6. Thinking Differently (II)
It is all about relationships

Reflections on how CBT makes us think differently about responding to disadvantage
A lot of people must have been thinking that CBT was the answer, a scalable product that brings relief to at least some of life’s ills. But for me it represents one of many starting points to finding that answer. In fact, at this point in my studies, it is posing more challenges than solutions.
When I talk to people who say the course of their life has been altered by strong relationships, the role of cognition consistently shines through. Once the relationship solidifies they say they begin to entertain different thoughts about their life and the decisions that affect their future life chances. They ask themselves ‘why am I doing this?’ for example sleeping rough. Or they say ‘I think I might be able to do that’, for example get a place to live, get a job, or restore a broken family relationship.
I also see lots of evidence of cognition mutilated by emotions of shame, guilt and pity.
When I talk to people who say the course of their life has been altered by strong relationships, the role of cognition consistently shines through.
But what do we mean by cognition? In CBT, as I understand it, therapy clears the way for seeing the world as it actually is, unclouded by emotions. I think the young people talking to me about the effects of a healthy relationship with somebody who wants to help them are getting at something similar. Earlier in the series I wrote about Bowlby’s internal working model, a succession of mental representations that help the infant child understand themselves, those around them and the physical world. That is something more. Now as scientists explore the limitations of CBT they are drawn into the wealth of new data on the human brain which point to the potential for each of us to have multiple selves. Now my grasp of what is meant by cognition is lost.
Disentangling all of this evidence to draw out those elements amenable to influence by healthy relationships or therapies like CBT has to be a priority for those of us interested in the potential of relational social policy.
Some forms of CBT question whether a relationship is a necessary part of the equation. In recent adaptations the therapy is self-administered, or it is delivered online. It is easy to imagine a future in which people will buy robots to clean their house, and download a program to get the robot to deliver CBT in the evenings.
Those with relational capability retain enduring attachments to the people they help, and they remain as a mental representation long after the day to day connection has ceased. A therapist generally sees her client for 20 hours in total. How long does it take to turn the cogs of cognition?
Maybe we will be in relationships with our robots? CBT throws up an interesting challenge. Can it work as effectively without interaction with another human being, or an android? The procedure laid down in a manual, qualified people can be trained to deliver it according to the book. No need to bring along their personality, no need to make any kind of attachment with the patient.
The helpers I talk to have no manuals, just their relational capability. Are they doing the same thing only intuitively and differently? Or are they doing something different, better maybe? One difference I can see is the way those with relational capability retain enduring attachments to the people they help, and they remain as a mental representation long after the day to day connection has ceased. A therapist generally sees her client for 20 hours in total. How long does it take to turn the cogs of cognition?
Which brings me to another challenge both to CBT and my own work on relational capability. What happens when cognition is impaired. Some of us think more and quicker than others. Is CBT on the one hand and relational capability of helpers on the other most effective with those who have the greatest capacity to think for themselves?
Which brings me to another challenge both to CBT and my own work on relational capability. What happens when cognition is impaired.
A few years ago the team I was working with were invited to the Harvard Center on the Developing Child to consider new ways of scaling impact of programmes on children’s lives. One example they considered involved CBT. An initial trial of the therapy for people with anxiety showed modest effect sizes. But in the second round of the experiment, people who had experienced child sexual abuse, which often leaves its mark on cognition, were excluded. Effect sizes doubled.
Many of the young people I am working with are living in conditions where the most intellectually sophisticated person would find it impossible to think; sleeping rough; malnourished and hungry; addled by alcohol and drugs. In these circumstances, is it reasonable for relationships or therapy of any kind to leave their mark?
