Review of CBT: The Cognitive Behavioural Tsunami, by Farhad Dalal

Back in 2014, I posted a series of essays critiquing cognitive behaviour therapy (CBT) in terms of its philosophical and ethical problems. The idea that I had at the time was to provide a rebuttal of CBT that was not from within the parameters of its own assumptions, but which examined CBT from first principles, and also in terms of its political positions. The data may supposedly be in support of CBT, I reasoned, but such data was largely irrelevant if it pertained to incoherent theories and concepts, and was used to prop up a series of coercive and unethical practices. There were many critiques of my articles, on Reddit, for instance (here is an example), though practically none of them attempted to defend the theory of CBT. Few people seem to seriously uphold CBT concepts, even among advocates of this approach. Rather, the main objection to an a priori critique of CBT was ‘evidence’, which clearly proves CBT to be the ‘industry gold standard’, at least for now. Since CBT ‘works’, principles – first, or otherwise – simply do not matter.

Enter Farhad Dalal and his book CBT: The Cognitive Behavioural Tsunami, which provides an excellent overview of the flaws of this approach, including a review of the evidence as well as the theory and politics. It is a topic that he has been working on for several years. Dalal begins his book with reference to the Neem tree, used by farmers in India as a pesticide for millennia. In 1992, a US corporation patented the tree as a pesticide, and the farmers could not use it without risk of being sued. The farmers could only have the patent overturned if they could demonstrate that it was not novel, but this required that knowledge of the tree be documented via a ‘scientific journal’, and thus 2-3 millennia of local, orally-transmitted knowledge counted for nought. Dalal’s argument through the book is that ‘in this hyper-rationalist world, it is the presence or absence of documentation that is the ultimate arbiter of truth and reality’.  Or, in other words, the ‘science’ of psychological treatment is often less a scientific than a political contest.

Dalal situates the rise of CBT within the context of the parallel ascendancy of neoliberalism, and its attendant obsessions with marketization, efficiency, quantification and managerialism. Neoliberal doctrine speaks of the ‘freedom’ of markets but tends, in practice, to result in authoritarian systems of command and control. This will to mastery is exemplified by British economist Richard Layard, who advocates both for neoliberal economics and CBT, and who is discussed at length by Dalal. According to Layard, the raison d’être of CBT is for human beings to ‘conquer’ and ‘control’ their inner life. Structural lack and subjective division are completed abolished from this ‘rationalist’ account of the human mind, which links the subject of CBT with the homo economicus of the dismal sciences.

Dalal does an excellent job of demonstrating how the ideology of CBT systematically equates ‘rationality’ with happiness, thus rendering human suffering a form of pathology. The DSM is called to service to organise the different forms of human suffering into supposedly discrete, medical entities, and Dalal’s portrait of the DSM deftly shows how it is both arbitrary and crudely reductionist. Dalal also highlights how CBT simply commandeers methods from sources such as psychodrama to Buddhism, diminishing them to pure ‘technique’ in isolation from their underlying philosophies, as if the Buddha was fixated on matters of compliance and productivity. The so-called second and third waves of CBT are often in direct contradiction with each other, but this does not stop each of them being gathered under the same signifier.

Dalal gives an account of the history of the psychotherapies in order to show the extent of CBT’s colonisation of the field, and whilst I found this account useful, I have some objections with the psychoanalytic portion of it. Psychoanalysis was not just the domain of the wealthy, idle and privileged; there is a long and strong tradition of low-cost psychoanalysis for all social classes, from Freud’s free clinics, to the CPCT clinics in France, Gifric in Quebec, and the widespread proliferation of psychoanalysis in Argentina, for example. That aside, Dalal provides considerable evidence to show how ‘evidence-based’ treatment in the psy-disciplines is a highly contested, politicised arena, driven by personal agendas and power-mongering as much as pure empiricism. So-called anti-depressant medications are a clear example of this, with research unfavourable to SSRIs being shelved rather than published. Likewise, ‘CBT has flourished not so much because of its merits as a treatment, but because it was useful to sections of the profession of Clinical Psychology in its battle for status within the medical profession’. (p. 65).

Another factor in CBT’s success is the widespread implementation of neoliberal social and economic policies, and austerity, and Dalal’s book nicely illustrates the uncanny parallels between the quantitative reduction of CBT and the ideology and methodology of Milton Friedman. Both doctrines are uninterested in the causes of distress, and Dalal observes that any examination of causes would likely confront CBT’s proponents with an ‘unpalatable fact’, namely, that a certain portion of the suffering that CBT purports to treat is caused by neoliberal policies, and that CBT legitimises and collaborates with these policies. And, for all of the supposed scientificity and efficiency of CBT, Dalal’s examination of the IAPT (a UK program rather similar to Australia’s grossly underperforming Headspace). Despite being a not-for-profit public service, IAPT is measured, marketised and bureaucratised within an inch of its life, and naturally, its treatment consists of the standardised administration of CBT and SSRIs. The selection of these treatments is essentially rigged in advance, and determined by the shoddy methods of the evidence base and the politics of the governing bodies. In the case of CBT, Dalal makes a compelling and well-researched case that ‘there is a paucity of robust empirical evidence’ for its efficacy, despite inflated claims to the contrary. When applied to the IAPT system, these entails that a patient has had a ‘completed treatment’ if that have had two sessions and not returned. Compliance with this KPI is demonstrative of ‘recovery’. It’s a system ideal for neoliberal bureaucrats, but not for practitioners, and still less for patients. Far from being something therapeutic, CBT comes across as a mode of applied austerity.

Dalal’s scope is necessarily broad, and it is not difficult to deduce that for advocate of CBT, the arguments are best kept away from politics and philosophy and reduced to the narrowest of technical matters. Quite rightly, Dalal refuses these terms, and his work functions as a provocation for clinicians to think beyond mere technique. Likewise, his writing style is much more engaging than the tedious, slightly imbecilic faux-objectivity of psychology journals, and he presents his case clearly and with apt illustrations.

The pathologisation of unemployment is a phenomenon to be found throughout the Anglophone world, and Dalal shows the complicity of CBT in this. Dalal does not deny a place for CBT altogether, and allows for its use in certain limited situations (such as for some phobias, or for OCD), but the overall impression one gets from reading this book is that CBT is as unscientific as it is unethical, and that its ascendancy is the result of a moribund epistemology at the heart of the psy-disciplines, and the financial and political interests of neoliberal policy wonks. The famed ‘evidence-base’ turns out to be ‘one-off experiments with very small numbers of participants’, and very often even these are equivocal. It is vitally important to have this data – and the arguments that Dalal provides – synthesised concisely in this text, and, apart from providing a strong reason for clinicians, policy makers and ideologues alike to read his book, it delivers a comprehensive critique of a pernicious doctrine that has captured and devastated a discipline.