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.

 

Leave a Reply

    • Change in behavior, even if forced at first, certainly opens you up to new experiences and confronts you with new challenges. Oftentimes, however, if you don’t address the emotional undercurrents that motivate a particular behavior, old habits are likely to return quite quickly.

      • Exactly! I see CBT as a bandaid (which, is not bad if needed quickly). However, I’d rather stop the underlying reason for bleeding, rather than having that wound keep opening up consistently.

  1. Trauma usually comes with lack of concentration (consequently induces memory problems), anxiety, depression, fears and phobia. CBT therefore is only helpful for some people and research has shown that for many it works short-term only before the original symptoms return. But I believe that would go for any therapy that has not released the underlying cause of the symptoms a person is trying to get past. If we haven’t dealt with our problem, it is like putting a bandaid over a festering wound without healing it.

    • I agree. Proper CBT is not superficial at all! It can lead to profound discoveries of early life events and emotions. The aim is not just to change every day thoughts and behaviours but to discover unhelpful core beliefs, rules and assumptions and to develop and practice new more helpful ones. This work can be long term (20 plus sessions) and very in depth.

  2. The fundamental goal of CBT is to discover underlying beliefs that are currently maladaptive to the client’s experience. If therapy is thorough, it is inevitable that both the therapist and the client will discover the origins of the identified maladaptive belief. Hence, an exploration into the client’s early life experience.

    In short, CBT is not a quick fix. It has never been. It simply has been a recognized form of effective therapy, abused and manipulated by insurance companies.

  3. What I find supremely problematic with CBT and with psychodynamic, though to a lesser degree, is the assumption of the context-free-individual being properly basic to lived experience. Thoughts are seen arising entirely from within the construct of the phenomenological “I” and therefore any changes must come from within in the form of a “Me to It” causal connection. The world in that model is a passive object waiting for the subject to interact.

    In the Relational Dynamics In Identity Theory (RDIIT) I’ve been building, the individual identity begins first as a relational construct, utilizing Siegel’s notion of the “me that is we.” The questions that come up are then:

    1. How do my relationships shape and contribute to my experience(s)?

    2. How does my perspective define and determine my experience(s)?

    3. What barriers to expanding my experience(s) do I believe exist?

    4. What are other paths provided within my community to explore who I am?

    These are predicated on the notion that all development, whether described as internal or external, is contingent upon a context of variables relationally connected.

    • David, interesting model. I would be interested to know how it is practiced. One of the key differences between psychodynamic therapy and CBT is in my opinion the attitude adopted toward the client and toward the therapeutic process. Do you teach the client and transfer knowledge from your theory to their life? Or are you taught by the client and beholden to an emerging truth that can be validated only through an emotional self-evidence in the highly contextual interplay between therapist and client? In my opinion, psychodynamic therapy subscribes to the last viewpoint.

  4. Although I am a psychodynamic psychologist, I would ask a good question: What does the client want? Not everyone is a good candidate for psychodynamic, and some clients don’t want it. They want something more concrete and brief like CBT. Rather than “which therapy is “better”? I’d ask, which is better for each client? and which does he/her prefer?

  5. And is it a coincident that when the when the Professors got into the therapy biz, lo, it turns out that everybody just needs more schooling and homework? It has always seemed to me implausible that, to put it baldly, all mental problems arise from either not knowing enough or having learnt the wrong things. Nowadays it is sometimes added that the problems may have arisen from overt or covert problem of the brain, though the then the problem is the familiar hypotheses that the patient is either ignorant or badly instructed about how to deal with the problem at hand. Hard to believe? When you put it that baldly, it sure is.

    • Good point about professors trying to shape therapy into a form of teaching. What I like about psychodynamic therapy is its attempt to bypass rational knowing and in an effort to make a more emotional impact. Rational knowledge can only take you so far…

  6. great post; good flow. I have had training in both CBT and psychoanalytic; the latter is refreshing when the patient is aided to discover themselves. Psychoanalytic understanding is through transference and the therapist’s emotional attunement. As Shedler says in his article, CBT often unwittingly uses these tools, although it is not part of the CBT theory.

    • Chris, great to have a psychiatrist? join the conversation… It is a good point that different theoretical approaches sometimes converge and become less of a “pure” type. I, like most therapists I know, also sometimes utilize CBT techniques, but always within a fundamentally non CBT attitude. I try to pursue greater complexity, openness, curiosity, possibility, not simply to provide standard solutions to set problems…

  7. Interesting. I am really eclectic in my approach and incorporate cbt into my work but I, like you, am fairly psychodynamic. I have treated patients who had structured cbt in past. They had mediocre results at best. One woman told me she was reporting symptom improvement even when she wasn’t doing better because she felt like a failure if she didn’t. Obviously, many people improve with CBT but its not for everyone.

    • I like your distinction between CBT techniques and structured CBT, which I think are quite different things. CBT techniques as described in my article can be quite useful, but one would often need to go beyond them to truly impact a person at an emotional level.

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

    This is what I have felt. Some of the earliest psychotherapies now feel a bit medieval, but CBT feels quintessentially modernistic. Psychotherapies a bit behind some other fields in the seismic and paradigmatic shift to postmodern incarnations. Psychodynamic therapy does have a fuller and more complex taste to it, as does, in my experience, symbolic-experiential psychotherapy.

    Respectfully,
    Blake Griffin Edwards

    On LinkedIn at https://www.linkedin.com/profile/public-profile-settings?trk=prof-edit-edit-public_profile and Twitter @edwardsmft.

  9. This is a very interesting point about CBT arising in the context of deinstitutionalization. Taking a cue from Foucault, CBT would seem to be a method of internalizing the institution; certainly the people who have had CBT, that I’ve known, do seem to behave very much as if they were under observation from some always-present authority.
    Could you please refer me to any journal articles (or anything else that you might have) that make this link?

    Thanks,
    Francesca

    • Francesca, that is a really good point. Sounds like you already know about Foucault’s concept of the panopticon. I don’t have specific articles or books in mind that make this link. To me someone like Habermas and the idea of the “colonization of the lifeworld” by technical-instrumental thinking (or Heidegger’s existential critique of technology, or Adorno’s critical theory) comes to mind. Thanks for contributing!

      • Rune, thanks for replying, and for the references. I was asking more about the connection between de-institutionalization in the 70s and the rise of CBT, though ; apologies if this is something that’s already obvious to others. I’ve never read it anywhere.