Many, perhaps the majority, of those who go to see their family doctor have some type of psychological problem which makes them anxious or unhappy. There may be a fairly obvious reason for this – the loneliness of widowhood or the stresses of bringing up a family – or it may be that their mental state is part of their personality, something they were born with or a reaction to traumatic experiences in their lives. Despite being so common, I soon discovered after starting in general practice over ten years ago that this type of mental disturbance (usually described as a neurosis to distinguish it from the psychosis of those with a serious mental illness like schizophrenia) is particularly difficult to deal with. What are the options? Well, there are always drugs – minor tranquillizers, antidepressants and sleeping pills. It is certainly easy enough to write a prescription and more often than not the patient feels a lot better as a result, but there is no getting away from the fact that drugs are a chemical fix. Sometimes this is all that is necessary to tide someone over a difficult period, but more usually the same old problems recur when the drugs are discontinued.
The alternatives to drugs are the ‘talking therapies’ ranging from psychoanalysis to counselling that seek to sort out the underlying cause of anxiety or unhappiness. Psychoanalysis is out of the question for many, being too prolonged – often lasting for years – and too expensive. Counselling certainly can be helpful for no other reason than that unburdening one’s soul to a sympathetic listener is invariably therapeutic. But once the counselling sessions were over, I got the impression it was only a matter of time before the psychological distress reappeared.
Here, then, is one of the great paradoxes of modern medicine. Doctors can now transplant hearts, replace arthritic hips and cure meningitis but, confronted by the commonest reason why people seek their advice, they have remarkably little to offer. And then a couple of years ago I started to hear about a new type of psychological treatment – cognitive therapy – which, it was claimed, was not only straightforward but demonstrably effective. I was initially sceptical as I found it difficult to imagine what sort of breakthrough insight into human psychology should lie behind such remarkable claims. The human brain is, after all, the most complex entity in existence, so it would seem unlikely that someone had suddenly now at the end of the twentieth century found the key that unlocked the mysteries of neuroses – a key that had eluded human understanding for hundreds of years.
The central insight of cognitive therapy is not, it emerges, a new discovery, but rather is based on the profound observation originally formulated by the French philosopher Descartes that the essential feature of human consciousness was ‘cogito ergo sum’ – ‘I think therefore I am.’ We are our thoughts and the contents of our thoughts have a major influence on our emotions. Cognitive therapy is based on the principle that certain types of thought that we have about ourselves – whether, at its simplest, we are loved or wanted or despised or boring – have a major effect on the way we perceive the world. If we feel unloved, the world will appear unloving, and then every moment of every day our sense of being unloved is confirmed. That, after all, is what depression is all about. These types of thoughts are called ‘automatic thoughts’ because they operate on the margins of our consciousness as a continual sort of internal monologue. If these thoughts are identified and brought out into the open then the state of mind that they sustain, whether anxiety or depression or any of the other neuroses, can begin to be resolved.
So this type of therapy is called ‘cognitive’ because it is primarily about changing our thoughts about ourselves, the world and the future. The proof of the pudding, as they say, is in the eating and the very fact that this type of therapy has been shown to work so well, in countless well-controlled studies, is powerful confirmation that the underlying insight that our thoughts lie behind, and sustain, neurotic illnesses is in essence correct.
Nonetheless, some may be forgiven for having misgivings. The concept of cognitive therapy takes some getting used to and it is certainly hard to credit that complex psychological problems can be explained by such an apparently simple concept. There is perhaps an understandable impression that it all sounds a bit oversimplified or trite, that it fails to get to the root cause of the source of anxiety or depression.
So it is necessary to dig a bit deeper to examine the origins of cognitive therapy and perhaps the easiest way of doing this is to compare it with what for many is the archetype of all forms of psychotherapy – psychoanalysis. Psychoanalysis claims to identify the source of neuroses in the long-forgotten and repressed traumas of early childhood, so it is less concerned with thoughts themselves than with the hidden meaning which (it claims) underlies them. The important question, though, is whether psychoanalysis does make people better, or at least less unhappy. Many people certainly believe they have been helped, but when Professor Gavin Andrews of the University of New South Wales reviewed all the studies in which the outcome of psychoanalysis had been objectively measured in the British Journal of Psychiatry in 1994, he was unable to show that it worked any better than ‘just talking’.
In cognitive therapy, the importance of human thoughts lies precisely in their content and how that influences the way a person feels about themselves, a point well illustrated by one of its early pioneers, Aaron Beck. Back in the sixties, while practising as a psychoanalyst in Philadelphia, Beck was treating a young woman with an anxiety state which he initially interpreted in true psychoanalytic fashion as being due to a failure to resolve sexual conflict arising from problems in childhood. During one session he noticed that his patient seemed particularly uneasy and, on enquiring why, it emerged she felt embarrassed because she thought she was expressing herself badly and that she sounded trite and foolish. ‘These self-evaluative thoughts were very striking,’ Beck recalled, ‘because she was actually very articulate.’ Probing further he found that this false pattern of thinking – that she was dull and uninteresting – permeated all her relationships. He concluded that her chronic anxiety had little to do with her sex life but rather arose from a constant state of dread that her lover might desert her because he found her as uninteresting as she thought herself to be.
Over the next few years, Beck found that he was able to identify similar and quite predictable patterns of thinking in nearly all his patients. For the first time he realized that he was getting inside his patients’ minds and beginning to see the world as they experienced it, something he had been unable to do in all his years as a psychoanalyst. From that perspective he went on to develop the principles of cognitive therapy.
Compared to psychoanalysis, cognitive therapy certainly does appear much simpler, but we should not take this to mean that it is less profound. The central failure of the founders of psychoanalysis was that they did not recognize the true significance of thoughts in human neurosis. Once that significance was grasped by those like Aaron Beck then human psychological disorders became more readily understandable and therefore simpler, but it is the simplicity of an elegant scientific hypothesis that more fully explains the facts. It can’t be emphasized too strongly the enormous difference that cognitive therapy has made. Now it is possible to explain quite straightforwardly what is wrong in such a way that people are reassured, while allowing them to be optimistic that their problems can be resolved. Here, at last, is a talking therapy that works.
Professor Gavin Andrews in his review in the British Journal of Psychiatry identified cognitive therapy as ‘the treatment of choice’ in generalized anxiety, obsessive compulsive disorders and depression. It has in addition been shown to be effective in the treatment of eating disorders, panic attacks and even in the management of marital and sexual difficulties, in chronic pain syndromes and many emotional disorders of childhood. Its contribution to the alleviation of human suffering is remarkable.
James Le Fanu, GP