If you've ever been to your GP with depression, chances are you're aware of, or have been offered, CBT. Cognitive Behavioral Therapy, to give it its full name, looks at the links between thoughts, feelings, and behaviors, and helps you develop techniques for challenging negative patterns of thinking. It has long been the treatment of choice for many people suffering from depression, as well as for pretty much every other mental condition out there thanks to studies demonstrating its efficacy. But could its halo be slipping?
A recent study suggests CBT's effectiveness as a treatment for depression has been falling steadily since the 1970s. With more of us now on antidepressants than ever before, what does this mean for the future of treating depression?
There are various theories about what's gone wrong. With CBT long hyped as a "gold standard" treatment, one possible reason it's not hitting the spot anymore is that more and more novice therapists are joining the CBT bandwagon without proper training or experience, and there's no guarantee they're all very good at it. With the exception of psychologists, arts therapists, and psychiatrists, there's currently no statutory regulation of therapists in the UK, so anyone can practice, and accreditation by a professional body like the British Association for Behavioral & Cognitive Psychotherapies (BACP), which demonstrates therapists meet industry standards, is often voluntary.
Researchers also suggest that the placebo effect, which is always stronger with innovative new treatments, could have dropped off as, over time, we've become more pessimistic in our expectations of CBT.
Consultant clinical psychologist Professor Eric Davis agrees: "CBT was initially a sort of great white hope; people were attaching a lot of importance to it, and various commentators and practitioners were saying how marvelous it was. But CBT is not a panacea. There's a facile notion that the latest therapy must therefore be the best and possibly only therapy, but of course that doesn't stand up, because any therapy has strengths and weaknesses."
However, if a positive belief in CBT is key to its effectiveness, self-described "CBT swot" Calum is top of the class. He's had CBT several times over the last ten years and suggests that it's more about what you put into it than anything else. For him, completing the "homework," such as mood diaries or specific tasks set during sessions, is central to that.
"I found CBT extremely effective, but I do think it's one of those things where you have to know how to make it work for you," he says. The most effective CBT program he's been on, he adds, "felt very much like school, or like a training program. "There was a lot of time given to discussing the homework, giving feedback about what you'd learned, and if you hadn't done it there was a sense that you weren't really making the best of it," he says. However, particularly in group CBT sessions, Calum felt some people didn't really bother.
Perhaps the longer CBT's been hyped as an effective treatment, the more people go into it expecting a miracle cure, without really understanding what's involved. There's little doubt that if you walk into CBT expecting it to work like a pill, you probably will end up feeling short-changed. Could there be a link between this desire for a quick fix and the fact that antidepressant prescriptions have increased by 97 percent since 2004?
"I think secretly we're all looking for a quick fix," says clinical psychologist Louise Watson. "That was one thing CBT offered that previous therapy didn't. With psychodynamic therapy, it was all about staying in therapy for a year or two, whereas CBT promised this six-to-12-week fix, which I think is very seductive."
Maybe we're more impatient than we were in 1977, expecting our therapy to be like Netflix, providing instant results without too much effort on our part. But it's also clear that the availability and quality of CBT is pretty variable. For Louise L, who didn't want group therapy, telephone therapy was the only type of one-to-one CBT available on the NHS in her area. "I didn't find it particularly effective at the time because talking to somebody on the phone wasn't enough. I felt like I needed something that was a bit more of a personal intervention."
However, she adds, "What I would say is that about three months after the therapy had finished, I did notice I had actually started to feel more aware of how I was feeling and how to prevent myself falling into a low mood, probably due to CBT having introduced the concepts to me."
Even when it's available and done well, CBT still isn't a one-size-fits-all solution. As Calum says, "The behaviors, qualities, and attitudes you need to have in order to engage and make it work properly are often those that people who are depressed don't have in abundance. I think if I'd gone when I was in a much lower mindset, I might not have got as much out of it."
Meanwhile, older psychoanalytic approaches, which look at past experiences, are increasingly difficult to access because they tend to last longer and therefore cost more money, but Louise L feels these approaches could help to fill in the gaps that are missed by CBT's "here and now" focus. After her disappointing experience with phone CBT, she now favors what psychologists call "integrative" therapy, which draws on different approaches tailored to meet your individual needs and tackle depression from different angles. Besides the older therapeutic models, there are new techniques emerging as CBT falls out of favor, which Watson sees as part of an evolution, building on and learning from what went before.
As Professor Davis explains, "CBT says 'You can change anything you want to,' but actually sometimes you can't. That in itself can be a problem because, if you're prone to depression, you end up being hard on yourself and thinking 'I should have been able to change all this by now.' Acceptance can actually be a more positive outcome."
Mindfulness, which blends CBT with traditional Buddhist meditation practices, is fast becoming the psychological treatment du jour and having its own moment in the spotlight, with advocates including comedian Ruby Wax, who has a master's degree in mindfulness-based CBT from Oxford University. More broadly, there's a general move towards ideas of mindfulness, acceptance, and compassion, as seen in therapies like dialectical behavioral therapy (DBT), which was originally developed to treat borderline personality disorder but can also be helpful for depression, acceptance and commitment therapy (ACT), and compassion-focused therapy.
Like plain old CBT, mindfulness-based therapies aren't a universal hit, with many praising the approach as a miracle cure and others feeling it does nothing for them. Mindfulness acknowledges CBT's limitations, but neither approach can or will have the same effect on everyone. As Watson points out, regardless of the treatment, a positive relationship with a well-qualified therapist probably remains the factor most likely to influence a recovery from depression.
By Sharon Graham - Vice/July 10, 2015
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