Towards A Constructive Dialogue
House, R and Loewenthal, D (Ed)
PCCS Books, 2008, pp313
This could hardly be a more topical subject for psychotherapists, coming as it does when the psychotherapy profession is having to face up to state regulation and the impact of the UK Government’s Improving Access To Psychological Therapies (IAPT) initiative, both of which are backing a massive increase in the number of trained therapists – in order to combat depression and its associated healthcare and economic costs. More precisely, influenced by the National Institute of Health and Clinical Evidence (NIHCE – this subject area seems to be characterised by large numbers of Orwellian sounding acronyms!) the Government is backing Cognitive Behavioural Therapy (CBT) on the grounds that it is evidence based – in other words it seems to work – and to be cost-effective.
All this has stirred up some fierce controversy. Is the evidence base of CBT really as sound as it is claimed to be? Is CBT a form of behaviour correction and thought adjustment that pathologises, personalises – and thereby neutralises – discontent and suffering that has social, cultural, political and economic roots, rather than being located in some ‘deficiency’ of the suffering individual diagnosed with ‘depression’? Or is CBT a pragmatic, genuinely collaborative, open and evolving set of ideas and methods which can really help people to deal with a range of debilitating psychic states – and do so within the confines of costs and resources available to the NHS? Are the critics of CBT attacking an authoritarian caricature – a version of the Enforcement Droid in Robocop, as Warren Mansell suggests in his (pro CBT) Chapter? Maybe there is an element of envious attack by rival therapeutic modalities who fear being pushed out of the picture as the favoured son receives not only huge funding but the backing of apparent ‘scientific’ authority and credibility.
This book presents both sides of the debate. There are thoughtful contributions from proponents of CBT and those more critical of it, although in terms of space the book gives more to those critical of CBT: there are three chapters written by CBT advocates and twenty by its opponents. The discussion is thorough and stimulating, and the issues are explored from paradigmatic, clinical, epistemological/research and political/cultural perspectives, with the chapters grouped under these headings.
The book will challenge and stimulate readers of any therapeutic persuasion –whether CBT, humanistic, psychoanalytic or other – to think deeply about their therapeutic philosophy – about why and how they work with their clients.
One intriguing possibility that emerges (an optimistic, but not inconceivable, one) to which the book alerted me is of CBT as a ‘Trojan horse’. Speaking the language of ‘science’, one form of talking therapy has now received unprecedented backing from the public purse. Now inside the citadel of the NHS, CBT can and will evolve. For example, Jane Milton suggests (from a psychoanalytical perspective) in her Chapter that ‘CBT practitioners are beginning to rediscover the same phenomena that psychoanalysts earlier faced, and are having to change and deepen both their theory and practice accordingly’ (p101). It is also possible that the agenda of consumer choice, as well as the weight of research evidence pointing to the quality of the therapeutic relationship rather than the modality of therapy as the variable with the strongest influence on therapeutic outcome, will ensure that CBT does not gain a total stranglehold.
I would recommend this book to anyone interested in these issues.
Steve Silverton is a Core Process Psychotherapist and Supervisor living and working in London.