CBT is the treatment of choice in the NHS for moderate to severe depression. What are the benefits and limitations of this decision.
The WHO predict (Murray & Lopez 1997 – cited in Yapko) that depression will be the second most common cause of human suffering by 2020. This places depression above those old bugbears of malaria, tsetse fly and famine. The Depression Alliance (2009) state that one in six British people will experience (at present rates) an incidence of depression during their lifetime. Fifteen percent of these patients, it is estimated, will commit suicide. The human cost, therefore, is considerable and growing rapidly. The economic cost, furthermore, is staggering. £9 billion was lost to the UK economy alone, in 2000, as a result of depression.
It is no wonder, then, that policy makers within health care systems take this issue seriously. Depression ruins lives, ends lives and brings with it considerable economic burdens.
The profits of drug manufacturers have increased in line with this growth in depression.
The combined sales of anti-depressant medications reached $14 billion, worldwide, in 2004. Prozac, in 2001, was responsible for over a third of pharmaceutical giant Eli Lilly & Co’s $3 billion profit (Business Week 2001). The manufacture of anti-depressants is big business and their marketing budgets give them considerable sway over Health Care Trusts and GPs.
Are anti-depressant interventions effective? Is there any need for psychotherapy at all? Yapko (2001) states that the rationale behind the explosion of pharmaceutical interventions is that depression is a biological illness, a chemical disorder of the brain. Yapko discusses how terms such as “serotonin deficiency” and “biochemical imbalances” (p5) are used to justify this pharmacological approach to the issue. The NDMDA, in 1999, concluded their study of antidepressant users (with their evident dissatisfaction with those drugs available to them) as being “we need more and better drugs.”
And yet, as Yapko (2001) explains, anti-depressant medication cannot hold the answer alone. Serotonin and other brain chemicals are not “unidirectional.” Experience and biochemistry are “bidirectional.” Negative experiences can affect biochemistry as surely as biochemistry can cause a negative interpretation of experience.
Depression is not, therefore, a purely or necessarily biological condition.
It is not an illness in the classic sense of the term and so drugs may not be the only or most appropriate answer. Indeed, Yapko (2001) asserts that they are not any answer at all, in themselves, since they merely cover the activating events and maladaptive cognitions which bring about depression’s onset. Alladin (2007) supports Yapko, insisting that to be effective, a therapy must resolve the issues underlying the patient’s depressive symptoms. Pharmacotherapy, alone, is akin to prescribing morphine for a severed arm whilst making no attempt to repair the wound.
Furthermore, Yapko (2001) describes how anti-depressant medication can externalise a client’s locus of control, reinforce passivity and bring a number of possible side effects. There are, in consequence, higher rates of relapse when compared with treatment through psychotherapy. Patients need to be taught self-coping mechanisms if they are to acquire the tools with which to forestall future incidences of depression.
And yet anti-depressants have their place.
Yapko (2001) explains how anti-depressant medication can reduce symptoms of depression faster than can psychotherapy. It is also more effective than psychotherapy in treating the “vegetative” symptoms such as sleep and appetite disturbances.
A 2007 study by Professor John March (Pulse 2007) found that 73% of patients undergoing combination therapy responded to treatment within 12 weeks, compared to 62% of those who took fluoxetine alone and 48% of patients whose treatment was restricted to CBT. Such medication, therefore, has its place and is still more effective when in alliance with psychotherapy.
The question remains: of all the “talking therapies,” is CBT best placed to deliver results for people suffering from depression?
Dryden (2007) explains the importance of Beck’s 1977 study, which showed the results of cognitive therapy to be comparable with pharmacotherapy. Pharmacotherapy had, hitherto, been seen as the more effective approach. Dryden (2007) goes on to explain the importance of Blackburn et al (1981) and Teasdale et al, (1984) in demonstrating the efficacy of CBT when dealing with depressive patients. Burns (1999) supports these findings in his description of research conducted by Rush, Beck et al (1977). This research demonstrated that three times as many patients recovered through CBT alone than through anti-depressant medication alone.
It should be noted, however, that this study predated the invention of more effective SSRI medication and so these figures might not be repeated in a modern re-enactment of this study. Nonetheless, a later study by Baxter & Swartz et al (1992) demonstrated that CBT was as effective as SSRI medication in altering brain chemistry.
These studies thus demonstrate the efficacy of CBT when used to treat depressed patients. Before these studies it had been thought that CBT was less effective than anti-depressant medication or that the techniques used in American private practice were unsuited to use within an NHS setting. With the conclusion of the studies detailed above, this prejudice could continue no longer.
Clinical psychologists are now common users of CBT (Dryden 2007) within the NHS. NICE guidelines recommend CBT as a core component of its provision when dealing with depression and other psychological disorders. A publicly funded health care provider requires empirical evidence before committing tax payers’ resources to treatments.
CBT, therefore, is ideally placed since it stems from a behavioural tradition which extolled the virtues of scientific rigour.
Aaron, Beck and others, founders of CBT, continued with this effort to lend scientific weight to their therapies. As Burns (1999) states (page viii) “there has probably been more published research on cognitive therapy than on any other form of psychotherapy ever developed, with the possible exception of behaviour therapy.” Healthcare providers seeking to justify their spending with hard data need not look too hard with CBT.
So, if we have established that CBT is seen as an effective means of treating clients with depression, as evidenced by empirical studies, what is it which makes it effective and could not other therapeutic traditions be equally effective?
NHS Choices (2010) explains, as detailed above, that one perceived advantage of CBT is its efficacy when compared to medication. Empirical evidence is cited as proof of its efficacy. The evidence does suggest that CBT can be effective, but does not rule out the possibility that other forms of psychotherapy could be equally effective.
The same website also states CBT to be a short term therapy and “can be completed in a relatively short time compared with other talking therapies.” This is, of course, desirable for patients in need of relief from their symptoms but also benefits healthcare providers and their budgets.
Furthermore, NHS Choices explains how “because it is highly structured, CBT can be provided in a number of different formats such as through computer programmes, groups and self-help books.” Such provision may well suit those patients who cannot or will not visit a therapist in person, for example. They also, it must be said, offer a cost saving for the NHS.
Also, one aspect of CBT’s structured approach is to regularly review progress on a numerical scale, charting the change in client viewpoints. This is ideal within a health care setting because the numerical data which this process generates can be used to demonstrate efficacy on a regular basis. Clinicians seeking to justify expenditure on a scientific, empirical, basis have the ideal tools to hand.
Finally, the NHS believes CBT to be a worthwhile offer because “The skills learnt in CBT are useful, practical and helpful strategies that can be incorporated into an individual’s life to help them cope better with future stresses and difficulties.” Teaching self-coping skills is a facet of CBT which Burns (1999) believes explains the lower rates of relapse of CBT patients compared to those patients only using medication. Again, not only does a lower rate of relapse (Yapko (2001) states the median number of lifetime relapses to be four in patients treated by medication alone) help the patient, it also frees the NHS of a financial burden.
A thirty day course of Prozac cost the NHS £14.21 in 2009 (BNF 2009).
This appears a small sum. Gelenburg & Freeman et al (2010) recommend, however, that patients remain on fluoxetine (at their usual dose) for four to five months following the successful resolution of symptoms. This in itself can take over six months. Three further relapses, on average, and the bill for Prozac runs into hundreds of pounds. Together with the cost of GP time, suicide attempts and subsequent medical care and other factors, the price of a swift bout of solution-focused CBT therapy, which deals with the issues underlying the patient’s depression and thus prevents relapse, would begin to appear as value for money. If some patients can be attended to via computerised CBT or group therapy, the cost diminishes still further.
Briers (2009) states CBT to be popular with the NHS because the skills necessary to provide such therapy
can be quickly (and thus cheaply) taught. The skills needed by the client are also easily taught. We thus have a therapy for which suppliers can be easily trained and patients swiftly instructed. Waiting lists for therapy can thus be reduced, patients will be cured more rapidly and thus more targets will be met. The therapy itself is relatively swift and so everybody wins: providers, taxpayers and patients all.
The weaknesses of this approach to the treatment of depression are manifold.
CBT may well be an effective treatment for many patients but, as Yapko (2001) explains, the regimented structures employed within many health care settings do not suit all clients. Firstly, “depression” is a global construct which presents differently in every client. it is not a uniform condition and so a uniform approach to its solution is inappropriate.
There is also the question of whether any theoretical approach is better than another. Trower & Jones et al (2011) state that the therapeutic alliance is the crucial ingredient in the success of a therapy. Mearns & Thorne (2007) agree, stating that the level of trust between client and therapist determines the quality and success of work done. Jacobs (2010) believes that it is the experience and quality of the therapist (rather than the school to which he belongs) which determines success.
CBT may be a useful tool but it is the therapist and not some miraculous therapeutic system which will resolve a client’s issues.
Over-emphasising the efficacy of CBT risks ignoring the importance of the therapist utilising its tools, a therapist who may well achieve similar, perhaps better, results with other therapeutic approaches. After all, none of the studies of which Burns (1999) is so fond suggests that all patients made a recovery through CBT. None of these studies compared the efficacy of CBT to the efficacy of other therapeutic approaches.
No study can scientifically link the success of psychotherapy to the quality of the therapeutic alliance. Person centred counselling is, therefore, at a distinct disadvantage if schools of therapy are judged by empirical evidence. Furthermore, believing CBT to be a cheap fix which can be delivered by those who are quickly and inexpensively trained to deliver a mere process, risks denying the importance of the therapeutic alliance entirely.
People who responded to a recent (2010) survey on Oxfordshire’s provision of Counselling indicated that a wider provision of psychotherapies was desired, commenting that:
‘CBT can be useful for some problems, I don’t think it should be the only option available for service users at a primary level’.
‘Have other methods been considered, including the use of group therapy and virtual networks? – range of services e.g. CBT, person-centered, psychodynamic.’
‘many patients do not fulfill Talking space referral criteria – not able to use CBT.’
Respondents included both GP providers and service users, indicating that both groups felt a degree of frustration at the concentration of resources on CBT.
As Yapko (2001) explains, therapists should respond to the client before them. “Depression” is a global term and clients are evidently different in their needs, personalities and difficulties. Depression is also commonly associated with a wide range of comorbid conditions and these complicate matters further. If no two clients are the same then no two responses to depression can be both the same and equally effective. Perhaps, as Yapko (2001) explains, “perhaps it would be more valuable to empirically validate therapists than therapies” (p11).
Trower & Jones et al (2011), Beck (1980) and Burns (1999) all discuss target setting as being useful interventions with depressed clients. Beck (1980) describes how even a small success can begin a virtuous circle in the client’s mind. Success breeds confidence which in turn brings further success. Feedback from set tasks informs progress reviews and it is this which provides the numerical data of which the NHS is fond. The setting of tasks between sessions and the review of their success is not, however, the sole preserve of CBT. Success may breed confidence.
The CBT therapist who causes his client to set and achieve such a target has done his client a good turn. How much greater an impact would such a success have, however, if a person centred approach had seen the client devise his own target, if the client himself had come to realise the desirability of setting such a target to begin with? Such an internalised locus of control would give the client one of the tools for future self regulation which CBT therapists rightly see as being important but which is not theirs to own.
Another weakness of following a rigidly CBT approach to the treatment of depression lies in its neglect of the unconscious.
Breuer & Freud (1895) argue that neuroses are caused by the repression of painful memories. A psychoanalytical or psychodynamic approach might therefore concentrate on locating the repression and bringing about catharsis by abreaction. If we accept this criticism then CBT is of limited utility. As Beck (1980) explains, CBT deals with conscious cognitions and corrects maladaptive thinking. It cannot deal with unconscious causation.
The importance and existence of repressed memory is, however, controversial. Brandon (1998) stated that “no evidence exists for the repression and recovery of verified, severely traumatic events, and their role in symptom formation has yet to be proved.”
Hartland goes still further. He argues that there is a good argument for disputing the very existence of memory or of an unconscious mind which seeks to repress them. There is merely knowledge which is at the forefront of our minds or which is held in reserve for future use. There is no repression but merely a system of defences with which knowledge of our past is “dealt with” in order to minimise its capacity for causing discomfort in the present. If repression does not exist, what use is regression, as we currently define the term?
This argument risks disappearing into a stalemate of semantics. We do not yet understand the biochemical structure of “memory,” thus nobody can win the dispute. Hartland (2009) proposes a compromise, citing Myers (2000) who claims that “….some individuals, more than others, have a coping mechanism characterised by the avoidance of cognitive activity that is threatening and anxiety provoking.” Memories may not be repressed, therefore, but clients may have developed self-defeating methods of coping with their consequences.
Alladin (2008) supports Hartland, stating that activating events trigger the client’s schema and so need to be understood. CBT as defined by Beck, therefore, goes too far, perhaps, in rejecting the importance of activating events. Defences and repressions, conscious or otherwise, will need to be resolved before a client can consciously reconstruct maladaptive cognitions.
It is here where the work of Yapko and Alladin, amongst others, might prove useful in remedying the weaknesses of the CBT approach to depression. As Burns (1999) explains, one of the benefits of cognitive therapy is its inculcation of coping strategies, which “will make you feel better whenever you are upset.” (p11). This is surely the function served by that which hypno-psychotherapists would term the “anchoring” of positive emotions and which teaches self-relaxation.
Beck (1980) talks of the therapeutic effect of visualising pleasant scenes in order to bring about cognitive modification (p268).
Hypno-psychotherapists might use a similar technique to teach self-relaxation or to reframe unpleasant memories and associations.
Yapko, in fact, writes in his foreword to Alladin’s (2008) book that he once saw Beck employing what he called “success imagery” on a client. Yapko recognised the technique as an exercise in hypnotic age progression. Beck, however, denied Yapko’s implication that this was hypnosis. Yet, as Yapko explains, there are many more similarities between the two therapeutic approaches.
CBT talks of eliminating automatic negative thoughts. Hypno-psychotherapists build “positive ideocognitions.” CBT attempts to teach self coping strategies whilst hypno-psychotherapists anchor positive associations, self relaxation techniques and render positive responses automatic. It is for this reason, recognising the potential for an alliance between CBT and hypnotherapy, that Yapko and Alladin worked to develop “Cognitive Hypnotherapy.”
Combining the two approaches would work to remove two of CBT’s weaknesses in particular: that CBT ignores the unconscious and that CBT alone is too inflexible to cope with the complexity of comorbid conditions such as anxiety. It also, explains Yapko (2001), focuses on the positive, upon the inner and frequently unremarked strengths of the client rather than simply homing in on “negative” and “maladaptive” cognitions.
Furthermore, Alladin (2008) provides a theoretical and evidence based justification for his integration of the two modalities. Should this evidence based approach be accepted by the NHS then the improvement of its approach towards the treatment of depression could be significant. Alladin (2008) claims that his approach is assimilative, advocating a case formulation approach, and that this approach grants Cognitive Hypnotherapy the flexibility with which to treat clients in all their different forms. As Yapko (2001) states, psychotherapy is an art, not a science and the maximum flexibility is thus necessary if clients are to be treated effectively. CBT as it stands does not suit everybody. Cognitive Hypnotherapy could thus widen the net of psychotherapy within the NHS’ drive against depression.
And yet reforming CBT in such a manner and providing this reformed therapy through the NHS would simply allow a greater number of depressed clients to find relief through psychotherapy. It would not assure that every single client found such relief, because we would still be talking of a school of thought which stuck to its core principles despite being open to assimilation of certain techniques from other therapeutic approaches. It would still be a half way house towards the real solution: the provision of a wide range of therapies in order to better treat as many clients as possible.
Rogers (1961) argues that establishing a therapeutic alliance with the client, through demonstrating the three core humanistic principles, is generally enough to secure change and recovery.
Posing as the expert, as a corrector of cognitions, would be anathema to Rogers and to other humanistic practitioners. Beck (1980), however, explains how “talking about how miserable and hopeless they felt and trying to squeeze out anger often seemed to accentuate the patients’ depression…” (p263).
“Often” is a key word here. Those for whom such a conversation did prove therapeutic may well have found themselves still more at home and helped more effectively by Carl Rogers than by Aaron Beck. Some clients will simply find the humanist approach to therapy more successful. Others will find relief through other therapeutic approaches and some will, indeed, thrive on CBT.
CBT is evidence based but is cost effective only where it works.
It does not work, however, on every patient and a publically funded health care provider cannot write off those patients for whom its preferred approach is ineffective.
Pharmacotherapy is not, as Yapko (2001) has demonstrated, an answer in itself and so a truly responsive NHS would return to a client centred approach, where therapy matches the need and character of the client and the nature of his or her condition. CBT is a perfectly valid therapy and Cognitive Hypnotherapy is an exciting development. Still more exciting would be an NHS which ceased to act as a body of experts on the topic of depression and which chose, instead, to allow the client to determine the nature of his or her own solutions.
There are many things in life which are valued despite our inability to measure their value or to predict their desirability to any one person. The ability of any given piece of music to lift the mood of any one listener cannot be prejudged by a soi-disant expert in a distant office. If psychotherapy is an art and not a science, then we must accept that beauty is in the eye of the beholder. It is not defined by the views of the provider.
If we accept that the role of the NHS is to provide a world class service to British citizens, longer-term talking therapies should be offered where these best suit the needs of the client. Doctors will happily prescribe a different form of antibiotic if the first course failed to cure an infection. Some schizophrenics respond better to one drug than another. Treatments are individualised in these cases and so should they be with depressed patients. Psychoanalysis may be a longer-term therapy than CBT but you would need a great number of psychoanalytical sessions in order to match the human and economic cost of each individual depression-related suicide
About the author
Paul Hughes is a UKCP registered psychotherapist working in Reading, Thame, Wallingford and Oxford, Berkshire and Oxfordshire, UK.
He can be contacted on 01183 280284/ 07786 123736 / 01865 600970 or via firstname.lastname@example.org
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