The Debate on Directive Treatments in Psychology

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Here are some responses to points/questions that recently arose on twitter, in longer than 140 characters:

What do CBT and Mindfulness™ have to do with austerity and coercion? The practice manuals that list how to implement these techniques mention ‘collaboration’ and nice stuff like that.

Austerity is not only the state cutting mental health services, but the services themselves internalising the prerogatives of the state. Hence the proliferation of short-term treatments, technique over transference, cheap online ‘educational’ content, standardisation, state-corporate ideals of ‘wellness’, and directive and authoritarian approaches.

That ‘collaboration’ is invoked in the above approaches is not only not surprising, but entirely consistent with neoliberal austerity. The ‘collaboration’ in question here is that discussed by Foucault, in which the ‘client’ is called upon to become the principle of his own subjection. Buzzwords such as ‘collaboration’ and ‘client-focused’ also assist practitioners in suspending their own ethical and political judgements. Consequently, if you believe, as many practitioners do, that austerity worsens psychological welfare, it follows that short-term, reductionist approaches such as CBT are not a cure but an obstacle to mental health. And whenever we hear a word like ‘collaboration’ used as the handmaiden of power, we should not forget the more sinister meaning this term acquired in the middle of the 20th Century.

But #notallCBT and mindfulness is coercive. And besides, mindfulness isn’t just about getting people to accept everything.

Perhaps not. It is difficult for any generalisation to be universally true, and besides, in the case of CBT in particular, the term is frequently just a Trojan horse used by practitioners and researchers to make their work appear officially acceptable. Whatever is supportive or directed toward maintenance of the transference in ‘CBT’ treatment is non-standardised and, by definition, not CBT. Thus, there will always be some slipperiness of definitions and semantics when it comes to non-self-identical concepts.

But in some cases, at least, mindfulness, CBT, ‘positive psychology’ and the like are not about getting people to accept ‘everything’, but getting them to accept bad things. And often, it isn’t merely ‘acceptance’ of the bad thing that is aimed at, but affirmation of it. A case in point is Martin Seligman’s ‘spiritual fitness’ program in the US military, in which the exhausted soldier is ‘rehabilitated’ into ‘reframing’ an odious order into a personal compliment. Another case is that of workfare in the UK and Australia, in which mere compliance by ‘clients’ is insufficient, and a more marketable ‘positivity’ is directed. One doesn’t just tolerate Big Brother, but is obliged to love him also.

We could regard it as mere coincidence that the same kinds of directive psychological treatments are put to abusive ends, but that would be a little disingenuous, wouldn’t it?

Isn’t mindfulness like physical exercise, namely, generally beneficial, or perhaps both good and bad, depending on the circumstances?

Maybe – but beneficial for whom? ‘Wellness’ as it is generally conceived, is for the boss, just as rest is encouraged in workers so that they can be more productive for their employers. If situated within a Masters or University discourse or for this sort of ‘wellness’, the ‘benefit’ is measured directly in terms of compliance with the Other.

The idea that mindfulness (and other) techniques can be variously good or bad, depending on their uses, recalls the familiar ‘Guns don’t kill’ argument, in which tools and technologies are wrongly construed as ethically and politically ‘neutral’. Since the same psychological technologies and ideologies keep turning up in coercive practices, we have no reason to assume these technologies and ideologies are ‘neutral’.

We should also consider how paradigms deal with coercive or unethical behaviour. When psychoanalyst Masud Khan came to sessions drunk, and had sex with patients, he eventually lost his status as a training analyst. Today, no analyst would consider his behaviour to be acceptable. By way of contrast, Martin Seligman and followers can torture dogs in the lab, and manipulate soldiers in the military, without ever being called into question from within their own paradigm. Indeed, such manipulations are widely praised, and handsomely rewarded. In CBT and Mindfulness, the coercion and manipulation is so systematic within the paradigm as to be largely invisible to its adherents.

Finally, peddling hints and tips for ‘wellness’, whatever the discourse or intention, is a bizarre and inept method of practicing psychotherapy. I recall, a few years ago, attending a presentation for mental health practitioners, in which a guest speaker who, among numerous other suggestions (including one about not providing treatment to anybody who used drugs) extolled the virtues of giving patients dietary advice on salmon and vitamins. Now, to be clear, I don’t doubt that salmon has nutritional value, and that it is a fine fish in culinary terms. But salmon is not psychology. If you went to university for 7 years in order to hand out generic fact sheets on diet to all your patients, you probably did the wrong course. You are treating the ‘client’ like an idiot, and becoming one yourself in the process.

What about the voluntary nature of CBT or mindfulness? Don’t clients have agency?

The short answer is that the unified subject naively presupposed by CBT and mindfulness simply does not exist. Consequently, it makes no sense to attribute agency to such a subject and then to consider this fictitious ‘agency’ a proof of a treatment’s legitimacy.

We should also recall the near-identical similarity between these arguments from ‘consent’ and, for instance, libertarian apologias of sweatshop labour. Any exploitation or danger to a worker can be justified on the basis that the worker contracts to do it freely. But ‘freedom’ and ‘consent’ require more than the ability to submit, but also the ability to refuse.

This ability to refuse is often minimal or non-existent in the application of CBT and ‘positive psychology’ techniques. First, whenever psychological treatment is being applied in an involuntary setting – be it forensic, forced hospital admission, workfare, etc – the ‘treatment’ is almost always CBT and its cognates. Again, this is not a coincidence, but a direct result of the sorts of problems these techniques are designed to treat.

Second, in Australia and certain other places, free or low-cost treatment seldom involves anything other than CBT or mindfulness, or some other short-term, didactic, directive approach. A person who is suffering with one problem or another may find themselves unable to access any treatment at all unless they can finance it. In Australia, this problem is notable in all places, but especially severe in rural areas. Since cheap short-term treatments may be the only ones funded by bureaucrats and insurance companies, the ability for a patient to refuse is very limited. It isn’t a matter of CBT vs proper therapy, but of CBT vs no therapy, or dubious medications.

But even assuming that a patient could ‘freely’ and knowledgably choose CBT/mindfulness, would there not be a question here as to why anybody would want a self-proclaimed expert to correct their distorted thoughts, or to accept their own suffering as caused by a lack of pseudo-spiritual pacification? What sorts or ideological and fantasmatic props are necessary for such ‘therapy’ to be possible? To be sure, we could see ‘voluntary’ subjugation to power as a triumph of free enterprise, but of course, this is far from being the only possible interpretation.

 

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10 thoughts on “The Debate on Directive Treatments in Psychology

  1. I enjoy reading your blog, but I think it is starting to lose any kind of balanced perspective.

    The majority of people don’t think psychoanalysis has any place in treating MH problems…. Why are they all wrong?

    I’m not arguing that CBT is perfect or helpful for everyone, I have big ideological problems with it myself, but it is not in anyway as bad as you set out.

    Also, we don’t “correct” thoughts in CBT. It’s a common misconception of cognitive restructuring.

    • Hi there, Elphaba,and thanks for the comment.
      I’m not really interested in a ‘balanced’ perspective so much as offering perspectives that are excluded from the discussion.

      The majority of people don’t think psychoanalysis has any place in treating MH problems…. Why are they all wrong?

      Which majority are we talking about? The majority of regulators, psych academics and health insurance companies think that way, but I wouldn’t use them as a basis for generalisation. In many countries, especially those with Latin languages, psychoanalysis is alive and well. In my country, Australia, there has probably never been more psychoanalysts. There are more than in the past, and their practices are thriving. They are not, however, in the hospital or community sector, and they are not spoken of within mainstream discourse. If psychoanalysis fell out of favour (and CBT rose to number one with bureaucrats) during the Reagan/Thatcher eras, we perhaps ought to look at the relevance of timing, and political-economic concerns.

      I’m not arguing that CBT is perfect or helpful for everyone, I have big ideological problems with it myself, but it is not in anyway as bad as you set out.

      Also, we don’t “correct” thoughts in CBT. It’s a common misconception of cognitive restructuring.

      I would think the thought correction claim is entirely uncontroversial. Fixing ‘distorted’ or ‘maladaptive’ thoughts is at the heart of Beck’s approach and of cognitive restructuring. Basically, it’s people illiterate in elementary logic and philosophy coaching others in how to think, rather like MacDonald’s offering courses in dietetics.
      When it comes to critiquing CBT, I have tried to show in several posts where it’s coming from, ideologically speaking. I’ve also given empirical examples of how it has been used abusively, and why it’s about as ‘evidenced-based’ as Lysenkoism. My prediction is that future historians will assign CBT to the same place as lobotomy and Soviet psychiatry.

      • Lobotomy and Soviet psychiatry! Crikey!

        In regards to correcting thoughts.. How is socratically asking people to list things that don’t support thier thoughts to get some flexibility of thoughts coercive? Since when is there only one side of the story? I don’t see how asking people to find thier own grey areas is an expert correcting thoughts :/

      • Asking questions might be one thing, but I don’t think that really captures what goes on in CBT. At any rate, it’s not remotely similar to the CBT manuals and textbooks, in which erroneous thoughts are considered pathogenic, and have to be extirpated, initially by the practitioner, but mainly through the patient in the form of ‘homework’. This process cannot be anything other than profoundly authoritarian, however noble the practitioner imagines themselves to be.
        One factor that mitigates against the general Huxley-like awfulness of CBT is the ease and frequency with which it is discarded. When treatment gets serious, the practitioner often follows commonsense and puts down the manual and glib slogans, going back to basic counselling. However, in doing this, they renounce the ‘empirically-validated’ standardisation which is the raison d’être of CBT. In short, there is no longer any reason for anybody to be doing CBT, whether we give it a bureaucratic name like ‘restructuring’ or, more simply, call it bogus philosophy in the service of power.
        The ‘Socratic’ element to all this is rather interesting, not least since there’s little in the literature to suggest anybody in CBT has grasped Socrates (or Plato, for that matter). The sort of ‘Socratic’ approach involved in CBT is very much the sort of Socrates critiqued by Nietzsche, where reason=virtue=happiness/absence of pathology.

      • Ah I don’t know, CBT really isn’t for everyone and for a lot of people CR does feel pointless /invalidating…. Hence the third wave therapies to a certain extent. Mindfulness is pretty much the opposite of CR. I wonder how much of CBT actually practiced is the CBT set out in the old school Beckian manuals. I know the CBT offered in the NHS is just not Beckian.
        I can relate to throwing out the manual! But not when it gets serious, more as a fluid process depending on what is going on in the room.

        Have to agree with you on the reason=virtue=happiness thing. If we can all just be good logical scientists we will be fine! Weirdly enough the mind just doesn’t work like that, however much the control freaks would like it too.

        What’s the beef with mindfulness? Can you put it in a nutshell?

    • “The majority of people”? In many countries psychoanalysis has an important place. Should I call all my former patients to tell them “sorry, I was wrong, you are not better”, just because some people has decided “It is not scientific”?

  2. “”Lobotomy and Soviet psychiatry! Crikey!””

    Elphaba, this kind of exclamation is very typical of CBT practitioners and their patients. The implication is that David is being unreasonable and exhibiting some kind of cognitive distortion. I don’t agree. The abuses of psychiatry are many it’s reasonable and responsible to keep them in mind. The real cognitive distortion in my view is the CBT notion that we live in a just world where most people behave reasonably and ‘playing by the rules’ is all that is needed for a happy fulfilled life. So not true.

    As a member of the general public, I get very fed up with CBT types ‘shooting the messenger’ like this. Remembering history is not and should not be an impediment to a good life. For many (intellectual, creative type people, the type usually better served by psychoanalysis), awareness like this is enriching. Maybe not financially enriching, though, which seems to be the definition of enrichment espoused by CBT. Honestly, I’m getting more and more fed up with this pathologizing of anything besides normalcy and the “corporate picnic” (as David put it in another post)

    • Yeah I don’t think David is having some kind of cognitive distortion, I don’t really know what distortion means, I think we all have thoughts for valid reasons, doesn’t mean they are wrong. He is obviously completely entitled to his opinion, just because I find this particular comparison really OTT doesn’t mean anyone is shooting the messenger, it’s good natured debate eh?

      I agree, the abuses of psychiatry are many and we all have a responsibility to keep them in mind and do everything we can to avoid further abuses.

      Pathologising everything under the sun is (imo) a huge huge problem. I really hope we can move past the medical model in the future, not much would please me more!

  3. ” One doesn’t just tolerate Big Brother, but is obliged to love him also.” EXACTLY!!!!! then if you don’t they think you must be a “narcissist.” The sin become exposing peoples complicity in systemic oppression.

    What I find truly terrifying is when you actually expose it and it just doesn’t even register!! It is like people just don’t want to know so they continue on their path to “getting in touch with [their] true self.” because they “want to be free.” It reminds me of that line from The Girl With the Dragon Tattoo, “Isn’t it fascinating that facists always manage to adopt the word freedom?”

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