The Future of CBT In Practice

niNext month is Aaron Beck’s 100th birthday and the journal which he founded ‘Cognitive Therapy and Research’ has a great editorial https://doi.org/10.1007/s10608-021-10232-6, wishing him well and looking at possible developments in CBT for depression, envy, schizophrenia and OCD. But there is a yawning gap between the experiences of the beneficiaries of randomised controlled trials (rcts) of CBT and what UK citizens receive in routine practice. In terms of the model below, going clockwise, there has been a fundamentalist translation of the rcts to determine policy, such that key elements of context such as ensuring reliable diagnosis have been left out, implementation has been determined in a ‘Stalinist’ way e.g the possibility of sanctions if a 50% recovery is not reached, there has been no independent monitoring of the policy, there is a claimed risk reduction, but this is based on responses to the ambiguous suicide item, item 9 on the Patient Health Questionnaire PHQ-9. But there is no evidence that the ‘Science’ is looking at these matters anytime soon. The deliberations of bodies like the British Association for Cognitive and Behavioural Psychotherapy (BABCP) appear to occur in a parallel universe.

Recently Drew et al (2021) https://doi.org/10.1016/j.socscimed.2021.113818 examined transcripts of IAPT (Improving Access too Psychlog ical Therapies)  sessions and the take home message was that clinicians were preoccupied with their own agenda and not really listening. This echoes what  Omylinska-Thurston et al (2019) https://doi.org/10.1002/capr.12249   found when interviewing former IAPT clients:

participants discussed difficulties with the outcome measures they had to fill in each week. Clients said they did not feel comfortable filling them in. Clare said it felt “disheartening… because … it brings it home…just how bad you’ve been feeling”. Clients also said that the scales felt disrespectful to their experience. For some, it was difficult to pinpoint the accurate answer and for others the measures did not reflect the nuances. For example, Jenny said about the self-harm question on PHQ9 “…to harm myself? No, but I know I wasn’t eating …well”. Also Jason said “there’s a difference between wishing you were dead and wanting to die … the question really is: do you think you should kill yourself rather than do you think you’d be better off dead?” Participants also commented that they learnt how to score the measures to get more services or sessions. Jenny said about the self-harm question “If I’ said ‘yes’ then they …‘right, shit’, but because you don’t put that they do ‘OK, see you next week’.” Jenny also worried that “if you put it was only one day this week, does that mean you don’t get any more sessions?” Measures were also reported as focusing on the negative side and did not catch positive change

Difficulties with assessment

Six clients discussed issues they had with the assessment process. Clients said that they were not assessed for the right type of therapy. For example, Adam said “if I had been…assessed better, that therapist doing CBT could have been helping another person”. Clients also said that CBT was not explained to them and Michael commented that he “didn’t know exactly what CBT things were going to entail”. Clients said that assessment involved a lot of paperwork and form filling and did not focus on their needs. Jason commented that he had to fill in a measure first and the score decided that he was depressed rather than a discussion first supported by a measure. Maurice talked a lot about the phone assessment and said it was “uncaring, robotic and intrusive”. He was concerned that people will not engage in therapy following telephone assessments’.

Yet what struck me when I met Beck in 1997 in Canterbury, was how much he genuinely listened. The rcts on CBT continue to generate high expectations but the jury is out on whether they have made or will make a real-world difference.

Dr Mike Scott

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