“Let's look at the errors in that way of thinking.” "What is the evidence to support that thought?" "How can we replace that with a positive thought instead?"
Cognitive Behavioural Therapy is often the first thing that doctors or psychiatrists will recommend when referring a patient to therapy—not because it's the best treatment in all cases, but because it is arguably the most commonly known. It's pretty much exclusively what we're taught in psychology programs (including Master's programs, which is ridiculous imo), and it's one of the most highly-researched modalities. And there's nothing "wrong" with it! In fact, I used it for a while when I was starting out in the field.
And... I disagree wholeheartedly with its fundamental assumptions. Though there are *some* elements of the model that are helpful and crossover nicely to the approach I take now, there are glaring issues in the way it is traditionally used that I can't ignore, and that's why I decided to write this post. Here are the major reasons why I don't use Cognitive Behavioural Therapy in my practice:
It encourages the belief that there is "positive" and "negative" or "healthy" and "unhealthy" parts of our experiences.
Ironically, for a model that claims to help us break free from our own self-judgments and unhelpful beliefs, it immediately steps on the judgment train by classifying certain parts of our experience as "bad" or "negative." All of my clients know that I rarely, if ever, use the terms "bad" or "good" (or any variation of that—right/wrong, positive/negative, etc.), because that comes with inherent shame and judgment. Maybe this is me taking language a little too literally, but I always imagine the words "negative" or "unhealthy" coming with a metaphorical slap on the wrist; with some implication that this thing is wrong, and it's up to you to fix it. Calling something negative or unhealthy implies that this thought/behaviour/whatever is a problem. What if, instead, we just recognized that we're experiencing what we're experiencing—without classifying it as bad or good? Then we still have all the freedom in the world to change it, if we want to, but we're no longer shackled down by the burden of this thing being a "problem" that we need to solve. As a side note, this also encourages the pathologizing language of mental "illness" and mental health diagnoses. I have no problem with using diagnoses as labels if they help us feel validated and more knowledgeable about our experience—I've been diagnosed with several things throughout my lifetime and, at the time, they helped me gain clarity on what I was going through. The problem occurs when this language is used to suggest there's something wrong with you. I'm here to say that the presence of intrusive thoughts, self-blaming thoughts, fearful thoughts, are all perfectly normal to experience. Even those that would fit a more "extreme" diagnosis like PTSD or psychosis—you aren't suddenly unhealthy just because you're experiencing this list of symptoms, and labeling them as "negative" or "unhealthy" doesn't make us any more equipped to manage them.
We end up getting into arguments with our own thoughts, which can intensify how much we struggle with them.
An integral component of CBT is the identification of unhealthy/negative thought patterns—and specifically the awareness of "thinking errors" or "cognitive distortions". Then, in response to these thoughts, the most common approach within this model is to look for the evidence that supports the initial thought, and then counter it with evidence that doesn't support the thought. What's the problem there? That seems logical, right? And for most of us, it's our immediate reaction to try to give the opposing evidence. HOWEVER,
the very nature of that process puts us into an argumentative state with our own minds. This can be extremely frustrating, and if you're like me, the argument back and forth could go on for hours.
If we don't follow this process, though, and we resist the urge to "prove them wrong", we can have a much easier time moving on from them. Dr. Russ Harris (a proponent of Acceptance and Commitment Therapy") has an amazing 2.5 minute video to demonstrate this, but you can also look up the "struggle switch" for other examples of this point.
The labeling of "cognitive distortions" or "thinking errors" implies that we are doing something wrong when we have distressing thoughts—and it implies that we should be able to change or stop them.
I don't know if this one needs much explanation, but I'll give one anyway. In the same vein as calling something "negative" or "unhealthy," the label of having thinking errors suggests that there is, in fact, an error in how we're thinking, which further implies that there is a mistake or problem that we should fix. Let me ask you this: have you ever tried to think of a distressing or unhelpful thought? Probably not. So should there really be any personal responsibility or blame for having them? Thoughts are like the weather; we can't control if it's raining, or sunny, or a hail storm, but we can choose whether or not we go outside, if we put on a raincoat, and if we choose to ruminate on how crappy the weather is. The time and place for personal responsibility and action comes in when we decide how we choose to respond to those thoughts (if we decide to let them constrict or control us, or just let them be), but we don't need to call them "errors" to do so.
CBT has been ineffective for most clients in my professional experience, especially for trauma—and this is supported by some research as well.
As part of my initial phone consults with prospective clients, I make a point to ask them about past experience in therapy, and specifically what did and didn't work for them. I'd say, conservatively, 7 times out of 10, people say that they've tried some form of Cognitive Behavioural Therapy in the past and they didn't find it helpful in the long-term. Some people report that it was helpful to gain some coping skills for the immediate situation, but it didn't allow them to understand the deeper roots of their issues. Or, just as often, I'll hear people say that they found it extremely difficult to just replace their negative thoughts or interrupt those thoughts, so they gave up on themselves and the process entirely. I heard that feedback over and over again when I was working almost exclusively with severely traumatized individuals (at an addiction + mental health organization), because when our body has been traumatized or chronically stressed, we have very little control over the things that automatically come up for us. It's not easy to just recognize a thought like "nobody likes me" and learn to calmly regulate and counter that thought, because our bodies are so severely dysregulated. This article by Corrigan & Hull (2015) eludes to some similar points, speaking to the complexity of people's experiences post-trauma, and how the structured, time-limited nature of traditional CBT just doesn't fit the bill.
As a point of comparison, for those who are interested, I primarily use Acceptance and Commitment Therapy (ACT) in my practice, bringing in elements of polyvagal theory/nervous system work, and Internal Family Systems (IFS).
I'm not saying all of this to scold or berate those who use CBT, nor am I trying to crap on any clients who have benefited from the model. I have many friends and colleagues who use CBT wonderfully, and I'm happy for them. For some people, in some circumstances, it has worked extremely well. But for me, my practice, and my beliefs, these things do not work. And I was tired of getting referrals of people who were blindly told to get CBT, without being shown all the other approaches and modalities out there that could be a way better fit.
As always, your transparent, genuine, and friendly neighbourhood psychotherapist,