CBT: Band-Aid Solution or Sufferer's Balm?

United Kingdom · CPD points & talks · Psychologists

I am fascinated by the transition in the history of psychotherapy from psychoanalysis to cognitive-behavioral therapy, as well as the relative benefits and disadvantages of each approach. Making a cursory survey of the psychoanalytic critiques of CBT, I find a humanistic emphasis on the individuality of each patient; CBT, on the other hand, has objective standards, often ones that are in line with societal expectations, that the patient is encouraged to meet (oftentimes he is given homework). The variation in this regard stems, I think, from different approaches to the symptom. For Freud, the symptom is an expression (like an artwork?) of psychical conflicts: it is necessary, and perhaps even desirable. For Beck, Ellis, et al., the symptom is a localized aberration that can and ought to be excised.

For all its sense of the self’s inviolability and profundity, I react to the psychoanalytic critique of CBT with some exasperation. In an article about the rise of CBT [i], Darian Leader compares a patient’s “little book,” in which he finds sayings that he can read in order to neutralize instances of negative thinking, to Mao’s infamous booklet of maxims. More generally, Leader seems to lament the resonance that great literature once had, because it seemed to limn the region of the “deep soul,” as opposed to the worldview underlying CBT, which detects only surfaces.

But therein lies the paradoxical profundity of the system developed by Beck. It limns the region of the soul that, because of the exigency and extremity of its suffering, has gone beyond culture. The desire to return to any version of normalcy is a desire that must be honoured when dealing with potentially severe conditions like bipolar disorder and obsessive-compulsive disorder. “Suddenly,” writes Leader, “the world of human relations described by novelists, poets and playwrights for the past few centuries can just be written off.” Precisely. John Berryman, in his fourteenth Dream Song, conveys this sense of the futility of culture to serve as a palliative to pain: “Ever to confess you’re bored / means you have no / Inner Resources.’ I conclude now I have no / inner resources, because I am heavy bored. / Peoples bore me, / literature bores me, especially great literature…”

This is not to say that CBT is easy. On the contrary, one of its features is a sort of no-nonsense, tough-mindedness. How this manifests clinically will of course vary depending on the disorder being treated. In my case, as someone who has fought OCD for upwards of a decade, it meant finally coming into explicit, unflinching contact with the negative thoughts that for years I had been futilely trying to suppress. For me, Exposure and Response Prevention, the “behavioral” arm of the CBT approach to OCD, entailed doing things that were perhaps more difficult than unearthing the underlying meaning of my symptoms: I had to own them, agree with them, and take full possession of them, so that by the time my treatment was over, I was bored with what were hitherto extremely distressing thoughts. Contrary to the “band-aid” canard, it was the opposite: slowly tearing off that which covered my wound. During analysis, I could develop theories about why I was doing absurd, time-consuming things, and these theories were a kind of comfort. CBT, in ignoring the supposed meanings behind the symptoms, was a means of refusing to play the game that my OCD mind was intent on playing. In other words, it offered, rather than multiple, labyrinthine ways out, only one: the battering ram of behavioral modification, a process that seems to have turned my suffering brain into a “normal” one, and a life stuffy with thoughts into one with the space to pursue those pastimes that my illness had forced me to shunt aside. It’s not that the depths ought not to be plumbed – they should be – but to dismiss CBT as a superficial, Band-Aid solution, is to fail to confront how urgently sufferers want to be reconciled to the average, capitalist, workaday world.

[i] Leader, D. (2008). A quick fix for the soul. Available at https://www.theguardian.com/science/2008/sep/09/psychology.humanbehaviour