The current special issue of Behavioural and Cognitive Psychotherapy contains four revealing articles about what are described as “new and emerging areas” in CBT: metacognitive therapy, mindfulness, acceptance and commitment therapy, and self-help.
It’s unusual to see these subjects described with such clarity, making it all the more disappointing that these articles are only available to the journal’s subscribers and purchasers.
The four approaches have more in common than simply being (falsely) touted as new, however. They each represent a way for therapists to evade core elements of CBT, raising fundamental questions about the nature of psychotherapy.
Metacognitive therapy is based on the idea that psychiatric disorders arise because of faulty thinking styles, or dysregulated thinking, and have little to do with actual thoughts themselves. It is unlike cognitive therapy, which is based on specific thoughts and on the beliefs and schemas that give rise to them.
That is, metacognitive therapy asserts that cognitive therapy is wrong. You might wonder how an article about metacognitive therapy comes to be included in a journal about cognitive and behavioural therapy. I wonder too.
To underline its separateness from CBT, the article begins with a reference to A.T. Beck:
Beck (1976) describes the content of negative automatic thoughts and schemas as giving rise to emotional disorder. In contrast, the metacognitive approach focuses on mental processes of thinking style, attending and controlling cognition.
So let’s see what Beck actually wrote back in 1976 (Chapter 9 — Principles of Cognitive Therapy):
The patient’s appraisal of reality may not be distorted, but his system of making inferences or drawing conclusions from his observations may be at fault … the basic premises may be erroneous or the logical processes may be faulty.
This is clearly not a focus on negative content. It includes the possibility that systems and processes may be the cause of the patient’s problems. The claim that metacognitive therapy is separate from CBT is false. Cognitive therapy always included this kind of approach.
Why make this false claim? Is metacognitive therapy really just the same as CBT? The answer is that metacognitive therapy is designed to evade aspects of CBT that some therapists find uncomfortable.
The key to understanding metacognitive therapy is not simply to look at its claims, but to look at what it omits. It omits dealing with specific troublesome emotions, giving the therapist an excuse to avoid having to work directly with emotions. That’s the metacognitive evasion.
The result of this evasion is that patients exposed to metacognitive therapy can learn a thinking style that appears to be dysfunctional in itself. It may interfere with the patient’s normal emotional states to the same extent that it disrupts the patient’s troublesome emotional states.
The good news is that patient now has a method of coping with the original problem, but the bad news is that the patient now has a different problem that is admittedly less severe, but more pervasive, and more difficult to diagnose and treat.
Mindfulness is about incorporating elements of Buddhist thinking into CBT. I described it in more detail in a recent post: Sati
The journal article on mindfulness is generally muddled, reflecting the generally confused state of those practitioners who have been struggling to make connections between CBT and Buddhism. But there are illuminating moments:
…in their exposition of mindfulness meditation, Bishop et al. are not totally clear on the difference between concentration and contemplative forms of meditation with regard to attention. We suspect that there will continue to be different definitions of mindfulness in psychological research…because mindfulness is not a unitary concept devoid of context.
In other words, no one in this field really knows what they are talking about, and the situation is unlikely to improve. I don’t really agree. In Sati, I described a well-defined mindfulness approach, and I think it pretty likely that there are others.
Well defined or not, no one really claims that mindfulness is new. One of the few points of agreement among its proponents is that it is old.
As I argued in my previous post, the effect of mindfulness in psychotherapy is to maintain the original psychological problem and add a degree of depersonalization as a coping strategy. Once again, here is a technique that teaches patients a pervasive and mildly dysfunctional way of thinking in order to mask the more severe and specific symptoms of their illness. It’s not just the therapist who gets to evade working with emotional difficulties directly, the patient gets a way to evade them too.
Acceptance and Commitment Therapy
Acceptance and Commitment Therapy (ACT) generally hides behind some difficult and abstract philosophical concepts. It is unusual to see an article that comes right out and says what ACT is all about. This one does.
Like metacognitive therapy, ACT was originally presented as a challenge to CBT, so we can only wonder that it is now included in a CBT journal. And like the other approaches here, it is not new, being a partial rehash of behavioural techniques going back to 1945, even if the hashing was more recent.
The acceptance part of ACT means that patients stop trying to resolve their difficulties, and instead just accept them. ACT incorporates mindfulness to help with this. There are some other elements whose real effect is unclear, and which might well be no more than obfuscation.
The commitment part means that patients take action to live life in a different way, using conventional behavioural techniques to overcome symptomatic obstacles. So ACT boils down to conventional behaviour therapy with mindfulness, leaving the patient’s emotional difficulties unresolved.
ACT’s overcomplicated theories and reliance on philosophical mumbo-jumbo make it seem more like a cult than a therapeutic model. The words “acceptance” and “commitment” are such nice, harmless-sounding words…how could there be anything bad in it? But like the mindfulness and behavioural techniques on which it is based, ACT evades working directly with emotions.
The article on self help is by far the most candid and the best argued, explaining in some detail why conventional approaches to CBT do not work well in the wider context of a healthcare system. Lack of competent therapists, consequent long waiting lists in some areas, and other related problems of large-scale delivery mean that CBT delivered conventionally by experts can never be expected to meet the demand for effective treatments.
The article acknowledges some Internet (though not blogosphere) critics of the move towards self-help forms of CBT in the NHS, and it summarizes what is known about the effectiveness of self-help approaches. It even discusses problems with the associated stepped care models. (For more on stepped care, see: Steps, merry-go-rounds and slides.)
Unfortunately some of the article’s conclusions are paradoxical. Self-help forms of CBT only work well if a therapist is involved. The therapist does not have to be particularly well trained, and there are no clear differences between different forms of self-help materials.
It’s not hard extend the article’s somewhat limited conclusions. From the evidence presented, it would seem that the therapist really is the important element in CBT after all. The key to an effective self-help approach is that it’s not really self help at all, it’s the use of therapists who can be quickly and cheaply trained. Perhaps the real problem causing a shortage of therapists is that conventional therapist training is now far more costly and theoretical than it needs to be.
Once again, however, the ideas the article presents as new go back a long way. Are we really only now discovering that people can help themselves a little by reading books, but it’s better if they have a person to help them?
Self help approaches are a deliberate evasion of proper psychotherapy. The real effect on people’s lives (not just on their symptoms) is not explicitly discussed, but it is at least hinted at in the idea that people who have had ineffective self help might be harder to treat in the conventional way afterwards. It is a faint acknowledgement that self-help approaches might be potentially harmful.
One might assume that psychotherapy is like other branches of medicine, that it aims to identify abnormal states and correct them as far as possible. One might assume, for example, that if a patient has a broken ankle it is better to set the bone in plaster than to amputate. But what if some doctors find plaster unpleasant to work with, and prefer to amputate? What if amputation is cheaper for the healthcare system?
This is the situation that psychotherapy finds itself in. CBT involves working with emotions, which some therapists would prefer to evade. And CBT is expensive for healthcare systems. So questions about what kind of outcome is really best for the patient are not asked.