CBT: Part of the Solution, Part of the Problem, an Illusion, or All of the Above?

Ron Unger, LCSW
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Cognitive behavioral therapy or CBT has been pretty heavily criticized by a number of Mad in America (MIA) bloggers and commenters in the past few years.   In a way that isn’t surprising, because most MIA bloggers are looking for radical change, and CBT often appears to be part of the establishment, especially within the therapy world.

But while I’m all for criticizing what’s wrong with CBT, especially with bad CBT, I think there’s also a danger in getting so caught up in pointing out real or imagined flaws that we fail to notice where CBT can be part of the solution, helping us move toward more humanistic and effective methods of helping.  I would propose that we instead attempt a “balanced approach,” noticing both where CBT is likely to help and where it is not, and discovering what can be done to build on the strengths of CBT while avoiding problems with the misapplication or overstated marketing of it.

My own background in relation to CBT is that I spent years as a critic of the mental health system before deciding to become a therapist, which I chose to do in order to help pioneer ways of providing alternative approaches for people who don’t want to rely bio-psychiatric ways of framing their experience and on medication.  I have found that CBT, especially CBT for psychosis, is a helpful framework for bringing some of these possibilities into the mainstream, and for retraining professionals to see people as capable of becoming active agents in their own recovery.  I’m involved in teaching this approach to professionals and others and have even created an online course on the topic (more info below).

So I definitely see CBT as part of the solution, in particular in regards to the difficulties that get called psychosis, where other accessible solutions are in short supply.  I should caution though that I’m not proposing that it’s the best overall approach for psychosis:  I recognize Open Dialogue as being probably the best method developed to date.  But Open Dialogue, and other intensive options like Soteria, are quite difficult to implement without a kind of broad support that is lacking in most areas, while CBT for psychosis can be introduced wherever one or more clinicians become willing and able to offer it. And as I’ve pointed out elsewhere, CBT for psychosis can be complementary to approaches like those offered within the Hearing Voices approach, while also bringing many HVN type ideas to people who would never attend a group or otherwise access peer support.  

One feature that CBT for psychosis shares with other forms of CBT is that it has been well researched in randomized studies, and can claim to be “evidence based.”  This is very helpful in helping to crack the door open to bringing in a psychological method in areas where the mental health system is currently dominated by bio-psychiatry.  CBT sees people as capable of learning to change what they think and do in ways that can reduce or eliminate their problems, and once people are understood to have this ability, the bio-medical view of people as passive victims of an active biological illness is shown to be clearly inadequate.

To be fair, it’s also important to note that there is also a possible “dark side” to CBT being well researched compared to most other methods.  That is, this research may be used to portray CBT as “the answer” while other approaches, not so well researched but possibly as good or better, might be pushed aside.

It’s often noted that common factors in therapy, like the ability of the therapist to form a good relationship with the client, and the ability of the therapist to provide a sense of hope, are much more important than the exact type of therapy.  When CBT is directly compared to other forms of therapy, for example, there often is little difference in outcome (though there are some exceptions, such as a study that compared 5 months of CBT with 2 years of psychoanalytic therapy and found the CBT dramatically more effective.)

At any rate, while the “common factors” it therapy are clearly the most important, it should also be noted that a therapist will likely be unable to form a positive relationship with a person in a way that conveys hope if the therapist himself or herself cannot see reason for hope and understand how the therapy can be helpful.  Unfortunately, many existing forms of mental health therapy not only fail to include ideas about how to relate to people in the extreme states we call psychosis, but they often at least in my experience actually warn practitioners not to even attempt to apply the methods to people whose experiences can be labeled psychotic.

People with lived experience of course often have hope even when the system doesn’t teach hope, and so hiring more people with such experience is an important part of the solution.  But it’s unlikely that everyone hired by the mental health system will be someone with lived experience anytime soon, and it’s also true that even many people with lived experience may find themselves running out of ideas on how to  relate and convey hope when working with people with extreme states.  That’s why having one or more systematic psychological approaches like CBT for psychosis, that can be researched and then taught to people coming into the field, could contribute to better practice, at least if promoted in a way that is complementary to rather than competitive to “peer” approaches.

There are of course some other systemic psychological approaches that do address psychosis, and of these the psychoanalytic approach is the best known.  So how best to think of CBT versus a psychoanalytic approach for psychosis?  Rather than wonder about which approach is “better” it may be more productive to be curious about when a CBT type approach might be most helpful, versus when a psychoanalytic approach might be more effective.  That’s the approach demonstrated by Douglas Turkington, a CBT for psychosis expert, and Michael Garrett, a psychoanalytic therapist, in their article CBT for psychosis in a psychoanalytic frame.

In practice, once a doorway in the mental health system is opened to bringing in a psychological approach like CBT for psychosis, the door is also opened to bringing in other psychological approaches.  And there typically is no clear distinction between when one is bringing in an additional approach, versus when one is just expanding and deepening the practice of CBT.  It actually seems to be part of the CBT style to attempt to bring in everything that seems likely to work, while framing it in a CBT kind of way and integrating it with other CBT practices.

This tendency of CBT to incorporate other approaches hasn’t however gone without criticism; in Cognitive Behavioural Therapy Does Not Exist Jay Watts describes CBT as an overly narrow method, but then claims that in a kind of “smash and grab approach” CBT practitioners have tried to “co-opt” all possible moderators of change into the “CBT vortex.”  She goes on to state that really good ideas about how to help people belong not to CBT, but to human experience.

I agree with Jay that CBT has no real ownership of the better ideas about how to help people change in positive ways.  In the field of psychology, ideas are always being discovered and then forgotten and then being rediscovered and described in new ways, so it is hard to say any idea is entirely new.  What can be new however is the packaging or bundling up of the ideas, and I do think CBT has something important to bring to the table in that respect, especially in regard to psychosis.

Lots of psychological approaches are not open ended enough to integrate other methods.  They are often too bound up in their own complex constructs, jargon, and assumptions. CBT on the other hand revolves around fairly simple concepts, examining the interactions between life situation and the thoughts, feelings, and behaviors that arise in response.  This simplicity makes it relatively easy to conceptualize any new and/or very old and traditional idea about how change can happen, as being just a variation on standard CBT practice that can then be integrated into CBT.  Is this a kind of “cooptation” that should be prevented?  Or a positive kind of integration of methods of change that should be encouraged?  I would argue that a lot depends on the style with which it proceeds.

We need an integration of methods that reasonably gives credit to sources, that keeps alive the best of what is being integrated, and that doesn’t then become a dogma that precludes further development of innovative new ideas.  CBT, at least some of the time, accomplishes those objectives, and so I would argue that CBT remains real and helpful as we expand it to include other modalities of change.  I would also agree though that it is important to maintain awareness that any integration of methods is just one way of integrating; there are always likely other ways of accomplishing the integration, with other pros and cons.

So I guess I’m saying CBT is both “real” and “an illusion.”  CBT is just one way of attempting to package up what works for people.  It doesn’t really own what works, those instead are facts of human experience as Watts points out.  And CBT isn’t the only possible way of putting together methods that are likely to work.  But it is really important, at least in some circles, to have at least one way to put together ideas about what might work into a coherent form that can make sense to everyone from mental health administrators to new trainee clinicians to families and also the individuals having the experiences themselves.

Of course, trying to develop such a coherent and integrated approach means dealing with the contradictions and conflicts within and between particular psychological approaches.  That’s often where things get interesting, because resolving the conflicts often means paying attention to patterns that lie below superficial differences.  As an example, let’s take a look at the conflict Watts and others have described between earlier forms of CBT that emphasize being able to refute a dysfunctional thought, and later or “third wave” approaches which encourage instead a mindfulness based approach of becoming able to create a space between one’s self and the thoughts.  Are these approaches really completely contradictory?  I would argue they are not; let me explain.

If I have a thought or a voice that tells me I am worthless and need to kill myself, and if I really believe it, I will have no motivation to “put a space between myself and the thought” or the voice.  Instead, my motivation will be to find an effective way to kill myself as soon as possible.  I may need at that point to learn how to refute or cast doubt on the belief in order to put the brakes on the impulse to destroy myself.  But if I then focus my efforts on further trying to change or eliminate the thought or voice that says I’m worthless etc., I might find that this effort itself becomes self-defeating (like trying to not think about green elephants) and becomes a distraction from my life.  I might do better by instead using mindfulness to support my ability to have a space between myself and the thought.  In other words, the best approach might be to first work on to some extent refuting the dysfunctional thought, then using the more “third wave” mindfulness approach; the two approaches can really be seen as complementary.

But mindfulness type approaches may also be unhelpful if they are used in an attempt to avoid being influenced at all by the part of me or voice within me that feels worthless and would like to die.  The healthiest option may involve alternating a mindfulness approach with times of getting curious about why part of me feels badly about how my life is going and feels worthless.  Psychodynamic or other approaches (such as some developed by the hearing voices network) might help me explore this, and I might also benefit from learning to be compassionate both towards the parts of me that are profoundly unhappy and also the parts that are disturbed by and resentful of the parts that are so unhappy, using perhaps a compassion focused therapy approach.

I hope this example illustrates the importance of integrating multiple approaches and then using the right one at the right time.  I do think it is possible to accomplish this kind of integration within a CBT framework, though of course it is not the only way to do it.

But what about when internal change isn’t really what’s needed, and external change is needed instead?  CBT, like most all psychological approaches, is most commonly seen as a way to help people adjust to their circumstances.  Interpreted that way, it fails to recognize the key reality that adjustment is only a good strategy some of the time, while at other times and for other situations we need more of what Martin Luther King called “creative maladjustment.”  The mental health field in general needs to be pushed toward recognizing the value of such maladjustment.  But I don’t think any over-focus on adjustment is locked into the nature of CBT – instead, it would be fully consistent with CBT to point out a need to balance the benefits and costs of adjusting to various things with the benefits and costs of engaging in creative resistance, and to notice how this balance is different in different situations.

The notion of “balance” and “balanced thinking” is close to the core of CBT, and it seems to me that many critiques of CBT are really pointing out flaws in bad CBT, where this kind of balancing is neglected.  For example, Richard Lewis in his MIA article Cognitive Behavioral Therapy: The Good, The Bad, The Limitations  frames CBT as being about getting people to “focus on evaluating their “negative” thought patterns and look for and reframe the “positives” in their thinking” and then points out all kinds of situations where it would be not just unhelpful but actually extremely damaging to do that!   But good CBT is not about trying to help people be more “positive” regardless of the situation:  rather, it’s about exploring the evidence, seeing what fits or is “balanced” in regards to a particular situation.

Often, people coming in for counseling are seeing things very negatively, for example expecting everyone to dislike them, when in reality probably only some people will do so.  So helping people experiment with being more positive may be very helpful.  But at other times or in other ways people may not be seeing things negatively enough, and their efforts to avoid listening to critical voices, from within themselves or from others, may be the problem.  In that case, helping people include the critical perspectives into their decision making would be part of good CBT.

Of course, I’m sure there are lots of CBT therapists and even CBT educators who over-emphasize the positive, and who are very narrow in their approach, and so are fully deserving of Richard’s critique!

Another common criticism of CBT has to do with the notion that CBT is about going to a therapist who knows everything about what is involved in being balanced and rational, and who then teaches the client to comply with those particular notions.  I would argue that while it may be very common to run into CBT practitioners who practice that way, this is really poor CBT.  When CBT is practiced well, it is a collaborative investigation into what is going on and what might work, and the therapists is aware that his or her knowledge is limited, so the goal is to explore together to discover what might work for that individual in that individual’s circumstance.  It’s an experimental activity, and the aim is not to overwhelm anyone’s autonomy but only to assist people in creative efforts to find out what might work for them.  So good CBT is definitely not about the therapist doing something to the client or imposing something, but helping the client discover something for themselves.

The “joint discovery” kind of approach is especially important with psychosis.  When people hold views that are extremely different from what is conventional, it’s often very difficult to avoid getting caught up in either confronting them in a way that damages relationships (and usually causes people to defensively and rigidly to dig in on their own views) or pulling away from them and disengaging.  CBT provides a third path, exploring how people came to their views but also exploring other factors, contradictions or discrepancies, that can lead to views evolving and improved ability to communicate about views with others.

CBT is often criticized for being too simplistic, and certainly there are practitioners who insist on simplistic explanations that don’t fit, but I think a great advantage of CBT can be its interest in finding simple explanations that do fit.  Instead of seeing people as biologically defective, it is often possible to see them as simply trying too hard to protect themselves in one kind of way, and so inadvertently causing themselves problems in another way.  For example, a person who tries too hard to never miss clues that they are about to be betrayed, may put way too much weight on possible evidence of betrayal and then frequently see betrayal happening when it isn’t.  Tracing out exactly how this might be happening often helps people both avoid thinking of themselves as “just crazy” and helps them start balancing the need to avoid betrayal with the need to avoid being overly suspicious.

A key point of complexity theory is that complex patterns can often result from just simple changes in key variables.  I may be going off on a tangent here, but I was impressed when news came out the other day on a method that causes computer based “neural networks” to “hallucinate.”  Essentially, the networks are set to look “too hard” for patterns like animals, and then start seeing them pretty much everywhere.  The images that result are pretty amazing, and sometimes nightmarish; you can see more about that here.  So how does this relate to humans with psychosis, and CBT?  It may be that many human hallucinations result from a similar process of looking “too hard” for certain patterns; for example when a person is looking too hard for certain threats they may start seeing them when they aren’t present, just as when I don’t want to miss a call I am more likely to feel my phone vibrating when it isn’t.  CBT can help people frame their problems as possibly simple at their root, something that can be changed by learning to look at the world differently, rather than a complex biological disorder that can only be addressed by drugs.

While it might be nice that CBT has ideas about simple things people might try doing differently in order to reduce problems, some people fear that CBT is about offering people only a limited set of simple solutions and then offering nothing if those don’t work.  I would say that is just the way bad administrators try to use CBT:  better CBT is actively curious about what works and what doesn’t, and is willing to search as widely as necessary to find something that will work.

By the way, this notion that problems can possibly go away when people make just simple changes is not incompatible with the notion that people’s problems may be due to past experiences.  Rather, it is possible that the person chose a strategy to deal with difficult past experiences that worked for a while but then backfired and caused the current problems.  Understanding the relationship with the past may be helpful (and so may be part of CBT), but there may also be times where it is not necessary to understand how current patterns are connected with the past in order to make simple changes in strategy that results in positive change in the present.

If you want to know more about how CBT can be applied in a flexible and humanistic way to helping people experiencing the extreme states known as psychosis, you might want to check out my online course on that subject.  It’s available at a discounted rate of $49 to professionals, and free to non-professionals, until July 15, 2015.  You can preview parts of it or register for it by following this link.

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54 COMMENTS

  1. Hi Ron,

    This is an excellent well balanced article, though personally I find that the way CBT is used and marketed is a major problem in the mental health field. Certainly cognitive and psycho-educational techniques can be helpful to people though these have been a part of good therapy long before CBT was invented. A significant issue with CBT is the way it is taking over in mental health institutions, often used in the most simplistic manner, despite the lack of substantive evidence to show that it works well. By this I mean that pretty much all of the diagnosis and symptom based research, whether using medication or therapy, tends to show mediocre results, though showing statistical significant difference with placebo or sham therapies. The results obtained in these research studies are far worse than one would want to achieve in clinical practice. So empirically based therapy is not the same as good therapy. Furthermore, if one wants to consider a body of research to be substantive then it should be cohesive. One should find that the results from looking at an issue from various forms of research, as well as including clinical experience and patient reports all hang together. The research on aspects of therapy and therapists that correlate with good outcomes all point to relational issues. This research does correspond well with clinical experience and what patients report useful in therapy. The only research that supports CBT is at odds with these other forms of evidence. In may years of practice, I have never seen anyone who reports significant change with CBT or has described CBT techniques as highly useful. Patients do speak of the empathy, understanding and wisdom of their therapists. So while CBT claims to be empirically based, to date, hard evidence about the effectiveness of the techniques is lacking. What makes the situation fro the mental health field worse, is that many institutions are taking any relational component out of the CBT type therapy they offer, and focusing only on teaching techniques. This is troublesome. You refer to the article comparing therapies for bulimia. That is an important study as it does point to the idiocy of certain approaches. Having headed an eating disorder unit for many years, it is clear that nutritional, psycho-educational, and structural approaches are necessary, though one would ideally also want to address emotional issues. There are very good therapists, who use multiple modalities to address the real needs of patients. We should learn what we can from different approaches. The problem is the way CBT is being promoted and taught. Many CBT therapists do not know enough developmental and emotional theory to help people in emotional distress, yet claim superiority on limited empirical evidence. I have seen many people who have felt worse after their experience with CBT therapists who have tended to prohibit any talking about “negative” feelings, and have given n overall pejorative message that a person should be able to control their feelings with their thoughts. There is good therapy and there is bad therapy. Empathy and in-depth understanding of a person is always an aspect of good therapy. Any therapy that claims this is unnecessary has to be questioned.

  2. CBT for me did not help I am deeply sad after losing best thing in my life in 2010 .
    My husband & I were partners in life. I do whats expected of me, but walk around feeling 1/2 dead much of the time. I am a caretaker as well and struggle to pay bills since my husbands hard won pension was slashed ! Why is that even LEGAL in America ? Answer is Powerful Corps – lobbyists & billionaires control & run our gov’t – our Supreme court , our anti middle class pro wealth laws & policies. This is NOT the America I grew up in . Have been on Prozac for 3 yrs Afraid to get off , may get more sad – more empty – more anxious . At a loss what to do

    • Hi Dian–

      I wouldn’t miss the opportunity to hear you out if you came to me for that. You need to think of things that haven’t occurred to you, if you haven’t gotten on the bearable side of some issue. Or you need and want to understand some things it make you think of in a different light, want more of one feeling then another so that you get perspective on what to do. You need uplifting feelings to know what might give you more realistic chances to work through grief in the first place. I feel sorry for your loss. Maybe Prozac by itself also keeps you from flowing with ideas that are most realistic. Maybe take one or two day vacations from it each week and journal about it, see how the Prozac off days compare to the Prozac on days. Try the competing modes of experiencing your sadness and look at all the similarities and differences in thought as well as feeling. Act like your situation–the real one–house, car, hobbies, errands, friends, scrapbooks, pleasures, pains–is just undicovered for how you need it to be. That it’s impossible to work with might seem true or be true enough, but the answer is what to change about both you and it, and the range of answers includes just scrapping your situation and gettingyourself onto more and better. So I am suggesting that if you vary your drug intake safely and predictable and keep track of that outcome, and if you on purpose get the freshest looks you can and work on naming the similarities and differences to how you were that was better at the time, or how you want to be–then you just will have better chance to talk anything over. The better prepared you are to say anything more particular and seen from a range of different angles on it, especially once you realize that you don’t have the final perspective on all this one thing might connect up with, you can work through bits and pieces of your issues lots better in talking them out. You can definitely do that since you say things clearly. Someone somewhere will want to talk with you, happily. They won’t know your answers but should like what you do for yourself when you look inside to get the meanings of your pain sorted out. You need company somehow, as you obviously realize. What the person or persons who finally seem like the best company to you call themselves in life is hard to say, though. They might not be listed as talking professional help, or they might be. You never know. But you have gifts of expression and some good and some bad luck with connecting with people and with sorting your issues out and getting them into working order, and those just are the things to improve, as the drugs are like hamster wheel solutions to any real life matter. I hope you are turning things around decisively soon, and believe you can.

      • Just one note — I’m all for exploring life without Prozac but tapering off it SLOW and STEADY is the way to go. Trying “a couple days on, a couple days off” has proven to be a real DISASTER for most of us.

        These drugs change your nervous system, and the withdrawal is real. You can end up on a roller-coaster of emotional and physical misery. The worst thing is if you believe that utter misery you feel is “just the way life is without drugs.” That’s what kept me helplessly, hopelessly coming back for twenty-odd years. IT’S NOT. It’s withdrawal.

        This is THE most important thing you need to know if you seek to help people put their lives back together without drugs. Hope that doesn’t sound nervy, but it’s true.

        • Hi Johanna – That’s nice that you have a solid opinion on the matter of tapering. I didn’t say anything bad about the highly popular and more and more frequently approved program of tapering. The idea of taking med vacations came to me from a doctor who helped me when my position was silimar to Dian’s. That is, Johanna, I didn’t know WHAT to do. Tapering also is not guaranteed. But I wouldn’t automatically have thought of anything to get started on one for any drug ever, except that this considerate doctor who was a careful listener and flexible in weighing possible solutions gave me the tip of trying “med vacations”. He plainly indicated that he had gotten enough feedback about ways that other patients coped to say “vacation” instead of “non-compliance” if he learned about some lack of consistency that seemed OK to him. Thus, he had bothered to think up this name that seemed to frighten and displease you beyond all the ways of connecting it that I shared so far.. You don’t think saying “I took a med vacation today” indicates way out dangerous thinking, do you? That’s all I suggest to dian, that a med vacation of a day can work out, but then I mean exactly what I say, Johanna. So thank you for adding your worries about the specific meaning of the words “one” or “two”, if those were the ambiguities that scared you. I meant one or two days per each week, like I said to Dian, exactly. And suggested something good could happen if she were to do that purposefully in order to get some varieties of experience and to keep track of her different thoughts and feelings for talking about. But as dian is obviously the adult in question and not a misfit or infant unable to think rationally for herself, I don’t think we should assume she just went off her Prozac all at once and started freaking out. Wake up to the idea of getting receptive to your own needs in a variety of ways, Johanna. I had to ask me some questions, you have to ask you some questions. Dian has to ask her own questions, too. And that it is up to dian if she decides to start a taper or anything else or not, totally, as things stand. And that she should try to get to her thoughts shared with someone that appreciates that Dian is Dian, so that the sharing gravitates toward some kind of process for an unfolding of the complications she experiences from her pain and how her pain comprises her freedom to enjoy life. Remember pain, Johanna? Is the whole idea of confronting someone else’s pain about saying things about tapering for you or what? Whoa! yourself, Johanna. She might do it, it might work, nothing might. But something should. No one knows what. Read John Dawes!

        • Hi Johanna,

          I totally agree with you. Some people can go off more quickly, and have a miserable few weeks, but for most, slow and steady is necessary. It can take up to a year to get off these meds, as they do change your brain, and it takes time for the brain to re-grow neuroreceptors. One of the problems with modern psychiatric drugs is that they are only available in large increments. So, for example, Prozac, only comes in a minimal dose of 10 mg. Some pharmacies will compound smaller doses, but this can be expensive, or with capsules one can divide up capsules oneself. It’s a larger problem with the extended release pills that some drugs come in. One thing that I do at times, if people have trouble weaning off, is adding a small amount of nortriptyline which is available in small increments. While it is not ideal to start using a second medication, it can help some people eventually get off all “antidepressants”.

    • oh dian, you have a right to grieve, and I hope nobody (CBT therapist or otherwise) told you that was just “negative thoughts”! I’ve had a lot of losses but never lost a loving life partner. My sister did, and one thing that helped her so much was the company of other women who had been in the same boat. The other is she decided early on this would take her several years to deal with, and she was not going to tolerate anyone urging her to “cheer up” or trying to book her a tourist vacation or a date with a new fella.

      You also have a right to be mad! This is more & more a country of, by and for the 1% and it’s putting TERRIBLE pressure on millions of people who deserve a bit of leisure and peace of mind after working hard for 40 years. Any small thing you can do to fight back, whether political protest, volunteering to help others or whatever suits you, can help.

      As for that numb and half-dead feeling, I know that one. And strange to say, I actually felt better after getting off the damn anti-depressants. Drugs like Prozac “work” in part by causing emotional numbing, making you less “sensitive.” That might be good for some people for a short time but it’s a crappy way to live. There are lots of tips on this website as to how to do this slowly & carefully to minimize withdrawal-related trouble. There’s lots of good tips & good company in general, so keep coming back OK?

    • I’m not surprised it didn’t help – neither drugs nor CBT cure real life problems. In fact drugs can make it worse. I’d advice you to go off the drug if possible but that of course is dependent on if you can afford a possible withdrawal. There are good resources on MIA and elsewhere how to taper off anti-depressants.
      As to your other problems whatever they may be I only see one thing that really helps -get involved. Seek out people who suffer similarly and become a activist. I know it’s easier said than done but it’s better than being stuck in hopelessness and alone.

  3. I was helped by cognitive therapy, which is essentially about relearning responses to stress. The assumptions made by the Behavioral Therapy I see as deeply flawed. According to BT, behaviors consists of voluntary and involuntary behaviors as a result of experiences in the environment; every person is a passive product of his or her environment. Strict behaviorists believe that cognitive events are not significant in producing behaviors and that current behaviors are the result of events that occur before and after the behavior. Positive reinforcement is when reinforcement occurs shortly after some response that increases the likelihood of the response happening again. Negative reinforcement is when a response is taken to avoid something adverse. Dysfunctional behaviors arise from a failure to learn needed behaviors. Behavior changes when environmental contingencies change. Therapeutic punishments can be utilized by counselors to inhibit certain behaviors. These therapeutic punishments can range from time-outs—the separation from a group or activity—to mild electroshock, similar in strength to an elastic band being snapped on the wrist, or a two-second shock at 15.5 milliamps or even 45 milliamps, as used at the Judge Rotenberg Center (JRC) in Canton, Massachusetts. (much of this can be found in Theoretical Models of Counseling and Psychotherapy. , 2004 by Kevin A. Fall, PhD, Janice Miner Holden, EdD, Andre Marquis, PhD.) In cognitive therapy it is believed individuals have differing temperaments beginning at birth, and these differing temperaments push people in different directions. Individuals are active participants in their environments, evaluating various stimuli, interpreting events and sensations, judging their own responses, and actively seeking and creating goals. Individuals become distressed when they experience a threat to their interests. The greater the threat is perceived to one’s well-being, the more intense the distress. Distress is a signal that one is not handling the pressure one faces very well. Much of cognitive therapy is about learning to deal better with the stresses one can face. While CBT – which is a mixture of both Cognitive and Behavioral Therapies, is, in my opinion, a vast improvement over strict Behavioral Therapy, assuming that individuals are passive products of their environments is a flaw that severely limits its ability to help nearly anyone.

  4. Hi Ron,

    I would really appreciate your perspective here. I feel like as a practitioner with a graduate educational background that emphasized CBT, and as someone who has worked for organizations recommending or prioritizing CBT as a preferred mode of therapy, I ought to be less confused about some of the core concepts. Yet, my experience over the years has been to hear many different things about the “essential” features of CBT that are often contradictory.

    My question comes without an preconceived judgement: simply put, do you feel it is accurate to say that an essential feature of CBT in all (or most) of its variations is a process of (a) identifying unhelpful and/or problematic thoughts, (b) identifying more helpful and/or accurate thoughts and (c) working to replace problematic thoughts with accurate and helpful thoughts?

    I know that there is more nuance to CBT, so I don’t mean to imply that this is the only component involved. I only wanted to hear if you felt like it is accurate to say that this is one distinguishing feature of CBT as an overall approach?

    Thanks for your time!

    • Hi Andrew – In CBT workbooks so far I have believed that authors continually made deliberate efforts to impress the need for me the reader to assess the realistic connection of any thoughts to the people and things they were about in actuality. I appreciate the detail and practicality of your question as you spelled the logic out for doing that out according to the implications just of good and bad thoughts themselves in relation to how you tackle just thought-relationships. Thank you.

  5. Hi Ron, thank you for the very informative article.

    I have never religiously attended CBT but I found the background ideas helpful. I think descriptions like ‘Catastrophising’ or ‘Emotional Reasoning’ explain exactly how the mind works in everyday human terms.

    I found “CBT” very helpful in coping with the stress reaction problems attached to psychotropic withdrawal syndrome.

    I see CBT as understandable Psychotherapy not as a quick fix, I think the work on changing habits is still there.

  6. Ron

    In my blog, “Cognitive Behavioral Therapy: The Good, The Bad, and the Limitations”,which you referenced above, I stated the following:

    “So let’s get real about CBT. At the beginning and end of the day CBT is nothing more than a pragmatic and sometimes useful tool that has serious limitations due to its’ fundamentally “idealist” philosophical origins in understanding the world. CBT comes out of the school of thought that says we are what we think we are, or if we take it a step further, “I think therefore I am.” This way of thinking implies that there is no material reality independent of our thoughts; so there can be multiple realities based on any one person’s interpretation of the world. This is in direct opposition to a “materialist” philosophical perspective that says “I am therefore I think.” The latter view postulates that thoughts, ideas, and theories come from one’s interaction with the material world. If that world is, in fact, oppressive to the humans interacting with it, this will be directly reflected in the thinking and behavior of those human beings. Of course when ideas (emerging from interaction with the material world) are subsequently put into action they can influence and change the material world in an ongoing dialectic or spiral development of change.

    CBT, being part of the “idealist” school of thought, tends to sever the relationship between the specific nature of the material conditions in the environment that gives rise to a person’s thoughts, and leaves it up to the interpretation of the listener (often a therapist) to determine whether or not the environmental source of those thoughts was actually traumatic or oppressive or more positive and humane.

    So in reality the pragmatic value of CBT as a therapeutic method (in the short run) can be achieved without any type of moral compass or historical barometer to determine if the end result actually advances the cause of humanity, or if it only meets the immediate selfish needs of its user in the moment. In other words, we need to ask the important question: for whom is the CBT method being used, and for what purpose?”

    This above quote represents more of the essence of my argument about the limitations of CBT. Does it fundamentally promote the transformation of both the environment and self within an overall historical forward motion for all of humanity, OR does it tend to promote a transformation of individual thought and behavior to facilitate an accommodation to, and acceptance of the status quo, no matter how oppressive? Obviously, I believe it tends (in its overall practice) to do the latter.

    Ron, my overall reaction to your blog is as follows:

    1) Based on how you describe your approach counseling, if myself, or any other person I cared about, was in a psychological crisis, I would want someone like you to be the person coaching me, or them, through that crisis.

    2) I would choose you NOT because of your knowledge of CBT methodology, but because of your common sense, compassion, and wisdom about facing difficult life experiences. Your knowledge and PARTICULAR approach to CBT would just be ONE aspect of that overall wisdom.

    3) You have taken the basic theory and practice of CBT and combined it with several other approaches and experiences in an attempt to somehow render it more profound than it actual is in the real world.

    4) Practically every therapist today would state that they use aspects of CBT in their practice. Every progress note written in the community mental health system must indicate what interventions were used, and as a matter of course CBT will be listed. The whole therapy session could have been a discussion about baseball or cooking and CBT will still be listed in the progress note. In this context it means virtually nothing and does not really exist.

    5) Most therapists only know the general concepts of CBT. Very few therapists actually use the strict CBT guidelines in the way they conduct a therapy session, and if they did use these strict guidelines in every session or situation, they would be often ignoring the needs of the person seeking help, and often harming that person if they failed to be trauma informed or deeply aware of the oppressive nature of the world we live in. Dan Mackler has correctly stated in his writings that a good therapist must actually be some type of Radical or Activist for social change.

    6) Good therapy and therapists are a rare phenomena in today’s world because of the oppressive gravity of all the institutions in today’s world, and especially the pernicious influence of the theories and practice of Biological Psychiatry; its poison runs very deep and affects all of us (even the well intentioned) in so many ways.

    7) Discussion of more liberating approaches to solving complex human problems without discussing the need for revolutionary changes in the world, including the complete dismantling of the current mental health system, is nothing more than a pipedream.

    Richard

    • Richard,

      Well said: you understand that mental distress (emotional suffering) is the natural, normal reaction (neurobiology) to distressful experiences.

      Poorly said: some of your best points including your substantial support for Ron’s position are hidden because your post is so long.

      Best wishes, Steve

    • Hi Richard – I appreciate you heart. But you are in error to say that the cogito leads to no real world of things. That’s false. Funny, too–where did you come up with that “inference”? The cogito, correctly understood works out as the only absolute truth. But still, it is a degraded proposition. You can’t get the “I am” and the “I think” to guarantee that the “I” in both refers in each case to the same realities. But furthermore, against your position on it, the ultimate implication is that other than this absolute truth and the apodictic truths of math and logic, we live in a world of probabilities and so have to choose our enjoyments and the objects of our passion with care. Because everything is dangerous, period.

  7. So in reality the pragmatic value of CBT as a therapeutic method (in the short run) can be achieved without any type of moral compass or historical barometer to determine if the end result actually advances the cause of humanity, or if it only meets the immediate selfish needs of its user in the moment. In other words, we need to ask the important question: for whom is the CBT method being used, and for what purpose?”

    This is one of the reasons I wouldn’t bother with a psychologist again. It’s not up to the preson you’re paying to decide whether or not they’ll help you or not. You pay them, they help you.

    For example: “oh I won’t teach this person x or y until they decide to get a job at a fast food restaurant, take their drugs, marry a single mother” etc etc. Not the psychologist’s place, when does it just become brainwashing ? When you say “short term” it seems like you might be making a judgement call that really is showing arrogance.

    • Just to add, I do think it’s pretty much the height of scumbaggery to take someone’s money, often times a substantial amount of money that could go towards something else, and then essentially, manipulate a person instead of providing a service.

    • Hi Barrab, You get your point across to me about the arrogance well. Since you say showing and in the context of so many careful attention to the reflections that all mattered for your comment, it is clear to me what your intention is. I have already in a few moments started thinking what good advice that is and why, to look at whether my thoughts and actions are revealing a bad kind of arrogance or a bad side of myself that could change with some deliberate attention to getting something straight about who I was or was not. Especially who I was to tell someone else who they could or should be. Good job, here, for you, I think.

  8. As a family member I am finding Ron’s online course for CBT for psychosis enormously helpful. The slides are brilliant – one can just scroll through slides to get a snapshot or reminder of a part of the course. The explanation of ‘dialogue’ , and the graphs that explain the difficulties when good internal dialogue is interrupted helped me understand my loved one’s distress so much better. Also the emphasis on hope and trust in relationship is helping me remember the importance of infusing our daily life with a more hopeful and calm context, and to find comfort in the fact that even though change is so painstakingly slow, seeing our loved ones trust in us returning is actually steps forward, We found the concepts outlined in Ron’sCBT for psychosis course, alongside the ideas of compassionate focused therapy, extremely helpful in building our confidence in how to ‘be’ with our loved one.

  9. This article posted on the front page of yahoo is misleading. You should make it evident that you are specifically discussing CBT in terms of psychosis. CBT is extremely effective for panic disorder and phobias. The success rate for remission is around ninety percent within twelve weeks; the scientific american mind magazine had an article about it several months ago showing the efficacy of CBT for children with anxiety disorders. But you are right that too often CBT is advertised as a one size fits all solution. For example, a person with borderline personality disorder would be much better off doing dialectical behavior therapy, etc.

  10. Hi Ron,

    I don’t know about psychosis, but if anyone is using CBT for depression, you might be interested in this

    http://egg.bu.edu/~youssef/SNAP_CLUB/

    It’s spreading on-line and has been used in the Behavioral Activation group at Brigham and Women’s hospital in Boston. It’s new, and I could be wrong, but I do think that this is really right. I think that depression really is caused by one single specific unconscious habitual thought process. It explains what symptoms should appear, how a depression should evolve over time, why there won’t be a simple biological marker for depression and which therapies should work and which shouldn’t.

    I have tried CBT in the past for my own depression. I found it to be helpful and interesting, but not transformative. In retrospect, I think the basic problem is that the thoughts and beliefs that it is aimed at are really symptoms of a depression and they are not quite the root of the problem. I would say that a problem with Beck’s approach specifically is that many of the most painful negative thoughts of depressed people actually are perceptive and correct and if you examine the “evidence for” and “evidence against” dysfunctional thoughts it’s not going to help.

    – Saul

    • Hi Saul,

      Well stated, and thanks for the interesting information. As you point out, CBT does not aim at the root of the problem, certainly not for depression. When a symptom has taken on a life of its own, then that symptom may become the problem itself, and working towards eliminating that symptom makes sense. When deeper issues are causing a symptom, if one controls that symptom, then other ones will arise, and the underlying problem continues. In my experience, symptoms are not usually the problem in themselves, and in most of the people that I see, the type of symptoms that respond to CBT usually dissipate quickly with normal integrative therapy, without having to make them the focus of the therapy. My main objection to the CBT movement is how it is being used in the industry, with many systems dropping therapy services that will work with more complex emotional issues in favour of short-term CBT clinics that work from a DSM diagnosis model and only look at the particular set of symptoms for which the individual was assigned to a therapist. Thus, if a person was assessed for panic symptoms, that person will receive 12 weeks of CBT for panic, and nothing else. I have rarely seen anyone who just has symptoms and not complex life issues that they need to address. While their are many good therapists that use CBT techniques, the overall trend in the mental health industry has been to treat symptoms and not people by using simplistic and made up diagnoses to direct treatment and then methods like medication and superficial CBT to dull symptoms enough so the patient will go away, and the system can continue to believe that it is doing its job.

  11. CBT can be part of the solution were it not so challenging to find a therapist who actually practices CBT. I went through this as did another family member and of all the therapists who claimed to utilize CBT not a one actually utilized this approach. Treatment was rarely more then that which the therapist found to be most comfortable, convenient and least taxing for him or her.

    Where we are often told that medication is not effective or is unsafe it should also be remembered that non-medication alternatives skillfully delivered are too rarely available.

    • Hi Joe,

      Service availability is certainly a problem as is having so many schools of thought in psychotherapy. I find that many therapists these days, who claim one approach or another, or call themselves “eclectic” tend to have their own limited basket of tools that they pull out based on their comfort or discomfort level. So if one thing doesn’t appear to be working they quickly pull out another modality. Using various modalities is important, but should be in response to understanding what will be helpful to any individual, and not to serve the comfort level of the therapist. I advocate what I call the “One Therapy Model”, which is that for any individual there should be a specific combination of approaches and way of understanding the person that will be optimal, and that it is the job of the therapist to try to discover this therapy. Clearly to find this “one therapy” is not completely possible, but one should always attempt to make the therapy fit the client and not the other way around. One of my concerns with CBT is that, according to many patient reports, many CBT therapists insist that the patient adopts to the therapy, and will berate people if they don’t.

  12. Many who need it can not afford therapy. In my experience CBT may help some but for deep grief it may NOT. I struggle to get by , having little control over my life at this point.. (yes I know all I can control is how I react ” I’m so sick of hearing that At 72 My best days are over. Tired, sick stressed, missing my husband. That’s just reality and NO amount of ‘deluding myself will change that ‘ . I’ve talked it out many times, went to grief therapy. I assist a elderly sick pal, been a caretaker for 3 yrs for my daughter, who had a stroke. She is unable to find work that pays a Living wage . First thing our gov’t cuts after they squander our hard earned earnings is help for disabled, mentally ill, public education, kids in need, but gov’t always finds money for WARS – for corp tax cuts,subsides, and loopholes, I think US has lost its moral compass. Yes there are generous giving people out there, but the greedy corrupt corps & billionaires control our gov’t, pass anti middle class policies, even write our laws. Best to all here. Thanks for allowing me to express my views.

  13. Your views. like anyone views, are crucial to all of us understanding life’s ups and downs. One of the issues with CBT, is that many of life’s problems are not caused by negative or wrong thoughts, but are caused by life’s pain. We evolved to have adaptable brains that learn from our environment. Many people’s life experience has been traumatic, with their brains being properly vigilant or sensitive to possible trauma. Life is not all happy, and it is often very reasonable to feel sad, or anxious about life. Losing someone close to you is always very painful. There is no way of talking or thinking away the pain. I remember being at a funeral for a friend’s mother, and someone said to the father “It will get better”, and I replied,” no, it doesn’t get better, it just gets different”. There are all kinds of theories on grief, and all different ways that people find to feel somewhat more at peace with death, but the reality is that we are not able to comprehend or deal well with death. From an emotional and attachment point of view, death doesn’t make any sense. A person we love is there, and then they are not, and a huge hole is left in our hearts and minds. People’s feelings are always important and we should not be trying to explain them away, or diagnose them. One always has to be careful in helping people to handle certain feelings or symptoms better to not inadvertently invalidate their pain. I wish you some peace.