‘Why didn’t CBT work for me? What’s wrong with me?’
This is the question from Susan (not her real name) who sits in my private therapy room staring at the floor. She is hunched over, seriously over-weight, simply dressed in leggings and a thin jumper. Everything about her appearance suggests defeat. She has come for help with depression and fibromyalgia which she has suffered from since childhood. She has three children and lives in a small Norfolk village on welfare benefits. Her partner left her two years ago. She has never had a job. She is twenty-five. Susan is estranged from her abusive mother. Her only family contact is her Gran who is paying for the sessions. She tells me she takes anti-depressants and has been referred for cognitive-behavioural-therapy (CBT), delivered by the NHS, three times. She has had three rounds of therapy of ten sessions each. It hasn’t worked. She tells me she feels worse than ever.
There is a wealth of research suggesting CBT is successful in the treatment of depression, but it hasn’t worked for Susan. A closer look at the studies reveals between 15-45% of clients undergoing a course of CBT do not get well. It works for some people but not for everyone. CBT is not the panacea and cure-all one might think it is from a perusal of the NHS website or the home pages of mental health charity websites. Why does CBT not work for people like Susan? Why might it not work for you?
CBT is widely used in the NHS. Treatment usually focuses on helping the client to change their ‘faulty’ beliefs with a series of structured exercises. There is an assumption that the client’s conscious thoughts affect his or her emotions and reactions to events and that these thoughts can be changed. These ideas were formulated by Beck as far back as the 1970s. Not all psychologists accept these assumptions. It may be that a depressed person’s negative thoughts spring from bad experiences which they have been undergoing rather than their depressive thinking style.
The little research which has been carried out on CBT failure has tended to focus on problems within the individual. Studies have drawn attention to low motivation, unemployment, negativity towards CBT, presenting with other illnesses, shortness of time, poverty, lack of child care, stigma, lack of transport, aggression and dislike of direction and homework. A recent study claimed that lack of motivation is the most important factor in therapy failure. It is noticeable that all of these studies seem to be blaming the client for their mental illness. Harmful effects of social and material adversity are not emphasised. It may be that factors in the family and the wider society are causing mental distress. By focusing on the individual and their failures CBT protects those in power in society by drawing attention away from widespread social inequality and the abuse of privilege, which is contributing heavily towards mental health issues. The CBT therapist is attempting to achieve client conformity with society’s values and norms rather than working towards social change.
Another recent study found that CBT failed when the therapist was not skilled or competent enough. Again, this is blaming an individual rather than the structures within the society. However skilled the therapist is at delivering CBT, he or she is not able to make the client richer, find them meaningful work, enrich their spiritual lives, nor give them social connection.
In contrast to this individualised view of mental conditions, critical psychologists have drawn attention to toxic environments which lead to distress in many people. Social and economic inequalities mean lots of people experience the world as a terrible and dangerous place. The UK in recent times has been a place of economic, political and social upheaval which has affected the well-being of the population. The effects of these changes are felt most by those at the margins of society: the poor and powerless. Attempts such as CBT to modify thoughts and behaviours can only have limited success in the long-term unless the social and material influences affecting clients are also addressed.
Let us return to the case of Susan. Rather than giving her endless courses of CBT, or indeed any other kind of individual therapy, she needs to be able to confront the environmental causes of her depression in the structures of rural Norfolk with few job opportunities, no affordable childcare, poor transport links and limited social events. It is not helpful for Susan or her therapist to attempt to challenge her supposedly distorted thoughts. She needs to be brought to an understanding that there is nothing wrong with her. She is having a perfectly understandable and normal reaction to a dysfunctional world. Her mental health is a consequence of her circumstances, her life history, which includes many traumatic events, and the system of oppression built in to the society she lives in. Suggesting that all of this does not matter and it’s just the way she thinks about it that needs to change seems morally wrong. Who is benefiting from this kind of therapy? It certainly isn’t Susan.
However, there is a way to escape from this gloomy picture. Some critical psychologists have broken away from the therapy model and begun community grassroots projects to help those with mental health issues. A psychologist called Evans and his colleagues began a project like this at the Oasis Centre, a community based human services organisation in the United States of America. A member of the research team made a presentation to raise awareness that working at an individual level was not achieving results. There was much dialogue between the researchers and the staff members which resulted in a statement of shared values. These values were put into action in the community, working collaboratively with families to achieve social change. Constant reflection and dialogue took place with all members of the organisation, including the clients. Through shared action and dialogue, a better society is achievable.
Susan needs an Oasis Centre in Norfolk.