Reading Oliver James on CBT

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The Daily Mail has run an interview with Oliver James, a media psychologist who recently made an appearance at a conference organised to challenge the dominance of CBT. In the Mail interview James is dismissive of CBT, suggesting that it is a “scam therapy” and a “waste of money”. This seems a surprising conclusion given how widely touted CBT has been. What is the basis of James’ comments and what are we to make of them?

“Leading Psychologist”?
The Mail describes James as a “leading psychologist”, but what does this mean? A “leading” figure in any profession is perhaps someone who heads a professional or scientific body and who thus speaks on behalf of its members. Alternatively, it might be someone who is recognised by colleagues as having particular professional or scientific expertise. In neither case should such a person’s comments be taken at face value (even professional leaders and highly knowledgeable experts have agendas and biases), but it is usually worth giving them serious consideration. we should note that James has written several popular books on psychology and mental health and has come to be very well known as a result. He is certainly a “famous” psychologist, but “leading psychologist” is up for debate.

James’ critique of CBT is vague and inaccurate:
The conference at which James recently spoke was described by its organisers as “not an anti CBT conference seeking to dismiss CBT in its entirety”. This is plainly not a sentiment shared by James, who calls CBT (not just one specific form of CBT; not just CBT for one particular disorder) a “scam therapy”. This is a strong and general claim, one which we might reasonably expect to see evidence for (especially when being made by a “leading psychologist”). It is also so hopelessly vague that it is hard to know where to start.

James claims that “rafts of studies” have shown CBT to be ineffective, with “extensive evidence” showing that people are no more likely to have recovered two years on. I don’t know what evidence James means here so it is hard to refute specific points. Is he claiming that CBT is ineffective altogether, or only after a period of follow up? Is it effective for some sorts of problem but not others? These sorts of specific questions can be answered to a greater or lesser extent. There is substantive research demonstrating CBT’s efficacy for anxiety disorders, and for mood disorders such as depression. Evidence of this sort should be discussed in detail, and there is currently an important debate about whether CBT can be substantively helpful for psychosis. James seems to want to skip over these tedious details. He can’t.

To the extent James is more specific, he is wildly inaccurate. He is quoted, for example, as saying “research shows CBT is no more effective than placebo in treating anxiety or depression”. Which research is he referring to? The depression study I have linked to above reports an effect size of 0.67 (in the “medium” range) for CBT compared to other treatments (some of which are placebos, others of which are more active). The Anxiety article suggests an effect size of 0.51 in CBT’s favour, and again this is in comparison with other treatments.  This is all a long way from “no more effective than placebo”. Perhaps James has other studies in mind, but he does not seem forthcoming about what they are.

Picture from the Mail Article. Does CBT stand for "Chairs Brought Together"?

Picture from the Mail Article. Does CBT stand for “Chairs Brought Together”?

Metaphors and Rhetoric:
Much of the body of the Mail article is made up of James’ sweeping generalisations and colourful metaphors. “However filthy the kitchen floor of your mind” he says “CBT soon covers it with a thin veneer of ‘positive polish”. This vivid turn of phrase is clearly going to appeal to people whose contempt for CBT is already established, drawing as it does on a particular perspective of what the mind is and how it can be changed. However, on its own it is no more than a metaphor. Whether that metaphor has much bearing on how psychotherapy works is a question that needs to be settled by various lines of evidence, evidence that neither James nor the Mail are making explicitly available. This approach to the debate isn’t really an argument at all.

Later in the piece James claims that “CBT appeals to politicians and NICE because it is quick and cheap”. He’s right to raise this concern, though we should be wary of drawing too firm a conclusion from it. Length and expense of therapy are not virtues in themselves. If a therapy takes much longer and costs much more, we should expect it to deliver proportionate benefits over alternatives.

Sampling Error:
James says: “Working as a psychotherapist, I rarely encounter patients who haven’t been subjected to CBT, which failed to help them.” Even if we take this to be true, there is an important problem with drawing conclusions from such information. Notice that James is referring to a specific group of people, namely those who seek his services as a psychotherapist. This should immediately make us cautious. People who seek therapy usually do so because they are dissatisfied with some aspect of their lives. This means that to the extent James is meeting people who have tried therapy before, he is disproportionately exposed to those who haven’t found it helpful. Conversely those who have are presumably not seeking his help. If James wants to know more about who is and isn’t helped by CBT, he would do well to ask everyone who has received it, not just those who go to psychotherapists.

Perhaps we should be glad that James is challenging the prominence of one form of therapy, and if he starts a detailed debate on its evidence base, we would have good reason for gratitude. The “evidence base” for any therapy is a dynamic thing, changing as our research methods improve and more studies build up supporting one approach or another. However, unfortunately the Mail interview is seriously misleading, and James seems untroubled by this. This is not the first time James has made claims which invite inaccurate conclusions. Is this the behaviour of a “leading psychologist”?

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About the author

I am a PhD student and trainee clinical psychologist based in New York. My research is on the mechanisms of Auditory Hallucinations and the social epidemiology of psychosis. In addition to this I am also interested in the philosophical and conceptual problems around diagnosis and the history of Schizophrenia. Follow me on Twitter: @huwtube