The Improving Access to Psychological Therapies (IAPT) programme has one principal aim – to help primary care trusts (PCTs) implement National Institute for Health and Clinical Excellence (NICE) guidelines for people suffering from depression and anxiety disorders. At present, only a quarter of the 6 million people in the UK with these conditions are in treatment, with debilitating effects on society.
These “debilitating effects”, according to the governments own strategic plan for mental health promotion, include an estimated £105 billion negative impact on the English economy alone, with treatment costs predicted to double in the next 20 years. With these facts in mind it is obvious that something has to be done about all of this. But could CBT be part of the problem? And if so what might an alternative psychological intervention be?
Historically, CBT is usually traced back to the work of Albert Ellis and Aaron T Beck who developed their Rational Emotive Therapy and Cognitive Therapy(respectively) in the mid to late 20th century in response to, and as a rejection of, Freudian psychoanalysis. The work of Ellis and Beck, combined with that of some behavioralist techniques, was later repackaged as CBT. The great insight by these pioneers of CBT appears to have been the realisation that there is a connection between thoughts, feelings and behavior. This insight then led to the idea that we can change the way in which we think in order to change the way we feel and behave.
So the theory goes; people feel depressed (for example) because they have depressing thoughts, which in turn lead to behaviour that reinforces the way in which they think and feel. According to Beck, depressed individuals make negative evaluations of (1) themselves, (2) the world, and (3) the future. This is sometimes referred to as Beck’s cognitive triad. Underlying these evaluations are negative (often automatic) thoughts which are understood as cognitive distortions which come in a number of identifiable types, including:
- Catastrophic thinking: this involves giving too much credibility to the worst possible outcome.
- Dichotomous reasoning: this includes all-or-nothing / black and white patterns of thought.
- Labelling / mislabelling: this involves the overgeneralisation of a persons actions to their character as opposed to some other factor.
These modes of thinking are associated with many types of mental health problems, and it is not hard to see how such thinking would lead to, or at least strongly contribute to, low mood. The technique used in CBT to address such cognitive distortions is called cognitive restructuring. This cognitive restructuring is a process that involves the identification of negative thoughts and the cognitive distortions within them. Following from this identification process alternatives to the cognitive distortions are formulated and used to challenge the negative thoughts.
I don’t know what you think but I have very mixed feelings about all of this. On the one hand, I really like the common sense reasoning that underpins and informs CBT. I suspect that most people can, at least to some extent, recognise within themselves some of the cognitive distortions highlighted above. I am sure that we can all understand how cognitive distortions can generate emotional disturbances and dysfunctional behaviour. Furthermore, in recognising and understanding this we are empowered to challenge our thoughts-emotions-behaviours and work towards changing them in ways that improve our quality of life. It is these relatively easy to understand characteristics of CBT that, I suspect, makes it so appealing to both service providers and service users.
However, on the other hand, I also find CBT troubling for a number of reasons. One of these reasons is the way in which CBT seems to locate the source of the problem – i.e. cognitive distortions – within the individual without taking seriously the realities of the socio-economic context in which we live. This, of course, is why CBT is so appealing to a government that wishes to address the “debilitating effects” mental health problems are having on society (highlighted above) without tackling the social factors that contribute to emotional problems in the first place. The UK government cannot do this for the simple reason that it is a major part of the problem. IAPT trained CBT therapists – who are blind to the social factors that contribute to cognitive distortions – cannot do this for the very same reason. In fact, CBT practitioners could be helping to distract people away from the real solutions to emotional distress.
Based on a set of World Health Organisation (WHO) studies the British psychologists – Oliver James – identified a set of social values that, if internalised, increase our vulnerability to emotional distress. These values include “placing a high value on money, possessions, appearance (physical and social) and fame” – which, collectively, James refers to as the affluenza virus. According to James, this virus is spread on the back of global capitalism. As capitalism promotes its values we see an increase in vulnerability to emotional distress.
Notice that these social values are exactly the same ones as those being promoted by the UK government – both abroad and at home – as they pay lip service to the psychological well-being of the general public. Also notice how the process of cognitive restructuring could be used as a tool to get people to conform to social institutions that are known to be psychopathological – all in the name of mental health promotion.
It is also important to understand that such pro-capitalist values did not become dominant within society all by themselves. On the contrary! Placing a high value on things like possessions and appearance is the result of massive and continuous propaganda campaigns that serve elite interests. As Alex Cary pointed out in his pioneering work on propaganda managed democracies:
“The twentieth century has been characterised by three developments of great political importance: the growth of democracy, the growth of corporate power, and the growth of corporate propaganda as a means of protecting corporate power against democracy.”
From this I think we can begin to develop a very different understanding of where cognitive distortions, and the resulting emotional distress, may originate. Political and economic elites work very hard to make sure that the democratic process functions in ways that are acceptable to privileged minority interests. Naturally, this psychological manipulation has a massive impact on the general public’s sense of confusion and hopelessness, which in turn can only impact negatively on their mental health. The question now becomes: What kind of psychological intervention can we conceptualise that can begin to address emotional distress from this point of view?
One possible way forward is suggested by Noam Chomsky in his Necessary Illusions, in which he writes:
“My personal opinion is that citizens of democratic societies should undertake a course of intellectual self-defense to protect themselves from manipulation and control, and to lay the basis for more meaningful democracy.”
This idea of intellectual self-defense (ISD) – a term that is pretty much self-explanatory – could be used to inform a new type of psychological intervention for mental health promotion, as an alternative to CBT. ISD would have a very different explanation for cognitive distortions and the resulting emotional distress, and could be developed as a talk therapy that addresses the issues of elitist psychological manipulation and control head-on. Furthermore, ISD therapy could inform a movement of service providers and users committed to taking back the democratic process as a social intervention for mental health promotion. As David Edwards – of Media Lens – has stated, ISD “threatens to raise the spectre of more sane ways of living”.