Cognitive Behavioural Therapy and access to help..

[Tulpa]

This may be a little challenging as the majority of practitioners of CBT I have known and worked with would count themselves as reasoned thinkers. However....
I am worried that the foundation for this therapy is fundamentally flawed. Based as it is on the connections between thoughts, feelings and behaviours, the model taps into normal human function and helps the patient review management strategies through a step by step, experience based treatment plan. It is, on the surface of it, a perfectly logical system that 'does no harm'.
My concern is that the model has no lasting effect. It provides a 'toolbox' of quick fix strategies that do not differ from any other psychological approach but this elastoplast method merely encourages the patient to continue thinking of themselves as potentially 'ill' in order to function. If the (necessarily brief) therapy is not immediately helpful, then the patient is assessed as 'Not suitable' and another candidate secured.
CBT is currently the government's 'chosen one' and millions of pounds are being poured into the creation of groups of practitioners attached to GP surgeries throughout britain. This approach removes the funding for more generalist mental health workers and further complicates the public perception of 'how to get help' when feeling emotionally compromised.
Working in secondary care psychiatry, I see more and more patients inappropriately directed to our service because the CBT practitioners are refusing to assess. We therefore turn many people away because our service, designed to assist with psychosis and longer term or more serious illness is not suitable for them.
Any thoughts from CBT therapists or GPs would be useful.

[Pebble]

Afraid I am neither a CBT monger nor GP, but work in cardiology. COme across CBT through the smoking cessation service.

There is clearly some very flawed logic going on in terms of the efficacy claimed, however as I understand the Govt. position it is fairly simple CBT has worked in studies and is therefore evidence based. Since other techniques have not been able to demonstrate evidence of clinical outcomes in studies funding is being moved away from them toward that which has evidence.
Clearly no one has thought through what to do with those for which the evidence based approach does not work.

[Tulpa]

I agree with your general point but I have asked a few CBT lecturers to provide 'evidence for evidence base' and the research methodology is not always easy to retrieve! Looking at the literature, it would appear that proper studies have not been specific, merely 'cherry picked' from a raft of work covering a number of different talking treatments.. I am trying to be positive about it but, dealing daily as I do with those who fall from the CBT waggon, I remain skeptical...

[Pebble]

Need some pointers as to the precise problem. The literature abounds with RCTs of CBT, there are obvious limitations comparing a 'motivational' approach with other therapies, but allowing that this is a structural limitation of any such trials, the data seems sensibly collected in many - for example:

http://jama.ama-assn.org/cgi/content/full/301/14/1460

Would this kind of trial still leave you cold? Or is the problem that sufficient numbers of high quality trials have not been conducted and shown success in enough conditions?

http://www.cochrane.org/reviews/en/t...7_reviews.html

Cochrane suggests that the overall evidence in the areas looked at are less than convincing - perhaps that is what bothers you?

[Tulpa]

Yes, that aspect rankles certainly.. I have been party to a trial also and was aware of the kind of massaging that I suspect is only too easy when trying to assay human traits and foibles! CBT is in a strange state at present. The psychologists responsible for provision seem to be tightening the criteria for acceptance at primary care level but loosening them to include everyone and his dog (Probably!) as a 'specialist service'. .... CBT for pets. It's only a matter of time!

[Drop Bear]

I'm not sure I understand the term.

Does this approach include techniques such as as Rational Emotive Therapy and ignore techniques with an emphasis on insight and immediacy?

My own background includes working with psychologists in a large government department for over 25 years. I worked as a lifeline counselor for a couple of years.

I have had a long fascination with less mainstream approaches ,from Gestalt, to TA to Neo Reichian psychology.

Some observations over 30 odd years:

Most therapeutic approaches work for some people, some approaches for a lot of people. (eg drug therapy for depression and bi polar disorder) I'm not aware of any approach which works for everyone.

Most interventionist therapies seem to have a poor long term prognosis,especially after treatment ceases.This is especially true in the treatment of addictions. Here my government uses the 'harm minimisation' approach, which has a behavioural theoretical base. It has been a spectacular failure,like all methods currently used to treat addictions*.

Unqualified politicians choose systems from vested interests which promise cost effective, high level high visibility results. Such systems are sold to an only slightly brighter and qualified public as a panacea, or with the obfuscation of 'the best available option'.


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*I'm a sober member of Alcoholics Anonymous. (7 years, 8 months,1day) The [long term] success rate of AA is less than 5%. The most expensive clinics do no better.

I make no claims about AA although I endorse it as the refuge of last resort. (my home group has 40 odd members,almost half of whom are secular humanists and atheists)

[Tulpa]

Hi Dropbear..
have a look... http://en.wikipedia.org/wiki/Cogniti...vioral_therapy

Not an easy concept to explain fully in short but the basic premis is that we all have physical responses to specific stimulii. This is 'Hard wired'. In anxiety for example, a pattern of physical symptoms, immediate thoughts about that and resultant behaviours designed to relieve distress are employed. This cycle is self propogating, then thoughts and feelings driving eachother as the resultant behaviour remove the person from the threat of continued discomfort. In this way, the person does not learn how to manage distress, rather he/she assumes that without employing the behaviour, the feeling will return.

Whew!

[Drop Bear]

@Tulpa

Thank you. I think I get it. Seems reasonable enough,as do most therapeutic models.

I accept the approach as one which would probably work to some extent. I'm not able to accept it as necessarily best practice. I remain unconvinced there is any such animal in psychological/psychiatric therapy ,and remain cynical about outcome claims.

My cynicism would be assuaged by seeing some long term studies,say 2 to 5 years after treatment ceased as a minimum. The sample size would need to be several thousands and cover a diverse range of conditions.

[Tulpa]

Agreed, Drop bear. I am further dismayed by a recent training project near my place of work that has resulted in a number of referrals to our service. All three of those that I have picked up have come with an identical story about their therapeutic 'journey' so far. Down to the days they were offered the same intervention being synchronous. If the trainees continue with this model, they are at risk of mistaking manualised therapy for individualised problem solving and the patient will, as you suggest, fall by the wayside later....