CBT replaced? - Could a new wave of talking therapies replace CBT?

Could a new wave of talking therapies replace CBT?

Anna Magee

7 December 2015 

Throughout her 20s, Tracey Butler found life a series of performances, what she called her ‘Jazz hands moments’. At work, at home and in relationships, she pretended everything was fine when inside, she felt isolated and confused. The slightest thing could knock her off track: ‘I could hold grudges for months over a single look,’ Tracey, now 41, remembers. ‘I had such trouble handling my emotions that I would go home and self harm by burning myself with cigarettes, or pulling out my hair. But each morning I would get up for work and act like everything was okay’. Diagnosed with depression and then anxiety respectively, Tracey was referred for two courses of Cognitive Behavioural Therapy (CBT) on the NHS over the next five years. ‘It was all about changing my thought patterns which I just couldn’t do – my thinking was the way it was.’
When the government first declared it was taking the nation’s mental health problems seriously by increasing access to therapy, there was applause all round.  And for the last four years since the launch of its Increased Access to Psychological Therapies (IAPT) in 2011, problems such as depression, anxiety, phobias or Obsessive Compulsive Disorder (OCD) have tended to be referred by GPs for a course of Cognitive Behavioural Therapy or CBT. However, as another £600 million is earmarked for improving mental health services, many experts are calling for a move away from a one-size-fits-all model of therapy, arguing that more modern hybrids of CBT are more effective as they are based more on brain science.

‘CBT therapy is helpful for anxiety but once you move into problems such as more severe depressions and bipolar, patients struggle,’ says Paul Gilbert, Professor of Psychology at the University of Derby and author of Mindful Compassion (Robinson £12.99) who received an OBE in 2011 for services to mental health. ‘If they haven’t recovered in the eight weeks of therapy, they end up feeling like a failure, which further fuels their problems.’
Indeed, figures released last month by the Health and Social Care Information Centre show that only around 40 per cent of patients return to health after a course of therapy.   ‘That’s still four out of ten people that wouldn’t have otherwise been helped,’ says Brian Dow, Chief Executive of mental health charity Rethink.  ‘But we need a more tailored model of psychological therapies,’ he says. ‘The government’s recommended 16 hours of CBT may work for those with mild depression or anxiety but not for those with more serous depression and other mental health roblems.’

"After all those years of trying to change who I was, having permission to say to myself it’s okay to feel this way - upset or betrayed - was a light bulb moment."

Tracey Butler

CBT – developed in the Sixties - is based on understanding of thought patterns or behaviours that lead to mental health problems and gives learning tools to change them. It’s no nonsense. It’s fast. It’s delivered either by omputerised programme, self-help books (books on prescription) or one-to-one counselling for around eight to 16 weeks. Whereas other talking treatments such as interpersonal and psychodynamic therapies take longer and
may delve into one’s past, CBT is focused on the here-and-now.  But a paper in January this year in the journal Psychological Bulletin,found that CBT seems to be getting less effective over time.  The authors
analysed 70 papers published between 1977 and 2014 and concluded that CBT was roughly half as effective in treating depression today as it used to be in the 70s.

Tracey Butler, who now runs a mental health training company called Raise Credit: Philip Hollis

By 31, Tracey Butler, who now runs her own mental health training company Raise and lives in Basingstoke with her partner Mike and son Nathan, 15, was in the grip of severe mental health difficulties and her psychiatrist diagnosed Borderline Personality Disorder (BPD). She recommended Tracey try a more recent treatment called Dialectical Behaviour Therapy (DBT) which had become available on the NHS to help her handle her intense emotions. ‘At first I thought it was nonsense,’ says Tracey. ‘But then, something clicked. ‘We learned a technique called ‘Radical Acceptance’ where you simply accept your life, your emotions and yourself exactly how you are,’ Tracey remembers. ‘After all those years of trying to change who I was, having permission to say to myself it’s okay to feel this way - upset or betrayed - was a light bulb moment.’ Many more followed. Tracey learned skills such as Interpersonal Effectiveness in which you learn to name your feelings and communicate them to others without aggression. ‘Being able to say to myself that it’s okay to feel angry and learning to name my feelings and what might be beneath my anger was so useful and now I use those techniques automatically everyday. I can honestly say DBT saved my life – I just wish it was more accessible to more people.’
The newer hybrids of CBT are still based on practical, result-orientated tools and therapies but they also take into account what we now know about how the brain works. And, as Prof. Gilbert explains, they’re proven to work on more intense problems.  So, what are they?

THE NEW COGNITIVE BEHAVIOURAL THERAPIES

Compassion Focused Therapy (CFT)

Focuses on learning ways to nurture, support, and soothe yourself from the habitual negative thought patterns that cause unhappiness.  Helps identify various ‘selves’, for example Compassionate Self, Angry Self or Anxious Self as internal forces that sit alongside one another in one’s thought patterns, explains Prof. Gilbert, creator of CFT. Patients cultivate their own Compassionate Self through techniques such as writing letters to one’s self, kind self-talk and relaxation breathing.
Proven to work for: Eating disorders, severe depression, bipolar disorder, trauma and schizophrenia.
How can you  get it?  
CFT is still not available on the NHS but you can find out more at compassionatemind.co.uk or find a therapist at balancedminds.co.uk. The book The Compassionate Mind (Robinson £12.99) by Professor Paul Gilbert is also useful.

Acceptance and Commitment Therapy (ACT)

Based on accepting the things in your life you can’t change and the emotions you’re feeling, it shows you the tools to identify what you want and value most and helps you find specific ways to commit to taking action to be happier.  ‘ACT is not about fighting your painful thoughts and feelings, but about learning to accept them,’ says psychologist Marie Chellingsworth, Executive Director of the CBT Programmes at the University of East Anglia and the author of How to Beat Worry and Generalised Anxiety Disorder One Step at a Time (out April next year).   ‘It
teaches you to think about your behaviour and how that’s impacting on your values and goals.’
Proven to work for: Chronic pain, depression, anxiety, OCD and psychosis.
How can you get it?
ACT isn’t yet available on the NHS, says Chellingsworth. You can find a private ACT therapist at the British Association for Behavioural and Cognitive Psychotherapies.

Dialectical Behaviour Therapy (DBT)

Created to help people with Borderline Personality Disorder (BPD) which affects around one per cent of the population, it’s taught through individual weekly sessions with a therapist for up to a year. Patients first learn to accept who they are and then to identify the strategies that can help them deal with intense emotions and/or black-and-white thinking (see case study) causing problems in their romantic, family and friend relationships.
Proven to work for: BPD, bipolar disorder, self-harm, eating disorder and substance abuse.
How can you get it? 
DBT is available on the NHS for people who qualify so talk to your doctor or self-refer at iapt.org.uk. Alternatively, find a private therapist at British Association for Behavioural and Cognitive Psychotherapies.

Mindfulness Based Cognitive Therapy (MBCT)

Learned in a group and practiced at home, it helps process emotions and changes the way you think using a combination of mindfulness meditation and CBT techniques.
Proven to work for: People who have already been treated for depression or anxiety and recovered – to help prevent relapse. Those with problems related to stress and anxiety.
How can you get it? 
MBCT is available on the NHS to prevent depression relapse, talk to your GP, self-refer at iapt.org.uk or find a private therapist at itsgoodtotalk.org.uk.