What is cognitive behavioural therapy (CBT)?
“… for there is nothing either good or bad, but thinking makes it so.” Hamlet, Act 2, Scene 2
CBT is a form of ‘talking therapy’ and operates from the model that conditions like panic attacks, obsessions and depression are caused because of the unhelpful way an individual thinks. A simple example: An individual terrified of dogs might perceive something about their environment (e.g. a dog running loose in the park) which triggers an unhelpful set of thoughts and emotions (e.g. ‘it’s aggressive and dangerous!’ <fear> ), which leads to a maladaptive response to that situation (e.g. avoiding the park in future).
This sequence of what you think, how it makes you feel and how you respond to it can lead to some vicious cycles. For example, someone who notices that their heart rate has risen and who interprets this as an impending heart attack will likely feel scared – which tends to raise their heart rate. This increase in heart rate apparently confirms that something is seriously wrong, making them feel even more scared – and so on.
CBT operates to try and intercept these unhelpful thought processes; to encourage people to think about the sequence of thoughts and feelings that lead to behaviours they want to change.
The use of CBT for various anxiety disorders has been common for a while, but it has also been used for conditions like depression. The length and duration of therapy varies (The Royal College of Psychiatrists suggests between 5-20 weekly or fortnightly sessions of between 30-60 minutes and lists it as effective for moderate and severe depression). However, the evidence is not exactly clear cut.
Hofmann et al (2013) conducted a review of meta-analysis studies into the efficacy of CBT (a meta-meta-analysis?) which helpfully relates the assessment of effectiveness for different problems – including addiction, schizophrenia, eating disorders, etc. They conclude:
“In general, the evidence-base of CBT is very strong, and especially for treating anxiety disorders. However, despite the enormous literature base, there is still a clear need for high-quality studies examining the efficacy of CBT. Furthermore, the efficacy of CBT is questionable for some problems, which suggests that further improvements in CBT strategies are still needed. In addition, many of the meta-analytic studies included studies with small sample sizes or inadequate control groups.”
What is mindfulness-based cognitive therapy (MBCT)?
MBCT was developed to help prevent relapse in people suffering clinical depression. Some versions appear to use the principles of CBT (as described above) plus it encourages metacognition and guided meditation – being aware of thoughts and feelings as they arise but not holding onto them or responding to them. The principle idea appears to be that for individuals who relapse after CBT, unhelpful thought processes are once again triggering depression. The intention behind MBCT is to encourage the client to recognise that holding on to these thoughts and feelings is unhelpful – to allow these thoughts to pass ‘through the mind’ rather than become incorporated into ‘the self’; thereby preventing these unhelpful thoughts from causing stress and triggering depression. Another aspect of mindfulness training involves the person focusing on the present rather than worrying about the past or the future – and again, this appears a plausible way of reducing the impact of stress.
MBCT is also sometimes contrasted to traditional CBT. For instance Sipe and Eisendrath (2012) suggest that the emphasis isn’t on ‘fixing faulty thinking’ but rather relating to those thoughts in a different way.
A systematic review and meta-analysis of MCBT was conducted by Chiesa and Serretti (2011) who suggested that MCBT showed considerable promise as an adjunct to care in the treatment of major depression, reducing relapses rates in depression and in reducing symptoms in some anxiety disorders. However, they note that this evidence base did contain problems:
“However, several methodological shortcomings including small sample sizes, non-randomized design of some studies and the absence of studies comparing MBCT to control groups designed to distinguish specific from non-specific effects of such practice underscore the necessity for further research.”
An interesting question arises where MCBT utilises the principles of CBT; should we be surprised that it has some of the same benefits? The issue is whether the mindfulness element of the therapy is more effective than CBT approaches. My limited access to research articles means I’ve not been able to find a systematic review that looks at this comparison – but if a reader happens to know of one, I’d be keen to take a look at it.
Are there any side-effects?
It’s widely held that any adverse effects of CBT based therapies are far less severe and common than for pharmacotherapy (aka drugs). However, it seems fair to say that the tracking and monitoring of adverse reactions to psychotherapy hasn’t been consistent. A point made by Linden (2012)
“Empirical research on the negative effects of psychotherapy is insufficient, partly because there is a lack of theoretical concept on how to define, classify and assess psychotherapy side effects.” …
“Key Practitioner Message
•If you do not find adverse treatment effects, then ask yourself why and do not assume that there are no side effects.
•The detection and management of adverse treatment effects is not a sign of bad but of good clinical practice.”
and also by Fricchione (2013)
“In contrast to all pharmacotherapy studies in groups of patients, there is precious little information about the safety of psychotherapeutic interventions, which are also, in some patients and in some instances, associated with adverse events that need to be noted. Actually empirical research on the negative effects of psychotherapy is largely insufficient, partly there is a lack of theoretical concept on how to define, classify and assess psychotherapy adverse effects.”
There’s not much specific on mindfulness-based psychotherapies, but there are reports of adverse effects for meditation techniques – clearly related to the sorts of things that might occur during MBCT. Perez-De-Albeniz (2000) relates a range of adverse reactions related to the practice of meditation:
For example, Shapiro (1992) reported that 62.9% of participants reported adverse effects during or after meditation – 7.4% were reported as ‘profoundly adverse’. These adverse effects included feelings of anxiety and panic, increases in tension, decline in motivation, boredom, pain, impaired reality testing, confusion and disorientation, feeling ‘spaced out’ or depressed, increased negativity, being more judgemental and addiction to meditation.
Shapiro also noted that in some forms of the practice these adverse effects were seen as ‘part of the journey’ which invites a comparison to the fallacious circular reasoning regarding the efficacy of psychoanalysis; “insight causes cure; if you are not cured, by definition you need more insight”.
The causal relationship between meditation and these adverse effects are not clear. It may be that individuals more prone to these kinds of adverse reactions are drawn to the idea of meditation, or perhaps meditation causes these effects in some individuals. Either way, it appears to suggest that meditation isn’t devoid of potential contraindications when used as a psychotherapy.
There have been attempts to define these contraindications. For example, Dobkin et al (2011) examine possible adverse effects for mindfulness-based stress reduction (MBSR) and admit that we simply don’t know for whom MBSR is contraindicated. They do make some sensible suggestions in order to reduce the possibility of harm to their clients. For example a screening process for participants with serious psychiatric problems, posttraumatic stress or addiction; and ensuring there is a referral system in place for individuals who suffer adverse effects. One of the suggestions sort of implies that the adverse effects are an expected part of the process and that individuals should be taught strategies to deal with unpleasant experiences during meditation.
“Third, people can be ‘primed’ with regard to the type of commitment needed and informed about what to expect vis-à-vis types of practice and ‘homework.’ … For example, they suggest informing the person that early practices may be challenging and providing strategies regarding how to respond when disconcerting emotions arise (e.g., techniques for stabilizing the body and mind through breath awareness).”
Should we have CBT and Mindfulness in schools?
As a psychology teacher, I’m not principally worried about the efficacy of either CBT or MBCT as clinical interventions for anxiety or depression. (I’m interested in an academic sense because I teach A’ level students about these therapies and I don’t trust textbooks to always provide the full picture.) However, there is a track record for psychotherapeutic techniques inveigling their way into schools. For example, Neuro-Linguistic Programming (NLP) has been discredited as a psychotherapy and isn’t recommended by NICE but has found a niche within the “immune-deficient” environment of schools to peddle its wares. Not that I would put CBT and mindfulness in the same camp as NLP. The mechanisms behind the therapies are plausible given our current understanding of the role of cognition in mental illness, and there are on-going efforts to provide evidence of efficacy which are utterly lacking in pseudoscientific approaches.
My concern is that CBT and mindfulness are forms of psychotherapy which are being gently scaled into schools in the name of developing ‘resilience’ or ‘well-being’. I suppose my question is; should these forms of psychotherapy-lite become a mainstay of educational institutions?
Part of the push towards psychological interventions in schools (I’d include ‘Growth Mindset interventions in this list) is to develop children’s self-regulation strategies and improve attainment. If the suggestion was to offer low doses of a therapeutic drug to help children in school, teachers would be up in arms – yet, we appear remarkably blasé when low doses of ‘talking therapy’ are being offered. If the aim is to improve well-being, then there are still important questions to answer. Do all children need psychotherapy to maintain their well-being within school? How do we screen for the children who would benefit from a psychological intervention and which children would not – and most importantly, children for whom it might have a negative effect?
If these techniques are effective, then at the very least we need to ask more questions beyond ‘what is the average effect size?’. The use of cognitive-based interventions in schools needs tough protocols and ethical guidance; to ensure informed consent (including parental consent), minimum standards for qualifications, training and implementation, and a rigorous system of monitoring possible adverse effects. If these techniques are ineffective, then we shouldn’t be wasting time with them anyway!
At the last though – does soft- psychotherapy have a place in education at all? I worry that the drive towards these interventions in schools is a desperate effort to make up for the woeful lack of resources committed to mental health services for children in the UK.
Are we hoping that “amateur psychotherapy” carried out by teachers will make up for the lack of professional services easily available to children? For me, I’d be reassured to see more campaigning for the latter and a little less enthusiasm for the former!