The BACP warned this month that counselling could be removed from the NICE Guidelines for Depression, leaving NHS patients only access to CBT. What could this mean for the mental health of the UK?
Favouring cognitive behavioural therapy (CBT) over counselling is not a new thing.
The NICE guidelines for Depression already recommends CBT as its frontline therapy. While they ask therapists offering counselling to discuss with their patients how uncertain the effectiveness of counselling can be.
What’s the difference between CBT and counselling?
Both CBT and counselling are used to support people with similar issues like anxiety and depression. And they’re both forms of talking therapy and can be used for short term work.
But while CBT therapists and clients work together to change a client’s behaviour or thinking patterns, counselling is less directive and through listening, empathy, encouragement and challenge counselling hopes to help the client to better understand themselves and find their own solutions to cope with the issues that face them.
Arguably someone could equally benefit from being supported by both interventions at different stages of their lives.
What does the NHS currently offer?
The NHS currently runs the Improving Access to Psychological Therapies (IAPT) programme which offers CBT first and counselling after.
First a patient is assessed by a psychological wellbeing practitioner who mostly go on to treat patients using CBT. It is only then if patients are severe at referral or if they do not respond to CBT are they stepped up to receive counselling.
Two years before IAPT was rolled out the Depression Report argued that services were not implementing therapies according to NICE guidelines.
IAPT was brought out to fix this. It purported to be cost effective and evidence-based. At the time there was also a huge need for quick return on investment, with savings on benefits hoping to balance the costs of any programme.
What’s so good about CBT?
CBT is easy to prove and also easy to prove that it’s cost effective.
The benefits of counselling are harder to show. Counselling is collaborative and non-directive so benefits can appear long after sessions have finished. Patients may suddenly start to make links and gain insights at a later date, making it harder to prove its effectiveness.
Research into counselling is catching up
There is plenty of evidence out there that shows the benefits of CBT for treating anxiety and depression. But research looking into counselling is starting to catch up.
A recent analysis of data collected from 33,243 patients across 103 IAPT services in the journal BMC Psychiatry this year found that the type of therapy someone attended did not predict an improved PHQ-9 score, a screening tool for mental health.
The researchers Jo Pybis et al said: “It is apparent from the findings presented here that counselling is not inferior to CBT.”
What if counselling was removed from the NICE clinical guidelines?
The British Association for Counselling and Psychotherapy (BACP) say that the impact of removing counselling from the NICE guidelines for depression could be ‘disastrous’, adding that it could lead to counselling no longer being offered on the NHS and restricting patient choice and depriving people of a proven intervention.
Julia Britton, Director of charity Open Door, a community service for young people, said: “Easily accessible counselling and psychotherapy has been essential to the Open Door service over many years and we have helped thousands of young people through evidence-based interventions.
“There is ample evidence to suggest the efficacy of counselling in the treatment of depression and anxiety and it would be a huge loss to young people if it were to be removed from the NICE guidelines and their access to counselling diminished.”
Michaela McCarthy, MBACP, Managing Director of The Awareness Centre that provides NHS IAPT programmes said: “If NICE did downgrade, or remove, counselling from their guidelines for treating depression it would seriously restrict the range of help available to people.
“Counselling is not necessarily a “quick fix” but a lot can be achieved for a client with depression in six or 12 weeks, such as psych-education and reducing feelings of isolation, or of being unheard and unseen, which can help people to adjust their mood for the better and recover.
“If NICE did downgrade or remove counselling for depression from the services offered it would be denying a client group, which is already seriously under-resourced, of a valuable way of managing their mental health.”
With evidence for counselling catching up with CBT it doesn’t make sense any more to pit one type of therapy against the other. Both can help people and Mental Health Today believes that both should be invested in.
What are your thoughts? Do you agree?
What is the difference between CBT and counselling?
There is certainly some overlap between counselling and CBT, and many people could benefit from either type of therapy. They are both an opportunity to talk to a non-judgemental and supportive person, to better understand your current problems, and to identify strategies to help you problem solve.
You might choose counselling over CBT when the problem in your life is caused by something that can’t be changed (like a job loss or bereavement), or when you’re not sure whether or how you want something to change (like a difficult relationship in your life). Counselling is particularly recommended for adjusting to difficult circumstances. It can also be helpful if you are not really sure what the problem is.
You might choose cognitive behaviour therapy over counselling when you are working towards changing repeated patterns in your life, and when you know what it is that you would like to change. It focuses on what you can do differently to change how you feel, or to change the impact your emotions have on your life. CBT is particularly useful as a treatment for anxiety, behaviour change and breaking vicious cycles.
What is the difference between psychotherapy, counselling and CBT?
Psychotherapy is sometimes used as a general term to cover all talking therapies, including counselling and CBT. It is also used to describe psychodynamic psychotherapy, which involves uncovering deeper patterns and internal conflict that might be underlying your problems. It is usually longer term and less structured than counselling or CBT, giving the patient the freedom to explore deeper issues that might not be addressed in other forms of therapy.
CBT might use your past experiences to help make sense of your current patterns, but the focus remains on making changes in the here and now. Psychodynamic psychotherapy is particularly useful when unresolved issues from childhood and adolescence get in the way of making changes in your life.
If you are not noticing any changes from CBT and you find that issues from the past keep coming up, it might be worth exploring psychotherapy as an option. If you are currently in psychotherapy and you feel you have understood and processed your past difficulties, but this is not translating into changes in the present, perhaps CBT could help you to make that shift.
What is the difference between a psychologist and a CBT therapist?
The term “psychologist” refers to a therapist’s qualification, while “CBT therapist” refers to the type of therapy he or she practices. A CBT therapist can come from a range of backgrounds, like psychology, social work, nursing, or occupational therapy. CBT therapists can be accredited by the British Association for Behavioural and Cognitive Psychotherapies (BABCP), indicating a high level of training and commitment to this particular type of therapy. Some psychological therapists might use aspects of CBT in their practice, but might not call themselves CBT Therapists if this is not the main type of therapy they use.
Psychologists who are registered with the Health and Care Professions Council (HCPC) have usually trained to a doctorate level or equivalent. There are different types of psychologists who specialise in different areas. Counselling Psychologists usually specialise in counselling and psychodynamic psychotherapy. Clinical Psychologists are trained to assess and treat people with a wide range of difficulties, but then tend to specialise in a particular area at the end of their general training. Specialty areas include common mental health problems, long term mental health problems, children and adolescents, health psychology, older adults, and learning disabilities. They will learn a range of therapies and then continue to develop skills in the therapies that are most useful for their particular specialisation. Both types of psychologists can also be CBT therapists.
Which therapy is right for me?
Ultimately it is up to you which type of therapy you try. The decision might be based on the nature of your problems, your personality and preferences, the individual therapist and, of course, time and money.
What is the difference between NHS and private therapy?
Counselling, psychotherapy and CBT are all available on the NHS, and I usually suggest that people explore these options through their GP first. Therapy in the NHS is provided based on national recommendations for treatment, and you should not be offered a type of treatment unless there is evidence that the therapy is helpful for your particular problem. The NHS also works on a “stepped care” system, which means that you will first be offered the least intrusive type of treatment that your assessing therapist thinks will be helpful for you, based on your current problems, psychological history and prior treatment. If what you are given is not helpful enough, then you may be “stepped up” to a more intensive treatment, or offered an alternative.
Many therapists who work in private practice also work in NHS services, and so one is not necessarily “better” than the other. The decision to have therapy privately could be for any number of reasons. Sometimes it is more practical or convenient to choose your therapist, time slot or location. Some people want more support than is offered under the NHS, are put off by waiting lists, or prefer the style of a particular therapist. If you are unsure, it is probably worth speaking to your GP to find out what is available in your area. If you have limited options, then you may decide to have therapy through private practice. This may give you more flexibility to find the therapy – and therapist – right for you.
Some NHS services don’t require a GP referral. If you are looking to access CBT for depression or anxiety through the NHS, find your local IAPT service here.
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Click here to check if a psychologist is registered with the HCPC.
