A couple of decades ago the advice to those who were depressed and out of work was to get "on yer bike". Today it is as likely to be to get on the couch.
Cognitive behaviour therapy (CBT) has revolutionised the way doctors approach the treatment of depression. Whereas in the past GPs might have prescribed Prozac or other anti-depressants, CBT is now the treatment of first choice – where it is available – for the millions who turn up complaining they cannot cope.
But now CBT itself is under attack. A group of leading psychotherapists has warned that CBT is being used as a catch-all solution to depression and that patients are missing out on other forms of therapy which might be more suitable for them.
CBT works as a course of six to eight half-hour sessions with a trained counsellor who offers practical help to think positively – seeing the glass half full – as a way of challenging negative thoughts and feelings of hopelessness. Instead of focusing on the causes of distress or symptoms that may have surfaced in the past, it looks for ways to improve a person's state of mind now.
Earlier this year, Alan Johnson, the Health Secretary, announced that an extra 3,600 therapists would be trained to provide the treatment on the NHS at a cost of £173m a year from 2010. Guidance from the National Institute for Clinical Excellence (Nice) suggests that CBT should be the first treatment offered to patients with mild to moderate depression, followed by drugs only if that proved unsuccessful.
But such enthusiasm for CBT was challenged by experts speaking at an international counselling conference at the University of East Anglia yesterday, who declared that claims of CBT being more effective than other types of therapy were a myth.
Speaking to an audience of 400 therapists from around the world attending the World Association for Person Centred and Experiential Psychotherapy and Counselling conference, Professor Mick Cooper, an expert in counselling at the University of Strathclyde, said that although he welcomed the increased funding for psychological therapies, the focus on CBT was not logical.
He and three colleagues from Britain and the United States issued a statement warning that while there had been more studies on CBT, that did not necessarily mean it was more effective than other types of therapy.
"It is scientifically irresponsible to continue to imply and act as though CBT is more effective, as has been done in justifying the expenditure of £173m to train CBT therapists throughout England," he said. "Such claims harm the public by restricting patient choice and discourage some psychologically distressed people from seeking treatment."
Other forms of treatment such as person-centred and psychodynamic therapy could be equally effective and were supported by substantial, though smaller, bodies of research. But these approaches were ignored while undue emphasis was given to CBT even when research suggests that it is the patient's relationship with a councillor and their motivation which often determines the chance of success. CBT, argued Professor Cooper and his colleagues, can sometimes just amount to putting a "sticking plaster" on problems rather than getting to the root causes of an individual's depression.
Art Bohart, a psychotherapy researcher from the Saybrook Graduate School in the US and a co-signatory of the statement, told the conference: "There is evidence that some clients prefer an approach to counselling where the focus is on helping you explore and understand yourself. The outcome is that you make choices that move your life in new, more meaningful and personally satisfying directions. The counsellor's expertise lies in their ability to create a relationship where you have companionship and support on your journey to understanding.
"Other clients prefer the therapist to take the lead in teaching you particular cognitive and behavioural skills, such as how to think. Since both work about equally well, it is important both be available to the public."
Chaand Nagpaul, a GP in Harrow, north-west London, who chaired the Nice committee that recommended the use of CBT, said it should still be the treatment of choice and was certainly better than drugs
"For mild depression, it should be the first-line treatment," he said. "Handing out antidepressants just reinforces the illness mentality."
But he said the debate about the effectiveness of CBT versus other therapies missed the point that there were not enough resources to provide any type of person-to-person counselling in some areas. "In my area there is a six-month wait for CBT," he said. "It plays on my conscience when I have to prescribe a drug and I don't want to. But I have no choice. GPs overprescribe antidepressants because they have no alternative. It creates a dependency culture rather than helping patients to develop the skills to overcome their depression."
Sam Everington, a GP in east London, has a psychologist available two days a week for the practice's 14,000 patients. "As a result of years of working with psychologists, most of the time I do it myself," he said. "CBT can range from a brief intervention – a 20-minute consultation – to six to eight sessions of half an hour each, which would be done by the psychologist.
"People tend to think of therapy as answering the question why I got to where I am – what happened to me in childhood. I say to them: 'You are where you are – how can I help you get to where you want to be?' Then we talk about the practicalities of getting there – which may involve very basic tasks such as getting them to eat a proper meal each night.
"The big gains in the future [of medicine] will be in self-management. The age when the doctor delivered the cure is gone."
Cognitive behavioural therapy
Based on positive thinking – seeing the glass half full not half empty – it teaches patients to challenge negative thoughts and feelings of hopelessness.
Focuses on relationships and problems such as difficulty communicating.
Offers support and practical help to think about problems and find new ways of dealing with them.
Offers more intensive treatment aimed at revealing the unconscious impulses driving behaviour, but briefer than classic psychoanalysis.
Long-term treatment which may last years involving a detailed exploration of the psyche in which the analyst acts as a blank canvas on which the client can project their feelings.
Helps some people with depression. Douglas Adams, author of The Hitchhiker's Guide To The Galaxy, said running helped him cope with depression.
Increasingly seen as a second-line treatment, if exercise or talking treatments do not work.
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