Friday, 6 February 2009

cbt ain't so bad after all

I've been fortunate enough to experience, recently, three perspective shifts on CBT (you know, the popular psychotherapeutic, not the sadomasochistic, practice), aided in part by my convincingly CBTish, and even more so convincingly humane and therapeutic, supervisor. The shifts have simultaneously helped me to develop a more apt, and in some ways less literal, understanding of both the theory and practice of CBT, and also brought that understanding closer to a 'one take on just what decent generic psychotherapy is all about' perspective on the very notion of cognitive behavioural therapy.

The first shift concerns the status of 'beliefs' in CBT. It's easy to knock CBT for containing an overly intellectualist psychology - as if it really did hold that all feelings and behaviours - especially those which we see in the clinic - are driven by doxastic states of the belief variety. Doubtless there are some die-hard, signed-up-to-good-old-fashioned-epistemology, CBT pundits out there who really do imagine that the everyday notion of 'belief' or 'idea' is, as it stands, with the kind of cognitive penetrability and intrinsically linguistic criteria for individuation that beliefs typically enjoy, apt for describing the foundations of psychopathology.

But the truth is that CBT beliefs are far more akin to semi-conscious automatic structures of anticipation or expectancy than they are to workaday hypotheses. My supervisor said something like 'beliefs are the kinds of things that, when the client is able to arrive at their articulation, typically provoke tears'. That by itself shows something of the distinctive characteristic of beliefs in CBT. The process of the articulation of a so-called 'belief' is not one of simply identifying that which, through the process of identification, retains the same form. The articulation process is one of itself giving increasing structure and differentiation and consciousness to forms or habits of expectancy that hitherto have lurked in the background, as constraining structures of experience. The foregrounding, in its way, creates rather than simply voices what we normally think of as beliefs. A murky from-where of attention becomes something which now, in its very status as belief, acquires an optionality for the believer.

I have a half-lingering doubt that says: perhaps even what we ordinarily describe as 'beliefs' have much more akin to semi-conscious background structures of embodied anticipation than I am here admitting. In other words, perhaps my prior prejudice against CBT's talk of beliefs was more a function of my own overly intellectualist conception of what genuine belief is, rather than CBT's overly intellectualist conception of the foundations of our emotional lives. But I'll leave this whole 'learning', as Rogers would have said, here for now.

The second perspective shift turns on the mechanism of belief change in cognitive-behavioural therapy. For it seems to me that the typical idea of CBT in the wider academic and clinical circles in which I move is one of a verbal technology of merely or at least primarily rational disputation - as, say, Ellis' REBT is typically and perhaps more correctly viewed. Even the hallowed behavioural experiments in CBT can be described, within and without the discipline, as ways of simply 'testing hypotheses'.

This seems to me to be almost entirely wrong. For the entire point and continued relevance of the 'behavioural' in cognitive behavioural therapy is that the underlying structures of expectancy driving the psychopathology (the 'beliefs') are, by their very nature, far less opaque to active experiential challenge than they are to verbal discussion of however forceful a hue.

The process of much decent CBT seems then, to me, to work something like this: We invite the client to discuss their difficulties and their formative experiences, so far as they understand them. Together with them we reach an admitedly rather intellectual (i.e. cognitive, representational, schematic) understanding of what distortions may obtain in their relations to the world. For example, they automatically expect on the basis of some unfortunate yet unrepresentative experience that, say, men will be dangerous rapists unless precautions are taken against them. The counter-productive or, at least, problematic expectancy-maintaining, character of these precautions is mutually explored. At this stage the alliance with the healthy ego of the patient, and the content of the discussion, allows for an idea of how change might be possible. However the emotional change - the change in affective expectancies - has not often yet occurred. What now does the real work, in terms of changing the shape of the underyling structures of anticipation, is the behavioural activation - the tentative dropping of the safety behaviours - the learning not merely from, but within, experience.

CBT, as I see it, can then best be understood as a kind of cognitively-, and therapeutic-relationship-, stabilised behaviour therapy. Where by 'behaviour therapy' I don't mean some mechanistic, dry and dusty simple-phobia-exposure treatment, but a therapy which involves active immersed experiential change of the sort that allows for learning within experience to take place. (The relevant behaviour might, for example, and admittedly in an extention from mainstream CBT, even be taken to involve trying to drop both internal and external defences to avoided emotions and thoughts to which a greater tolerance would be therapeutic.) This active element is, it seems to me, one of CBT's greatest strengths; rather than run the risk of simply talking about change, or accruing merely intellectual insight, the therapy promotes real experiential transformation through alteration of bodily praxis.

Rather than explore this further, I want to comment on my third 'learning', which involved me in what I now see as an unwarranted devaluation of CBT at the expense of ACT or other third-wave (cognitive) behavioural therapies. ACT tells us that what is most therapeutically effective is often not thought-challenging - i.e. not trying to alter the content of thoughts - but rather the comprehensive distancing from them - i.e. an alteration in our relationship with our thoughts, or an alteration in their form. To engage in questioning thoughts was, I thought, potentially to invite people into arguments with themselves which were, possibly, ultimately counter-therapeutic.

Well, I now suspect that this may be based in part on an oversimplification of the relationship between form and content. Moreover, though, I suspect that it is based on a failure to appreciate how one of the best ways of changing one's relationship with one's automatic thoughts is through questioning their truth. Furthermore, questioning their truth can be a darn sight more therapeutically easy than learning mindfulness techniques! Done sympathetically, and with an encouragement to the person in their sympathetic treatment of themselves, the questioning of the content of a thought which has hitherto been treated as a fact is a great way to turn that thought into a mere hypothesis. From being something which presents itself as a bit of world disclosure, we get something that acknowledges itself as a possibly mistaken take on the world. And that is itself a significant transformation in our relationship with the belief itself.

None of the above three recantations are meant to suggest an acquiescence in, say, modes of therapeutic practice or theory which devalue therapeutic ingredients not explicitly recognised in the above - say, the power of the therapeutic relationship itself. Nor do I wish to condone forms of therapy which seem to fail to appreciate the intrinsic significance of the ethical - of the power and the bloody hard work of offering true recognition to someone else. CBT is doubtless as guilty as many other therapies when it comes to underestimating the value - and the practical difficulty - of the human/e encounter. I also don't mean to condone the therapeutic fundamentalism that obtains in often highly visible sections of the CBT (and, for that matter, psychoanalytical) community. But these are concerns for another day.