Over the past two or three decades, there has been something of a revolution in the field of psychological treatment. Freud and his followers had a major impact on the way in which psychological therapy was conceptualized, and psychoanalysis and psychodynamic psychotherapy dominated the field for the first half of this century. So, long-term treatments were offered which were designed to uncover the childhood roots of personal problems – offered, that is, to those who could afford it. There was some attempt by a few health service practitioners with a public conscience to modify this form of treatment (by, for example, offering short-term treatment or group therapy) but the demand for help was so great that it had little impact. Also, whilst numerous case histories can be found of people who are convinced that psychotherapy did help them, practitioners of this form of therapy showed remarkably little interest in demonstrating that what they were offering their patients was, in fact, helpful.
As a reaction to the exclusivity of the psychodynamic therapies and the slender evidence of their usefulness, in the 1950s and 1960s a set of therapeutic techniques was developed, collectively termed ‘behavior therapy’. These techniques shared two basic features. First, they aimed to remove symptoms (such as anxiety) by dealing with those symptoms themselves, rather than their deep-seated underlying historical causes (traditionally the focus of psychoanalysis, the approach developed by Sigmund Freud and his associates). Second, they were scientifically based, in the sense that they used techniques derived from what laboratory psychologists were finding out about the mechanisms of learning, and they put these techniques to scientific test. The area where behavior therapy initially proved to be of most value was in the treatment of anxiety disorders, especially specific phobias (such as extreme fear of animals or heights) and agoraphobia, both notoriously difficult to treat using conventional psychotherapies.
After an initial flush of enthusiasm, discontent with behavior therapy grew. There were a number of reasons for this, an important one of which was the fact that behavior therapy did not deal with the internal thoughts which were so obviously central to the distress that many patients were experiencing. In particular, behavior therapy proved inadequate when it came to the treatment of depression. In the late 1960s and early 1970s a treatment for depression was developed called ‘cognitive therapy’. The pioneer in this enterprise was an American psychiatrist, Professor Aaron T. Beck. He developed a theory of depression which emphasized the importance of people’s depressed styles of thinking, and, on the basis of this theory, he specified a new form of therapy. It would not be an exaggeration to say that Beck’s work has changed the nature of psychotherapy, not just for depression but for a range of psychological problems.
In recent years the techniques introduced by Beck have been merged with the techniques developed earlier by the behavior therapists to produce a therapeutic approach which has come to be known as ‘cognitive behavioral therapy’ (or CBT). There are two reasons why this form of treatment has come to be so important within the field of psychotherapy. First, cognitive therapy, as originally described by Beck and developed by his successors, has been subjected to the strictest scientific testing; and it has been found to be a highly successful treatment for a significant proportion of cases of depression. Not only has it proved to be as effective as the best alternative treatments (except in the most severe cases, where medication is required), but some studies suggest that people treated successfully with cognitive behavior therapy are less likely to experience a later recurrence of their depression than people treated successfully with other forms of therapy (such as anti-depressant medication). Second, it has become clear that specific patterns of thinking are associated with a range of psychological problems and that treatments which deal with these styles of thinking are highly effective. So, specific cognitive behavioral treatments have been developed for a range of anxiety disorders, such as panic disorder, generalized anxiety disorder, specific phobias, social phobia, obsessive compulsive disorders, and health anxiety, as well as for other conditions such as drug addictions, and eating disorders like anorexia nervosa and bulimia nervosa. Indeed, cognitive behavioral techniques have been found to have an application beyond the narrow categories of psychological disorders. They have been applied effectively, for example, to helping people with weight problems, couples with marital difficulties, as well as those who wish to give up smoking or deal with drinking problems. They have also been effectively applied to dealing with low self-esteem.
At any one time almost 10 per cent of the general population is suffering from depression, and more than 10 per cent has one or other of the anxiety disorders. Many others have a range of psychological problems and personal difficulties. It is of the greatest importance that treatments of proven effectiveness are developed. However, even the armory of therapies is, as it were, full, there remains a very great problem – namely that the delivery of treatment is expensive and the resources are not going to be available evermore. Whilst this shortfall could be met by lots of people helping themselves, commonly the natural inclination to make oneself feel better in the present is to do precisely those things which perpetuate or even exacerbate one’s problems. For example, the person with agoraphobia will stay at home to prevent the possibility of an anxiety attack; and the person with bulimia nervosa will avoid eating all potentially fattening foods. Whilst such strategies might resolve some immediate crisis, they leave the underlying problem intact and provide no real help in dealing with future difficulties.
So, there is a twin problem here: although effective treatments have been developed, they are not widely available; and when people try to help themselves they often make matters worse. In recent years the community of cognitive behavior therapists has responded to this situation. What they have done is to take the principles and techniques of specific cognitive behavior therapies for particular problems and represent them in self-help manuals. These manuals specify a systematic program of treatment which the individual sufferer is advised to work through to overcome their difficulties. In this way, the cognitive behavioral therapeutic techniques of proven value are being made available on the widest possible basis.
Self-help manuals are never going to replace the need for therapists. Many people with emotional and behavioral problems will need the help of a qualified therapist. It is also the case that, despite the widespread success of cognitive behavioral therapy, some people will not respond to it and will need one of the other treatments available. Nevertheless, although research on the use of these self-help manuals is at an early stage, the work done to date indicates that for a great many people such a manual is sufficient for them to overcome their problems without professional help.
Many people suffer silently and secretly for years. Sometimes appropriate help is not forthcoming despite their efforts to find it. Sometimes they feel too ashamed or guilty to reveal their problems to anyone. For many of these people the cognitive behavioral self-help manual will provide a lifeline to a better future.
Professor Peter J Cooper