Improving Access to Psychological Therapies - the rise and rise of CBT

Ah, the government have another new initiative. We are now going to have massive CBT centres filled with a new breed of CBT therapists delivering CBT to the masses. Quite how these CBT therapists are going to be trained, hasn't quite been worked out, but we're going to be dishing out CBT to anyone with depression or anxiety in primary care. Hooray.

Actually, I welcome this move (although I am somewhat skeptical as to how it will work in practice). I think it is good that someone presenting in primary care with mild-moderate depression or anxiety can access psychological therapy and not just medication. That is good and to be welcomed.

I am concerned, that the government may see this as improving access to clinical psychologists. It is not. Clinical psychologists will not be delivering manualised CBT for people with simple mental health problems in primary care. We are far too expensive a resource and work primarily with complex cases, integrating multiple treatment models. We work with staff teams, provide consultation, training and supervision and encourage psychological thinking within MDTs. That's our job.

But, you wouldn't think that from what the government say. It seems that instead of increasing clinical psychology provision, we'll get more CBT therapists. I am worried that clinical psychologist is being seen as equal to CBT therapist. I'm worried that psychological therapy is being seen as CBT. There are many more tools in the box.

I'm worried about CBT being seen as the most amazing cure-all known to man. Yes, it works. There's ample research demonstrating its effectiveness and in day to day clinical practice, I've seen some dramatic changes in people who really engage in the CBT process (and that's working with people with complex difficulties, not simple anxiety or depression.) And, I like CBT. It's an empowering, collaborative way to work. I enjoy it and it makes a lot of sense to me. It makes a lot of sense to most of the people I work with too.

But its not everything. No other therapy has been so extensively researched and there are no studies that have demonstrated the effectiveness of CBT over other approaches. Indeed, when its compared with other approaches, and when you look at effect sizes in studies, CBT comes up pretty much on a par with other therapies. Then of course, there's all the issues with transferring what comes out in the research to clinical practice. I always wonder where they get their participants from in these studies - they usually don't have any comorbid diagnoses - which just never happens in my clinical work. There's also plenty of research demonstrating that what matters most in psychological therapy is the therapeutic relationship. Without that, you can forget it. If the client doesn't like and trust you and you don't warm to and respect the client, neither of you are going to get very far.

CBT isn't like drugs. You can't look at a person and say, so you're anxious/depressed, here have some CBT. You can't dish it out like that. It has to be based on a shared formulation about the biological, social and psychological roots reasons why that person has developed and continues to have difficulties. The medical language that now couches CBT is risky imho because we might stop thinking psychologically and start applying techniques willy-nilly. Reminds me of someone at work who had done a couple of training sessions in CBT. She decided to tell all the CPNs to stop asking their patients how they were, and start asking them what their thoughts and feelings are. Rubbish - that's not CBT, that's applying a technique. Yes, I do ask my clients what their thoughts and feelings are as part of a CBT approach. But I usually start the session in the waiting room with a smile, inviting the person to come through and then asking how things have been. It's a genuine expression of interest and concern. It builds rapport and starts a therapeutic relationship - which is, as we know, the basis of all good psychological therapy. I don't just ask random questions, I'll ask questions that revolve around our shared understanding of that individual's difficulties and their goals for therapy.

So, I like CBT. I use CBT. CBT is my preferred treatment modality, but its not the be all and end all of psychological therapies. In my work, I pick and choose my treatment approach based on a mutual understanding of the client's difficulties. If I want to do CBT, but bring in some family therapy, then I will. If I think a bit of psychodynamic thinking is going to be useful, then I bring it in. If I want to go all behavioural, then that's exactly what I'll do. I also know that CBT is nowhere near as simple as it says it says on the tin. Most importantly, my work is always based on building and maintaining a therapeutic relationship.

So I think psychologists need to stick our heads above the parapet and get talking about CBT, its uses and its limitations. We need to be talking about other therapies and the many aspects of our jobs. We need to make sure that people don't see filling in a cognitive worksheet or doing a bit of in-vivo exposure as CBT. Those are techniques and they are useful, but forget the therapeutic relationship and you've sunk the ship before it even sets sail.

I'm also wondering what is going to happen in 3, 5, 10 years time with this CBT trend. It all seems a little too fashionable to me right now.

The doctor who hears voices...

There seems to be an influx of clinical psychologists on TV at the moment with Tanya Byron's "Am I Normal?" series on BBC2 and "The Doctor who Hears Voices" documentary on Channel 4. Both are worth catching on BBC-iplayer or 4OD.

I love Tanya Byron - she is obviously an excellent clinical psychologist, weaving science and practice together, communicating clearly and with her compassionate but ever so slightly sassy way about her. I watch her and think, "One day, I might get to be just a little bit as good as she is." She is easy to watch and I see her as something of a role model. But then again, I can sit back and watch her without having to think because I agree with virtually every word that comes out of her mouth. Last night's documentary on body image was fantastic imho but it didn't make me think differently. Perhaps because I've worked so much with body image issues, that I've already done a lot of reflection. I think she did a fab job of picking apart what is unusual behaviour and what is dangerous and potentially an illness.

Rufus May on channel 4 was a different matter. At some points I wanted to scream at the TV, at other points I wanted to applaud him.

He came across as such a lone-ranger and that is never something I would want to be. I am sure he did a risk assessment, but I got the sense he relished his independence a little too much. I don't consider myself to be particularly risk averse, but I wouldn't want to take on responsibility for a client with such an active psychosis without the support and professional accountability supervision and team-working provides. Then again, I don't know what supervision Rufus had behind the scenes. And then to invite a client home for the weekend is, well....Mr. Shrinkwrapped might have some objections. I see it as healthy to have some therapeutic boundaries and not just for my own safety. I don't see the people I work with as fundamentally different from me (whatever Rufus might have implied). If I wasn't their therapist and we met in another context, I can often imagine that we would probably get on very well as friends. But I am their therapist and they have their own lives to lead outside therapy and I mine. In some ways, I can imagine nothing more depressing than spending a whole weekend with your shrink! I have friends with mental health problems - but they're friends, not clients and that's how they get treated. They can call me in the middle of the night and they can have more than one hour of my time once a week and yeah, they can come round for dinner and sometimes we might not speak for several weeks or even several months and I don't send the CPN round to check they've not done something regrettable.

I like that he challenges the medicalisation of psychosis but I don't like his attacks on psychiatry and mainstream mental health services. I don't know anyone who works in mental health who would immediately prescribe medication for and/or section someone who was hearing voices. People with active psychosis live in the community and many of them live with their voices in positive and creative ways. Most of them use medication and most are happy to. They find it helpful. As far as I'm concerned, if they know the pros and cons, then it is their choice either way and its not my job to intervere.

Medication doesn't preclude me from working with someones voices, exploring their meanings and understanding where they've come from and what role they play in their lives. I didn't think Rufus's approach was all that radical. I've never had a conversation with someone's voices but its standard practice in clinical psychology to think about the meaning of people's voices to them. I've come across nurses "doing CBT" which basically involves having an argument with someone telling them all the reasons their voices or delusions are irrational. That's not what I do and it's not CBT either for that matter. It's bad practice. Meanings, symbolism and exploration is all par for the course in good psychological therapies. Rufus you are not the only psychologist in the village.

I found the narration really irritating. It was basically voices = mad = sectioning, unless you're seeing Rufus, who loves "mad people". By implication, I guess mainstream mental health workers must have it in for "mad people". In case you haven't realised, I don't like the word mad either - its far too stereotypical. People who hear voices don't run around talking to themselves doing crazy stuff or any of the other stereotypical "mad" stuff. To say that voices = madness = sectioning is a terrifying prospect for someone who is hearing voices and the fear of going mad will only serve to exacerbate their difficulties and might stop some people seeking help.

Romme and Escher clearly showed us that voices don't equal madness (http://en.wikipedia.org/wiki/Hearing_Voices_Movement). I was shocked once when I asked a very informed client if she'd heard of Romme and Escher and she hadn't. She was extremely interested and went off to read about it. It's a shame she hadn't been told earlier as it fit so well with her experience and thinking about voices. I am glad I introduced her to the ideas, but disappointed no-one else did years ago. People need to be made more aware of this - both voice hearers and those who work with them.

And voices, even, even ones that tell you to kill yourself or others does not automatically result in a section. People live with voices and never act on them. Ruth clearly recognised her voices as a voice and didn't act on them. I don't think she would have been sectioned in the CMHT I did my placement in, but I'm going to ask my approved social worker friend next time I see her to make sure.

I object to this characterisation of all psychiatrists as the enemy. Don't get me wrong, I have met some psychiatrists who are, to be frank, an embarrassment to their profession. But I have met just as many excellent ones. I worry Rufus's approach alienates those of us who prefer to take a non-medicalising approach from our more medically-minded colleagues. Our approaches can complement and I would rather co-operate than fight.

But what was most frightening of all was the fact that both Rufus and the psychiatrist (Trevor Turner?) advised people to deceive occupational health. That's awful. If voice hearers who hold down jobs and live productive lives within our communities hide, what chance do those who are really struggling with their voices have? Voice hearing isn't a life sentence to mental institutions - it is simply part of the vast range of human experiences. Sometimes it is incredibly distressing and needs treating with medication and/or psychosocial therapy. Sometimes it is a pain in the ass that people learn to live with. Other times, it is life enhancing and positive. We need more voice hearers to go public and help us to rethink our wider cultural perspective on voices. But that is easy to say - if I was a voice hearer, I wouldn't tell you. I have some colleagues I would tell (notably, the ones who work in psychosis) but there are plenty I wouldn't be comfortable telling. I'd like to know how occupational health would assess someone's suitability for work if they had a mental health problem - would they be as obstructive as the programme suggests? I like to think of occupational health as being there to support people in their jobs - not prevent them from doing it, but perhaps I am too naive and idealistic.