The British Journal of Psychiatry
Against and for CBT: Towards a Constructive Dialogue?
Chess Denman

By 31 bc, Rome had completed its military conquest of Greece. Perhaps few then could have foreseen the changes to both Roman and Greek civilisations that the next 250 years would usher in. Greeks rose in power in the Roman world even to the level of senators. Romans took on Greek culture and kept Greeks as slaves and tutors to their children. Powerless but civilised, the Greeks worked a quiet revolution in Rome.

So I think it may be with cognitive–behavioural therapy (CBT) and the rest of the therapeutic world. Like the Romans, CBT is efficient and effective and it is poised to conquer all the warring city states of therapeutic Greece. Yet, even as it conquers maybe it will begin to be civilised, taking on ‘ Greek’ ideas (third-wave CBT) and responding to Greek critiques.

Against and For CBT is a collection of essays, largely by ‘ therapeutic Greeks’ revolted by or attempting to civilise the barbarisms of their ‘CBT conquerors’ but it kicks off with three powerful chapters by CBT therapists, all of whom show signs of Hellenisation. Mansell, Clarke and Hemmings all in their different ways paint a picture of CBT that is far removed from the utilitarian and ethically naive therapy that its detractors at once construct and attack. I learnt a lot from these chapters.

The following section on paradigmatic perspectives consists of attacks centred on the ethical and political stances that the authors find to be implicit in CBT. It was interesting and helpful to have CBT set within the context of the history of ideas. For me, inclined as I am to see more value in positivist and empiricist philosophical views and ethics that are said to be implicit in CBT, the appeal to the postmodern turn and the failure to examine the ethically dubious areas of this world view was not perhaps the knockout blow it might be for others. Martin Heidegger appears in two of the more philosophical chapters but his profound pro-Nazi sympathies do not.

I also enjoyed many of the chapters in the section on clinical perspectives. As an author trained in cognitive-analytic therapy, I found the section on dialogic cognitive therapy by Strong, Lysack and Sutherland particularly fruitful. However, in these chapters it is clear that proponents of alternative approaches always have to struggle with the evidence base and essentially three lines of attack can be found. The most clean-cut is Milton’s view that once proper studies are done psychoanalytic therapies of sufficient duration will be shown to produce lasting change that cognitive therapies cannot. Others, such as Winter, attack the ecological validity of the evidence base. A final line of assault lies in attacks on the very notion of evidence-based practice itself, for example in the chapter by Lees.

Quite large parts of this book are by no means an easy read and this is particularly true of the section on epistemological and research perspectives. There is little about research here but a great deal about epistemology. Two brutally tough chapters by Bohart and House hack away at the difficulties inherent in the methodology of the randomised controlled trial and despite some intimidating passages contain an important critique of scientific methodology as applied to human psychology. Even tougher is the chapter by Fred Newman, who covers philosophers such as Quine and Davidson, with whom he had discussions both real and imaginary. I had thought I was doing quite well to have read and admired these philosophers, but I was left bleeding and outdated by the end of the chapter.

By the time I got to the final section on political and cultural perspectives I was hoping for a little gossip. Sadly, there is none, but three important chapters add a social dimension to the critique of CBT and particularly importantly discuss power dynamics in therapy relationships. Of these I thought Moloney and Kelly’s chapter ‘Beck never lived in Birmingham’ telling and helpful.

Overall, as a therapist with both Greek (Jungian) and Roman (CBT) sympathies I got value from this book but only after considerable struggle and I was left with a strong regret: Hellenised Rome succumbed first to the enticements of Christianity and then at the last to the barbarian hoards. The medical model and the National Health Service as institution of the state both vie for the role of barbarian in this volume. Hated by both sides of the debate, doctors, supposedly the drug-wielding dupes of the medical industrial complex, and managers, characterised as bureaucratically limited, cost-cutting servants of a malign authoritarian state, are an easy target against which to unite. It is a shame that a book set up to encourage respectful debate could support this only in the face of uncritical manufacture of a common enemy.