Abstract
DEAR SIR
I write in relation to a letter from Dr Paul Coombe in a recent issue of Australasian Psychiatry 1 commenting on the clinical practice guidelines that were published in March 2003. 2– 4 I too feel it is important to add to the debate surrounding these guidelines and wish to present a very different view to that of Dr Coombe. I should state here and now that I am a psychiatrist who practises almost entirely using cognitive behavioural approaches, particularly in the treatment of anxiety disorders. In this regard I am one of the very few psychiatrists who practise cognitive behavioural therapy (CBT), a matter that itself requires urgent attention.
I take great issue with Dr Coombe's negative comments about the treatments and the guidelines for treatments presented for panic disorder and agoraphobia. 2 Dr Coombe and other psychoanalytically orientated psychiatrists need to acknowledge that the only significant research into the treatment of panic disorder and agoraphobia with psychological measures shows that CBT approaches are effective, in contrast to psychoanalytically orientated approaches where very few treatment outcome studies have been performed. Although this does not prove that psychoanalytically orientated approaches do not work for panic disorder, what it does say is that the evidence overwhelmingly supports CBT in this condition.
Certainly it is well recognized that clinical practice guidelines have limitations and weaknesses, and this has been discussed by Morris. 5 Problems with rigidity and the presence of comorbidities are certainly relevant for some patients with panic disorder and agoraphobia. However, I would suggest that favouring a psychoanalytical approach to panic disorder over CBT is similar to favouring a naturopathic treatment over an evidence-based medical treatment for the treatment of, say, asthma or diabetes. That is to say, it might work, but we have only anecdotal evidence to support that contention, the kind of evidence that is often presented very strongly by advocates for that particular form of therapy. For my part, I am extremely disturbed that basic CBT approaches to panic and agoraphobia such as breathing retraining, cognitive restructuring, interoceptive exposure and graded exposure are not the very first line of treatment for this condition. These treatments are practical, well accepted by patients and effective; to my mind, it is close to a scandal that so few psychiatrists treating these conditions have any knowledge of them whatsoever.
Dr Coombe also raises the old chestnut of symptom substitution with regard to successful treatment of panic disorder, an idea that has been well and truly put to rest over recent years. I also note with amusement Dr Coombe's acceptance that non-psychodynamic treatments for bipolar disorder are now accepted as treatments of choice. I fear that if he had been writing this letter 30 or 40 years ago, this would not have been conceded and a detailed discussion of psychoanalytic approaches to bipolar disorder would have been presented as being the best treatment for that condition too. One senses again the fear of psychoanalytic psychotherapists that their choice of therapy is gradually being removed from the list of effective and acceptable treatments recognized by governments, patients and many of the non-psychiatric medical profession. I note in this context that it will soon be mandatory for all patients with bulimia in the UK to receive CBT as first-line treatment for this condition (Fairburn C: pers. comm. 2003).
On a more conciliatory note, I must say that I tend to agree with much of what Dr Coombe has written in the second half of his letter. I, too, am concerned that most trainees complete their training with minimal knowledge or experience in the ongoing management of any psychiatric conditions outside of schizophrenia and chronic bipolar disorders. In general, the knowledge that trainees have of anxiety disorders is very limited and there is also limited knowledge of cognitive behavioural approaches for these and other conditions. Certainly, some of the training programmes and university education programmes are attempting to address this issue, but I would agree with Dr Coombe that it does take many years of ongoing selfdirected training for psychiatrists to obtain the knowledge, understanding and ‘psychotherapeutic skills’ neces sary to provide effective treatment. It remains a concern that psychiatric training enables trainees to assess patients and make diagnostic formulations, but gives little effective help in teaching trainees about long-term psychiatric treatment, the most fundamental of our roles as psychiatrists.
Training in cognitive behavioural therapy is also difficult to obtain in Australia for psychiatrists, with few colleagues practising CBT and a very limited number of experienced psychiatrists working in this area able to provide advice or supervision. In fact, most of the useful training experiences I have had in CBT have come from local and overseas conferences run by psychologists. For example, the Australian Institute of Rational-Emotive Therapy (RET) has presented courses in RET in the past, as has the Australian Association for Cognitive Behaviour Therapy (AACBT). Overseas, there are large conferences run annually in the USA and Europe. The World Congress of Behavioural and Cognitive Therapies is held every 3 years. These are all useful conferences with leading figures in CBT running workshops or seminars. As Dr Coombe has mentioned, reading is also an important part of ongoing professional education.
In conclusion, there needs to be more recognition of the importance that the psychotherapies play in the treatment of all psychiatric patients. I would also point out that psychoanalytically orientated psychotherapy does not ‘own’ the word ‘psychotherapy’ – cognitive behavioural therapists are skilled in providing effective talking therapies for many psychiatric disorders; therapy that includes an extensive assessment process, effective techniques and strategies, and all of the ingredients of supportive psychotherapy, including the ability to listen, empathize and help the patient through suffering and pain.