In my last post I said I thought that CBT (Cognitive Behaviour Therapy for those of you who don’t know) was good and worthwhile for anyone with anxiety. I stand by that but today I want to give a different opinion about CBT, I want to argue that it is being missold to us.
First we had psychoanalysis, then we had CBT. Psychoanalysis went out of fashion because it took too long and that made it expensive. It also made it hard to prove worthwhile in terms of efficacy. These days scientists, medical practitioners, psychologists and bureaucrats alike need to be able to prove their brainchildren to a skeptical public. That means they need quantitative data. People like percentages. They like to know that 80% of people found CBT helpful, or that of those people who go through a programme of CBT less than 30% relapse into depression (these statistics are just examples, please don’t take them seriously). That is all well and good but it doesn’t tell the whole story.
There is a time and a place for quantitative data, but the time isn’t always and the place isn’t everywhere. Let’s take anxiety as an example (although we could take and illness or many other things). Experiencing anxiety can have many different facets. There is the possibility of panic attacks, feelings of disassociation or feeling detached, there’s insomnia, stress, irritability, agoraphobia, co-morbid depression…the list goes on and on. These things, as any anxiety sufferer will testify, are often very hard to put into words. Often the first struggle is to make people understand what you are feeling. What I am arguing is this: anxiety is not a quantitative thing. You can’t count it or represent it on a graph. Anxiety is a qualitative thing – you know how you are feeling. It is more of an instinct. So when I see statistics that tell me how good CBT is I become suspicious. How do you put people’s anxiety recovery into a graph. In all honesty I trust one detailed testimonial from an impartial source more than a ten thousand patient data-set.
This matters because governments and health insurance companies don’t take anxiety and depression seriously and never have. Drugs and CBT are relatively cheap, can be justified through statistics, and keep people quiet as they think they are getting the best treatment available. Oftentimes they are not. All too often a more analytical approach would be more suitable and more successful. I know because I have been there. If I had been surveyed about CBT I would have answered quiet positively. It did help, and I did feel better. But, and it is a bug but, I did not feel as good as I did after proper Jungian style therapy that helped me understand myself.
Have CBT! It’s good, But unless you have a simple phobia, I would recommend you only see CBT as part of your treatment.
Psychologists have been measuring anxiety for decades – and doing it in ways that are reliable.
Internal reports of levels of anxiety are generally extremely useful. If someone tells you that their anxiety is 8/10 and now has been reduced to 3/10 – and that report of 3/10 remains month after month. Then you can assume you have some real improvement.
CBT was developed by Professor Aaron Beck a highly rigorous psychologist. It was made available and popular by David Burns. Get his book “Feeling Good” (the no.1 self-help book as rated by therapists) – he details many studies done comparing CBT and self-help CBT vs anti-depressants for mild to moderate clinical depression. The results make impressive reading. Clients doing self-help CBT showed improvement with strong relapse prevention – and they really secured those long term gains.
There seems to be an idea around that because CBT is brief therapy that the gains are only temporary. If conducted properly nothing could be further from the truth. Clients who respond well to CBT secure their gains long-term and showed continuing improvement over the long term.
I agree that anti-depressants have been used as any easy solution to depression and anxiety. I don’t think that anyone who has really done the rigorous homework required between 12 sessions of CBT would call it an easy solution. It is effective and common-sense – and puts the power back in the hands of the client (rather than ascribing it to the past or to an organic dysfunction in the brain.)
The problems with studying psychoanalysis were that treatments takes years (Freud recommended 1200 sessions I belive). When compared to the normal way many cases automatically resolve (called regression to the mean) and the placebo effect of expecting to get better because of the therapeutic benefit it was shown that psychoanalysis had NO net therapeutic benefit. Infact it seems that psychoanalysis might even be making you worse than if you just had someone to chat to or did nothing!
Add on the fact that the father of psychoanalysis – Mr Freud – only saw 30 clients in his whole life (and one of them was his daughter!) and you have a ridiculous basis for messing with people’s heads.
(FYI – Andrew Salter probably preceeded Aaron Beck in basically throwing down the gauntlet to psychoanalysis. He famously said he could treat 10 people while the psychoanalysts were getting ready to treat one.)
Anxiety and depression can be measured. Self-reports as well as observable behaviour are, by definition, the only way we know if anxiety exists (unless you include physiological markers like muscular tension and galvonic skin response).
When you’ve asked 1000 people if they felt better because of XYZ and they 80% of them say they feel 65% to 85% better then, yes, you can turn that into a statistic and use it to guide a policy of national health.
Just make sure the studies are solid and statistics are sound – and that good therapists are trained.
Well said Mark Davis! Couldn’t put it better.
I’m looking through your flippant criticisms of psychoanalysis trying to find a coherent argument, Mark. The thrust of it seems to be in your fifth paragraph:
“When compared to the normal way many cases automatically resolve (called regression to the mean) and the placebo effect of expecting to get better because of the therapeutic benefit it was shown that psychoanalysis had NO net therapeutic benefit.”
“it was shown”? Where? Psychoanalytic/ psychotherapeutic literature documents many, many cases of people benefiting from therapy. Try Yalom’s “Love’s Executioner” for a very readable and insightful collection of stories.
“Infact it seems that psychoanalysis might even be making you worse than if you just had someone to chat to or did nothing!”
This is just your ungrounded and unwarranted speculation. Google for “psychotherapy mistakes” and you’ll find a collection of thoughtful, self-critical books and articles on the risks of psychotherapy, written with a view to mitigating and preventing therapy “making you worse”.
I understand CBT to be a generally rigourous framework and approach to mental health, but depending on the sheer will and determination of the client to ensure it’s success. It’s crucially undermined by the failure to recognise or work with the unconscious, transference or counter-transference between client and therapist.
In simpler language, it lacks an appreciation of how what we don’t know about ourselves can sabotage us, the kind of relational processes required to understand ourselves deeply enough to identify and address these self-damaging elements, and their tremendous force. Hence much of the criticism of CBT derides it’s successes as mere symptom substitution; an unbalanced, but not unfair criticism.
I’m 65% to 85% sure that you can’t quantify anxiety.
Psychologists are all quacks. I remember when I was at Uni it was the fall back course to do when all else failed. And NO. They are not Doctors. They have just studied course material at a University in pretty much the same way you would study History or English. Pseudo quack science and pretty much most of their theories have been dis-proven including Freud who made up most of his material. Please note a Psychiatrist is a qualified medical Doctor. A Psychologist who calls himself a Doctor is a joke. That’s like these idiots with Phds in English calling themselves Doctor.