This article appeared in Clinical Psychology, 2004, issue 34, pp 4-10
Beck never lived in Birmingham:
Why CBT may be a less useful
treatment for psychological
distress than is often supposed
Paul Moloney and Paul Kelly, Solihull & Birmingham Mental Health
NHS Trust
This article suggests that CBT has a long way
to go before addressing the difficulties of
typical NHS patients attending clinical
psychology services.
distress encountered by CBT therapists working
in public services, and to the consequent need
for therapeutic approaches that emphasise social
action over the exploration of putative internal
psychological spaces.
In recent years, a growing number of central
government agencies and therapeutic psychologists
have argued that Cognitive Behaviour
Therapy (CBT) should be the therapy of
choice for mental health practitioners – and
particularly for those working in the time-limited
and pressured circumstances of primary care
services.
This position is supported by claims that
CBT may be the most effective of all therapies,
that it is well founded in clinical outcome research
and in the findings of cognitive science and, finally,
that CBT offers a collaborative and inevitably
empowering way of helping people in distress (e.g.
Beck, 1995; Fenell, 1997). In this paper we wish to
question all of the above claims. We suggest that
the current popularity of CBT may at least equally
reflect the needs and values of the mental
health professions, and of those political and
social institutions that help to shape their aims
and activities.
The paper will begin with a brief discussion of
the nature of CBT as practised within the NHS,
and will then move on to a critical examination
of the approach from three perspectives. These
will include, first, a body of psychological research
that may cast doubt on the conceptual
basis of the CBT approach; second, that section of
the psychotherapy outcome research literature
that bears on the effectiveness of CBT; and third,
the mental health epidemiological literature, which
may point to the social origins of much of the
The scope and nature of CBT
In the UK, CBT has enjoyed a strong historical
association with the profession of clinical
psychology, particularly in NHS outpatient settings
(Clegg, 1998; Pilgrim & Treacher, 1992). After a
recent period of therapeutic eclecticism within
clinical and counselling psychology, CBT may be
returning as the preferred approach for most
therapeutic psychologists working in the public
health services, as supported by recent government
planning for mental health care (Department
of Health, 2001; NHS Executive, 1996).
In terms of both theory and application, the
term ‘Cognitive Behaviour Therapy’ encompasses
a group of perhaps 15 approaches, in which the
link between practice and theoretical foundations
may vary widely (Chadwick et al., 1996; Boyle,
2002). The origins of CBT are likewise
multistranded, and include an (arguably
incompatible) mixture of applied learning theory,
the more accessible aspects of the psychodynamic
tradition, selected elements of laboratory-based
cognitive psychology and pragmatic clinical
experience (Beck & Weishaar, 1989; Hawton et
al., 1989; Willis & Sanders, 1997).
In general, CBT practitioners tend to share a
view of the human condition as a product of the
four interacting elements of cognition, physiology,
behaviour and emotion. Perhaps for most CBT
therapists, the treatment of distress will entail a
process of enabling the client to change ‘unhelpful’
beliefs and behaviours by means of a series of
structured exercises. This process is based upon
the key assumptions that the client’s more
accessible thoughts – and the deeper patterns or
‘schemas’ that are said to underlie them – will
mediate their reactions to events, and that these
thoughts can be readily examined and then
modified so as to yield therapeutic change
(Davidson, 2000; Padesky, 1994; Trower & Casey,
1989).
Conceptual difficulties with CBT
Perhaps one of the strongest arguments in favour
of CBT is that the therapy is seen as being derived
from a scientifically valid body of knowledge
based within the discipline of cognitive science.
However, this claim may be challenged on a
number of different levels.
As already noted, CBT is based on the idea that
cognitive processes are fundamental in the origin
and amelioration of personal distress (Beck, 1995;
Beutler & Guest, 1989). Yet, as some reviewers
have recognised, evidence for this idea is equivocal
at best (Bracken, 2002; Cromby & Standen,
1998; Godsi, 1998; Hughes, 1997). For example,
although there are indications that depressed
people may say negative things more frequently
(or quickly) than non-depressed individuals, this
may actually reveal little about any causal
relationship between cognition and emotion. Such a
process could easily reflect the effect of aversive
environments having primed many individuals to
more readily access pessimistic beliefs about
themselves and their world. Likewise, the finding
that successful completion of laboratory
tasks by depressed individuals can elevate their
mood may offer little support for the claim that
this has been achieved by the direct falsification
of the person’s underlying negative beliefs (e.g.
Beck, 1995). A more reasonable interpretation of
this work may be that the person’s basic belief
repertoire includes positive dimensions that are
activated by positive experiences, and that a given
individual’s prevailing negativity may be far more
an outcome of the kinds of negative experiences
that they have recently been undergoing (Erwin,
1996; Fancher, 1995).
However, we would argue that perhaps the key
flaw within most models of CBT lies in the poor
fit between the concepts of mind offered by many
writers in the field (e.g. Hawton et al., 1989;
Padesky, 1994) and those offered within other
branches of psychology.
For example, the wider perspective of both
historical and cross-cultural research indicates
large variations in the way in which human beings
have customarily understood the causes of their
thoughts and actions and behaviours, in turn
suggesting that currently accepted Western views
on the nature of the self need have no special
claim to validity (Crook, 1980; Gray, 2002; Sue &
Sue, 1990). In the context of clinical problems,
there is some evidence that the self-abnegating
language commonly found among depressed
Westerners may be much less common among
other cultural groups, including South East Asians
and Africans (Marsella, 1981; Littlewood &
Lipsedge, 1997). One reason for this difference
may be that, for depressed non-Westerners, the
explanatory repertoires offered by their cultures
are less likely to promote those expressions of
guilt and responsibility that derive from Western
Christianity and the Protestant work ethic (Chan,
1990; Sue & Sue, 1990). Conversely, when seeking
to account for the likely origins of their own
experiences of ill health, contemporary Westerners
may be inclined to discount the effects of those
social and material adversities with which they
may be struggling (Blaxter, 2003; 1997; Cornwell,
1984).
Indeed, the practice and theory of CBT seems to
be premised upon the quintessentially Western
idea of our being able to scrutinise and then
modify our own thinking, although it is sometimes
unclear whether this Cartesian notion of
an internal observer should be regarded as a
metaphor or a reality (see Baars, 1997).
Nevertheless, a wide variety of research suggests
that the process of introspecting into the causes of
our thoughts, feelings and actions may often be
inaccurate and misleading, and to an extent that
seldom seems to be recognised within the cognitive
and behavioural therapies (e.g. Beck, 1995;
Willis & Sanders, 1997).
In the field of neuropsychology, for example,
the well-known experiments conducted with
people whose brains have been surgically divided
have shown that the explanations that they give
for the causes of their feelings and actions can be
blatantly in error from the standpoint of an external
observer, yet completely compelling for the
individuals concerned (Gazzaniga, 1993; McKay,
1980). These results agree with a number of similar
findings in other branches of clinical neurology,
which suggest that even for physically normal
individuals, there is no necessary link between
beliefs about the sources of subjective experiences
and of conduct on the one hand, and their
demonstrable neurological, bodily and
environmental underpinnings on the other (Claxton,
1999; 1996; Dennett, 1991; Parfitt, 1987). Indeed,
neuroscientists increasingly view the brain as a set
of parallel systems without any central controller or
‘Cartesian theatre’ in which thoughts may be
viewed and then manipulated in the way that many
CBT writers seem to imply (Blackmore, 2001;
Damassio, 1994; Dennett, 1991; Norrentranders,
1998).
The results of several decades of social
psychological research seem to complement this
picture. Here, researchers have consistently shown
that our degree of insight into the likely reasons for
our thoughts and behaviours can be surprisingly
limited, and that we may instead habitually rely
upon a priori (and often erroneous) causal theories
in order to explain ourselves to ourselves
and to one another (Caldini 1994; Nisbett &
Wilson, 1980; Wegner, 2002; Wilson, 2002).
Overall then, the notions of consciousness,
introspection and deliberation that are central to
the theory and practice of CBT seem to match
poorly with current knowledge of the mind. This
incongruence may underline both how the
therapeutic task of finding a cognition that
putatively causes other thoughts or feelings may be
far from straightforward, and also how the
sensations of viewing and controlling our thoughts
within CBT may have little connection with the
webs of social and material influence that may in
reality shape much, and perhaps all, of our
experience and conduct (Smail, 2001; Smillensky,
2000; Wegner, 2002).
CBT and the psychotherapeutic
outcome research literature: A critique
Despite the above difficulties with the theoretical
bases of CBT, there seems to be a growing
consensus within the mental health field that the
effectiveness of this approach is well supported
by clinical research (Department of Health, 2001;
Roth & Fonagy, 1996). This research appears
to provide valid evidence, based largely upon
randomised control trials (RCTs), of the
effectiveness of CBT in the treatment of many
forms of distress. However, a thorough review of
the literature reveals that this claim may lack firm
support, for a number of reasons.
To begin with, many RCTs involving CBT have
included inadequate control groups for comparison
purposes – usually individuals who remain
on a waiting list or receive an unconvincing form
of pseudotherapy, delivered with limited
commitment by the researchers (Bolsover, 2002;
Holmes 2002; Mair, 1992). Second, CBT has
indeed sometimes compared well with other
therapies in a number of trials involving selected
research populations, which may often comprise
middle class university students and therapeutic
practitioners who are strongly convinced of the
efficacy of the CBT approach (Dawes, 1994; Mair,
1992). The situation may be different when
comparisons are made within inner city
community-based clinical settings, characterised by
hard-pressed clinicians serving populations that
experience high levels of social and economic
deprivation (cf. Hagan & Donnison, 1999;
Richards, 1995). Here, comparisons of CBT with
other psychological therapies have suggested that
the former may offer little or no significant
additional benefit in the treatment of such problems
as alcohol and drug abuse, depression, chronic
anxiety, and behavioural and emotional disturbance
(Dawes, 1994; Dineen, 1999; Eisner, 2000;
Epstein, 1995; Elkin et al, 1994; Hemmings, 2002;
Leff et al., 2000; Sandell et al., 2000; Sanders &
Tudor, 2001).
A third challenge to the evidence base for the
effectiveness of CBT consists in the large body of
comparative clinical outcome literature that has
accumulated over the last half century. This has
convincingly shown that, for a wide range of
clinical problems, such effectiveness as
psychotherapy does have may bear scant relation to
the therapist’s theoretical position, extent of
professional training or alleged expertise (Dawes,
1994; House, 2003; King-Spooner, 1995; Spinelli,
2001). These startling conclusions seem to have
passed almost unremarked in the professional
training literature. Indeed, particularly in the field
of CBT, it seems to emphasise the acquisition of
ever more refined clinical skills (see Proctor, 2002).
Finally, it is perhaps worth noting that even
strong proponents of CBT recognise that this
treatment, like all other psychotherapies, will
significantly help only about two-thirds of all
recipients, even under ideal research trial
conditions (Bergin & Garfield, 1994; Smith &
Glass, 1977; Tarrier, 2002). Both in the
professional literature and in discussions of clinical
practice that we have witnessed, this commonplace
observation rarely seems to prompt any searching
discussion as to why this might be so or as to what
alternative forms of help might be offered. Yet this
issue is clearly an important one, when lack of
clinical improvement can all too readily be
attributed to a failure of motiv on the client’s part
(Pilgrim, 1997; Smail, 2001; Willoughby, 2002).
An alternative view: social inequalities
as the fundamental determinants of
personal distress
In contrast to this individualised view of the
genesis of human difficulties, many writers and
researchers in the mental health field have
highlighted the importance of toxic social
influences in the origins of personal distress. There
are abundant indications that the incidence and
severity of a range of familiar psychological
disturbances (including anxiety, depression,
psychosis, substance abuse and self-harm) are
linked to the cumulative effects of widespread
social and economic inequalities (Bruce et al.,
1992; Godsi, 1998; Mirowsky & Ross, 1989;
Prilleltensky et al., 2000; Wilkinson, 2001). Critical
psychologists have described these processes by
reference to the operation of varieties of social
power, which may work to profoundly (and
negatively) shape the identity and self-efficacy of
the least privileged individuals – and indeed of
wide swathes of the population during times of
economic and political upheaval (Bordieu, 1984;
Smail, 1993; Stoppard, 2000; Wilkinson, 1996).
In the context of the practice of CBT, this
analysis suggests that, for the distressed person,
any attempt to modify their ‘negative’ thoughts
will have little capacity to beneficially change their
psychological state in the long term, beyond
that individual’s power to alter the landscape of
social and material influences in which they are
embedded (Franzblau & Moore, 2001; Smail,
2001; Wilkinson, 1996). However, these kinds of
observations have at best been embraced with
ambivalence by the mental health professions.
Perhaps because they have always had to operate
in political and institutional climates that have
favoured individualised and technical or
treatmentoriented approaches to distress, of which
CBT may be a paradigmatic example (Ferudi,
2003; Hansen et al., 2003).
Conclusion
As the title of this paper suggests, our overall
argument is that although aspects of CBT may be
helpful – particularly those parts that encourage
the client to confront the environmental causes
of their distress where this is possible – it may
none the less be the case that, overall, the theory
and practice of CBT can be seen as effective only
if viewed from the standpoint of those in positions
of socio-economic privilege. For the majority of
clients seen by psychologists in areas of relative
deprivation (such as many parts of Birmingham,
for example), the emphasis of CBT on alleviating
distress through challenging thoughts may be
profoundly misleading for the client and for the
therapist alike, and may indeed constitute a poor
reflection of their shared clinical experience. In
the long run, this emphasis may also serve to
obstruct the growth of a therapeutic psychology
that seeks to reflect the experiences of ‘ordinary’
people, to place their distress firmly in a social
and material context, and perhaps to help them to
find ways of making that context a more tolerable
one in which to live.
Acknowledgements
We would like to thank Guy Holmes and David Smail
for their helpful comments on early drafts of this
paper.
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