Why is CBT not working any more?
Cognitive behavioural therapy (CBT) has been around since the 1970s, and it’s the talking therapy you’re most likely to be referred for if you go to the GP with a mental health issue like depression or anxiety. The chances are you know someone who’s been helped by it – perhaps that includes you. While the older, psychoanalytic forms of psychotherapy are rooted in delving into your past, exploring your deepest fears and examining childhood damage, CBT works mainly in the here and now. Rather than taking time to burrow into the deep-seated childhood causes of mental health issues, it addresses the way you think, feel and behave, encouraging you to challenge unhelpful beliefs so you feel more positive and in control, and make different decisions.
‘Whereas someone could be in psychotherapy in the long-term, CBT can often make a difference quickly, meaning it’s cheap, which is one of the reasons the NHS loves it – after all, it has to offer cost-effective treatments,’ says psychologist Dr Meg Arroll. ‘And it can be very effective. There’s a strong evidence base for CBT for certain conditions, chiefly anxiety and depression, both very common mental health issues.’
But some research suggests it might not work as well as was once thought – in fact, strangely, it seems CBT has actually become less effective. A review of studies published in the journal Psychological Bulletin looked at research into CBT from 1977 to 2014, and found in that time, it became 50% less effective for treating depression. So, does CBT still work?
The therapist theory
The study identified inexperienced therapists as the chief factor. ‘It’s always about the therapist,’ says Arroll. ‘When you look at meta-analyses across different types of therapy, they all show about the same effectiveness – it’s the skill of the therapist that matters more than the type of therapy.’ And that’s key to the drop in CBT’s effectiveness, she says. ‘Originally, trained psychologists were the only ones who offered CBT,’ says Arroll. ‘That means you’ve done an undergraduate degree in psychology plus three years’ more training for a doctorate, at a minimum – and through all this time, you’ve been in continual therapy yourself.
‘A psychologist will also be experienced in other types of therapy, not just CBT. But in 2008, the NHS introduced a scheme called Improving Access to Psychological Therapies (IAPT), which meant a lot more therapists were needed. So they set up one-year postgraduate courses to train people purely in CBT. What this means is that now, you could potentially be referred to a therapist in their early 20s, only trained in one type of therapy, with little life experience – in fact, many people having CBT on the NHS are probably not referred to a very skilled therapist. Interestingly, when I was teaching on doctorates, I sometimes saw those therapists who did the shorter training boomerang back into study when they realised they just didn’t have the skills to see people with complex issues.’
Part of the issue may be not just lack of experience, but also the pure focus on CBT can actually limit the extent to which it works. ‘It’s great for certain conditions, but often cases are complex,’ says Arroll. ‘For example, you may be referred for it if you have a condition such as IBS or fibromyalgia. While CBT can play a role here, you’ll often need other therapies, too – for example, gut-centred hypnotherapy has been shown to be very helpful for IBS. Someone who’s only trained in CBT won’t be able to offer this.
The study also highlighted a possible placebo connection. There was a lot of fanfare about CBT in its early years. When you believe in something, it’s much more likely to work. But as time went by, and studies emerged showing CBT wasn’t quite the magic bullet it had been portrayed as, the placebo effect may have slipped. Now, people go for CBT believing it may not work for them – and so it isn’t.
And there could be a wider social issue at play, says Professor Ronald Purser, author of McMindfulness. He believes CBT, like mindfulness – which shares an emphasis on observing and changing your thinking, and is sometimes prescribed together with CBT – both put excessive emphasis on our responsibility as individuals for our own mental health, when the true root cause of anxiety and depression may be wider issues, particularly at the moment, as we face huge problems such as the global pandemic, climate crisis and growing economic inequality. ‘The approach tells us it’s the individual who needs to learn to adapt to changing social, political and economic conditions,’ says Purser. ‘We’re told our culture is suffering from a “thinking disease” – that it’s not the capitalist economy or the mass marketing of digital distraction by tech companies, it’s your own mind that’s the problem. And you need to retrain it. This is all wrong.’ Instead, he believes, the answer lies partly in connecting with your community, and in pushing back against the policies that cause misery.
All that said, it’s important to remember that CBT does have some important uses and does work for certain individuals. ‘It really can be very effective, particularly for depression, anxiety, OCD and insomnia,’ says Arroll. ‘So don’t be put off seeking it if you need help. It does require some commitment – you have to do “homework” in between sessions to make the most of it. But it helps a lot of people.’ And despite some doubts around it, CBT looks set to be the talking therapy of choice for the foreseeable future.