CBT is Aristotle with Facebook brain – A note on paranoia as an epistemic ideal

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In Cognitive Behaviour Therapy (CBT) discourse is reduced to data, and this data is further submitted to the Aristotlesque requirement of non-contradiction, albeit, without any Aristotelian depth of intellect.

Consequently, cognitivism and CBT affirm the existence of an unconscious, but this unconscious is entirely continuous with the conscious. It’s more of the same, more or less. Contrast this with the Freudo-Lacanian unconscious, which is disruptive, punctual, discontinuous, and structurally incapable of completion.

It’s no coincidence that CBT first arose when cognitivism was displacing the increasingly-discredited behaviourism from the laboratory (though not yet the clinic, in the Anglosphere at least). This was the age of Festinger’s cognitive dissonance, in which, like good Aristotelians, the subject abhors contradiction. Since contemporary CBT reaffirms a data-based, continuous unconscious, Festinger’s ideas fester still. Show the subject that his suffering arises from the faulty conviction that he always bungles his relationships/work/studies – show him the contrary evidence, the errors in his logic – and he will be obliged, by way of contradiction, to renounce his conviction, and thereby eliminate his suffering.

It was not until the era of neoliberalism that these Aristotelian outtakes reigned supreme over the clinic, for reasons that I have attempted to explicate elsewhere, but which are largely economic and biopolitical in character.

At the heart of the adventures of Freud and Lacan is the proposition that, in at least a thousand different ways, human subjects, divided as they are, exist in permanent, structural contradiction. There are so many examples of this in the centuries that preceded them that I would say that Freud and Lacan merely articulated and formalised, rather than discovered this fact. My experience is that it is common knowledge amongst the uneducated, and that perhaps the educated have some catching-up to do.

The clinical work of psychoanalysis cannot, on this basis, be oriented toward either completeness or consistency, if one means by this the overcoming of contradiction. Repression, disavowal, denial, foreclosure, the law of the exception, the law of the not-all are but some of the psychoanalytically-articulated responses to contradiction. After Gödel,he who trades consistency for completeness deserves neither.

But let us suppose that the psychoanalytic premises are wrong, and that the cognitivists are really as evidence-based as they say. In principle, the latter would be able to work with a subject to produce an image of perfect consistency, with the offending data eliminated. The outcome would resemble nothing so much as the most brittle paranoid delusion. The subject attains an image of coherence with all that is unassimilated sent packing, much line a refugee ship at Australia’s borders. This is the best case scenario for treatment by CBT principles, and we need only look at the outcome of excessive Facebook consumption to see what befalls those who cannot live in contradiction.

Drone Psychology: A Profession Digging Its own Grave

The following reflections were inspired by a Facebook thread, responding to this article. The article gushes that, according to some corporate consultants, mental health services in Australia could be delivered for $9.70 annually, saving on the inefficiency of training psychologists for face-to-face clinical work. People suffering with problems could anonymously read fact sheets, and undertake generic courses in CBT.

Language and Diagnosis

 

The BPS has been tackling some important issues in mental health. In 2014, this involved publishing the ‘Understanding Psychosis’ report, and more recently, the BPS has published guidelines on ‘functional’ diagnostic nomenclature,  in which clinical conditions and treatments are articulated in non-medical language. In both cases, the BPS has identified an area of difficulty – perhaps even crisis – in mental health. Psychosis is poorly conceptualised and haphazardly treated. Diagnostic language in psychiatry was never ‘scientific’, and the farcical DSM-5 has eliminated any last vestige of credibility from these sorts of conceptual systems. There can be no doubt that the BPS has the best interests of what it calls ‘service users’ at heart when it attempts to tackle these problems and devise workable solutions to them.

Why psychologists (and others) should have a psychoanalysis

First anecdote.

It was my first year in a Masters of Clinical Psychology, and this was my first patient at the university clinic.

One of Freud’s Asides

I recently had occasion to re-read Freud’s case of the Ratman, and was struck by a passage in which Freud attempts to educate his obsessional neurotic patient in the underlying principles of psychoanalysis:

On ‘deep-brain stimulation’ for depression

 

A response to this post:

I think the author of this post is quite right to ask questions about the nature of evidence of these radically invasive, bio-reductionists ‘treatments’ for depression.

Paradigm Shifts after the Decline of the Medical Model

‘Neuroenhancement’ in its various forms, whether applied to cognitive tasks, or social functioning, looks initially like one more medical intervention. This, however, is misleading. For all of its flaws, the medical model is relatively simple and static. The idea is to identify pathology or malfunction, and to remedy it. Where the pathology in question is a positive symptom or syndrome, medical intervention is relatively free of controversy.

Suicide, selfishness and “illness”

A celebrity has died, apparently by his own hand. Amidst expressions of grief and condolences to the bereaved are a profusion of obviously incorrect, deeply ideological pronouncements on the nature of suicide.

Love, technology, ideology and ethics: A critique of “neuroenhancement”.

“The medicalization of love”[1] is one of a series of papers[2][3] in which Earp, Savulescu and others explore the ethical ramifications of administering neurochemical interventions to address problems of love. The authors rightly observe that love is, in many ways, already ‘medicalized’, and anticipate some ethical objections to neurochemical interventions in human relationships. Specifically, the authors reject charges of neural reductionism, and disagree that neurochemical interventions need necessarily increase “pathologization” and the expansion of medical-social control. I wish to argue that these conclusions are, from many points of view, misleading, to say the least.

CBT for psychosis?

 

The recent Maudsley debate examined the question of whether CBT for psychosis had been ‘oversold’. This is my minor contribution to the debate.

There are no theoretical grounds for supposing that any of the ‘techniques’ specific to CBT are of any therapeutic benefit to psychosis in any respect. CBT was developed as a doctrine designed to treat disorders of affect, particularly anxiety and depression. This doctrine was itself linked to a specific cognitive theory of the emotions which, whilst utterly wrong, theoretically and empirically, at least had the virtue of containing some minimal internal coherence. Even this modicum of reason is lacking in CBT treatments for psychosis, which probably accounts for why the methods of such treatment are typically vaguely-worded by their proponents.

Delusion is the hallmark of psychosis, and to go about ‘correcting’ delusions via CBT is to utterly misunderstand their nature and function for the subject who bears them. Above all, delusions are characterised by certainty. Such an enterprise – panel-beating delusions until they adopt a ‘rational’ form – is arguably delusional itself. The figure of the clinician in this set-up is to be, as always, in CBT, an all-knowing, coercive. Other. Such an Other is the perfect fodder for paranoia, and CBT’s authoritarian techniques are dangerously likely to be construed as persecutory by a psychotic subject. In short, we have reason to expect that CBT with psychotics is not merely useless, but harmful, and indeed, the outcome studies show disturbingly high levels of drop outs and death. Indeed, the psychoanalyst Florencia Fernandez Coria Shanahan recently touched upon, in a fine case study, the ‘disastrous effects’ of CBT on a psychotic woman.*

Some supporters of CBT for psychosis argue that CBT’s limited (probably non-existent) success with psychotic symptoms is no deterrent to the treatment because, after all, there is more to psychological therapy than symptom reduction. This kind of position could conceivably be credible with therapies which value ‘insight’, the ‘therapeutic alliance’, ‘growth’ or whatever, but not with purely technical, standardised, manualised approaches like CBT, which derive ‘scientific’ status precisely through relentless and reductive focus on symptom reduction. If CBT conceded that, for instance, the quality of the therapeutic relation was the curative factor, and not some dubious technique or theory, the entire ideology would disappear in a puff of smoke.

All of this inevitably raises questions about the nature of the psychoses, and their treatment. In my view – and this view is psychoanalytic, but not indicative of anybody but myself – psychosis is not curable in any strict sense, though it can be stabilised. Indeed, there are many recovered psychotics who leave happy and meaningful lives, but the means they took to stabilisation vary widely in each case, and merit further study. My suspicion is that these means will be generalisable only at the very highest levels of abstraction. I have never encountered a psychotic subject who was helped by coercive attempt to bludgeon their delusions away through CBT. In short, the path to stabilisation involves something like the construction of a sinthome, and not adherence to some trite, bureaucrat’s notion of functionality as defined by CBT.

In view of this, two facts are unsurprising. First, as one would expect from a theoretical perspective on psychosis, there is no credible data to support the use of CBT as a treatment. Second, the proponents of CBT are utterly undeterred by this lack of scientific evidence, and continue to speak, act, and construct policy without the slightest compunction. But then, such debates are fundamentally ideological and political, and are about control much more than scientific evidence. CBT has virtually none of the latter, and far too much of the former.

 

 

*Fernandez Coria Shanahan, F. (2012). In me more than me. Psychoanalytic Notebooks, 24.