Think yourself well

It's the upstart newcomer of psychotherapy. Patients love it, it's quick and straightforward and there's evidence that it helps 'just about everything', according to supporters. So why isn't cognitive behavioural therapy more widely available? Julia Stuart reports
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When Kas Michael went to university, she suddenly started experiencing fainting fits. It took a year for doctors to diagnose a blood-pressure condition. In the meantime, however, she started suffering severe panic attacks, which became even more frightening than collapsing in public.

"I'd get a pain in my chest and become all hot and sweaty. Although part of your rational brain knows very much that you are being totally ridiculous, you just think, 'Oh my god, I'm going to die! I'm going to die!'" says Kas, now 26.

After nine months of outpatient treatment at Leeds General Infirmary, Kas has not had a panic attack since. She was helped by fortnightly, and then monthly, sessions of cognitive behavioural therapy (CBT), which is becoming increasingly popular among people with psychological problems because of its speed and effectiveness. Such is the demand for CBT that those wanting to jump NHS waiting lists are paying for it privately. Alastair Campbell, who once suffered a breakdown, has spoken of its benefits. So have Monty Don, Trisha Goddard and Rory Bremner.

"CBT in psychotherapy is regarded as a bit obnoxious, because basically there is evidence that it helps just about everything," says Paul Salkovskis, professor of clinical psychology and applied science at King's College London, and clinical director of the Centre for Anxiety Disorders and Trauma at the Maudsley Hospital in London. "For all the anxiety disorders, CBT is now the treatment of choice - obsessive compulsive disorder, post traumatic stress disorder, social phobia, specific phobia, depression and eating disorders."

Treatment is often short - panic disorder is usually treated in seven to 12 sessions, which last an hour, and obsessive compulsive disorder in 12 to 18 sessions. Some NHS patients are even opting for intensive treatment in just a day. "This is very helpful if you have childcare or work issues," Salkovskis says. "There's some indication, though it's not strong at this point, that it works at least as well and possibly better."

Unlike most therapies, CBT does not delve deep into childhood, but deals with the present. It is based on the idea that people suffer from emotional problems because of distortions in their thinking. For example, anxiety is caused by people believing that situations are more dangerous than they really are, and depression is caused by people believing that their situation is more hopeless or more negative than it really is, Salkovskis says.

CBT empowers people to think differently. Kas, for example, was misinterpreting her own bodily sensations as a sign that she was dying, which made her sense of panic even worse. CBT helps to correct such distorted thinking. "There is very strong evidence that it works," Salkovskis says. "In anxiety disorders and depression, CBT has been compared with the best available pharmacological treatment and has been shown to be even better or equivalent in the short term and invariably better in the longer term. With obsessive compulsive disorder, for example, drug treatment will make an improvement, but if you stop it, 90 per cent of people will relapse within seven weeks. The relapse rate for CBT and anxiety disorders is of the order of 20 per cent in two years."

Patients are encouraged to examine the thought behind negative feelings. Some therapists ask their patients to fill in charts, headlined Feeling, Situation, Thought, Alternative Thought and Outcome, to monitor their negative emotions. The "feeling" might be anxiety, the "situation" might be that a friend hasn't returned a call, the "thought" might be "she doesn't like me", which can spiral into catastrophic thinking such as "everyone hates me, I have no friends, there's no point in living".

Patients are encouraged to ask themselves what evidence there is to support such a belief. The "alternative thought" might be "she's away" or "she might have forgotten to return my call as I sometimes do hers". Filling in the charts also helps to discover Core Feelings that keep returning, such as "I'm terrified of being alone" or "I'll be abandoned", which can be worked on.

Virginia Ironside, The Independent's agony aunt, has filled in her share of charts, having had CBT once a month for two years. It was, she says, "extraordinarily effective". Over 25 years she has undergone a total of 12 years of therapy, including analysis, psychotherapy, counselling, group therapy and psychodrama. CBT is the only one she would recommend. "It's very, very popular at the moment as a kind of quick fix. 'Quick fix' sounds rather trivial, but in fact it's extremely successful," says Ironside, who discovered CBT six years ago when she was rushed into the Priory, depressed and suicidal. "It's based on common sense, really. That's what I like about it. Ordinary therapy expects you to do all the work and you don't know what sort of work you are expected to do. With cognitive therapy you pay your money - if you don't get it on the NHS - and you receive something.

"What you receive are strategies that have worked for people down the ages. They are very simple ideas. A lot of people have been brought up by parents who just haven't given them those guidelines. They are strategies about how to think, and think in a way that is most useful for you and makes you feel more able to cope. We tend to indulge our miserable thoughts and therapy has taught us that indulging them and ruminating and mulling over them can provide a solution. The truth is that mulling and ruminating is just what a horrible thought wants. It grows on it."

Lewis Wolpert, professor of biology as applied to medicine at University College, London, and author of Malignant Sadness: The Anatomy of Depression, describes himself as an "evangelist for cognitive therapy". "It's been unbelievably helpful," says Wolpert, who has undergone the treatment for short bursts when he felt the need. "I had three episodes of depression, and the point about depression is that all your attributions are negative, so you have a whole set of false beliefs. What cognitive therapy makes you realise is that you have these automatic negative thoughts, and it tries to make you change the way you think. It's nothing to do with your unconscious or what your mother did to you. It's training you to think in a different way and to recognise that many of your attributions are false."

CBT has also been used with some success with patients with schizophrenia. Much of the distress and unhappiness patients experience is concerned with what they think about the voices or delusions, and the therapy looks at their distorted thinking. Drug users are also experiencing its benefits. For the past three years, CBT has been the basis of treatment at the Marina House Stimulant Clinic in Camberwell, which is part of the South London and Maudsley NHS Trust. The centre, which treats about 100 clients a year, offers one-to-one counselling to users of cocaine and crack in particular. Clients range from City workers to people living in crack houses. Dr Luke Mitcheson, clinical psychologist at the centre, says: "We have clinical evidence that people reduce the amount they use and make significant changes in their social circumstances consistent with long-term recovery. CBT works by helping people to understand their addictive behaviour by exploring their belief about their drug use and their abilities to change that behaviour."

Dr Judith Beck, clinical associate professor of psychology in psychiatry at the University of Pennsylvania, is the daughter of Aaron Beck, the psychiatrist who developed CBT in the 1960s. She says the therapy has also been shown to be effective in a range of medical disorders, including irritable bowel syndrome, chronic pain, chronic fatigue syndrome, hypertension, migraine headaches, colitis and sexual dysfunction.

It is little wonder that Salkovskis believes that CBT should be offered more widely on the NHS. "We are in a strange situation with CBT in that it is the treatment of choice for most emotional disorders, but it is not the commonest form of psychological therapy delivered. There are more people trained in other forms of psychotherapy and we are not increasing the number of people training in CBT. The other psychological treatments, with a few rare exceptions, are not empirically grounded - they don't have an evidence base for their effectiveness - but we continue to offer them. The obvious example of this is psychoanalysis.

"I believe what is happening within the field of psychotherapy is getting dangerously close to being scandalous. We now have extremely strong evidence of the effectiveness of CBT and that patients particularly like it and see it as empowering. But it is not being delivered as much as it should be. CBT is the upstart newcomer, and there is massive conservatism within the field of psychotherapy."

Most health authorities offer some CBT, but it is a small proportion of the psychological therapy available, Salkovskis says. "I would say less than 30 per cent, if you're lucky. In some places it's less than 5 per cent. Meanwhile, large parts of the private sector have gone over exclusively to CBT."

COGNITIVE THERAPY: A BRIEF HISTORY

Cognitive therapy was developed in the 1960s by Dr Aaron Beck, a psychiatrist at the University of Pennsylvania who had studied as a psychoanalyst. He carried out experiments to test some of the psychoanalytic concepts, expecting the research would validate them. When it failed to do so, he began to look for other ways of conceptualising depression. Through working with patients he found that some were reporting a stream of spontaneous beliefs, which he called automatic thoughts, which had to do with negative ideas about themselves, the world and the future. He began working with these automatic thoughts and found that by teaching patients to identify them and evaluate them realistically they started to see reality more clearly and had improved behavioural reactions.

If you believe you would benefit from CBT, ask your GP. Many family doctors can refer you for treatment on the NHS, though there may be a waiting list. Alternatively, you can contact British Association for Behavioural and Cognitive Psychotherapies and they can put you in touch with a therapist in your area.

BABCP, The Globe Centre, PO Box 9, Accrington, BB5 OXB (01254 875277; www.babcp.com; e-mail: babcp@babcp.com)

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