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

Orla

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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
journals.


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
Psychotherapies


"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
others.

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
imperious.

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 regimes..how 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
journals.

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.
------------------------------
 

Jenny

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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!

Jenny
 

Mark

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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!
 

Orla

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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.

http://www.babcp.com/silo/files/cbt-today-dec-07.pdf 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
materials.

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
 
G

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!
 
G

Gerwyn

Guest
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!
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.
 

Anika

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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.

Anika