Wednesday, September 10, 2008

If it's broke, dont fix it

A bizarre piece in Tuesdays Guardian on Cognitive Behavioural Therapy (CBT) and why it's bad for the soul. CBT is a form of therapy which focuses on symptoms: e.g. someone with obsessive-compulsive disorder is exposed repeatedly to something which makes them anxious (the symptom), with the result that anxiety is reduced, and the obsession/compulsion comes under control.

The article argued against CBT, in favour of 'traditional therapy' where patient and therapist form a relationship to go deeply into the patients past and psyche.

So the basic argument is:
1. CBT works better than traditional therapy
2. It does so more quickly
3. It does so without going into a whole load of personal issues that may have nothing to do with it.
4. So we should avoid CBT.

Houston, we have a problem. The authors main issue seemed to be with the style of CBT, rather than its results. But if I were seeking treatment for a mental problem, I'd want the thing that worked and worked quickly. So what if it's 'mechanical'? So is injecting yourself with insulin every day, or taking a blood pressure pill. Mental illness often isn't that difficult from physical illness, there is chemical stuff going on in the brain - i.e. a physical component to the mental problem - so why insist on treating it differently?

I do have some sympathy with what he's getting at:
CBT promises change just as swiftly. Unwanted character traits or symptoms are no longer seen as a clue to some inner truth, but simply as disturbances to our
ideal image that can be excised. Instead of seeing a bout of depression or an
anxiety attack as a sign of unconscious processes that need to be carefully
elicited and voiced, they become aspects of behaviour to be removed

- reducing all mental illness merely to 'symptoms' can just mean you're avoiding deeper stuff. But I know people who've done all the deeper stuff and the symptoms have remained, and CBT has been the only thing which has worked. Not everything has some deep Freudian root.

The other thing which bugged me was the complete lack of evidence for his argument. Though the article covers several pages in the G2 section, the only piece of evidence he brings in, oddly, counted for CBT rather than against it:
Lord Layard stunned therapists earlier this year with the following vignette:
"The most striking experience I've had in the last few years was when the chief
executive of a mental health trust ... said his life had been saved by CBT ...
He said he is a fully fledged bipolar case but he has not had a day off work for
the last 15 years. He has a little book, which he carries around and whenever he
has funny thoughts coming into his mind, he turns to the relevant page,
according to what kind of thought it is or if he has a mood attack, and he does
exactly what it says on the page. Now, you could say that's mechanical. I say
that it's brilliant and not so different, you know, from what Jesus or any other
great healer did for people."

Yes we should pay attention to the soul, but that goes for everyone, not just people who are mentally distressed. And for someone suffering with a crippling mental disorder, is it better to give them what works, or be purists and prolong their suffering?


  1. Surely the point is that it is wrong to treat symptoms without at least understanding the underlying causes. Doctors will tell you that about physical illnesses, and surely the same is true of psychological ones. If there is no treatment of the underlying illness, or that will take some time, it may be necessary to treat the symptoms, if done in a way which doesn't make the illness worse. But just treating symptoms can make the underlying illness worse, with much worse long term results when the treatment of symptoms fails.

  2. A one size fits all approach to psychology is always a dangerous one and it is one that the NHS is increasingly being forced down in relation to CBT. Yes, it's successful for some people, no it's not a universal panacea.

    CBT is effective for the people it's effective for. It's utterly ineffective for others. But by making it the mainstay of the NHS's treatment programme for such a large and varied group of mental illnesses it removes the opportunities for people to have other types of psychotherapy which may be more useful.

    To treat the causes of mental illness as irrelevant and only concentrating on the symptoms, you devalue the experiences that have helped to create the illness in the first place. That is a critical failure of CBT (in my everso humble opinion.)