The narrative explicit in this blog reminds us that independent practitioners are in a privileged position to add a nuance to their practice, often denied to competent and committed therapists in institutionalised primary health care.
There are two types of questions to be explored. Firstly an examination of the philosophical imperatives which justify the current position of CBT, and secondly what additional philosophical idea might serve best to develop our therapy in a way which better helps the afflicted.
Mental health care is always likely to be a contested area, and the fact we all work in an impossible profession, means the search for solutions is likely to be a continuous struggle, but it also means that any particular dominant idea should not be above critical observation.
In order to address the first question above one needs to ask: ‘what defines us as CBT therapists as opposed to practitioners of other modalities?’
Fundamentally if one is a clinician working in the NHS IAPT system one is trained and encouraged to work in a way, which accepts the notion of truth and knowledge based on positivistic assumptions -evidenced based therapies. There are those who vehemently deny such an observation but given the roots of hypothetical deductive qualitative research upon which CBT is currently advocated, there is more than a hint of skulduggery about such denials.
It might also be the case that readers of this blog have never delved into the philosophical assumptions which guide their professional and personal lives, yet these questions are fundamental to the way we practice, and particularly so for those of us who practice in the independent sector.
We might not be aware of the philosophical fundamentals by which we live and work, but we most certainly are using them on a daily basis. So why not try and understand them better? At least, that gives us a chance of choosing some, which we find agreeable.
Integrating philosophical ideas in our practice in a more knowing and intentional way is one of the luxuries that IP’s can enjoy, and use to full clinical advantage. It’s the central theme of the blog.
However readers deserve an explanation, which demonstrates such an idea is more than a polemic whim.
Arguably the ‘IAPT’ model is one based on a ‘medical’ paradigm – protocol driven therapy, claimed as evidence based research ideally founded through RCT’s [the so called ‘gold standard]. Whilst this model has given therapy in general respectability, and has been particularly kind to the progress of CBP in particular, it is not without its detractors, since in its pure form it leaves so much out. Even if the NHS resources were unlimited, clinical training in a ‘single file’ model, which does not question the presumptions about the validity of RCTs, and choses to ignore so called ‘common effects,’ leaves newly qualified clinicians unprepared for the difficulties of dealing with clients who will not conform to a medical model, and for their own professional and personal development. One often finds that therapists brought up on this ‘diet’ express a sort of guilt should they stray from their protocols.
This is not a criticism but a critique. As a supervisor of therapists who work in many parts of the NHS mental health care system I admire and love my supervisees for the dedication and skills they bring to bear in helping those who are referred to them, but they are working under tight budgets, and even tighter philosophical parameters!
Evidence based therapy has led to difficulties of which clinicians working in the independent sector are all too aware. Third party providers restrict session numbers on the basis of partially quoted and dubious N.I.C.E. guidelines, which become so short one might as well send a get well card, or instruct the therapist that one must only deal with the psychological effects from the trauma….. whatever that means – “no you cannot deal with the fact that your client’s wife has just left him because she cannot bear the fact he lost a leg in a motorcycle accident!”. Collateral damage does not count!
All of this is not original or new stuff. More than fifty years ago Thomas Szasz argued that :-‘today, a belief in mental illness implies — nay, requires–therapy along medical or psychotherapeutic lines’. He concluded by writing : ”I have tried to show that the notion of mental illness has outlived whatever usefulness it might have had and that it now functions merely as a convenient myth”.
The notion that ‘mental health’ issues are problems with living and not an illness is far from an original idea. Szasz used this very phrase and years before that Adler introduced the idea as he developed the concept of individual therapy.
Adopting this idea most certainly does not mean that those of us who suffer with psychological difficulties should not have the same empathy, care, and guidance, as any other ‘human’ ailment.
Well, Dr. Szsaz, and Dr. Adler, like the message of other great contempories your message has been lost.
In the 21st century the medicalization of mental illness has become even more established as a shibboleth. Indeed there are those who would argue that far from IAPT being introduced by a benevolent government, its introduction, on the basis of cost effectiveness because it would get the ‘mentally’ ill back to work, was in fact the miss-use of medical practice as an ideological state weapon.
That such a critique is not to be seen as a solitary polemic rant, the intellectual background for this argument may be found in the writings of Wampold and Zac’s – ‘The Great Psychotherapy Debate’. It is highly recommended since the authors explore in great detail the assertion that several important aspects of psychotherapy, which can be labelled ‘common effects’, have been ignored to the detriment of understanding how psychotherapy works, to policy, and to practice. [p35]. Equally, for a fuller understanding of the dilemmas and debates in health care, including a searing critique of RCT’s Brown, Crawford and Hick’s excellent book –‘Evidence-Based Research’ is another recommendation.
Viktor Frankl declared there is no psychotherapy without a theory and philosophy of man. The opening sentence of Alfred Adler’s book, ‘What Life Should Mean to You’, first published in 1931, reads “Human beings live in the realm of meanings. We do not experience things in the abstract; we always experience them in human terms.” Jordon Peterson’s book “Maps of Meaning” has become a best seller. In his essay, The Philosopher as Expert, Richard Rorty entertainingly observes …”It is unfortunate, but not inhuman, to know nothing of botany. It is inhuman to simply ignore either art or philosophy, and no one really does………..Nor is there anyone who doesn’t feel that “what the philosophers are looking for is what he himself has known all along, only he can’t express it!”
Much nearer our line of professional experience, in 1990, R.D. Laing wrote that the clinical psychologist wishing to be objective or scientific in his understanding of the patient before him has set out on an impossible task, because we do not see the signs of neurosis in a neutral way. If we wish to fully understand another we must be willing to enlist all the powers of every aspect of ourselves in the act of comprehension. One cannot avoid interpretation.”
Are they really all ‘wide of the mark?’
These are the most profound of observations, which demonstrate the limitation of how far one can trust the use of the term ‘evidenced based’ interventions as an accurate description for any particular type of psychological therapy.
Idiosyncratic meaning is the ‘death knell’ of factual evidence. ‘Meaning’ becomes a confounding variable, which even the most tightly controlled hypothetical deductive experiment cannot cope with. So called evidence based therapy can demonstrate this seems to work better than that, but as to why that is the case, it doesn’t offer a clue.
The merest glance at these statements reveals the weakness of the argument that a therapy adhering to the notion that RCT’s tells the truth, the whole truth, and nothing but the truth. Unfortunately a whole industry has been built around this myth.
It was Jordon Peterson who provocatively proclaimed that psychologists either pursue a career or seek the truth. Most, he added, pursue a career.
One of the additional difficulties with psychologists, who adhere to a medical model based on positivist ideals, is that they become entrapped in their particular notion of how truth can be established. Maintaining the status quo blinds them to alternative, realistic values of what constitutes truth, or even utility.
Quantitative research studies rarely, if ever, expose their ‘underbelly’ to the methodological roots, upon which the study is based. Such embarrassments, like therapist effects or a therapist’s commitment to his or her particular modality [common effects], are to be assiduously dodged!
Recently I submitted a sample of my book on perfectionism, shortly to be published, to a well -known ‘traditional’ publication. The reviewers were overwhelming condemnatory in their observations, defending unknowingly and without thought, the very positivist ideology I was critiquing. In other words ….if you don’t do your research this way, and then back it up with controlled trials in this way, not only are your ideas likely to be ‘untruthful’, but might be dangerous!” These type of silly observations are typical of the waste of time spent arguing about the merits or demerits between qualitative and quantitative enquiry.
Here was an example of psychologists pursuing a review on the basis of one particular dominant philosophy. It rests on the notion that we are able to collect information about the psychological state of the individual and then declare they suffer with some defined mental state, which will yield to a pre-determined intervention. Whilst this, of course, has served the treatment of physical ailments exceptionally well, there are all sorts of reasons why the ‘truth’ of a psychological presentation will not yield in this way. This is why adopting the scientific practitioner model is favoured by the thoughtful – lets gather some information and form a hypothesis and work with it, being willing to change the hypothesis as new information is revealed.
There is more than a whiff of pragmatic philosophy about the scientific practitioner model too – a topic I shall briefly address later.
But for those who would wish to embrace Laing’s search for clinical ‘meanings’, it is axiomatic we must necessarily strive to know ourselves, which includes the philosophical underpinnings which drive our practice, and personal lives, especially if our practice is to have direction and obvious commitment.
I think I am on safe ground when I suggest CBT is based on the idea that emotions, behaviour and cognitions are interactive. Such a view developed, in part, from a distinctly European culture emanating from the Greek Spartan tradition. According to J.S. Mills if the Greeks had not defeated the Persians in their battles between 480 and 490 BC, western culture would have been fundamentally different. Be that as it may J.S. Mill’s observations are based on the fact that Greeks and Persians had fundamentally different ideas of what constituted the meaning of life and the way it ought to be lived.
Thus it is that Albert Ellis acknowledged the views of Epictetus that men are not disturbed by events but by their views of them, and upon which he developed the fundamentals of REBT and CBT. Likewise a favourite REBT notion of unconditional self and other acceptance, can be seen without the slightest intellectual endeavour, to have its roots in Kantian moral philosophy.
Beck and Ellis agreed about the fundamentals of CBT. The former became a brilliant academic and the latter essentially a genius of theory and clinical practice, but actually there is little more than a ‘fag’ paper between their ideas. As with many things its not what you do it’s the way that you do it!
Despite the paradoxes of classical Greek thought and society, some of its core philosophies remain a central feature in Western culture.
In a telling article written in the Psychologist journal entitled ‘Confessions of a Psychologist, Professor Paul Brocs explains that at a time of great crisis in his life, what sustained him most were not the ‘tricks’ of therapy, but fundamentals of Stoic philosophy. In other words the meaning he ascribed to life and a way of living.
However this doesn’t in any way mean that protocols are redundant, far from it; they are useful tools to make formulations and help sufferers re-construct the meanings of their lives that drive them.
Over 150 years ago Nietzsche made three predictions of the utmost enormity: Our culture will shake to the roots, we will become nihilistic or totalitarian, or we shall find a new meaning. He also added that in the 20th century we would slaughter millions of our own kind in the most cruel of ways.
These predictions turned out to be accurate and Jung also echoed Nietzsche’s prediction that western culture would search for a new meaning, in several of his publications – most notably ‘Modern Man in Search of a Soul’ and ‘The Undiscovered Self.’
There is considerable support for the notion that western society is still searching for a new meaning, and evidenced by us when the undeniably privileged turn up at our clinics depressed, anxious or angry [or all three], and we discover, without too much effort, that more often than not, they have no meaning in their lives or the meaning they did have was some sort of ‘false prophet’. Evidenced based therapy just does not address this type of issue- symptomology-yes, most certainly – but a core meaning to ones life that adds contentment – no. So then what?
This leads to the second question above concerning what type of philosophy might help us all to lead more contented lives and how might that be woven into traditional CBP?
Frankl, in his book ‘Man’s Search for Meaning’, gave heart- rending examples of people who losing the meaning of their lives turned over and died. Despite criticism of Frankl, as being authoritarian, his ideas and philosophy remain very much sought after. Skilled therapists, like skilful professionals in all fields after all need to be authoritative – but not authoritarian.
Frankl suggested that meaning for humans was intrinsic, and happiness was not to be sought but rather was a product of activity. He named this therapeutic activity as logo-therapy. Such claims are unlikely to be confirmed or slayed by the researcher, but that misses the point and leads me to the philosophy of the 19c American pragmatic movement, which has seen a resurgence of interest. The work of Charles Sanders Peirce, William James and John Dewey, not to mention later post ‘classic pragmatists like Richard Rorty, developed ideas to find a useful solution to the philosophical, epistemological and ontological issues scientists and philosophers had been wringing their hands about for at least two hundred years.
Though Bertrand Russell spoke warmly of William James he was not a fan of pragmatism, but neither was he keen on the idea that thoughts, emotions, and beliefs would yield to scientific endeavour stating clearly that he considered they were beyond the reach of science and would always likely to remain so.
Rorty in ‘Philosophy and the Mirror of Nature,’ suggests he would prefer to dissolve rather than solve the endless search for a traditional philosophy, which helps with the question of knowledge in empirical psychological research.
I’m with Rorty for kicking such endless and most likely unsolvable issues into the long grass.
So what might be chosen to better aid us in our helping professions?
It most certainly is not a continuing uni-directional reliance on protocol driven therapy, which might still have some ‘tweak’s’ left in it, but basically has reached the end of its developmental process, in a riot of more twists and turns than the Brandenburg variations, especially if reports of dismal outcomes turn out to be accurate.
Pragmatism is not a sloppy solution. It requires great clarity of thought and the dignity to identify consensus of practice, which is useful. It demands that one should not reject possibilities out of prejudice, and always keep in mind that despite solutions appearing to be helpful, they may in fact, turn out to be defective and require rejection or adaption.
A paradigm which combines the best of carefully researched therapy which has useful guidelines and interventions, with positive ideas for a way of individual living which generations of humans have found to be inspirational and aid contentment, seems to me a most likely way to help those of us, who for the time being, have fallen by the wayside.
This may indeed involve using traditional forms of CBT, which is supported by a body of opinion, but the central argument in this blog advocates it be enhanced by the addition of some other form of intervention.
I am much convinced by collected data and historical observations that if individuals and societies can pursue meaningful goals based on a generosity of actions, then the individual finds inspiration and contentment, and the society they live in flourishes.
Whilst shades of such aspirations may be seen in the likes of DPT programs, it is doubtful sufficient national resources can be found to make them effective for the many. In addition it is unlikely those who ‘control’ the development of conventional CBT are going to change. The political ramifications for such moves make it highly unlikely.
In our own sphere of activity BABCP, despite some rhetoric, continues to pursue the ‘party line,’ with the scientific committee in particular demonstrating it has no interest what so ever in extending a platform to independent practitioners who wish to explore the rewards which might be gained in combining traditional forms of CBT with the type of ‘logo-therapy’ advocated by Frankl.
This is why I suggest independent practitioners have a special role to play in developing and using traditional CBP with wider philosophical ideas. Not only should we be doing so we should also be saying so too – applied psychology demands it of us.
Today, a belief in mental illness implies — nay, requires–therapy along medical or psychotherapeutic lines.
I have tried to show that the notion of mental illness has outlived whatever usefulness it might have had and that it now functions merely as a convenient myth.
The Myth of Mental Illness
By Thomas S. Szasz (1960)
First published in American Psychologist, 15, 113-118.
Dr David Baker will be talking about treating Perfectionism for a CBT Psychotherapist Briefing’s webinar at 9.30am on Wednesday, December 12th. Follow the link for further details: https://www.eventbrite.co.uk/e/a-good-enough-webinar-on-perfectionism-tickets-52505437176