CBT is wrong in its understanding of mental illness

Cognitive-behavioral therapy (CBT) is one of the most popular forms of talk therapy. It is the treatment of choice for depression and anxiety and is an essential part of public healthcare systems, such as the NHS and Australia’s Medicare system. CBT’s understanding of mental illness and therapeutic techniques is already mainstream – accusations of ‘catastrophizing’ and calls to ‘reality check’ beliefs is everywhere. Like a Washington Post article put it: “For better or for worse, cognitive therapy is quickly becoming what people mean when they say they’re ‘going into therapy’.”

One of the reasons for the meteoric success of CBT is the amount of evidence supporting its effectiveness treat a host of mental health issues. Although there is evidence for the effectiveness of CBT, the evidence for its theory, particularly its understanding of mental illness, is much more mixed. To put it another way, we know CBT works, but we don’t know how or why it works.

Aaron Beck, the founder of CBT.
Sipa US / Alamy Stock Photo

CCT cognitive model of mental illnessinitially developed by Aaron Beck in the 1960s, hypothesized that disorders such as depression were characterized by certain thought patterns that engender the negative emotions and behaviors typical of mental illness. These thought patterns are called “cognitive distortions” or “negative automatic thoughts.”

But what exactly is wrong with these thoughts? What makes them “deformed”? Generally, vague answers are offered in response. For example, the American Psychological Association describes these thoughts as being “defective” or “useless”. Look distortion listsoffers clues.

Most distortions focus on faulty reasoning, where someone “jumps to conclusions”, makes the wrong inference (“overgeneralization”), is biased in how they view a situation (“black or white thinking”) , or, more simply, when he believes something wrong or inaccurate. CBT then goes on to suggest that if this flawed reasoning were resolved, the “unnecessary” negative emotions and behaviors would change.

Three reasons to doubt the model

There are three reasons to doubt the cognitive model and the association of mental illness with reasoning errors.

First, the kind of issues that CBT draws attention to — biases, false beliefs, wrong inferences — are all relatively common, even in mentally healthy people. Like many psychological research showed, we are all prone to bad reasoning. And even with mental disorders that seem to involve obvious mistaken thinking, such as schizophrenia or psychosis, it is very difficult to tell the difference between a delusion and a strange belief. For example, what distinguishes delusions from the kinds of beliefs associated with conspiracy theories or belief in the supernatural? “Wrong” thinking is obviously not correlated with mental illness.

Second, although CBT researchers have studies showing that mental disorders have something to do with cognitive distortions, there is a problem with the tests or measures used in this research. Many of these tests ask questions that have nothing to do with poor reasoning. They often ask people to answer questions that are simply about how they feel (“I’m so disappointed in myself”, Automatic Thoughts Questionnaire), need a lot more information, perhaps population-level data to answer (“I do few things as well as others”, Inventory of cognitive distortions), or seem to be about moral or practical matters rather than bad reasoning (“To take even a small risk is foolish because the loss is likely to be a disaster”, “To be a good, moral and worthwhile person, I must help all who need it,” Dysfunctional Attitude Scale).

Finally, research suggests that it is mental health rather than mental illness that is linked to poor reasoning. The “depressive realism hypothesis” shows that depressed people more specifically: predict the degree of control they have over the results, assess their performance and recall comments.

Mentally healthy people, on the other hand, succumb to an “illusion of control” and tend to remember their own performances and comments in an excessively rosy light. Although most of this research has focused on depression, some studies suggest that schizophrenia may be associated with better theoretical reasoning and autism is sometimes characterized by enhanced logical and theoretical reasoning.

Not supported by research

Not only is there evidence to the contrary showing that reasoning problems are widespread and potentially associated with mental health rather than mental disorders. But the evidence in favor of CBT treating mental illness is flawed because the tests used in these studies don’t even track reasoning problems. CBT provides a compelling story about mental illness – mental illness is associated with “flawed” thinking, and by addressing this, negative behaviors and emotions are addressed. Unfortunately, research does not quite confirm this story.

One can wonder if it is important. After all, CBT seems to work, so why should we care if it works or if it’s fake in its history of mental illness?

It is important from an ethical point of view. It’s one thing to point out that certain thought patterns are “useless” or cause negative emotions and behaviors, it’s quite another to suggest that someone is irrational or reasons poorly when the evidence for this is fragile. This is what the philosopher Miranda Fricker calls “epistemic injusticewhere a member of a disenfranchised (i.e. mentally ill) group is told that their claims are flawed or cannot be taken at face value. Worse still, with CBT, they are told this when they come for help. Disturbing at best, unethical at worst.

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