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A blueprint for ‘Philosophical CBT’

Imagine being able to practice philosophy through the NHS. The idea is not as far-fetched as it sounds. In fact, therapists and counselors in the UK are beginning to put together something called ‘Philosophical CBT’, which could radically change how people see philosophy and the wider humanities.

CBT, or Cognitive Behavioural Therapy, is now at the heart of the British government’s mental health policy. Successive British governments have committed a combined £580 million to a policy called Improved Access for Psychotherapies (IAPT), which hugely increases the availability of CBT through the NHS, and will train 6,000 new cognitive therapists by 2014. It is the boldest expansion of mental health services anywhere in the world.

While many mental health charities have welcomed this initiative, others in the mental health industry have fiercely criticized it. Therapists from other traditions say it has too much of a ‘one size fits all’ approach, and that 8 to 16 weeks of CBT only offers a short-term fix that ‘papers over the cracks’. Others have criticized CBT’s intense focus on an individual’s thoughts and beliefs rather than their socio-cultural and economic context.

Speaking personally, I found CBT very useful when I had depression and anxiety in my late teens. I went to a CBT support group: there wasn’t actually a therapist present, but we followed a CBT tape course, did the ‘homework’ and, after a few weeks, I stopped having panic attacks and got on the long road to recovery. That experience of CBT piqued my curiosity, because CBT reminded me very much of ancient Greek philosophy.

I started to research CBT, and interviewed the two founders of it – Albert Ellis and Aaron Beck – and discovered they had been directly inspired by ancient Greek philosophy, particularly by Stoicism, which insisted that ‘it’s not events, but our opinions about them, that cause us suffering’. CBT also takes from ancient philosophy the ‘Socratic method’ – Socrates’ idea that humans can be taught to examine their minds, bring unconscious beliefs into consciousness, and then rationally consider and challenge any beliefs that make them sick.

Ellis and Beck took ideas and techniques from ancient philosophy and brought them into the heart of western science, but in doing so, they removed any mention of ethics, values or the ‘higher meaning’ of life. They also removed the social, political and religious aspects of ancient philosophy, and turned it into a ‘tool-kit’ of non-moral, instrumental techniques for the individual. Beck then tested out the therapeutic effectiveness of these techniques with a barrage of empirical tests. This impressive body of evidence for CBT is what convinced our government to put half a million pounds into making it more available.

Yet something was lost along the way. Ancient philosophy wasn’t merely a set of instrumental techniques for the individual. Schools like Stoicism, Epicureanism and Scepticism also offered ethical theories about the good, which linked the personal to the social, cultural, political and cosmic. These schools didn’t agree on whether God existed or whether there was a higher meaning to human existence, but at least they recognized that was a conversation worth having. CBT narrowed the focus down to just the individual, and the result is a somewhat atomized and amoral version of self-help.

What we’re now seeing is the rise of the so-called ‘third wave’ of cognitive behavioural therapies, including mindfulness-CBT, Acceptance and Commitment Therapy (ACT), and Positive Psychology. These therapies often engage more directly with Eastern philosophies (particularly the mindfulness techniques of Buddhism), and in the case of ACT, they’re less afraid to include questions of values in therapy.

Positive Psychology has also included some mention of the ancient Greek philosophical schools that gave rise to CBT. Jonathan Haidt, for example, includes the Stoics and Aristotle in the course on ‘flourishing’ that he teaches at Virginia University. But on the whole, few cognitive therapists are aware of the links between CBT and ancient Greek and Roman philosophies, sadly. The emphasis is on training new practitioners and putting them to work, rather than teaching them where their techniques come from, or allowing them to question some of CBT’s ethical assumptions.

That’s beginning to change, however, thanks to a handful of therapists and counsellors here in the UK. Last year, a psychotherapist called Donald Robertson brought out an excellent book called The Philosophy of CBT, which expertly traced the many connections between ancient philosophy and CBT. He’s started to give workshops in ‘resilience’ that combine CBT, Positive Psychology and ancient philosophy.

Tim LeBon is another who has championed the integration of CBT with philosophy. His 2001 book Wise Therapy argued for the synthesis of philosophy and traditional therapies – including CBT. Tim was one of the first to set up a philosophical counseling practice in the UK, but found that the market for PC was small and that many clients benefitted more from a combination of philosophy and more traditional therapy rather than from philosophy alone. He undertook specialist CBT training and now combines a private practice with NHS work. Tim has successfully run workshops on ‘the good life’, which teach ideas from philosophy within the format of group discussions, and believes such a workshop could be adapted to work successfully within the framework of the NHS. You can read my interview with Tim about philosophical CBT here.

The UK is uniquely well-placed to develop ‘philosophical CBT’. We have in this country a wealth of talented people who are interested in the therapeutic benefits of philosophy – people like Mark Vernon, Antonia Macaro, Julian Baggini, Clare Carlisle, Alain De Botton, Robert Rowland Smith and others. And we also have a government uniquely committed to mental health services, and to a therapy whose roots are in philosophy. It would be valuable to strengthen the links between these two movements, as people like Donald and Tim are beginning to do.

Philosophical CBT would bring together the empirical, practical focus of CBT, and the more values-conscious, open-ended and participatory approach of philosophy. It would bring together the sciences and the humanities, drawing on the best of both worlds.

It would teach practical and evidence-based techniques for self-management, but also explore the original philosophical contexts for these techniques, and create a space for philosophical discussion about wider questions – what am I seeking? what is the goal of life? what is the good society? – which could be discussed in a non-directive and open way, with a facilitator who drew links to different philosophical answers to these ‘big questions’.

As the psychotherapist and philosophical counselor Antonia Macaro puts it: “It’s useful to combine the reflective approach of philosophical counseling with a more practical, therapeutic one (for instance that of CBT) because then you’re better equipped to help people to clarify conceptual and value issues as well as make concrete changes if they want to. That combined approach doesn’t really exist so far – people like Tim and me have had to bring the two together piecemeal.”

How and where could we practice this ‘philosophical CBT’? First of all, we could provide workshops for cognitive behavioural therapists who are interested in exploring the historical and philosophical roots of CBT, and who want to discuss some of the wider assumptions of CBT – for example, what do we mean by ‘flourishing’ or ‘the good life’?

Secondly, clients and service users could be given access to philosophical CBT workshops on themes like resilience, flourishing and the good life. The NHS already provide ‘self-help workshops’ at their IAPT centres around the country, so there is a space and a precedent for this.

And thirdly, philosophical CBT could inform how we teach well-being in schools. The government has already looked at teaching Positive Psychology in schools: the problem with Positive Psychology is it presents itself entirely as a morally neutral science of the good life. That means it teaches a technocratic, instrumental model of the good life that leaves out goodness. It leaves out the important role of ethics, and of practical deliberation over values and ends. It tells people to seek a ‘higher purpose’, but leaves out any deliberation over whether the purpose you’re serving is good or bad. It tells people to seek ‘flow’ by engaging intensely in an activity, but leaves out the question of whether the activity you’re engaging with is genuinely worthwhile or not.

You can’t teach the good life without bringing in these subjective questions of values and ends. Positive Psychology tries to steer clear of ethical debate (that would be messy and unscientific), but the result is a process where people passively consume happiness techniques and ‘thinking styles’, and are deprived of the possibility of engaging in a conversation about the good life.

And the source material for ‘well-being classes’ is typically badly written, bureaucratic and (I’m sorry to say) soulless. Why not at least mention some of the original source material for these ideas? Philosophers like Seneca, Marcus Aurelius, Epictetus and Plato are some of the greatest writers our culture has ever produced – so why not introduce young people directly to them?

It’s exciting that our government is taking well-being and mental health seriously, both in schools and in the wider society. But the danger of the ‘politics of well-being’ is that it becomes technocratic, illiberal and elitist. The scientific experts get to decide what ‘well-being’ means, and the masses are simply conditioned in the correct techniques and lifestyles, rather than being empowered to engage in the ethical conversation as autonomous reasoning persons.

Philosophical CBT could be one way forward, combining the evidence-based approach of CBT with the more open-ended and values-conscious approach of philosophy. And it would introduce people to philosophies that connect the personal to the social and political, and that empower us not merely to overcome emotional disorders, but also to follow richer and more examined lives.

Philosophy on the NHS

Havi Carel had everything going for her. At 35, she had recently met the love of her life, she’d just brought out her first book, and she was about to start her dream job, teaching philosophy at the University of West England, in Bristol (UWE). The future looked bright. Then, she started to notice she lost her breath very easily. She had always been fit and healthy, yet suddenly she couldn’t keep up with her aerobics class, or walk up a hill while talking on her mobile. She thought she might be getting asthma.

On a visit to her parents in Israel in 2006, her father, a doctor, suggested she have a CT scan of her lungs. The evening after the scan, her father suggested they stop off at the radiology clinic so he could pick up the results. Havi tells me: “I sat in the car and waited for him to come back. And waited. After half an hour, I knew something was wrong, so I went into the centre. I walked into the lab, where my father and the radiologist were staring at a CT scan of my lungs. My father looked in shock. The radiologist looked surprised and embarrassed to see me there. He said to me: ‘Do you know what you’ve got?’ I said I didn’t. ‘Have a read.’ And he handed me this enormous diagnostic manual, opened at an illness called Lymphangioleiomyomatosis (LAM). It was full of dense terminology, but at the bottom it said ‘prognosis: 10 years’. I felt this deep, physical shock, and just kept thinking, I’m going to be dead by 45.”

At first Havi thought it must be some mistake. Then she was furious. She was an atheist, but she still found herself railing against fate. “I didn’t smoke, I didn’t drink, I didn’t take drugs, I’d always been good, and now I get this incredibly rare illness? It seemed deeply unfair. Why me? Then I wondered if I was somehow being punished. I’d just finished my first book, about death. I wondered if writing about that subject had somehow caused the illness. It was really difficult to accept the randomness of it – the fact that it was simply a one in a million piece of very bad luck. Then I had to cope with the social reality of having a life-threatening illness: first of all, you’re often treated by medical staff just as a body with an illness, rather than a person experiencing an illness. And then many of your friends and acquaintances don’t know what to say. So they leave you alone, when in fact, I was terrified of being alone. The first few nights after the diagnosis, I slept in the same room as my sister, with the light on.”

Then, after a few months, Havi decided to use one resource she had: philosophy. “I thought, how will philosophy help me now? If it couldn’t, there was no justification in carrying on with it.”
She found Epicurus to be her most helpful mentor. She says: “I knew my future had been curtailed, but I could still find happiness even within illness, by using the Epicurean technique of focusing on the present. I tried to really enjoy whatever I was doing at that moment: yoga exercises, say, or going for a walk, or talking with my husband. Epicurus is right: we don’t need that much to be happy.” And yet, Havi is less sure about the Epicurean claim that ‘what is painful is easy to endure’. In fact, as her condition deteriorated, she found it harder and harder to endure. “You get used to a stage of the illness, and then suddenly it gets worse, and your world shrinks further. I really found that hard.”

Luckily, in 2007, a new drug treatment stabilized her condition. The clouds have lifted, and her prognosis is much more positive. Havi says she’s incredibly relieved to have come through the experience. Yet she also says: “You think you will never forget it, that you will never forget not to worry about the small stuff and to enjoy each moment that you have like it’s your last. The sad thing is, you do forget it. You get caught back up in the small stuff.”

Nonetheless, Havi seems to have been transformed by the experience – not least, her concept of philosophy has changed. She’s no longer so interested in an “academic, highly specialized” subject that is cut off from ordinary people’s concerns, and is now organizing a pilot programme to provide a ‘philosophical tool-kit’ in the National Health Service for people confronting serious illness.


Havi’s story made me wonder if other philosophers are working within the NHS. I know there are some ‘humanist chaplains’ working in some hospitals, and that a colleague of Theodore Zeldin’s, John Reed, is doing some work in a GP clinic in London. There’s a philosopher at Oxford called Hanna Pickard who is also a therapist at the Oxford Complex Needs Service,
using Aristotle to help people with personality disorder. And there’s Derek Bolton of Kings University in London, who’s a philosopher and also a clinical psychologist at the Maudsley Clinic.

And I think we’re beginning to see more ‘philosophical counsellors’ get training in cognitive behavioural therapy, to work within the NHS Improved Access for Psychotherapies scheme. I hear
Tim Le Bon recently trained in CBT, for example – I’ll be interviewing him about it next week. The ancients, of course, thought of philosophy as a ‘medicine for the mind’ – wouldn’t it be wonderful if the NHS provided brief philosophy classes for cognitive therapists, to introduce them to the philosophical roots of their practice?

Even better, people coming through the CBT conveyer belt could then be eligible for a ‘CBT Plus’ class, introducing them to some of the traditions that CBT draws on (Stoicism, Epicureanism, Socratic philosophy, Buddhism) so that they could use these philosophies for life, rather than just for eight weeks. I wonder if doing so would encourage them to practice more often, thereby lowering the risk of relapses?

Havi Carel’s 2008 book, Illness, talks more about her experience.


This conference on psychotherapies in the NHS looks good, on 24th and 25th of November in London. Speakers include David Clarke, the main advisor on Improved Access for Psychotherapies (IAPT), and Sir Gus O’Donnell, head of the civil service, who is talking about measuring well-being.

Here’s some free podcasts by Mark Williams, the Oxford Uni-based pioneer of mindfulness-based CBT, on the treatment of depression.


I went to the Landmark Forum last weekend, for their 3-day course. Pretty intense! It was research for my book. Landmark was invented by Werner Erhard – check out this interview with him from Adam Curtis’ great documentary, the Century of the Self. It’s 31 minutes in.


Sad to see Giles Fraser resign as the Dean of St Paul’s. Giles was the driving force behind the St Paul’s Institute, a sort of ethical finance think-tank set up last year, which aimed ‘to recapture the cathedral’s ancient role as a a centre of public debate’ and ‘engage the financial world with questions of morality and ethics’. Isn’t that exactly what the Occupy movement is doing? Yet perish the thought the occupation was costing the Cathedral money. Now St Paul’s is seeking an injunction to evict the occupiers. Jesus ejected the money-lenders from the temple – today, they want to eject the anti-money-lenders.

See you next week,