Against and for CBT: Towards a Constructive Dialogue?

February 19, 2009

It would be difficult for anyone outside the therapy professions to get their head around this book without knowing something of the politico-economic background that generated it. For at least the second half of the 20th century, the field of "talking" treatments for psychological distress was the scene of strenuous competition between a number of "schools" of therapy, each wanting to establish that it had at least as much right to its clients' money as any other.

In the process, a voluminous literature accumulated, suggesting that, in fact, none was particularly better than any other, and indeed that it was quite difficult for any to claim success beyond placebo levels. Relatively recently, however, all that changed, and one treatment method - cognitive behavioural therapy, or CBT - has emerged triumphant in this competition, at least in the English-speaking world. CBT, in other words, has cornered the market.

This coup was the result of some astute manoeuvring by, in particular, clinical psychologists at the University of Oxford, University College London and the Institute of Psychiatry. It was due also to the enthusiastic support of Richard Layard, an economist at the London School of Economics, who was at the crucial moment an adviser to the Blair Government. CBT has thus become the treatment of choice for a range of "disorders", is held to be "evidence-based", is recommended by the National Institute for Clinical Excellence and has received fairly substantial government funding.

The somewhat nervously entitled book under consideration - in fact almost solely "against" CBT and not noticeably embodying any kind of "dialogue" - is for the most part a collective howl of anguish from a range of practitioners whose technical and theoretical orientations threaten to be eclipsed by CBT. There are 24 contributions, ranging widely in quality. Two or three are highly competent and will offer some insight into the issues for the interested inquirer; many amount to special pleading for some non-CBT form of therapy or other, and two or three can only be described as abysmal in their intellectual and scientific quality (although one should note that, for most of the contributors, "science" is a dirty, Enlightenment word that has no place in our postmodernist age).

Collectively, the chapters rehearse to the point of tedium all the objections that can be raised against the credentials of CBT: the bogus nature of its "evidence base", the questionableness of its scientific validity, its gross oversimplification of the philosophical and psychological issues involved, and so on. In this respect, the book may certainly be of interest to professional therapists and other interested parties who are looking for ammunition to defend their anti-CBT stance, though they would probably be wise to eschew some of the wilder postmodernist flights. But the elephant in the room that remains unremarked by almost everyone is the questionable nature of therapy itself.

Nearly all of these writers are therapists defending therapy, arguing that the basis on which CBT claims its fame - its demonstrable success in "random controlled trials" - fails to do justice to the complex interpersonal and moral undertaking that is psychotherapy. These arguments are by no means necessarily wrong - indeed most of them are right - but there is a further, more fundamental question crying out to be asked and answered: "Is any form of psychotherapy demonstrably effective?" None of these writers, however, is willing to advance a criterion of success for his or her own undertaking.

There may be a very good reason for this (acknowledged directly by only a couple of the contributors), which is that the causes of psychological distress are not internal and individual, and hence amenable to therapeutic ministrations, but originate in wider society and call principally for political solutions.

Against and for CBT: Towards a Constructive Dialogue?

Edited by Richard House and Del Loewenthal. PCCS Books, 320pp, £20.00. ISBN 9781906254100. Published 29 October 2008

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