Sunday, April 22, 2007

Anyone for CBT...? (Part 3)

“CBT is the New Coca-Cola: This house believes that cognitive behavioural therapy is superficially appealing but over marketed and has few beneficial ingredients.”*

I have a colleague of whom I am extremely fond. He is warm, compassionate and highly intelligent. He is also a good therapist. He is good at making relationships with his clients because he is essentially likeable and trustworthy and cares a great deal about their situations. He does not pay heed to any relational dynamic in sessions, however, even if the dynamic is getting in the way of dealing with the content. He is confident in his therapeutic skills, but also aware of the limitations of his particular modality and is not afraid to refer someone on if he feels unable to help them. He will usually refer on either to myself (a humanistic psychotherapist) or to one of our person-centred colleagues. He is a clinical psychologist and a CBT practitioner.

We often discuss the differences in our methodology, theory and philosophical assumptions. Sometimes we agree. Sometimes we agree to differ. But we maintain a mutual respect both for each other and for our different disciplines and we share an understanding that we both have significant contributions to make to the clinic in which we work.

My colleague is very experienced in his field, having worked as a psychologist for the best part of 20 years. He believes that there are people for whom CBT just doesn’t work. These include:

  • Those who have experienced early trauma or abuse resulting in a fractured or disordered sense of self.
  • Those who have experienced early significant relational deficits, resulting in attachment difficulties.
  • Those who present with rigid defensive processes that they are ‘unwilling’ to give up (often referred to as ‘de-motivated clients’.)
  • Those who engage with the world primarily on a feeling and/or behavioural level, and find it harder to engage their thinking.
  • Those with a schizoid - or ‘shut down’ - process who have difficulty articulating their interior world.

The clinic in which I work has some very skilled and experienced practitioners, all trained in different modalities. We understand that we share many commonalities and that our ways of working are much more similar than they are different. We share a common assumption that the therapeutic relationship is of paramount importance. There is little dogma regarding modality, although there is occasionally some friendly banter. Irvine Yalom - an existential psychotherapist - said that we find a different therapy for every client. I like to think that I and my colleagues work in this way. That we use a wide range of skills, knowledge and processes to genuinely meet people in a place where they can start to contemplate change.

I think the key to our success is that we are skilled at assessing different psychological presentations and processes and ensuring that the individual is referred to a practitioner who is skilled at working with that particular process. For example, I am not so hot at working with the schizoid process. This is nothing to do with my training, knowledge or experience but is part of my own psyche. I am damn good at working with an ‘anti-social’, narcissistic or paranoid presentation however, which is lucky because most of my colleagues would see that as a definite hospital pass and are happy for me to take the referral. And so, hopefully, clients get an individual response to their individual needs.

My CBT colleague is as critical of the government’s current proposals as I am. (Which, in case you missed it, is to significantly increase NHS provision of psychological therapies, providing that the therapy is CBT. See previous post if you can be bothered.)

The government's proposals mean that a therapy will be prescribed before anyone has done an assessment of the individual's needs. I love Stray's analogy in the comments thread of my previous post: we have found that a plaster cast works well if you have a broken arm. You do not have a broken arm? Well, I'm sorry, then we can't help you. An ideal world would see NHS provision working along similar principles to the clinic in which I work, where rigorous assessment is the cornerstone of good practice and human beings run the system rather than the system running us. I can live in hope, I suppose.

*Debate held at the Institute of Psychiatry in 2005. I just fancied being provocative.

91 comments:

anticant said...

The Government's approach sounds like Henry Ford - "You can have any colour you like, as long as it's black".

"Stomach ache? Try one of our universal plaster casts."

Typical Blairism - makes one despair!

Boris said...

I have an idea, why don't we just add EFT to the National Curriculum and have done with it?

(rattle rattle)

Boris

Ms Melancholy said...
This comment has been removed by the author.
Ms Melancholy said...

Hey anticant, I despair too. I fear that we are having imposed upon us an obsessive-compulsive cultural identity: rules, regulations, structure, evidence-based practice, performance indicators and target culture. Whatever happened to creativity, intellect, professionalism, intuitive processes and trusting the essential integrity of human beings?

Hey Boris, great idea. And I could get a job at Morrisons. (Boris is referring to Emotional Freedom Technique for those who don't recognise the TLA.) Stop being provocative Boris. I am slowly losing the will to live.

Dandelion said...

Convince an enemy, convince him that he's wrong is to win a bloodless battle where victory is long.

Dandelion said...
This comment has been removed by the author.
Dandelion said...

Sorry. What I meant to say was this

Stray said...

Oh, thanks for the nod Ms M.

Dandelion ... I don't understand what the guardian article has to do with the discussion really?

I'm a mathematician. I apply my maths skills and my logic skills making computer software. I am a scientist, with an engineering degree and a specialism in modeling processes.

I know about the difference between reliability and accuracy, I laugh at the people on Deal or no deal who think the quarter million is 'due' to come to the table ... but I am still not a computer. I can't write down the sum of my life experiences and I can't tick a single box that ever describes an emotion I have experienced completely.

My personal experience, and one that many people I have spoken to seem to share, is that I am in therapy because life is simply not the logical, black and white, measurable thing I'd like it to be.

I think a lot of therapy (and this is just mho) is about finding the courage to be yourself. Faith, courage, love ... don't come out of problem solving exercises, they come out of experience ... and often they are about borrowing a little of someone else's (my therapist's) first, to lend to my own pile of acorns.

I don't doubt that if you can identify the problem - "Fear of flying" for example - then you can apply a particular solution. But, if the difficulty is that you simply don't know how to bear existing, CBT seems to me to present a really great solution: Change your mind or kill yourself. Fab!

Sx

Dandelion said...

Hi Stray

I just think people are being a bit unfair to CBT, when some of the principles of it work very well for some people. In some of the discussion, the words baby and bathwater spring to mind. If you "dumb down" any therapy, I think the result would be equally ridiculous.

I mentioned the journal article in the context of the objectivity issue, and the importance of research in making any claims about therapy, rather than resting arguments on our intuitions, however self-evident they may seem.

Ms Melancholy said...

Hey Dandelion, I am unsure as to what you want to convince me of?! I haven't said that CBT should be 'thrown out with the bath water' and I don't think anyone else is saying this either. Maybe you could convince me that it should be the only therapy available on the NHS? That seems like a much more extreme, biased, uninformed and blinkered view than the one that I am proposing.


The research component of the argument is interesting. I repeat what I said in the previous post:

Hi again Dandelion, the evidence base for CBT is wildly exaggerated. There is an increasing body of evidence from neuro-science (proper boffins with white coats and everything) that paying full attention to the therapeutic relationship/dynamic results in different neural pathways being formed and an increase in positive neuro transmitter activity. It's very exciting new research for psychotherapy. Will post some links at some point.

Böbø said...

Oh Stray, I think I'm developing a crush on you. It must be Ms Mmmmmm's crushology vibe leaking out and infecting me. Yes, that must be it. Oh, and your wisdom.

Böbø said...

The research approach to therapeutic effectiveness is limited about what it can tell you.

You cannot do RCTs on depth therapy, where the content is so personal, the length too unmanageable, the subjects to vulnerable, and where the act of observation has an impact on the event.

How do you measure attachment, or a greater sense of self other than by reported internal experience? What of spiritual changes that can often occur during an intense period of personal reflection.

Science devalues the personal experience as evidentially untrustworthy. Because of that, research findings can only offer one, partial, and limited perspective on therapy.

The difficulties are such that even research into brief therapies such as the limited form of CBT the government is pushing lack significant longitudinal studies.

As in other areas of public life, targets and tests have become fetishised as the only means of exerting government policy control. Yet, in Local Government management by target is being abandoned, in Education, the narrow focus of teaching on to English and Maths and their continual repeated assessment by Sats is in retreat.

Statistical assessments such as CORE are a pretence of numerical certainty in a complex world than it can capture. My clients laugh at the questions when they fill them in and I cringe at the crassness.

So it is odd that Brezhnev-style management by targets is being foisted on to the provision talking therapies.

Psst: MsM, I got a badge for you from Cas, if you got stampeded in the rush and couldn't get your own.

Stray said...

Oh Dandelion - I didn't say anywhere that CBT should be chucked out the window! I think becoming conscious of our consciousness is a truly transformational experience, and for many people CBT is a first step towards that.

However, restricting ourselves to stuff we can measure, when the range of rulers we employ are so clearly not measuring much of significance, just seems to me to be silly.

I am particularly cheered when I read that finally it is being acknowledged that so much of what psychologists proclaim to be measured 'fact' is simply the narrow experience of undergraduate psychology students that the tests were performed on.

There was a famous fuckup on a NASA space project, when it turned out that pressing the thingmywatsit button brought up a light which was triggered not by the execution of the intended task being successfully completed, but by pressing the button. The light showed nothing more than that the button had been pressed. I'm sure that data 'proved' something, but I'm not sure it was useful.

I'm all for CBT in it's place, but when, as I've already said, my local mental health team can only offer me CBT, that's a messed up situation.

Bobo, thanks for the crush sweetie. You look big enough to actually physically crush me. Which is a bit scary!

Sx

Boris said...

Hello gorgeous, can you please explain to me why the NHS (or whoever has made the decision) has decided that CBT is the only therapy they are going to offer?

Where is the research which favours this particular style? Is there something else going on here? I am looking for a conspiracy theory, but as far as I know BigPharma don't get anything out of CBT and neither does the EU so who exactly is pushing CBT?

I have nothing against CBT, but only offering this therapy is like only offering one kind of painkiller ("Sorry, mate it's dihydrocodine or nothing") which a) doesn't happen, and
b) would be stupid, as:

all patients have individual needs and one size cannot and never will fit all (except for those glittery stretch tops in the market of course)

Being arrogant, I would like this to be the last word on the matter so can we have Part 4 now please?

Boris

Ms Melancholy said...

Hi folks, thanks for some great comments and debate. We may have to agree to differ on this one. Personally, I am unconvinced that Dandelion believes that CBT should be the only therapy that the NHS offers. And the discussion around what is 'scientific' evidence could rage and rage, but thanks for some very enlightening comments. I think we should call it a day :)

anticant said...

I am sceptical of the value - or possibility - of "scientific measurement" of the relative effectiveness of different therapies, or of any therapy.

What counts more than the particular therapeutic model is the sensitivity and insight of the therapist, which depends upon training of adequate length and depth and competent supervision.

Presumably the government bias towards CBT has to do with presumed cost effectiveness, but I don't know how this can be reliably measured either.

In the end, the only reliable judge of whether the therapy has been helpful is the client.

trousers said...

I'm curious as to the deleted comments - were they irrelevances, abuse or something else?

Forgive me being nosey.

Ms Melancholy said...

Hi Anticant, I am inclined to agree with you about the quality rather than modality of the therapy. I know some very, very fine therapists/counsellors and they all come from different modalities. I do think there is a fundamental problem with borrowing a medical model, however. I agree that ultimately we cannot scientifically measure the effectiveness of different therapies. CORE attempts to do this, but it is crude and clumsy. But we do need to start providing some evidence base for other therapies, if we are to limit the hegemony of CBT.

Ms Melancholy said...

No, trousers, nothing like that. Dandelion just posted twice by mistake. I have a policy of not deleting comments, unless they are very offensive. Don't worry, all is well here!

trousers said...

Thanks Ms M - its nice to know, though I wasn't smelling anything fishy. Just curious was all :)

Dandelion said...

LONG, SORRY.
Bobo, reports of personal experience are widespread in psychology, and lend themselves perfectly well to various analyses. But introspective reports are shown to sometimes be hopelessly inaccurate, and sometimes not. The trick is to know which type you are dealing with at any given time.

As for not being able to measure "spiritual changes", sorry but that's hogwash. If something (even something perceived subjectively as "spiritual") changes you, makes you feel better, or behave better, you can measure the benefit - otherwise, how on earth do you know that it's happened?? If you can answer that, I'll eat my words very happily.

Science does not devalue the personal experience, it simply distinguishes in its method and its remit between shared experience and the idiosyncratic, and for good reason. Experimental psychology is built on the individual experience, so I'm afraid I really don't get where you're coming from.

Ms Mel, I want to convince you that there is a *reason* why the NHS is only offering CBT - it may not be a reason you respect, but from a pragmatic point of view, it is quite understandable. I agree that it's totally rubbish in practice but it's because there isn't at present a better way of allocating services ALL THINGS CONSIDERED. Just because something isn't perfect doesn't mean that it's not good enough. And just because something isn't good enough, doesn't mean it's not the best thing available.

Vis-a-vis the evidence base, I think the point of interest, whether it's exaggerated or not, is in its comparison to the evidence base for other therapies.

I have some issues with evidence-based medicine myself, but once you start moving away from it, you do in principle open the door to the loony left. (I mean the loony left, not the non-loony left). Once you start making funding decisions based on people's intuitions, you might as well chuck the money down the drain, for the reasons in the Guardian link I posted.

Of course I don't think CBT should be the ONLY therapy, but I can understand why it is going that way, and I think that understanding that is the key to reversing that trend. The question is do we want to do something positive, or do we just want to bitch at a straw man whose hands are tied?

Ms M didn't want to talk about the 10-weekers issue, but I think in the discussion, the 10-weekers have been conflated with CBT-proper, and that I think is a great shame. If we're not addressing the 10-weekers problem, then we shouldn't be bringing them to bear in a discussion about therapeutic totalitariansim per se.

ps I wasn't the only one to delete a comment! And mine wasn't a mistake, I got the link wrong first time.

pps Would love to see the neuro links. Ms M.

ppps Stray, the samples used in psychological experiments have always been acknowleged. Always. It's part of the procedure. The stuff wouldn't have got published otherwise.

Ms Melancholy said...

Ok, Dandelion, will try and pull out some links. The research is very new but very exciting. It may take some time.....!

(But for starters Fonagy's book on Affect Regulation is fab, if not a very difficult read.)

Ms Melancholy said...

Just one more thing Dandelion! All of the experts in the field, including many CBT practitioners, are opposed to this dumbing down of our profession because that is exactly what it is. It is another example of anti-intellectualism and anti-professionalism. How do you account for such widespread dismay? And you need to take on board that 'the evidence' is nowhere near as clear cut as you seem to believe.
The government likes CBT because it is cheap. And that is a world away from cost-effective.

Stray said...

The government likes CBT because it is cheap. And that is a world away from cost-effective.

Which is exactly the point I was making with the NASA button. Measuring the input rather than the output is not a source of information that is very valuable in this case.

I have that a lot with my clients. "Your website isn't working for you" I say. "But we spent loads of money on it" they reply. Oh, well that must mean it's great then!

Sx

Dandelion said...

I did some work for Peter F!

I thought I made it clear - I'm not saying the evidence is clear-cut, I'm just saying on the basis of what there is, people could have been forgiven for thinking that CBT is the best bet.

I completely agree with the other points in your second comment ("and another thing, Dandelion"). I don't think I've said anything to imply otherwise.

Ms Melancholy said...

Hey Dandelion, if you have worked for Peter Fonagy then you probably know more about the research on affect regulation than I do. I have only read his book. I think the difficulty with providing a clear evidence base for other modalities has arisen partly because we are first and foremost clinicians and that is where our passions lie. Not many of us want to get involved in the research field as we continue to be challenged and stimulated by the rigour and demands of working at depth with damaged individuals. This is slowly being addressed by, of all people, neuro scientists, who are starting to scientifically demonstrate what psychotherapists have been theorising for the past 70 years or so - that the therapeutic relationship, if attended to skillfully and with awareness, is healing in and of itself. This is a world away from working purely with thoughts and behaviours.

I was going to write a separate post on the use of computer-aided instruction and the 10 week training, as I think they are separate issues and should be dealt with separately. I think I have lost the heart for the discussion, though! Maybe later....

PatientGuard said...

Ahh a therapist at last that reports some opinion/sense about how CBT cannot reach the broken parts that other therapies delve within ..Well done on behalf of the "Coggy DWP Workass Awards Committee" which is trying to determine whether empathy still exists out there in the emotional navigation zones ...And does rare empathy software exist in computerised versions of CBT ? I always say of CBT there's nothing like self invalidation to get rid of your problems.....Very british really ..

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The Government's approach sounds like Henry Ford - "You can have any colour you like, as long as it's black".

"Stomach ache? Try one of our universal plaster casts."

Typical Blairism - makes one despair!

אתר הבית-פסיכיאטר said...

רעיון יפה שפסיכותראפיה מסוג CBT היא לא בהכרח הדבר המושלםא בל מה הפשרויות האחרות?