CBT: The Cognitive Behavioural Tsunami

Managerialism, Politics and the Corruptions of Science

Farhad Dalal

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429855856
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Is CBT all it claims to be? The Cognitive Behavioural Tsunami: Managerialism, Politics, and the Corruptions of Science provides a powerful critique of CBT's understanding of human suffering, as well as the apparent scientific basis underlying it. The book argues that CBT psychology has fetishized measurement to such a degree that it has come to believe that only the countable counts. It suggests that the so-called science of CBT is not just "bad science" but "corrupt science".

The rise of CBT has been fostered by neoliberalism and the phenomenon of New Public Management. The book not only critiques the science, psychology and philosophy of CBT, but also challenges the managerialist mentality and its hyper-rational understanding of "efficiency", both of which are commonplace in organizational life today. The book suggests that these are perverse forms of thought, which have been institutionalised by NICE and IAPT and used by them to generate narratives of CBT's prowess. It claims that CBT is an exercise in symptom reduction which vastly exaggerates the degree to which symptoms are reduced, the durability of the improvement, as well as the numbers of people it helps.

Arguing that CBT is neither the cure nor the scientific treatment it claims to be, the book also serves as a broader cultural critique of the times we live in; a critique which draws on philosophy and politics, on economics and psychology, on sociology and history, and ultimately, on the idea of science itself. It will be of immense interest to psychotherapists, policymakers and those concerned about the excesses of managerialism.

Chapter 1
Introduction

Hyper-rationality

Cognitive Behavioural Therapy (CBT) has come to dominate the field of psychological therapy, particularly within the NHS in the UK, but also in other sorts of institutions such as prisons and schools. This state of affairs is reproduced in many other countries across the world. If you go to your GP because of feeling depressed for some reason, in your ten-minute consultation your GP is almost certain to offer you anti-depressants or/and the ‘one-size-fits-all’ manualized treatment called CBT. The ‘treatment’ will try to teach you to replace your ‘negative’ thoughts with ‘positive’ ones. Your CBT therapist will have little interest in why you are depressed (perhaps you have been bereaved) because they think depression to be an illness, rather than a reasonable response to a devastating life event. According to the latest edition of the psychiatric bible, the Diagnostic and Statistical Manual V (DSM V, 2013), if you are still grieving a whole two weeks after your bereavement, it is because you are suffering from a mental disorder, because you should have come to terms with your loss by then.

How on earth did we get here? How is it that so many of the great and the good, researchers, regulatory authorities as well as hard-nosed economists and commissioners all come not only to think that there is nothing odd about this way of thinking about human suffering, but also that it is a sensible, scientific way of thinking?

In part, this has come about because in more recent times in some quarters of the academy, the notion of scientific knowledge itself has become progressively corrupted and degraded by the self-serving manoeuvres of a number of interest groups. This is somewhat ironic, because the function of the scientific attitude when it first emerged during the Enlightenment was precisely to expose the self-serving rationalizations of the then ruling elites to be fantastical fictions, not facts.

Once upon a time in the west . . .

Once upon a time in medieval England, anyone caught simply reading the Bible in the English language, would be in deep trouble, branded a heretic and quite likely burnt at the stake. The official Bible – the Vulgate – was in Latin. The Church said that to render the Word of God from ‘high’ sonorous Latin into thelow commoner’s tongue – English – was heresy as it would defile it. In this way the priest rationalized and protected his privileged position as gate-keeper between God and mammon. The Bible’s impenetrability for the masses served the interests of both princes and priests, who used self-serving Biblical readings not only to claim that they were chosen by God to do his work, but also to give divine sanction to their political intrigues. Pope Urban II used biblical imagery to launch the first of the Crusades by conflating the Saracen with Satan, and in the same breath declared a fatwah on Jews everywhere. In June 1643, the Puritan English parliament actually passed a law – The Covenant to be Taken by the Whole Kingdom – which was supposed to be a Covenant with God. This celestial legal contract was an agreement between the English parliament and the Almighty, in which the Almighty agreed that the English would do God’s work on earth (expanding His Kingdom), and He in turn would look after them. It was also agreed that God would replace Jews with the (Protestant, Puritan) English as his Chosen People.¹ Having sole access to the word of God, the utterances of priests and princes had absolute authority. To question the proclamations of Kings was treason, to question the Church was heresy. Either was a sure way to book a place in the medieval torture chamber.

Then, in the late Middle Ages this despotic world order began to be challenged right across the land that would come to be known as Europe. Perhaps surprisingly, it was philosophy that was in the vanguard of this revolution. Philosophers like Locke, Hume, Descartes and Kant were amongst the first to challenge this tyranny. The radical revolution that they triggered transformed the world; it came to be called the Enlightenment because it brought the Light of Reason into the darkness of superstition. Kant cried out to humanity at large: Sapere Aude! Dare to think for yourself! (literally, ‘Dare to know’). Intrinsic to the Enlightenment were the ideas of equality and freedom – the freedom to question, the freedom to think. And think humanity did. Rational thought became the organizing principle of society at large. Science itself grew out of this movement, bringing us unimaginable benefits in all kinds of arenas from technology to agriculture to leisure to medicine.

Physics envy: only the countable counts

But then, things began to change. Entranced by the predictive powers, advances and insights of the natural sciences, all kinds of disciplines and social practices began to suffer from a kind of ‘physics envy’. And so, they began to try to emulate the empirical methods of natural scientists in order to garner for themselves the prestige of being a ‘science’.

Today, it is hard to move without falling over all manner of things that claim to be scientific and evidence-based: evidence-based policy, evidence-based probiotics, evidence-based decision making, evidence-based fitness, evidence-based software engineering, evidence-based teaching, evidence-based investing, and of course, evidence-based psychological treatment.

However, the version of evidence that has come to prevail has meant that the virtues of the rationality of the Enlightenment have become perverted and distorted into a kind of hyper-rationality. Whereas Enlightenment rationality valued the freedom to think and question all things and anything, hyper-rationality uses a distorted and corrupt version of science to close down thinking. Rule-following comes to triumph over questioning and thinking. Where Enlightenment rationality brought freedom and light, hyper-rationality brings authoritarianism and darkness.

The virtues of rationality itself cannot be overstated. It has brought untold benefits to our lives and our ways of life. But the extreme versions of rationality, hyper-rationality, are corrosive to these very ways of life. As William Barrett put it, ‘the untrammelled use later thinkers made of human reason [i.e. hyper-rationality], applying it like an acid solvent to all things human or divine’ (Barrett, 1990, p. 26).

Hyper-rationality is the use of a reductive version of rationality in contexts that are not suited to it. Hyper-rationality insists that only evidence-based claims are valid. This sounds fine until we discover that hyper-rationality insists that this evidence be only of the arithmetic kind, because numbers and measurements are objective and real. If something can’t be counted, if it can’t be measured, then it does not exist; it is not real. This belief then allows all kinds of bizarre things to take place.

The Neem tree

For example, for over 2,000 years, components of the Neem tree have been used by farmers in India as pesticide. In 1992 an American agricultural company called ‘Grace’ patented a version of the pesticide. Having patented it, they claimed to be the legal owners of all such uses of the Neem tree. If any Indian farmer then used the Neem tree as a pesticide on his plot of land, then he was breaking the law and would be sued by Grace. Understandably, the farmers were outraged and took to the streets in protest. But protest counted for nothing, because in patent law, a challenge to the novelty claim of the patent could only be allowed if it could be demonstrated that the prior knowledge had previously appeared in a printed publication, preferably in a ‘scientific’ journal, at some time before the application for the patent. In other words, the legal system required documentation, something tangible as ‘proof’. Patents are supposed to be granted when they meet the legal criteria of ‘novelty, non-obviousness and utility’. In this case, the patent claim was neither novel nor non-obvious, and its utility was already well known. But this being folk knowledge, there was no evidence of the approved kind in print. Because of this, the courts declared that there was no evidence. The observable visible reality, the actual use of the Neem tree by farmers for millennia, was declared anecdotal and dismissed as unscientific.

In this hyper-rationalist world, it is the presence or absence of documentation that is the ultimate arbiter of truth and reality.

Encouraged by the findings of the courts, three years later two Indian researchers, Sumin K. Das and Hari Har P. Cohly at the University of Mississippi Medical Center, jumped on the same bandwagon. In 1995 they patented ‘the use of turmeric in wound healing’. Being Indian, they of course, knew that Indian families had used turmeric paste for millennia to help speed up the healing of cuts, bruises and wounds. Their use of the patent law was entirely exploitative, cynical and self-serving. Astonishingly, their patent also granted them the exclusive right to sell and distribute turmeric. In one fell swoop, not only had they commandeered the uses of turmeric, but also all commercial activities around it. They were going to become very rich indeed.

Eventually, after years of legal battle, both patents were revoked. In the Neem tree case, the patent was revoked after a manager of an Indian agricultural company was able to demonstrate that he had been producing oil from the tree for the same use as the patent, but prior to the patent. And in the turmeric case, written evidence for its prior use was produced from ancient Ayurvedic texts from 500 BC. However, there remain a large number of patents in place on other uses of the Neem tree as well as turmeric. This kind of bio-piracy is only able to take place because the procedures and protocols of patent law are hyper-rationalist.

The point to be underlined is this: that the idea of evidence itself is up for grabs. What counts as legitimate evidence (real, objective data), is determined by the ruling definition of evidence. This ruling definition also has the effect of ruling out other kinds of evidence, even though it is also objective and there for all to see. This is the kind of hyper-rationalist reality that we find ourselves beleaguered by, in which so-called evidence or lack of, is being used to mystify and deny the existence of self-evident realities.

As things stand today, in order for something to count, it has to be countable. But further, and more worryingly, in some contexts the number itself becomes more real than the thing it is apparently representing, so much so that in some instances the numbers become the reality.

Rationality, Truth and Madness

The activity of science is supposed to be the production of objective knowledge by rational means. The ‘means’ themselves are a mix of observation (empirical evidence) and logical argument. CBT claims to produce scientific knowledge in this way, and on this basis assert that its claims are rational, objective and value free. In short – that they speak the truth.

Because the claims of CBT are rational, then any that question them are bound to be irrational. Why else would they deny the objective reality staring them in the face? They must be mad, or at the very least misguided. Even more, the notion of truth evokes its opposite – the lie. What this means is that anyone that questions the truth of the CBT thesis must not only be somewhat mad, in some way they must also be bad. It is in this sort of way that the evidence-based therapies buttress themselves and dismiss those that question them as deluded anti-science Luddites.

However, the arguments of this book are that the claims of CBT are not rational but hyper-rational, and that its observations as well as its logical arguments, fall far short of the standards required by good science.

Neoliberalist efficiencies

Hyper-rationality has infiltrated all levels and arenas of social life. It is the basis not only of much of what passes for psychological science, but is also the basis of neo-liberalism and the ethos of New Public Management. These three territories powerfully come together, to interlock, bolster and sustain each other, to create a peculiar world view that is promoted as both normal and sensible, despite its peculiarity.

This book is primarily about the first element of the unholy trinity, about the ‘science’ of psychology, and more specifically about the psychology of Cognitive Behavioural Therapy. But in order to better understand how CBT has come to prosper, the book will also consider the other two components of the trinity: managerialism and neoliberalism as it was in their interests that CBT should flourish. In return, CBT supplied them with hyper-rationalist legitimations for their endeavours. In this way the argument of the book also functions as a broader cultural critique of the times we live in.

A key doctrine of hyper-rationality is a distorted and amoral take on ‘efficiency’. We can see it in play in the workings of neoliberalism. To begin with, neoliberalism uses a shallow and instrumentalist definition of efficiency having to do with profit and money, to rationalize and legitimate deregulation. It follows this up by calling on efficiency again to legitimate the austerity measures that are deemed to be necessary to repair the damage done by the deregulation in the first place. The actual implementation of austerity itself is devolved to managerialist bureaucrats who do the dirty work of decimating our public services and institutions. But the dirty work of making ‘cuts’ and causing harm is made to look sanitary and rational by alluding to ‘cuts’ as ‘savings’ – and camouflaging it to make it look as if it is all taking place in the service of increased efficiency. These cuts then result in human distress, distress which is framed as a mental disorder. By this means managerialism and neoliberalism sanitize their activities and then, in a gesture of good will, offer CBT treatments for the unfortunates who are deemed mentally ill. It is in the name of efficiency that bureaucracies fund CBT over and above the other forms of therapy, on the basis of the claim that CBT’s efficacy has been scientifically demonstrated; it also just happens to be the case that CBT treatments are inexpensive and relatively quick to implement (that is, they are ‘efficient’). In sum, CBT is a managerialist creation, not the scientific one that it claims to be.

Command and control

The watchword of hyper-rationality is ‘command and control’; its expectation is that we should be able to control everything: not only the world, not only the functioning of organizations, but also our very beings. This ethos is shared by both managerialists as well as cognitivists. Richard Layard, the godfather of CBT in Britain, informs us that ‘Human beings have largely conquered nature, but they have still to conquer themselves’ (Layard, 2005, p. 9). If we can’t control something, then this is because we have yet to figure how it works. ‘The inner life . . . determine[s] how we react to life . . . So how can we gain control over our inner life?’ (Layard, 2005, p. 184).

Once we have learnt how to take control of our inner life, then we ought to be able to make it do what we want it to do. In this way, its command and control ethos claims to be able to conquer inner psychological life itself. As we will come to see, it is believed that you should be able to choose and determine what you feel and think. If you feel depressed say, then it is because you have not yet understood how to take control of your inner life. This is where CBT will come to the rescue: it will explain to you how your inner life works; it will then train you in techniques to control its workings. If, after all this, you still cannot control your inner life despite having understood the mechanism, then either this is of your choosing, or it is because you are still in the grip of your mental illness. In which case you will be the beneficiary of an additional diagnosis granted by the researchers: ‘CBT resistant’ (for example, Otto and Wisniewski, 2012).

Hyper-rationality is infused by two other doctrines that go along with that of ‘efficiency’, these being atomization and decontextualization. We will come to see how these doctrines start to play out in the course of this book.

The rhetoric of the proponents of CBT would have us believe that the reason that it has come to dominate the psychological field, is simply because it is the best in the field, the most efficient player. But as we will come to see, CBT has succeeded not because it is the best player in the game, but because (along with its allies) it has adapted the rules of the game to favour its own method. In other words, CBT’s succ...