Thursday, September 11, 2008

CBT and psychoanalytic snobbery

Darian Leader, a psychoanalytic therapist and writer, is (unsurprisingly) critical of cognitive behavioural therapy.

To his credit, he offers a passable opening summary of its approach:

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.

For example:

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.

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.

Without knowing the details of this case (assuming it is a real case), it’s hard to say, but it strikes me as very unlikely that somebody would have this one irrational belief about their smell and nothing else. CBT would indeed help her to discover that she doesn’t smell unusual, but that would be only a small part of the process.

The biggest psychoanalytic lie about CBT is that it only looks, superficially, at “symptoms”. It takes feelings of anxiety, depression, phobia and the like that the client personally judges to be a major problem in their life, and the client and therapist then investigate what lies underneath these feelings – which situations tend to bring them out and which don’t? What thoughts go through their head in these cases? What, if anything, do they do to avoid or reduce this distress? Then, through careful and utterly personalised exploration, the pair try to work out not just which thoughts are linked to which feelings, but what the deeper, underlying assumptions are that lead people to think, feel and react in such distressing ways. These assumptions may be things that the client has never explicitly articulated, or finds so fundamental as to be beneath notice, or perhaps finds embarrassing to admit even to themselves.

Then these deeper beliefs in turn are articulated, questioned and challenged. It’s by changing these that the symptoms – nervousness in public places, feelings of worthlessness, etc. – are removed. This process, in Leader’s terms, does precisely “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”. The eventual dealing with the symptom is not a stifling but a dissolution.

CBT is fast to get results as well as cheap, compared with psychoanalysis. Hence Leader’s dismissal of it as a “quick fix” – as if being slow and expensive are themselves virtues in a form of therapy.

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. … The new psychology is thus in the service of the market.

This is just partisan nonsense. Of course CBT is something you can pay for – you can also get it (alas, with a waiting list) on the NHS. You can also pay – typically more – for Leader’s own brand of less directed therapy, where an “expert” (another of his bogey words for CBT) will help you to self-explore in the desired way. If that’s what you want, fine.

He doesn’t deny that CBT can achieve results, but he argues that these are narrowly defined and quantified in way that diminishes the human experience:

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. …
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.

Well, what’s written “on paper” is the client’s own judgement of how they feel and whether their life has improved as they had hoped. Certainly, there are diagnostic questionnaires that do indeed abstract a long way from the individual’s state of mind – but no practitioner would dream of using them in isolation. What determines whether a client’s depression has been satisfactorily dealt with is how they feel, not whether the therapist thinks the client is superficially functioning the right way.

And what “alternative symptoms”? Is there evidence that people successfully treated with CBT develop these more than those not successfully treated? What evidence is there of post-CBT “acts of violence”? This looks overwhelmingly like hostile hand-waving based on the view that the ‘psychological energy’ involved in a neurosis has to go somewhere, and can’t possibly be effectively dissipated by something as crudely ‘practical’ as CBT. But this view is pure ideological snobbery on the part of the psychoanalytic industry.

As Maureen Rice says:

The fact that classical psychotherapy is slow, hard to quantify, of limited availability and wildly varying quality are not by-the bys – they go to the heart of the roll-out of mass CBT and the rise of the quick fixes.

Most – though not all – classical psychotherapists make Leader's argument, and a gorgeous, moral high-ground argument it is. The fact that it's totally disengaged from the way most people perceive their own problems, their aspirations for dealing with them, or the way they perceive or receive help for them is something they don't seem to consider or grasp.

3 comments:

Paul said...

Critical/community psychologists would maintain pretty strongly that getting pulled into a psychoanalysis/CBT either/or debate misses the point that misery is social, and that medicalising it in any form only reinforces it. See this statement on the plans for CBT roll-out - http://www.compsy.org.uk/changing%20minds.pdf

anticant said...

It's typical of this Nanny-minded government to decide in its lofty wisdom that what everyone needs to cure their depression is one type of officially approved therapy - in this case CBT. [It never seems to occur to them that a lot of us are becoming more and more depressed because of the political and social mayhem caused by their witless and inane policies!]

As an eclectic therapist primarily trained in and using Gestalt/Transactional Analysis perspectives, it seems obvious to me that people need to recognise and integrate their emotional and irrational sides with their thinking and practical approaches to life's problems. Personally I favour a middle-of-the-road approach to these issues, eschewing the excessive mystification of psychoanalysis on the one hand and the sometimes too superficial matter-of-factness of CBT on the other.

william said...

The Greeks believed there was nothing inherently 'sinful' about the self. It could certainly be stupid, irrational and self-destructive. Indeed, the Stoics believed that, in the words of Albert Ellis, '99% of the world are out of their fucking minds". But the potential for emancipation through reason and self-knowledge is almost always there.
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