On a fateful day in 2021, we met on a year-long training course in Low Intensity Cognitive Behavioural Therapy (LICBT). Our own experiences of distress and trauma and of being two of only a handful of brown, queer and trans people on the course made us see cracks in (LI)CBT that no one else around us saw. We supported each other in understanding why (LI)CBT felt, and continues to feel, at best, limited and, at worst, harmful. We see (LI)CBT as a tool for a capitalist state, serving economic purposes, that individualises and depoliticises our distress. We recognise this tool might have helped some to cope better, but this is a call for care that offers more than survival.
The creation of a capitalist mental health system
We are two of thousands of people who were paid to train in LICBT as part of an NHS initiative started in 2006 called ‘Improving Access to Psychological Therapies’ (IAPT) at the time, now ‘NHS Talking Therapies for anxiety and depression’. We were plainly told IAPT was born out of economic arguments at the beginning of our training, and when looking further into it, we realised IAPT was economist ‘Lord’ Layard’s vision of a capitalist mental health system. In several reports and at the 2005 Government’s Strategy Seminar on Mental Health, Layard highlighted that “mental illness . . . imposes heavy costs on the economy”. He had a vision where “mental health services, together with JobcentrePlus, should help clients return rapidly to work wherever possible, and to remain in work”; this is part of what’s called the ‘welfare-to-work’ approach. These mental health services were designed specifically for the workforce, in Layard’s words, “people of working age who are outside of prison”. He stated that “CBT has . . . been found to double the rate at which unemployed people find work”, and argued for “some 10,000 extra psychological therapists to be trained over the next five years”; all “practising CBT or other evidence-based therapies”. In 2006, the first two IAPT treatment centres opened. We trained in LICBT under IAPT 15 years later, when nearly 1.2 million people accessed treatment through IAPT that year alone. NHS Talking Therapies (formerly IAPT) currently offers the most accessible form of free mental health support, and most of the interventions people access within it are CBT-based.
After the economic crash of 2008, David Cameron announced the ‘age of austerity’ in 2010, introducing billions of pounds worth of cuts. This resulted in detrimental impacts on the NHS which is reported as now having a maintenance backlog of around £10 billion. The initiatives of IAPT/NHS Talking Therapies around this time may seem contradictory to the broader context of austerity because of how seemingly abundant and accessible they make therapy seem. But CBT fits perfectly into neoliberal austerity measures as it provides fast and cheap ‘support’, aimed at saving the Government money by getting people back into work.
CBT and our LICBT training
One of CBT’s core principles is that “psychological problems are based, in part, on faulty or unhelpful ways of thinking . . . and unhelpful behaviour”. CBT aims to try to change these ‘faulty or unhelpful’ thoughts and/or behaviours, in an effort to alleviate symptoms of the mental health issue a person is experiencing.
We thought we would give an outline of our training, to show how robotic and superficial this form of support is. We were taught to recognise ten ‘common mental health issues’, including depression and different forms of anxiety ‘disorders’ or ‘phobias’. We were explicitly trained to work on the surface-level and to ignore ‘core beliefs’ (deeper beliefs that someone has formed about themselves and the world throughout their life). This confirms that LICBT is a superficial form of support, often offering a plaster to deep wounds. We were to deliver an hour-long assessment session, consisting of a diagnostic questionnaire, a 20-30 minute interview that follows a strict structure, communicating a ‘probable diagnosis’ with one of the eight LICBT interventions picked on the spot, and creating goals. As children and young people’s practitioners, we were meant to work with ‘patients’ for 6-8 weeks after this, during which we would apply the intervention and monitor progress through self-rating scales. We were marked against our ‘fidelity to the model’ and how well we stuck to this rigid process.
Individualised and depoliticised mental health
When CBT feels like it’s not working, professionals will often point to service users or practitioners as the problem. We, however, believe the problems lie with CBT itself. Aaron Beck, dubbed the father of CBT, stated that the philosophical underpinnings of CBT “go back thousands of years to the time of the Stoics who considered man’s conceptions (or misconceptions) of events, rather than the events themselves, as the key to his emotional upsets.” CBT labels depressive and/or anxious thoughts as ‘cognitive distortions’, and offers ‘cognitive restructuring’ as a treatment. This creates a power dynamic where the CBT practitioner knows how to think and behave correctly and rationally, and needs to teach an irrational patient who would feel better if they stopped committing errors. In other words, CBT individualises and depoliticises distress by making the way an individual thinks the problem and solution, without considering wider contexts and oppressive systems individuals live under.
Beck’s references to Stoicism and ir/rational thought also highlight the connection between CBT and Western ideas that underpinned colonialism. Most people today wouldn’t identify CBT as a product of colonial thought. Instead, CBT is marketed as a neutral and objective tool whilst it quietly perpetuates colonial assumptions, including the binaries of ir/rational, normal/abnormal, healthy/ill, good/bad.
Another aspect of our training that pushed us towards decontextualising the people we worked with was the emphasis on diagnosis. Our course referenced the ICD (the International Classification of Diseases) and the DSM (the Diagnostic and Statistical Manual of Mental Disorders) as the sources to define the mental health ‘conditions’ we worked with. Both the ICD and DSM come from 19th century efforts to classify people experiencing distress into different categories of ‘diseases’ and ‘disorders’, reducing them to symptoms, with complete disregard to contexts and identities.
We both respectively did targeted work with young Black people and people of colour and LGBTQIA+ young people. The inadequacy and gaslighting of CBT was especially made clear to us in this context. When supporting young people experiencing queer/transphobia and racism, it felt harmful to use interventions aimed at challenging their distressed thoughts about themselves and the world, as these thoughts were valid in the environments they existed in. We ended up having to move away from CBT interventions and spent more time in sessions giving space to young people’s feelings. We validated their experiences of and reactions to oppression and violence and focussed on improving the material conditions and environments they were in. These experiences taught us that anyone who can’t think their way out of pain or suffering does not fit within the CBT approach. When considering chronic health conditions, neurodivergence and structural violence, it becomes clear that CBT cannot hold our distress. People accessing support, however, are often left with no choice but to fit within this approach especially when it’s one of the few forms of free mental health support available.
Beyond surviving and getting by
There is no wonder that CBT is the most commonly available form of mental health support on the NHS. It keeps us isolated and internalising that problems lie within us, not the system. This ultimately serves the government’s aims to keep us coping enough to be productive and compliant.
It’s argued that although CBT can’t solve all of our issues, it is a good tool for surviving or getting by in a world where structural change can’t happen overnight. Although we would probably agree with this, we seek to imagine what addressing distress could look like if the aim wasn’t to just get by or survive. What would it look like if the end goal was not to serve capitalism?
We both moved away from CBT and forms of ‘support’ that pathologise our reactions to living in a harmful world. We’re inspired by Martin Luther King, Jr.’s words, and we hope you will be too: “Modern psychology has a word that is probably used more than any other word in psychology. It is the word maladjusted . . . But I must honestly say there are some things in our nation and the world to which I am proud to be maladjusted . . . I never intend to adjust myself to segregation and discrimination . . . I never intend to adjust myself to economic conditions that will take necessities from the many to give luxuries to the few.” May we never adjust to the injustices around us.
Mental Healthcare in a Failing State
This blog is part of our “Mental Healthcare in a Failing State” series which ran between July and October 2024. All the blogs in the series are available here.