2014年经济学人 精神疗法 垂死挣扎（在线收听）

Psychotherapy

Expanding the shrinks

The popularity of CBT is freezing out more traditional forms of therapy

THE unexamined life may not be worth living, but the overexamined life can be difficult, too. Many people are turning to a relatively young branch of “talking therapy”, called Cognitive Behavioural Therapy (CBT) to get them through the (day and) night. CBT, which teaches people to bypass unhelpful thoughts, has been elbowing aside the talk-about-your-childhood psychoanalysis favoured by believers in Freud and Jung. Up to 43% of all therapy courses in Britain are now CBT, and the practice is increasing: around 6,000 new therapists have been trained since 2007 and CBT absorbs much public funding. In 2012, 213m went on a National Health Service programme delivering CBT, while 172m was spent on all other forms of psychoanalysis and psychotherapy.

The growing popularity of CBT was consolidated in 2007, when the government adopted the treatment as standard. Three things had swayed it. The newish practice had accumulated a body of evidence proving it worked (students of Freud and Jung have been slower to move from couch to lab). It was very good at getting patients back to the office: a 1997 study found people with psychological problems had significantly higher employment rates after CBT than after traditional psychoanalysis. It was also speedy, getting results after just ten one-hour sessions (psychoanalysis can, expensively, take a lifetime). So CBT therapists were trained up and given all the plum NHS jobs, consigning other therapies largely to private practice.

As a result couch-based psychotherapy, once dominant, now caters mostly to the rich—an hour's session costs between 50 ($80) and 500—and is geographically skewed: there are more psychoanalysts in NW3, a posh London postcode, says Phillip Hodson, a fellow of the British Association for Counselling and Psychotherapy, than in the counties of Devon and Somerset combined. CBT therapists, via GP referrals and hospital departments, can now reach anyone nationwide for free. Private practice psychoanalysis is also set to struggle as evidence-based results and regulation become more important. In 2007 non-NHS therapists resisted a proposed regulatory body, claiming it would squash creativity—a mistake in a profession so easily infiltrated by quacks.

Meanwhile the CBT boost has expanded the British therapy industry: since 2007, spending on psychotherapy has moved from 3% to 7% of Britain's mental health budget-the difference mostly spent on CBT. In shrink-happy America, by contrast, the psychotherapy industry is declining. In 1998, 15.9% of America's depression and anxiety cases were referred to therapists. In 2007 that was down to 10.5%. The British therapy boom is also a triumph for consumer choice: a recent survey showed patients preferred therapy to medication by a ratio of three to one.

Peter Fogarty of University College, London argues that CBT has entered a virtuous circle: money pours into research, evidence accumulates, more financial support is given to the newly credible treatment and other forms of psychotherapy are excluded. Even if they are not, the complexity of the NHS means it may be hard to switch gears. Policymakers will not be keen to disentangle CBT from the vast NHS machinery, nor to write off years spent training new therapists.

CBT is no panacea, and psychoanalysis has been shown to be better in treating illnesses like eating disorders. It is finally launching studies to measure its effectiveness in an effort to regain some ground. Either way, it appears the stereotype of the buttoned-up Brit, unwilling to delve into his or her subconscious, may be eroding.