July 5, 2023

One of the more entertaining parts of my training in Rational-Emotive Behaviour Therapy — an austerely philosophical style of CBT — was how tribal our course leader was about its merits. He got particularly exercised about psychoanalysts. If a prospective client reveals that they’re looking for psychoanalysis, he would say, you need to get them out of your therapy room, stat. Other therapists I knew shared his animus. Psychoanalysts were creepy, power-tripping grifters; the people who went to them were at best naïve, and at worst whiny, self-centred and broken by terrible ideas.

REBT is characterised by a kind of rugged psychic individualism. In this view, if you hope to be psychologically fixed by relying on others, if you seek healing from interpersonal woo-woo like transference, you’ve already made a key philosophical error. You’ve outsourced your agency. And that’s before getting into the most eccentric elements of psychoanalytic theory — penis envy, the Oedipus complex, Melanie Klein’s baffling idea of the bad breast as persecutory object. To read Freud is to grit one’s teeth at the relentless dogmatism of his prose, the certainty with which assumptions that look absurd in the context of observable reality somehow grew legs and ran for decades. If you are looking for relief from mental distress, is it wise to procure it from people who believe in resentment-drenched theories that could only ever make sense to the pathologically horny and disturbed?

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More generously understood, psychoanalysis is based on the idea that mental distress tends to arise from unconscious inner conflicts, and that past experiences — especially those of early childhood — exert a long-term effect on our thoughts, feelings and actions. The analyst assists the patient in exploring the depths of their mind, unearthing hidden meanings. Change happens by means of the therapeutic relationship, with the patient unconsciously acting out past conflicts. The process can take years.

Albert Ellis, the originator of REBT, was a psychoanalysis refusenik, as was Aaron Beck, the father of CBT as we know it today. Their early careers were largely an accident of history: both happened to train in clinical practice in the post-war era, when psychoanalysis was dominant. Both soon observed inconsistencies between the theoretical claims of how analysis worked and their own observations of patients. Beck noticed that negative views of the self, the world and the future characterised depressive episodes in patients, rather than the repressed feelings that Freud held to be their cause. The psychoanalytic process was only supposed to work if you saw the patients daily, maintaining the relational magic, but Ellis noted that his patients who only came in once a week did just as well, and that they did even better when he ditched the psychoanalytic theory and talked to them about philosophy instead.

What emerged from this was cognitive behavioural therapy. Rather than getting stuck into the past, it operated in the here and now, looking for the habits of thought and behaviour that maintain our distress, and finding ways of thinking and behaving that might work better. The therapist’s role was not as ersatz parent or interpreter, but as Socratic teacher, helping guide the patient’s reasoning to more pragmatic ends. This seems to have worked well: in the English-speaking world, the dominance of CBT makes Freud look more like a kooky curiosity in the history of ideas than the father of psychology.

The ideological descendants of Freud have strong feelings about this. They’re not all psychoanalysts: there’s a genealogy of therapeutic styles that see human distress as the product of relational problems, from maternal attachment to structural oppression. They tend to see the solution as lying in the deepest layers of the self. Another thing they often have in common is really, really hating CBT.

The arguments vary. Psychodynamic psychologist Jonathan Shedler has suggested that its evidence base for CBT is skewed by selective reporting. Its heavy reliance on manuals, which therapist Nancy McWilliams criticises as rigid and simplistic, leads it to be mistakenly thought of as scientific. By focusing on the individual locus of control, CBT is a tool of neoliberalism, ignoring the systemic inequalities that shape people, telling us to grit our teeth and smile rather than try to change the world. For Jungian psychotherapist Paul Atkinson, CBT mostly serves industry, rather than the people it’s supposed to treat; it’s designed to make you a better cog in the machine. Since 2008, it has been provided for free by the Improving Access to Psychological Therapies (IAPT) programme, conceived by New Labour’s “happiness czar” Richard Layard, to improve economic productivity by way of public wellbeing. As a public investment, CBT was a good one: it is short-term, taking as few as six sessions to complete in straightforward cases, and therefore cheap. It is also highly structured, gathering its own data via regular symptom inventories, meaning it could be accountable to the public purse. Choosing CBT was following the science.

This infuriated CBT’s detractors, provoking a backlash against IAPT and CBT in general. Doubts have been raised over whether IAPT data supports the impressive results it claims; studies of CBT’s efficacy elsewhere have found it to fall over time, with one finding it no more effective than its nemesis. Given that it’s being offered for free to anyone who wants it, if CBT worked, you’d expect things to be going pretty well by now. Instead, we are less happy than we have ever been, with the ONS finding the UK prevalence of moderate or severe depressive symptoms at 21%. If, as the accusers declare, CBT isn’t really therapy but a coercive lever to make people economically productive, it’s not working: record numbers are out of work due to mental ill-health.

Each era brings its own problems. In Beck and Ellis’s time, sexuality was repressed in favour of propriety, which fed depression. In the 21st century, our wellbeing has been eviscerated by technology; the impact of the internet and smartphones is well-documented. Relationships, as we used to understand them, have collapsed. The world of work has changed: there are fewer casual, pleasurable digressions between colleagues; work is increasingly seen as something that happens in isolation, rather than in concert with people you care about. If the online world turns out to have rewired our attention, this may undermine our ability to maintain the cognitive control that allows the mechanics of CBT to happen.

Economics plays its part, too. Even before inflation and housing shortages piled on extra pressures, it was hard for a family to keep a roof over its head without two adults working full-time, which impacts time spent with loved ones. You can blame this on the capitalist pursuit of profit, or the creep of technological slavery, but the outcome is the same either way. We’re swimming in material goods, and relationally impoverished. This is where the psychoanalysts might have a point. Even if cognitive-behavioural therapists can train our thoughts, downplaying the influence of the external world on our wellbeing is unwise. Psychological studies are in agreement: the quality and quantity of our relationships strongly predict our wellbeing.

But there’s something perverse about the very idea of therapy when we think about it, as the psychoanalysts do, in the terms of a relationship. We have always spent money on the services of soothsayers, acupuncturists or hairdressers, but those transactions weren’t intentionally about paying for human contact. We have also always exchanged money for sex, though it has usually been social taboo. Now we pay similar prices for the more basic intercourse of being listened to. We don’t trust people who sell sexual affection, because that affection lasts only while they’re paid, but we place uncritical confidence in those who sell us empathy.

CBT may not be the panacea it was hoped to be, but psychoanalysts accusing it of neoliberalism are being hypocritical. Selling committed, long-term relationships looks a lot like commodifying humanity. And if state-funded therapy threatens your livelihood, you’re more likely to get cross about it.

Beck described the therapeutic relationship as necessary but not sufficient for change, which comes, first and foremost, from the patient methodically practising new habits of action and mind. By contrast, the labyrinthine doctrines and relational focus of psychoanalysis make it easier to abandon agency: you can hand over your wellbeing to someone with a parental-style command of what is really going on in your head, who can give your world meaning and keep you feeling safe. It’s more comfortable, at least in the short term, to be told that our problems came from others, but it carries interpersonal risks. Being told we’re victims of fate tends to make us resentful. If you’re feeling low and you’re told that the reason is probably a failure on your mother’s part, your attitude to relationships probably won’t improve. The same is true if you’re feeling bruised from a tricky break-up and are told that you’ve been traumatised.

CBT is, in some sense, classically liberal, in that it sees the individual as having autonomy over one’s own mind. It’s harder to pin down a single position for its detractors. A relational view of the world — especially one where attachment to the mother dictates later wellbeing — is fundamentally conservative. Current discourse around attachment and trauma, rooted in socio-economic forces, is mostly Leftist in character. The philosophies underlying therapeutic approaches should, in theory, have a profound impact on patient outcomes. But this doesn’t happen.

Psychological studies find that there’s remarkably little difference in outcome between wildly different therapeutic styles. This is known as the Dodo-bird effect, from the famous scene in Alice in Wonderland where all must have prizes. The stories we tell about our minds may have social consequences, depending on what or whom we find accountable when things go wrong, but they don’t make much difference to therapy itself. Individual studies of this or that approach will continue to make grand claims of their power. Other studies will erode them. But therapy’s value seems to stem from sitting in a room being listened to by someone we like. In which case, can’t we replicate this experience with friends or relatives in our lives?

What we can say with certainty is that in the decades since we normalised paying to be listened to, we haven’t become any happier. We know, too, that we do best when our lives are rich with relationships and meaning. Maybe it was always a stretch to think that these things could be bought, or provided by the state. Internecine squabbles between opposing forms of therapy might disguise a conclusion that looks bad for all of them. We don’t need shrinks or ever-growing datasets to work out if we’re okay: we’ll know things are looking up when we stop employing people to listen to us talk.