The Cognitive Behavioral Mafia

I recently posted on my Psychology Today blog what I had written in a previous post from this blog, The Limits of Cognitive Therapy.  In it, I had the audacity to criticize one very prominent technique used in Cognitive Behavioral Psychotherapy (CBT), and discussed how it neglects a type of cognition that is central in personality pathology (the family myth). I also complained that CBT therapists grossly exaggerate the strength of their evidence base from randomized controlled psychotherapy outcome studies while simultaneously blocking funding research into other forms of treatment.

Researchers who look at other psychotherapy techniques and are members of the Society for Psychotherapy Research (a group I used to hang with for several years), refer to the "cognitive behavioral mafia" at the NIMH, which systematically blocks grants for research into other therapy schools.  Leading trauma researcher Bessel van der Kolk couldn't get a psychotherapy research grant at one point because of it!

They also blocked me from getting a small grant to study my therapy paradigm, unified therapy.  The grant I had applied for was supposed to be for researchers to get preliminary data – called pilot data – for new ideas.  Although the rejection I got did point out some very valid things I needed to change with the proposed study design (and would have been readily agreeable to doing so and then resubmitting the grant proposal), their biggest criticism of my proposal was that I did not have any pilot data! 

Writing two books on psychotherapy and having 20 years of clinical experience (at that time) did not count at all.  I did not get a low score, I got no score. Roughly translated: faggetaboutit.

In response to my Psychology Today post, not surprisingly The CBT folks went on the attack.  In fact, another blogger on Psychology Today named Robert L. Leahy posted a rebuttal on his blog. I was accused of being a – horror of horrors – psychoanalytic psychotherapist, which I of course am not in the least.

While I can see how many people might have mistaken my post, because of my broad style, for an attack against the entire CBT treatment model - which if you read the post carefully it decidedly is not - I was accused of mischaracterizing the entire field because I was talking about one specific although very central intervention they use.

Cognitive therapy pioneer Albert Ellis called it active disputation and the other cognitive therapy pioneer Aaron Beck called it collaborative empiricism. Interestingly, some other commenters implied that the technique I focused on  is no longer being used at all by the other main innovator of CBT, Aaron Beck.   This is patently untrue.  He just changed the name to cognitive restructuring  or guided discovery.

In the post, I had given an example of a family myth in action in a psychotherapy case.  In the early 1980’s, I was trying out a technique from paradoxical psychotherapy called reframing, in which a family member labels something as bad and the therapist changes the valence to good.  For instance, an acting out child is described as the savior of the parents marriage because he or she is distracting them from their arguments.  (Technique used best by family systems therapy pioneer Salvador Minuchin). 

I was accused by the critics of “arguing with my patient” and that I was both doing and oversimplifying the cognitive therapy technique. Some of them also seemed to dismiss Albert Ellis in favor of Beck, as Ellis definitely did argue with patients until he died, although in a very empathic way. 

Salvador Minuchin

This contention might be true if one’s definition of argument is limited to the type of argument seen in Monty Python’s argument clinic:

 “Yes it is.”

“No it isn’t!” 

“Yes it is!”

 “No it isn’t!” 
 

What Beck does instead is examine the “empirical evidence” for the patient’s “irrational” thoughts to see if it is consistent with the facts.  That, my friends, is a form of argument (as is reframing –also not merely contradicting the patient).

From a discussion of cognitive therapy on Psych Central: “Cognitive-behavioral therapy, in a nutshell, seeks to change a person's irrational or faulty thinking and behaviors by educating the person…”  They won’t get an argument from me.

Another thing I was accused of was that I did not acknowledge that CBT has changed from the early days and has become a much more complete treatment, even though my original post clearly stated:

It is interesting that when CBT therapists start to deal with more significant self-destructive behavior, such as that seen in severe personality disorders, then what they do starts to look a lot more like what humanistic or relationship-oriented psychotherapists do.  

This criticism was actually one I considered to be fair, and I quickly acknowledged that CBT has evolved considerable from its early days.  However, I pointed out that the evolution mostly consisted of stealing, slightly reinterpreting, and renaming concepts and techniques from other psychotherapy schools.  Even the central psychoanalytic concept of transference, vehemently denied by both behavior therapy and cognitive therapy since their inception, is merely redesignated as “the client's underlying schema about themselves and others.”

Speaking of schemas, the critics particularly complained that I wasn’t acknowledging them because I said that both Beck and Ellis (not CBT in general) have both said repeatedly that they believe that human beings are fundamentally irrational.  The concept of schemas, or mental models of how relationships and other things in the world are supposed to work, did not originate completely within CBT circles. 

Mardi Horowitz was one of the first widely read psychotherapists to talk about it - and he was psychoanalytically-oriented.  The concept of life scripts, which are basically several schemas linked together to form a plan for one’s life, was originated by another therapy school called transactional analysis.

I also happen to know Jeff Young, who is the main champion of using cognitive schemas in therapy.  He had in fact been a protégé of Aaron Beck, and was one of the cognitive therapists in the big NIMH collaborative study on depression in the 80’s (which incidentally also found interpersonal therapy equally effective to CBT in "depression"). Jeff personally told me that many of his former colleagues in cognitive therapy circles turned on him when he started to talk more about issues such as the effects of child abuse.

It is also true that Jeff Young had to go to Holland to get funding for a psychotherapy outcome study of schema therapy.

Another person commenting accused me of "whining" about the CBT mafia because I mentioned that I was blocked by them from getting research funding.

Still another thing that I was accused of doing was denigrating psychotherapy research in general, which is also something I did not do.  I had merely opined that the CBT people were over-selling the strength of their research results. 

Critics immediately jumped into my favorite form of sophistry: circular reasoning.  They basically made the point that because cognitive therapy was scientifically proven (not!), money should not be wasted on studying other paradigms!  In other words, why do we need more studies when we're already convinced.

Many of the critics also seemed to be saying that CBT was some sort of monolithic entity and did not acknowledge that there are several sub-schools of CBT which all approach patients differently  and which argue among themselves about who is right.  There is ACT, REBT, DBT, and schema therapy, to name but a few.  Schema therapy in particular is quite unlike the original form of cognitive therapy, as it not only looks at the developmental origins of so-called irrational ideas but sees the origins as central to the actual therapy. 

At least one critic went on to accuse me of being unscientific because I was not using CBT therapy exclusively with my patients, as well as being possibly unethical because I used "unscientific" treatments:  “It is also clear you practice a therapy with no established evidence base. An eclectic mix that where you've picked and chosen what you like from different schools without the package being subject to evaluation. Overall this sounds like deeply unethical (and potentially dangerous) clinical practice.”

Oh, like that isn't what all therapists do - including CBT therapists who pick and choose from a multitude of CBT interventions based on their experience and preferences and the patient in front of them without having their "whole package" subject to evaluation. Of course, by the critic's reasoning, the originators of all the CBT techniques were all unethical because they undoubtedly tried them out on patients before packaging them for outcome studies.

This critic illustrates another point of confusion: a basic misunderstanding of psychotherapy research. As I said, CBT therapists in treatment studies pick and choose from a multitude of CBT interventions based on their experience and preferences and the patient in front of them and then subjecting the "whole package" subject to evaluation. Since every therapist in the study is doing something somewhat different with each patient, a truly scientific evaluation of “the “package” would be quite a feat!

In fact, outcome research does not focus on specific techniques but on some overall strategies. Finding out which techniques were valuable and which superfluous on their menu of interventions would require something called dismantling studies, which are few and far between. Psychotherapy process research, on the other hand (of which there is a huge literature that dwarfs the outcome research) does focus on specific techniques, and often shows that techniques used by more humanistic and relational therapies are highly effective for certain therapeutic goals.

Adherence to the therapy model by the different therapists participating in an outcome study is another big issue. If it is measured at all, it almost always shows wide variation. There is usually no "red line" by which, if a therapist's adherence to the model goes below a certain point, his or results are not included in the study! So what really worked?  We don't know. 

The critics on both Psychology Today blogs seem to be proving my point that CBT grossly exaggerates its science base. When I and another commenter pointed out specific and highly significant weaknesses in their literature, the silence was deafening.

Also noteworthy that not a single critic had anything to say about the issue that was the main point of my blogpost – the existence and importance of family myths. I asked them for references where this issue or where any social psychological concept that was similar had been discussed by CBT therapists. Not a word.

To my knowledge, cognitive therapists have never written about how many allegedly irrational ideas are held collectively by kin groups.  Ignoring collective phenomena is actually a problem with almost all forms of individual psychotherapy, because therapists are entirely wrapped up only with what goes on inside people's heads.

The sole complaint of the only critic that even mentioned family myths was that I had not brought it up until the tenth paragraph of my original post. (That was because I had to explain some concepts from cognitive therapy before my criticism would make sense). So sue me.

I was too lazy to quote a bunch of studies to demonstrate the weaknesses in their science, and I figured they would merely cherry pick some counter-examples and then summarily declare victory.  However, another reader came to my rescue.

****Submitted by Philip on November 26, 2011 - 6:34am.

I have been reading a number of outcome studies recently because I am seriously worried by claims that 6 to 20 sessions of cognitive behavioural therapy are sufficient to cure such disorders as major depression and anorexia nervosa.

Allow me to summarize, briefly, the findings of a meta-analysis of CBT for bulimia nervosa. The rate of recovery for patients who completed treatment was found to be around 45%. This is quite substantial - a substantial minority of patients recover after and average of 12 sessions of CBT or behaviour therapy (they are equivalent in effect). It should be noted that there is very little follow-up data by which to judge whether or not these patients remained well.

However, consider the following:

20% of patients dropped out of treatment. 40% of patients who were initially considered for inclusion in the studies were excluded from treatment. This is because, as Dr Allen correctly noted, such studies exclude co-morbid patients (those with multiple diagnoses). Thus, the treatment samples are composed of less complex cases.

As an aside, most outcome studies of CBT for depression exclude around 60-70% of patients - again, because these cases are considered too complex to treat with CBT.

Back to bulimia. On average, after completing treatment, patients continued to binge/purge twice per week. So, although the treatment resulted in a statistically significant reduction in symptoms, many - perhaps most - patients remained symptomatic.

Thus, 45% of a restricted sample (which excluded severely disturbed patients bulimia, patients with bulimia and drug or alcohol addictions, suicidal patients with bulimia and patients with 'borderline personality' disorder and bulimia) reportedly recovered (with little follow up data to support this conjecture).

One of the authors of a study reporting these results concluded that CBT is the "treatment of choice" for Bulimia Nervosa. It is the only treatment that has been adequately studied. This is what Dr. Allen is referring to when he notes that the credentials of CBT are exagerated.

If we actually think about Bulimia in the real world - where most patients have severe co-morbid disorders, and 50% also have a borderline pattern of symptomalogy - these studies tell us little about the efficicy of CBT. In the lingo of researchers, outcome studies have little 'external validity'.

Why is it that researchers are unwilling to apply CBT to complex or co-morbid cases? They claim it is because they want to exercise experimental control - they want their studies to have internal validity. That is, they want to know which treatment works for which disorder.

It is also very likely that, were researchers to attempt to treat severely disturbed patients with CBT, they would fail to obtain results which reflect well on CBT. They also would have a hard time getting their work published, for journals do not like to publish null [negative]-findings.

If one is willing to read the research carefully, and has a basic education in statistics and research methods, the evidence supporting the effectiveness of CBT is very modest. Indeed, CBT contains a smaller and less diverse 'evidence base' than does cotemporary psychoanalytic psychotherapy.

What CBT has more of than other psychotherapies is outcome research. However essential outcome studies are, they "prove" nothing about the validity CBT. For all they show, the patient might be cured because of a placebo effect or because of cognitive restructuring. Same same but different.

This is called, by the way, the dodo bird effect: the finding that all treatments are equivalent (whether they be behavioural therapy, CBT, 'psychodynamic' therapy, interpersonal therapy and so on). That's what outcome studies tell us. And we don't know why. It seems that the debate is only just starting, and some have already declared CBT the winner.

Thanks, Philip.

When it comes to getting people to change their behavior, thoughts and feelings, there is always a multitude of ways to skin the proverbial cat.  And every patient responds to interventions differently. This is where social sciences differ from hard sciences like physics.

"CBT therapists are superior to therapists from all other schools of thought, so come see us." This exaggeration of the research results by CBT folks looks a lot like the same phenomenon seen in drug studies these days: it isn’t so much science as marketing.

The Limits of Cognitive Psychotherapy

The purveyors of the type of psychotherapy known as cognitive-behavior therapy (CBT), which is currently the predominant psychotherapy paradigm being taught in psychology graduate degree programs, like to claim that their type of therapy is the most "evidenced based" of all psychotherapies and is therefore vastly superior to the more humanistic and relationship-oriented types of psychotherapy. 

It is true that they have more studies than anyone else, but that is because they have very limited treatment goals which are very easy to measure, and they do not study complex people who have a lot of different (comorbid) psychological problems.  Even so, their claims of the superiority of their evidence base are highly inflated.  I go into exactly how in detail in How Dysfunctional Behavior Spurs Mental Disorders. 

It is also true that they control the funding for psychotherapy outcome research and deny the followers of other schools a chance to prove their mettle in randomized clinical trials.  Psychotherapy researchers refer to the "cognitive behavioral mafia" at the National Institute of Mental Health.

One of the major components of CBT is cognitive therapy, first pioneered by psychologist Albert Ellis and then refined by psychiatrist Aaron Beck.  Cognitive therapy is based on the idea that human beings are fundamentally irrational creatures in that they make a lot of logical errors whenever they assess the risks and benefits of various situations and courses of behavior.  These irrational ideas then lead to out of control emotions like unreasonable anger and depression.

Albert Ellis

 Ellis speaks of people "depressing themselves" with worst case scenarios (catastrophizing), or by drawing broad conclusions from single examples (e.g., "Since I failed this test, I'll fail all the ones in the future" - overgeneralizing), or by setting up absurdly high standards for themselves with a lot of musts and shoulds.  He liked to call this last one "shoulding all over yourself."

Aaron Beck

Cognitive therapy is designed to employ something called collaborative empiricism.  The patient and therapist get together to discuss the logical fallacies in some of the patient's thinking and to objectively examine the "evidence" for his or her beliefs.  If the individual can become more of an objective, empirical, scientific type, he or she will not experience chronically negative emotional states - or so the reasoning goes.

A current and popular version of cognitive therapy is called Acceptance and Commitment Therapy (ACT).  At slight risk of oversimplifying this therapy, it consists almost entirely of trying to teach people that they do not have to believe everything that they think.

It's interesting that when CBT therapists start to deal with more significant self-destructive behavior, such as that seen in personality disorders, then what they do starts to look a lot more like what humanistic or relationship-oriented psychotherapists do.  IMO, one big reason for this is the existence of certain types of beliefs that human beings tend to hang on to as if their lives depended on it, notwithstanding even the most obvious evidence to the contrary. 

This type of belief was first identified by psychoanalytic pioneer Karen Horney.  She referred to them as positive value blockages, for reasons I will describe shortly.  They are held by individuals.  Later on, family systems therapists noted a similar phenomenon at the level of the kin or family group.  They called these collectively held notions family myths.  Of course, dogmatic myths are also seen at the level of the subculture, where one might refer to them as theology.

Karen Horney

Try to challenge these beliefs, and in response you get a version of," My mind is made up; don't confuse me with the facts." Trying to challenge the rationality of positive value blocks or family myths using cognitive therapy is like trying to convince a Birther that President Obama was born in Hawaii.

Horney's idea of positive value blocks, which she conceptualized as defense mechanisms, is tied to the idea of a false self, which also called a persona.  Children growing up in dysfunctional families who are subjected to rejection, brutality, withering criticism, ridicule, and/or hostile control will feel safer when they act in certain ways which are rewarded by the family environment, but which may run counter to the way they really feel deep down inside of them.  The different sorts of behavior that fill this bill leads them to develop certain character types. 

According to Horney, when such children - and later when they become adults - act in these ways, they often pretend to be proud of their behavior, but deep down they feel alienated from themselves and full of self-hatred.  This neurotic or conflictual pride is a glorification of a phony self.  This false pride is usually supported with a number of ideas which justify the character type.  These ideas often take the form of proverbs or slogans such as, "Nice guys finish last."  Such ideas act as blocks to the expression of a person's true self (which might wish to be nice), and this is what is meant by the term positive value blockages.

An individual's family often not only shares these beliefs, but lives by them.  Some beliefs can be specific to certain individuals within the family (for example, what one family member is "really" like and who within the family he or she is closest to), while others apply to everyone.  The ideas in this context are what is referred to as family myths.  They justify and support a set of rules which dictate how each family member should behave, and what family roles each must fully and compulsively play, in order for the family to function in a predictable way (family homeostasis). 

The myths function as a belief system which the family uses, often defensively, to explain its experience to itself.  They are sometimes not verbalized explicitly so as to avoid any challenges to them. They can be taught implicitly through various forms of acting out and family rituals.  However, they may also take the form of oft-verbalized adages just like positive value blockages do in individuals. 

I had one patient who justified never trying to change a bad situation with three different proverbs:  "the grass is always greener on the other side," "the devil you know is better than the devil you don't know," and "you've made your bed so now you have to lie in it."  All three slogans had been repeated to her ad nauseam by her parents when she was growing up.

Therapists, challenge these ideas without understanding how central they are to a person's psychology at your own risk.  Your patient will fight you tooth and nail, and you will get absolutely nowhere. Cognitive therapists, put that in your pipe and smoke it.  Or is that just another family myth?