The government has started recruiting thousands of more cognitive behavioural therapy-trained therapists in a bid to “cure” 450,000 people with depression and anxiety in England and Wales. But cognitive behavioural therapy is based on a desperate simplification of what lies at the heart of distress, argues Dorothy Rowe
In mental distress the real problem always arises from some kind of threat or insult to the sense of being a person. This can be hard to uncover, and difficult to ameliorate. It is never amenable to a quick fix.
New Labour has always favoured the quick fix. Children can’t read and write? Set a national curriculum and test them. Methicillin-resistant Staphylococcus aureus (MRSA) a problem in hospitals? Deep-clean them. The fact that weighing piglets doesn’t fatten them, and that it’s people, not walls and floors, that pass on infections is irrelevant.
The next problem was that people who are depressed are unlikely to be good workers. Anti-depressants are expensive and inefficient, so let’s use the simplest of all the therapies, train people quickly and cheaply as therapists, and get these depressed people back to work.
If only life were that simple! Many experienced CBT (cognitive behavioural therapy) therapists have found that it isn’t. About ten years ago, they discovered that they needed to take into account how the client saw the therapist, something that Freud had called it ‘counter-transference’. Next, some CBT therapists concluded that doing prescribed homework wasn’t enough to change those pesky dysfunctional cognitions. What was needed was mindfulness, something that the Buddha mentioned. Now what’s important is compassion, something that features in all religions. Although it’s possible now to do a Master’s degree in mindfulness, and to write academic papers on compassion, it’s not easy to put mindfulness and compassion into a CBT formulation.
Mindfulness is concerned with how we experience our individual existence. I try to write about this, but I always find that there’s a dearth of words in English to describe these powerful experiences. Compassion concerns those other powerful experiences when, in some extraordinary way, we’re able to make a connection with another person, even though each of us is trapped in our own world of meaning. Again, our language lacks the words with which to talk about these experiences.
All my work has been concerned with how we experience our sense of existence and our connections to other people, and how we make sense of our world. My first article on this was published in 1971, and I’m still writing about it because I can never come to the end of understanding what it is to be a human being. I continually see something new, or something that I’ve seen before, but now from a different angle. No one can ever be a trained therapist. You can acquire a certain amount of experience with which you might be let loose to engage in a conversation with a trouble person, but you never come to the end of discovering what you need to know.
CBT is a dishonest therapy in that it fails to acknowledge the basis on which it has been built. The use of the categories as set out in the DSM in the curriculum of the IAPT (Improving Access to Psychological Therapies) implies that the dysfunctional cognitions in depression are caused by that disorder. Many CBT therapists don’t acknowledge, or perhaps don’t know, that CBT is actually based on the proposition that what determines our behaviour isn’t what happens to us, but how we interpret what happens to us. This proposition has a secure base in what neuroscientists have discovered about how our brain operates. Neuropsychologist Chris Frith wrote, “Even if all our senses are intact and our brain is functioning normally, we do not have direct access to the real world. It may feel as if we have direct access, but this is an illusion created by our brain.” He also wrote, “Another of the many illusions which my brain creates is my sense of self. I experience myself as an island of stability in an ever-changing world.” [i]
What we experience isn’t the real world but the guesses which our brain has constructed about the world, using the interpretations of our past experience which our brain has stored. Since no two people ever have exactly the same experience, no two people ever see anything in exactly the same way. Our constant stream of interpretations in the form of thoughts, feelings or images develops a kind of whirlpool which we call our self or our sense of being a person. Whirlpools aren’t stable. Our self, the most important part of our existence, is made up of guesses that can be proved wrong by events. When this happens, we feel that our sense of being a person will vanish like a wisp of smoke in the wind, and we are terrified. We create all kinds of defences to prevent our self being annihilated. Some of these defences are what CBT therapists call dysfunctional cognitions.
When I was training as an educational psychologist in 1961, one of my teachers, Bess Kemp, told me the one thing that is always found in therapy. She said, “the presenting problem is never the real problem.” In mental distress the real problem always arises from some kind of threat or insult to the sense of being a person. This can be hard to uncover, and difficult to ameliorate. It is never amenable to a quick fix.
Ref: [i] Making Up the Mind Blackwell Publishing, Oxford, 2007, p.40, p.169.
* Dorothy Rowe is a clinical psychologist and author of 15 books, including Depression: The Way Out of Your Prison and Beyond Fear. Her latest book, What Should I Believe? considers beliefs about death. Dr Rowe is Emeritus Associate of the Royal College of Psychiatrists