Last week, the UK government launched the biggest state-funded mental health initiative ever. It pledged £170 million to create “a ground-breaking therapy service in Britain”, according to health minister Alan Johnson. The service will include 3,500 new therapists, who will have to be found and trained by 2011, if targets are to be met.

At the heart of the government’s new initiative is their tremendous belief in cognitive behavioural therapy (CBT). CBT was invented in the late 1950s, by two American psychologists working independently of each other – Albert Ellis and Aaron Beck. Both were trained as psychoanalysts, both were increasingly frustrated with how little psychoanalysis seemed to help the patients who came to them with problems such as depression and anxiety.

They started to shift the focus of therapy onto an individual’s thoughts and beliefs in the present. They embraced the insight of the Stoic philosopher Epictetus – it’s not events, but our opinions about them, that cause us suffering. It’s not someone laughing at us that causes us suffering, but our belief that their opinion of us is all important. If we realize the extent to which our own thoughts and opinions cause us suffering, we can gradually become aware of our habitual destructive thought patterns, and choose to reject those patterns and choose more healthy beliefs, such as ‘so what if that person rejects me, who needs their approval anyway’.

This rejection of old habitual beliefs and choosing of new ones is not easy at all. It’s like giving up smoking, only harder. It involves a lot of suffering, but it’s easier suffering than before, because you choose it, you choose to put yourself in anxious situations, in order to overcome them, in order to face your fears.

Speaking personally, I found CBT helped me overcome post-traumatic stress disorder and social anxiety, both of which made my life a misery when I was at university. CBT helped me overcome my most acute symptoms within a few months, and I carried on getting better over the next three years, to the point where now I don’t think I have either conditions chronically anymore, though I still get the blues occasionally, like every human being.

CBT has become incredibly successful over the last decade. That’s in large part thanks to a number of clinical trials that Aaron Beck carried out in the 1980s and 1990s, which seemed to prove that CBT successfully ‘cured’ depression and other emotional disorders within 15 weeks or so, in around 80% of cases. And CBT patients were less likely to suffer a relapse than patients who had got better through pharmaceuticals.

So here was a treatment that was cheap, quick, effective, and proven in clinical trials to work. Naturally, governments started to take an interest.

The UK government took a stronger interest than most. The New Labour team has always been into mental health and quality of life issues. Back in 1999, the New Labour think-tank Demos published an influential pamphlet called The Good Life, which asked why British people were richer than ever before, but apparently increasingly unhappy? This seemed like a failure of the Labour post-war project, to unlock human potential by increasing economic prosperity. Politicians started chasing that elusive snark –‘well-being’.

A few years ago, a London School of Economics professor turned government advisor called Lord Layard worked on a report that outlined mental illness as the biggest social problem facing Britain today. The report pointed to the Psychiatric Morbidity Survey, which suggested that one in six of British people would be diagnosed with depression or anxiety at some point in our lives. Yet only one in four of people with emotional disorders receive proper treatment.

“This”, said the report, “is a waste of people’s lives. It is also costing a lot of money. For depression and anxiety make it difficult or impossible to work, and drive people only incapacity benefits. We now have a million people on incapacity benefits because of mental illness – more than the total number of unemployed people receiving unemployment benefits.”

Layard’s efforts seem to have now borne fruit. The government’s new £170 million initiative makes sense politically: the government can look progressive, it can do it relatively cheaply compared to the enormous amounts needed to do anything in the NHS, and (a cynic might say) it can create a way to get some of the scroungers off incapacity benefits – if they show no willingness to attend CBT, they can label them malingerers, and put them to work.

At the same time, the initiative has its detractors. The main critics of CBT are, naturally, psychoanalysts and other practitioners of long-term person-centred therapies, who don’t like this upstart therapy bouncing into the room with its talk of 15-week cures.

Professor Andrew Samuels at the Centre for Psychoanalytic Studies in the University of Essex wrote to the Times to say: “Everyone knows the limitations of CBT - except, it would seem, the government. The science is inadequate, the methods naive and manipulative, and the reluctance to engage with the key aspect of psychotherapy - the deep and complex relationship that develops between client and therapist - really very careless. Clients who enter CBT are approached in a mechanistic way, required to be passive and obedient. Hence what is going to be on offer is a second-class therapy for citizens deemed to be second class.”

Well…at least CBT has the guts to be tested in some clinical trials. The trials may not be perfect, CBT may indeed be superseded by a much better therapy in the future, but it is highly unlikely that therapy will be psychoanalysis, which has an even weaker basis in science, and even less evidence or clinical trials to support it.

And why do we need a therapist father-figure, with whom we are supposed to fall in love, in order to get better? I personally overcame social anxiety through CBT, and I didn’t even attend sessions with a therapist. I used a tape course, and my own will and desire to get better. It’s like saying you can only worship God through a priest. It’s psychoanalysis, not CBT, that requires the patient to be “passive and obedient” to the high priests of analysis. And how come the University of Essex still has a centre for psychoanalysis? Do they have a centre for Marxism-Leninism as well?!

The psychotherapist / journalist Oliver James, meanwhile, has accused CBT of being American “faux happiness”– forcing patients to smile and see the world through rosy spectacles. Only hardcore long-term psychotherapy, he says, has any real intellectual validation. CBT is simply a light-weight quick fix.

This is wrong too. CBT, as I’ve repeatedly written, has a firm grounding in Stoic philosophy. That was the inspiration for Albert Ellis’ thinking, and Greek philosophy obviously informs Aaron Beck’s work too. The cognitive theory of emotions is from Stoicism. The idea in CBT that thought patterns are habitual, and therefore we have to get into good cognitive habits and out of bad cognitive habits, is also from Stoicism. The CBT idea that we should keep thought-journals to keep track of our thought patterns is also from Stoicism. So is the idea of the value of focusing on the present and not letting our mind be dragged into the past or the future. So is the importance of accepting negative events in our past and moving on. So are many other cognitive techniques from CBT.

So the theory and practice of CBT is deeply informed by Stoic philosophy, a philosophy that has been around for 2,500 years, which has attracted some of the greatest thinkers of European culture, which had a huge influence on Christianity, and on the Enlightenment. In fact, Stoicism has had a greater influence on European culture probably than any other single philosophy. What CBT has done is to put Stoic ideas into practice, and to prove their worth in clinical trials.

So CBT actually has a lot more intellectual validation and substance to it than some psychobabble thought up ten years ago.

Some criticisms of CBT are just…well…crazy. One comment piece in the Guardian, by the psychoanalyst Darian Leader, says: “CBT-style therapies were last used on a mass scale in China in the cultural revolution. Separated from loved ones – having perhaps witnessed their murder – people were taught to deny the legitimacy of their symptoms: depression was just the outcome of false beliefs.”

Say what? I know CBT may be undercutting your market, Darian, but isn’t comparing CBT to one of the most bloody and violent revolutions of modern times just a teensy bit hysterical? I don’t remember seeing my parents killed in any CBT group session I attended…

Quite often, people will criticize CBT, and then quietly admit that actually, they tried it and found it very helpful. Thus the journalist-philosopher Mark Vernon took me to task for an article I wrote in Prospect, which lauded CBT. Vernon declared that CBT was actually just a quick-fix therapy which re-inforced the ego, and was thus very much part of consumer culture.

I disagreed with him, pointing out that it came from Stoicism, and Stoicism in turn came from Cynicism, which was anything but a consumer philosophy. Both Stoicism, Cynicism and CBT are concerned with taking responsibility for your negative emotions and thoughts, rather than running away from them into ‘retail therapy’ or other destructive coping mechanisms like binge eating, boozing or porn.

Vernon then admitted to me that he’d used CBT himself and found it useful for overcoming a minor neurosis. So why is he knocking it?! Why is he getting in the way of other people getting the benefit from it?

Vernon is an intelligent commentator, but too many other people in the ‘well-being’ business, it seems to me, are really just in it for the business, to make a career out of it, which means defending their particular vested interest – psychoanalysis, gestalt therapy, philosophy, whatever – or just getting their name in print with the wildest accusation they can come up with (as Darian Leader successfully has).

Such people are just muddying the issue. They very often have no experience of overcoming a serious emotional disorder themselves. They’ve only ever told other people how to get better, never struggled to get better themselves.

A much better criticism, it seems to me, was raised by one CBT therapist in The Times, who wrote: “I am concerned that ‘advisers’ have handed a baton to all-too-eager politicians who will run with it regardless of direction or consequence. We hear that, in this most sensitive of areas, the Government plans to ‘recruit’ up to 3,500 CBT practitioners to combat the huge and costly effects of these debilitating psychological conditions. Does the Government seriously believe that there are so very many unemployed, qualified and fully experienced therapists idly sitting around waiting for the call, or does it have confidence that training will produce this vast number on demand? I suspect that to fill the need there will arise all manner of unregulated ‘colleges’, offering inadequate and laughably short courses, receiving huge amounts of taxpayers’ money and churning out ersatz therapists of dubious quality.”

This seems to me a serious concern. One also needs to make the point that one can’t simply legislate well-being. You can only get better if you really want to get better. And many people with mental illness don’t get to that stage for a long time. They are too scattered, too full of whirling emotions of self-pity, fear, rage, or emotional drama, to focus properly on the goal of getting better. Only one in four people receive proper treatment for mental illness because it may be that only one in four is ready to receive proper treatment. You have to hit rock bottom to make a really firm resolution to do everything you can to overcome your problems.

Without that firm inner resolution, CBT is a waste of time and money. So is every other form of therapy. Until you make a firm resolution to face your demons, you are just treading water, trying to keep your head above it.

So we shouldn’t expect mental illness to be a thing of the past by 2011. The human mind is not that straight-forward. Sometimes it seeks out darkness and suffering, and holds on to it. Sometimes we choose to embrace an outsider status, we choose to be misunderstood and wounded.

That doesn’t mean that the government’s CBT initiative is a waste of time and money. I know from my own experience and meetings with others that there are thousands of people out there who really want to get better, who don’t realize there is quite a straightforward and successful treatment one can use.

But don’t expect all those people to get better. You have to really want to get better, to leave your comfort zone, and be prepared to suffer along the journey to health. Returning to health is all about intentionally facing suffering, learning to become resistant to it. Many people just aren’t prepared to do that, or have to wait for the right moment, when they finally are prepared to go through it.

CBT provides an invaluable framework to help people return to health. But at the end of the day, it’s not what the therapist says or the psychoanalyst or the GP or the minister of health. It’s the individual, wrestling with himself or herself, finding the courage to get up again and go forward.

Jules Evans, a columnist of Eurasian Home website, London

October 16, 2007