Busting Some Myths About Cognitive Behavioural Therapy.

“CBT is only a sticking plaster, it doesn’t go deep and doesn’t create long-lasting change. CBT is delivered by emotionless barely adult robots. CBT blames me as the client when I don’t feel any better. CBT feels mechanical and superficial, it doesn’t see me in all my complexity. CBT doesn’t do emotions or warmth. CBT isn’t interested in relationships it’s all tools and technique….”

These are some of the many myths that you’ll hear about Cognitive Behavioural Therapy if you do a quick Google on the subject. My favourites are the expletive littered Mumsnet ones. In this two-part blog post I’ll bust some of the common myths about CBT and explore where they might have come from and why.

Myth 1 – CBT is only a Sticking Plaster it doesn’t go deep and doesn’t create long-lasting change.

This myth has been promoted by a number of therapists including Oliver James, and there’s an interesting history to this. Back in the  late 1980s and early 1990s Psychology staged a coup over the elitist psychodynamic and psychoanalytical forms of therapy that had been a mainstay of public services in the UK.

Suddenly many therapists found their livelihood under threat.  Part of this culture change shifted the focus from the therapist as an unquestionable authority, towards a requirement for therapists to demonstrate how their work helped other people. In other words proof of efficacy through evidence.  

Until relatively recently, many of the other schools of therapy were unable to do this. The research tradition had been quite weak because no-one had questioned how or why therapy works.

A turf war ensued.

The result of this was an emphasis on the intuitive “unproveable” qualitative components of therapy which only the “highly trained and analysed therapist” had access to – transference, free association, projection, the therapist’s interpretation of the client’s dreams and so on. Many schools of therapy dug their heels in assuming that eventually it would all pass and things would carry on as before. It didn’t.

A secondary element of this criticism was to emphasise the “B” in CBT (which stands for behavioural) to argue that Psychological Therapy was a crude form of reward and punishment to affect change. CBT was seen as a form of “token economy” with the unethical Machiavellian therapist shaping the client’s behaviours without their informed consent.

The Behaviourist tradition in Psychology has always struggled to explain the role and function of emotions and this is why the “C” (which stands for cognitive) was integrated into Behavioural Therapy. Cognitions include the meaning and imagery that we associate with emotions and offers a way to explore the function of emotions in our lives. There is a very sophisticated cognitive theory of emotions (and transference) which can hold its own against any other model.

CBT works with Underlying Assumptions (the rules we live by) and Schemas (the way we make sense of ourselves, other people and the world) and these parts of the CBT model are equivalent to what other therapy approaches would call transference and transactional ego-states (in Schema work) or interpersonal dynamics (in Underlying Assumptions).

Further to this, any competent CBT therapist will be helping the client to work out where these rules and beliefs came from – through exploration of the person’s life history, relationships, socialisation and culture.

Interpretation plays a role through the collaborative testing out of hunches about a person’s problem too.

This is where long lasting change happens – when someone understands the unhelpful rules and beliefs they’ve been operating by, and then decides to try out some new ones. This would be called individuation or self-actualisation in other therapeutic models.  

Most research into all schools of therapy seems to suggest that no one therapy creates longer lasting changes than any other. (Clarkson, 1995). Most research covers a 12-month period and there are few comparative longitudinal research projects over decades.

Currently most people’s experiences of CBT in the NHS will come via the IAPT service which offers a very particular version of CBT. 70% of people who pass through the doors of an IAPT service are given a limited “dose” of “low intensity” CBT for 6 sessions by practitioners trained in a partial version of CBT.

The interventions focus on testing the accuracy of Negative Automatic Thoughts (NATs) which are the “surface” thoughts that pop in and out of our head and are the outer layer of the CBT onion. While helpful, this is probably not enough to create long-lasting change.

Like any other therapeutic approach we must go deeper – into the rules for living and schemas that shape our experience of being-in-the-world. This is what happens in the “High Intensity” part of IAPT. However, not everybody wants to do this, and sometimes the “light touch” is enough.

Finally, it should be noted that there is currently a “replication and legitimacy crisis” going on in Psychology. The old foundational experiments are being re-run again and the results are failing to be consistent with what happened before. This includes research that suggests that as people find out more about CBT and how it works, it becomes less effective!

This replication crisis has been used to criticise CBT in particular, because the approach is so closely tied to the quantitative discipline of Psychology. However, it’s a problem for all therapeutic approaches, and the consequence of this is that the research consistently shows that it’s the quality of relationship that matters in the end, not what theory the therapist uses.

Myth 2 – CBT is delivered by emotionless, barely adult robots.

I have some sympathy with this myth. There is definitely a “type” of chilly CBT therapist for better or worse, who crops up again and again in frontline NHS primary care therapy services. This is usually someone who is quite academic and clinical, fresh out of college, in their 20s and probably middle-class and white. Thankfully, this is changing as Psychology finally starts to grapple with its own previously (mostly) silent relationship to class, race, sexuality, gender and the diagnostic medical model of distress.

One thing to be aware of is that often therapists themselves are quite anxious, especially when working in the public sector. One of the ways humans (and institutions) try and cope with anxiety is by becoming rigid around procedural activity in order to minimise uncertainty.

Foundational CBT training often emphasises a “manualised” approach to common problems and this combination of anxiety, systemic rigidity and manualisation creates an environment in which the therapist dissociates from the relational interactions in the room. They lose embodiment and presence.

Good CBT therapists stay aware of this, remain focused on the therapeutic alliance, and when necessary (i.e. most of the time) throw the manual away. Skilled CBT therapists draw upon meta-competencies to flexibly and mindfully respond to the person in the room while holding research models in mind.

Judith Beck, one of the leading CBT therapists in the world, is very clear about this – she has publicly stated she is against manualisation outside of research trials.

Her father Aaron Beck (the founder of CBT) states repeatedly in his books that without a good therapeutic alliance, therapy won’t work.  Aaron Beck also emphasised the importance of Carl Rogers' “core conditions” of person-centred counselling: empathy, unconditional positive regard and congruence, as a necessary requirement of good CBT.

Long story short: If your CBT therapist is an emotionless robot, it’s time to find a new therapist.

Myth 3 – CBT blames me as the client when I don’t feel any better.

This myth links back to the therapeutic alliance again.

At the start of therapy there should be clearly agreed goals and tasks to frame the work. This leads to a good “bond” between therapist and client as both parties know what they are meeting to do, even if the journey may not be quite clear yet, we may get lost, and there will be inevitable “bumps and holes” in the road. However, these experiences of not-knowing and confusion can be the times when the most progress is made.

A good CBT therapist will be curious about why the client isn’t feeling any better and see it as an indication that further exploration and conceptualisation is needed rather than the client doing something wrong.

Proficient CBT therapists stay alive to power dynamics in therapy and make sure that the person in the room stays central to the work.

CBT therapists are trained to experience CBT “from the inside” by trying it out on themselves. If you feel your CBT therapist is blaming you for not “doing” therapy correctly, it may be because they haven’t explored their own beliefs and schemas about being a therapist or the goals, task and bond for therapy need revisiting. This might also include exploring your assumptions and beliefs about therapy and the therapist too. Let your therapist know what's going on, it could be a turning point.

So that’s it for part one of this series of CBT myth-busting. In the next article I’ll tackle some of the other criticisms of CBT, including the myth of “symptom reduction” to see whether they are true or not.

If you feel that you’d like to warmly(!) explore relationally focused CBT for an issue in your life, you can find me at Rhizome Practice.