Cognitive-behavioural techniques in practice

The randomised controlled trial reported by Turkington & Kingdon (2000) demonstrated therapeutic benefit from a general psychiatrist using cognitive—behavioural techniques with patients experiencing psychotic symptoms. However, the conclusion that “general psychiatrists could help their patients with schizophrenia by using cognitive—behavioural techniques” (p. 101) may not fully reflect the fact that the sole therapist in this study is an international expert in cognitive—behavioural therapy (CBT) with psychosis, who has co-written one of the seminal texts (Kingdon & Turkington, 1994).

Lack of time is highlighted as the main difficulty for psychiatrists wanting to use CBT, but other limiting factors may include the knowledge, skills and attitudes of the psychiatrist. Experience as a clinical psychologist supervising trainee psychiatrists suggests that the knowledge base is not generally problematic — medical training equips practitioners with the ability to assimilate new information rapidly.

Skills development in CBT is more difficult. The difference between the Turkington & Kingdon approach and cognitive therapy is that a formulation is not used, but it may be that an experienced CBT practitioner (as in their study) employs an implicit individualised formulation, whereas a more typical general psychiatrist would not. Cognitive—behavioural techniques can be powerful, and using these techniques without a formulation can be clinically dangerous. For example, undertaking attributional change in a patient with paranoia without regard for the link between persecutory delusions and selfesteem (Lyon et al, 1994) may trigger depression. Cognitive—behavioural skills development requires clinical supervision.

Attitudinal change is most difficult. Consider the response of a psychiatrist to a patient's question, “Should I take my medication?”. Valid responses might include “Yes” from a biological psychiatrist, and “Here's the evidence of effectiveness…” from a social psychiatrist. However, a response such as “How will you decide?” is a more appropriate cognitive—behavioural response. Psychiatrists can develop these alternative attitudes, but a ‘psychiatric’ mind-set often re-emerges in therapy.

Improved access for patients to psychological therapies is imperative. However, although it may serve the profession of psychiatry well to indicate that the use of CBT is easily within the grasp of all its practitioners, it is not clear that this is empirically demonstrated.