Psychoanalysis was the first of the systematic talking therapies. The first couple of generations of psychoanalysts consisted principally, with some notable exceptions, of Central European Jews from Vienna, Budapest, Berlin and elsewhere. By the 1930s, this part of Europe had fallen to fascism, and this cataclysm was ominous (and eventually catastrophic) for Jews. A diaspora ensued, with Freud himself relocating to London, and many others moving there also, with other prominent destinations including Paris and the Americas. In these diverse environments, various sub-schools of psychoanalysis emerged, with considerable differences in their theory and practice. ‘Ego psychology’ was the sub-school which dominated psychoanalysis in the US to such an extent that it came to be identified (by some) as the only ‘true’ form of psychoanalysis. It was out of this context – post-war US, mass demand for psychological interventions, and the growing influenced of managed care – that Beck’s CBT first emerged.
The identification of ego psychology as the true bearer of Freud’s legacy is problematic, in that Beck and his followers seem entirely unaware that it does not represent the whole of psychoanalysis. Ego psychology in Chicago and New York was a very different sort of psychoanalysis to that practiced in London, Paris, and Buenos Aires or, for that matter, by Freud himself. One can imagine that if CBT emerged in London, perhaps its practitioners would have had a better grasp of relational psychology, through Klein and Winnicott. In Paris, Beck might have learned something about linguistics and philosophy under Lacan, who spent the 1950s critiquing his US counterparts. Instead, Beck tried and failed to become an ego psychologist, eventually splitting from them, but retaining a number of their features.
What were the problems with ego psychology? The sharpest critique of ego psychology comes, in my view, from within psychoanalysis, namely, from the work of Jacques Lacan in the 1950s. Lacan’s objections to ego psychology are worth noting, if only because the apply even more emphatically to Beck’s ideology. First, ego psychology functioned as the police bureau of international psychoanalysis through its Stalinist capture of the institutions (i.e. the IPA). CBT has continued this tradition in various settings where its proponents have won bureaucratic control, and where they try to regulate other perspectives out of existence (through protocols, or credentialism). The moniker ‘evidence-based’ does some heavy-lifting in justifying these purges, in which CBT relates to the rest of clinical psychology much as ego psychology dominated the rest of psychoanalysis.
Secondly, ego psychology positioned itself as ‘classical’ psychoanalysis, its practitioners the true heirs of Freud, much as CBT asserts its place as a properly scientific form of psychology and intervention. Of course, the ego psychologists displayed considerable ignorance of the texts of Freud (and the other founders of psychoanalysis), and deviated from the latter’s teachings to the point of constructing a brittle dogma that was frequently antithetical to them.
Thirdly, both ego psychology and CBT are directed towards a conformist mode of ‘adaptation’, in which subjects develop a ‘conflict-free’ ‘autonomous ego’ or free themselves from ‘distorted cognitions’, the better to take their place as automatons in a consumerist-liberal social context. Unsurprisingly, in the context of post-war USA, CBT has taken up this normatising, conformist role with more ruthless efficiency than the ego psychologists ever could. Why spend years, multiple times per week, gradually identifying with your ego psychologist’s ‘healthy ego’, when a CBT practitioner can simply panel beat your distorted cognitions into the correct shape in a few sessions? Whenever one hears the claim that CBT is the more ‘effective’ treatment, we can confidently translate this to refer to its role as the most cost-effective form of psychological social control.
Fourth, the very notion of an autonomous consciousness, of a conflict-free zone within the ego is more or less shared by both ego psychology and Beck. (Of course, the latter has appropriated the discourse of cognitive science rather than ego psychology, but has essentially duplicated the same aims and concepts). Both approaches presuppose a wilful ignorance and devaluation of the unconscious, even though the unconscious is the fundamental concept of psychoanalysis (and a significant, if not absolutely vital concept for cognitive science). If the unconscious exists, then there literally cannot be an ‘autonomous ego’ any more than there can be truly ‘non-automatic cognitions’, as these phenomena would both be subject to a causality that lies elsewhere. Such logical niceties, however, are of even less interest to CBT than they were to the ego psychologists. The consequences of this ignorance are nonetheless grave. Both CBT and ego psychology are committed to a ‘correcting’, or making ‘healthy’, or strengthening of the ego. Both are directed towards greater ‘self-reliance’, and a managerialising (or even militarising) of the self. The self that is assumed by these ideologies is always, of course, the alienated subject of neoliberal economies. (This is well-illustrated by some recent, hubristic declarations that CBT promotes ‘human rights’ for psychotics. The rights in question are, our humanitarians tell us, those of ‘consumer empowerment’. This grotesquery of neoliberal buzzwords is not satire.)
Fifth, perhaps the final key point of Lacan’s critique of ego psychology was its ahistoricism, namely, its utter failure to register that these sorts of means and ends – ‘adaptation’, a ‘conflict-free’ ego, and so forth – were entirely historically contingent, and specifically localisable to a US context. The notion that one should pursue ‘happiness’ at all (and the other notions of ‘growth’, ‘self-actualisation’, etc, beloved of US psychology) is stripped of its inherently narcissistic, consumerist and individualist historically-specific context. Moreover, this applies also to the notion that one attains a ‘healthy ego’ or ‘non-distorted cognitions’ through indoctrination and identification with a supposed ‘expert’. These notions – so ubiquitous as to be virtually self-evident in the Anglophone world at the present time, would be recognised by many in (say) Russia, or China, or Greece as glib and patronising idiocy. Nevertheless, the explicitly ‘corrective’ function of psy-intervetion was introduced into psychoanalysis not by Freud but by the ego psychologists, and greatly exacerbated by Beck and his followers. (It should be added that psychoanalysis in the US has, for some decades, moved away from the ego psychology of the 1950s and 60s).
Thus it was that in virtually every key respect, Beck the failed psychoanalyst remained an ego psychologist par excellence, and took its goals for granted, albeit, with a more hardnosed, Taylorist focus on efficiency, productivity and micro-management. The main differences between ego psychology and CBT are in the ‘scientific’ language employed by each, with Beck (presciently) taking his nomenclature from the experimental discipline of cognitive science. Cognitive science is an attempt to study mental processes on the functionalist analogy of the mind as information processor. It has lent some empirical rigour to the study of certain phenomena, such as learning and memory, though it is fatally constrained by its assumptions. For instance, it operates on the basis of almost-total metaphysical/ontological ignorance, and completely distorts certain topics (such as language, or emotion, neither of which are primarily or principally reducible to mere ‘information’). Still, cognitive science has some merits to go along with its limitations. Unfortunately for CBT, Beck borrowed the latter without also taking the former, and CBT stands in roughly the same relation to cognitive psychology as does Gestalt therapy to Gestalt psychology. This is to say that, apart from some appropriation of language, they have virtually nothing whatsoever to do with each other. ‘Cognitive’ terms and language help to market CBT as a credible discipline (in spite of the positive thinking, distraction, managerialism and other ‘strategies’ it deploys) but one should not imagine any underlying continuity between the two disciplines. CBT emerged from a failure in US psychoanalysis, and not from a then-nascent experimental science of mind.
Beck and his followers based their ostensible rejection of psychoanalysis on two primary arguments. The first was Beck’s rejection of Freud’s theory of wish fulfilment, and the second was Beck’s rejection of the psychoanalytic theory of melancholia. Both of these rejections derived from Beck’s attempts to test the above experimentally, which his mentors in the IPA bureau took as proof of his resistance to psychoanalysis (hence his failure to become an analyst). An analysis is essentially a private matter, and we are in no position to ascertain whether Beck was ‘properly analysed’, but his experiments, if nothing else, produce the clearest evidence available that he barely understood a word of basic psychoanalytic theory (not to mention linguistics, philosophy, science…). Nevertheless, both Beck’s entry into psychoanalysis and his attempt to refute it were unambiguous failures.
Let us tackle Beck’s ‘refutation’ of the psychoanalytic theory of wish fulfilment. (As ever, Beck appears largely ignorant of the psychoanalytic literature, and apparently does not take into account Freud’s later modifications of his theory, in Beyond the Pleasure Principle, for instance). Beck attempted to study dreams experimentally by surveying the dreams of depressed and non-depressed individuals, hypothesising that depressives should dream in such a way as to exhibit hostility, ultimately for themselves.
The problem, however, is that neither Freud nor any other analyst of note ever claimed that dreams could be interpreted in an ad hoc, experimental context outside of an analysis. To attempt to interpret the dreams of others – even if one rejects psychoanalysis – involves ascribing a meaning to their language as if it were transparent and self-evident. Yet this is obviously not the case, which means that Beck’s attempts to make dream interpretation empirical not only missed the ‘latent’ content entirely, they completely and more grievously did violence to the manifest content. To borrow from Walter Benjamin on translation, Brot and pain are strictly not ‘interchangeable’ words which can stand in for some universal notion of bread, in that a German and Frenchman refer to specifically different things by these terms. Moreover, these differences are amplified further when one turns from entire cultures to individuals. ‘Bread’ as symbol or signifier cannot be given a universal, self-evident meaning. It may mean something different to a baker than to a gluten-intolerant person, and something different for a Catholic (for whom it is linked with the Body of Christ) than to a Russian (who may have heard from his or her babushka stories of horror involving bread during the siege of Leningrad). In short, there is literally no way to interpret such a symbol except with a detailed knowledge of a subject’s history and linguistic/conceptual associations (i.e. by a subject interpretating for themselves within a psychoanalysis, or something closely resembling it). This richness of difference, the intricate nuance of each symbol in a subject’s psychic life was bulldozed and levelled off in its entirety by Beck, who imposed his own interpretations onto his experimental subjects. As ever in psychology, qualitative phenemona are distorted to the point of destruction when forced to submit to some quantitative fetish. With such woeful misunderstandings of the theory he was ‘testing’, and with such a grossly inappropriate experimental method, the results of Beck’s labours are literally irrelevant, and tell us nothing either about psychoanalytic theory or dreams in general. This sort of slapdash engagement with psychoanalytic ideas is characteristic of CBT attempts at rapprochement, and if Beck’s early efforts were intellectually embarrassing, they are nonetheless brighter and more honest than those of his followers, who eschew the close reading of theory entirely.
The second plank of support for Beck (and CBT’s) ‘empirical’ repudiation of psychoanalysis is a critique of the psychoanalytic theory of melancholia. All that Beck appears to have gathered from the many psychoanalytic papers on the topic is that depression has something to do with ‘internalised’ or ‘retroflected’ hostility. Beck tried to refute this on the basis of experimental data, arguing that depressives actually did not want to be depressed, but, for instance, sought encouragement from others. Beck then observed (correctly) the depressives exhibit harsh self-reproaches, or pessimistic statements about the future or the world, and inferred (rather wildly) that these views were necessarily irrational and causal of the depression itself.
There is so much amiss with Beck’s position here that an essay-length response is needed, and I will offer a few mere remarks. First, we should recall that Freud’s key text on depression (‘Mourning and melancholia’) was a speculative paper written during a transitional period. It makes no reference to introjection, to masochism, to the superego, or to any of the other concepts that dominated US ego psychology theories of depression, to say nothing of the many other psychoanalytic works on the matter available in the UK or France. Freud made little reference to aggression, instead emphasising, above all, ambivalence and libidinal withdrawal. It is not difficult to demonstrate that, once again, Beck was recklessly reductionist in his treatment of psychoanalytic concepts, to the extent that he could not possibly have examined them ad hoc and experimentally, or any other way. There was always much more to melancholia than ‘internalised anger’, and a less dogmatic and provincial approach to things might have led Beck to a closer reading of Freud, or to the ideas of Klein, or Lacan, or Winnicott, or Spitz, or Bowlby. Instead, he was left ‘experimenting’ with nonsensical concepts in order to refute the straw-theories of his imagination, which is to say, setting an example followed by much CBT research since. Moreover, just as dream symbols are strictly non-generalisable, so are depressive complaints and symptoms. Beck would be suffering from cognitive distortions of his own if he thought that he could magically divine the proper meaning of utterances in experimental subjects whom he did not know. For Beck, symptoms, symbols and signifiers all become mere units that take on a bland, meaningless equivalence, with the necessary consequence that his ‘refutation’ of psychoanalysis actually has nothing to do with psychoanalysis.
Beck apparently saw (and sees) language and thought as interchangeable, when patently, they are not. If Beck had considered that others’ ‘cognitions’ were by definition unknowable, and had instead focused on patients’ discourse, he might have been able to see beyond a one-to-one correspondence with speech and subjective suffering in depression. (For instance, in a given context, a depressive self-reproach may have little to do with a patient’s worldview, but instead be an invitation to an interlocutor to offer praise or comfort. The nature of language is exchange, not cognitive ‘information’). Moreover, Beck’s explanation for the statements of his depressives is hopelessly tautological. It is definitional of melancholia that the subject experiences subjective misery, and, in general, that he or she says unkind things about self, world or future. One of Molière’s doctors, when asked how it is that opium causes sleep, says that it is due to the ‘sleep-inducing faculties’. Like the good doctor (and like psychometricians), Beck attributes depression to the depression-inducing faculties. Of course, such answers belong in comedy.
With such inauspicious and unscientific beginnings, it is worth wondering how it is that CBT could have become so successful. A certain proportion of its success can be explained by its capture of the bureaucracies, and its penchant for senseless quantification and standardisation, beloved of policy makers and corporate health providers. It was radically unscientific and unempirical, but was nonetheless able to market its laughable notion of empiricism as a kind of scientific norm. It also took what are to my mind the very worst elements of ego psychology – its unethical, and subtly coercive push toward ‘adaptation’ – and made it quicker and cheaper. Unsurprisingly, Beck’s followers are embarrassed about CBT’s origins, and are unreserved when it comes to attacking psychoanalysis. Is this tendency not itself a little symptomatic? In Australia, a majority of the population is terrified and outraged by asylum seekers arriving by boat, an anxiety which perhaps harks back to the original ‘boat people’ (i.e. British colonisers) who indeed did conduct a program of land seizures and extermination. In the shrill attacks on psychoanalysis from CBT, one would be deaf to hear only fair-minded ‘scientific’ criticism.
Reblogged this on Freud in Oceania and commented:
Part two of a series
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Thank you for taking the time to articulate some of the problems with CBT. There is much here to chew on for a long time. Interesting what you were saying about Beck too. I’ve tried googling him to see if I can find out much about him – but unlike most of the prominent early figures in psychoanalysis there seems to be very little known about who he was as a man and what his particular context was. As this is the closest we can probably get to having an “objective” view of where a theory has arisen from, it’s concerning – and seems somehow to fit with CBT’s desire to generalise and remove from context. I’ve just had a year long course in CBT; an experience that raised so many questions. Questions weren’t welcome on the course though so I have been unable to chew and digest the experience. (and eliminate waste). That’s what I’m trying to do now. So….thanks! I’m looking forwards to reading the next part of your critique.
Thanks for the comments, Mary. I believe that the founders of CBT – Beck and Ellis – both had a background as renegades from US ego psychology, which shares a few of their values and aims. The aims of the latter tended to focused on ‘ego strengthening’, making the ego a ‘conflict-free zone’, ‘adaptation’, etc. As I understand it, Beck largely accepted these aims (albeit, in the language of cognitivism rather than psychoanalysis) but thought that it would be quicker to achieve them with homework, ‘techniques’ etc rather than free association and a transferential relationship.
Thanks David. That does help – although I’m much more familiar with the object relations school. Probably as a result I found myself wondering about Beck’s personal background and the relationships in his life.
It’s interesting that he was rejected by the psychoanalytic establishment. He has carried out quite a vendetta against them.
CBT lacks scientific foundation. It is funny first accusing CBT and then citing a well known charlatan like Lacan. Typical for a left wing ideologist. The song is always the same. CBT is a method to create fitness for the social rat race and prevents to work for the communist utopia and is not a method to understand your mind, which might be helpful even the communist society will be achieved, because what Freud called the discomfort in culture will always remain.
The critique of CBT that I offer here is not particularly Lacanian, and it stands or falls irrespective of one’s views on Lacan. I was attempting to critique the supposed ‘science’ of CBT on first principles, and for that, one needs no recourse to psychoanalysis.
And whilst it is true, I suppose, that I am a ‘left wing ideologist’, I really wonder who on the right would be so stupid, unethical, and ignoble to endorse something like CBT. No doubt, the same sort of person who speaks of creating ‘fitness’. Others may have different views, but if we were to situate CBT politically, I would place it with the various forms of numbers-driven, reductionist, technocratic forms of right-wing liberalism that are so prevalent in the Anglophone world.
I think the followers of Lacan have most of the times an inferiority complex. They strive for superiority and hide their inferiority beneath incrompehensible gibberish, which gives them powers over their adepts. Lacan was successful in this. He had a lot of women. By the way with Alfred Adler their is a bridge between psychoanalysis and CBT.
‘It’s incomprehensible’ – this is the shriek of the child who hasn’t bothered to do any homework.
As for Adler, I read his books at length many years ago. In the end, he rejected virtually every principle of psychoanalysis. If there is a bridge between analysis and CBT, I think it is to be found in the Anglophone analysts who, like CBT, debase themselves before pseudo-empiricism and appropriate attachment theory, pop neuroscience, Adler, psychometrics and whatever else will help them sell their shoddy wares on any given day.
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Right off the bat, you make very major errors that say to me you haven’t done enough reading on CBT to properly critique it:
In part 1 you state: ” insofar as these notional CBT practitioners [listen and respond, in vivo and empathically, to a suffering person] they are not doing CBT, and moreover, they are not performing a standardised ‘evidence-based’ treatment.”
Listening and responding empathically to patients (or more accurately, being perceived as such by the patient) is an absolute necessity of CBT. It’s evidence based insofar as evidence based interventions cannot be properly taught and implemented where the therapeutic alliance is weak. Evidence based medicine has long understood and emphasized the critical role that patient values and preferences makes to the effective implementation of evidence based practice. Here’s a link to a video by Judith Beck (daughter of Aaron Beck) emphasizing the importance and essential nature of empathy to the therapeutic alliance: https://youtu.be/N65OWrTbQNg
In his seminal work on the treatment of depression, ‘Cognitive Therapy of Depression’, Aaron Beck states that he actually considers CBT a Humanistic approach to therapy.
In part 2, you state: “CBT [is] directed towards a conformist mode of ‘adaptation’, in which subjects develop a ‘conflict-free’ ‘autonomous ego’ or free themselves from ‘distorted cognitions’, the better to take their place as automatons in a consumerist-liberal social context.”
Totally false. Cognitive restructuring has nothing to do with making patients into “automatons”, or enforcing conflict free thinking or expunging distorted cognitions. To give you an example – when a patient is depressed, they tend to interpret reality through the lens of their depression, at the expense of considering evidence and alternatives to the contrary, and neglecting to examine the potential implications and helpfulness of their beliefs.
“I’m ugly and I’m never going to find love. I’ll die alone and miserable” thinks the depressed patient. The good CBT practitioner encourages the patient to think about this belief critically – What does it mean to be ugly? Is it a subjective or objective value judgement? Has anyone ever found you attractive in the past and contradicted this belief? Can you really predict the future with such accuracy? To what degree is this a self-fulfilling prophecy when your beliefs create the circumstances by which you never look for love in the first place? etc..
Good CBT is the opposite of encouraging conforming – it encourages us to question and critically examine everything (most especially ourselves). It doesn’t strive towards an impossible “conflict free ego”, if anything it encourages conflict with one’s automatic negative assumptions through critical thought, where one’s automatic negative thoughts are considered as just one interpretation among the many potential interpretations and viewpoint that get over-looked. This is nowhere near comparable (or even vaguely adjacent) to your mischaracterization of it as some kind of indoctrination of an ideology of “correct thought” to serve the capitalist overlords (or whatever asinine, unsophisticated misinterpretation of Leftist thought you spout above)
It’s ironic that you say that CBT would have perhaps benefited from having originated in London and the Kleinian psychoanalytic tradition, because what CBT practitioners do and teach patients during cognitive restructuring (ie. challenging distorted cognitions) is akin to encouraging a shift from a paranoid-schizoid mode of thinking to a more depressive mode of thinking (to use Kleinian psychoanalytic terms).
Thanks for engaging with my post, Henri. A couple of points:
I’d be a little more sceptical, if I were you, when it comes to the Becks whispering sweet philosophical nothings into your ear. AT Beck and Ellis are magpies with philosophical doctrine, grabbing little out-of-context snippets from myriad sources when it suits their purposes. They do this with stoicism, and existentialism, without ever seriously engaging with these doctrines. They can’t engage with them robustly, because if they did, CBT wouldn’t stand up. So when I hear claims of ‘humanism’, I think that we should recall that CBT owes much of its ideology to behaviourism and to the information processing model, which are two of the most radically mechanistic and reductionistic paradigms to be found in psychology The treatment itself, insofar as it is manualised (and thereby standardised and ‘evidence-based’) is also mechanistic. If this is humanism. Viktor Frankl was a brown shirt.
My point about empathy was, among other things, not that CBT practitioners necessarily lack it, but that its epistemically vague (and not really as ‘evidence-based’ or standardisable as all that) and instrumentalised for compliance. For the likes of Carl Rogers, or Hein Kohut, empathy is an end in itself, but not for CBT, where it’s yet another technique to promote the clinician’s agenda..
when a patient is depressed, they tend to interpret reality through the lens of their depression, at the expense of considering evidence and alternatives to the contrary, and neglecting to examine the potential implications and helpfulness of their beliefs.
This is a restatement of the basic CBT thesis, namely, that negative affects arise from an error of reason (i.e. a failure to consider evidence, or the helpfulness’ of beliefs). It’s false, in the first instance, and authoritarian in any case.
Is it a subjective or objective value judgement?
If we find a CBT practitioner who thinks he knows something about ‘objective value judgements’, the only thing of which we can be assured is that we are dealing with an authoritarian.
If CBT was merely some gentle questioning as you suggest, that may be one thing, but Beck and the library of treatment manuals contradict you. CBT is explicitly directive, and yes, it is oriented by adaptive ends (according to the clinician). Negative thought is subtly but systematically pathologised, and CBT places itself in stark opposition to the vast tradition – from Sophocles to Ecclesiastes – which asserts that truth and wisdom are painful, rather than pacifying.
And yes, you’re correct to suggest that I hold a leftist perspective, broadly speaking, in this piece. I would struggle to find a non-leftist thinker of any worth who would endorse CBT. Can you imagine Dostoevsky filling out a pleasant activity schedule? Or Nietzsche doing homework to check himself for catastrophizing? CBT is much more on the side of paranoia or obsessionality, since it assumes a unified subject who can think his or her way out of trouble. It is directly used to extract compliance and conformity in the clinic and the workplace – see Seligman’s work with the US defence department for clear examples. It’s a scam in other words, and you’ve been had.
> “For the likes of Carl Rogers, or Hein Kohut, empathy is an end in itself, but not for CBT, where it’s yet another technique to promote the clinician’s agenda”
Rogers and Kohut fundamentally misunderstand the role of empathy in therapy – It’s no good if the therapist feels empathy with the patient if the patient ultimately doesn’t feel empathised with or understood. CBT attempts to bring empiricism into the room by asking for feedback on the nature of the therapeutic alliance after every session. It seeks qualitative data from the patient on the nature of the alliance, and to that degree, it’s in keeping with evidence based practice. In this sense, CBT is the only therapy that really cares about real empathy as it’s experienced by the patient, rather than the solipsistic approaches of the other schools that only care if the therapist feels it.
> “This is a restatement of the basic CBT thesis, namely, that negative affects arise from an error of reason”
Beck has stated consistently that we don’t fully understand the etiology of depression (or any mental illness, for that matter), he’s been saying this since at least the 70s: “The Cognitive model does not address itself to the the question of the possible ultimate etiology or cause of depression” (Beck, A. (1979). Cognitive therapy of depression. New York: Guilford Press. Page 19). Cognitions impact affect (which is the only assertion CBT has ever made, despite the many people mischaracterizing CBTs position). Depressive symptoms don’t necessarily arise from “an error of reason”. Depression can have numerous and complicated biopsychosocial causes, and cognitions and behaviors just are one piece of the puzzle.
You have to do your reading if you’re going to attempt a take-down of CBT. You can’t talk this arrogantly and yet be this sloppy in your research.
> “If we find a CBT practitioner who thinks he knows something about ‘objective value judgements’, the only thing of which we can be assured is that we are dealing with an authoritarian.”
The question of subjectivity and objectivity is put to the patient, to explore where they derive their values from, not to spoon feed them answers. Guided discovery in CBT might go something like this: “Is there such a thing as someone being objectively attractive? If so, how did society arrive at this conclusion and who gets to be the arbiter of this standard? And even if you believe there is such a thing as objective beauty, and you don’t believe you embody it, does that mean that nobody could ever find you attractive by their own subjective standards? Does being unconventionally attractive preclude you from being loved? Can you think of any unconventionally attractive people who have happy relationships?” etc. etc. Exploratory (not rhetorical) questions like that are anything but authoritarian, they’re explicitly anti-authoritarian.
If a patient says he doesn’t agree with you or want to do something in therapy, you have to listen or you’re doing bad CBT. The rationale for everything needs to be explained to every patient as standard in CBT because patients are regarded as equals. You want to talk about authoritarians, look to the psychoanalysts (not all, but many). You don’t agree with my interpretations? That’s resistance to unconscious material. How do I know that? You don’t need to worry about that, I’ve had my own analysis, you haven’t. You want to know the rationale for my interpretations? That’s resistance to the work. If authoritarianism is your bete noire, you might want to aim your criticisms closer to home first.
> “CBT places itself in stark opposition to the vast tradition – from Sophocles to Ecclesiastes – which asserts that truth and wisdom are painful, rather than pacifying.”
Truth isn’t inherently painful or pacifying. In CBT, the glass is neither half full nor half empty; it’s a glass with a 300ml capacity with 150ml of water in it, and we’re going to explore why you assume and interpret this to be half full or half empty. You accuse CBT of authoritarianism and yet here you are, making cheap appeals to authority.
This comment is becoming a tome, and I know I’m never going to convince someone whose career and income are tied to them never acknowledging what I’ve said, so i’ll leave it on this point – psychoanalysis has a place as an art, to explore meaning, personality and narratives, similar to any other work of performance. Where psychoanalysts respect their patients’ autonomy, make tentative interpretations and make clear from the outset that analysis is art and is not about cure or feeling better but creative personality exploration – I have zero qualms with it, in fact, I have a great deal of respect for it.
My issue is with analysts who want to argue that because evidence based medicine isn’t perfect, everything else is as legitimate as EBM, baby out with the bathwater, when it’s not. All of the criticism aimed at evidence based practice in psychiatry and psychotherapy can be aimed at medicine in general, and only the most disingenuous of people would tell someone with an physical illness “The health industry is in the pockets of big pharma, only 13% of all medical treatments have a good evidence base (this is a real statistic!), and research papers which find negative results are underpublished… so maybe it’s time for you to consider crystal healing.” Even with all its flaws, evidence based practice is preferable to all the alternatives.
Most patients want a reduction of symptoms and practical problem solving as expediently as possible, and that is what CBT aims to deliver through evidence based practice. Symptom reduction from depression and anxiety is a priority for most patients because (no surprises here) they want to be able to function in their daily lives as quickly as possible, first and foremost, and as a bare minimum. We have a duty to be able to find out how to do that effectively and provide that as therapists. “But what about the greater truths at the heart of what it is to really live?” I can hear you splutter, well most people don’t want to spend years on a coach navel gazing and soul searching, and psychoanalysis doesn’t guarantee you’ll find it even when you do. You can sit there and scoff “You’re just shaping people to be cogs for the capitalist system man!”, but let’s be real – the sort of people who go to Lacanian psychoanalysis are the university educated, wealthy middle-class who have enough disposable income and leisure time to engage in analysis. And good for them, but don’t position yourself as some kind of class warrior against the capitalist system when your entire approach locks the working class out of therapy and restricts it to the elites. The utilitarian and resourceful nature of CBT at least attempts to combat this.
I don’t have the time or energy to address everything you’ve said Henri but that’s a horrible misreading or non-reading you have done of Rogers and Empathy right there. He was concerned with being non-judgmental and actively checking understanding. If you’d experienced good Rogerian therapy you would know – it really is wonderful to be listened to properly. He as also a huge propronent of seeing what works and what doesn’t work in therapy which is how he boiled therapy down to the “conditions”. His conditions take into account the fact that everyone is individual so that one therapist being congruent is very different from another therapist who is being congruent – but the point is that the other person in the room is real.
CBT, in an effort to fit in with the hard sciences, has bent itself all out of shape, with extensively prescriptive manuals which preclude much of a relationship ever developing between therapist and client. Happily therapists are people and, as far as I’ve been told, don’t follow the manual as soon as they’re no longer being taped. This is good in the short-term (for the client) but it means the understanding of what CBT is is horribly skewed and perpetuates a belief amongst people who don’t know, like GPs, that CBT is in some way a “treatment of choice”.
I think psychoanalysis misbehaved in terms of grasping for power and met its downfall (not permanent, but it fell on its face badly) – I see the same thing in process with CBT and that’s a good thing.
I’ll leave aside, for now, the misconception of empathy that you are working with, and the customer satisfaction type feedback promoted by CBT, and more applicable to washing powder. I’ll also leave aside this monumental fib: ‘Depressive symptoms don’t necessarily arise from “an error of reason”’. Beck and co have repeatedly stressed the ‘primacy’ of cognitive symptoms in depression and taken that as the basis of their cognitive focus. A couple of caveats won’t alter the fundamentals.
My issue is with analysts who want to argue that because evidence based medicine isn’t perfect, everything else is as legitimate as EBM, baby out with the bathwater, when it’s not.
This is not my argument, and it’s a very secondary point from my perspective anyhow, as I think that analysis has fundamentally different aims to CBT. Irrespective of the fortunes of analysis, however, it is essential that the epistemically and ethically bankrupt foundations of CBT and similar approaches are exposed, and that includes laying bare the myth that they are ‘empirically-validated’ treatments, the talking equivalent of a pharmaceutical dose.
Most patients want a reduction of symptoms and practical problem solving as expediently as possible, and that is what CBT aims to deliver through evidence based practice.
Only a cognitivist peddling some cartoon Cartesianism could believe this. People do not want to be able to be rid of their symptoms, but rather, they wish to enjoy them. This is the scandalous finding of psychoanalysis, and any treatment approach ignoring the radical divisions of subjectivity is mere gimmicky. In the case of CBT, it’s clearly Taylorist gimmickry.
You can sit there and scoff “You’re just shaping people to be cogs for the capitalist system man!”, but let’s be real – the sort of people who go to Lacanian psychoanalysis are the university educated, wealthy middle-class who have enough disposable income and leisure time to engage in analysis. And good for them, but don’t position yourself as some kind of class warrior against the capitalist system when your entire approach locks the working class out of therapy and restricts it to the elites. The utilitarian and resourceful nature of CBT at least attempts to combat this.
I’ve made the point in many places that CBT and its kin are deeply reactionary, but I was amused to see this old myth about psychoanalysis being for the rich and idle. It may have been true in the US, in the 1950s and 60s, but it’s completely false now. There are extensive networks of free/low-cost clinics throughout Europe and parts of Canada and Latin America, and psychoanalysis in these countries – as well as my own, Australia – is accessed across all social classes. Studies have shown that wasting one’s money one repeated rounds of CBT is actually a bigger waste of time and income than an analysis. CBT is the therapeutic equivalent of McDonalds, and whilst it may be accessible everywhere, it’s no friend to the working classes.
Hi, Thank you for taking effort to criticise CBT in a scholarly and in well argumented way. I think that the analysis misses the important point of the possibility of misuse of CBT by corporations who might pay CBT therapists and encourage employees or contractors to undergo CBT in case there is a conflict at work.
I am a victim of such practice and have been looking for ways to voice these concerns for 2 years now.
I have been harmed by a group of people – organised without my permission and against my will during CBT therapy paid for by the corporation I used to work for.
It was done after a conflict with a senior male colleague (with a CBT course in his bio…) who for a couple of months kept whispering strange things to me using lewd words, making veiled sexual allusions, mimicking my movements or words (distorting their meaning), making me feel guilty and twice touching me and making me upset.
I reacted hysterically to all this following which he reported on me. I was then talked into therapy paid for by the corporation (but at no stage informed this would be CBT with exposition and that my colleagues would be involved).
The hell which unleashed after “therapy” started is uncomparable to anything I had ever survived and cost me serious physical and nervous issues (panick attacks, sleepless nights, shattering teeth, palpitations, feeling of helplessness lack of legal protection etc). Male colleagues at work were either rubbing themselves against me or shouting in a lewd manner behind my back or giving account of “games” allegedly played at work to decide “who would shag whom”. A senior member of staff flashed me with her breast on a video call. People were mocking things painful and sensitive to myself (my family are II WW victims – during exposition I suddenly had to listen to laughing at victims of Auschwitz concentration camp). People were repeating words of the colleague who harmed me, multiple people were touching me and repeating the same sentence. It was a sheer nightmare straight from the horror movie. I am unable to describe the feeling of utter helplessness, panick, despair which all of this caused. What’s worse when I tried to beg the CBT therapist and management to stop the organised madness they accused me of mental illness, paranoia, I was shouted at, accused of “not being fit to work” told that I was “reacting badly to my colleagues” or told in an email by the therapist that they acted within the limits of professional behaviour etc.
Fortunately I could return to my home country. I was also shortly afterwards fired from that place but fear and helplessness stayed with me for a long time. There were attempts of members of that corporation (including a boss feared by everyone who never before tried to be friends with myself) to stay in contact with me and influence me.
My case shows how easily CBT skills can be used (1) for an egoistic purpose of a pickup artist using NLP at work and then treating his victim with more NLP to avoid responsibility, (2) by a corporation hiring a CBT psychologist and organising CBT exposition with work colleagues to sweep under the carpet whatever harm had been done.
The easiness of this is striking.
Nothing is easier after all than telling everyone at work that the victim has “mental issues” so she is crying and might react in a nervous way and that her colleagues should stop speaking normally to her if they want to “help her recover with CBT therapy”.
How many people who want to keep their jobs would not agree to follow such guidelines. How many people would ask themselves if “X has agreed to the CBT therapy with exposition”, “if X has been informed of side effects (which include suicide and mental illness)”, “if X’s family knows about it”, “if X has any loans or children (who would have to pay the loans if X’s harmed)” and “who would be responsible if it all goes wrong”.
This is all too horrible and to easy to organise and requires to be a subject of some wider debate.
I would be determined to fight against it if it happened to anyone else.
Realistically though I do not think any legal restriction is likely to prevent such practices. In every law there is a loop and rich corporations usually have good lawyers.
An “ethical standard” of “protecting private life of employees and contractors” similar to GDPR laws in EU would probably be better.
Likewise I do not think it would be possible for a scared, panicking victim to fight the “almighty corporation” having a psychologist at their services. But it would be possible for a firm of psychologists to adopt a “code of conduct” making sure they do not interview members of a corporation if a patient is suffering in that corporation. There is an obvious conflict of interest here.
I also think one way of helping potential victims of CBT at work is exposing the possibility of misuse of the CBT.
@Henri – You state
“You can sit there and scoff “You’re just shaping people to be cogs for the capitalist system man!”, but let’s be real – the sort of people who go to Lacanian psychoanalysis are the university educated, wealthy middle-class who have enough disposable income and leisure time to engage in analysis. And good for them, but don’t position yourself as some kind of class warrior against the capitalist system when your entire approach locks the working class out of therapy and restricts it to the elites. The utilitarian and resourceful nature of CBT at least attempts to combat this”
On the one hand, the above speaks truthfully about the elitist nature of psychoanalysis, but you omit the fact that CBT can (and sometimes does) have the effect of pacifying the working class. It is the dominant type of therapy used in nhs mental health services, which means its accessible to all, but time and time again the predominantly middle and upper middle class therapists who administer it strip patients of social context, resulting in overly individualized advice – Ive witnessed said professionals advising their predominantly poor and working class patients to be ‘mindful’ when their benefits are stopped, and to do ‘anxiety hot cross buns’ or some other cbt tool when their employer is blatantly exploiting and/or discriminanting against them. A similar ideology exists in the dwp, which treats unemployment as a psychological problem, utilizing cbt techniques in trying to coerce people into low paid jobs. Meanwhile, many cbt therapists are silent on said practices.
@Henri – also, while your accurate about the class position of psychoanalysts, cbt therapists are of the same class. Its also true that poor and working class people are locked out of psychoanalysis, while cbt is easily accessible. However, as stated in my first reply, this often entails the middle/upper middle class cbt therapists overly pathologizing their predominantly poor and working class patients, giving unrealistic advice, and in the case of dbt, feeling scolded and patronized.