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Is CBT the most appropriate option always?

Often people will seek CBT without really knowing why they want that particular orientation of therapy for their particular difficulties. NICE tends to recommend CBT as the frontline option for all difficulties, regardless of the particular presentation and despite equal outcomes being repeatedly found across therapies. Therefore, it is not that CBT is more effective than other interventions, but it does have a significant evidence-base and is seen to be cost effective.

NICE relies on evidence largely from randomised controlled trials which are most suited to therapies that adopt diagnostic categories, adhere to standardised protocols, and obtain quantitative data. Those therapies that do not frame difficulties in terms of disorders, are client-led, explorative and adopt differing aims are less conducive to measurement by RCTs, with their aims and outcomes being harder to quantify. Many such therapies favour qualitative research into client experiences of therapy, over that of quantitative data on symptom reduction that do not always capture the whole picture for each individual, but this is only just starting to be recognised as a valid form of evidence by NICE and therefore these therapies are seen to have less of an evidence-base.

Take the treatment of PTSD in adults, NICE omits counselling as an option and recommends trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR). NICE states that these need to specifically address the trauma memories and for those not ready they are referred to non trauma-focused CBT to ‘promote uptake to a trauma-focused intervention’.

However, many therapies that includes a tri-phased approach – first establishing a good therapeutic relationship with emotional safety and regulation, followed by trauma reprocessing (uniting implicit and explicit memories into a comprehensive narrative of the trauma at the same time as eliminating arousal symptoms connected with those memories) and integration, are equally appropriate. Also somatic therapies can be very beneficial for somatic trauma memories that are stored non-verbally and are often hard to reach cognitively. Therefore, the type of therapy clearly cannot be ‘one size fits all’, but has to be tailored to individual needs.

As an example, the question of ‘to process or not to process?’ comes to mind. 

Some clients do not want to revisit and reprocess traumatic memories. Rothschild’s concept of trauma ‘recovery’ versus trauma  ‘resolution’ is useful here. If the impact of the trauma is no longer significantly affecting the quality of the client’s life then the client may consider this a good enough outcome, or recovery, without having to revisit the trauma memories, the decision should be the client’s. But if past traumas are constantly being triggered with flashbacks, nightmares, the client is living in an extreme state of arousal and sees threat everywhere, resulting in their lives becoming more and more restricted to avoid trauma triggers, the client will inevitably want these experiences to be reduced and to gain some control over their lives and responses again, which will require the deeper trauma work of revisiting and reprocessing trauma. But all therapy has to be first underpinned by client safety due to the possibility of retraumatisation, a substantial phase to establish emotional regulation and grounding techniques before the next phase can be addressed. However, this means that therapy can not always be entirely non-directive and client-led as such tools take time to establish and so for clients who just want to talk about the trauma experience as quickly as possible, they may need to be slowed to avoid the client becoming emotionally overwhelmed.

Hopefully NICE will begin to promote a wider range of therapies by giving more weight to qualitative evidence and enable more orientations that adopt a compassionate-collaborative stance of ‘what happened to you?’ over an expert-symptom-driven one of ‘what is wrong with you?’ to be embraced. 

But in the meantime, the most important thing as with any decision, is to make an informed choice about the type of therapy that best suits your needs. Understand their differing aims, philosophies, outcomes, whether you want symptom reduction primarily or to understand the meaning and potential causes of your symptoms before the consideration of their removal, whether you want a forward-focused therapy, past-focused therapy or one that gives equal weight to the temporal stages depending on your experience etc. Be sceptical of what you have seen advertised most and what is deemed as an evidence-base. All therapies have revealed equal outcomes so it’s far more about the relationship with your therapist and what particular intervention fits your needs at a particular point in time and your own attributes that you bring to the therapy ie. levels of engagement, involvement, motivation, proactiveness, willingness to reflect between sessions. 

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