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.