An old journal article that surfaced again recently criticized the value of CBT in the NHS, apparently with particular reference to Birmingham.
The article is Beck never lived in Birmingham, written by two NHS psychologists, Paul Moloney and Paul Kelly, and published in Clinical Psychology (February 2004) , the journal of the British Psychological Society’s Division of Clinical Psychology.
The article’s punchline was:
For the majority of clients seen by psychologists in areas of relative deprivation (such as many parts of Birmingham, for example), the emphasis of CBT on alleviating distress through challenging thoughts may be profoundly misleading…
A letter in the April issue of the same journal easily demolished this:
If some people’s difficulties are indeed fundamentally determined by socio-economic factors in the manner that Moloney and Kelly describe then it is hard to see any logic in offering these people any sort of therapy at all. And if CBT does not currently address ‘the difficulties of typical NHS patients attending clinical psychology services’, perhaps this is a reflection of our grandiosely over-inclusive acceptance of referrals rather than a failing of CBT.
Of course, in more recent years the government’s Improving Access to Psychological Therapies (IAPT) programme has pushed therapy in the NHS even further towards a social work or social engineering role. Now it’s explicitly aimed at getting people back to work.
Distress
The key phrase that reveals the article’s fundamental error of thinking is the phrase, “psychological distress”, very often generalized even further to simply “distress”. Life can be distressing, and everyone finds it distressing at times. It’s no more distressing in Birmingham than in other places. In fact, Birmingham is almost certainly less distressing for most of its inhabitants than many other places in the world are for theirs.
But distress is not mental illness. Distress is a normal response to many of life’s events and circumstances. So distress does not in itself require psychotherapy, which is for treating mental illness.
It’s not easy to understand how two writers who had presumably spent a lot of time learning about psychology and psychotherapy could be so very out of touch with reality. Perhaps it an indication of how distant the academic training of psychologists is from clinical practice.
And the fundamental error that is the basis of the whole article is compounded by other errors.
Conceptual difficulties
In a frank admission that the authors do not understand the basis of CBT, the article describes some of the sources of their confusion. These are common confusions, it turns out, and the kind of thing that I have often written about here.
They start with their confusion over the role of scientific evidence in CBT. The common error is to think that CBT is derived from scientific research, and these authors fall right into it. (The truth is that CBT is derived from common sense, and that scientific research cen be derived from CBT.)
Then there’s the confusion over ‘negative thoughts’. The common error is to imagine that CBT is about telling patients to stop thinking negative thoughts, and these authors fall right into this one too. (The truth is that CBT is about helping patients to align their underlying patterns of thinking more closely with reality, even if that makes their thoughts more negative — the important thing is to have thoughts that make sense and that accurately reflect the external world.)
Another confusion is over the role of what is now called ‘mindfulness’ (a term that these authors do not use, although it appears in an advertisement in the same journal). The common error is to imagine that detached self-monitoring is helpful in CBT, and these authors fall right into this one as well. (The truth is that CBT helps patients to give up their self-monitoring and to regain trust in the reality of their inner feelings.)
Clinical trials
When discussing clinical trials the authors demonstrate better understanding. They rightly criticize the quality of much of the research into psychotherapy. This makes me think that perhaps they themselves were better trained in research methods than in treatment methods.
Interestingly they make another common error that is typical of researchers — the assumption that the results of research into a selected groups of subjects can be generalized to the whole population. Thus they generalize from research evidence that CBT can be effective, coming up with the false notion that it must be universally effective, and then criticizing it for not being universally effective:
…even strong proponents of CBT recognise that this treatment, like all other psychotherapies, will significantly help only about two-thirds of all recipients, even under ideal research trial conditions…
It’s amusing to note the phrase “ideal research trial conditions” in that quotation, again suggesting that only research, and not real life, is ideal for these authors.
In the present
In the present, the article is still a focus for discussion amongst some therapists, and I think that’s indicative of a deep-seated insecurity and lack of confidence in the meaning and value of CBT. It would be a better sign if such a badly conceived article were easily dismissed as the nonsense that it is, just as it was in the Correspondence pages of the April issue.
