The Invisible Casualties of CBT

This article just below reads like a companion piece to my earlier post on my late wife’s Alison’s struggles with chronic pain.

I agree almost entirely with Alana Saltz, the author of the article, and am saddened that Alison isn’t here to read it (in fact, I had to fight my initial impulse to send it to her). Saltz lays out many of the criticisms of CBT that Alison had made to me over the years, both as a therapist herself, and as someone with chronic pain. Before hearing those criticisms, I’d always had some vague unease about CBT that I wasn’t quite able to pinpoint. It wasn’t until Alison started expressing her criticisms of CBT in the direct, concrete, and vehement way characteristic of her that I was able to re-focus my own vague, nebbish doubts about it. I wrote some of those criticisms up for grad seminars in CBT back when I was a grad student in counseling, but never did anything with what I wrote. Saltz’s piece reinforces my confidence in my criticisms; maybe I ought to take the time to write them up. Here, in any case, is a quick summary.

Despite its self-avowed claims to rationality, CBT lacks two crucial things: (a) a full-fledged commitment to the reality principle, and (b) a refusal to deal with critical questions about the many assumptions it takes for granted.

I realize, with respect point (a), that CBT claims, in theory, to adhere to the reality principle, and to induce adherence to it in its practitioners and clients. My point is that its understanding of that adherence is fundamentally skewed, in just the way that Saltz suggests in her article. What CBT does is to take the promotion of subjective “happiness” as its overriding end, and to conceive social conformity as an essential means to that end. It then demands that clients “adjust,” in the name of the reality principle, to socially-constructed expectations, taking those expectations as a proxy for unalterable “reality.” This is, in fact, not just a problem with CBT, but with the theory and practice of mental health across the board, at least in the United States (obvious to anyone who makes their way through DSM-5). I’m inclined to think that CBT has a worse problem in this respect than other modalities, but I’m content to say that comparisons aside, the problem is there.

In many cases, this amounts to the victim-blaming demand that people “adjust” to injustice and irrationality, where the “adjustment” consists in “putting the past behind you,” forgetting that it happened, and “moving on,” whatever the issue, whatever the stakes, and whatever the price. In other cases, it requires clients to think or will their way out of anatomical-physiological or other environmental conditions–like pain–on the premise that since states of mind undeniably “affect” (i.e., have some effect on) physical states, physical conditions like pain are, through assiduous effort, amenable to amelioration by mental effort. This is to take a truth with very limited application and convert it into a snake-oil nostrum with almost none.

It’s worth drawing a distinction here between coping better with pain whose existence one acknowledges, and wishing away pain that is there, pretending (by some dubious CBT technique) that it isn’t there. Practitioners of CBT are amazingly resistant to drawing this basic distinction, in part, I think, because their (under-emphasized) behaviorist inheritance requires them to treat it as unscientific and unimportant.

The New York Times article that Saltz criticizes is a very clear case in point. The article describes CBT as an “alternative” to painkillers. It absolutely is not. It claims that CBT is “proving to be as effective or more so than medication.” The claim is as vague as it is preposterous: proving to be as effective at doing what than medication? In the absence of an answer to that question, the claim is impossible to interpret or evaluate. But no answer is given, even by implication. 

The author of the Times article cites a research paper from JAMA Psychiatry intended to bolster her claims, but the JAMA paper doesn’t even claim to do so. A close reading of the JAMA paper suggests that it proves literally nothing about the efficacy of CBT (vs. medication) in the crucial cases where the pain is caused by an underlying anatomical/physiological condition that is itself not amenable to direct change by cognition (such cases are explicitly beyond the scope of the paper).

The author of the Times article admits that the JAMA article’s findings are an outlier in the literature, but fails to cite any of the findings in the literature that contradict it in any of the relevant cases (i.e., cases where CBT is compared with medication for pain caused by underlying anatomical-physiological conditions). Embarrassingly enough, the article does cite a paper contradicting the JAMA Psychiatry one; what this paper shows is the modest success of CBT as against non-pharmacological interventions, not the greater success of CBT to medication in the medically relevant cases. The author apparently interviewed Saltz to get a dissenting voice, but failed to quote a single claim Saltz made. Indeed, she failed even to paraphrase or mention a single thing Saltz had said.

The result is a classic puff piece masquerading as science journalism, marketing-level hype intended to promote CBT while exploiting public cynicism about the pharmaceutical industry. Every individual quoted in the Times, presented as a representative of the CBT establishment, is quoted as suggesting that CBT is a viable alternative to medication despite the notable absence of evidence cited anywhere in the article for this breathtakingly ridiculous claim. Not one individual sounds a cautionary note about the many (many, many) cases in which it obviously is not an alternative. To put the question bluntly: how well does mindfulness work in the amelioration of post-operative pain as compared with, say, Tramadol, Oxycodone, or fentanyl? The article doesn’t even pretend to address the question.  But the question stares any reader with any grasp of the issue squarely in the face.  

Contrary to the impressive-looking research cited in favor of it–as well as the utterly unimpressive-looking research that often guides everyday mental health practice, including the awarding of CEUs–there is no credible evidence that CBT-based therapies can substantially ameliorate chronic pain that is caused by underlying bio-pathology. Put simply, if you have (say) a bona fide spinal problem, meditation and mindfulness are not going to make it go away, no matter how hard you meditate and how mindful you get. Beware of anyone who tells you it can. CBT’s more zealous advocates have done incalculable harm by exploiting the credulity and cynicism of the public on this subject.

That brings me to issue (b). I don’t deny that CBT has some notable successes to its credit. Aaron Beck’s recent death at the age of 100 is occasion to remember his (and his colleagues’) many important contributions to the field, particularly to the treatment of depression and anxiety. But CBT remains very much in denial about its blind spots and failures.

CBT’s basic defining insight is the claim that psychopathology is caused by bad reasoning and false or otherwise defective “core beliefs” about the world. The claim has a certain plausibility, but despite the decades that have gone by since CBTs beginnings, the CBT literature has done a patently inadequate job at addressing some fundamental questions about its defining thesis, among them:

  • How much psychopathology is explained by way of faulty cognition, and how much is not? CBT is notably vague on the answer, particularly on the latter half of it.
  • What exactly is the relationship between cognition and affect as CBT conceives it (however the distinction between cognition and affect is itself to be defined)? Is every affect caused by some cognition without exception? Or is the thesis, rather, that every adult affect is so caused? How can we be so sure even of the latter claim if adults occasionally regress to the level of children in their thoughts and behaviors? To the extent that CBT therapies depend on answers to these questions, those therapies will be limited by CBT’s failure to address them. But I would say that the literature raises more questions here than it answers.
  • Why is it that people come to adopt what practitioners of CBT regard as defective “core beliefs”? What is the source or mechanism of those core beliefs, and how is it to be identified? If we distinguish sharply between CBT and psychodynamic approaches to clinical psychology, CBT on its own has little in the way of resources to answer these questions.
  • How would a practitioner of CBT adjudicate a dispute with a client about whether a given belief was in fact defective? Is there a reliable, impartial, truth-tracking procedure for doing so, or is it just a matter of the asymmetric power relation between therapist and client? Advocates of CBT strike me as remarkably complacent about this issue. It’s easy enough to ignore if you assume that the therapist is always right, and the client always wrong.

I don’t doubt that some of the more sophisticated theorists of CBT have made attempts to address and answer these questions. But having made my way through at least part of the literature, I’ve found their attempts notably unconvincing. And on the whole, I would say that the CBT literature does not attempt to deal with these questions. Much of it churns out “findings” intended to confirm CBT’s domination of the field.  

It’s time for us to face the fact that American society has a serious chronic pain problem, one that can’t be handled by mantras like “follow the science,” cured by fads like mindfulness, or wished away by a war on opioids. The Times article is one symptom of our society’s failings in that respect, but there are many others. From hard experience: The average brain and spinal surgeon lacks even a basic knowledge of ergonomics. The average psychiatrist has no idea how to take a proper history and physical. And the average practitioner of CBT lacks even a basic knowledge of the physiology or psychopharmacology of pain.

This is just the tip of the iceberg of the many inverted priorities that predominate in our culture. Until we get our priorities right, people will continue needlessly to suffer and die. Perhaps what practitioners of CBT need is fewer puff pieces and more of a taste of their own medicine: a bit of CBT to ferret out and resolve the defective core beliefs at the heart of their belief system. Once they give it a try, it might occur to them that things are rarely as simple as CBT suggests, and far from simple here.

Thanks to Gareth Fenley, Robert Mack, Chris Paglinco, and Raymond Raad for feedback on an earlier version of this post. Ht to Red Lawhern for pointing out the Saltz article. 

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