What's wrong with CBT?
I am sometimes approached by people who want quick fixes. This is totally understandable. Unbearable suffering needs an urgent response. But many modern therapy approaches simply shuffle the decks, without going deeper. So the suffering reappears in a new guise. If you go to your GP, you're likely to be referred to a CBT therapist who will see you for upto six sessions. This may offer some relief, but it's such a short time! The first few sessions are often just about getting familiar with the setting and the the therapist and other niceties. As soon as you get talking, it's time to hold back, because you know the last session is approaching and forms will need to be filled out. It's a difficult position for both therapist and patient. Just as things are starting, you have to stop. Over summer, I often re-read articles that have struck me as thought-provoking. The psychoanalyst Darian Leader's reservations about CBT and market-led approaches is worth reading...(Guardian, 2008)
A quick fix for the soul
The government is promoting cognitive behavioural therapy as a cost-effective, no-nonsense remedy for our psychological ills. It's the triumph of a market-driven view of the human psyche, says Darian Leader
Awoman convinced that she emits an unpleasant smell is persuaded to travel around o
A woman convinced that she emits an unpleasant smell is persuaded to travel around on public transport with a portion of fish and chips to monitor how people react to her. This will allow her to assess the "evidence": she will realise that there is a difference between times when she is the bearer of a strong smell and when she is not, and this will help her to "correct" her beliefs.
This will allow her to assess the "evidence": she will realise that there is a difference between times when she is the bearer of a strong smell and when she is not, and this will help her to "correct" her beliefs.
Welcome to the world of cognitive behavioural therapy (CBT), which has enjoyed a massive expansion over the past 10 years, not only in Britain but in much of the west. Where once a diversity of therapies flourished, today CBT is progressively replacing the older treatments. It's cheap, it shows results on paper and it chimes with a commonsense, problem-solving view of the world.
Developed by the American psychiatrist Aaron Beck in the 1960s, CBT was based on the idea that our emotions and moods were influenced by our patterns of thinking. The aim of therapy was to "correct" these processes, "to think and act more realistically". It would allow the patient to avoid the misconstruction of reality that had led to their problems.
Rather than focus on the patient's history - say their childhood and early experiences - like most other psychotherapies, CBT is mostly directed to the here and now. Patient and therapist agree on targets and formulate ways to achieve these in each session. Patterns of negative thinking are pinpointed and alternatives discussed. Homework is set at the end of each session, which might include self-monitoring, record-keeping and other tools of self-inspection.
After her strange sojourn on the tube, the woman with the fish and chips would meet her therapist and discuss the events of the day. If she realised that people in fact reacted to her less when she didn't have the malodorous meal, then she might be able to change her thought pattern, to see her life in a more positive way. She would learn that her symptom was an incorrect interpretation of reality and hopefully come to see the world as everyone else does.
But why did she suffer from this olfactory symptom in the first place? What function did it have in her life? If she was certain about it, what role did certainty play for her? Could it have been a solution to some other, less obvious problem? And if so, what would be the consequences of trying to remove it?
Most therapies aim to hear what is being expressed in a symptom: not to stifle it, but to give it a voice and to see what function it has for the individual. CBT, by contrast, aims to remove symptoms.
The popularity of CBT with government agencies is no surprise. This year has seen the launch of Improving Access to Psychological Therapies (IAPT), an initiative to train a "workforce" of mostly cognitive therapists to cure the nation's anxious and depressed inhabitants. Lord Layard, the so-called happiness tsar and one of the architects of this new project, is delighted. At last, everyone will have access to proven treatments that have the right scientific credentials. And we will save a lot of money into the bargain. Depression and anxiety cost the economy around £12bn a year - 1% of the total national income - yet the new therapies will be able to cure people for only £750 a head. The saving on drugs bills and incapacity benefits is staggering.
But what might the real costs of this initiative be? And what does the rise of CBT tell us about the world we live in today? The government also plans to regulate mediums and spiritualists. It will no longer be up to us to believe in them or not, but a higher power will tell us who is legitimate and who is not. Just as a new rhetoric of "science" tells us that CBT is the best treatment, so it will arbitrate the "other side" - and all government has to do is back up science with legislation.
These are extraordinary developments in our times. And they highlight a strange paradox of the modern self. We are told that we are responsible for our own lives, that we have the power to transform ourselves. Yet at the same time we are treated as minors who lack the faculty of critical judgment and must be protected against unscrupulous and dangerous predators.
Today it is plasticity and change that govern our self-image. Personality itself is represented as a set of skills that we can learn and modify. Just as we can alter our bodies through cosmetic surgery, so we can change our behaviour through "work" on ourselves. Reality TV displays princes who become paupers, children who swap parents and geeks who become Don Juans. The possibilities of transformation seem endless. Thatcher's dream of social mobility has become not just nightly entertainment, but also individual imperative.
CBT promises change just as swiftly. Unwanted character traits or symptoms are no longer seen as a clue to some inner truth, but simply as disturbances to our ideal image that can be excised. Instead of seeing a bout of depression or an anxiety attack as a sign of unconscious processes that need to be carefully elicited and voiced, they become aspects of behaviour to be removed.
The market has triumphed here, as our inner worlds become a space for buying and selling. We pay experts such as life coaches to teach us how to change in the desired way. Aspects of ourselves, such as shyness or confidence, become commodities that we can pay to lose or amplify. Depression or anxiety are seen as isolated problems that can be locally targeted without calling into question the rest of one's existence, in the same way that a missile attack on a terrorist installation is supposed to get rid of the problem posed by terrorism.
This is a modern self for which depth has become surface. In soaps and reality shows characters share their innermost feelings and emotions, as if there were a perfect continuity between interior and exterior life. If there's any ambiguity, a panel of experts is there, as on Big Brother, to explain people's motivations. The self is no longer a dark cave; everything is laid bare. In effect, we have been robbed of our interior lives.
Many social theorists have seen this atomisation as a consequence of market-led economies. As the market governs all, it was only a matter of time before basic human attributes would come to be taken as commodities and relationships as transactions. Students became clients of educational services, children clients of their parents. And it was no surprise that the view of human beings as subjects competing in the marketplace for goods and services would need a psychology to underpin it.
This new psychology broke radically from traditional ideas. The self had once been understood as a place of conflict: between reason and passion, between the will and understanding, between repressed desires and their inhibition. But, as Nikolas Rose observed in his study Governing the Soul, the self is now no longer intrinsically fractured, it just needs to "actualise" itself.
The divided self dear to the 60s has vanished, along with the recognition that grief, despair and frustration strike at the heart of our image of self-possession and fulfilment. The psyche has become like a muscle that needs to be developed and trained. There is no place for complexity and contradiction here: the modern subject is represented as one-dimensional, searching for fulfilment. The possibility that human life is aimed at both success and failure and never simply at wealth, power or happiness no longer makes sense. Suddenly the world of human relations described by novelists, poets and playwrights for the past few centuries can just be written off. Self-sabotage, masochism and despair are now faults to be corrected, rather than forming the very core of the self.
The new psychology is thus in the service of the market. Symptoms become understood as deviations, pieces of learned conduct that can be undone by short courses in re-education. This is the soil in which CBT came to flourish. Its textbooks refer unashamedly to "belief modification" and to "selling the treatment" to the patient. It follows a market-led vision of the psyche in which a symptom, for example depression or insomnia, is not seen as a general problem in a person's existence - which, if unravelled, might lead to the unravelling of the self - but as a local disturbance that can be managed and put right.
This commodification of the psyche is reflected in the change in mental health diagnoses. In the early 20th century, there were between a dozen and two dozen discrete diagnostic categories - breaking down different aspects of mental health. By the early 90s there were more than 360. Easily observable surface symptoms, such as shyness, have been taken to define disorders. Many of these have been developed and advertised by drug companies in order to carve out market niches for new drugs. Social phobia, for example, was sold as a diagnosis by the makers of a drug - moclobemide - that claimed to cure it.
The new focus on surface behaviour makes cognitive-style therapies seem more scientific. As Ian Parker, professor of psychology at Manchester Metropolitan University, observes, if a disorder is defined by symptoms, get rid of the symptoms and you've got rid of the disorder. The therapist carries out a more or less mechanical procedure, a series of protocols formulated in advance, which have been approved by management and checked by inspectorate. On paper it looks good: symptoms appear reduced. But there is no tracking of so-called "alternative symptoms", the problems that will emerge in mind or body when the original symptom is removed. A woman troubled by a dog phobia may be able to overcome this with a behavioural treatment, but what of her relationship with her father, a concentration camp survivor who became terrified of German shepherds after the war? If her symptom articulated a certain identification with his anxiety, how would this find expression once she was deprived of the phobia?
These important complexities have little place in a society where depth has become surface. What matters are quick-fix cosmetic solutions, rubber-stamped by so-called experts. Where articles and books once used to develop concepts and ideas, today the expression "Research shows ..." encourages us to stop thinking. Not long ago the media excitedly carried the "news" that research had shown that depressed fathers had an effect on the wellbeing of their children. Well, who would seriously have thought otherwise? Was it really necessary to have a government grant to show this? And in fact, the methodology in most of these studies is deeply flawed.
This is a world in which nothing counts as knowledge unless it is sanctioned by experts. Advice on baby-rearing or nutrition may seem sensible, but can there really be a correct way to conduct a relationship, to fall in love or to maintain beliefs? Knowledge has become almost synonymous with a product: any new idea or discovery has to demonstrate how it can be practically put to use - which means sold. Researchers have to specify the "outcomes" they seek and how these will be beneficial. Even a public sculpture project has to explain what use each detail will have.
In today's outcome-obsessed society, people must become countable, quantifiable, transparent. And this leads to a grotesque new misunderstanding of psychotherapy. Therapy is now conceived as a set of techniques that can be applied to a human being. This makes sense if we see it as a business transaction with a buyer, a seller and a product. But it totally ignores the most basic fact: that therapy is not like a plaster that can be applied to a wound, but is a property of a human relationship. Therapy is about the encounter of two people, and the real work is done not by the therapist but by the patient. As the psychoanalyst Donald Winnicott observed, the therapist provides a space in which the patient can construct and create something. The therapist encourages and facilitates, but whether a therapy takes place or not depends entirely on the patient.
Unlike CBT, traditional therapies do not aim to give access to a common, scientific reality but to take the patient's own reality seriously: to explore it, to define it, to elaborate it and to see where it will go. No outcome can be predicted in advance: the patient may go back to work but equally they may give up a well-paid job to pursue another path.
Therapies such as CBT, which claim to deliver a product, can certainly be helpful for some people. But it is crucial to distinguish the question of whether a therapy works and how it works. For any therapy to get started, unconscious belief systems need to be mobilised. Human belief is a very powerful thing and no external authority can tell us what to believe in, although the persecution of religion groups shows that this is hardly self-evident.
Lord Layard stunned therapists earlier this year with the following vignette: "The most striking experience I've had in the last few years was when the chief executive of a mental health trust ... said his life had been saved by CBT ... He said he is a fully fledged bipolar case but he has not had a day off work for the last 15 years. He has a little book, which he carries around and whenever he has funny thoughts coming into his mind, he turns to the relevant page, according to what kind of thought it is or if he has a mood attack, and he does exactly what it says on the page. Now, you could say that's mechanical. I say that it's brilliant and not so different, you know, from what Jesus or any other great healer did for people."
Mao would perhaps have liked this story, and hoped that the little book was his own. And indeed, cognitive therapy was perhaps used most widely in the Cultural Revolution in China, where people were taught that depression was just wrong thinking. Separated from their families, unable to contact loved ones, subject to cruel punishments and witness to the murder or "vanishing" of those closest to them, millions of people were "taught" to devalue their reactions. The world should be thought about in a different way, and happiness and enthusiasm replace despair and despondency. Positive thinking should banish unhelpful negative attitudes.
This denial of the legitimacy of people's symptoms may have dangerous consequences. Diverting psychological processes from proper working through can result in both new symptoms and acts of violence. CBT's effort to ignore the effects of an individual's history in favour of a shallow analysis of the here and now sets a bleak example to those who believe that if the 20th century had any lesson, it was precisely not to deny the significance of human history and memory.