“Just Treating Symptoms” can be a great approach

In a review of Thrive: The Power of Evidence-Based Psychological Therapies, Jenny Diski is suspicious of CBT as a form of therapy.  She’s concerned that it’s focused on managing symptoms of distress, rather than causes, and that, ultimately, it’s more focused on making mental illness bearable for bystanders than for the person who is ill.  She writes:

CBT fulfils the authors’ admirable desire for an improvement in mental health provision. It takes at most 20 sessions, often far fewer; it is so standardised that therapists can be trained very quickly, and use a manual (they talk of manualised conversations) to conduct their sessions. It is so standardised that patients can be treated by phone, online or with self-help books. It is cheap, and has as good a recovery rate, we are told, as medication. CBT deems patients who are depressed and anxious to be having wrong thoughts. These thoughts are examined in the sessions and found to be negative. Repetitive negative thoughts are called rumination and patients are trained to alter their thinking to be positive. If I claimed, say, to be depressed about the fact I will die sooner rather than later, perhaps I would be told to focus on the fact that I’m not dead today. This is true, but doesn’t alter the inevitable, which it might be useful for me to think about and come to terms with. Exercises and homework are given that are said to reprogramme the mind, put a stop to brooding, and replace negative thoughts with positive ones. It is, they claim, as simple as that. And the results are measurable, patient improvement is quantified after every session and at the end of each course.

There is no need to dig into the past, to look for trauma. The mind, as if it were a material entity, can simply be changed by some outside process without reference to causes. Thoughts, we are told, are not facts. It brings us back, once again, to behaviourism: at least one of the discoverers of CBT looked to Pavlov’s experiments. Thrive quotes Aristotle’s belief that “the key to a good character is good habits” and tells us the aim is to replace those negative thoughts with “realistic ones”. Just change those bad habits. And if they return, get a CBT top-up. Person-centred psychotherapy and analysis guide the patient to investigate herself, her past and her complex behaviour to discover the reasons for her symptoms. It makes understanding the goal, and assumes, along with Socrates, that the unexamined life is not worth living.

I think Diski winds up selling CBT pretty seriously short, even if I accept her premise that it’s important for a patient to understand all the causes of her distress (though I’ll note that we don’t expect the same understanding of patients who need surgery).  Sometimes, interventions like CBT and medication don’t address root causes but do give patients the space and peace to investigate and deal with them later, from a place of greater stability.

Imagine that there was a really unpleasant noise happening in your immediate surroundings.  Ultimately, you want to find the source of the noise and make it stop, but, if the sound is nails-on-a-chalkb0ard-y enough, the sheer unpleasantness may slow down your search.  The unlucky homeowner might be well served by buying earplugs, taking a little period of rest, and then keep investigating the sound without being distracted by its effects.

CBT often treats mental noise that is every bit as distracting as a fire alarm.  Intrusive thoughts, loops of self-criticism, etc can make it hard to think or make plans (or decide you’re the kind of person who can pull plans off, or whose well-being is worth working on).  Sometimes, CBT makes it easier to have the space to solve whatever underlying problem is fueling those thoughts, and sometimes, short-circuiting them is enough by themselves.

When you’re stuck in a rut for long enough, the initial cause that drove you into it may no longer be in effect by the time you step out.  In a more physical analog, people who experience phantom pain after an amputation or serious injury probably do so because the brain has fallen into a habit of misfiring.  If the habit can be broken, there’s no persistent cause that would start the pain up again.

CBT also has a fair number of curb cut effects (named for the dips in curbs to accomodate wheelchairs, that turn out to be useful for bicyclists, parents pushing strollers, people wheeling suitcases, etc).  As I discussed in “The Rotten Orange and the Kingslayer” it’s not uncommon to label ourselves or others with unpleasant homeric epithets that make it hard to change or grow.  Those habits may not be pathological enough to bother seeing any kind of therapist, but are still worth noticing, evaluating, and modifying as needed.

P.S. If you or a friend is unhappy and wants to try out CBT-lite, David Burns book Feeling Good is supposed to be a pretty good workbook for picking up some of the benefits of CBT solo.  If you might prefer to see a therapist, Kate Donovan has a great guide to that process.