Working towards What?

Do you know what your goals are? And if so, are you certain that if you achieved them you would be happier, or more satisfied, than you are now?

I think many of us might answer negatively to at least one of those questions, and I’m surprised that CBT thinks that most of us know what our goals are, but that we just have difficulty working towards them.

I’m closer to thinking that most of us would be able to work towards goals that we have identified that are meaningful to us (they would be inherently aligned with us and therefore more likely to be motivating), but our difficulty is more often rather in identifying what is important to us.

So while CBT sounds like it’s a therapy that believes in the agency of the individual, I think more exploratory approaches like psychoanalysis or psychodynamic approaches have more faith in the individual’s agency to achieve their goals.
CBT assumes that we know what our goals are, just need help achieving them with a boost of willpower.
Psychoanalysis assumes that we are pretty good at going after what we want, but we often need help clarifying and unearthing those ‘truer’ or more authentic values and goals.

What sparked this thought was a guilty feeling, because I have recently started twice-weekly psychoanalysis, whilst clinician-me delivers six 30-minute sessions of Low Intensity CBT to clients suffering from similar (if not far more debilitating) mental health difficulties than patient-me. I know that if I switched roles, if I approached myself as PWP, and was told by PWP me to identify ‘Goals’ to work towards across 6 weeks in ‘therapy’, I’d be stumped. It would be totally meaningless, and potentially even distressing. What I am beginning to identify – slowly, tentatively – in psychoanalysis, is that sometimes seeking and going after goals is a blind race towards, or perhaps more accurately away from, something else as-yet-unidentified. And we don’t necessarily know what we should be striving towards or moving away from until we have stopped for a moment to reflect, and I don’t mean for a matter of moments or even days, but a stretched-out kind of reflection that happens best in the presence of a non-judgemental other. I think I am learning that healing (sometimes) can come from a moment of pause, or stillness, where for a couple of times a week you don’t need to press forward towards an unending improvement.

Admittedly, this will not apply to everyone. Despite my belief to the contrary, many of my clients say that they have found our sessions helpful and they even seem to ‘recover’ as according to the PHQ-9 and GAD-7. So, clearly, the approach taken by psychoanalysis as opposite to CBT is not for everyone, sometimes we do just need that boost of motivation, or a few handy techniques for stopping worrying so much. But maybe it’s a question then of time of life, sometimes we need CBT goal-oriented help, and at other times we need just a space to think and speak.

A Common Criticism of CBT

Some critics of Cognitive Behavioural Therapy (CBT) have focussed their attack on its underlying theoretical assumption that our ‘beliefs’ cause mental distress. That’s a pretty easy target, though, once you look at the correlations between factors like poverty, abuse, systemic oppression; and mental distress – in those cases, would you really call their thinking ‘faulty’ when it reacts against these conditions? It seems more mistaken not to be distressed in those cases. So naturally, CBT theorists adjusted and now recognise that external factors play a significant role in contributing to mental distress.

In practice, that meant that CBT moved away from the ‘C’ and towards the ‘B’ (Behaviour): instead of telling the individual to change their thoughts, the idea now was to get them to change their behaviour, which would hopefully go some way towards fixing their unhelpful environment. For example, if poverty is making you depressed, why not get a job? If your husband’s drunken violence is causing you anxiety, why not go to a friend’s house next time this happens?

There are obvious problems with this – most glaringly that the focus is still on the individual (rather than the structural or societal), however, I do understand that psychologists are limited in the areas that they can help with – they aren’t politicians or social workers, after all.

Another way that the CBT theorists tried to update the underlying philosophy of CBT was to think in a less linear (‘x causes y’) fashion, replacing this with a cyclical framework of our thoughts, behaviours, emotions and physical feelings as all interrelated and mutually reinforcing.

This served to disperse the blame, so now we can’t ever quite say for certain which came first: the faulty thoughts or faulty environment… Do we pick poor husbands because we think badly of ourselves, or do we think badly of ourselves because of our abusive partners?

The 5 Areas Model we are taught appears comprehensive, but I still get the feeling that the CBT-based approach is missing out on some vital aspects of human life. Predominantly, I begrudge the lack of a detailed discussion on affects and moods as non-propositional, and the importance of intersubjectivity. CBT seems to be based on some unhelpful and out-dated conceptions of how we exist in the world. The underlying theory describes the human being in a mechanistic, representational manner – someone that understands the world in propositions (or mental images) and then acts accordingly.

I am not breaking new ground by arguing that CBT feels impoverished in these respects – Anthony Ryle’s psychoanalytic alternative to CBT, CAT (replacing ‘Behavioural’ to ‘Analytic’), attempts to redress this individualistic approach by creating a space for ‘Reciprocal Roles’ formed in our early relationships with caregivers. I have not yet read as much about CAT as I would like to (I’ve only just started reading Introducing Cognitive Analytic Therapy [Ryle & Kerr 2020] – and am very much enjoying it so far), but I think there’s a chance that it also remains too firmly representational, and doesn’t fully conceptualise things like affects and moods that couldn’t easily be formulated into propositions. From what I know so far, and as suggested by its name, CAT takes a similarly computational approach to the human psyche, only it has broadened the roots of these cognitions to include our early relationships, instead of keeping the focus on the individual as a separate being. It sees cognitions as arising within intersubjective relationships and from the roles we assume within those relationships. I like this expanded concept, and perhaps I’ll find that it is a good enough update to the theory, but I will save that conclusion until I’ve finished the book. From where I stand now, however, I don’t think that we should limit ourselves to cognitions that can easily be translated into propositions or even mental images.

I’ve developed this view through my reading of phenomenological approaches to psychology, starting with Maurice Merleau-Ponty who argued that perception is direct (and hence against the subject-object distinction), similar arguments put forward by the ‘Ecological’ psychologist James Gibson, the philosopher of psychiatry Thomas Fuchs who writes of affects and moods as existing in the ‘backdrop of an experiential field’, and Enactivist philosophers of mind (Varela, Thompson, De Jaegher) who stress the ‘embodied, embedded and extensive nature of mentality’…  

Perhaps it’s a matter of temperament, but these thinkers seem to capture something that fits more with my experience as a human being. I can’t convince myself that ‘representations’ or mental images play as large a role in our thoughts, feelings and behaviour as cognitive scientists seem to believe. Maybe I have a distinctly empty inner world, but I hardly ever seem to be thinking of any clear representations of things, or even thoughts in words. From his case studies it sounded like Beck’s clients had similar difficulty in formulating what they were thinking. Of course, if I were to be asked, as they were, ‘what thought went through your mind when you last felt sad?’ I could probably think of something (as they did) but I have a feeling that I’d be creatively guessing rather than faithfully reporting what was going on my mind. Usually when I feel low it is due to a more vague sense of wrongness, more like a mood that colours my entire environment, rather than a clear ‘negative thought’; and might be due to some kind of interpersonal shift in atmosphere that I will have picked up from my partner, for example. These are distorted once they are forced into the form of a clear proposition – ‘my boyfriend doesn’t like me’ – would be the forced answer I’d give to Beck, but that wasn’t really what I thought, so if he started listing reasons as to why that might not be the case I’d find it a waste of time, or if he did a bad job and didn’t persuade me, insulting.

At the same time, I don’t believe that we need to make this an either/or dilemma – I don’t want to say that cognitive representations do not exist full stop – they may well do when we are more explicitly remembering or imagining. I just don’t think that ‘internal representations’ are all that we have – more often it feels as though we are behaving in a more automatic-pilot way – perceiving and responding to the world as it happens, and as we move through it. And I think that our moods and feelings are born and played out within interpersonal relationships and situations, rather than our inner mind observing and formulating its own little images.

The counterargument could be made, however, that maybe the CBT ‘philosophy’ doesn’t quite capture it all, but this isn’t important because the therapy works. My tutors on the Psychological Wellbeing Practitioner course are always drilling it into us not to think too much about our client’s past experiences or even their thoughts – because it’s their behaviour that we need to change, as this will have the biggest benefits. How would I go about shifting someone’s mood anyway, if it really is that nebulous thing that I have described? Beck wanted to make a practitioner’s science, not a philosophy of mind. But the low intensity CBT approach in IAPT is getting only 50% recovery rates at the moment, so I don’t think anything’s decided yet, and we should probably keep thinking and revising…

Coaches or Clinicians?

I’ve recently started training to become a Psychological Wellbeing Practitioner in an IAPT (Improving Access to Psychological Therapies) service, and what that means is that I will soon be able to deliver Low Intensity Cognitive Behavioural Therapy to ‘clients’ with mild to moderate common mental health problems such as depression and anxiety.

The training is delivered 2 days per week by lectures and seminars from University College London, and the remaining 3 days per week I spend working at my IAPT service doing assessments and low-intensity treatments.

One thing in particular that we learnt in the first week threw myself and my fellow Trainees: the fact that we should not think of ourselves as therapists or clinicians, but as coaches. We didn’t do so big-headedly, but in our previous role (when we were doing Triage Assessments and offering people Step 2 Guided Self-Help, or Low Intensity CBT), we always thought that Step 2 was a sort of CBT-lite, and so the Step 2 clinician was therefore a sort of therapist-lite.

Also, when I was learning about IAPT as an outsider, I was wrongly led to believe that the program is training ‘therapists’ not coaches. David Clark says so himself in his ‘IAPT at 10: Achievements and Challenges’ post, he writes (under the dramatic title ‘A revolution in mental health’), that to overcome the shortage of psychological therapy available to people suffering from common mental health problems, ‘the NHS has trained over 10,500 therapists and deployed them in new psychological therapy services’ (emphasis added). This is misleading, and I often find evidence of IAPT’s main advocates (usually people with a stake in the game), claiming more for the service than it deserves. I think Clark and others should be more cautious in over-selling IAPT, because it will eventually lead to disappointment when people’s expectations aren’t managed.

Thanks to that misinformation, when I used to allocate people whom I had triaged to Step 2 treatments, I always sold it as a ‘guided cognitive behavioural therapy over 6 weeks, for 30 minute sessions’. But now that we are training to be those Step 2 ‘clinicians’, we find that we are not that at all, and what we offer isn’t Cognitive Behavioural Therapy, but rather a life-coaching session.

But – I agree with this. We shouldn’t think of ourselves as clinicians or therapists because we don’t have those skills – we aren’t taught about what happens within the therapeutic relationship, and how to more supportively guide our clients through more long-lasting psychic change. I think it also serves to prevent us from feeling also like counsellors, whose role is to sit and listen to the client as they talk about whatever they feel like getting off their chest. By reminding us that we are there to encourage behaviour change (and that’s essentially it), it makes a lot of sense to call us coaches.

Having said that, however, it’s now clearer to me just how difficult I’m going to find this year in how it jars with my fundamental values and assumptions as to how psychological therapy should be. It’s odd, and I must try to check it, but I have an almost instinctual aversion to CBT and the phrase ‘evidence-based treatment’. Aaron Beck (the founder of CBT), gives me an uncomfortable feeling, I can’t help but think he’s getting something terribly wrong, or turning something complex into something robotically simple (to its detriment). I don’t have enough learning or experience to quite put into words what exactly I distrust about Beck’s cognitive approach, and I know that it has changed and improved a lot since his day so I’m probably being hugely unfair to modern practitioners of CBT, but I have read a couple of things recently that have started to confirm my uncomfortable feeling about it…

The first was a blog post by philosopher and clinical psychologist Richard Gipps, on how Beck’s turn away from psychoanalytic psychotherapy was caused by his own misunderstanding of the theory, rather than with any fundamental flaw in the approach itself.

And the second was a journal article by Michael McEachrane on the flawed assumptions that Cognitive Therapy is based on to do with what it really means to ‘think that p‘.

I’m tempted to share these two articles with the other Trainees on my course to see what they think, but I don’t want to be the bad, critical one in the bunch.

And, I do understand why IAPT uses the CBT model so religiously. The aim of IAPT is to ‘democratise psychological therapy’ – it wants to make it accessible on the NHS, and this I fervently agree with. Unfortunately, however, CBT is the only kind of therapy that can be made ‘efficient’ and ‘wide-spread’ in this way, because it’s less about the relationship that the client has with their therapist, and more about the ‘tools’ that they learn from them. So, the therapists can be quickly and inexpensively trained, because it’s not really about them and their skills.

Research has shown that this can be effective (with about a 50% recovery rate; not bad, not good?), but the jury’s out as to how long those benefits last for, and I have a feeling that the main function of having Step 2 low-intensity treatments available on the NHS isn’t so much for the good they do, but as a sifting mechanism for finding out who are the really serious cases on the waiting list who need longer-term therapy. Without Step 2, we would have one big, long waiting list for CBT Proper (Step 3), and that wouldn’t be good for anybody.