Since 2006, CBT has been the fuel that drives the government’s mental health initiative, the “Improving Access to Psychological Therapies” scheme: 6,000 new CBT therapists have been trained since then, and in 2012, the government spent £213 million delivering CBT through the NHS. CBT is the default non-pharmaceutical service offered by the NHS for most common forms of mental distress. Other kinds of therapy get squeezed out.
CBT has faced heavy criticism over the years. Now author and psychologist Oliver James is leading the charge, calling on the government to take a more holistic approach that embraces other talking treatments such as psychodynamic therapy. Why? Because, says James, CBT simply doesn’t work.
He writes: “A quarter of us suffer from a mental illness at any one time, mostly anxiety or depression. The cost to our economy is enormous—£105 billion a year, never mind the personal anguish—and for too long the only treatment was pills. What a tragedy, then, that the first attempt to provide talking therapy to patients nationwide is using the wrong kind: cognitive behavioural therapy.”
What is CBT?
In the 1950s, Aaron Beck became disillusioned with the-then prevailing approaches to psychological treatment. On offer was either psychoanalysis, which suggested clients were at the mercy of their unconscious processes, or behaviourism, which suggested they were at the mercy of their external environments. Beck felt little consideration was given to people’s power as conscious beings able to make good choices. In working with clients with depression, he came to understand their condition as arising from unhelpful thinking or “cognitive distortions”—negative thoughts which are fed by underlying beliefs or assumptions or “rules for living.” CBT was an unlikely marriage in the 1970s between this cognitive approach and more traditional behavioural ideas.
These days, CBT takes a broader approach, considering emotions and the body, too. All four “elements of life” interact with each other, often in a negative spiral. So while a person’s thought and behaviour patterns are the focus of CBT—considered the twin engines in creating and curing psychological distress—practical, skills-based steps to improving emotional and physical wellbeing are also encouraged, such as exercise, sleep, meditation, yoga and nutrition. CBT has evolved and expanded and branched off, too, incorporating other ideas and practices. Some of the new “third wave” forms are mindfulness-based CBT, Dialectic Behaviour Therapy; compassion-focused CBT, Schema therapy.
In a course of standard CBT treatment, typically anything from 2 to 12 weekly, 50-minute sessions, you and your therapist will break down your problems into their separate parts using worksheets such as Padesky’s “hot cross bun.” Unrealistic or unhelpful thought and behaviour patterns will be identified, and together you will come up with better alternatives. These will be practised during sessions and also between sessions with “homework” assignments such as keeping a thought record or carrying out behavioural experiments where you try to expose yourself to feared situations. Says the NHS: “The eventual aim of therapy is to teach you to apply the skills you have learnt during treatment to your daily life. This should help you manage your problems and stop them having a negative impact on your life—even after your course of treatment finishes.”
The case for CBT
• It offers a common sense, structured, systematic approach with a focus on problem solving in the here-and-now. No need to spend years (and fortunes) in analysis, lying on a couch ruminating about your childhood. CBT is a practical, non-threatening approach, especially for clients experiencing psychological treatment for the first time.
• It’s easy to grasp, and offers clients some certainty, clarity and an action plan. In the midst of the storm of a crisis, that can be very comforting.
• It’s short-term, and can therefore be delivered economically.
• It’s an evidence-based treatment. Since the days of Beck, it has been subject to extensive testing, especially in the form of randomized control trials. This research claims CBT is an effective treatment for anxiety, depression, panic disorder, personality disorders and many other forms of psychological illness, including some psychoses.
According to the National Institute for Health and Clinical Excellence: “CBT’s evidence base, short-term nature and economical use of resources have made it attractive to clients, practitioners and service purchasers."
• CBT is an absurdly simplistic, quick-fix approach. It’s just common sense—thinking and behavioural hygiene—dressed up as something grander. At its worst it offers little more than Bob Newhart’s comic “Stop it!” therapy. The idea that a person’s complex distress will be resolved after a few sessions of having their thoughts and actions challenged is laughable—like putting a tiny sticking plaster on a deep, long-standing and festering wound.
• CBT only targets symptoms rather than underlying causes. There are deep unconscious processes at play, often forged in childhood, and unless these are explored, brought to light and processed—this is the domain of psychodynamic therapy—nothing will ever really change.
• It’s a manualised, one-size-fits-all method that is imposed “top-down” on the client, rather than starting with the client and their experience and working together in a “bottom-up” way. Unlike physical diseases, psychological distress does not so easily lend itself to being pigeon-holed into different, neat and tidy “diagnoses”—one person and their “anxiety” for instance, might be very different from another, and they might benefit from very different approaches.
• It’s patronizing and disrespectful to the client to imply they should have “recovered” after a few sessions of CBT, which blithely attempts to whitewash over difficult childhoods, traumas, hardship, and the very real consequences of the oppression resulting from a deeply unequal, divided society. The “blame-the-victim” ethos that’s inherent to CBT—all your problems are the result of your faulty thinking and behaviour—only makes people feel even worse when the treatment inevitably fails to make a difference.
• CBT comes from a narrow, ethnocentric world view, making assumptions for instance that all individuals are rational, autonomous, in charge of their own destiny, disregarding for instance those who might be more collectively-minded, or generally less amenable to logic, homework, psycho-education and the cognitive model.
• The “evidence” for CBT is highly questionable. Any positive effects of CBT in research tend to be very small. The few long-term studies show little or no lasting benefit. And some favourable research is biased, bogus and politicized—often it’s a somewhat rigged, circular process in which CBT looks for and finds results that portray itself in a favourable light, like a schoolboy left to mark his own homework. It is doubtful that CBT is at all effective in the long term in the real world of clinical practice, especially for chronic, complex, or long-term conditions. Writes James: “After two years, those given CBT have no better mental health than ones who have been untreated.”
Concludes psychiatrist and writer Jeremy Holmes: “It is hard to escape the suspicion that cognitive behavior therapy seems so far ahead of the field in part because of its research and marketing strategy rather than because it is intrinsically superior to other therapies.”
The case for integration
There is something to be said for CBT. It has a place. It’s a good starting place for a lot of clients; a way in. The benefit of symptom reduction can’t be underestimated. I have incorporated some CBT into my work as a counsellor, particularly some CBT ideas around assessment, formulation, psycho-education, self-monitoring and reality testing. Considering each client through a CBT lens is a worthwhile exercise and should be a part of any therapist’s toolkit.
But overall I tend to agree with James. CBT is rather too superficial, pedantic, and highly directive, sometimes oppressively so. Rather than imposing fixed goals and tasks on the client, I prefer a more open-ended, collaborative way of working, one which allows the encounter to unfold organically, with a sense of exploration. “Being with” is better than “doing unto”; allowing a therapeutic relationship to emerge is preferable to attempting to batter away a client’s symptoms with a CBT bludgeon.
Human dis-ease is as varied as humans are, and clients rarely come seeking goal-oriented solutions to tangible, well-defined problems. And symptoms often exist for very good reasons. They serve a psychological purpose—and so we defend our neurosis, as Freud said: “like a lioness defends her young.” Untangling unconscious and conscious motivations, intrapsychic and interpersonal conflicts, and environmental constraints and challenges—it’s a tricky business. Better to go with an integrative, flexible, and reflective therapist who has had plenty of therapy of their own than an insensitive, dogmatic CBT evangelist who demands that you get with the program. Better for the government to offer a flexible, pluralistic, comprehensive therapy service than only a simplistic, dogmatic, ineffective one.