Two features of CBT give it a ‘real-world feel’ a) relapse prevention conducted towards the end of therapy and b) homework set after each session with review at the next session. Without these two elements CBT is, at best, just a chat. But NHS Talking Therapies (and its’ predecessor IAPT) have never furnished any documentary evidence that relapse prevention strategies and homework are a part of routine practise. As a consequence there is a ‘revolving door’ in mental health Menzies et al (2024) with most people having more than one episode of disorder. These authors call for an extension of relapse prevention.
Relapse prevention is important as at the end of therapy clients have to anticipate the likely hurdles post-therapy and come up with a protocol for handling them. This is usually fine-tuned in the final sessions. Without such attention to the client’s real-world they are likely to fall as difficulties arise.
Homework is a summation of key learning points in a session and their planned application in the real-world, with review and if necessary refinement at the next session. This provides continuity between sessions and stops them descending into a purely abstract/academic discussion of issues.
CBT – An Endangered Species
CBT is dying in routine practice for lack of homework and relapse prevention strategies. In the 100’s of NHS Talking Therapies/IAPT communications I have examined for the Courts I have not found one case where there has been a clear delineation of relapse prevention strategies and the setting and review of homework. So much for accountability. Courses advocate the Cognitive Therapy Scale to help decide who is a competent therapist [ Branson, Shafran and Myles (2015)] but their findings did not demonstrate a relationship between competence and outcome. Homework and relapse prevention strategies are a simple, litmus test, for adherence to a CBT protocol, albeit that it does not directly address the issue of competence. But without adherence there can be no competence, adherence is necessary but not sufficient.
The Neglect of the Added Value of CBT
The selling point of CBT over medication was that it had half the relapse rate after discontinuation. With a failure to distil relapse prevention strategies in routine practise, can it be seriously claimed that CBT is being delivered?
Despite the dissemination of NHS Talking Therapies to over a million clients a year, there is no documentary evidence of either the provision of relapse prevention or of the routine setting of homework ( a hallmark of CBT). Taken together there is a paucity of evidence as to fidelity to any evidence-based treatment. NHS Talking Therapies has signally failed to measure treatment integrity.
NHS Talking Therapies Is In the Mire Over Relapse Prevention
NHS Talking Therapies has one hand tied behind its back when it comes to relapse prevention, as the latter can only be measured if the person has had a meaningful period of recovery, usually taken as 8 weeks (the period used to distinguish one episode of a disorder from another). But NHS Talking Therapies has never evaluated clients in such a follow up, so it cannot boast that it delivers on relapse prevention. To compound matters NHS Talking Therapies has never utilised independent observers using a standardised diagnostic interview to evaluate outcome, so its’ very notion of ‘recovery’ is highly problematic.
NHS Talking Therapies Problems With Relapse Prevention Are Even More Acute When It Comes To Low Intensity Interventions
NHS Talking Therapies ignore the fact that there is no evidence that relapse prevention strategies have a place in low intensity interventions. Rather it is assumed that they must be relevant because they were a feature in the randomised controlled trials that are better mirrored by high intensity interventions.
Workshops – a Corrective?
Attending CBT Workshops recently, the great and the good are totally silent about what is happening in routine practice. This may simply be a lack of awareness. But they seem to have little appreciation that there are any problems in the translation of their fare (which can indeed work ) to the coal face. However I don’t doubt the tremendous efforts that have been put into the materials for these workshops but I have concerns about the engagement power of the suggested modus operandi for most clients.
Dr Mike Scott