Category Archives: CBT

Why I am Not a CBT Therapist…

In today’s therapeutic landscape, people have to be aware of multiple competing approaches to dealing with life struggles and emotional pain.

Sometimes in the public eye, it would appear that an approach named CBT or Cognitive Behavioral Therapy is the only effective choice. That view at least is promoted by many psychiatrists, who in recent years have turned away from their psychoanalytic past, and have rebranded themselves as men and women of science.

It is also promoted by many psychology departments, who have been quick to embrace a more mechanical approach to therapy because of the ease with which such an approach can be studied using a scientific method.

However, despite this seemingly enthusiastic endorsement of CBT as the treatment technology of choice, it serves us well to revisit the history that accounts for why CBT became so popular. This will help us consider if CBT’s claim to superiority is really as justified as it would seem on the surface…

Why CBT Became Popular…

Cover of One Flew Over the Cuckoo's Nest
Jack Nicholson in “One Flew Over the Cuckoo’s Nest”

CBT was developed to fit a need that arose in the 1970s, when it was decided to deinstitutionalize the treatment of severe mental illness. The chronic institutionalization of the mentally ill, parodied in movies such as One Flew Over the Cuckoo’s Nest was no longer in political favor. Instead people were now to be treated in outpatient community settings that seemed less restrictive and more humane.

Thousands of community mental health settings now arose, typically understaffed and underfunded, and these centers were in need of some effective alternatives to the long-term treatments that had been offered when clients were in hospital care.

Most of the patients seen in community settings had severe problems functioning successfully in their day-to-day lives and might only be able to afford a few number of visits. Psychoanalysis, with its long term exploration of the root causes of people’s problems was therefore no longer a realistic or practical treatment option.

Luckily, through a series of accidental discoveries, new medications such as the SSRI’s, were now available to psychiatrists, and psychologists were quick to fill the remaining treatment vacuum with a toolbox of cognitive behavioral methods intended to bring about quick relief.

CBT had a market and an ally in community mental health and in a reinvented medication-based psychiatric profession. Clinicians in community mental health settings, scrambling to provide effective solutions to take the place of more structured long-term care, were happy to embrace practical skills they could teach their clients.

What is CBT?

If I were to simplify what CBT is, I would say that it consists of methods to help you: think straight, face your fears, and manage your problems.

In order to think straight, patients are taught to examine the realism of their emotion-driven and often unrealistic thoughts.

In order to face their fears, patients are helped to break down daunting goals to more manageable tasks, and are nudged by their therapist to take small risks and baby steps in the right direction.

In order to manage problems, patients are helped to think of “coping skills”, which consist of a tool box of practical activities, mental reminders, or things you can tell yourself to help you get through your day. These skills help you distract yourself or counteract negative emotions or thoughts that bring you down.

The Benefit of CBT:

Such CBT skills work wonders when you have grown up in invalidating environments without good role modeling or practical life management skills, and they are easy to dispense in a short amount of time. They help support and build problem-solving abilities and to encourage the discouraged through active coaching.

In community mental health settings where the goal was to increase people’s ability to function in their day-to-day lives, these techniques were just what the doctor ordered.

Furthermore, it is quite easy to study whether or not patients who receive these skill-boosting sessions actually manage to use them to live more functional lives, and research shows that they do. Hence CBT can be marketed as a scientifically validated or empirically supported treatment for life’s many problems.

This accomplishment helped cement both psychology and psychiatry as scientific disciplines, and was easy to brand to the public eager for an economical and quick fix for their problems. It also won the affection of third party insurance payers who demanded proof of effectiveness before reimbursing treatment providers, and who liked the promise of briefer and more targeted therapies.

So What is Wrong with CBT?

Most psychologists I talk with express at least some discomfort while learning CBT. It often feels infantilizing to teach people how to think or how to problem-solve, and it is hard to really believe in the effectiveness of such an approach, beyond some temporary boost of optimism and self-efficacy.

Clients, too, often feel like the suggestions, advice, and exercises offered to them through CBT are rather superficial.

Simply pointing out why a thought is irrational, doesn’t really alleviate the emotional attachment to a more irrational belief. People often end up challenging their own thoughts and replacing them with more rational ones without really believing in what they are telling themselves.

Furthermore, it is hard to believe that a simple toolbox of skills is really going to address the fundamental issues of your existence and really help you get to the root of your deep psychological issues. The ability to distract yourself, tolerate pain, calm yourself down, and so forth, seem at best a good set of tools to have when embarking on the real emotional work that is the hallmark of longer term therapy.

Problems of living and the experience of unpleasant or inhibiting emotions, such as excessive guilt, shame, and psychological pain, will at one point require a confrontation with one’s past, and will necessitate an emotional experience of working through this past. Simply functioning better or dealing more effectively with one’s emotions in the present, is a poor substitute for examining one’s life, and experiencing a real emotional transformation in how you feel about yourself.

This kind of emotional work that transforms you from within, is slower to unfold, and may not be the place to start if you are barely functioning in your life. But this does not mean that CBT should become the treatment of choice for everyone and anything. If you are ready to go beyond problem-solving to truly discover the emotional causes of your current distress, and if you want to confront the deeper question of how you became the person you are today, I would choose a different therapeutic approach.

Why I am a Psychodynamic Therapist:

Psychoanalysis may have been dethroned from psychiatry and may not be a practical therapy in mental health settings, but it still has a lot to offer for those who are willing to invest the time and money in a deeper experience of change.

Psychodynamic therapy, which is a briefer and modified form of psychoanalysis, is a very viable and cost-effective alternative to CBT that takes you beyond simplistic solutions to life’s problems.

The goal in psychodynamic therapy is a transformation in how you feel about yourself through greater self-understanding and a confrontation with your past. It is in my opinion the superior choice for someone who really wants to understand themselves, and who instinctively knows that their problems are not external issues to be managed, but something missing deep inside of them.

If you want to read more about psychodynamic therapy, read my earlier blog post: What is Psychodynamic Therapy?

To read about the effectiveness of psychodynamic therapy, check out Jonathan Shedler’s article from The Scientific American, dispelling some common myths about this type of therapy.

The Making of DSM-IIIFor more about the fall of psychoanalysis, and the rise of CBT and medication-management in psychiatry, have a look at the excellent book by Hannah Decker: The Making of DSM-III. A Diagnostic Manual’s Conquest of American Psychiatry.

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Dr. Rune MoelbakAbout Me: I am Rune Moelbak, Ph.D., a psychodynamic therapist in Houston, TX. I provide deep treatment of people’s issues. Click here to read more about my approach to therapy.

 

Psychotherapy: Does Insight Cure?

Over the past 100 years, therapists have asked themselves the question: what really produces change in people? In this connection, the role “insight” plays in helping us resolve our issues has often been a point of contention… So does insight really cure?

Insight in Psychoanalysis

In the heyday of psychoanalysis, a prevalent belief was that change resulted from understanding our unconscious conflicts, or making the unconscious conscious. The main tool of the psychoanalyst was believed to be the offering of an interpretation of the unconscious truth of which the client was unaware. Unfortunately to get to this point, people often needed to be in “analysis” for years, and the outcomes weren’t necessarily that consistent nor impressive.

The Cognitive-Behavioral Critique of Insight

This led to a wave of criticism against the psychoanalytic idea that insight is a sufficient condition for change.

Cognitive Therapy:

The dissatisfaction with the slowness of change led a psychoanalyst like Aaron Beck to focus instead on making the client aware of the more immediate automatic thoughts that exist just beneath our conscious awareness. He invented what has now become known as cognitive therapy, an approach where the therapist uses logic to help the client refute their “irrational” emotion-driven beliefs. Instead of spending years probing the unconscious in search for “truth”, Aaron Beck and his followers instead engage directly with the client’s thoughts and help them realize the absurdity or contradictions of some of the things they tell themselves.

Unfortunately this kind of rational approach to change often does not really address the logic contained in a person’s emotional responses and it ends up reinforcing an untenable division between the emotional and logical dimensions of existence. Clients end up at war with themselves, and the unaccepted emotional impulses eventually tend to return with a vengeance.

Behavioral Therapy:

Other therapists have responded to the dissatisfaction with lack of change through insight by emphasizing “practice” over “understanding”. They advocate that you take concrete steps to change something about your life and help nudge you in that direction by addressing all the obstacles that get in your way. Unfortunately this kind of behavior therapy often leaves you feeling that you are acting against your own will or against your own emotions. Although you may succeed in changing your habit for a while, most people end up back in their comfort zone once therapy is over and they have no “coach” yelling in their ear.

Both the cognitive and the behavioral approaches to therapy are essentially ways to speed up the process of change by tackling problems directly, and circumventing the slow process of insight. However, ironically, they often do so by not having sufficient insight into the problems they set out to change. They frequently offer premature solutions to inadequately understood problems and they often don’t really have a complex enough understanding of the forces at work within the person.

Insight as Experiential Truth

In my opinion, a lot of the backlash against insight-oriented approaches to change, has to do with a premature definition of what insight really entails. If we define insight as intellectual understanding, then the critics are probably right: Nobody was ever really changed by simply knowing about their problems or having an explanation for why they do things the way they do them.

However, insight is not the process of passing information from one mind to another. That would be teaching, not therapy. The insight that good therapy produces is both intellectual and emotional, or rather, it is existential. It addresses the person as a whole, at a level where no division exists between mind and emotion. The quality of such an insight is that it is irrefutable.

We have these kinds of insights throughout our lives, and we can recognize them as such, because they do not allow us to go back to the way things were. Once they happen, they transform us. They are the insights that we get from watching a really thought-provoking movie that impacts both emotions and mind and let’s us see the world in new ways. They are the insights about ourselves that we gain from being in a romantic relationship, or breaking up a relationship. In short they are the insights from life’s many little significant moments that make us realize something about who we are or what the world is like.

Existential philosopher Martin Heidegger speaks of this kind of truth as Aletheia or unconcealment. It refers to the moment when something that was always already there, is shown to us. When this happens, I don’t experience it as some intellectual understanding, but as a homecoming or a return to something which had been forgotten or covered over.

Psychotherapy as an Experience of Truth

Psychotherapy is a process of unconcealing these irrefutable truths contained within our own experience. These kinds of insights return me to myself and give me no room for argument.

The best way to reach them is not to provide explanations to people, to engage in logical arguments with them, or to suggest ways for them to act differently. It is to provide an experience.

Insight is therefore not just about what is revealed, as the critics often assume. It is also about how it is revealed. Simply telling someone a truth is not effective and is easily refutable. Letting someone experience truth, on the other hand, is quite a different story. My experience can teach me something about myself that I can just as little refute as I can refute that I have a nose, or that I have two ears. If I had a good time at a party, for example, this truth is irrefutable. It does not matter if someone else tells me it was a bad party. My truth is irrefutable. I cannot undo the fact that the party was enjoyable for me.

Therapy is a process of giving a person an encounter with the truth of their own experience. This is what insight as aletheia is really about.

It can be as simple as giving a person the realization back that a word he seems to be using creates a tie between his history of being sexually abused and his current social anxiety. “I don’t speak much in social situations”, he says. “You don’t speak much, or you keep silent?”, I utter. Without me telling him, the client has now been given back an experience of the connection between his shyness and the fact that he has had to keep a secret about his abuse all his life. I did not provide a laborious explanation, but used my words to “unconceal” something; to show him rather than tell him. The result was a visceral reaction in the client who now experienced himself in accordance with a new truth. He had been given a new foundation for his thoughts and experiences, revealed to him by his own words and his own unmistakable reaction to my words. He had learned a truth which could not be undone.

Therapy proceeds through such little insights, and a person changes without ever really forcing a new behavior or battling a single thought. So to answer our question: Does insight cure? The only way to tell is to experience it for yourself…

Note: If you would like to read more about therapy as an experience of truth, read my article: “On Cultivating the Therapeutic Moment. From Planning to Receptivity in Therapeutic Practice.”

About me: I am Rune Moelbak, an insight-oriented therapist in Houston, Texas. Visit my website for more information. 

Psychotherapy: The Shortest Distance is Not Always a Straight Line

In psychotherapy the shortest distance between two points is not necessarily a straight line. The laws of math that apply to the physical world often seem to be suspended in the therapist’s consulting room.  And yet the geometry of straight lines has an orderliness to it that makes it appealing to clients and therapists alike…

The Therapist’s Fascination with Straight Lines

Were you to peek inside most “behavioral health” agencies today, you would see the logic of straight lines applied everywhere. The fascination with geometric rationality is here so dominant, that you would be excused for wondering if their psychotherapists had a background in engineering, rather than psychology…

Psychotherapy in these settings has become a very rational and well-planned endeavor that is usually centered around a geometrical road-map, also called “the treatment plan”.

Guided by the dictates of the treatment plan, therapists in these settings are asked to first identify the client’s problem, next help the client set some goals, and finally devise a plan to most quickly and efficiently achieve those goals. From then on therapy is supposed to follow the plan in a straight line from start to finish. Any deviation from the road map is considered disruptive and tangential. It threatens the geometric principles of treatment.

In line with this approach you can hear well-respected cognitive behavior therapists (the engineers of the field) speak of “potentially therapy-disrupting behaviors” that include “attempts [by the client] to overly control the pace of topics of conversation during the interview” (Wright, Basco, and Thase). You can also hear statements such as: “One of the challenges in this treatment is to avoid getting distracted by discussions of other problems the client may be facing” (Safren). In short, we must straight-jacket the process to make it fit with the plan. We must shape the territory to make it look like the map!

Two Different Views of Psychotherapy

So what is wrong with this picture? To the rational mind, planning psychotherapy ahead of time and directing treatment with an authoritative hand toward definite goals can seem very intuitive and appealing. And yet, I would argue that it misses the point altogether…

Psychotherapy is not about getting somewhere that is known in advance. In fact, therapy is itself a process by which we discover where we want to go and what we want. To determine the goals in advance of the therapy is thus much like putting the carriage before the horse…

If we use the metaphor of a road-trip to describe what psychotherapy is, then we can perhaps compare the two approaches in the following way:

In the first more “planned” approach, we are trying to get the fastest way possible from New York to Los Angeles. We therefore take the freeway in a straight line to the destination, missing all the sights along the way. We end up in Los Angeles in record time, but have learned very little along the way. We have reduced the journey to a simple means of transportation to get us from point A to point B.

In the approach I advocate, we might also begin our journey toward Los Angeles. Instead of zooming past all the sights, however, we allow time to get off the beaten path and leave ourselves open to new experiences along the way. What might then happen is that we discover that we would rather go to Cleveland, or that it isn’t really so important to get to Los Angeles right away. Maybe it is more interesting to make a detour to the Grand Canyon, or to follow our chance encounters.  We may even decide that our whole enterprise has been a mistake and return back home.

I am speaking metaphorically here, of course, about the nature of the human psyche: Contained within us there are many unexplored territories, and many memories and experiences that can teach us something new about what we really want in life. Going in a straight line may therefore not be the fastest way to get where we ultimately want to be…

Psychotherapy and the Dance of Life

The irony is that when we plan psychotherapy too much, we miss out on all the key therapeutic moments. The real “stuff” of psychotherapy is not about getting to the destination, but about all the little surprises that happen along the way. The goal of psychotherapy is not to get us from point A to point B in the most direct way possible, but to help us undergo a journey where the destination itself can change as we discover new things about ourselves. In fact, even if we ultimately end up in the same place, from a therapeutic perspective it matters how we got there. If we took the freeway, likelihood is we bypassed all the realizations and all the emotional twists and turns that would have given us the true conviction that Los Angeles is where we need to be. We would have exchanged one place with another without being none the wiser…

The intellectual insight a person can have in session 1 can also be the one they ultimately end up with in session 20. However, it took the twists and turns of therapy, to make the person know what they knew, in their gut. To the outsider it may look like nothing much has happened, since after all the person is back just where she started. And yet to the person who did the traveling, this place is completely changed now, and it feels like she has made a quantum leap in her understanding of herself.

Trying to bypass the journey to simply get to the result is to mistake intellectual insight for an emotional experience of truth. It is to cut out the “therapeutic middle” which is where all the action happens…

On this point, I am reminded of a very insightful video, based on the teachings of Buddhist philosopher Alan Watts. In the video we are shown how a linear pursuit of higher and better accomplishments ends up being a failed strategy in the end. Once we arrive at the promised destination, we realize that there is always another goal to be accomplished. Once we finally reach the top of the mountain in our final age, we discover to our dismay that all we are really left with is a sense of emptiness and hollowness; a bitter realization that it was all for naught…

Why? Alan Watts reminds us: Because life wasn’t about getting anywhere. It was about a dance. The point of a dance, as with a musical piece, is not to quickly get to the end. It is about the dance, and about the music. Therapy is also a dance, and if we get somewhere too fast, we might just end up missing the point…

To read more about the perils of a rational/planning approach to  psychotherapy, download my article: Cultivating the Therapeutic Moment: From Planning to Receptivity in Therapeutic Practice.

About me: I am Rune Moelbak, a psychodynamic therapist in Houston, Texas. Click here to visit my website.

Sources:

Safren, S. A., Perlman, C. A., Sprich, S., & Otto, M. W. (2005). Mastering your adult ADHD. A cognitive-behavioral treatment program (Therapist guide). New York, NY: Oxford University Press.

Wright, J. H., Basco, M. R., & Thase, M. E. (2005). Learning cognitive-behavior therapy. An illustrated guide. Washington, DC: American Psychiatric Publishing.

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