Academic journal article Health Sociology Review

The Hegemony of Cognitive-Behaviour Therapy in Modern Mental Health Care

Academic journal article Health Sociology Review

The Hegemony of Cognitive-Behaviour Therapy in Modern Mental Health Care

Article excerpt


This paper focuses on the approach of health policy in Anglo-American democracies to grant cognitive behavior therapy (CBT) dominion over mental disorder. The application of CBT to 'depression' is offered as a particular example of this trend. The paper derives its argument from a critical historical reading of the psychological literature and an engagement with a particular example of the process of public policy development in the UK.

Whilst sociologists and other critical thinkers (for example, Foucault 1988; Giddens 1992; Rose 1990) might understand misery in society as a public issue open to contestation from different social groups about its nature, causation and solution, CBT renders it a private trouble to be solved by therapeutic means. These writers note that in late modernity social forces are individualised, thereby readily obscuring the social and psychological technologies offered as personal and interpersonal solutions to rule transgressions, including the transgression of 'emotion rules' (Thoits 1985). Therapy does not merely crush subjectivity; it also constructs it (Miller and Rose 1988).

Rule transgressions occur in a context of the norms of rationality required for socioeconomic efficiency and the regulation of relationships between social groups. For example, de Swaan (1991) noted that the mental health problems of women came to the fore as they entered public spaces. 'Depression' represents a threat to socio-economic regulation as a fiscal burden and as a contributor to the loss of productivity. By rendering depression a personal malady amenable to technical remediation, misery is decoupled from its immediate social context and norms and its public policy relevance can be obscured.

The therapeutic optimism that CBT represents is part of a wider socio-political restructuring of welfare capitalism's response to the disruption and burden of chronicity. This wider policy trend includes 'de-institutionalisation', 'community care', 'self-management' and 'recovery' (Pilgrim 2008). Within that trend, the ideological baggage that CBT brings with it includes:

* A narrowness of scope about mental health problems, which are seen as being cognitive errors inside the minds of individuals, without reference to their social context or by only referring to the individual's perception of the latter. This pre-empts the possibility that psychological distress is an authentic response to oppressive social forces.

* A tendency to reduce psychological formulations about mental health problems to a limited set of therapeutic techniques, which may understate the complexity and diversity of views within psychology, thereby potentially undermining the professional and disciplinary interests of the latter.

* A tendency to accept the legitimacy, uncritically, of a hierarchy of medical evidence (even though ostensibly it is a psychological form of intervention). This particular frame of 'evidence- based practice' considers that psychological interventions can be investigated as if they were drug interventions targeted upon diagnostic related groups. This is a challengeable assumption.

* A tendency of policy makers and service managers to limit support for people with mental health problems to a combination of CBT plus medication. This precludes or undermines a range of other psychosocial possibilities in mental health services.

These points of contention give a sense in advance of why CBT has been a matter of professional disputation. Before unpacking this disputation, I provide a brief outline of the technical tradition of CBT in order to situate it historically and socially.

A brief history of CBT

The first indication of professional interest work to be noted about CBT is that its history can be told in two ways. One is a narrative of psychiatric treatment (a medical story). The other is told as a form of applied psychology (largely a story about the progress of clinical psychology as a profession). …

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