One Size Can't Fit All
Chances are you’ve heard of CBT, or Cognitive Behavioural Therapy. It is the predominantly offered ‘talking cure’ by NHS England and by NHS Trusts in Scotland. This offer is based on guidelines laid down by NICE (National Institute for Health and Care in Excellence in England and Wales) and SIGN (Scottish Intercollegiate Guidelines Network), the recommending bodies for treatment within the NHS. NHS Inform, the public point of access to information on treatment available, for the whole UK, defines CBT as ‘a talking therapy that can help you manage your problems by changing the way you think and behave.’
The tables below, extracted from NICE and SIGN guidelines, show how wide and predominant an offer CBT is as an NHS solution to all manner of diverse issues requiring or indicating a need for some form of psychoanalytic, mental health therapy or counselling intervention or treatment.
It isn’t difficult to trace the ascendancy of CBT as the NHS prescription of choice. It follows the general trajectory of applied therapies worldwide.
A fairly well-worn narrative has been established when it comes to therapy and the relief of emotional or psychological suffering. At the start of this story, so it goes, Freud has largely been debunked. A jumble of theories developed in his wake, as therapists attempted to put their endeavours on a more apparently sound empirical footing. From the tumult of these, often conflicting approaches, attempting to establish dominance, it is generally agreed, one emerged victorious.
CBT is considered, by its advocates, a down to earth technique, focused not on the past but on the present, dealing not with opaque inner drives but with adjusting ‘unhelpful’ thought patterns causing ‘negative’ emotions. A typical CBT exercise might involve filling out a flowchart to identify self critical ‘automatic thoughts’ which occur when a setback is faced. It appears practical and deterministic.
Yet CBT, from the outset, has had it’s critics. It’s appeal and rapid, widespread uptake by state sponsored mental health initiatives worldwide, due to it’s relative low impact on budgets, alongside the emphasis on getting people quickly back to ‘productive’ work, make it a politicised, functionalist approach. Even those opposed to CBT and its widespread implementation have found it difficult to question how it ‘gets the job done’ though.
Since first emerging in the 1960’s and 1970’s, many studies have stacked up in support of CBT. The clinical jargon ‘empirically supported therapies’ has become synonymous with CBT, implying it is the therapy ‘based in fact’.
Seek any kind of mental health referral through the NHS and you are extremely unlikely to end up in anything resembling traditional analysis or therapeutic counselling. You are much more likely, regardless of the reason for referral, to find yourself in a short series of highly structured meetings with a CBT practitioner, or learning methods to ‘adjust your thinking’ via prescribed PowerPoint presentations, books, workbooks or online ‘mood cafes’.
There can be little doubt CBT has helped millions, at least to some degree. It’s increasing prevalence gave it a good chance of some ‘hit rate’. This was never more true than in the periods which gave rise to its use as an NHS panacea. This followed the economist, (NB not a therapist) Richard Layard, a vigorous CBT evangelist, becoming Tony Blair’s ‘happiness tsar’. CBT’s reach and adoption by the NHS continued apace thereafter, resulting in the current situation, where it has become increasingly difficult to be referred for any other kind of therapy or counselling.
Yet it has been hard to shake the notion, for therapists, counsellors and for everyone implied when phrases like ‘a mental health crisis’ become commonplace, that something big is missing from the CBT model of the suffering mind. We experience our inner lives and our relationships with others as often bewilderingly complex. Could the answer to any and all woes really be something as superficial sounding as ‘identifying automatic thoughts’ or ‘modifying your self talk’ or ‘challenging your inner critic’. Could any kind of therapeutic counselling really be as straightforward as to be able to receive it from interaction not with a human but with a workbook or a computer?
The issue which has allowed this situation to develop has been the availability and nature of the data. Early psychoanalysts often came to view themselves as practitioners under fire, requiring the retreat of specially developed institutions to nurture their work. It became all too easy to form cliquish organisations around these institutions, developing their field in many ways at some distance from university led, considered more empirical by the wider scientific community, research.
By embracing the empirical, which was less of a threat to their functionalist models, cognitive and behavioural approaches gave themselves a head start. With this growing body of more widely accepted evidence it was a hop, skip and jump to claiming CBT is a results driven therapy, ‘based in fact’, thus claiming also to debunk other modes of therapeutic analysis which did not have the same supporting body of evidence.
It was the 1990s before empirically evidenced studies of psychoanalytic techniques started hinting at a flawed consensus around the cognitive approach. In 2004, a meta-analysis concluded short term psychodynamic approaches, derived from psychoanalytic techniques, were at least as good as other routes for many issues and left recipients of treatment better off than 92% of all patients prior to therapeutic counselling. In 2006, a depression and anxiety related disorders comparative research study found in favour of psychodynamic techniques too. A 2008 study of personality disorders concluded 87% of patients treated with a psychodynamic approach did not have their diagnosis after treatment.
Increasingly, as more comparative empirical research is done to support the use of alternate therapies, CBT will be the ‘treatment as usual’ in the study, the one predominantly used. Stark differences emerge when the comparisons are made in this way. At their core is a fundamental difference with regard to how each therapeutic approach views human nature.
CBT embodies a very specific view of painful emotions. They are treated as primarily something to be eliminated, or at least made manageable. A condition like depression is treated a little like a malignant tumour. It may be useful to figure out where it came from but it’s more important to get rid of it. CBT claims distress is caused by irrational beliefs and it's within the adherent’s power to change those beliefs.
Therapies, not rooted in behavioural or cognitive approaches, would contend things are a good bit more complicated than that. Psychological or emotive pain, primarily, need first be understood, not eliminated. In this model, depression is seen less like a tumour and more like an indeterminate stabbing pain. It’s telling you something and you need to find out what. Achieving balance or happiness can be elusive because it requires understanding the mind and a mind, and how they make emotive connections.
We may see life through the lens of our earliest relationships but don’t realise how. We often want contradictory things and change can be slow and difficult.
A study published in May 2015, by two Norwegian researchers, examining scores of earlier trials, concluded the effectiveness of CBT had fallen by half since 1977. If the trend they detected persists it would render CBT, as recommended across the NHS, useless within a decade or two. Peer consensus around the report’s conclusions was that CBT, due largely to the enthusiastic evangelism with which it was systemically embraced, had benefitted from a placebo effect. Because it had been sold as a managerial cure-all, for a time at least, it became a cure-all.
The starkest differences between CBT and other therapeutic approaches emerge some time after therapy has ended. Asking people how they are as soon as treatment ends results in positive responses for CBT. Returning months or years later finds many of the benefits have faded, while the benefits of other therapies, which are based on addressing underlying issues, remain or have even strengthened. Evidence is building to suggest other therapeutic approaches are far better than ‘treatment as usual’ at helping restructure or heal the personality/mind in a lasting way.
It is no surprise then, to find even the NHS’ own research, published by the Tavistock Clnic in October 2015, being the first rigorous NHS study of long-term therapeutic treatment for chronic depression, concluded longer periods of therapeutic counselling or treatment worked far better than ‘treatment as usual’ within the NHS. Almost simultaneously, in Sweden, a report from government auditors surfaced in the press. The audit had discovered a multi-million pound scheme to re-orient healthcare towards CBT had proved completely ineffective in meeting any of its objectives.
CBT’s pre-eminence, if not entirely its effectiveness, certainly seems to be built on sand. Alongside the growing body of evidence lending much needed empirical support to other approaches, pointed questions are also being asked of the studies which first fuelled CBT’s ascendancy. Following on from the results of a 2004 study, researchers increasingly conclude that in the desire for research with clearly interpretable results supporting CBT, studies had often excluded up to two-thirds of participants. This was done largely because those excluded displayed multiple psychological, emotive, trauma related or other mental health issues. The results would focus on a specific targeted issue and exclude all other data.
The practice is in some ways understandable. It is far more difficult to untangle the lines of cause and effect when more than a single issue presents itself. But when is anything we experience of the human mind ever about a single, isolated, disconnected issue?
It also means the numbers, the data which has been held up in support of CBT, the statistics which led to it’s widescale adoption, are not ‘based in fact’, but rather based on studies of people who are extremely atypical.
In real life our psychologies, our mental health is deeply embedded in our personality. An issue you bring to a therapeutic session may not be the one which emerges after several sessions. In some ways, particularly in this regard, the cognitive approach may actually make things worse.
CBT’s implied promise is in it delivering a relatively simple step by step guide to gain mastery over suffering. There is a hubristic sense of its lacking an acknowledgement of how little control over our lives, our emotions and other people’s actions we may genuinely have. Is the seductive promise of ‘mastery’ in finding ways to manage your mental health simply a postponement of the point at which you must attempt fuller understanding and lasting change? Perhaps even in engagement with the deferral of cognitive techniques there is another implicit acknowledgement that we as human beings are often deeply emotionally invested in preserving our ignorance of unsettling truths.
Your life examined is unique. The role of therapeutic counselling is to help you find and understand fully your own unique story. Understanding and facilitating lasting change requires real connection. It requires the fundamental sense of being held in the mind of another person not implicit with ‘treatment as usual’, of at least approaching understanding. Even if only for a short period, once a week.
When you experience mental or emotional uncertainty, you know a computer program, no matter how artificially intelligent, a PowerPoint presentation or a workbook do not have the capacity to understand. How could they?
We agree wholeheartedly, at All-of-You Therapy, with finding therapeutic means which genuinely work for our clients. We will always try to remain abreast of current developments in research and training, not simply follow ‘where the money is’ in terms of NHS, being the single most used route into any form of healthcare across the UK, referrals, or any attendant politicised agendas.
Much of what we have covered in this article attempts to show what genuinely works and what doesn’t work in therapeutic counselling practice and more importantly, how it works and why. Before concluding, we’d like to refer to a direct practical, comparative study which has resonance for how we approach our work.
Helen Hadfield, is an experienced therapeutic counsellor. At the time of conducting her research, between 2011 and 2014, she had been working in private practice and as part of a GP’s surgery for just under 20 years and in primary care for 10 years. Her research looks at training in CBT, as undertaken by her, and contrasts working with that training to her returned to, current, integrated work of person centred, attachment and compassionate mind theory.
The research was based on Hadfield’s personal client portfolio, where just under half had undergone CBT treatment and 100% of these found it to be unhelpful or damaging. She balances out her quantitative results with more qualitative, ethnographic interviewing. She describes how a majority of clients in England, where she is based, are referred to their local IAPT service (Improving Access to Psychological Therapies) and comments, ‘It’s scary, when going to the IAPT most are referred to CBT.’
Initially training in CBT due to an overwhelming referral rate for treatment and a genuine fear of unemployment if she wasn’t trained in the techniques, Hadfield reports a shift in NHS policy, in line with a 4 year governmental plan. As a direct result thousands of therapists underwent extra training to cope with an increased official demand for CBT.
Clients Hadfield spoke with in her integrative sessions stated they were afraid of honesty in speaking about the results of CBT. They expressed concern at being told their thinking was faulty and they shouldn’t feel as they did. It was also often the case, if concerns were raised with regard to any efficacy of the techniques, they had simply been informed they couldn’t be doing it properly.
Years of experience in other techniques and then in applying her CBT training were brought to bear in Hadfield’s seemingly simple conclusions. Her research showed, in a large percentage of cases, more so than are comfortable in relating truthful results in CBT efficacy studies or feedback, CBT doesn’t always help. Hadfield couldn’t continue telling clients their thinking was ‘wrong’ or simply trying to eliminate behaviours without understanding them. She couldn’t claim to help without looking at reasons for behaviours and triggers.
Hadfield particularly didn’t see how, in CBT she could bring herself to almost work in tunnel vision mode during treatment if a client had suffered trauma and not explore it, approach some kind of understanding. Clients gave examples of only being given 20 minutes to talk and the remainder of the session would include homework and giving out paperwork. Examples were given where clients felt they had no therapeutic connection and counsellors ‘came across as cold’.
Hadfield’s conclusions are derived from research using private practice as well as her work within the NHS. It spans across clients from different walks of life and ability/willingness to pay for treatment. Ultimately, she applied the same principles she would with a client in assessing whether to continue practising CBT. She used the equivalent of what Carl Rogers calls ‘the organismic valuing process’, being the actualising tendency where we select goals based on our inner nature and sense of purpose. Given the nature and high incidence of serious client issues with the CBT process, Hadfield had concluded it will one day be seen as almost barbaric, in the same way electro-convulsive shock therapy is now. She doesn’t use CBT with clients any more, meaning she has to practice primarily in private sessions due to the predominant use of CBT within the NHS.
Much like Hadfield, we are integrative counsellors at All-of-You Therapy. We work within person-centred and psychodynamic models. We couldn’t imagine not giving any client the time and space to explore what may be going on for them. Understanding yourself and commitment to the process of change it instigates is the only way to genuinely grow and effect lasting change from any kind of therapy, as far as we are concerned. Showing judgement and overt criticism of equally valid emotions or thoughts is absolutely contrary to the basic condition s of person-centred therapy. The issues this raises over conditions of worth is always likely to create imbalances in the therapeutic relationship.
Using integrative techniques, which use psychodynamic direction as aspects of the person-centred model, only happens ‘in the room’ at All-of-You Therapy when patterns underpinning relationships, with the client’s self and with others, are observed and when the relationship between client and therapist has been firmly established. These aspects of the integrative model help manage change and growth, what counselling is for.
CBT ceasing to be the ‘go to’ therapy for the UK government and the NHS appears to be some way away. The distinction in SIGN guidelines, in contradiction to NICE guidelines applied in England and Wales, which are not as ‘blanket’ in their CBT recommendation, is a good starting point. The Scottish Government website links to NHS services offered in Scotland, stating different types of therapies are available and what to look out for in a counsellor, stating you should feel a connection, and gives a link to BACP directory, the counselling governing body. In practice, currently though, this means most NHS services still predominantly refer to CBT practitioners, with the option to find private counselling being what is implied through the website link. In some cases, largely with regard to trauma, psychodynamic treatment is offered.
The general advice may be helpful but it does raise financial issues. It states that the NHS may not be able to fund some services. As the body of evidence in support of other therapies when compared to ‘treatment as usual’, currently CBT, grows this attitude must, can and will change. Awareness around mental health is increasing and issues concerning treatment are being raised within parliament on a regular basis. Funding is being made available for various mental health projects which are not CBT based.
We are a wholly private practice at All-of-You Therapy. We can access funding for some types of trauma counselling and play-led therapy in some child cases. If you have significant concerns about the types of therapy available to you or your child within the NHS and are experiencing issues with funding private counselling, please do enquire and we will treat your enquiry with the utmost discretion, offering as much advice and funding as we can.
At All-of-You Therapy, we don’t use CBT. We don’t apply sticking plasters either.