I found an interesting show on Radio 4’s website this morning, called All In The Mind, which is a weekly programme on psychology presented by Claudia Hammond. I guess it’s the most mainstream regular show on psychology in the UK media.
Anyway, the show I listened to was on CBT, and looked at the roll-out of the Improved Access for Psychological Therapies (IAPT) programme, in which the British government is spending £300mn to train “an army of more than 3000 therapists in CBT”. This is “the biggest investment in talking therapies that there’s ever been”, as Hammond put it.
On the show, Hammond got two experts to debate whether the IAPT is a good idea – supporting IAPT was David Clark, from the Institute of Psychiatry at King’s College, who is the main organiser of the programme; and the sceptic was John Marzillier, clinical psychologist at Oxford University.
Marzillier’s main criticisms of IAPT were:
(1) CBT is too focused on techniques, rather than on engaging with and treating the whole person. This is a variant of the criticism that CBT is too ‘gimmicky’, and doesn’t delve into the deeper levels of the unconscious like other psychotherapeutic treatments.
(2) Because it is short-term, and teaches techniques, CBT loses the emphasis on the psychotherapeutic relationship that other forms of therapy have. And this is what patients most appreciate. This is particularly true of the ‘low intensity practitioners’ being trained by IAPT, who will only give short, eight-week treatments.
(3) CBT has all the ‘evidence’ supporting it mainly because it makes overly-rigid DSM-type classifications of illnesses, saying ‘this person has social anxiety’, for example, then testing them to see if they still have it after two months. It’s symptom-focused, rather than approaching the whole person, like other psychotherapies.
I want to respond to these points.
(1) Yes, CBT teaches techniques of self-management. This is exactly what ancient philosophy, from which CBT evolved, taught its students. Ancient philosophy was less a rigid system of belief (like, say, psychoanalysis), and more a set of practices, exercises, and techniques designed to counter specific emotional problems. Read Pierre Hadot’s excellent essay, Spiritual Exercises and Ancient Philosophy, for the classic introduction to this topic.
Stoicism, for example, which is the principle inspiration for CBT, taught its students to track their mental habits using a ‘thought journal’ (as CBT does), to train their attention to the present moment (as CBT does), to memorise short ‘power statements’ that come to mind automatically in situations (as CBT does), and to go out and test their new beliefs in real-life situations (as CBT does).
The advantage of this flexible, technique-led approach is that it isn’t one-size-fits-all. Some techniques will be more useful for some people, others will work better for others. Different techniques will be useful at different times. It is not dogmatic or faith-driven – it doesn’t demand that you accept the entire unwieldy edifice of orthodox psychoanalytic theory in order to get better. If this is ‘gimmicky’, then it is no more gimmicky than Buddhism, for example.
(2) Yes, CBT, like Stoicism, is more about learning how to manage yourself, rather than learning to depend on someone else (priest, parent, therapist) for your self-worth. Both CBT and Stoicism still emphasize the importance of the teacher / philosopher / therapist, who like Socrates would awaken you to your own thoughts, and your own responsibility for them. But the crucial step to health is taking responsibility for your own thoughts, and no one can do that but you.
By insisting on the inescapable mediating role of the psychoanalyst in patients’ return to health, psychoanalysis is creating a priest class, and saying the only way for the unhappy or mentally ill to return to health is through them, through the Church of Psychoanalysis. This is self-serving, false and pernicious.
Stoicism and CBT are about learning to take back to yourself the power that you have given away to externals. It is about not looking to those outside of you for affirmation – including over-paid avuncular therapists. So CBT champions a DIY, self-help culture, which I support, rather than promoting a mediating, even parasitic, priest caste.
However, that’s not to say you are completely on your own. While your CBT course might be relatively brief, the culture of Stoicism and CBT is rich, and involves really a lifetime of study. Stoics didn’t study Stoicism for eight weeks. They studied and practiced it their whole lives, and constantly talked to and compared notes with other practitioners, as well as studying with various teachers. But they hardly ever had gurus who they worshipped and obeyed absolutely – unlike Christianity and Buddhism, and unlike psychoanalysis.
(3) What’s the alternative to an evidence-based approach to therapy? The alternative is to rely on a handful of untested case studies. This is how Freud ‘proved’ that psychoanalysis worked. It then turned out he had fabricated or hidden the facts of his case studies.
Any therapy must be able to show that it has worked to be worth pursuing at all. What does that mean? It means a person feels noticeably better, stronger and more at peace after practicing the therapy. You can test this, by asking the person how they feel over a period of time. That’s what CBT does. Why don’t other therapies do that too?
Yes, CBT focuses on specific illnesses – that’s because people with social anxiety have very similar thought-processes. Just look at a social anxiety website, such as www.social-anxiety.org.uk. Look at how similar the thought patterns expressed there are. It’s the same with OCD, with depression, and other emotional disorders.
The spread of internet forums for these emotional disorders have allowed the layman to see, for the first time, quite how similar people’s experiences of these emotional disorders are, and how similar are the head trips they get into. And that means you can actually tailor the cognitive exercises they are taught quite specifically to the head trip of their condition.
Sometimes, of course, people have more than one condition – I suffered from social anxiety and post-traumatic stress disorder with comorbid depression, for example. But the CBT course I did for social anxiety still helped me, because it taught me basic skills to be aware of my thoughts, and to challenge my thoughts, and I could use these skills to challenge both depressive and anxious thoughts. And, in fact, a lot of my depression came from a low self-evaluation of my social skills, so tackling social anxiety also helped me tackle the low self-worth of depression.