If you are reading this, you will almost certainly have heard of it. Cognitive Behavioural Therapy (CBT) is all the rage these days. As a cost-effective, evidence-based treatment for an ever-expanding wide range of conditions it has quite understandably won favour with health-care providers and been widely publicised as a ‘magic bullet’ for all manner of problems. Fresh with its gleaming seal of approval from the National Institute of Clinical Excellence, CBT is widely perceived as the modern, efficient and scientific cure. CBT is ‘therapy à la mode’ and its practical, skills-based approach to managing your own mental health sits very comfortably within the expectations, desires and ethos of our busy modern world.

So effective has CBT been at promoting itself that at the practice where I work we regularly get phone calls from clients who specifically request CBT before they have even been assessed or considered other options. This is because they are already persuaded that CBT is the gold standard treatment of choice: in their minds science has proved beyond all doubt that it works and they don’t want to be fobbed off with anything else, especially not that drawn-out business with the threadbare couch, those awkward silences, and the murderous rage you feel whenever you think about Daddy ‘accidentally’ blowing out the candles on your fifth birthday.

The central premise of CBT, that by changing the way we think we can also change the way we feel, is a powerful one and the techniques of CBT have undoubtedly helped a lot of people dig themselves out of some pretty deep holes. I use CBT in my own clinics. I’ve even written a book about it, so I’d definitely count myself as a believer. However, I am also a believer with reservations. I don’t think that Cognitive Behavioural Therapy is necessarily the answer to every contemporary ailment. I believe that there is still a place for other types of therapy and I think there is a risk that CBT may be somewhat overplaying its hand.

Supporters of CBT make a big fanfare about its solid evidence base, but while CBT has certainly been ahead of the game in appreciating that the reputation of the treatment was going to depend on proper outcome studies, so far the results have not been quite as dramatic as people tend to assume. For example, in the spring of 2008 Stefan Hofmann and Jasper Smits performed a meta-analysis of CBT treatment outcomes for anxiety disorders – one of the conditions with which CBT is most closely associated. While many of the studies they looked at failed to satisfy even reasonable standards of rigour, of the ones that remained they calculated that CBT had produced a treatment effect of 0.33 for anxiety symptoms and had notably less of an effect on depressive symptoms. Now that may not mean a lot to you (depending on how much you like to hang out with statisticians), but as a crude rule of thumb you might want to think of 0.2 as small, 0.5 as medium and 0.8 as large effects. By this estimation CBT produced a positive result, albeit a modest one. However, Dr Peter Kramer rather puts this result into perspective by helpfully pointing out that, ‘With an effect size of .33, three quarters of treated patients, even if doing somewhat better, would continue to experience symptoms in the range suffered by untreated patients’.

Moreover, while CBT might perform as well, and sometimes better, than certain other types of therapy in the short term, some studies suggest that long-term psychotherapy may actually be a better treatment for chronic depression, or those more complex cases where depression occurs alongside other mental-health problems. In a post on the website for the British Psychoanalytic Council in 2009, Daniel McQueen accuses the National Institute of Clinical Excellence of choosing to ignore this research because of its own bias towards CBT and cheap, quick treatment protocols. He further claims that evidence for the effectiveness of even shorter-term psycho­dynamic therapy was binned simply because a larger number of studies existed supporting claims for CBT and Interpersonal Therapy. McQueen protests that ‘such vote counting is simply misleading’. The bottom line is that we need to be a bit more sanguine about touting CBT around as some kind of miracle cure. The existing evidence base certainly doesn’t suggest that.

In any case, the truth of the matter is that the nature of your relationship with your therapist is far more significant in determining how much benefit you will get from treatment than any particular school of therapy they may belong to. Based on a careful literature review conducted in 1992, M. J. Lambert estimated that while the particular techniques employed account for only approximately 15 per cent of the effectiveness of therapy, the quality of the therapeutic alliance forged between therapist and client contributes a whopping 30 per cent. This is only one in a whole range of studies that would suggest it doesn’t matter so much what particular brand of therapy is being used as how you feel about the person doing it. In 2001 Bruce Wampold, a former statistician who examined the outcomes for treatment of depression, supported Lambert’s conclusions and reported that no one modality of treatment emerged as significantly better than any other – including CBT. More recently the American Psychological Association sponsored a task force to sort out once and for all what works in the therapy relationship. Once again, the same conclusion emerged: the consensus of several thousand studies was that the nature of the therapeutic relationship had just as much impact on whether clients improved (or failed to improve) as any particular treatment method.

Efficacy apart, it seems to me that there are some fundamental theoretical issues that CBT hasn’t really addressed. In founder Aaron Beck’s original model, your thoughts, feelings, physiological reactions and behaviour are all connected in a system of mutual influence. If you work with a CBT practitioner, before long you will inevitably find yourself sitting in front of a fetching diagram plastered with two-way arrows illustrating these pathways of mutual cause and effect. However, while the kingdom of the mind thus described may look like a democratic polity in which the wards of thought, sensation, feeling and action all enjoy equal status and influence, when it comes down to the nitty-gritty of actually doing the therapeutic work, you will find that most attention is concentrated on one particular area: your thought life. The mutterings of that critical voice in your head, those unwanted thoughts that pop unbidden into your mind – these are the primary targets of CBT and get the lion’s share of its attention. In the realm of CBT, to misquote George Orwell’s Animal Farm, while all the factors involved are supposedly equal, some appear to be more equal than others.

CBT remains a largely top-down model. To listen to the more zealous CBT therapists speak, you would conclude that if the head doesn’t always rule the heart, it potentially always can and probably should. CBT has encouraged a widespread and misplaced assumption that our thoughts (positive or negative) are always the root cause of our emotions and on the back of this rides the expectation that we can reliably mobilise our thoughts to subdue any emotions we don’t want around.

But, as any honest CBT therapist will tell you, one of the recurrent problems that crops up in CBT sessions is the difficulty of isolating the relevant ‘automatic thoughts’. Negative automatic thoughts – as the name implies – are supposedly the thoughts that inconveniently pop into one’s mind as a result of certain biases of interpretation: ‘I’m rubbish’; ‘Things never go my way’; ‘I can’t cope with this’ and so on. We are all familiar with the persecutory little voice that whispers such things to us, and your CBT therapist will be keen to pinpoint such cognitions since they are believed to be the switches that open the floodgates of unpleasant feelings.

But often these negative automatic thoughts prove surprisingly elusive. Clients will describe situations that left them flooded with feelings of panic or despair but really struggle to identify any conscious thoughts that may have been involved. Sometimes the therapist will helpfully suggest a way that the client might have been construing the scenario in question, or use their existing knowledge of the client to tie the reaction into other beliefs that the client has about themselves. Often they will fall back on the old cliché that these thoughts are just so habitual that while we may scarcely notice them any more, they’re still there dragging us down nonetheless. But this is just cheating isn’t it? What if those thoughts genuinely were never there in the first place?

It’s certainly not so unreasonable to suggest they might not be. While there has been much discussion about the precise nature of the unconscious mind, most cognitive scientists agree that a great deal of our processing of the world goes on below the level of our conscious awareness. The trouble is that we can’t access or exercise conscious control over cognitive processes we don’t know anything about. For us this level of processing is automatic and effectively invisible, made known only by its effects. Sometimes these processes may percolate up to the surface where they appear as conscious thoughts but there is no guarantee that this is always the case, and no reason to believe that the flow of traffic is necessarily always two-way.

A fascinating and well-known finding by Benjamin Libet, replicated over many successive investigations, indicates that what goes on in our conscious minds may turn out to be far less important than we assume. There have been reliable but counterintuitive studies that indicate that our brains start to initiate movements by booting up the motor cortex 300 milliseconds before we are even aware of making the decision to move. This result implies that while we may believe we are making conscious choices to do things, the level of our minds that really governs some choices is operating at a pre-conscious level. According to these studies the conscious decision that we think causes the action never did: it’s just an illusion our minds play on us after the event. Psychologist and broadcaster Susan Blackmore believes that these experiments indicate that ‘conscious experience takes time to build up and is much too slow to be responsible for making things happen’. If our brains have a life of their own that we are not even aware of, the notion that reprogramming our conscious minds is going to alter things at these subterranean levels starts to look a little optimistic.

Then again, just which brain are we trying to reprogram? It may come as a surprise to learn that every human being has not just one brain but two. Most of us are familiar with the brain resident in our skull, but in fact your gut also has a ‘mind of its own’. Its lining is embedded with some 100 million neurones, which work together to coordinate the surprisingly complex task of digesting food and expelling waste. The enteric brain has its own reflexes and senses, and although it is connected to the central nervous system through the vagus nerve, it can also operate completely independently of it. The enteric brain employs more than 30 neurotransmitters to coordinate signals and impulses across the system and 95 per cent of the body’s seratonin (the hormone that the most widely-used antidepressants attempt to keep at optimal levels in your brain proper) is to be found in your bowels.

Significantly, this enteric brain plays a major role in the way we experience emotion: we all know what it is like to get ‘butterflies’ when we feel nervous or to feel ‘sick to our stomach’ when contending with distressing or shocking news. Emotion is often a visceral business, and it may be no coincidence that the ancient Taoists associated anger, anxiety, fear, worry and sadness with different regions of the soft organs that are all linked parasympathetically by the vagus nerve and sympathetically by the splanchnic nerves. The most crucial point for the current discussion is that, due to the way the vagus nerve is constructed, 90 per cent of the nerve fibres are dedicated to transmitting information up towards the main brain, leaving only 10 per cent committed to sending information down in the other direction. This may suggest that while the enteric brain may have significant input into what we experience mentally, our conscious thought life may have relatively little leverage when it comes to controlling what our guts are already screaming at us.

Then there is the thorny issue of how much purchase rationality has over our unwanted thoughts and emotions anyway. One thing that has always slightly irritated me about CBT is its tendency to define any thought that makes us feel uncomfortable as ‘irrational’. This is tantamount to saying that if I don’t like it then it can’t be true. I’m sorry, but sometimes your most paranoid and pessimistic interpretations of the situation are entirely correct. Maybe your friend actually was avoiding you; it really wasn’t that she failed to spot you or was rushing to the bathroom or any of the other supposedly ‘rational’ alternative interpretations you and your therapist come up with.

For Freud and the psychoanalysts, of course, the activity of the conscious mind was just the tip of the iceberg visible above the waterline, while the elemental forces that really drive human lives do their work unbidden and unseen within the murky depths of the unconscious. And according to Freud and Jung, the world of the unconscious mind has little truck with the niceties of logic and reason. It is an anarchic dark void of fleeting impressions and semi-formed ideas, a vortex of turbulent emotion populated by phantoms, fantasies and dark desires. Freud argued that the so-called ‘primary process’ thinking that occurs in the unconscious is marked by its complete disregard for conventional logic or the laws of causality. In the world of the id anything is possible. It doesn’t have to make sense.

So if only a fraction of what originates in the unconscious bubbles up to the surface to assume the form of thoughts (negative or otherwise) there may be a great deal of highly emotive material left below that lies forever beyond the reach of reason. Jung also believed that when the contents of the unconscious mind do percolate through they can often take the form of images rather than words. This begs the question: how do you argue or reason with a picture? If the unconscious doesn’t even speak the language of its more reasonable conscious counterpart, we might be on a hiding to nothing trying to reason with it.

Rationality may be of particularly limited use when facing situations that trigger our fight-or-flight reflexes, one of our most primitive protective systems. How often have you heard people who have survived disasters saying that ‘there was no time to think’, ‘my mind froze’ or that they ‘have no idea how we ever got out of there’? When we feel threatened we are designed to stop thinking and let our instincts take over. The primitive reptilian brain pulls rank and does the job it has been doing successfully for over two million years: that of helping you survive. What this means though is that various unpleasant feelings, the sort we associate with danger and threat, are more likely to switch off the higher centres you need to reason with your crazed, fear-filled mind. Not only will certain negative emotions stand less chance of emerging as clear thoughts but, once in the grip of them, your rational mind may not even be fully online to address them.

Finally, I suspect that sometimes we may be trying to enlist the wrong kind of logic altogether. CBT tries to treat us all like good little miniature scientists. It assumes that we are essentially rational, reasonable creatures – a proposition that frankly even the most cursory examination of our actual lives blows clean out of the water. While scientists and philosophers may lean on the power of reason and dutifully sift and weigh evidence, in our daily lives most of us operate under the auspices of a very different kind of ‘logic’ and sense making. The latter has much more to do with the ethos of myth and story-telling than it does with the world of lab coats and test tubes.

CBT treats ‘negative beliefs’ as if they exist in discrete bubbles that can be easily detached and held up to the light of reason. But a story is more like a tapestry. Its meaning is encoded within the whole narrative and the relationship between its parts. While you can trace an individual thread, a particular theme or focus in on one area of the picture, you can’t ever really examine any of these in isolation. It’s as if every part of the story simultaneously touches every other part of itself so you can’t pull bits out without unravelling the whole thing. One of the supposed advantages of CBT is that it allows you to ignore the past and just focus on what happens in the present. However, our personal stories, unlike abstract beliefs, extend through time. While they can be conceived as a whole, they cast shadows upon our past and illuminate a pathway towards a yet untold future.

The only consistency we require from stories is that they ‘feel right’ to us. This may have little to do with whether they make logical sense. Like Lewis Carroll’s Queen of Hearts, when it comes to our personal narratives, we are all capable of believing ‘as many as six impossible things before breakfast’. Rationality has nothing to do with it. Narrative tone and thematic coherence are what count.

Logic also comes up pretty empty-handed when we are dealing with what matters most to us – our values, our ethics, our loves and hates. Shakespeare was right when he said that ‘Love and reason keep little company together’, and by translating the flow of consciousness into staccato abstract thoughts which are then evaluated according to how reasonable or useful they are, CBT all but ignores a crucial and all-pervasive dimension of consciousness: the fact that in everyday life the stories we weave to make sense of the world invariably carry a moral or ethical charge. Something in the makeup of the human psyche makes it almost impossible for us to experience the world and our lives except in these terms.

Pick up today’s newspaper. The events that have grabbed the headlines are all issues that connect immediately with our moral awareness. As I write this, they happen to concern a sea captain who may have deserted his ship before the passengers were escorted to safety, the ethics of city bankers paying themselves inflated bonuses, and a phone-hacking scandal that has called the integrity of the press into question.

Our brains willingly and instinctively process these facts into moral fables, tales of men and women doing good and bad things. And it’s not just current affairs that we tend to infuse with moral significance: we make these kinds of value judgment the whole time, applying them liberally to almost every area of life that matters to us. Yet, as the parables of Jesus and the fables of Aesop demonstrate, the moral undercurrents of life are best translated into stories rather than the kind of discrete thoughts and beliefs that end up in the bubbles in CBT formulations. When it tries to address the ethical issues that preoccupy real-life human beings, the conventions of CBT all too readily dislocate meanings from their contexts, often with really unhelpful results. It’s a bit like text-speak. It leaves us trying to translate something quite subtle into a clumsy stylised language with a really limited vocabulary. It forces us to collapse, condense and delete important nuances of our experience rather than highlighting them. It’s a literal case of what philosophers and mathematicians call reductio ad absurdum. When it comes to moral meaning often the story is the message. It can’t be processed into some convenient abstraction, simply because that happens to be the currency CBT likes to deal in.

People often come into therapy not because they are plagued by illogical thoughts but because they instinctively feel that the stories they have sought to live by are unravelling. Something has happened that threatens to undermine the integrity of their personal narrative, or they suddenly find themselves cast by events into roles they never intended or chose for themselves. For others, the opposite is true. These clients are locked into stories and roles from which they feel powerless to escape. The stories we tell ourselves are powerful organising forces. They exercise an inexorable pull over our actions, feelings and choices, rather like a magnetic field draws scattered iron filings into alignment with its own invisible lines of influence.

When dealing with the steady undertow of someone’s implicit narrative, reason and logic often prove feeble instruments. If an action, a feeling or a belief ‘fits’ within the dynamic of the tale being told it will be embraced, however illogical or absurd it may be. Recasting and rescripting such stories is always destined to be an art as much as a science. Therapy can be about so many things, but at its heart it is often an attempt by two people to forge a new narrative together that both therapist and client can sign up to, hopefully one that reinterprets the past or opens up new possibilities for the future. These stories certainly have to make sense, but the sense that they make is often of a very different order to the ‘sense’ that CBT trades in.

In 1877 the Italian astronomer Schiaparelli saw something through his telescope that looked like channels on the surface of Mars. The American astronomer Percival Lowell, greatly enthused by Schiaparelli’s work, set up an observatory in Flagstaff, Arizona, and had soon not only mapped out a complete network of canals but was enthralling the public with his lectures about Martian civilisation and tales of how the inhabitants had constructed the canals in a desperate attempt to channel water from the ice caps as the planet slowly heated up and died. Unfortunately Lowell had got a bit ahead of himself. When the unmanned craft Mariner 9 mapped the red planet in 1972 no evidence of the famous canals was found. Today it is known that they are a product of an optical illusion. Lowell was a brilliant man but he got carried away and assumed too much.

The danger with Cognitive Behavioural Therapy is that we do much the same. CBT absolutely has already made a genuinely valuable contribution to our ongoing quest to understand how our minds work and how we can best fix things when they go wrong. However, until we do have a more adequate understanding of what goes on inside our heads, let’s not carry on as if we already have the whole business sussed, as fans and practitioners of CBT are rather wont to do.