{"id":2896,"date":"2015-04-20T14:04:44","date_gmt":"2015-04-20T13:04:44","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=2896"},"modified":"2015-04-20T14:04:44","modified_gmt":"2015-04-20T13:04:44","slug":"the-talking-cure-taboo","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2015\/04\/20\/the-talking-cure-taboo\/","title":{"rendered":"The Talking Cure Taboo"},"content":{"rendered":"<p><em><strong>Guest post by C Blease<\/strong><\/em><\/p>\n<p>Talking cures have never been so accessible. \u00a0Since 2007 the UK government has invested \u00a3300 million launching its Improved Access to Psychological Treatments scheme. \u00a0The goal is to train up to 4000 therapists in a particular branch of psychotherapy \u2013 cognitive behavioural therapy (CBT). \u00a0CBT is the most widely researched and most commonly used \u201ctalking therapy\u201d in the world. \u00a0It is also on the rise: globally, a quarter of all practicing therapists use it.<\/p>\n<p>The UK government\u2019s decision to invest in CBT seems praiseworthy: as Bob Hoskins used to counsel in the old BT adverts, \u201cIt\u2019s good to talk\u201d. \u00a0It is certainly a sentiment shared by the British Association for Counselling and Psychotherapy (BACP) \u2013 which adopts the familiar tag line for its URL (<span style=\"color: #0000ff\"><a style=\"color: #0000ff\" href=\"http:\/\/www.itsgoodtotalk.org.uk\">www.itsgoodtotalk.org.uk<\/a><\/span>).<\/p>\n<p>On the face of it, this seems like good advice. \u00a0Even a cursory look at the evidence base is encouraging. \u00a0Meta-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. \u00a0They 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. \u00a0Given 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. \u00a0The 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 \u00a311 billion annually, and prescription rates for antidepressants are now at an all-time high.<\/p>\n<p>Yet <em>talking about<\/em> talking cures is still taboo.<!--more--> \u00a0Discussion of the ethics of psychotherapy is rare. \u00a0Unlike medicine (and like most complementary and alternative medicine) psychotherapy is still not statutorily regulated in the UK, USA and most of Europe. \u00a0And 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 \u2018open and honest\u2019 with patients about treatments. \u00a0But a closer examination of these codes and their implementation exposes ethical blind-spots.<\/p>\n<p>Consider the conventional wisdom about how CBT works. \u00a0Depression, we are told, \u201carises because of faulty learning, and cognitive therapy works by challenging the patient\u2019s maladaptive cognitive styles, and helping the individual to become more realistic in their thinking\u201d. \u00a0This explanation for its effectiveness is factually wrong. \u00a0The theoretical tenets of CBT were formulated nearly 40 years ago: the theory is so out of date it warrants the epithet \u201cpseudoscience\u201d. \u00a0Yet psychotherapists trained in CBT are taught to take this explanation at face value. \u00a0The consequence is that misinformation is passed on to patients.<\/p>\n<p>Indeed, while there is still some debate, there is considerable evidence that CBT and other versions of psychotherapy are all equally effective. \u00a0Tension arises because different schools of psychotherapy adhere to very different ideas about how this success is obtained. \u00a0More than 300 studies show that less than 1 per cent of variability in patient outcome is owed to the specific techniques of different treatments. \u00a0Epistemic faddism in respect of CBT is unwarranted.<\/p>\n<p>So what explains the success of psychotherapy? \u00a0Research shows that the relationship between the patient and the therapist is the most significant factor influencing outcome. \u00a0We also know that therapists\u2019 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). \u00a0Placebo effects (patients\u2019 and therapists\u2019 expectations about treatment) also play a role in augmenting therapeutic outcome.<\/p>\n<p>On the basis of information provided to them, are patients adequately informed about what to look for in therapy \u2013 namely <em>the right therapist<\/em>? \u00a0If we rely on conventional wisdom and current (including NHS and NIMH) guidelines the answer is \u2018no\u2019. \u00a0Current practices, I argue, breach informed consent. \u00a0With a drop-out rate of around 20 per cent, psychotherapy cannot afford to ignore patient (and therapists\u2019) understanding of how these treatments work. \u00a0To do so risks trust in the profession at a time when, it could be argued, patients need psychological treatments more than ever.<\/p>\n<p>Talking therapies do not look like injections and pills. \u00a0By their very nature (\u2018talk\u2019) they bring out the Cartesian in us all. \u00a0We assume that talk is somehow ineffable \u2013 that it cannot harm \u2013 perhaps especially when it is well-intentioned. \u00a0But 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. \u00a0Therapists and forms of therapy can be harmful. \u00a0And it is time ethicists and healthcare professionals talked more about this.<\/p>\n<p><em>Read the full paper <span style=\"color: #0000ff\"><a style=\"color: #0000ff\" href=\"http:\/\/jme.bmj.com\/content\/early\/2015\/04\/17\/medethics-2014-102641.short\">here<\/a><\/span>.<\/em><!--TrendMD v2.4.8--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Guest post by C Blease Talking cures have never been so accessible. \u00a0Since 2007 the UK government has invested \u00a3300 million launching its Improved Access to Psychological Treatments scheme. \u00a0The goal is to train up to 4000 therapists in a particular branch of psychotherapy \u2013 cognitive behavioural therapy (CBT). \u00a0CBT is the most widely researched [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2015\/04\/20\/the-talking-cure-taboo\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[968,2153,443,2152,328,576],"tags":[],"class_list":["post-2896","post","type-post","status-publish","format-standard","hentry","category-clinical-ethics","category-guest-post","category-jme","category-mental-health","category-philosophy","category-the-art-of-medicine"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - 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