Sunday, July 29, 2012

Dispelling the CBT Cartoon

        Recently, I have been spending a lot of time thinking about clients who come to therapy and what they might be looking for and expecting in the work that they will do with a therapist. I focused on finding the right therapist, exploring what an eclectic approach to therapy would look like and looked specifically at behavioural therapies in my last post. Although I feel that post gives a useful snapshot view of three popular approaches to therapy in the behavioural wave of therapies; I recognize that there is a "CBT cartoon" that exists; This is something I especially understand as a social worker who recognizes, uses and appreciates cognitive behavioral therapy techniques in my own direct practice - my colleagues love to give me a hard time about using CBT. In this post, I am going to do what I can to make sure that the common misconception of CBT that I hear gets dispelled.


Misperceptions of CBT

        A Cognitive Behavioural Therapist will only use CBT, no matter what my issue is. This simply is not true, CBT is not an appropriate intervention for all types of issues that people attend therapy for but it has implications for the every day life of clients. An example of this may include someone who has experienced the loss of a loved one, CBT would not be my preferred way of working through the conversations with this person, showing sensitivity and supporting them in the context of therapy. However, CBT can be an effective intervention for this person. Therapists can demonstrate how effective a CBT intervention may work here to deal with issues related to normalizing feelings, exploring what is missed, and talking about looking toward the future including coping with future losses. Yea, CBT does that (did I just come up with a new CBT catchphrase!?) The point is that CBT is useful here, in this situation.

        Cognitive Behavioural Therapy is a restricted methodology, the therapist has very little autonomy and ability to work creatively in treatment. This is completely based on the clinician doing the therapy; a therapist like any other professional is human and ultimately will have different styles, training and approaches to therapy. The need for training after graduate school is very high for therapists, new and old to therapy, being a Cognitive Behavioral Therapist does not necessarily say anything about how the therapist integrates their knowledge or simply how creative they are. CBT is simply the theory and tools behind the way the therapist will approach treatment.

        The treatment will be brief and I won't have an opportunity to talk about my past in Cognitive Behavioural Therapy. Yes and no. CBT is rather standardized in public healthcare systems in Canada, it is meant to be a short-term intervention (less than twelve sessions, often time six to eight sessions). For this reason, insurance companies approve CBT at a high rate for Employee Assistance Programs (EAP), etc. This is not unusual in psychotherapy, Solution Focused Therapy is also a rather brief intervention however, there are opportunities to talk about your past, to consolidate your history and to collect memories. This also does not preclude a client from returning to CBT after their sessions are up. A final point that is nice about CBT is that there are numerous resources out there from workbooks and even apps that clients can continue to work on themselves or at least keep track of their thoughts, feelings and emotions - empowering clients outside of the therapy room.

        Thoughts can't change. This is false, thoughts can change through theories of language and cognition. For example language acquisition and constructing a new repertoire; there are empirical studies that show this increasing of your repertoire is possible. It may be difficult but it is possible! Note here that I make mention of increasing repertoire, not getting rid of things that don't work. I will talk about this more in the next section.


What does and does not work in CBT?

        In dispelling the CBT cartoon, I also do not want to give the impression that I fully buy-in to CBT. It is an intervention that can be fun to use, clients like the activities and at times it has made conversations in therapy a little easier. I would like to spend some time looking at CBT critically and understanding what does work and does not work about this way of thinking about human behaviour.

CBT works on information and talking about it in different ways. The conversations that are held in CBT are about what is happening in your life now and dealing with present issues. CBT usually looks at what is rational or irrational, this is a big part of the traditional model but is hard to make work. Here is what I mean by "work." The literature/data does not support this right/wrong (rational/irrational) way of thinking. From the data, you could argue that traditional CBT invites people to struggle within. For example, bad cognitions leads to bad emotions and bad outcomes, this is or should be according to the theory, manipulable. There is a way to change bad cognitions (thoughts) so that people don't have bad emotions which result in bad outcomes. The work that a CBT therapist does here is around challenging cognitions. This may be in the form of asking clients to think about things differently and to look at the functionally important correlations here. This is cognitive restructuring or changing peoples' thinking. Now, this isn't a CBT therapist somehow worming their way into a clients brain and literally changing the way they think. No, that sounds rather sinister. Instead, it is the CBT therapists position to ask questions and some therapists may make comments. For a lot of clients, they see this as substantial work and call it helpful. It also creates situations like what I described earlier where a client may struggle within, changing the way you think is difficult work, CBT is not easy work. In fact, the neuroscience on this subject shows that changing your thoughts, removing, deleting them, etc. is not really that possible.

        Approaching this therapy with respect and understanding it as a science, a CBT therapist can move forward in new and interesting ways; Instead of doing the above failed component analysis of cognitive restructuring, there is some new things in CBT such as cognitive reappraisal that are evidenced to work. Sometimes this concept of cognitive reappraisal is called "flexibility." Psychological flexibility is thinking about things in different ways and being selective about what behaviour works. Discussions around psychological flexibility and not cognitive restructuring are known as a contextual CBT method. For example rather than using "but" statements, try using "and." This is asking people to try things in a different way which at first glance seems like more cognitive restructuring but contextual CBT is more about variation, selective reinforcement, allowing the client to evolve rather than narrowing the repertoire. I would like to try and be more clear that this is not traditional or classical CBT but is still a part of CBT. Often, contextual CBT is referred to as the third wave of behaviourism. What I am describing here, contextual CBT is more about the relationship to cognitions and avoiding thinking about the "proper" or "correct" ways of thinking. This also makes therapy a more comfortable experience for therapists because it continues to tear down the expert role and places the therapist without judgement or "knowing" about what is right and wrong and allows the client to say "this does or does not work for me."

Yea, CBT does that.

Timothy Gordon, MSW
Registered Social Worker and Psychotherapist
Hamilton, Ontario

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