While absent from blogging for a time, I changed my tune a little on the differences between real CBT and fake CBT.
The old tune was that CBT is a fairly well-defined form of psychotherapy, but some therapists practise something quite different and call it ‘CBT’ misleadingly. In the past I have referred to those two ways of working as real CBT and fake CBT.
Although I still think that’s a true description as far as it goes, I’m not sure that it’s as helpful to patients as it could be. The fake CBT comprises a good many different practices, some of which are more fake than others. So I spent some time trying to think of a way to describe a situation that is more complicated than real/fake implies.
The historical background to the way the term CBT is used and misused in the UK is a matter of organizational politics amongst training providers and the NHS.
Politics
When CBT was invented, it was called Cognitive Therapy (and it is still widely called that in North America). That was because, even though it incorporates behavioural elements, it is quite distinct from behaviour therapy.
However, by the time Aaron T. Beck wrote Cognitive Therapy and the Emotional Disorders in the 1970s, confusion between the two approaches was already apparent. He tried to address it as follows (p. 325, original emphasis):
In order to avoid confusion produced by the use of the term behavior therapy, it is important to distinguish between a particular method and its mode of action. Many of the techniques used by behavior therapists are aimed at the patient’s overt behavior… When the mode of action is analysed, however, it is usefully explained in cognitive terms; that is, its success depends on modifying the patient’s interpretations of reality, his attitudes, and his expectations.
In the UK, the new cognitive therapy was adopted by the behaviour therapists’ organization, the BABP, which changed its name to BAB C P in recognition of the importance of the cognitive approach. Politically, this expressed the spin that CBT is merely a variation on behaviour therapy, perpetuating the confusion that Beck had tried to avoid.
More recently some new approaches loosely based around meditation have emerged, and they have adopted the same political model and spin — attaching themselves to the established organization, to behaviour therapy and to CBT so as to make it seem that the approaches are all linked.
Waves
This supposed linkage between approaches to therapy is expressed as ‘waves’.
The second wave is taken to mean cognitive therapy.
The third wave is taken to mean the various meditation-based approaches.
All three waves are loosely termed ‘CBT’.
In addition, many practitioners pick out elements of some of these approaches, apply them in an incoherent way, and call that ‘CBT’ too. These practitioners may be well-qualified in some other profession like psychology, nursing or counselling, and they might have had some training in some kind of CBT, but they have not understood it.
Although this wave classification expresses a more complex view of the various approaches to therapy than the real/fake view, it does not do so in a way that is very useful for patients. Instead of hearing about theoretical and political divisions between therapists, patients want to know what is going to happen to them — whether they are going to be helped to recover.
A new classification
My new classification is designed to model what actually happens in therapy. As a patient, the definition of your illness is that you can describe things you want to change — symptoms. The important thing for you is how therapy deals with your symptoms.
Broadly, there are three ways to deal with symptoms amongst all the various approaches that might be called CBT. These three ways to deal with symptoms do not exactly match the three waves, and they provide a more patient-centred classification.
sCBT
One approach is to address symptoms directly. I’ll call this symptomatic CBT, or sCBT.
sCBT is the traditional approach used by (first-wave) behaviour therapists, who essentially train you not to do whatever it is you are doing.
For example, I once saw a TV documentary in which a man was troubled because he always wore sunglasses. Even in the dark, he wore sunglasses. He went to a CBT therapist who told him: “Try not wearing sunglasses.” So he went away and tried not wearing sunglasses, and he was soon cured. Seriously.
That TV documentary might have not have shown all of the therapy that took place, but it illustrates the essence of the sCBT approach. This approach is not limited to first-wave behaviour therapists. It can be found in the other waves, too.
A badly-trained (second-wave) cognitive therapist might use the same approach. For example, many people who have therapy from incompetent cognitive therapists try to control their thoughts. It doesn’t work, but they try anyway. That is an essentially sCBT approach — if a thought troubles you, control the thought.
Amongst the third wave therapies, mindfulness-based CBT (MCBT) can also be seen as an sCBT approach. For example, if you feel depressed, mindfulness-based CBT teaches you to enter a dissociated state in which you don’t mind being depressed (or you feel like someone is depressed, but it’s not you). It addresses your symptom directly.
lCBT
The second approach is broader than the first. Instead of only addressing your symptoms, you apply CBT techniques to everything in your life, including your symptoms. I’ll call this lifestyle CBT, or lCBT.
The lifestyle approach is typical of the third wave, but it’s not exclusive to the third wave. For example, in DBT and ACT it’s your whole approach to life that’s addressed — the way you think about your past and your future, your relationships, and all the details of how you live from moment to moment, not just while you are in therapy but forever. These therapies are a little like joining a cult. Like cults, they often incorporate group effects, deliberately-disorienting paradoxes, and quasi-religious statements about the meaning of life.
Lifestyle-CBT approaches based loosely on (second-wave) cognitive therapy can also be found. For example, there’s a one-off diagnostic exercise called a thought-record sheet that has almost become a cult on its own. There are people who always carry thought-record sheets around “just in case”, as if they are a kind of magic charm that will make any eventuality OK.
fCBT
The third approach goes in the opposite direction. It narrows the target of therapy by focusing on an underlying pattern. Because this process is often known to therapists as ‘formulation’ I’ll call the approach formulated CBT or fCBT.
Formulated CBT includes the original cognitive therapy, which is what I have previously called real CBT. Beck described the process of narrowing the target from a wide range of symptoms down to a single underlying pattern, as “problem reduction.”
There are also rare examples of (first-wave) behaviour therapists who also use a formulated approach. Instead of simply trying to address individual symptoms, they take a focussed view of a range of symptoms and behaviours, making a specific underlying learned behaviour the target of treatment.
How to tell?
How can you tell what kind of CBT you are having? It a simple matter of looking at how your symptoms are being addressed.
If each symptom is being treated directly, then you’re having sCBT (symptomatic CBT). In my opinion, sCBT only works well if you have just one mild symptom. That’s because if you have more than one symptom, or you have a severe symptom, it is very likely that there is an underlying cause and that treating the symptom alone will not be effective.
If your whole approach to life is being addressed, then you’re having lCBT (lifestyle CBT). In my opinion, lCBT never works well, although it can be rewarding and take your mind off your problems while you remain a member of the group or while you are in a relationship with your therapist. That’s because changing your whole way of life only replaces one kind of abnormality (your symptoms) with another kind of abnormality (your unusual way of life).
If your symptoms are not individually being addressed at all, but instead your therapist is looking for the underlying pattern that causes all your symptoms, then you’re having fCBT (formulated CBT). In my opinion, fCBT almost always* works well, and in some cases it works astonishingly well. That’s because treating the underlying pattern is most likely to prevent your symptoms from recurring, and it avoids messing with other aspects of your life that are OK.
Finally, you might be having some kind of CBT that is none of those three. There are therapists around who use the term CBT for anything and everything — from Freudian mud-stirring in the depths of your childhood to plain old-fashioned advice-giving. Fake is the only word for that kind of CBT — yes, I changed my tune a little, but only a little. Caveat emptor
*In the not too distant future I’ll explain why I used the phrase ‘almost always.’
sCBT rings too many bells!
Looking back on the whole ED phase of my life, yes it’s easy to come to the conclusion that eating more would be the key to not being “anorexic”, or not throwing up would stop “bulimia”, but fighting those urges for the rest of my days would have been torture. No wonder I fell straight into such a messy anxious depressed state when I tried to do that. Nothing was better, in fact it was worse to have all the same bad feelings and on top of that no coping mechanisms.
I’ve changed my views somewhat on mindfulness, I used to be quite scathing of it, I now feel it has it’s place. But in my opinion certainly not as a treatment for mental illness. Being aware of feelings and acknowledging them has been a big aid to me, but not with a view to separating from them. I already had that problem! Simply noticing them, accepting them for what they are (feelings – part of being a human being not cause to harangue myself for being evil) , and validating them works far better for me.
Lola x
Very interesting. I’ve never thought about the different therapies as having different scopes. And I’d say you’re right in your criticism of them.
However, I really wish you’d separated the criticism from the description, as it makes it hard to determine which parts are purely opinion, and which are well defined facts.
Mmm… Yes. I’ve been inundated with all three, and all in terrible terrible ways. sCBT and lCBT have kind of overlapped. There were worksheets for planning assertive or confrontational conversations, for countering negative thoughts, for writing impulses to self-injure and coming up with an alternative plan, for weighing the risks of a particular action, for most everything. There were affirmations and positive thinking and gratitude, which were supposed to become part of your lifestyle, even though they were really symptom-targeted exercises. Avoiding black and white thinking was meant to become our new mode of thought (note that I phrased it as avoiding black and white, not looking for nuance, because they are not quite the same and it is only the former I have encountered). Independently, each of these things might be useful as a treatment for particular symptoms, as in your description of sCBT, but in my experience, they want me to do all these at once and accept them as overarching truths of the world, even though that leaves me with contradiction and outright lies. (Point that out and they will only lie to you more and be more insistent in those lies.)
fCBT has shown up too. Not that they have tried to treat the pattern, but that they have proclaimed their discovery of the pattern, which usually involved some trauma that never happened. The slightly more reasonable have insisted that there is a pattern, that I know something that I am hiding from them that will be immensely revelatory and answer all the questions.
Have you talked about cognitive distortions at all? I’ve been given a list of them out of “The Feeling Good Handbook” by David Burns dozens of times. The way I’ve been taught about distortions, I would have to be braindead for it to be any use to me. I wonder if this is a contention I have with CBT or its presentation.
Yes, you have picked out some aspects that I did not cover. There is often some overlap between the approaches. The trauma that exists only in the therapist’s imagination is a form of trickery that I have not yet written about (related to ‘false memory syndrome,’ of course). Cognitive distortion can be a perfectly valid way to describe the source of an individual person’s troubles, but it certainly makes no sense at all to read lists of other people’s cognitive distortions from a book and hope, or fear, that they apply to you.
I see CBT working reliably time after time — not quite a mechanical process, because it involves a close and genuine human relationship, but nevertheless a methodology that comes with an expectation (from my point of view) of permanent recovery. So it seems to me that your contention is with the presentation.
That seems like a very useful framework.
A bit off topic but do you think “problem reduction” will always reduce a patient’s problems to one underlying formulation? Or could someone have multiple, independent problems. Like, say, the common case of someone with depression, who also suffers panic attacks.
A formulation might involve more than one schema or belief, but the whole point of problem reduction is to recognize that, for example, depression and panic might have a common cause in the case of a particular patient. A single dominant schema or belief is sufficient formulation in almost all cases.
There is an impressive approach to borderline personality disorder that interprets the rapid switching of mood as switching between different schemas, so that the patient seems to have multiple, independent problems — perhaps depressed at one moment, and then suddenly panic-stricken.