Although cognitive-behavioral therapy (CBT) has been around for several decades, its exalted status within the fields of psychology, medicine, and healthcare insurance has reached a fever-pitch the past few years. One of the most researched and popular forms of psychotherapy, CBT is increasingly hailed as the “gold standard” of treatment for depression, anxiety disorders, and insomnia. In addition, CBT has been enthusiastically embraced and promoted by insurance companies because it is considered an effective, short-term therapy. Owing to the hundreds of research studies documenting its efficacy in treatment for the above illnesses, CBT is the quintessential “evidence-based treatment.” In fact, there is currently a movement within the field of psychology which maintains that only evidence-based treatments–especially CBT and its derivatives–should be taught in post graduate psychology and social work programs and practiced by psychotherapists.
CBT is a blending of two psychological approaches to the human personality: behaviorism, which focuses on techniques for changing behavior through conditioning processes (punishment, reinforcement, desensitization, etc.), and cognitive therapy, which emphasizes the role of thinking in behavior and emotions. From the perspective of cognitive therapy, emotional problems arise from maladaptive/irrational thoughts and assessments we carry towards ourself and the events of our life. Straighten out your thinking and problematic behaviors and emotions will melt away. Both behaviorism and cognitive therapy essentially deny the existence of the unconscious, or deem it irrelevant to the origin and healing of mental illness. The result is a truncated view of the psyche, somewhat akin to a horticulturist who ignores the role of roots and soil upon a plant’s health.
With its overriding emphasis upon the power of thoughts, CBT essentially glorifies the mind and “rationality.” While it is true that our thoughts affect our emotions and behaviors, it is also true that the psyche is an autonomous entity which has reasons and goals which the “rational” mind and ego may never understand. In fact, some illnesses occur precisely because the “logical” ideas and beliefs that a person has tried to sell himself fail to convince his core personality.
In some ways, obsessive thoughts and irrational fears are like germs; they are always present but only become our problem when they have something to latch onto. That something is our inner psychological process. For example, a person does not usually develop recurring thoughts of death or suicide simply because his appraisals of life and self took a negative turn, but because the theme of death resonates with his deeper process–perhaps the need for change and transformation. A young mother does not develop a persistent phobia of her child being kidnapped just because she read a newspaper article about a kidnapping and overestimated the danger. At an unconscious level part of her may wish that someone would take this “burden” off her hands. And the frequent traveler might not have developed a fear of flying if there was not a part of him that desperately needed to come back down to earth.
What traditional CBT theory is reluctant to acknowledge is the fact that our inner world is projected outward, manifesting itself in unbidden but very symbolic thoughts (and also in symbolic behaviors and physical symptoms). Approaching such thoughts from a literal perspective, or with the rationality of the conscious mind (be it the client’s or the therapist’s), may reassure the ego for a time, but is unlikely to satisfy the deeper psyche. Perhaps this is why the “effectiveness” of CBT seems to be enhanced with the use psychoactive medication. Anti-depressant and anti-anxiety medications typically dull a person’s connection to their emotions, perhaps allowing the ego bounce back with its “rationality” intact, and without all of those pesky emotions.
Other explanations for the apparent effectiveness of CBT have been offered in the past several years. A 2004 paper by psychologist Steven Hayes discusses anomalies in CBT research which indicate that what was once assumed to be a key therapeutic component of CBT, namely, the challenging of clients’ “irrational” thoughts, is not the cause of their improvement after all. In other words, the “active ingredient” of CBT may not be more rational thinking. Some psychologists believe that it is the behavioral components of CBT that are the real catalyst of change. Perhaps, but research by psychologist Bruce Wampold offers another possibility. In an extensive meta-analysis of psychotherapy research, Dr. Wampold found that the methods and techniques unique to a given therapy account for only a modest portion (roughly 8%) of the overall treatment effects. On the other hand, factors common to all therapies accounted for far more (over 70%) of the effects of treatment. These shared factors include things such as the quality of the therapy relationship (trust, rapport, and therapist empathy), the client’s confidence in the therapist, and the therapist’s confidence in herself and her methods. What this implies is that the efficacy of CBT stems less from its particular methods, and more from the factors it shares with other psychotherapies. Interestingly, Dr. Wampold’s meta-analyses also showed that despite CBT’s privileged status among therapy approaches, its effectiveness is not appreciably better or worse than most other forms of psychotherapy. This is a rather humorous development, especially considering the volumes of research done on CBT over the years to bolster its resume (and market share).
Research into the efficacy of different types of psychotherapy has focused primarily upon their differences and unique interventions, but Wampold’s research is showing that the quality of psychotherapy hinges more upon the attributes of the therapist than his/her particular methods and theory. Of course, different therapists–like clients–are drawn to different ways of perceiving and engaging the psyche, and finding the right match can be as important in the work of psychotherapy as it is in marriage. Some people have argued that if there is not just one best way to provide psychotherapy, if psychotherapy is as much art as science, should it be considered a science at all, and mightn’t you just as well talk to a friend about you problems than see a psychotherapist? Perhaps the best answer is that psychotherapy derives its unique healing power from the fact that it is both science and art. When done well, it is the soul of a healer making contact with the soul and “inner healer” of the client. All of the theory and techniques mean nothing and amount to nothing if this fundamental relationship cannot be established.
- Baker, T.B., McFall, R.M., & Shoham, V. “Current Status and Future Prospects of Clinical Psychology: Toward a Scientifically Principled Approach to Mental and Behavioral Health Care.” Perspectives on Psychological Science, 9(2) 2009.
- Hayes, S.C. “Acceptance and Commitment Therapy and the New Behavior Therapies.” In S.C. Hayes, V.M. Follette & M.M. Linehan (Eds), Mindfulness and Acceptance: Expanding the Cognitive Behavioral Tradition. Guilford Press: NY 2004.
- Wampold, Bruce E. The Great Psychotherapy Debate (2nd Ed.): Models, Methods, and Findings. Routledge Publishing: NY 2008.
Copyright © Andy Drymalski, Ed.D.
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