The National Institute for Clinical Excellence provides guidelines for good practice in all health care based on systematic reviews of randomised controlled trials. In the world of mental health some therapies have been very on the ball with outcome measures and lend themselves well to being developed into treatment protocols for specific sets of problems, or diagnoses. CBT is one of these, which is why CBT is still the main therapy on the menu in the NHS. CBT does not have to be delivered in protocol fashion, but to be NICE Guideline compliant it does.

How are NICE guidelines established?

The Cochrane collaboration does systematic reviews of randomised controlled trials of treatments for all types of illnesses and conditions, and these are used to inform NICE Guidelines.

Let’s look at CBT for GAD

This is still looking promising. So let’s look at an example, a very common mental health problem, that of Generalised Anxiety Disorder, often referred to as GAD by those in the know. 

Here is some of what the Cochrane review has to say:

 “….The review showed that people attending for psychological therapy based on a CBT approach were more likely to have reduced anxiety at the end of treatment than people who received treatment as usual or were on a waiting list for therapy. CBT was also very effective in reducing secondary symptoms of worry and depression….. None of the studies comparing CBT with treatment as usual or waiting list looked at the long-term effectiveness of CBT. It is not clear whether people attending for CBT sessions were more likely to have reduced anxiety than people attending for psychodynamic therapy or supportive therapy, because only one study compared CBT with psychodynamic therapy, and the six studies that compared CBT with supportive therapy showed differing results. ….More studies should be carried out to establish whether psychodynamic and supportive therapies are effective for GAD, and whether CBT is more helpful than other psychological therapy approaches in treating GAD.”

NICE pathway for GAD

This, and a review of applied relaxation training for GAD, has been used to issue the NICE guideline care pathway which says that people with GAD should be offered CBT or applied relaxation. It also says that if it is CBT that is offered it should be based on the treatment manuals used in the clinical trials of CBT for GAD. We can see the problem here can’t we? The research does not actually tell us that CBT is better than other therapies and further research is recommended to establish this. Even if CBT does trump other therapies, this will be based on a significant percentage of people making a significant recovery with the use of CBT, and this being more than with other therapies. For instance, 60% of people receiving CBT making a 60% recovery. In this example, which is not an unrealistic example, we would still be left with 40% of the sample not benefiting from CBT. So what can we offer these people?


Here NICE guidelines fall short. NICE guidelines are recommending what they are calling evidence based practice, but what about practice based evidence? This is where therapists adapt their therapy in creative ways to suit their client and the particular issues their clients are bringing. This then becomes of interest and can get tested with randomised controlled trials, potentially bringing us back to the Cochrane review loop. Additionally, and importantly, there are good therapists who are working in this way, with good supervision, who are being creative and flexible in their approach to helping their clients.

CBT based therapies helpful for GAD

I should say here that as a CBT therapist I am not arguing against CBT, rather in favour of fairness and reason. As it happens, in my experience a CBT based approach probably is best suited to helping people with GAD, but with other problem areas a psychodynamic, cognitive analytic or counselling approach may be equally or more effective. In this example of GAD - often CBT itself is helpful, but many therapists and their clients are noticing that people with GAD (especially if they are asking for help for a second time and have already done CBT) are finding Mindfulness Based Cognitive Therapy helpful. Keep it to yourself though as it is not what is recommended by NICE!