I was scanning the pages over at Mad in America and found the following article by Jay Watts entitled Cognitive Behavioural Therapy Does Not Exist. I enjoyed Dr. Watts’ article because she makes several points that I have also made concerning CBT or cognitive behavioral therapy. I contacted Dr. Watts and she graciously gave me permission to liberally quote from her article. So, liberally quote I shall. If you like the quotes I provide here, then please read Dr. Watts’ article in its entirety over at Mad in America.
Dr. Watts starts her article thus:
Since the 1980s, a type of psychotherapy called Cognitive Behavioural Therapy (CBT) has become dominant. Like it or loathe it, CBT is now so ubiquitous it is often the only talking therapy available in both public and voluntary health settings. It is increasingly spoken about in the media and in living rooms across the country. Yet when we speak about CBT, what are we talking of? For CBT only exists—as we will see—as a political convenience.
If you take nothing more from this Quick Look, take this: behaviorism as an ideology (along with its methodology of CBT) is mostly used as a political convenience. I would add that it is also used as an economic convenience. Behaviorism is an economic convenience principally because it fits well with the medical model that most insurers use: psychological therapy in the shortest number of visits (usually less than ten). Simply put, behaviorism is the darling of insurers.
As a paradigm, behaviorism rules. We no longer talk about mental health; we talk about behavioral health. Here in New Mexico, we have the New Mexico Behavioral Health Collaborative. Here’s a description of the collaborative from their web site:
The Collaborative was created by Governor Bill Richardson and the New Mexico State Legislature during the 2004 Legislative Session. The Legislation allows several state agencies and resources involved in behavioral health prevention, treatment and recovery to work as one in an effort to improve mental health and substance abuse services in New Mexico. This cabinet-level group represents 15 state agencies and the Governor’s office.
It’s a long story but the idea for the collaborative came out of negotiations that took place between Governor Richardson and Newt Gingrich (see the Addendum below for more on this story). Simply, this story shows us behaviorism as an ideology being used as a way of channeling public Medicaid dollars to both for-profit and non-profit therapy service providers. So, yes, Dr Watts is correct: there’s a powerful alliance between government, private insurers, and for-profit and non-profit service providers that turns around the ideology of behaviorism.
Because of these powerful alliances, Dr. Watts correctly points out that there is great pressure to place all methodologies and interventions under the rubric of behaviorism. Yes, there are behavioral framings of attachment theory (RAD or reactive attachment disorder would be an example). Here’s how Dr. Watts describes the pressure to frame all methodologies and interventions using the worldview of behaviorism:
Examples of things which get sucked into the CBT vortex include attachment theory (from psychoanalysis), mindfulness (from eastern wisdom traditions) and compassion (from Plato and, well, everyone). Practitioners using these other approaches—which have no family resemblance to Becksian thinking [note: Dr. Aaron T. Beck developed CBT back in the 1960s]—are often complicit in placing their therapies under the umbrella of CBT because there are power interests vested in doing this—money, grants, faculty position, shared membership in what CBT apologist Richard Layard evangelically frames as a “forward-looking” and “progressive” movement.
I’ll give Dr. Watts the last word as she poignantly points out why both government and insurers love behaviorism: the ideology of behaviorism fits nicely with the ideology of neoliberalism. Here’s the other “take home” idea you should keep in mind: there’s nothing liberal or progressive about behaviorism. (1) I’d be remiss if I did not point out that back in the 1920s and 30s John B. Watson—arguably the father of behaviorism—went on to become a huge mover and shaker in the then emerging field of mass persuasion we now know as advertising.
By conflating a number of vastly divergent approaches with strikingly different ideas of what it means to be human and to suffer, and calling them CBT, its proponents can delegitimize critics by claiming that they do not know “modern CBT.” Yet this response negates the actual reality—that for all the seeming variation, the overwhelming majority of CBT still operates through Becksian principles of normalisation, fitting a governmental agenda of producing good, quiet, working subjects who contribute to the economy and shut up [emphasis added]. The price of locating newer therapies with very different ideas and promising research findings under the CBT mantle, despite the lack of family resemblance, is thus that it props up normalising therapies which cohere with an individualistic, neoliberal agenda that equates worklessness with worthlessness.
Addendum: The Story of the Richardson – Gingrich Behavioral Alliance
I was able to retrieve an article from the news agency Business Wire (dated September 29th, 2006) entitled “Newt Gingrich, New Mexico Governor Richardson Praise ValueOptions’ Path-breaking Medicaid Program.” Here’s the first part of that article:
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NORFOLK, Va. — A national conference on “Creating a 21st Century Medicaid System” featured ValueOptions’ innovative Medicaid mental health program in New Mexico this week.
“The program provides better access for the poor and offers the prospect of saving taxpayer money,” said New Mexico Governor Bill Richardson in an address at the conference. “It’s a better use of dollars,” he said, adding that the program “created more possibilities,” “increases accountability,” and “should lower providers’ administrative costs.”
“No one else has tried it,” the governor said of the initiative that brings together a mix of 18 separate state agencies [collectively known as the NM Behavioral Health Collaborative]. ValueOptions manages public funding and delivery of care for mental health and substance abuse in the program. Under a “braided funding” model, ValueOptions has brought the state’s diverse resources together [e.g., the Collaborative] to increase access to and the quality of care for people in need.
The state of New Mexico took the lead in braided funding when it passed legislation in 2004 to form the Interagency Behavioral Health Purchasing Collaborative. This organization brings together multiple state agencies and provides oversight for the program as a whole. In addition to the state collaborative, there are also 15 regional groups that assure a response to diverse needs throughout the state.
“It’s an interesting program,” said former House Speaker Newt Gingrich, whose Center for Health Transformation hosted the conference in Washington. He said that ValueOptions’ program prevented people from “getting lost in the system.”
Governor Richardson commended ValueOptions and spoke of its “strong partnership” with the state. He highlighted some of the program’s accomplishments in its first year and underlined its path-breaking efforts with Native Americans.
ValueOptions CEO Barbara B. Hill, speaking at the conference, said “ValueOptions has spent many years serving public behavioral health. We are very proud to participate in visionary discussions such as these and share our expertise and experience with state leaders who are looking to make changes to their own system of care.”
A Web cast of the conference is available at www.healthtransformation.net.
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I should point out that not too long after the above article was written ValueOptions was effectively thrown out of New Mexico. Apparently there were allegations of fraud and mismanagement of funds. For more on these types of fraud allegations (sadly, there have been others), see the following article: Criminal Allegations in NM Behavioral Health System No Surprise to One Advocate.
Notes:
(1) For a good biography of Watson’s life and work, see Mechanical Man: John B. Watson and the Beginnings of Behaviorism by Kerry W. Buckley. What I found interesting were Buckley’s attempts to draw a comparison between Watson’s early upbringing in a very strict, conservative, “fire and brimstone” religious environment (which bordered on abusive at times) and the strict, conservative nature of Watson’s theory of behaviorism. (2) It was Watson who famously declared:
Give me a dozen healthy infants, well-formed, and my own specified world to bring them up in and I’ll guarantee to take any one at random and train him to become any type of specialist I might select—doctor, lawyer, artist, merchant-chief and, yes, even beggar-man and thief, regardless of his talents, penchants, tendencies, abilities, vocations, and race of his ancestors.
Believe it or not Watson started out as an ethologist. He studied sea birds. So, Watson was very familiar with the idea of innate behavioral systems, such as attachment. But he later advocated the idea that a strict behavioral hand can (and should) trump any and all innate behavioral systems. In essence, behaviorism promulgates the idea that strict nurture (which Watson himself received) should triumph over whatever behavior nature could dish up (like the desire to be loved). As you would expect, Bowlby was not a big fan of Watson’s rather simplistic theory. He voiced his objections in his trilogy of attachment in the context of Watson’s Little Albert experiment.
(2) The “early childhood experiences – adult theory development” connection does not hold true for just Watson. In fact, it holds true for most psychological theorists from Freud to Bowlby to Ellis to Rogers. To paraphrase that classic Country Western song, “Mama don’t let your babies grow up to be theorists.”
