A re-evaluation of CBT

The story began with a sense of deja vu. I kept meeting new conversation partners who, in the past, had worked with a CBT practitioner or who had studied CBT quite assiduously. Not to mention that I kept having conversations with acquaintances who swore by CBT; that I kept seeing, as if by Humean association, philosophical practice “pared up” with REBT and other cognitive therapies; and that I kept hearing how much CBT resembled ancient Stoicism and rational approaches more generally. The desire to understand what had attracted my conversation partners to CBT in the first place and why they may have sought me out afterward was most certainly on my mind. So was the question of what relationship, if any, obtained between forms of cognitive therapy and my philosophical practice.

The story I am about to tell is one of dissatisfaction and sorrow. For what grew, over the course of 6 months dating back to early October, was a feeling of great sadness as well as a sense of compassion. I want to speculate about the emergence and ongoing appeal of cognitive therapies in the US and UK. I speculate freely and without consideration of evidence or appeal to historical facts. What follows, therefore, is a lived logic that seeks to answer the following: what therapy would likely emerge under such and such social conditions?

We might imagine the often heated, sometimes acrimonious debates over the efficacy of Freudian psychoanalysis and its progeny (ego psychology, object relations theory, and so on) as forms of treatment as leaving an opening for a more rational and objective approach to therapeutic engagement. That opening would go something like this: if psychotherapy is not a science but an art, a question that has dominated Freudianism from the start, then what therapeutic approach could be more like a science, actually making good on its promise of delivering measurable and replicable results?

I imagine that individuals like Albert Ellis and Aaron Beck, two champions of similar kinds of cognitive therapies, would have arisen in order to fill the social void. They would have asked: could there be a rational form of therapy that could reliably work in a clinical setting on the more run-of-the-mill cases of mental illness such as anxiety disorders and mild to moderate forms of depression? Would it be possible, they would have wondered, to train the client, in the course of 5-10 50 minute sessions, to think more usefully about himself? And could it be as simple as discovering false thoughts or targeting unhelpful beliefs, bringing them to conscious awareness, and then developing techniques and tools to dispute them, thereby replacing them with true or more helpful beliefs? And, lastly, could the results conform to the rigors of science, to the criteria of predictability, measurement, and control?

In the speculative story that I am telling, I will use the end of the 1960s (why not?) to mark the fall of Freudian analysis and the rise of cognitive therapies. For at some point the economy is booming, educated men and women are now working, yet the pressures of the modern social world are bodying forth in the rise of ‘mild forms’ of ‘mental illness.’ So that it would be necessary, in order to maintain the social order, for a therapy like CBT to come along in order to put the client back into her life, regardless of the nature of that life. The market anyway would be there, a market in which one would, in time, be able to charge $200/hr. and upward for being an expert in practicing and teaching this set of techniques. (And insurance companies would also be keen to nudge individuals toward kinds of therapy that would be short order yet long-lasting.)

It would also be convenient, if CBT is to gain traction, for therapy to draw–but not in a conscious or worked-out manner–on a Weltbild that resembles Stoicism but without all the talk of metaphysics (the nature of reality) and ethics (the art of living). It would have to be a form of thinking, an everyday logic, that appealed to what was within the client’s control, steering him away from what was beyond his control and back into his ‘private thoughts’ and ‘private will.’ And that line between what’s within my control and what is beyond it would have to prove especially rigid: it would have to be easy to identify and easy to mark. For such a treatment to be effective in 10 sessions within the setting of ‘the modern clinic,’ it could not be messy, could not therefore incline itself toward grander discussions of history and modernity and spirituality.

Complexities of all sorts would have to be “bracketed” from the start: complexities concerning the shape of human life, the form that human life takes as it unfolds through its many turns in the modern social world, and finals aims toward which human beings have striven and might continue to strive. Simplicity would be the rule of the day. Let me see your low beliefs and we will work on disputing them. We will combat them. In time, I will teach you to remove them. We will imagine you, timelessly, in the middle of a situation. You will have a negative thought, and we will consider evidence to the contrary. Or before you enter a scene that might be frightful, you will train yourself, with rigor and discipline, to consider the worst case scenarios. I will give you assignments, and you will complete them. And after a time, you will be able to live more thick-skinnedly in the world you have inherited. Yes?

Yet what if a single belief about myself does not come in an isolable form? What if my belief about myself is embedded within a web of beliefs which, in turn, are shaped by worldviews and dwell within conceptual frameworks? What then? And what do we make of the claim that our beliefs come to us from the world through which we have passed and in which we will pass again once we step out of the clinic? Does that matter? And does it matter that we here take the self to be an ‘atom’ with its own discrete ‘set of beliefs,’ and not as a social being who is interdependent on goodly (or not so goodly) others? Would that matter? And if the self were not an atom, if it were dialogical from first to last–would this not give this approach the lie? But now tell me: do we truly learn about ourselves in 10 hours in a clinic, or might learning be an ongoing adventure, with twists and turns and dead ends? And why–let me venture one final, if I may–are we presuming at the outset that the world is hostile till the end and that we must learn to acclimate ourselves to it, preparing ourselves for conflict and misunderstandings and disappointments? (For do we not laugh and smile and sing?)

Quite apart from CBT’s dubious philosophical assumptions which I have not considered here, the whole thing would come to sadden me and to sadden me still. I think of all the individuals who had gone through this, who are going through it still. I think of a society devoted to quick fixes and easy remedies. I think of the individuals whom I have worked with who had learned that, in “disputing” and “combating” false beliefs, to be very hard on themselves indeed, as if they were redoubling their efforts at each turn. I feel compassion for all those for whom life is rich, complex, multilayered, a dramatic performance. And, not the least, I wonder why we have whited out the importance of joys, the role of desires, the place of higher values. For would not the successful client still be left wondering why she is doing all of it, any of this, when the question of existence is still very much up for grabs? Why bother, right?

It was around this time that I began to understand that my philosophy practice and cognitive therapies were so radically different as to be non sequitorsA joke: “How are you?” “Yes, a duck.”

Below, I have decided to include a book review I wrote in early November but could not bring myself to submit. The comments in brackets are recent. The strikethroughs indicate only some of the changes my thinking has undergone. In an effort to reveal some of my errors with regard to cognitive therapies, I have elected not to white out or strikethrough every sentence. How generous, I know.

Book Review of Donald Robertson, The Philosophy of Cognitive-Behavioural Therapy (CBT): Stoic Philosophy as Rational and Cognitive Psychotherapy (London: Karnac, 2010).

Donald Robertson, a practicing cognitive therapist and certified clinical hypnotherapist, is currently the principal at The UK College of Cognitive and Behavioural Therapies. In The Philosophy of Cognitive-Behavioural Therapy (CBT): Stoic Philosophy as Rational and Cognitive Psychotherapy, Robertson attempts to facilitate a rapprochement between Stoic philosophy and cognitive behavioral therapy, between philosophical understanding and therapeutic engagements.

Thankfully, there has been something of a renaissance of late in the conception of philosophy as a way of life. As David E. Cooper points out in his remarkable essay, “Visions of Philosophy,” the picture of philosophy as a form of therapy practical vision should be distinguished from that of philosophy as an “essentially theoretical, speculative enterprise” (1). In the first vision, the Good is more primitive or basic than the True. Cooper thus:

For those whose image of philosophy is that of a therapy, a spiritual exercise, edifying poetry or politics, philosophy is, in essence, a practical, vital enterprise. Its orientation is towards the Good, towards Life as it should be. The Good in question might be that of the soul, of the mind, of society, maybe of the world as a whole. (1)

Academic research on the practical dispensation continues apace. Clare Carlisle and Jonardon Ganeri, in the “Introduction” to Philosophy as Therapeia, a collected volume likewise published in 2010, state that Eastern and Western philosophers once saw philosophy as a “cure or remedy for the maladies of the soul” (1). The scholars contributing to this book therefore seek to strengthen these connections. Moreover, no one has done more in recent years than the ancient scholar Pierre Hadot to reclaim the venerable tradition of philosophy as a “spiritual practice,” thereby illuminating the ways in which philosophy shades into religion. And even the most cursory glance at the index of The Philosophy of CBT will reveal the extent to which Robertson is indebted to Hadot for deepening his understanding of Hellenistic therapeia.

To date, however, much of the work on philosophy as an edifying practice has been conducted by professional scholars or popular philosophers meaning to nudge philosophy in a therapeutic direction. Robertson’s book, then, is a welcome contribution inasmuch as, beginning in the other camp, it hopes to turn therapeutic practice toward philosophical concerns.

But how exactly is this meeting to be brought about? Robertson suggests three different ways: by introducing professional philosophers to the practical applications of CBT; by broadening CBT practice by means of familiarizing practitioners with Stoical concepts and techniques; and by widening the scope of therapy such that it can open out from a set of techniques applied during discrete 50 minute sessions toward a broader focus on human flourishing and final aims.

As it is currently practiced, the measured but important wrongheaded goal of CBT is to put individuals back in the saddle. As the client overcomes his fears, anxieties, and regrets, he is given back the life he wishes to lead [despite a pronounced agnosticism over whether that life is actually worth leading]. CBT is thus designed to be a fitness program for the mind, a de-cluttering of mental space, an untying of painful, tightly wound, irrational knots. “The central method of cognitive therapy consists,” Robertson informs us halfway through, “of monitoring one’s thoughts and challenging those ones that are irrational or unhelpful and the beliefs that underlie them” (169). By means of strenuous, habitual mental exercises, the client learns how to prepare for events that would otherwise prove unsettling as well as how to move more nimbly from mental disturbance to equipoise and equilibrium. On this construal, thinking better instrumental reasoning implies living more tranquilly.

CBT practice is grounded on three fundamental principles. The first is the “Stoic Fork” (60). In the spirit of Epictetus, the CBT practitioner makes and reinforces a “sharp distinction between two domains” (60): the domain of what is within our control and the domain of what is not. As Epictetus shows repeatedly in The Enchiridion, individuals run into all kinds of conceptual muddles when they miscategorize an event by filing it in one folder when it properly belongs in the other; or when they confuse these domains by concerning themselves with events about which nothing more can be said or done; or when they extend one domain beyond its limits—the domain of moral purpose into that of the external world or the domain of fate breaching the outer walls of the “inner citadel.” In a word, a rational person keeps good accounts, an irrational person accrues sizable debts, solicits credit, and expects to receive undue favors.

The second principle [I find the fact/value split problematic] is that the order of value and the order of fact are absolutely disjunct. Pace moral realism, the fact/value split obtains in CBT such that facts designate states of affairs whereas values are our colorings or interpretations of these states of affairs. In view of this, the well-trained client needs to learn how to re-describe events in value-free language (“According to the thermometer, it is 25 degrees Fahrenheit outside today.”) rather than in value-laden language (“My God is it unbearably cold. It’s as if I’m being punished.”) Likewise, others’ actions: “So-and-so has bumped into me” should not be confused with “So-and-so willfully and deliberately harmed me. She meant to do that.” CBT, accordingly, teaches the client not just to identify the order of value with the domain of moral purpose but also to distinguish physical descriptions from value judgments and to stand back and “dispute” the validity of her value judgments.

The third and final principle of CBT is that cognition is a “constituent of emotion” (99). Thus does CBT take on board a cognitive theory of emotion, albeit a rather fuzzy one. In Chapter 4, where the view is canvassed, Robertson remains agnostic about the exact formulation of the CBT theory of emotion. Nonetheless, such theoretical haziness may, in some clinical cases, be practically moot as asking a client to “‘describe your feelings as if it were a thought’” (77) might suffice to unearth, say, the belief about deliberate harm that is at the heart of the client’s upsurge of anger.

Conjointly, these principles imply that CBT is a rational inquiry into the client’s state of mind. To make his account of mental fitness more perspicuous, Robertson divides the book into two sections. In Part 1, he explores the theory and history of Stoicism alongside those of earlier and later cognitive therapies. In Part 2, he describes the particular exercises shared among Stoics and CBT practitioners.

Part 2, “The Stoic Armamentarium,” is where things get interesting. One imagines a glorious gymnasium in the center of a beautiful school where the spiritual exercises Robertson describes—contemplation of the sage in Chapter 7, premeditatio malorum in Chapter 11, and the view of the cosmos in Chapter 13, among others—were very much at home. For philosophical counselors who wish to make spiritual exercises an important part of their practice, Robertson’s catalogue of Stoic exercises will prove especially useful. Indeed, before Robertson sorted, collected, and curated these exercises, your best bet was to forage through Hadot’s What is Ancient Philosophy? in hopes of finding one here or there.

Another task Robertson sets himself is, in Appendix I, to reconstruct the Stoic daily regime of exercises. And his is no antiquarian history or speculative guesswork but an honest, pragmatic attempt to present a Stoic’s exercise routine from morning premeditations to mid-day self-awareness to evening retrospection all as a unified whole. Robertson implies, and I would agree, that all of these exercises are well-suited to the project of working on the modern self.

Robertson’s conception of rationality is also a refreshing alternative to the commonsensical view I often find when I begin working with new conversation partners. As common sense would have it, one gains theoretical insight about oneself and thereafter one can, at will, on command, and without fail, apply this insight to one’s everyday affairs. Through the burst of once-gained theoretical insight, it seems, we are changed ever more and for good. Not so, I’m afraid. Instead, negative thoughts hang around past the appropriate leave-taking, and so good reasoning, as Robertson shows, can be a “powerful weapon” against the “onslaught” of negative emotions and false beliefs. [The general line of thought that good reasoning is “spiritual exercise” is true; however, the marshal metaphors employed in CBT is rather disconcerting.] On this reckoning, a more muscular reasoning requires unlearning and re-learning, vigilance and caution, struggle and persistence. The process could be likened to the Christian tradition in which temptations can draw us off away from God whereas prayer and meditation can strengthen one’s resolve against stirrings and cravings.

Robertson’s book sheds light on the limitations of CBT as a clinical practice and his account as a the philosophy of CBT. In the first place, I’m not sure [read: he doesn’t, I’m afraid] that Robertson has achieved the three objectives he lays out in the opening chapter. Has he shown that Stoicism is the “origin of CBT” (261), that is, that Stoicism is the “philosophy of REBT and CBT” (5)? It seems that Robertson has fallen into the post hoc fallacy, presuming that because P comes before Q that P must be the cause of Q. Yet if the case for Stoicism being either the historical origin or the philosophical foundation of CBT remains unargued for, it is also the case that his claims tend to be more moderate. In most places, he says that he wants to “draws attention to the relationship between CBT and Stoic philosophical therapy” (5) and throughout he speaks of this relationship in terms of “analogies,” “likenesses,” “resemblances,” and “parallels.”

The dilemma is that either Stoicism is “practically” identical to CBT—in which case CBT practitioners have no reason for consulting Stoical philosophy—or Stoicism is the philosophical backbone to CBT—in which case CBT may be playing second fiddle. In other words, if Stoicism so “closely resembles” CBT that its terms are readily translatable into those of CBT (and vice versa), then what relevance does this have for the CBT practitioner who is working with a client in her office and what bearing does it have on the ancient scholar who is keenly focused on providing perspicuous accounts of Stoical logic, metaphysics, epistemology, and ethics? [The answer, unfortunately, is none.]

Recall that the second aim had to do the ability of Stoicism to expand a clinician’s toolbox (261). And yet, if one so closely resembles the other as to be amenable to direct translation, then in what sense is Stoicism adding new tools to the clinician’s toolbox? By my count, the only time Robertson actually mentions that some Stoical exercise is wanting in the CBT repertoire is during his elucidation of the Stoic’s meditation on the View from Above. The rest of the exercises outlined in Part 2 seem to be held in common.

And is the view that Robertson recommends a fully worked-out art of living? [Again, it is not and, more damaging still, it lacks the philosophical equipment to provide a philosophy of life.] One of my conversation partners told me that when it came to reasons for acting his CBT practitioner had advised him to “act in accordance with your values.” For him, a highly self-reflective individual, this statement was thoroughly puzzling. Which values exactly? How should they be rank-ordered? Are any of them of intrinsic value, or might some or all be trivial, misguided, or evil? And what about values that conflict with each other? Or about the problem of dirty hands? Are there better or worse ways of pursuing final ends? And supposing my conversation partner were able to determine that the final aim was thus and so, does the manner of striving toward thus and so matter? How much? And so on.

Because Robertson does not discuss intrinsically worthwhile final ends and because he does not consider fully enough the other limbs of the Stoical tree (namely, metaphysics and logic) as a whole picture of a flourishing life, his picture of CBT cannot be more or less than a set of useful, isolable exercises performed in a certain style of reasoning. [In this respect, CBT cannot answer the problem of nihilism. It is rather like spending 2 hours a day at the gym without any reason for doing so. The desire for physical longevity is the forgetfulness of human mortality. Accordingly, it is not a sufficient reason for persisting in one’s existence. And exercising for its own sake is utter madness.]

Second, CBT presumes that what goes on in one’s head is the starting point and end point of clinical sessions. As a result, it does not take seriously the degree to which presiding social institutions can have a profound (and deleterious) impact on the overall well-being of its clients. This too is puzzling given that persons do not exist apart from the social worlds into which they are embedded and if that social world is hostile to the prospect of a well-led life, then those forces are bound to “show up” and thence to “take up residency” in one’s head. The upshot is that the source of the problems may lie elsewhere; they may lie in our collective forms of life.

Third, CBT’s conception of rationality is a thoroughgoing instrumentalism. The assumption Robertson makes is that thinking more rationally will be “better for you.” Indeed, we learn how to think more reasonably for the sake of arriving at equipoise. However, there are plenty of cases where getting things right, however much pain that may cause us, is far more important than feeling better about ourselves. Accuracy, honesty, truth-telling all, in the right contexts, may and ought to trump instrumental reasoning. [This is pretty much the reductio ad absurdum of CBT: reasoning well, while remaining agnostic to the question of accuracy, merely for the sake of feeling good. To me, this is sheer horror.]

Notwithstanding these criticisms, I believe Robertson’s book is a good guide for any philosophical practitioner who wants to works closely with conversation partners on the art of good reasoning. Without a doubt, these exercises, forged in the Stoical stove and tested by a maimed slave, a prisoner of war, and a Roman emperor, are good at bringing us peace of mind. In addition, they help us to cultivate worthwhile virtues such as circumspection, discrimination, courage, patience, and fallibility, virtues without which we cannot hope to live flourishingly. By means of such training, we learn to develop a capacity for second looks and third thoughts. Finally, CBT, as I have found in my philosophy practice, can serve as preparation for individuals who wish thereafter to begin philosophical inquiry into radiant visions of well-led lives.

References

Cooper, David E. (2010). “Visions of Philosophy.” Conceptions of Philosophy. Anthony O’Hear (Ed.). Cambridge: Cambridge University Press. 1-14.

Nussbaum, Martha. (2001). Upheavals of Thought: The Intelligence of Emotions. Cambridge:
Cambridge University Press.

Philosophy as Therapeia. Royal Institute of Philosophy. Supplement 66 (2010). Clare Carlisle and
Jonardon Ganeri (Eds.). Cambridge: Cambridge University Press.

Further Reading

At the end of October 2011, I wrote a two-part series on CBT. (Here is Part 1 and here Part 2.) Since then, I have come to regard CBT as more misguided than I had initially believed. There is, I now realize, also an error in being too generous.

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