In yesterday’s post here, Bears, I made some negative remarks without suggesting any positive solutions. So I thought I’d correct that today.
Je n’ai fait celle-ci plus longue que parce que je n’ai pas eu le loisir de la faire plus courte.
I only made this so long because I have not had time to make it shorter.
My excuse is the same. 😦
“CBTing your thoughts”
A common misconception about CBT is that it teaches you ways to control your own thoughts. The idea is that you have certain bad thoughts, and you can overcome them by using other thoughts.
For example, perhaps you are plagued by the thought that you might vomit. You don’t actually feel nauseous, but even so you are convinced that you could vomit at any moment. The feeling is with you almost all the time, but it’s strongest at times when it really would be a very bad idea to vomit — for example, when you are in a meeting with important customers.
So you go to a therapist. The therapist teaches you techniques for “CBTing your thoughts”. Perhaps he tells you to list the things you have eaten recently and check that all of them are harmless, so that you have no reason to vomit. Now you have three thoughts in your head, all fighting each other. There is 1) the original thought that you might vomit, 2) the assumption that thought 1 is bad and must be prevented, and 3) thoughts about what you have eaten.
In reality, controlling your thoughts with other thoughts doesn’t work well. It creates a ritualistic pattern of thinking in which you become dependent on a bad-thought good-thought cycle, and the underlying problem is never addressed.
You go to another therapist, and she is the real thing. One of the early stages in CBT is what it’s inventor, Aaron T. Beck, called “problem reduction”. This second therapist takes into account all of the things in your life that concern you, and focuses on what seems to be the underlying difficulty, ignoring all the other difficulties.
Unfortunately the term “problem reduction” makes this seem simple, but really it requires the therapist to have a lot of skill and experience to be able do it well. In particular, it requires skill in creating an emotionally close relationship in the very first session or two of therapy, and experience in knowing what to listen for when hearing patients tell their stories.
As a result, what you thought was the underlying difficulty might not be what a good therapist thinks. In this example, your therapist notices that your thoughts about vomiting became a problem two years ago, at around the time when your father was released from prison. Although you refuse to have anything to do with him, he started phoning your sister, and your mother is very worried about it.
Problem reduction is very specific to the particular story of your life. There’s no formula for it, no book that you can look up under V for vomiting and find the answer. (I know, I know, it would be under E for emetophobia, but that’s not the point — the point is, there’s no such book.)
Your therapist spends several sessions exploring your role and your relationships within your family. She gives you homework tasks that involve trying to relate to your mother and your sister in a different way. Part of the work does involve testing the validity of certain of your beliefs and assumptions — all of them about your family, none of them about vomiting.
Several weeks into this work, you realize that you have not thought about vomiting once since you started seeing this second therapist. That’s CBT.
“Own your own feelings”
The “own your own feelings” superstition is a paradox. The point of having feelings is that they provide a kind of executive summary of how things are for you at the moment. It’s like your life has many departments — food, sex, family, health, work, money, … — and in each department complicated things might be happening.
Your conscious mind is like the Chief Executive Officer, the CEO. As CEO, if you ask for full status reports from all the departments you’ll be snowed under with data. It’ll be impossible to digest it all, to make sense of it, and to decide what the current priorities are.
Instead of that, there’s an automatic mechanism that makes sense of everything in your life and sets the priorities. As CEO, you just get a brief summary in the form of emotion. If the emotion is weak, it is low-priority and you can pursue whatever project you like. If the emotion is strong, it is high-priority and you must act on it.
So the important thing about emotions is for them to be an accurate indicator of what’s important in your life. As CEO, if you start ignoring the status reports, your life is going to start collapsing.
But the automatic mechanism has to work. If the mechanism is faulty, it is going to come up with emotions that are not accurate. That’s mental illness. (It does not describe all forms of mental illness, but it describes the forms that CBT is commonly used to treat.)
The paradox of “own your own feelings” is that it is only ever said to you by an authority figure (a therapist or the writer of a book, perhaps). So it’s really saying that this authority figure, not you as CEO, knows best. And it’s also telling you as CEO to argue with and falsify the status reports of your own emotions. It’s telling you to disown your own feelings. The words “own your own feelings” really mean “disown your own feelings and subject yourself to external authority”.
When CBT therapists investigate troublesome emotions, there are two situations that they can discover. One situation is that the troublesome emotion is accurate, but the reason for it is mysterious. The other situation is that the troublesome emotion is inaccurate because of a fault in the automatic mechanism.
For example, the CEO gets a status report thats says: “Be afraid…be very, very afraid.” But it doesn’t say what to be afraid of. A CBT therapist might investigate and discover that there really is something to be afraid of. Therapy would then work on what prevented you from discovering that for yourself.
Alternatively, a CBT therapist might investigate and discover that the fear is the result of a faulty assumption or belief. There is no way for anyone to work out from the symptom alone, from the feeling of fear itself, whether it’s accurate or not. So CBT has to treat a whole person in the context of life, not just a symptom.
The effect of CBT is that you remain in charge as CEO. A CBT therapist is not an authority figure. And the effect of CBT is that you can again trust the status reports of your emotions, that you can really own them and act on them without dismissing any of them as “negative”.
I’m reluctant to spend much time on the subject of ‘regulation’ because I feel it’s a storm in a teacup. The decision to ‘regulate’ psychotherapists has already been made. There will be some fussing over details for a while, and then the new system will settle down.
Personally, I do not know anyone who will be much affected by it. There will be new forms to fill in and a new stealth tax to pay, but nothing will actually happen.
Not far away from this CBT practice there is an alternative practitioner who will not be ‘regulated’, and who will be affected even less — not even having to fill in forms or pay the tax.
Not far way in another direction there is an NHS department where nurses or psychologists with no proper training in CBT mislead patients into thinking that they are getting CBT when they are getting nothing of the sort. ‘Regulation’ will not change that.
The three simple ideas that I outlined in my previous post lead to equally simple conclusions.
Credibility: Instead of therapists being able to buy credibility by paying money to a training establishment and then, as a direct result, being rubber-stamped by government (or its quango), professional credibility is better linked to actual results.
This already happens in the private sector. If you set up as a private CBT therapist but you are unable to cure anyone, you’ll soon go out of business. Why? Because word gets around.
But in the NHS that doesn’t happen. It doesn’t matter how bad you are, you can carry on doing what you’re doing until you collect your huge public sector pension. If the NHS measured actual outcomes the way the private sector does, then ‘regulation’ would be redundant.
Protection: Protection for the public is best provided by professionals themselves. If you look at cases where members of the public really were harmed by medical professionals, you almost always find that those professionals either worked in isolation, or their colleagues knew about what was going on.
All it takes to protect the public is to ensure that professionals never work in isolation, and that colleagues who know something is wrong but do nothing about it are held equally liable for the consequences. The proposal that ‘regulation’ will protect the public is a scam.
There’s nothing new in these ideas. Accredited CBT therapists are already required to have constant supervision by other therapists. And in law an accessory is already criminally liable for allowing a crime to be committed by someone else. But, mysteriously, these ideas are not applied throughout medical practice.
Accountability: If a professional makes a mistake, the professional should have to take personal responsibility for it. That helps to make professionals careful and precise. But if a bureaucrat makes a mistake, it can be covered up by blaming the system.
So if something important has to be done, it’s more likely to be done in a responsible way by a professional than by a bureaucrat. It doesn’t much matter what kind of professional. If there were a Royal College of Bureaucrats, and if bureaucrats were personally responsible for their work, that would solve the problem in a different way.
A simpler solution is to ensure that any important task has a professional in charge, not just a bureaucrat.