Is Cognitive Behavioural Therapy (CBT) a therapy in decline?
According to the UK NHS, CBT is a talking therapy that can help you manage your problems by changing the way you think and behave. It is most commonly used to treat anxiety and depression but can be useful for other mental and physical health problems.
How CBT works
CBT is based on the concept that your thoughts, feelings, physical sensations and actions are interconnected, and that negative thoughts and feelings can trap you in a vicious cycle.
CBT aims to help you deal with overwhelming problems in a more positive way by breaking them down into smaller parts.
You’re shown how to change these negative patterns to improve the way you feel.
Unlike some other talking treatments, CBT deals with your current problems, rather than focusing on issues from your past.
What happens during CBT sessions
If CBT is recommended, you’ll usually have a session with a therapist once a week or once every 2 weeks.
The course of treatment usually lasts for between 5 and 20 sessions, with each session lasting 30 to 60 minutes.
During the sessions, you’ll work with your therapist to break down your problems into their separate parts, such as your thoughts, physical feelings and actions.
You and your therapist will analyse these areas to work out if they’re unrealistic or unhelpful, and to determine the effect they have on each other and on you.
Your therapist will then be able to help you work out how to change unhelpful thoughts and behaviours.
While IAPT can provide access to a number of CBT sessions free at the point of delivery, there are always going to be costs.
For example, in 2013, the estimated average cost of a high intensity session was £177 and the average cost for a low intensity session was £99.
The average cost of treatment was:
- £493 (low intensity)
The cost per recovered patient was £1043 (low intensity) and £2895 (high intensity).
Also in 2013, Chester University used Freedom of Information gather data from 108 PCTs with similar costings of £102.38 for low intensity and £173.88 for high intensity.
In 2020, British CBT & Counselling Service quotes £140.00 per hour for individual therapy but does not state as to whether this is for high intensity or low intensity. Their private healthcare sessions are quoted as £225.00 per hour.
We are aware that, for 2016-17, IAPT incurred a cost of £92m for the assessment of 1.39 million referrals (a more current figure is being sought for the 1.6 million referrals targeted for 2021-22).
In the space of five years the proportion of clients completing therapy has dropped from nearly two-thirds to slightly more than half. If this were a school it would have long ago been in ‘special measures’. (Barry McInnes, Therapy Meets Numbers)
A VICTIM OF QUANTITY VS QUALITY?
There is a reason for us referring to IAPT within the NHS: it is the largest advocate / user of CBT with the greatest funding (£4bn) but, while IAPT claims a 50% recovery rate, Dr Mike Scott’s own analysis suggests that it is nearer to 9-10%.
The key argument for Litha at this point is about CBT’s effectiveness as the cost argument is being challenged by the proliferation of CBT-based Apps and also by the UK Government’s new commitment to Most Advantageous Tender (MAT) as opposed to Most Economically Advantageous Tender (MEAT).
In effect, the public spend on mental health solutions will be increasingly emphasising the success and impact of the product / service rather than ‘cheapest is best’.
This focus on CBT will, as a trickle-down, affect the numerous Apps and services offered that rely on CBT.
Professor Ronald Purser, author of McMindfulness believes CBT, like mindfulness – which shares an emphasis on observing and changing your thinking, and is sometimes prescribed together with CBT – both put excessive emphasis on our responsibility as individuals for our own mental health. In fact, the NHS refers to CBT as self-help.
“The approach tells us it’s the individual who needs to learn to adapt to changing social, political and economic conditions. We’re told our culture is suffering from a “thinking disease” – that it’s not the capitalist economy or the mass marketing of digital distraction by tech companies, it’s your own mind that’s the problem. And you need to retrain it. This is all wrong.” (Ronald Purser).
In 2015, Tom Johnsen and Oddgeir Friborg concluded that CBT is roughly half as effective in treating depression as it used to be.
One theory is that, as any therapy grows more popular, the proportion of inexperienced or incompetent therapists grows bigger. But the paper also references the placebo effect. The early publicity around CBT made it seem a miracle cure, so maybe it functioned like one for a while. These days, by contrast, the chances are you know someone who’s tried CBT and didn’t miraculously become perfectly happy for ever.
Could its over-prescription mean that, over a certain duration, CBT is a waste of time?
A THERAPY IN DECLINE?
In 2018/19, 1.6 million people were referred to IAPT from UK GPs with just 1.09 million starting treatment and only 583,000 completing treatment.
In 2019/20, 1.69 million people were referred to IAPT and 32% (521,312) ended without having been seen by the service. A total of 1.13m were seen, and were recorded as either ‘Ended having been seen but not treated by service’ (30,665), ‘Ended having only one treatment appointment’ (489,547) or ‘Ended having finished a course of treatment’ (606,192).
In practice, ‘Ended having finished a course of treatment’ refers to clients that had two or more treatment sessions but gives no indication as to how many sessions are being attended.
Of the 606,192 clients that had two or more sessions, 570,138 (94%) were at or above ‘caseness’ level (the condition or fact of meeting the diagnostic criteria for a psychiatric disorder) and could potentially achieve recovery. (A client is ‘recovered’ if they finish treatment and move from caseness to non-caseness by the end of the referral).
Of the 570,138 clients that were above the caseness threshold, 291,371 were recorded as having moved to recovery.
This represents 51.1% of eligible referrals, and 26.6% of those that actually entered therapy.
“There is no compelling evidence that the Improving Access to Psychological Therapies (IAPT) service is any better than a placebo, yet its’ expansion continues to be funded, despite £4 billion having already having been spent on it. (Source: Michael Barkham & David Saxon).
UNFIT FOR PURPOSE?
In 2018, Cambridge University conducted the survey, “Policing: The Job & The Life” on behalf of Police Care UK where researchers analysed responses from 16,857 serving officers and operational staff. Amongst key parts of the research, analysis looked at the prevalence rates of Complex Post-Traumatic Stress Disorder (PTSD) for the first known time in a policing population. The research team found that 90% of police workers who responded had been exposed to trauma. Of these, one in five reported experiencing either PTSD or Complex PTSD symptoms in the past four weeks.
“The service has real challenges around recognising and responding to the signs and symptoms of trauma exposure and is heavily reliant upon generic NHS provision that isn’t equipped for the specialist treatment needed.”
In 2009, ‘Contemporary Psychotherapy’ invited the thoughts of psychotherapy professionals including Dr Elizabeth Campbell, president of the British Psychological Society to discuss government regulation of the profession and the funding of a massive CBT programme throughout the country.
“All those interviewed recognised CBT as a valuable therapeutic tool, but warned that it is over-rated and tends to be used as a ‘one size fits all’ tool. There were also concerns that the NHS, trying to deliver CBT cheaply, will fail to treat mental health problems appropriately and effectively; some therefore considered that the private sector may become an important influence in maintaining a necessary therapeutic diversity.”
In a report on research into whether CBT is more clinically effective than treatment as usual (TAU) for treating depression in people with advanced cancer, the researchers Multilevel modelling, including complier-average intention-to-treat analysis, found no benefit of CBT.
“Although it is feasible to deliver CBT through IAPT proficiently to people with advanced cancer, this is not clinically effective. CBT for people widowed, divorced or separated needs further exploration.”
As a tool to address the symptoms of anxiety, stress and mild-moderate depression, CBT has some validity but, as with anything, it’s not as cut-and-dried as that.
Just as our psychology is multi-faceted and nuanced, so should be the treatment for it.
True psychotherapy is all about asking key, guiding questions and then giving the individual an opportunity to reflect, think, and talk through their thinking. As an evidence-based therapy, CBT is much more directive, loaded with a toolkit of actions and logs.
Part of the issue, in this instance, is that CBT is trying to be a psychotherapy approach when it is, in fact, a sticking plaster. It works on symptoms but doesn’t actually address underlying causes – and this is why there is a lack of sustainability about its use.
This isn’t to say that CBT is bad, but how it is being deployed is bad.
We won’t say that CBT is rubbish or CBT is a waste of time – this helps nobody.
Politically, within the NHS, IAPT is untouchable at the moment – much-lauded by the Labour Party and a great short-term fix for the Conservative Party during the pandemic. But CBT is helping to kick the mental health can down the road and doing a major disservice to people.
An interesting article by Paul Atkinson about the colonisation of the NHS can be found here.
With the rise of mental health issues (and, maybe, a reflection of contemporary culture), people are fed up with 6-8 week waiting lists and so turn to apps. The primary issue here is that CBT-based apps are directional – telling people what to do; lack context; don’t work to understand the background or underlying issues.
The suggestion is that we are increasingly familiar with CBT and so lose respect for it (the same being seen at the moment with regards to Mindfulness) and this will always be the case when people are offered the quick-fix, superficial approach of self-help – and this creates a compelling argument for increasing access to psychotherapy instead.