Health: Quick-fix therapy for people in a hurry: Conventional psychotherapy can take years to work, but a new system claims to help patients function again in only 10 to 15 sessions. Annabel Ferriman investigates

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The Independent Culture
WHEN Bob Edwards's wife left him on his 43rd birthday last year, he was not a happy man. Nor did his mood improve when she moved in with a wealthy businessman and started driving round in a BMW with personalised number plates.

If he had been a New Yorker instead of a Londoner, he would undoubtedly have called up his analyst to discuss the hidden meaning of his wife's betrayal, and how to cope with his misery about it. But London is not Manhattan. The British, on the whole, are still suspicious of psychotherapy. They think it involves hours of discussion about potty training. Nor do many people have a spare pounds 100 a week, which intensive therapy can cost, or a desire to spend up to two years puzzling out the unconscious conflicts that their childhood traumas have set up. Some of us remember Woody Allen's words in Sleeper, when he awakens after a 200-year sleep. 'God, I haven't seen my analyst in 200 years; if I had been going all this time I might be starting to feel better.' Like Bob Edwards, we want to tackle today's problems today.

FOR those who want a simple oil change rather than an overhaul, there is a new, upbeat therapy which claims that it can change how you think and act in only 10-15 sessions. It is known as cognitive behaviour therapy.

The bible of this fast-expanding trade is a book called Feeling Good, by the American psychiatrist David Burns. The punchy 'headlines' on the back cover sum up the Burns gospel: 'Discover how to: nip negative feelings in the bud, deal with guilt, overcome love and approval addiction and beat 'do-nothingism' '.

Unlike traditional psychoanalysis, cognitive behaviour therapy tries to address the patient's immediate problems without delving too deeply into his or her past. It is concerned with conscious, rather than unconscious thoughts, and consequently the therapist does not ask about patients' dreams or consider any other signs of their unconscious processes.

If, for example, a therapist discovers that a patient has a social phobia, a serious fear of meeting people in social situations, he or she will try to discover why such social occasions are so painful. Does the conversation always judder to a halt? If so, is the patient ignoring the simple social expedient of asking questions to keep the conversation going? Should this be the case, the patient is asked to go away and practise that particular technique.

Cognitive behaviour therapy derives, as its name suggests, from two strands of psychology: behaviourism, which was developed in the 1900s, and cognitive therapy, expounded in the US in the 1970s by the psychiatrist Aaron Beck and a psychologist, Albert Ellis.

Some of the tasks which patients are given to do as 'homework' between sessions are reminiscent of behaviourist techniques used in the 1960s and 1970s. In the case of phobias, for example, patients are encouraged to address their fears by facing up to them step by step - a strategy called graded self-exposure. Someone with a fear of spiders, for example, might be encouraged first to look at them safely contained in a glass tank, then free at a distance and finally close-up.

Cognitive therapists take the view that people's moods are often influenced by their thoughts and that thinking habits can be changed. They believe that consistently negative moods, which cause misery in complaints such as depression, are caused by distorted, unnecessarily pessimistic thinking.

Depressed patients, claim proponents of the therapy, misinterpret many of the things that happen to them, giving events the most gloomy explanation. If they are walking down the street and they pass a friend who does not acknowledge them, for example, they immediately think that the person does not like them any more. They dismiss other possible reasons.

Such negative thinking habits, cognitive therapists say, can be broken. 'We try to encourage patients to think realistically and to challenge their self-defeating beliefs,' said David Veale, a consultant psychiatrist at Edgware and Barnet general hospitals and at the Grovelands Priory private hospital in north London.

'We try to get patients to question how they are interpreting events: whether it is true or logical or helpful. Depressed people are beating themselves all day, as to how inferior they are. It serves no purpose. We try to teach people to accept themselves,' he added.

Another leading exponent of CBT, with the memorable name Windy Dryden, is professor of counselling at Goldsmiths' College, London. He employs some wonderfully flamboyant methods to get his message across.

Many unhappy people tend to exaggerate their mistakes and generalise from them, he says. So to bring home the difference between a stupid act and a stupid person, Professor Dryden will drop on to all fours and bark like a dog. He then asks the client to comment on his outlandish behaviour. Most readily admit that although his behaviour is pretty silly, he is not a stupid and silly person. So the point is made.

According to Professor Dryden, patients need to understand that the world will not collapse if they do something foolish. So he devises deliberately ridiculous exercises by which they can prove this to themselves: he suggests that when travelling on the Underground, for example, they announce in a loud voice each stop along the route; or he asks them to go into a chemist's shop to ask for a gross of condoms (small size), demanding a discount because 'one uses so many'. Those who pluck up their courage and plunge in learn that being a laughing-stock does not produce the awful consequences they might have feared.

THE claims and methods of cognitive behaviour therapists are disputed by those from the psychoanalytic tradition, however, who think that they are useful for people with clear, well-defined problems but not much help for the thousands who just feel their lives are empty or meaningless.

Dr Lionel Kreeger, a Freudian analyst, says: 'Often the problem is the tip of the iceberg. The patient may deal with the immediate problem, but might still be left with personality difficulties. You have to explore in much deeper regions to understand really what is going on in that person's life and relationships.'

But there is no question that cognitive behaviour therapy does help some people. Bob Edwards, whose wife left him, came to see that it was senseless constantly thinking that she 'should not have done it'.

'The therapy was hard because it challenged my moral beliefs. I felt it was morally wrong for someone to break up a family as my wife had done. But I came to see that you cannot change people and that she did not know any better. I saw that my bitterness was damaging me far more than it was hurting her. It was like hitting your head with a mallet all day long.'

Provision of the new therapy in the National Health Service is patchy, even though it is increasingly in use. Part-time training courses are offered at Goldsmiths' College and the Institute of Psychiatry in London, at the Warneford Hospital, Oxford, and the Cognitive Therapy Centre, Newcastle upon Tyne - but the numbers trained are still small.

Unlike many other forms of psychotherapy, CBT has been subjected to numerous trials to assess its efficacy. In a large-scale analysis of 28 studies involving more than 1,300 patients, published in the Journal of Consulting and Clinical Psychology, it was found to be more effective for depression than drugs, behaviour therapy, and other psychotherapies.

Given its success rate, it is puzzling that more lay people are not aware of it. Professor Dryden, who has written extensively on the subject - including the only book ever published on sulking - believes this is because 'the intelligentsia in this country love the subtleties and complexities of the psychodynamic tradition, and are suspicious of the comparative simplicity of cognitive therapy'.

GUY Loveridge, a 23-year-old studying communication, arts and theatre, is another patient who, like Bob Edwards, believes he has had his sanity restored by cognitive behaviour therapy. 'When I first saw a therapist last year, I was suffering from acute student depression, social phobia and hypochondria. I had reached the stage where, if something disturbing happened I could make myself ill. Within a few minutes I was throwing up,' he said.

'A combination of circumstances led to it. I had had to leave the RAF, which was training me as a pilot while I was at university, because I developed irritable bowel syndrome, which it took doctors months to diagnose. I had envisaged being a pilot after graduating and it was a terrible blow to have to give that up.

'The illness itself made me lose confidence; if I went out and had a drink, I would feel ill and get a disorientated feeling in my head. I went to see my father's GP in Harley Street, who said I had student depression and put me on anti-depressants.' Guy continued to deteriorate, and after visiting several other doctors he ended up seeing Dr Veale, who gave him intensive treatment at the Grovelands Priory Hospital. For two hours daily he had group therapy, followed by sessions with Dr Veale.

'We learnt a technique known as the ABC method. You make several columns. The first is A for the activating event which precipitates a crisis, the second is B, for your belief about it, the third is C for the consequence, how it made you feel or act. The last column is D, for how you will 'dispute' or tackle it.

'In the first column, you might record a row with your girlfriend, in the second what it made you think, such as, 'Oh no, it is all going wrong, she hates me,' then in the third how it made you feel: sick, angry, depressed or whatever, and then in the fourth how you were going to tackle it.

'At first, I could never think of anything positive to put in the last column, but gradually I got better at seeing that some good things might come out of bad situations. A row, for example, could lead to a better understanding in the end. I had six weeks of treatment. It made a huge difference to me. I learnt to see things realistically, not to over-dramatise things, to become more balanced.

'I am more self-confident now. My friends would say I was very loud and outspoken before. But I used to expect people to rate as important the things that I had done, and I got very annoyed if they didn't. Now I just think that, as I am not interested in everything they do, I cannot expect them to be interested in everything I do. It has helped me to cope with things going wrong, such as breaking up with my girlfriend.'

Guy, whose treatment was paid for by his father's medical insurance company, is now back at university and studying for his finals next summer. His testimony is a strong advertisement for the therapy. 'It gave me hope. Before I got help, I was on a downward spiral; now I am on an upward curve.'

Signs are emerging that this newer, quicker therapy is gaining acceptance from the medical establishment. The Defeat Depression Campaign, run by the Royal College of Psychiatrists and Royal College of General Practitioners, recently issued guidelines on the diagnosis and treatment of depression, saying that such specific psychological treatments had a key role in the management of depressed patients.

So cognitive behaviour therapy does seem useful for the seriously ill and those who just want a 'mental tune-up'. As Woody Allen might have said: 'Any therapy that takes less than 200 years has got to be good news.'


Books on cognitive behaviour therapy: Feeling Good, by David D Burns MD, published by Avon Books, New York, available through selected bookshops in this country. Coping with Depression, by Ivy Blackburn, published by W & R Chambers, Edinburgh. Thinking Your Way to Happiness, by Windy Dryden, published by Sheldon Press, London.

People wishing to see a cognitive behaviour therapist should consult their GP. A UK Council for Psychotherapy is being established which will provide names of therapists in various branches of psychotherapy.