A constant downpour of material on the Internet and in other media asserts, wrongly, that CBT is just some kind of skills-training or standardized procedure that can be applied without involving emotions. At the same time, a steady drip of material asserts, rightly, that effective CBT requires a close personal and emotional alliance with a therapist.
That need for a close personal alliance seems to rule out CBT by telephone…or does it?
It seems to me that there two factors making telephone calls unsatisfactory for real therapy.
One is that in face-to-face therapy, the therapist provides a controlled environment in which therapy takes place.
This can sometimes be less than it seems. For example, you might see a therapist in a room allocated by an organisation. It might be someone else’s office, with their personal stuff lying around. It might be noisy or badly heated, and so forth. But still there is a sense in which the therapist ‘owns’ the place where therapy takes place, and takes responsibility for making it a safe place for you to talk about troublesome things.
On the telephone, the therapist does not have this control and responsibility. That seems to change the nature of therapy in an important way.
The second factor is that body language and physical presence in the same place together play a large part in creating the kind of close, trusting relationship that is needed for a therapeutic alliance. Obviously, that is lost on the telephone to some extent.
What’s not clear is whether the elements of conventional therapy that are lost on the telephone are essential elements. Even if it feels very different, it might still be effective CBT.
‘Low intensity CBT’
It’s not surprising that telephone calls can be used to provide support in what is sometimes called ‘low-intensity CBT’, or guided self-help. The older name gives it away — this form of treatment is really self-help from a book or a website.
In its most recent form, in parts of the NHS, patients who are given books or websites to ‘learn CBT’ are also given regular encouragement by telephone or e-mail. This is a response to research studies showing that self-help materials on their own had a high drop-out rate.
People who are just given stuff to read and forms to complete in a book or a website often give up before getting to the end. Regular contact with a support worker encourages people to stay the course and get the maximum benefit from the materials.
This kind of treatment is not really CBT, despite the name. The content of self-help materials does genuinely reflect some of the things that real CBT therapists might work on with their patients, but there is not necessarily any therapeutic alliance with your support worker, and those telephone calls or e-mails are not intended to be used for working with emotions.
I recently reviewed the Samaritans web site. This organisation poses a problem for my theory. Clearly, Samaritans do work with very emotional people at times. And they have a long tradition of doing this work by telephone (although they also do some face-to-face work).
So, although Samaritans do not seem to cultivate extended therapeutic alliances, they do seem to be able to work effectively with emotions by telephone. No doubt their training is specifically designed to make this possible.
In another recent post, I wrote about prolonged therapy for complex mental illness. The document I quoted from there describes how telephone support can be used to deal with emotional crises:
We have learned that in many cases empathic listening and talking to the patient on the phone dampens the crisis in 15 to 20 minutes.
Here is telephone support being used by therapists as part of a very close therapeutic alliance, to deal with very intense emotions.
NHS Living Life
So it seems that it is possible to use telephone calls to work with emotions, and that it is also possible to do this effectively as part of an existing therapeutic alliance. Is it possible to create a therapeutic alliance by telephone in the first place, and do real CBT without any face-to-face work?
An NHS pilot scheme in Scotland seems to be designed to do just that. It will offer self help based on the well-established Living Life to the Full website, together with what looks like proper CBT. Former BABCP president and adviser to the scheme, Dr Chris Williams, has described it like this:
NHS Living Life in Scotland offer[s] the prospect of significantly increasing access to CBT by introducing low intensity working alongside higher intensity work. However delivering this work is easier to describe in written documents than in reality.
Those written documents containing details of the ‘higher intensity work’ are difficult to find, though, and I wonder whether that tiny change of wording from ‘high-intensity CBT’ (which should mean proper CBT) to ‘higher intensity work’ (which could mean something less than proper) conceals something important.
It is also difficult to find private therapists who are doing proper CBT by telephone. I searched the Internet for accredited CBT therapists who offer this form of treatment in the UK, cross-checking by surname in CBT Register UK to verify accreditation. At the time of writing this search turned up only one accredited therapist.
A sponsored link on that search page, and also a few other hits I found in wider searches, turned up people who are accredited for other things — but not for CBT — offering CBT by telephone anyway.
It’s hard to draw any firm conclusions. I suppose the NHS will continue to introduce more telephone therapy because it costs less than face-to-face therapy, and I suppose that will lead to an increase in its use in private practice too.
Well, no, it’s not hard to draw any firm conclusions. I know exactly how to draw firm conclusions. I’ll have to try it for myself one day…