By Professor Kevin Gournay
Behaviour therapy is rooted in experimental psychology and most books will tell you that behaviour therapy is based on the principles of Pavlov (of the salivating dogs) and Skinner (of the rat box). However, in my view, much current behaviour therapy is based on a practical, pragmatic approach rather than fossilised psychological therapy.
The original applications of behaviour therapy can be traced to the 1950s when Joseph Wolpe, a South African psychiatrist working in America, applied systematic desensitisation to the treatment of simple phobias. This approach was based on the idea that if you taught people to relax, this was incompatible with feeling anxious. Wolpe called this process “Reciprocal Inhibition”, i.e. one emotion cancelling out another. As well as using relaxation, Wolpe also taught his patients to evoke feelings of anger or sexual arousal in association with their phobic fear and these were as successful as relaxation. Wolpe’s original ideas still have some utility today. Perhaps, the next time you are anxious you should try to imagine something which makes you angry or something which … (write to the editor with your views on this).
During the 1960s and 1970s, behaviour therapy rapidly expanded and treatment became much more based in real life. For example, helping the patient to enter their phobic situations, often with the help of a therapist, or training the patient to deal with obsessional impulses by sitting out the anxiety or performing some kind of competing activity. Certainly, by the 1980s behaviour therapy was indicated for approximately 30% of problems going to outpatient psychiatrists and these included not only obsessions, simple phobias and complex phobias such as agoraphobia and social phobia, but also sexual difficulties, social skills problems, a whole host of habits and, more recently, the application of behaviour therapy to physical illnesses such as asthma, irritable bowel syndrome and even cancer.
In recent years, behaviour therapy has grown to embrace cognitive therapy. This involves treating thoughts in the same way as one treats behaviour, i.e. treating thoughts as recurrent and habitual patterns which are open to modification. Therefore, for example, in the cognitive therapy of depression, depressive thoughts are treated as learned bad habits and patients are trained to identify the when, where and how of these thoughts and to replace negative thoughts with more realistic or coping thoughts.
Behaviour therapy is now much more widely available although, as most of you know, some areas are better than others. Currently, behaviour therapy is offered by about 100 nurse behaviour therapists nationwide, by some clinical psychologists and, encouragingly, by an increasing number of psychiatrists and general practitioners who have learned behavioural procedures in their training. General practitioners now receive 3 years training before going into general practice and very often they spend some of this time with a department of psychiatry and may spend some of that attachment with a behaviour therapist. Indeed, since 1978, I have been responsible for giving dozens of psychiatrists and GPs a period of apprenticeship in behaviour therapy and I can vouch for the fact that some of these GPs spend a considerable amount of their time helping patients with behavioural procedures. In years to come there will be many more GPs and psychiatrists using this approach as, thankfully, there is now considerable evidence to show that the stranglehold of the old psychoanalytical approaches is lessening and doctors are now much more interested in acquiring skills in procedures which are known to be efficacious.
Whether you are referred to a psychologist, a nurse, or a doctor with a background in behaviour therapy is, in some senses immaterial. What probably counts most is having confidence in that person and if you have a good rapport with your therapist, this is probably much more important than whether they spent 7 years at medical school or completed a period of specialist training after qualifying as a nurse. The research carried out on who makes the best therapist indicates that the results of treatment are much the same for nurses, doctors and psychologists and therefore you should have no concerns provided the person has undertaken the appropriate training. Currently, in this country, there are several ways to train in behaviour therapy and although there are, of course, cutbacks in the educational provisions in the health service, training in behaviour therapy is gradually becoming more accessible to a larger number of health professionals. Overall the results of behaviour therapy with anxiety states are very good. The rule of thumb is that 70% of people who complete treatment will improve by 70% or more and this figure probably holds for obsessional rituals as well. However, treatment outcomes with obsessional thoughts are not quite as good, although behaviour therapy is still worth trying.
Patients very often ask me about the drugs they have been prescribed and probably 50% of those referred to me are taking some sort of medication. Overall, the evidence is that most medications prescribed for phobic states are not very helpful. Certainly, tranquillisers produce very significant problems in the medium and long term and I have no need to describe the horrendous addiction problems which have occurred with hundreds of thousands of people. Like tranquillisers, beta-blockers often work in the short term but in the long term, there is no real evidence of their efficacy. In my textbook on agoraphobia, we reviewed the evidence regarding beta-blockers and could find no long term evidence that they were in any way successful. The one group of drugs which may be successfully combined with behaviour therapy is antidepressants, although it is likely that they are only helpful where major depressive illness accompanies the problem or in some specific cases of obsessive/compulsive disorder. In my view, there is very little reason why antidepressants should be prescribed in phobic disorders as any benefit for phobics as a group is probably outweighed by the longer-term difficulties associated with antidepressants, which can include a very significant weight gain. Although there is some encouraging evidence that people respond to antidepressants, one must bear in mind that many of these studies are only of a few months duration and that there is very little evidence that in the long term, people who take antidepressants do any better than people who don’t. Overall, therefore, the message is that antidepressant drugs can be helpful in certain cases of phobic anxiety and obsessive/compulsive disorder but this represents a small minority. Anyone being offered medication for their condition should seek to find out why the medication is being offered, for how
long it is being prescribed, what evidence there is that it is useful in that particular kind of condition and, last but by no means least, ask for a full account of side effects.
Overall, therefore, behaviour therapy is a useful treatment for many phobics. It can certainly transform people’s lives but it is by no means a panacea. While there is little doubt that many patients can have their symptoms markedly alleviated by behaviour therapy, there is, in my view, no real cure for any of the phobic and obsessional problems which come for treatment; rather people may at best aim to become 98% better. There are, of course, some rare exceptions to this and in my career, I can certainly remember more than a handful of patients who have described themselves as cured. Overall, though, my feeling is very much that phobic disorders are underpinned by a genetic cause as well as the causes which are rooted in learning and, although my treatment approach is very much a psychological one I still believe that we should place considerable research effort into looking for genetic and biochemical aspects of phobic and obsessional disorders.
Professor Kevin Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. He is based in Cheshunt Hertfordshire.
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