louise Pembroke, mental health activist, London
Date:
October
15, 2008
I believe most things have a place, including CBT, but Dorothy has
a point in that CBT has been somewhat evangelised no matter what
the evidence base is.
Our
mental health services on the whole offer medication and CBT - little
else. Now this is fine if you find medication and/or CBT helpful,
but pretty dire if you don't. 'Psychological interventions' all
too often means only CBT and I think there's more to psychological
support than CBT alone. It has been politically hijacked [along
with the equally evangelised "recovery movement"] because
it suits political agenda
.....
Rowe's out-of-date
tirade
From:
Sharif El-Leithy, clinical psychologist, Trauamtic Stress Service,
South West London and St George's Mental Health NHS Trust
Date:
October 16, 2008
As for similar recent tirades (1,2 see below), Dr Rowe's understanding
of CBT seems to rely on a simplistic and frankly out of date analysis.
Understanding
and constructing meaning in relation to the self lies at the heart
of modern CBT (3 see below), but with it comes an emphasis on empiricism.
Dr Rowe would do well to test her own assumptions out first, before
criticising others. As Veale notes: "Anecdotes and personal
experience for a particular approach are for the media – not
for making public
policy decisions"
1)
Leader, D. (2008) A
quick fix for the soul. The Guardian, 9th September 2008,
2)Samuels,
A (2007) Letter
to the Guardian, October 12 2007
3)Butler,
G., Fennell, M. & Hackmann,A. (2008)Cognitive-Behavioural therapy
for anxiety disorders. G uilford press.
4)
Veale, D. (2008)
Psychotherpay in dissent. Therapy today, February 2008
.....
Inaccurate
and unfair criticism
From:
Kelly
Elsegood, clinical psychologist, CAMHS, Liverpool University.
Date:
October 29, 2008
I was surprised by Dorothy's underestimation of CBT therapists'
understanding of their model, by stating: "Many CBT therapists
don’t acknowledge, or perhaps don’t know, that CBT is
actually based on the proposition that what determines our behaviour
isn’t what happens to us, but how we interpret what happens
to us". I strongly suspect that ALL CBT therapists will be
aware of this fundamental proposition, which is integral to CBT.
Indeed, in their first therapy session, many clients are 'socialised'
to the CBT model using an example of a protagonist who reacts differently
to an ambiguous event depending on how s/he interprets the event.
I
absolutely agree that CBT is not the panacea for all, however I
feel that this particular criticism of CBT therapists is inaccurate
and unfair.
.....
Theoretical
flexibility helps outcomes
From:
Chris Spencer, CBT therapist, Telford & Wrekin Primary Care
Trust
Date:
November 5, 2008
As previously described, CBT is based on sound research evidence.
In addition to its strong scientific basis it also has intuitive
appeal.
However,
as I'm sure many CBT therapists would to agree, it is better when
the peg fits the whole, and when it does CBT works extremely well.
Unfortunately,
however, people do not usually fit into neat little boxes, which
is where CBT can become (in my opinion) unstuck.
In
this situation a grounding other theories and techniques can provide
the flexibility required to ensure good outcomes.
Fortunately
I believe that practicing CBT therapists can recognise that a strict
and unbending adherence to the CBT model is not a good idea. And
those who cannot probably step outside of the model without even
realising it.
.....
Meta-analysis
shows relationship more important than therapy-type
From:
Brent Magee, psychotherapist,
Harley Street, London.
Date: January 19, 2009
There is some truth in what Rowe says. For example, in Germany were
therapy is provided by health insurance, there is a strong emphasis
on CBT. Most psychologists in Germany would agree that this is because
insurance companies don’t want to pay for therapy for any
length of time. The CBT approach which is short term intervention,
suits the insurance companies and therefore this is the preferred
approach.
Perhaps this is what Rowe is getting at. Because of the nature of
CBT, and the timescales involved in therapy, CBT is an attractive
and cheap option. However, that is not to say that CBT is not effective
in the short term, and that CBT can help people in some cases. But
as I think most therapists would agree, not one therapy fits all.
I have a great respect for CBT. In a way it is a reductionist approach
to therapy. I say this because it takes from other models the core
principles of the perception of our selves, and the world around
us, and attempts to change our perception and ideas about ourselves
and the world. This is absolutely nothing new. All models of therapy
have the same principle; however, most other therapy models also
consider “our story”, our past”, and “our
journey”, as well as the emotional impact of all these things
on our lives.
As I mentioned before, all therapy models in one way or another
seek to change our beliefs about ourselves, our past, and the world
around us. This is why in the last meta-analysis, no one therapy
type was considered to be better than another. In the meta-analysis
it was stated that this was due to the relationship between the
therapist and the client.
However, more importantly it was because all models have at their
core the principles I have already mentioned. They all have the
ability to help change our ideas and beliefs about ourselves, and
the world around us.
Also, correct me if I am wrong. But is most of the evidence for
the effectiveness of CBT not based on questionnaires? For example,
the client states how bad they feel on a scale, and then how they
feel after CBT on a scale. I am not sure if this is what would we
could call scientific evidence, however tempting it might be to
assume this. Questionnaires are not the most effective form of evidence
gathering, as the information given is both subjective and can be
affected by many other uncontrolled variables.
Finally, there is no doubt that CBT is a very effective form of
therapy, but like models before it, CBT will be one day be replaced
by something else. This is the history of psychotherapy.
......
Criticising
CBT as one therapy is meaningless
From:
Charles
Hamblet, cognitive therapist/supervisor, Staffordshire, UK
Date:
May 28, 2009
The term CBT includes so many different approaches that to criticise
or indeed recommend CBT as therapy per se is, I believe, actually
becomingly increasingly difficult to quantify, (for instance this
could be referring to behavioural, cognitive or schema-focused psychotherapies
or some of the 3rd or 4th wave therapies such as ACT, mindfulness
etc, although I’m aware the BABCP has broad definition for
this) so to criticise CBT as one specific type of therapy is actually
meaningless .
CBT
has over the last two decades or so enjoyed an ever increasing evidence
base (whatever that should mean, and critics of RCTs will look dubiously
on this I know) for its effectiveness.
Critics
of CBT often describe how the approach has stolen interventions
from Gestalt or psychodynamic approaches - well okay to some extent
this may be the case. However crossover concepts such as transference
and counter-transference can’t possibly be exclusive to specific
schools of thought, can they? Such concepts when used in CBT have
very different connotations in cognitive psychotherapy than, say,
when used in a psychodynamic arena, depending upon the type of psychodynamic
approach that is.
In
addition to this I would suggest that most psychotherapies have
been influenced by other preceding schools of thought in psychology
and in turn philosophy of mind. Surely this is how theories develop
and become therapies in their own right ?
Some
of the comments I have read regarding criticisms of CBT seem a little
outdated by today’s ‘CBT’. Right now, I would
also suggest the biggest problem facing CBT is its own popularity
and unfortunately the manner in which the delivery of CBT is being
managed by some NHS managers who have little understanding of psychotherapy
or, dare I say, people, appearing to suggest that people should
be given only x amount of sessions as this is what the guidelines
say they require? This
is setting up CBT to fail, as it is presenting CBT in precisely
the way that the critics have described, making CBT seem like a
cold, uncaring reason-obsessed therapy which essentially is about
‘pulling yourself together’. In addition to this I would
suggest the job descriptions of the IAPT workforce such as high
and low-intensity workers is unhelpful, as I fear it coveys the
wrong message to the patient.
Finally,
I get so flippin' tired of hearing from the latest all ‘knowing
celebrity expert psychologist or psychiatrist’, who let's
face it, probably has their own latest book to promote. How many
more times will the BBC or ITV wheel out these people?
What
these people express are only opinion and statistical interpretation
and not the absolute truths of some all-knowing god, which sometimes
I fear is the manner in which they are presented!!
This
I fear creates a misrepresentation to the general public, and creates
a poor impression of what I feel are the genuine good intentions
and hard work of the IAPT (even with all its faults) programme.
......
Rowe, Voltaire
and friends helped me
From:
Sarah Staynings, unemployed, London
Date:
June 19, 2009
My experience of CBT is from a patient's point of view, but as a
sufferer of OCD and anxiety I found CBT 'homework' impossible to
benefit from as I was being asked to make note of events and emotions
at the very times when I felt like crap and couldn't manage to deal
with anything.
I
have also found many counsellors and phsychotherapists knowledgeable
in psychology, but deeply lacking in worldliness and life experience.
They seemed non-plussed by a case that doesn't adhere to the textbooks,
which is a shame.
I
have a copy of Rowe's book on depression, which is not strictly
what my mental health problem problem is, but I did relate to alot
of what she advised and speculated over and as an outsider who has
experienced various practitioners of the CBT technique I have to
say I agree with her in part. I found I made more of a personal
breakthorugh from the information in her book and from reading philosophers
like Voltaire a long with the support of friends.
......
Yes, a quick
fix
From:
Victoria Nicholas, gardener, Cornwall, UK
Date:
August 3, 2009
I have been experiencing depression and anxiety for over 10 years
now. I've seen doctor after doctor, taken different medications
and sat in the middle while psychiatrists battle over my diagnosis.
I
successfully fought for NHS help last year and at last won. My CBT
sessions started in January. I've experienced more progress since
January than ever before - so yes it is a quick fix! I've still
got a long way to go and I know it'll be a life long battle, but
for me it helps remarkably. If it helps in some way surely that's
good. I don''t think there is one all-encompassing therapy to beat
all aspects of mental ill health
Add your
comments
What
do you think? Email your comments on the above
article to the editor using the form below. Selected comments will
be displayed.
© 2001-7 Psychminded Limited. All
rights reserved
Email
a colleague
about this article
|
|
