Making sense of psychiatry: the cognitive behavioural therapy debate

Posted on Friday 8th February 2013
Photograph of Lisa Bortolotti

Mental health is back on the political agenda with both government and the opposition claiming that it is one of their priorities, and the press debating the worth of different treatment options. Unfortunately, polarised views on the role of psychiatry and on the nature of mental illness underlie recent debates on the effectiveness of talking therapies. According to one camp, psychiatry aims at fixing damaged brains, and “mental illness” is a misnomer for biological dysfunctions and chemical imbalances. The use of medication to address mental health issues is smiled upon and there is scepticism about the positive contribution of talking therapies. The other camp maintains that psychiatry is about solving people’s problems of living –“mental illness” is again misleading. Problems of living involve mental states and the lived experience more broadly, but are not illnesses. The suggestion is that, whilst our bodies can be treated as broken machines, our minds cannot. The limited success of medication is emphasised, but Cognitive Behavioural Therapy is not necessarily endorsed, as other forms of therapy such as psychoanalysis, life coaching or meditation may be preferred to it.

The two pictures are based on a narrow conception of medicine. In the business of restoring physical health, intervention is considered to be appropriate at the sub–personal, personal, and even interpersonal level. Doctors prescribe medication, but also offer advice about lifestyle changes that will contribute to recovery and help prevent further problems. Why shouldn’t psychiatrists do the same, and combine medication with other forms of treatment when there is robust evidence for their effectiveness?

Critics who target the use of cognitive behavioural therapy in particular complain that it demystifies our problems of living, which all of a sudden become mundane and manageable; and that its implementation will be negatively affected by financial constraints — therapists may not be adequately trained or may be asked to offer fewer sessions than required. The latter concerns are fully legitimate, but they are not arguments against the appropriateness or effectiveness of CBT as such. The former concerns are inspired by a picture of the mentally ill as discontinuous with the mentally well which is not conducive to either good health care or good policy.

Let me offer an example of the risk posed by this discontinuity picture. Clinical delusions are symptoms of schizophrenia. They are beliefs that do not seem to be well supported by evidence and that resist counterargument. They sometimes have bizarre contents too. Could people with delusions benefit from CBT? Traditionally, people with delusions have been depicted as incapable of engaging in rational argumentation. People with non–delusional beliefs are amenable to reason and benefit from exercising critical thinking, whereas people with delusions live in their own fictional world and are not responsive to reason.

This is a very psychologically unrealistic conception of cognition: we all have beliefs that are badly supported by evidence and which resist counterargument, such as inflated beliefs about our own worth. It is not clear whether CBT can positively intervene on the anomalies of reasoning that are responsible for the formation of delusions, but people with schizophrenic delusions who participated in trials offering CBT have been found to be more open to challenging the content of their delusions, and less preoccupied with the theme of their delusions than people who had been offered different treatment, even if they were not necessarily in a position to abandon their delusional beliefs as a result of CBT.

This suggests that the discontinuity picture is mistaken: we all have irrational beliefs, and we all benefit from adopting a more critical attitude towards them.

Dr Lisa Bortolotti

Reader in Philosophy, School of Philosophy Theology and Religion
University of Birmingham

Author of Delusions and Other Irrational Beliefs (OUP, 2009)