CBT – An evaluation from a therapist’s viewpoint
The objectives of this article are two-fold, with both relating to the title.
The first objective is to provide information about CBT and the evaluation of it as a form of therapy that can be used as an evaluation as a therapeutic approach within AS and A2 lessons.
The second objective is still about information, but goes much further than the classroom and relates to what is happening within counselling and psychotherapy world, in the UK right at this present time. It relates to changes, in fact huge changes that affect service users and providers within the counselling and psychotherapy world. Changes that have stirred up comments and controversy.
Actually I am going to start with the second objective as this will cast light on, and inform, the first. It will make clearer some of the criticisms that are levelled against CBT and the clinical application of it within therapy. Up to this point in time in the UK ‘counsellor’ and psychotherapist’ and even ‘psychologist’ have not been protected titles. That is anybody could use the term even with the least amount of training if any at all. Get out the brass plate, shine it up, and fix it up outside the door and wait for the customers to come along. Although that was possible there has been organisational self-regulation in place. For example, this has been true within the therapeutic world with organisations such as the BACP and UKCP. These organisations regulate their member-practitioners by requiring certain amounts of training and the adherence to codes of ethics and practice. If these are breached in any way then the practitioner could lose their membership. This process was developed over a number of years and has taken into consideration a wide and disparate range of theoretical ways of working. A difficult task in view of the different interpretation of the therapeutic relationship and process which in turn will lead to differing goals and aims. Given that, in the opinion of many, this self-regulation has been effective and has worked at keeping the profession ethical.
However, this is changing. In a white paper published in February 2007, called Trust Assurance and Safety, the Department of Health stated the Government’s intention to regulate psychologists, counsellors and psychotherapists as a matter of priority. ‘Psychologist’, ‘Counsellor’ and ‘Psychotherapist’ will become protected titles which will mean that anyone using those titles as a description of themselves will have to be registered (Department of Health, 2007). The 1 July saw the start of this with the opening of a register for Psychologists. Registration is in the hands of the HPC (Health Professions Council). A minimum standard will be required of the practitioner before registration is permitted (as far as counselling and psychotherapy are concerned, in the opinion of some, it will require lower levels than at present within BACP and UKCP accredited membership). These changes have been welcomed by many therapists. It now gives a base-line for practice and a protection for the public. If complaints are made they can be made to a central source. If upheld and the matter is serious enough then the therapist will lose their practitioner certificate and will not be able to legally practice using the protected title of ‘counsellor’ or ‘psychotherapist’.
However not all have welcomed these changes and regulation. On 5 April this year there was a conference in London organised by therapists who are objectors to the proposed regulation. The conference was entitled ’Against State Regulation’. Subsequent to this, the ‘Alliance for Counselling and Psychotherapy’ issued a statement outlining their objections. Look closely here because implicit within the statement is criticism of CBT, which of course ties in with my first objective and the title of this workshop/seminar.
Among other points, the Alliance states:
‘Although many counsellors and psychotherapists work in medical settings, their work is not a branch of medicine nor an activity ancillary to medicine. Most forms of therapy do not focus exclusively on the relief of symptoms, but emphasise creating and exploring a relationship. If there is a goal it is a general improvement in the quality of life (so that client satisfaction, rather than the improvement of an isolated symptom, is the appropriate measure of effectiveness). Regulation through the HPC implies medical values and criteria which are in many ways antithetical to psychotherapy and counselling.
‘Many practitioners see their work as more of an art than a science: a series of skilled improvisations in a relational context, where each client offers unique issues and demands unique responses. Such an activity cannot be captured by a list of competences . Yet regulation by civil servants, who themselves know nothing of the field they are regulating, demand an objective version of practice, even if this falsifies its nature.
‘The initiative to regulate psychotherapy and counselling is itself a symptom of our tick-box society: of an obsession with safety, a compulsion to monitor every activity, an illusory belief that everything can be brought under control. In many ways psychotherapy and counselling inherently expose this illusion: they support us in tolerating uncertainty, difference, risk, and the unknown.’
The point has to be made here that all these views and the content of the Alliance statement are the views of the Alliance and is contrary to the stated view and official line of The British Association for Counselling and Psychotherapy (Aldridge, 2009).
A speaker at the London conference who is a well-respected therapist and writer, Brian Thorne, in his paper ‘A collision of Worlds’ asserts that statutory regulation will do little or nothing to protect clients, but will sap therapists of their creativity. He argues that therapy is not a medical-associated activity that concerns itself with symptom reduction treatment plans and empirically validated procedures (all these terms are familiar to and used in CBT). But, Thorne says, therapy is about relationship, depth and about extraordinary intimacy. So that a person who is suffering can find hope, alleviation from pain, a sense of meaning and a way forward. He states: ‘To subject therapists to statutory regulation has about the same incongruity as putting ballet dancers under the direction of a regimental sergeant major’ (Thorne, 2009).
To continue with a final point in the Alliance for Counselling and psychotherapy statement:
‘NICE clinical guidelines and IAPT privileges a single form of ‘evidence based’ therapy [referring no doubt here to CBT] over all other modalities and promise to reduce access to long term, relationally oriented therapy; to reduce client choice; to medicalise the field; and to rigidify training’
Above there is reference to NICE clinical guidelines and IAPT. Two collections of initials that need explaining. NICE is an acronym for the National Institute for Health and Clinical Excellence. NICE produces guidance in three areas of health:
• public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS
• clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.
This organisation provides recommendations based on research for best clinical practice within the NHS. CBT, because of its abundance of evidence-based research, is strongly favoured as a therapy preference for many common mental health problems.
Improving Access to Psychological Therapies
Now to the other acronym IAPT. This stands for Improving Access to Psychological Therapies. In 2006 the London School of Economics published a report advising that psychological therapy should be made more widely available to everybody in the UK. This has come to be known as the Layard report, named after its principal author Lord Richard Layard. It has led to the government funded initiative IAPT programme. The proposed focus of this is to provide increased therapeutic access and availability to help adults with common mental health problems such as depression and anxiety. This initiative will total a massive £300 million and represents the largest programme ever to support the provision of psychological therapies in Britain. Layard’s economic analysis is based on the assumption that the cost of this will come from the benefits of savings of reducing absenteeism, getting people back to work and reduced use of NHS resources (Layard et al. 2007). Incidentally, its critics say that the analysis is predicated on what they call in the May 2009 edition of the ‘Psychologist ‘a naive view of mental health problems, essentially a simplistic illness model and of an overly optimistic assessment of how effective psychological treatments can be’ (Marzillier and Hall 2009).
So now put all his together. Regulation which means developing a way of measuring competences; NICE guidelines which look to the paradigm of measurable evidence-based research; and the NHS IAPT programme strongly influenced by NICE recommendations.
You can see that CBT rides high in being in a favourable position as contrasted to practitioners from other approaches who may see their positions and way of working as being under threat. The British Association for Behavioural and Cognitive Psychotherapies (BABCP) is the leading organisation for Cognitive Behavioural Therapy in the UK.
Also of note is that recently, that is within this last year, BABCP has withdrawn its affiliation to the United Kingdom Council for Psychotherapies (UKCP). In letters to members it was stated that ‘autonomy and independence of the BABCP is particularly important at this time’ as they ‘are now actively involved in key developments in relation to the Government’s agendas on HPC regulation and New Ways of Working for Psychotherapists, as well as their central involvement in the implementation and expansion of the IAPT programme’. According to this letter, ‘the UKCP has not only failed to support CBT but has been highly critical of it, particularly in regard to IAPT’.
All the foregoing has its effect on the therapeutic community here in the UK. An increasing number of jobs are requiring CBT training and expertise. Primary care counsellors in various PCTs have been required to re-train in CBT or have lost their jobs working within GP practices.
CBT – against and for
It is no wonder that therapists from other approaches have reacted in protest to what they see as a monopolising of practice and a marginalisation of alternative therapeutic methods and philosophies. There have been many articles published of late objecting to what has been seen to be the exclusivity of CBT, the emphasis on the medical model (Sanders, 2007), and the questioning of its evidence base (Fairfax, 2008). A book recently published by PCCS Books puts the arguments forward written by opponents and supporters of CBT. It is edited by Richard House and Del Loewenthal. The title of the book is ‘Against and For CBT: towards a constructive dialogue’.
The major areas of criticism raised are: The alleged superficiality of the approach with the focus only on accessible cognitions and the ignoring of deeper motives and desires Philosophical critiques of the assumptions underpinning CBT such as technicism and rationality. The mechanistic determinist view of the human condition. The focus on a medicalised model that plays down meaning and purpose in clients lives. The strong cultural bias with the taking to task of Layard-type thinking with its socio-economic flaws. The collusion with psychiatric power structures and being used by the Government as a way of upholding a political and social economic system. The reliance on flawed research paradigms for support. (House and Loewenthal, 2008).
Last month there was a debate held at the Royal Geographic Society in London organised by Intelligence Squared. The subject and proposal of the debate was ‘Psychotherapy does more harm than good’. A subject that has echoes of the Eysenck study (Eysenck, 1952). In a pre-debate Radio 4 interview on 17 June, two of the debaters were interviewed. They were Jeffery Masson, an eminent opponent of therapy and author of ‘Against Therapy’, and Richard Layard. In the discussion that followed Masson referred to CBT as more of a marketing device than a therapy. He went on to say that: “CBT says that you are looking at the world in the wrong way. But who is to say that they are looking at the world in the right way? It is a political difference. Why should their way be better than your way? You will not be harmed by talking to a friend; you may be harmed by talking to a therapist.” (Incidentally, the result of the debate was 30% For, and 63% Against the motion ‘Psychotherapy does more harm than good).
As a practising CBT therapist I, of course, do not completely agree with such a statement and look at things from a different perspective. CBT is a well-researched method of helping people overcome difficulties that they are experiencing in their lives. It has helped people to return to a functioning and fulfilling way of life. It is evidenced-based, that means it has been developed and continues to be developed on what works and what has had long term beneficial effects. However, I do think it is important and healthy to consider the voiced criticisms. There can be a danger in the conveyor belt-type application if practising a rigid manualised CBT. This can dehumanise and disempower individuals (Merrett and Easton, 2008). Not to be underestimated is the importance of the therapeutic relationship and the empathic interaction of the therapist (Thwaites and Bennett-Levy, 2007). Cognitive Behaviour Therapy is an umbrella term that encompasses a growingly varied way of working therapeutically. REBT, ACT (Acceptance and Commitment Therapy), Schema-Based CBT, Compassion focussed therapy and Mindfulness-Based CBT are a just a few that come under that umbrella. The popularity and growth in the diverse angles of focus give evidence of the applicability and livingness of this as a therapy. All these varying ways of applying the principles and philosophy that underpins the approach offer in themselves a powerful response and reply to many of the criticisms that have been made.
Stuart is an accredited CBT therapist /supervisor. He is an accredited member of BACP and a UKCP registered psychotherapist. He is Features Editor of the Journal of the International Stress Management Association UK and a member of the Faculty of Healthcare counsellors and psychotherapists and works in private practice and in primary care. He also teaches psychology.
Aldridge, S. (2009), Making your mind up, Therapy Today, Vol.20, No. 4, p18-20.
Department of Health. (2007). Trust, Assurance and Safety – the Regulation of Health Professionals in the 21st Century. London: Department of Health.
Eysenck, H.J.(1952), ‘The effects of psychotherapy: an evaluation’. Journal of Consulting Psychology, Vol.16, p319-324.
Fairfax, H. (2008), ‘CBT or not CBT is that really the question? Reconsidering the evidence’. BPS Counselling Psychology Review, Vol.23, No.8, p27-35.
House, R., Loewenthal, D. (2008) ‘Against and for CBT’, PCCS Books.
Layard, R., Clark, D., Knapp, M., Mayraz, G. (2007), ‘Cost-benefit analysis of psychological therapy’. National Institute Economic Review, 202, p90-98.
Marzillier, J., Hall, J. (2009), ‘The challenge of the Layard initiative’, The Psychologist, Vol.11, No.5, p406-408.
Merrett, C., Easton, S. (2008), ‘The Cognitive Behavioural Approach: CBT’s Big Brother’. BPS Counselling Psychology Review, Vol.23, No.1, p21-31.
Sanders, P. (2007), ‘Decoupling psychological therapies from the medical model’. Healthcare Counselling and Psychotherapy Journal, Vol.7, No.4.
Thorne, B. (2009) ‘A collision of worlds’. Therapy Today, Vol.20, No.4, p22-25.
Thwaites, R., Bennett-Levy, J. (2007) ‘Conceptualising Empathy in Cognitive Behaviour Therapy: Making the Implicit Explicit’. Behavioural and Cognitive Psychotherapy, Vol.35, p591-612.