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.

Disavowal and its Vicissitudes

One of the biggest questions for Lacanian psychoanalysis in the 21^st Century – perhaps the biggest – is the question of psychosis. The classical formulation of clinical structures largely divides them into two (and then to subsequent sub-types). These two structures are, of course, neurosis, and psychosis, which correspond to the operations of repression (Verdrängung) and foreclosure (Verwerfung) respectively. One question is whether these two categories are adequate to capture contemporary clinical phenomena and, if not, what alternative formulations may look like, especially with respect to ‘borderline’ symptoms. (It is not the patient, but only ever the clinician who is on the ‘borderline’, hovering between a diagnosis of neurosis or psychosis). The later work of Lacan points to this (the theory of the Sinthome), as does Jacques-Alain Miller’s notion of ‘ordinary psychosis’, and Paul Verhaege’s theory of ‘actualpathology’. These are still early and contested formulations; I’m yet to see much of Verhaege’s work applied in the Anglophone world (though happy to stand corrected if such work exists), and much of what is said or ordinary psychosis could, on closer inspection, apply equally to regular, extraordinary psychosis.