CBT is wrong in how it understands mental illness Sahanika Ratnayake - the conversation

[Cheshire]

CBT’s cognitive model of mental illness, originally developed by Aaron Beck in the 1960s, hypothesised that disorders such as depression were characterised by certain patterns of thought that give rise to the negative emotions and behaviour typical of mental illness. These patterns of thought are referred to as “cognitive distortions” or “negative automatic thoughts”.

But what exactly is wrong with these thoughts? What makes them “distorted”? Generally, vague answers are offered in response. For example, the American Psychological Association describes these thoughts as being “faulty” or “unhelpful”. Looking at lists of distortions, offers clues.

https://theconversation.com/cbt-is-wrong-in-how-it-understands-mental-illness-175943

 

[Trish]

I think it is interesting that the author accepts without question that CBT is effective for, it seems, practically everything. Their argument seems to be that the explanation of why CBT works is wrong.

CBT is, as I understand it, based on the idea that people have mental health problems because their reasoning is faulty and they therefore end up with faulty beliefs and resulting negative repetitive thoughts. And CBT is supposed to somehow help people learn to change repetitive negative thoughts to more rational positive thoughts. And that as a result of this change from faulty to rational thinking people recover from their illness and behave rationally. Or something.

At its best I imagine CBT enables individuals to be more aware of whatever repetitive thoughts they are having that they don't themselves like, and want to challenge, and to feel a bit more in control and able to make life decisions they are comfortable with. That seems to me little different from good counselling or having someone to talk things over with.

I think the author is arguing that the fixing faulty reasoning explanation for CBT can't be right because lots of people who are regarded as mentally healthy and not in need of CBT have faulty reasoning and irrational beliefs about all sorts of things too. So mental ill health is not caused by faulty reasoning that needs fixing.

Edit to add. My own experience of a short course of CBT was entirely negative and harmful, as the therapist tried to get me to put a positive spin on my negative experiences and to erase and deny my natural sadness about some events in my life.

 

[Jonathan Edwards]

I think the author is arguing that the fixing faulty reasoning explanation for CBT can't be right because lots of people who are regarded as mentally healthy and not in need of CBT have faulty reasoning and irrational beliefs about all sorts of things too. So mental ill health is not caused by faulty reasoning that needs fixing.

This sounds like someone, maybe RD Laing, who long ago claimed that mad people thought correctly and that ordinary people were the irrational ones.

It is an indication of just how divorced psychology can be from humanity. Patients are like peep-show exhibits to theorise over.

 

[Caroline Struthers]

This sounds like someone, maybe RD Laing, who long ago claimed that mad people thought correctly and that ordinary people were the irrational ones.

It is an indication of just how divorced psychology can be from humanity. Patients are like peep-show exhibits to theorise over.

I remember very few nuggets from my degree course in (ahem) Psychology many moons ago. But I do remember a lecturer saying words to the effect that people with depression had a better grasp of reality than those who were not depressed. I have never forgotten that, and weirdly, don't find it depressing. I also have no idea whether there is any evidence for it. Evidence wasn't really a thing in the 80s

 

[CRG]

Depressive realism - https://en.wikipedia.org/wiki/Depressive_realism

"the hypothesis developed by Lauren Alloy and Lyn Yvonne Abramson[1] that depressed individuals make more realistic inferences than non-depressed individuals. Although depressed individuals are thought to have a negative cognitive bias that results in recurrent, negative automatic thoughts, maladaptive behaviors, and dysfunctional world beliefs,[2][3][4] depressive realism argues not only that this negativity may reflect a more accurate appraisal of the world but also that non-depressed individuals' appraisals are positively biased."

More on evidence and criticism at WP.

 

[Art Vandelay]

I think it is interesting that the author accepts without question that CBT is effective for, it seems, practically everything.

This was my first thought too. What evidence is there to back this up?

What are the clinical trials of CBT for depression etc like? Are they as poor quality as those for ME/CFS? I wouldn't be surprised if they were.

 

[dratalanta]

I thought this was quite a helpful intervention, notwithstanding the overly rosy picture of CBT's efficacy.

It is one thing to point out that certain patterns of thinking are “unhelpful” or bring about negative emotions and behaviour, quite another to suggest that someone is irrational or reasoning poorly when the evidence for this is shaky. It is what the philosopher Miranda Fricker terms “epistemic injustice”, where a member of a disenfranchised group (that is, the mentally ill), is told their claims are plagued by errors or cannot be taken at face value. Even worse, with CBT they are told this when they come seeking help. Troubling, at best, unethical at worst.

Increasingly the argument is being made about ME (and all chronic illness) that if patients say they feel better (whatever that means), then that is all that is important. Ratnayake is arguing that even if CBT does help people to feel better, if CBT practitioners achieve this by falsely telling patients that their beliefs are faulty, then doing so is unethical and constitutes epistemic injustice as defined by Fricker.

While I am astonished that this should be necessary, I am glad that at least one philosopher of psychiatry is arguing that gaslighting patients is unethical regardless of the perceived (by the practitioner) benefits of the treatment.

 

[Caroline Struthers]

Depressive realism - https://en.wikipedia.org/wiki/Depressive_realism

"the hypothesis developed by Lauren Alloy and Lyn Yvonne Abramson[1] that depressed individuals make more realistic inferences than non-depressed individuals. Although depressed individuals are thought to have a negative cognitive bias that results in recurrent, negative automatic thoughts, maladaptive behaviors, and dysfunctional world beliefs,[2][3][4] depressive realism argues not only that this negativity may reflect a more accurate appraisal of the world but also that non-depressed individuals' appraisals are positively biased."

More on evidence and criticism at WP.

Interesting - many thanks for this. I have now actually read the article about CBT in The Conversation, which refers to the theory. The lecture I remember was in 1982 or 1983, so before the Alloy and Abramson hypothesis was published...

 

[Caroline Struthers]

One of the comments under the article caught my eye..and not in a good way

 

[Sean]

When there is no explanation, there is a million of them.

 

[Humanytip]

I agree with Dr. Beck’s characterization regarding “cognitive distortions” or “negative automatic thoughts,” because there is overwhelming evidence demonstrating that rumination (i.e., constantly worrying, being preoccupied with depression, being anxious about the future, etc.) is a transdiagnostic risk factor for mental illness, and that mindfulness practices can significantly reduce rumination. So, if mindfulness practices are incorporated into CBT, this mode of therapy could be very effective. These practices are also capable of changing areas of the brain that are associated with stress/anxiety. See for example the following references:

Kaplan, D. M., et al. (2018). Maladaptive repetitive thought as a transdiagnostic phenomenon and treatment target: An integrative review. Journal of clinical psychology, 74(7), 1126-1136.

Sevinc, G., et al. (2020). Hippocampal circuits underlie improvements in self‐reported anxiety following mindfulness training. Brain and behavior, 10(9), e01766.

Keng SL, Smoski MJ, Robins CJ (August 2011). "Effects of mindfulness on psychological health: a review of empirical studies". Clinical Psychology Review. 31 (6): 1041–56.

Tomlinson, E. R., Yousaf, O., Vittersø, A. D., & Jones, L. (2018). Dispositional mindfulness and psychological health: a systematic review. Mindfulness, 9(1), 23-43.

Tang, Y. Y., et al. (2015). The neuroscience of mindfulness meditation. Nature Reviews Neuroscience, 16(4), 213-225.

Querstret, D., & Cropley, M. (2013). Assessing treatments used to reduce rumination and/or worry: A systematic review. Clinical Psychology Review, 33, 996-1009.

McLaughlin, K. A., & Nolen-Hoeksema, S. (2011). Rumination as a transdiagnostic factor in depression and anxiety. Behavior Research and Therapy, 49, 186-193.

 

[Snowdrop]

So, if mindfulness practices are incorporated into CBT, this mode of therapy could be very effective.

The question is effective for what? For rumination this may be useful as suggested. For anything else I'm not sure there is any evidence provided.

 

[Trish]

Maybe CBT can be helpful if someone is doing something they don't want to be doing, or not doing something they want to be able to do. For example rumination, obsessive compulsive disorder or phobias. If the person feels stuck and unable to change their thoughts or behavior without help, then maybe CBT and/or mindfulness with a skilled and empathic therapist may enable them to make steps in the direction they want to go.
That seems to me very different from claiming to cure anxiety, depression or other psychological disorders, let alone physical diseases.

 

[Sean]

Not sure why 'rumination' is a pathology. How else do we solve difficult puzzles?