Unmasking the Politics Behind CBT’s Rise to Prominence

Cognitive Behavioral Therapy (CBT) has long been hailed as the premier treatment for mental health problems. However, a new article published in The Medical Research Archives by Helen Rowland raises significant concerns about the validity of CBT’s acclaimed effectiveness. Rowland’s critical examination delves into the socio-political influences and methodological flaws that underpin the widespread adoption of CBT in the UK.

Rowland, psychotherapist and writer, supports her arguments with a critical literature review and systematic examination of existing research on CBT. She explores the nuanced critiques from prominent leaders in the field of critical psychiatry, such as Dalal, Davies, and Moncrieff, to uncover the underlying assumptions and biases that influence mental health practice.

She writes:

“While there appears to be a significant body of scientific evidence for the efficacy of CBT, a further systematic review of this evidence highlights a research culture with weak research protocols and an unscientific manipulation of statistical evidence. Qualitative research suggests that the primacy of CBT needs to be understood within a political context: it is the only psychological therapy that receives high levels of both public funding and private funding from pharmaceutical companies, and so one can legitimately ask the question as to whose interests are being served by the ongoing ‘success’ of this research?”

Rowland reviews the existing research on CBT, revealing methodological issues and biases that have inflated its perceived effectiveness. She argues that the promotion of CBT aligns with neoliberal values, emphasizing individual responsibility and depoliticizing mental distress. Substantial funding from both the public and private sectors further reinforces this political agenda. Rowland’s analysis highlights the need for a more nuanced and contextually aware approach to mental health treatment, one that considers the broader social and political factors contributing to mental distress.

Cognitive Behavioral Therapy (CBT) has surged in popularity over the past fifteen years, largely due to the UK’s Improved Access to Psychological Therapies (IAPT) program. Despite being touted as the ‘gold-standard’ treatment for various mental health issues and backed by numerous quantitative studies, the increase in CBT’s use has not corresponded with improved national mental health outcomes. Critics, including Helen Rowland, argue that many CBT studies suffer from methodological flaws and biases, heavily relying on quantitative measures that may obscure the therapy’s effectiveness. These studies often lack transparency in their methods and fail to account for the complexities of therapeutic practice, leading to a potential overestimation of CBT’s efficacy. The dominance of CBT is also seen as aligned with neoliberal ideologies, emphasizing individual responsibility over socio-political contexts of mental distress.

Examining the Evidence

Given that most of this research relies heavily on quantitative methods, emphasizing measurable and empirical data, Rowland stresses the need for a critical examination of the evidence used in these studies. She highlights Shedler’s four main criticisms: exclusion of complex patients, inadequate control groups, overstated superiority of CBT, and publication bias. Shedler argues that many CBT studies exclude patients with multiple diagnoses or severe symptoms, which limits their real-world applicability. Control groups often lack proper therapeutic alternatives, skewing results in favor of CBT. Additionally, the supposed superiority of CBT is challenged by reviews showing minimal differences when compared to other therapies. Lastly, publication bias favors positive outcomes, misrepresenting the true efficacy of CBT. These critiques suggest that the dominance of CBT is not just a result of its empirical support but also influenced by socio-political factors and methodological shortcomings.

She highlights that studies validating CBT often rely on a narrow positivist worldview, excluding broader societal and philosophical perspectives. She uses the concept of “scientification” to emphasize the application of scientific methods to areas like human behavior and psychology, where objective truth is hard to determine. She advocates for a more comprehensive approach incorporating insights from philosophy and sociology and stresses the need for research protocols to address these complexities when studying psychological interventions like CBT.

The Politicization of Research

CBT remains the only therapy that receives high levels of funding in the UK, thus, Rowlands asks “what task might it perform on behalf of the government?”

Bringing in Davies’s critiques, Rowland explains how successive UK governments heavily invest in CBT because it aligns with the values of new capitalism: emphasizing individual responsibility, decontextualizing and depoliticizing it from social conditions or determinants, and reframing distress as a “medical problem.”

Additionally, Rowland notes how CBT is highly adapted to the culture of managerialism, such as using outcome measures, performance metrics, and a tendency to quantification, further supporting how “evidence-based” therapies have a political agenda.

The government’s investment permits them to appear as invested in the cause while ignoring the significant amount of evidence supporting social and political causes of mental distress.

The Process of Medicalization

Rowland uses a Critical Discourse Analysis to investigate the conceptual framework in which CBT is situated and to understand its link with medicalization. This process informs readers of concepts, values, and epistemology, all of which are missing from quantitative measurements.

Rowland explains how the discourse of individualization and scientification leads to the medicalization of human distress. The language used to interpret mental distress, a preference for medication intervention, and the incorrect assumption that a chemical imbalance causes mental distress collectively reinforce the pathologization of mental distress.

In cognitive-behavioral therapy, the central theoretical concept is that human distress is caused by “distorted thoughts.” The practitioner’s role is to uphold a core set of principles about what constitutes a “typical” thought, and they must assume that the patient is engaging in irrational cognitive distortions. As a result, normal responses to significant life events become medicalized.

Rowland concludes her article with the following:

“What this article seeks to demonstrate is that the dominance of CBT plays a role in producing the conditions of possibility for the medicalization of ordinary distress in its tendency towards pathologization, individualization, and scientification.”

“The evidence provided regarding the epistemic framework and the discursive practices of CBT can be seen as actively reinforcing the pathologizing processes. Its foundational epistemology produces individualized understandings, stripping mental distress of its social and political context and locating both cause and solution firmly within the psychology of the individual. This is not a ‘neutral’ or scientific position, but a sociopolitical one.”

Despite many leaders in the field acknowledging the complexity and plurality of mental distress, public health response remains focused on CBT and medication. Rowlands’s exploration contributes to a growing body of work that directs our attention to the sociopolitical aspects of mental distress, highlights the potential harm of CBT, and challenges the dominant position of traditional mental health interventions.

First published on Mad In America

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Rowland, H. (2024). Unravelling the Dominance: An Exploration of the Relationship Between the Medicalisation of Ordinary Mental Distress, the Primacy of Cognitive Behavioural Therapy, and the Influence of Neoliberal Ideology in the UK Mental Health Economy. Medical Research Archives, 12(5). https://doi.org/10.18103/mra.v12i5.5399 (Link)