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Article: "Arrogant, Inflexible, Remote and Imperious"? Is this what's wrong with CBT?

Discussion in 'Action Alerts and Advocacy' started by Orla, Feb 10, 2010.

  1. Orla

    Orla Senior Member

    I thought this was a really interesting article, from the magazine of the British Association for Behavioural & Cognitive Psychotherapies, which people might find of interest.

    It contains a criticism of the CBT school from a CBT Therapist (not ME/CFS specific). In a way it is more interesting seeing this criticism in a non-ME/CFS context, as it is not just us having these sorts of problems. It could be useful to quote sometime.

    This is a little quote to give you a taste, the rest is below:

    "It is hardly surprising that our detractors are suspicious.

    They are right to accuse us of a selective use of the evidence, our
    prized and cherished weapon of choice

    They have many other objections: we ourselves write the research
    questions which now get funded; reviews have shown that RCTs can both
    exaggerate and under-estimate the likely real effect of a treatment;
    RCTs do not easily help us understand treatment mechanisms and are
    fiendishly difficult to use in order to understand how we should
    organise care; most CBT trials are small and poorly executed; quality
    thresholds for RCTs in NICE guidelines are notoriously low, allowing
    the results of meta-analyses of small poor quality studies to direct
    policy; we pay no attention to qualitative evidence in sociological

    I could go on, the criticisms are endless."

    The Article:

    From: BABCP Magazine Volume 36, Issue 7: March 2007

    News from the British Association for Behavioural & Cognitive

    "ARROGANT, INFLEXIBLE, REMOTE AND IMPERIOUS"? Is this what's wrong with CBT?

    David Richards, Professor of Mental Health at the University of
    York, replies to Henck van Bilsen's article in the last issue.

    In the December 2006 issue of the BABCP Magazine (34:4) Henck van
    Bilsen asked a very pertinent question, "What is wrong with CBT?"

    In answering his question, Henck purported to describe an
    unassertive movement which was reluctant to nail its colours to the
    mast. Ironically, by the tone of his article he unwittingly
    demonstrated exactly what is wrong with CBT.

    One of the major planks of Henck's argument (pretty much the only one
    he cites), and indeed the one to which we CBT
    therapists constantly return, is that of 'evidence.'

    We believe that the scientific method has delivered us a cast iron
    evidence base.

    The last 25 years has seen an explosion of empirical
    activity 'proving' that CBT works.

    We in the CBT world sit in our robustly secure evidence-based
    citadel, cocking a snook at our Luddite detractors.

    Sadly, instead of the applause we think we deserve, we find our
    professional colleagues despising of our efforts.

    Henck bids us to become more cocksure, more dismissive of those that
    question our approach.

    He suggests we browbeat the opposition.

    Is he right? I think not.

    Surely, a therapist always attempts to understand the way in which a
    patient views their world, using empathy to see the problem from the
    patient's perspective. What is wrong with CBT? Can we answer Henck's
    question with a little more empathy? Can we try and see the world
    through others' eyes?

    It is easier than one might think. We used to be the opposition. Not
    so long ago, CBT was a minor irritation to the established
    psychotherapies. We developed our treatments out of a profound
    distrust of opaque 'clinical' procedures and expertise
    gathered through personal experience of psychotherapy. We chose a
    scientific route to develop our therapy, a strategy laughed out of
    court by our detractors. The BABCP inparticular was an alliance of
    strategists, theorists and empiricists, all united in a belief that
    there had to be a better way.

    Sadly, we have badly botched our transition from heresy to orthodoxy.

    Rather like many anti-colonial freedom fighters suddenly finding
    themselves in power, CBT has adopted the manners and
    behaviours of the old ruling psychotherapy elite. The criticisms of
    arrogance and inflexibility now arrayed against CBT are exactly those
    the early CBT pioneers used against the established psychotherapy
    schools in the 60s and 70s.

    Proponents of CBT are now seen as supercilious and imperious,
    characteristics we ourselves previously found so reprehensible in

    Consider the following story. I write, of course, as a former chair
    of the BABCP, indeed as the last chair of the BABCP. At
    the end of my time of office, after the 1997 25th anniversary of the
    BABCP - the first time it had more than 1000 people at
    its annual conference - the BABCP voted to change the name of its
    elected head from 'chair' to 'President'. An insignificant
    change perhaps.or perhaps not. A chair is one thing, a President
    quite another thing altogether. To many of us steeped in
    the movement (for that is what it was), it was massively symbolic of
    an organisation which had moved rapidly
    from agitating outsider to mainstream psychotherapy guild.

    Sadly, the values of the past were not to be those of the future.

    I am reminded of the fate of another organisation which also had a
    momentous 1997.

    Who in 2007, now remembers the public trust and surge of hope
    embodied by the election of Blair's New labour in 1997.

    [photograph of Tony Blair]

    'In power', CBT, just like New Labour, is perceived as remote and

    Nor is this attitude confined to an arrogant dismissal of other
    supposedly 'non evidence-based psychotherapies'.

    Despite Henck claiming that CBT is a 'large house with many rooms'
    the voice of the cognitive lobby within CBT has drowned out most
    other approaches.

    At a meeting recently I was astonished to hear a very senior person
    in our fraternity unable to comprehend that a
    member of the CBT family of treatments could be conceptualised
    outside of a cognitive paradigm, could even regard cognitions as
    inconsequential private events.

    All this despite the treatment in question - a contextual,
    socialbehavioural one - being the subject of nearly 20 randomised
    controlled trials demonstrating at least equivalent effectiveness to
    cognitive therapy.

    Henck makes the same mistake by asserting that 'A core element of
    all cognitive behavioural interventions is that they work towards
    change by influencing thinking.'

    Not so Henck.

    So, more similarities with totalitarian long before
    putsches and purges drive out those of us who do not subscribe to
    Henck's mistaken assertion on the primacy of cognitive change?

    Sadly, many have already left. Did anyone notice?

    This huge paradox - that at the brink of unprecedented success CBT
    finds itself vilified in professional and public media - is not just
    down to jealous professional power politics as Henck asserts.

    It is down to a lack of humility, openness and a nave belief that
    the Randomised Control Trials is the only weapon we now need.

    Evidence gathering is not all there is to it.

    Henck seems to suggest that the scientific activity underpinning CBT
    has been conducted in a value-free environment. Facts is facts. Can't
    dispute 'em.

    But of course, such assertions are many miles wide of the mark.

    Human activities of all shapes and sizes are conducted in wide array
    of cultural and political contexts.

    One must also consider the issue of what research has been conducted,
    when, where and by whom.

    Imagine your reaction, dear reader, to a drug developed by a
    multinational company which they claim cures agoraphobia. The company
    allows no independent use of its product and insists in controlling
    the specific nature of the compound, training its own pharmacists and
    using its own measures of effect. Rightly, you would be a little
    cautious at least in accepting their results.

    And yet, we in the CBT world base our clinical practice on the
    activities of our own high profile product champions.

    These product champions are ferocious guardians of product quality,
    insisting on extensive 'quality control' procedures.

    Should anyone attempt to replicate experimental findings without
    first running their experimental and clinical methods past these
    product guardians, they are routinely vilified.

    Consider the UCL trial of CBT in primary care which found no
    difference between CBT and counselling.

    Even though these researchers had replicated and quality controlled
    the CBT delivered, they were roundly criticised by the CBT world for
    spoiling the evidence-based party.

    But what use is a treatment if it is so specific to it's product
    champions that it cannot be replicated reliably?

    Critically, it is an unproven contention that it is possible to take
    the results of experiments conducted by charismatic product champions
    in highly controlled environments and implement them in the
    widespread manner suggested by Layard and advocated by Henck.

    And yet that is where we are heading.

    It is hardly surprising that our detractors are suspicious.

    They are right to accuse us of a selective use of the evidence, our
    prized and cherished weapon of choice.

    They have many other objections: we ourselves write the research
    questions which now get funded; reviews have shown that RCTs can both
    exaggerate and under-estimate the likely real effect of a treatment;
    RCTs do not easily help us understand treatment mechanisms and are
    fiendishly difficult to use in order to understand how we should
    organise care; most CBT trials are small and poorly executed; quality
    thresholds for RCTs in NICE guidelines are notoriously low, allowing
    the results of meta-analyses of small poor quality studies to direct
    policy; we pay no attention to qualitative evidence in sociological

    I could go on, the criticisms are endless.

    So Henck, in answer to your question, 'What is wrong with CBT?' the
    answer is, 'absolutely nothing.' It is the wrong question. It is a
    fine family of treatments.

    However, given the old adage that power corrupts, but absolute power
    corrupts absolutely, no wonder CBT is the subject of such hostility.

    The question should be, 'What is wrong with Cognitive Behavioural
    Therapists?' Answers on a postcard please. Better make it a big one.
  2. Sunday

    Sunday Senior Member

    A very refreshing viewpoint! Thanks for putting this up here.
  3. Abraxas

    Abraxas Senior Member

    Thanks Orla ;)
  4. Jenny

    Jenny Senior Member

    Thanks Orla.

    It's intereesting too how CBT is often practised in an extremely simplistic way. I'm a psychologist, and one of my research interests is the relationship between various kinds of psychological interventions and psychological theory. In CBT (as well as in other interventions) practitioners often just pick and choose techniques that suit them and which bear very little relationship to any underlying theory. And research suffers acutely from what's called the 'file drawer' problem - studies with positive results get published while those with negative findings remain in the researcher's filing cabinet.

    What's worrying as well is that the UK government are rolling out a programme encouraging the unemployed to receive CBT to increase their employability! Thousands of CBT practitioners will be trained in CBT techniques. Thiey seem to assume you can train people to offer this in a few sessions!

  5. Mark

    Mark Former CEO

    Sofa, UK
    WOW! Quote City! It's all there: compare and contrast approaches to replication of results for example! And what a crucial insight into the mindset of an emerging new scientific approach to psychiatry grown inflexible and dishonest in its determination to cement its status as a 'real science'. Which one's Pinocchio?

    Thanks Orla!
  6. Orla

    Orla Senior Member

    Hi all, thanks for the comments. I came across this reply to the article from the same magazine, which is also interesting (I have highlighted a particularly interesting comment). I think these 2 pieces juxtapose quite well with the recent BMJ editorial. go to page 2 or reproduced below:

    R e a d e r s l e t t e r s

    Insulting, arrogant and unaware - verdict on a BABCP conference

    It was with some surprise that I perused
    the last edition of CBT Today (Issue 2, June
    2007) to find that it contained no response
    to Professor David Richards article
    Arrogant, Inflexible, Remote and
    Imperious? Is this whats wrong with CBT?.
    I was quite persuaded by some of the
    arguments put forward by Professor
    Richards. A few weeks later I attended a
    two-day conference co-organised by the
    Child and Adolescent Section of BABCP and
    identified a significant evidence base to
    support Dr. Richardss criticisms.

    There was much evidence to support the
    view that at least some of the leading lights
    in the CBT lobby are arrogant. An example
    may support this.

    One presenter identified five different levels
    for the application of CBT.

    Level 1, the lowest level, consisted of
    preventive measures eg promoting resilience
    in children. Essentially it was curriculum
    material which could eventually be delivered
    by teachers. Level 5, the highest level, was
    CBT Therapy conducted by Accredited
    Cognitive Behaviour Therapists.

    The proposition put forward was that all
    professionals engaged in delivering
    cognitive behavioural interventions at levels
    1 to 4 should be labelled as CBT
    technicians. The presenter expressed
    what appeared to be general surprise when
    I, a practitioner engaged in cognitive
    behavioural approaches for 20 years or so,
    expressed the view that to be referred to as a
    technician was insulting and demeaning.

    A further presentation described the
    introduction of cognitive based curriculum
    materials in schools. The presenters
    involved made reference to the teachers
    involved as CBT technicians.

    Again, when it was put that there was no
    need for such a label and that the teachers
    should be seen as qualified professionals in
    their own right, the presenters seemed
    unaware there was an issue.

    Their attitude towards teachers and the
    categorisation of teachers as CBT
    technicians was the equivalent of the
    teachers involved referring to them, as
    classroom assistants - for they were in
    school delivering to small groups of
    children narrowly defined curriculum

    Much of the clinical contents of the
    conference involved descriptions of work
    addressing anxiety in children. The
    presentations were characterised by very
    narrow references to work - mostly carried
    out by the presenters and colleagues/
    friends, with little reference made to other
    workers in the field.
    [Orla - I put this in bold to highlight]

    It seemed incomprehensible to me that any
    presentation in the area of anxiety with
    children could be made without any
    reference whatsoever to the work of
    Philip Kendal.

    This lack of acknowledgment of the work of
    others was pervasive throughout the
    conference presentations.

    For example, in a presentation in which the
    presenters were introducing the audience
    to curriculum materials aimed at building
    up resilience in children, no reference at all
    was made to the extensive curriculum
    material that already exists in the field.

    Perhaps the most obvious and
    professionally interesting incident which
    provided substantial support for Professor
    Richardss observations was during a Panel
    Debate. Professor Bolton, from a
    Developmental Psychologists prospective,
    put forward the argument that core beliefs
    and schemata were inappropriate
    conceptualisations with regard to children
    and adolescents.

    Much of the previous days presentations
    had focused on the identification of core
    beliefs and schemata as a prelude to
    formulation and intervention. A number of
    presenters who had previously given papers
    focusing on the importance of this were
    present, yet none challenged Professor
    Boltons assertion.

    Professor Richards ended his article with
    the question What is wrong with cognitive
    behaviour therapy?

    My answer to this is nothing. However,
    often influential members of the BABCP
    present as arrogant to the extent that they
    fail to recognise the clinical competencies
    and abilities of non-accredited CBT
    professionals - who apply cognitive
    behavioural strategies. Some appear to
    believe they are engaged in cutting edge
    developments with regard to CBT, when a
    wider examination of the literature and
    resources in the field would reveal that
    while they are making a significant and
    valuable contribution, it is not unique.
    Dr. E. McNamara.

    Chartered Educational Psychologist
  7. George

    George Guest

    I just goes to show

    250,000 patients can't be wrong! (grins)

    But this is really a great find Orla, thank you for posting this. And the comments for the paper are great too!
  8. Gerwyn

    Gerwyn Guest

    If you tried to market a drug with the same evidence of efficacy as CBT NICE would shoot it down in flames and the medicines agency would have fits of hysterical laughter

    CBT can be a useful sticking plaster There is more to the mind than thought processes The activities of the right hemisphere are not conciously accessible but boy are they important I,m an attachment therapist so I should declare my interest in this matter.
  9. Anika

    Anika Senior Member

    I found this very interesting - thank you, Orla! Especially interesting, the comments on self-referencing only one's own research, ignoring that of other researchers.


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