What follows in the next few posts is a longish essay on CBT as the dominant force within applied psychology, and its place as an ideology which supports various practices of domination.The length of this essay is unwieldy for a blog format, so I have broken the piece into sub-sections, which I will publish one at a time, before eventually assembling the piece into pdf form. As ever, discussion is welcome.
The structure of the piece is as follows:
1. Cleaning the Augean Stables
2. The Founding of CBT,and Beck’s Foundational Errors
3. Psychology, Epistemology, and CBT
3a. A Note on Psychometrics
4. The Ethics and Politics of Intervention
4a. Two Brief Case Studies in Biopolitics
5. Project for an Unscientific Psychology
- Cleaning the Augean Stables
It seems to me an urgent task to critique the dominant ideology which has psychology in its grasp, namely Cognitive-Behaviour Therapy (CBT). As a general rule of thumb, whenever one sees an acronym in psychotherapy, one can assume the presence of glib, corporate-friendly pseudo-scientific pap, and that is entirely the case here. However, unlike NLP, for instance, (I do not mention more popular doctrines, but I mean them), CBT is taken seriously by many clinicians and patients alike. Despite numerous signs of its weakening, CBT remains strong where it is most influential, namely, in academia, third-party payers, and among regulators.
The widespread influence of CBT has led to it being regarded by some as self-evidently ‘scientific’, ‘empirically-validated’, and above all, effective at relatively low cost. This view is necessarily at odds with slower, non-directive treatments, including my own, namely, psychoanalysis. When it comes to the above entities – academics, third-party payers, and regulators – one should not imagine that a range of treatment options exist harmoniously alongside each other in some therapeutic marketplace. On the contrary, CBT’s predominance comes at the expense of everything else, and many of CBT’s supporters are actively calling for other treatments to be regulated away. Psychoanalysis, in particular, seems to arouse an ire that borders on the irrational, and that should lead any good psychologist to question whether something symptomatic is afoot.
Calling CBT into question is not without some risk for a psychologist. Psychology polices its dogmas all the more fanatically for being beyond the domain of legitimate science. Assumptions underpinning the discipline are largely unquestioned, despite there being no agreed-upon, a priori foundation for psychology in the first place. This is the intellectual and cultural milieu in which CBT has thrived, and this is why there is a pressing need to clean out the Augean stables, or, to put it in Marx’s terms, to wade through psychological filth.
To this end, there are a number of points that I wish to demonstrate, and above all, I wish to show that CBT is not merely useless, but harmful, and more harmful precisely where it is ‘effective’. I shall argue that CBT was begun by Beck on the basis of a series of foundational errors with respect to its schism with psychoanalysis. Further, despite splitting from US-based ego psychology, Beck retained and exacerbated the worst elements of this discipline, and these remain to this day. I will demonstrate also that CBT is an empirical and epistemological failure, and finally, that it is ethically and politically disastrous in its aims, applications and effects. It quite openly makes each individual ‘the principle of his own subjection’, to borrow a phrase from Foucault. Finally, I will suggest some positive alternatives. In what follows, there are few empirical citations, because my emphasis here is on errors of reason or, as they have been rebaptised, ‘cognitive distortions’.
A couple of further points are worth making by way of introduction. First, debates in psychology are not generally resolved through ‘science’, but rather, the triumph of money and institutional power. A case in point is the example of CBT for schizophrenia. CBT is widely promoted as an intervention for psychosis (for instance, by NICE in the UK), despite the lack of one shred of evidence supporting its effectiveness. Even by the warped and pseudoscientific standards of CBT, CBT itself fails to make the grade. None of this, however, seems to disabuse certain zealots and regulators of their faith in it. CBT is eminence-based therapy, evidence be damned, and one can be but pessimistic about the fate of arguments lacking in eminence.
Secondly, in critiquing CBT, I have no intention of besmirching the many psy-practitioners who operate under its banner. I am perfectly aware that many clinicians who notionally regard themselves as practicing CBT do not do so dogmatically. If they did, their patients would not return for a second session. Of course, these notional CBT practitioners incorporate elements from ‘non-empirical’ psychotherapies. Of course they will, at times, put down their standardised manuals, and listen and respond, in vivo and empathically, to a suffering person. Of course, they are careful about implementing the patronising ‘tools’ and advice of their discipline, and of course, many take an ethical stance with regard to their patient’s rights. In short, they do therapy, or something very much like it. Nevertheless, insofar as these notional CBT practitioners are doing these things, they are not doing CBT, and moreover, they are not performing a standardised ‘evidence-based’ treatment. Since this latter is CBT’s great claim to fame, relinquishing the imprimatur of scientific authority also deprives CBT of its sole raison d’etre. CBT either trivialises human relationships where it is not opposed to them; it is not for nothing that CBT is the computerised treatment of choice, abolishing direct human relations altogether. (The primacy of ‘efficiency’ over the relational is a defining feature of CBT). Naturally, this sort of thing is proffered in support the ludicrous notion that the scientificity of a psychological treatment resides in its being ‘standardised’ in the manner of a recipe book. As an aside, the other ‘scientific’ notion of outcome studies, namely, quantifying subjective suffering, is equally absurd, but this absurdity is to the shame of psychometricians rather than CBT per se). As we shall see, CBT (and its friends in the DSM and elsewhere) need to draw on a discourse of public health, in the first instance, to warrant authoritarian interventions into ‘harm’ reduction, and then need to invoke scientific discourse to justify the latter. However, invoking the trappings of scientific discourse is no more a guarantee of scientificity than is invoking alchemical discourse a proof of making gold in one’s basement.