Why I . . . use CBTBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5650 (Published 23 September 2019) Cite this as: BMJ 2019;366:l5650
All rapid responses
“Lord, protect me from my friends; I can take care of my enemies.” Voltaire
Pledges about benefits of CBT are most welcome but the one in the Journal deserves warnings.(1)
First, the use of the term “compassion” is not adequate.(2) According to the Cambridge Dictionary compassion is “a strong feeling of sympathy and sadness for the suffering or bad luck of others and a wish to help them”. The emotion that anyone can feel in response to the suffering of others is a slippery slope for tearful thoughtfulness or grieving solicitude which can only worsen patients’ despair. Empathy “the ability to share someone else's feelings or experiences by imagining what it would be like to be in that person's situation” is a skill that can be developed and improved. "In Their Shoes", a program for inflammatory bowel diseases, equips participating healthcare professionals with a smartphone app for receiving daily recurring messages such as "You have ten minutes to go to the toilet". The participant must find and send a photo of the bathroom door. This program deserves kudos as the scarcity of clinical trials using quality of life as a criterion for judgment and the craze for non-validated surrogates endpoints (e.g., progression-free survival in oncology) bear witness to our misunderstanding of our duties.
Second the capacity to understand what another person is experiencing needs neither a masters as highlighted (1) nor a PhD degree. Similarly, it is not specific to CBT, it is the cornerstone of psychological support (Rogerian or else) and motivational interviewing.(3) To make it simple, it is reflexive listening: reformulating not only patient’s concerns and complaints but also their values.(4) This not only reassures but also promotes autonomy. Simply, take time, be open and listen, remove barriers, let the patient explain, be committed. Accordingly, “Using CBT in General Practice: the 10- minute Consultation” may seem a Catch 22 situation.
Third, the claim “It’s about caring for a patient as a unique person” is not only a paradox _it is a “generalisation”_ but is hype flying in the face of reality. How many people are so unique they need and can afford tailor-made clothes? Who is so brilliant and has enough time for tailor-made approaches? There is a common simple thread: the need to provide reassurance and help. Person centred care is not tailor-made medicine!
Fourth, O’Dowd said: “I use (CBT) on myself …”,(1) despite evidence Based Medicine advocates relying on well-designed randomized controlled trials rather than personal case reports. Certainly, doctors’ wellbeing is a prerequisite for adequate care, and exhaustion and the burden of responsibility cannot be overlooked.(5) However, research has consistently highlighted the organisational origins of physician burnout and the Practitioner Health Programme and Dochealth in the UK is a step forward.(5,6) In contrast, self-treatment is a denial of the consequences of stress among doctors in terms of their morbidity and the risk to patients. Sadly, the plege for self-treatmenthas shown that little change in mind set have happened despite the Journal warning in the mid-1990s that sick doctors do not seek help because of denial, lack of insight into personal illness, and fear of confiding in an intervention scheme.(7)
O’Dowd’s insight could be useful for France, where the costly and mandatory healthcare scheme enduringly refuses to reimburse psychotherapies in contrast to Belgium and Quebec which copied and pasted the “Improving Access to Psychological Therapies programme” from England. This program has been providing for more than a decade individual or group therapies, largely cognitive-behavioural treatment approaches, to people and without the barrier of a doctor, and in-depth interviews showed most GPs in England keep in mind the dictum “Jack of all trades, master of none” when calling for increasing resources for this program.(8)
1 O'Dowd A. Why I ... use CBT. BMJ. 2019;366:l5650.
2 Braillon A. The Good, the Bad, and the.Empathic. Am J Med. 2015;128:e27
3. Motivational interviewing. Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B. BMJ. 2010 Apr 27;340:c1900.
4 Braillon A, Bewley S. Shared Decision-Making for Cancer Screening: Visual Tools and a 4-Step Method. JAMA Intern Med 2015;175:1862.
5 Elton C. Doctors can't care for patients if the system doesn't care for them-an essay by Caroline Elton. BMJ 2019;364:l968.
6 Shanafelt TD, Noseworthy JH. Executive leadership and physician wellbeing: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc2017;92:129-46
7 Brown RM. Helping sick doctors. Confidential voluntary scheme has been set up in Britain. BMJ 1996;312:1675.
8 French L, Moran P, Wiles N, Kessler D, Turner KM. GPs' views and experiences of managing patients with personality disorder: a qualitative interview study. BMJ Open 2019;9:e026616.
Competing interests: AB is a member of the High Council for Public Health (French DoH). He was publicly shamed as “lacking subtlety as public health actors working second hand on scientific publications, without contact with patients.”(Presse Med 2015;44:125-7. doi: 10.1016/j.lpm.2014.11.003)