This article is the latest salvo aimed at bashing cognitive-behavioural therapy (CBT), an evidence-based psychological treatment which has inspired the ire of psychoanalysts for recently being heavily funded by the UK government.
CBT is a psychological therapy that typically looks at the link between thoughts, feelings and behaviour and is usually time-limited to 12 or 16 sessions. It is evidence-based with meta-analyses and randomized controlled trials showing it to be effective for various conditions and it is subject to improvement and testing by cognitive science.
Not only that, but the research has been almost entirely funded independent of industry or special interest groups, meaning some of the major conflicts of that pervade mental health are absent (although some remain relevant).
Leader’s article repeats several common accusations which, when not plain wrong, are just a bit bizarre.
Chief among these are the fact that CBT does not go ‘deep enough’ and doesn’t address the root problem, and this is apparently related to a ‘quick fix’ capitalist view of human nature (a criticism often made by UK psychologist Oliver James).
There are two parts to the ‘doesn’t go deep enough’ criticism. The first is that psychoanalysis says that symptoms are not the problem, they’re just the expression of an underlying conflict, so if you treat the symptom another will appear in its place unless you’ve dealt with the unconscious turmoil. Virtually the only verifiable aspect of this is the idea of ‘symptom substitution’ which is both testable and entirely without evidence, as we discussed previously.
Leader refers to the fact that something could be empirically testable as the ‘new rhetoric of “science”‘ (yes, those are really scare quotes around the word science), but that aside, psychoanalysis certainly does go ‘deeper’ than CBT. This is because it continues for years on end.
Owing to the fact that public health organisations are reluctant to fund poorly validated treatments, there are few psychoanalysts who work in the health public system, so a typical session from the many hundreds of you will need can set you back about ¬£60-100 pounds a hour in the UK.
I only mention this because it strikes me that a psychoanalyst is the last person who should be accusing anyone of mental capitalism, let alone focusing his criticism on a therapy that’s widely available on the public health system.
The rest of the article is full of curious straw men, saying that CBT aims to ‘correct’ people’s thinking (it doesn’t, it trains people to test themselves for how useful their assumptions and beliefs are), that it is unconcerned with early experiences (it isn’t and considers that many of our assumptions come from earlier life and childhood), and that symptoms are just seen as meaningless aberrations of the mind (if this was the case, why would CBT even try to tackle them?).
A further irony is that when actually tested with “science” – sorry, science – psychoanalytically-inspired therapies of the briefer kind actually do quite well for the limited evidence that exists. This seems to be particularly the case for people diagnosed with ‘personality disorder’ – a vague and controversial category but one which suggests the person has pervasive problems with sustaining relationships.
Interestingly, transference is one of the genuinely important, testable and innovative ideas to come out psychoanalysis, and it specifically describes how experiences of past relationships affect how we interpret social interactions.
Unfortunately, psychoanalysis has always had something a little homeopathic about it, suggesting that it treats people ‘holistically’ and so empirical studies and “science” are irrelevant. Oddly, Freud was quite convinced of the opposite – that he was doing science, despite virtually avoiding anything scientific during the development of his now famous therapy.
It comes down to the fact that if you want any particular therapy funded by the government or your health insurance company you need to do studies to show it’s effective.
Now let me give my statement of ‘full disclosure’ – I’m trained in CBT and have used it regularly. I don’t think it’s perfect or a cure all, but it is a very useful and effective way of working with distressed people, despite its drawbacks.
I think a lot of psychoanalysis is bunk but I also think other parts, like transference, are wonderful and innovative. Psychoanalytically-inspired therapies seem also to be powerful and effective on the basis of the little rigorous evidence that exists.
What’s odd is that rather than being pleased that a psychological therapy is being widely promoted and throwing their ideas into the mix, some psychoanalysts seem to have gone on the attack and retreated into the the “we’re above science” position, while this actually seems a perfect opportunity to take the chance to test the evidence for psychoanalytic treatments while the funders are listening.
I’m constantly struck by the irony that for a practice that focuses on resolving conflicts, psychoanalysis has a long tradition of infighting. This latest episode seems to be the most recent manifestation of this recurrent pattern. Troubled infancy perhaps?
UPDATE: With uncanny timing, today’s New England Journal of Medicine has published a meta-analysis on the effectiveness of long-term (1 year+) psychodynamic psychotherapy in complex mental disorders, finding it a useful and effective treatment. It’s not a huge sample of studies (11 RCTs and 12 observational studies) but clearly suggests the benefit of this type of psychological treatment (thanks Ben!).
Link to oddly acerbic ‘A quick fix for the soul’ article.