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.