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 . 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.