Psychological treatment

The ordinary forms of counselling - the sort widely available, sometimes in GP surgeries - are popular with patients. However, there is little evidence of effectiveness; the evidence base is for structured forms of psychological treatment such as behaviour therapy and cognitive-behavioural therapy (CBT).

For example, take the treatment of a specific phobia, such as that of water, using CBT principles. Components of treatment would include the following:

• assessment interview

• leading to the building up of a trusting therapeutic relationship

• the patient is encouraged to set practical goals, such as resuming swimming

• patient develops anxiety hierarchy

• plan of graded exposure

• regular review sessions, achievements recognized, blocks assessed and dealt with.

By anxiety hierarchy is meant a series of situations in which the person is exposed to the feared stimulus in a gradually increasing manner. In this case, it might include

• thinking about a swimming pool

• looking at a picture of a swimming pool

• walking past the swimming pool and similar actions

• working up gradually to jumping into the swimming pool.

As will readily be surmised, the approach is common sense and practical, and it can to some extent be systematized; therefore, computerized versions have been developed, both for anxiety and for depression. NICE has recently opined (http:// that there is evidence of effectiveness of these computerized versions, and that they should be considered for clinical use. However, it seems unlikely that they will completely replace the need for skilled therapists. It seems more likely to me that they will form a component of therapy - for example, for use if the patient has to wait for treatment - but that there will still be a need for the therapist to see the patient.

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