Since the 1980s, a type of psychotherapy called Cognitive Behavioural Therapy (CBT) has become dominant. Like it or loathe it, CBT is now so ubiquitous it is often the only talking therapy available in both public and voluntary health settings. It is increasingly spoken about in the media and in living rooms across the country. Yet when we speak about CBT, what are we talking of? For CBT only exists – as we will see – as a political convenience.
When most critics invoke (or, rather, evoke) CBT, they are referring to Beck’s CBT – a logico-rational entrerprise between a therapist and a client, focusing on changing cognition, or thought. Let’s consider a standard session. A client is given a ‘thought record,’ and asked to identify the ‘hot cognition,’ which is bothering them; this thought is then rated for ‘evidence for’ and ‘evidence against’ this belief. Most often this jury type examination will result in the writing of a new belief. Thus ‘I can’t do anything’ might be replaced by the belief ‘I can sometimes do things, but sometimes struggle.’ In Beck’s model, common problems like social anxiety or depression are seen as linked to certain dysfunctional ways of thinking and information biases.
Thus someone with anxiety, might be seen as having ‘danger-oriented beliefs’ and be prone to ‘jumping to conclusions.’ Childhood origins are not up for discussion. Rather, clients in this therapy are heavily socialised into certain ideas – that problems can be changed by thinking differently, that emotional difficulties like depression and anxiety can be cured, and that people can be trained to think in non-disordered ways. Yet the core notion behind these claims – that CBT works through changing the content of thoughts – has been called into question.
For a couple of decades now, there has been considerable unease about whether the logico-rational techniques of thought challenging is actually what changes things in a CBT. As a result of this unease, a number of therapies started to bubble up in the late 90s which focused not on the content of thought but on one’s relation to it — or, metacognition — the very process of thinking itself. As well as springing from radically different ideas about the relation between language and suffering, these approaches give the client a very different clinical experience. In comparison to the Becksian example above, a session might involve the client eating a raisin incredibly slowly, attending to each and every texture and sensation to become present in the moment, or creating and visualising a safe place to provide an anchor point at moments of trauma.
These new approaches were initially ridiculed, with their leaders parodied as guru-like. However, they have since been welcomed into the CBT world as they have shown even Becksian CBT might not actually work through changing the content of thoughts, but through producing a space between the self and thoughts. This revelation, along with evidence that approaches focusing simply on behaviour, can be just as effective, and that the therapeutic relationship itself is the greatest moderator of change have seriously dented Becksian claims that it has something unique to offer, and that its theory is coherent with its practice.
However, the humility that these realisations of what actually produces change might be expected to produce have been hindered by a smash and grab approach to any new moderator of change, all of which come to be co-opted as CBT. Examples of things which get sucked into the CBT vortex include attachment theory (from psychoanalysis), mindfulness (from eastern wisdom traditions) and compassion (from Plato and, well, everyone). Practitioners using these other approaches – which have no family resemblance to Becksian thinking – are often complicit in placing their therapies under the umbrella of CBT because there are power interests vested in doing this – money, grants, faculty position, shared membership in what CBT apologist Richard Layard evangelically frames as a “forward-looking” and “progressive” movement. A typical example of how such vested interest and politicking work includes the popular philosophers who claim, when it is in their interest, that the Stoics got their first, but become part of CBT when there are books to sell or grants to be won.
Similarly the radical possibility for mindfulness to exist as an alternative, leftist antidote to suffering – equally effective as CBT but with a more community-focused ideology – is lost by its increasing subsumption as a form of CBT. In this transaction, CBT as a brand gets to position itself as ‘cutting edge’ though the explanations of change given to the majority of its clients and gospelised to the public no longer fit the science. It also gets to boost its membership with new recruits – eager to belong and pay heavy organization-boosting membership fees.
Such politicking provides a useful shield to criticisms. By conflating a number of vastly divergent approaches with strikingly different ideas of what it means to be human and to suffer, and calling them CBT, its proponents can delegitimize critics by claiming that they do not know ‘modern CBT.’ Yet this response negates the actual reality – that for all the seeming variation, the overwhelming majority of CBT still operates through Becksian principles of normalisation, fitting a governmental agenda of producing good, quiet, working subjects who contribute to the economy and shut up. The price of locating newer therapies with very different ideas and promising research findings under the CBT mantle, despite the lack of family resemblance, is thus that it props up normalising therapies which cohere with an individualistic, neoliberal agenda that equates worklessness with worthlessness.
Consider in more detail mindfulness, which now has an evidence-base equal to Becksian CBT. Co-opting meditation as a CBT to be offered as a treatment option by the state alongside outcome measures communicating that the goal is functional relations, happiness and work, individualises pain. This is a different political act to supporting meditation’s rise in the community, a growth which nearly always leads to a focus on compassion and radical social action — as community is one of the only ways to ensure daily practice is continued after the initial high that comes with doing something new. This is one of multiple examples of how the interests of CBT and government are now closely intertwined.
How, then, is the idea of CBT achieved? If we look closely at the literature, some refer to CBT as an ‘umbrella’ of techniques. Of course, the idea of an umbrella implies a commonality, a family resemblance at least. Yet each and every attempt to locate this is problematic. A focus on cognition and behaviour? Find me a talking therapy that does not attempt to alter thinking and behaviour through speech! Evidence-base? Why, psychodynamic and systemic family approaches also play the evidence-base game nowadays! Goal-directed and present-focused? But many of the newer CBTs spend a lot of time focusing on childhood, and many therapies which are based on the present and goal-directed are not CBT. As these attempts at commonality fail, we are sold a shared history, a development from first-wave behaviourism, to second-wave (predominantly Becksian) CBT, and then third-wave often metacognitively focused therapies.
Though the metaphor of waves implies these things come from the same sea, the manufacturing of the story of CBT in this way is a politicised choice. Other ways of story-telling are available to us. For example, one could see Becksian therapy as just as much about earlier psychoanalysis as earlier behaviourism. Beck, after all, was responding to his frustration at his early career as a psychoanalyst, and it is perhaps not coincidental that the great proponent of Becksian CBT in the UK – Lord Layard – grew up in a Jungian household where his father was a practicing analyst. The metacognitive therapies cluster as much with the story of meditation from the caves of Tibet as fromPavlov’s original experiments with dogs.
However, the most persuasive re-storying of CBT — for me, at least — springs from putting aside therapy brands and considering how therapeutic practice actually advances. The most celebrated CBT theorists in the new wave of therapies draw not from science but from their own experience of pain. The founder of one – Steve Hayes – developed his techniques from his own destabilising panic attacks, whilst the leader of another — Marsha Linehan — draws from her experiences as a psychiatric inpatient. These sufferers found some solace in ways of living that bubbled up from their own profound experience of pain, and which they modified from eastern wisdom traditions.
Theory? Research? Packaging? Those came later. It was precisely their rejection of contemporary brands which allowed them to discover something new. Thus, therapeutic change comes from challenging norms – not from trying to impose them. The more attached we become to brands — the more we insist on stamping them on therapists and the experience of therapy — the less we allow clients to follow the great therapeutic innovators and create therapy anew for themselves. Practice and theory have produced some ideas that can help — that control may be the problem not the solution, that avoiding experience leads to squashed lives, that childhood serves the template for how we live.
These belong, however, not to CBT — but to human experience.
wow – great article.
I wonder if you are aware of the Milands Psychology Group?
There wepage says this. ”
“We are a group of clinical, counselling and academic psychologists who believe that psychology—particularly but not only clinical psychology—has served ideologically to detach people from the world we live in, to make us individually responsible for our own misery and to discourage us from trying to change the world rather than just ‘understanding’ our selves. What are too often seen as private predicaments are in fact best understood as arising out of the public structures of society.”
Here is the link: http://www.midpsy.org/
that should read, “Midlands Psychology Group.”
Must try to proof read more….
I know of them a little from cyberspace. Excellent approach and acknowledgment of clin psy’s vested interests! Thank you for the link – Jay
You suggest that my work on Stoicism’s connection to CBT is an example of a sinister ‘vested interest’ between money and power. You write:
Practitioners… are often complicit in placing their therapies under the umbrella of CBT because there are power interests vested in doing this – money, grants, faculty position, shared membership in what CBT apologist Richard Layard evangelically frames as a “forward-looking” and “progressive” movement. A typical example of how such vested interest and politicking work includes the popular philosophers who claim, when it is in their interest, that the Stoics got their first, but become part of CBT when there are books to sell or grants to be won.
And you link to my site in the last sentence.
You’re saying, if I understand you, that I only imply there’s a link between Stoicism and CBT in order to sell books and win grant money? And that the whole ‘Stoicism Today’ research project (which you also link to in that sentence) is likewise a cynical grab for grant money and influence?
That’s a bizarre and itself very cynical and (I’d say) mean-spirited and nasty suggestion. What I noted in my book Philosophy for Life was that CBT (which has helped me personally) was directly inspired by Stoicism – both Albert Ellis and Aaron Beck told me so in interviews. And CBT uses many of the Stoics’ therapeutic techniques. But I also noted CBT leaves a lot of Stoicism out – and that many contemporary people prefer to use the original philosophy rather than CBT. I wrote that book because I find that topic interesting, and if it sells copies, great, I hope other people find it interesting too.
As for Stoicism Today, we’re the worst-funded research project imaginable – we’ve been going three years, with six people involved, and have had, in total, £10K in funding over that three years, with which we’ve run Stoic Week 2012, 2013 and 2014 – an online course which thousands of people took part in; and Stoicism Today conferences in 2013 and 2014, which a total of 600 people came to. We’ve also produced a book of essays, and an online blog, and been covered in media including the New York Times, Forbes, Newsweek, Radio 4’s Today show and so on. And we did all that with £10K in three years! None of the participants make money from that research project, the people involved do it because they believe in it passionately. So to use us as an example of the greedy vested interests using CBT to get money is totally wrong. I wish we got serious funding for this project – so far, we haven’t.
I met you back in 2010, you came to speak to my philosophy club about Lacan. I have to say, give me CBT over Lacan any day of the week. By the way, I love your expression ‘play the evidence-base game’ – spoken like a true Lacanian.
Hi, Jules Evans. I understand from what you said that you do not do what you do out of greed or desire for power over other people. I looked at your website which seems to back up your statements, which I understand as this; you are a person, an individual, who felt that CBT helped you therapeutically, as did the study and practice of Philosophy. I can see why you feel unjustly accused of acting out of impure motivation. I think I agree with you about that, at least with the information I have.
At the same time, I have been treated with CBT, and do not like it. Perhaps my experience of it was different with respect to my mental health diagnoses and the way a therapist might have treated me as opposed to someone (I am assuming at my own risk) who may not have been diagnosed with a major mental health problem. Maybe I am just from a different school of thought that would not be as much in accord with CBT, or what you yourself believe as an individual. More specifically, it was not what I was looking for in a treatment modality. I was not looking for someone to tell me that I feel the emotions that I experience because I have false beliefs originating in my past and having little to no relation to my present, and that in order to be “helped” I needed to submit to allowing my beliefs to be replaced by a more “positive” system. Because if I am blue because the sky is blue, then maybe if I thought it was yellow I’d feel better, and for that reason alone, I should think so, in order to achieve one of my goals (to be happy). My problem with that had to do with the concept I have of an objective truth, as well as the positive beliefs not being based on postive evidence, and my own current “negative” beliefs not being conclusively proven false in my own mind. It felt like a form of brainwashing to me.
Which is one of my reasons for liking Jay’s article so much. Perhaps if she had stuck to attacking a philosophical/psycho-therapeutic system rather than improperly characterising any undeserving people in a villanous way it would have been better not to presume with regard to the motivations of others. However, as someone who has experienced injury as a direct result of c0erced psychiatric treatment (not necessarily CBT alone) I still see her as being helpful to me in my search for understanding of my own experiences.
Well put, I agree 100%, especially with this analogy:
“Because if I am blue because the sky is blue, then maybe if I thought it was yellow I’d feel better, and for that reason alone, I should think so, in order to achieve one of my goals (to be happy). My problem with that had to do with the concept I have of an objective truth, as well as the positive beliefs not being based on postive evidence, and my own current “negative” beliefs not being conclusively proven false in my own mind. It felt like a form of brainwashing to me.”
Thank you for this stimulating article.
I describe my recovery as being due to ‘CBT’, but I am not well up on the technical side of this, and I have never really gotten into classic CBT.
I suffered dreadful anxiety when I discontinued strong psychiatric drugs. What worked for me was a type of ‘abandoning of thinking when overwhelmed – to return later when calm.’ But when I became calm things seemed okay (this was more difficult to do than it sounds). Mindfulness was useful for this process.
I describe this as CBT because I was able to learn to recognise how my anxiety dynamic worked and what I could do about it.
I had come off very strong psychiatric drugs at that time and would have been classified as a long term chronic SMI case.
I now recognise my main problem at that time as being ‘Dopamine Supersensitivity Syndome’. So I do support practical psychotherapy as a solution for SMI (because in a sense I suffered from an exaggerated version of this).
On withdrawal from strong drugs I also suffered from a lingering melancholy. I attribute my recovery from this, to Buddhist Breathing meditation.
They say CBT ‘can get you out of trouble’ but this was what I needed to do – to get myself out of trouble; and I still use my ‘CBT’ in my present day life.
I’m sorry if I wandered off on a tangent in my post and thank you again for your thought provoking article.
Fiachra, You are always eloquent and concise about your experieince, and it has mattered to me a number of times that you quietly bespoke your conviction in sharing and talking (and meditating) as the way in toward a solution, and out toward the needed change. Nothing at all is amiss in experiencing the absolutely unmitigated sadness (the forlorn aspect) of life. Probably you have very interestingly considered what is the actual right manner of knowing the forlorn recognition of ineluctable doubt about most aspects of the human condition and what is by contrast the distress that goes by the same name as doubt or sadness, but which reveals your unnecessary “personal” contribution to the pattern of suffering. Your words are very easy to respect and to understand and you make your story, as hard as it once became to endure, beautifully accessible and turn the private into the universal. The technical details which Jay will connect with in your comment go a bit over my head, but have the unmistakable ring of truth, and inspire perseverance.
Thanks a lot travailler-vous, the word forlorn really does describe my melancholy. It was like the Buddhist meditation changed things at a deeper level, but I’m glad the melancholy lifted.
Yeah, Fiachra, you make cogent remarks when you say casual things and elegant statements of more complex things, and I’ve come to reflect on the value of social acknowledgement and the efficacy of relationships in the determination of personal change…on account of your thoughts about it, more than once.
I don’t know what I would do without the support of like minded people.
Fiachra – You write so beautifully about finding your own solutions to “get myself out of trouble”. Im a huge fan of Buddhist Breathing meditation too (I used to live in an ashram!). I also very much agree with your emphasis on anxiety being the problem, and ‘abandoning of thinking when overwhelmed – to return later when calm.’ I look forward to reading more of your words and insights on MIA and elsewhere- Jay
My personal experience with CBT is that it doesn’t really stick, it doesn’t reach the core, but seems to me to be more of an in-the-moment mental exercise to appease the moment. Sometimes it seems rather manipulative to me. I certainly can’t speak for every case in which it’s administered, but I’ve perceived this a lot.
The shift in thought pattern is, generally, not followed through to completion, following the domino of shifts that would naturally occur for long term change to be achieved–that is, allowing the information to penetrate the body on a cellular level. That’s when we embody new information, rather than just think it, which is not really applying it.
It’s not just mind—it’s mind/body/spirit. They work in tandem, as a unit. For healing to occur, follow through must be done consciously, which reveals a person’s creative process. These have been my findings.
I have to agree with you 100% I did CBT for about 2 years and now 2 years later I’m back in CBT. I find that CBT only works for me when I am not too deeply depressed or when the anxiety level isn’t too high. If my “core beliefs” where really changed then you’d think I’d go “on auto-pilot” when highly stressed and be able to pull myself out of a downward spiral, but that is not the case.
As a professional researcher I have access to almost every journal ever written. I should do a search to see if there are any studies on the long-term effectiveness of CBT,
Hi Dr._X, yes, that’s what I’ve found, that when we do shift our core beliefs, which means that we’re shifting our cellular vibration and would feel this as a physical change–as well as perception and attitude shift toward whatever tends to cause us distress–then we are shifting at the core, and there’s no going back because we’ve not only shifted our neurons, we’ve shifted our energy entirely, on a cellular level, which corresponds to those neural pathways, from old to new. We move forward in our evolution in a whole new way, with a clearer and cleaner process, which is ‘ease.’ That’s transformation.
What I’ve learned is that as we shift our thoughts in the moment, there is a corresponding physical vibration that also must shift. That can also be done in the moment, by chewing a bit on what is being considered, where the triggers are, allowing different perspectives to emerge, until the one that feels right to us, based on our spirit truth, becomes clearer by how it relaxes our heart. That is, it rings true in our heart, and therefore, in our body.
That connects the feeling of the physical shift with the shift of the thought. Each thought we have has a specific vibration (constrictive vs. expansive), and when we shift thoughts, we also shift vibration, which is physical and emotional, in nature. That would be core healing, and validating to our own spirits as having the power to self-heal.
I’d also be interested to know if any of this is connected with CBT, but as far as I know, this hasn’t been addressed. Not that I’ve ever seen, anyway.
Also, due to the fact that thoughts and beliefs are habits we practice for years, it can take some time and conscious focus to make the shift entirely. I have very specifically focused meditation exercises I offer to clients to practice daily. With diligence, it really doesn’t take that long to make the shift, because the universe ALWAYS brings us real like opportunities to remember what we’ve learned and apply it in the moment. That’s actually the moment where healing occurs, for real, because we’ve put it into action. Sooo empowering!
I mean…real LIFE, not ‘like.’
Yes, do! the more of us researching the better, especially those with lived experience.
“It’s not just mind—it’s mind/body/spirit.” Couldn’t agree more, Alex, again with your emphasis on us finding our “creative process”.
While I think in general “talk therapy” is better than popping pills I don’t have a good opinion about it either. CTB sounds like mind control and brain-washing to me. Going into the office of some guy you don’t know, telling him/her very private and intimate things and let them interpret your life is a very risky business. You’re better off dealing with your problems yourself.
Thanks for your comment, B. Any shrink of any persuasion who interprets someone’s life like that is dodgy to me. Becksian CBTers can be so indoctrinated into their model that they fail to see the power issues in doing this – especially important as so many have suffered abuse of power early on.
Ms. Watt, Great work here, and most importantly an attitude worth emulating. I learned from an article online years ago that cognitive psychology couldn’t support an ontology for proving its determination–that was by this psychologist …
Anyway, don’t take me for advocating Freudian approaches, but the news mentioned was like finding money if you know what I mean. And it may be a bit one-sided stated so simply, but Beck does seem as old-fashioned to me as though he missed everything that phenomenology showed about what can and can’t happen to affect persons internally or externally, and then actually receive explanations appropriate to the psychic and the egoic functions of conscious experience.
I had tried working with two CBT books, one on DPAFU and PTSD, as these cover my presenting symptoms, but I couldn’t get anywhere until I risked a naturalistic experiment–right here, actually. My hyperawareness, and consequently my hypervigilance had been through the roof, to the moon, and back again, for years, and I couldn’t see what cognitive behavioral sins I was committing to keep them so intense. Meanwhile, I almost never felt anything worth talking about besides stress. I had been saddled with the label bipolar and was compliant for fifteen years, but had types of episodes (that I now know were flashbacks of life-threatening events) that the label never explained. Problematically, the mood stabilizers masked the emotional aspect of anything like triggers or the manifestations of derealization and I just got used the the irresistible contemplative moods that we call depersonalization.
So, what I attempted was play-acting like I was angry with someone who could conveniently stand for a psychiatrist or “the bad guy” according to his style of commenting in the thread. How hasty and not risk-averse is that in this venue? Anyway, anecdotal as it may be, it is historically true that upon doing my best to present some retaliatory spirit, I had immediate reduction in hypersensitization, interpreting this as the release of frustration from always trying to control my reactions. My house fronts a street and many of my life threatening expereinces happened due to to endangerment in traffic beyond my responsibility for causing the wrecks or potential end of life “visions”.
Anway, CBT then let me learn some things, once the inroad developed to seeing more than bodily cues of emotional life, feeling again, even if it was all pain for awhile. I find undying humor for my personal predicament, which is the most help. The second most help, however, has been counseling. Except for me it was from lawyers.
thank you so must for your comment. I also very much believe in not quashing what you eloquently call the “retaliatory spirit”. And this “I find undying humor for my personal predicament, which is the most help”. YES!
Dr. Watts – The reason for expressing my first remarks originated with my apprehension of the fact that your critical thinking style suggested receptive social manner and attitudes, as counterintuitive as that may seem to folks who think you’re spiteful to deconstruct these images of scientific perfection, or who don’t see why apparatchiks of the power brokers don’t get a lot of money but still deserve heat.
From the first, it was apparent to me that CBT philosphy fails to square up with age-old criticisms of talk therapy for failing to acknowledge the social reality and clients’ place in it–their money needs and auxiliary to work social life and class obligations, for instance. All the problems are located beneath the skin for Dr. Beck. Additionally, I’d looked at the working theories for PTSD myself. (BTW, Here we had a nice turn of events when George Bush declared that we didn’t need the “D” there. Now we have the Man saying “It’s just like diabetes!”) So, the leading candidate for explanatory sufficiency is dual representation theory.
By making use of the concept of a Verbally Activated Memory and a Situationally Activated Memeory they fill out the concept of fragmented memories, where the affect (I guessed mass affect to be most appropriate) is triggered subpersonally by environmental cues associated with things you don’t literally recall. This can help explain the crazy effect of feeling all kinds of strange because you don’t have any evidence experientially of your ongoing flashback. Instead you have to read off the bodily cues and changes in your desires and inclinations, whereupon the idea is to get onto the relevant memory or the general type of connection to the most likely trauma sequence and revive the connectedness between SAM and VAM, and then let go and move on.
“Fragmented memory” was too big a word for CBT, and forget about VAM and SAM. They handle the problem with descriptors like “lack of empathy”, which is only so apt, and they never stop indicating “Say you are emotionally numb, victim–” like I did above. It hints deceptively at the real nature of the phenomenon, however. More accurately, there is a consciousness dwelling on the stress itself, I feel, and an attempt to ferret out the sympathetic reactions tied into to the myriad constant triggers. Also, you may or may not be reflectively engaged so that you are judging that consciousness. I think it is important to spend lots of time just experiencing stress without trying to watch what your mind is telling you about it–just keep busy with things.
My flashbacks have recently gone from almost continuous re-plays of time-slices of a near crash on a bike (hey–a Triumph), lasting for between seconds for the emergency part to maybe hours for the ride up to it, happening many hundreds of times in a day, down now to dozens of theses reminders in every few hours’ time, but no more. But it took the idea the CBT hierarchy and authors left out, that they could not have been acquainted with. More interestingly, just as Peter Breggin asserts in Toxic Psychiatry, this event took place more than fifteen years ago, never bothering me significantly at the time, and only magically resurfaced only after a vehicular attempt on my life a couple of years ago, which happened to me while crossing the street near my home. Breggin, who deserves mention for his service to the cause, also asserts his belief in the dangers of mental hospitalization as sources of trauma. Now the CBT guide for PTSD will have none of that antagonism, but know lots about it, because as you can see elsewhere, like in their DPAFU manual, in sotto voce terms they admit to systemic deficiencies in terms of malign neglect of much more subtle dimensions than outright abrogation of civil rights visits on patients. Once–very slightly they disclose their awareness that they are helping with problems in the trade. But, of course, it pans out to be helping psychiatry onto the good track that includes them. And you know they read up on Dual Representation Theory before putting their work out, too, this CBT press group. But they want everything their way, and all is not well for us with that.
So the intended meaning is that CBT publication authors are not possibly UN-acquainted with general theories and models (that they haven’t they trademark for)…and sometimes I should say “CBT standard-bearers” and “authors” instead of “they”…
I think the only issue I have with this article comes from the spiteful vibes it gives off towards CBT, and it seemingly poses CBT as some perpetrating entity that is ruining it for all the other theoretical orientations. For example, Stephen Hayes has written articles trying to reconcile ACT as a cognitive-behavioral model despite it’s subjectivity (the meaning making process of our relationship to the self, aka acceptance through metacognition), whereas some devout second-wave CBT theorists are actually reluctant to say that ACT is truly cognitive-behavioral in its philosophical roots – which is primarily an attempt at an objective understanding of reality. They don’t want it! This is contrary to what the article suggests, which is that CBT eagerly absorbs and intentionally takes credit for all these “innovative” breakthroughs, which have in fact been accounted for in other orientations and philosophies for hundreds/thousands of years. As the article suggests, the issue is more-so one of government, insurance companies, and our current scientific method which all put a premium on objective outcomes, which just so happens to lend itself to CBT. The issue is not CBT, but the dogmatic preference of CBT by powerful people outside the field who have little to no understanding of psychology and the subjectivity of what a positive outcome actually entails. The government/insurance companies do not want to hear, understand, or pay us because we helped a client achieve a more “cohesive sense of self” (whatever that means) because science can’t objectify it, or that we used “holding”, “containing”, and the “therapeutic relationship” to get there. It’s not only what actually creates the outcomes, but how should the outcomes even be defined? There are limits to objectivity such as the essence of experience, the meanings we make of experiences, “the self”, and simply the entirety of what it is to be a human that we likely will never be able to quantify, yet our governing system neglects these dialectically opposing truths that are incompatible with objectivism. Contrary to popular belief, subjectivity doesn’t have to negate objectivity, it’s just a matter of tolerating the paradoxical existence of both as true in their own way. Third-wave CBT is one of the few orientations that has lent itself to attempting to integrate the opposing subjective and objective philosophical foundations of the theories, in contrast to the decades long war between the orientations. CBT shouldn’t be slighted for its attempt and capacity to do so, albeit limited. The greater the certainty, the less the tolerance. However, as integration in theory continues to develop, I think it is going to have to account more and more for things like attachment, relationship, and factors that psychodynamic object relations has known for years as Allen Schore’s (The Science of the Art of Psychotherapy) research is suggesting. Ironically, science is showing that non-science, the “art” of psychotherapy is making the difference. When those things become more evident, the required outcomes and techniques that we get payed for will have to change, or at least that is my fantasy haha.
Well, I’m not sure I’d agree with “spiteful” but… I’ve a lot of time for Schore, who you mention at the end of your post, and think the best chance of advancing therapy practice is giving up on brands and working with what people who have suffered tells us works. Thank you for posting a comment.
I am a survivor of therapy, and I’m also a religious cult survivor. My cult experience happened before I even knew what the MH system was, nor ever dreamed I’d show up at a therapist’s office. I looked back and wondered how it was the this cult and other cults had such a hold on people, especially young college-age folks like me. How had they brainwashed people so that they gave up their former lives, emptied their bank accounts to the cult, and stayed inside this regime for years instead of continuing with thier lives? I learned that these cults use the same brainwashing techniques that were used on POW’s by the Japanese and later, to Korean War POW’s.
Any and every therapy I’ve ever had used the same techniques. Call it what you want. I was convinced to drop my promising career as student and join up. I was told things that most people would have scoffed at, but I believed these things and not only that, would fight for them.
“Oh yes, Mom and Dad I do have a real illness and this is where I belong!”
“The therapists know what they are doing. Of course they do!”
“Oh no, I’m not being harmed by this at all, Mom and Dad. You’re wrong! This is healthy!”
I recall many such arguments. My brothers gave up on me as a lost cause, lost to the cult of mental health care. What these therapists had done was to replace my good ideas, ones that not only were working fine for me, but worked for many students, with false notions.
I was praised for conceding my independence. I was praised for begging for help. I was told I was a clever girl for having made colorful charts of my “symptoms.” Childish behavior was reinforced over and over, ensuring that all the wonderful qualities that I once had, which reflected my maturity and unusually strong self-reliance, were lost. From then on, I was kept in isolation, either imprisoned in a “hospital,” or stuck in the world of “programs.” There were either real or symbolic walls surrounding the ghettos were we were forced to remain.
I look back now that I have left the cult of MH “care,” and I see otherwise talented adults completely brainwashed, not only that, these young people are spellbound by drugs. I say “young people” because most don’t make it very far, they die young. I see these young people demanding better pills. They complain that they are being turned away from prisons, convinced that these hellholes are their only avenue to wellness.
Even worse is the self-policing. I suffered from eating problems which many might call a severe eating disorder. I watch in horror as young people brainwashed from ED “care” police their own thoughts.
“I can’t weigh myself nor own a scale. I should never know my body’s measurements.”
“I should keep numbers out of my vocabulary.”
“I must follow my meal plan to the letter and ask permission if I want to change it.”
“Wanting to be thin is Ed talking.”
Who is Ed? These are the new eating disorders therapies that convince the sufferer that there’s a made-up guy named Ed (acronym for eating disorder) who tells them what to do. I don’t know one patient who has in fact heard the Voice of Ed, nor seen this dude, and I’ve never seen evidence that anyone is married to a made-up character.
This is done as yet another brainwashing technique. As soon as you begin to think for yourself and question, the “therapists” tell you to censor these thoughts. “What? Human rights? These are not your real thoughts. Ed is putting these into your head.” “if you reject our care or anything we tell you, that’s because you are listening to Ed. Get him out!”
Ed is the equivalent of what the cult called the Devil. Anyone who spoke out or left the cult was said to be influenced by Satan. I saw seasoned cult members doing ridiculous rituals in attempt to eradicate “Satan.”
In the end, it puts millions of dollars into the hands of these treatment centers and therapists who, I suppose, enjoy ruining kids’ lives. Why should one more life matter? It’s an income, a shrewd and deceptive business tactic. They know just what to do. They know how to take the money from thousands of families and above all not get sued, nor allow any of this to surface into the realm of the public eye.
Julie Greene (and Puzzle)
your comment reminds me that although some people diagnosed with anorexia die those who have been hospitalised are more likely to die.
Hospitalisation is often about forced diets and calory intake control. This takes away the contorl the person has and deminishes them.
However my definition of Therapy and Counselling is a conversation between two or more people where at the end at least one person feels slighly better and that this conversation is based on understanding and encouragement. Now I think such conversations happen between freinds, family members, might come from teachers, community workers, self help groups and a whole host of other people as well as counsellors and therapists.
Any conversation that does not result in someone feeling better, and is not based on understanding and encourgement is by definition not any kind of therapy.
I think your comparison of the mental health industry to cults is interesting. Jeffrey Masson wrote a book called Against Therapy in which he made that very comparison. Interestingly the introduction iss by Dorothy Rowe, a retired clinical psychologist. She also took part in a debate on whether therapy had cuased more harm than good and she was on the side that said it had. While I am not prepared to throw out all therapists and see them as cult members you are not alone in how you see counselling and therapy.
Thanks, John, I am looking up the book you linked to. Economics plays a part as well. I found that as my economic situation sank, so did the quality of “therapists” I was able to find. Very few accepted public insurance. In the Boston area I couldn’t find any that both took care/caid combination AND knew about eating disorders enough to be any help. Many patients are in the same boat right now. The few I found were either unlicensed fakers, controlling and abusive, or totally off the wall in some way. Before I got so poor, I was able to find “nice ones” but these were really no better. They served to keep me in therapy longer. Some did slipshod CBT not really knowing what they were doing. Because I saw so many bad ones later on, I was able to more clearly see the truth and walked out of the mental illness system for good. The bad ones did me a favor. Of course, I’m lucky they didn’t kill me first.
I find your comments on economics interesting. Basically the poorer you are the less choice you have and the more likely that you will meet an incompetant therapist/counsellor/support worker.
Here in the UK a lot of people get support workers from organisations that work with homeless people, former homeless people and those at risk of being homeless or from other agencies who specilise in helping other clients. The workers are often minimally qualified and not offered much supervision. Sometimes they can be great and sometimes they can be patronising, though often better than mental health workers, sometimes they can be activley damaging.
I found that helping anyone with any kind of behaviour or way of expressing distress was not too difficult provided Istuck to some basic principles and then did some research on the problem they were presenting with. I have not spent a lot of time with people with eating disorders but I know that if Iwas going to I would read anything I could by Suzy Orbach who definitly is not into pursuading anyone to contorl thier food intake.
Hi Julie, I think this is a very good point often overlooked. Therapy is a business. I remember when I worked in a clinic before my position against drowning people in psychiatric drugs made me unemployable. I was scolded for telling a 21 client he was getting better (his presenting problem of depression was pretty much gone) and I reduced him to every other week. The supervising psychologist said this was irresponsible, even though it made my client feel even better. The supervisor was a Freudian and Freudians did that all the time, Tannan Dineen in her brilliant book discusses the techniques for Manufacturing Victims. There are many.
The only alternative to this is to reorganize the economy–and the cultural premises upon which it is based. The false premise is that someone who does something is “earning her keep” even if its building bombs or putting black pot smokers in prison.
Another premise that should be integral to therapy is the client not the therapist should be the judge on when to stop. It’s the clinics who have the interest in keeping the revenue source flowing. And that create a tendency to manufacture victims. The whole economic arrangement militates against the client’s good, the common good. This is true in almost every realm, so that income should not be entirely dependent on doing “work”–since so much work is destructive of the social good.
So I don’t see that CBT is any worse than other modalities. The best are short term. And another premise, alluded to– there are many things therapeutic from becoming part of a group, to acquiring a pet, to falling in love. Things happen which is why passage of time is often as effective as therapy.
But I must admit in the 1980s I found doing family therapy was a very effective modality. For all the reason mentioned. The therapist focused on the present, not the irreversible past. Therapy was intended to be short. Salvador Minuchin whom I studied with (1980s) advocated every other week for a few months, Haley’s maximum was a few weeks. And best of all there was no patient. The patient was the family.
The most important goal was to extricate “patient” from “Identified Patient” role. This carried lasting benefits—a sense of abiding self respect. But it worked in the short term too. Minuchin did acknowledge there were dysfunctional families–but they were comprised of individuals whose strengths went unacknowledged in the pathologizing world of individual therapy in most cases.
Minuchin became famous in the 1970s because he had a 95% cure rate with anorexics.
For Minuchin–similar to R D. Laing–everything that happened in the family was about power. Since Susie’s parents did everything FOR her—a typical enmeshed family— not eating became her only way of asserting herself. I remember great videos of Minuchin sitting down to eat with the family and urging Susie not to eat. TYpically Minuchin would prevent the parents from assuming control over Susie as in “Susie you must eat your dinner or you will die.” Susxie was trapped in the role of ID. As soon as Minuchin normalized HER behavior and defined the parents as extremely intrusive, Susie felt free to develop more creative ways to assert herself. Then Minuchin would work on teaching Mom and Dad to do things together as husband and wife. Again the emphasis is on strengths, not “pathology” and on the present not the past. In just a few months you had “borderline personality disorders” and “narcissistic personality disorders “cured.”
Whereas I had been taught as a psychoanalyst these was incurable. This was a revolution.. This could not last –it was not lucrative. When the drug companies were invited to take over, Susie was put on half a dozen drugs, and defined as a borderline with an eating disorder.
Nothing can last as long as we live in a corporate dominated society. Dysfunctional therapy and the new Jim Crow and near term extinction global warming etc etc are themselves merely symptoms of capitalism which itself is a manifestation of a society based on the illusion that every person is a skin encapsulated ego. The solution here is based on a metaphysical shift in each soul. This is an issue raised by few therapist. These were the questions R D Laing raised in The Politics of Experience.
Seth Farber, Ph.D., The Spiritual Gift of Madness: The Failure of Psychiatry and the Rise of the Mad Pride Movement
Seth, Eating disorders (or rather, eating problems, to avoid their word) happen for a variety of reasons, not just one. There is no one answer. All families have power struggles, but only some end up with ED kids. Many people develop ED long after they have left their families and begun lives of their own. I am convinced that a small portion of the population has a differing physical reaction to starvation. Alcoholics have a different physical reaction to booze than people who never become alcoholics. This has little to do with “defective brain.” More likely, it has to do with liver processing and endocrine factors. I am not an alcoholic. I have tried and failed to become one because I don’t have the right chemistry to get addicted. Problem is, after therapy and drugs, the variety in human biology remains hidden, usually for life, because we’re told we have an “addictive personality.” That’s a totally bogus concept, but it does convince people that they have all kinds of nonexistent mental ailments. While I can’t seem to get addicted to booze, if I starve, I can’t stop. One thing I often write about is the crossing over of that line from “just dieting” to that point of no return. It’s tough to get a person back from that place.
Katie Higgins and I are currently knocking heads together on this and will be coming out with a statement.
As for family therapy, that was the one biggest waste of time I’d ever been through. How many therapists did my family have? Ten? Fifteen? I’d say of all the therapies in which I partook, family therapy served best to destroy my family. The only way I could love any of my bio family again was to reject what family therapy taught me. I am awaiting the day when my brothers and other relatives see the truth of what occurred. Our family wasn’t any more dysfunctional than any other. Family therapy made us an unhealthy family. Actually, that’s true of just about anyone I know. The only family therapy I have heard to be helpful is spiritually based. You can bring your family to church and that might work better than anything that happens in an office. Or just go camping or canoeing. (Don’t bring those money-making therapists along with you.)
I found most therapists had huge power issues of their own. That was MY biggest power struggle later in life.
I found your article educational, interesting, and thought provoking.
I have worked in the community mental health system for 22 years. Very few therapists I know actually carry out a specific approach to conducting therapy with clients. They may call it CBT but it has very little meaning in what actually takes place in the current environment. I would say it is an overall “eclectic mess” with very little oversight, and very much overshadowed and dominated by the takeover of the medical model.
I witnessed the takeover of the diseased based/psychiatric drugging model promoted by Biological Psychiatry in collusion with the pharmaceutical industry. This model totally dominates what takes place within the therapeutic process pushing counselors in the direction of being more focused on “what’s wrong with you” not “what happened to you.” The cocktails of psychiatric drugs that most clients are on creates major barriers, with very few positive examples of people emerging out of this madness.
As a blogger here at MIA I wrote an article posted two years ago titled “Cognitive Behavioral Therapy: The Good, The Bad, The Limitations”; you can access it under writers (Richard D. Lewis) or here http://www.madinamerica.com/2013/05/cognitive-behavioral-therapy-the-good-the-bad-the-limitations/. I am curious as to your feedback on my article. I also use EMDR in my work with trauma survivors and find it helpful for people. What is your opinion of this therapeutic approach?
Wow, Jay, I always love your stuff, but this one really grabbed me. What I’m seeing behind the presentation is that the very CAUSE of much distress that exists is the commodification and branding of everything (and the power dynamics behind that process), and that any real and effective therapy has to be in the place of looking at and potentially undoing those dynamics. But the therapy industry has an interest in maintaining the status quo and hence promote branding and controlling of therapy, and specifically controlling it away from any examination of the external conditions that may be creating these “mental diseases” in the first place. Don’t know if I’m saying that clearly enough: therapy (if we want to call it that) should help resolve power and control issues, with parents, school, work, society as a whole, whereas the industry wants to keep the patients in the low power position so that the powerful can profit and the powerless won’t rebel. And CBT fits the bill perfectly – if you are distressed, it’s because you’re thinking the wrong thoughts. It has nothing to do with your history or events that you were involved with, and it has nothing to do with political or social conditions you are exposed to. If you just learn to think happy thoughts, everything will be OK!!!
I have always been of the opinion that good therapy is different for each person, and I have never been a fan of manualized therapy approaches. This blog has helped me realize what was behind this intuitive sense of distrust in this “evidence-based therapy” movement. It always seemed biased toward more “present-time” approaches and against any attempt to put a person’s narrative history into perspective, even though the latter seemed to be at least an essential part of any effective therapy I’d done or seen done.
I’ve always been eclectic in my approach, as was my own good therapist years ago. I use CBT concepts and teach them, but only as a possible skill-based option for those who seemed to find it helpful. My measure has always been, “If it works for the client, it’s good. If it doesn’t, stop it and do something else. It has always bothered me how CBT took over, and this has given me a much more thorough grasp of both the politics and the fear and greed behind the politics. So thanks again, Jay!
Exactly – ” CBT fits the bill perfectly – if you are distressed, it’s because you’re thinking the wrong thoughts.,” and the government likes the idea that with a bit of CBT, and maybe some drugs, you can return to work pretty damn quick. Or at least that is how it seems to work in the UK. So that results in a conspiracy between therapists and government funders and policy makers to provide lots of short term CBT and not look at the underlying causes of distress.
To look at the underlying causes might mean both governments and therapists engaging as equals with a variety of spcial interest groups such as trade union, women’s groups, ethnic minority groups, survivor groups etc etc and conceding considerable power to the marginalised.
Fortuanately some professionals do engage with special interest groups as equals…
I met someone once who did the booking for a CBT service. He pointed out to his manager that they got an awful lot of clients returning again and again. So the short courses were not working. The manager was not best pleased. But then the companies bid to provide a service where people get packages of care. They have to proove that there perticular service is value for money. The way teh evidence for that is collected and analysed is squewed, much like drug company drug trials are skewed in favour of the drug. That tends to mean that looking at what actually is needed is not valued very much and what makes money for the service provider is more important.
I registered only to show support. You nailed totally nailed.
I’d also add that it’s funny how CBT had to come closer to psychodynamic approach in order to actually do some significant long lasting (structural change) effect in therapy (like scheme therapy).
Psychology lost the “psyche” – the soul long ago so no wonder that cognitive-behaviour approach dominates in the world of psychology.
I also only signed up/in to express my support on your comment and to express myself about cognitive-behavioral approach. It is indignant how popular it has become to treat people with low resources. Much more, it is permeating negatively the psychological and psychiatric world. Excuse me, but people who have been victims of abuse -like myself- CANNOT TOLERATE MORE ABUSE TO GET “CURED”. Besides, I wonder who needs to get “fixed”, the abusers and bullies or the abused and victims. I wonder who was the STUPID who generalized the use of such monstruous psychology. The fact that it might have worked in some cases does not mean it is applicable in all cases. This is one of those cases in which one size does not fit all.
I recently started to date a guy who happens to be a psychologist. Seeing that I have unresolved issues, he said that he was trying to help me. He soon started to treat me as if I were one of his students or a patient. I noticed his cognitive behavioral background immediately. I have almost sent him to the curb already. I was a college professor myself long ago, and I left the career for a better fit. I studied psychology as part of my career. But I also have been very close to victims of abuse -having been one myself in the past. And I wonder who was the STUPID who thought that making a victim of abuse suffer more would help her/him overcome her/his issues. I have stronger words to qualify the STUPID who generalized the use of that therapy. I’d make that person raped, abused, bullied, belittled, humilliated and then submit him (it was surely a male a**) to that mental torture. He’ll find out it’s a stupid idea to surpass the suffering threshold of a person to “fix” her/him, that I may assure you…
“I wonder who needs to get “fixed”, the abusers and bullies or the abused and victims.”
Great point. I remember wondering about it too – the whole approach looked like telling rape victim: “here is how you learn how to not dress provocatively”. It seriously made me want to punch the guy in the face. The whole psych field is all about protecting abusers and blaming the victim. It’s not about helping – it’s about covering up and making sure that the victims take it on themselves and don’t make waves.
I bought four books on CBT. One of them wanted you to list the “pros and cons” of medication for you; as if there are any “pros” since, they damage your mind, body, and spirit so horribly. I worked on one CBT book’s little exercises. I found out that all it did was emphasize the “anger” I already had towards my psychiatrist who still considered me “defective” and “in need of medication to prevent a relapse.” I ended up staying awake all night trying to deal with this “anger” I already knew I had. In retrospect, I know I wasted my money. I had been told how great CBT was. Now, I know it is a sham. I know that some may disagree with me; but, for me I have found the only real help in God, Jesus Christ, and Biblical Scripture and the community I have been able to find in a new local church. I pray each person finds the way that works for you; so, you can see the truth and realize you are not “defective” after all; but a real live human being with a real live destiny and life purpose. Also, realize that is truly okay to be yourself and not deny who you really are. And someday, you can say to yourself like the old hymn; “it is well in my soul.”
I registered too.
I long didn’t see the dangers of CBT until last weekend I had a CBT teacher in class.
He was in favor of bullying others into submission and proud of how much he treated his patients like stupid children.
CBT may work for people who are used to being abused and accept authority.
My inner most self revolts against such hideous attacks against my integrity and I feel compelled to attack such methods of making people comply.
Great article. Congratulations.
Whoa, this was a really great read. Since this has suddenly come up again on the comments feed – Jay, I wonder if you’ve seen this essay by an anti-psychiatry nurse making a similar critique?
A couple more things: If you want to change your thinking, read books! Get educated! Take classes! Do art! Go for a run! My guess is that in the long term, or even the short term, MH “care” is most likely far more expensive than college! How many of us had to defer on college loans? How many parents had to give up the idea of paying off the mortgage?
#2: Remember, many therapists work fee-for-service. For those of you who don’t know (or live in places where this doesn’t happen) this means if the client doesn’t show, the therapist doesn’t get paid. The request by a supervisor to “get your numbers up,” means “improve your clients’ attendance.” A salaried position is considered to be more lucrative for the therapist since income is more reliable and steady. The therapists liked me. I was meticulous about showing up, not only that, on time. (I feel so flattered knowing that I was mere commodity for over three decades.)
I guess nowadays I’m meticulously noncompliant. If it’s possible to do a thing unconventionally, differently, offbeat, outside the box, rule-breaking, creatively, or weirdly, I most certainly do! Why bother with recipes when you can make up your own? (A year ago today, I baked my own invention, a “Liver birthday cake” for my Puzzle, my dog, decorated with green pepper icing and carrot stick candles, eight in all with one to grow on….)