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.


        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.
Hamilton, Ontario

Comparing and Understanding Behaviour Therapies

        In my last post, I discussed finding the right therapist. That process takes a little bit of work and research on the part of a client seeking out someone to treat them. The matter gets more complicated when you're investigating specific therapies and if they are relevant or not to you and if they fit with how you want to do the type of therapeutic work you're involved with. During my searches, I found that Cognitive Behavioural Therapy (CBT) is extremely popular amongst clients, they simply have heard of it. Now, I am not going to make an over-generalized sweeping like "CBT is crap." Although it has become quite posh for therapists to talk trash about CBT and other Behavioural interventions; I respect CBT for what is, a sometimes useful intervention that many people have found helpful. 

So, what is my opinion!? Well, it's complicated so just give me a few minutes to explain - then you can be the judge.

I think any therapist who has an interest in helping people will use some behavioural skills some of the time as the skills are easily accessible for clients, fun to teach and highly effective. There are numerous types of behaviour therapies and I have not covered all of them here but these are the ones I know best because I have been trained and supervised on all three of them.

Dr. Linehan's Cognitive Behavioural Treatment of Borderline Personality Disorder (aka, Dialectical Behaviour Therapy) Skills Manual is pictured above.

        My career as a therapist began in forensics at St. Joseph's Healthcare in Hamilton, ON. At this site Dialectical Behaviour Therapy (DBT) is the predominant system of therapy. Before arriving at the hospital, I had heard many of my Master of Social Work colleagues speak out against Behavioral Therapy - specifically CBT, calling it oppressive, judgemental, manipulative and superficial. They asked pointed questions and were generally unfriendly to a guest speaker who came from Toronto to speak with us about the use of CBT in their direct practice. One of my patients mistakenly referred to DBT as "Diabolical Behaviour Therapy" and I thought to myself "Man, people really do have a bad impression of this stuff."

I read the book, a handful of journal articles and did the online training and quickly came to realize that DBT is not manipulative at all. In fact, I found it extremely ethical. DBT is heavily based around skills and skill training, it puts the proverbial ball in the court of clients, telling them that if they want to see changes in the way people respond to them and what is happening in their life, they need to make changes themselves with how they interact with those people. At times in DBT, the therapist closes space and confronts clients about their decisions and actions, the therapist then asks how the skills clients learned could have helped and clients have the opportunity to constructively work through situations and problems using the skills. What is rather nice about this is that therapists can be validating here, telling clients "Yes, I agree that guy was being a jerk to you. How do you feel about how you reacted though?" This also places the therapist as an ally rather than an adversary. However, the therapists role as the expert still exists here in this position.

DBT requests clients to have a level of acceptance which is referred to in this model as "radical acceptance." This is a concept that can be empowering for some and infuriating for others. The core principal here is that clients accept the narrative of their lives, their history for what it is - accepting the situation just as it is. This is best illustrated during the online DBT training where a client remarks that they were abused as a child, that the abuse never should have happened. The therapist agrees with the client and tells them that acceptance is not the client conceding to the abuse and saying it's okay the abuse happened. No. Instead the client accepts that history as a part of their life "I am a person who experienced abuse." This is an essential concept to the next behavioural intervention I will discuss, Acceptance & Commitment Therapy (ACT) however, note that ACT goes deeper into this concept of acceptance and in my experience, puts acceptance in a more appropriate perspective.

This self-help book encourages introspection and treats therapy as a journey.

        Acceptance & Commitment Therapy (ACT) has the word acceptance right in the title, so you know some sort of submission to the way your life is, is just going to be a part of the program. Well, that is true but I would argue that this position in more comforting than what clients would experience in Dialectical Behaviour Therapy. ACT recognizes the pain and utter despair that living can be and really puts the acceptance of what your life is, into perspective. ACT's acceptance is similar to the radical acceptance of DBT by stating that accepting what is happening in your life and your past does not make it okay or say that you are in favour of it. ACT goes farther and states that it's

ACT really looks for what is important and meaningful for the client. This important distinction sets ACT apart from other behavioural interventions. There is a thorough assessment in ACT for therapists to work on with clients to discover clients values and make a commitment to taking action, being true to oneself to be the person you want to be.

Let's take a moment here and acknowledge how scary this can be for some. Just discovering your values alone and committing to taking action to fulfill them in your life and make them a part of living your life is a task, an obligation. Some might see this as a burden. ACT attempts to make this experience empowering and offering some freedom for clients to acknowledge the way they want to live their life.

CBT is popular, it's like the Michael Jackson of therapy, you may not like him, you might even think he's unethical but you've definitely heard some of his tunes and he has a number of gold records because of them.

        I don't know about you, but I think that is a catchy line "Change how you feel by changing the way you think." It's simple and sounds incredibly accessible. It's like an epiphany or lightbulb moment: "DUH! The problem with how I feel is the way I think!!!!" Well, as it turns out it's not necessarily that easy all the time and sometimes your thoughts are completely accurate. The intervention offered here, Cognitive Behavioural Therapy (CBT) is about getting the right story in your head about who you are. This is a good way of challenging and disputing thoughts. However, how easy is it to really identify distortions in thinking. It isn't. Anyone who argues any differently is once again playing that role we social workers love to hate, the expert.

The work that is done in Cognitive Behaviour Therapy is rigid, what I mean by this is that the therapy is a process which is manualized or structured. This results in specifications over how the therapy sessions are conducted, what skills are taught when, how they are taught and what they address. A critique here is that the CBT process is "cookie cutter" or simply not unique to each client. Some argue that this is not a bad thing, insurance companies in Canada and mental health hospitals seem to have it at the top of their lists or some times even the only treatment on their list approved. This does not come as a surprise to me, the research shows that CBT is effective and it is short-term, you don't need many sessions or hours with a therapist to work through the material.

I have as of yet to see a sophisticated clinician who is a Cognitive Behavioural Therapist in Hamilton or even in the greater academic community but that does not mean they are not out there.

At the end of the day, it's about what works best for clients. I ask myself, how can I use what I know to be useful with the person sitting across from me in the therapy session?

        After having been trained in all of the above therapies, practicing and being supervised on each individually I have come to find that Acceptance & Commitment Therapy (ACT) fits best with my practice. I do not wish to devalue any of the other therapies, I still use DBT skills and found the training extremely helpful. Likewise, with CBT, I was able to put the intervention into practice which has been foundational to my understanding of behavioural interventions in general and has been greatly beneficial to the work that I do in ACT because at the end of the day, ACT is still a behaviour therapy!

Just working towards being a better clinician,
Tim Gordon.
Hamilton, ON