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Cheap and effective, CBT became the dominant form of therapy, consigning Freud to psychology’s dingy basement. But new studies have cast doubt on its supremacy – and shown dramatic results for psychoanalysis. Is it time to get back on the couch?
Dr David Pollens is a psychoanalyst who sees his patients in a modest ground-floor office on the Upper East Side of Manhattan, a neighbourhood probably only rivalled by the Upper West Side for the highest concentration of therapists anywhere on the planet. Pollens, who is in his early 60s, with thinning silver hair, sits in a wooden armchair at the head of a couch; his patients lie on the couch, facing away from him, the better to explore their most embarrassing fears or fantasies. Many of them come several times a week, sometimes for years, in keeping with analytic tradition. He has an impressive track record treating anxiety, depression and other disorders in adults and children, through the medium of uncensored and largely unstructured talk.
To visit Pollens, as I did one dark winter’s afternoon late last year, is to plunge immediately into the arcane Freudian language of “resistance” and “neurosis”, “transference” and “counter-transference”. He exudes a sort of warm neutrality; you could easily imagine telling him your most troubling secrets. Like other members of his tribe, Pollens sees himself as an excavator of the catacombs of the unconscious: of the sexual drives that lurk beneath awareness; the hatred we feel for those we claim to love; and the other distasteful truths about ourselves we don’t know, and often don’t wish to know.
But there’s a very well-known narrative when it comes to therapy and the relief of suffering – and it leaves Pollens and his fellow psychoanalysts decisively on the wrong side of history. For a start, Freud (this story goes) has been debunked. Young boys don’t lust after their mothers, or fear their fathers will castrate them; adolescent girls don’t envy their brothers’ penises. No brain scan has ever located the ego, super-ego or id. The practice of charging clients steep fees to ponder their childhoods for years – while characterising any objections to this process as “resistance”, demanding further psychoanalysis – looks to many like a scam. “Arguably no other notable figure in history was so fantastically wrong about nearly every important thing he had to say” than Sigmund Freud, the philosopherTodd Dufresne declared a few years back, summing up the consensus and echoing the Nobel prize-winning scientist Peter Medawar, who in 1975 called psychoanalysis “the most stupendous intellectual confidence trick of the 20th century”. It was, Medawar went on, “a terminal product as well – something akin to a dinosaur or a zeppelin in the history of ideas, a vast structure of radically unsound design and with no posterity.”
A jumble of therapies emerged in Freud’s wake, as therapists struggled to put their endeavours on a sounder empirical footing. But from all these approaches – including humanistic therapy, interpersonal therapy, transpersonal therapy, transactional analysis and so on – it’s generally agreed that one emerged triumphant. Cognitive behavioural therapy, or CBT, is a down-to-earth technique focused not on the past but the present; not on mysterious inner drives, but on adjusting the unhelpful thought patterns that cause negative emotions. In contrast to the meandering conversations of psychoanalysis, a typical CBT exercise might involve filling out a flowchart to identify the self-critical “automatic thoughts” that occur whenever you face a setback, like being criticised at work, or rejected after a date.
CBT has always had its critics, primarily on the left, because its cheapness – and its focus on getting people quickly back to productive work – makes it suspiciously attractive to cost-cutting politicians. But even those opposed to it on ideological grounds have rarely questioned that CBT does the job. Since it first emerged in the 1960s and 1970s, so many studies have stacked up in its favour
that, these days, the clinical jargon “empirically supported therapies” is usually just a synonym for CBT: it’s the one that’s based on facts. Seek a therapy referral on the NHS today, and you’re much more likely to end up, not in anything resembling psychoanalysis, but in a short series of highly structured meetings with a CBT practitioner, or perhaps learning methods to interrupt your “catastrophising” thinking via a PowerPoint presentation, or online.
Yet rumblings of dissent from the vanquished psychoanalytic old guard have never quite gone away. At their core is a fundamental disagreement about human nature – about why we suffer, and how, if ever, we can hope to find peace of mind. CBT embodies a very specific view of painful emotions: that they’re primarily something to be eliminated, or failing that, made tolerable. A condition such as depression, then, is a bit like a cancerous tumour: sure, it might be useful to figure out where it came from – but it’s far more important to get rid of it. CBT doesn’t exactly claim that happiness is easy, but it does imply that it’s relatively simple: your distress is caused by your irrational beliefs, and it’s within your power to seize hold of those beliefs and change them.
Psychoanalysts contend that things are much more complicated. For one thing, psychological pain needs first not to be eliminated, but understood. From this perspective, depression is less like a tumour and more like a stabbing pain in your abdomen: it’s telling you something, and you need to find out what. (No responsible GP would just pump you with painkillers and send you home.) And happiness – if such a thing is even achievable – is a much murkier matter. We don’t really know our own minds, and we often have powerful motives for keeping things that way. We see life through the lens of our earliest relationships, though we usually don’t realise it; we want contradictory things; and change is slow and hard. Our conscious minds are tiny iceberg-tips on the dark ocean of the unconscious – and you can’t truly explore that ocean by means of CBT’s simple, standardised, science-tested steps.
This viewpoint has much romantic appeal. But the analysts’ arguments fell on deaf ears so long as experiment after experiment seemed to confirm the superiority of CBT – which helps explain the shocked response to a study, published last May, that seemed to show CBT getting less and less effective, as a treatment for depression, over time.
Examining scores of earlier experimental trials, two researchers from Norway concluded that its effect size – a technical measure of its usefulness – had fallen by half since 1977. (In the unlikely event that this trend were to persist, it could be entirely useless in a few decades.) Had CBT somehow benefited from a kind of placebo effect all along, effective only so long as people believed it was a miracle cure?
That puzzle was still being digested when researchers at London’s Tavistock clinic published results in October from the first rigorous NHS study of long-term psychoanalysis as a treatment for chronic depression. For the most severely depressed, it concluded, 18 months of analysis worked far better – and with much longer-lasting effects – than “treatment as usual” on the NHS, which included some CBT. Two years after the various treatments ended, 44% of analysis patients no longer met the criteria for major depression, compared to one-tenth of the others. Around the same time, the Swedish press reported a finding from government auditors there: that a multimillion pound scheme to reorient mental healthcare towards CBT had proved completely ineffective in meeting its goals.
Such findings, it turns out, aren’t isolated – and in their midst, a newly emboldened band of psychoanalytic therapists are pressing the case that CBT’s pre-eminence has been largely built on sand. Indeed, they argue that teaching people to “think themselves to wellness” might sometimes make things worse. “Every thoughtful person knows that self-understanding isn’t something you get from the drive-thru,” said Jonathan Shedler, a psychologist at the University of Colorado medical school, who is one of CBT’s most unsparing critics. His default bearing is one of wry good humour, but exasperation ruffled his demeanour whenever our conversation dwelt too long on CBT’s claims of supremacy. “Novelists and poets seemed to have understood this truth for thousands of years. It’s only in the last few decades that people have said, ‘Oh, no, in 16 sessions we can change lifelong patterns!’” If Shedler and others are right, it may be time for psychologists and therapists to re-evaluate much of what they thought they knew about therapy: about what works, what doesn’t, and whether CBT has really consigned the cliche of the chin-stroking shrink – and with it, Freud’s picture of the human mind – to history. The impact of such a re-evaluation could be profound; eventually, it might even change how millions of people around the world are treated for psychological problems.
How does that make you feel?
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"Freud was full of horseshit!” the therapist Albert Ellis, arguably the progenitor of CBT, liked to say. It’s hard to deny he had a point. One big part of the problem for psychoanalysis has been the evidence that its founder was something of a charlatan, prone to distorting his findings, or worse. (In one especially eye-popping case, which only came to light in the 1990s, Freud told a patient, the American psychiatrist Horace Frink, that his misery stemmed from an inability to recognise that he was homosexual – and hinted that the solution lay in making a large financial contribution to Freud’s work.)
But for those challenging psychoanalysis with alternative approaches to therapy, even more troublesome was the sense that even the most sincere psychoanalyst is always engaged in a guessing-game, always prone to finding “proof” of his or her hunches, whether it’s there or not. The basic premise of psychoanalysis, after all, is that our lives are ruled by unconscious forces, which speak to us only indirectly: through symbols in dreams, “accidental” slips of the tongue, or through what infuriates us about others, which is a clue to what we can’t face in ourselves. But all this makes the whole thing unfalsifiable. Protest to your shrink that, no, you don’t really hate your father, and that just shows how desperate you must be to avoid admitting to yourself that you do.
This problem of self-fulfilling prophecies is a disaster for anyone hoping to figure out, in a scientific way, what’s really going on in the mind – and by the 1960s, advances in scientific psychology had reached a point at which patience with psychoanalysis began to run out. Behaviourists such as BF Skinner had already shown that human behaviour could be predictably manipulated, much like that of pigeons or rats, by means of punishment and reward. The burgeoning “cognitive revolution” in psychology held that goings-on inside the mind could be measured and manipulated too. And since the 1940s, there had been a pressing need to do so: thousands of soldiers returning from the second world war exhibited emotional disturbances that cried out for rapid, cost-effective treatment, not years of conversation on the couch.
Before laying the groundwork for CBT, Albert Ellis had in fact originally trained as a psychoanalyst. But after practising for some years in New York in the 1940s, he found his patients weren’t getting better – and so, with a self-confidence that would come to define his career, he concluded that analysis, rather than his own abilities, must be to blame. Along with other like-minded therapists, he turned instead to the ancient philosophy of Stoicism, teaching clients that it was their beliefs about the world, not events themselves, that distressed them. Getting passed over for a promotion might induce unhappiness, but depression came from the irrational tendency to generalise from that single setback to an image of oneself as an all-round failure.
“As I see it,” Ellis told an interviewer decades later, “psychoanalysis gives clients a cop-out. They don’t have to change their ways … they get to talk about themselves for 10 years, blaming their parents and waiting for magic-bullet insights.”
Thanks to the breezy, no-nonsense tone adopted by CBT’s proponents, it’s easy to miss how revolutionary its claims were. For traditional psychoanalysts – and those who practise newer “psychodynamic” techniques, largely derived from traditional psychoanalysis – what happens in therapy is that seemingly irrational symptoms, such as the endless repetition of self-defeating patterns in love or work, are revealed to be at least somewhat rational. They’re responses that made sense in the context of the patient’s earliest experience. (If a parent abandoned you, years ago, it’s not so strange to live in constant dread that your spouse might do so too – and thus to act in ways that screw up your marriage as a result.) CBT flips that on its head. Emotions that might appear rational – such as feeling depressed about what a catastrophe your life is – stand exposed as the result of irrational thinking. Sure, you lost your job; but it doesn’t follow that everything will be awful forever.
If this second approach is right, change is clearly far simpler: you need only identify and correct various thought-glitches, rather than decoding the secret reasons for your suffering. Symptoms such as sadness or anxiety aren’t necessarily meaningful clues to long-buried fears; they’re intruders to be banished. In analysis, the relationship between therapist and patient serves as a kind of petri dish, in which the patient re-enacts her habitual ways of relating with others, enabling them to be better understood. In CBT, you’re just trying to get rid of a problem.
The sweary, freewheeling Ellis was destined to remain an outsider, but the approach he pioneered soon attained respectability thanks to Aaron Beck, a sober-minded psychiatrist at the University of Pennsylvania. (Now 94, Beck has probably never called anything “horseshit” in his life.) In 1961, Beck devised a 21-point questionnaire, known as the Beck Depression Inventory, to quantify clients’ suffering – and showed that, in about half of all cases, a few months of CBT relieved the worst symptoms. Objections from analysts were dismissed, with some justification, as the complaints of people trying to protect their lucrative turf.
They found themselves compared to 19th-century medical doctors – bungling improvisers, threatened and offended by the notion that their mystical art could be reduced to a sequence of evidence-based steps.
Many more studies followed, demonstrating the benefits of CBT in treating everything from depression to obsessive-compulsive disorder to post-traumatic stress. “I went to the early seminars on cognitive therapy to satisfy myself that it was another approach that wouldn’t work,” David Burns, who went on to popularise CBT in his worldwide bestseller Feeling Good, told me in 2010. “But I passed the techniques to my patients – and people who’d seemed hopeless and stuck for years began to recover.”
There’s little doubt that CBT has helped millions, at least to some degree. This has been especially true in the UK since the economist Richard Layard, a vigorous CBT evangelist, became Tony Blair’s “happiness czar”. By 2012, more than a million people had received free therapy as a result of the initiative Layard helped push through, working with the Oxford psychologist David Clark. Even if CBT wasn’t particularly effective, you might argue, that kind of reach would count for a lot. Yet it’s hard to shake the sense that something big is missing from its model of the suffering mind. After all, we experience our own inner lives, and our relationships with others, as bewilderingly complex. Arguably the entire history of both religion and literature is an attempt to grapple with what it all means; neuroscience daily reveals new subtleties in the workings of the brain. Could the answer to our woes really be something as superficial-sounding as “identifying automatic thoughts” or “modifying your self-talk” or “challenging your inner critic”? Could therapy really be so straightforward that you could receive it not from a human but from a book, or a computer?
A few years ago, after CBT had started to dominate taxpayer-funded therapy in Britain, a woman I’ll call Rachel, from Oxfordshire, sought therapy on the NHS for depression, following the birth of her first child. She was sent first to sit through a group PowerPoint presentation, promising five steps to “improve your mood”; then she received CBT from a therapist and, in between sessions, via computer. “I don’t think anything has ever made me feel as lonely and isolated as having a computer program ask me how I felt on a scale of one to five, and – after I’d clicked the sad emoticon on the screen – telling me it was ‘sorry to hear that’ in a prerecorded voice,” Rachel recalled. Completing CBT worksheets under a human therapist’s guidance wasn’t much better. “With postnatal depression,” she said, “you’ve gone from a situation in which you’ve been working, earning your own money, doing interesting things – and suddenly you’re at home on your own, mostly covered in sick, with no adult to talk to.” What she needed, she sees now, was real connection: that fundamental if hard-to-express sense of being held in the mind of another person, even if only for a short period each week.
“I may be mentally ill,” Rachel said, “but I do know that a computer does not feel bad for me.”