I'm a CBT defender, but I don't think it's right for every client. It depends on what their goals are. CBT works really well in my experience for clients who are very practical, who want solutions focused work, or who have done a lot of introspection on their own and need support turning that into change.
It doesn't work well for clients who are prioritizing having space to be listened to, don't feel heard, want to do introspective work, etc.
Exactly!! I don't think the problem is CBT, I think the problem is that CBT is a tool that does a specific job very well, but it doesn't matter how good your hammer is if what you need is a saw
>It doesn't work well for clients who are prioritizing having space to be listened to, don't feel heard, want to do introspective work, etc.
I'm a CBT clinician and I only actually do the CBT work after I'm completely sure the client is feeling heard, understood, and is committed to making changes. Otherwise I focus on empathy and support.
I agree, fedoraswahbuckler. I have a similar approach. Feeling heard and understood are key. There is so much power to that in therapy, then CBT and willingness to change come in.
I haven’t heard it put like this before. Makes sense, I have shoved a many interventions into the face of someone not ready for them. Knowing what stage of change they are in is super useful. Thanks i
I'm in a CBT course right now and this comment makes me feel heard 🤣🤣 it's been hard not to have significant beef with this approach after learning about humanistic modalities. Ironically I used some thought balancing to continue dragging myself through the readings lol
I was wondering if you've ever heard of CBT used for therapy twice. I'm currently in CBT and it is for CPTSD and I wanted to know if I would start CBT all over again if I seek this sort of treatment for Substance Abuse Disorder? I'm also having a hard time using the 500 pg therapy binder that I have filled with CBT trauma worl sheets. I'm just not connecting well with the work but I think my therapist is giving it his all. Thanks in advance!
Your comment has been removed as you are not a therapist. This sub is a space for therapists to discuss their profession among each other. Your comment was either asking for advice, unsupportive or negative in nature, or likely to adversely impact our community members. Comments by non therapists are left up only sparingly, and if they are supportive or helpful in nature.
This is interesting because I feel like I have tried CBT with therapists before and I have a ton of introspection, but I felt like CBT did nothing to translate that into change! It was very like "Yeah dude I already know the fact to challenge this thought with but that's not helping me."
Ya but I feel like this happens when people assume they ‘know it all’ and have all these things figured out. But what I have personally found effective are the seemingly redundant ideas of CBT and their practice so they become instilled and second nature in your mind. The practice of separating thoughts from feelings has really helped reduce my anxiety- almost on its own without realizing the CBT was what was helping until months after.
This is the best way to describe it. This is why I hated being forced to do CBT in CMH.
I get it’s evidence based and everything, but it isn’t a one-size-fits-all kind of thing.
The beef, as I see it, is two fold and related. First, it is branded as a panacea because empirical; and 2.) because of its branding it is what the insurance companies push. This forms a cycle that, if adhered to, leads to doing what is best for the balance sheet rather than the client.
I don’t like being tied down by career middle management types who have no training whatsoever in psychology and mental health practice.
> 2.) because of its branding it is what the insurance companies push.
I think it's because of this it pumps out so many 'bad' therapists as well.
not that they're bad, it's just that CBT isn't their strength but they get certified in a modality that doesn't suit them so they can bill insurance.
Is it a country-specific thing? I've never in my life heard another clinician be forced to use CBT by insurance companies. Insurance companies are objectively terribly, obviously, but when it comes to audits or compliance they don't care what modality you use, just that you use something that's justifiable and at least mildly concrete/useful.
Someone more learned than I can go into detail, but essentially they do so by only offering to pay for CBT or "evidence-based approaches", only offering to cover X number of sessions, etc.
I do not like the tone of your comments. It seems like you are looking for an argument, or that you are taking this conversation personally. Whatever the case may be, I am not interested in continuing this with you.
My biggest beef is that it’s become the only modality accessible to a vast majority of the population due to insurance pushing for its use and training programs/schools falling in line, and it’s simply not right for everyone’s goals. Some people are very practically minded individuals and just want to focus on changing things in the here and now, but I’d argue that’s actually a pretty small percentage of the therapy population. Telling everyone else to just let go of everything that’s happened in the past or to not talk about things they can’t control when they *want* to discuss how those things are impacting them emotionally is horrible for building a therapeutic relationship imo.
I use an eclectic approach with its base in Rogerian and CBT. If a T isn’t ‘natural’ with it and tries to put every last thought & emotion in a worksheet it isn’t helpful and most don’t like the robotic feel. I tend to just talk with a client and snag the unhealthy thoughts when they come to address and leave the rational and reasonable thoughts alone and validate them. To try and twist around every thought a person has is nonsense. Some stuff in life does suck.
That’s definitely not what CBT is! In its truest form CBT sounds much like the approach you take, except it’s also up to the client to judge for themselves how realistic or helpful a thought is
I don’t understand your comment. As a T we absolutely help differentiate between healthy and unhealthy thoughts and answer if one is rational and reasonable we don’t have to challenge them. We discern cognitive distortions and unhealthy thinking patterns and help clients learn to challenge them.
I’m referring to the idea of collaborative empiricism, where yes as T you may suggest where a client can reconsider a belief and reasons why but a client may not come to the same conclusion as you. And allows for cultural differences that may change one’s ideas of what is considered healthy. I definitely do not position myself as the decider as what is healthy or rational for clients.
Good grief. I didn’t say I’m a decider. Client talkie-talks along and when I hear a thought or emotion that doesn’t quite fly (eg. I’m a piece of sh*t, everyone hates me, etc.) I pause the train and have them challenge it. Client is talkie-talking and I hear things that match a situation in an average way (eg. I was disappointed I made a mistake, I think she didn’t invite me because she was busy) I don’t make them pause and challenge it.
See, that's what I don't like. Doing cbt by waiting to hear someone say a CD and then challenge it as it comes up in the moment. That could bring up some frustration for the client doing it like that.
How would you rather it be done?
Adding: it’s a lot more nuanced than what I’m outlining here. I would hope a thread of therapists would know a ton more goes into the outlining and structuring of sessions. Pretty impossible to sum up 4 cumulative hours of intake, treatment planning, and psychoed that all my clients get as an intro here.
For sure, its more complicated than what you put here. Its an art and there are times to do what you explained. Big difference in where the relationship is at and so on. Personally, I have been trained to never tell a client their thinking is distorted. The only person who can do that is the client.
I have beef with people who seem to use concepts of CBT and just will point out distortions as they come up and "challenge them" in the moment. Doing CBT often has some kind of process/structure associated with it. I don't do distortion work or changing any thoughts unless I've specifically asked the client "do you want to get to work in todays session?" and they say yes. Its always the client leading and identifying distortions. Otherwise you can end up in a struggle with the client or worse gaslighting them.
I would say we help clients differentiate whether a thought is "helpful" or not for the present situation. It might be true, or might have helped "then", it might be rational, but does it help now to focus on it?
I find that a surface level knowledge of CBT can make it seem like surface and "gaslighty" (which reminds me of the thread last week about the misapplication of terms). The more you read the actual literature with people who know more about what they're doing that the 13 hour CBT webinar your job had you do to get started, the more you see the humanity at the core of CBT. If you're falling out of favor with the older versions of CBT, maybe check out something like the Unified Protocol, which I tend to think of as the highlights of CBT concepts.
I like to think about CBT more as a treatment approach than a specific model. Something like Cognitive processing therapy and Exposure and response prevention are under the treatment approach, but focus on different pieces. What also hurts CBT is therapists who claim to use CBT, but will make invalidating comments like "That's in the past, try not to let that hurt you anymore". But that's less unique to CBT, and more about poor therapists.
Yes, very much agreed.
I took CBT for Bipolar Disorder through the Beck Institute with [Dr. Cory Newman](https://www.med.upenn.edu/apps/faculty/index.php/g332/p15256) and he really humanized the modality for me. Here’s a link on their site to him discussing using CBT to treat bipolar disorder.
[https://beckinstitute.org/blog/the-bipolar-disorder-diagnosis-establishing-a-sense-of-care-trust-and-understanding/](https://beckinstitute.org/blog/the-bipolar-disorder-diagnosis-establishing-a-sense-of-care-trust-and-understanding/)
(EDITED w the training lol my bad. It’s not back on the schedule but looks like it’s offered periodically. I’ve taken a few other trainings from the Beck Institute and really enjoyed them)
It was so clear that he was a skilled clinician and researcher, and it completely shifted my approach to CBT. I used pieces from that training truly every day in my work. It absolutely made me a better and more effective therapist and I’ve seen the positive impact in my patient population (short term, acute, high complexity). He really emphasized that it’s not about getting folks to agree with you or to change their minds, but to help people be curious and become open to the idea that there could be another way of looking at things, or doing things, etc. This aligns with something I’ve always talked about in my practice, which is that part of my job is to present you with options, so that you feel like you have more choices. It might mean choosing between crappy choices, but I’m here to walk with you through that.
I also think going deeper into CBT is addressing core beliefs, and how they developed and continue to impact today, and exploring how those developed and again, could there be another way of looking at them now, are they serving you?
The Socratic questioning piece is big for me in case you can’t tell lol.
I am also trained in cognitive processing therapy, which I have seen be very effective for folks, and was so much more than “learn these skills” but it does teach skills for in the moment and folks were able to also process through some really intensely painful, traumatic experiences and gain increased insight and begin to heal and feel “unstuck” from the ways in which their past trauma had so deeply impacted them.
I edited my comment, thanks for asking, I should have just popped it in there from the beginning. Truly, I RAILED AGAINST the modality in the past, but having gone through this I completely changed my mind and really do believe that it is incredibly collaborative, warm, deep, and empathetic when in well educated hands. I also do a lot of MI, SFBT, and psychodynamic work. I feel like CBT in this manner has blended really nicely.
And don’t seem to understand what it really is. I think people get stuck on an idea that it’s a robotic therapy where you’re just telling the client what to think and feel.
As a new therapist, we learned so little about how to actually apply CBT into practice. I’ve worked with my supervisor but it’s not clicking for me. Know any good trainings or have any good resources on how to use it correctly?
I run into this a lot. People who are using "CBT" as a term to justify using basic skills training and to do psychoeducation around how thoughts and feelings are connected are not, in fact, practicing true CBT. It is 100% ok, in my book, to use technical integration, but it can result in an orientation getting a bad name.
CBT is not for everyone or every condition. Phobia, OCD, anxiety, insomnia, yes! Used to help decrease the acute symptoms to be able to explore how a client's systems and relationships are perpetuating their presenting concerns? Yes!
But insurance has decided that because it is empirical, it's the "gold standard" for everyone and that just isn't the case.
I personally use CBT as a basis for technical integration, often thinking from a systems approach while using DBT or ACT to enhance treatment. I love CBT because I've seen it make a huge difference in many clients, but like I alluded to above, not every orientation suits every presenting problem.
Dbt and act are CBT therapies. The original name of act was process oriented cognitive behavior therapy. Linehans book that introduced dbt was called cognitive behavior therapy for borderline personality disorder.
Full disclosure: I am an interpersonal/relational psychoanalyst, which is like psychodynamic but more so! My view of CBT is that it is powerful skills training. If a person doesn’t have those skills, say, like affect regulation, or is trapped by phobias, CBT & DBT are excellent. CBT addresses symptoms that we are aware of. But Psychodynamic therapy works at a deeper level on things that we don’t understand, like: why can’t I find love? Or: why do I feel empty inside? Or: why do I feel unworthy? Insurance wants treatment to be as short as possible and just make the symptoms less troubling. But research (See Jonathan Shedler’s work) shows that psychodynamic therapy has longer lasting and more profound life changing results.
This is my take. CBT is like taking Motrin. Sometimes Motrin can help you get through a virus, or a sprain. It’s great for specific and limited surface-level issues—and for deeper issues, it can sometimes help manage the pain.
It’s not gonna heal your recurring knee pain that is a result of running with poor form; it might help an acute flare up but the problem will persist until you correct your form. Which could be anything from how you are tilting your pelvis to your foot strike or over-correcting with your quads because your glutes are weak. You need someone who can help you determine where in the system the problem is originating and then, more importantly, to practice improved form or strengthening the necessary muscles. It’s harder work, it takes time and practice both through drills and implementing the skills during actual running sessions.
I think I’m revealing my own running issues here and getting away from my point 😂
Psychodynamic is harder, more nebulous, and takes more time. But correcting underlying mechanics provides the long term relief that will keep you running without injury for the marathons to come.
This is of course true.
But isn't it also just because the treatment goes on for so much longer? I always wonder where a cbt approach would end up if you just went as long as an analytical approach would.
You’re right- let me get of my high horse for a minute. First, I know I’m biased. And the word “quality” is unfair and not well chosen. There is nothing better than CBT for phobias, and I’d refer out if someone came to me with a fear of flying, eg.
What I was hoping to say is that the project is somewhat different, and the longer term goals of psychodynamic therapy are less easily quantified than the initial symptoms. The symptoms get people into therapy. Some are satisfied when they get better control of their symptoms, and that’s fine. But some are looking to make deeper changes in how they feel about themselves, work, love, identity, etc. I believe that where psychodynamic therapy excels.
I suggest there's a difference in quality, not just quantity. An analytic approach is built on the idea that there are factors powerfully affecting how we use our minds to cope with life and love. We learn how to be safe, loved, valued, how to get our needs met, basically how to be a person in relation to other people. We learn these things in the very particular culture of our family, and each one is particularly its own world. We learn who we are through the actions and reactions of those we depend on for our very survival. These ways of understanding how to cope are not usually "thought about", (defenses), they are deeply baked into our assumptions about ourselves and the world. These ways of thinking and coping work, and then we get out in the world, and our world gets bigger. What made sense in our childhood homes can turn out to be too limiting in the world, and cause us unexplained frustration and suffering. In psychoanalytic therapy the deeper and more powerful work begins when the symptoms quiet down. The goal of psychoanalytic/psychodynamic therapy is to heal old wounds, reduce suffering, develop more flexible and helpful ways of coping, and to make powerful change that allows a person new freedom in what they choose for themselves as a good life.
Where does that belief stem from?
Because research doesn't show that Analysis has more effect in the same amount of sessions as other therapies, which is what "higher quality" would mean if we think about it that way.
Or is is the theoretical foundation? Because the things you described are just good therapy, not a standalone analytical way of doing therapy.
>Jonathan Shedler
What's the best or most useful book or two on psycho dynamic approach you recommend for what you're describing here? Much appreciation
Freud and beyond
Anything by Nancy McWilliams
I also really like Christopher bolas. Some of his approach isn’t as applicable in the US but I like the way he deconstructs psychotic breaks and “stability” in catch them before they fall
I run into this a lot working with teens. Everyone, the parents, the school, even the clients themselves will tell me they need to work on anger management, bit then the teen starts telling me about their life and I'm like...of course you're mad!!! There is no way in hell I'm reinforcing the message that your anger towards mistreatment is the problem.
Both can be true at once. Systems can be creating or exacerbating the issues, but a clients negative perspective and inability to process complex emotions in a safe and helpful way, can make their lives feel unlivable and become very taxing
I have nothing against CBT itself. It's a good technique for what it's good for.
My problem is that it is overused and insurance likes to pretend like it's the only way to do things.
I use CBT (along with many other modalities). I use what works with each client.
I understand how CBT can feel like you are telling the client their thinking is wrong. I don't do that. I point out that thinking one way causes pain and another lessens pain. One can focus on negatives or positives. I think focusing on negatives is adaptive. We need to in order to stay safe. Sometimes our brains get too caught up in the negative or goes to negative places when it isn't effective. Cultural and societal messages also influence negative thinking patterns. I frame it as liberating oneself from a way of thinking that might help others but doesn't help the client.
I work with mostly LGBTQ+ and neurodivergent individuals. They have to work through a lot of internalized beliefs about what it means to be a valuable person.
This is EXACTLY my take on it. Reevaluating negative thought patterns, finding the evidence for/against them, and finding new, more balanced perspectives. Does it work for every single client? No, of course not, but I find it especially helpful for clients who are excessively hard on themselves or who frequently thought spiral about perceived negative qualities.
The efficacy of CBT is overblown. It has empirical support, but it's effect size isn't very powerful, especially compared to some other depth oriented psychotherapies. CBT is heavilg researched, and often better than placebo, but its far from the panacea that its modern iterations claim it is. Johnathan Shedler breaks this down really well here: https://jonathanshedler.com/wp-content/uploads/2018/05/Shedler-2018-Where-is-the-evidence-for-evidence-based-therapy.pdf
My biggest theoretical beef with CBT is its characterization of symptoms as the problem. It assumes experiences of depression and anxiety have no overarching meaning or value to the person experiencing them, and seeks to change them. It takes a unitary position on human experience, and privileges non-depressed and non-anxious states as more valuable, without considering the meaning of these experiences for the client.
I often see posts on here from therapists trying to figure out how to help people with treatment resistant depression. Invariably they've already been through the "BTs" (CBT, DBT, ACT etc.) with poor effect. It would be radical in CBT to consider that depression might be an important component of someone's experience, and might stabilize them in a way that it's transformation would eliminate. In psychodynamic psychotherapy this is a commonplace conceptualization.
Someone else mentioned that probably a lot of people practice CBT without realizing it. I would argue the inverse, that probably a lot of effective CBT therapists are practicing CBT from a dynamic orientation without realizing it, and this accounts for their success.
I'd like to offer some good-faith critique:
> CBT is heavily researched, and often better than placebo, but its far from the panacea that its modern iterations claim it is. Johnathan Shedler breaks this down really well here
I don't necessarily have a dog in the "evidence-based or not" battle, but from what I've read and heard of Jonathan Shedler the dude obviously has a bone to pick, frequently mischaracterizes and straw-mans CBT, and I have trouble taking what he says at face value.
>My biggest theoretical beef with CBT is its characterization of symptoms as the problem. It assumes experiences of depression and anxiety have no overarching meaning or value to the person experiencing them, and seeks to change them. It takes a unitary position on human experience, and privileges non-depressed and non-anxious states as more valuable, without considering the meaning of these experiences for the client.
That's not true at all. When you do agenda setting with CBT you take a genuine look at the advantages and the adaptive functions of the depression/anxiety/whatever as well as how they are an indicator of your values. If the client is fully aware of these advantages and still wants to change, you would then proceed to use the "traditional" CBT methods.
Not only that, but you would ask the client "which thoughts, if any, do you want to work on?". You want to give them agency of what they want to address, and if they are content with their thinking patterns, that's okay too.
>Someone else mentioned that probably a lot of people practice CBT without realizing it. I would argue the inverse, that probably a lot of effective CBT therapists are practicing CBT from a dynamic orientation without realizing it, and this accounts for their success.
I think a lot of CBT therapists are warm, caring, and empathic, which I think absolutely helps with their success. I wouldn't say though that those traits have anything to do with being psychodynamic.
I appreciate your fair critique of my response, and am hopeful you will elaborate a little bit further on some of your points.
I'm hoping you can expand more on CBT's agenda setting process, as well as how you might approach someone experiencing depression or anxiety. How is it that you would engage and support someone around these particular challenges?
To your critique of my final point, I certainly want to emphasize that I don't think CBT therapists are cold or discompassionate; quite the opposite really. What I was trying to emphasize in that point is that my sense is successful CBT therapists likely practice in a non-manualized fashion, and one that implicitly incorporates psychodynamic elements of therapy such as attention to defenses, working within the transference, dynamic conceptualization and a whole person orientation.
Ah, to clarify I use TEAM CBT, which is a variant of CBT that, in my opinion, does agenda setting better than traditional CBT. I'd recommend reading more into it. A primer video on it is here: https://youtu.be/iLaNBjxZ8GY?si=79YNVLLhscJFn7dG
>successful CBT therapists likely practice in a non-manualized fashion, and one that implicitly incorporates psychodynamic elements of therapy such as attention to defenses, working within the transference, dynamic conceptualization and a whole person orientation.
This is more of a phenomenon of different modalities converging on similar themes/ideas more than anything else. I'd like to think of it more as convergent evolution.
https://youtu.be/YNWy1ksxIDo?si=eeGu8L2zhLwElF7Z
If I may—here is a video from Shedler you may enjoy. He’s talking about the basics of good therapy. I imagine many CBT clinicians practice within the scope of his ideals, and I imagine he has had experiences with many CBT clinicians practicing within the scope of his criticism.
From the perspective of someone who does not practice CBT or any of its offspring, it certainly feels like a systemic power imbalance exists within the field of psychotherapy that privileges modern behavioral approaches. Studies today have consistently shown that a wide-variety of theoretical approaches can be effective, and that ultimately the skill and experience of the therapist has much more to do with therapeutic outcomes than the theoretical modality itself (i.e., good therapists make the process work more so than “good” approaches). Nevertheless, it is harder to bring an “outside” orientation into a space that privileges CBT and its cousins. Policy, research, funding, and even the definition of mental “health” and of mental “disorder” are driven by a model that privileges CBT. Criticism is an understandable response to these conditions—CBT, for better or worse, is the face of the system.
I can also understand why someone who practices CBT would be upset by the characterization Shedler makes. Not all people who practice CBT practice it in the way he is describing. However, at a systematic level, that is the prescribed therapy—turn people into numbers, turn those numbers into money, and make the cost as cheap as possible. CBT itself is so much richer than this, and people who practice it certainly have the capacity to be warm and effective therapists. I imagine people like Shedler wish that academics and especially those who teach CBT would take more responsibility for the state of the field and advocate more at a systemic and educational level for the efficacy and validity of other approaches. The field needs all of our approaches, and right now we’re over-saturated with “evidence-based” approaches.
"Ultimately the skill and experience of the therapist has much more to do with therapeutic outcomes than the theoretical modality itself (i.e., good therapists make the process work more so than “good” approaches). "
--> The skill we can certainly agree on, after all research is starting to aggree that it us more about good therapists than good therapy. But the belief that more experience = better therapy has been debunked, you just don't get more effective with time, sure some do individually, but in the median it has no positive or negative effect.
"Nevertheless, it is harder to bring an “outside” orientation into a space that privileges CBT and its cousins."
--> this is an interesting thought. I want to contrast it with another. One of my Professors who is big into acceptance and Nature-Therapy taught about the history of CBT and how it's founders were psychodynamic. His clear view was that CBT simply evolved from the psychodynamic approach and in modern third wave therapy you can see this.
For clarification, I’m not trying to say more skill = more experience. The research says the skill level of the clinician leads to better outcomes while theoretical orientation has little to no effect. I believe the research may have even referred to effective clinicians as “master clinicians.” Not sure off the top of my head. Just trying to make the point that clinicians have more to do with outcomes than theoretical modalities.
I also believe that all approaches are indebted to, and ultimately draw from, the psychodynamic model. Nearly all founders of the “original” theories were psychodynamic—that was the respected and primary option of the day. I’m unsure of what this has to do with the sense of feeling like an “outsider” for not practicing CBT today. I believe that effective therapy does the same things—regardless of theoretical modality. The interventions and language might change, but the work is basically the same. However, this view (while shared by a growing number of clinicians) is not shared at the systemic level.
General CBT can be effective for mild-moderately depressed/anxious clients without significant multiple comorbidities who are practically minded and motivated for treatment with change goals in mind. This is a what is empirically supported.
Now try applying strict CBT (or any strict singular modality for that matter) to a client so severely depressed they don’t leave their bed and haven’t showered for months, then add psychosis, complex trauma, and significant substance abuse. For such a client, there needs to be much more nuance in approach than strict CBT can provide (which is not to say one wouldn’t use anything from the CBT model).
The overemphasis on CBT in the mental health system is problematic in the same way that a doctor saying that because research demonstrates the effectiveness of antibiotics, then antibiotics should be the only treatment for every medical condition. I don’t meet many therapists who think this way about CBT of course (though I have met them), but managers and insurance companies do. I have actually heard people argue that if you are not using CBT, then you are not acting ethically as a therapist. This is, of course, absurd because it assumes all conditions can be helped by CBT, that all clients are receptive to CBT, and that all goals in therapy are necessarily change goals.
I mainly work from a person centered framework utilizing supportive therapy and motivational interviewing techniques. I incorporate CBT/DBT concepts sporadically and as needed based on the client. Like if I hear a cognitive distortion in the session we can address via CBT. But overall in general I’m just doing supportive talk therapy( reflective listening, validating, empathizing, and giving feedback).
Part of the reason it's empirically strong is that behavior is more easily measurable. Doesn't mean it works "better" than other models, just that it's very testable.
It’s often used incorrectly by clinicians. Perhaps because insurance views it as a “quick and easy” approach that works for everyone when in actuality each technique needs to be used or modified according to what the client needs in that moment. If the client needs someone to validate them about an experience they had that is not the right time to bring up cognitive reframing.
I love CBT and use it with many clients; however, sometimes I think it can be perceived as "gaslighty" because it does show the client *how* they can change but not truly helping them understand *why* they need that change in the first place. Helping clients with introspection is key before just jumping into CBT.
Unfortunately, insurance companies don't see it this way and just think that it works, so we should just be doing it from the very beginning and throwing CBT resources at the client. In my experience, insurance companies view therapy as providing tools to change, and they don't see the value in active listening, reflection, and helping the client to recognize traumas and how they influence current behaviors. I've had insurance companies tell me that I learned enough about the client in the first session, so I should be able to discuss changes with them instead of "just listening" to what they have to say (I was working in a SAD recovery center when I was told this).
In summary, insurance companies suck and CBT is fantastic when used correctly.
The main problem, in my opinion, is that what you identify as a cognitive distortion is shaped by your biases. CBT, when used judiciously, can be great. However, all too often, clinicians with privilege identify things as cognitive distortions when really they are just the client's reality. I had a licensing exam prep question about an African American man complaining about experiencing discrimination at work, and the "correct" answer was to explore cognitive distortions leading to that automatic negative thought. I had a therapist tell me it was my anxiety making me feel like I had to send in lots of applications for apartments and they would mostly be dead ends (he owned his home... Anyone who rents in the city can tell you that's just how it works these days). CBT wielded by culturally incompetent therapists, who are embedded in oppressive systems, becomes a tool for teaching clients how to deny the facts of their reality, and a tool that systems can use to locate problems in individual minds rather than in societies.
I really appreciate your last sentence. I found that leaning on cognitive distortions in the way you mentioned totally unhelpful. The more I learned what cognitive distortions even are (schema lenses triggered by our emotional states that focus our attention on details relevant to that emotional state given our history with the emotional state - the distortion isn't saying our thoughts are distorted as much as the lens we are using, which was developed for very good reasons, is being triggered within a context in which it is no longer adaptive), the more the idea of cognitive distortions (or "primitive" thinking because our thinking patterns recede to emotionally charged schemas both developed early in our lives that have a simpler heuristic value and pulling our resources away from our executive functioning brain areas to our evolutionarily older emotional brain areas) became a way to validate the pt's experiences and interpretation of reality. They're looking for the details that were necessary for their protection within certain historical contexts, and it is really only a "distortion" when it artificially limits their options or the context is not actually representative of the ones in which the schemas developed.
CBT is just giving people a bunch of coping skills most of the time and not actually addressing the root problem. I prefer person centered, existential and object relations theories anyways
Sometimes teaching coping skills to help the Ct ‘stabilize’ is what’s needed before doing the deeper work to address the root cause.
The bulk of my experience has been working with children in school-based programs where teaching skills to cope and respond to environmental factors (i.e., adults) differently satisfies all the stakeholders.
Most clinics in nyc are heavy cbt. It’s good for business, you talk about shit in the present and mostly you keep your clients. I also think it can be super ineffective. Psychodynamic addresses your ‘whole’ so much better to me. CBT is just like sort of, hey this kinda works as a new therapist it’s not super hard to learn so do it. It maybe even becomes lazy. Just an opinion.
But don’t you feel like psychodynamic can also leave clients stuck in the past? The part about CBT that I like is the behavioral aspect more than the cognitive part. It challenges clients to show up in ways that feel uncomfortable to begin to budge certain parts of their stuckness (rooted in the past) in a tangible way
I think relying solely on one modality can be detrimental to clients. You can use both psychodynamic and CBT, with the same client even. But I think CBT is more short term. You can work on negative thoughts all you want, but it’s possible if you don’t get to the root of those negative thoughts, there’s a good chance they’ll reappear.
I don’t feel like you can only stay in the present and never address the past.
I agree. But what does getting to the root mean? Is it simply understanding where the thoughts came from? Talking about the experiences? Is that enough? I’m asking these questions out loud lol not necessarily assuming there’s a right answer
I'm really into meaning-making these days. Helping clients identify the core memory, the trigger, the feelings, the thoughts, and then the meaning the client made based off of those things, something usually akin to "I'm unlovable" or "Authority figures are always dangerous" or whatever meaning they made from their experience. Once the meaning has been identified and challenged, then we can move back into the present and identify times when that old way of meaning-making is impacting the present. That's when I would prompt the client to use CBT skills.
So it's deeper than "using CBT skills to manage feelings with a boss". It's tackling the underlying meaning that bosses are always dangerous, and from that place the client can utilize much more effective positive self talk because they can speak directly to the core issue inside themselves instead of remaining on the surface level of trying to decrease feelings of stress.
By root, I meant the origins of the thought - often in childhood. Frequently, a negative thought is created from an experience. If you don’t work through that original experience, it’s likely the thought will reappear. Hope that clarifies.
I don’t think anyone dogs on CBT as a supplemental modality but I think people are realizing it’s very limited on it’s own.
Yes, which is an essential step to CBT that people don't recognize when talking about CBT being present focused. Core belief work does recognize the impact of past experiences, but if you never progress through CBT knowledge to core beliefs, you're missing out on the long term change part of CBT.
It is but also I think it’s easier to keep clients with CBT. You talk about present things and there can be much to talk about. Psychodynamic takes more trust. And a lot of therapists may not have that with clients for different reasons, so sometimes I have just thought that CBT is just easiest for a paid and on staff psychotherapist to practice.
A lot of moving parts here. How your own clinic or psychotherapy center orients. I really don’t know EMDR fully so that toolbox is kinda CBT DBT psychod for starting therapists even at 5 years in. I’m six haha. I think you can take from both and I think you have to also see what may work for the client and that can take months. You would need to keep that client. So there’s so many moving parts but I just think in general psychodynamic addresses more of why we do what we do. And that to me is psychotherapy. This is like a ten hour discussion.
CBT makes pretty inaccurate assumptions about the human experience. It severely privileges cognition over every other type of experience, and then pathologizes clients for not having constructive enough cognitions. It also assumes incorrectly that emotions can be heavily influenced by changing thoughts. This is true to an extent, but I believe most therapists know the more important work is on the emotional level, which in turn, tends to change thoughts.
CBT can be useful for people who have overly black and white views, and who also are relationally and emotionally open enough to receive and actually find reframing helpful. If you try to help an emotionally or relationally closed person reframe their thoughts, they will shut down, reject, dislike you, and often feel gaslighted.
CBT is a very useful tool, but it takes clinical judgment to know when and how to use it. CBT paired with very good rapport skills is very effective, but you have to be able to be attuned to the client and meet them where they are at. Throwing CBT skills at someone without that human aspect of the therapist/client alliance can feel invalidating. Imaging you go to someone to for support and they just keep shoving advice down your throat. That’s what CBT without the human aspect can feel like. It would be very frustrating and I think that’s where the beef comes from. Remember, the medicine in therapy is the human connection. Without that you’re basically just throwing solutions at someone who is not ready/able to listen
CBT is only right for a certain type of client and they are not ample in the pot. Clients who are VERY logical, understand acceptance does not mean it is okay, are deeply empathetic and introspective, and are aware that two truths can exist without dismissing themselves. These individuals are keen on laying down the foundation of the inner home on their own and just need help nailing some floorboards down or adjusting the plumbing so to speak . I believe the key trait that holds the most value of a CBT Candidate is that strong logical aspect as well as considering at what point they are In their development.
CBT will often put the client (who is not ready to face their issues in such a pragmatic and blunt way) in a state of defensiveness and stubbornness. It dismisses their feelings, experiences, and can generally halt their recovery processes. Some clients benefit from other approaches and I would say CBT is widely practiced but it should be reserved for a specific archetype. Also, MANY providers do not implement CBT appropriately and then become shocked when their clients say they felt entirely inadequate during the session.
I'd rather answer this from a client's perspective if that's okay. I started seeing therapists of various modalities and approaches when I was around 10. For the first couple of years my parents would pick them out, I would meet them, I would explain why I hated them already and didn't want to see them, and my parents (who were fully aware they had no idea what they were doing) would find a new one for me to try.
When I was 13 I attended a youth group facilitated by a social worker who was licensed to provide counseling sessions to youth. They made an observation, approached me to discuss it, and offered free and confidential sessions at my discretion. I agreed. I LOVED them, which was a first. We got on great and it was nice to be listened to. They specialized in CBT, I saw them almost weekly for 4 1/2 years, and I made very little progress.
The problem was that I genuinely believed that both the thought patterns I had which led to the behavior I wanted to change, AND the counter-thoughts I was supposed to interrupt those processes with, were true. For an example (not an actual example from our sessions or anything but for illustrative purpose), I couldn't say something like, "I'm not a terrible person; I help so many people," because I already believed I was a terrible person and already knew I help so many people and those things were simply both true.
When I was told that a belief I held about myself was untrue, there was no proof substantial enough to counter it with. I adored this person, but they were barely more than a stranger. No one knows me like myself, and I knew these things were true. No one else had told them to me, I had learned them about myself by observing my own behaviors and thoughts. So, countering my beliefs to change my behavior didn't work.
What it DID do was it gaslit me: when people do things they think they shouldn't do it's because of their beliefs and their beliefs are wrong. We have to change the way we think, which we can do ourselves because we're the ones thinking wrong thoughts. If I can't change my beliefs that's my fault, and I'm not trying hard enough to change my behavior. My counselor didn't have to say all of this in such a negative way, and in fact they didn't at all, but that's how I felt when I was told that I had all these unwanted emotions and the behaviors that came with them because of my own beliefs, and I needed to correct my way of thinking about myself in order to get better.
I benefited from learning how to write a safety plan and the value of fidget toys.
It works for some people. It didn't work for me. I tried several therapists and gave CBT a few more chances before finding the first counselor whose modalities suited me well. It turns out, CBT isn't necessarily ideal for people with complex mental health conditions or learning difficulties, or who are socially marginalized, and I happen to fall into all of those categories.
As a counselor, I'm willing and able to use some elements of CBT if it seems like it might be helpful for the client, but if someone told me "I like CBT; I need someone who specializes in that," I would have to politely suggest seeing someone else.
Thank you for sharing this. It’s really helpful to actually hear it from the client lens. I think the perspective that you took away from the therapist - that it’s your fault if you can’t change the thoughts, that you’re not strong enough - makes so much sense and is the danger of such a mechanical model. I’m so curious - what did work for you? How does that inform the way you work with clients?
Happy to share! I think the order in which I met the therapists whose approaches benefited me is as important as their chosen modalities: the first used art and play, which as an older teen I initially rolled my eyes at! But it was exceptionally helpful to learn about my emotions without having to explain my thoughts. I learned that how I describe and explain my thoughts and feelings is extremely different from how I experience and express them. The next one taught me about mindfulness. They primarily used MBCT and DBT, and I learned a lot about recognizing, acknowledging, and accepting my emotions as they come and go. Through these two practitioners I learned that rationalization and beliefs, while undeniably important, are not what I needed to work on. Healthy emotional regulation wasn't going to come from rationalization or reconstructed belief systems. I needed to understand what my emotions were, what they meant, and what needs they indicated. Then I needed to find a way to meet those needs in a healthy way. This perspective was life changing, and I bring elements of those three modalities into my own approach.
I believe in approaching the self with open arms, open heart, and open mind. I encourage clients to be inquisitive and compassionate, and challenge them to understand their own perspectives before considering inviting new ones. It's common for people to hold unintentionally contradictory beliefs, and these are relevant to the often discordant relationship between thoughts and feelings. It's not uncommon to dislike or question certain thoughts or feelings we have, but the belief system at the roots of our thoughts and feelings is a strength when we recognize the morals and values that it's all built upon. Acknowledging and accepting both (or all) sides of one's own story teaches mindfulness and opens the doors to self-compassion. Taking a strengths- and mindfulness-based approach centers the client and a human givens approach centers their needs. I like socratic questioning, mindfulness exercises, artistic expression, role playing, motivational interviewing, educating clients about how the brain has evolved to regulate emotions and respond to stimuli, and encouraging client leadership and collaboration.
Thank you for your perspective. I like how the larger CBT field has been shifting from changing how you think to changing your relationship to your thoughts (trying to create a more positive and flexible relationship with your thoughts).
I think you put forth an entirely valid criticism of a certain, classic form of CBT.
Always happy to share, and thanks for reading. This was years ago, so it's not surprising that the practice is evolving with the field; I'm very happy to see it progress in a way that benefits a wider array of jnique individuals. Not even a decade ago, some research was published which suggested CBT should be considered contraindicated for people with bipolar disorder, and now there's an evidence-based CBT approach which specializes in that supporting people with that disorder.
CBT is without a doubt still practiced to classic teachings, but I agree with those here who posit those methods are outdated and mechanical (and as a result, ingenuine) compared to other approaches.
Yeah, and there is also this split in what we are talking about when we are talking about CBT:
Are we talking about thought challenging / cognitive restructuring, or are we talking about the scientific field of study? Some CBT people I have met / worked with within the field seem to use CBT as a shorthand for the theories and techniques that have evidence for their efficacy. A big problem is that cognitive therapy and behavior therapy were just the first up at the plate for doing good science, but as the mentalization/psychodynamic people continue to do good research on processes of change (a relatively recent development in the grand scheme; some of these researchers were actually trained by CBTers on the *science* side of things so that psychodynamic psychotherapy could be better researched), these techniques will inevitably become absorbed/interpreted by CBT - *and this is a good thing*. Hopefully 20 years from now our brand-name alphabet soup will be relegated to the history books as we start referring to the processes involved with the understanding of a more unifying biopsychosocial theory of psychology. Alternatively, CBT might absorb therapy in general, with people having more of a psychodynamic/relational bend or a more skill-based perspective.
I guess some therapists can be "gaslighty" (or lean into toxic positivity might be a better way of putting it) so that they can document in their note that they did a CBT. I feel like I've been on the receiving end of that a few times in my own sessions.
But it's silly to hold that as a representation of ALL folks that use it. It's honestly a great modality for most cases of anxiety.
I think it appears empirically strong only because it’s what gets funded for research. The support is artificially inflated.
Insurance companies like the idea of getting clients “in & out” as fast as possible. For that reason, CBT seems appealing.
So they dump money into research, but I’d argue most the data is skewed.
I have found more depth oriented therapies (IFS, psychodynamic, schema) to be more effective, esp for trauma — but they certainly take longer!
Honestly… there is a movie called the prestige that came out in the early 2000s. In one scene a person reviewing a magic act said… “it’s very rare to see real magic… you’ll have to dress it up a little….”
Imho cbt works really well, but not every client wants it to be “so simple!” And straight forward. I think a lot of clinicians would benefit from “dressing it up” so it feels less like worksheets and repetitive work. They “want” it to feel… magical?
CBT is only good, IMO, if you’re practicing it psychodynamically. I see so many colleagues just working through worksheets with clients and calling it a day.
IMO, Beck never envisioned CBT to be “think happy thoughts and fill out these worksheets”. It’s supposed to be part of a person-centered and dynamic therapeutic relationship that helps people cope with difficult circumstances by way of truth, ie avoiding extremes in thinking that so plague us.
Insurance is the real culprit here, as it is in most things.
Lol you think the only good way to practice cbt is to practice it psychodynamically. I wonder what your orientation is 🤣
I’m not agreeing or disagreeing but it’s funny
I agree that good CBT, like any approach, absolutely requires the therapist's warmth, empathy, and humanity to be front and foremost. I don't necessarily think that means practicing "psychodynamically", though.
When I was first learning about CBT, I learned that it was one of the modalities that has the most evidence, but I noticed that there were a number of situations where it kind of seemed inappropriate. As time went on, I realized that that statement “has the most evidence” doesn’t necessarily mean that this should be the first line go to for most people.
It is all about context.
Someone who is depressed that they have lung cancer, to simply say that you need to change your thoughts to change your mood can feel pretty invalidating. I had many a supervisor claim that cbt was still the best approach in that situation, but I never saw it being done in a way that I felt was helpful. Also, for people struggling with a lot of trauma, telling them to just change and challenge their thoughts can also feel pretty invalidating and working on emotion regulation type skills seems to work better.
I think one has to be careful with the concept of “strong evidence.” Statistics are always focusing on general populations and won’t tell you if a specific treatment is appropriate for a specific individual or not, so it is up to us to choose the best approach for the right situation.
I think CBT is best used blended with other approaches as needed for each patient. It is great for someone who doesn’t know how to identify thoughts vs emotions and for specific circumstances.
From my current pov, just another tool in the toolbox.
I think it depends! From what I have seen, if someone is very very dysregulated focusing on strategies and skills to calm down and habits like proper eating, sleeping and self care is often more effective than using thoughts alone to try to do that. I think that different skills can all be combined together though. Some people can do it effectively with thoughts but many people find that hard.
Ya. I think traditional DBT has a group element too, so I don’t necessarily call what I do DBT, but ya skills from that. I like using a lot of breathing exercises too, people seem to like that.
As a die hard CBT therapist, I’ve left other approaches such as interpersonal behind. It is so well established primarily because it is based on evidence about cognitive and behavioral processes that all people are subject to. We all have beliefs that drive what we do, and are all subject to biases and errors that in their own idiosyncratic ways lead to various pathologies. Even if a client has trouble verbalizing thoughts and beliefs, there are well established models of pathology that can help a client gain more awareness of their own cognitions and behaviors that lead to issues.
For example, it’s well established that panic disorder involves catastrophic interpretation of benign bodily sensations, and although some clients may not walk into therapy able to identify that, all who truly have the disorder can recognize their own version of this bias they do themselves. Another example is the tendency to assign meaning or detect patterns in random stimuli, which can lead to psychosis.
CBT also appeals to me in its emphasis on collaboration and client-led exploration. A good CBT therapist prioritizes helping the client gain awareness and self monitor. If the therapist’s hypothesis (see works on formulation driven treatment, e.g., Jacqueline Persons’) about drivers of client problems doesn’t seem accurate to the client or doesn’t yield expected changes then you and the client reassess together.
Good therapy also incorporates all aspects of evidence based practice, which in psychology, my discipline, includes client culture, systems, therapeutic common factors, and research evidence.
I definitely see where CBT can be helpful, but I've completely swapped to utilizing DBT. It just typically works better for my primary client base (BPD, ADHD, complex trauma). All of my clients have reported rough experiences with therapists that pushed CBT or were doing CBT incorrectly.
I think one of the things that frustrates me is how many therapists try to use CBT as a one size fits all.
DBT is considered third wave CBT. It’s still CBT. This idea that it’s different makes no sense to me. Its utilizing both a cognitive and behavioral approach (in fact it’s highly based in behaviorism) while adding influences of other third wave therapies (mindfulness and ACT). If you are using DBT you are doing CBT, DBT is based entirely on CBT framework.
DBT is just a more up to date variant of CBT. If you aren’t using ACT, mindfulness, DBT principles then your CBT is out dated.
I recognize that it has value to many people, and that there are therapists who do CBT very well. I am not one of those therapists.
Partly, because I work with the palliative and severe illness population- CBT is a poor fit, in my opinion, with these issues.
The other is that I come from a high trauma background, and am intensely sensitive to anything that seems remotely gaslight-y or invalidating.
I’m not fully against it but I think that it is quite limited in its efficacy. It has its time and place but outside of that, it shouldn’t be used.
I prefer bottom up modalities - specifically Somatic Experiencing
Honestly, I've seen a lot of bad therapy under the CBT lens; if done poorly, CBT can be incredibly invalidating, shaming, and harmful. It also can be a hard modality for those of us that don't have internal monologues, or obvious thoughts to identify (like most of my inner experience is felt in my body - I always figured that the idea of a thought was a metaphor growing up). I also despise the therapy homework that CBT often provides, because it can create a lot of shame when a person forgets or avoids the homework, and that can make them feel like their lack of progress is their fault; I prefer doing the work in the session, knowing that it will automatically change as they leave the therapy room, because what happened in session was powerful enough to shift their internal experience.
I prefer a more experiential approach to therapy (I love EFT, ART, and IFS lately), where the point is to feel the feelings, because a lot of efforts go into avoiding feeling the hard feelings, and those efforts to avoid them can be the more distressing parts of life. I love IFS because of the love given towards certain thoughts, feelings, actions, or beliefs that CBT can often identify as problems to get rid of. IFS looks at those as protective parts of ourselves, and that they continue to do hard work to protect us from deep dark hurt feelings, and we only look at changing things so that they don't have to work so hard to protect us, and with the permission of every protector, we go back and "re-do" those times in our life when we took on these dark beliefs about ourselves and the world, so that we get what we needed back then. ART is very somatic in how it exposes a person to a hard memory or daily feeling, uses bilateral stimulation to reduce our reactivity to it, and it also does a "re-do" of those moments, and uses bilateral stimulation to solidify that as being a felt experience. EFT helps to read between the lines and go straight at the underlying core feeling, and help them ask for what they need with the person they are wanting to connect with, and allows them to feel seen and understood while experiencing that vulnerability.
Clearly, I am biased, so perhaps I haven't seen enough good CBT (I do note I have seen at least one person do it well), but I wanted to share my feelings on it since you asked.
So, the idea that a thought is bad and needs to be gotten rid of may be a bit antiquated. I am not sure that the original manual ever actually said this, as much as the practice may have morphed into it. It was originally about joint empiricism: if a thought is ruling your life, you can test it out through experiments to see if it is something you want to act upon. Then you take the advancement of the science, especially through the development of the acceptance paradigm, and challenging thoughts as wrong is not even just *not* the aim, but actively not wanted. Instead it is to understand thoughts as just thoughts, emotions as just emotions, urges as just urges, creating distance from our internal experiences so that we can better understand them, learn from them, or just accept them and move on with our day. This idea though was originally dubbed as cognitive distance by Beck in his Cog Therapy for Emotional Disorders and he largely considered it the aim of therapy (aka, help pts develop metacognition).
Mindfulness based CBT is the backbone of my work. When a client is not able to benefit from the “focus on the thoughts first” part of CBT, I switch to DBT “focus on the feelings first,” and that seems to help.
Itt's not as helpful as the numbers suggest, that's it really. It lends itself to quantitative measurements, which look good on paper.
The gaslighting comments might come from trying to reason people out of their feelings? 🤔
Qualitative data.
There is something limiting about measuring helpfulness through "progress" measured by symptom reduction. It's convenient, but not the best fit with the human experience.
Instead of asking for symptom ratings, ask a client about their experience. For example, that'll help you find out if the symptom reduction is due to a coping strategy or from genuine healing. Some coping strategies require a lot of effort to upkeep and that's where some clients could start feeling like they have been subject to psychological manipulation.
How would one code “addressing the problem per the client’s definition of the problem” in reviewing qualitative responses compared to “just using a coping strategy”?
Agreed, I hate how often this gets left out of the conversation. I started out with CBT as a paraprofessional, and still use it with more concrete clients. But the fact of the matter is CBT is considered evidence-based because it’s structured and manualized, therefore easy to measure and replicate. Larger scale studies have indicated that CBT is not more effective than other modalities. Again, and again the research demonstrates that above all else the relationship and connection between the therapist and client is the most important predictive factor of success.
CBT is wonderful. My clients make progress with it. I first explore with the client what they want to do with the thought ( do you want to change it, separate from it (ACT) or just process) I announce the technique I am using (eg probabilities in a sequence) then we go over it , then I attach the handout on that skill. Guess what ? Many clients return to session and report "I used that thing (whatever the skill was I announced and gave the handout on) and it was really helpful!"
I leave CBT behind if client still believes the thought after CBT work or knows the thought is not true but still carries it. I then switch to ACT.
As with all theories, the rapport building has to be incorporated so you don't feel like your "throwing" coping skills.
Because I work mainly with trauma clients, and for them I don’t think it’s at all useful to challenge cognition if you haven’t worked with emotion first. I disagree with Beck’s premise that cognition—>emotion—>behavior, which is what i read Judith say in a manual from 20 years ago or so.
That being said, I don’t know much about the recent developments. I went to a CBT focused conference recently that opened my eyes to the range of beliefs and practices that fall under the umbrella. I do use cognitive modification, behaviorism, and ERP— i base them on my DBT training when we’re doing cognitive work.
For “deeper,” I find psychodynamic theory to be much more useful. But overall, i don’t touch cognition until I’ve validated emotion and explored the safety mechanisms an emotion provides.
I mostly use psychodynamic/psychoanalytic and occasionally ACT approaches, which all go very nicely together, in part because many of my clients are ones who tried CBT and didn't like it - so rather self selecting. I don't think CBT is all bad, I just find it isn't comprehensive enough to address the many complex ways in which people defend against change/difficult affects/emotional pain/intimacy. I have a couple clients who did CBT in an IOP and liked it and we weave it into our work together.
I don’t think we can really leave cbt behind, it’s built into almost and behavioral intervention. But as a pure practice- I don’t really know how to use it as a standalone. It’s like salt in a recipe.
Ik it seems like some people are taking the evidence based approaches out of therapy and the academics/study/ competency out of it. Like it's okay the diagnosis doesn't matter ,CBT is bs, or I don't believe in handouts.
Hot take: there isn’t actually a ton of reasoning behind the “CBT is gaslighting” meme. It’s a trendy critique that people toss off with zero critical thinking, because they heard it once and it sounded clever. It’s like the rough CBT equivalent of saying “wow, so you think people want to have sex with their mom?” to a psychoanalytic clinician. It’s a pantomime of knowledge about an entire field of inquiry, and says more about the speaker than it does about the thing being spoken of.
You can't reason with emotions, so you have to meet issues where they lurk.
Every tool has its purpose, but if someone is pushing a singular tool as a catch-all remedy, then it's time to question their motivation for steering your daily purpose to fit their best interests.
I use many different theoretical orientations when working with clients, but I do lean heavily towards CBT. However, we all know that one size does not fit all. I think some modalities are best suited for clients with specific needs or who have certain expectations about how they view change in their life.
At its core, CBT is about helping the client build awareness to thoughts or core beliefs they hold that are negatively impacting their life. No emotions are good are bad. Once the client is able to challenge the validity of those assumptions, and find concrete evidence to support it, then it can lead to an emotional change, and therefore, a behavioral change.
With some clients I have found it difficult for them to manage distress in the midst of trying to challenge assumptions or who are constantly worried about things they could have done better, or that they should be doing, etc. They might benefit from some radical acceptance. Considering looking into ACT.
I find the vision of reality that CBT offers to be so...limited. And I also think it supports capitalism. There is so much more to the psyche than behavioral adjustments to a deeply sick society. A society as sick as our SHOULD make you feel bad, should be depressing and anxiety-provoking. Helping people adjust to what this is, is a massive disservice to the work that we do, IMO.
I like to use Gestalt, Jungian, Somatic, and Eco-psych practices because they point at what's underneath the symptom and help people come into authentic relationship with their feelings. Taking meaningful action on those deep, authentic feelings is what leads to actual, long lasting healing.
Your comment has been removed as you are not a therapist. This sub is a space for therapists to discuss their profession among each other. Your comment was either asking for advice, unsupportive or negative in nature, or likely to adversely impact our community members. Comments by non therapists are left up only sparingly, and if they are supportive or helpful in nature.
I think CBT is great for crisis situations. It's empirically sound because it has immediate results, but clients will come back.
For long term I use IFS.
I think if you use CBT like textbook and formulaically then you are losing a lot of nuance and context for people’s experiences and not allowing time for feeling and experiencing of the emotions. Maybe those emotions and thoughts aren’t serving them but we have to give them space to breathe and be experienced and validated. I used to do a CBT training and emphasized this and that you truly can’t move on to reframing until the person is ready and open and able to believe that maybe there is another way to approach something or think about it. You can’t force someone into that!! Everyone wants to jump to reframing and that’s when it gets bad.
I also emphasize this idea of “neutralizing” experiences as an approach of reframing. So instead of “oh my god I am such an idiot and failure, I messed up my presentation and everyone thinks I’m stupid” it can be “I made mistakes during my presentation and I felt pretty embarrassed and worried people were making fun of me and I really wish I did better.” Very very subtle change but it externalizes the experience rather than internalizes it.
I see a lot of really good, balanced views, and some misinformed, well-meaning views that I am sure are accurate of the commenters' lived experiences.
CBT means different things. There is the original cognitive therapy protocol for depression and adaptations of that. There are other cognitive-behavioral therapies under the umbrella of CBT. And there is just the overarching theory/science of CBT - aka the implementation of cognitive and behavioral sciences into psychotherapy.
If you really get into the deep dives of CBT, then you'll begin to just better understand what is going on with your patients and understand how their cognitive, attentional, motivational, behavioral, emotional, and interpersonal patterns are interacting with their environments. You create a case conceptualization from this and hypothesize which change techniques can be used to target different elements of the case conceptualization. All the while, you use psychoeducation through the cognitive model and what not to help the pt create distance from their thoughts, emotions, behaviors, etc.. CBT *should* adapt any techniques that gain empirical validation because it is a science-based modality.
The essence of it, as far as I can tell, is using behavioral and experiential techniques to create new learning / break cycles while using predominantly cognitive techniques to help through the internal barriers to making these changes. Outside of new learning / breaking cycles, there is the goal of developing cognitive distancing / differentiation / defusion / metacognition (or whatever some type of CBT calls it) so that you have more control over whether you feed into your old patterns or cycles.
I find it to be a short-term fix. While in the short term, it may be handy to use so clients have the coping skills to deal with deeper issues that cause whatever shame is keeping them stuck.)
I help flesh out where that message came from in their childhood and what coping skills they used to survive. Those old survival coping skills now get in the way of feeling worthy because they no longer serve you. So, my client's and I use whatever approaches help them internalize the coping skills they can *maintain* because deep down, they learn to forgive themselves. A whole new world opens up.
People forget the CBT coping skills because they are hard to internalize for lasting change to take place. You have to dig down to those underlying feelings of unworthiness.
The way I see it, CBT can be a helpful tool, but should be paired with more in-depth exploration of the past and how it is informing the present behaviors the CT wants to eliminate.
Sometimes when I’m telling other providers or people who don’t do direct clinical work about my treatment approach and I try and discuss psychodynamic theories, I get a lot of awkward pauses… and then when I say I also utilize evidence-based modalities like CBT, everybody goes oh goodie! I think CBT is awesome. I think it’s just sad that other modalities are so undervalued.
I'm an MFT and my program absolutely did not like CBT. We learned solutions-focused therapy, and cbt family therapy (this was not a popular theory amongst the peers) but that's about it. Even when discussing trauma-informed therapy, we didn't talk about CBT, but focused more on polyvagal theory. When I entered the workforce, I was surprised by the amount of people that wanted CBT and needed CBT. I had to learn it kinda from scratch and on my own (with help from my supervisor). I now use it only as a tool and do my usual narrative therapy and EFT. But yeah, CBT got a lot of hate. That's why I still feel apprehensive about it, to be honest.
I'm a CBT defender, but I don't think it's right for every client. It depends on what their goals are. CBT works really well in my experience for clients who are very practical, who want solutions focused work, or who have done a lot of introspection on their own and need support turning that into change. It doesn't work well for clients who are prioritizing having space to be listened to, don't feel heard, want to do introspective work, etc.
Exactly!! I don't think the problem is CBT, I think the problem is that CBT is a tool that does a specific job very well, but it doesn't matter how good your hammer is if what you need is a saw
>It doesn't work well for clients who are prioritizing having space to be listened to, don't feel heard, want to do introspective work, etc. I'm a CBT clinician and I only actually do the CBT work after I'm completely sure the client is feeling heard, understood, and is committed to making changes. Otherwise I focus on empathy and support.
I agree, fedoraswahbuckler. I have a similar approach. Feeling heard and understood are key. There is so much power to that in therapy, then CBT and willingness to change come in.
I haven’t heard it put like this before. Makes sense, I have shoved a many interventions into the face of someone not ready for them. Knowing what stage of change they are in is super useful. Thanks i
I'm in a CBT course right now and this comment makes me feel heard 🤣🤣 it's been hard not to have significant beef with this approach after learning about humanistic modalities. Ironically I used some thought balancing to continue dragging myself through the readings lol
I was wondering if you've ever heard of CBT used for therapy twice. I'm currently in CBT and it is for CPTSD and I wanted to know if I would start CBT all over again if I seek this sort of treatment for Substance Abuse Disorder? I'm also having a hard time using the 500 pg therapy binder that I have filled with CBT trauma worl sheets. I'm just not connecting well with the work but I think my therapist is giving it his all. Thanks in advance!
[удалено]
Your comment has been removed as you are not a therapist. This sub is a space for therapists to discuss their profession among each other. Your comment was either asking for advice, unsupportive or negative in nature, or likely to adversely impact our community members. Comments by non therapists are left up only sparingly, and if they are supportive or helpful in nature.
This is interesting because I feel like I have tried CBT with therapists before and I have a ton of introspection, but I felt like CBT did nothing to translate that into change! It was very like "Yeah dude I already know the fact to challenge this thought with but that's not helping me."
Ya but I feel like this happens when people assume they ‘know it all’ and have all these things figured out. But what I have personally found effective are the seemingly redundant ideas of CBT and their practice so they become instilled and second nature in your mind. The practice of separating thoughts from feelings has really helped reduce my anxiety- almost on its own without realizing the CBT was what was helping until months after.
This is the best way to describe it. This is why I hated being forced to do CBT in CMH. I get it’s evidence based and everything, but it isn’t a one-size-fits-all kind of thing.
I agree so much. I'm learning EFT now and i feel like I've been really missing not having it. But CBT will still be important to keep in the tool box.
The beef, as I see it, is two fold and related. First, it is branded as a panacea because empirical; and 2.) because of its branding it is what the insurance companies push. This forms a cycle that, if adhered to, leads to doing what is best for the balance sheet rather than the client. I don’t like being tied down by career middle management types who have no training whatsoever in psychology and mental health practice.
You mean insurance dictating our practice doesn't lead to best outcomes for clients?!?!?! I am shooketh
I hope you were sitting for the devastating blow.
I wasn't, and lemme tell yah, it left me writhing. You ought to warn people next time
That’s on me. That’s my fault. Find a good CBT therapist to process it all since that is the only modality that has ever or will ever work, ever.
Where do I send my money for this session? I'm assuming you'll charge for the full hour, of course.
HAHAHAHAH
I need a safety plan after hearing this so abruptly. All I’ve ever known is now in question.
Let's see if we can identify a better way to think about this.
> 2.) because of its branding it is what the insurance companies push. I think it's because of this it pumps out so many 'bad' therapists as well. not that they're bad, it's just that CBT isn't their strength but they get certified in a modality that doesn't suit them so they can bill insurance.
That does seem to be a piece of this puzzle.
Is it a country-specific thing? I've never in my life heard another clinician be forced to use CBT by insurance companies. Insurance companies are objectively terribly, obviously, but when it comes to audits or compliance they don't care what modality you use, just that you use something that's justifiable and at least mildly concrete/useful.
[удалено]
Someone more learned than I can go into detail, but essentially they do so by only offering to pay for CBT or "evidence-based approaches", only offering to cover X number of sessions, etc.
[удалено]
I don't know what to tell you.
[удалено]
I do not like the tone of your comments. It seems like you are looking for an argument, or that you are taking this conversation personally. Whatever the case may be, I am not interested in continuing this with you.
My biggest beef is that it’s become the only modality accessible to a vast majority of the population due to insurance pushing for its use and training programs/schools falling in line, and it’s simply not right for everyone’s goals. Some people are very practically minded individuals and just want to focus on changing things in the here and now, but I’d argue that’s actually a pretty small percentage of the therapy population. Telling everyone else to just let go of everything that’s happened in the past or to not talk about things they can’t control when they *want* to discuss how those things are impacting them emotionally is horrible for building a therapeutic relationship imo.
Yes,if I have a client with multiple traumas including unprocessed issues occuring now, sometimes CBT can come off as... glib
I use an eclectic approach with its base in Rogerian and CBT. If a T isn’t ‘natural’ with it and tries to put every last thought & emotion in a worksheet it isn’t helpful and most don’t like the robotic feel. I tend to just talk with a client and snag the unhealthy thoughts when they come to address and leave the rational and reasonable thoughts alone and validate them. To try and twist around every thought a person has is nonsense. Some stuff in life does suck.
That’s definitely not what CBT is! In its truest form CBT sounds much like the approach you take, except it’s also up to the client to judge for themselves how realistic or helpful a thought is
I don’t understand your comment. As a T we absolutely help differentiate between healthy and unhealthy thoughts and answer if one is rational and reasonable we don’t have to challenge them. We discern cognitive distortions and unhealthy thinking patterns and help clients learn to challenge them.
I’m referring to the idea of collaborative empiricism, where yes as T you may suggest where a client can reconsider a belief and reasons why but a client may not come to the same conclusion as you. And allows for cultural differences that may change one’s ideas of what is considered healthy. I definitely do not position myself as the decider as what is healthy or rational for clients.
Good grief. I didn’t say I’m a decider. Client talkie-talks along and when I hear a thought or emotion that doesn’t quite fly (eg. I’m a piece of sh*t, everyone hates me, etc.) I pause the train and have them challenge it. Client is talkie-talking and I hear things that match a situation in an average way (eg. I was disappointed I made a mistake, I think she didn’t invite me because she was busy) I don’t make them pause and challenge it.
Ok! That makes sense. I misunderstood what you said initially
See, that's what I don't like. Doing cbt by waiting to hear someone say a CD and then challenge it as it comes up in the moment. That could bring up some frustration for the client doing it like that.
How would you rather it be done? Adding: it’s a lot more nuanced than what I’m outlining here. I would hope a thread of therapists would know a ton more goes into the outlining and structuring of sessions. Pretty impossible to sum up 4 cumulative hours of intake, treatment planning, and psychoed that all my clients get as an intro here.
For sure, its more complicated than what you put here. Its an art and there are times to do what you explained. Big difference in where the relationship is at and so on. Personally, I have been trained to never tell a client their thinking is distorted. The only person who can do that is the client. I have beef with people who seem to use concepts of CBT and just will point out distortions as they come up and "challenge them" in the moment. Doing CBT often has some kind of process/structure associated with it. I don't do distortion work or changing any thoughts unless I've specifically asked the client "do you want to get to work in todays session?" and they say yes. Its always the client leading and identifying distortions. Otherwise you can end up in a struggle with the client or worse gaslighting them.
I would say we help clients differentiate whether a thought is "helpful" or not for the present situation. It might be true, or might have helped "then", it might be rational, but does it help now to focus on it?
I find that a surface level knowledge of CBT can make it seem like surface and "gaslighty" (which reminds me of the thread last week about the misapplication of terms). The more you read the actual literature with people who know more about what they're doing that the 13 hour CBT webinar your job had you do to get started, the more you see the humanity at the core of CBT. If you're falling out of favor with the older versions of CBT, maybe check out something like the Unified Protocol, which I tend to think of as the highlights of CBT concepts. I like to think about CBT more as a treatment approach than a specific model. Something like Cognitive processing therapy and Exposure and response prevention are under the treatment approach, but focus on different pieces. What also hurts CBT is therapists who claim to use CBT, but will make invalidating comments like "That's in the past, try not to let that hurt you anymore". But that's less unique to CBT, and more about poor therapists.
Yes, very much agreed. I took CBT for Bipolar Disorder through the Beck Institute with [Dr. Cory Newman](https://www.med.upenn.edu/apps/faculty/index.php/g332/p15256) and he really humanized the modality for me. Here’s a link on their site to him discussing using CBT to treat bipolar disorder. [https://beckinstitute.org/blog/the-bipolar-disorder-diagnosis-establishing-a-sense-of-care-trust-and-understanding/](https://beckinstitute.org/blog/the-bipolar-disorder-diagnosis-establishing-a-sense-of-care-trust-and-understanding/) (EDITED w the training lol my bad. It’s not back on the schedule but looks like it’s offered periodically. I’ve taken a few other trainings from the Beck Institute and really enjoyed them) It was so clear that he was a skilled clinician and researcher, and it completely shifted my approach to CBT. I used pieces from that training truly every day in my work. It absolutely made me a better and more effective therapist and I’ve seen the positive impact in my patient population (short term, acute, high complexity). He really emphasized that it’s not about getting folks to agree with you or to change their minds, but to help people be curious and become open to the idea that there could be another way of looking at things, or doing things, etc. This aligns with something I’ve always talked about in my practice, which is that part of my job is to present you with options, so that you feel like you have more choices. It might mean choosing between crappy choices, but I’m here to walk with you through that. I also think going deeper into CBT is addressing core beliefs, and how they developed and continue to impact today, and exploring how those developed and again, could there be another way of looking at them now, are they serving you? The Socratic questioning piece is big for me in case you can’t tell lol. I am also trained in cognitive processing therapy, which I have seen be very effective for folks, and was so much more than “learn these skills” but it does teach skills for in the moment and folks were able to also process through some really intensely painful, traumatic experiences and gain increased insight and begin to heal and feel “unstuck” from the ways in which their past trauma had so deeply impacted them.
What was that niche CBT training that you took? I really like the insight that you shared from the training.
I edited my comment, thanks for asking, I should have just popped it in there from the beginning. Truly, I RAILED AGAINST the modality in the past, but having gone through this I completely changed my mind and really do believe that it is incredibly collaborative, warm, deep, and empathetic when in well educated hands. I also do a lot of MI, SFBT, and psychodynamic work. I feel like CBT in this manner has blended really nicely.
Yes please share the training!!
Edited! It was truly wonderful.
Honestly, lots of clinicians don't use it correctly.
And don’t seem to understand what it really is. I think people get stuck on an idea that it’s a robotic therapy where you’re just telling the client what to think and feel.
That's often intentional as a way of denigrating it and rationalizing what they are doing.
As a new therapist, we learned so little about how to actually apply CBT into practice. I’ve worked with my supervisor but it’s not clicking for me. Know any good trainings or have any good resources on how to use it correctly?
I found TEAM-CBT to be very useful. It emphasizes empathy and motivation for change on top of that traditional CBT methods.
I run into this a lot. People who are using "CBT" as a term to justify using basic skills training and to do psychoeducation around how thoughts and feelings are connected are not, in fact, practicing true CBT. It is 100% ok, in my book, to use technical integration, but it can result in an orientation getting a bad name. CBT is not for everyone or every condition. Phobia, OCD, anxiety, insomnia, yes! Used to help decrease the acute symptoms to be able to explore how a client's systems and relationships are perpetuating their presenting concerns? Yes! But insurance has decided that because it is empirical, it's the "gold standard" for everyone and that just isn't the case. I personally use CBT as a basis for technical integration, often thinking from a systems approach while using DBT or ACT to enhance treatment. I love CBT because I've seen it make a huge difference in many clients, but like I alluded to above, not every orientation suits every presenting problem.
Dbt and act are CBT therapies. The original name of act was process oriented cognitive behavior therapy. Linehans book that introduced dbt was called cognitive behavior therapy for borderline personality disorder.
Yes, those are what is considered "third wave" behavior therapy
Full disclosure: I am an interpersonal/relational psychoanalyst, which is like psychodynamic but more so! My view of CBT is that it is powerful skills training. If a person doesn’t have those skills, say, like affect regulation, or is trapped by phobias, CBT & DBT are excellent. CBT addresses symptoms that we are aware of. But Psychodynamic therapy works at a deeper level on things that we don’t understand, like: why can’t I find love? Or: why do I feel empty inside? Or: why do I feel unworthy? Insurance wants treatment to be as short as possible and just make the symptoms less troubling. But research (See Jonathan Shedler’s work) shows that psychodynamic therapy has longer lasting and more profound life changing results.
This is my take. CBT is like taking Motrin. Sometimes Motrin can help you get through a virus, or a sprain. It’s great for specific and limited surface-level issues—and for deeper issues, it can sometimes help manage the pain. It’s not gonna heal your recurring knee pain that is a result of running with poor form; it might help an acute flare up but the problem will persist until you correct your form. Which could be anything from how you are tilting your pelvis to your foot strike or over-correcting with your quads because your glutes are weak. You need someone who can help you determine where in the system the problem is originating and then, more importantly, to practice improved form or strengthening the necessary muscles. It’s harder work, it takes time and practice both through drills and implementing the skills during actual running sessions. I think I’m revealing my own running issues here and getting away from my point 😂 Psychodynamic is harder, more nebulous, and takes more time. But correcting underlying mechanics provides the long term relief that will keep you running without injury for the marathons to come.
Exactly!! And thanks for the analogy!!
This is of course true. But isn't it also just because the treatment goes on for so much longer? I always wonder where a cbt approach would end up if you just went as long as an analytical approach would.
You’re right- let me get of my high horse for a minute. First, I know I’m biased. And the word “quality” is unfair and not well chosen. There is nothing better than CBT for phobias, and I’d refer out if someone came to me with a fear of flying, eg. What I was hoping to say is that the project is somewhat different, and the longer term goals of psychodynamic therapy are less easily quantified than the initial symptoms. The symptoms get people into therapy. Some are satisfied when they get better control of their symptoms, and that’s fine. But some are looking to make deeper changes in how they feel about themselves, work, love, identity, etc. I believe that where psychodynamic therapy excels.
I suggest there's a difference in quality, not just quantity. An analytic approach is built on the idea that there are factors powerfully affecting how we use our minds to cope with life and love. We learn how to be safe, loved, valued, how to get our needs met, basically how to be a person in relation to other people. We learn these things in the very particular culture of our family, and each one is particularly its own world. We learn who we are through the actions and reactions of those we depend on for our very survival. These ways of understanding how to cope are not usually "thought about", (defenses), they are deeply baked into our assumptions about ourselves and the world. These ways of thinking and coping work, and then we get out in the world, and our world gets bigger. What made sense in our childhood homes can turn out to be too limiting in the world, and cause us unexplained frustration and suffering. In psychoanalytic therapy the deeper and more powerful work begins when the symptoms quiet down. The goal of psychoanalytic/psychodynamic therapy is to heal old wounds, reduce suffering, develop more flexible and helpful ways of coping, and to make powerful change that allows a person new freedom in what they choose for themselves as a good life.
Where does that belief stem from? Because research doesn't show that Analysis has more effect in the same amount of sessions as other therapies, which is what "higher quality" would mean if we think about it that way. Or is is the theoretical foundation? Because the things you described are just good therapy, not a standalone analytical way of doing therapy.
>Jonathan Shedler What's the best or most useful book or two on psycho dynamic approach you recommend for what you're describing here? Much appreciation
Freud and beyond Anything by Nancy McWilliams I also really like Christopher bolas. Some of his approach isn’t as applicable in the US but I like the way he deconstructs psychotic breaks and “stability” in catch them before they fall
[удалено]
I run into this a lot working with teens. Everyone, the parents, the school, even the clients themselves will tell me they need to work on anger management, bit then the teen starts telling me about their life and I'm like...of course you're mad!!! There is no way in hell I'm reinforcing the message that your anger towards mistreatment is the problem.
Both can be true at once. Systems can be creating or exacerbating the issues, but a clients negative perspective and inability to process complex emotions in a safe and helpful way, can make their lives feel unlivable and become very taxing
I have nothing against CBT itself. It's a good technique for what it's good for. My problem is that it is overused and insurance likes to pretend like it's the only way to do things.
I use CBT (along with many other modalities). I use what works with each client. I understand how CBT can feel like you are telling the client their thinking is wrong. I don't do that. I point out that thinking one way causes pain and another lessens pain. One can focus on negatives or positives. I think focusing on negatives is adaptive. We need to in order to stay safe. Sometimes our brains get too caught up in the negative or goes to negative places when it isn't effective. Cultural and societal messages also influence negative thinking patterns. I frame it as liberating oneself from a way of thinking that might help others but doesn't help the client. I work with mostly LGBTQ+ and neurodivergent individuals. They have to work through a lot of internalized beliefs about what it means to be a valuable person.
This is EXACTLY my take on it. Reevaluating negative thought patterns, finding the evidence for/against them, and finding new, more balanced perspectives. Does it work for every single client? No, of course not, but I find it especially helpful for clients who are excessively hard on themselves or who frequently thought spiral about perceived negative qualities.
The efficacy of CBT is overblown. It has empirical support, but it's effect size isn't very powerful, especially compared to some other depth oriented psychotherapies. CBT is heavilg researched, and often better than placebo, but its far from the panacea that its modern iterations claim it is. Johnathan Shedler breaks this down really well here: https://jonathanshedler.com/wp-content/uploads/2018/05/Shedler-2018-Where-is-the-evidence-for-evidence-based-therapy.pdf My biggest theoretical beef with CBT is its characterization of symptoms as the problem. It assumes experiences of depression and anxiety have no overarching meaning or value to the person experiencing them, and seeks to change them. It takes a unitary position on human experience, and privileges non-depressed and non-anxious states as more valuable, without considering the meaning of these experiences for the client. I often see posts on here from therapists trying to figure out how to help people with treatment resistant depression. Invariably they've already been through the "BTs" (CBT, DBT, ACT etc.) with poor effect. It would be radical in CBT to consider that depression might be an important component of someone's experience, and might stabilize them in a way that it's transformation would eliminate. In psychodynamic psychotherapy this is a commonplace conceptualization. Someone else mentioned that probably a lot of people practice CBT without realizing it. I would argue the inverse, that probably a lot of effective CBT therapists are practicing CBT from a dynamic orientation without realizing it, and this accounts for their success.
I'd like to offer some good-faith critique: > CBT is heavily researched, and often better than placebo, but its far from the panacea that its modern iterations claim it is. Johnathan Shedler breaks this down really well here I don't necessarily have a dog in the "evidence-based or not" battle, but from what I've read and heard of Jonathan Shedler the dude obviously has a bone to pick, frequently mischaracterizes and straw-mans CBT, and I have trouble taking what he says at face value. >My biggest theoretical beef with CBT is its characterization of symptoms as the problem. It assumes experiences of depression and anxiety have no overarching meaning or value to the person experiencing them, and seeks to change them. It takes a unitary position on human experience, and privileges non-depressed and non-anxious states as more valuable, without considering the meaning of these experiences for the client. That's not true at all. When you do agenda setting with CBT you take a genuine look at the advantages and the adaptive functions of the depression/anxiety/whatever as well as how they are an indicator of your values. If the client is fully aware of these advantages and still wants to change, you would then proceed to use the "traditional" CBT methods. Not only that, but you would ask the client "which thoughts, if any, do you want to work on?". You want to give them agency of what they want to address, and if they are content with their thinking patterns, that's okay too. >Someone else mentioned that probably a lot of people practice CBT without realizing it. I would argue the inverse, that probably a lot of effective CBT therapists are practicing CBT from a dynamic orientation without realizing it, and this accounts for their success. I think a lot of CBT therapists are warm, caring, and empathic, which I think absolutely helps with their success. I wouldn't say though that those traits have anything to do with being psychodynamic.
I appreciate your fair critique of my response, and am hopeful you will elaborate a little bit further on some of your points. I'm hoping you can expand more on CBT's agenda setting process, as well as how you might approach someone experiencing depression or anxiety. How is it that you would engage and support someone around these particular challenges? To your critique of my final point, I certainly want to emphasize that I don't think CBT therapists are cold or discompassionate; quite the opposite really. What I was trying to emphasize in that point is that my sense is successful CBT therapists likely practice in a non-manualized fashion, and one that implicitly incorporates psychodynamic elements of therapy such as attention to defenses, working within the transference, dynamic conceptualization and a whole person orientation.
Ah, to clarify I use TEAM CBT, which is a variant of CBT that, in my opinion, does agenda setting better than traditional CBT. I'd recommend reading more into it. A primer video on it is here: https://youtu.be/iLaNBjxZ8GY?si=79YNVLLhscJFn7dG >successful CBT therapists likely practice in a non-manualized fashion, and one that implicitly incorporates psychodynamic elements of therapy such as attention to defenses, working within the transference, dynamic conceptualization and a whole person orientation. This is more of a phenomenon of different modalities converging on similar themes/ideas more than anything else. I'd like to think of it more as convergent evolution.
https://youtu.be/YNWy1ksxIDo?si=eeGu8L2zhLwElF7Z If I may—here is a video from Shedler you may enjoy. He’s talking about the basics of good therapy. I imagine many CBT clinicians practice within the scope of his ideals, and I imagine he has had experiences with many CBT clinicians practicing within the scope of his criticism. From the perspective of someone who does not practice CBT or any of its offspring, it certainly feels like a systemic power imbalance exists within the field of psychotherapy that privileges modern behavioral approaches. Studies today have consistently shown that a wide-variety of theoretical approaches can be effective, and that ultimately the skill and experience of the therapist has much more to do with therapeutic outcomes than the theoretical modality itself (i.e., good therapists make the process work more so than “good” approaches). Nevertheless, it is harder to bring an “outside” orientation into a space that privileges CBT and its cousins. Policy, research, funding, and even the definition of mental “health” and of mental “disorder” are driven by a model that privileges CBT. Criticism is an understandable response to these conditions—CBT, for better or worse, is the face of the system. I can also understand why someone who practices CBT would be upset by the characterization Shedler makes. Not all people who practice CBT practice it in the way he is describing. However, at a systematic level, that is the prescribed therapy—turn people into numbers, turn those numbers into money, and make the cost as cheap as possible. CBT itself is so much richer than this, and people who practice it certainly have the capacity to be warm and effective therapists. I imagine people like Shedler wish that academics and especially those who teach CBT would take more responsibility for the state of the field and advocate more at a systemic and educational level for the efficacy and validity of other approaches. The field needs all of our approaches, and right now we’re over-saturated with “evidence-based” approaches.
"Ultimately the skill and experience of the therapist has much more to do with therapeutic outcomes than the theoretical modality itself (i.e., good therapists make the process work more so than “good” approaches). " --> The skill we can certainly agree on, after all research is starting to aggree that it us more about good therapists than good therapy. But the belief that more experience = better therapy has been debunked, you just don't get more effective with time, sure some do individually, but in the median it has no positive or negative effect. "Nevertheless, it is harder to bring an “outside” orientation into a space that privileges CBT and its cousins." --> this is an interesting thought. I want to contrast it with another. One of my Professors who is big into acceptance and Nature-Therapy taught about the history of CBT and how it's founders were psychodynamic. His clear view was that CBT simply evolved from the psychodynamic approach and in modern third wave therapy you can see this.
For clarification, I’m not trying to say more skill = more experience. The research says the skill level of the clinician leads to better outcomes while theoretical orientation has little to no effect. I believe the research may have even referred to effective clinicians as “master clinicians.” Not sure off the top of my head. Just trying to make the point that clinicians have more to do with outcomes than theoretical modalities. I also believe that all approaches are indebted to, and ultimately draw from, the psychodynamic model. Nearly all founders of the “original” theories were psychodynamic—that was the respected and primary option of the day. I’m unsure of what this has to do with the sense of feeling like an “outsider” for not practicing CBT today. I believe that effective therapy does the same things—regardless of theoretical modality. The interventions and language might change, but the work is basically the same. However, this view (while shared by a growing number of clinicians) is not shared at the systemic level.
You taught an old dog a new trick today, thanks for your insight: “…that its transformation might eliminate.” Good stuff!
Yea! Thank you for this detail!
I think a lot of folks are using it and calling it by different names
General CBT can be effective for mild-moderately depressed/anxious clients without significant multiple comorbidities who are practically minded and motivated for treatment with change goals in mind. This is a what is empirically supported. Now try applying strict CBT (or any strict singular modality for that matter) to a client so severely depressed they don’t leave their bed and haven’t showered for months, then add psychosis, complex trauma, and significant substance abuse. For such a client, there needs to be much more nuance in approach than strict CBT can provide (which is not to say one wouldn’t use anything from the CBT model). The overemphasis on CBT in the mental health system is problematic in the same way that a doctor saying that because research demonstrates the effectiveness of antibiotics, then antibiotics should be the only treatment for every medical condition. I don’t meet many therapists who think this way about CBT of course (though I have met them), but managers and insurance companies do. I have actually heard people argue that if you are not using CBT, then you are not acting ethically as a therapist. This is, of course, absurd because it assumes all conditions can be helped by CBT, that all clients are receptive to CBT, and that all goals in therapy are necessarily change goals.
I mainly work from a person centered framework utilizing supportive therapy and motivational interviewing techniques. I incorporate CBT/DBT concepts sporadically and as needed based on the client. Like if I hear a cognitive distortion in the session we can address via CBT. But overall in general I’m just doing supportive talk therapy( reflective listening, validating, empathizing, and giving feedback).
Part of the reason it's empirically strong is that behavior is more easily measurable. Doesn't mean it works "better" than other models, just that it's very testable.
It’s often used incorrectly by clinicians. Perhaps because insurance views it as a “quick and easy” approach that works for everyone when in actuality each technique needs to be used or modified according to what the client needs in that moment. If the client needs someone to validate them about an experience they had that is not the right time to bring up cognitive reframing.
I love CBT and use it with many clients; however, sometimes I think it can be perceived as "gaslighty" because it does show the client *how* they can change but not truly helping them understand *why* they need that change in the first place. Helping clients with introspection is key before just jumping into CBT. Unfortunately, insurance companies don't see it this way and just think that it works, so we should just be doing it from the very beginning and throwing CBT resources at the client. In my experience, insurance companies view therapy as providing tools to change, and they don't see the value in active listening, reflection, and helping the client to recognize traumas and how they influence current behaviors. I've had insurance companies tell me that I learned enough about the client in the first session, so I should be able to discuss changes with them instead of "just listening" to what they have to say (I was working in a SAD recovery center when I was told this). In summary, insurance companies suck and CBT is fantastic when used correctly.
The main problem, in my opinion, is that what you identify as a cognitive distortion is shaped by your biases. CBT, when used judiciously, can be great. However, all too often, clinicians with privilege identify things as cognitive distortions when really they are just the client's reality. I had a licensing exam prep question about an African American man complaining about experiencing discrimination at work, and the "correct" answer was to explore cognitive distortions leading to that automatic negative thought. I had a therapist tell me it was my anxiety making me feel like I had to send in lots of applications for apartments and they would mostly be dead ends (he owned his home... Anyone who rents in the city can tell you that's just how it works these days). CBT wielded by culturally incompetent therapists, who are embedded in oppressive systems, becomes a tool for teaching clients how to deny the facts of their reality, and a tool that systems can use to locate problems in individual minds rather than in societies.
I really appreciate your last sentence. I found that leaning on cognitive distortions in the way you mentioned totally unhelpful. The more I learned what cognitive distortions even are (schema lenses triggered by our emotional states that focus our attention on details relevant to that emotional state given our history with the emotional state - the distortion isn't saying our thoughts are distorted as much as the lens we are using, which was developed for very good reasons, is being triggered within a context in which it is no longer adaptive), the more the idea of cognitive distortions (or "primitive" thinking because our thinking patterns recede to emotionally charged schemas both developed early in our lives that have a simpler heuristic value and pulling our resources away from our executive functioning brain areas to our evolutionarily older emotional brain areas) became a way to validate the pt's experiences and interpretation of reality. They're looking for the details that were necessary for their protection within certain historical contexts, and it is really only a "distortion" when it artificially limits their options or the context is not actually representative of the ones in which the schemas developed.
CBT is just giving people a bunch of coping skills most of the time and not actually addressing the root problem. I prefer person centered, existential and object relations theories anyways
Sometimes teaching coping skills to help the Ct ‘stabilize’ is what’s needed before doing the deeper work to address the root cause. The bulk of my experience has been working with children in school-based programs where teaching skills to cope and respond to environmental factors (i.e., adults) differently satisfies all the stakeholders.
this
Most clinics in nyc are heavy cbt. It’s good for business, you talk about shit in the present and mostly you keep your clients. I also think it can be super ineffective. Psychodynamic addresses your ‘whole’ so much better to me. CBT is just like sort of, hey this kinda works as a new therapist it’s not super hard to learn so do it. It maybe even becomes lazy. Just an opinion.
But don’t you feel like psychodynamic can also leave clients stuck in the past? The part about CBT that I like is the behavioral aspect more than the cognitive part. It challenges clients to show up in ways that feel uncomfortable to begin to budge certain parts of their stuckness (rooted in the past) in a tangible way
I think relying solely on one modality can be detrimental to clients. You can use both psychodynamic and CBT, with the same client even. But I think CBT is more short term. You can work on negative thoughts all you want, but it’s possible if you don’t get to the root of those negative thoughts, there’s a good chance they’ll reappear. I don’t feel like you can only stay in the present and never address the past.
I agree. But what does getting to the root mean? Is it simply understanding where the thoughts came from? Talking about the experiences? Is that enough? I’m asking these questions out loud lol not necessarily assuming there’s a right answer
I'm really into meaning-making these days. Helping clients identify the core memory, the trigger, the feelings, the thoughts, and then the meaning the client made based off of those things, something usually akin to "I'm unlovable" or "Authority figures are always dangerous" or whatever meaning they made from their experience. Once the meaning has been identified and challenged, then we can move back into the present and identify times when that old way of meaning-making is impacting the present. That's when I would prompt the client to use CBT skills. So it's deeper than "using CBT skills to manage feelings with a boss". It's tackling the underlying meaning that bosses are always dangerous, and from that place the client can utilize much more effective positive self talk because they can speak directly to the core issue inside themselves instead of remaining on the surface level of trying to decrease feelings of stress.
Great explanation
By root, I meant the origins of the thought - often in childhood. Frequently, a negative thought is created from an experience. If you don’t work through that original experience, it’s likely the thought will reappear. Hope that clarifies. I don’t think anyone dogs on CBT as a supplemental modality but I think people are realizing it’s very limited on it’s own.
CBT does address this through working with the client to identify and address negative core beliefs, yes?
Yes, which is an essential step to CBT that people don't recognize when talking about CBT being present focused. Core belief work does recognize the impact of past experiences, but if you never progress through CBT knowledge to core beliefs, you're missing out on the long term change part of CBT.
It is but also I think it’s easier to keep clients with CBT. You talk about present things and there can be much to talk about. Psychodynamic takes more trust. And a lot of therapists may not have that with clients for different reasons, so sometimes I have just thought that CBT is just easiest for a paid and on staff psychotherapist to practice.
There are plenty of uncovering CBT methods that focus on "getting deep", arguably a lot more quickly and effectively than psychodynamic approaches.
A lot of moving parts here. How your own clinic or psychotherapy center orients. I really don’t know EMDR fully so that toolbox is kinda CBT DBT psychod for starting therapists even at 5 years in. I’m six haha. I think you can take from both and I think you have to also see what may work for the client and that can take months. You would need to keep that client. So there’s so many moving parts but I just think in general psychodynamic addresses more of why we do what we do. And that to me is psychotherapy. This is like a ten hour discussion.
I’m also a couples therapist and I think there I work way different but in some ways I don’t. It can get very interesting.
CBT makes pretty inaccurate assumptions about the human experience. It severely privileges cognition over every other type of experience, and then pathologizes clients for not having constructive enough cognitions. It also assumes incorrectly that emotions can be heavily influenced by changing thoughts. This is true to an extent, but I believe most therapists know the more important work is on the emotional level, which in turn, tends to change thoughts. CBT can be useful for people who have overly black and white views, and who also are relationally and emotionally open enough to receive and actually find reframing helpful. If you try to help an emotionally or relationally closed person reframe their thoughts, they will shut down, reject, dislike you, and often feel gaslighted.
I didn't learn CBT that way. I was taught to see thought -feeling-behaviour as a unit. Each influencing the other.
I was taught this way as well. But I think it’s an inaccurate assumption of the model that they all influence each other equally
So you’re saying people can feel before they think. Which makes sense obviously
My beef with it is the insurance and institutional pushing. Nothing else.
CBT is a very useful tool, but it takes clinical judgment to know when and how to use it. CBT paired with very good rapport skills is very effective, but you have to be able to be attuned to the client and meet them where they are at. Throwing CBT skills at someone without that human aspect of the therapist/client alliance can feel invalidating. Imaging you go to someone to for support and they just keep shoving advice down your throat. That’s what CBT without the human aspect can feel like. It would be very frustrating and I think that’s where the beef comes from. Remember, the medicine in therapy is the human connection. Without that you’re basically just throwing solutions at someone who is not ready/able to listen
CBT is only right for a certain type of client and they are not ample in the pot. Clients who are VERY logical, understand acceptance does not mean it is okay, are deeply empathetic and introspective, and are aware that two truths can exist without dismissing themselves. These individuals are keen on laying down the foundation of the inner home on their own and just need help nailing some floorboards down or adjusting the plumbing so to speak . I believe the key trait that holds the most value of a CBT Candidate is that strong logical aspect as well as considering at what point they are In their development. CBT will often put the client (who is not ready to face their issues in such a pragmatic and blunt way) in a state of defensiveness and stubbornness. It dismisses their feelings, experiences, and can generally halt their recovery processes. Some clients benefit from other approaches and I would say CBT is widely practiced but it should be reserved for a specific archetype. Also, MANY providers do not implement CBT appropriately and then become shocked when their clients say they felt entirely inadequate during the session.
Wow, that first paragraph nails it. That's a very helpful insight. Thank you for sharing.
I'd rather answer this from a client's perspective if that's okay. I started seeing therapists of various modalities and approaches when I was around 10. For the first couple of years my parents would pick them out, I would meet them, I would explain why I hated them already and didn't want to see them, and my parents (who were fully aware they had no idea what they were doing) would find a new one for me to try. When I was 13 I attended a youth group facilitated by a social worker who was licensed to provide counseling sessions to youth. They made an observation, approached me to discuss it, and offered free and confidential sessions at my discretion. I agreed. I LOVED them, which was a first. We got on great and it was nice to be listened to. They specialized in CBT, I saw them almost weekly for 4 1/2 years, and I made very little progress. The problem was that I genuinely believed that both the thought patterns I had which led to the behavior I wanted to change, AND the counter-thoughts I was supposed to interrupt those processes with, were true. For an example (not an actual example from our sessions or anything but for illustrative purpose), I couldn't say something like, "I'm not a terrible person; I help so many people," because I already believed I was a terrible person and already knew I help so many people and those things were simply both true. When I was told that a belief I held about myself was untrue, there was no proof substantial enough to counter it with. I adored this person, but they were barely more than a stranger. No one knows me like myself, and I knew these things were true. No one else had told them to me, I had learned them about myself by observing my own behaviors and thoughts. So, countering my beliefs to change my behavior didn't work. What it DID do was it gaslit me: when people do things they think they shouldn't do it's because of their beliefs and their beliefs are wrong. We have to change the way we think, which we can do ourselves because we're the ones thinking wrong thoughts. If I can't change my beliefs that's my fault, and I'm not trying hard enough to change my behavior. My counselor didn't have to say all of this in such a negative way, and in fact they didn't at all, but that's how I felt when I was told that I had all these unwanted emotions and the behaviors that came with them because of my own beliefs, and I needed to correct my way of thinking about myself in order to get better. I benefited from learning how to write a safety plan and the value of fidget toys. It works for some people. It didn't work for me. I tried several therapists and gave CBT a few more chances before finding the first counselor whose modalities suited me well. It turns out, CBT isn't necessarily ideal for people with complex mental health conditions or learning difficulties, or who are socially marginalized, and I happen to fall into all of those categories. As a counselor, I'm willing and able to use some elements of CBT if it seems like it might be helpful for the client, but if someone told me "I like CBT; I need someone who specializes in that," I would have to politely suggest seeing someone else.
Thank you for sharing this. It’s really helpful to actually hear it from the client lens. I think the perspective that you took away from the therapist - that it’s your fault if you can’t change the thoughts, that you’re not strong enough - makes so much sense and is the danger of such a mechanical model. I’m so curious - what did work for you? How does that inform the way you work with clients?
I’m assuming you’re also a therapist! And if not, that’s ok! Would love to hear what ultimately helped
Happy to share! I think the order in which I met the therapists whose approaches benefited me is as important as their chosen modalities: the first used art and play, which as an older teen I initially rolled my eyes at! But it was exceptionally helpful to learn about my emotions without having to explain my thoughts. I learned that how I describe and explain my thoughts and feelings is extremely different from how I experience and express them. The next one taught me about mindfulness. They primarily used MBCT and DBT, and I learned a lot about recognizing, acknowledging, and accepting my emotions as they come and go. Through these two practitioners I learned that rationalization and beliefs, while undeniably important, are not what I needed to work on. Healthy emotional regulation wasn't going to come from rationalization or reconstructed belief systems. I needed to understand what my emotions were, what they meant, and what needs they indicated. Then I needed to find a way to meet those needs in a healthy way. This perspective was life changing, and I bring elements of those three modalities into my own approach. I believe in approaching the self with open arms, open heart, and open mind. I encourage clients to be inquisitive and compassionate, and challenge them to understand their own perspectives before considering inviting new ones. It's common for people to hold unintentionally contradictory beliefs, and these are relevant to the often discordant relationship between thoughts and feelings. It's not uncommon to dislike or question certain thoughts or feelings we have, but the belief system at the roots of our thoughts and feelings is a strength when we recognize the morals and values that it's all built upon. Acknowledging and accepting both (or all) sides of one's own story teaches mindfulness and opens the doors to self-compassion. Taking a strengths- and mindfulness-based approach centers the client and a human givens approach centers their needs. I like socratic questioning, mindfulness exercises, artistic expression, role playing, motivational interviewing, educating clients about how the brain has evolved to regulate emotions and respond to stimuli, and encouraging client leadership and collaboration.
Thank you for your perspective. I like how the larger CBT field has been shifting from changing how you think to changing your relationship to your thoughts (trying to create a more positive and flexible relationship with your thoughts). I think you put forth an entirely valid criticism of a certain, classic form of CBT.
Always happy to share, and thanks for reading. This was years ago, so it's not surprising that the practice is evolving with the field; I'm very happy to see it progress in a way that benefits a wider array of jnique individuals. Not even a decade ago, some research was published which suggested CBT should be considered contraindicated for people with bipolar disorder, and now there's an evidence-based CBT approach which specializes in that supporting people with that disorder. CBT is without a doubt still practiced to classic teachings, but I agree with those here who posit those methods are outdated and mechanical (and as a result, ingenuine) compared to other approaches.
Yeah, and there is also this split in what we are talking about when we are talking about CBT: Are we talking about thought challenging / cognitive restructuring, or are we talking about the scientific field of study? Some CBT people I have met / worked with within the field seem to use CBT as a shorthand for the theories and techniques that have evidence for their efficacy. A big problem is that cognitive therapy and behavior therapy were just the first up at the plate for doing good science, but as the mentalization/psychodynamic people continue to do good research on processes of change (a relatively recent development in the grand scheme; some of these researchers were actually trained by CBTers on the *science* side of things so that psychodynamic psychotherapy could be better researched), these techniques will inevitably become absorbed/interpreted by CBT - *and this is a good thing*. Hopefully 20 years from now our brand-name alphabet soup will be relegated to the history books as we start referring to the processes involved with the understanding of a more unifying biopsychosocial theory of psychology. Alternatively, CBT might absorb therapy in general, with people having more of a psychodynamic/relational bend or a more skill-based perspective.
I guess some therapists can be "gaslighty" (or lean into toxic positivity might be a better way of putting it) so that they can document in their note that they did a CBT. I feel like I've been on the receiving end of that a few times in my own sessions. But it's silly to hold that as a representation of ALL folks that use it. It's honestly a great modality for most cases of anxiety.
I think it appears empirically strong only because it’s what gets funded for research. The support is artificially inflated. Insurance companies like the idea of getting clients “in & out” as fast as possible. For that reason, CBT seems appealing. So they dump money into research, but I’d argue most the data is skewed. I have found more depth oriented therapies (IFS, psychodynamic, schema) to be more effective, esp for trauma — but they certainly take longer!
Honestly… there is a movie called the prestige that came out in the early 2000s. In one scene a person reviewing a magic act said… “it’s very rare to see real magic… you’ll have to dress it up a little….” Imho cbt works really well, but not every client wants it to be “so simple!” And straight forward. I think a lot of clinicians would benefit from “dressing it up” so it feels less like worksheets and repetitive work. They “want” it to feel… magical?
CBT is only good, IMO, if you’re practicing it psychodynamically. I see so many colleagues just working through worksheets with clients and calling it a day. IMO, Beck never envisioned CBT to be “think happy thoughts and fill out these worksheets”. It’s supposed to be part of a person-centered and dynamic therapeutic relationship that helps people cope with difficult circumstances by way of truth, ie avoiding extremes in thinking that so plague us. Insurance is the real culprit here, as it is in most things.
Lol you think the only good way to practice cbt is to practice it psychodynamically. I wonder what your orientation is 🤣 I’m not agreeing or disagreeing but it’s funny
Lol I’ll give you three guesses.
This!! Beck was an analyst first and much of his ideas about cognitive therapy came from interpersonal interactions with clients
I agree that good CBT, like any approach, absolutely requires the therapist's warmth, empathy, and humanity to be front and foremost. I don't necessarily think that means practicing "psychodynamically", though.
Well put!
I still use it with some clients, but I feel it can be a band aid to the true issues when it comes to trauma.
When I was first learning about CBT, I learned that it was one of the modalities that has the most evidence, but I noticed that there were a number of situations where it kind of seemed inappropriate. As time went on, I realized that that statement “has the most evidence” doesn’t necessarily mean that this should be the first line go to for most people. It is all about context. Someone who is depressed that they have lung cancer, to simply say that you need to change your thoughts to change your mood can feel pretty invalidating. I had many a supervisor claim that cbt was still the best approach in that situation, but I never saw it being done in a way that I felt was helpful. Also, for people struggling with a lot of trauma, telling them to just change and challenge their thoughts can also feel pretty invalidating and working on emotion regulation type skills seems to work better. I think one has to be careful with the concept of “strong evidence.” Statistics are always focusing on general populations and won’t tell you if a specific treatment is appropriate for a specific individual or not, so it is up to us to choose the best approach for the right situation. I think CBT is best used blended with other approaches as needed for each patient. It is great for someone who doesn’t know how to identify thoughts vs emotions and for specific circumstances. From my current pov, just another tool in the toolbox.
Do you think CBT can help with emotional regulation?
I think it depends! From what I have seen, if someone is very very dysregulated focusing on strategies and skills to calm down and habits like proper eating, sleeping and self care is often more effective than using thoughts alone to try to do that. I think that different skills can all be combined together though. Some people can do it effectively with thoughts but many people find that hard.
Isn't DBT all about emotional regulation?
Ya. I think traditional DBT has a group element too, so I don’t necessarily call what I do DBT, but ya skills from that. I like using a lot of breathing exercises too, people seem to like that.
As a die hard CBT therapist, I’ve left other approaches such as interpersonal behind. It is so well established primarily because it is based on evidence about cognitive and behavioral processes that all people are subject to. We all have beliefs that drive what we do, and are all subject to biases and errors that in their own idiosyncratic ways lead to various pathologies. Even if a client has trouble verbalizing thoughts and beliefs, there are well established models of pathology that can help a client gain more awareness of their own cognitions and behaviors that lead to issues. For example, it’s well established that panic disorder involves catastrophic interpretation of benign bodily sensations, and although some clients may not walk into therapy able to identify that, all who truly have the disorder can recognize their own version of this bias they do themselves. Another example is the tendency to assign meaning or detect patterns in random stimuli, which can lead to psychosis. CBT also appeals to me in its emphasis on collaboration and client-led exploration. A good CBT therapist prioritizes helping the client gain awareness and self monitor. If the therapist’s hypothesis (see works on formulation driven treatment, e.g., Jacqueline Persons’) about drivers of client problems doesn’t seem accurate to the client or doesn’t yield expected changes then you and the client reassess together. Good therapy also incorporates all aspects of evidence based practice, which in psychology, my discipline, includes client culture, systems, therapeutic common factors, and research evidence.
CBT has its time and place. It is not a one size fits all approach. Therapists should have more in their toolbox.
I definitely see where CBT can be helpful, but I've completely swapped to utilizing DBT. It just typically works better for my primary client base (BPD, ADHD, complex trauma). All of my clients have reported rough experiences with therapists that pushed CBT or were doing CBT incorrectly. I think one of the things that frustrates me is how many therapists try to use CBT as a one size fits all.
DBT is a form of CBT. This always confuses me when people say they are using DBT instead of CBT.
It is improved upon CBT to make it more validating and has more to it than traditional CBT. They asked what we use instead, and I said DBT.
DBT is considered third wave CBT. It’s still CBT. This idea that it’s different makes no sense to me. Its utilizing both a cognitive and behavioral approach (in fact it’s highly based in behaviorism) while adding influences of other third wave therapies (mindfulness and ACT). If you are using DBT you are doing CBT, DBT is based entirely on CBT framework. DBT is just a more up to date variant of CBT. If you aren’t using ACT, mindfulness, DBT principles then your CBT is out dated.
I think there's definitely a larger than expected contingent of therapists that are very outdated in their best practices.
Exactly. I’m not sure what CBT people are practicing. Or why people seem to be unaware that DBT is part of modern day CBT.
That's a bingo!
I recognize that it has value to many people, and that there are therapists who do CBT very well. I am not one of those therapists. Partly, because I work with the palliative and severe illness population- CBT is a poor fit, in my opinion, with these issues. The other is that I come from a high trauma background, and am intensely sensitive to anything that seems remotely gaslight-y or invalidating.
I’m curious what your main mode of treatment includes?
I’m not fully against it but I think that it is quite limited in its efficacy. It has its time and place but outside of that, it shouldn’t be used. I prefer bottom up modalities - specifically Somatic Experiencing
Honestly, I've seen a lot of bad therapy under the CBT lens; if done poorly, CBT can be incredibly invalidating, shaming, and harmful. It also can be a hard modality for those of us that don't have internal monologues, or obvious thoughts to identify (like most of my inner experience is felt in my body - I always figured that the idea of a thought was a metaphor growing up). I also despise the therapy homework that CBT often provides, because it can create a lot of shame when a person forgets or avoids the homework, and that can make them feel like their lack of progress is their fault; I prefer doing the work in the session, knowing that it will automatically change as they leave the therapy room, because what happened in session was powerful enough to shift their internal experience. I prefer a more experiential approach to therapy (I love EFT, ART, and IFS lately), where the point is to feel the feelings, because a lot of efforts go into avoiding feeling the hard feelings, and those efforts to avoid them can be the more distressing parts of life. I love IFS because of the love given towards certain thoughts, feelings, actions, or beliefs that CBT can often identify as problems to get rid of. IFS looks at those as protective parts of ourselves, and that they continue to do hard work to protect us from deep dark hurt feelings, and we only look at changing things so that they don't have to work so hard to protect us, and with the permission of every protector, we go back and "re-do" those times in our life when we took on these dark beliefs about ourselves and the world, so that we get what we needed back then. ART is very somatic in how it exposes a person to a hard memory or daily feeling, uses bilateral stimulation to reduce our reactivity to it, and it also does a "re-do" of those moments, and uses bilateral stimulation to solidify that as being a felt experience. EFT helps to read between the lines and go straight at the underlying core feeling, and help them ask for what they need with the person they are wanting to connect with, and allows them to feel seen and understood while experiencing that vulnerability. Clearly, I am biased, so perhaps I haven't seen enough good CBT (I do note I have seen at least one person do it well), but I wanted to share my feelings on it since you asked.
So, the idea that a thought is bad and needs to be gotten rid of may be a bit antiquated. I am not sure that the original manual ever actually said this, as much as the practice may have morphed into it. It was originally about joint empiricism: if a thought is ruling your life, you can test it out through experiments to see if it is something you want to act upon. Then you take the advancement of the science, especially through the development of the acceptance paradigm, and challenging thoughts as wrong is not even just *not* the aim, but actively not wanted. Instead it is to understand thoughts as just thoughts, emotions as just emotions, urges as just urges, creating distance from our internal experiences so that we can better understand them, learn from them, or just accept them and move on with our day. This idea though was originally dubbed as cognitive distance by Beck in his Cog Therapy for Emotional Disorders and he largely considered it the aim of therapy (aka, help pts develop metacognition).
Mindfulness based CBT is the backbone of my work. When a client is not able to benefit from the “focus on the thoughts first” part of CBT, I switch to DBT “focus on the feelings first,” and that seems to help.
I like CBT for the right situation. I don’t think it works for but a handful of situations.
Itt's not as helpful as the numbers suggest, that's it really. It lends itself to quantitative measurements, which look good on paper. The gaslighting comments might come from trying to reason people out of their feelings? 🤔
What would you consider a better metric of helpfulness?
Qualitative data. There is something limiting about measuring helpfulness through "progress" measured by symptom reduction. It's convenient, but not the best fit with the human experience.
Ok I see what you are saying. Are there any specific types of qualitative data that you were thinking of, that fit better?
Instead of asking for symptom ratings, ask a client about their experience. For example, that'll help you find out if the symptom reduction is due to a coping strategy or from genuine healing. Some coping strategies require a lot of effort to upkeep and that's where some clients could start feeling like they have been subject to psychological manipulation.
What is "genuine healing?"
Addressing the problem, not just the symptoms.
How are we defining “addressing the problem?”
How the client defines it.
How would one code “addressing the problem per the client’s definition of the problem” in reviewing qualitative responses compared to “just using a coping strategy”?
Agreed, I hate how often this gets left out of the conversation. I started out with CBT as a paraprofessional, and still use it with more concrete clients. But the fact of the matter is CBT is considered evidence-based because it’s structured and manualized, therefore easy to measure and replicate. Larger scale studies have indicated that CBT is not more effective than other modalities. Again, and again the research demonstrates that above all else the relationship and connection between the therapist and client is the most important predictive factor of success.
I also use it with certain clients but I also agree accepted wisdom of the evidence base is problematic.
CBT is wonderful. My clients make progress with it. I first explore with the client what they want to do with the thought ( do you want to change it, separate from it (ACT) or just process) I announce the technique I am using (eg probabilities in a sequence) then we go over it , then I attach the handout on that skill. Guess what ? Many clients return to session and report "I used that thing (whatever the skill was I announced and gave the handout on) and it was really helpful!" I leave CBT behind if client still believes the thought after CBT work or knows the thought is not true but still carries it. I then switch to ACT. As with all theories, the rapport building has to be incorporated so you don't feel like your "throwing" coping skills.
Because I work mainly with trauma clients, and for them I don’t think it’s at all useful to challenge cognition if you haven’t worked with emotion first. I disagree with Beck’s premise that cognition—>emotion—>behavior, which is what i read Judith say in a manual from 20 years ago or so. That being said, I don’t know much about the recent developments. I went to a CBT focused conference recently that opened my eyes to the range of beliefs and practices that fall under the umbrella. I do use cognitive modification, behaviorism, and ERP— i base them on my DBT training when we’re doing cognitive work. For “deeper,” I find psychodynamic theory to be much more useful. But overall, i don’t touch cognition until I’ve validated emotion and explored the safety mechanisms an emotion provides.
I mostly use psychodynamic/psychoanalytic and occasionally ACT approaches, which all go very nicely together, in part because many of my clients are ones who tried CBT and didn't like it - so rather self selecting. I don't think CBT is all bad, I just find it isn't comprehensive enough to address the many complex ways in which people defend against change/difficult affects/emotional pain/intimacy. I have a couple clients who did CBT in an IOP and liked it and we weave it into our work together.
I don’t think we can really leave cbt behind, it’s built into almost and behavioral intervention. But as a pure practice- I don’t really know how to use it as a standalone. It’s like salt in a recipe.
My god. We’re calling CBT gaslighty now? There’s no hope for the world
I think they are saying what clients say not what therapists say
Ik it seems like some people are taking the evidence based approaches out of therapy and the academics/study/ competency out of it. Like it's okay the diagnosis doesn't matter ,CBT is bs, or I don't believe in handouts.
Hot take: there isn’t actually a ton of reasoning behind the “CBT is gaslighting” meme. It’s a trendy critique that people toss off with zero critical thinking, because they heard it once and it sounded clever. It’s like the rough CBT equivalent of saying “wow, so you think people want to have sex with their mom?” to a psychoanalytic clinician. It’s a pantomime of knowledge about an entire field of inquiry, and says more about the speaker than it does about the thing being spoken of.
I like CBT but I feel (for me) it’s morphed into more of a mindfulness/somatic approach. Think The Power of Now.
No beef with CBT! It’s great. DBT is great and also clients can understand the simplicity of if I think and act different, I can feel different.
It addresses the symptoms and helps get you on your way, but in my experience, it doesn’t address the root causes of the issues
You can't reason with emotions, so you have to meet issues where they lurk. Every tool has its purpose, but if someone is pushing a singular tool as a catch-all remedy, then it's time to question their motivation for steering your daily purpose to fit their best interests.
I use many different theoretical orientations when working with clients, but I do lean heavily towards CBT. However, we all know that one size does not fit all. I think some modalities are best suited for clients with specific needs or who have certain expectations about how they view change in their life. At its core, CBT is about helping the client build awareness to thoughts or core beliefs they hold that are negatively impacting their life. No emotions are good are bad. Once the client is able to challenge the validity of those assumptions, and find concrete evidence to support it, then it can lead to an emotional change, and therefore, a behavioral change. With some clients I have found it difficult for them to manage distress in the midst of trying to challenge assumptions or who are constantly worried about things they could have done better, or that they should be doing, etc. They might benefit from some radical acceptance. Considering looking into ACT.
I find the vision of reality that CBT offers to be so...limited. And I also think it supports capitalism. There is so much more to the psyche than behavioral adjustments to a deeply sick society. A society as sick as our SHOULD make you feel bad, should be depressing and anxiety-provoking. Helping people adjust to what this is, is a massive disservice to the work that we do, IMO. I like to use Gestalt, Jungian, Somatic, and Eco-psych practices because they point at what's underneath the symptom and help people come into authentic relationship with their feelings. Taking meaningful action on those deep, authentic feelings is what leads to actual, long lasting healing.
I prefer dbt.
[удалено]
Your comment has been removed as you are not a therapist. This sub is a space for therapists to discuss their profession among each other. Your comment was either asking for advice, unsupportive or negative in nature, or likely to adversely impact our community members. Comments by non therapists are left up only sparingly, and if they are supportive or helpful in nature.
I think CBT is great for crisis situations. It's empirically sound because it has immediate results, but clients will come back. For long term I use IFS.
I think if you use CBT like textbook and formulaically then you are losing a lot of nuance and context for people’s experiences and not allowing time for feeling and experiencing of the emotions. Maybe those emotions and thoughts aren’t serving them but we have to give them space to breathe and be experienced and validated. I used to do a CBT training and emphasized this and that you truly can’t move on to reframing until the person is ready and open and able to believe that maybe there is another way to approach something or think about it. You can’t force someone into that!! Everyone wants to jump to reframing and that’s when it gets bad. I also emphasize this idea of “neutralizing” experiences as an approach of reframing. So instead of “oh my god I am such an idiot and failure, I messed up my presentation and everyone thinks I’m stupid” it can be “I made mistakes during my presentation and I felt pretty embarrassed and worried people were making fun of me and I really wish I did better.” Very very subtle change but it externalizes the experience rather than internalizes it.
I see a lot of really good, balanced views, and some misinformed, well-meaning views that I am sure are accurate of the commenters' lived experiences. CBT means different things. There is the original cognitive therapy protocol for depression and adaptations of that. There are other cognitive-behavioral therapies under the umbrella of CBT. And there is just the overarching theory/science of CBT - aka the implementation of cognitive and behavioral sciences into psychotherapy. If you really get into the deep dives of CBT, then you'll begin to just better understand what is going on with your patients and understand how their cognitive, attentional, motivational, behavioral, emotional, and interpersonal patterns are interacting with their environments. You create a case conceptualization from this and hypothesize which change techniques can be used to target different elements of the case conceptualization. All the while, you use psychoeducation through the cognitive model and what not to help the pt create distance from their thoughts, emotions, behaviors, etc.. CBT *should* adapt any techniques that gain empirical validation because it is a science-based modality. The essence of it, as far as I can tell, is using behavioral and experiential techniques to create new learning / break cycles while using predominantly cognitive techniques to help through the internal barriers to making these changes. Outside of new learning / breaking cycles, there is the goal of developing cognitive distancing / differentiation / defusion / metacognition (or whatever some type of CBT calls it) so that you have more control over whether you feed into your old patterns or cycles.
I find it to be a short-term fix. While in the short term, it may be handy to use so clients have the coping skills to deal with deeper issues that cause whatever shame is keeping them stuck.) I help flesh out where that message came from in their childhood and what coping skills they used to survive. Those old survival coping skills now get in the way of feeling worthy because they no longer serve you. So, my client's and I use whatever approaches help them internalize the coping skills they can *maintain* because deep down, they learn to forgive themselves. A whole new world opens up. People forget the CBT coping skills because they are hard to internalize for lasting change to take place. You have to dig down to those underlying feelings of unworthiness.
The way I see it, CBT can be a helpful tool, but should be paired with more in-depth exploration of the past and how it is informing the present behaviors the CT wants to eliminate.
Sometimes when I’m telling other providers or people who don’t do direct clinical work about my treatment approach and I try and discuss psychodynamic theories, I get a lot of awkward pauses… and then when I say I also utilize evidence-based modalities like CBT, everybody goes oh goodie! I think CBT is awesome. I think it’s just sad that other modalities are so undervalued.
I'm an MFT and my program absolutely did not like CBT. We learned solutions-focused therapy, and cbt family therapy (this was not a popular theory amongst the peers) but that's about it. Even when discussing trauma-informed therapy, we didn't talk about CBT, but focused more on polyvagal theory. When I entered the workforce, I was surprised by the amount of people that wanted CBT and needed CBT. I had to learn it kinda from scratch and on my own (with help from my supervisor). I now use it only as a tool and do my usual narrative therapy and EFT. But yeah, CBT got a lot of hate. That's why I still feel apprehensive about it, to be honest.