A brief history of cognitive behavioural therapy, part 1

Part One: Psychoanalysis & war

There are no panaceas in mental health. There is not a single mental health professional who will disagree with that statement. For some this is because there are and can be no magic bullets, for others it is because those magic bullets have yet to be found. While people like Joana Moncrieff [1] do great work on showing how psychiatric drugs don’t treat mental illness, and others like David Healey [2] and Robert Whitaker [3] continue to reveal how long-term psychopharmacological therapies do significant harm, still more have shifted their hopes to other territories. Among these territories is the resurgence in the field of talk therapies. Service-users themselves regularly call for better access to these therapies, rightly looking to them as less restrictive forms of treatment. But the thirst for a panacea merely displaces itself from drugs to talk and does so in such a way that it seems to answer the call from service-users. The consumer has spoken: long live CBT!

Cognitive behavioural therapy has become the dominant form of psychotherapy in our society, displacing psychoanalysis as the way of understanding the psychopathology of everyday life. Today, CBT is recommended for almost every psychologically codified ill, from mild depression to schizophrenia, and it has fast become a linchpin in the UK’s early intervention strategy (alongside neuroleptics) in managing first episodes of psychosis in young people. Just as psychoanalysis was once regarded as a self-sustaining industry, so CBT has now become a thorough psych-factory churning out thousands of qualified practitioners. While psychoanalysis could only be performed by psychoanalysts, a variety of subject-groups are trained in CBT including GPs, nurses, psychiatrists and social workers. Unlike most other forms of psychotherapy, everybody in the UK can get at least 6 sessions of CBT entirely free on the NHS. All of this sounds welcome, and up to a point it is; but just like its predecessors in psychotherapy and the drugs it complements and increasingly replaces, CBT is far from an entirely neutral tool being wielded in the patient-consumer’s best interest. To understand what CBT is we first have to look to those earlier forms of therapy that form part of its ontogenesis.

At the same time that biological psychiatry was being set into the form we recognise it in today by Emil Kraeplin, Sigmund Freud was giving birth to the first form of psychotherapy. Set amid the turbulence of the industrial revolution’s overcoming of old values and established forms of life, the revolutionary upheaval of capitalism led to the articulation of radical re-evaluations of what it was to live as a human in the present. Every aspect of existence came to be questioned, and every established rhythm of that existence was set into new manic tempos. As Marx wrote, all that is solid melts into air. This was also true of how work was organised and carried out, how men and women comported themselves, how families were structured, where they lived, what they ate, and what they believed and how they understood themselves. It was in this tempest, as God’s shadow receded from the world, as Man arrived as the subject that could know and control itself, nature and His own destiny, Freud stepped forward to answer the question of Man’s mental life.

The key to all psychodynamic therapy is Freud’s invention of the unconscious. I say he invented it because by its very nature, if it exists at all, the unconscious isn’t something we can really say is discovered. The unconscious is mute, lacking its own voice, and can only communicate by way of hijacking desires, behaviours, and quasi-conscious mental phenomena: the unconscious speaks through the wish, the dream, and the symptom. While this isn’t the place to go into detail on the nature of the Freudian unconscious, it is important to note that it is prior to language, to the development of a sense of self, and that it is both without time and without place (this is why childhood trauma can still be present in adulthood). When I claim that Freud invented the unconscious I’m not trying to make the claim that he made it up out of thin air, and I am not saying that it doesn’t really exist: instead, I’m simply saying that once Freud theorised the unconscious as a depth interior, a primordial and primeval submerged aspect of “us” that came before and held power over “us”, the unconscious as discursive-object came into existence.

Over time, and in a variety of significantly revised forms, psychoanalysis came to be the dominant form of psychiatric treatment in that part of the world that would profoundly change psychiatry. At the height of its dominance in 1940s America almost all medically trained psychiatrists were also psychoanalysts who used talk therapy in combination with prescription sedatives. By this point, biological psychiatry had been set aside, marginalised but never completely erased, and the answer to depression and anxiety, the neurotic illnesses that were treated in community private practices, were seen as the result of unconscious traumas, of repressions of latencies, and of other defence mechanisms that analysands were using to shield themselves. Where Freud and his early followers saw psychoanalysis as a hermeneutic field in which the analyst and analysand sought to uncover the meaning of dreams or symptoms together, in the United States of the 1940s this had given way to a passive psychoanalysis wherein free association dominated: the patient spoke, the analyst listened, and meaning would be a breakthrough, a revelation. When Woody Allen is asked how long he has been seeing his shrink in Annie Hall, he replies ’17 years...but I’m making good progress’. The cultural prominence of psychoanalytic psychiatry is also observable in films from the time, not least those made by Hitchcock that today make Zizek’s seemingly inspired film readings possible.

In part, American psychoanalysis came into ascendency following the experiences of war. While World War 1 had provided a challenge to Freudian orthodoxy- how were the war neuroses explainable in terms of Oedipal metapsychology?- World War 2 helped to augment psychoanalytic dominance. The work of a military psychiatrist, Karl Menninger, led to the development of the ‘Medical Roster 203’, a heavily Freudian inspired document that would serve as the blueprint to the original DSM, the bible of American- and later world- psychiatry. Chief among its psychoanalytic inheritance was a fixation on unconscious reaction formations and defences, such repression and displacement, that had been the cornerstone of Freud’s enterprise. A core group of psychiatrists who had served during WW2 came together in 1946 to found the Group for the Advancement of Psychiatry (GAP), an organisation that took upon itself the goal of modernising American civilian psychiatry away from an emphasis on organic disease models. According to psychiatric historian Mitchell Wilson, quoting GAP from its height, it declared that its role was to produce a theoretical consideration of ‘Man in relation to with his cosmos’ [4]. I have added emphasis to highlight not only GAP’s ambition but also its correlationist conviction that the world could only exist for a universal human subject, putting it in line with the bulk of idealist continental philosophy that was being produced and placing it against the (reductive) naturalism that was rife in the American Psychiatric Association at the time.

Aside from the quasi-mystical narcissism of the declaration above, this culminated in GAP’s six item inventory of what a socially responsible psychiatry would accomplish [5]. This included the redefinition of mental illness away from a bi-polar concept (mad/sane; sick/well) toward an approach that saw everyone as situated somewhere on a continuum between sickness and health. It also involved a commitment to a social materialist understanding of mental illness as caused by “social factors”. The GAP report concludes with a mission statement, eerily foreshadowing Deleuze’s conviction that psychiatry had become part of the new society of control: ‘This, in the true sense, carries psychiatry out of the hospital and clinics and into the community’ [6].

Essentially, GAP was composed of hotshot young psychiatric radicals who wanted to break with the biological reductionism they saw at work in America. Within this group was the desire to push for deinstitutionalisation (partly inspired by all those demobilised soldiers) and to expand psychiatry into the world of social activism. So this group of radicals managed to steer psychiatry away from reductionism but at the same time introduced the idea that psychiatry should concern itself with what the psychosocial psychiatrist Adolf Meyer had called mental hygiene, what today goes by public health- or the biopolitical management of psychiatric populations.

Meyer’s role in mental hygiene in the early 20th century was motivated by his sense that the rapid industrialisation and concomitant urbanisation, with the massive social and existential upheavals they brought with them, were destroying individuals and communities. For Meyer, the revolutionary nature of industrial capitalism threatened to destroy Man’s ‘potential for continuous adaptability and constructive activity’ [7]. GAP, especially Karl and William Menninger, did much to use Meyer’s ideas to challenge the Kraeplinian emphasis on disease and institutional care that amounted to little more neglect and abuse, but they also inherited aspects of Meyer’s politically romantic anti-capitalism. For instance, Karl Menninger would later go on to synthesise Freud and Meyer in a position that can be distilled in a single quotation from 1947:

‘Let us define mental health as the adjustment of human beings to the world and to each other with a maximum of effectiveness and happiness’ [8].

At first blush this seems like a statement any anarchist would agree with; we aren’t looking for a world in which we’re all radically disengaged from one another, we want a world of mutual aid, co-operation in which happiness, or the good life, can flourish. However, it should be noted that what Menninger actually meant here was that what was called mental illness was actually a failure to adjust to reality, to adapt to the social fabric, to conform to the world as one found oneself thrown into it. In other words, madness was the symptom of a dissensus with society. Perhaps we would agree with that, but no anarchist would agree with GAP’s conviction that the goal of psychiatry was to bring patients back into agreement with the world that had produced their alienation. According to this perspective, madness is a failure of the individual in his capacity for adaptation to reality.

As such, the psychoanalytic psychiatrists were the first well meaning step towards psychiatry’s colonisation of everyday life, in a move that resembles the outline of Tronti’s reversal of the Marxist-Hegelian dialectic: the activity of the radicals themselves engendered the forces of recuperation that would establish the following generation’s struggle [9]. They also gave birth to one of the ideas at the heart of CBT: that the individual is responsible for repairing maladaptive, or irrational, patterns of thought and action.

It is against this backdrop that the pioneers of CBT emerged. Seeking to liberate themselves from what they (and the medical insurance companies that paid their high salaries) saw as psychoanalysis’s pseudo-scientific pretentiousness and embarrassing political radicalism. They also held the view that psychoanalysis was little more than an elitist club that perpetuated it-self through dominating training regimes. By the 1960s biological psychiatrists and the new field of clinical psychology wanted to undo what they saw as the psychoanalytic erosion of mental health as a reputable science. More to the point, challenges to funding and the cognitive legitimacy of a psychiatry that was not legitimated by a link to natural medicine threatened the many individuals’ private wealth and prestige, while also hoarding it all for the chosen few. Just like the psychoanalysts that preceded them, the founders of CBT were radicals reacting against a stale orthodoxy.

At the more social level we find the ontogenetic cartography of CBT beginning to draw a map that shows innovation in psychological images of the species accompanied by conceptual and technical advances being triggered, accelerated and propagated by war. Of course, from our perspective these wars, as complex and singular as their concrete historical conditions might have been, were nevertheless wars between imperialist capitalist states that had consequences for the history of class struggle. Also worth thinking about is the context of how psychotherapies developed in wartime and post-war economic conditions. Those considerations are beyond this article’s scope at the moment & I’ll come back to them later as without the experience of war it’s hard to know what routes psychotherapy might have taken.

In the next part of this brief history of CBT, I’ll outline its more direct predecessor: radical behaviourism. Later in this history it will also be necessary to return to psychoanalysis & it's afterlives.

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[1] For instance: Moncrieff, J. 2009 The myth of the chemical cure. London: Palgrave-MacMillan.
-----------------------Moncrieff, J. 2013. The bitterest pill: the troubling story of anti-psychotic drugs. London: Palgrave-MacMillan.

[2] Healy, D. 2002 The creation of psychopharmacology. London: Harvard University Press.
[3] Whitaker, R. 2010. Anatomy of epidemic: magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. New York: Broadway Books.
[4] Wilson, M. 1993. DSM-III and the transformation of American psychiatry: a history. American journal of psychiatry.1993; 150.
[5] Group for the Advancement of Psychiatry. 1950. The social responsibility of psychiatry: a statement of orientation. In: Bartemeir, L. Ed. 2012. Psychiatry and public affairs: group for the advancement of psychiatry. Chicago: GAP. pp.1-15.
[6] Ibid. p.15.
[7] Meyer, A. 1921 [1948]. The contribution of psychiatry to the understanding of life problems. In: Lief A, editor. The commonsense psychiatry of Doctor Adolf Meyer. New York: McGraw-Hill; 1948.

[8] Menninger, K. 1947. The human mind. London: Allen and Unwin Ltd. p.
[9] Tronti, M. 1976. The strategy of refusal. [Online]. Available at: http://libcom.org/library/strategy-refusal-mario-tronti.