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. 


Some questions to consider from a conference on Shame

Shame is a primary emotion and therefore is something that we will all be familiar with experiencing it. Shame has an adaptive pro-social function so its not about eliminating all experiences of shame, but identifying if and where we experience toxic/chronic shame.

Q. What was your earliest experience of shame? and how do you feel you adapted your future behaviours as a result of this? Often compensatory behaviour occurs as a result of shame – for example if you can’t read and write, but have physicality then you may compensate with violence  Or if you feel a lot of shame about your body or sexuality you may disguise this by being hypersexual. Can you think of any compensatory behaviour that you may display born out of shame?

Parents use adaptive shame, but if this is too extreme then it can develop into chronic shame. Q. How do your parents use shame?

Some examples that shame-based families will experience are: disapproval of spontaneity, rigid expectations of behaviours, shame linked to curiosity (for asking questions etc), fault-blame focused families (most vulnerable child is scapegoated and carries all the fault and blame of the whole family), suppression and invalidation of feelings and needs, constant comparisons to others, lack of affect regulation (told how you should be feeling and sex, drugs, food, alcohol relied on to manage feelings with expression of feelings being deemed as too needy, involved, wet etc), objectification (where children are an accessory for image of family, not accepted in their own unique being), lies and reality invalidated and unrealistic expectations.

Q. What kind of shame is in your family? Has shame linked to certain areas been passed down your family tree? Does your culture instill shame over certain behaviours/values/experiences?

Shame is often a feeling of being less than an ideal/norm and linked to feelings of inclusion/exclusion. Where do you transgress social norms that you feel self-conscious about?

Q. What defences against shame do you use, with whom and in what situations? For example you may withdraw, become self-reliant, become appeasing, perfectionistic, or be grandiose or attach other. You may self-shame and blame or split off certain aspects of yourself and develop social v private self.

Q. What is your non-verbal communication when you experience shame? How does your posture change?

Exercise – write down the word ‘SHAME’ and then write down every word, experience, visual image, person, sensation that comes to mind when you think of ‘shame’.

Exercise – make a pie chart and identify the key areas that you hold shame. Here are some examples to get you started:

Cognition – Shame around lack of academic achievement, reading, bizarre ways of thinking, presenting, game playing, memory games

Body – disability, physique and how fits the norm, weight – thin shaming – depends on cultures and friends, shape of body with current norm (neutral or curvy or muscular)

Sense of self – vulnerability not acceptable, emotions not acceptable, shyness, posture, handshake/wave, what emotions are deemed acceptable or not

Sexuality – orientation, performance, STIs, virginity, puberty, mutilation, termination, circumcision or not, submission/dominance, promiscuity, preferences like BDSM/fetishes  How was your sexual script formed?

Relationship – dependence v independence, fear of abandonment and shame if have been left, parenting with emphasis to be perfect

Beliefs – religious, values – Brexit and potential beliefs (eg. Academic seen as non-Brexit and uneducated as Brexit)

Ageing – loss of potency, agency, less sharp, physical change, increasingly invisible especially as a woman, hair loss

As i searched for these images linked to shame it made me realise how particular emotions can also be very linked to shame and particular images and colours are attached to it. What image from your own life, or more generally would encapsulate your understanding of or the core of  the shame you feel?


Rising mental health referrals for young people

Consultant psychiatrist Sami Timini wrote an interesting piece that questions whether there is a massive increase in mental health problems among young people requiring CAMHS involvement, or whether as a society we are increasingly unable to tolerate our children’s expressions of distress and are too quick to want to hand them over to ‘experts’, who then medicalise, diagnose and prescribe. While there are clearly unique pressures impacting children today with social media, he makes a really valuable point that if we popularise the idea that there is an epidemic of mental health issues among young people and they all need expert help, the young people, parents, teachers and others who care for them will start to think that any display of emotion that concerns them, feels painful or annoys them or causes problems to themselves or others is a sign of mental disorder and not part of what it is to have the full range of human emotions – distress or certain idiosyncrasies become far too quickly pathologised. He argues “We are becoming afraid of our children’s emotions and behaviours. We are not allowing space for the ordinariness of unhappiness, anger, pain and suffering”. It’s best to promote caregivers and parents to be with difficult emotions, feel empowered to offer ordinary, relational ways to help and not feel an expert needs to be involved for fear of incompetency. There are of course those that greatly need expert intervention, but far too many children who are presenting with normal dilemmas, emotions and difficulties in living are being pathologised and medicalised, which will inevitably significantly shape their future.



“Shame is the intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging….Shame erodes the part of ourselves that believes we are capable of change. We cannot change and grow when we are in shame, and we can’t use shame to change ourselves.” (Brene Brown)