Why CBT doesn’t help GP’s to treat depression

TEACHING GPs the skills to offer brief cognitive behaviour therapy (CBT) to patients with depression has “no discernible impact” on outcome for the patients, a recent randomised controlled trial has found.[1] But, alas, instead of questioning whether there might be a more effective way for GPs to offer brief therapy for depression within their time constraints, the researchers appear to conclude that GPs need much more training to acquire cognitive behaviour therapy’s “complex skills”.

Eighty four GPs from practices in North London and 272 of their patients who scored highly on a scale for anxiety and depression took part in the trial. Half of the doctors underwent four half days’ training in CBT, designed not only to teach new skills but to increase GPs’ belief in their ability to manage patients with depression.

Six months later, the knowledge and attitudes of the doctors who had received the training were little different from that of a control group who had received no training, and there was no evidence of an impact upon patients. In fact, the GPs who had done the training were more likely to refer their patients for specialist help, which lead researcher Professor Michael King and colleagues explain thus: “[The finding] would suggest that the doctors had acquired sufficient skills to know when their own management was likely to be unproductive. Thus training may have had a paradoxical effect in making them feel unable to deal with more complex cases.”

The researchers also propose that the focus on patients with severe anxiety/depression or long term problems meant GPs were obliged to use the methods on people they might have considered unsuitable for cognitive behaviour therapy. Another possibility they offer is that GPs did learn new skills but didn’t have the time to apply them.

All this is rather sad and does surely indicate a rather slavish adherence to models of therapy shown to be effective in some settings but not others. As the researchers point out, CBT is certainly known to be as effective as medication for the treatment of depression and also reduces rates of long term relapse. It is most effective when given by practitioners, including GPs, who have had extensive instruction in the technique, but it doesn’t necessarily transfer very well — as this trial shows — to the setting in which GPs ordinarily work.

The researchers are humble enough to admit that their findings run counter to others where GPs have used brief therapy methods successfully. Brief interventions have worked well when GPs applied them with problem drinking and diabetes. Behavioural and educational self help materials have also been used successfully by GPs to deal with depression and obsessive-compulsive disorders. So why not CBT? “Our finding of no benefit suggests that acquiring more complex skills in CBT is not straightforward for general practitioners,” the researchers suggest.

We would agree. Training in CBT is not straightforward. It takes a simple, excellent, common sense idea that faulty thinking can affect mental health, the basic tenets of which can be learned in a day or two, and makes a complicated mystery out of it. The concern should be not that GPs need more training but that they need less. For CBT works from an out-of-date premise, which makes it less effective than it could be. It has been discovered that emotion precedes reason and perception and, as a result, some emotional reactions and consequent emotional memories can be formed without any conscious participation from the thinking brain at all.[2]

The APET model

Whereas CBT assumes that anxiety or depression arises from faulty belief systems, the APET model takes into account the latest knowledge about how the brain works and enables it to be used for more effective therapy.[3] For example, black and white thinking, which underlies all the thinking style categories identified by cognitive therapists, is not dysfunctional thinking in the way they define it but the binary thinking style of the emotional brain. It is the result of emotional arousal and conditioning, not the cause.

The A in APET stands for activating agent: any event or stimulus in the environment. Information about that stimulus, taken in through the senses, is processed through the pattern-matching part of the mind (P) which is tagged with an emotion (E) which may inspire certain thoughts (T). Accordingly, the APET model provides many more points of intervention in therapy than simply helping a client to alter their beliefs and attitudes. Each letter of the model symbolises a point of possible change. Sometimes it may be most effective, for instance, to work to change the activating agent (ie an individual’s life circumstances). Very often an inappropriate pattern match needs to be changed. So a woman who unconsciously pattern matches to the mental cruelty of her first lover every time she embarks on a new relationship, and consequently sabotages it, needs help to uncouple the connection between the past experience and her present circumstances.

Emotion (the E of the model) always needs to be calmed down before a client can learn to think in a less black and white fashion. It is impossible to communicate fully with anyone who is overly emotionally aroused, and depression is just as aroused an emotional state as anger, even if it is not so apparent to the onlooker. We maintain, unlike in cognitive therapy, that it isn’t individuals’ faulty thinking which causes a problem but the fact that emotional arousal, with its black and white logic, blocks access to the more subtle reasoning of the higher brain. (Thus the depressed person thinks everything always goes wrong and no relationship will ever work, because there are no greys in black and white thinking.) Teaching people relaxation techniques and working with them while in a state of deep relaxation reduces the emotional brain’s paralysing hold over the neocortex.

Finally, as every good cognitive therapist knows, it can be important to work with any unhelpful thoughts or belief patterns (T) when a person’s attributional style of thinking is exacerbating the depression.

Whereas cognitive methods are laborious and slow and involve clients in adjusting to the therapist’s reality (learning to identify the many categor-
ies of faulty thinking), the human givens approach, based on the APET model, requires therapists to enter the client’s reality, and enables them to offer diverse meaningful interventions simultaneously, effecting powerful positive change extremely quickly.

The kinds of techniques used can be seen in the new training video, “In control again“, in which a self harming, clinically depressed single mother suffering panic attacks and feelings of paranoia is helped to take control over her life again in just one session of human givens therapy, working from the APET model. We would suggest that GPs could learn more about the nature of depression and how to lift it from studying this than attending any amount of CBT training.

The techniques which make up the armoury of the human givens approach (see “How to lift depression quickly and safely”, Human Givens, vol 9, no 1, pages 34—36) are applied not systematically but in accordance with the individual needs of each individual patient. They have been shown to work reliably time and again and are not complex to learn or apply, for either practitioner or patient. As supporters of research into what works, we would welcome the chance to participate in any trial that researchers into psychological therapies might care to construct.

 

References

1. King, M et al (2002). Effectiveness of teaching general practitioners skills in brief cognitive behaviour therapy to treat patients with depression: randomised controlled trial. British Medical Journal, 324, 947—950.

2. Le Doux, J (1998). The Emotional Brain. Weidenfeld & Nicolson.

3. Griffin, J and Tyrrell, I (2000). The APET model: patterns in the brain. HG Publishing.

This article is taken from Vol 9, No 2 of the Human Givens Journal and I feel it’s very relevant considering how ‘fashionable’ CBT is becoming in the UK at the moment.

Posted by: Eleanor

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4 responses to “Why CBT doesn’t help GP’s to treat depression

  1. Good blog. Have been having a look at it following the comment you left on my blog. This post is interesting in that I have just been reading the booklet about the APET approach. I will be adding you to my blogroll if you don’t mind. BTW, yes you correctly recognised me from the Stephen Fry forum!

    Regards,
    Sisiphus

  2. Thanks for the feedback, glad you found it interesting! I will add your blog back too :)

  3. Much of this human givens stuff is interesting but I’m concerned at the claims of superiority insinuated over CBT and the apparent differences. There is an inference that CBT folk believe that all problems, centered around beliefs, originate in the prefrontal cortex. nothing could be further from the truth. One only has to read major influences in CBT like Padesky and Michenbaum to know this is not the case. In fact Michenbaum’s model for working with folk is the description of a clock. 12 = activating agent of human givens, the environmental trigger, 3 = the affect and corresponding physioligical arousal associated, 6 = thoughts that arise in the emotionally charged state and 9 = any associated berhaviours. I fail to see the distinction between this and your APET model. it appears that there is some confusion in human givens as to what constitutes a “thought”. “Schema” is a term associated with CBT and from everything I read about human givens, your “patterns” are CBT “schemas”. No self respecting CBT therapist believes that problems arise fundamentally in the “reasoning” centres of the brain. “schemas” are set through integration of early experiences. As a result of these schemas beliefs do become established and reinforced over time. Challenging beliefs and assumptions arising in the emotional centres of the brain through activation of the cortex is at the heart of CBT, but CBT has long been associated with many techniques to calm down emotional arousal before attempting to engage in such processes. There are studies of combination of CBT with applied relaxation and hypnosis. Every CBT therapist I know is trained to calm people down before attempting to engage in trying to challenge existing beliefs and assumptions. If human givens really does have something new to contribute it would be nice to see a more colaborative and less confrontational language used, particularly when, as yet, it seems, there is a complete dirth of any sort of established evidence, recognised by the scientific community for its efficacy. New ideas are wonderful and we all want to see new ideas come forward to be of more help to more people. However, there appears to be something confrontational about the approach as well as a mis-representation of information about elements of other approaches. “thoughts” in CBT terms represent everything happening in the mind,- imagery, sounds etc, those instantaneous happenings within the mind, that human givens appears to describe as “patterns”.

  4. I wonder if the confrontational appearance of human givens is idiosyncratic rather than intentional? In the several years I have been reading their work the only time I have come across something I would consider particularly confrontational was Joe Griffin and Ivan Tyrrell’s ‘attack’ of post-modernism (in Human Givens a new approach to emotional health and clear thinking pp. 12-13) I found it confrontational because I am a practicing installation dance artist (in one of my persona’s) who utilizes postmodern theory with regard to deconstruction of movement. Meaning that all movement is valid; if you can move from one foot to another you are dancing. I do not dispute that there are various degrees within this broad concept of dance thus there are hierarchies of dance and specialists in specific movement modes but everyone can dance. I have come to understand the position that Griffin and Tyrrell were/are coming from but do include post-modern psychology theory in my own practice/study (in my other persona as psychology/religious studies undergrad with intention to practice psychotherapy using the human givens approach) especially in regard to human agency, experimental approaches, and concept of self. I also agree with Griffin and Tyrrell that there are natural measurements of difference between people which I strongly believe postmodern theory (in psychology and the humanities) celebrates rather than homogenises. We are all different and this pluralism is important especially in the face of globalisation/homogenisation. This is also important in a therapeutic setting, that each individual case is approached as well, individual.

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