A Little More Conversation

By The Guardian1st July 2006News England

It is hailed as a quick fix for depression, schizophrenia, ME – even infertility. Now the government sees it as the answer to Britain’s widespread mental health problem. So what is cognitive behavioural therapy? And does it really work? Helen Pidd investigates.

From her early teens, Katie had two nicknames. They were “Fat Sharon”, inspired by Pauline Quirke’s character in Birds of a Feather, and the more self-explanatory “Womble”. Though meant in jest, the taunts cut deep, and by the time she was 16 she desperately wanted a way to make the bullying stop.

More than a decade has passed since she first managed to stick two fingers far enough down her throat to trigger the vomiting reflex. Now 27, the chronic blisters below her knuckles are testimony to her long struggle with bulimia, formed after more than 3,000 brushes with her upper teeth. She has tried “everything” in order to shake the condition. “Self-help books, self-help groups, acupuncture, psychiatrists, both the NHS and private, psychologists, people-centred counsellors, antidepressants,” she lists. “And probably some others I’ve forgotten.”

One approach she has tried over the past few years, and continues to be treated with regularly, is cognitive behavioural therapy (CBT), a “talking” therapy which was largely ignored until 10 years ago but which, as well as being used as treatment for bulimics, is suddenly being touted as the best “evidence-based” (ie rigorously scientifically tested) cure for just about everything, from depression and phobias to schizophrenia, ME, obsessive compulsive disorder and obesity. In perhaps the most astonishing study yet, scientists last week from Emory University in Atlanta, Georgia, US, suggested that it could even combat infertility. In a small pilot study of women who had not had a period for at least six months, CBT appeared to kick-start ovulation in some 80% of cases.

All this, from between five and 20 hours of very structured conversation. No wonder many people are asking where the catch is with this ostensibly quick “fix”, which undoubtedly appeals to our modern consumer instincts. In a world where everything from food to weight-loss is delivered in double-quick time, a therapy that can apparently be knocked off in a matter of months has a definite allure.

It is definable, in general terms, as a kind of talking therapy which is based on the belief that psychological problems are the products of flawed or irrational ways of thinking about yourself, the world and other people. Its very broad aim is to evaluate realistically – using a rigid, structured approach, often including the setting of homework – why a person feels a certain way, in order to modify their negative thoughts and improve not just their mood but also their behaviour. In fact, CBT works on the assumption that while it is often easy to talk about doing something, it is much harder actually to do it. It is a bit like getting a helping hand from a sort of benevolent thought police, administered one-on-one or in a group by a doctor, nurse, social worker, occupational therapist, physiotherapist, counsellor, teacher or psychologist. Anyone, in fact, who decides they want to practise CBT. You can even do it on yourself, with the help of a CD-rom or self-help book.

Every Tuesday, Katie goes to her local community mental health centre in Essex for a one-on-one session with a psychotherapist trained in CBT. When her name is called, she goes into the small room, gets out her homework – a food diary, risky situation worksheet, shifting core beliefs worksheet, thought monitoring worksheet and other assorted bits of paper – and the therapist asks her to go through everything she has written down. Where was she when she started to binge? What was she doing? Who was she with? What may have triggered it? How did she feel before/during and afterwards?

There is no couch, no “tell me about your childhood/dreams/father”. Barely any mention will be made of her past. Instead, the therapist tries to encourage Katie to rationalise her thoughts now, to see the connection between her feelings and her actions. He tries to recognise unhelpful patterns of behaviour (“I ate a whole loaf of bread, then made myself sick because I felt ugly and fat”) and replace these with more realistic or helpful ones (“I don’t need to binge. I have other ways of controlling my emotions, like calling a friend or going kickboxing). This very practical, proactive approach is rather different from the classic modes of therapy, which one CBT convert describes as “frustratingly fluffy and meaningless” and “encouraging you to feel you are not responsible for your own personal wellbeing”.

Getting people to talk about their problems in a logical, meaningful way is not rocket science, but it is this sort of therapy that the government, with the help of its “happiness guru”, economist Professor Richard Layard, wants to ramp up and make available for the one million people receiving incapacity benefit in Britain because of mental illness. According to the Depression Report, released last week by Layard and a group from the London School of Economics, mental illness has taken over from unemployment as today’s greatest social problem, costing £17bn a year. It came hot on the heels of the results of a huge public consultation conducted by the Department of Health last year for the Our Health Our Care white paper, which showed that the second most popular thing people wanted from the NHS (after free care for the elderly) was access to more counselling and therapy.{mospagebreak}

In the face of not-terribly-strong competition from more “traditional” forms of psychotherapy, which have tended not to be subjected to rigorous clinical trials and are generally far more costly because of the longer time involved, CBT has been pinpointed as the most economically viable and evidence-based answer to Britain’s widespread mental health problem. Layard and co claim that with fewer than 16 meetings with a therapist (at a cost of just £750 to the state), at least half of people with depression or clinical anxiety can be cured completely. It is this kind of hype which has prompted some to hail the treatment as the new cure-all – or as one rather more sceptical psychiatrist put it, “the bollocks du jour”.

It was as recently as 2003, almost 30 years since an American doctor called Aaron T Beck developed CBT, that Nice, the government body set up to advise on best treatment, began to recommend CBT as either the first-line treatment or an adjunct treatment for anxiety, depression, eating disorders, obsessive compulsive disorder, post-traumatic stress disorder and schizophrenia. Despite – or because of – these recommendations, demand far outstrips supply. Though the Department of Health says that there are as many as 60,000 practitioners trained in CBT in the UK (48,553 of whom are psychiatric nurses), this figure is misleading, because the majority do not exclusively practice CBT. According to Layard, the waiting list for an NHS referral through a GP for CBT can be up to 18 months, but if a government-led series of pilots goes to plan, from 2008 CBT could be offered to millions of Britons.

Jennie Bowden, a 29-year-old recruitment administrator from Sheerness, is one beneficiary. She had been having seizures for three years, unexplained fits that would put her in a trance for minutes at a time. Initially diagnosed as frontal-lobe epilespy (a brain disorder), doctors subsequently decided that the roots of her condition were psychological and that her seizures were non-epileptic. She started seeing a therapist at the Maudsley psychiatric hospital in south London for an initial course of 10 one-hour sessions, and less than a year on, is now having only one fit a day (compared with five, pre-CBT).

“It’s like going back to school,” she says. “I take notes – it’s like taking lessons in how to retrain your brain.” It is, she says, a very pragmatic approach. “One thing I discovered that sets off my seizures is – and this might sound strange – the cord of a telephone. If I stared at it for too long, I’d have a seizure. CBT has taught me how to concentrate on just one tiny detail of the cord, rather than the whole thing, and channel my energy into that rather than the whole thing. And it works so quickly.” The somewhat jaw-dropping speed at which CBT reaps results is, of course, particularly appealing in today’s fast-moving society, and marks a real cultural shift in the way mental health is treated. Compare it, for example, to psychoanalysis, which often takes many years to “complete”.

There is no doubt that CBT has the weight of scientific evidence behind it when compared with other forms of psychotherapy, such as the let-them-talk-freely ideas of Rogerian counselling or psychodynamic therapy, which tend to be much harder to subject to clinical trials because of their more nebulous nature.

But while there are few, if any, mental health specialists prepared to dismiss CBT out of hand, there are a significant number of experts who feel that CBT is being grossly oversold. The primary objection seems to be that it doesn’t work for everybody (not even nearly, say some), and that this one-size-fits-all approach may ride roughshod over more traditional forms of therapy which can be just as – if not more -worthwhile in many cases. A year ago, there was even a debate at the Institute of Psychiatry entitled: “CBT is the New Coca-Cola: This house believes that cognitive behavioural therapy is superficially appealing but overmarketed and has few beneficial ingredients.”

Phil Richardson, professor of clinical psychology at Essex university, who also heads the psychotherapy evaluation research unit at the Tavistock clinic in north-west London, is one voice of dissent. “While I am in no way against putting more money into mental health, the available empirical evidence does not support many of the claims that are being made for CBT,” he says. “There is a risk that those involved in delivering the psychological therapies will end up with egg on their face when the wild claims are shown eventually to have been false.”

Richardson thinks that Layard’s big idea – the notion that it is possible to get depressed people off incapacity benefit and back into work with up to 16 hours of CBT – is fundamentally flawed. “While many studies have shown that it is effective for people with simple, uncomplicated depression, there is no good evidence to suggest that the kind of depression suffered by people who are signed off work – that is, those who have been treated with no success at least once – can be helped by CBT,” claims Richardson. He and a colleague have conducted a systematic review of the available evidence and says that the trials are almost exclusively conducted on patients with mild, first-time depression – “those who have nothing else wrong with them to complicate things”. He concedes that the logic behind this is reasonably sound: traditionally, good clinical trials use a clearly defined treatment on a clearly defined group of people because they are relatively easy to control. But the problem is that in order to be signed off work, the chances are that your depression has gone past the mild stage.

Katie, who is soon to become an in-patient at a London hospital, and whose bulimia prevents her from holding down a job or having any real structure to her life, agrees. “It’s good that CBT deals with the here-and-now, and I do find it helpful to a certain extent, but for me it has come too late. My problems were left undiagnosed and untreated for too long. I had already been bingeing for more than four years when I first sought treatment.”

Another woman told the Guardian that she was turned away from one private CBT therapist for having “too many intertwining problems”. Though she went along ostensibly to address her depression, when she admitted underlying problems with an eating disorder, the therapist refused to treat her. “CBT is very inflexible,” she says.

While the jury is out on whether CBT can really help those with serious, complicated and long-term mental health problems, it is in some way becoming the “acceptable” face of therapy for those with less chronic problems – particularly those who would rather suffer in silence than lie on a couch and tell strangers about their dreams.

Take Stefanie, a 37-year-old primary school teacher. “I’m not an introspective person,” she says. “I’m not the sort of person who goes to therapy.” But she did, last year, for eight sessions at £45 an hour, after a harrowing experience when her child very nearly died. “After my son was so gravely ill I started to react out of all proportion at any sign of illness. Because something so catastrophic had happened, I lost the ability to know when to fear the worst. CBT taught me how to recognise the difference between rational and irrational anxiety. After just eight hours I feel that I now have the tools to draw on if I need to.” Karen liked how specific it was. “It’s not a huge commitment, like going into analysis. It can be done relatively quickly.” {mospagebreak}

But despite CBT taking a relatively small amount of time, it can be a deceptively large commitment. “In theory it’s fantastic, but in practice it’s completely useless unless you are incredibly self-motivated and have the time and determination to put the effort in,” says Janice, a 31-year-old advertising executive who had seven hours of private CBT a few years ago after her GP told her there was a two-year waiting list for NHS treatment. “If you don’t bother doing one, if not two, hours of homework every night – recording and monitoring your moods and thoughts – it won’t help at all.” And there is one other key thing: “You have to already have admitted to yourself that you have a problem.”

Even CBT’s greatest proponents admit readily that the treatment has its limits and caution against billing it as healthcare’s great white hope. “There is the danger that CBT is being oversold as a cure-all. But no treatment is a cure-all,” says Philippa Garety, professor of clinical psychology at the Institute of Psychiatry and head of psychology at the South London and Maudsley Trust, who has conducted a lot of research into CBT and schizophrenia. “What is true, however, is that CBT is useful for quite a number of problems because so many things are related to how we experience and make meaning of the world.”

It seems unbelievable that a condition such as schizophrenia, which is not just “all in the mind” but, most people now accept, is a brain disease, can be ameliorated by a talking therapy such as CBT. But, says Garety, it can – not as an exclusive treatment, but typically as an adjunct to medication. “Medication often helps change people’s acute psychotic experiences, to reduce the over-arousal of the brain, but it doesn’t always help to change how they felt about them at the time. As an example: a schizophrenic man who, after medication, had stopped seeing things jump out of mirrors at him, was still acutely troubled by the sense that he was being watched. He thought there were cameras on every street corner, above his bed, in his flat. Nothing was private any more and he was very distressed about it. Although the acute episode had been resolved, he couldn’t change the way he felt, and he didn’t want to take drugs in the long term. CBT was able to help him, because we looked at how he was making sense of his experiences, and at his triggers. We looked at why when a family member phoned up and said, ‘Are you ok? you sound down,’ he interpreted that as meaning that they had put a camera in his flat which is how they knew he was having a bad day. We were able to unpack these thoughts and feelings in the context of his relationships, and discuss what we termed his ‘paranoid default’. After 20 hours of CBT spread over a year, this man (who had been schizophrenic for 10 years) stopped thinking that he was being watched.”

But while the Department of Health diverts money to CBT, what happens to other therapists? The psychodynamic therapists? The family counsellors? Perhaps understandably, they are feeling rather left out. “It’s a short-sighted policy,” says Keith Hagenbach, who since 2001 has been a self-employed NHS psychotherapist. “Therapists should be free to adapt an approach to each particular client rather than being forced to practice just CBT, which I think is only really effective in 10% of cases I see.” The Royal College of Psychiatrists, however, says that CBT is “the most effective psychological treatment for moderate and severe depression; as effective as antidepressants for many types of depression”.

Hagenbach thinks that the reason CBT is so popular among policy makers is because of their innately rational and logical bias. “It appeals to people on committees because those sort of people are likely to take an intellectual, rather than emotional, approach to an issue.” He and others worry that CBT is being seen as a one-size-fits-all treatment, “when the truth is that different people who have had relatively similar experiences can respond totally differently to the same treatment.” Another worry is that not everyone is very good at practising CBT – and that the CBT industry is currently unregulated. Anyone can set themselves up as a therapist despite the existence of an accrediting body, the British Association for Behavioural and Cognitive Psychotherapies.

But despite the grumbles of dissent, one thing is sure: everyone involved appears delighted that mental health, so often described as the “Cinderella” of healthcare – underfunded and unappreciated – is finally getting the attention, and cash, is deserves. “We are often horrified and outraged that not everyone has access to certain cancer treatments,” says Professor Garety, “yet tens of thousands are suffering enormously from mental health problems, particularly depression and anxiety, and being denied access to treatments that have been proven to be effective.” CBT may not be a cure-all, but it can cure some. And for many, that’s enough

Some names have been changed.