CBT is the treatment of choice in the NHS for moderate to severe depression
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Depression, as we shall see, poses a significant threat to the well being of many people in the UK and worldwide. It is considered to be one of the top five leading causes of disability throughout the world (Caspi et al, 2003: 386). It is surely right then that the body charged with providing adequate healthcare in the UK, the NHS, chooses the treatment considered to be the most appropriate and effective for this condition, and provides access to that treatment for those in need. This essay will place in context the political, economic and health-related pressures that have acted as drivers in the decision to make CBT the treatment of choice for depression. There will also be an exploration of the benefits and limitations of this decision and how this may impact on the client seeking help and the therapist responsible for providing the therapy within this treatment framework.
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The World Health Organisation report (2005), Mental Health – Facing the challenges: building solutions, clearly sets out the issues facing not just the UK but all countries belonging to the EU in terms of mental health issues. At the time of publication it was estimated that there were 100 million people suffering from anxiety or depression with a huge variation in levels of access to either psychiatrists or psychologists. Access to any form of treatment ranged from only 10% up to 45% in countries where more organised health care systems existed, these were mainly in Western European countries. Interestingly despite the recognition of need within the EU, the budget allocation for treating individuals with mental health issues, including depression, was on average only 5.8% of the total health expenditure and, perhaps shockingly, ranged from a mere 0.1% to 12% between different countries. What this report also draws attention to is that this money was focussed on treatment rather than on health promotion or prevention. Considering the personal, social and economic impact depression has then one may wonder if adequate resources have in fact been allocated and whether those resources are being used in the most effective way.
If we put this in context of the situation in the UK, it is estimated that 5% of the population are suffering from major depression at any one time with a further 5% presenting with milder episodes and 10% showing depressive tendencies. 3% are diagnosed by their GP each year, however the same number go unrecognised during their consultation with their GP and only 10% are referred for treatment (Paykel and Priest 1992:1192 – 3).
The WHO report, rather than initiating the discourse on treatment for depression, only added to the debate which occurred as a consequence of the publication of the Department of Health Report (2001) Treatment of Choice in Psychological Therapies and Counselling. This report provided guidelines for medical practitioners about the relevant therapies for depression (amongst other mental health disorders) and made clear recommendations for the use of CBT (and IBT). This was followed by several other related publications including the substantial NHS Strategic Review of Psychotherapy Services in England (Parry, 1996). Again the focus was on the provision of “coordinated, evidence-based, comprehensive, safe, and equitable provision of psychotherapy”. The reason why it is important to put the choice of CBT in context is that once a decision of such magnitude has been made it becomes difficult to retract it or revise it in any substantial way. It is obvious that there has been a huge investment in time, resources, creation of infrastructures and research to reach this decision so there is a lot of pressure and expectation on individuals, health organisations and government bodies to ‘make it work’. This of course can create the danger of making the patients ‘fit the ‘system’ rather than the ‘system’ meeting the needs of each individual patient.
Is this the view of a cynical observer or do the benefits really far outweigh any perceived limitations to individuals being referred for CBT treatment to alleviate their depression?
Firstly though, what exactly is depression? According to Paykel and Priest (1992:1198) depression is a description of a ‘continuum of phenomenon’ which ranges from everyday low moods to a more severe condition. They state that in almost all cases of depression there is a characteristic way of thinking; that of having persistent negative thoughts. Further, Abramson et al (1989:359) have put forward the theory of a sub set of depression, which they classify as ‘hopelessness depression’. This theory is based on the notion that depression is a complex group of disorders rather than a single disorder. Certainly it is clear that depression not only affects the way an individual thinks but also, their mood, levels of motivation, their behaviour and it also has biological effects such as poor sleeping patterns or loss of appetite (Trower, 1988: 122).
Given the spectrum of the condition and the uniqueness of the experience for each individual it comes as no surprise to find that many ‘tools’ have been devised to help practitioners assess the severity of depression. The Hamilton Rating Scale for Depression devised in 1979 is a questionnaire containing 21 questions covering the range of factors relating to mood, behaviour and physical symptoms (http://healthnet). Possibly one of the best known scales is the Beck Depression Inventory published in 1961, which has stood the test of time in research studies (Weishaar, 1993:23). More recently patient health questionnaires (PHQ-9) have been devised and a successful study undertaken to assess effectiveness of telephone based assessment (Pinto et al, 2005:738). These are just three examples but suffice to say that many practitioners find these tools useful for assessment purposes when working with clients with depression.
So what is the theory behind Cognitive Behavioural Therapy and how does it benefit clients suffering from depression? Albert Ellis and Aaron Beck are the two main contributors to the development of CBT. There have been other significant contributors, for example, Donald Meichenbaum (1977), but for the purpose of this paper the focus will be on Ellis and Beck (Corey, 2001:318). Ellis developed what he called Rational Emotive Behaviour Therapy (REBT). Ellis believed that people with anxiety or depression held what he called ‘irrational beliefs’. For example, ‘my relationship has failed so all other relationships will fail’. These irrational beliefs are compounded by the fact that they tend to be held by the individual in a very rigid manner. They are considered to be ‘absolute, intolerant and demanding’ (Todd and Bohart, 1999:354). This tendency for either rational or irrational ways of thinking is, according to Ellis, a mixture of nature and nurture. Some individuals have a tendency for self defeating behaviour and thinking from birth with additional specific irrational beliefs learnt through childhood experiences. He also believed that self actualization is an inborn trait in some individuals but not in others, thereby allowing those without it to be easily defeated by thoughts and behaviours. Importantly Ellis argued that events weren’t the cause of people feeling anxious or depressed but rather it was their cognitions about the events, their perceptions that caused the distress. This certainly provides an explanation for why different individuals react so differently to a similar type of life event. In addition Ellis suggests that people develop ‘needs’ which in reality are actually ‘preferences’ and then develop rigid cognitions around them including, ‘I should..’, ‘I must…’, which Ellis calls ‘musturbatory thinking’. This creates further disturbance within an individual about an issue that they are already disturbed about. For example, they feel they ‘should’ be confident at all times so are disturbed by this thought. They have a pattern of negative thinking about their perception of their ability to be confident and the disturbance is exacerbated. (Corey, 2001: 306)
Beck, who is probably considered to have had most influence in the development of cognitive therapy, considers that individuals suffering from anxiety and depression have, what he calls, maladaptive cognitive processes. This is when the normal methods of processing information malfunction. This malfunctioning is ‘fed’ by negative beliefs, thoughts and ‘schemas’ that are often generated in childhood and then triggered by subsequent life events. Schemas are deeply held core beliefs and if negative are constructed in ways such as, ‘I am not good enough’, ‘I am not lovable’. Negative automatic thoughts (NATs) are triggered by events but are based on these schemas, for example, ‘There is no point going to the party, because no one will like me’ (NAT) because ‘I am not good enough’ (schema) (Weishaar, 1993:55, Corey, 2001: 309 – 310). Hammen (1985 in Corey, 2001:363) makes the interesting assertion that schemas can be categorised between ‘dependent self schemas’ and ‘achievement self schemas’. With the former, depressed people will for example be affected by their perception of their dependency on others and will be affected by negative ‘interpersonal events’. Whereas the latter self schema relates to a sense of achievement, so negative thoughts and emotions will occur if a person feels they have not been ‘successful’. In addition such individuals generate other ‘cognitive distortions’ through a range processes. These include ‘catastrophising’, thinking of the worst scenario although there is no supporting evidence; selective abstraction, jumping to conclusions based on isolated detail which reinforces the negative view; ‘over generalisation’, applying a belief to every person/situation/event without supporting evidence; ‘magnifying or minimising’, perceptions are greater or lesser than the situation deserves; ‘personalisation’, always relating what happens externally to the person and assuming they have done something wrong; ‘labelling and mis-labelling’, choosing one’s own identity based on perceived imperfections; ‘polarisation’, everything is perceived in black or white or in absolutes (Corey, 2001: 311). Interestingly, Beck believed that anxiety and depression are maintained by what he describes as a ‘cognitive triad’. This is where an individual holds negative views about themselves, their future and the world at large or more specifically ‘their’ experiences within that world. What is important to note here is that it is the person’s ‘perceptions’ of the different aspects of the triad that create the interplay in maladaptive cognitions not necessarily the reality of the three aspects (Todd and Bohart, 1999: 346). Also Beck argued that depression isn’t caused by maladaptive cognitions, although they certainly maintain it, but rather the negative schemas being activated by life events. His view is that depression is caused by a complex mix of ‘genetic, biological, developmental, personality, environmental and cognitive factors (Beck ,1967 in Weishaar, 1993: 55). This certainly fits with Abrasom et al’s (1989) view of the complex interplay of factors in the theory of ‘hopelessness’ depression.
So why is the NHS so keen on CBT and what specific benefits does it provide for clients with moderate to severe depression? Well as mentioned earlier, costs and effectiveness are two of the main drivers for choosing specific treatments and CBT is considered by key decision makers to have adequate empirical evidence of its therapeutic effectiveness and has been compared to other forms of treatment and therapy. Equally it is considered to be a cost effective form of therapy because in essence it only relies on trained therapists operating from suitable premises with minimal other resources and it has been shown to be effective even when offered in a time limited fashion (Davies-Smith, 2006: 28; www.evidence.nhs.uk; Harrington et al, 1998:1559). There are however other views that in fact CBT is no more effective than other psychological treatments ( Wampold et al, 2002: 159) and that even were trials have appeared to ‘prove’ its effectiveness the researchers themselves state that the trial sizes are small (Harrington et al, 1998:1556). Interestingly one study on CBT which didn’t show it to be more effective was considered to be due to the fact that the therapists hadn’t received as much intensive supervision compared to other studies. This is an interesting angle when considering whether it is the therapy or the therapist that is having the effect and the consequences for adequate support and supervision for therapists, which undoubtedly would have a cost implication for the NHS (Elkin et al, 1989: 988).
Whether we agree with the various commentators or not the fact remains that currently CBT is the treatment of choice for depression. One significant benefit of this decision is a drive to recruit and train more therapists in order to provide access to what is considered to be suitable treatment. Considering the relative paucity of services as detailed in the WHO report (2005) this can only be a welcome result.
The benefits to clients undergoing CBT treatment for depression appear to be fairly well established through research as already discussed. The premise of contemporary CBT therapy is that it is firstly based on establishing a ‘therapeutic alliance’ between the client and the therapist. It is also based on challenging negative thoughts, assumptions and beliefs and providing activities and ‘homework’. These help the client understand the challenges which, in turn, aim to reconstruct their cognitive processes and ultimately provide a new, and hopefully lasting, awareness and set of functioning strategies. Implicit in this process is the requirement for the client to be a willing and active participant. It also requires appropriate skills in terms of literacy, articulation and adequate levels of motivation. Where these conditions exist therapists can help clients unpick their negative automatic thoughts and assumptions and tease out the schema that underpin them and then work on reconstructing the schema to a more positive and functional cognitive process (Trower et al, 2007:20).
CBT therapy is a very structured approach and where patients fully engage it has been shown to be effective. This is part of the reason why the NHS is able to set limits on the number of sessions as there is a clear therapy process with evidence of benefits. What is critical at the outset of the therapy is that the therapist is able to gather enough information about the presenting problem and to work with the client to undertake a detailed assessment so the scope and depth of the issue is clear to both parties. The ABC model is utilised and where used appropriately will provide, through a range of questioning techniques, an understanding of the activating events (A), which trigger the thoughts which, themselves, are underpinned by the beliefs (schemas), (B) and an identification of the consequences in terms of behaviour and emotions. Trower et al (2007:22) recommend using several ABC sheets as there may be different responses to different events but what it will reveal are belief ‘patterns’ that are common to the individual’s cognitive processes. The danger is that the therapist can get mired in irrelevant detail as clients will present with many negative thinking patterns so it is important to sift out the significant beliefs and work on those. This is important as it helps clarify the goals of the therapy (Davies-Smith, 2006:28). Beck stressed the importance of explaining the conceptual model to clients. He believed that by doing this is it stopped Cognitive Therapy being just a ‘set of techniques’ and meant that the therapeutic alliance between client and therapist would develop (Weishaar, 1993: 47). This would help ‘educate’ the client but at the same time they would benefit from that relationship. There is already a broad consensus that any therapeutic relationship based on respect and trust can in itself be ‘healing’ irrespective of the type of therapy offered (Mitchell and Cormack, 1998:51).
During the therapy sessions the therapist will utilise Socratic questioning. This technique allows elicitation of how thoughts link to feelings and behaviours from the client’s perspective, this is an important element of ‘learning’ for the client. Open questions such as, ‘what’s the worst that can happen?’ or ‘what does that mean for you? are part of the ‘guided discovery’ process. Once the negative thoughts and beliefs are exposed their ‘validity’ can be challenged. One method is to ask the client, ‘where is the evidence for that?’ (Davies-Smith: 2006:28). This process can be continued by the client between sessions as part of the ‘behavioural tasks’ set as homework. Utilising Beck et al’s (1979) Daily Record of Dysfunctional Thoughts enables the person with depression to identify each activating event, their thoughts and feelings but also provide a ‘rating score’ for their belief and then to challenge themselves by providing a ‘rational’ response combined with an amended rating. Finally a re-evaluation of the original thoughts and feelings occurs (Beck 1979 in Weishaar, 1993: 76 – 77). All of the information that is gathered both within and in between the therapy sessions via ‘homework’ provides the therapist with a ‘case conceptualisation’ for the client. It may take several sessions to gather adequate information but once complete provides the therapist, and client, with the understanding, the ‘hypothesis’, of how core beliefs affect thoughts, assumptions and emotions. It provides the ‘problem list’ that needs to be focussed on during therapy. It is has been previously acknowledged how clients with depression may over generalise, catastrophise and believe that there is nothing in their life that is good. The use of an ‘activity schedule’ that details the sense of pleasure and achievement of every activity undertaken in a day can help shift this set of cognitions. It will show that they have had pleasure in what may be considered very simplistic tasks, such as walking the dog. However the act of writing it down and discussing it with the therapist helps reconstruct their world view. It can also be used to schedule activity, any form of ‘action’ is seen as a positive step for a person whose depression may have emotionally and physically immobilised them (Burns, 1999:77).
It seems that for people with depression there appears to be a systematic, effective form of treatment. Does it work for all clients with moderate to severe depression though and are there limitations even with clients perceived to be eminently suitable for CBT treatment?
Perhaps one of the major criticisms of CBT is that it only deals with the present and doesn’t focus on either issues held within the unconscious, or childhood experiences that are in the client’s awareness, even when there is an acknowledgment by the therapist or indeed the client, that this is where negative beliefs may have developed. The concern is that CBT is reduced to a form of ‘technique based’ therapy that provides ‘symptomatic relief’ rather than long lasting change. The argument against this is that where a skilled therapist is working in collaboration with the client and able to identify the core beliefs amongst what are often superficial negative thoughts, then deep and lasting cognitive reconstruction can occur. It is interesting to note that research undertaken to identify efficacy of integrating hypnosis with CBT, which can deal with childhood experiences both conscious and unconscious, appears to demonstrate that it enhances the effectiveness of the therapy, especially important where there is a time limit on sessions (Nolan, 200: 38). Importantly this research also identified other key therapy conditions, that of strong motivation levels and compliance in undertaking and completing homework. This is an important aspect to consider when working with clients who are depressed. Client’s depression may be as a consequence of ‘real’ social and economic conditions for which depression may be considered to be a perfectly ‘legitimate’ emotional response. It therefore isn’t necessarily an ‘irrational fear’ or even a ‘dysfunctional set of cognitive processes’ but a ‘normal’ reaction to a set of circumstances over which an individual may genuinely have little or no control. Sampson (1981: in Todd, 1999: 363) argues that the danger with the general application of CBT is that it assumes that distortions are within the individual and doesn’t take account of the very real ‘depressing’ situations that people find themselves in. Without due regard given to these situations, individuals can be made to feel as if they are to ‘blame’ for their plight and for the fact the cognitive ‘reconstruction’ may not work.
Even where the depression is being maintained by genuinely distorted perspectives and cognitions, the efficacy of CBT therapy still relies on clients being motivated enough to engage in what is essentially a set of problem solving activities. In addition the client also has to be willing to accept that there is a link between what and how they think and the way they feel and behave. This requires some level of ‘introspection’ which may not suit everyone and also a level of acceptance of self-responsibility, which again may not sit well with certain clients (Moorey in Dryden, 2007:309). There is evidence to suggest that for clients who accept and understand the theory of CBT, engage with the dialogue and homework and have some early success then a positive outcome is more likely ( Fennell and Teasdale, 1987:270). Importantly, basic literacy and functioning skills are critical to enable the client to engage and understand the ‘talking’ aspect of the therapy and to be able to undertake the homework tasks. There are seven million people in the UK with poor literacy and numeracy skills and therapists should not underestimate the impact this can have on an individual’s ability and willingness to understand and complete the homework tasks (Leitch 2006:10). There are some concerns that where depression is severe or of a chronic nature then CBT may not be as effective and may require medication to help improve a patients mood to the point at which they effectively engage (Moorey in Dryden 2007:308). This situation can be exacerbated when individuals have an ‘external’ locus of control, whereby they feel they have no control over events even when not in a depressed state (Banyard, 1996: 174).
In conclusion, it is probably fair to suggest that as with any therapy there is no guarantee of efficacy for all levels of depression in all individuals. As mentioned earlier the decision taken by the NHS to provide access to CBT has undoubtedly benefited many clients. The fact that there is significantly greater access to trained ‘therapists’ will prove helpful for many if only because it may be the first opportunity to share their anxieties and for someone to listen to them. Good rapport and a relationship built on trust and respect will in itself provide therapeutic benefits to clients with depression. The efficacy of CBT for many seems in little doubt and it continues to be subject to many research studies. There are still the concerns as detailed earlier that for some clients with severe to moderate depression, CBT on its own, or at all, may not be the therapy of choice and the ‘system’ must ensure that this is recognised and that appropriate treatment can be utilised rather than the NHS ‘machine’ churning out ‘cognitively reconstructed’ clients, who may then have to return to what many would consider to be depressing lives. The need for therapists to use whatever integrative and eclectic approach that truly meets the needs of their clients must remain a choice that therapists are able to make. Equally the need for therapists, agencies and government bodies to work together to ensure that individuals don’t fall foul of a ‘blame culture’ for economic and social situations that are surely out of their control. However, the contribution that Ellis and Beck have made must not be underestimated. They, and others, have contributed to the creation of a therapy that can be taught reasonably easily, can be understood by most clients and provides a clear, systematic, useful framework to enable both clients and therapists to work together to provide relief from the distress caused by depression (Todd and Bohart, 1999: 366).
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