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by Kristy Hall and Furhan Iqbal
Karnac Books, 2010
Review by R.A. Goodrich, Ph.D. on Nov 16th 2010

The Problem with Cognitive Behavioural Therapy

One ringing endorsement of cognitive behavioural therapy is Lord Richard Layard's The Depression Report of June 2006. He extols it as the "most developed" amongst the "evidence-based," "short, forward-looking treatments" (2006: 3), treatments that are positively re-enforcing and "cost effective" means of countering depression and anxiety disorders (2006: 6ff.).  As Kirsty Hall and Furhan Iqbal openly state, their booklet, The Problem with Cognitive Behavioural Therapy, wishes to question "whether Layard's assertions are entirely justified" (xi).  They contend that this is especially needed when cognitive behavioral therapy is no longer targeting depression, but nowadays is in fact employed by practitioners from a variety of professional backgrounds for debilitating illnesses ranging from arachnophobia and bulimia nervosa to chronic fatigue and schizophrenia.  In what follows, we shall firstly review the crucial kinds of questions raised by Hall and Iqbal before concluding briefly with one about the role of language that they fail to pursue fully.

I

Psychological hypotheses and their attendant patterns of treatment have often been characterized by lengthy periods of largely unchallenged if not always uniform adherence by practitioners.  Part of the reason may well lie in the sheer persistence and personality of their founders.  Part of the reason might equally centre upon the interlocking endorsement by clinical, educational, and governmental institutions.  The longevity of cognitive behavioral therapies in the Anglophone world seems to be a case in point.  Whilst cognizant of the successes and spread of such therapies, Hall and Iqbal are certainly not prepared to leave them unchallenged.

Whilst initially surveying socio-political and intellectual factors behind the rise of cognitive behavioral therapies, Hall and Iqbal proceed by recapitulating their evolution from behavioral antecedents onwards first highlighted by Stanley Rachman in the late 'nineties (7ff.).  However, it immediately becomes obvious that they are pre-occupied with one major variant of the melding of behavioral and cognitive approaches, namely, Aaron Beck's so-called cognitive therapy that emerged after the mid-'seventies.  Omitted from their account are, for example, the rival claims of Arthur Ellis' rational emotive behavior therapy that arose in the late 'fifties.  No explanation is proffered why Beck, but not Ellis, is regarded as crucial to the hold cognitive behavioral therapy has upon current practice (cf. 11).  Nor, for that matter, is the debate between both men in the Journal of Cognitive Psychotherapy of 2003 and 2005 over their empirical rather than theoretical credentials given any attention.

Concluding their survey with the present British context, Hall and Iqbal direct their readers' attention to the seeming efficacies of cognitive behavioral therapy in what is at times a politically charged synopsis.  The apparent strengths of the merging of behavioral and cognitive strands are said to be at least four.  These include, firstly, the focus upon accessible "consciously experienced thoughts and images"; secondly, the direct involvement with "human experience and behaviour" without deviating into analogies with other species and laboratory experiments;  thirdly, the "sophisticated formulations and targeted interventions," thereby maintaining the "legitimacy" and "hegemony of scientific discourse"; and, fourthly, the growing appeal to the "middle classes" where "a reframing of individual problems" from an hierarchical, bio-medical towards an egalitarian, "talking therapies" perspective has taken place (12-14).

Conceding that different disorders involve different emphases, the second of the four main chapters of The Problem with Cognitive Behavioural Therapy aims to disclose the underlying nature of Beck's handling of depression.  In brief, depression is construed in terms of cyclical negative attitudes permeating past, present, and future experience.  For Hall and Iqbal, Beck's "central...assumption" is that

individuals' emotions (affects) and behaviours are dependent on how the individual organises his/her experience of the external or internal world.  The importance of cognitions, images, and verbal events consciously experienced...is stressed; these are deemed to have primacy over emotions and behaviours.  In depression, it is thought that cognitions resulting in disturbance of emotion and behavior are frequently inaccurate.  They are deemed to be the result of faulty information processing (23).

The authors immediately begin to criticize Beck and his followers for not resolving a number of crucial issues.  They question the primacy assigned to cognition as others have done, querying whether, in fact, emotions, behavior, and cognition might have a "reciprocal impact on each other" (23) even when behavioral experiments and tasks, in preference to "dredging the past" (27), are to be sequentially undertaken by patients as steps in the rational monitoring of their own experiences, perceptions, and thoughts.  This is rapidly followed by other questions. For instance, if depression is what is supposedly measured by the Beck Depression Inventory, then is depression unlike personality disorders "in a sense, self-reporting" (28)?  Next, if people need persuading to be rational to use cognitive behavioral therapy, then what makes them non-rational or dysfunctional in the first place and who decided "what constitutes dysfunctional behaviour" and when (30)?  Again, in so far as cognitive behavioral therapy concentrates upon the individual alone, upon his or her rationality and responsibilities, does it ultimately uphold the status quo and, in so doing, deny that social problems such as mass unemployment and the like play any causal role (cf. 38-40)?  Furthermore, are all patients with depression capable of distinguishing between rational and non-rational thinking, and, if not, how can cognitive behavioral therapy gain any purchase with them short of "impos[ing] a structure of thought" (40-41)? 

The third and longest chapter focuses upon two widely disseminated claims about cognitive behavioral therapy: that it is scientific and that it is empirically grounded.  In a section entitled "Philosophical arguments" (38-44), Hall and Iqbal eventually provide a compressed summary of debate over the contested notion of the scientific, as represented by Thomas Kuhn, Karl Popper, Imre Lakatos, and Paul Feyerabend since the 'sixties, in an effort to demonstrate its socially rather than logically constructed nature (41-43).  Their aim, when concluding that "the reader may wish to bear the debate outlined above in mind," is to cast doubt upon identifying the success of cognitive behavioral therapy with it being "inherently better than other forms of treatment" let alone with it being more "scientific" (44). 

During the course of the next section of Chapter Three, "Statistical arguments" (44-53), supplemented by an Appendix of six critically annotated, frequently cited "earlier foundational papers" (69-79), methodological problems affecting evidence adduced in favor of cognitive behavioral therapy are reviewed.  The need to do so is warranted as the unquestioning acceptance of statistical arguments in support of cognitive behavioral therapy continues unabated as exemplified by even a cursory glance at the 2010 edition of Clinical Guide to the Diagnosis and Treatment of Mental Disorders by Michael First and Allan Tasman.  Hall and Iqbal adroitly probe the appropriateness of variables and measures, sample size and selection, methods and results, especially of randomised control trials, affecting all forms of psychotherapy equally.  The authors then embark upon classificatory changes affecting the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases (53ff.).  If, they ask, diagnostic categories prove susceptible to revision with each successive edition of the D.S.M.  or the I.C.D., then are "multiple," if not "conflicting," diagnoses a burden to be borne by all therapies, including the cognitive behavioural (55)? 

Finally, Chapter Three ends by questioning the British Psychological Society's response, prepared by Andrew Gumley and colleagues in December 2008, to the Bristol-based Skills for Health and its proposed professional standards for the practice of cognitive behavioural therapy.  Here, Hall and Iqbal claim, the response shows how a consequence of "an evidence-based approach to mental health...encourages the notion that treatment can consist of a fixed process" (56).  Indeed, they also contend, the demand for intensified accountability in order to minimise malpractice might also run the risk of "ruining the very delicate fabric of words that forms the material of all talking cures" (60). 

II

It is with the foregoing remark about the "delicate fabric of words" that we shall conclude this paper.  Scattered throughout The Problem with Cognitive Behavioural Therapy and embedded within its brief final chapter are the beginnings of a critique of the role of language which many readers may consider worthy of separate treatment.  Early in the booklet is a pointed observation directed at behavioural approaches where

The rather significant issue that alone amongst animals, human beings use language in an extremely complex way was largely ignored as was the related fact that language itself influenced behaviour (9).

Later, psychodynamic interpersonal approaches are also critiqued.  These, not unlike other therapies including the cognitive behavioural, "assume that the patient is capable of making...connections and understanding hypotheses" (52).  And, in doing so, they also presume that "mixed feelings would be part of the process of developing a shared understanding through the development of a language, use of metaphors etc." (52). Yet cognitive behavioural therapy treats language as if it were entirely transparent.  This seems to be the case despite its teachability in the form of manuals which are replete with instructions about the introducing and reviewing, checking and enquiring to be undertaken by practitioners.  The seeming invisibility of language remains despite the hypothetical samples of utterances found in, say, the March 2000 manual focusing upon adolescents with depression by John Curry and colleagues.

You and I will be looking at your emotions, your thoughts, and your activities like scientists working together to understand something better (2005: 38).

Hall and Iqbal believe that cognitive behavioural therapy, in fact,

has little if anything to say about the properties of language.  Yet, like many other forms of therapy, it relies upon speech both as the medium of communication and as a largely undefined means of recording the feelings of the patient (64).

Hence, they would not be satisfied with one recent suggestion about recording the feelings of patients.  It would not be enough, as Alec Grant has done in the second edition of his collaborative anthology Cognitive Behavioural Therapy in Mental Health Care just published, to uphold the use of autoethnographic accounts. Part of the difficulty here is that such a suggestion is modeled on the literary fictional practice of The Ethnographic I  by Carolyn Ellis and fails to confront the implications of her desire to "keep the boundaries blurry and inclusive" (2004: 39). 

As implied but not foregrounded by Hall and Iqbal, perhaps what appears to be needed is to return to a closer examination of how the frameworks of practitioner and patient differ.  For instance, in terms first coined by Elliot Mischler in his 1984 The Discourse of Medicine, how does the contrast between the "voice of medicine" and the "voice of the lifeworld" manifest itself?  Arguably, the former "voice" construes the meaning of events through abstract rules that in effect decontextualize those events from the latter's specific personal and social circumstances.  Or, as Arthur Kleinman in his 1988 volume The Illness Narratives expresses it, the patient's story basically aims to give coherence to the distinctive events and suffering endured; it does not simply reflect his or her experience, but actually contributes to that experience and its symptoms.    The linguistic manifestations of such narratives, of such voices, have already started to be revealed in, for example, the more generalized interactional analysis of therapeutic discourse by William Labov and David Fanshel a generation ago and more recently developed by Kathleen Ferrara amongst others.  It is these writers who are noticeably missing from an otherwise timely and provocative booklet deserving of our attention.

 

© 2010 R.A. Goodrich

 

R.A. Goodrich teaches in the School of Communication & Creative Arts, Deakin University, Melbourne, Australia, co-edits the online refereed arts-practice journal, Double Dialogues, and co-ordinates with Maryrose Hall a longitudinal project investigating behavioral, cognitive, and linguistic aspects of higher-functioning children within the autistic spectrum of disorders.