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

By Ron Unger

Cognitive behavioral therapy or CBT has been pretty heavily criticized by people within the “alternatives” community and in particular by a number of Mad in America (MIA) bloggers and commenters in the past few years.   In a way that isn’t surprising, because many of us 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.  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 being 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’m not however proposing that it’s the best 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 a possible “dark side” to CBT being well researched, while other methods are not.  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.

But it should be noted that a therapist is 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 reach 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.

There are of course exceptions, and of them the psychoanalytic approach is the best known.  So how should we think of CBT versus a psychoanalytic approach for psycosis?  To start with, I would suggest avoiding assumptions that CBT is always “better” than the psychoanalytic approach just because it has been more extensively researched.  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 the door 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 boundary 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.

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, but 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.

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 appear to 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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ronRon Unger is a therapist and educator specializing in cognitive therapy for psychosis, Ron Unger explores emerging understandings of psychosis and of efforts to change mental health treatment to support human rights and full recovery. Visit his blog here: Recovery From Schizophrenia and Other Psychotic Disorders


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