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 this 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 psychodynamic therapies and the slender evidence for their usefulness, in the 1950s and 1960s a set of techniques was developed, broadly 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. Second, they were techniques, loosely related to what laboratory psychologists were finding out about the mechanisms of learning, which were formulated in testable terms. Indeed, practitioners of behavior therapy were committed to using techniques of proven value or, at worst, of a form which could potentially be put to the test. The area where these techniques proved of most value was in the treatment of anxiety disorders, especially specific phobias (such as fear of animals or of 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 patients were experiencing. In this context, the fact that behavior therapy proved so inadequate when it came to the treatment of depression highlighted the need for major revision. In the late 1960s and early 1970s a treatment was developed specifically for depression called ‘cognitive therapy’. The pioneer in this enterprise was an American psychiatrist, Professor Aaron T. Beck, who developed a theory of depression which emphasized the importance of people’s depressed styles of thinking. He also 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 depressions but for a range of psychological problems.
In recent years the cognitive techniques introduced by Beck have been merged with the techniques developed earlier by the behavior therapists to produce a body of theory and practice which has come to be known as ‘cognitive behavior therapy’. There are two reasons why this form of treatment has come to be so important within the field of psychotherapy. First, cognitive therapy for depression, 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 antidepressant 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 anxiety disorders, like panic disorder, generalized anxiety disorder, specific phobias and social phobia, obsessive compulsive disorders, and hypochondriasis (health anxiety), as well as for other conditions such as compulsive gambling, alcohol and drug addiction, and eating disorders like bulimia nervosa and binge-eating disorder. Indeed, cognitive behavorial techniques have a wide application beyond the narrow categories of psychological disorders: they have been applied effectively, for example, to helping people with low self-esteem and those with marital difficulties.
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 when the armoury 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 therapists. Many people will need individual treatment from 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 cognitive behavioral self-help manuals is at an early stage, the work done to date indicates that for a very great many people such a manual will prove 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 manuals will provide a lifeline to recovery and a better future.
Professor Peter Cooper
The University of Reading