In undertaking the negative task of criticism, it has been with the view to identifying the shortcomings of CBT (and psychology), not merely to point them out, but to avoid them in constructing a better psychology. To create an alternative psychology is no easy task, but there are some useful starting points.
Any rigorous psychology must accept and take into account subjectivity, both that of the ‘client’ and that of the clinician. This may be inconvenient to some, and scandalous to others. There is a misguided notion that subjective problems – such as depression, or anxiety – are somehow less ‘real’ than organic, biological diseases. A shift to subjectivity may not sound radical, but it is, insofar as it involves the overturning of the current model of person-as-object which rules empirical psychology. It is time to acknowledge that this is a failed formula, both ethically and theoretically, whether we construct individuals as objects of assessment or as objects of intervention. Nor is there any reason to encourage people to objectify themselves, to intensify their forms of alienation through CBT techniques, or to ask them to internalise their own subjection through homework tasks and the like. This necessarily must involve the psychologist taking account of his or her own subjectivity, a task which is difficult, but not impossible. Yes, there are biases in subjectivity, but we have reason to prefer them to the biases in pseudo-scientific calculation, at least insofar as they are more transparent and honest.
Moreover, any psychology that wishes to be more than a hollow, technocratic discipline, must not only address subjectivity, but listen to the subjected. Much of psychology, and CBT in particular, is an exercise in listening to not-listen; listening only in order to correct, root out, abolish, silence. When Freud listened to the sufferings of his patients, he allowed them to speak freely; he took measures to cultivate the therapeutic relationship (by way of regular meetings); and he thought that he heard in his patient’s complaints something concerning desire, a desire which the patient herself did not want to know about. In contrast, when Beck heard his patients’ sufferings, he thought he heard stupidity, idiocy. He heard wrong thoughts to be corrected, directly by the clinician, to be ‘mastered’. Anybody who prefers this latter form of ‘listening’ belongs more properly with prison wardens and police officers than with psychologists.
Beyond this, what are some considerations in produce a more epistemologically rigorous, and more ethical psychology? There are some who believe that one cannot criticise a paradigm without offering something by way of alternative. This is nonsense, of course, and one can criticise charlatans without having solved every problem oneself. Some interlocutors claim that we must stick to the shoddy theory and practice in psychology as this is the only ‘realistic’ option; such ‘realism’ is really a reflection on the interlocutor’s lack of wit and imagination. Nonetheless, I shall list some proposals here in a spirit of generosity, and without any claim to them being comprehensive.
Psychologists must attempt to situation their discipline where it belongs, which is properly speaking not the sciences at all (neither ‘hard’, mathematically precise sciences, like physics, nor the historical sciences, like biology or geology). Psychology is the heir of a Western metaphysical tradition, and unconsciously carries the biases and emphases of this tradition. This unconscious is precisely what needs to be examined, lest it accumulate statistical data in the service of Scholastic irrelevancies. A discipline can be rigorous without strictly being scientific, and in the case of psychology, this is a reasonable ideal. The historian, for instance, can engage in high-quality, methodologically-considered research, marshalling evidence and theories to produce valuable work with ‘real-world’ effects. Yet, for all this, the historian would not be doing science. The psychologist is much closer to the historian than the physicist. It is true that, at certain points, psychology is part of what is called scientific discourse, but one should not mistake this for science itself. Some psychologists, no doubt, will be alarmed at the prospect of their discipline abandoning its scientific pretensions, but as I have argued, psychology only needs the imprimatur of ‘science’ if it assumes for itself the right to dispense authoritarian, coercive treatments. If these latter are abolished – and they should be – the ridiculous aping of scientific conventions need no longer be required. I should emphasise here that I am not championing anti-intellectualism or some kind of Romantic tendencies, but simply rigour, without scientistic affectations.
Notwithstanding this, there is no reason why psychologists should not engage with established sciences. Hitherto, this has often come in the form of bioreductionism and wild-eyed prophesying about the future of genetics and neuroscience. At this point, neuroscience in particular has done much to elucidate the workings of the brain, but as I understand it, remains at an early stage, and is yet to yield much of clinical utility. To be able to document the neural correlates of attachment, or trauma, for instance, is an intellectual achievement worth celebrating, but it does not necessarily alter daily clinical practice (or life, for that matter). Naturally, this will not deter the shysters peddling the virtues of ‘mirror neurones’ and the like, appending the epithet ‘neuro-‘ to their creeds. Moreover, psychological intervention is never directly at the level of the brain, but always at the level of language. Neither brains nor genes wander about the world, unmediated by language, law, and the social order. (For a basic illustration of the primacy of language on psychological operations, one could, for instance, consider the Stroop effect). There is nothing ‘natural’ in human existence, and this fundamental point has not been changed by any findings in genetics or neuroscience to date.
Given that psychology operates on language, it makes sense for language to be that which constitutes the bulk of psychological research. This research would probably involve qualitative investigations for the most part. Consider, for instance, the NIMH project to localise ‘biomarkers’ for different diagnoses in the brain. It is curious that the existence of such markers is presumed to be self-evident, despite the diagnoses themselves being social constructions, but even more curious that few have bothered to examine linguistic markers. One possible line of psychology research, therefore, could involve abandoning the 21st Century phrenology of the NIMH and to take a linguistic turn. A heightened sensitivity to language (in research) should also alert us to the many metaphors and analogies involved in psychology, many of which are dubious. The entire system of outcome studies rests on a preposterous analogy with quantifiable medical disorders, for instance. Qualitative thinking could do much to avoid such absurdities. Kandel, for instance, points to Freud’s early work, and to Freud’s desertion of biological hypotheses, but fails to grasp that if Freud (and Jung, among others) took language and symbols as their starting point, this was for sound conceptual reasons.
One predictable objection is that qualitative research, guided by the subjectivity of researchers, will inevitably lapse into bias. This is partially true. Nevertheless, it is possible that such biases are made transparent. As it stands, there is plenty of bias in the ‘scientific’ model of empirical psychology, but its subjective constitution s simply disavowed by the researcher and reintegrated at the level of theory and method. Again, the RCT in psychology is a good example of this. It is true that, in observing, the observer constructs his or her object through subjectivity, but this is even more the case in empirical psychology, where observational biases of constructed objects are insidiously replicated at every point in the conceptual apparatus.
It goes without saying that for any psychology to be epistemologically, ethically and politically viable, it should acquaint itself, if not emerge directly from the marginal school of thought known as critical psychology. The work of Ian Parker is a fine place to start, and other theorists of psychology as biopower – from Foucault to Agamben – should be essential reading for any psychology student. Psychology cannot divorce itself from ethics, irrespective of scientific status.
Of course, psychoanalysis meets many of the requirements for this kind of psychology. The point here, in my view, is not that one should necessarily promote the theories of Freud (or Lacan, or Klein, or whoever) but to continue to explore the field opened up by them. To this end, I advocate a return to the unconscious, whether this unconscious be construed on psychoanalytic lines, or linguistically, or neuronally. The absurd myths of CBT and contemporary psychology – no unconscious, perfect self-reflexivity, lack of subjective division – ought to be banished to the pre-19th Century milieu from which they emerged.
We should be wary at any claims of a therapy or system to be ‘integrative’, or ‘eclectic’, if only because the different treatments are up to fundamentally different things. Treatment either allows for an unconscious, or it does not. Treatment either guides the patient into conforming with the clinician’s preconceptions, or it does not. The ‘integrative’ impulse is best understood as a kind of forced assimilation or theoretical colonialism, plundering from this or that approach. Nonetheless, it presumes an atheoretical standpoint from which this integration can be implemented, as well as a kind of meta-language to render the integration into theory. None of this is the least bit tenable. There is no ‘trans’ or ‘beyond’ of theory, and any integration, to quote from Derrida, is ‘never the face-to-face of two terms, but a hierarchy and an order of subordination’. In this, as elsewhere in psychology, there is an urgent need to recognise and respect that which is unique, ‘one-off’, and strictly limited in its generalisability. If you want generalisability, you must, of necessity, become more abstract. In this regard, one can turn to Eli Zaretsky’s history of psychoanalysis as an essentially pre-Fordist treatment; it retains a view of the individual subject which preserves his or her uniqueness, his or her ‘aura’. In contrast, the treatments deriving from the post-war US are as industrial, mass-produced and generic as the patients receiving them (in the view of these paradigms).
‘Well-being’ is a fundamentally narcissistic pursuit, and it is to be lamented that the existential psychiatry of old Europe devolved into orthopaedics of ‘personal growth’ once it crossed the Atlantic. Well-saying and well-doing are broad aims which escape the narcissistic traps of ‘positive psychology’, ‘humanism’ and the like. Those who attempt to evade the hard work of historicism through an appeal to the ‘hear and now’ fundamentally misunderstand the concept of time. In any event, the past itself is malleable.
I have spoken of diagnosis elsewhere, but my view is that psychoanalytic/Lacanian diagnosis could replace the current DSM debacle. Psychoanalytic diagnosis has changed over the years, but retains some connection with classical psychiatry, which was always better in its description and observation than the disease-mongers of APA committees. Assimilating unique subjects into generalised categories is as useless as it is epistemologically bankrupt, unless diagnosis is oriented to logic and structure, and never on the basis of norms. Diagnosis cannot be rooted in any notion of ‘mental health’, since no coherent version of this concept exists. There are some who find all diagnosis intrinsically stigmatising, but it is difficult to see how this could be the case if everybody, in principle, had one. Moreover, the advocates of formulation, if they are serious, must realise that the sort of detailed, individualised diagnosis that they would like to see is possible only in the context of a long-term, non-directive, non-coercive setting – that is, in a psychoanalysis, or something very much like it.
Some will say that these goals are ‘unrealistic’, that resources are limited. Yet I see no reason why any psychologist should advocate third-rate treatments simply in order to better accommodate corporate or bureaucratic imperatives. It is difficult to imagine an orthopaedic surgeon recommending stretching exercises in order to heal a complex fracture on the basis of supposed expediency, yet this is precisely the case with those in psychology who promote treatment on the basis of its low-cost.
It is necessary to reject all forms of reductionism, whether of the bio- sort (notions of unmediated genes or brains wandering about, with the ‘social’ tacked on as a conceptual afterthought) or of the ‘social’ reduction ad trauma (where ‘What happened to you?’ is used to efface subjectivity, as if history, even if traumatic, produced self-evident effects).
Urgent questions – such as the psychological treatment of the psychoses, for instance – will not be answered by way of generic ‘strategies’ and standardised cures. There is good reason to believe, on the back of evidence dating from Saul Rosenzweig, that it is the relationship between clinician and patient that is the primary means of treatment. Can such as relationship be quantified, or standardised through technocracy? Perhaps, but the quantification will miss the essential components (which are qualitative, after all) and a ‘technological’ relationship, even if possible, would be repellent for other reasons.
Any psychology that purports to be ethical should divorce itself from forensic, corrective aims and methods. Judgement and punishment ought not to be smuggled into the discipline under the banners of assessment and treatment.
Psychology is not physics, and its theories are never reducible to mathematically precise formulae, but are, rather, inseparable from the language in which they are cast. For this reason, bad writing is tantamount to bad thinking, and psychology scholars who fail to produce a close reading of relevant texts are literally debasing their would-be science.
In sum, CBT, and a great deal of the disciplinary psychology that supports it, should be abandoned as a matter of urgency. If this causes anxiety in academics or regulators, perhaps they should seek an appropriate referral. CBT is not scientific. It is not ethical. To the extent that it produces calculable effects, these are the result of coercive methods directed to conformist ends. There are superior alternatives both in the clinic, and in academia, such as psychoanalysis, and psychology of the critical, qualitative and discursive schools. (Not to mention the non-coercive, non-conformist groups such as Hearing Voices, or Soteria). CBT is a problem that cannot be regulated away, as even its most abusive practitioners – such as the workfarists, for instance – are well inside the regulatory tent. Its practice and teaching should cease immediately, and those who continue to peddle this sinister doctrine disabused of their scientific pretensions.