Professor Ravetz is right. Cognitive behaviour therapy is Labour’s new therapy of choice. But why is it suddenly popular in government circles not previously noted for their interest in psychological treatments?
Talking therapies are nothing new, but despite their long history many have struggled to prove themselves in a health service dominated by the economists. Psychoanalysis looks at deep-seated reasons for why we are the way we are – but even if it can answer questions about the human condition, it has not proved a success in treating specific disorders, and often takes years not doing so. In contrast, counselling is usually brief and cheap, but is sometimes not much more than sympathetic listening and empathy. Neither is much good when it comes to treating well-defined conditions such as panic disorder, phobias, obsessions and compulsions.
Cognitive behaviour therapy does represent a genuine advance in the treatment of many conditions. Unlike psychoanalysis it does not depend upon searching inquiries into childhood or early life, or speculative forays into the unconsciousness. CBT is about identifying conscious thoughts – thoughts about dying when having a panic attack, for instance, or about being useless when in the presence of other people. And then it is about how we react to these thoughts and how these behaviours in turn impact back on our thoughts and feelings. Perhaps I was in a road accident some years ago. Now I refuse to get into a car in case it happens again, and get tense and anxious even thinking about it. What I need is to identify my fearful thoughts, understand how they relate to my experiences, and then start a cautious programme of overcoming these fears by gradually spending more and more time in cars, as I learn that it is not inevitable that history will repeat itself. CBT is directive – it is not enough to be kind or supportive, although CBT therapists should be both – what is also needed is clarifying the thoughts which are determining our reactions and planning new behaviours as alternatives to these previously unsuccessful ways of coping or managing symptoms.
CBT has one further advantage over its predecessors. Because it is easier to describe, monitor and evaluate successes and failures, and because it deals in measurable outcomes, it lends itself to the empirical approach. And so there is now a wealth of evidence sufficient to satisfy even the most sceptical health economist that CBT can and does improve outcomes in various disorders.
Randomised controlled trials, which remain the gold standard of evidence, have shown that CBT is effective not just in the classic psychiatric disorders such as post-traumatic stress disorder, major depression, agoraphobia or schizophrenia, but also physical disorders such as cancer or rheumatoid arthritis, and even disorders such as irritable bowel syndrome or chronic fatigue syndrome that lie somewhere in between. Of course, CBT does not cure cancer, schizophrenia or arthritis, but it does improve mood, coping and quality of life.
CBT is not a panacea. And yes, it is trendy. Too trendy – since in the largely unregulated bear pit that are the psychotherapies virtually anyone can, and many do, claim to be carrying out CBT. To become a skilled CBT therapist takes about the same length of time as it does to become a doctor. That raises legitimate questions about the new “Improving Access to Psychological Therapies” initiative. Sometimes known as the Layard initiative, after the economist who has steered the scheme through government, this is intended to add 3,500 new CBT therapists to the NHS workforce.
A predecessor, the “Graduate Psychology Programme”, which gave GPs access to psychology graduates who had not completed any clinical training and who became known colloquially as “barefoot psychologists”, ran into difficulties since many GPs found that these willing but unskilled personnel lacked the experience and qualifications to make any meaningful impact. The Layard scheme has learned from the past, but will need to ensure that improving access is not at the expense of standards.
Finally, is this really a sly scheme simply to reduce the staggering costs of disability benefits? The answer is no, not directly. The aim is to give everyone who is suffering from clinical depression or an anxiety disorder the option of an effective psychological treatment, regardless of whether they are on benefits or not. However, if that also means that some are able to re-enter the world of work, then so much the better. If there is one thing that has been established by a generation of psychiatric research, it is the strong relationship that exists between mental health and unemployment.
Simon Wessely is head of the department of psychological medicine at the Institute of Psychiatry, King’s College London
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