psychology

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CBT is the treatment of choice in the NHS

The National Institute of Clinical Excellence (NICE) offers guidance to government (statutory services including the National Health Service) as well as other organizations in public, private and voluntary sectors on matters concerning health and clinical governance (http://www.nice.org.uk/aboutnice/).

It is upon their recommendation that the National Health Service (NHS) advocate the use of Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy [1] (IPT) in conjunction with appropriate prescribing of anti-depressant medication for the treatment of moderate to severe depression (2007 Clinical Guidance 90 p. 24).

In order to discuss this recommendation I will first give some attention to the organization that makes it (NICE) and consider some of the criteria behind the guidance; I will also consider the therapeutic intervention itself (CBT) before discussing relevant benefits and limitations of the recommendation in the given context.

NICE came into being in 1999 in response to public concerns over what became called in the press the ‘postcode lottery’ (see: Norton in the Independent Newspaper 2000; also Butler, 2000). This term referred to discrepancies between Primary Health Care Trusts (PCTs) in different parts of the country in terms of which drugs were available on prescription for illnesses such as Motor Neuron Disease (Jones & Irvine 2003) and cancer (Norton 2000). Thus this ‘independent’ [2] watch dog organization was instigated to scrutinize and assess medical treatment options- specifically at that time pharmaceutical ones- and to make recommendations to the NHS based on their efficacy (evidenced by clinical trial outcomes) and cost efficiency (based on overall treatment costs/patient). A seemingly straightforward remit, however since that time NICE has been frequently the subject of controversy and debate in the press and from Patient, Doctor and other stakeholder representative groups as the criteria for making recommendations have become more and more complex. A key parameter used by NICE for evaluating the cost/effectiveness of a particular drug therapy is something called a “Quality-Adjusted-Life-Year” (QALY) which is a mathematically constructed computer generated model incorporating outcome data from clinical trials of a particular drug, chances of side effects, cost and potential improvements to health for a patient with a particular disease. The degree to which clinical and therapeutic matters, as well as something as subjective as ‘quality of life’ may be reduced to measurable quantifiers is perhaps in itself debatable and a theme for further discussion in this essay. However these are not the only variables in play: when a newly licensed drug comes on to the market, the pharmaceutical company that developed it and invested in its clinical trials hold patents on the branding for which they can charge according to their invested interests and their need to accrue large profits. BBC h2g2 (1999) edited guide comments:

One of the first drugs to be evaluated by NICE was the anti-influenza drug Zanamivir. NICEs decision not to approve the drug was met with heavy criticism by the drugs manufacturer Glaxo-Wellcome, with the company’s chairman threatening to remove future research from Britain….NICE issued a new guidance a year later - based on ‘new data’ the drug was recommended for use with the elderly and those at risk of death through influenza..

http://www.bbc.co.uk/dna/h2g2/A50669823

It may be observed therefore that the financial and political constraints imposed upon NICE by the realities of public and corporate funding make its job a rather difficult one. Over the years however, the organizations’ remit has extended beyond the issues of access to drug treatment options and now makes assessments of therapeutic interventions resulting in Clinical Guidelines (C.Gs) for the full range of services offered by the NHS - including depression and anxiety. The panel that oversaw the review of this guideline consisted of three G.Ps; an ear nose and throat surgeon and a lay person – no psychologists or psychotherapists - (2007 N.G 90 p.61) they carried out the task of incorporating stakeholder input with relevant clinical and financial considerations. NICE is of course only able to evaluate therapeutic interventions that have available some clinical trial or evidence-based outcome data. In terms of the wide range of ‘talking therapies’ that have evolved over the last 100 years since Sigmund Freud’s pioneering work with patients lying on couches recalling their dreams, only CBT was ready with that kind of data when it was required.

Cognitive Behavioural Therapy was developed during the 1970’s principally by Aaron T. Beck (Beck,1976; Beck et al,1979). Beck was an admirer of the work of Albert Ellis (1913-2007) an American psychologist who developed a model called Rational Emotive Therapy (REBT) which describes the links between thoughts (rationale) emotions and behaviour (Ellis, 1962). Although Ellis had been in turn influenced by Adler, the philosophical roots of both REBT and CBT go back to the stoic philosophers including Epictetus.  Epictetus wrote in The Enchiridion,- ‘Men are disturbed not by things, but by the view which they take of them’ (in Dobbin, 2008 p.175). Ellis was part of a movement away from Freudian psychoanalysis with its emphasis on unconscious drives and also a departure from the more humanistic theorists such as Rogers (1902-1987) whose approach relied upon the relational aspects of the therapeutic alliance and Perls (1893-1970) with his attendance to a focus on the ‘here and now’ and some more existential considerations in so-called Gestallt Therapy (see: Perls, Goodman & Hefferline 1951) and towards the empiricist and behavioural theorists.

Beck was also interested in the development of behavioural studies such as those of Skinner (1904-1990) and many of his early collaborations involved comparative studies in academic settings between purely behavioural learning patterns (classical conditioning) and those that included rational and emotive elements, thus laying the foundations for later therapeutic evidence-based outcome studies (see Beck 1970). Becks initial published work was on the clinical application of this approach to depression (1967) Depression, experimental, clinical and theoretical aspects; however Sanders and Wills (2005 2nd ed) suggest that since that time, the theory and practice of CBT has developed rapidly with many ‘fast-moving developments’ (p.3). Sanders and Wills describe a ‘second wave’ (ibid p.4) of cognitive behavioural approaches that have involved the recognition of the relational aspects between the client and the therapist in good therapeutic outcomes and now a ‘third wave’ which has incorporated experiential focus, mindfulness and acceptance into the practice. I would argue at this point that CBT has thereby collected and enriched itself with aspects of those approaches already mentioned that it once sought to distance itself from.

A central idea in CBT is the notion that our perception of an event or experience powerfully effects our emotional, behavioural and physiological response to it (Greenburger & Padesky 1995). The model posits a mutually reflexive field of influence between cognitions, (thoughts) affects, (emotions) physiological responses and behavioural strategies. Thoughts are viewed as a product of underlying beliefs and experiential learning but these may or may not have a basis in objective (or rational) fact, rather they may be the product of limited or negative learning outcomes from the past that may be brought to bear on current situations with unhelpful results. Although the focus of the approach is often the cognitions themselves, captured by means of of a written thought record, Sanders and Wills (2005) stress that in the modern CBT practice these are chiefly a way to access the associated emotions and thereby seek to improve the emotional response by means of modifying the cognitions in line with rational and empirical (verifiable by experience) perceptions. The therapeutic practice of CBT includes behavioural experimentation, where the client and therapist agree various homework tasks (including activity scheduling, thought recording, mood monitoring and actual behavioural experiments). These experiments are designed to offer empirical evidence to the client (or patient as this rather more medical model would refer) which may then be helpful in dispelling old or limiting beliefs and in the creation of new behavioural strategies. A key orientating attitude of CBT is that of a collaboration between the patient and the practitioner, in which the co-creation of behavioural experiments are supported by the relationship with the practitioner and outcomes interpreted and understood with the help of the application of the CBT model itself. The approach is so geared towards empowerment of the patient in a self-directed way that the role of the therapist may in some cases be seen as superfluous, as in the computer-based programs and self-help books such as Mind Over Mood (Greenburger & Padesky 1995).

In considering CBT as a therapy of choice at this time, it might be interesting to consider the notion that social and cultural paradigms follow the technological advances of that epoch [3] (Smith, Merritt Roe & Leo Marx 1994). In the light of this thought for instance, Freud’s theories of internal drives and unconscious pressures came about in the era of the development of steam power. CBT was born into the era of information technology and is shaped around the ideas that information (thoughts & beliefs) will determine behaviour. A closer match and more recent innovation along this line is that of Richard Bandler and John Grinder’s Neuro Linguistic Programming (NLP) where internal process are described absolutely in terms of the computer technology (programs) of which Bandler himself was an early master (Bandler & Grinder 1975).

Turning now to the recommendation by NICE of the use of this therapy as the treatment of choice for cases of moderate to severe depression, I will first outline the criterion for this diagnosis. The full clinical guideline (CG 90 2009) runs to 64 pages and includes breakdowns of diagnostic thresholds and so-called ‘stepped interventions’ (p16) which describe low intensity psychological interventions (such as a computer accessed CBT course – CCBT or group CBT sessions) to high intensity interventions for moderate to severe depression (or subthreshold depression that has not responded well to earlier stepped interventions). The CG 90 utilises the Diagnostic and Statistical Manual –fourth edition (DSM IV) for the identification of mild, moderate and severe depression, and states that this is because these criteria are most commonly used for identification purposes in clinical trial data.

DSM-IV system requires at least five out of nine symptoms for a diagnosis of major depression (referred to in this guideline as ‘depression’). Symptoms should be present for at least 2 weeks and each symptom should be present at sufficient severity for most of every day. At least one key symptom of low mood, loss of interest and pleasure or loss of energy will be present.

. (C.G 90 p.4)

A high intensity individual psychological intervention program (of CBT)is recommended as being 16 -20 sessions delivered over 3 to 4 months with a suggestion that twice weekly sessions are used at the outset of treatment. This would be in conjunction with prescribing of anti-depressant medication.

From the information already set out it can be seen that there are a number of pragmatic reasons why CBT might be the ‘treatment of choice..’ but is it suitable? And if so, is it more appropriate or cost effective than any of the other possible psychotherapeutic interventions? From the perspective of trying to find an empirical answer to that question we are immediately in the same dilemma as the NICE clinical guidance panel: where is the information upon which one might make a judgment? Until a great many comparative and evidence-based studies are done across modalities and in comparable clinical conditions and presentations, there is no way of knowing for sure. Hollon (2003) sumarises his inquiry into whether CBT interventions have an enduring effect thus:

CBTinterventions have been shown to have an enduing effect that extends beyond the end of treatment; they reduce risk for relapse in chronic disorders and risk for recurrence in episodic disorders. Whether CBT is truly curative remains to be seen, but there is more good evidence for CBT having an enduring effect than for any other intervention in the field today. (p.71)

Of course the lack of good evidence isn’t the same thing as a lack of good therapies. It may also be observed in passing that measurement is an intrinsic part of CBT itself; as a solution-focused approach, subjective base-line data is established at the outset of treatment. Here is how the National Association of Cognitive Behavioural Therapy describe thus it in their website:

CBT is very similar to the “Scientist Practitioner Model” where the clinical practice and research work is done from a scientific perspective. This method places an emphasis on measurement. ( http://www.nacbt.org/historyofcbt.htm)

This may be in the form of a scaled questionnaire such as the Hospital Anxiety and Depression Index (HADs) commonly used by G.Ps, or in terms of self-evalutated Subjective Units of Discomfort (SUD scales). Progress is monitored and reviewed against this data throughout and at the end of treatment thereby providing an in-built frame of reference for the client and of course for the purpose of evidencing efficacy to interested funding bodies. Follow-up studies such as the one cited above have also been conducted and have shown some enduring benefits to the CBT intervention and the acquisition of new thinking skills. Again there is little comparable information from other modalities as to the enduring benefits of those therapies on particular presentations.

However as a therapist in the field, with a practical working understanding, and experience of both CBT and a number of other theoretical and clinical approaches, I do feel able to at least discuss the topic. During 2009-2010 I worked delivering a program called Condition Management Program (CMP) funded by government and administered by a number of NGO’s (non governmental organizations) across the country, this program was aimed at helping people on long-term sickness benefits to become fit to work by learning to manage their symptoms more successfully (cynically, it could be seen as an initiative to get people off higher levels of benefit and registered as fit to work therefore only eligible for Jobseekers allowance). The program was run initially over an 8 week period and was in the format of day long group seminars that provided information about a variety of conditions and used CBT to enhance skills in managing the symptoms thereof. A high proportion of those referred to these groups were off work through debilitating anxiety and/or depression, many of these falling into the diagnostic criteria of moderate to severe (other presentations included chronic pain, chronic fatigue, PTSD etc). The program was geared around the collection of initial assessment data (HADs and another scaled questionnaire for social functioning) which were then compared with exit scores once the course was completed. My own evaluation of the processes involved here would take more scope that this essay would permit, however one salient observation of mine is that the issues underlying the diagnosis of ‘anxiety’ or ‘depression’ could not be adequately attended to in this format. For many individuals the skills and alternative strategies for managing well-being were indeed very helpful. Others reported that the most valuable thing for them was the realisation that they were not alone with their particular problem and that others suffered in similar ways, in other words the group and social contact was most facilitative.

I have observed it to be a very helpful realization indeed for a client to learn that their thoughts are not the same thing as their feelings, and that one influences the other very directly. The simple concepts of CBT are user friendly for both the practitioner and the patient, once assimilated they can be adapted for many differing circumstances. I have also had clients referred to me privately who claim that CBT has ‘saved their lives’ during times of deep depressive illness. There is no doubt in my mind of its usefulness therapeutically speaking, however I would personally feel under-resourced for work with complex presentations where ‘depression’ has been clinically diagnosed but the underlying issues include loss, trauma, personality disorders, substance abuse etc, if I only had CBT to draw upon.

In my private practice I have seen more than one client whose G.P had put them onto anti-depressant medication and then some months later as the symptoms of tearfulness, panic, sleeplessness, loss of interest in activities that once were enjoyable etc continued to appear, signed them off work with severe depression and the suggestion that they might try ‘counselling’. An initial assessment in one case revealed that the client had been nursing a terminally ill parent over many years whilst trying to juggle work and a failing marriage, when their parent had finally died six months earlier the pressures were lessened- but the depression set in. Another client had not worked for many years and had a clinical diagnosis of anxiety disorder and depression, (she also had an active eating disorder which was the reason for her referral to me) this person had some serious and unresolved abuse issues from childhood that had been triggered when her own daughter reached the age that she had been when the abuse had happened to her. In both these cases, and in many others of a similar nature, I have been more inclined to utilise an integrative mixture of supportive psychotherapy, (acknowledging humanistic process led concepts such as the need to grieve) alongside strategic interventions of CBT, NLP or hypnosis designed to improve internal or external resources. Once the underlying issues are resolving, and if necessary the prescribed medication is satisfactorily in place, the more habitual elements of depression can be well addressed with behavioral experimentation and mood management techniques.

I use a metaphor for depression: a car with a flat battery and a cold damp engine- on your own it is nearly impossible to get going with a car in this state (unless you live at the top of a hill!) you need someone else, either with another car to apply some energy to the battery or to push and get the car moving so that it can begin to generate its own ‘heat’. When a depressed person begins to connect with another person, and particularly when they can be encouraged to participate in certain activities they will begin to make their own internal ‘heat’ or ‘feel good factors’ (neuro-transmitters such as serotonin, endorphin and dopamine). Recurrence of depressive symptoms can be watched for so that warning signs are identified an earlier point and appropriate actions taken thereby giving the client an empowering sense of knowing what to do when the ‘car wont start’ on cold winter mornings. It is not my intention here to trivialize the issues surrounding depression, quite the opposite, I consider the NICE guideline to be under-informed (about alternative approaches) and under-informing about the subtleties and difficulties that are often concomitant to a diagnosis of depression. A further consideration is that of training where CBT is concerned, although this approach is their ‘treatment of choice’, patients on the NHS can wait for months for a referral to a specifically trained CBT practitioner, such a practitioner may have completed a stand alone course in a year or less and have little or no knowledge or experience of complex presentations. As the trainings are practice not process led, graduates of these certificated programs may have little or no awareness of their own vulnerabilities nor the potential difficulties encountered when working with, for instance, personality disorders or PTSD.

Finally I return to my earlier question about whether human experience can really be justifiably reduced to measurable quantifiers? This is very much the language of budget driven and resource-constrained politics, and also carries with it the technological paradigm of mega-bites and pixels. I would argue that humans are more than these component parts, though a good working knowledge of how they operate is helpful to technicians and therapists alike.


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