A critique of CBT – Part 1
by Andrew Taggart
Update: I’ve written some later reflections on CBT entitled “A Re-Evaluation of CBT.” The latter post is the culmination of over a year of working with conversation partners whose previous experiences were in cognitive therapies. Throughout, it should be borne in mind that I consider philosophical practice (for more about which, see here) to bear no resemblance to the therapeutic dispensation.
Kant’s Concept of Critique
Kant’s concept of critique should not be confused with a commonsensical notion of criticism. For Kant, a critique of reason involves a proper assessment of the powers of reason: an analysis of the nature of the instrument, an attention to the functions it serves, and a pellucid understanding of its inherent limits. We get in trouble, Kant thinks, when we seek to use an instrument without first examining its proper uses and applications. We get into a conceptual muddle because we expect the instrument to fulfill tasks that go beyond its inherent capacities.
In the spirit of Kant, I want to perform a critique of the powers of Cognitive Behavioral Therapy (CBT). Today, I want to analyze what it does, what ends it serves, what uses it has. Tomorrow, in Part 2, I mean to clip its wings. My general conclusion from Parts 1 and 2 will be that CBT provides us a highly limited set of techniques or tools we can use to achieve a state of equilibrium. The trouble with CBT is that it cannot provide us with any reason for living–that is to say, with any reason for using these tools in the first place. For this, we need philosophy.
Method and Aim
“The central method of cognitive therapy,” Donald Robertson writes in The Philosophy of CBT, “consists of monitoring one’s thoughts and challenging those ones that are irrational or unhelpful and the beliefs that underlie them” (169). The aim of this exercise (or set of exercises) is to move the ‘client’** from a state of mental disturbance to a state of mental equilibrium.
The Foundations of CBT
CBT is based on 3 fundamental assumptions.
1. The Ontological Distinction Between Control & Lack Thereof. Like the Stoics, CBT practitioners assume that there are some ‘basic things’ or ‘basic activities’ that are up to me and some that are not. The question, “What is within our control and what is not?” therefore looms large in any CBT session. According to CBT practitioners, many ‘psychological problems’** stem from running together what’s within our power with what is not; or from acting as if what’s not within our power should be; or from presupposing that there’s not within our power when, as a matter of fact, there is; or from expecting–outlandishly–thus and so without having reason to expect thus and so; and so forth.
2. The Axiological/Ontological Distinction Between Facts & Values. The natural and social world is the place of ‘facts’ whereas the mental apparatus is the place of ‘values’. (The mind as positer of value, the mind as ‘label maker.’) Hence, “It is cold outside” is not to be confused with “It is awful and unbearable outside.” Or: “P has bumped into me” is not be to confused with “P willfully and deliberately harmed me. P meant to do that.” CBT, therefore, teaches the ‘client’ to disentangle physical descriptions from value judgments and then to question the validity of these value judgments.
3. Cognitive Theory of Emotions. Our rational or irrational beliefs are constitutive of our emotions. (I’ve found the accounts of emotion rather muddled in the CBT books I’ve thumbed through. The philosopher Martha Nussbaum has written a lucid book, The Upheavals of Thought, in which she offers a clear account and defense of a Stoic-derived cognitive theory of emotion.) Take fear. Let’s say that fear is the belief that (a) I am not self-sufficient and (b) such-and-such can harm me or mine (or such-and-such poses a great harm). (Perhaps there is more to the definition of fear, but put that question aside for now.) The CBT practitioner could ask, “Are you not self-sufficient, or is there something that could be done to prepare you for this?” More fundamentally, he would ask, “Is this the kind of thing that can actually harm you, or are you ‘catastrophizing’”?
The Importance of Habit Retraining
CBT insists that human beings have picked up bad reasoning habits that must then be identified (hence the importance of self-monitoring) and replaced with better reasoning habits. The ‘client’ learns to dispute negative emotions, which spring from lots of confusions in 1-3 above, seeking to substitute ‘healthy’ lines of reasoning for ‘unhealthy’ ones. The point is to make ‘healthy’ thinking second nature.
Examples Amenable to CBT Treatment
Mild forms of depression, social anxiety, irrational fears, deep-seeded regrets, and excessive demands are all ripe for CBT.
- ‘Mild Depression.’ CBT’s Explanation: Perhaps you have underestimated your powers of acting or overestimating the ‘fatedness’ of the world (Assumption 1). Perhaps you have confused a misfortune with a horrible, life-altering event that you cannot overcome (Assumption 2). Or perhaps you have inherited a set of irrational beliefs that are ‘triggering’ your mood of always feeling sad or down.
- ‘Social Anxiety.’ CBT’S Explanation: You are overvaluing the opinions of others when these are beyond your control. You have forgotten that, to a large extent, good or bad reputation is outside your ken.
- Gnawing Regrets. CBT’s Explanation: The past, just because it is past, is beyond your control. You must learn to accept that, must learn that there is nothing that can be done or changed (Assumption 1). The only thing you can change is your attitude toward the past (Assumption 2).
- Excessive Demands. CBT’s Explanation: Careful with the ‘shoulds’ and the ‘should nots,’ the ‘musts’ and the ‘mustn’ts.’ You are overestimating your powers of action, or you are engaging in wishful thinking (as if the world should bend itself to your whims) (Assumption 1).
CBT engages in a series of exercises–note taking, journaling, visualization, etc.–in order to retrain the mind to think more ‘heathfully.’
The Limits of CBT
As an exercise in confronting trying episodes, CBT can be incredibly useful. Yet as a philosophy of life, it offers some pretty thin gruel. In Part 2, I examine 4 fundamental problems that CBT faces and for which it can have no answers.
- The Pollyanna Problem. Can one learn to think ‘healthfully’ in the middle of the Holocaust? In hell? In the hold of a slave ship? When working for an exploitative corporation? (Contra Assumption 1)
- The Fact/Value Split. Are facts the kinds of things that are ‘over there’ and values the kinds of things that are ‘in here’? Moral realism, for instance, begs to differ. (Contra Assumption 2)
- Teleology. Suppose you’ve mastered every CBT technique. Do you have a reason for living? You could be a master of CBT, could have achieved this ‘zero state’ of equilibrium, yet could also be wasting your life. Or you could simply be a terribly dull or boring person. Etc. “What you should aim at” or “How you should live”: these are questions that CBT cannot answer and, worse yet, has no way of asking. (Contra lack of final end)
- Instrumentalism. CBT’s standard of good reasoning is ‘healthfulness.’ The reason I don’t get angry with Jane is that I have told myself that Jane is ignorant or misguided or isn’t malicious and so on. But is achieving a ‘zero state’ the same thing as being accurate or truthful? Is the only or main standard of reasoning that I feel better? What of truth and accuracy, of getting things right for their own sake? (Contra aim of reasoning)
** In this post, I’ve put common psychological terms between single quotes (‘ ‘). The reason is that I’m generally skeptical of the accuracy, validity, and usefulness of psychotherapeutic categories. I’m not sure, e.g., why “Jane is feeling rather sad” is any less accurate a description of Jane’s mental state than “Jane has been diagnosed with a mild form of depression.” I also don’t see why “Jane thinks that her mother thinks too much of herself and not enough of Jane” is a less clear description of her mother’s cast of mind than “Jane’s mother is a narcissist.” The second, however, does make us sound smart. It’s as if we’ve really gotten to the bottom of things and so need look no further. (Perhaps philosophical inquiry begins where dated labeling ends…)
There is a second problem with psychotherapeutic terminology. We seem to believe that “P is a narcissist” is an explanation when, in reality, it is just a re-description or a re-categorization. “Why is P this way?” “Oh, because P is a narcissist.” And why is a cat this way? Oh, because it is a feline. Ah.
In my philosophy practice, I’ve been following the sci-fi writer Ursula Le Guin’s poetic approach. How are our powers of discrimination–of perceiving what is going on with this person in this way at this time–strengthened once we unhook ourselves from worn-out categories and once we think in terms of poetic re-descriptions and conceptual constellations?