David Zigmond: Depression needs more than formulaic treatment

david_zigmond2An eminent academic psychologist, Professor David Clark, recently broadcast on the BBC’s Today programme (1 July) authoritative hope to the many sufferers of depression. He informed us how current scientifically formulated, measured, and monitored cognitive behaviour therapy (CBT) is positively transforming the efficiency and economy of care.

To me, this picture is a misleading exaggeration. I know this from several decades of working in the NHS with the mentally anguished. Yes, CBT certainly has much to offer in terms of apparent clarity, comprehensibility, reproducibility, and thus mass production—little wonder then, that it has ready allure for service designers, economists, and politicians.

But human fear (anxiety) and dispiritedness (depression) is often not so straightforward as Clark says. For example, he says 98% of his studied patients completed pre and post treatment measurements (questionnaires), and that these were predominantly positive in outcome. It seems to me that this must be an extremely select group: most depressed people that I see are struggling to find a personal language for their experiences. They do not want, nor are they able to cooperate with, that kind of systematic self-objectification—at least at first.

There are other problems with such measurements. These questionnaires are, in fact, self reports, and thus highly contentious and corruptible, albeit unwittingly. How, for example, do we factor in the shamed avoidance of masked depression? Or the person who wishes to please, interest, avoid, or punish authority figures? Or the subtle influences of the practitioner, whose prospects may be dependent on the results?

A CBT approach can undoubtedly help some patients: those whose life or psychological problems can be approached in a more structured and explicit way by words and systems thinking. But there are many who also respond to other less measurable and less verbal human activities: providing safe sanctuary; trustworthy engagement; and finely tuned, unobtrusive understanding and guidance. Most worryingly, it is this kind of unmeasurable but humane activity in our NHS that has become increasingly rare—often driven out by the kind of structured approaches vaunted by Professor Clark.

In this respect, I disagree with Professor Clark: there have not been “massive developments” in the science of therapeutic psychology. Instead, it is measurements, systems, and informatics that has grown. I wish I could share his optimism.

David Zigmond is a GP in London.

Competing interests: I declare that I have read and understood the BMJ policy on declaration of interests and I have no relevant interests to declare.