The term neurosis is often regarded as obsolete, but the concept has its uses in CBT. Perhaps it’s time to think again.
Some CBT therapists manage to complete an academic course, then flounder when it comes to treating patients. This can happen, for example, when the course’s teaching of basic CBT skills is swamped by irrelevant theoretical knowledge. Or it can happen when the course does not teach basic CBT skills at all.
One result of this is therapists who look for specific theoretical guidance in each and every case. For example, if a patient has a fear of carrots, the therapist will ask around for published research in the field of root-vegetable phobias. Well, OK, I’m exaggerating a little. I’ve never actually been asked about root-vegetable phobias, but I’ve often come across requests of a similar nature.
Done properly, CBT is barely symptom-specific at all. The basic methodology of CBT identifies root causes (no, no, I don’t mean carrots) of psychological problems independently of the symptoms they happen to cause. So CBT works even when the symptom-based diagnosis is unclear, or when it seems to have changed over time. The diagnostic criteria of the drug companies are very little use.
This relationship between symptoms and underlying causes — or rather, this lack of relationship — is something that CBT has in common with the old-fashioned diagnosis of neurosis, a concept developed by Sigmund Freud.
Sexuality and treatment
The Freudian theory of neurosis emphasises sexuality and the experience of early childhood in a way that is unhelpful in CBT. That is not to say that sexuality or early childhood is never relevant. It might turn out to be relevant in some cases and not in others, or to some parts of a patient’s story and not others, but it’s not relevant in the theory.
Also, Freudian treatment of neurosis tended to be hit-and-miss, so that therapy could take a very long time or fail completely. The discovery at the heart of CBT makes treatment logical and direct, and therefore much quicker.
When you read about neurosis, therefore, you have to filter out references to sexuality and childhood by mentally inserting words like ‘sometimes’ and ‘maybe’, and you have to filter out completely any references to outdated treatment methods.
A couple of papers available online illustrate what I mean.
Dr. C. George Boeree, professor of psychology at Shippensburg University in Pennsylvania, outlines neurosis well in his 2002 paper, A Bio-Social Theory of Neurosis.
The papers on his website tend to be lightweight and to miss the point somewhat, but he writes clearly and succinctly:
Neurosis refers to a variety of psychological problems involving persistent experiences of negative affect including anxiety, sadness or depression, anger, irritability, mental confusion, low sense of self-worth, etc., behavioral symptoms such as phobic avoidance, vigilance, impulsive and compulsive acts, lethargy, etc., cognitive problems such as unpleasant or disturbing thoughts, repetition of thoughts and obsession, habitual fantasizing, negativity and cynicism, etc. Interpersonally, neurosis involves dependency, aggressiveness, perfectionism, schizoid isolation, socio-culturally inappropriate behaviors, etc.
Note how this cuts across DSM treatment categories, acknowledging the possibility that complex patterns of symptoms can coexist in a single relatively simple condition. This parallels the experience of effective CBT therapists, who find that confusing or wide-ranging symptoms are no barrier to recovery.
This account gets closer to patients’ inner worlds:
Unfortunately, as part of neurosis, we mistake…unconscious fantasies…for something real and we project those fantasies onto the world, unconsciously setting up our lives so they resemble the drama inside us. More specifically, we set up our lives so they will be full of limitations, thus keeping ourselves contained within a narrow realm.
The striking thing about this account is the understanding that it shows of the patient’s experience of neurosis, of there being a ‘true self’ engaged in a struggle with the illness (from the second page):
We see evidence of this true self…because most behavior is a mix of health and neurosis in a constantly shifting balance, so that even in very neurotic expressions one can decipher disguised yearnings for, and attempts to attain, a state of psychological health and wholeness. And we see evidence of this true self in the fact that even some very disturbed people are conscious of feeling that somewhere “down there” there is a sane person who isn’t taken in by the craziness but feels helpless to stop itself from acting as if it is.
How and why
I disagree with Ken Sanes when he writes that that “understanding how and why this takes place is a key to the emancipation of humanity.” Another problem of psychoanalytic theory is that it too easily gets sidetracked into fanciful metaphor and grandiose ideals.
I would say, rather, that understanding the how and the why in each individual case is key to the patient’s recovery. This how and why is exactly what CBT is good at. Done well, it is not sidetracked by the details of symptoms, nor by magical thinking and metaphor.
If it were scrubbed clean of some of Freud’s weirder notions, disentangeled from obsolete hit-and-miss treatments, and generally brought down to earth, the concept of neurosis could be seen as central in CBT.