It’s time for me to face it. CBT just doesn’t work (in some cases). Even formulated CBT with an experienced therapist can sometimes be a failure.
The reasons why CBT sometimes fails are easy to deduce by thinking through how CBT works.
CBT starts with a therapeutic alliance, a close and trusting relationship with your therapist. This relationship, in turn, is built on a person-centred model of human interaction, exactly the same as the model that humanistic counsellors use.
The relationship will fail if your illness means that you the way you relate to other people is severely abnormal. Mental illnesses that severely affect interpersonal relationships are known as personality disorders. So in general CBT does not work with personality disorders, because the illness prevents the therapeutic alliance from ever getting going.
Things are not quite as simple as that generalization, however. If you have only a mild personality disorder, then a good therapist might be able to create an alliance anyway. It depends on how severe your disorder is versus how good your therapist is. For example, if you have mild narcissistic personality disorder (a desperate need to feel special and separate from other people) a good therapist might be able to reassure you about how special and individual you are, playing to your strengths in order to form an effective alliance.
Borderline personality disorder (BPD) is a special case for two reasons. First, it is appallingly often misdiagnosed and so there are lots of people going around thinking they have BPD when they do not really have any personality disorder at all. Second, even if you really do have BPD, it is not quite as difficult to treat using CBT as other personality disorders (although the treatment is likely to take much longer then a simple emotional disorder like, say, depression).
Very severe cases of other disorders can also interfere with the formation of a therapeutic alliance. For example, if you have very severe depression you might not be able to form a relationship with anyone, and CBT might not be appropriate until other treatments (drugs or electrical therapy) have made your condition less severe.
As CBT progresses, your therapist starts to get a clear idea of why you are ill. This work is commonly known as formulation.
When formulation fails, the most likely reason is that there is no mental illness. The sequence of events is like this: something happens that causes you to have symptoms, then someone misdiagnoses your symptoms as a mental illness and refers you for CBT, you form a therapeutic alliance with your therapist, and then your therapist discovers that you are not ill at all — you are reacting normally to some event or circumstance. Obviously, therapy comes to an abrupt end when this happens.
A typical scenario is when someone you live with is mentally ill, but you are not. For example, if your mother has a personality disorder, it might make you depressed. But your depression is not an illness because it is a direct and normal reaction to your circumstances. The best your therapist can do is point out that you are not ill but your mother is. Your therapist cannot treat your mother by remote control through you.
Formulation also fails when there is a physical illness presenting as a mental illness. Typical examples are thyroid gland dysfunction and chronic fatigue syndrome (CFS, also known as ME), both of which can present as depression. In the case of thyroid dysfunction the condition is usually treatable by a doctor. In the case of CFS the condition is often untreatable, although the symptoms can often be managed very successfully, and CBT techniques may be helpful to reduce elements of genuine depression.
The general process of recovery through CBT can fail if there are external pressures maintaining your illness. The most common form of external pressure is from family members.
For example, you might have had generalized anxiety disorder (GAD) since childhood. You married and have teenaged children. Now, for the first time, you are diagnosed and referred for CBT. Within a few weeks or months you begin to improve noticeably. But your spouse and children were not expecting this. For years they have been used to you the way you were. They might push back against your new freedom, and find ways to reinforce your familiar anxious behaviours.
Even with a good therapeutic alliance and formulation, CBT can fail if other people in your life are maintaining your illness. Those other people might not be ill themselves — it might simply be that they have become used to the way you were when you were ill, and they do not want to change. (A situation I described before in Partners.)
Sometimes, recovery can mean moving on from the people you were with when you were ill, even from family members, but sometimes that’s too much to ask.
The factors I have mentioned so far are pretty much out of your control. But CBT fails far more often because of controllable factors. In these cases there are simple, practical things that you can do to make CBT a success.
The environment in which therapy takes place contains many controllable factors that can make therapy fail. For example, therapy in a group requires the therapist to be much more skilled and experienced than individual therapy. Or you might find yourself having therapy in a place that is noisy, or that is not private.
Any of these things can easily be changed, especially if they are in your own control. If they are in the therapist’s control, it is usually enough to point them out. Occasionally, you might have to make a formal complaint.
By far the most common controllable factor is an incompetent therapist — especially in the NHS, where members of other professions without adequate training in CBT may try to provide CBT on the cheap. You can control this by using your first meeting with your therapist as a kind of job interview, and by ensuring that you feel an immediate bond of trust. You should have a strong gut feeling that your therapist is on your wavelength and on your side, and it should be clear to you that your therapist understands how formulated CBT works.
As therapy progresses, be aware of whether your therapist is developing a formulation (a common-sense explanation for why you feel the way you do). A therapist who flounders around trying to teach you techniques and give you advice is not providing CBT.
If you have doubts about your therapist, check that their qualifications really are CBT qualifications (not, for example, psychology, nursing, interior design or plumbing). In the UK you can use the CBT Register for this, although there have been reports that only the search by surname works well. If your therapist is not properly qualified, try to be referred to someone who is specifically qualified in CBT.
Note that I do not say you must check your therapist’s qualifications before you start therapy. I only suggest doing that if therapy does not go well. This is because there are some excellent therapists who are not fully qualified yet, and even some who do not see the point in becoming qualified. If you have an excellent therapist, qualifications are irrelevant.
If a properly qualified CBT therapist turns out to be incompetent, or if you are refused access to a properly qualified CBT therapist by your health insurer or the NHS, consider making a formal written complaint. People who make serious formal complaints based on fact tend to get better treatment afterwards.
There are a few common misconceptions about factors that make for successful therapy.
Your motivation is not a factor. This old joke is a joke:
Q: How many psychotherapists does it take to change a lightbulb?
A: Only one, but the lightbulb must want to change.
What should happen in therapy is that you enter into a trusting relationship with your therapist. The changes that will occur depend on that relationship — they do not depend on how much willpower or determination you have.
That means it is OK to enter into CBT without any commitment to it. You can go along just once to see what happens. If your therapist is any good at all, you’ll want to go back. If you don’t want to go back, the therapist was at fault — find a better one.
Hopefulness is also not a factor. If things have been bad for you for a long time, perhaps since childhood, you might have decided that life will never be good, that you do not have that possibility in you. Feeling like that is no barrier to CBT. You do not have to be hopeful before you start.
Your symptoms are another non-factor. CBT is a general-purpose methodology that treats a huge range of symptoms. It does not matter whether you have just one symptom or a hundred, it does not matter whether they are mild or severe (unless they are so severe that you cannot relate to your therapist), and it does not matter how long you have had them — it is OK if you have had symptoms for as long as you can remember.
This also means that you do not need to find a CBT therapist who specializes in certain symptoms. You do not even need a medical diagnosis. Any competent CBT therapist should be able to treat any symptoms related to emotions and feelings, with or without a diagnosis.
The common and the rare
I do not have statistics on the numbers of people whose therapy is affected by the factors I have mentioned here. I get the impression that controllable factors, incompetent therapists in particular, account for most of the failures of CBT.
The next most common reason for failure, in my experience, is that external pressures, usually from family members, maintain the illness. The best a therapist can do is to make the situation clear, and then there is a choice to be made — get away from the pressures and recover, or stay and remain ill. Sometimes people choose to stay and remain ill. Better the devil you know, perhaps.
People who are not mentally ill at all are probably the next most common category. Sometimes they find that a few sessions of counselling (in effect) from the therapist are helpful to make their situation clear.
People who have real and severe personality disorders, or very severe depression, are only very rarely referred for CBT. Again, they are usually easy to identify in the first session or two, so that they can be referred on for more appropriate treatment.
People who have little hope of recovery, who are afraid that their symptoms are too unusual, or who do not believe in CBT, are all fairly common, but of course these are non-factors. These people, like all the others, recover.