Service-Users Who Found CBT Unhelpful Offer Their Perspectives

Counseling clients in the UK who found CBT unhelpful were interviewed about their experiences.

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A recent study published in Counselling and Psychotherapy Research interviewed clients from an economically deprived area of the UK about unhelpful factors in Cognitive-Behavioral Therapy (CBT). Nine participants who reported unsatisfactory experiences with CBT were involved in the study. The researchers conducted semi-structured interviews with clients from Improving Access to Psychological Therapies (IAPT) services and performed a thematic analysis of the data. They found several common themes, such as dissatisfaction with CBT itself, skepticism toward the counselors, and practical barriers related to physical and mental health.

“The empirical research suggests that it is the client who is at the heart of change in therapy. Cooper suggested that about 75% of therapeutic outcomes are due to client factors. Therefore, it is important to research a client’s subjective perspective on change processes in therapy as these factors will have a significant impact on the therapeutic outcome,” the researchers, led by Omylinska-Thurston, write.

“As CBT is a main treatment in IAPT (with a local CBT dropout rate of 40.2%), it is important to focus on the unhelpful aspects of CBT. If the unhelpful factors in CBT are responsible for the high dropout, not addressing these issues will have ethical and economic implications.”

Photo by Sydney Sims on Unsplash

Cognitive-Behavioral Therapy (CBT) is a therapeutic modality that emphasizes the relationship between thinking, feeling, and behaving. A CBT practitioner may attempt to assist a client with identifying “unhelpful ways of thinking” and other “cognitive distortions,” in addition to focusing on behavioral modification, such as creating a treatment plan that might involve the “homework.” For example, showering daily or leaving the house once a week would be a form of homework.

Even though Cognitive-Behavioral Therapy is the primary therapeutic modality offered by the UK’s National Health Service, not everyone is convinced about its “gold standard” status. Though CBT is recognized as having a strong evidence base, some research suggests that it has been losing its clinical effectiveness over the past several decades.

Other psychologists have criticized CBT on political and philosophical grounds, arguing that it is based on an outdated scientific model of the isolated and faulty brain, ignoring the effects of social and economic realities. Despite these misgivings, CBT is still considered a first-line treatment for many conditions and stands unquestioned as “the best we have at the moment” for many psychologists.

The current study seeks to expand clinical understanding around unhelpful factors associated with the CBT modality of therapy. CBT has steadily been losing its clinical effectiveness, and not a great deal of research has been conducted on why CBT fails some people.

To understand the issue, Dr. Omylinksa-Thurston and co-authors conducted semi-structured interviews with nine research participants from a deprived area of the UK. They followed the interviews with a thematic analysis of the data, hoping to find common themes among participants’ experiences that could shed light on CBT’s inadequacy for some clients.

The nine participants were recruited through the UK’s IAPT program—improving access to psychological therapies—in the north of England. Only participants over 18 were included. Participants must have reported a negative experience with CBT, and individuals in crisis, such as those in too much distress to be interviewed or currently abusing drugs were not included.

“A literature search revealed limited studies specifically focused on unhelpful factors in CBT. This may be due to the ‘file‐drawer’ effect—where trials finding negative effects of therapy are not published. It might also be related to the fact that clients who find treatment unhelpful often drop out of therapy without discussing the difficulties in therapy,” explain the authors.

Six common themes emerged from the data:

  1. Difficulties with CBT itself
  2. A negative perception of therapists
  3. Clients’ unhelpful internal patterns
  4. Physical health, mental health, and psychosocial barriers
  5. Unhelpful IAPT processes
  6. Consequences of unhelpful treatment

Among clients’ difficulties with CBT itself, clients struggled to identify negative thoughts, found the examples used by therapists too general, and had trouble completing the homework projects. Clients did not feel as though CBT was tailored to their personalized needs but reflected a kind of generic program they were meant to follow. It was common for clients to complete homework the night before the next session, rather than throughout the week as intended, suggesting that they did not find it worth engaging or could not find the time.

“The idea of capturing negative thoughts was very hard […] because they weren’t out of the ordinary…They were just my normal day‐to‐day thoughts that I’ve had for the last…30 years,” reported one participant.

The second theme, negative perception of therapists, expressed suspicion toward therapists’ commitment to the clients. Participants reported feeling that CBT practitioners were not invested in helping them. Instead, they felt that the work was being offloaded back on to them. For example, therapists suggested that participants do their research and read books outside of the sessions. Also, participants reported a lack of empathy from therapists.

“Barbara said that her therapist would suggest to ‘accept…your health, you’re doing the best you can. No… I don’t want to.’”

Some participants struggled with CBT on a more internal level, such as having unrealistic expectations, being self-critical, and having an overly negative focus. Some participants expected a magic pill from CBT or blamed themselves rather than the treatment, saying they could have tried harder. Others felt that the whole exercise was pointless and they were not able to engage meaningfully with the work.

Three participants reported barriers to effective treatment related to health or psychosocial issues. Although CBT is recommended as an effective treatment for depression, one participant stated that her low mood prevented the reflective mental capacities necessary for the work. Another participant found that CBT was impractical given where she was at presently:

“If you’re trying to put roofs on etc., and you haven’t put the foundation, it’s going to collapse.”

Medical issues and psychosocial issues such as needing childcare were also discussed.

Most participants also reported barriers associated with the clinic itself, rather than CBT specifically. These included long waitlists, inadequate assessments, administrative issues, and a “monopoly of CBT” as the only treatment modality available. Clients said that the assessment process, for example, involved a lot of paperwork but did not focus on their immediate needs, and some participants felt that they were assessed incorrectly. Though not directly related to CBT, the authors thought that these criticisms should be included, as part of the surrounding therapeutic milieu of the clinic.

Finally, participants reported adverse outcomes associated with unhelpful factors of CBT. These outcomes included feeling as though core issues were left unaddressed, that significant feelings were left unattended, being unconvinced or aggravated by the CBT protocol, and other issues. Some participants reported feeling worse after undergoing CBT treatment.

“Five clients were not convinced by CBT. Marie shared that CBT was too clinical. Carl said that ‘there is no room for the kind of silences that would force you to… properly reflect.’ Carl said the structure of CBT meant ‘it was more artificial.’ For Barbara, ‘it threw up more things than actually resolved,’ and she did not feel that CBT put difficulties into perspective.”

The authors did report some limitations to the study, such as the small sample size associated with an in-depth qualitative project and the difficulty of relying on client self-report and recall of past experiences.

“It seems important to conclude that the above unhelpful factors are likely to be present in most therapies and it is important to engage in a thorough assessment before therapy and regular therapy reviews asking clients what is helpful and unhelpful in therapy. It is also crucial to respond and be flexible to clients’ needs, as well as being sensitive to clients’ preferences and internal patterns,” the authors conclude.

“The participants clearly identified that other approaches should be offered alongside CBT as the first line of treatment. Interestingly, in 2010, the Swedish government decided to fund other approaches than CBT. They found that ‘CBT monopoly’ is not helpful, as people need to have a choice for their therapy to be effective. Will we be brave enough to listen to this evidence in the UK?”

 

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Omylinska-Thurston, J., McMeekin, A., Walton, P., & Proctor, G. (2019). Clients’ perceptions of unhelpful factors in CBT in IAPT serving a deprived area of the UK. Counseling and Psychotherapy Research. (Link)

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Micah Ingle, PhD
Micah Ingle, PhD
Micah is part-time faculty in psychology at Point Park University. He holds a Ph.D. in Psychology: Consciousness and Society from the University of West Georgia. His interests include humanistic, critical, and liberation psychologies. He has published work on empathy, individualism, group therapy, and critical masculinities. Micah has served on the executive boards of Division 32 of the American Psychological Association (Society for Humanistic Psychology) as well as Division 24 (Society for Theoretical and Philosophical Psychology). His current research focuses on critiques of the western individualizing medical model, as well as cultivating alternatives via humanities-oriented group and community work.

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14 COMMENTS

  1. Something I have heard from clients that recoil at CBT I’d like to share as well, and it boils down to our two brains. We have a Wise Mind (Neocortex) and a Reactive Brain (Reptilian and Limbic) and they often operate at cross-purposes. CBT asks we Wisely “tell” our Reactive brains when they are spouting untruths with an accurate statement. 3 things:
    1. It does work with practice! But to be effective, our Wise Mind has to be engaged. When overly stressed, the Wise Mind shuts down, making reason difficult to engage.
    2. The affirmations, truths, actualities have to really be strongly believed, or the automatic negative thoughts will win (cuz they’re the loudest and most persistent).
    3. Which can lead to arguing in our heads over what is real and true. And again, negative often wins, because negativity assists survival (tho often poorly). So a client can come in with persistent negative thoughts, and we ask them to get into arguments with those thoughts. That can be exhausting, make things seem worse, and can lead to people just giving up.
    Simplistic, but it’s a post, so please forgive my simplicity.
    For these clients I like to use Acceptance and Commitment Therapy’s thought defusion. Rather than arguing thoughts, you can simply let thoughts be, let them come and go, and carry on with trying to live a meaningful life no matter what your Reactive Brain is yapping at you.
    Any way, my 2euros.

    JN Olympia, WA

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    • jnicholas – #2 – “loudest and most persistent”

      When actually – in order to overcome a “negative” thought, you need to replace it with THREE positive ones, because the “negatives” – the stress-based thoughts – are vital for our survival as a species.

      “Must watch for tigers” is embedded more deeply in our survival than “cheer up.”

      Therefore the “negative ruminations” (as they might be called in therapy) have been developed as a coping strategy, and are more deeply embedded. You might say the limbic ones are more concerned with survival, while the neocortex is more concerned with executive functions (which, as you say, “short out” when under stress & duress).

      So – in order to overcome a survival “tape” – it takes 3x as much effort as it would to overcome a less emotional one.

      I feel like I’m not quite expressing myself well…I know that in relationships, because survival is so linked to the “negative” statements – that if you criticise your partner once, make sure you compliment them 3 times.

      It’s like I’m oversimplifying, but maybe it really is that simple?

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  2. Point of contention: showering daily is not healthy for anyone who is not being exposed to healthcare pathogens. For one thing, it washes off the vitamin d that your skin oils produce in response to exposure to UVB light and which takes time to absorb back into the skin and blood stream. It’s also not particularly good for your surface microbiome, and the skin is our first line of defense against illness. Also, literally none of the most financially successful people I know showers on a daily basis.

    Secondly, CBT (actually ALL of the manualized therapies) places the onus on an individual to adapt to their situation and develop better coping skills and internal regulation rather than acknowledging and assisting the client to change the circumstances leading to the distress.

    It’s no wonder that treating people as if they’re to blame for their problems and calling it “therapy” doesn’t make them feel better. Most of the time I was in “therapy”, I was high achieving, an honors student, traveling, involved in my community and being gaslighted by treatment providers as not really being invested in my own wellbeing or simply being “seriously mentally ill”. Too bad it took so long and I took so much abuse before my Lyme diagnosis. Even with my trauma history, I was kicking ass and taking names while being tremendously physically ill.

    I certainly hope the providers of these “services” will take the feedback from service users to heart.

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  3. “Other psychologists have criticized CBT on political and philosophical grounds, arguing that it is based on an outdated scientific model of the isolated and faulty brain, ignoring the effects of social and economic realities.”

    I think this is the problem. People’s difficulties are not caused by faulty brains, or chemical imbalances in their brains, that’s just lies the psychologists and psychiatrists spew at their clients and the world. People’s problems are caused by real life issues and crimes.

    Both psychology and psychiatry are about distracting people from their real life problems, by defaming their clients with make believe and scientifically “invalid” diseases, then the psychologists have the psychiatrists neurotoxic poison their clients.

    And since no “mental health” worker may ever bill any insurance company for ever helping any child abuse survivor ever, unless they misdiagnose all victims of sexual assault.

    https://www.psychologytoday.com/us/blog/your-child-does-not-have-bipolar-disorder/201402/dsm-5-and-child-neglect-and-abuse-1

    Covering up child abuse is, and has been, the number one actual societal function of both the psychologists and psychiatrists, and their many “mental health” minion, apparently for over a century.

    https://www.indybay.org/newsitems/2019/01/23/18820633.php?fbclid=IwAR2-cgZPcEvbz7yFqMuUwneIuaqGleGiOzackY4N2sPeVXolwmEga5iKxdo

    https://www.madinamerica.com/2016/04/heal-for-life/

    And all this psychiatric and psychological child abuse covering up also functions to aid, abet, and empower the pedophiles, and this is helping to destroy America.

    https://www.amazon.com/Pedophilia-Empire-Chapter-Introduction-Disorder-ebook/dp/B0773QHGPT

    I’m quite certain America would be a better place if our “mental health” workers would end their aiding, abetting, and empowering of pedophiles, by turning the child abuse survivors, and their concerned parents, into the “mentally ill” with the psych drugs.

    https://www.alternet.org/2010/04/are_prozac_and_other_psychiatric_drugs_causing_the_astonishing_rise_of_mental_illness_in_america/

    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome

    https://en.wikipedia.org/wiki/Toxidrome (anticholinergic toxidrome)

    We should start arresting the pedophiles instead. I know Epstein was arrested, but then poof! He’s gone.

    But given the huge percentages of child abuse survivors who are mislabeled with the DSM disorders, the psychologists and psychiatrists would have next to no business, if they got out of the multibillion dollar child abuse covering up business.

    What a sad state of affairs our world is in. I had no idea that the religious/psychological and psychiatric child abuse covering up crimes committed against my family, would end up exposing a world wide, multibillion dollar, primarily child abuse covering up, scientific fraud based, BS “mental health” system.

    https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml

    https://www.wired.com/2010/12/ff_dsmv/

    First they came for the fiscally responsible, non-bailout needing, non-“trillions in homes stealing,” non-war mongering and profiteering, ethical American banking families ….

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  4. What my eye casually caught of this article lead me to believe I would have shared many of the author’s opinions. Once I realized it was in reliance on a single other paper which itself seemed presented as a “scientific study” with a sample size of only nine, I lost all interest. There is no reason to berate the present author but I’d respectfully recommend he seek some academic consultation about article presentation. Commit to a certain threshold of citations and as well, make sure the cited studies are “good” ones before “making it look” scientific. In the alternative, if you have something of value to write about, do so – just don’t ride that edge. There are too many forces in the world today which make it difficult for people to understand what science is and isn’t. Don’t be one of them. Good topic though.

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  7. I’ve been referred for cbt many times since 2009, and I agree with everything here. It doesn’t work on autistic people either (diagnosed or undiagnosed). Since 2015 I was told I was too complex for iapt and no referral to secondary care, just more and more antidepressants I can never taper off, and developed a chronic illness from all the stress

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  8. First and foremost psychiatry torture is unacceptable. – it inflicts high levels and types of harm. Destroys. Kills.

    Then moving on to about CBT:
    I had a few sessions of CBT. It was not helpful to me. I never had heard of it before. As they were teaching what it was, it was not applying to my personal circumstances. It was “group” sessions. I listened and thought about it and replied that I believe CBT can apply in particular types of experiences; i.e. if someone is enjoying being rude to you or attempting to degrade you purposely, hurting you with words or however, you can obviously get hurt and keep getting deeper in hurt. However if you realize that what that person is doing is really that hurtful person’s problem and not yours you can rethink how you are reacting emotionally. You may even be able to diffuse it some by reacting to them with smiling at them and being polite and telling them to have a nice day and just let their words slide off your shoulder and back onto theirs. Probably in events even more seriously harmful to you, you could accomplish that in a similar way.

    However, if we are talking about totally different types of events, i.e. about an event that is very traumatic and it was actually the way it was, let’s say a horrific happening, i.e. witnessing severe horrific harm or horrific death, or something along those lines, and if you have feelings and you are not a robot, then that is going to cause severe pain in you as well, especially if it’s a loved one. You cannot change what happened, and you also cannot rethink it into candy coating it or rethink it into something other than it was just so you can lessen your pain. It may work for some people to pretend to themselves or to avoid it so their emotions can react differently, but realty is realty. Also it would be minimizing the horror the loved one went through and minimizing their worth, and in my opinion that would add to the pain.

    The heart and mind cannot be disconnected. We are not parts of a robot.

    My opinion is in order to try and heal or help another to heal, there has to be honesty (by all) about what happened and then go from there. That seems to be missing in any “treatments” out there.

    Drugs certainly are not the answer, and I could go on a lot about that. It is ridiculous that drugs are pushed the way they are. Deadly.

    We cannot pretend we are not sentient beings. I would hate to think what life would be like without being sentient beings, and all the sentient beings. It wouldn’t be life. We just have to figure out the appropriate ways to deal with the real legitimate deeply painful things in a realistic way because, simply, it is real. We cannot solve real pain with fake remedies.

    It is not as someone wrote “we inflict ‘all’ pain on ourselves, and we can adjust ourselves from doing it”. As in cold heart…cold mind, cold mind…cold heart?

    The most reasonable healing possibility is: honesty, reality of it, and “be your own therapist”.

    “Be true to yourself”

    “Heal thyself”.

    “In times of trouble” “there will be an answer” JPM

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