NOTE: This article gives (1) a brief summary of the effectiveness of psychotherapy, particularly with regard to empiricist approaches like cognitive-behavioral therapy (CBT); (2) a discussion of some of the conceptual limitations and potential problems with approaches like CBT; and (3) a detailed example of such problems in an actual therapy session conducted by Aaron Beck.
Examples of a different (less empiricist and more constructivist) approach to psychotherapy can be found here.
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In considering any type of psychotherapy, people often ask how helpful it is. Therefore, research on psychotherapy frequently focuses on two questions: (1) Is this type of therapy effective? (2) Is this type of therapy more or less effective than other types of therapy? Unfortunately, these questions are far more difficult to answer than they may initially appear to be. For example, researching a type of therapy requires us to define exactly what that therapy consists of; but there are numerous ways in which any given kind of therapy is practiced, depending on such things as the style of the therapist, the personality of the client, and the nature of the problem. Furthermore, it is notoriously difficult to define what it means for a therapy to be “effective.” For example, has a therapy been effective if a client gains self-understanding but does not seem to act much differently, or if a client changes a problematic behavior but does not seem to be any happier? There are no simple answers to these questions.
Psychologists have responded to such dilemmas in a number of ways, but they tend to favor one of two strategies. The first is to conduct increasingly rigorous forms of research, including randomized controlled trials (RCTs) comparing a nontreatment group to a treatment group receiving an exactly specified therapy for an exactly specified problem under exactly specified conditions. This narrowly scientific approach to knowledge-gathering and its associated philosophical tradition of logical empiricism have been extremely influential in the United States, particularly in research institutions such as major universities. They have led to a great deal of increasingly sophisticated “quantitative” research which has generated a mass of complicated and sometimes inconsistent statistics about the effectiveness of different kinds of psychotherapy. Most of the studies on “effectiveness” described in psychology textbooks in the U.S. exemplify this approach.
The second strategy is to argue that psychotherapy is so complex and interactive that many of the most important questions about its effectiveness do not have definite answers; that is, different approaches to therapy are based on different perspectives which construct reality in different ways that are not entirely comparable. This perspective, in the philosophical tradition sometimes called “constructivism,” is associated with the European academic tradition and generally takes a more skeptical stance toward controlled experimentation. For this reason, constructivism is sometimes seen as critical of all scientific research; however, constructivism is consistent with a second and broader understanding of science that encompasses “qualitative” methods like unstructured interviewing and that aims not so much to measure which kind of therapy is “more” effective as to identify how different kinds of therapy are effective – i.e., how they are practiced, how they are experienced by clients, and how clients may respond to them. The case studies that students encounter in psychology textbooks roughly exemplify this second approach to knowledge-gathering.
It should also be noted that different kinds of therapy themselves tend toward either logical empiricism or constructivism. For example, behavior therapy (which is based on laboratory research), cognitive therapy (which employs many tools of logic and empiricism), and cognitive-behavioral therapy (which combines the two) all draw heavily from the logical empiricist tradition. Hence their practitioners tend to be strong supporters of experimental psychotherapy research. On the other hand, psychodynamic therapies, and humanistic therapies like existential therapy and gestalt therapy, all assume inherent complexities and ambiguities of knowledge that link them closely with constructivism. Hence, their practitioners tend to describe and analyze actual cases and sometimes resist the use of controlled experiments to evaluate psychotherapy.
To further complicate the matter, funding organizations, including both government agencies and insurance companies, also have an interest in this debate. Since they frequently pay a significant share of the costs of psychotherapy, they prefer to reduce those costs as much as possible by limiting payment to types of therapy that have widespread and “proven” effectiveness. Thus, they are inclined to look favorably on experimental research designed to identify types of therapy that produce quick and measurable successes when practiced on a large scale. It should be noted, however, that while this kind of efficiency may be a legitimate expectation in a cost-benefit analysis, it may not address important kinds of problems and may, in some cases, run the danger of being “penny wise and pound foolish.”
In the U.S., the dominance of logical empiricism and the increasing importance of cost containment have led to thousands of controlled experiments on the effectiveness of various kinds of psychotherapy. Keeping the above considerations in mind, the findings of these studies can be summarized as follows:
(1) Overall, these studies support the effectiveness of psychotherapy. Practitioners of essentially all major types of therapy can point to controlled experiments demonstrating that people who are treated with their techniques show greater improvement than those who receive no treatment. Of course, this is good news: therapy seems to work. Furthermore, the more careful and sophisticated the research, the more likely it is to support the effectiveness of a wide range of different kinds of psychotherapy.
(2) An especially large number of experimental studies have been done on therapies that can be loosely described as cognitive and/or behavioral, again indicating that they are effective. These results have sometimes been over-interpreted by cognitive and behavioral therapists as indicating that these types of therapy are proven superior because they have “more support” than other kinds of therapy. (Strictly speaking, it is true that these therapies have “more” experimental support; however, this is irrelevant to the issue of superiority because there are more studies on this orientation to begin with). However:
(3) Some studies suggest that cognitive and behavioral therapies are more effective than other kinds of therapy at reducing certain specific symptoms (e.g., particular types of phobia in particular situations). Again, this is good news. Cognitive and behavioral therapies are relatively effective in treating certain well-defined symptoms. Again, though, it is important not to over-interpret these findings. Because controlled experiments examine precisely defined behaviors treated as discrete variables, it is relatively easy for these highly focal research designs to detect the successes of techniques that target specific behaviors (such as cognitive and behavioral therapies aimed at treating specific and well-defined phobias). I will describe a case below that illustrates the circular and potentially problematic character of this kind of reasoning when applied to more general questions about the effectiveness of psychotherapy.
At a more general level there is consistent evidence across many studies that experimental researchers of all orientations tend to find their own brands of therapy more effective than other types. This is called the “allegiance effect.” It becomes most obvious in research on cognitive and behavioral therapies, in part, because these studies are the most numerous. The allegiance effect is understandable considering the issues discussed in the first paragraph, above, about the problems of definition and conceptualization in research on psychotherapy. Researchers tend to think about therapy (and design psychotherapy research) in ways consistent with their own orientations; hence, their findings are likely to be more favorable to their own orientations.
A more positive way of putting it, and one that is more consistent with the constructivist point of view, is that there are probably genuine differences in the effectiveness of various kinds of therapy for specific problems treated in specific ways, but that these specific differences in effectiveness are usually not generalizable to conclusions about overall effectiveness of any given type of therapy. That is, each type of therapy has its own unique (and potentially documentable) advantages and disadvantages, but gross comparisons among therapies are probably questionable. This would suggest that in seeking treatment it is generally most important for the client to find a therapist whose orientation and style fits his or her own perspective, wishes and concerns.
I would like to turn now to some social and political dynamics entailed in the development of the two major approaches to psychotherapy – the empiricist and constructivist approaches – and to draw out some of the implications of these dynamics for the notion of psychotherapeutic effectiveness. For the sake of simplicity, in discussing the empiricist approaches I will focus primarily on cognitive-behavioral therapy (CBT), which has become the most popular representative and exemplar of this school; and when discussing the constructivist approaches I will focus primarily on psychoanalysis and humanistic therapy (using the latter term broadly to include existential therapy, gestalt therapy, client-centered therapy, and a variety of other related orientations).
The empiricist therapies came into existence in the 1950s and 1960s partly as a reaction against psychoanalysis and humanistic approaches. Psychoanalysis, in particular, had become a dominant force in the field of psychotherapy and had come to be associated in the minds of many with high costs, lengthy treatment, and questionable pathologizing; humanistic approaches, on the other hand, were regarded by many as somewhat naive and superficial. Many of the critics of these approaches – particularly psychologists in academic settings – wished to see a more scientifically oriented approach to psychotherapy that could quickly identify specific symptoms and target them efficiently and effectively. Cognitive and behavioral approaches appeared to fit this bill, and in the 1960s and 1970s they became a serious focus of attention by academic research psychologists. Operating in university departments of psychology and gradually gaining control over clinical training programs, these psychologists led a movement to change the face of psychotherapy.
To a large extent, these psychologists were successful in overthrowing the old regime. Cognitive-behavioral therapy is now perhaps the most common orientation to psychological treatment in the U.S. and holds unchallenged dominance in many places. Not so well appreciated, however, is the fact that the ascendance of CBT has created, in some respects, another hegemony that has brought with it a new set of problematic consequences. Because CBT draws its inspiration from scientifically rigorous paradigms and the empiricist values of objectivity, efficiency, precision and control, it implicitly rejects other values that have historically been considered important to psychotherapy, including inwardness, reflection and acceptance of ambiguity. Of course, CBT’s straightforward approach to psychotherapy has real and important benefits. Clients want relief from their suffering, and when they have clearly defined symptoms that cause them pain and disrupt their lives they appreciate the availability of quick and effective treatment. For example, if a client suffers from an incapacitating fear of public places, immediate help in overcoming this fear by practicing new ways of thinking and acting can be invaluable. Even if this kind of treatment has its own limitations, it would seem, at a minimum, to be worth considering. This is where I believe the true value of CBT and related empiricist approaches lies.
Psychological symptoms, however–even clearly defined ones–are not always so amenable to targeted treatment. They often involve underlying investments and ramifications that are not readily apparent on their surface. Furthermore, the way that such symptoms are conceptually constructed within the cognitive-behavioral framework may steer both the client and therapist in a direction that leads them, jointly, to overlook or misperceive certain social and ethical dimensions of the client’s situation that are central to his or her suffering. To illustrate this point it will be useful to consider a particular example: an educational video made some years ago (Ratner & Shostrum, 1989) featuring Aaron Beck, one of the founding fathers of cognitive (and cognitive-behavioral) therapy. In the video, Beck gives a brief introduction to his approach and then exemplifies it by conducting a 30 minute session with an actual client, a man named Mark. The session is an interesting one as it illustrates a number of Beck’s basic techniques in a way that students find easy to understand and appreciate. In addition, the video format makes it possible to follow the events of the session in considerable detail.
In the session, Mark presents with symptoms of procrastination and anxiety. More specifically, he reports difficulty making decisions on his job as a plant manager primarily because of doubts about how his decisions will be received by the workers he supervises. Beck establishes these basic facts and then proceeds, over the next half hour, to demonstrate the fundamentals of the cognitive-behavioral approach.
Beck interprets Mark’s problems as stemming primarily from social anxiety. For example, in considering Mark’s procrastination at work, Beck directs attention to the thoughts and feelings underlying Mark’s difficulty making decisions. These decisions involve setting pay rates for his workers, and Beck and Mark quickly establish that Mark’s reluctance to make these decisions comes from his fear of upsetting the workers, having to defend his reasoning to them, and possibly having them quit in anger. In discussing these issues – which constitutes much of the session – Beck works to reduce Mark’s anxiety about his job. He gently argues, in a number of different ways, that Mark’s fears, while understandable, are unduly self-critical and/or unlikely to be realized. For example, in most cases Mark’s workers will not confront him regarding his decisions, and even if they do the consequences will not be as bad as he anticipates. Beck ends the session by encouraging Mark to practice handling similar situations in the future by writing down his anxieties and challenging these anxieties with the kinds of reassuring responses that Beck has been demonstrating. Mark indicates that he will do so and reports that he feels much better.
On the face of it, this session seems productive. Beck appears to have identified the problematic thinking behind Mark’s symptoms and has given him specific techniques for modifying it in the future. On closer inspection, however, some significant questions can be raised about Beck’s conceptualization and techniques. To begin with, it is not entirely clear that Mark’s problems can be encompassed by the concept of social anxiety. Because empiricist approaches like CBT grow out of the intellectual tradition of operational science and precisely defined empirical categories, they are particularly vulnerable to overemphasizing the importance of categorical diagnoses like social anxiety. In reality, clients rarely fit neatly into diagnostic categories, and Mark is no exception. Social anxiety usually refers to excessive embarrassment generally accompanied by actual or feared social awkwardness. While Mark does exhibit many of these symptoms, his primary concern centers around something very different: the actual distress and anger of the workers under his supervision. On two occasions, Beck asks Mark whether he would rather focus on his concerns regarding social settings or work, and on both occasions Mark chooses to focus on work. Even so, Beck continues to frame Mark’s worries about his workers’ reactions as social anxiety, and on at least two other occasions Beck changes the focus of the session from work to social situations. In steering things this way Beck appears to be falling into a trap that both psychoanalytic and humanistic therapists (particularly the latter) have long warned about: the trap of taking diagnoses so seriously that one loses touch with the client’s actual concerns and leads him or her in a direction of the therapist’s rather than the client’s choosing.
The fact that the tensions Mark faces at work are real – and not simply the product of cognitive distortions – is indicated not only by Mark’s comment during the session that his workers are frequently unhappy with the pay rates he sets but also by the fact that his plant employs a wage-setting system long associated with labor-management tensions. Early in the session Mark comments that his plant is a clothing factory and that his job is to set piece-rates for workers operating sewing machines. Such piece work (paying workers by unit produced instead of time worked) has a troubled history in the garment industry. When mechanized sewing was introduced in the Nineteenth Century, piece work was used to simultaneously increase production and lower wages – a situation which led to the term “sweatshop” and fueled the movement for labor reform. Since that time piece work has frequently been a focus of disputes about the relative values of productivity versus humane working conditions. Beck’s session with Mark occurred during an economic downturn when the outsourcing of jobs in the garment industry to underdeveloped nations was accelerating. It is not difficult to guess in which direction the piece-rates for Mark’s workers were being adjusted nor the reason for the workers’ anger – an anger for which Mark is a convenient target. It is also not unreasonable to hypothesize that Mark is a sensitive individual who is not entirely happy with his rate-setting job and the tensions it inevitably entails.
None of this is considered by Beck, who never questions Mark about the details of his job nor about his relationships with his superiors and underlings. Rather, Beck unwittingly aligns himself with the management policies of Mark’s employers and persistently interprets Mark’s concerns as purely social anxieties which need to be systematically dismantled by reframing them as unreasonable. One could equally take an opposite and pro-labor stance by asking Mark how he imagines his workers feel about the new piece-rates and how he himself feels about being the one who has to put them into effect. However, neither a pro-management nor a pro-labor stance is likely to be helpful to Mark, who needs to genuinely assess his position in this labor-management conflict and sort out his own beliefs and values. One might, for example, point out that Mark’s job seems to be a difficult one and ask him to say more about his experiences and feelings connected with the job. Whatever the shortcomings of psychoanalysis, one of its strengths lies in its recognition that the suffering of individuals is often rooted in larger social and cultural dynamics, that the individual’s perception of these dynamics and their consequences is often incomplete or impaired, and that the opportunity to explore one’s thoughts and feelings about such dynamics can be transformative and empowering. Beck, however, assumes the opposite stance: a complacent confidence that Mark’s social situation is essentially unproblematic, that Mark needs to bring himself into compliance with it, and that he (Beck) needs to gently lead him in the direction of doing so.
In fact, Beck’s leading of Mark plays a major role in determining both the tone and the content of the session. From the very beginning Beck assumes the stance of the psychological expert who understands the causes of and solutions to Mark’s problems. His questions are directed not so much at getting to know the client and his experiences but at applying his own expertise to resolve Mark’s concerns as Beck has already conceived them. At times Beck takes the role of teacher, explaining how anxiety and its physical effects are generated. At other times he makes pronouncements about the unreasonableness of Mark’s thoughts and fears, like “What we’re beginning to see is that the self-criticalness gets you nowhere.” At still other times, he asks rhetorical questions to impel Mark to specific insights, such as “What value have you gotten from all this self-condemnation?” One such interaction is especially revealing about the assumptions underlying Beck’s approach. When Mark is describing concern about wage adjustments causing experienced employees to quit, Beck asks, repeatedly, “How awful would it be?” Mark has to admit that it would not be “the end of the world.” Pushed by Beck to elaborate further, Mark adds that it would be no worse than getting a flat tire, “just inconvenient.” In reality, this is not consistent with Mark’s earlier statements that he values his workers and worries significantly about losing them, but Beck does not seem to notice this. His intent is humane – to show Mark that the loss of these workers would not really be so bad. There is, however, an additional message implicit in the trajectory of Beck’s questioning: that Mark should buck up, steel himself against his worker’s dissatisfaction, and recognize that it is, after all, best to regard these workers as essentially interchangeable, like tires that occasionally go flat.
The above interactions exemplify Beck’s technique of “guided discovery” by which clients come to see their “errors in logic” (Beck and Weishaar, 2008, p. 278). But most of these issues are not matters of logic; they are questions about Mark’s evaluation of his own experience, worded, however, in such a way as to indicate what Beck feels Mark’s responses – and by implication his values – should be. As Beck asks these leading and/or rhetorical questions, Mark generally gives the expected answers, but his demeanor sometimes suggests that he is not entirely comfortable with Beck’s direction. On several such occasions his verbal responses become almost inaudible, and/or he qualifies his answers with wording like “I guess not” or “It seems [so].”
In fairness to Beck, this session does not occur under normal circumstances. It is a demonstration exercise, and Beck has only a half an hour to show the main features of his therapeutic approach. It should also be noted that the actual practice of CBT is often more intuitive and flexible than indicated here, and that newer variants like dialectical behavioral therapy and acceptance and commitment therapy have attempted to bring a more reflective and open character to cognitive and behavioral techniques. But the problems noted above – the over-reliance on diagnosis, the tendency to focus on immediate symptoms, the obliviousness to larger social dynamics, and the orienting of the treatment around the therapist’s conception of the problem, even in the face of possible reservations by the client – are dangers that are rooted in the assumptions of CBT, and, for the most part, in those of other empiricist psychotherapies as well. These dangers are increased rather than diminished by the empiricists’ emphasis on scientific validation when such validation is operationalized, wholly and simply – as is often the case in empiricist research – in terms of discrete and measurable “variables” like categorical diagnosis, pre-specified treatment techniques, and client progress defined by ratings on scales. Thus, one can easily imagine a client like Mark participating in a validation study and rating himself, at the end of several sessions like the one described above, as significantly improved, only to realize weeks, months or years later that his central concerns had never been touched. Such conceptions of psychotherapy and healing lie behind the frequently exaggerated claims, noted above, about the effectiveness of empiricist approaches to psychotherapy. Moreover, these oversimplified conceptions of insight and healing have emboldened some adherents of empiricist therapies to label these approaches “best practices” or “treatments of choice” for many or all diagnosed conditions and to advocate the eradication of competing approaches (for example, see Baker, McFall & Shoham, 2009).
The overthrow of the psychoanalytic hegemony, therefore, while undoubtedly a positive development in the history of psychotherapy, may have been achieved at the cost of the entrenchment of a new hegemony – endorsed by clinicians, scientists and insurance reviewers, and rife with its own brand of conceptual gaps and therapeutic missteps.
Psyche and Sense 