Does Cognitive Therapy Work?

Once upon a time psychoanalysis ruled the mental health profession. Most of you were not born when such was the case, but, whatever.

Psychoanalysis was everywhere, in the media, in movies, in classrooms. Everyone was studying Freud and Jung.

But then, several decades ago a psychiatric resident named Aaron Beck discovered that psychoanalysis was largely ineffective as treatment. It was especially ineffective in treating clinical depression. So, Beck invented what he called cognitive therapy in order to provide effective treatment for depression. Later he extended it to anxiety.

Of course, it took quite some time for cognitive treatment to take over the mental health field. Even today, when it is ascendant, it is still not practiced by all mental professionals. 

Many therapists continued to practice psychoanalytically inspired treatments, to little avail, especially for their depressed patients. Thus it happened that when Prozac arrived on the scene a few decades ago, the press was filled with stories about patients who had undergone psychoanalytically inspired treatment for decades, without there being any improvement. But then, they started taking Prozac and they improved.

The debate has lately become complicated, and I wrote about it in a previous post.

In short, alternative treatments have been proposed and practiced because psychoanalytically inspired treatments failed clinically. The same applies to the behavioral treatment for phobias. Since these have been significantly more effective than psychoanalytically inspired treatments, they are today the treatment of choice.

Today, Britain’s National Health Service will only allow cognitive treatments for mental health issues. 

Naturally, this has caused large amounts of soul searching for those who persist in practicing psychoanalysis. Among those who pretends to be defending psycho analysis is one Bradley Murray. Dr. Murray has written an article explaining that cognitive treatments are not perfect-- as though you needed a serious article to know that. He also explains that cognitive treatments are based on rational thinking-- which he feels is not sufficiently soulful. It feels especially whiny-- but what were you expecting.

In the meantime, if you read through the article you will discover that he never mentions that psychoanalytic treatment works. Psychoanalysis might help you scavenge through your past memories and recover your prior experiences, but when it comes to treating what ails you effectively, it obviously fails.

But, Murray does present the evidence suggesting that cognitive treatments do work:

… I have seen many patients like her in my practice who have found that CBT doesn’t resonate with them. Yes, research consistently shows that patients who receive this form of therapy are more likely to experience an improvement in symptoms than those receiving no treatment at all (or receiving placebos). And yes, CBT is one of the most widely used, well-researched and well-funded forms of therapy in the world, accessible through mental health clinics, online therapists, or even apps. But it is not perfect.

The fact that it does not work in all cases does not discredit the technique. The studies should factor in the different skill levels of practitioners, along with other human variables. But, working half the time is surely better than working none of the time. 

One recalls that famed French Freudian Jacques Lacan once opined that if anyone got better during a psychoanalysis, it had to have been a fortunate accident, not a consequence of the treatment. Now they tell us. Lacan also declared that psychoanalysis was a scam, but I have discussed that elsewhere.

In any event Murray tends toward vague and meaningless concepts like growth and development. I doubt that he knows it-- Lacan would have recognized it immediately-- but his thinking derives from Church mystics who underwent journeys into their minds in order to find God. Among the best writers in this tradition were Bonaventure and St. Teresa of Avila. Dare I say, it has nothing to do with science.

So, Murray champions soulful emotional states, as though our culture were not wallowing in them:

I believe their concerns can be best understood if we acknowledge that not all adult emotional problems ultimately stem from failures in thinking and reasoning, as CBT maintains.

Not all problems can be solved quickly through what CBT practitioners call ‘cognitive restructuring’. Understanding the limits of this popular form of therapy requires us to ask a difficult question: can CBT ever help us to fully develop psychologically?

And then, Murray follows Aaron Beck in suggesting that cognitive treatments derive from Stoic thinking. This is not really true, and one emphasizes that cognitive treatment has its origins in Aristotle, in the notion that symptoms were bad habits-- one might say, bad mental habits-- and that one could cure bad mental habits by replacing them with good mental habits. Since Freud’s work began when he decided that hysterical symptoms were meaningful expressions of repressed wishes, you can see that finding the meaning and correcting a bad mental habit are not the same thing:

Its philosophical roots go all the way back to ancient Greece, to the age of the Stoics. A faith in the power of reason can be found in most ancient Greek philosophy – and in much philosophy since. When we suffer, the logic goes, it’s because we’re letting our emotions get the better of us, pulling us away from seeing reality. Reason, these early philosophers argued, allows us to learn about things that truly matter, including how to be happy, live a good life, and free ourselves from negative emotions including depression, worry, anger, envy and jealousy.

Beck wrote that the philosophical underpinnings of CBT ‘go back thousands of years, certainly to the time of the Stoics, who considered man’s conceptions (or misconceptions) of events rather than the events themselves as the key to his emotional upsets.’

Of course, cognitive treatment does not involve thought reform as much as it involves reality testing. It involves something that is very like the scientific method-- taking thoughts, especially self-deprecatory thoughts, and making them seem less than totally convincing by testing them against reality. As long as we have evidence that shows these thoughts to be potentially untrue, we can think more clearly.

Learning to think differently about events is what CBT therapists call ‘cognitive restructuring’. Changing thinking patterns is what CBT therapists do when they teach their patients to avoid errors in reasoning and to view reality more accurately.

As I said, this is just the scientific method, empirical reasoning. It comes from Aristotle, for the record.

Even today, according to the CBT model, psychological disorders generally fit this mould: the patient is committing cognitive errors that lead to negative emotional states. Helping the patient reason more accurately is key to helping them feel better.

From the point of view of CBT therapists like Beck, the point of exposure is to teach the patient to think more rationally by giving them direct evidence that shows why their thoughts don’t align with reality.

One understands that in today’s culture more and more people do not believe that reality should have any say in their most cherished beliefs. Consider the transgender movement, for example, as I did yesterday.

The differences between CBT and psychoanalysis are striking. Whereas the structure of CBT sessions is meant to be directed by the therapist – who will assign homework at the end of the session – the structure of a psychoanalytic session is left open-ended by the therapist. The patient is encouraged to gain comfort over time speaking whatever comes to mind. Whereas CBT emphasises using a set of tools to form new habits of thinking and behaving, psychoanalysis involves an ongoing, collaborative and transformative process involving therapist and patient. During this process, the therapist notes ways in which the patient might, in the here-and-now of the therapy itself, unconsciously experience repetitions of situations from the past. These repetitions, known as ‘transference’, can indicate core psychological conflicts from childhood or adolescence – often moments when needs went unmet while growing up. But perhaps the major difference between CBT and psychoanalysis is that psychoanalytic therapy does not view all psychological problems as problems of thinking. There is no expectation that these problems can be resolved merely by helping the patient think more carefully and accurately.

Murray does not say it-- his approach is rather vapid-- but cognitive therapy does not see all problems as problems of thinking. After all, one of the side treatments advanced by cognitivists relies on the patient’s ability to change his behavior, to conduct himself differently in his everyday life. About this aspect of cognitive therapy, Murray has nothing to say.

So, Murray, who does not think very clearly, explains that cognitive treatments are effective, but not for all people at all times. Since these treatments require patients to engage in independent work on their problems-- it is not just about taking a pill-- one would expect as much.

It is true to say that CBT is an evidence-based therapy and that it is effective. But it is also true that many people are not helped by CBT.

So, Murray ends up with an insipid recommendation that patients should really get mired in their past, should try to access their "submerged selves"-- true, it’s an idiotic notion-- and should find themselves. Perhaps we should just give them a fishing pole:

But for patients like Valerie, the approach is too structured and educational to foster the kind of maturation and development they desire. It would be heartbreaking if these patients were made to feel like failures just because their concerns do not fit the CBT model. Not all psychological problems are thinking problems, and not all problems require correcting through cognitive restructuring. Given the chance, people like Valerie can learn to address their submerged selves, forgotten or ignored by therapies that focus on cognitive tools for viewing reality more accurately. Given the chance, these people can learn, instead, to empathise with their earlier selves in nuanced ways. They can begin finding themselves.