Cognitive Behavior Therapy: A Critical Review
Cognitive behavior therapy (CBT) has become the dominant psychological treatment in the past few decades. In the late 1960s, it spread from the USA to the rest of the world together with the belief in the malleability of people, and nowadays it’s presented as one of the few “scientifically proven” therapy forms. While this “evidence-based” statement is in reality quite questionable.
With CBT there are a few helpful steps like getting a more realistic view of your problems and actively confronting your depression or anxiety. It is typical “American” in its assumption that the way you think will influence your feelings. Therefore, when you are depressed, you should challenge your irrational, negative thoughts (“positive thinking”).
But from clinical practice, we know that you can tell a depressed person a hundred times that he should think positively, but that won’t bring about a lasting change. We can’t think ourselves happy. You simply have to understand and come to terms with the disturbing feelings that cause these thoughts; you can’t push them away or ignore them.
These feelings are too strong, and they invariably will surface again, but then much more powerfully. If you don’t deal with your feelings, your feelings will deal with you.
Especially after the introduction of “managed healthcare”, more emphasis has been placed on the use of so-called “evidence-based therapies”. It created a tunnel vision by using methods from the pharmaceutical industry (such as “randomized controlled trials”), which when used in the social sciences have strong methodological shortcomings, and as a result, they are only applicable to very few therapy methods.
Research invariably shows that sustainable psychotherapy efficacy depends for the most part on the therapeutic relationship (trust, attention, and willingness to listen) and the extent to which clients feel that they can play an active part in the therapy. Psychotherapy based upon emotions (cognition/behavior plus the present/past) is often a far superior approach to mainly cognitive-based therapies (these focus primarily on symptoms, thoughts, and the present).
Removing symptoms without paying attention to the underlying emotional root causes often leads to the “recurrence” of, for example, depression.
Emotions (simply put, the limbic system regulates them) are, in an evolutionary sense, much older than thoughts (which are controlled by the cerebrum). Since the anatomical structure of the brain is quite a hotchpotch, the different parts of it are not always in sync with each other. Trying to influence your emotions with your thoughts (as CBT tries to do) is a hopeless enterprise.
It’s essential to listen to the client's whole story, which usually explains the current symptoms. Depression and anxiety are not just a handful of symptoms (as mentioned in the DSM5) but an idiosyncratic ontogenesis of these or other mental illnesses. CBT only focuses on the present, has no environmental or societal context, and has the flawed underlying assumption that insight and cognitive change are the correct remedies for symptoms like depression or anxiety.
There are other forms of therapy, like (short-term) psychodynamic therapy that go far beyond that. It’s not only the cognitive part (understanding) but most and foremost the emotional realization that counts. An insight must be experienced and lived through. It should incorporate conscious emotions, unconscious ones, and underlying conflicts. By emotionally experiencing it under proper professional guidance, it gets “worked through,” and after several times, the impact diminishes. Many clients time and again acknowledge the richness and depth of this, and it often leads to a real change in their lives.
The concept of “evidence-based therapies” has had an enormous negative impact on the field of psychotherapy. Nowadays, universities and managed health care providers solely concentrate on these “evidence-based therapies”. But because of the way that psychotherapies are evaluated through this concept, it basically means that only brief cognitive behavior therapy can be “accepted”. In medical science, “randomized controlled trials” (RCTs) are allegedly seen as the “golden standard” for research regarding medications. There is a lot of criticism about these RCTs, but in this article, there is no space to discuss them. Concerning the use of RCTs with psychotherapies, it should be noted that these RCTs are strictly regulated in an artificial environment,
(not “real life”) and meant for extreme short-term treatments. Most therapies can’t be molded into an RCT format, which means that RCTs favor certain methods (like cognitive behavior therapy) only because of the nature of the RCTs. Another caveat is that the lack of access to primary data from most clinical randomized controlled trials with psychotropic medications (since the pharmaceutical industry finances them and restricts access) makes it difficult to detect biased reporting. The often misleading conclusions from these publications force us to be very careful with statements from the pharmaceutical industry regarding the concept of RCTs.
Why is CBT so popular? CBT is seen as a relatively “quick fix”, is comparatively cheap, and appeals to our sense of logic: think positively, be strong, and you have to work for it! While in reality, coming out of depression means accepting and actually feeling your painful emotions. This is also a lot of work, but in a quite different sense! Depression is an emotion, and it has nothing to do with our thoughts. Emotions are, in an evolutionary sense, much older than our cognitive brain, and in the long term, they usually “win”. Trying to influence your feelings with your thoughts is a hopeless enterprise. Feelings want only one thing, and that is to be felt! So the best way to come out of depression is not to fight it with our thoughts but to actually start to feel it and find out where it stems from. Depression has to do with your past history and what others have done or said to you.
It’s difficult to measure therapeutic success; it depends on the school of thought that lies behind the specific method. With CBT, success is seen as having fewer negative beliefs. With psychodynamic therapy and psycho-analytic therapy (the latter usually last for years!), it is about understanding yourself, balancing your feelings, and learning to live with your issues. With these last two forms of therapy, “depression” means something quite different than with CBT, and it isn’t simply about a lower score in a general depression test.
Most of the research with CBT is done like this: a group of depressed people -> CBT intervention –> results. And of course, the outcome is often that CBT “works”. But when you compare different therapy methods with each other (taking into account the observations made above), there isn’t much distinction in success between the methods. There is a robust amount of research on this. One example is a big meta-analysis (2013 PLoS Med 10(5): e1001454) where seven psychotherapeutic interventions for depression (including CBT) were compared. The findings were that none of the therapies stood out as being better than the others. This means that there must be other factors (like the therapeutic relationship and an active client) that are responsible for the efficacy of psychotherapeutic interventions and not the researched method.
Cognitive behavior therapy is accepted because it supposedly generates (usually short-lived) results in, for instance, depressed patients. But it is a wrong assumption to think that CBT works. “Evidence-based” research concerning the effectiveness of therapies is a minefield. Based upon what meta-studies have shown so far, extraneous factors like the role of the therapist and an actively participating client are crucial to the success of therapy, and not so much the chosen method of therapy. If cognitive behavioral therapy was that powerful, then there wouldn’t be any depressed psychologists! Reality tells us something quite different.Therapy is an individual journey, depending on the context and history of the client, and there are no one- size-fits-all fail-safe methods. Psychotherapy based upon emotions (cognition/behavior plus the present/past) is often a superior approach to suffering than mainly cognitive-based therapies (which focus primarily on only symptoms, thoughts, and the present). Removing symptoms without paying attention to the underlying causes often leads to “recurrence” of, for example, depression. It’s important that root causes be uncovered and dealt with. After that, it’s about learning how to deal with triggers and underlying emotions.
The American psychologist PhD Dr. Jonathan Shedler wrote an excellent article, ‘Where is the Evidence for “Evidence-Based” Therapy?’ (The Journal of Psychological Therapies in Primary Care, Vol. 4, May 2015: pp. 47–59). The key points of this article are:
The term evidence-based therapy has become a de facto code word for manualized therapy—most often brief, highly scripted forms of cognitive behavior therapy.
It is widely asserted that “evidence-based” therapies are scientifically proven and superior to other forms of psychotherapy. Empirical research does NOT support these claims.
Empirical research shows that “evidence-based” therapies are weak treatments. Their benefits are trivial; few patients get well, and even the trivial benefits do not last.
Troubling research practices paint a misleading picture of the actual benefits of “evidence-based” therapies, including sham control groups, cherry-picked patient samples, and suppression of negative findings.
We can’t understand human suffering with quantitative empirical scientific methods because the human being is far too complicated for a simplistic empirical approach. Quantifying suffering is impossible. Depression, for example, is different (root causes, process, and impact) for different people. It is possible to select certain symptoms and then categorize and label them as depression (like the DSM does), but that doesn’t mean that you can quantify them. When you have one hundred depressed people, then there are one hundred different stories, personality structures, and developmental stages, and each of these people need tailor-made approaches and not just one-size-fits-all cognitive behavior therapy (with all its limitations).
Whether it’s the illusion that emotions can be directed by our thinking (‘cognitive behavior therapy” or “positive psychology”) or that changing our exterior will make us happier, or if everything fails, there is always medication, the existential quest for meaning in life and the individual meaningfulness of your own life are hardly touched. It’s a given that life is, for the most part, trying to handle unfulfilled longings. At the same time, there are the alleged “euphoric accomplishments” of both genetic and biological factors in psychiatry, which in reality are virtually non-existent. Psychotherapy with an empathic professional psychologist can give you answers to the deeper emotional layers of your problems.
Critique on the DSM5.
The psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM, fifth edition), is an arbitrary classification system with little psychological or psychiatric use. Despite the term “statistical” in the title, it does not mean that the book is based upon sophisticated research about types of psychiatric problems. On the contrary, the classification criteria and categories were chosen by vote by people in working committees who have strong financial ties with Big Pharma. The DSM-5 is written as an extension of the powerful pharmaceutical industry. There is neither a solid theoretical foundation nor a clinically pragmatic practice.
It’s an arbitrary descriptive psychiatric classification system with little diagnostic value (see, for example, Stijn Vanheule: “Diagnosis and the DSM, a Critical Review”). The described labels are scientifically and clinically untrustworthy (they are not reliable or valid), and they describe symptoms with no biomarkers (see above). While with all DSM-5 pseudo-medical classifications (“disorders”), the underlying assumption is that they are biological or genetic, there is no medical or scientific evidence of these assumed genetic/biological causes. Even worse, about half of the patients can’t be diagnosed with the DSM-5 because their issues do not fit in any category, and even if they do fit in two or three, there is no intrinsic link with a particular treatment.
Almost all DSM-5 labels show three layers: psychological, social and medical. The psychological aspect is the noticeable exterior: with BPD, for example, frequent angry feelings make you emotionally unstable. The second layer, the social norm, is more concealed behind words that signify too much or too little: with BPD, for example, intense, marked, frequent, recurrent, persistent, and frantic. It’s too much or too little in terms of implicitly applied social norms. The third layer is the most obscure and is found in the introduction of the manual. It’s a hopeful assumption that the described disorders are located in the brain, despite the absence of convincing scientific proof.
What is missing in this useless quest of symptom-hunting is context. It's much better to listen to the whole story of the client, determine the root causes of the client's present issues, and treat those (instead of a form of cognitive behavior therapy like dialectical behavior therapy) with an effective form of long-term individual psychotherapy that covers the present, past, emotions, cognition, and behaviour.
Do we need a diagnosis for mental health issues?
A six-year-old child has a cough, a fever, inflamed eyes, a sore throat, and white spots inside the mouth. The worried parents phone their family doctor for a house call. He or she checks the child, concludes that it has the measles, reassures the parents, and advises rest and some supportive medications.
This is a perfect example of the medical diagnostic model, which also has an implicit social relationship: the power of the “expert doctor” and the “layman patient”. The symptoms are bundled into an objective general syndrome (in this case, “measles”). They are based on an underlying knowledge system with a clear distinction between health and illness. The end result is a diagnosis and prognosis, assisted by diagnostic instruments. The aim is assessment, treatment, and a return to the status quo ante.
A 35-year-old man comes for consultations. His marriage is on the rocks; he feels depressed; he has aggressive moods (shouts at his wife and young children); he has a drinking and drug issue; and he has suicidal thoughts. In what way can we compare the psychodiagnostical process with the above-described medical process?
In the first session, the client gives further information about his present situation with his family and at work. He also provides some more information about his suicidal thoughts and about his drinking and drug habits. It appears that the client drinks and takes drugs to suppress anxious emotions. Although he is well educated, he has a strong feeling of inadequacy. His suicidal thoughts have to do with a feeling of utter loneliness.
In the second session, the psychologist focuses more on the history of the client's life, how he was raised, his schooling, and his previous work environments. His father was aggressive and loud, and his mother was rather submissive and quiet and tried to manage the two children and the household. His mother was physically, emotionally, and sexually abused by his father. The client can clearly remember the many nights that he couldn’t sleep because of the shouting and crying. The client was put down many times by his father too because he was the son and his father wanted to dominate him. The outside world didn’t notice because his father was the perfect gentleman outside the house. The client could not talk to anybody about this because nobody would believe him.
In the third session, the client feels that he can trust the psychologist and tells how he was sexually abused by an uncle (a brother of his father) when he was five years old. The uncle came often and took the client to a room in the house “to play with him”. His parents trusted the man, and it lasted for two years.
With the knowledge gained from the three sessions, the symptoms at the start of this example have a completely different meaning. A psychiatrist who uses the medical process only focuses on the symptoms, typically doesn’t have more than 5 to 10 minutes to spare and prescribes medicine which usually has nothing to do with the root cause of the problems. In addition, we know that there exists no effective medication for depression, anxiety, suicidal thoughts, substance abuse, low self-esteem, and loneliness. Having said this, medication for certain mental illnesses can be extremely helpful. Some time ago, I witnessed a client in acute psychosis. In situations like this, one can’t help but be thankful for the availability of reliable medications for this condition. The same goes for the very rare, if correctly diagnosed, illness of bipolar depression.
In his book “On being Normal and Other Disorders: a Manual for Clinical Psychodiagnostics” the Belgian psychologist Prof. Dr. Verhaeghe discusses the
differences between the two diagnostic processes.
The first difference with the medical diagnostic process is that in the psycho-diagnostical process it’s not just about one individual but also about the context in which this individual lives. The “diagnosis” usually doesn’t come at once but much later after more sessions, and very often it will be adjusted.
A second difference is that in the medical model, one works from the individual person to generalized diseases. The symptoms (high temperature, muscle pains, etc.) lead to the conclusion of fever (a very common condition, N=millions). Psychologists, on the other hand, start with a general story and end with N=1. Mental conditions are typically very individual and extremely difficult to generalize. In the above example, the psychologist gathers more information, and the situation becomes more specific.
A third difference is that in the medical diagnostic system, the view is central; it’s focused on the discovery of signs that direct to objectively measurable parameters.
Whereas within the clinical psychological perspective, the therapist is primarily listening to signifiers, which remain open to interpretation. Medical signs refer to an illness scenario, while signifiers derive their meaning and function from a special relationship with the context.
A fourth difference is that in the medical field, the disparity between illness and health can be measured and generalized. But psychological normality and abnormality are always relative and therefore individual. In addition, certain psychological symptoms can be interpreted as solutions for deeper lying problems.
The comparison between medical and clinical-psychological diagnostics is one with predominant differences. What works well with symptoms related to physical illnesses doesn’t necessarily work with mental illnesses. The final “diagnosis” is a description of an individual case and not some generalized label. So, you can ask yourself if a diagnosis of mental health issues is warranted.
Again, it’s about the context. It's much better to listen to the whole story of the client (N=1), determine the root causes of the client's present issues, and treat those (instead of treating symptoms with cognitive behavior therapy) with an effective form of long-term individual psychotherapy that covers the present, past, emotions, cognition and behaviour.
CBT, when embedded in the client’s proper historical context with an empathic counsellor, with an emphasis on emotions, and with a focus on root causes in the past, can be beneficial for a client. But then it goes beyond the conceptual framework of CBT.
Much of the suffering that psychologists try to alleviate can only be addressed by a response from humanity and a non-judgmental understanding of the individual. It can’t be done with a standardized protocol based on some rigid and shallow theory or research. Human relationships are much too complicated and much too individualistic to grant an approach that is said to be applicable to everybody.
All different therapies are based on different underlying beliefs about human nature, and practitioners who use these theories are (unconsciously) accepting these beliefs.
It’s important to realize this because the underlying concepts may not be in accordance with your own values. Cognitive behavior therapy, for example, urges us to think rationally, but we frequently perceive the world as mysterious and non-rational, and human behavior is often unpredictable.
Many so-called scientific therapies ignore meaningfulness, spirituality, self-awareness, intuition, morality, introspection, creativity, literature, and the arts (which teach us a great deal about human nature). All of these are hard to prove in an experimental design. There is no scientific answer on how to deal with, for example, changing jobs, leaving a marriage, a major loss, loneliness, or spiritual questions. All these issues demand the entire personality of the therapist - everything he or she has learned or experienced through life (of which emotional maturity, compassion, and empathy are essential).
Empathy in therapy is a key concept, and although it’s complicated to define it, generally speaking, we assume that it’s their ability to imagine oneself in the situation of others and to sense the emotional state. The therapist should make it clear that he or she understands the emotions of the client. Besides this affective aspect, empathy also has a cognitive part, and it enables us to understand the other person's perception of the environment.
The quality of empathy increases when the therapist is able to be authentic with himself or herself and in contact with the client (congruent). The importance of an empathic therapist for people with mental illnesses can’t be emphasized enough.
Psychotherapy practiced by an empathic professional therapist with an active client does work. Depression, for example, has everything to do with feeling depressed. Since depression is about stuck emotions, it makes sense to treat it from that angle. An empathic psychotherapist with sufficient knowledge about depression can coach the client to make the stuck feelings “fluid” again. It’s about making the client feel that he or she is understood and that his or her story and symptoms are taken seriously. It’s about empowering people. In therapy, there is a lot of talking, but in essence, it’s about venting your feelings, letting them sink in, and coming to terms with yourself. Depression has to do with a person’s past history and what others have done or said to him or her. So therapy should focus on the emotional link between the triggers in the here and now and the painful causes in the past. The next step should be the painful job of trying to feel these stuck emotions. It’s crucial that the client have a well-trained professional psychologist who supports him or her. When the client feels more emotionally balanced because the influence of his past has diminished and the client has learned to handle his or her past emotions, then the time has come for the therapist to step back.
Dr. Marcel de Roos, PhD., is a psychologist from the Netherlands, now living in Sri lanka. He has more than 30 years of experience as a psychologist. His website is: https://www.marcelderoos.com/