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Wednesday 17 August 2011

COGNITVE BEHAVIOUR THERAPY - psychiatrists define good practice- From Royal college of Psychiatrists website

 Dereck Sommerfield-psychiatrist.

A model of ‘disease’ and passivity is just irrelevant to CBT. From the outset, a cognitive–behavioural therapist develops a shared formulation that emphasises both the meaning the patient places on internal or external experiences and the way in which that person has responded with avoidance and safety behaviours or ways of attempting to control their inner world. Psychopathology is therefore differentiated from normal human suffering when it results in the individual coping in ways that make their suffering worse and means that they can no longer follow their valued directions in life. Once a patient has a good psychological understanding of how they are exacerbating their distress and handicap, then during therapy they have the responsibility to change. This might include testing out whether a belief is true, whether a cognitive process (e.g. ruminating or self-focused attention) is helpful or whether behaviour such as avoidance or substance use maintains their symptoms in the long term. The homework and goals of therapy are focused on the patient’s valued directions in life with an expectation of graded normalisation for a return to employment and social roles. Cognitive–behavioural therapy does not ignore the social context of mental disorder. Competent therapists are aware of the effects of, for example, poverty, continuing abuse or the lack of social support. They take care to facilitate the process by which the person becomes their own agent of change in a hostile environment, including interactions with relatives or friends who are critical or overprotective. Practitioners address these issues and work collaboratively on solutions that might be helpful in overcoming these obstacles.

You seem to lack awareness of current best practice in CBT and your personal experience as an occupational psychiatrist seems to me to lend weight to the Layard proposals. They are not just about increasing access but are also designed to improve the quality of the service. The efficacy of CBT differs according to who delivers it and how it is delivered. You (and readers) might like to audit your local psychology or psychotherapy service with the following questions.

    Are the therapists delivering CBT accredited (or accreditable) by the British Association of Behavioral and Cognitive Psychotherapies as reaching a minimum standard for training? Qualification as a clinical psychologist is not adequate as CBT is a postgraduate qualification.

    Do the therapists follow empirically driven written protocols for a disorder derived from randomised controlled trials?

    Do the patients have a formulation shared with them that identifies the meaning they attach to events or internal experiences and the avoidance and safety behaviours that are maintaining their symptoms?

    Do the patients have agreed goals which include a return to their valued directions in life such as employment or social roles?

    Do patients participate in the setting of relevant homework between sessions and is this monitored at the beginning of each new session?

    Are the therapy sessions audio- or video-taped and a copy given to the patient to enhance learning and to the therapist to ensure quality control in supervision?

    Do the therapists work in teams specialising in a particular disorder or group of disorders for supervision by a senior therapist or by their peers?

    Do the staff receive continuing professional development and attend workshops and conferences in CBT to maintain their accreditation?

    Do the staff use standardised outcome scales and employment data that can be audited and is the effect size compared against clinical trials for a particular disorder?

    Can a service offer CBT promptly and in a stepped care model so that those with more severe problems and comorbid disorders can be routed to more experienced therapists?

These are features of a quality service for evidence-based psychological treatment. Thus, CBT is not a ‘technical fix’ but it is derived from research into cognitive processes and behaviours and is a very pragmatic approach to helping individuals to return to their normal roles in life.

You disparage the assumption in the proposals that 16 sessions of CBT are adequate without any other initiative. First, the proposals aim to integrate CBT with employment advisors in the same service. The ‘Pathways to Work’ pilots for people on incapacity benefit have shown that eight work-focused interviews plus the return-to-work bonus had no effect on rate of return to work of people with mental disorder but a large effect on those with physical illness.14 Such individuals were more likely to return to work after CBT and the employment advice.

Second, one needs assumptions for economic modelling. Sixteen is the average number of CBT sessions, from various randomised controlled trials. Cognitive–behavioural therapy can be shorter for some people, especially those who understand the rationale and are able to work on homework consistently. However, factors such as comorbidity, personality and social circumstances can complicate the therapy and extend its time frame. Thus, a clinical service can be flexible and the experience after the Omagh bombing is pertinent. It was found that of 91 patients, 34 (37%) were treated with CBT in 5 or fewer sessions, 59 (64%) in 10 or fewer and 78 (87%) in 20 or fewer. Patients with additional comorbid diagnoses needed more sessions and one individual received 75 sessions.15 Equally, for many disorders, if a person is not engaged in CBT and starting to do homework by the sixth session, then the obstacles need to be identified and the problem solved. It is otherwise better that a patient is discharged and has the option of returning when they are ready to change.

As far as I am aware, Illich never commented on cognitive–behavioural therapists as a new priesthood nor as a source of power and doctrine which has deprived people of responsibility and caused them to feel alienated from treatment services. Illich, true to his principles, refused all medical treatment administered by doctors and died from cancer in 2002. I would have liked to have discussed CBT with him as he argued that health is a personal task and that self-awareness and self-discipline largely determine public health. At the heart of CBT is a programme of structured self-help which empowers individuals to make changes; they can build resilience by inoculating themselves against the slings and arrows of misfortune. The goal in CBT is to help people get back to their valued directions in life by helping themselves. The first rung in a stepped care model of several NICE guidelines is self-help guided by bibliotherapy or computers. This will be incorporated into the proposed psychological therapy services, which will offer a range of intensity and expertise provided at all levels from CBT support workers to senior therapists. As the technology progresses, computer programs are likely to become more sophisticated; people will be able to log onto the web and follow a program without needing a therapist. I am sure Illich would have approved.

Of course CBT is not a universal panacea and cannot offer a quick fix. However, after about 30 years of research, it is doing pretty well and is more cost-effective than medication for depression and anxiety disorders in the long term. The effect size and range of disorders it treats increases with every new generation of researchers. For example, we now have evidence suggesting that CBT is superior to psychodynamic transference-based psychotherapy for borderline personality disorder.16 The proposed therapy services are multidisciplinary and the Royal College of Psychiatrists needs to ensure that all psychiatric trainees are competent to deliver an evidence-based psychological therapy and have a career path so they can become some of the senior therapists and the directors of the new services.

David Veale-responds

Psychiatric categories are manufactured constellations emerging as DSM or ICD committee decisions. That is indisputable, so why do we treat them as if they were facts of nature identifiable ‘out there’, as is, say, a tree or a broken leg? Population screening is inherently ludicrous: how many British Journal of Psychiatry readers believe that 16% of UK citizens have a mental disorder requiring treatment?

A World Health Organization study in 15 cities around the world found that those whose ‘depression’ was recognised by doctors did slightly worse than the ‘depressed’ who were not recognised.17 In a study of 18 414 patients attending 55 general practitioner practices in Hampshire, 48% of the variance between practices in prevalence of depressive symptoms was accounted for by a measure of socio-economic deprivation.18 What did these people really need?

The UK is a very multicultural society, yet the detached introspection of talking therapies is grounded in an ineffably Western version of a person. Is this meant to fit everyone?

The psychiatrisation of everyday life may serve to legitimise the marginalisation of people who do not fit. Some issues here are shifts in what is seen as ‘economic’ work, the individualisation of the workplace, and the widening gap between the ‘haves’ and ‘ have nots’. Even the Department of Work and Pensions (DWP) website talks of ‘the significant weakening of the labour market for less skilled workers’. The DWP report14 that Veale cites has nothing specific on mental health, nor any reference to cognitive–behavioural therapy.

Cognitive–behavioural therapy per se is not under attack but it is being peddled as a brightly coloured patent medicine labelled ‘ cures almost all known ailments!’. Society is not a clinic writ large. This self-aggrandisement of the mental health industry is risking hubris, and perhaps deserves it.

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