On a fine summer morning, a young man walks across the lawns of his university campus, up to the doors of a lecture theatre. There, he hesitates, then turns, head down, hurrying away against the flow of students, back to his room where he can be alone. Later that week, he sits miserably in front of a kindly looking woman: he always means to go to lectures, he tells her; he often gets as far as the doors but chickens out at the last moment.
What is he afraid of? “That someone will sit next to me, or speak to me or ask me a question.” And if they did — what do you think would be the worst thing that could happen? “That I would say something stupid and go red and people would laugh about me afterwards.”
Social phobia — or social anxiety disorder — is one of the most common causes of psychological distress and, according to Professor David Clark of the Institute of Psychiatry and King’s College London, it destroys lives. It begins in childhood and is highly disruptive: sufferers leave school early, drop out of university, miss out on promotion, self-medicate with alcohol and drugs. “The young man who can’t go to lectures is typical,” says David Clark.
“He is obsessed with what people will think of him; if he has to have a conversation, he will be memorising and monitoring what he says to check if it makes sense and is clever enough. This requires a lot of attentional capacity so he appears distracted and the other person loses interest.”
This just confirms what the poor young man fears — that he is a social dead loss — and discourages him from risking further encounters. But the kindly woman can help: she is a cognitive behavioural therapist and a new study by Professor Clark and colleagues, published this month in the American Journal of Consulting and Clinical Psychology, reports that a course of this therapy relieved symptoms in more than 80 per cent of social phobics.
Clark’s results will add social anxiety to a growing range of disorders for which CBT has emerged as the treatment of choice: panic attacks, post-traumatic stress disorder, anorexia, chronic fatigue syndrome, manic depression and schizophrenia have all been successfully treated with CBT in a raft of controlled trials and approved for treatment by NICE (the National Institute for Health and Clinical Excellence), which has also recommended a CBT computer programme for patients with depression and anxiety.
While visiting my GP last week, I mentioned that I was writing about CBT: she held up both hands, fingers tightly crossed. “Bring it on,” she said, fervently. Practically every other patient she sees could do with it, she told me: “I deliver scraps of CBT advice, ad hoc, across my desk several times a day; the most needy patients I refer to our mental health services, but there’s a huge waiting list.” Thanks to Richard Layard, economist and author of the newly released Depression Report, over the next seven years the prayers of my GP and thousands like her should be answered.
If Layard gets his way, the Government will spend £600 million in training 10,000 new therapists to deliver CBT across the land.
Britain is in the grip of “crippling depression and chronic anxiety,” he says, yet only two per cent of NHS money is spent on these conditions, which account for a third of all disability. One million mentally ill people are on incapacity benefit, each one costing £750 a month in payments and lost taxes — not to mention expensive medication. Getting them back to work with 16-week courses of CBT would quickly pay for itself. “This offers the greatest release from misery,” enthused one commentator, “a quick win, an easy happiness hit.”
Cognitive behavioural therapy has been around since the 1980s, one of a range of so-called talking therapies, patchily available on the NHS and costing up to £150 a session for those who can afford to go private.
Patients seeking relief at their GP’s surgery may be offered a range of psychological treatments, including counselling, family therapy and psychodynamic therapy, but for a remarkable number of disorders, NICE guidelines favour CBT over all other therapies.
CBT’s appeal lies in its perceived efficiency: unlike some other psychotherapeutic models, it is not open-ended, does not dwell on childhood events or traumas, but offers a course of task-oriented, one-hour sessions — typically between 12 and 20 — looking at the patient’s self-denigrating, fearful and negative thoughts, exposing them as hypotheses that can be tested and found to be “faulty”. The theory is that it is not events in themselves that upset us but the meaning we give them. If we can learn to correct our “faulty” thinking and entertain other possibilities, then our fears lose their power.
It is this approach that upsets critics of CBT, such as the psychologist Oliver James, who says that therapists are too prone to see thoughts as causing feelings, and to flatly refuse to attend at all to childhood causes of depression: “This can lead to superficial therapy which can seem risibly simplistic, especially to educated patients,” he says. “To many depressed people, being taught tricks for consciously eradicating negative, self-attacking ideas may bring temporary relief, but it does not take long for the depression to reassert itself.”
A young woman, whose ten-year secret eating disorder finally sent her to the GP with rotten teeth and internal bleeding, told me that CBT was helping her to develop strategies for overcoming her bulimia: “But it doesn’t do anything for the feeling of emptiness here,” she said, placing her hand over her diaphragm.
“A person’s problems may have very deep rooted causes,” says Joy Dalton, a consultant psychiatrist and a trustee of the Women’s Therapy Centre, “and it won’t be just a matter of learning how to cope in the here and now, but of going back to look at those early causes in a more psychodynamic way. This means exploring early relationships and may involve transference in which the patient re-enacts those relationships with the therapist. Psychodynamic therapy has regard for the potential in the space between the two individuals; CBT is more mechanistic — about reframing thoughts and finding solutions.”
Comparing therapies is a fraught area, admits Dalton, and there is no doubt that CBT is good at dealing with a range of specific problems. But she worries that, because it ticks boxes, it will gobble up funding at the expense of other therapies that are less measurable and marketable: “The thought that it will be acceptable to everyone to sign up for CBT or log into a computer to get over all the things that assail us is concerning.”
Last week, Britain’s family therapists wrote to Tony Blair to object to the emphasis placed by the Depression Report on cognitive behavioural therapy and the assumption that not only was it more effective than other therapies, but that it was universally applicable to all clients.
“Neither claim stands close scrutiny,” said Barbara Warner, chairwoman of the Association of Family Therapists. “We work with families, individuals, couples and the wider communities, supporting change not only within the individual but also in their family relationships and beyond, so that people are supported in continued recovery. Systemic family therapies should be part of the package available in clinics.”
Joy Dalton adds that good therapy depends on good therapists. Can we really produce 10,000 of them, with good enough skills to relieve the miseries of a nation?
Therapies: a suitable case for treatment?
About 2.75 million people visit GPs each year with mental health problems. Of these, 1 per cent receive cognitive behaviour therapy, three per cent receive other forms of psychotherapy and four per cent receive counselling. Most are offered medication but complain that psychological help is not more widely available.
TREATMENTS
Psychodynamic therapy: derived from Freud; the underlying assumption is that emotional problems are repetitions and variations of earlier experiences. Relies on developing a relationship between client and therapist to foster understanding.
Brief psychodynamic therapy: aims to achieve the above in a limited number of sessions.
Counselling: underlying assumption is that, with support, most of us have the capacity to resolve our problems. Therapist listens, reflects and shows empathy.
Cognitive behaviour therapy: assumes that many problems are the result of the way we think about ourselves and others. It is a talking therapy that tests these assumptions and involves homework.
Cognitive analytic therapy: takes elements of CBT and analysis. It’s limited to 16 weekly sessions — four to address childhood, the rest to focus on presenting problems.
Family therapy: assumes that the problem is often systemic within the family group: works with members to improve communication and understanding.
