A couple of articles promoting CBT at the Huffington Post recently made some good points, but failed to take into account the wider context in which psychotherapy operates.
Their author, Judith S. Beck, is the daughter of Aaron T. Beck, one of the originators of CBT. Although she is world-renowned in her own right, she seems to have bitten off a little more than she can chew with these articles.
The first article, The How and Why of Cognitive Behavior Therapy, starts well by poking fun at stereotypical psychotherapists portrayed by the media:
…know-it-all shrinks who are sure they are right when you agree with them and are sure they are right when you disagree with them. (In the latter case, they would probably say you are using a “defense mechanism” that prevents you from recognizing the truth.) I just cringe when I hear that.
But the article contains some errors — not exactly errors of fact, but rather errors of judgment about how people view psychotherapy.
The first error concerns evidence. It is perfectly true to point out that:
…not all psychotherapy is the same. Some modalities have a strong evidence base that demonstrates their effectiveness. Other modalities have never been shown to be effective. Yet they continue to be practiced by psychotherapists who consider an evidence base to be unimportant.
This is not an important difference between modalities, however. Supporters of any mode of therapy can easily generate as strong an evidence base as they please. The model of research evidence set up by pharmaceutical companies as a form of marketing for drugs is perfectly easily adapted for marketing psychotherapies.
Therefore, arguing for the superiority of CBT because of its evidence base gets nowhere.
The next error concerns the power of CBT. The description is nothing but true:
In the context of solving your current problems, you learn skills, such as how to correct your unrealistic or unhelpful thinking and how to modify your behavior to reach your goals. You and your therapist discuss what solutions you want to implement and what cognitive (thinking) and behavioral changes you want to work on between sessions.
Although it is nothing but the truth, it is far from the whole truth. The origin of CBT was the discovery of a shockingly powerful methodology that goes right to the heart of a patient’s problems, and that overturned the conventional thinking of the time.
Conventional thinking had been that psychiatric illness had its origins in unconscious thoughts that are inaccessible to the patient, making conscious cognitive work almost useless. Aaron T. Beck showed that, on the contrary, in many psychiatric illnesses the key thought processes are accessible if the therapist knows how to track them down.
It is that skill in tracking down and accessing the relevant thought processes (the patient’s ‘core belief’ or schema) that distinguishes CBT from other modes of therapy. To describe this merely in terms of goals and changes trivializes it.
The third error concerns the role of childhood in other therapies. Again, the statements are true enough in themselves as a description of how CBT works:
You don’t lie on a couch. You don’t talk for the whole hour about whatever pops into your mind. You don’t assume that you need to delve into childhood issues.
What’s missing from this is that lying on a couch, talking about whatever pops into your mind, and delving into childhood issues all have a serious purpose in psychodynamic therapy. The purpose is to convince the patient that something significant is happening by evoking childhood feelings of dependency.
That dependency means that when some CBT guru comes along and writes an article criticizing these techniques, dependent patients feel like they are little children whose parents are being attacked. They stop thinking rationally and lash out.
It was not surprising to see some very antagonistic comments to the article. Victims of that kind of psychodynamic dependency are stuck in a kind of managed childishness, but ordinary readers only see that the article caused anger, and they find the anger difficult to interpret. So they are left with the impression that the article had something wrong with it, while being unable to work out exactly what.
Another error concerns people’s experience of CBT. The second article, Cognitive Behavior Therapy: Myths and Realities, addresses some common misconceptions about CBT, and it address them well as far as it goes. For example, here’s the first one:
Q: Doesn’t Cognitive Behavior Therapy downplay the importance of the therapeutic relationship?
A: No! CBT requires a good therapeutic relationship.
Very true. But what it doesn’t address is why people think in the first place that CBT downplays the relationship. People do not just think that for no reason. They think that because it is a common experience.
All the misconceptions covered in the article are the same in this respect. They are all common experiences that patients really have. And, of course, after patients have those bad experiences of CBT, they tell their friends and family. Word gets around.
The reason many patients have bad experiences of CBT is the same in the US as it is here in the UK — they are getting something called CBT from a therapist who does not really know what CBT is, and who does not have the skills to do it right.
In the case of the therapeutic relationship, for example, many of those people who would like to be psychotherapists but who do not have the necessary interpersonal skills give out advice that they have read in ‘CBT’ self-help books. They have no relationship with their patients, but they claim to be providing CBT anyway.
They can do this because professional registration in the US, just like in the UK, does not require actual skill. It only requires academic credentials. Anyone capable of book-learning can pretend to be a psychotherapist.
‘Regulation’ by the state, by the way, has no influence on this whatsoever. A state-licensed psychologist in North America is no more guaranteed to have any skills in psychotherapy then a state-regulated psychologist in the UK.
The result of all this is that many people think they have tried CBT only to find that it was a complete failure. All the so-called misconceptions in the second article are things that have really happened to people who thought they were having CBT.
Ironically, the article makes reference to this situation without explaining its relevance:
Unfortunately, many people call themselves CBT therapists when they are not employing even the most fundamental elements of this kind of treatment. I frequently discover this when I give workshops.
It would be wonderful to see more of this kind of participation in the public arena from Judith Beck and from others of her standing in the profession. They should understand, however, that it is not enough just to make assumptions about what people think, and to contradict.
Like CBT itself, putting forward an effective argument requires more listening than talking, more understanding than assuming, more analysis than guesswork. It is a difficult context, and one in which over-simplifications can easily backfire.