CBT

On therapuetic evangelism and why we should employ professional skepticism

Occasionally, when I am at a loose end, I think of three-letter acronyms and try to think of a model of therapy which might use that acronym. Amusingly (for a psychologist-type, anyway), more often than not, you come up with something that does indeed refer to a therapy which exists in the psychological literature. Despite stating over here  that there are three basic models of therapy, over the years, psychology has evolved and we are now in the situation where we have therapeutic models coming out of our ears. For the unitiated, here is a brief rundown of the main models we have at our disposal:

Acceptance and commitment therapy, Attachment-based psychotherapy, Behaviour therapy, Compassion-focused therapy, Cognitive analytic therapy, Cognitive behaviour therapy, Dialectical behaviour therapy, Emotion-focused therapy, Eye Movement Desensitisation and Reprocessing, Functional analytic psychotherapy, Intensive short-term dynamic psychotherapy, Interpersonal therapy, Mindfulness-based cognitive therapy, Mindfulness-based stress reduction, Mentalization-based treatment, Narrative therapy, Person-centred therapy, Positive psychology, Rational emotive behaviour therapy, Rational living therapy, Schema Focused Therapy, Solution focused brief therapy, Transference focused psychotherapy, Wilderness therapy.

And those are just the ones I am familiar with and which didn’t seem too left field. I haven’t included adapted models such as CBTi (for insomnia) or CBTp (for psychosis). It is, it would be fair to say, mind-boggling.

Lots of psychologists just rub along doing whatever seems to work for our patients. Whatever the clinical guidelines may say, one person with depression is rarely the same as another person with depression because they exist in a different family, with different experiences and goals, so the overwhelming majority of clinicians adapt their approach to fit the person.

Increasingly, however, there seems to be a slight culture of evangelism around particular models. There has always been debate, of course; I have a bit of a soft spot for family therapy, but I wouldn’t consider myself exclusive to any model. But more and more, there seems to be an air of exclusivity amongst some clinicians. This is easily observable via social media, where CBT for psychosis seems to be the current topic of (interminable) debate. I don’t object to the discussion of these things on Twitter (although you have to admit that 140 characters is hardly the best medium for it) but what irks me is that the majority of those involved in such discussions seem to have no intention of changing their view and are simply content to hammer away at the same points over and over again. That’s not debate, and I would suggest that trying to persuade people who are as certain in their views as you are in yours is a bit of a waste of time.

But I don’t write this purely to grumble about Twitter debates. My concerns are a little bigger than that, and perhaps the best illustration is mindfulness. Mindfulness is very much in vogue at the moment and was the topic of a very good piece in the Guardian recently. Mindfulness derives from Buddhist meditation but its proponents are very keen to point out that it ‘doesn’t involve any religion’. Disclosure: I (attempt, often unsuccessfully) to meditate, but I do it firmly from the Buddhist point of view. I like some philosophy to back up my inner serenity. Mindfulness spurns the philosophy and adapts the practice and it is often used with depression and anxiety. I have attempted to use it with patients, with varying degrees of success.

I happen to own a well-known mindfulness book (I took part in some research purely to get this book) and recently I was flicking through it. I was stunned by the language, not because it was offensive or profane, but because it seemed like the sort of blurb you would find in the sacred book of some new-age cult. I shall not, for reasons of professionalism, identify the book or quote passages, but the general thrust was that a) you need mindfulness; b) mindfulness will, without a shadow of a doubt, change your life. And though I may be paraphrasing, I am not exaggerating. And I am worried that statements such as these are being made because there are people out there who will take them as Gospel.

Let me be clear: mindfulness, like any other therapy, will work for some people with some problems. It is not a magic wand. It is an unfortunate truth that in psychology, there is no magic wand. I cannot promise that I will help you to rid yourself of your difficulties and I make that apparent with every person who comes to see me. We can try something and see if it works. If it doesn’t, we’ll try something else. It is constant trial and error, combined with clinical experience. It’s not magical or mysterious; it’s simply having a go.

The problem is that virtually every therapy in that list was invented by someone. Someone, somewhere, developed it, tested its efficacy and wrote a book. They probably run training courses and charge for accreditation. They may well be earning a fortune from it. Obviously, they are hugely invested in that therapeutic model. I don’t think that’s great for science or for our patients. There has been much in the media (partly thanks to Ben Goldacre) about the corruption, falsification and suppression of clinical trial results and psychology is not immune from such things. If you have built an entire career from a therapeutic approach, you need it to work. You also need people to apply it and for it to remain credible. This means that you might promote it more than it deserves or that you might claim that its scope is wider than it really is. Lots of therapies might be of some use in some people with some problems; I challenge you to show me a therapy which works for all people with all problems. If that is too hard, show me one which works for all people with one problem. I doubt you’ll be able to. But some theoretical models are being funded more than they ought and are being pushed more than they ought and the result is that clinicians are being forced to work in ways which may not fit the patient, and that is no good for us or for our patients. I never promise anyone a cure, but the very least I want to do is offer them something which might have a decent chance of helping them. The only way to do that is to remain open-minded and to remain skeptical. There is no panacea for psychological distress. If you develop your own theory or model and the evidence suggests that it can work, that is all to the good. But you really owe it to your colleagues and your patients, not to mention to yourself, to consider that model critically, to accept its limitations and to admit it when something better comes along.

Schizophrenia: Does psychological therapy make symptoms worse?

In the field of mental health, schizophrenia is one of the most famous labels out there. It’s often misunderstood, but it’s also relatively common in the general population. Antipsychotics are often criticised for the effects they have on the physical health and mortality of those who take them and emotions on both sides of the argument run rather high.

Psychologists don’t prescribe medication and we often like to think that the treatments we dispense have far fewer side effects. That’s not necessarily the case though – if you’re working with someone who’s traumatised, it’s perfectly possible to retraumatise them through therapy (although we try our absolute best to avoid doing so. But we’re not immune and it would be pompous to pretend that we do nothing but nothing but good.

This paper appearedn recently in The Journal of Nervous and Mental Disease. It was designed to investigate the effect of psychological therapy on symptoms associated with schizophrenia. Schizophrenia symptoms are typically divided into ‘positive’ and ‘negative’ (there is a third category but it simply refers to cognitive functioning). The former are the things we tend to associate with the label: delusions, hallucinations and unusual or disordered thinking. The latter are less flamboyant: they tend to be a certain ‘flatness’ in mood, lack of spontaneous speech and limited pleasure from daily activities. Often, the negative symptoms look very much like depression and they can be the first things you notice.

This study looked the effect of cognitive-behavioural therapy on negative symptoms. It’s an interesting study, because CBT is the recommended intervention fro depression and is one of the recommended interventions for schizophrenia. At the same time, there has been little investigation into the adverse effects of CBT in this population. Psychologists may not be medical doctors, but the old adage of ‘first do no harm’ remains pertinent. CBT was compared to cognitive remediation therapy. For those unfamiliar with either, CBT looks at the patterns between thoughts, feelings and behaviours. It considers how you interpret events and how these interpretations affect the way you respond. CRT is designed to diminish the cognitive decline associated with schizophrenia by providing training in domains such as attention, memory and learning. 198 patients (only 1/3 of those who were eligible) consented to participate and were randomly allocated to receive either CBT or CRT. The effect of random allocation is that you even the sample out – if you knowingly allocate you might skew the groups in terms of age, gender or severity of symptoms. Because we’re all vulnerable to biases, it’s preferable to randomise and to have the randomisation done by machine so that the research team doesn’t know which participants are getting which treatment (this is referred to as ‘blinding’ and the researchers will get the data collected rather than carrying out the treatments as this would obviously mean they knew who was getting what).

So. The results. No one died through suicide during the course of the study, which is good, especially as there is a higher suicide rate associated with schizophrenia. One made an attempt, however, and one had a ‘suicidal crisis’. Those allocated to CBT had slightly elevated scores on a measure of psychotic symptoms compared to those given CRT following treatment, but it was a very light increase; essentially, the risk only increases from a baseline of 1 to 1.1. However, those allocated to CBT were significantly more likely to report elevated depressive (negative) symptoms than their CRT colleagues.

So what do we make of it? Negative symptoms may protect against suicide and some research suggests this is the case. But equally, we don’t want to exacerbate negative symptomatology. In general, CBT had no more ‘side effects’ than CRT: some of those given CBT reported more symptoms at the end of treatment, but their symptoms were no more severe than those of the participants with CRT. Unfortunately, there was no ‘control’ group; a group of people who had similar demographic characteristics to the rest of the sample but who were given no treatment. So although we can state that there is an association between CBT and this increase in symptoms, we can’t attribute one to the other.What this means clinically is that we still don’t know how bad CBT is for your health. What we do know is that it doesn’t prevent those receiving it from going through a crisis (that probably won’t come as a surprise to many) but that, for some people, it may be linked to more negative symptomatology. What clinicians have to do, therefore, is closely monitor the people they see and ensure that crisis and risk plans are both kept updated and implemented as necessary, as well as be prepared to offer more intensive interventions when necessary. Crucially, we need to remember that there are potential risks when engaging in psychological work, just as there are when taking medication.