What’s Wrong with CBT?

“This is like a cookbook. What is this about giving people homework to do? What type of message are we sending?” Vladimir, a physician colleague and close friend, articulated these points with frustration in his voice, after assisting in an all clinical staff meeting, asking clinicians to start formal training in Cognitive Behavioral Therapy (CBT). “What exactly is the concern, Vladimir?” I asked, trying to understand his frustration, and Vladimir responded, “This is such a reductionist view of the mind and the brain, and it sounds more like a quick fix.”

Is CBT merely a reductionist view of the mind and the brain?  Is it a quick fix? To answer these and some related questions, let us look deeper into this commonly known modality, Cognitive Behavioral Therapy (CBT).

As a physician, psychiatrist and psychoanalyst, Aaron Beck, MD treated patients with depression, using psychoanalytic principles, which have proven effective in reducing symptoms of depression. However, a subgroup of his patients was noted to remain symptomatic, not getting better, as if untreated, and a common denominator among all of them related to what he later called “automatic thoughts.”

Automatic thoughts, for these patients, were the negative thoughts that led to depressed mood and behaviors associated with their depression. He explained that these patients had negative thoughts about themselves, about the world, and about their future. This has become what is known today as the Cognitive Theory of Depression. Beck made his observation, and he formulated his hypothesis; he then needed to pursue the experimental phase. Instead of continuing with the psychoanalytic principles that he had been using for this patient subgroup, Beck adjusted his approach, helping the patients,

(1) identify their automatic thoughts;

(2) evaluate such thoughts;

(3) substitute them with healthier ones, which would thereby

(4) change their feelings and behaviors accordingly.

He saw effective changes in these patients, changes that were not only sustained but also replicated in his other patients. Beck called this approach Cognitive Therapy, which later became Cognitive Behavioral Therapy. Many of these negative thoughts were often associated with core beliefs these patients had about themselves, which, indeed, colored or shaped the way they felt about the world and their future.

This approach has generated much interest, leading to almost one thousand studies, proving its effectiveness, not only for depression, but also for anxiety and a variety of other psychiatric disorders, emotional distress, and general medical conditions. CBT for insomnia, ADHD, PTSD, and for eating disorders are some examples of how CBT has been successfully used, following the principles and approaches I described above, though with a different formulation, based on the specific condition. Some of the additional benefits of CBT relate to

(1) the shortened duration of treatment, as it is more solution focused, and

(2) the outcome that patients learn transferrable skills for other areas of their lives.

Contrary to what my friend, Vladimir thought, doing CBT well is far from following steps as you would in the use of a cookbook. Remember, there is the individual patient, for whom an assessment is required, with whom a therapeutic relationship needs to be established, and with whom a collaborative plan has to be formulated.

As you can already see, for CBT to be effective, all the other conditions that are required in psychodynamic psychotherapy based treatment, for example, must be present as well.  In fact, a clinician wearing a psychodynamic hat has certain advantages when doing CBT, because the core beliefs become easier to identify.  Even Beck told me how his psychoanalytical training was the foundation for him to be able to develop the approach of CBT.  “Listening with a third ear,” as we say in psychoanalysis, was necessary for him to start hearing the negative thoughts of his patients.

“This is like a cookbook. What is it about giving people homework to do? What type of message are we sending?” Vladimir, a physician colleague and close friend, articulated these points with frustration in his voice, after assisting in an all clinical staff meeting, asking clinicians to start formal training in Cognitive Behavioral Therapy (CBT). “What is exactly is the concern, Vladimir?” I asked, trying to understand his frustration, and Vladimir responded, “This is such a reductionist view of the mind and the brain, and it sounds more like a quick fix.”

As you now can see, CBT emanates from psychoanalytical principles, and instead of a “quick fix,” it touches on the core beliefs of our patients andclients, and the resulting changes have been shown to be long lasting.