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

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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 (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

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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.

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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.

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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.

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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

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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

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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.

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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.

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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.

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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.

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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.

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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

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The curse of other therapists simplifying CBT

From: Anonymous, IAPT Trainee, London
Date: September 27, 2010

I couldn't believe what I was reading when Dr. Rowe wrote '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 laughed out loud.

Dr Rowe does not acknowledge or perhaps does not know the fundamental principle of CBT, which Kelly Elsegood explained so succinctly..'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.'

Simplicity seems to have got the point across here and thus simplicity is not always a bad thing. As a trainee on an IAPT CBT course, which has been delivered by expert clinical psychologists, I struggle with other therapists cursing CBT and being the culprits of simplifying it. This therapy is indeed a goal-focused, short term therapy which is suitable for some but not all individuals. When it seems that an individual and CBT is not 'working' (though nobody said anything about a 'cure' except for Dr. Rowe), clinicians look for alternatives and refer on as appropriate. It is unfortunate however that there are very long waiting lists for the other therapies .

This therapy is 'collaborative' - another hallmark of CBT - the individual is an equal partner, asked to devise meaningful homework tasks to help them generalise what happens in the session in the real world. If the homework tasks are difficult, that's the point of it - if they were easy, they would be pointless.

The clinician is supposed to facilitate the individual to find the courage, mindset and rationale to do the homework task. Homework is about helping the individual to be their own therapist, so they can help themselves if the problem arises again - see no "quick fixes" 'or "cures" Dr. Rowe, we anticipate 'relapse', it's only human after all. It is the individual who came to therapy, and it is the individual who is deemed to be the expert of their difficulty.

CBT is not about simplifying people's problems, it's about offering an alternative theoretical perspective, from the clinician who is the theoretical expert, (not giver of cures) to the client to help them make sense of their difficulty in some kind of framework.

This framework is based on realms of evidence, (not always so sound but certainly not so un-sound that it can be ridiculed or ignored) and this framework is merely a guide which helps to devise interventions targeted at what maintains the problem. Yes, Dr. Rowe, us CBT therapists focus on the here and now, at what maintains the problem in the present day - it is this which you might be confusing with simplicity. We are interested in a person's history, it can give us clues about their interpretations they make but it is only a clue, we can never be sure. Thats why we rely on Socratic Dialogue - another hallmark of our profession - constantly asking the client what something MEANS to them - this is how we access their INTERPRETATION Regarding the government's decision to offer 'chea' and the 'simplest' of therapies..the clue is in the name 'IAPT' - 'Increasing Access to Psychological Therapies' - making psychological support more available to more people. Is this such a bad thing? It does not rule out other therapies or suggest that they are no good. CBT is just one option and many people prefer the shorter term option and the goal-orientated approach. Many people probably do not prefer that, I've got clients who I feel probably do not really like the CBT approach or maybe they don't like me. Ooops - I better not go there, CBT therapists couldn't possibly entertain the concept! of dynamics between client and clinician - that's too complex for CBT isn't it! Funny, all of this, I'm actually writing an assignment and typed in google 'conceptualising transference in CBT' and found this article! OMG - I couldn't dare to poach a psychodynamic idea could I? Yes I bloody well can! It's an idea that influences my understanding of myself as a clinician - yes, CBT therapists even reflect on their practice you know!

My therapy may not be based on ideas such as transference and counter-transference but I can still reflect these ideas. CBT is a practical focused therapy, helping individuals to change their behaviour and recognise unhelpful thinking styles so that they can be aware of how their mood changes in relation to thought and behaviour (and in relation to one another.) But this doesn't mean that there aren't inetrpersonal dynamics between people that affect how people present and interact within sessions. I can still value that idea can't I? I won't incorporate it into my formulation (sadly, admittedly) but why do we have to be so damn precious about these ideas?

I am glad to refer some of my clients to psychodynamic therapy because I value the principles of psychodynamic therapy. They are different to CBT and the approach is different and suits some people. It's a shame Dr. Rowe has been so derogatory about CBT. It's not the fault of CBT therapists that the government decided to fund a roll-out programme 'IAPT' to help the masses. It doesn't mean that CBT therapists do not value other therapies. The way you and I interpret things is indeed very different Dr. Rowe. Anyway, I'm ranting and avoiding my work. Avoidance - a key CBT idea: my behaviour - of avoiding things - maintains my sense of not being able to cope and my thoughts of being a fraud and my inner belief that really, I'm a failure. So, perhaps I could change the avoidance behaviour and test out how that makes me feel..I usually find that dropping the avoidance tends to make me feel better as I discover that I can actually do these things, maybe not as well as Dr. Rowe, but good enough.

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From:Katherine Riley, CBT therapist, Midlands, UK
Date: September 28, 2010

It is interesting that Dorothy Rowe writes this article on the dawn of the new IAPT training which began in 2008, and I cannot but imagine that much of these debates and criticisms 'may' be about other therapists/counsellors feeling threatened.

Thus, as Dorothy Rowe refers to here, is Dorothy herself not feeling threatened by the influx of CBT therapists into the NHS? Thus, a threat to her sense of self that she refers to here and her therapeutic background?

These debates appear to go round and round in circles. As a CBT therapist myself it is pointless defending my position as those not in favour of CBT will just come back with further counter arguements in order to defend their own positions. I can only say I am tired of such debates. I am also concerned for patients 'googling' CBT that they are reading such biased accounts of CBT.

As CBT therapists we could criticise other therapies for their perceived shortcomings but what would we gain from doing so? Every therapy has its flaws and limitations, human beings are complex and we will never get it completely right' whichever therapeutic or personal backgrounds we come. Indeed as therapists we are human beings who make mistakes regardless of our particular therapeutic background! We cannot claim also that there is one therapy that works for all. However, it is possible that some people may benefit from CBT, others may benefit from Psychodynamic and others may benefit from a Person Centred approach and so on.....

I know there have been some recent moves to the integration of more therapies (other than just CBT) into the NHS and CBT therapists would be overjoyed to have other therapists and counsellors join them! Bring it on! We can then all get together and WORK together rather than attempting to defend our own positions as if they are polar opposites!

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From: Vicky Thomas, Service User Involvement, Leeds
Date: January 17, 2011

I received cognitive therapy and whilst the occasional thing was useful, it needed to be combined with other things. Bits of paper given to me were not that helpful, as I was too anxious to take them in.

The stuff the therapist came out with, often I didn't believe and he tried to make everything too positive. Whilst positive reassurance is really helpful, I can't help thinking that I could deliver that to someone, and why would you train for it?

It didn't unwind me, it didn't solve things, and it didn't give me clarity, rather it actually made things worse by brushing over things and trying to make things as though they were okay. Unrealistic, patronising.

Bits of CBT can be useful, but to be entwined with more general counselling or therapy. CBT on it's own is inadequate - it's the tomato sauce on a bacon sandwich, the tomato sauce on it's own won't do the job!

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Rowe book dangerously dedicated to case against medication

From: Service user, UK
Date: August 29, 2011

I recently obtained Dorothy Rowe's book 'Depression - The way Out of Your Prison' and I found it extremely unhelpful. She thinks medication is useless (rubbish!) and that those who are depressed are suffering from a case of extreme self-centredness rather than an actual chemical imbalance in the brain. All this I gleaned in the first 100 pages, before I put the book down in disgust.

When I was 21 and experienced a psychotic depression, without a short course of chlorpromazine I would still be wandering round catching buses in my bare feet in the January ice no less, and thinking God is talking to me. Once the chlorpromazine had done its noble duty, I began to take a tricyclic antidepressant, and have done since - I am now in my early 30s.

Over time I have been able to decrease the dosage, as my brain rebalances itself (seems that's what it is doing!), from 50mg daily, bu monitoring myself on the lowest therapeutic dose. At the current rate of dose reduction (20mg right now) I should be off it altogether by age 40, and I credit both drugs with saving my life, and restoring my personality.

Nor is depression about 'punishing' members of the family by 'Retiring To Your Bedroom In High Dudgeon' (p88) as she puts it. It's about getting away from other people, for their benefit as much as your own, whilst you recover from the low mood that has descended upon you out of nowhere. Seems to me she was so badly affected by her mother's attitude towards her, who from Dorothy's descriptions sounds more like she had a personality disorder like borderline rather than depression, that she has made a career out of it, simultaneously lacking the self awareness that she needs therapy herself!

Both CBT and medication have proven results in patients, of all diagnoses. It's frankly dangerous to dedicate an entire book to the case against medication, and encourage people with severe mental illnesses to chuck the tablets that keep them (and society) stable! By her reckoning (see page 260 of the book for the entry on schizophrenia) those with severe illnesses like schizophrenia, bipolar and other disdorders should not be on medication, because chemical imbalance has never been 'proven' biologically. I am living proof, having suffered a psychotic episode, that I NEEDED medication! No amount of reasoning from those around me could have brought me down from the rafters, and I shudder to think what would have happened to me had I been living 50-100 years ago before the drugs were developed. Honestly - read her book, this is the basic premise of it. It's actually quite dangerous, not just irritating and insulting to those of us with depression.

Medication and therapy (especially CBT) are essential for recovery from mental illness whether acute or chronic. Dorothy Rowe is a disappointment to say the least, considering her apparent status in the psychiatric community, and I recommend you read her books for entertainment purposes only, seeking healing elsewhere.

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