What I Like and Dislike about CBT
Let’s talk about what I like and dislike about Cognitive Behaviour Therapy (CBT). CBT is a structured therapy which typically involves 4 to 20 one-hour sessions that occur weekly or biweekly. It is the recommended treatment for many mental health concerns because the research shows that it works! However, there is some criticism about this therapeutic modality. I work primarily from a CBT approach in my practice, but am aware of its limitations and ensure that I address the areas where this approach is lacking by integrating other approaches where necessary.
Let’s get into it first with what I like about CBT.
The focus on formulation
Formulation is therapy talk for truly understanding what is going on for the person. This means taking the time to propose a hypothesis about why a person is experiencing what they are, and confirming this hypothesis with the person. In CBT there is a large focus on completing a thorough intake, really getting to know the person and their history. Getting to know how all of their struggles relate to each other and coming to an initial hypothesis along with a proposed plan to address these struggles developed collaboratively with the client.
The reason that I prefer having a solid formulation from the get go is that I then have a theoretical basis that I am pulling my interventions from as opposed to what feels like for me, throwing jello at a wall, and not understanding the reasoning behind certain interventions.
It is also important to me because if you as a therapist are offering the same coping skills to all of your clients without a thorough understanding of their struggles, you could be in fact making things worse for them. For instance, if a person is experiencing obsessive compulsive disorder, and you are suggesting they challenge their negative thoughts, you may in fact be increasing their symptoms.
A focus on measurement based care
Though not every CBT practitioner adheres to measurement based care, it is more commonly associated with CBT. Measurement based care is the use of standardized assessments as part of the therapy process. These assessments will track the client’s perspective and progress over time to monitor how things are going in the areas of life that they are concerned about. It is important in order to ensure that what the client is dedicating their time, energy and money to is making a difference. Research shows that measurement based care significantly improves progress.
When a therapist uses measurement based care and they see that there are areas that are not improving in accordance to goals, it’s time to re-assess. Am I as a therapist missing something? Do we need to change our approach? Is there a service that is better suited to meet the client’s needs? Tracking progress over time allows the client to see the forest for the trees, in other words, to see this bigger picture. Sometimes we lose sight of our progress when depression or anxiety blocks our view. It allows for very specific and targeted use of your time in therapy.
Structure
CBT is a structured therapy. This means that the therapist generally will set an agenda at the beginning of the session. They will follow up on homework/tasks from in between sessions. There will be time to work on current concerns as well as overall concerns, time to set new homework for the week and to offer feedback at the end of the session.
Personally, structure allows me to have a container to do my best work. Without this structure it is easy to get lost and lose sight of the client’s goals. I believe that it also allows for continuity from session to session.
The parallels to Buddhism
When I started studying Cognitive Behaviour Therapy (CBT), I started to notice the parallels to Buddhist teachings which was great for me because in my personal life, I have been drawn to Buddhist teachings. For instance, Buddhist meditations, which focus on helping us to distance ourselves from our thoughts and to become the observer of our thoughts can be likened to what in CBT we call this decentering: the ability to view cognitions as mental events, rather than as expressions of reality (Beck, 1979).
The use of homework
Oof homework. This can be a triggering word for many. However many of my clients appreciate tasks in between sessions. They generally follow through on tasks that they have assigned to themselves or that we have assigned to them collaboratively. The use of homework ensures that there is continuity from session to session, and that there is observable change occurring.
The interventions
I appreciate many of the interventions used in CBT. Many of the interventions that are used in CBT are focused on the process vs the content. What this means is that instead of delving into each worry, concern or thought to reach the “route cause” we are zooming out and taking a more macro look at what is going on. This allows for the discovery of patterns that are keeping us stuck. It helps clients to create distance from their thoughts and to learn ways of managing that they will be able to utilize in many situations, not just for one particular concern. This also means that the client doesn’t end up relying on the therapist to work through every worry that comes up, they are able to utilize the tools they have learned to work through it themselves.
I like the focus on what we call experiments. The idea with experimenting is to try doing things differently. It can be very playful and fun. I help clients identify the beliefs they have that may be holding them back, and then experimenting with doing things differently based on a new belief. For instance, believing that “if I don’t plan where I am going to park ahead of time, I will get really flustered, I won’t know what to do and I will not be able to figure it out.” I ask them to try something different, try not pre- planning parking when you are going somewhere where it is okay to be a bit late, let’s see what happens?
I like the focus on exposure. Helping people face their fears. We do this gently and with consent. People are able to build their tolerance for distress as well as learn that they are stronger than they believed themselves to be.
Let’s move into the limitations of CBT/what I dislike about this approach.
The misuse of CBT
Just like any form of therapy, CBT can be misunderstood and misused. I believe that there is a general misunderstanding of what CBT is and part of the reason for this is that introductory courses in CBT tend to only focus on thought diaries and “challenging negative thoughts”. This is only the cognitive part of CBT. There is also an emotional and behavioral component. We utilize thought diaries to really get to know what is going on for the person, and though this creates increased awareness for the client, this is not the sole intervention.
Because of the use of exposure, even with clients who have PTSD, there is a risk of “throwing people into the deep end” when it is not executed properly; slowly and with consent. Behavioral activation, often used in treating depression, can be mis-applied if we are just telling people to get off the couch and get moving. The idea of behavioral activation is to help people understand how their behaviors impact their thoughts and feelings, as well as what may be getting in the way of them engaging in behaviors/activities that would be bringing them joy or filling their cup, then helping them to address those barriers.
The language used
Some of the language associated to CBT I find to be somewhat pathologizing. For instance, “Cognitive distortions” or “Safety behaviors”.
The focus on diagnosis
Many criticize CBT for its focus on diagnoses as they are outlined in the DSM. I understand that this could become problematic depending on how diagnoses are understood by the specific therapist and could lead to pathologization of the client. I do not worry about this in my own practice because I feel solid in the way that I see diagnoses. I am aware of the problems associated with the development of these diagnoses within the DSM to begin with. However, I see diagnoses as a starting point. They are a grouping of symptoms which allows me to understand what is going on for a person. It also allows me to take a look at what interventions I have access to/ which ones are recommended when a person is struggling with a grouping of symptoms.
Can sometimes be “cold” or “rigid”
When I first learned CBT I believed that it was very rigid and it did not align with the way I interact with the world. The focus on structure, the use of a whiteboard, thought diaries, agenda’s, and writing everything down visually can become very robotic. However, there are ways to be flexible within the structure and your own personality can shine through.
Much of the research on CBT is not generalized to culturally diverse populations
Within clinical and counseling research, omitting ethnic and cultural information is widespread. This is also the case for CBT research. Historically, CBT has been largely focused on European Americans. Though about 4% of the research into CBT has taken into account cultural diversity, the emphasis on European Americans can lead to various problems in practice. For instance if the focus is too much on the individual and doesn’t account for their environment, victim blaming can occur. Another example would be neglecting to pull on the person’s cultural/religious practices as part of their coping toolkit.
There is a risk of using the wrong intervention at the wrong time when working with anyone, but more specifically when not taking into account cultural diversity. For instance, supporting someone to become more assertive within a South Asian household or gathering could potentially have consequences that the person is not consenting to. Or for instance, having someone use mindfulness or imagery when there are structural/systemic/safety issues at hand is irresponsible. This example illustrates this perfectly:
“So, when my sister is leaving her kids alone in a house for some unknown reason, and I’m trying to convince her . . . don’t do that, it’s irresponsible. I’m supposed to believe that my nieces are like floating on a leaf as the police get called? (Fuchs et al., 2016, p. 478)”
There is a slow integration of culturally focused research in CBT which considers ethnic, racialized and minority groups, sexual minorities, specific religious groups, rural populations and refugees.
To conclude, there is much to value when it comes to CBT and I believe that CBT alone in its current form cannot be used in isolation. We must pull from other teachings in order to ensure inclusivity. For me, this includes my social work background, trainings geared specifically to Culturally Adapted CBT as well as more somatic interventions.
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References
Written by
Tara McRae MSW RSW
Registered Social Worker, Psychotherapist