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Cognitive Behavioural Therapy Is Not Always the Answer for Anxiety and Depression

There is however a large number of people whose symptoms of anxiety and depression are caused by a myriad of other factors and for whom CBT is not necessarily the panacea it is sometimes promised to be.

Improving Access to Psychological Therapies (IAPT) is part of a huge programme launched by the UK government in 2008. According to Jules Evans, it is the biggest expansion of mental health services anywhere in the world, ever' (2013). And it's goal? Well, as it says on the tin: to improve access to psychological therapy.

Estimates of spending on the programme range from £400 to £600 million and according to Evans it has doubled spending on mental health services from 0.3% to 0.6% of the annual NHS budget. The economic justification for spending such vast amounts of money on psychological therapy lies in the theory that if symptoms of anxiety and depression can be successfully treated then this will reduce absenteeism from work and reduce the number of people claiming benefits for mental health reasons.

There are undoubtedly good things about IAPT. Any government that takes so seriously the state of its citizens' mental wellbeing that it is willing to invest significant amounts of money to improve mental health services, and more specifically psychological therapy services, should be applauded.

But IAPT is controversial for many reasons: that its view of mental health problems is simplistic and naive; that its economic analysis is flawed and unrealistic; and that the implicit return-to-work agenda is not necessarily compatible with the values on which a therapeutic alliance is formed between a patient and their therapist.

Another area of controversy is the prominence given to cognitive behavioural therapy (CBT) by the IAPT programme. Although a handful of other forms of therapy are also approved, such as interpersonal therapy and brief dynamic interpersonal therapy, the emphasis is very much on CBT.

The reason for this focus on CBT by IAPT is because, as far as the National Institute for Health and Clinical Excellence (NICE) are concerned, this is the treatment of choice for people with symptoms of anxiety and depression. In other words, this is the form of therapy that evidence from research studies suggests is the most effective.

As a clinical psychologist who has worked in the NHS for many years, I have worked with people with a wide range of symptoms of anxiety and depression. In my experience there are a large proportion of people who are greatly helped using CBT, sometimes when used in conjunction with psychotropic medication.

For people suffering from obsessive-compulsive disorder or panic attacks, or who have social anxiety or low self-esteem, CBT can be life-changing. The extent to which it is is determined by a number of factors such as the skill of the therapist, the quality of the relationship between the patient and the therapist, and the willingness and motivation of the patient to apply what they are learning in sessions to their life outside the therapy room. But in theory, problems such as these can be significantly helped by CBT.

There is however a large number of people whose symptoms of anxiety and depression are caused by a myriad of other factors and for whom CBT is not necessarily the panacea it is sometimes promised to be. For this reason I question IAPT's over-dependence on this model as a means of conceptualising and 'treating' a person's emotional distress.

I would like to mention one particular sort of individual that I came into contact with over and over again in NHS services and with whom I found it especially difficult to work using CBT.

For these people there was often no obvious cause or trigger for their symptoms of anxiety and depression. They were nonetheless troubled by what many described as a crippling feeling of anxiety or even of doom and dread.

A recurring theme in what these people said they wanted and needed was some sense of meaning in their lives. As far as they could make out it was this that was the underlying cause of their distress. They were victims of the epidemic of meaninglessness that I believe exists in our modern society and have written about at

It's difficult to admit but there were definitely times when I would dread these particular sessions. For weeks I battled on using a cognitive behavioural approach. Whilst such an effective treatment for so many forms of anxiety and depression, with someone afflicted by a more generalised existential anxiety it got me nowhere. In fact, I just backed myself into corners. I found I was working with people to identify core beliefs that I then couldn't challenge, because arguably they were true. Life is transient. It will one day end. It's meaning, if there is one, is not known.

I felt helpless. How could I help them find meaning if they weren't able to find it for themselves. What could I offer them that would be of real, practical value, but that would not seem patronising? They didn't have especially low self-esteem or difficulties in their relationships with others. They weren't especially inactive or avoidant of particular places or people. They certainly weren't deluded. In fact, you could argue that, if anything, they saw the world and the universe more clearly than the rest of us.

There is an argument that psychological distress related to these issues is a part of being human and that such people shouldn't fall within the remit of mental health services. But in my experience they are being referred to and seen by mental health services, and not in insignificant numbers either.

And perhaps rightly so. These were people who were often suffering greatly and to say that this sort of distress is part and parcel of being human is not to trivialize it in any way. I believe that many of these individuals did require some form of psychological therapy and there are effective ways of working with such individuals that can bring enormous relief to their distress. But CBT is not it.

For this reason, my concern regarding IAPT, and the wholesale attempt to treat every diagnosis of anxiety or depression using manualised CBT, is that it simply cannot deliver on expectations which its founders have inadvertently built up to an unattainable level.

The ensuing disillusionment takes it's toll on every party: for the patient in that they believe CBT 'doesn't work' (when maybe it just wasn't suitable for their particular difficulty), and they don't get the help that they need; for the therapist in that they feel useless when they aren't able to help their patients (when actually it's not that they aren't good at their job. It's simply that they are attempting to work with someone using an approach which isn't suitable, because that's the only one which has been sanctioned); and for managers, budget holders and politicians in that they think money spent on psychological therapies is a waste because IAPT has failed to deliver what it promised (when it was a flaw in the way IAPT was designed and the 'one-size-fits-all' approach to psychological therapy that was really the problem).

It's all been very quiet on the IAPT website ( ) recently - in fact there has been virtually no activity since late 2012. This is despite the whole IAPT programme supposedly being funded up to 2015. This year will certainly be a critical year for IAPT - after years of staggering amounts of funding, people (budget holders, politicians, voters and tax payers) will be wanting to know, has it delivered?

Personally, I sincerely hope the conclusion is that it has. This is not to say I don't think the programme could be improved upon, because I think it could, not least in the way the type of therapy recommended could and should be better tailored to individual need.

Clinical practice is messy and complex and therapy cannot simply be prescribed and uniformly administered in the way that medication is. Not even CBT.