How depression, alcoholism and erectile dysfunction are ALL being tackled by the same treatment on the NHS – as experts raise troubling fears over dangerous side effects

When Kendall Platt, 39, sought help because she was crying for hours and feeling overwhelmed, her GP referred her for a course of cognitive behavioural therapy (CBT).

This is a type of talking therapy increasingly used on the NHS and privately to treat everything from alcohol misuse to menopausal symptoms and erection problems – and to reduce over-reliance on medication and its associated problems.

But rather than making things better, Kendall emerged from her CBT feeling failed and ‘perilously alone’, says the married mother of two from Reading, Berks.

Based on the idea that what we think and do affects the way we feel, CBT aims to help patients address their symptoms by changing how they think, feel and act.

As the NHS puts it: ‘CBT deals with your current problems, rather than focusing on issues from your past. It looks for practical ways to improve your state of mind on a daily basis.’

The health service currently offers CBT sessions on a massive scale. Over the past 12 months the NHS provided more than 2million appointments for CBT in England – since April 2015, there have been 18million CBT appointments, according to NHS England.

Such numbers are testament to the success of a therapy originally developed to treat depression in the 1960s by the University of Pennsylvania psychiatrist Dr Aaron Beck.

Evidence from clinical trials in the 1970s showed it could work as well as, if not better than, antidepressant drugs, prompting greater interest in CBT.

Since then CBT has been added to guidelines by the official UK treatment watchdog, the National Institute for Health and Care Excellence (NICE), as the psychotherapeutic treatment of choice for adults with ADHD, as well as a broad array of mental and physical conditions.

But some experts now question whether CBT is being used too enthusiastically, leading to patients receiving treatment that is inappropriate, unhelpful – even harmful.

Kendall saw her GP in 2017 when she feared she was on the brink of a breakdown, suffering anxiety and panic attacks.

‘I would wake in the night with the terrifying sensation of being crushed,’ she says. ‘I had no interest in anything. I was working in a highly pressured job in forensics and had suffered workplace bullying. On top of that a dear friend was dying of cancer.’

Kendall, who was diagnosed with ADHD that year, says she had always felt her ‘brain running fast’. ‘I had habitually suppressed it, having been brought up to be a good and quiet girl and to keep everything inside. My brain would get overwhelmed and anxious. This manifested physically as nausea and bad stomachs.’

Her GP suggested an online course of CBT. ‘I diligently went through the course of 12 45-minute sessions,’ says Kendall. ‘But I struggled because CBT is about interrupting your thought patterns and reformulating them.

‘My mind is so quick that I can’t just interrupt my thoughts and reshape them like that. My brain was already past the thought and three miles ahead of it when the suggestion to reformulate that thought was made.

‘Rather than helping, the process left me feeling frustrated and perilously alone. I went back to the GP to tell them, but they said CBT was the only option they could offer me.’

NICE recommends CBT as the psychotherapeutic treatment of choice for adults with ADHD.

However, research shows that Kendall’s bad experience with CBT is sadly common.

Last year a study by psychologists at Nottingham University, published in the journal Frontiers in Psychiatry, involving 46 people with ADHD who had undergone CBT therapy, found that the majority had negative experiences, ‘overall’ finding it ‘unhelpful, overwhelming and at times harmful to their mental wellbeing’.

This in turn, ‘led to an increased sense of failure, low self-esteem and a sense of self-blame. The ineffectiveness of therapy increased their feelings of hopelessness and disappointment in themselves,’ said the researchers.

The study quoted one participant as saying: ‘CBT made me feel more inadequate as I felt I couldn’t do the stuff I was supposed to. You can’t change how you think when your brain is wired differently. ADHD isn’t a thinking or positivity problem. CBT seemed to assume it was.’ The study concluded that ‘to mitigate potential harm’, any CBT programme delivered to people with ADHD should always be specifically adapted to provide ‘concrete strategies for managing the core symptoms of inattention, hyperactivity and impulsivity’.

The NHS is using CBT for an ever-widening range of problems. As well as depression and anxiety disorders, NHS England recommends it for bipolar disorder, anorexia, bulimia, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), alcohol misuse, psychosis, schizophrenia and sleep problems such as insomnia.

The NHS also offers CBT for erection problems and irritable bowel syndrome, and last November NICE added new guidance saying CBT can be useful for helping women cope with menopausal symptoms, such as hot flushes and night sweats.

In a typical CBT session, you will talk about situations you find difficult, and then work out different ways of approaching these – this might include role-playing.

Regardless of what CBT is used to treat, there appears to be a significant risk of side-effects, according to a survey of CBT therapists published in the journal Cognitive Therapy and Research in 2018.

This identified more than 400 bad outcomes among their clients, who had a variety of conditions – leading researchers to estimate that 43 per cent of clients had experienced at least one unwanted side-effect from CBT. The most frequent were negative wellbeing, distress and worsening of symptoms.

More than 40 per cent of side-effects were rated as severe or very severe – including ‘suicidality, break-ups, negative feedback from family members, withdrawal from relatives, feelings of shame and guilt, or intensive crying and emotional disturbance during sessions’. This therapy ‘is not harmless’, the researchers warned.

Such concern is shared by Keith Laws, a professor of cognitive neuropsychology at the University of Hertfordshire, who has been lobbying NICE to stop recommending CBT for people with psychosis and schizophrenia.

He has previously published reviews showing there’s no medical evidence to support claims that CBT can alleviate any of the classic symptoms of schizophrenia and psychosis such as delusions. A 2018 analysis in the journal BMC Psychology that he co-authored, involving evidence from 36 previous studies, covering more than 15,000 patients with psychosis, found ‘no evidence that CBT for psychosis increases quality of life’.

He told Good Health that the findings were starkly clear: ‘We found it neither reduces distress nor improves social functioning.’

Professor Laws argues: ‘NICE’s endorsement of CBT in its treatment guideline is in dire need of reconsideration. It has remained unchanged since 2008, even though the low-quality evidence it used back then to support its endorsement is 17 years out of date at the very least.’

‘CBT itself is not a danger to these patients,’ he says. ‘But what worries me particularly is that some influential people in this treatment area have been pushing CBT as an alternative to medication. There have been a couple of studies where people voluntarily came off their medication and had CBT trialled on them,’ adds Professor Laws.

‘About a third dropped out of these trials and another third had to be sectioned under the Mental Health Act because their conditions had deteriorated so badly.’

On top of this potential danger is the waste of precious NHS money, says Professor Laws: ‘NICE recommends for psychosis 16 one-to-one sessions with a CBT therapist. These therapists have to be trained. It is very expensive.’ He points to a review published by the highly reputed Cochrane Group in 2014, which concluded that CBT showed ‘no clear and convincing advantage’ for psychosis over simple non-psychotherapy approaches such as befriending, which involves talking with the patient about neutral topics of interest, such as music, sport and pets.

He stresses: ‘I want NICE to revise these guidelines. If we want an accessible, cost-effective and equally potent alternative, why not listen to the Cochrane Group? We might do just as well with befriending.’ But while sceptics such as Professor Laws acknowledge ‘CBT is particularly useful for the things for which it was originally developed, such as depression’, other experts doubt even this and claim its benefits are being wildly overstated, even for core uses.

For example, a study by psychiatrists at Yale University School of Medicine, published in the journal Clinical Psychology Review in 2018 examined 100 clinical studies on CBT used to treat adult anxiety disorders, and found that the average rate of remission (where a patient’s symptoms had improved significantly) was 51 per cent.

In other words, CBT had failed to give effective help to about half the patients.

Why might CBT not help – or even prove unhelpful in so many cases? This can happen even when the therapy has been delivered well, according to Dr Elena Makovac, a senior lecturer in clinical psychology at Brunel University of London, who attests to its efficacy and uses it effectively with her own patients.

‘But I’ve also seen that it doesn’t work for everyone,’ she wrote in a recent Brunel news bulletin.

‘Even when CBT is conducted correctly, side-effects such as worsening of symptoms and increased distress are sometimes reported.’

She believes one possible reason is that CBT requires patients to confront their negative feelings head-on, which can be ‘challenging’ and even ‘overwhelming’.

This can be particularly true for those who’ve experienced complex trauma – ‘simply modifying thought patterns does not tackle the deep-seated issues that underpin their symptoms, which are often rooted in early childhood’.

She adds that other patients can feel dismissed: ‘The therapy’s focus on rational thinking and evidence-based beliefs can seem to dismiss their emotions.’

Dr Makovac told Good Health: ‘I do not think it is the case that CBT has overspilled its boundaries or is overused, but rather that we need to approach its use with caution.’

She believes that potential patients could initially be screened to check if CBT is appropriate for them. Left to rely on her own resources, Kendall found a personal curative therapy – in the form of mindful daily gardening. It has helped her so much she now runs gardening courses tailored for people who have with ADHD and similar conditions.

‘It gives them the skills to create a therapeutic garden for themselves where they can get fully immersed in a way that helps them to calm their busy brains,’ says Kendall. ‘There are many other things besides CBT that you can do to support your brain and body.’

A NICE spokesperson told Good Health: ‘Our independent committee looked at the evidence for CBT in 2020 for people with severe mental health conditions who don’t respond to standard treatments. It found the evidence was similar to that used to develop our 2014 guidelines.

‘We stand ready to review our recommendations if new evidence becomes available.’