Thinking about the treatment of anxiety: is CBT all it's cracked up to be?
It is a common scenario for me as a clinical and counselling psychologist to have clients who request Cognitive-Behavioural Therapy (CBT) for anxiety and depression because they have been told that it is the most effective psychological treatment. Having undertaken a Masters in Clinical Psychology at La Trobe University, it is one of the modalities I have trained in.
The problem with the request for CBT is that it implies that we have found the holy grail of psychotherapeutic treatment. If only! I think it is important that the community become better informed about outcome research which tells us what actually works in therapy. There are something like 250 models of psychological/psychotherapeutic treatment. Overall, the outcome research of the last 40 years suggests that the treatment approaches achieve roughly equivalent results. In other words, it is the similarities rather than the differences which account for the effectiveness of psychotherapy. Outcome research also shows that, if you think about factors that account for therapy outcome, 15% is hope and expectancy; 30% is accounted for by the relationship with therapist; 15% is treatment model or technique (which is what us therapists spend heaps of time and money on) and a whopping 40% is client or non-therapy factors eg. chance events.
What this says is the clients not therapists make therapy work and that in order to maximise therapeutic outcomes for clients, treatment must be tailored to the client's characteristics. The quality of the working alliance with the therapist is thus crucial to the outcome for the client.
So back to my topic as to the efficacy of CBT. It would seem that the effectiveness of CBT or any therapy is going to depend on the therapist's ability to structure treatment to suit the client. So the therapist needs to be change-focussed rather than problem focussed and able to amplify and potentate the client's contribution to the change process. The client's theory of change and the accommodation of the therapist and the therapy goals to that theory is crucial for a positive outcome.
My experience in practice bears out the importance of the therapeutic alliance and the balancing of therapeutic modalities/interpretations and client experience and explanation. Constantly checking with the client whether the conversation you are having with them makes sense and is useful, is alliance building and ultimately is what sets therapy goals. The therapeutic alliance with a client, in my experience, is formed within minutes and is relatively set by the end of the first session. There is room for "mistakes" in aligning with the client but they have to be repaired within the first session for further sessions to occur and be helpful. I try to get clients to give me feedback regarding our relationship and/or the helpfulness of the work we have done together via short questionnaires or specific questioning.
So when looking for the "right" treatment for anxiety or depression, for example, look for someone who is qualified and registered to do the job, but also notice whether you feel a working alliance forming with them. CBT may be the method for you or some other treatment modality, but the helping relationship you form with the therapist will be a better predictor of outcome over time.
If you are interested in reading more about outcome research in
psychotherapy, check out www.talkingcure.com.
Good luck.
Kaye Frankcom
Registered Psychologist
Williamstown
