Junk medicine: Cognitive behavioral therapy
November 04, 2006
by Phillip Hodson, The Times
Talking cure is cheap The five main mental health charities [in the UK] have announced their support for the planned expansion of NHS psychotherapy, with a broad emphasis on Cognitive Behavioral Therapy (CBT). But is CBT – a talking therapy that attempts to train your thought patterns then alter your behaviour – the best investment?
An ideological struggle has broken out between two of our leading “happiness thinkers” about whether the claims made for CBT can be justified. On one hand, Tony Blair’s adviser, the economist Professor Richard Layard, is about to launch a health service program of CBT nationwide employing 10,000 novice recruits. On the other, psychologist Oliver James tells Daily Mail readers that CBT only appeals to Tony Blair because it is “quick, cheap and simplistic” but is seriously lacking in long-term efficacy.
So what does the evidence say? First, that it is reasonable for the Government to turn to the psychological therapies as the front line treatment for conditions such as anxiety and depression when the routine prescription of benzodiazepine tranquillizers and antidepressants costs more than £11 billion a year and can yield disappointing results.
In CBT’s favor is the fact that, as a talking therapy, it does what it says on the label. To take the simplest example, if you believe nobody loves you then CBT therapists believe they need only to produce evidence that one person does love you for you to be proved wrong and for your behaviour to change.
The fact that, in a relatively short period, CBT has produced an impressively positive research base must be qualified by the observation that because CBT is tasked with “symptom removal”, not “treatment of the whole person”, research has proved relatively easy and cheap to undertake. Setting out to measure whether someone has got rid of a single symptom (such as spider phobia) leads to only two relevant answers: yes or no. It is much more difficult to evaluate a therapy seeking to show whether you have gone from “greater” to “lesser” unhappiness but the experience in itself might prove more life-changing.
Critics also observe that the case for standard CBT has been favored by the way the guidelines on anxiety and depression, sponsored by the National Institute for Health and Clinical Excellence (NICE), are presented. Much of the pro-CBT information is to be found in headline summaries; significant qualifying remarks about other valid therapies are found in the small print.
This matters because Oliver James is right about research in the longer term. According to the most authoritative sources, at least half those patients receiving CBT for panic disorder had suffered relapse or sought new help after 24 months, which isn’t very cost effective.
Last Monday, at a conference on Practice-Based Commissioning in Manchester, Professor Layard admitted that CBT is appropriate for only about 40 per cent of patients overall. Stunningly, the largest body of evidence into counselling outcomes, the 35,000 cases comprising the CORE Survey, has been totally ignored by NICE and Layard alike. Looking at the figures just for depression, CORE shows there is no significant difference in the long-term success rates for CBT over traditional forms of therapy such as “person-centered” or “psycho-dynamic”: CBT works for 75 per cent of patients; the rest for 76 per cent.
So a summary of the evidence tends to show that all talking treatments are roughly equal in effectiveness because it is the relationship with the therapist that counts. Patient choice should count, too. I suggest the NHS would be unwise to put all its eggs into a CBT basket.
I find debates like this distressing on many levels. First, the push toward fast, short-term “solutions” for all patients by governments, corporations, and EAP providers is based solely on financial considerations, not on the best interests of the patient or on clinical outcome research. On the other hand, opponents of the move to short-term solutions, like the author of this article, are equally biased, if in the opposite direction, and they seem to be more interested in territorial protectionism than in what is best for the patient. The facts are as follows:
1. CBT is a very effective component of a good treatment plan for many and probably most patients suffering from depression or anxiety disorders, and an excellent adjunct therapy for disorders such as schizophrenia, bipolar disorder, and borderline personality disorder, among others.
2. Pretty much every study that has ever examined the issue has concluded the medication plus psychotherapy is more effective than either alone for depression and anxiety disorders, both in managing the initial symptoms or crisis and in preventing relapse.
3. CBT is NOT simply symptom management. Individuals suffering from disorders such as depression and the various manifestations of anxiety DO exhibit faulty and distorted patterns of thinking and self-talk and there is no longer any doubt that this contributes greatly to these disorders. Thus, addressing and altering those negative self-talk patterns should be an integral part of any treatment plan for most patients with these disorders.
4. In a total treatment plan, CBT is an excellent way of helping the patient acquire symptom or crisis management strategies. However, it is often the case that once that goal is reached, it may be necessary to use interpersonal therapies or other treatment approaches to address the underlying and more chronic issues.
I would also suggest (a) that government economists and corporate financial advisors are not in the best position to evaluate the effectiveness of treatment approaches; and (b) that it is the obligation of mental health professionals to act more responsibly to educate those who are making such decisions. Articles and statements such as the one printed in The Times are simply not helpful – those charged with making the decisions will simply find the holes in the rhetoric and dismiss it as uninformed and oppositional.
CBT, cognitive behavior therapy, psychotherapy, research-based therapy, politics of health care, mental health care