BABCP Response - NICE Consultation January 2022

CBT V’s Production Line

CBT is in principle, user and client friendly. But in practice over two thirds of CBT practitioner’s experience burnout [Westwood et al (2017) see previous blog]. Recent evidence Kat Wheatley (2023) suggests no improvement, since the identification of the problem. Practitioners returning to work today, after the Coronation weekend, could be depicted as Lowry-like figures.What is going on?


I think that is is probably a combination of proximal and distal factors. The distal factor may be the commodification of psychological treatment, in which therapists are no longer regarded as people, but as individuals that are instrumental in achieving  targets: such as number of clients seen, waiting times and delivering on the Organisations metric of recovery.

The proximal factor may be a failure on CBT courses and the delivery of workshops, to ever mention the ‘irreducible complexity’ of therapy. Rather it has been implicitly accepted that it is possible to deliver CBT by selecting components of it to deliver vis a vis low intensity therapy.  But the studies of the efficacy of low intensity are of such poor quality e.g no independent assessment, that they offer no firm foundation for the delivery of effective treatment. In CBT the whole is greater than the sum of its’ parts.

Arguably it is the therapist as a human being interacting with another human being, utilising appropriate CBT strategies, that explains the potency of the therapeutic enterprise. Assembling components of CBT at various points on a production line, is unproductive. The idea of receiving a better component down the line, the much vaunted stepped-care approach, just does not work. Rather it is the synergistic interaction of two human beings in a context in which there are specific strategies available for the different disorders, that makes for the ‘living cell’ that is therapy. Just as a living cell cannot be constructed from inanimate parts (pace macro evolutionists). There is an ‘irreducible complexity’. The popular selling of individual parts of CBT, in self-help books is unlikely to make a real-world difference to the readers life,  unless the material is somehow personalised.

Dr Mike Scott