Letter 4 – Clinical Inquiry

“For a range of clinical problems, specifically cognitive interventions do not produce superior outcomes to the behavioral components of CBT [cognitive behavioral therapy].”

—  Richard Longmore and Michael Worrell,

      “Do we need to challenge thoughts in cognitive behavior therapy?”


Before I left for Russia, I asked a professor at Duke what to read about the individual psyche. We discussed mainly psychoanalysis and affect theory, but finally, she said, “You could always try scientific psychology.”

“Oh,” I said, suddenly recalling the tedium of empirical articles I read for my abnormal psychology class. “Historically, I haven’t found them to be very… inspirational.”

“Yes,” she said, “I know what you mean.”

But since that conversation in May, I’ve experienced growing cognitive dissonance: How can I be seeking to learn about the individual psyche in good faith while rejecting an entire field named after the psyche? Given the rate at which I invoke “hermeneutic generosity,” the specter of hypocrisy compelled me to detour through the world of clinical psychology research.

When I was learning about cognitive behavioral therapy (CBT), the leading psychotherapy, in class, I was constantly and “maladaptively” annoyed by its underlying theoretical assumptions. I’m sure it works decently, but to me there is something distasteful about a therapeutic model which diagnoses “real” and “distorted” thoughts as though the emotional and affective realms could be assigned truth values. I decided to read an article on precisely this: “Do we need to challenge thoughts in cognitive behavior therapy?” (2007), published in the field’s top journal: Clinical Psychology Review.

Essentially, this article reviewed the key studies that had tried to compare the cognitive elements of therapy with the behavioral ones. Cognitive therapy involved “restructuring” the patient’s thoughts by logically disproving their “distorted” thoughts and replacing them with “reality-aligned” ones. Behavioral therapies involved exposure to the feared stimuli and increased behaviors that brought pleasure and mastery, warding off depression. Across the board, the study found “no difference in effectiveness between the cognitive and behavioral components of CBT.” In study after study, the authors reported surprisingly similar clinical improvements. It’s not that neither worked; it’s that they worked equally well. From this, the authors proposed future research questions, including whether or not behavioral and cognitive systems might interact so that therapies addressing one system also impacted the other.

To reach this hypothesis, the review cites nearly 100 articles from research which took decades and millions of dollars. Because I’d been reading Freud’s Interpretation of Dreams (1900) earlier in the week, I recalled several points at which he said things like: I’m not going to prove this any further, because anyone can confirm this from their own experience. Especially given that Freud is lampooned as a pseudo-scientific figure in clinical psychiatry, I think the contrast between his methodology and that of clinical psychiatry is illuminating.

Unlike any of the researchers cited in the article, Freud makes overt use of introspection. Because of this, he does not assume that the human being is a black box, as the studies in the review did. They treated the patient like an unknowable algorithm, and thus thought it would be instructive to compare inputs (therapy packages) with outputs (symptom reduction over time). Those researchers evidently did not speculate about the subjective experience of patients undergoing various types of therapies. Had they, I’m sure they could have imagined that actively facing a fear might change your cognitive assessments about the potency of its threat and your ability to survive it. Instead, clinical psychiatry’s “empiricism” precluded introspection.

Freud shows that what gets lost in the fetishization of empiricism is the step that precedes the empirical experiment: the formulation of the hypothesis. His work implies that the hypotheses generated by introspection and intuition better approximate reality than do those formed by making no prior causal assumptions under the banner of scientific neutrality. I plan to keep reading clinical psychology articles, since it was nevertheless very instructive to begin understanding the methodologies and value systems of the discipline. I can’t wait to see how the clinical texts will converse with the literary and theoretical texts I will read over the next four weeks. I suspect that, like the cognitive and behavioral systems, these two intellectual systems can inform each other.