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Depression needs more than mass-produced talking treatment

Has there really been a breakthrough in talking treatments for depression as claimed, or are formulaic policies driving out more humane interactions with the mentally unwell?

Earlier this month eminent academic psychologist Professor David Clark broadcast authoritative hope to the many sufferers of depression. He informed us how current scientifically formulated, measured and monitored Cognitive Behaviour Therapy (CBT) is positively transforming the efficiency and economy of our care.

But this picture is a misleading exaggeration. I know this from several decades working in the NHS with the mentally anguished. Yes, CBT certainly has much to offer in terms of apparent clarity, comprehensibility, reproducibility and thus mass-production. Little wonder it has ready allure for service designers, economists and politicians.

However human fear (anxiety) and dispiritedness (depression) is often not so straightforward as Professor Clark wishes to believe. He tells us 98% of his studied patients completed pre- and post-treatment measurements (questionnaires), and these were predominantly positive in outcome.

If this is true, it is an extremely select group: most mentally anguished people that I see are struggling to find a personal language for their experiences. They do not want, nor are they able to cooperate with, that kind of systematic self-objectification – at least at first. There are other problems with such measurements. Such self-reports are highly contentious and corruptible, albeit unwittingly.

How for example do we factor in the shamed avoidance of ‘masked depression’? Or the person who wishes to please, interest, avoid or punish authority figures? Or the subtle influences of the practitioner whose prospects and finances may be dependent on the results?

A CBT approach can undoubtedly help some: those whose life or psychological problems can be approached in a more structured and explicit way by words and systems-thinking. But there are many more mentally anguished who respond to other less measurable and less verbal human activities: providing safe sanctuary, trustworthy engagement and finely tuned unintrusive understanding and guidance. Most worryingly, such unmeasurable but humane activity in our NHS has become increasingly rare: often driven out by the kind of structured approaches vaunted by Professor Clark.

In this respect I disagree with Professor Clark – there have not been ‘massive developments’ in the science of therapeutic psychology: instead, the burgeoning is of measurements, systems and informatics. I wish I could share his didactic optimism.

 

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About the author

David Zigmond is a GP in London. He is also trained in psychiatry and psychotherapy. His writings on themes of humanism and healthcare can be found on his website.

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