Friday, October 10, 2014

The Triumph of Cognitive-Behavioral Therapy

I don’t know why The Economist thinks it’s news, but I don’t know all the facts about psychotherapy in Great Britain either.

Apparently, cognitive-behavioral therapy (CBT) has invaded Albion and the Economist is concerned that it is “freezing out” more traditional psychoanalysis, the kind deriving from Freud and Jung.

This should not be very puzzling. After all, Charles, Prince of Wales has long been an aficionado of Jungian therapy, having been a close personal friend with a notable Jungian thinker named Laurens van der Post.

And we recall that when Diana, Princess of Wales was suffering the torments of her borderline condition, her husband sent her first to consult with a notable Jungian, by the name of Alan McGlashan.

Considering how well Jungian psychoanalysis did in those cases, one will be forgiven for finding The Economist’s alarmist rhetoric difficult to understand.

The Economist reports the data:

THE unexamined life may not be worth living, but the overexamined life can be difficult, too. Many people are turning to a relatively young branch of “talking therapy”, called Cognitive Behavioural Therapy (CBT) to get them through the (day and) night. CBT, which teaches people to bypass unhelpful thoughts, has been elbowing aside the talk-about-your-childhood psychoanalysis favoured by believers in Freud and Jung. Up to 43% of all therapy courses in Britain are now CBT, and the practice is increasing: around 6,000 new therapists have been trained since 2007 and CBT absorbs much public funding. In 2012, £213m went on a National Health Service programme delivering CBT, while £172m was spent on all other forms of psychoanalysis and psychotherapy.

In a country that practices socialized medicine, the decisions of the NHS define the situation.

Why did England turn to CBT? Even if you have not read my new book, you could have guessed it. CBT works; psychoanalysis does not.

As The Economist puts it:

The growing popularity of CBT was consolidated in 2007, when the government adopted the treatment as standard. Three things had swayed it. The newish practice had accumulated a body of evidence proving it worked (students of Freud and Jung have been slower to move from couch to lab). It was very good at getting patients back to the office: a 1997 study found people with psychological problems had significantly higher employment rates after CBT than after traditional psychoanalysis. It was also speedy, getting results after just ten one-hour sessions (psychoanalysis can, expensively, take a lifetime). So CBT therapists were trained up and given all the plum NHS jobs, consigning other therapies largely to private practice.

One cannot fail to notice the coy suggestion that psychoanalysis has been “slower to move from couch to lab.”

Allow us to be slightly more serious. Psychoanalysis has been around for well over a century. If it could produce measurably good clinical results, we would all know it by now. The truth of the matter is that psychoanalysis, whether Freudian or Jungian is an ineffective therapy.

Another fact that might be anguishing the editors at The Economist is that in Great Britain psychiatric patients prefer CBT to medication:

Meanwhile the CBT boost has expanded the British therapy industry: since 2007, spending on psychotherapy has moved from 3% to 7% of Britain’s mental health budget – the difference mostly spent on CBT. … The British therapy boom is also a triumph for consumer choice: a recent survey showed patients preferred therapy to medication by a ratio of three to one.

More therapy is being made available to more people. And the people who receive it seem to like it. They like it so much that they stay away from medication. Tell me again why there is something wrong with this picture.

The Economist offers this:

CBT is no panacea, and psychoanalysis has been shown to be better in treating illnesses like eating disorders. It is finally launching studies to measure its effectiveness in an effort to regain some ground. 

Again, if psychoanalysis were effective it would not have waited for more than a century to launch studies.

As for the claim that psychoanalysis is the best treatment for eating disorders, The Economist has allowed itself to be played. And, that's being charitable. Since there is no real evidence for the effectiveness of psychoanalytic treatment of eating disorders, the statement is more wish fulfillment than reality.

Being located in Great Britain the magazine should know, better than any of us do, that the best treatments for eating disorders come to us from CBT. And that the pioneering work in that field has been performed at the Maudsley Hospital in London. 

In fact, the Maudsley treatment program is becoming the standard. No one who knows anything would ever imagine that psychoanalysis could treat anorexia or bulimia.


Sam L. said...

I'm guessing their political outlook is greatly offended by the success of CBT and the refusal of medication. Empowerment of the people, doncha know.

Stuart Schneiderman said...

For all the good thing about The Economist, it is still a left-leaning publication. And as everyone should know, Freudian theory is one of the pillars of radical leftist thought. So I agree with you that they are offended by science, by evidence based-therapy and by treatment that produces real improvements.

Ignatius Acton Chesterton OCD said...

Why, Stuart? Because, as your book points out, Freudianism is the land of make-believe? Is this not the world of the Left? Of course they are offended. Reality has that impact on people who believe the world is not as it should be. Evidence? Ha!

Ares Olympus said...

The word "triumph" sounds vaguely spiteful, while you know whatever success CBT finds, it has its own unknown limits, and will be misused by its own enthusiastic supporters.

Maybe the Wikipedia article needs adjustment, at least it calls it a "psychotherapeutic approach" while you see "psychotherapy" as exclusively "talk" therapy, or "psychoanalysis" I guess?
"Cognitive behavioral therapy (CBT) is a psychotherapeutic approach that addresses dysfunctional emotions, maladaptive behaviors and cognitive processes and contents through a number of goal-oriented, explicit systematic procedures."

It would be nice to imagine there was a real science to these methods, and that it was possible to quantify any specific treatment's success or failure.

But more what makes sense to me is to accept a "trial and error" reality to any sort of therapy. So the question is "How long do you need to try a certain therapy on a certain patient before you try something else?"

Like thinking about the ideas of "habits", there's some idea that you need 6-12 weeks of daily practice to change a behavior, or learn a skill. So whatever the truth of that idea, it means you need a patient who is committed to that duration, and success or failure can't be guaranteed by a doctor if the patient isn't committed to it.

It all does seem pretty intense, and if patients are not able to do what's needed, then other treatments might do better.

And I can see why drugs would be a popular idea, if they can suppress or mask the anxiety or whatever, it certainly seems easier, and maybe will enable enough "right thinking" to help a patient change their habits in ways they couldn't do under their afflictions.

I don't know what I'd do as a government or insurance provider. How do you ever validate any costly treatment?

It makes as much sense to me that there is "art" to all therapeutic practices, and so it may be the intuition of the practicer determines success or failure more than proper abstract procedures for categorical imagined afflictions.

I guess I'll stick to computer programming. Here it is always the programmers fault if the patient doesn't act properly.

Glengarry said...

Somewhat relatedly: any professional views on the efficacy of personality testing (Myers-Briggs and all that)? Valid or the oil of the snake?

Jocker said...

A lot of government money for climate change, because of scientific evidences. A lot of money for CBT because of this same reason. Maybe CBT can stop gender revolution? ;)

Unknown said...

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Cognitive Behaviour Therapy