The Talking Cure Taboo

Guest post by C Blease

Talking cures have never been so accessible.  Since 2007 the UK government has invested £300 million launching its Improved Access to Psychological Treatments scheme.  The goal is to train up to 4000 therapists in a particular branch of psychotherapy – cognitive behavioural therapy (CBT).  CBT is the most widely researched and most commonly used “talking therapy” in the world.  It is also on the rise: globally, a quarter of all practicing therapists use it.

The UK government’s decision to invest in CBT seems praiseworthy: as Bob Hoskins used to counsel in the old BT adverts, “It’s good to talk”.  It is certainly a sentiment shared by the British Association for Counselling and Psychotherapy (BACP) – which adopts the familiar tag line for its URL (www.itsgoodtotalk.org.uk).

On the face of it, this seems like good advice.  Even a cursory look at the evidence base is encouraging.  Meta-analyses show that around 80 per cent of people who undergo psychotherapy for the treatment of depression are better off than those who receive no treatments.  They are also significantly less likely to relapse than those treated with antidepressants; some evidence even indicates that psychotherapy acts as a prophylactic, preventing future lapses into depression.  Given that the WHO estimates that depression will be the leading cause of disability in the world by 2020, the health benefits of psychotherapy carry enormous promise.  The potential relative healthcare costs of successfully treating (and preventing) depression with psychotherapy are significant too: in the UK depression incurs annual costs in lost earnings of £11 billion annually, and prescription rates for antidepressants are now at an all-time high.

Yet talking about talking cures is still taboo.  Discussion of the ethics of psychotherapy is rare.  Unlike medicine (and like most complementary and alternative medicine) psychotherapy is still not statutorily regulated in the UK, USA and most of Europe.  And while doctors, for the most part, refer patients to psychotherapists who belong to professional organisations such as the BACP, the codes of ethics and practice of its members are worthy of investigation. Like their medical colleagues, therapists are obligated to be ‘open and honest’ with patients about treatments.  But a closer examination of these codes and their implementation exposes ethical blind-spots.

Consider the conventional wisdom about how CBT works.  Depression, we are told, “arises because of faulty learning, and cognitive therapy works by challenging the patient’s maladaptive cognitive styles, and helping the individual to become more realistic in their thinking”.  This explanation for its effectiveness is factually wrong.  The theoretical tenets of CBT were formulated nearly 40 years ago: the theory is so out of date it warrants the epithet “pseudoscience”.  Yet psychotherapists trained in CBT are taught to take this explanation at face value.  The consequence is that misinformation is passed on to patients.

Indeed, while there is still some debate, there is considerable evidence that CBT and other versions of psychotherapy are all equally effective.  Tension arises because different schools of psychotherapy adhere to very different ideas about how this success is obtained.  More than 300 studies show that less than 1 per cent of variability in patient outcome is owed to the specific techniques of different treatments.  Epistemic faddism in respect of CBT is unwarranted.

So what explains the success of psychotherapy?  Research shows that the relationship between the patient and the therapist is the most significant factor influencing outcome.  We also know that therapists’ allegiance to their version of therapy is more important than their adherence to its techniques (in fact, there is evidence that strict treatment adherence can lead to undesirable outcomes).  Placebo effects (patients’ and therapists’ expectations about treatment) also play a role in augmenting therapeutic outcome.

On the basis of information provided to them, are patients adequately informed about what to look for in therapy – namely the right therapist?  If we rely on conventional wisdom and current (including NHS and NIMH) guidelines the answer is ‘no’.  Current practices, I argue, breach informed consent.  With a drop-out rate of around 20 per cent, psychotherapy cannot afford to ignore patient (and therapists’) understanding of how these treatments work.  To do so risks trust in the profession at a time when, it could be argued, patients need psychological treatments more than ever.

Talking therapies do not look like injections and pills.  By their very nature (‘talk’) they bring out the Cartesian in us all.  We assume that talk is somehow ineffable – that it cannot harm – perhaps especially when it is well-intentioned.  But science tells us otherwise; despite the success rate of psychotherapy, it is estimated that the mental health of 10 per cent of patients deteriorates as a result of it.  Therapists and forms of therapy can be harmful.  And it is time ethicists and healthcare professionals talked more about this.

Read the full paper here.