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EDUCATION AND DEBATE: Jeremy Holmes, Roger Neighbour, Nicholas Tarrier, R D Hinshelwood, and Nick Bolsover All you need is cognitive behaviour therapy? • Commentary: Benevolent scepticism is just what the doctor ordered • Commentary: Yes, cognitive behaviour therapy may well be all you need • Commentary: Symptoms or relationships • Commentary: The "evidence" is weaker than claimed BMJ 2002; 324: 288-294 [Full text]

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COUNSELLORS UNITE BEHIND NEW NATIONAL BODY

Dick Underwood   (1 February 2002)

CBT – a Cognitively Biased Therapy?

Max Lagnado   (2 February 2002)

A psychiatric trainee's view

D. Senthil Kumar   (2 February 2002)

More understanding of philosphy of science required

Michael van Beinum   (3 February 2002)

Which Psychotherapy Works Best ? - A Response

de Wet S Vorster   (4 February 2002)

What insomniacs need is cognitive behaviour therapy

Colin A. Espie   (5 February 2002)

What we need is some balance

John L Taylor   (6 February 2002)

The evidence base of cognitive behavioural therapy

Tom Sensky, Jan Scott   (7 February 2002)

What is psychotherapy anyway?

Nick C K Totton   (7 February 2002)

Why make this debate one of psychology vs. psychiatry?

Christopher A Booth   (9 February 2002)

All you need is cognitive behaviour therapy?

Brian J Darnley   (9 February 2002)

Evidence based therapy AND therapeutic relationships

Steve Williams   (11 February 2002)

The Politics of Psychotherapy

Paul Blenkiron, Bootham, York, YO30 7BY   (13 February 2002)

Specific - rather than 'brand' therapies

Arieh Y Shalev   (18 February 2002)

Diversity in psychotherapy is essential.

Rhona J. Sargeant   (18 February 2002)

Psychotherapy and psychopharmacotherapy

Detlef Degner, Borwin Bandelow   (21 February 2002)

Abandonment Anxiety and Avoidance

Nuno M Torres   (21 March 2002)

Re: COUNSELLORS UNITE BEHIND NEW NATIONAL BODY

PHILLIP I HODSON   (27 March 2002)

Informed consent

susanne stevens, none   (30 October 2002)

COUNSELLORS UNITE BEHIND NEW NATIONAL BODY 1 February 2002
Dick Underwood, General Secretary 'Counselling' M46 9TA Send response to journal: Re: COUNSELLORS UNITE BEHIND NEW NATIONAL BODY	In the article 'All you need is Cognitive Behavioural Therapy' the conclusion is reached that 'Patients in the 21st century deserve therapies that transcend old rivalries and concentrate on effectiveness, common factors, the search for active ingredients that go beyond brand names, and development of the skills needed to deliver them' In an attempt to transcend the old rivalries between various counselling organisations a new national counselling body has been set up to unite the counselling profession. This has seen remarkable growth during the past year and now has members affiliated from all the major national counselling bodies and counselling related charities. This is a major breakthrough in what has hitherto been a highly segmented profession, and heralds the start of a new era in ‘talking therapy’ within the UK. Counselling as a profession has always been plagued by differences between the many factions responsible for counsellors and counselling training. One of the main reasons why it proved impossible to include the regulation of counsellors in the 2001 NHS Reform and Health Professions Bill was that counsellors themselves were divided on all the major issues. There were differences in the amount of confidentiality counsellors keep, some believing confidentiality should be absolute whereas others believing confidentiality should be broken if a client is suicidal. There were other differences. Some counsellors believed that to be effective they themselves had to also receive regular counselling whereas others believe that not to be necessary. Even the very definition of what it means to be a counsellor, and the length of training required, has been hotly debated. These differences have led to the creation of many different counselling bodies within the UK, each catering to it’s own point of view, and each highly combative when it comes to defending that viewpoint and the counsellors who hold to it. Now all that is set to change. ‘Counselling’ an organisation set up in 1998 with the aim of bringing unity to the profession has been steadily gaining ground and gaining recognition. After wide consultation a Code of Conduct was formulated that counsellors from all the different factions could each adhere to, but which still had the flexibility required by each of those factions. It has been a long hard road and a lot of consultation has gone into getting the wording just right. At the same time as satisfying the needs of counsellors our over-riding concern was to produce a Code of Conduct that both clients and counsellors could easily remember and understand. The evidence that we have accomplished what we set out to do is found in the increasing number of counsellors adhering to the code, and the feed back from clients.
CBT – a Cognitively Biased Therapy? 2 February 2002
Max Lagnado, Medical Director Chameleon Medical Communications, Park House, 111 Uxbridge Road, Ealing, London W5 5LB Send response to journal: Re: CBT – a Cognitively Biased Therapy?	In discussing the validity of cognitive behaviour therapy (CBT), Tarrier [1] fails to mention two important biases that may lead to an over -estimation of treatment benefit. First, for many exponents of CBT their academic and professional survival relies on them persuading others that CBT works. Second, I suspect that the reporting of CBT studies suffers from the same ailment as the reporting of drug treatments–publication bias. For some it may be very comforting to believe that a cure for psychological distress can be achieved by “thought control”. However, an over-reliance on this unproven idea could provide governments with an excuse for not tackling social and economic injustices. Reference 1. Tarrier N. Yes, cognitive behaviour therapy may well be all you need. BMJ 2002;324:291-292.
A psychiatric trainee's view 2 February 2002
D. Senthil Kumar, SHO Solihull Hospital Send response to journal: Re: A psychiatric trainee's view	As a part of the training I am trying to learn CBT under the supervision by two Clinical Psychologists. I have learnt a lot from both my sesions with the patients and the supervision sessions. I found the experience useful and worthwhile.The feedback I get from patients suggest that they have benefitted from the therapy(they are on psychotropics as well). More than anything the process of CBT helped me with a "language" to talk to and understand the patients. Since the "language" is relatively easy to understand and "talk", I found CBT an accessible method of starting to explore the field of psychological therapies. Having said that during the therapy I was unable to ignore the feeling inside me that there are more to what I was doing. I am pretty sure (admittedly subjective) that the most important facet of the process was the relationship which probably enabled the "techniques", to make an impact. It was also insightful to learn from the supervisors that CBT in pure form is hardly possible with most of the clients who are seen in the present psychiatric services. My reading suggests that CBT is gradually broadening its scope, incorporating concepts which would traditionally belong to the psychodynamic school, but paraphrasing in the vocabulary of cognitive science. Even the traditional practice of 12-16 sessions is becoming longer and longer. I wonder if the whole structure, process and practice of "talk therapy" is a reflection and product of the prevailing socio-economic-cultural understanding and narratives and that CBT would probably give way to some other model in the future.
More understanding of philosphy of science required 3 February 2002
Michael van Beinum, Consultant child psychiatrist Child and family clinic, 194 Quarry st. Hamilton, Lanarkshire Send response to journal: Re: More understanding of philosphy of science required	Your education and debate pages (1,2,3, 4) raised an important issue. There appeared to be little understanding by the various authors of philosophy of science, notably epistemology. Instead, the question of what constitutes admissible evidence when evaluating the various psychotherapies was confused with concerns about classification, developmental psychopathology and the 'drug treatment paradigm'. Hinshelwood (3) came closest in asking readers to consider the underlying assumptions made by researchers in making truth claims, but even he lost the plot by implying that the intuition of therapists about patient progress was a reasonable outcome criterion. Good research is only as good as the questions asked, and the methodology adopted depends upon the nature of the question and the assumptions made about ontology. The logic of the double blind control trial is faultless; unfortunately, is it not only extremely difficult to do well but the assumptions underlying it, such as the reversibility of time and the disregard for meaning and language, make it an inappropriate device for answering many questions about psychotherapy. Nonetheless, the question of which (psycho)therapeutic interventions, by which kinds of therapists, are most effective for which kinds of patients, cannot be avoided by doctors working in the NHS. Qualitative research strategies can make a significant contribution here. It would be absurd to require a double blind controlled experiment to prove beyond reasonable doubt that a man was guilty of fraud in court - just as the intuition of the policeman would not be considered sufficient. Instead, independent corroboration of evidence is required, and the same should apply to evaluation of the components of psychotherapy. Furthermore, state funding agencies should support far more outcome research in the psychotherapies. The therapeutic landscape is currently badly distorted by the enormous financial clout of the pharmaceutical industry, not all of whose published results can be taken at face value (5). The ubiquitous presence of drug companies, and the instrumental rationality they represent, may result in a distortion of the doctor patient relationship by valuing one component above all others- a simple pill for a single disease - at the expense of the many other dimensions of the caring relationship. 1. Holmes, J. All you need is cognitive behaviour therapy? BMJ 2002; 324: 288-290. 2. Tarrier, N. Commentary: Yes, cognitive behaviour therapy may well be all you need. BMJ 2002; 324: 291-2. 3. Hinshelwood, R. D. Commentary: Symptoms or relationships. BMJ 2002; 324: 292-3. 4. Bolsover, N. Commentary: The evidence is weaker than claimed. BMJ 2002; 324:294. 5. Evans, S. and Pocock, S. Societal responsibilities of clinical trial sponsors - Lack of commercial pay-off is not a legitimate reason
Which Psychotherapy Works Best ? - A Response 4 February 2002
de Wet S Vorster, Consultant Psychiatrist Private Practice, South Devon Send response to journal: Re: Which Psychotherapy Works Best ? - A Response	Dear Sir, Holmes J (2002) “All you need is cognitive therapy” BMJ 7332: 288 – 294 The comments were very pertinent to the needed emphasis on wide ranging psycho-therapeutic treatment methods for future health planning. A survey by The National Schizophrenia Fellowship (NSF) revealed that of 2,400 users and carers only half of them were offered psychotherapy/counselling. Those receiving these therapies derived benefit. 80% from psychotherapy – 70% from cognitive therapy. A large percentage also valued practical help – employment assistance and help from their family and community support. I have noted long waiting times for NHS Outreach and many isolates cannot be seen as regularly as needed. Befriending from a trained voluntary worker may be an alternative or, indeed, even more acceptable for those who are seen as negative and/or resistant. I understand that the Scandinavian practice stresses the need for a “whole person” treatment of psychoses. Teaching a fairly broad range of counselling skills is vital at medical/nursing schools to fulfil the whole person ideal as well as short courses for voluntary workers. These would, of course, include listening and teaching relaxation. Dr de Wet Vorster MB, ChB, DPM, FRCPsych, DipPsych (McGill). Consultant Psychiatrist. Sancta Maria, Wrangaton Road, South Brent, Devon TQ10 9HJ Brian Martindale, Anthony Bateman, Michael Crowe & Frank Margison (eds) (2000) Psychosis: Psychological Approaches and their Effectiveness Gaskell NSF: Best Practice Conferences (2000) “A Question of Choice: People’s View of Treatments Used in Mental Illness” 8th December 2000
What insomniacs need is cognitive behaviour therapy 5 February 2002
Colin A. Espie, Professor of Clinical Psychology/ Head of Department of Psychological Medicine, Univ. of Glasgow Gartnavel Royal Hospital 1055 Great Western Rd. Glasgow G12 0XH Send response to journal: Re: What insomniacs need is cognitive behaviour therapy	I have read with interest the articles and commentaries on CBT in the recent issue of the BMJ. In the lead article Holmes posed the question, "all you need is cognitive behaviour therapy?" In response, Tarrier essentially answered "yes", and provided evidence, in relation to at least some mental disorders, that CBT may be the psychosocial therapy of first choice. This is helpful because I cannot see how informed debate can take place unless such specification is introduced ie. "CBT is an effective treatment for condition X in situation Y". Otherwise, we are likely to remain at a level of evidence that is not only "opinion", but generalised opinion; leaving aside the further subjectivity of who is/ is not an "expert". Unfortunately, almost everyone has generalised opinions, and most appear quite expert in their exposition! With this specification in mind I would like to report that CBT is an effective treatment for persistent insomnia in primary care. There are over 50 RCTs, 2 meta-analyses and a systematic review which support this statement (1-3). Furthermore, recent studies confirm that CBT for persistent insomnia is clinically effective in relatively unselected general practice populations, and that it can be administered cost- effectively in manualised format by Health Visitors trained as CBT therapists (4,5). By comparison, hypnotic drugs have a poor outcome in persistent insomnia (6) and are largely contraindicated (7). Similarly, treatment with anti-depressants is not evidence-based. Insomnia often predates first episode and recurrent depression (8, 9) and may persist relatively unchanged for many years (10). The evidence for the effectiveness of CBT for insomnia probably exceeds that of any other disorder. My question is when will we say to our patients "all you need for your insomnia is CBT?" References 1. Morin CM, Culbert JP, Schwartz MS. Non-pharmacological interventions for insomnia: a meta-analysis of treatment efficacy. American Journal of Psychiatry 1994; 151: 1172-1180. 2. Murtagh DR, Greenwood KM. Identifying effective psychological treatments for insomnia: a meta-analysis. Journal of Consulting and Clinical Psychology 1995; 63: 79-89. 3. Morin CM, Hauri PJ, Espie CA, Spielman A, Buysse DJ, Bootzin RR. Nonpharmacologic treatment of insomnia: report prepared by a Task Force of the American Sleep Disorders Association, Standards of Practice Committee. Sleep 1999; 22: 1134-1156. 4. Espie CA, Inglis SJ, Tessier S, Harvey L. The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: Implementation and evaluation of a Sleep Clinic in general medical practice. Behaviour Research and Therapy 2001; 39: 45-60. 5. Espie CA, Inglis SJ, Harvey L. Predicting clinically significant response to cognitive behavior therapy (CBT) for chronic insomnia in general practice: analyses of outcome data at 12 months post-treatment. Journal of Consulting and Clinical Psychology 2001; 69: 58-66. 6. Morin CM, Colecchi C, Stone J, Sood R, Brink, D. Behavioral and pharmacological therapies for late-life insomnia: a randomised controlled trial. Journal of the American Medical Association 1999; 281: 991-999. 7. Kripke D. Hypnotic drugs: Deadly risks, doubtful benefits. Sleep Medicine Reviews 2000; 4: 5-20. 8. Ford DE, Kamerow DB Epidemiologic study of sleep disturbances and psychiatric disorders. Journal of the American Medical Association 1989; 262: 1479-1484. 9. Eaton WW, Badawi MD, Melton B. Prodromes and precursors: epidemiologic data for primary prevention of disorders with slow onset. American Journal of Psychiatry 1995;152: 967-972. 10. Mendelson WB. Long-term follow-up of chronic insomnia. sleep 1995; 18: 698-701.
What we need is some balance 6 February 2002
John L Taylor, Principal Lecturer in Clinical Psychology/Consultant Clinical Psychologist Centre for Clinical Psychology Research, University of Northumbria, Newcastle NE7 7XA Send response to journal: Re: What we need is some balance	Dear Sir, I understood that debate is meant to be balanced in presenting the arguments pertaining to particular issues. Holmes(1) and three of the four commentaries that followed are sceptical concerning either the evidence base or the benefits being claimed for cognitive behaviour therapy (CBT). Three of these articles appear to promote pschoanalytic or psychodynamic approaches which, they suggest, are receiving a raw deal from policy makers and commissioners of services. There are many inaccuracies, errors and logical inconsistencies in these articles, some of which I would like to comment on. A cursory glance at the discussion sections of journal papers by researchers and systematic reviewers in field of CBT shows that in general nobody is making extravagant claims about the evidence for these approaches. Invariably authors are cautious concerning the limits of the methodologies employed and the meaning of any statistically significant results obtained in terms of clinical effectiveness, generalisability and long-term maintenance. Further, many of the same people conducting trials in this field are also utilising more qualitative methods to investigate and report on process issues in therapy. This is because cognitive behaviour therapists, like their traditional psychotherapy colleagues, understand all too well that successful interventions require development of trusting, safe and mutually respectful relationships between clients and therapists. Bolsover(2) in his denigration of the evidence base for CBT makes at least one elementary error. He asserts that the evidence for these therapies is weaker than has been claimed if one accepts that at the 5% level of confidence many of the reported significant effects “will be false positives”. In fact, at this arbitrarily high statistical threshold, the opposite is likely to be the case. That is, given the relatively small sample sizes used in most outcome studies of psychological therapies, the statistical power available to detect significant effects is reduced. The probability of type II errors is therefore increased, meaning that null hypotheses are upheld when in fact they should be rejected (3). The excuses for the tardiness of proponents of traditional psychotherapies to demonstrate meaningful changes in clients are many and varied. Hinshelwood(4) suggests that applying the standards of evidence that apply elsewhere in health and human services is unfair because in traditional psychotherapy the focus is "changes in relationships", not simple symptom change. Is it unreasonable for people to ask the psychotherapist, despite the borderline personality client apparently making good progress in her relationship with the therapist after two years of treatment, “is the client is still cutting herself?”. A further feature of the assembled criticism of CBT in this debate is the narrow focus on mental health problems. This ignores the significant and growing impact of these therapies in other areas held to be important in society, including treatment of offenders with histories of violence, sexual aggression and other anti-social behaviours(5). It seems that traditional psychotherapists want to further their cause and convince policy makers of the value and relevance of their wares. Perhaps they should stop dismissing the success of CBT as simply due to effective “branding” and “marketing”, substitute the terms ‘research’ and ‘dissemination’ and find ways of emulating the effort of colleagues in the CBT field. John L Taylor Principal Lecturer in Clinical Psychology/Consultant Clinical Psychologist Centre for Clinical Psychology & Healthcare Research, University of Northumbria at Newcastle, Coach Lane Campus, Newcastle upon Tyne, NE7 7XA john2.taylor@unn.ac.uk 1. Holmes J. All you need is cognitive behavioural therapy. BMJ 2002;324:288-290. (2 February) 2. Bolsover N. Commentary: The “evidence” is weaker than claimed. BMJ; 324:294. (2 February) 3. Rosnow RL. & Rosenthal, R. Focused tests of significance and effect size estimation in counseling psychology. J Counsel Psychol 1988; 35: 203 -208. 4. Hinshelwood RD. Commentary: Symptoms or relationships. BMJ; 324:292- 293. (2 February) 5. McGuire J. What Works: Reducing Reoffending: Guidelines from Research and Practice. Chichester: Wiley, 1995.
The evidence base of cognitive behavioural therapy 7 February 2002
Tom Sensky, Reader in Psychological Medicine Imperial College, West Middlesex University Hospital, Isleworth, Middlesex TW7 6AF, Jan Scott Send response to journal: Re: The evidence base of cognitive behavioural therapy	EDITOR- The article by Jeremy Holmes and the accompanying commentaries1-5 are essentially about evidence for the efficacy and effectiveness of the psychotherapies, and how this evidence base should be applied in everyday clinical practice. It is ironic that in their arguments against cognitive behaviour therapy (CBT), these papers include numerous instances of idiosyncratic use of research evidence. The examples below illustrate this point. Arguing that the evidence favouring the benefits of CBT is relatively weak, Bolsover5 selects three studies for comment which happen to fit his argument. He has conveniently ignored the scores of published studies which have demonstrated the clinical benefits of CBT. The Cochrane database is widely acknowledged (and sometimes criticized) for the close attention in its reviews to research studies of high methodological quality. The Database of Systematic Reviews contains two full reviews focusing on CBT, and the Database of Abstracts of Reviews of Effectiveness (DARE) includes five systematic reviews of CBT used to treat a variety of clinical conditions6. Papers selected for abstraction in Evidence Based Mental Health or Evidence Based Medicine similarly go through a process of rigorous methodological review. Papers on CBT appear regularly in these journals. We would challenge Bolsover to apply his arguments to these papers. Holmes1 argues that CBT works well in university based clinical trials with subjects recruited from advertisements, but the evidence about how effective it can be in the real world of clinical practice is less secure. To support this, he cites a single paper from a study also cited by Bolsover. This caricature may have applied to a limited extent to the early trials of CBT in depression conducted thirty years ago, but is certainly irrelevant now. To give just two examples of many possible, the MRC funded trial of CBT for chronic depression7,8 specifically recruited individuals who had depressive disorders that had failed to respond to adequate trials of standard pharmacological and psychological treatments (including previous psychotherapies) in both primary and secondary care. Second, the Cochrane review of CBT for schizophrenia includes examples of ‘real world’ interventions, although the reviewers argue that further similar studies are required to be confident that these interventions are generalisable9. Holmes also argues that leading cognitive therapists are starting to question aspects of their discipline and recognize some of its limitations. CBT was first developed as a treatment for depression, and its exponents have been very cautious about widening its applications. The two apparent critics of CBT cited by Holmes are quoted out of context; in both cases, the criticisms refer to the need to adapt and develop the basic CBT model developed for the treatment of depression and anxiety to enhance its effectiveness in other applications. Far from being a weakness of CBT, the critical review of its methods by its practitioners is an important reason why it has been evaluated in an increasingly wide range of conditions. Hinshelwood4 argues, without evidence, that while psychoanalytic psychotherapy is compliance-neutral, CBT relies heavily on the compliance of the patient. On the contrary, CBT has been shown to be effective in improving overall adherence among people with acute schizophrenia10,11. Hinshelwood also argues that CBT ignores the relationship between therapist and patient. The first treatment manual in CBT included a checklist for rating the process of therapy, which has a subscale evaluating generic therapeutic skills and interactions12. True, there is no direct equivalent in CBT for “transference”, but the relationship between patient and therapist can certainly form a major focus of the therapeutic work in CBT, particularly in treating people with personality disorders. We agree with Holmes that it is unhelpful to expect to evaluate psychotherapeutic interventions (including CBT) using only the same research methods applied to drug trials. However, if clinicians and researchers aspire to an evidence-based health service, they have to accept two challenges. First, there is the challenge of evaluating what they think they do. We look forward to the evidence base of the psychodynamic psychotherapies developing, to allow more valid comparisons between the psychotherapies. Until then, there is no way escaping the fact that robust evidence exists for the use of CBT in a growing variety of clinical conditions and settings, and much of this research evidence is applicable to the NHS. The second challenge is for clinicians and commentators to understand and respect the critical appraisal of the evidence base. Regrettably, some of the contributors to this series of articles have failed in this. Tom Sensky, Reader in Psychological Medicine Imperial College of Science, Technology and Medicine West Middlesex University Hospital Isleworth Middlesex TW7 6AF Jan Scott, Professor of Psychiatry University of Glasgow Gartnavel Royal Hospital 1055 Great Western Road Glasgow G20 6DW References 1. Holmes J. All you need is cognitive therapy? BMJ 2002; 324: 288-290. 2. Neighbour R. Commentary: benevolent skepticism is just what the doctor ordered. BMJ 2002; 324: 290-291. 3. Tarrier N. Yes, cognitive therapy may well be all you need. BMJ 2002; 324: 291-292. 4. Hinshelwood RD. Commentary: symptoms or relationships. BMJ 2002; 324: 292-293. 5. Bolsover N. Commentary: the “evidence” is weaker than claimed. BMJ 2002; 324: 294. 6. The Cochrane Library, Issue 1, 2002. Oxford: Update Software. 7. Paykel E, Scott J, Teasdale J, Johnson A, Garland A, Moore R, Jenaway A, Cornwall P, Hayhurst H, Abbott R, Pope M. Prevention of relapse in residual depression by cognitive therapy: A Controlled Trial. Archives of General Psychiatry, 1999, 56, 829-835 8. Scott J, Teasdale J, Paykel E.S, Johnson A, Abbot R, Hayhurst H, Moore R, Garland A. The effects of cognitive therapy on psychological symptoms and social functioning in residual depression. British Journal of Psychiatry, 2000, 177, 440-446. 9. Cormac I, Jones C, Campbell C. Cognitive behaviour therapy for schizophrenia (Cochrane Review). The Cochrane Library, Issue 1, 2002. Oxford: Update Software. 10. Kemp R, Hayward P, Applewhaite G, Everitt B, and David A (1996). Compliance therapy in psychotic patients: randomised controlled trial. BMJ 312, 345-349. 11. Kemp R, Hayward P, Applewhaite G, Everitt B, and David A (1998). A randomised controlled trial of compliance therapy: 18 month follow-up. Br J Psychiatry 172, 413-419. 12. Beck AT, Rush AJ, Shaw BF and Emery G. Cognitive Therapy of Depression. New York: Guilford Press, 1979.
What is psychotherapy anyway? 7 February 2002
Nick C K Totton, Psychotherapist in private practice 86 Burley Wood Crescent, Leeds LS4 2QL Send response to journal: Re: What is psychotherapy anyway?	Your interesting feature on CBT leads on to two deep issues around psychotherapy. The first of these is implicit in some of the articles: What sort of research is appropriate to relational therapies? The double-blind model simply does not fit - what it measures is not what we need to find out, and vice versa. Seligman (1995) gives five examples of features which are central to the clinical situation but ignored by efficacy studies: most psychotherapy is of open-ended duration, is self-correcting in terms of treatment approach, clients often actively seek out their preferred practitioner or modality, they usually have multiple problems, and clinicians are usually focused on overall better functioning as much as on symptom reduction. These features of clinical work in fact introduce the second theme - which, unsurprisingly, none of your contributors address: much of the practice and theory of psychotherapy tends strongly to support the shocking notion that psychotherapy is not in fact a medical or paramedical activity - indeed, that psychological distress is not a medical condition, and that the whole concept of ‘mental illness’ is a rather poor and misleading metaphor. The fact that a good deal of the available funding for psychotherapy currently comes from health services should not confuse us. The unpalatable truth seems to be that if our society really wants to address the causes of psychological distress, it needs to look at its own deepest assumptions and structures - its ways of dealing with emotion, with relationship, with work and with sexuality, for example. The practice of psychotherapy constantly points outside the box of symptom relief, and draws our attention to the largest possible social, political and indeed philosophical context. Reference Seligman, M. The effectiveness of psychotherapy. The Consumer Reports study. Am Psychol 1995;50:965-74.
Why make this debate one of psychology vs. psychiatry? 9 February 2002
Christopher A Booth, Consulting Psychiatrist, Maples Adolescent Treatment Centre, Burnaby, BC, Canada Maples Adolescent Treatment Centre, 3405 Willingdon Ave., Burnaby, BC, Canada, V5G 3H4 Send response to journal: Re: Why make this debate one of psychology vs. psychiatry?	I found this discussion interesting, and I personally have general misgivings regarding the rise of any technique, be it psychoanalysis, CBT, solution-focussed, or most recently EMDR when proponents claim it is a fix -all solution. Clearly, CBT does have something to offer for a number of disorders. I was particularly troubled by N. Tarrier's comments regarding the psychiatric profession. While I cannot peak about the atmosphere in Great Britain I can say that during my training at the University of Toronto, in Canada that I enjoyed supervision and seminars given by a variety of people from different disciplines. For example, I enjoyed seminars with Richard Swinson MD, Dr. M. Antony, PhD, both proponents of CBT, and both have published on the subject. I also received training in psychoanalytic concepts and other models and this included seminars given by psychologists, some trained as analysts! Simply put, I have seen little evidence of a clear split across disciplines. Training in North American schools is including greater emphasis on CBT. Also, one of the great pioneers in CBT is Aaron Beck MD. I would humbly suggest that Dr. Tarrier consider that perhaps what he is dealing with is in fact a cognitive distortion which needs to be addressed more fully than with a simple phone call regarding membership in a professional organization. Perhaps keeping a diary, with a careful examination of associated affects and possible maladaptive behavioural responses may be helpful. If this does not address the issue perhaps another modality may be worth pursuing.
All you need is cognitive behaviour therapy? 9 February 2002
Brian J Darnley, Senior House Officer Belle Ridley Day Hospital, Waterlow Unit, Highgate Hill, London N19 5N Send response to journal: Re: All you need is cognitive behaviour therapy?	I enjoyed reading the article by Dr Holmes (1) and subsequent commentaries. Despite being a psychiatric trainee ultimately interested in doing further psychoanalytic training I was somewhat dismayed by the lack of overall balance presented in this 'debate'. Moreover I continue to be preocccupied and concerned that the day will come when I will end up inheriting this type of 'either or' psychiatry. Furthermore whilst I understand some of the viewpoints expressed I have yet to be convinced that psychiatry, in whichever manner it is practised, is anything other than about relationships. There is little doubt that CBT is an effective intervention for a wide range of conditions and that it is also patient friendly. Whether it is useful in severe mental illness depends largely, and I think this is fairly self evident, on what you are attempting to do. However we must not loose sight of the fact that this is an effective tool, and of course, like any other intervention needs to be used appropiately. We should also not forget that this type of treatment does not preclude a later treatment of a more psychoanalytic bent. In fact CBT can very usefully act as an appropiate stepping stone in this direction. Throughout all of this it might also be beneficial for the patient to be taking psychotropic medication and for their social situation to be assessed. I often feel that this more integrated approach gets neglected whilst the various factions which tend to segregate on one side of the 'either or' divide fight it out(2). Even if the popularity of CBT were the result of a superior marketing policy there can be little doubt that there is a substantial amount of research by which to judge their enterprise. Unfortunately the same cannot be said about psychoanalytic psychotherapy. Whilst psychoanalysis has a vast literature base it mainly consists of subjective opinion backed up by the use of specific case examples to illustrate a particular viewpoint. This is not to say that these are not helpful in getting us to think about our own patients' narratives but essentially one cannot generalise from these case examples with any degree of confidence. This is not only because we cannot say whether these patients are representative of our practice population but also because it is unlikely that we could replicate the intervention. The time has come for the psychoanalytic camp to prove that a psychodynamic approach can work in NHS psychiatry. Bateman and Fonagy (3,4) have clearly shown that it can be done. Furthermore whilst I appreciate Dr Hinshelwoods comments I think the time has come for us to assess what it is about the relationship that is therapeutic and whilst I don't doubt that there is a limit to the extent to which one can objectify something so subjective I don't think that this should stop us from trying to do so. If there isn't an easy way of measuring relational change then let us try and find one. Once found let us apply it not just to research in the psychotherapies but also to research into psychopharmacology where there is little doubt that a drug prescription is more than simply the prescription of a drug (2). Dr Brian Darnley Senior House Officer Camden & Islington Mental Health NHS Trust Belle Ridley Day Hospital Waterlow Unit Highgate Hill London N19 5N bjmdarnley@blueyonder.co.uk 1 Jeremy Holmes, Roger Neighbour, Nicholas Tarrier, R D Hinshelwood, and Nick Bolsover BMJ 2002; 324: 288-294 2 Gabbard G, Kay J. The fate of integrated treatment: whatever happened to the biopsychosocial psychiatrist ? Am J Psychiatry 2001; 158: 1956-1963 3 Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of Borderline Personality Disorder: a randomised controlled trial. Am J Psychiatry 1999 156: 1563-1569 4 Bateman A, Fonagy P. Treatment of Borderline Personality Disorder with a psychoanalytically oriented partial hospitalization: an 18 month follow up. Am J Psychiatry 2001 158: 36-42
Evidence based therapy AND therapeutic relationships 11 February 2002
Steve Williams, General Practitioner & Cognitive Behavioual Psychotherapist The Garth Surgery, Rectory Lane, Guisborough, Cleveland. TS14 7DJ Send response to journal: Re: Evidence based therapy AND therapeutic relationships	The well deserved airing of the issues surrounding CBT was tempered by the somewhat dichotomous debate into the relative importance of the relationship in therapy as “opposed” to the more specific techniques involved in CBT. Such “either or” / “black and white” thinking is itself hardly characteristic of emotional health. One of the aims of a cognitive approach to therapy is to re-establish a more normal and flexible pattern of thinking better capable of addressing serious life difficulties and problems. In CBT as in any form of therapy the therapeutic relationship is of proven importance(1). However, unlike a psychodynamic approach, it is not the primary context, where therapy is played out via the processes of transference and counter-transference. Rather, in CBT the therapeutic relationship provides the vehicle which drives and motivates the patient / client to apply the principles and processes of therapy to the reality of their everyday life and in particular to their own relationship to and within their social, interpersonal and materiel world. Rather than the single “therapeutic hour” forming the focus of therapy, by utilising “homework” and a self-help approach, CBT endeavours to harness the remaining hours of the week as the true “therapeutic workbench”, where the patient can practice and develop their skills with the ultimate aim of becoming their “own therapist” in the long term. This then leads to perhaps the most important evidence based achievement of CBT: - its ability not only to achieve recovery, but for example in major depression, to reduce its cripplingly high rate of recurrence (2) by at least 50% (3). What we need now are the means and resources to move this effect from the confines of specialist interventions and relationships out into the cultural “thinking water” where its true benefits and implications can be realised. Dr Steve Williams General Practitioner & Cognitive Behavioural Psychotherapist References 1. Duncan BL, Hubble MA, Miller SA. Psychotherapy with ‘impossible’ cases: The efficient treatment of therapy veterans. New York: Norton, 1997. 2. Judd LL. The clinical course of unipolar major depressive disorders. Archives of General Psychiatry 1997; 54: 989-991. 3. Blackburn IM, Eunson KM, Bishop S. A two-year naturalistic follow- up of depressed patients treated with cognitive therapy, pharmacotherapy and a combination of both. Journal of Affective Disorders 1986; 10:67-75.
The Politics of Psychotherapy 13 February 2002
Paul Blenkiron, Consultant in Adult Psychiatry Bootham Park Hospital,, Bootham, York, YO30 7BY Send response to journal: Re: The Politics of Psychotherapy	EDITOR It appears from the articles by Holmes and Tarrier (1) that a political spectrum of psychotherapies is now emerging. On the “Left Wing” we have traditional Freudian psychodynamic therapy, which addresses the causes of human distress via an understanding of unconscious conflicts rooted in the past(2). It contains an implicit assumption that gaining insight will lead to clinical improvement. Such “black couch” therapy as championed by Holmes usually lasts many months or years. The message exhorted is that we should spend a lot of taxpayer’s money on it despite a lack of evidence of benefit. On the “Right Wing” of psychotherapies lies cognitive behaviour therapy, as originally promoted by Aaron Beck (3). It asks “What can practically be done?” by addressing specific problems in the here and now. CBT adopts a “short, sharp, shock” approach by being time limited (usually 8-20 sessions in total) and by emphasising personal responsibility for change (“homework”). Where does this leave other psychotherapies? Cognitive analytic therapy occupies the centre ground (4)as the New Labour of talking treatments (“Tough on the problem, tough on the causes of the problem”). The Independent Party (interpersonal therapy(6)) and the Green Party (Family and Group Psychotherapies) emphasise that individuals depend upon each other for effecting lasting change. However, the voters’ favourite is surely non-directive counselling. Like the Liberal Democratic Party, there is popular local support (counselling within primary care), although this “feel good” factor wanes in general elections (randomised trials of efficacy) (5). Finally, stress debriefing after trauma has been widely embraced as the Monster Raving Looney option, with good evidence of no benefit, and even possible harm(7). Psychotherapists and politicians have much in common. They presume a relationship of trust, and believe that real change can be achieved by talking. They seldom answer questions directly, and employ silence as a therapeutic tool. Grand inquisitors such as Archie Cochrane and Robin Day, if alive today, would be impressed with the range of talking treatment options now available. For voters and patients alike, “You have never had it so good”. 1. Holmes J. All you need is cognitive behaviour therapy? British Medical Journal 2002;324:288-94. (Also commentry 2002;324:291-294). 2. Bloch S. An introduction to the psychotherapies. Oxford University Press, London, 1979. 3. Beck AT. Cognitive therapy and the emotional disorders. International Universities Press, New York, 1976 4. Rees H. Cognitive-analytical therapy – a most suitable training for psychiatrists? Psychiatric Bulletin 2000; 24:124-126. 5. Harvey I, Nelson SL, Lyons RA, Unwin C, Monaghan S, Peters TJ. A randomised controlled trial and economic evaluation of counselling in primary care. British Journal of General Practice 1998; 48:1043-1048. 6. Weissman MM, Markowitz JC, Klerman GL. Comprehensive guide to Interpersonal Psychotherapy. New York: Basic Books, 2000. 7. Wessely S, Rose S, Bisson J. Brief psychological interventions (“debriefing”) for immediate trauma related symptoms and the prevention of post-traumatic stress disorder. Cochrane Library 1998: Update Software. The author has no competing interests (professional or political) to declare.
Specific - rather than 'brand' therapies 18 February 2002
Arieh Y Shalev, Professor of Psychiatry Hadassah University Hospital, Jerusalem Send response to journal: Re: Specific - rather than 'brand' therapies	Debating the pros and cons of CBT is enlightening, because in one's practice one encounters both brilliant successes and total failures of patients referred to CBT (at least among severely traumatized survivors). The latter often appear as 'drop outs' or 'failure to engage' in CBT, and there are numbers of them. Careful CBT practitioners often know all too well where to draw the line and when to refer a patient back to additional care. Yet, a clear advantage of CBT therapists with whom I happen to work is that they have the tools to assess the situation, and can tell when things go wrong. I wish we were all so clearly bound to monitoring treatment progression. Yet, there is a lesson to be learned from this successes and failures: for some patients CBT is exactly what makes the difference between ill-health and better life, whereas for others there is place for different approaches, possibly because other dimensions of disturbed mental functioning dominate, and the clinical expression of their disease is driven by other forces. Yet, assuming that such driving forces preferentially involve 'relational,' 'attachment-driven,' or 'characterologic' dimensions may be imposing another a-prioi template, and therefore mistaken in many patients. For most of my traumatized patients, for example, life-situation, and ongoing adversities constantly fuel the expression of their illness. Others, however, get into critical conditions because disabling memory and concentration problems destroy their scholar or vocational careers. For the latter, an equivalent of neuro-cognitive rehabilitation might make the difference. What seems to be needed, therefore, is a reliable dimensional assessment of distress and disability in psychiatry, going beyond symptom counts, and leading to specific therapies - one of which would certainly be CBT. Packages of treatment may equally require dismantling and re-assembling, to test their active ingredients. Thus between 'Axis I,' 'Axis II,' 'Attachment theory' or "Applied learning theory" there is much to be discovered, if psycho-therapies are to become consistently and predictably effective, as desired.
Diversity in psychotherapy is essential. 18 February 2002
Rhona J. Sargeant, Senior Registrar in Psychotherapy Psychological Therapies Service, Dept. of Psychiatry, Royal South Hants Hospital, Soton SO14 OYG Send response to journal: Re: Diversity in psychotherapy is essential.	Editor- Holmes discusses some of the shortfalls of research in cognitive behaviour therapy. However Tarrier claims ‘traditional psychotherapy’ is expensive, time-consuming and unproven. The field of psychotherapy is multidisciplinary, both in terms of core professions (psychiatry, psychology, nursing, occupational therapy, counselling etc.), and therapeutic modality (psychoanalytic, cognitive behavioural, group analytic, family therapy, art therapy, drama therapy, dialectical behaviour therapy, cognitive analytic therapy etc). The needs of those referred for psychotherapy can be overwhelming. Waiting lists are large and the difficulties presented are often long term or lifelong. Trust budgets are tight. Managers have to make cutbacks to balance the books. With this backdrop we need a united front, but it is easy to see how we, as professionals, can become embroiled in a battle to save our therapy, theory, profession, status and livelihood. Patients are not a homogenous group. Some want to resolve symptoms without delving into the past - they may be better suited to a cognitive behavioural approach. Some need to tell their life story in depth and to learn to have relationships that work - an analytic approach could be a good option. Yet others have family problems - systemic therapy may be of benefit. Sometimes one type of therapy is helpful initially and another appropriate later. We need a variety of treatments in order to accommodate different people. Evidence based medicine appears to have given us something to argue about. Of course evidence is important, but I believe we are abusing it in order to fight an inter-professional battle which is fuelled by pressure on resources. If cognitive behaviour therapy is beginning to get a more robust evidence base that should be good news for all psychotherapists, not a means to denigrate other modalities. We need to work together to in order to maximise our capacity to heal. Rhona Sargeant senior registrar in psychotherapy Psychological Therapies Service, Dept. of Psychiatry, Royal South Hants Hospital, Brinton’s Terrace, Southampton, SO14 OYG rsargeant@doctors.org.uk 1. Holmes J. All you need is cognitive behaviour therapy. BMJ 2002;288-290. (2 February.) 2. Tarrier N. Commentary: Yes, cognitive behaviour therapy may well be all you need. BMJ 2002; 291-292 ( 2 February.)
Psychotherapy and psychopharmacotherapy 21 February 2002
Detlef Degner, M.D. Department of psychiatry,university of Göttingen(Germany) , D-37073 Göttingen, Borwin Bandelow Send response to journal: Re: Psychotherapy and psychopharmacotherapy	Dear Sir, the discussion of cognitive behavior therapy is very interesting.We believe that an efficient therapy of anxiety and affective disorders is a consequent psychopharmacological treatment.Psychotherapy is only one part in an integrative therapy regime.
Abandonment Anxiety and Avoidance 21 March 2002
Nuno M Torres Centre Psychoanalytic Studies, Un. Essex Send response to journal: Re: Abandonment Anxiety and Avoidance	Dear Sirs I have read the paper "All you need is cognitive behaviour therapy?" and its comments, and I have a brief note to it. I am participating in a study of assessment of a group psychoanalytic oriented emotional psychotherapy in Lisbon Portugal (Torres, Neto, Sanches, 2001), and we are using a questionnaire of Attachment and Close relationships (Brennan, Clark, Shaver, 1998), which measures two axis (Abandonment Anxiety and Avoidance). We decided to use this questionnaire, instead of a symptom focused one, precisely because in previous studies (Neto, personal communication) the symptoms showed an oscillatory evolution, (this phenomenon was verified in many other studies; Richardson, 2001) and therefore they don’t capture the real changes that people attain during the psychotherapy processes. Actually, the symptoms tended to diminish in the first six months of the therapy and then tended to increase again, diminishing afterwards and so forth. Therefore it is no surprise if brief therapies attain good results, but the real proof is in the long term. As Phil Richardson puts it ironically "the 'good therapist' is the one who releases the patients in the right moment of the curve" (Richardson, 2001). We hope that the assessment of attachment patterns and working models of the patients will prove more accurate than the superficial and atomistic assessment of symptoms. The amount of time in treatment had a significant effect in reducing abandonment anxiety. I wonder if the diminishing of abandonment anxiety is precisely an effect of enduring consistently an experience of therapeutic support for a rather long period of time. We verified that patients with history of chemical dependence had higher avoidance of close relationships, and people with masochistic tendencies had lower avoidance than average. Even if their neurotic symptoms decreases in the first months of therapy, their attachment patterns and working models will cause them to engage or maintain inadequate and frustrating interpersonal experiences, which in the long run will probably produce symptoms again. Sincerely Yours Nuno Torres (Psychologist, PhD Student at the Centre for Psychoanalytic Studies, Un. Essex; Training Fellow of ESBP- European Society of Bonding Psychotherapy; Member of Group Analytic Society -London) References Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998).'Self-report measures of adult romantic attachment. An integrative overview'. In J. A. Simpson & W. S. Rholes (Eds.), Attachment Theory and Close Relationships. New York: Guilford. (Summary available at http://psychology.ucdavis.edu/Shaver/brennan.html) Richardson, P. (2001) Communication presented at the Centre for Psychoanalytic Studies, Un. Essex, 2001 Torres, Neto, Sanches (2001) 'Evolution of patients on an ambulatory Bonding Psychotherapy group, according to the attachment theory'. Presented at 14th International ISNIP Conference ' Bonding psychotherapy: for whom, when and how?. Belluno, 22-23 September 2001
Re: COUNSELLORS UNITE BEHIND NEW NATIONAL BODY 27 March 2002
PHILLIP I HODSON, Fellow, British Association for Counselling & Psychotherapy CV21 2PJ Send response to journal: Re: Re: COUNSELLORS UNITE BEHIND NEW NATIONAL BODY	Dear Sir, The letter from Mr Underwood claiming leadership of the talking therapies in the United Kingdom is rather like Andorra purporting to be a superpower. It is factually incorrect. His opportunism as a website owner should not be allowed to confuse your readers. Since 1977, The British Association for Counselling and Psychotherapy (BACP) has been the only serious player in this field and now represents the overwhelming majority of British therapists across the specialties. As more healthcare trusts and GPs sign up for primary care counselling services, it is particularly important that the quality of our accreditation schemes, in place for public protection, should be recognised. Our standard of training to become a therapist now involves 850 hours of work, 450 of which must be supervised, in not less than three and not more than five years. We are the organisation campaigning for the statutory regulation of the talking therapies. We have in place the most sophisticated ethical and complaints procedures. By contrast Mr Underwood's code of conduct asks his members to respond to five simplistic questions with 'a promise to be good'. In our view, this is never 'good enough'. My claims could be verified at www.counselling.co.uk. Yours truly, Phillip Hodson, Fellow The British Association for Counselling & Psychotherapy
Informed consent 30 October 2002
susanne stevens, researcher 2 Pen Y Lan Rd Cardiff CF24 3PFnone, none Send response to journal: Re: Informed consent	Jeremy Holmes gained some of his experience at the practice where Iona Heath works - should that have been' declared? Very few people expect doctors to be perfect specimens of manhood 'striding about their hospitals'- they do infact expect a level of compassion, decency, skill and the ability to treat others with dignity and equality. If doctors conform to even the normal expectations of patients - they will be ok. As to psychological treatments, many people find this very intrusive - again this is not something which well meaning doctors should impose without informing people of their interest in psychodynamic treatment and gaining their consent. There may be a shortage of doctors but many practice to the satisfaction and benefit of patients without this specialist knowlege. Many people feel offended to realise they have been treated as some kind of specimen to be analised without their consent by a doctor - others welcome it - informed consent are the key words.