Justin Taylor has reposted David Powlison’s critique of Cognitive Behavior Therapy. Powlison is the author of the so-called Biblical Counseling chapter of the IVP Five Views book on psychology and Christianity.
I’m not going to worry about the issue, pointed out several times in the comments, that the Bob Newhart video has pretty much nothing to do with CBT. I have two main things to contribute to the discussion, (1) as a philosopher and (2) as a parent of a child who has taken part in cognitive behavioral methods.
Powlison bases a lot of his critique on the fact that CBT uses (sometimes consciously) methods that can rightly be described as Stoic in that they do have a strong enough similiarity to key ideas of the ancient Stoics that I don’t think the comparison is inapt. Stoicism, at least on the issues relevant here, involves one key claim. The Stoics didn’t think it’s worth worrying about something outside your control. The reason is that your life is made worse off by your worrying, but you can do something about the worry. You can’t do anything about the fact that George W. Bush won the presidential election in 2004 or Barack Obama won the presidential election in 2008. You can’t change the fact that lots of people died recently in China from landslides. You can do something to help those who remain, and you can do something to change people’s minds on policy issues and perhaps help elect a different sort of person next time, but there’s no point in worrying about something you can’t do anything about.
That element of Stoic philosophy seems entirely reasonable to me. The Stoics do go on to say that we should remove all emotions, but it’s important to be clear on what they meant. They defined emotions more or less as bad reasoning. Things we call feelings that aren’t bad reasoning and are compatible with good reasoning would not be emotions for the Stoic. So there’s no reason to complain about that view on the ground that it’s healthy to have emotions and inhuman not to. We should eschew the things they called emotions without actually eschewing emotions as we understand the term. They had a strange view about what we should call emotions, but the substance of their view is mostly right, as Augustine so deftly argued in his critique of the Stoics. Feelings of any sort should be submitted to reason, and those that are irrational are best removed. Augustine shows that the Stoic view, when reworked into ordinary language without their odd view of what counts as an emotion, is largely correct and fully compatible with Christian teaching.
Where the Stoic goes wrong, as far as Christianity is concerned, is in not submitting things to the lordship of Christ. I can’t even say that they don’t equate submission to reason with submission to God. They do. They just have a false view of what God is like. Does that affect the practical level? Not so much. Does it affect CBT? Not remotely. The reason is that CBT is really a method, a placeholder in which you insert the content you intend to replace the unhealthy and irrational beliefs. The Stoics insisted that irrationality comes from false thinking. They may have been wrong about that as a fully adequate explanation of all irrationality. But they were certainly right that a whole lot of irrationality comes from false beliefs. I know at least two cases of chronic depression that in large part involves flat-out false beliefs, even if there may also be neurological causes. In one case it’s someone who consistently interprets any possible information that could be stretched to show that people don’t like him or that he’s a failure as if everyone doesn’t like him and as if his abilities are the problem, when in many of these cases no one is even evaluating him negatively, and often enough their evaluations aren’t seen that way by the people doing the evaluating. Such a person might benefit from neurochemical supplements, but CBT would encourage him to replace those false beliefs with a more hesitant approach to such negative interpretations, one much more like how most people would respond.
CBT is offered as a correction to the biggest problem Applied Behavior Analysis therapy. ABA insists on treating only behavior without dealing with anything internal, e.g. unhealthy beliefs. It stems from the behaviorist model of psychology, according to which we shouldn’t postulate anything internal that can’t be measured empirically, and thus any psychologist who talks about beliefs, desires, and so on is engaging in unscientific behavior (notice that even the way I’ve constructed that sentence admits only to the behavior of such a psychologist; a behaviorist shouldn’t even say that such a psychologist has false beliefs about how psychology should be done, just that the speech and methods of such a psychologist are unscientific).
Behaviorism is crazy, and CBT is an improvement. It seeks causes in wrong thinking rather than trying to do psychology by ignoring its existence. Doing psychology by dealing only with behavior and ignoring the cognitive elements that lead to the behavior seems to me to be closer to the Bob Newhart video that Powlison holds up as an example of CBT, where the major therapy technique is to tell people to stop it. But CBT insists on changing false and harmful beliefs and replacing them with true and beneficial beliefs. It’s a methodology, not a comprehensive theory of which beliefs are good and healthy. The trick is getting the beliefs right.
Not all CBT therapists will, but some will do much better than others, even if the ones who aren’t believers won’t be going fully deeply enough when the issues that come up are ones that Christians have deeper insight into (and not all issues are like that, e.g. dealing with my autistic son’s attachment to his hat or his collection of pocket lint that he calls his fuzzy. It’s hard for me to imagine a serious effort trying to make such issues out to be primarily about sin, and Powlison’s critique of CBT as avoiding the sin issue in order to make people feel better misses the point. The point, at least sometimes, is simply to remove an irrational anxiety. CBT isn’t comprehensive, because sometimes the problem is just a neurological malfunction that can be corrected with medication that doesn’t have significant enough side-effects to be worth worrying about. In other cases, the problem is largely due to false and harmful beliefs that CBT can help someone to remove via unproblematic methods. The Christian should only worry about cases where actual sin is involved and the CBT therapist is pretending no one is doing anything wrong or elements Christians might disagree with the general populace would cause disagreement between a Christian receiving CBT and the therapist about those particular beliefs that the CBT therapist is encouraging to use as replacements for the unhealthy ones. But those are particular problems in how CBT might be practiced by an individual, not inherent difficulties with the model itself.
But what about cases where there really is a deeper issue that the CBT therapist is ignoring due to an attempt to be neutral on religion? Is it a band-aid if there’s a deeper solution? As Powlison says near the end, it might be. But he also says it’s better than nothing. I would say that it may be just what you need. If my autistic son is having fits over losing his hat, and he’s not at a point where telling him to trust God will do a thing, then CBT may be the band-aid that helps him handle the symptoms and stop worrying about it. If that’s the best that’s neurologically possible at his developmental level, then I would argue that it’s unbiblical to insist that counseling not use CBT methods, I would even say that such insistence would itself contradict more general biblical commands.
I would say, similarly, that ABA is wrong much of the time for ignoring the internal, but with a kid who is so impulsive and unable to communicate as my other autistic son it might actually be the only thing that will help him, because even CBT doesn’t work if you can’t talk about your thoughts, never mind the so-called biblical counseling that doesn’t work when you’ve got someone with severe enough disabilities to prevent understanding of what sin even is. I sure hope no one tells me to tell my two-month old to stop crying because it’s sinful not to appreciate his parents enough to wait patiently for that diaper change. It’s not much different when you’ve got an eight-year-old with severe enough impulsivity issues that much of his behavior is more like what you would expect of a toddler, just with the physical capabilities of a much older child and thus a much greater level of danger.
Reductionist approaches don’t capture the variety of causes of problems that people might want counseling or mental health professionals for. You could be reductionist about any of these methods. Many ABA practitioners won’t consider other methods worthwhile. Many MDs won’t consider non-pharmaceutical solutions. Sometimes medication helps a neurological deficiency enough to be worth it. With genuine cases of the overdiagnosed condition of ADHD, sometimes a stimulant is exactly what’s needed, because the frontal cortex functions much more healthily when it can be stimulated, and you get much greater ability to attend to tasks. Sometimes that approach can be disastrous. Sometimes false beliefs are operative in such a way that some CBT can help someone remove them without necessarily inputting anything differently-harmful. Sometimes ABA is what’s needed when physical impulsivity is the driving force, and physical changes are needed to habituate different responses to certain stimuli or to control for sensory integration problems or high sensory input needs. Sometimes someone just needs to repent of wrong behavior, but sometimes it’s tied up with some of these other things, and it’s worth considering different methods for dealing with these problems in different cases. It doesn’t seem to me that Powlison recognizes this.
August 24th, 2010 | 12:31 pm | #1
I don’t know anything about the psychology of Dr. Phil or Dr. Laura. I learned about cognitive behavior therapy by reading Martin E. P. Seligman, Ph.D. I found his drug-free methods incredibly effective and lasting in treating chronic depression.
August 24th, 2010 | 12:54 pm | #2
……so-called Biblical Counseling chapter
So, do you have an opinion on it?
Having said that, I am pretty sure I agree with you. What passes for “biblical” reviews on counseling generally has no understanding or demonstratable knowledge of what counseling actually is
August 24th, 2010 | 3:03 pm | #3
Nope, no opinion. But I don’t like the idea of calling one model of counseling the biblical one, when there are reasons to think lots of them are compatible with biblical faithfulness. I’m critiquing this post, not that chapter, which I’ve never looked at.
August 24th, 2010 | 4:24 pm | #4
Powlison’s critique of CBT rather reminds me of a critique of Alcoholics Anonymous — specifically the 12 Steps — that I read years ago (in “Christianity Today” I think).
That writer, as I recall, crafted a “biblical” perspective that rather neatly proved the 12 Steps resulted in addicts being unwilling to take responsibility for their self-destructive decisions and actions, nor to be accountable for changing their behavior.
The only problem with that critique is that it was contradicted directly by experience: every person I knew who was actively applying the 12 Steps had become, or was becoming, both responsible and accountable.
I’m working with a CBT therapist now, who’s not a Christian, probably not even a God-believer. But I’ve learned a lot about changing my inner false, self-defeating cognitions. And, to my surprise, have discovered how those beliefs have distorted my relationship with God.
I agree: it’s a methodology that gives someone one tool to have the “serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”
August 24th, 2010 | 5:06 pm | #5
That last quotation is very Stoic, and yet it’s also very Christian.
August 25th, 2010 | 10:48 am | #6
Thank you for your very helpful thoughts, Jeremy. I agree with your assessment almost entirely. I’ve been researching how some of the ‘best’ of Stoic philosophy made its way into the Christian therapeia, or cure of souls, of the early Eastern Fathers. Your nod to Augustine was helpful.
An aspect of CBT I find esp. promising, which you don’t spend much time on, is its critique of “talk therapy” (esp. psychoanalysis), on the notion that at times we need to act (or practice) our way into new ways of perceiving ourselves, rather than to think our way (on the couch) into new modes of behavior. CBT is not deaf to our “stories,” but it does suggest that moreso than the story itself, often what gets us “stuck” is a faulty conclusion regarding that story, which we repeat internally ad nauseum. For instance, if someone was raised without much regard from their father, they might conclude that they are, therefore, worthless. The conclusion, “I am worthless” becomes, in CBT parlance, a “core belief,” an internal mantra, out of which various distorted behaviors and cognitions arise. But rather than spend eons on the couch understanding *what* happened, CBT calls for a brief, logical assessment of the core belief “I am worthless.” Is that actually true? Why or why not? Assessing the belief in the light of reason then turns to formulating an alternate, *more truthful* statement, such as: “In truth, I am a much beloved child of God.”
But the crux of the therapy, as I see it, then comes with what CBT practitioners call the “homework.” Because the problem is only 1/4 solved by identifying the false belief and devising a truer one. The real work comes in reprogramming the brain, bit by bit, day by day, to actually believe and use this new, more truthful statement. That takes practice, practice, practice.
This idea of exercising oneself and re-training one’s emotional and cognitive responses to various situations was part and parcel of early Christian therapeia. The Desert Fathers, Abba Dorotheos, St John Cassian, Evagrius Ponticus, etc. are full of insight and wisdom along this path. These early Fathers knew the Stoics (and the Platonists and Neo-Platonists, and etc.), and, being every bit as intellectually capable as we are today, critically appropriated the best insights for the Christian faith.
But actually, it was not only the Stoics who promoted cognitive and even bodily exercises for personal formation. As Pierre Hadot has shown, the whole enterprise of philosophia, in antiquity, promoted “spiritual exercises” toward the attainment of virtue. Being a philosopher, he says, meant that one was laboring to hone one’s life around some core beliefs, to bring one’s life, bit by bit, into harmony with the logos. Hadot plays up the obvious difference between this notion of philosophy and the sometimes sclerotic, overly-theoretical and overly language-based notion one typically finds today.
Overall, I see CBT as a helpful corrective to current overemphasis on “couch” therapy. As a parallel, I see ancient conceptions of philosophy as helpful correctives to the current practice of philosophy, which also seems stuck on the couch!
August 25th, 2010 | 10:55 am | #7
Any resources/books on Stoic philosophy and CBT you would recommend?
August 25th, 2010 | 11:18 am | #8
Bill,
Jeremy probably has a better list, but I can recommend a few.
On Stoic philosophy:
–The Inner Citadel, by Pierre Hadot (an excellently written, readable commentary on Marcus Aurelius’ excellent ‘Meditations’)
–The Roman Stoics, by Gretchen Reydams-Schils (this one is more heady, but it overturns a number of longstanding myths about what the Stoics actually believed)
–Seneca’s “Letters to Lucillius”
–Epictetus’s “Handbook”
On CBT:
–Judith Beck, “Cognitive Therapy” (standard text)
–Albert Ellis and Windy Dryden, “The Practice of Rational Emotive Behavioral Therapy”
–There’s a newer book by psychiatrist Ronald Pies called “Everything Has Two Handles: The Stoics Guide to the Art of Living,” which explicitly traces links b/t Stoics and CBT. However, the book is really sloppy (editing errors everywhere, thin writing). But it does give some overview.
There’s are some helpful online articles:
–An very good interview with Ronald Pies: http://tuftsjournal.tufts.edu/2008/04/features/06/
–An article from Forbes entitled “Patient Fix Thyself”: http://www.forbes.com/forbes/2007/0409/080.html
–An article from the American Scholar on Aaron Beck, the founder of CBT, entitled “”The Doctor Is In”: http://www.theamericanscholar.org/the-doctor-is-in/
Hope that helps!
August 25th, 2010 | 3:52 pm | #9
On these issues, Epictetus might be a good start for the Stoic view. One short work is online here. You could also read the article on him in the Internet Encyclopedia of Philosophy. I have no idea about CBT resources. You could always start with Wikipedia.
August 26th, 2010 | 12:36 pm | #10
- A PRAYER FROM JESUS -
This prayer is from Jesus that we may here from Him, that He may meet our needs. It only consist of three simple steps.
1) We need to read one scripture. This will focus us in the word that brings everlasting life.
2) Since this prayer is from Jesus we need yo direct our prayer to Him personally. Too often Christian focus they’re prayer’s to G_D the father. Scripture proclaims that Jesus should be the focus of our prayer.
3) The simplest part of this Prayer is to ask Jesus one question. Please, all that is required for this question is to make it simple. Let Jesus Himself finish the question when He gives you that understanding through prayer.
The PRAYER
The scripture that is the focus of this prayer is “ACTS 2:38″. It’s not necessary to do any study into this scripture. Jesus Himself willl bestow the understanding that will resonate in your heart.
The most important part of this prayer is that we need to direct our prayer directly to Jesus. If you normally would say Father in your prayer, change your focus from the Father to Christ Jesus by lifting Jesus name up every time you would normally use Father in your prayer.
Maybe the hardest part of this prayer is the question that we need to ask Jesus. For man as we are, always try to understand the question and may add many additional quires. The simplest question is all that is required.
Simply ask Jesus ‘WHY’
September 2nd, 2010 | 9:05 am | #11
I’ve always understood CBT as telling yourself the truth. This is obviously what God wants us to do, not only to others but to ourselves.
Plus I see it as a technique for us to “take every thought captive to Christ” 2 Cor 10:5 in our own minds.
But as all therapeutic treatments it must be used wisely, understanding the side effects if not used properly.
September 7th, 2010 | 8:56 pm | #12
Oh really? Are we still in the middle ages? Let’s bring out the priest to exorcise those with schizophrenia!!! If ABA has flaws, then I challenge that you confront those flaws with valid peer-reviewed empirical research, not just speculation. We have done humanity a disservice by making psychotherapy an exercise in shamanism. Why don’t you clowns get off your butts and participate in the scientific community?
September 8th, 2010 | 7:25 am | #13
Tom, the one prayer model Jesus gave us says to address our prayers to the Father, not to him.
Paul, I never said a thing about ABA not having empirically-verifiable results. What I said is that ignores a whole dimension of humanity, i.e. the internal. Your challenge simply misses the point. It assumes behaviorism in order to defend behaviorism against the objection that behaviorism is incomplete. Ignoring a reality is wrongheaded regardless of the empirical results in terms of change of behavior. Behaviorism assumes all that should matter is behavioral change, and ABA relies on that assumption. Telling me that I need to show empirical research to challenge ABA is simply a question-begging reliance on the very assumption I’m questioning.
September 8th, 2010 | 10:00 am | #14
Jeremy,
Tom is, I fear, a bit of a troll.
As I scoot around the blogosphere from time to time, that exact same comment appears on various threads having nothing whatever to do with prayer…
Carry on.
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