February's free article
The Cognitive Therapy Paradox
Cognitive therapy seems to have won the argument so far as
psychological treatment is concerned. It is cost-effective,
evidence-based, and recommended by NICE as a better alternative to
medication for many conditions.1 From where I am
standing, there is only one fly in the ointment — it’s not what
patients want. My career could almost have been designed as an
experiment in what patients want, so let me explain.
From 1990 to 2000 I worked in the NHS as a clinical psychologist
doing adult psychotherapy. Cognitive therapy was the approved
approach, and that was what we did. It was when I left the NHS and
set up in private practice that I realised something strange was
going on. My clients covered the full range of age, education, and
occupation; they ranged from bus drivers and cooks through to
teachers and middle managers to Oxbridge-educated corporate lawyers
and eminent QCs. Almost without exception they sought me out for
cognitive therapy, and almost without exception we ended up doing
something else.
The reason was that, in a previous life, I had trained as a
psychoanalytic psychotherapist. I didn’t emphasise this to my
patients: they had come looking for cognitive therapy and had, I
thought, neither the time, the money or the inclination for a
lengthy analytical treatment. How wrong I was. However I tried to
keep to the cognitive therapy path, they ended up going in a
different direction. We had long discussions about their
relationships with their fathers, and they even brought dreams to
be interpreted. That was when I realised that these psychoanalytic
clichés actually represented a profound need — the need for
meaning. It wasn’t that cognitive therapy failed, but it missed the
point. By treating symptoms as the result of distorted thinking,
which could be changed without any enquiry into its origins, it
failed to satisfy.
Let me give an example; a man in his late 30s, with modest
educational achievements, working in a semi-skilled job. He had
come complaining of panic attacks, one of the easier problems to
formulate and treat in cognitive terms. However, an intuition led
me to comment that ‘I seem to be dealing with a very angry man.’ I
was right. We spent hours discussing his early life; his absent
father, handicapped sister and overburdened mother. Then we started
interpreting dreams. I could have resolved the panic attacks with a
straightforward cognitive treatment, but I doubt very much if he
would have accepted that approach — he would probably have ended
therapy. Otherwise, I suspect he would have been back soon enough,
his search for meaning unsatisfied, his underlying problem
manifesting itself in some other, harder to treat, pathology.
Perhaps it takes a private practice setting to determine what
patients want. Often, when consulting a doctor, patients simply
want their symptoms to go away, as quickly and painlessly as
possible. When it comes to the human psyche, however, the issue is
more complex. Patients, when they have the choice, seem to value
understanding over symptom removal.
It seems to me that there is an element of the human psyche
which rebels at being forced into a path determined by
considerations of efficiency, cost-effectiveness and statistically
proven efficacy. This is not welcome news for a doctor needing to
make a referral for psychological problems, but can’t be ignored.
Questions of meaning arise, which you ignore at your peril. Try to
deny this, and you will probably see the patient back in your
surgery quite soon.
Sara Dryburgh
Reference
1. NICE. Cognitive behavioural therapy for the management
of common mental health problems. London: NICE, 2007.
http://www.nice.org.uk/usingguidance/commissioningguides/cognitivebehaviouraltherapyservice/cbt.jsp
(accessed 6 Jan 2009).
DOI: 10.3399/bjgp09X395166
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