The definitive text What Works for Whom? by Anthony Roth and Peter Fonagy (£22.95, Guildford Press) critically reviews all the scientific evidence up to 1996. It shows that the vast majority of research is not nearly rigorous enough to provide clear answers as to which kind of therapy is best for depression.
The two main contenders are Cognitive Behavioural Therapy (CBT) and Psychodynamic Therapy (PT). CBT is the modern descendant of the behaviourist tradition started by BF Skinner. His Great Psychological Idea, which frankly seems bonkers today, was that we should forget about what we cannot see - thoughts or feelings - and only study what we can: behaviour. This can be productive in analysing animal psychology, but it results in a moronic account of humans. It's a bit like having a theory of painting in which only the size and shape of the canvases can be considered, never the pictures.
In the 80s, psychologists began to reintroduce thought as worthy of consideration. Increasingly, CBT practitioners are taking emotions and relationships into consideration. But CBTists are still over-liable to see thoughts as causing feelings, and to flatly refuse to attend at all to the childhood causes of depression. This can lead to superficial therapy which can seem risibly simplistic, especially to educated patients. To many depressed people, for example, being taught tricks for consciously eradicating negative, self-attacking ideas may bring a temporary relief, but it does not take long for the depression to reassert itself.
PT suffers from almost diametrically opposite faults. There can be too much emphasis on emotion-causing thought (eg, 'You feel low therefore you criticise yourself irrationally'). The patient's relationship to the therapist can be overexamined at the expense of direct scrutiny of the way parents created depressed feelings and thoughts in early childhood. Above all, PT often refuses to engage with practical steps for escaping depression.
Whereas the CBTist will engage with the practical mental steps necessary for change, the PTist all too frequently refuses to be drawn. If the depressed person is having trouble holding down a job or a relationship, the PTist effectively refuses to help, claiming their sole focus must be on 'deeper' matters.
The good news is that both sides are slowly taking on board the other's strong points, most impressively in Cognitive Analytic Therapy (Cat). Explicitly nicking the best bits from both, it is limited to 16 once-weekly sessions. The first four address the patient's childhood experiences; the last 12 put this knowledge to work in focusing on a problem. This includes the use of diagrams for typical patterns of thought and feeling.
I strongly recommend Cat, whether for hardened escapees from PT or CBT, or for first-timers. It is available on the NHS from the Munro Centre, Guy's Hospital, London (020 7378 3200) - which will send you a list of private practitioners or places that provide it outside London. If Cat does not sort you out, I advise good PT. The problem here is how to find it - next week's subject.
· Oliver James is unable to enter into any personal correspondence.