Are we asking the wrong question?
Our interest at Reach as to whether talking therapies are sufficient to meet the needs of clients has been in part fuelled by the on-going debate concerning the efficacy of different counselling/psychotherapeutic models and interventions. The rapid rise in cognitive-behavioural therapies has generated greater scrutiny concerning the effectiveness of other psychological approaches. This debate continues to be contested with vigour and some degree of tension between the opposing points of view.
Researchers – mainly from CBT backgrounds – argue that CBT is more effective for certain forms of psychological distress.1,2 On the other hand there are those researchers – generally from non-CBT backgrounds – who argue that the different therapies are about equal in their overall efficacy.3,4 Their argument is that other factors, such as the quality of the therapeutic relationship, are what really make the difference to therapeutic outcomes. And so the question, ‘does orientation really matter?’ continues to be examined but there still appears to be no consensus.
Presently, the amount of research generated by the interest in CBT and other psychological interventions that have emerged out of the CBT tradition, has pushed this modality much more into the ‘psyche’ of health organisations like the NHS, the media and the general public. As a result, programmes such as IAPT (Improving Access to Psychological Therapies) which began in 2007 have subsequently rapidly developed across the UK, as these programmes have been seen by the government as a more effective response to the growing concerns around mental health. However, for balance and perspective it is worth underlining, as Professor Mick Cooper states, that ‘quantity of evidence’ should not be equated to ‘evidence of superiority’5 – because as indicated earlier a number of studies have compared CBT directly with other therapies and have generally found them to be equivalent in efficacy.6
So, is the psychotherapeutic profession in fact focusing on the wrong question? We believe it is.
If we assume, as the evidence suggests, that therapeutic interventions, whatever their orientation, are generally equally effective – although some modalities may be marginally better than others for specific conditions7 – could it be that all the traditions are missing something, due to their predominant concern with the psychological dimension of the client/patient?
Reach was initially built on over ten years of client research (1979-1990) and it was that data that influenced our philosophy and approach. Our clinical experience spans more than thirty-five years and what we have learned in that time is that the client is always more than what s/he ‘presents with’ – ignoring the other ‘data’ that s/he brings into the room we believe is counter-intuitive to achieving the best outcomes. And so we began, as a group of therapists, to look outside of the generally accepted parameters of psychological enquiry, for other solutions, which would better meet the varied needs of clients.
Our backgrounds and training as nutritionists (as well as psychotherapists) were in part responsible for our thinking, because we’d experienced the power of nutrition/supplementation as a healing modality in its own right through our work. So it seemed logical to us that using those two disciplines (counselling/psychotherapy and nutrition) in tandem, in the best interests of the client, would produce better results than either of them by itself.
When asking the question is ‘enough’ being done therapeutically to meet the needs of the client, we also discovered a number of other fields of enquiry, which are starting to make a valuable contribution to this debate.
What are those other disciplines?
We appear to be at an interesting crossroads with regards to our understanding of the human condition. A variety of relatively new sciences offer some fascinating data, linking previously unconnected factors. The main contributors are: epigenetics, orthomolecular medicine, pyschoneuroimmunology (PNI) and cognitive neuroscience.
Epigenetics has helped us to understand that emotions actually have molecular consequences. That is to say that all emotions, from sadness to joy, from anxiety to bliss and from fear to love give rise to corresponding molecules (neurotransmitters and hormones). These molecules are generally produced in the brain and they affect both the way we feel and our physical bodies. Candace Pert’s research in the 1970s and 1980s led to her groundbreaking book Molecules of Emotion8, which acted as a powerful catalyst for subsequent research in this field. As a consequence of her discoveries and of the work of other neuroscientists, a ‘map of consciousness’ resulting from the brain’s activities is slowly being constructed.9
Orthomolecular medicine has been developing since the late 1950s. Its early pioneers (Dr. Linus Pauling, Dr. Abram Hoffer and Dr. Carl Pfeiffer) were scientists and psychiatrists who began to develop the idea that mental ill health was exacerbated and may even in some instances be triggered by poor nutrition. The extensive research they carried out led to a branch of medicine and psychiatry that actively uses diet and supplementation to treat a range of mental health issues such as bipolar disorder, schizophrenia, anxiety and depression – with some impressive results.10
Gomez-Pinilla, a professor in Integrative Biology and Physiology at UCLA Medical School, explains in his 2008 paper how dietary factors impact on neuronal function and synaptic plasticity (the brain’s ability to change and remodel itself). His research has revealed some of the vital mechanisms responsible for the action of diet on brain health and mental function. For example, several gut hormones have been discovered to enter the brain and influence cognitive ability. Understanding the molecular basis of the effects of food on cognition is unquestionably helping us to determine how best to use diet as a resource in order to increase the resistance of neurons to the numerous biological challenges they face and to promote mental fitness.11
Psychoneuroimmunology (PNI) has developed rapidly over the last 35 years and has gained respectability particularly in the fields of oncology and immunology. In essence, this discipline has been able to demonstrate that our thoughts and/or moods impact directly on the central nervous system, which in turn affects immune function.12
Its implications for how both psychology and medicine might develop are substantial, as the mind-body connection is increasingly well understood. A good example of this is The Psychobiology Group (a group of neuroscientists in the UK), Directed by Professor Andrew Steptoe, which is currently looking at how factors like socio-economic status, social isolation, hostility and work stress all influence biological functions in terms of health and disease.
Cognitive neuroscience is helping us to understand how the brain works and how its relationship with thoughts and feelings and their biochemical consequences shape the way we perceive and experience the world. An interesting development is that research in this field also supports the validity of neuroplasticity, which we referred to in the section on orthomolecular medicine. Here too, it has been discovered that the brain is not a static system and that it is affected by its experiences: the environment, food and nutrition appear to be key components in this relationship, but there are other factors such as nurture, attachment and stress which are also shown to impact significantly on the evolution of the brain and as a consequence alter our experience of the world.13,14
These disciplines are helping us to understand the interconnectedness of the human condition. Their findings suggest that compartmentalizing the human experience and ‘treating’ the presenting problems without consulting the many factors that make up the whole and impact on wellbeing could indeed be counterproductive to the healing process. We think that this accruing data justifies our attention and demands further exploration by the psychotherapeutic community.
The role of the environment
The research that we have undertaken clearly indicates that just as the psychological aspect of being human cannot be divorced from the biological reality, equally, neither of these dimensions can flourish whilst the planet is suffering. This would be like expecting crops to deliver an abundant harvest, when the soil is starved of the micronutrients essential for a rich yield.
This analogy is highly relevant to this discussion because soil erosion is considered one of the most serious environmental and public health problems facing humankind.15 Deficiencies in the soil, created by soil erosion and other environmental factors are clearly impacting on the nutritional status of the food that we are eating, which is directly affecting our brain function and as a consequence our mental health. And so, if we are to manage and treat psychological problems effectively, a theoretical and practical framework that understands and integrates the intimate relationship between the planet and the needs of the brain, body and mind is essential.
Findings released at the 1992 Rio Earth Summit confirm that the mineral depletion of our global topsoil reserve is critical. At the time, it was reported that U.S. and Canadian agricultural soils had lost 85% of their mineral content. Asian and South American soils were down 76% while throughout Africa, Europe and Australia soils were depleted by 74%, 72% and 55% respectively.16 This mineral depletion of our topsoil continues in the 21st century.
Added to the diminishing quality of the soil, which is reflected in the inconsistency of minerals and vitamins found in our fruits and vegetables, there is also the contentious debate surrounding ‘acid rain’, which, it is claimed, is altering the pH in the soil. Some researchers and health professionals suggest that this has dire consequences for health given that the pH of the body is considered by many to be the ‘regulatory authority’ that controls most cellular processes – the pH balance of the human bloodstream being accepted as one of the most important biochemical markers in human chemistry.17
In March 2006, the United Nations recognized a new kind of malnutrition – multiple micronutrient depletion. According to Catherine Bertini, Chair of the UN Standing Committee on Nutrition, the overweight are just as malnourished as the starving. In other words, it is not the quantity of food that is at issue – it is the quality.
If we are indeed altering the ecosystem as the research suggests, through lack of replenishment of our soils, as well as through over-farming, pollution, deforestation, global warming, and the contamination of water, then clearly anything that can offer some compensation for the impact this is having on physical and psychological health needs to be taken seriously. It appears that supplementation, although not a panacea, may well be a useful intervention, and should at least be part of any mental health strategy we implement.18
In our work, we have seen that when you address the person as a whole (and diet and nutrition as a critical part of that process) the outcome of therapy is greatly enhanced. This is because clients are empowered not just by the relationship and the merits of the therapeutic process, but also by the power of nutrition, which we have found encourages the individual to take responsibility for the other areas of their health and wellbeing.
This is why we devised, in 1990, ‘The Story of Health’, which has become the centrepiece of our model.19For those of you interested in finding out more about this unique, holistic approach to human health, please visit www.thereachapproach.co.uk.
A way forward
So, in summary, what these ‘new’ sciences and a review of the literature are highlighting is that there is clearly a relationship between human health and the environment. There is a growing consensus that climatic changes are indeed affecting the balance of the planet and its ability to keep meeting our needs, as demonstrated by the erosion of the soil, with the subsequent depletion of vital minerals and other nutrients; this is a serious cause for concern. These deficiencies make us more prone to mental imbalance, leading to greater stress, anxiety, depression and general physiological malaise.
Cognitive neuroscience and orthomolecular medicine have helped us to better understand that any depletion of nutrients undermines neurotransmitter production and brain development and as a consequence our emotional and psychological realities are negatively affected.
PNI and epigenetics have helped us to appreciate how the environment can impact negatively on our biology and psychology and cause us to be unable to respond creatively and constructively to life’s challenges. This is why we believe we increasingly need to look for ways to incorporate ‘mind-body awareness’ into our therapeutic approaches, in order to enhance the effectiveness of talking therapies.
It’s not sufficient, in our view, to tag these concepts and findings onto what we’re currently doing. They need to be considered an integral part of the models we’re working with.
So what might the future look like?
i) No matter how good our existing therapeutic models are we need to recognize that there are some clients and some issues that cannot be effectively addressed by talking alone.
For example, it is well documented that deficiencies in vitamin B6 and B3 are implicated in a range of mental health conditions, from depression to schizophrenia. A deficiency in essential fatty acids has also been shown to impact on brain function and is implicated in ADHD, Alzheimer’s and anxiety etc. 20
Another example of the mind-body dynamic is evidenced in how stress impacts on the immune system. The natural killer cells, which protect us from the environment/pathogens, are compromised under stressful conditions and given the interdependency of mind and body, when the immune system is weakened our mental health is also diminished.
So it is clear in these examples that talking alone is unlikely to provide an adequate response and that a more holistic approach, embracing the mind-body dynamic, is required.
ii) We believe that therapists need to actively increase their knowledge in the mind-body field by doing the necessary reading and research on these subjects and attending appropriate workshops, seminars and courses, to deepen their understanding in this area and then seek ways to integrate these findings into their work.
There are a lot of very good materials and resources that would help in developing new strategies and approaches. The excellent report Feeding Minds by the Mental Health Foundation (2006) is a very good example of the kind of integration we believe is required. Given the current data and knowledge available to us, our existing training programmes need to reflect these scientific developments, from introductory courses up to post-graduate level.
iii) If we are to progress along this path we need to actively form alliances with those who are leading the field in nutrition, PNI, cognitive neuroscience and orthomolecular medicine. There are numerous institutes and associations doing good research and offering training in these areas and psychotherapeutic organizations/associations could be drawing from that reservoir of knowledge and experience; this would help shape the on-going research in counselling and psychotherapy and influence policy, strategy and training to further ensure best practice.
Some examples of these organizations are: British Association for Applied Nutrition and Nutritional Therapy; Psychoneuroimmunology Research Society; British Association for Cognitive Neuroscience; Institute for Optimum Nutrition. This is not in any way a definitive list.
iv) Arguably the biggest change required for talking therapy traditions is to adapt their therapeutic models. Whatever their orientation, all models need to better reflect the reality that the mind is being continually affected by its environment. Understanding this relationship is much more likely to enable us to better help our clients.
We began by asking ‘Are talking therapies sufficient to meet our emotional and psychological needs?’ but perhaps the question we now need to ask is, “How can the numerous discoveries, which are increasingly recognised as having a significant impact on mental health, be pulled together and combined within existing psychotherapeutic interventions?”
Change in these areas may well take time and involve much discussion if we are to honour the broad church of counselling, psychology and psychotherapy with its many traditions. However, that should not deter us from what we believe is an essential undertaking.
We leave you with Plato’s words on this subject…
“The cure of a part should not be attempted without the treatment of a whole.
No attempt should aim to cure the body without the soul. If the head and body are to be healed, then you must begin by curing the mind – that is the first thing. Let no one persuade you to cure the head (the body) until they have first given you their soul to be cured, for this is the great error of our day in the treatment of the human body – that the physicians first separate the soul from the body.”
Plato (428 BC – 347 BC)
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