The Great CBT Experiment: How We Turned Mental Health Into a Production Line

Since 2008, the NHS has treated over a million people annually through IAPT (Improving Access to Psychological Therapies). It's been called a "world-beating standard."

During this same period, common mental health disorders increased from 17.6% in 2007 to 22.6% in 2023/4. One in five young people now has a probable mental health condition.

We're treating more people than ever. They're getting sicker than ever.

Something's not working.

The Economic Case for CBT

CBT dominates NHS mental health provision because it promises something irresistible: quick, measurable results that can be standardised and delivered at scale. Six to twelve sessions. Structured protocols. Questionnaire scores that show "recovery."

The economic case was explicit from the start. Richard Layard, the economist who championed IAPT, argued it would pay for itself through reduced welfare costs. Get people off benefits, back to work. £650 for therapy versus £650 per month in disability payments. Simple maths.

But here's what actually happens: 60% of people referred don't complete treatment. Of those who do, about half "recover" - meaning their questionnaire scores drop below a clinical threshold. Not thriving. Not understanding themselves better. Just scoring differently on standardised measures.

And they're back within a year. Same patterns, different symptoms.

What CBT Actually Treats

CBT treats your mind like faulty software that needs debugging. Negative thought? Challenge it. Catastrophising? Here's a worksheet. Anxiety? Let's restructure those cognitions.

It's compelling because it offers control. You can master techniques, complete homework, track your progress. For certain specific problems - a phobia of flying, panic attacks with clear triggers, some forms of OCD - this can be genuinely helpful.

But most human suffering isn't a technical problem. It's not about thinking errors that need correcting.

It's about patterns laid down before you could speak. Relationships that taught you who you had to be to survive. The gap between who you are and who you learned to perform. The rage you weren't allowed to feel. The grief that has nowhere to go.

CBT doesn't touch any of that. It teaches you to manage symptoms while the underlying patterns continue untouched.

The Questions Therapists Don't Ask Themselves

Here's something curious: CBT therapists rarely choose CBT for their own therapy. They know all the techniques, can spot every cognitive distortion, understand the protocols inside out. Yet when their own lives fall apart, they tend to seek something deeper.

Because when you're lying awake at 3am, you don't need someone to challenge your thinking errors. You need to understand why you keep ending up in the same painful place.

When your third relationship implodes in exactly the same way, you don't need a thought record. You need to understand what you're unconsciously recreating and why it feels so familiar.

When you've spent years being competent and capable and suddenly can't get out of bed, challenging negative thoughts won't touch what's actually wrong.

What Depth Work Offers Instead

Psychodynamic therapy starts from a different premise: your symptoms make sense. They're not errors to be corrected but communications to be understood.

Depression might be protecting you from rage you're not allowed to feel. Anxiety might be the only way your body knows how to say no. That pattern of choosing unavailable partners? It might be the only kind of love that feels familiar.

The exhaustion behind your competence. The performance your relationships have become. The gap between who you appear to be and who you actually are.

This work takes time because we're not fixing surface problems - we're understanding the machinery that creates them. It's not efficient. It can't be standardised. You can't measure it in questionnaire scores.

But it changes things at the root rather than managing symptoms at the surface.

The Conceptual Error

The mental health crisis isn't a treatment failure - it's a conceptual one. We've mistaken emotional suffering for a technical problem. We've confused symptom management with healing. We've prioritised getting people functional over helping them understand what's actually wrong.

CBT works brilliantly for what it was designed to do: reduce symptoms quickly and cheaply enough to get people back to work. The system is working exactly as intended.

But human suffering isn't a productivity issue. Trauma isn't a thinking error. The patterns that keep us stuck weren't created by faulty cognitions - they were survival strategies that made perfect sense at the time.

You can't worksheet your way out of patterns that were formed before you had language. You can't challenge thoughts about feelings you don't know you're having. You can't restructure cognitions when the problem is what you learned about who it's safe to be.

What We're Actually Measuring

The NHS measures "recovery" through questionnaire scores. Did your PHQ-9 drop below 10? Congratulations, you've recovered from depression. Never mind that you're back at your GP six months later. Never mind that the pattern that created the depression is still running.

We're measuring symptom reduction, not understanding. Functionality, not meaning. Return to work, not quality of life.

And we're calling this success while mental health continues to worsen.

The Choice We're Not Making

CBT isn't useless. For some people, in some situations, it's exactly what's needed. Learning to manage panic attacks or challenge specific phobias can be life-changing.

But we need to be honest about what we're doing. Teaching people to cope isn't the same as helping them heal. Managing symptoms isn't the same as understanding causes. Getting people functional enough to work isn't the same as helping them build lives worth living.

The question isn't whether CBT or psychodynamic therapy is "better." The question is: what are we actually trying to achieve?

If we want to manage symptoms and hit targets, CBT does that efficiently.

If we want to understand why people keep ending up in the same patterns, why the same problems keep recurring despite everyone's best efforts, why treating more people makes the problem worse - that requires something different.

It requires being willing to sit with not knowing. To tolerate messiness. To value understanding over efficiency. To work at the pace of actual change rather than the pace of questionnaire scores.

Most importantly, it requires admitting that the current system - despite treating more people than ever - isn't actually working.

The production line is running perfectly. We're just not sure what it's producing anymore.

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Luke Row is a BACP registered psychodynamic therapist in Croydon and online. I work with people who've tried managing their symptoms and are ready to understand what's underneath.