Cognitive Behaiour Therapy (OP)

4th May 2006

A brilliant article by Magnus Linklater in The Times (3/5/06) on Cognitive Behaviour Therapy…

>>Freud-lite: the ideal modern cure
Magnus Linklater

“WHAT PROGRESS we are making!” said Sigmund Freud. “In the Middle Ages they would have burned me. Now they are content with burning my books.” You were overoptimistic, I fear, Dr Freud. Today they are ignoring you altogether.
On this, his 150th anniversary, the great founder of psychoanalysis has been thoroughly sidelined. The profession he created has turned its back on the inventor of the Oedipus Complex and the interpreter of dreams, dismissing his science as flawed, his methods as slow and ineffective, his treatment of patients archaic and his attitude to women unspeakable. The “id” is out, the “super-ego” is redundant. The man himself was not only anti-feminist, his single-minded exploration of our repressed sexuality makes him fairly creepy as well. Freud? Avoid.

 He had it coming, of course. This is the age of the selfish gene, which maps the shape of our personality long before we have acquired a taste for the maternal breast. We know more — or we think we know more — about the chemistry of the brain than the good doctor ever dreamt of, and we have devised a sophisticated range of drugs to treat it.

The painstaking classification of neuroses that Freud devised, and his attempts to trace them back to buried episodes in our childhood, is generally dismissed in favour of a stiff dose of medication and a stretch of Care in the Community. We have neither the time, the inclination nor indeed the funds for long and intensive hours spent on the psychiatrist’s couch. We prefer the quick fix to the free association of ideas.

More seriously, it is generally accepted that deep-seated psychotic illnesses such as schizophrenia and manic depression are simply beyond the normal capabilities of the psychotherapist. Unless rapidly treated with the appropriate medication, they can spiral out of control, with damaging consequences for the patient and for anyone within his orbit. While Freud claimed that even these extreme cases could respond to his painstaking approach, few modern psychiatrists pretend that, without drugs, the wild hallucinations or the hyperactivity of the genuinely manic case can be controlled. An NHS that places a low premium on mental illness is not interested in lengthy periods of treatment. It prefers to have its patients off the couch and out of hospital as soon as is decently possible.

At the same time, Freud has had to cede his place as psychiatric father figure to a formidable new contender. Aaron Beck, the 85-year-old Yale-educated inventor of cognitive behavioural therapy, has not only become the most influential psychiatrist of his day, he has displaced Freud and the Freudians with an approach to mental illness that is far more in tune with the impatient approach of the modern era. Instead of delving into the past, CBT focuses on patients as they are now, dealing directly with their problems, and suggesting practical ways of handling them. A counsellor, who may not even be a trained psychiatrist, asks “How do you think about yourself and other people?”, “How do your actions affect your state of mind?”, “Can changing the way you think affect the way you behave?” and “Instead of looking back at the past, how can we change your state of mind now?”.

CBT is the big new thing in the NHS. It fits exactly with the brisk, short-term approach to treatment that is encouraged by hospital administrators and smiled on by politicians. It is also perfectly in tune with the emotion-led, confessional approach to modern neurosis, the stuff of TV shows such as Oprah Winfrey, and the essential theme of every tear-stained celebrity interview. It is used to deal with a shopping list of traumas, including anxiety, depression, panic, eating disorders, agoraphobia and a whole range of obsessive and compulsive behaviour. Patients give assessment of their problems in detailed questionnaires before being urged to break the bigger issues into smaller bits, and then to address them one by one.

If that sounds shallow, then perhaps it is. It veers away from the deeper, more complex aspects of the psyche, and addresses, instead, its surface symptoms. It assumes that patients can change their emotional patterns through positive thinking rather than dwelling on the traumas of the past. It benefits from one-to-one discussion, but not from building the patient-psychiatrist relationship to which the Freudians attached such importance. It is, in effect, Freud-lite, and the old man would have hated it.

As a metaphor for modern society, with its lack of interest in the past and its enthusiasm for instant solutions, CBT fits the bill perfectly. But it ignores the depth, the subtlety, and the wit with which the great doctor approached the human condition and attempted to understand it. He it was who said: “Neurotics complain of their illness, but they make the most of it. And when it comes to taking it away from them they will defend it like a lioness her young.” To this he added:

“A man should not strive to eliminate his complexes but to get into accord with them: they are legitimately what directs his conduct in the world.” He explored the roots of love, the importance of childhood, the way that civilisation should be weighed against instinct, and he did so with a breadth of knowledge and understanding that no modern counsellor, however well-trained, can possibly match. <<

I have experienced CBT at its worst. In my own case its crude application has, on occasion, contributed to a significant worsening of my illness. My worst experience was when, during a very bad bout of depression, when getting out of bed was in itself an enormous effort – with no benefit to my mental health whatever – and my capacity for speech was, as always at such times, limited to grunting, a CPN (Community Psychiatric Nurse – not the excellent one I have now) suggested that I should acquire an allotment. While this is something which I now find laughable, at the time it was deeply harmful and probably prolonged that particular bout by several weeks.

Another facet of CBT which Linklater does not mention is that it fits in perfectly with the Blairite obsession for targets and checklists. Today you will a.) exercise b.) have a bath c.) do a crossword etc. – tick the boxes and you will be cured. This is pernicious nonsense, but it can be set down on a form, tabulated, enumerated, formularised. The psyche is not really complicated, wild, unknowable, at the heart of the human mystery – it is just another piece of data which the application of formulas and targets will reduce to order. CBT in this context becomes a metaphor for the Blairite approach to the human condition. All the consolation one can draw is that it is utterly doomed. But the human cost along the way is enormous. How fortunate I am to have found a proper psycho-analyst, a caring and responsive Doctor.

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