The need for more uncertainty in therapy

I was disturbed recently by a long conversation with a friend who had recently completed his qualification in Cognitive Behavioural Therapy. I hadn’t been aware of how driven they had become by their interpretation of evidence-based practice. On the face of it, it seems a good idea, but from his reports it seems that the approach is causing them to become more and more set in the way clients can be treated – set protocols to be followed in response to particular diagnoses, the exclusion of anything that isn’t CBT, and a raising of orthodoxy to almost religious heights: my friend was actually marked down for diverting from an agenda set with his client in response to something the client brought up. Apparently the ‘correct’ thing to do was to agree on how much time to spend on this ‘diversion’, before returning to the set agenda. With 90% of our behaviour – including those we wish to change – being driven by our unconscious I find that such diversions lead to something more important far more often than something the conscious thinks is. And they seem so bound by their desire to classify the problem, to give each client a badge that neatly predicts their symptoms.

The trouble is, the minute you label a person’s problem you change it into something more than it is, or less than it is. It’s the nature of people to seek to give things names, but I think in therapy this can be extremely limiting. People do not fit neatly into boxes, any more than a list of symptoms to tick can fully conceptualise the individuals’ experience of their issue. In my opinion to work from the basis that therapeutic treatment should be dictated by a diagnosis leads us into stagnant waters. Let me explain why:

For someone to be diagnosed with a label like depression, or PTSD or anxiety disorder they have to have someone qualified to diagnose. For that person to be qualified they have to have a set of criteria to match against the clients symptoms. To be able to use that criteria they need to belong to an organisation that has agreed them. So we arrive at a situation where an organisation trains people to label other people through a set of agreed boxes to tick. Human nature being what it is, it isn’t long before, because they’ve labelled the problem, the members of that organisation begin to think they own it. It’s only a short step before the diagnosticians make the leap of saying that because they are the only people who can label the condition, they’re the only people who can treat it. A neat wall is soon built around the issue, policed by those within. And to prove that they have a right to deal exclusively with the sufferers they design experimental studies that rely on the diagnosis, and, to be scientific, they match specific protocols to each condition they want to own. Any therapist inside the wall has to stick to ‘the way’ of dealing with the problem, or else the results of their work can’t be considered ‘evidence’ of ‘the way’ working.

in the case of CBT , on the plus side, the evidence shows that the protocols work. On the negative side, they show they don’t work on everyone with the label, or completely in many cases – but still they’re pushing the government to only allow those approaches (i.e. within their wall) to be used for certain conditions. So what becomes of those not helped by CBT? At the moment they can come to someone else like me, but it seems that CBT is looking to close the door and exclude anybody using any approach that doesn’t fit their evidential criteria (i.e.that set by them to prove the efficacy of CBT).

At a recent NCH training event a senior CBT therapist told the audience that there was no evidence to support the use of NLP. In that audience were probably at least 20 people who were phobia or habit free – at the least – because of an NLP intervention. Couldn’t a raising of hands in that context be taken as evidence? From his position, no, because the approach used on each person had too many unknown variables for the conclusion to be safe. Zzzzzzzzzzz. And yet the 20 remain phobia or habit-free.

I think they could do with a dose of uncertainty.

In Cognitive Hypnotherapy we have taken the opposite path. We avoid a set way of working with set labels. We do not diagnose because:
a) We’re not qualified to – i.e. we haven’t jumped through the hoops to get inside the wall, and, more importantly,
b) We believe that every single person given a label doesn’t fit it exactly, and that those differences could be the key to their recovery.

So, if any client says “I have X (anxiety, depression, PTSD)”, our response is “How do you do that?” and we ask specific questions to identify and isolate the unique way the client creates and conceptualises their issue. From the understanding that arises from this process emerges a range of treatment options. And from CBT’s perspective that is a problem for us.

In Cognitive Hypnotherapy the flexibility that arises from the belief that there is no single protocol that works on all people, and that there are probably several different ways of achieving the same result with each client, means that it’s difficult to create an experiment to ‘evidence’ our approach in the way that CBT can. We like variables. We like creativity. We like using anything that works from anywhere. We follow the dictum of Perls and the great Gil Boyne to ‘deal with what emerges’ and don’t treat a client’s diversion from an agreed agenda as something to manage, but as something to investigate. How on earth do you evidence that? How do you evidence a therapy session where four different techniques might be strung together in response to what emerges during the therapy process? In a world where ‘one-size-fits-all’ approaches are held up as the gold standard, suddenly the skill that enables a flexible and creative solution for any client who can’t be squeezed into the approach becomes a thing to be avoided, derided, and even feared. Orthodoxy becomes prized, innovation avoided.

I think we need a change of philosophy.

In a recent exercise conducted by the magazine Edge, scientists and philosophers were asked their opinion on the question “What scientific concept would improve everybody’s cognitive toolkit?” Overwhelmingly the answer was to be comfortable with uncertainty, know the limits of what science can tell us, and understand the worth of failure. It came at a very good moment for me; embracing uncertainty was a key theme in my latest book, Cognitive Hypnotherapy: What’s that about and How can I use it? Two simple questions for change.

As Neil Gershenfield, a director at MIT says, “The most common understanding about science is that scientists seek and find truth. They don’t – they make and test models. Building models is very different from proclaiming truths. It’s a never-ending process of discovery and refinement, not a war to win or destination to reach. Uncertainty is intrinsic to the process of finding out what you don’t know, not a weakness to avoid. Bugs are features – violations of expectations are opportunities to refine them. And decisions are made by evaluating what works better, not by invoking received wisdom.”

Nothing works on everybody. Everything works on somebody. Any research should be with the intention of creating better and better models from what works – from whatever approach it emerges – until we reach therapy Nirvana, not use it to try to exclude approaches other than our own, or convince government that our way is the only way. If CBT manages to convince the powers-that-be as well as they seem to be convincing themself then what we could be left with is the exclusion of other ideas that have their place in the evolution of therapy – which can only be to the detriment of those in need. That is where I fear the current situation with CBT is leading.

We’re about to begin a research programme to show that the flexibility of Cognitive Hypnotherapy works – in a form that NICE and anybody else in the mainstream will accept – but what we want to come from it is to also show where it falls short and where it can be improved. Failure is simply information that can lead to improvement. And in the gathering of information we need to recognise what science is good at quantifying, and what it isn’t, and choose our evidential methods according to what is acceptably compelling, rather than purely scientifically measurable.

Imagine a world where all the walls erected around different therapies were taken down and we shared what we know – including that we don’t know enough.

In my book I finished with this: “Therapy should be a unified field bound by a communal curiosity about what can make us more skilled at being human. That’s what I want Cognitive Hypnotherapy to be about; permanent revolution driven by curiosity, united by uncertainty, guided by evidence, and always in a state of growth.”

It’s something to work for, isn’t it?