Decades of debate about the relative merits of counselling and cognitive behavioural therapy (CBT) means winners and losers in the NHS. CBT is now the therapy of choice for dealing with high rates of depression and anxiety in the UK despite research showing that there is little difference between the two when it comes to psychological improvement.

A research team led by Jo Pybis has now discovered that it is in fact the quality of service (and implicitly quality of therapist) that influences client outcomes. To test the quality of treatment and care received by people seeking psychological therapy services in England and Wales, Pybis and her colleagues explored data from all patients discharged from adult psychological therapy services in England and Wales between 1 st July and 31 st October 2012.

Writing in BMC Psychiatry, the researchers were interested in the 33,243 patients (23, 595 CBT and 9,648 counselling) being treated at 103 different sites, of whom 66% were female and 83.7% white British. A primary presenting problem was recorded for 21,105 of those patients, with the main categories being; depressive episode (15.8%), anxiety and depression (15.7%), and Generalised Anxiety Disorder (7.1%).

Amongst the 50.1% of patients who reliably improved on the Patient Health Questionnaire-9, 50.4% of these were CBT patients and 49.6% counselling patients. Surprisingly for the researchers while overall the two approaches may be comparable, counselling had higher recovery rates between 2 and 7 sessions, while for 8 or more sessions CBT had higher rates.

In addition, there is significant variability between sites with the mean recovery rates for the top and bottom 15% of sites being 59% and 43% respectively. What might this mean? The researchers suggest that; “[…] if the 16 less effective sites had outcomes similar to average sites, then a further 364 patients would have recovered across those sites in a 4-month time period”.

Maintaining CBT as the predominant front-line psychological intervention is therefore unconvincing and as Pybis’ team observe, any debate over the relative superiority of CBT and counselling now needs to move towards “more comprehensive understanding of the factors that contribute to some services-and therapists-yielding more effective patient outcomes than others and, more importantly, understanding why some sites are yielding less effective patient outcomes”.

Pybis, J., Saxon, D., Hill, A., & Barkham, M. (2017). The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: evidence from the 2nd UK National Audit of psychological therapies. BMC Psychiatry, 171-13. doi:10.1186/s12888-017- 1370-7