Cognitive Behavioral Therapy

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.

[cross-posted at Parableman]