Although some psychoanalysts claim I am part of a plot of CBT proponents against them, I am not and have never been a CBT therapist. Indeed, Aaron T Beck and I became friends because of his overtures and appreciation for my sustained critique of his cognitive therapy for depression.
I respect the commitment of American CBT researchers and clinicians to evidence and to both evidence- and science- based arguments. They are at the forefront of advocacy for evidence-based practice in the United States.
I have never thought much about differences in the CBT community the US versus the UK. I had limited exposure to CBT in the UK, other than a visit to University of Exeter where we had some lively debate followed by exceptionally good partying. I was left thinking that the CBT community in the UK is a bit different than that in the United States. They were a bit more nondefensive in hearing criticism– after all, they had invited me to give a keynote– and passionate in countering it. I had so much fun that I felt guilty accepting my speakers fee.
None of my past experience prepared me for the debate in the UK concerning CBT for persons with unmedicated schizophrenia.
When I took aim at both the press coverage and the Lancet article in a blog post, it was promptly hacked by someone who had intimate knowledge of the study and first claimed to be one of the authors before retracting that claim. The problem was so bad that I complained to a UK Internet provider that identified the source of the hacking in the neighborhood of one of the authors of that study. Apparently, this IP address had been the object of numerous complaints from others.
Now there is an embarrassing blog post that further demonstrates a lack of commitment to science and evidence by British clinical psychology.
The authors are Peter Kinderman and Anne Cooke, and they approvingly cites the recent Lancet study as indicating that CBT is a promising alternative to antipsychotic medication for treatment of schizophrenia.
In view of the downsides of antipsychotics it comes as something of a relief that there is a possible alternative. Psychological approaches such as cognitive behaviour therapy (or CBTp, the ‘p’ standing for psychosis) have become increasingly popular. NICE (the National Institute for Care Excellence) is sufficiently convinced of the effectiveness of these approaches to recommend that they should be offered to everyone with a diagnosis of schizophrenia. Traditionally they have been offered in addition to drugs, but a recent trial suggests that they might also be promising as an alternative.
If only that were true, a lot of us would be happier. But the study is basically a null trial dressed up as positive, starting with the hyped abstract.
There are formal standards for evaluating the process of producing guidelines and their output recommendations. Judged by these criteria, the NICE recommendations are woefully deficient and represent the consensus of professionals with self-interests at stake, rather than carefully assembled and considered best evidence, keeping in mind all of the limitations of this evidence. However, Brit psychologists seem hell-bent on waxing enthusiastically about these NICE guidelines, but then neglecting any balance in suggesting there must be an either/or choice in CBT versus antipsychotic medication.
Kinderman repeatedly argues from authority. I challenged him to refute the arguments contained in my PLOS Mind the Brain blog posts (1, 2) about the Lancet trial not producing usable data, but I can’t expect a response. He is a rather retiring fellow, once evidence is introduced.
Turning to the Maudsley debate, Kinderman finds it most worthy of comment that
all four debaters were white, male, middle class academics.
I thought that that was a funny thing for a Brit white boy to say.Certainly he would not get away with this in Philly. But then I looked on Google and found that like Steve Martin in the Jerk, Kinderman had been a poor black child born to sharecroppers.
Kinderman also dismissed skeptics of CBT for psychosis as “NHS clinicians with offices overflowing with drug company freebies.” I do not know if the audience at the Maudsley debate was taking notes with pens provided by the pharmaceutical companies, I only have the audio podcast. But I think that Kinderman’s raising of conflict of interest is an excellent idea, but it should be extended to the many psychologists who benefit from premature marketing of CBT for psychosis and those who hope for increases in demands for their services.
Kinderman repeatedly challenges evidence with anecdote. He presents himself as a champion of the Service Users (SU) perspective and suggest that random reports from the community trump systematic assessment of their response to treatment.
I wonder how service users feel about Kinderman and promoters of CBT appropriating their voice. And what do they think about Kinderman setting such a tone for the debate with his attacks on critics? Surely, he must have thought that they were watching.
Kinderman brings to mind Henry McGrath, a British advocate of complementary and alternative medicine with whom I clashed at the 2013 International Psycho-Oncology Conference in Rotterdam.
Me: do not you think it is outrageous when practitioners of complementary and alternative medicine cite users’ experience with alternative treatments like the coffee enemas that Prince Charles favors? Do you not you worry this kind of nonsense can discourage desperate cancer patients from seeking effective, but on pleasant treatments?
Henry: But I have certainly heard from users that they have gotten considerable benefit from coffee enemas. I cannot speak to their effectiveness.
Me: Really? Do they prefer cappuccino, lattes, or merely double espressos?
Some of Kinderman’s blog is simply silliness and can read in good fun. But then he says
The problem with many trials, and therefore with meta-analyses too, is that professionals decide in advance what they are going to measure and what counts as a ‘good’ outcome.
This is a rejection of the uncontroversial idea that investigators in clinical trials should commit themselves to primary outcomes and analyses in preregistration that occurs before the trials are done or the meta-analyses are conducted. Psychotherapy research is plagued by investigators having a battery of outcome measures and then choosing after the trial only the most favorable to emphasize.
Does Kinderman have no appreciation for what Archie Cochrane accomplished? Ben Goldacre’s campaigning for pharmaceutical companies to preregister and report all trials?
Kinderman titles his blog “a national scandal…” From across the pond I think that the British national scandal is there is such ignorance among British clinical psychologists about basic science-and evidence-based argumentation. He ends with a lament that
The issue is not one of overselling, it’s that psychological therapies are shamefully underprovided.
Maybe, Peter, that is what the accumulation of evidence will justify, but you doing very poorly with the evidence at hand.
The comments by Liverpool psychologist Richard Bentall are more disconcerting than Kinderman. He grunts “Duh” and dismisses arguments and evidence with “You don’t understand” without specifying what is misunderstood. Like Kinderman and Cooke, Bentall heavily relies on argument by declaration. This or that point with which he disagrees is demolished by declaring it demolished. I get the sense that for theses Brits at least, reading their blogs and comments is supposed to be strictly a spectator sport for readers.
Reacting to the first postings of criticism of his pontifications, Bentall angrily responded
I’m a bit tired of this debate, which is being pursued by a lot of people who don’t understand the pragmatics of RCTs, or who have never themselves tried to do anything to improve the well-being of psychiatric patients, or who are not clinicians and have never been in the position of not knowing what to do when faced with a patient who seems to be doing badly on standard treatments (if Keith Laws and I arrive together at St Peter’s Gate and there’s only room for one more entrant I won’t be too anxious). In a such a situation, a sensible clinician will ask herself ‘is CBT worth a shot?’ and the answer will be ‘yes’.
There is so much that Bentall says that I would like to dispute or at least demand the evidence for his claims so everyone can decide for themselves. For instance he claims that treatment as usual is conservative and reduces the possibility of finding an effect for an active treatment. Really? where is the evidence?
Rory Byrne, one of the authors of the Lancet study unleashed a lot of vituperation in the comments, but then someone other than Byrne quickly deleted his comments.
Another commentator stated
One of the biggest problems is that we are so dominated by a medical discourse that it is as if we can employ no other language in our critique of psychotherapeutic endeavour. It may be the case that some researchers believe that it is only by ‘medicalising’ research and attempting to think of psychotherapy as being akin to a drug, that they think their efforts will be taken seriously. Doubtless, they are perhaps more likely to gain research monies if they do this. Like it or not, psychotherapy is not a medical treatment and should not be evaluated as such.
Really? A solid RCT represents not medicalization, but fairest testing of whether an intervention works. A well done psychotherapy RCT is well done experimental psychology.
Update: after being away from his blog for a while Peter Kinderman has reemerged with a complaint
I am a little disturbed by the tone of some of the comments, and I think that personal invective is inappropriate and should be avoided…Let’s retain some dignity here.
A call for dignity? Peter, how disingenuous of you. You were the one who shamelessly appropriated the voices of those who are not “white, male, academics” as well as “users of services.” It was you who sweepingly characterized skeptics about the efficacy of CBTp as whores for the pharmaceutical industry. I think you should reflect on the tone that you set and the confusing message you give to consumers and their families.