I’ve only now caught up with a fascinating piece in the Guardian by Darian Leader examining the Government’s recent decision to place much greater emphasis on Cognitive Behaviour Theory (CBT) in combatting the UK’s growing mental health problem.
Put briefly, CBT is an approach to therapy that seeks to correct erroneous thinking patterns to enable behaviour to change so that patients are better integrated with their environment. Problems arose because patients’ thinking conflicted with reality. So, for example, depression is seen as the result of the individual’s bias towards negative interpretations of the world – which obviously feed on themselves when the patient has to deal with difficult situations. The task is to get out of the cycle.
It’s a school of therapy that can point to an impressive array of empirical evidence, and has gained enormously in influence in recent years. It is very much a “here and now” therapy, rather than considering in depth the childhood and background of the patient. It’s also a relatively cheap form of therapy, significant in an environment where - in Britain at least – the knee-jerk reaction of most GPs when faced with a depressed patient is to reach for the prescription pad.
It’s always had its critics, of course. Principal among these is the claim that it treats symptoms, not causes; and that its very cheapness has given it a head start with policy makers faced with a growing problem of depression and a shortage of resources to combat it.
Mental health and the market
Leader’s argument is that it is basically a market-driven approach to mental health. He describes what he calls the “strange paradox of the modern self”:
“We are told that we are responsible for our own lives, that we have the power to transform ourselves. Yet at the same time we are treated as minors who lack the faculty of critical judgment and must be protected against unscrupulous and dangerous predators.
Today it is plasticity and change that govern our self-image. Personality itself is represented as a set of skills that we can learn and modify. Just as we can alter our bodies through cosmetic surgery, so we can change our behaviour through “work” on ourselves. Reality TV displays princes who become paupers, children who swap parents and geeks who become Don Juans. The possibilities of transformation seem endless. Thatcher’s dream of social mobility has become not just nightly entertainment, but also individual imperative.
CBT promises change just as swiftly. Unwanted character traits or symptoms are no longer seen as a clue to some inner truth, but simply as disturbances to our ideal image that can be excised. Instead of seeing a bout of depression or an anxiety attack as a sign of unconscious processes that need to be carefully elicited and voiced, they become aspects of behaviour to be removed.
The market has triumphed here, as our inner worlds become a space for buying and selling. We pay experts such as life coaches to teach us how to change in the desired way. Aspects of ourselves, such as shyness or confidence, become commodities that we can pay to lose or amplify. Depression or anxiety are seen as isolated problems that can be locally targeted without calling into question the rest of one’s existence, in the same way that a missile attack on a terrorist installation is supposed to get rid of the problem posed by terrorism.
This is a modern self for which depth has become surface. In soaps and reality shows characters share their innermost feelings and emotions, as if there were a perfect continuity between interior and exterior life. If there’s any ambiguity, a panel of experts is there, as on Big Brother, to explain people’s motivations. The self is no longer a dark cave; everything is laid bare. In effect, we have been robbed of our interior lives.”
It’s a powerful thesis, and one with which I have a lot of sympathy. And I think there’s something rather deeper at work here; a sense that the model by which our ability to function normally is judged is conformity to prevailing social values. But what happens if those values are themselves distorted, or based on a false reading of the world? For example, we’ve seen in recent months the way in which the values of market economics have been shown to be, at the very least, fragile and at odds with a real world; and we’ve seen a lot of denial by those who wield power and wealth.
Just suppose that those people who can’t adjust to the values of the world around them – who may be showing symptoms of very real mental distress as a result – are the ones who perceive the truth?
The problem with the ideology (as one feels one must call it) of CBT is that it looks awfully like the belief that mental health lies in conformity with a society’s values; it can all too easily result in the branding of the non-conformist as sick. It’s a problem recognised by writers as diverse as the psychiatrist R D Laing and the historian Christopher Hill; taken to extremes it was an active part of the Soviet Union’s methods of political control, with dissidents being sent to asylums.
It’s hard to get away from the view that there are at least some among the advocates of CBT for whom, wittingly or not, its implication is to reinforce prevailing value systems. Or to put it another way; the distressed can keep on consuming until they get it right.