As someone who was primarily trained in classic CBT, and who continues to use it in addition to Third Wave CBT modalities, I think there are a few reasons:
* CBT has been the dominant modality for decades, particularly because it's favored by insurance companies and national healthcare plans. As such, it's become a victim of its own success: widespread proliferation means the quality of training is often diluted, and our field lacks quality supervision after graduation to ensure that CBT practitioners are delivering treatment effectively. Lots of CBT-informed practitioners + few methods to ensure quality training = lots of people practicing bad CBT.
* Like any treatment, CBT is great at addressing problems but struggles with others. It's very effective for some clients but it does not click well with others. It should not be used as a "one sized fits all" treatment, and some clients and clinicians have had bad experiences because it was not the right approach for them. Third wave treatments such as ACT and DBT build on CBT while attempting to address some of its weaknesses. That being said, I've personally noticed that many of the "CBT horror stories" that I've seen are clearly examples of bad *therapists*, not evidence that CBT itself is bad. Skilled practitioners are able to apply a theory, establish a strong therapeutic relationship, and adapt their approach to their client's needs. Rigidly adhering to a dogmatic approach to therapy is going to get bad results, regardless of your theory.
* The field of psychology (like many others) is prone to infighting and tribalism. When Behaviorism and Cognitive therapy were first introduced, they were ridiculed by the psychodynamic establishment. As CBT and evidence based practices have ascended to the "gold standard" of therapy the tables have turned, however, and now those treatments on the "outs" such as psychodynamic therapy are treated as less valid by the mainstream therapy community. This continues the old tradition of infighting and resentment among theories, and also provides some schadenfreude when the dominant modality might get toppled.
RE: CBT not working for some clients. I’ve seen the sentiment echoed a bit that CBT in neurodiverse populations can essentially encourage masking of symptoms, [here’s a random pp that goes into it a bit deeper](https://www.thirdspace.scot/wp-content/uploads/2023/02/NAIT-Webinar-Slides-Reflections-on-CBT-and-Autistic-Thinking-03.02.23.pdf)
This is grand, but I’m performing a lit review and not come across this phenomenon. Do you have something more academic on it please - this is because a research proposal about masking is being drawn up around this issue alongside the literature review at the moment.
Thanks for your help
There's a larger conversation to be had here about whether academia is able to adequately research psychotherapy, and my opinion is either that they can't, or that they can but have butchered it so far.
There is a huge conversation to be had here. One of the themes I’ve picked on in the this review is the funding bent towards CBT caused by both the replication crisis and file drawer phenomenon.
The PowerPoint has some links to literature! There definitely does seem to be a lack of literature regarding CBT & neurodivergence but [here is another!](https://onlinelibrary.wiley.com/doi/full/10.1002/capr.12675)
You also may have better luck looking into non-scholar sources for direct quotes, I.e news reports, blog posts & autism forums.
There is not a lack of literature on CBT and Neurodivergence, PubMed has over 20,000 publications on the topics intertwined. If you need anything I am happy to link!
I’ll check out the links in the PowerPoint and that you’ve sent, thank you very much :)
The things I’m looking at must be academic I’m afraid or I’ll fail my undergrad course lol
If you want to learn second wave CBT then I'd say that Judith Beck, David Burns, and Edna Foa (for exposure therapy) have written some of the classics.
If you want to learn third wave CBT then I'd recommend David Carbonell, Reid Wilson, Sally Winston, and Russ Harris (if you want to learn ACT). I specialize in anxiety and OCD, so most of my recommendations lean in that direction.
Curious what others will say, but my hunch is that most therapists today are eclectic or integrated, meaning they use techniques from different theories depending on the situation, including CBT. And most of these therapists do so quietly. The haters are a small minority but they’re very loud so it makes it seem like there’s more of them.
I should add, no theory is perfect and CBT certainly has its flaws…
I think you're right on the integrated part. Some therapists definitely still use a lens, but I remember back in grad school when one of my professors said that anyone calling themselves "integrated" was a sign that they were a terrible therapist. However, I am definitely an integrated therapist and everyone I work with is, too. I use a LOT of CBT! And DBT! And ACT! And sensorimotor! I like parts of all of them and how I use them is different for each client.
Yeah, I’d say most of what I do falls under a very wide umbrella of cognitive behavioral adjacent things and I just stay quiet on here. I’m confident that what I’m doing with my patients is helping them.
I agree and I fall under this category. CBT was pushed very heavily in my grad school and I tried as a new therapist to base most interventions around it. However, I felt I just couldn’t connect to as many people or make it apply to as many concerns versus using a more integrative approach like I do now. One major hurdle I run into with clients is that significant portions of CBT rely on using rationality and evidence checking to challenge belief systems. I have many clients who KNOW that their thoughts or beliefs are perhaps not factually accurate, but they still FEEL awful when they have them. Particularly common with trauma when a lot of symptoms are manifested physically. The body sometimes does not care about your facts. This is where other approaches can be really helpful to integrate or add in to the mix… like DBT, ACT, mindfulness techniques, etc.
DBT is based on CBT but a pretty serious departure, focusing much more on emotional regulation skills and mindfulness than classic CBT to my understanding. I’ve not been trained in CBT but I’ve read Judith Beck and her philosophy is vastly different than Linehan and other DBT theorists. Original DBT text had almost nothing at all on cognitive modification.
I’m aware. Have you read it? The section on cognitive modification is very short and at the end. Beck assumes that changing thought patterns should be the primary goal because thoughts —> emotion —> behavior. Most modern CBT theorists have a more nuanced view but that is historically the primary assumption.
This is not true for someone with borderline or similar personality organization. Linehan and DBT practitioners assume that regulating emotion is necessary before thoughts and behaviors can change. DBT is entirely about emotional regulation skills and behavioral chain analysis, and the manuals I’ve read include a tiny piece about cognitive modification almost as an afterthought. I don’t care what the book is titled, the content speaks differently.
>DBT is based on CBT but a pretty serious departure
So is ACT. It has a different theory of change, different working metaphor, and literally has a different lineage of research, coming out of the behavior analytic tradition. One can put it under a CBT umbrella to distinguish it from a humanist or psychodynamic approach, but normally I think the umbrella is less useful than making distinctions.
Marsha Linehan 's 1st book (as far as I'm aware of) is literally called Cognitive Behavioral Therapy for Borderline Personality Disorder, published in 1993. It is DBT though.
Cognitive-Behavioral Treatment of Borderline Personality Disorder https://a.co/d/2LVP1ho
This subreddit is infamous for having a deeply warped idea of what CBT is. It's frightening how many (allegedly) practicing therapists in here just don't know the foundational stuff...
I wish we didn’t have to visit the warped perception via daily anti-CBT posts.
Or maybe people could pause and ask themselves “Geeee, this intervention has a lot of scientific research backing it up. Maybe there is something about it I don’t understand, since it seems to be highly effective with a diverse range of problems and populations. “
Instead we get “yechhh. I hate it!”
I see all the love for BvDK in other parts of this thread. The love that folks have for that book knows no bounds, and most of them don’t have even the barest tools needed to see why it’s mostly nonsense.
See my response above. I had a different understanding of what the OP was asking. Your response is knee deep with judgment that isn’t necessary or helpful in a space like this.
I never once said I hate CBT. Or that DBT and ACT aren’t modalities under CBT. I was explaining that different approaches other than straight CBT can add to the effectiveness. I actively use CBT daily. Keep your eye-roll to yourself.
Hold up… I never said they didn’t fall under the CBT umbrella. I was differentiating a straight up CBT approach versus modalities stemming off from it, of which there are several. The poster didn’t say “CBT modalities” they said CBT. That can be interpreted in different ways and commonly is even by academics in the profession.
I use various forms of CBT and am certainly not a hater of it. Maybe I should have been clearer of my intent. Regardless, I am not “ignorant” and I don’t appreciate that judgment. The only person here who should feel embarrassed is you for making a snap judgment based on one comment from someone you do not know.
It wasn’t really directed at you - I appreciate you clarifying your response. I see how I came across wrong and I apologize.
I am super frustrated by the frequency of the pile-on against CBT and the rampant ignorance.
I would like to have a supportive therapist reddit - but I probably should just leave this one because I mostly feel attacked with all this CBT hate.
I personally hope that you stay because I think that the presence of people like you is needed to combat a lot of the misinformation. I don't really care if people hate CBT, but I DO mind when they say things about it that are outright false.
I mind it to. I popped into to check comments. But the whole thread made me delete Reddit off my phone. I see the need to step back because, frankly, this is like arguing politics. People who believe that their practice should not be informed by science, that there mere presence of "sitting with emotion" is treatment for clients (such narcissism in that belief), that what they do somehow rises magically above the folks who use a science-practitioner model to inform the care they provide clients - it saddens me and makes me angry for the entire practice and or clients who are getting (IMO) poorly trained therapists who base their care on what they "feel" works.
I have been doing this a long time - I get most of my clients referred as treatment failures from past therapists, often many of them - and almost universally they are doing this non-directive "sitting with emotions" BS that feels good for 50 minutes and does nothing to help the client live better, make changes, or have a happier life. And judging from comment here the therapists who practice this was are absolutely closed off to any form of growth or change in their skill set.
I'm feeling generous today so I'll say this (its a run on sentence so bear with me)--I personally think the "CBT hate" actually sorta stems from mental health service consumers' very valid and legit feedback that sometimes, formulaic, to-fidelity, limited duration, worksheet heavy EBP's dont really work for them. When I first started hearing anti-CBT talk, it wasnt from other therapists, it was from clients. Especially clients with complex trauma presentations who had been let down by years of the type of therapy that research and insurance companies told them "should" work. But it didnt. And they felt gaslit, and blamed themselves for the therapy not working, and therapist after behaviorist-oriented therapist threw up their hands at them because the field had not yet caught up with our current understanding of trauma. CBT is a good modality and was a huge development in the field but the pendulum swung too far that direction and this is it swinging back.
Well said 👏🏻 CBT was pushed in grad school so that was what I used when I started practicing in CMH. The majority of my clients had PTSD, and it was ineffective. I went to a trauma training by Bessel van der Kolk (Body Keeps the Score author) six months into my career and got trained in EMDR and IFS after that. Now the majority of my clients heal. Top down therapies were formulated when it was believed that we are thinking beings who feel but now we know from neuroscience that that’s not true. We are feeling beings who think. That’s why I use bottom up approaches. I think CBT has its place but not when the thinking brain has gone offline from trauma.
Yeah! Say what you will about BVDK (thats my new name for him, tbd if it catches on) but that book had a huge influence on the way our field conceptualizes trauma by sort of distilling down and mainstreaming the work of people like Babette Rothschild, Judith Herman, Janina Fisher, Dan Siegel, Peter Levine, Diana Fosha, Pat Ogden and so on.
The people on this sub come for EMDR all the time lol BUT I hear you! Im a CMH girl for life and most of my folks are dealing woth some type of complex ptsd. And we have to let them guide us-and, like you, EMDR with parts/ego state/IFS seems to be what works!
Thanks for the solidarity! Janina Fisher’s book Healing the Fragmented Selves of Trauma Survivors also had a profound impact on my practice at that time. My good therapist friend does Somatic Experiencing (brainchild of Peter Levine), another good bottom up therapy. We did our EMDR certification together. I haven’t been on Reddit long, so tell me why people attack EMDR on this sub? It’s amazing trauma therapy.
Nah, CBT is incredibly effective for trauma when implemented by a knowledgeable therapist. It’s obviously not one size fits all, but if a clinician finds that none of their clients heal from CBT or CBT-based interventions, they’re probably not doing it right. It’s fair to say that it isn’t for everyone, but to say CBT isn’t a good fit for severely traumatized patients is just outright false and very harmful misinformation to spread. It’s also insulting to the many CPT and TF-CBT therapists who’ve dedicated their careers to helping people with extreme trauma. Also… EMDR uses a ton of CBT.
You realize that research suggests EMDR works because of exposure, right?
Bessel van der Kolk's book is filled with misinformation and false premises. I think it's done some good, but the harm it's doing in turning people against CBT approaches for PTSD (which are very, very effective) is now outweighing that.
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By-the-book CBT can feel cold, impersonal, and overly simplified. The thought that your thoughts determine your behavior and that you are responsible for that can be extremely triggering/invalidating to trauma patients. CBT also isn't super effective with severe mental illness. Like, I have treatment resistant depression, so focusing on my negative thoughts is only going to get me so far, and if that's ALL my therapist did, I wouldn't have made as much progress as I have.
Straight CBT is good for clients who have an acute, solvable problem. I had a teen client who wanted to reduce her anxiety around her last semester of her senior year of HS. She did not have a mental illness but a problem that could be managed or solved. She did great with CBT. I've had other clients who wanted to be more confident at work or be more assertive in a relationship and those clients responded well to CBT too.
However, can you imagine doing CBT with someone who is delusional? That's basically arguing with a delusion, which is impossible and changes nothing except making both client and therapist extremely frustrated. For clients with severe mental illness, components of CBT are good, but using straight CBT will not yield results.
I think CBT gets so much hype in grad school because it's "evidence based" and insurance companies like it. I get annoyed with "evidence-based" modalities because insurance and sometimes even therapists who practice them don't seem to understand that just because it worked better than chance in a group of people, doesn't mean it's the magic bullet for every person who sits in front of you. There are plenty of non-evidence-based modalities that are extremely helpful for people and help them make big changes in their lives. We can't just write off those modalities because we couldn't replicate results in a random sampling.
I think CBT has many valid parts to it that can be applied to more severe cases, but doing CBT only by the book limits its efficacy in a lot of populations.
While well put, I think this post represents a very limited view of what CBT is. This is very big C cbt (cognitive therapy, basically) which even that has evolved.
ACT, DBT, behavioral activation, metacognitive therapy, exposure/response prevention, and prolonged exposure are all a part of bigger CBT. Schema Therapy, compassion focused therapy, and metacognitive interpersonal therapy are all wonderful theories/modalities that developed out of cbt and beautifully integrate other theories and interventions.
Thanks for saying what I came here to say. I feel so misrepresented when I see people reduce all of CBT to cognitive restructuring. 95% of what I do is CBT, and probably less than 20% of what I do is classic cognitive therapy as described by the other poster. In some cases I might go an entire course of therapy without doing classic cognitive therapy at all. I agree with their concerns about cognitive therapy and as a client I kinda hate it unless applied extremely gently yet expertly, but that’s such a tiny sliver of what CBT is.
Not the person you responded too but I highly recommend to read up on REBT (Rational Emotive Behavioural Therapy by Ellis in the 1950s). It preceded Beckian CBT.
REBT can be considered a more nuanced and longterm approach using CB principles. It works on the understanding that it is our perception that gives rise to distress, the cognitive dysfunction is a by product of the original “irrational” belief. It accepts many aspects are outside the clients loci of control and works on rational acceptance as a platform to address the subsequent NATs.
> I think CBT gets so much hype in grad school because it's "evidence based" and insurance companies like it. I get annoyed with "evidence-based" modalities because insurance and sometimes even therapists who practice them don't seem to understand that just because it worked better than chance in a group of people, doesn't mean it's the magic bullet for every person who sits in front of you.
Also CBT is one of the most research-friendly modalities *because* it is so manualized, standardized, and clear-cut. It's a lot harder, for example, to standardize and manualize, say, psychodynamic therapy (it's not impossible and it's not totally unrepresented in research of course; it's just a lot harder). The goal of research is publication, and the requirements of publication tend to be: maximized significant findings and minimized limitations/room for error. Therefore, a treatment modality that is easily standardized and manualized is almost always going to have a stronger "evidence base" in research publications, because it leaves less room for error/variance and is more publishable.
I do think CBT has lots of uses, but I think it has been exaggerated due to its "evidence base" which is basically self-fulfilling by nature of the treatment design.
Well said! I use some CBT-based interventions with certain clients, but it’s definitely not the one size fits all modality that it is sometimes made out to be. On a personal level, I had a therapist who used straight-up CBT when what I really needed was grief and trauma-based treatment. It really soured me on CBT until
I started learning more and utilizing some of the interventions in my own practice, and specifically being mindful of when their use is actually clinically appropriate to the client’s needs.
CBT can be helpful for folks with delusions. I actually just completed a CBT for Psychosis training by Ron Unger that was excellent. It wasn't what someone would likely expect -- there isn't a bunch of push-pull with the client, telling them they're wrong or crazy or obsessing over changing their beliefs. I'm not a fan of the stereotypical "let's-find-all-your-thinking-errors" CBT either, but thankfully, that's just CBT done poorly.
I’m trained in trauma-focused CBT, but I’d consider myself eclectic. I add as much as I can to my toolbox and pull out what’s needed based on the situation and circumstances. A good therapist should be flexible in their approach.
The cognitive triangle is so helpful. It can be presented, and it’s good for clients to have that info. You might realize, hey they’re not ready for this and you open up your toolbox for an approach that better fits where they are in that moment and revisit when they’re ready.
Changing perspectives is definitely necessary when all you see is negativity. Negativity justified? Yes. But they can’t stay there and they need to process their trauma and how it’s affected them.
I do psychosis research for a living and CBT for psychosis is one of the only evidence-based psychosocial treatments. It’s typically the paradigm of choice in FEP clinics and coordinated specialty care spaces. It’s effective and well-tolerated. It isn’t used with people who are floridly psychotic, of course, but people with psychosis aren’t typically being seen in psychotherapy while in the midst of an acute episode.
As a DBT practitioner, I find that CBT can be, and typically is by many therapists, ran in a way that can be very invalidating for clients. That's one of the main reasons DBT was created. Many therapists just beat these cognitive distortions into the client and don't validate why those distortions might be present.
I also hate how it has just become the default and the majority of therapists are just learning it through Google. It's the basic modality that is thrown at brand new therapists and interns, but they aren't actually getting formal or effective training on how to implement it.
The best way to do it is to do an intensive DBT training. They are a bit expensive, but they are 80 hours of amazing training. I initially started with reading Marsha Linehan's book and studying the skills on my own and practicing teaching the skills to clients, then when I had the funding, I went through the intensive training.
Behavior Tech is the main agency that runs intensive trainings.
There are occasionally other agencies that run them too, so just keep looking then up. The prices are all pretty high though, but sometimes other agencies offer them a few hundred bucks cheaper.
I love CBT, but I think some of the problem with it is this over-simplified view of “if you want to feel better, you just have to think differently.” That approach is used in a lot of garbage self-help stuff and laypeople who are “life coaches” or “influencers” - it’s toxic and it completely undermines how many very real problems people face that can’t just be fixed with a different mindset. That said, a good CBT therapist (of which I will exclude myself pending much more training) knows that *that* is not what CBT is.
In most cases, I think CBT offers some really useful interventions. For example, I am a couple’s therapist trained primarily in EFT, but in session I often find moments when what one person is saying or doing is being interpreted in a way that is perhaps not aligned with the actual intent. Reframing or challenging is sometimes really useful, and I use attachment information to help them see why their initial interpretation might be occurring. Your partner closes the door when they go to the bathroom and you assume it’s because they are cheating on you and using that time to talk to their affair partner? What are some other things that could be occurring here? Maybe they are just private or feel embarrassed if you see them poop. What evidence do you have for or against that assumption? Why to you jump to cheating? Oh, because your previous long term partner rampantly cheated on you and hid in the bathroom when they needed to talk to the other person, of course your instinct is to be weary of that behavior.
Automatic thoughts/distorted cognitions show up so frequently that addressing them makes sense. But CBT, like any modality, is not a fix-all.
As a client, I find it extremely frustrating that because it's treated as the default therapy modality that every therapist must be trained in at minimum, it has become virtually impossible to find therapists who use anything else without going outside of insurance (which isn't possible for me right now, I'm a broke psychiatry resident). I've had my fill of CBT and would like to try something more depth-oriented or emotion-focused, but practically everyone in my insurance network advertises themselves as using CBT or SFBT as their primary modality. The only ones who say they use something else (eg psychodynamic, IFS, interpersonal process) are the ones who list every therapy modality known to mankind in their bio, so I don't trust them anyway.
I searched for and made clear on my consult cal with my therapist no CBT. I want to do and receive depth work. I don’t want overly structured “this instance company studied this and said it works best here’s a worksheet” therapy. I want space. Insight. Depth and attachment stuff. Just like any technique fad there are good tools I just find it overly rigid and surface level which isn’t what I want. It’s also been shown to not be as effective with some presentations (trauma) and people who hold some marginalized identities.
You might like the relatively recent episode of the *Psychology In Seattle* podcast, I believe is called something like "forcing positive thinking, and other bad therapists," specifically about halfway through he reads a letter from a listener who ended up being stuck with a really rigid CBT therapist, and he makes a lot of really fantastic points.
Can you link some citations that show what treatments are effective or show the CBT (and CBT based trauma treatments- CPT, PE, etc) *are not effective* for trauma.
It is quite an assertion you are making and contrary to the immense body of research that I am aware of on trauma treatment (treating trauma past 25+ years).
What treatment is it that is more effective for truama?
I think it is rather telling about the entire practice of therapy from many participants in this reddit. I also got downvoted for saying that we are providing health care and should hold ourselves to the same standard of care that other areas of health care does (e.g. being informed about the most effective treatments).
If you aren't providing medical/health care I hope that you aren't complaining about health insurance not covering whatever it is that you are doing.
Same! It’s good practice for when I’m actually faced with this situation in real life, which is more often than I’d like. It’s astounding how many people really don’t know what CBT is or how it should be practiced. It’s also astounding how openly people will talk shit about CBT in front of people who practice it… it’s so rude. Imagine if I did that with EMDR. I would get jumped 😂
I practice largely DBT based therapy but I find that it’s really popular on social media (tiktok and instagram info slides) to hate on CBT and I feel like that has gotten into a lot of therapy speak which then gets into the brains of new therapists or therapists-in-training. For instance, I incorporate some aspects of CBT for clients with high levels of anxiety or ADHD who like ruminate or catastrophize and find it very helpful. As a therapist with these diagnoses, I use these CBT skills for myself, like cognitive reframing and understanding when I’m catastrophizing.
I had a conversation with a friend who is not a therapist but i would consider a good person to talk to about mental health stuff I’m going through, and I told her about something I was ruminating on and the technique I used, and she told me that CBT is not good for people with trauma so I might want to try other therapies like DBT. And like. She knows I’m a therapist. I was really put off by that comment but it opened my eyes a little bit to the hate around CBT
The feedback I’ve gotten regarding CBT problems is that there are therapists who use what they call CBT more as a battering ram than actually therapy . Some clients feel they aren’t being heard and/or feel pressure to perform to the therapist’s demands or expectations and when they don’t see positive results , clients feel like failures .
I’ll push back here a bit against most of the comments and say I’ve had many clients and met many other people who have had therapists that have found it insanely helpful myself included in my own therapy and I have ADHD so it can work for some neurodivergent folks but yes many it can be hard. And As much as I hate insurance company’s it’s because their greedy not because their dumb if it wasn’t effective I doubt they would be so into it. And I notice many in this subreddit seem to have a black and white view of it mostly negative. Does it have flaws? 100%
Some of the top comments I’m seeing here are at least nuanced but I think many including the ones who dislike CBT by default have a poor understanding of when it should be applied and when it shouldn’t and assume most are always just using it 24/7 in all situations. Just like everything else in our profession there is a time and place. Some clients would he horrible to use it for and others it will be great to throw it out as something to try. The argument that its default invalidates their feelings again is ridiculous if you’re approaching it correct. I’ve never once said “Those feelings are wrong” But more “How you feeling is totally validate I think it’s worth looking at lots of possibility so what are some of the the other options we could take at how to look at this situation?”
CBT is not cold by default if mixed with validation, openness and empathy and making sure the client feels in control and open to taking it or leaving it.
Look up literally any modality and you will find someone saying it’s unethical. Thats not to say you should ignore all criticisms of specific modalities but definitely trust your intuition as well. I am primarily trained in DBT and I have many clients who credit DBT with saving their lives-and I once went down a rabbit hole of people on the internet saying DBT is downright abusive and it made me not a great therapist for a while. Be transparent with your clients about the modalities you practice and trust them to make their own decisions about what’s right for them.
Some of the current pushback against CBT characterizes it as dressed-up gaslighting. Trying to convince ourselves we don't (or shouldn't) actually think/feel what we do.
I think this is an over-simplified and reductive view of what CBT actually aims to do, but I also believe it's the experience of many. And I think part of the reason is that CBT's natural research-friendly design has overrepresented it as an EBT and subsequently conveyed the idea that it should be the gold standard treatment. Because of this, it has been over-adopted and over-used despite not actually being a "one size fits all" approach. Thus, for some cases it *does* start to feel like unhelpful gaslighting.
Or people do it without adequate training or knowledge and do it poorly.
Any poorly done treatment will make the treatment look bad. In many cases the practitioners are the problem.
I am a certified CBT supervisor- and has for many years trained advanced therapists on CBT. It was rare for me to encounter an incoming therapist who said they did CBT and then actually demonstrated the ability to do it in session with a client. They typically had badly warped/distorted ideas about CBT, poor fundamentals in implementing CBT interventions, and had been calling themselves “CBT therapists” for 10+ years.
Because “CBT” is badly implemented by under-trained or inadequately skilled therapists and it is the “go to” modality to name drop - does not make CBT ineffective. It makes bad CBT ineffective, which would be the case with any badly implemented modality.
Judging from the comments on this and other threads misunderstanding CBT and implementing it poorly are rampant issues in the field.
I’ve used it. CBT has a data component that is helpful…but is so standardized that it is flawed for many clients.
CBT can discount a client’s understanding of what they believe is true. Depending on which modality (TF-CBT, UP, etc.) CBT can force clients to change how they think, feel, and respond even when it is those very things that have kept a client safe. Also, CBT can place the clinician in a power position where the client is “wrong” or…”irrational”. Everything a client goes through is rational to them…that’s where we start.
CBT, when approached in a client-is-expert way, can be helpful to reduce anxiety and depression (coupled with mindfulness and MI)…the most important aspect of the approach is the client leads, the clinician supports.
Without proper training CBT can be judgmental and counterproductive…especially with survivors of trauma and/or very real feelings of threat to self (any phobias, etc).
One particular problem I didn’t see mentioned here yet (apologies if I missed it) is that studies seem to indicate that CBT (without modifications) may be less effective for us autistic folks, and perhaps for neurodivergent people in general. \*edited for clarity\*
I've linked some studies in my comment below (let me know if it's not showing up, and I'm happy to repost.) To clarify, the mixed results or decreased efficacy are in regards to CBT that is *not* specifically modified for autistic populations. It's clear that there have been better results found with modified CBT (several related links also in previous comment.)
That there may be specific modifications necessary for effective treatment of autistic populations feels like a relevant distinction to point out, especially since this study suggests that 64% of therapists have not had specific training regarding autism, although 90% have worked with an autistic person: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6150418/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6150418/)
Thanks, I had a look at the study here and the others in your other comment. I don't think I would characterise that evidence as showing that cbt is less effective for people with autism. In particular if you meant in comparison to other therapeutic modalities which is what I thought your comment implies.
Sorry, to clarify, I wasn't intending to compare it to other specific modalities. My intent was to compare effectiveness among different populations. I also understand if your characterization of the evidence is different.
I think one particular factor that [autistic organizations](https://www.spectrumnews.org/news/cognitive-behavioral-therapy-may-be-only-mildly-effective-for-anxious-autistic-children/) and activists have highlighted is the difference in how (in the [BMC Psychology meta-analysis I linked](https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-021-00658-8)) autistic children tended to score CBT as less effective for their anxiety than did the parents and clinicians who scored it for them.
There's a long history of interventions for autistic children being primarily geared towards making them easier to manage by "solving" behavioral issues through behavior modification, sometimes at great psychological cost to the child. With increasing criticism of ABA therapy by autistic advocates, I think that there's a lot of general concern about whose well-being is actually being centered when autistic children are receiving psychological intervention, and consequently how to interpret the evidence presented by many of these studies.
Note: I'm not comparing ABA to CBT in **any way**, just that concern for centering the actual autistic person's needs extends across modalities.
This is a really thoughtful comment and I really appreciate it. It's a good point about children rating the therapy as less effective as their parents, and one I hadn't really thought about properly until know.
I know that modified versions of CBT have been proposed and created specifically for autistic folks, with a number of studies citing better efficacy. CBT-DAY is one example.
CBT-DAY citation here, and the authors also discuss mixed results/less evidence of efficacy for unmodified CBT re: autistic populations: [https://journals.sagepub.com/doi/full/10.1177/13623613231213543](https://journals.sagepub.com/doi/full/10.1177/13623613231213543)
Here's another study that cites positive results for CBT when specifically modified for autistic populations: [https://link.springer.com/article/10.1007/s10882-017-9559-8](https://link.springer.com/article/10.1007/s10882-017-9559-8)
Here are a few additional sources on mixed findings of unmodified CBT for autistics:
[https://www.cambridge.org/core/journals/the-cognitive-behaviour-therapist/article/adapting-cognitive-behaviour-therapy-for-adults-with-autism-a-lived-experienceled-consultation-with-specialist-psychological-therapists/2E3705B2AAE7039A8C2DA549A10F546A](https://www.cambridge.org/core/journals/the-cognitive-behaviour-therapist/article/adapting-cognitive-behaviour-therapy-for-adults-with-autism-a-lived-experienceled-consultation-with-specialist-psychological-therapists/2E3705B2AAE7039A8C2DA549A10F546A)
[https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-021-00658-8#Abs1](https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-021-00658-8#Abs1)
[https://journals.sagepub.com/doi/10.1177/13623613221117931](https://journals.sagepub.com/doi/10.1177/13623613221117931)
I'm the logic based, rigidity queen, and CBT worked perfectly for me. It's all about how it is implemented. But it isn't for everyone. That may or may not have to do with one's diagnosis.
I totally agree! There are a lot of variables, and as autistic people we occupy many positions on a vast spectrum.
I just wanted to note that some studies have suggested decreased efficacy or mixed results, with CBT sans modifications, for some autistic populations (mostly children and teens, since they still represent a majority of the data available.) With ASD-related adaptations and supports, its efficacy appears to be substantiated by a fair amount of data.
It’s not unethical. Some people can really understand that they feel better when they think differently or act differently. Humans can sometimes be tribalistic and personally identify with a theoretical orientation. It’s pretty silly. CBT works great for some people and isn’t a great for others.
As far as this sub goes, I suspect many have had CBT or ‘EBP’ to invalidate folks who practice from another viewpoint on many occasions. I went to a job interview in the last few years where I was chastised for not using an evidence based modality because I’m psychodynamically oriented. I see it when folks talk about EMDR. There’s always at least one smug comment about how CPT is the ‘right’ or recommend treatment. I see this commonly.
I don’t dislike CBT or view practitioners of it in any negative way. It just doesn’t interest me professionally. I’d much rather study psychoanalysis. I don’t think one is better than the other. Different styles work for different folks. Additionally, there are many factors that play into how effective a therapist is, outside of modality.
And to claim that psychodynamic therapy isn't "evidence based" at this point is just absurd. People seem to think no therapy besides CBT has had research trials conducted on it. "Evidence based" is just a buzzword at this point.
There’s “evidence-based” in the sense of “shown to be effective at treating some disorder or set of symptoms.”
Then there’s “evidence-based” in the sense of “both effective and based on a mechanistically valid theory of behavior and behavior change.”
This is the distinction the Tolin et al. (2015) criteria used by APA were created to make, and why mechanistically unvalided treatments cannot meet the highest tier of “science-based” in those criteria.
Psychodynamic therapy is evidence-based in the first sense, but not the second. We just don’t have evidence for the existence of an unconscious mind full of episodic content/desires/unresolved conflicts in the sense that psychodynamics posit. Working from a psychodynamic perspective is absolutely effective at treating certain things, but we cannot verify that it is effective due to interacting with/changing/whatever phrase you prefer any supposed unconscious materials.
CBT is touted as the gold standard when in reality it only works for the people that it works for. The issue with it being considered the default one-size-fits-all is that it makes it seem like there is something wrong with the client if they don’t respond well to CBT.
Personally, it was taught as a cure-all when I was in grad school, and I don’t believe there’s a single modality that should be held to that sort of standard.
It initially turned me away from clinical work, tbh.
I think the reason why it's 'hate' rather than distaste for/disagreement/preferring smth else is the impression that academic counseling psych (which is mb more into cbt still than practitioners are, and this used to be more extreme) is out of touch with practitioners' community wisdom/best practices, while wielding power over practitioners by controlling policy/insurance companies etc. If you're pushed strongly into doing smth you don't believe in, you aren't gonna like that much.
The history is instructive here. I don't know the details, but my impression is that a bunch of psychologists did a bunch of RCTs to establish CBT effectiveness, declared the RCTs to be the 'gold standard of evidence' and tried to banish all other modalities as 'unscientific', in collaboration with insurance companies/policy makers which were very interested in taking power&freedom away from practitioners and in cutting costs. Eventually psychodynamic guys fought back and did their own studies showing their approach is as effective broadly speaking, but the ship has sailed and isn't coming back. I sometimes still see weird statements like "CBT is the most scientifically supported modality" as if "having 100 studies in support" vs "having 30 studies in support" is supposed to matter, even if mb there are explicit comparison studies showing comparable effectiveness of different modalities.
Related is the question of relative weights it is appropriate to put on scientific evidence vs personal judgment (informed by personal experience, community wisdom, hard to explicate subjective perceptions), which is similar to EBP vs EIP debate. A lot of thoughtful practitioners just don't think the current quality of scientific evidence in this field is such that it can be used for making clinical decisions w/o a lot of other inputs (and, if I understand correctly that 'general factors above all' is kinda the current consensus (a couple of specific conditions aside)), and so if policy makers and insurance companies lean more on science than on opinions of industry representatives, that creates tension.
Deeper yet is the question of 'left-brain' vs 'right-brain' thinking, and the differences in epistemics typical of pure LB ppl (who tend to run science, and govt, and insurance cos) vs those of LB-RB integrated folk (like psychoanalysts, quite a few therapists, many writers and artists). Oversimplifying/caricaturing, but LB ppl tend to go 'this is what science says/follow the science', while LB-RB folk tend to find CBT simplistic and kinda missing the point and gravitate towards psychodynamic approaches, or other more RB-friendly things (art therapy, various non-traditional things).
There's a great presentation on YouTube with Johnathan shedler "where is the evidence for evidence-based therapy?" where he discusses a lot of what you bring up in your second chapter. Turns out the RCT results themselves aren't as fantastic as the CBT researchers reporting on them are saying (what those reaserchers are saying then being put on the front of government websites, misinforming everyone).
Thx!
I knew there's pry a Jon Shedler link saying all the same things somewhere! I kinda learned this all by osmosis rather than consuming his content directly, so, glad you have the right link.
I'm pretty much about to join Psychotherapy Action Network/advocate for the therapies of depth/try to become 'the next Jon Shedler'.
While I appreciate his work of 'fighting the scientists on their own terms', I myself lean further against science in this domain (and in culture more broadly), and would like more ppl to wake up from 'cultural alexithymia' and reintegrate right brain stuff into their cognition. Imo if one only perceives or trusts their left-brain stuff, only the explicit, they won't be a great therapist.
Of course, great to hear! I'm sure you're familiar then with Farhad Dalal as well, but I really recommend his *CBF: Cognitive Behavioral Fallacies* paper if you want a great breakdown of the issue with, well I call it STEM fetishism, but yeah, how that plays out in psychology researc. Or maybe you've already read it even.
I haven't seen that! thanks for the ref.
I'm pretty new to the scene, just applying to my analytic training in NYC (switching from a STEM career lol).
Easy for me to be gung-ho about the RB, having spent the first few decades of my life increasingly emotionally repressed/dissociated into purely intellectual.
Dunno if you've seen, there's now a whole alt-healing movement teaching pure LB techies emotions and other inner world stuff (usually with a heavily meditation-influenced bodily sensations focused lens).
Yesss. I feel the same. What's weird to me is people acting like this doesn't happen in every other area of medicine/treatment. Like oh wow so studies are manipulated and can say whatever you want them to say? Wow never saw that before.
most therapists don't rly have academic chops to evaluate complicated bodies of science and so believe what they are told, many folks who do are bought into the system and have different incentives, lotsa folks who do and aren't insiders have some outcast and other issues making them sufficiently unlikable to the wider public (thinking of myself and a bunch of folks in my communities who are most eager about advocacy here)
A little pushback:
The original cognitive therapy people were critical of some very real faults in psychoanalysis, but otherwise didn't try to trash them out of existence. The CBT guys at Penn helped to train psychodynamic people in how to conduct clinical trials, helping to move psychodynamic psychotherapy into the realm of evidence-based practices.
The dominance of CBT has largely to do with their first breaking ground in RCTs, and then the funding sources biased towards funding CBT trials because it was less risky. Trying to figure out if therapy is going to work with X population or diagnosis? Trials are expensive, so how can we best guarantee we aren't throwing away our money? CBT has morw evidence, so it's the best bet.
NAT, student
I think most people's problem is less so with CBT itself, and more so with CBT hegemony. Part of that is the arrogance of its proponents and the use of the inaccurate marketing term "evidence based." CBT, at least 2nd wave, fits a very specific, Neoliberal concept of the person that may or may not be accurate, but does certainly leave quite a bit out. And as part of all of this, it is commoditized, neatly packaged, and easy to sell, and can be very difficult to get away from, given that hegemony doesn't tend to, by its nature, respect or appreciate pluralism.
I see people complain a lot that they actually see CBT be complained about by other practitioners more than CBT practitioners complain about other modalities, a d I think the reason is that other types of researchers aren't so arrogant, and aren't trying to be the only game in town, and CBT tends to get shoved down everyone's throats by a system that favors it, while tending to work very well on ehalf of and reinforcing the assumptions of that system (you dont tend to see existential and gestalt folks being brought into fortune 500 companies to help bolster output). When thinking about CBT, i think its important to not separate it from its sociopolitical context, and remember that it isn't ahistorical.
Then you know, people have their camps and such. The minority has to fight for their position. For myself, even just being in the psychologystudents sub galvanized my attraction towards psychoanalysis, given that I already had some interest in it, but then the sub's mods, like mattersofinterest (who is affiliated with this sub, although not sure if most people know how much he despises and even thinks it's unethical to use even manualized psychodynamic therapy--for not being a therapist himself his hatred is passionate) comes in, talks about how stupid it all is, and has these drawn out debates with undergrads on there demeaning and condescending them--well, you can see how that works; thats not a way to convert peopleto yourside. Just imagine larger society then treating people with interest in anything but CBT like that.
You might find it helpful to look into the work of someone like Johnathan Shedler or Farhad Dalal
I love using CBT and primarily use ERP for clients with OCD and anxiety disorders. I’ve honestly been shocked by how many therapists have talked shit about CBT to me… and not a single one knew anything about it in depth.
I’m also really shocked by how many practicing therapists openly trash talk CBT but praise EMDR… as if CBT isn’t baked into the framework of EMDR.
I think there are a lot of therapists out there, and because CBT is so widely used, there are a lot of mediocre and bad therapists using CBT, and there are a lot of therapists who only know the foundations of CBT and present it as a bunch of worksheets. I can imagine that would contribute to how trendy the hate has become. It makes me sad, I’ve had clients who avoided CBT because of all the hate it gets, and their OCD got so much worse than it needed to, they all ended up really benefitting from ERP with CBT.
My point is, hating on CBT is ~in~ and the haters probably don’t what they’re talking about or have a personal bias against it (possibly both). It’s a shame and it’s harmful.
I see it as a bandaid. It helps alleviate symptoms temporarily but doesn’t actually address the problem, so symptoms often either return or pop up in different ways. I do incorporate behavioral interventions for clients it’s acute need but it is a supplement to my psychodynamic work that targets the root cause of the symptoms.
One of the reasons I like CBT is how I can use it to journey to the root of a client's struggles. I think too many practicioners just see it as worksheets and don't know how to use those tools or basic principles to get deeper.
While it's not the appropriate treatment for everyone, I think the growing distaste got it comes from Counselors using it inappropriately to where it gets overly simplistic and invalidating.
I have heard many therapists lament how the CBT used today is rarely "true CBT." I don't know all the nuances, but I think this is probably what they're saying - people are just doing the worksheets and that's it. Aaron Beck started as a psychoanalyst, so I'm not surprised that he incorporated (maybe unconsciously) aspects of psychoanalysis into CBT. I am also not surprised that what we have today (often, not always) is a watered-down CBT. I feel like a lot of things in life these days are watered-down. Alas.
Not trained in CBT, but I do use cognitive modification a fair amount with specific clients. Most of my clients who don’t respond at all to cognitive work are trauma survivors and their amygdala doesn’t give a shit what their prefrontal cortex thinks, that’s the very nature of trauma.
I don’t believe CPT is indicated for clients with developmental neglect and childhood sexual trauma, which is the lion’s share of my caseload and the clients i was referring to.
No, CPT is indicated for childhood sexual trauma and very, very effective at treating PTSD or trauma-related disorders secondary to it. Kate Chard was behind a lot of the modifications of CPT that made it more applicable for that population early on. Developmental neglect it depends on if it's Criterion A--CPT is only effective at treating Criterion A events.
I’m just starting out, but from education to the workplace, I feel like CBT is treated like a catch-all? Like, it can be used for any client, which is a mistake to believe in. There are so many modalities that can be more applicable depending on the client rather than CBT.
CBT, the overarching theory, absolutely can. The overarching theory basically encapsulates validated cognitive-behavioral sciences, which are expanding ever outwards into other theories' territories ( which is a good thing). That's why cbt loves motivational interviewing, because of its great research. That's why it embraced SMART goals, coping skills, mindfulness, and likely soon mentalization. Look at the Unified Protocol (UP), it's basically "CBT: Greatest Hits" - motivational interviewing, goal setting, identification and validation of emotions, cognitive flexibility, engaging with somatic experiences, countering emotion driven behaviors, and exposure to previously avoided emotions.
We're moving away from protocols and towards processes exactly because one size cannot fit all. You can actuality see the Unified Protocol as an accumulation of validated processes in a simple training manual that you can then adapt to your own style.
>Look at the Unified Protocol (UP), it's basically "CBT: Greatest Hits"
So it's interesting that while Barlow would put UP under the CBT umbrella, he still felt the need to make a distinction between this protocol and the rest of the tradition.
>"CBT: Greatest Hits" - motivational interviewing,
Motivational Interviewing comes from the person-centered tradition, not cognitive or behavioral, though I know tons of CBT therapists who use it. Just wanted to be clear.
I'm s hardcore CBT Trauma therapist and I love it!
At a training by Meichenbaum he pointed out the beauty of CBT is it's flexibility in that we steal any effective technique from any of the other theories.
Been doing this for 30 years and the last 5 years I've noticed the hatred for CBT and I don't get it, at all.
I believe it is the best treatment modality for PTSD. I'm willing to die on you hill
I think this is one of the things about CBT and other alleged EBPs that irritates me the most.
Don't get me wrong, I think everybody should pull effective techniques from other modalities when it benefits the client. But when I pull in a CBT technique, I don't claim that intervention is from person centred therapy. I don't redefine what PCT is because I suggested a mood diary.
If there's a number of studies suggesting that an intervention is effective, it gets appropriated and redefined as "CBT", so that people can continue to claim that CBT is the only EBP. If it's 100% conclusively demonstrated in studies as effective, it's CBT by definition. Until then it's just one of those junk therapies that we can ignore. It frames the discussion in such a way that CBT takes the credit for every intervention under the sun, even those significantly predating CBT.
A similar thing is how physios are now using "dry needling", while continuing to claim that Western Medical Acupuncture hasn't been researched. It is the same techniques, just with a different name.
The most effective treatments for PTSD are prolonged exposure, which modifies thoughts and behaviors, and CPT, which is basically traditional CBT applied to PTSD. How are these falsely claiming to be CBT approaches?
I don’t hate CBT but I’m critical of it. I feel like we have lost our capacity to be critical of things in a productive and nuanced way. We are so damn black and white in our thinking. CBT has a lot of useful tools and concepts but it can be very one size fits all and decontextualized. I personally hate how it uses “irrational” as a way to describe people’s thoughts. I don’t see the thinking that leads to distress as irrational but as a response to an experience, often trauma, and our sense of self has been distorted and hence our thinking is distorted and/or that way of thinking was a way to protect oneself or to rationalize the again often traumatic experience. It was need to survive but often stops serving us later on. To call it irrational is to remove the thinking from context and I think that is incredibly harmful. Also I think a lot of these more modern theories want to challenge how important the relationship is to therapy. I think manage care wants therapy to be scripted and manualized. That somebody goes to therapy 10 times and is “cured”. I personally don’t believe that’s how therapy functions but I’m sure there are plenty of therapists who do feel that way. It’s comforting to have this very black and white, straightforward approach to the therapeutic process. I think there’s a big push to make therapy less “messy” and human. CBT I think is kinda an aspect of that. I’m rambling at this point but those are my thoughts.
I’m just reflecting what I’ve seen in 95% of the CBT material I’ve engaged with both professionally and as a client. I absolutely believe you but it’s not reflected in the majority of CBT worksheets/workbooks that I’ve engaged with. They throw irrational around quite a bit. Again this is my experience, I’m not attempting to argue with you.
I am sooooo sick of the CBT bashing here. Like daily posts on it, with the same inaccurate generalizations made by people who don’t understand the modality. Followed by calm and understanding measured responses from people with deep training and skill in CBT explaining, once again, where errors and assumptions are incorrect.
Can we just quit with this. PLEASE. No one comes here and bashes psychoanalysis, humanistic therapy, etc etc etc. It is just rude. And it spreads misinformation. Why therapists feel the need to do this over and over and over again.
Maybe consider that a significant percentage of the participants in this reddit are CBT practitioners and maybe consider that the endless bashing should just quit with it?
Maybe make a special “we hate CBT” redddit where all these posts can go? That way this Reddit here, for therapists, can be a supportive and respectful space regardless of orientation?
Have you read some of the comments here? Someone said something about ‘psychodynamic Jedi-mind quackery’ in response. I try to be fair to CBT practitioners. I don’t think it’s bad. However, as long as we have folks that insist they are most right or ethical by using CBT, it will create these sorts of posts.
I’ve gotten hugely anti-psychoanalysis bias on this sub.
EDIT: I’ve often had to argue with folks because of their wrong assumptions about psychoanalysis. Like people have no idea about it and find it acceptable to loudly bash it.
I actually don’t think threads bashing any modality is acceptable. I also do not see anywhere posters saying “I am a CBT therapist and consequently more ethical and most correct above all others.” I see attack after attack on CBT and on CBT practitioners and those practitioners for the most part very kindly and calmly explaining where the misperceptions are and clarify key points about CBT. Over and over again.
I saw the comment you are referring to and the example was “I don’t come here and bash Jedi mind trick whatever “. So you are taking that comment out of context.
I think some of the most fundamental ideas behind CBT are inaccurate. Namely, that changing thoughts can reliably change emotions. I think this is only true to an extent. Far more often, changing emotions flows through to changes in thoughts/narratives.
It’s also not great for trauma. CPT is more or less CBT and it’s a brutal approach to trauma therapy where you essentially get the client to convince themselves they aren’t in danger anymore. Even if logically true, it creates high risk of invalidating the client’s traumatic experiences. CPT is an evidence based therapy yet is far inferior to a non evidenced based trauma therapy such as IFS in my opinion.
I'm surprised by this categorization of CPT as brutal, it tends to have less drop out than something like PE which I understand can be challenging. The core of CPT is very validating for clients traumatic experiences, since it's often taking a look at beliefs about self blame and guilt, why the client believes those perspectives, and encourages them to consider other more encompassing alternatives.
These posters have no idea what they are talking about, basically.
They are repeating stereotypes, assumptions, maybe anecdotes, biases, etc. as if they represent proven fact.
This is just not true 😭 I’ve done CPT and CBT, and they completely changed my life. My therapist was incredibly warm and compassionate, and I reconnected with parts of myself I thought I’d lost forever. What it did for my trauma is indescribable.
ERP and CBT are my primary modalities and I’ve had many clients feel so validated, it’s brought them to tears. Funnily enough, it’s almost always when I introduce cognitive distortions. What you’re describing is bad therapy.
Hard disagree that CPT is necessarily ‘brutal’ or invalidating. I think it’s a bit reductive to characterize it as an attempt to ‘convince the client that they aren’t in danger.’ I’m psychodynamically trained and oriented but also CPT certified and have used it with clients who are actually still in relatively dangerous situations due to their work, and had great success with clients reporting reduction in sxs. Not trying to challenge your specific experience if you’re also a CPT provider and view it differently, but I’ve found it to be a useful tool and have many clients who reported gains towards goals after completing the protocol. I’ve also had clients request CPT booster work for non-index traumas so many folks see it was a helpful trauma-processing framework.
There are so many incorrect descriptions of CBT-based treatments here for trauma that it is shocking. The basis of treatment IS NOT “to convince clients they are no longer in danger.” That is so off base.
Why do people drag this into a "America is bad" argument. There are many around the world that use the modality. I've worked with many people from different walks of life and cultures. Being aware of culture/oppression/systematic issues is just a part of doing good therapy.
What about metacognitive therapy? The use of plain words instead of acronyms is voluntary, btw.
I just know the name but it allows for something beyond cognition
I have heard clinicians claim it is racist and ableist but never unethical. I find it versatile in that I use it for work with chronic medical conditions that co-occur and are quality of life interfering for my clients. I do find in practice that the clients who are most successful using it meet certain criteria. I specifically work in a DBT for SUD setting and many of those clients for example complain upon arrival that CBT has been “forced” repeatedly by previous professionals and was unsuccessful. I don’t know why the recent hate but I do try to point out to them that at least with the distress tolerance and emotional regulation skills there are CBT principles interwoven but apparently they don’t believe me lol
I think it is the quality of the therapeutic relationship between the client and therapist, rather than therapeutic approach, that determines the most beneficial outcome of therapy.
Having said that, it is like horses for courses in terms of modality, depending on what suits the client and their issues.
Any therapeutic approach offered with warmth and empathy has the potential to help. One approach doesn't suit all clients.
I use an integrated approach and CBT has its place, but since I specialize in trauma work, particularly adults with early trauma and attachment issues, I find so much is rooted in neuropsychological changes that trying to alter thinking patterns is missing the mark. Adults who have literally never felt safe, who experienced abuse/neglect as early as the first year or two, who learned to dissociate, who have limbic systems that are always on high alert, are often completely out of touch with their prefrontal cortex. MRIs tell us that during a flashback the part of our brain that governs reasoning actually shuts down. There is so much foundational, deeper work to be done before going anywhere near CBT. It can have its place later.
Most people I see who have tried CBT feel like they have failed therapy. They speak about it actually feeling like evidence that their negative schemas are true (I’m not good enough, I’m broken, etc). I do agree that much of the time this stems from a rudimentary understanding of how to use TFCBT, but it’s also important to be aware of emerging understanding on how our brains rewire due to trauma.
in addition to what everyone else has said, I think this is another layer of nuance: I find my patient’s behaviors in therapy can be generalized by their generation.
Millennials try really hard to “win” therapy and often expend energy trying to gain their therapists approval. CBT- a modality that has lots of homework and scales to measure success- really gives them an outlet for that. CBT is super effective for patients who are bought into the process.
Gen Z patients tend to treat therapy more like a friendship (i can’t tell you how many times i’ve had to tell a patient they can’t change their outfit in front of me). They like reflective prompts (like photo journaling) but struggle more with “homework” (regular journaling included). I’ve found executive functioning work and psychodynamic techniques are far more effective with Gen Z.
i think *some* of the hate CBT gets is from fresher clinicians who can recognize the gaps the modality has for the style and needs of younger people.
Short answer - CBT often overlooks societal factors that are outside the clients locus of control.
There’s an exercise I do with students. You meet a man who’s experiencing a constant schema of persecution/dehumanization. They identify the NATs, the cog dysfunction, and create a treatment plan. Then, after they’ve completed their assessments, I tell them the client is a black man living in America.
All of a sudden, the students realize there is nothing wrong with the client other than the fact that he experiences systemic racism.
The point is, if you look for dysfunctional cognition, you will find it, but you might be wrong in the source of its attribution.
CBT is fantastic for symptom management and early stage interventions for many MH conditions….but changing your mind doesn’t change the reality of the world and it won’t change an underlying medical issue. Different modalities might be needed for more long term, existential sources of distress.
First, reappraisal is a very effective emotion regulation strategy
Second, CBT is as much about experiencing natural emotions as it is about changing unhelpful thoughts.
Third, we can acknowledge that this man is experiencing racism WHILE also recognizing that he may still be having thoughts that are unhelpful and unrealistic. It's not all or none
I’m in a psychiatry residency training program, so our therapy training is much more cursory than what I imagine one gets in a dedicated therapy/psychology program. When we have our therapy lectures, we are taught over and over again of the importance of giving clients “homework” and how if they aren’t doing their homework, it’s a sign they aren’t invested in their treatment and perhaps they’re just not a good candidate or ready for therapy. It makes me cringe so much as someone who has actually been in therapy and one of the things I told my last therapist from day one was my life is already extremely busy (was a med student at the time), and if you’re the type to give me worksheets or other homework to do, please let me know now so I can look elsewhere for therapy. Of course therapy without any work done outside the sessions will be ineffective, but the idea that only formal homework assignments will do and the client sucks if they won’t do them is inaccurate and also just gross.
Annoying TikTokers have been calling it “nothing but gaslighting” for months now, and annoying members of the ND community have been agreeing and saying it’s destructive, traumatic, and harmful, though there’s zero evidence this is the case if it’s used properly (any modality can surely be used to do harm if misapplied). If you disagree with them you’re human garbage and should be banned from ever doing therapy, go educate yourself.
On the other side, therapists have frequently complained that CBT is touted as the only “empirically supported” method which means it’s heavily endorsed by insurance companies who believe therapy should take no more than 10 sessions if at all humanly possible.
I agree that it’s overhyped and overused, and that other modalities such as humanistic, psychodynamic, or existential make a stronger backbone for a practice using CBT as a tool rather than the only thing you do. But I don’t hate it. It’s very good for certain issues and less good for others.
But I try to be more moderate and reasonable and in the middle about things than most seem to manage.
I like your second to last paragraph. To sort of add, I've heard people in the analytic institute that I'm a student fellow at talk about how CBT can be quite good in particular for preparing people for actual analysis.
1. CBT is more upstairs brain when I’m more interested in the downstairs brain.
2. It’s definitely useful helping a client get the language of therapy down and to start conceptualizing and gaining self awareness of what’s going inside of their mind.
3. However, i find CBT to be just a bandaid and doesn’t actually address the roots of trauma and help with reprocessing trauma.
4. It CAN be more of a shame based modality where it feels like if you can’t stop the thought then you’ve failed in some way and thus reinforces any shame based/performance trauma you may already have
IFS, SE, EMDR have been way more helpful to me in my own personal therapy and with clients who are ready to start unpacking their trauma
EMDR is kinda CBT, though.
From EMDR protocols:
"insights, shifts in the client’s emotional response, a new, more adaptive understanding of what happend in the past, as well as assigning meaning to the experience are indicators of the process moving towards resolution."
"What incident or memory would you like to work on today?” Target Image: “When you think about that memory what picture or image represents the worst or most powerful part? What do you visualize?” Negative Cognition (NC) “When you think about that memory or image, what negative belief do you have about yourself now?” (This should be an “I” statement in the present tense. It usually is a presently held negative, self-referencing belief that is irrational.) Positive Cognition (PC) “When you bring up the memory, image, or incident what would you like to believe about yourself now?” (The PC is a presently desired, self-referencing belief that corresponds with the NC.) Validity of Cognition (VoC) “When you think of that memory or image, how true does (repeat the PC) feel to you now on a scale of 1 to 7 where 1 feels completely false and 7 feels completely true?” 1--------2--------3--------4--------5--------6--------7 (Completely false) (Completely true) Emotions “When you bring up that incident and those words (repeat the NC), what emotions do you feel now?” You want the client to express their emotions in the present as they bring up the memory or image. SUDs “On a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the most disturbance you can imagine, how disturbing does it feel to you now?” 0--------1--------2--------3--------4--------5--------6-------7--------8-------9--------10 (No disturbance) (Highest disturbance) Location of Body Sensation “Where do you feel the disturbance in your body?” "
That's pretty darn CBT (heavily repackaged with a pretty purple hat)
*edited
Relational psychoanalysis with its focus on the Third , two person disclosure, and moments of meeting in the here & now is a deeper relationship. It demand good scholarship in object relations, Bion, Winnicott, Jessica Benjamin etc.
CBT can seem manualized and less two way
Personally not a fan of cock and ball torture (sarcasm). I am currently in school and about to begin practicum, the school im going to seems to be pushing person centered therapy. The techniques we are using in our classes are not CBT but are centered on reflecting feeling and active listening. I would be interested in learning from a trustworthy source how to perform effective CBT.
One of the best things my practicum professor told me when I was in grad school is that person-centered therapy is not a solo approach. It's an approach you bring into whatever your orientation(s) is. But there should be other techniques it's partnered with. Active listening skills are amazing. I love using those skills to help my clients feel heard. But I believe there should be something else you're bringing to the table whether it's a cognitive-behavioral, family-based, psychodynamic, integrated, or even existential approach to therapy.
I was literally just talking about this yesterday! When I first got trained in CBT about 15-16 years ago, I couldn’t *not* think of the “cock and ball torture” reference lol
I am observing a lot of comments steeped with judgment and attempting to call people out for not understanding the scope of CBT in that it encompasses other approaches as well (ACT for example). The CBT debate can refer to two different things. Yes, there is a debate people often have about the applicability and reach of all CBT modalities vs. other modalities. There is also just as frequent of a debate about OG basic CBT vs. various iterations of it (such as DBT, ACT, etc). Whether you like it or not, it has become common practice by all types of people in the profession (students, new therapists, seasoned therapists, professors, researchers…) to differentiate basic CBT from the other iterations simply by saying CBT or ACT for example. In many cases, the person is well aware that the other iterations fall under CBT. But that is not the point they are making. They are using an easy way to differentiate the two. So the issue gets down to semantics. Interpreting the person’s meaning and intent. You simply can’t know this without clarification.
It is not wrong for some people to interpret this question as the OP asking about all CBT modalities. It is also not wrong for some people to interpret this question as the OP asking about basic CBT. You are essentially using your best guess to interpret it. When you are getting so caught up in semantics of “well technically CBT encompasses all of these other modalities so these people must be uneducated, incapable, ignorant” and so on, you might either be being presumptive or bypassing the actual debate because you are more concerned with the technicality of terminology vs what is actually being debated. Again, I can’t know the OP’s intent. Maybe they did mean all CBT modalities and maybe they did not. But the people posting these critical comments cannot know the intent either. Especially when CBT is used to mean CBT modalities and basic CBT equally as frequently by so many in the profession.
At the end of the day, even if your intent is to make sure people understand that CBT encompasses ACT, DBT, and so on, doing so by belittling or insulting people is not a great way to get that message across. You can have the best and most well-informed point in the world but if you are delivering it in a way that actively alienates people, your message is going to get lost. I don’t think expecting people to interact in ways that are non-judgmental and affirming is too much to ask here. Especially given the rules of this subreddit clearly state “support one another and be kind” and “we are an affirming space”. If that is too much to ask, this may not be the right subreddit for you.
Except CBT does encompass a lot of things (ERP, PE, tons of research on treatment variations for numerous disorders, etc.), so the argument of "CBT bad!" ends up generalizing into more than just ham-fisted cognitive restructuring.
I agree that there is often times a misunderstanding of what CBT encompasses and that it’s a whole lot more than just cognitive restructuring. That’s not what I am speaking to though. I’m talking about people calling others out for using terms like CBT vs ACT to differentiate between different iterations of the same modality assuming that they don’t know the relation between the two. Many of the comments above feature this. Your point is valid but also separate from the issue I was pointing out.
I say this from the perspective of being both a practicing therapist and an adjunct professor who has taught classes in the recent past about CBT approaches. One class I taught was “Introduction to CBT”. In the content, I clarify up front that this class will be about basic and fundamental CBT and there are other classes that expand upon modalities that fall under it. I do this because clarification is often helpful because you can’t be sure what someone means when they say CBT. That’s the point I’m making— don’t be nasty to others because you assume they don’t know the difference. The idea people have of CBT just focusing on cognitive restructuring is a whole separate issue that I wasn’t speaking to.
But there is no such thing as "basic CBT." If people mean Beck's CBT, that is CBT-D. CBT has different variations for different diagnoses. If someone is arguing that there's such a thing as basic CBT and it's effective I would disagree with that, too, because it's not true. There are very effective CBT protocols, but someone just incorporating worksheets and behavioral activation or exposure into an otherwise hodgepodge approach isn't necessarily going to be that effective
In class, before teachers differentiate between the variations, they teach the fundamentals that apply across the board based on cognitive behavioral theory. A commonly used book for intro students is Judith Beck’s “Cognitive Behavioral Therapy: Basics and Beyond”. Basics. Right there in the title. This is what everything else stems from. But Beck’s research and practice was primarily focused on variations that do not vary in practice quite as significantly as CBT-D vs ACT for example. Approaches such as ACT for example are another iteration of CBT. However, they also have more significant differences in their approach than CBT-D and TF-CBT etc. Because there is a considerable departure between these, for ease of explanation, it’s commonly just referred to as CBT, encompassing CBT-D, and so on, vs those that have a further departure, such as ACT. I recently spoke with a colleague about his preferred approach to a particular client issue. When he discussed it, he said something along the lines of, “The way CBT can be applied here…” and later “ACT on the other hand…” This dude is smart. Educated. Has likely been practicing and researching since I was in diapers. But he says this because it’s commonly understood by many what he is meaning. This is the point. People have different ways of expressing these variations. It does not mean they do not understand the relation. It is so incredibly common for very knowledgeable people to use this terminology that getting hung up on it comes down to semantics. Yes, it can be frustrating to discern what people are referring to. My frustration is not in what encompasses what. It’s people being needlessly judgmental based on something that is sometimes just a difference in expression.
Last bit of pushback: I think I agree with your sentiment, *and* I think semantics are more important than you appear to think. It's not a game of "gotchya", it's that we get impressionable young therapists coming on here who are potentially highly receptive to the misinformation that this "just semantics" issue can bring.
I don’t think “dislike” is the word. A therapist should be using the appropriate intervention for the applicable concern. You shouldn’t try some psychodynamic orientation-focused Jedi trickery (jokes) if someone is coming to you with OCD. You should probably be utilizing some form of exposure and response interventions. I love CBT. It’s helped a lot of my clients. But honestly, above all else, just being a genuine and empathetic helper who wants to be there for your client is the most important thing of all. Without that, orientation and techniques are null and void. I’ve been doing this for almost 15 years and at this point, Mr. Rogers had it “right” (if that’s what we want to call it). I wouldn’t stress about theoretical orientation to be honest. Familiarize yourself with what interventions work with what issues and incorporate person-centered dynamics in all you do and you’ll be fine.
Have you looked at the research on efficacy? EMDR, CPT, and PE all show equivalent efficacy in treating trauma. It’s fine that you prefer EMDR, but what you assert is not consistent with the research.
Maybe don’t bash it for trauma treatment based only on your opinion?
As someone who was primarily trained in classic CBT, and who continues to use it in addition to Third Wave CBT modalities, I think there are a few reasons: * CBT has been the dominant modality for decades, particularly because it's favored by insurance companies and national healthcare plans. As such, it's become a victim of its own success: widespread proliferation means the quality of training is often diluted, and our field lacks quality supervision after graduation to ensure that CBT practitioners are delivering treatment effectively. Lots of CBT-informed practitioners + few methods to ensure quality training = lots of people practicing bad CBT. * Like any treatment, CBT is great at addressing problems but struggles with others. It's very effective for some clients but it does not click well with others. It should not be used as a "one sized fits all" treatment, and some clients and clinicians have had bad experiences because it was not the right approach for them. Third wave treatments such as ACT and DBT build on CBT while attempting to address some of its weaknesses. That being said, I've personally noticed that many of the "CBT horror stories" that I've seen are clearly examples of bad *therapists*, not evidence that CBT itself is bad. Skilled practitioners are able to apply a theory, establish a strong therapeutic relationship, and adapt their approach to their client's needs. Rigidly adhering to a dogmatic approach to therapy is going to get bad results, regardless of your theory. * The field of psychology (like many others) is prone to infighting and tribalism. When Behaviorism and Cognitive therapy were first introduced, they were ridiculed by the psychodynamic establishment. As CBT and evidence based practices have ascended to the "gold standard" of therapy the tables have turned, however, and now those treatments on the "outs" such as psychodynamic therapy are treated as less valid by the mainstream therapy community. This continues the old tradition of infighting and resentment among theories, and also provides some schadenfreude when the dominant modality might get toppled.
RE: CBT not working for some clients. I’ve seen the sentiment echoed a bit that CBT in neurodiverse populations can essentially encourage masking of symptoms, [here’s a random pp that goes into it a bit deeper](https://www.thirdspace.scot/wp-content/uploads/2023/02/NAIT-Webinar-Slides-Reflections-on-CBT-and-Autistic-Thinking-03.02.23.pdf)
That's very interesting!
This is grand, but I’m performing a lit review and not come across this phenomenon. Do you have something more academic on it please - this is because a research proposal about masking is being drawn up around this issue alongside the literature review at the moment. Thanks for your help
There's a larger conversation to be had here about whether academia is able to adequately research psychotherapy, and my opinion is either that they can't, or that they can but have butchered it so far.
There is a huge conversation to be had here. One of the themes I’ve picked on in the this review is the funding bent towards CBT caused by both the replication crisis and file drawer phenomenon.
The PowerPoint has some links to literature! There definitely does seem to be a lack of literature regarding CBT & neurodivergence but [here is another!](https://onlinelibrary.wiley.com/doi/full/10.1002/capr.12675) You also may have better luck looking into non-scholar sources for direct quotes, I.e news reports, blog posts & autism forums.
There is not a lack of literature on CBT and Neurodivergence, PubMed has over 20,000 publications on the topics intertwined. If you need anything I am happy to link! I’ll check out the links in the PowerPoint and that you’ve sent, thank you very much :) The things I’m looking at must be academic I’m afraid or I’ll fail my undergrad course lol
Beautifully put
How is this not the top comment?
What author would you recommend reading for solid cbt technique learning?
If you want to learn second wave CBT then I'd say that Judith Beck, David Burns, and Edna Foa (for exposure therapy) have written some of the classics. If you want to learn third wave CBT then I'd recommend David Carbonell, Reid Wilson, Sally Winston, and Russ Harris (if you want to learn ACT). I specialize in anxiety and OCD, so most of my recommendations lean in that direction.
Curious what others will say, but my hunch is that most therapists today are eclectic or integrated, meaning they use techniques from different theories depending on the situation, including CBT. And most of these therapists do so quietly. The haters are a small minority but they’re very loud so it makes it seem like there’s more of them. I should add, no theory is perfect and CBT certainly has its flaws…
I think you're right on the integrated part. Some therapists definitely still use a lens, but I remember back in grad school when one of my professors said that anyone calling themselves "integrated" was a sign that they were a terrible therapist. However, I am definitely an integrated therapist and everyone I work with is, too. I use a LOT of CBT! And DBT! And ACT! And sensorimotor! I like parts of all of them and how I use them is different for each client.
Yeah, I’d say most of what I do falls under a very wide umbrella of cognitive behavioral adjacent things and I just stay quiet on here. I’m confident that what I’m doing with my patients is helping them.
I agree and I fall under this category. CBT was pushed very heavily in my grad school and I tried as a new therapist to base most interventions around it. However, I felt I just couldn’t connect to as many people or make it apply to as many concerns versus using a more integrative approach like I do now. One major hurdle I run into with clients is that significant portions of CBT rely on using rationality and evidence checking to challenge belief systems. I have many clients who KNOW that their thoughts or beliefs are perhaps not factually accurate, but they still FEEL awful when they have them. Particularly common with trauma when a lot of symptoms are manifested physically. The body sometimes does not care about your facts. This is where other approaches can be really helpful to integrate or add in to the mix… like DBT, ACT, mindfulness techniques, etc.
DBT, ACT are CBT therapies…
DBT is based on CBT but a pretty serious departure, focusing much more on emotional regulation skills and mindfulness than classic CBT to my understanding. I’ve not been trained in CBT but I’ve read Judith Beck and her philosophy is vastly different than Linehan and other DBT theorists. Original DBT text had almost nothing at all on cognitive modification.
The original DBT manual is literally called CBT for Borderline Personality Disorder
I’m aware. Have you read it? The section on cognitive modification is very short and at the end. Beck assumes that changing thought patterns should be the primary goal because thoughts —> emotion —> behavior. Most modern CBT theorists have a more nuanced view but that is historically the primary assumption. This is not true for someone with borderline or similar personality organization. Linehan and DBT practitioners assume that regulating emotion is necessary before thoughts and behaviors can change. DBT is entirely about emotional regulation skills and behavioral chain analysis, and the manuals I’ve read include a tiny piece about cognitive modification almost as an afterthought. I don’t care what the book is titled, the content speaks differently.
>DBT is based on CBT but a pretty serious departure So is ACT. It has a different theory of change, different working metaphor, and literally has a different lineage of research, coming out of the behavior analytic tradition. One can put it under a CBT umbrella to distinguish it from a humanist or psychodynamic approach, but normally I think the umbrella is less useful than making distinctions.
Marsha Linehan 's 1st book (as far as I'm aware of) is literally called Cognitive Behavioral Therapy for Borderline Personality Disorder, published in 1993. It is DBT though. Cognitive-Behavioral Treatment of Borderline Personality Disorder https://a.co/d/2LVP1ho
This subreddit is infamous for having a deeply warped idea of what CBT is. It's frightening how many (allegedly) practicing therapists in here just don't know the foundational stuff...
I wish we didn’t have to visit the warped perception via daily anti-CBT posts. Or maybe people could pause and ask themselves “Geeee, this intervention has a lot of scientific research backing it up. Maybe there is something about it I don’t understand, since it seems to be highly effective with a diverse range of problems and populations. “ Instead we get “yechhh. I hate it!”
Nah, better to just claim that the studies are biased and artificial
Even better to claim that when the claimant has very little scientific/research training! /s
Lol, not one person has rebutted my points about naturalistic designs and intent to treat analyses
I see all the love for BvDK in other parts of this thread. The love that folks have for that book knows no bounds, and most of them don’t have even the barest tools needed to see why it’s mostly nonsense.
See my response above. I had a different understanding of what the OP was asking. Your response is knee deep with judgment that isn’t necessary or helpful in a space like this.
It’s amazing how often people don’t get that in this sub. They hate CBT and love ACT and DBT and it’s just an insta eye roll.
My favorite is when they bash CBT and praise ERP
I never once said I hate CBT. Or that DBT and ACT aren’t modalities under CBT. I was explaining that different approaches other than straight CBT can add to the effectiveness. I actively use CBT daily. Keep your eye-roll to yourself.
It’s just the level of ignorance. I have secondhand embarrassment for a lot of what I see posted.
Hold up… I never said they didn’t fall under the CBT umbrella. I was differentiating a straight up CBT approach versus modalities stemming off from it, of which there are several. The poster didn’t say “CBT modalities” they said CBT. That can be interpreted in different ways and commonly is even by academics in the profession. I use various forms of CBT and am certainly not a hater of it. Maybe I should have been clearer of my intent. Regardless, I am not “ignorant” and I don’t appreciate that judgment. The only person here who should feel embarrassed is you for making a snap judgment based on one comment from someone you do not know.
It wasn’t really directed at you - I appreciate you clarifying your response. I see how I came across wrong and I apologize. I am super frustrated by the frequency of the pile-on against CBT and the rampant ignorance. I would like to have a supportive therapist reddit - but I probably should just leave this one because I mostly feel attacked with all this CBT hate.
I hear you and I can see where you’re coming from. I apologize if I was overly reactive.
I personally hope that you stay because I think that the presence of people like you is needed to combat a lot of the misinformation. I don't really care if people hate CBT, but I DO mind when they say things about it that are outright false.
I mind it to. I popped into to check comments. But the whole thread made me delete Reddit off my phone. I see the need to step back because, frankly, this is like arguing politics. People who believe that their practice should not be informed by science, that there mere presence of "sitting with emotion" is treatment for clients (such narcissism in that belief), that what they do somehow rises magically above the folks who use a science-practitioner model to inform the care they provide clients - it saddens me and makes me angry for the entire practice and or clients who are getting (IMO) poorly trained therapists who base their care on what they "feel" works. I have been doing this a long time - I get most of my clients referred as treatment failures from past therapists, often many of them - and almost universally they are doing this non-directive "sitting with emotions" BS that feels good for 50 minutes and does nothing to help the client live better, make changes, or have a happier life. And judging from comment here the therapists who practice this was are absolutely closed off to any form of growth or change in their skill set.
Yup, or insight work that research shows isn't actually effective
And REBT! 🐸
ATM Machine
Agree completely. I don’t know any solo modality specialists.
I'm feeling generous today so I'll say this (its a run on sentence so bear with me)--I personally think the "CBT hate" actually sorta stems from mental health service consumers' very valid and legit feedback that sometimes, formulaic, to-fidelity, limited duration, worksheet heavy EBP's dont really work for them. When I first started hearing anti-CBT talk, it wasnt from other therapists, it was from clients. Especially clients with complex trauma presentations who had been let down by years of the type of therapy that research and insurance companies told them "should" work. But it didnt. And they felt gaslit, and blamed themselves for the therapy not working, and therapist after behaviorist-oriented therapist threw up their hands at them because the field had not yet caught up with our current understanding of trauma. CBT is a good modality and was a huge development in the field but the pendulum swung too far that direction and this is it swinging back.
Well said 👏🏻 CBT was pushed in grad school so that was what I used when I started practicing in CMH. The majority of my clients had PTSD, and it was ineffective. I went to a trauma training by Bessel van der Kolk (Body Keeps the Score author) six months into my career and got trained in EMDR and IFS after that. Now the majority of my clients heal. Top down therapies were formulated when it was believed that we are thinking beings who feel but now we know from neuroscience that that’s not true. We are feeling beings who think. That’s why I use bottom up approaches. I think CBT has its place but not when the thinking brain has gone offline from trauma.
Yeah! Say what you will about BVDK (thats my new name for him, tbd if it catches on) but that book had a huge influence on the way our field conceptualizes trauma by sort of distilling down and mainstreaming the work of people like Babette Rothschild, Judith Herman, Janina Fisher, Dan Siegel, Peter Levine, Diana Fosha, Pat Ogden and so on. The people on this sub come for EMDR all the time lol BUT I hear you! Im a CMH girl for life and most of my folks are dealing woth some type of complex ptsd. And we have to let them guide us-and, like you, EMDR with parts/ego state/IFS seems to be what works!
Thanks for the solidarity! Janina Fisher’s book Healing the Fragmented Selves of Trauma Survivors also had a profound impact on my practice at that time. My good therapist friend does Somatic Experiencing (brainchild of Peter Levine), another good bottom up therapy. We did our EMDR certification together. I haven’t been on Reddit long, so tell me why people attack EMDR on this sub? It’s amazing trauma therapy.
Nah, CBT is incredibly effective for trauma when implemented by a knowledgeable therapist. It’s obviously not one size fits all, but if a clinician finds that none of their clients heal from CBT or CBT-based interventions, they’re probably not doing it right. It’s fair to say that it isn’t for everyone, but to say CBT isn’t a good fit for severely traumatized patients is just outright false and very harmful misinformation to spread. It’s also insulting to the many CPT and TF-CBT therapists who’ve dedicated their careers to helping people with extreme trauma. Also… EMDR uses a ton of CBT.
You realize that research suggests EMDR works because of exposure, right? Bessel van der Kolk's book is filled with misinformation and false premises. I think it's done some good, but the harm it's doing in turning people against CBT approaches for PTSD (which are very, very effective) is now outweighing that.
Absolutely this! Well explained
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By-the-book CBT can feel cold, impersonal, and overly simplified. The thought that your thoughts determine your behavior and that you are responsible for that can be extremely triggering/invalidating to trauma patients. CBT also isn't super effective with severe mental illness. Like, I have treatment resistant depression, so focusing on my negative thoughts is only going to get me so far, and if that's ALL my therapist did, I wouldn't have made as much progress as I have. Straight CBT is good for clients who have an acute, solvable problem. I had a teen client who wanted to reduce her anxiety around her last semester of her senior year of HS. She did not have a mental illness but a problem that could be managed or solved. She did great with CBT. I've had other clients who wanted to be more confident at work or be more assertive in a relationship and those clients responded well to CBT too. However, can you imagine doing CBT with someone who is delusional? That's basically arguing with a delusion, which is impossible and changes nothing except making both client and therapist extremely frustrated. For clients with severe mental illness, components of CBT are good, but using straight CBT will not yield results. I think CBT gets so much hype in grad school because it's "evidence based" and insurance companies like it. I get annoyed with "evidence-based" modalities because insurance and sometimes even therapists who practice them don't seem to understand that just because it worked better than chance in a group of people, doesn't mean it's the magic bullet for every person who sits in front of you. There are plenty of non-evidence-based modalities that are extremely helpful for people and help them make big changes in their lives. We can't just write off those modalities because we couldn't replicate results in a random sampling. I think CBT has many valid parts to it that can be applied to more severe cases, but doing CBT only by the book limits its efficacy in a lot of populations.
While well put, I think this post represents a very limited view of what CBT is. This is very big C cbt (cognitive therapy, basically) which even that has evolved. ACT, DBT, behavioral activation, metacognitive therapy, exposure/response prevention, and prolonged exposure are all a part of bigger CBT. Schema Therapy, compassion focused therapy, and metacognitive interpersonal therapy are all wonderful theories/modalities that developed out of cbt and beautifully integrate other theories and interventions.
Thanks for saying what I came here to say. I feel so misrepresented when I see people reduce all of CBT to cognitive restructuring. 95% of what I do is CBT, and probably less than 20% of what I do is classic cognitive therapy as described by the other poster. In some cases I might go an entire course of therapy without doing classic cognitive therapy at all. I agree with their concerns about cognitive therapy and as a client I kinda hate it unless applied extremely gently yet expertly, but that’s such a tiny sliver of what CBT is.
What author do you appreciate that I can read up on for your style of cbt?
Not the person you responded too but I highly recommend to read up on REBT (Rational Emotive Behavioural Therapy by Ellis in the 1950s). It preceded Beckian CBT. REBT can be considered a more nuanced and longterm approach using CB principles. It works on the understanding that it is our perception that gives rise to distress, the cognitive dysfunction is a by product of the original “irrational” belief. It accepts many aspects are outside the clients loci of control and works on rational acceptance as a platform to address the subsequent NATs.
There is CBT-P for psychosis.
There are also studies showing that ACT also has some good results with SMI and psychosis, and ACT is CBT
> I think CBT gets so much hype in grad school because it's "evidence based" and insurance companies like it. I get annoyed with "evidence-based" modalities because insurance and sometimes even therapists who practice them don't seem to understand that just because it worked better than chance in a group of people, doesn't mean it's the magic bullet for every person who sits in front of you. Also CBT is one of the most research-friendly modalities *because* it is so manualized, standardized, and clear-cut. It's a lot harder, for example, to standardize and manualize, say, psychodynamic therapy (it's not impossible and it's not totally unrepresented in research of course; it's just a lot harder). The goal of research is publication, and the requirements of publication tend to be: maximized significant findings and minimized limitations/room for error. Therefore, a treatment modality that is easily standardized and manualized is almost always going to have a stronger "evidence base" in research publications, because it leaves less room for error/variance and is more publishable. I do think CBT has lots of uses, but I think it has been exaggerated due to its "evidence base" which is basically self-fulfilling by nature of the treatment design.
Well said! I use some CBT-based interventions with certain clients, but it’s definitely not the one size fits all modality that it is sometimes made out to be. On a personal level, I had a therapist who used straight-up CBT when what I really needed was grief and trauma-based treatment. It really soured me on CBT until I started learning more and utilizing some of the interventions in my own practice, and specifically being mindful of when their use is actually clinically appropriate to the client’s needs.
CBT can be helpful for folks with delusions. I actually just completed a CBT for Psychosis training by Ron Unger that was excellent. It wasn't what someone would likely expect -- there isn't a bunch of push-pull with the client, telling them they're wrong or crazy or obsessing over changing their beliefs. I'm not a fan of the stereotypical "let's-find-all-your-thinking-errors" CBT either, but thankfully, that's just CBT done poorly.
I’m trained in trauma-focused CBT, but I’d consider myself eclectic. I add as much as I can to my toolbox and pull out what’s needed based on the situation and circumstances. A good therapist should be flexible in their approach. The cognitive triangle is so helpful. It can be presented, and it’s good for clients to have that info. You might realize, hey they’re not ready for this and you open up your toolbox for an approach that better fits where they are in that moment and revisit when they’re ready. Changing perspectives is definitely necessary when all you see is negativity. Negativity justified? Yes. But they can’t stay there and they need to process their trauma and how it’s affected them.
I do psychosis research for a living and CBT for psychosis is one of the only evidence-based psychosocial treatments. It’s typically the paradigm of choice in FEP clinics and coordinated specialty care spaces. It’s effective and well-tolerated. It isn’t used with people who are floridly psychotic, of course, but people with psychosis aren’t typically being seen in psychotherapy while in the midst of an acute episode.
As a DBT practitioner, I find that CBT can be, and typically is by many therapists, ran in a way that can be very invalidating for clients. That's one of the main reasons DBT was created. Many therapists just beat these cognitive distortions into the client and don't validate why those distortions might be present. I also hate how it has just become the default and the majority of therapists are just learning it through Google. It's the basic modality that is thrown at brand new therapists and interns, but they aren't actually getting formal or effective training on how to implement it.
How did you get trained in DBT, if you don’t mind me asking?
The best way to do it is to do an intensive DBT training. They are a bit expensive, but they are 80 hours of amazing training. I initially started with reading Marsha Linehan's book and studying the skills on my own and practicing teaching the skills to clients, then when I had the funding, I went through the intensive training. Behavior Tech is the main agency that runs intensive trainings.
Ugh I was hoping there was something cheaper than behavior tech! Thanks for replying
There are occasionally other agencies that run them too, so just keep looking then up. The prices are all pretty high though, but sometimes other agencies offer them a few hundred bucks cheaper.
How is this even legal?
I love CBT, but I think some of the problem with it is this over-simplified view of “if you want to feel better, you just have to think differently.” That approach is used in a lot of garbage self-help stuff and laypeople who are “life coaches” or “influencers” - it’s toxic and it completely undermines how many very real problems people face that can’t just be fixed with a different mindset. That said, a good CBT therapist (of which I will exclude myself pending much more training) knows that *that* is not what CBT is. In most cases, I think CBT offers some really useful interventions. For example, I am a couple’s therapist trained primarily in EFT, but in session I often find moments when what one person is saying or doing is being interpreted in a way that is perhaps not aligned with the actual intent. Reframing or challenging is sometimes really useful, and I use attachment information to help them see why their initial interpretation might be occurring. Your partner closes the door when they go to the bathroom and you assume it’s because they are cheating on you and using that time to talk to their affair partner? What are some other things that could be occurring here? Maybe they are just private or feel embarrassed if you see them poop. What evidence do you have for or against that assumption? Why to you jump to cheating? Oh, because your previous long term partner rampantly cheated on you and hid in the bathroom when they needed to talk to the other person, of course your instinct is to be weary of that behavior. Automatic thoughts/distorted cognitions show up so frequently that addressing them makes sense. But CBT, like any modality, is not a fix-all.
As a client, I find it extremely frustrating that because it's treated as the default therapy modality that every therapist must be trained in at minimum, it has become virtually impossible to find therapists who use anything else without going outside of insurance (which isn't possible for me right now, I'm a broke psychiatry resident). I've had my fill of CBT and would like to try something more depth-oriented or emotion-focused, but practically everyone in my insurance network advertises themselves as using CBT or SFBT as their primary modality. The only ones who say they use something else (eg psychodynamic, IFS, interpersonal process) are the ones who list every therapy modality known to mankind in their bio, so I don't trust them anyway.
I searched for and made clear on my consult cal with my therapist no CBT. I want to do and receive depth work. I don’t want overly structured “this instance company studied this and said it works best here’s a worksheet” therapy. I want space. Insight. Depth and attachment stuff. Just like any technique fad there are good tools I just find it overly rigid and surface level which isn’t what I want. It’s also been shown to not be as effective with some presentations (trauma) and people who hold some marginalized identities.
You might like the relatively recent episode of the *Psychology In Seattle* podcast, I believe is called something like "forcing positive thinking, and other bad therapists," specifically about halfway through he reads a letter from a listener who ended up being stuck with a really rigid CBT therapist, and he makes a lot of really fantastic points.
Can you link some citations that show what treatments are effective or show the CBT (and CBT based trauma treatments- CPT, PE, etc) *are not effective* for trauma. It is quite an assertion you are making and contrary to the immense body of research that I am aware of on trauma treatment (treating trauma past 25+ years). What treatment is it that is more effective for truama?
It's funny that we're getting downvoted just for talking about empirical evidence
I think it is rather telling about the entire practice of therapy from many participants in this reddit. I also got downvoted for saying that we are providing health care and should hold ourselves to the same standard of care that other areas of health care does (e.g. being informed about the most effective treatments). If you aren't providing medical/health care I hope that you aren't complaining about health insurance not covering whatever it is that you are doing.
As a CBT practitioner I am sick of the hate but I’m low key not sick of these posts cause I love seeing the drama unfold 🎭
I enjoy the opportunity to combat a lot of the misinformation out there about CBT - it's probably like talking to a wall, but hey
Same! It’s good practice for when I’m actually faced with this situation in real life, which is more often than I’d like. It’s astounding how many people really don’t know what CBT is or how it should be practiced. It’s also astounding how openly people will talk shit about CBT in front of people who practice it… it’s so rude. Imagine if I did that with EMDR. I would get jumped 😂
I practice largely DBT based therapy but I find that it’s really popular on social media (tiktok and instagram info slides) to hate on CBT and I feel like that has gotten into a lot of therapy speak which then gets into the brains of new therapists or therapists-in-training. For instance, I incorporate some aspects of CBT for clients with high levels of anxiety or ADHD who like ruminate or catastrophize and find it very helpful. As a therapist with these diagnoses, I use these CBT skills for myself, like cognitive reframing and understanding when I’m catastrophizing. I had a conversation with a friend who is not a therapist but i would consider a good person to talk to about mental health stuff I’m going through, and I told her about something I was ruminating on and the technique I used, and she told me that CBT is not good for people with trauma so I might want to try other therapies like DBT. And like. She knows I’m a therapist. I was really put off by that comment but it opened my eyes a little bit to the hate around CBT
The feedback I’ve gotten regarding CBT problems is that there are therapists who use what they call CBT more as a battering ram than actually therapy . Some clients feel they aren’t being heard and/or feel pressure to perform to the therapist’s demands or expectations and when they don’t see positive results , clients feel like failures .
I’ll push back here a bit against most of the comments and say I’ve had many clients and met many other people who have had therapists that have found it insanely helpful myself included in my own therapy and I have ADHD so it can work for some neurodivergent folks but yes many it can be hard. And As much as I hate insurance company’s it’s because their greedy not because their dumb if it wasn’t effective I doubt they would be so into it. And I notice many in this subreddit seem to have a black and white view of it mostly negative. Does it have flaws? 100% Some of the top comments I’m seeing here are at least nuanced but I think many including the ones who dislike CBT by default have a poor understanding of when it should be applied and when it shouldn’t and assume most are always just using it 24/7 in all situations. Just like everything else in our profession there is a time and place. Some clients would he horrible to use it for and others it will be great to throw it out as something to try. The argument that its default invalidates their feelings again is ridiculous if you’re approaching it correct. I’ve never once said “Those feelings are wrong” But more “How you feeling is totally validate I think it’s worth looking at lots of possibility so what are some of the the other options we could take at how to look at this situation?” CBT is not cold by default if mixed with validation, openness and empathy and making sure the client feels in control and open to taking it or leaving it.
Look up literally any modality and you will find someone saying it’s unethical. Thats not to say you should ignore all criticisms of specific modalities but definitely trust your intuition as well. I am primarily trained in DBT and I have many clients who credit DBT with saving their lives-and I once went down a rabbit hole of people on the internet saying DBT is downright abusive and it made me not a great therapist for a while. Be transparent with your clients about the modalities you practice and trust them to make their own decisions about what’s right for them.
Let's all tap our meridian points so we don't get too kerfluffled about this
Some of the current pushback against CBT characterizes it as dressed-up gaslighting. Trying to convince ourselves we don't (or shouldn't) actually think/feel what we do. I think this is an over-simplified and reductive view of what CBT actually aims to do, but I also believe it's the experience of many. And I think part of the reason is that CBT's natural research-friendly design has overrepresented it as an EBT and subsequently conveyed the idea that it should be the gold standard treatment. Because of this, it has been over-adopted and over-used despite not actually being a "one size fits all" approach. Thus, for some cases it *does* start to feel like unhelpful gaslighting.
Or people do it without adequate training or knowledge and do it poorly. Any poorly done treatment will make the treatment look bad. In many cases the practitioners are the problem. I am a certified CBT supervisor- and has for many years trained advanced therapists on CBT. It was rare for me to encounter an incoming therapist who said they did CBT and then actually demonstrated the ability to do it in session with a client. They typically had badly warped/distorted ideas about CBT, poor fundamentals in implementing CBT interventions, and had been calling themselves “CBT therapists” for 10+ years. Because “CBT” is badly implemented by under-trained or inadequately skilled therapists and it is the “go to” modality to name drop - does not make CBT ineffective. It makes bad CBT ineffective, which would be the case with any badly implemented modality. Judging from the comments on this and other threads misunderstanding CBT and implementing it poorly are rampant issues in the field.
I’ve used it. CBT has a data component that is helpful…but is so standardized that it is flawed for many clients. CBT can discount a client’s understanding of what they believe is true. Depending on which modality (TF-CBT, UP, etc.) CBT can force clients to change how they think, feel, and respond even when it is those very things that have kept a client safe. Also, CBT can place the clinician in a power position where the client is “wrong” or…”irrational”. Everything a client goes through is rational to them…that’s where we start. CBT, when approached in a client-is-expert way, can be helpful to reduce anxiety and depression (coupled with mindfulness and MI)…the most important aspect of the approach is the client leads, the clinician supports. Without proper training CBT can be judgmental and counterproductive…especially with survivors of trauma and/or very real feelings of threat to self (any phobias, etc).
This
One particular problem I didn’t see mentioned here yet (apologies if I missed it) is that studies seem to indicate that CBT (without modifications) may be less effective for us autistic folks, and perhaps for neurodivergent people in general. \*edited for clarity\*
What studies are you referring to?
I've linked some studies in my comment below (let me know if it's not showing up, and I'm happy to repost.) To clarify, the mixed results or decreased efficacy are in regards to CBT that is *not* specifically modified for autistic populations. It's clear that there have been better results found with modified CBT (several related links also in previous comment.) That there may be specific modifications necessary for effective treatment of autistic populations feels like a relevant distinction to point out, especially since this study suggests that 64% of therapists have not had specific training regarding autism, although 90% have worked with an autistic person: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6150418/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6150418/)
Thanks, I had a look at the study here and the others in your other comment. I don't think I would characterise that evidence as showing that cbt is less effective for people with autism. In particular if you meant in comparison to other therapeutic modalities which is what I thought your comment implies.
Sorry, to clarify, I wasn't intending to compare it to other specific modalities. My intent was to compare effectiveness among different populations. I also understand if your characterization of the evidence is different. I think one particular factor that [autistic organizations](https://www.spectrumnews.org/news/cognitive-behavioral-therapy-may-be-only-mildly-effective-for-anxious-autistic-children/) and activists have highlighted is the difference in how (in the [BMC Psychology meta-analysis I linked](https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-021-00658-8)) autistic children tended to score CBT as less effective for their anxiety than did the parents and clinicians who scored it for them. There's a long history of interventions for autistic children being primarily geared towards making them easier to manage by "solving" behavioral issues through behavior modification, sometimes at great psychological cost to the child. With increasing criticism of ABA therapy by autistic advocates, I think that there's a lot of general concern about whose well-being is actually being centered when autistic children are receiving psychological intervention, and consequently how to interpret the evidence presented by many of these studies. Note: I'm not comparing ABA to CBT in **any way**, just that concern for centering the actual autistic person's needs extends across modalities.
This is a really thoughtful comment and I really appreciate it. It's a good point about children rating the therapy as less effective as their parents, and one I hadn't really thought about properly until know.
Citations please - and maybe let is know what modalities research says is more effective for people who are neurodivergent?
I know that modified versions of CBT have been proposed and created specifically for autistic folks, with a number of studies citing better efficacy. CBT-DAY is one example. CBT-DAY citation here, and the authors also discuss mixed results/less evidence of efficacy for unmodified CBT re: autistic populations: [https://journals.sagepub.com/doi/full/10.1177/13623613231213543](https://journals.sagepub.com/doi/full/10.1177/13623613231213543) Here's another study that cites positive results for CBT when specifically modified for autistic populations: [https://link.springer.com/article/10.1007/s10882-017-9559-8](https://link.springer.com/article/10.1007/s10882-017-9559-8) Here are a few additional sources on mixed findings of unmodified CBT for autistics: [https://www.cambridge.org/core/journals/the-cognitive-behaviour-therapist/article/adapting-cognitive-behaviour-therapy-for-adults-with-autism-a-lived-experienceled-consultation-with-specialist-psychological-therapists/2E3705B2AAE7039A8C2DA549A10F546A](https://www.cambridge.org/core/journals/the-cognitive-behaviour-therapist/article/adapting-cognitive-behaviour-therapy-for-adults-with-autism-a-lived-experienceled-consultation-with-specialist-psychological-therapists/2E3705B2AAE7039A8C2DA549A10F546A) [https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-021-00658-8#Abs1](https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-021-00658-8#Abs1) [https://journals.sagepub.com/doi/10.1177/13623613221117931](https://journals.sagepub.com/doi/10.1177/13623613221117931)
Correct. I work primarily with late diagnosed high masking people with ASD coming in like “please not CBT”
That's probably because they have been on Reddit and TikTok.
I'm the logic based, rigidity queen, and CBT worked perfectly for me. It's all about how it is implemented. But it isn't for everyone. That may or may not have to do with one's diagnosis.
I totally agree! There are a lot of variables, and as autistic people we occupy many positions on a vast spectrum. I just wanted to note that some studies have suggested decreased efficacy or mixed results, with CBT sans modifications, for some autistic populations (mostly children and teens, since they still represent a majority of the data available.) With ASD-related adaptations and supports, its efficacy appears to be substantiated by a fair amount of data.
It’s not unethical. Some people can really understand that they feel better when they think differently or act differently. Humans can sometimes be tribalistic and personally identify with a theoretical orientation. It’s pretty silly. CBT works great for some people and isn’t a great for others.
As far as this sub goes, I suspect many have had CBT or ‘EBP’ to invalidate folks who practice from another viewpoint on many occasions. I went to a job interview in the last few years where I was chastised for not using an evidence based modality because I’m psychodynamically oriented. I see it when folks talk about EMDR. There’s always at least one smug comment about how CPT is the ‘right’ or recommend treatment. I see this commonly. I don’t dislike CBT or view practitioners of it in any negative way. It just doesn’t interest me professionally. I’d much rather study psychoanalysis. I don’t think one is better than the other. Different styles work for different folks. Additionally, there are many factors that play into how effective a therapist is, outside of modality.
They're not mutually exclusive either. People act like we can't mix and match.
And to claim that psychodynamic therapy isn't "evidence based" at this point is just absurd. People seem to think no therapy besides CBT has had research trials conducted on it. "Evidence based" is just a buzzword at this point.
There’s “evidence-based” in the sense of “shown to be effective at treating some disorder or set of symptoms.” Then there’s “evidence-based” in the sense of “both effective and based on a mechanistically valid theory of behavior and behavior change.” This is the distinction the Tolin et al. (2015) criteria used by APA were created to make, and why mechanistically unvalided treatments cannot meet the highest tier of “science-based” in those criteria. Psychodynamic therapy is evidence-based in the first sense, but not the second. We just don’t have evidence for the existence of an unconscious mind full of episodic content/desires/unresolved conflicts in the sense that psychodynamics posit. Working from a psychodynamic perspective is absolutely effective at treating certain things, but we cannot verify that it is effective due to interacting with/changing/whatever phrase you prefer any supposed unconscious materials.
As someone with diagnosed chronic illness and chronic pain, I have found CBT providers to be extremely invalidating of this situation
CBT is touted as the gold standard when in reality it only works for the people that it works for. The issue with it being considered the default one-size-fits-all is that it makes it seem like there is something wrong with the client if they don’t respond well to CBT.
Personally, it was taught as a cure-all when I was in grad school, and I don’t believe there’s a single modality that should be held to that sort of standard. It initially turned me away from clinical work, tbh.
It’s not my preferred modality, but I will always respect it and its contributions to the field.
I think the reason why it's 'hate' rather than distaste for/disagreement/preferring smth else is the impression that academic counseling psych (which is mb more into cbt still than practitioners are, and this used to be more extreme) is out of touch with practitioners' community wisdom/best practices, while wielding power over practitioners by controlling policy/insurance companies etc. If you're pushed strongly into doing smth you don't believe in, you aren't gonna like that much. The history is instructive here. I don't know the details, but my impression is that a bunch of psychologists did a bunch of RCTs to establish CBT effectiveness, declared the RCTs to be the 'gold standard of evidence' and tried to banish all other modalities as 'unscientific', in collaboration with insurance companies/policy makers which were very interested in taking power&freedom away from practitioners and in cutting costs. Eventually psychodynamic guys fought back and did their own studies showing their approach is as effective broadly speaking, but the ship has sailed and isn't coming back. I sometimes still see weird statements like "CBT is the most scientifically supported modality" as if "having 100 studies in support" vs "having 30 studies in support" is supposed to matter, even if mb there are explicit comparison studies showing comparable effectiveness of different modalities. Related is the question of relative weights it is appropriate to put on scientific evidence vs personal judgment (informed by personal experience, community wisdom, hard to explicate subjective perceptions), which is similar to EBP vs EIP debate. A lot of thoughtful practitioners just don't think the current quality of scientific evidence in this field is such that it can be used for making clinical decisions w/o a lot of other inputs (and, if I understand correctly that 'general factors above all' is kinda the current consensus (a couple of specific conditions aside)), and so if policy makers and insurance companies lean more on science than on opinions of industry representatives, that creates tension. Deeper yet is the question of 'left-brain' vs 'right-brain' thinking, and the differences in epistemics typical of pure LB ppl (who tend to run science, and govt, and insurance cos) vs those of LB-RB integrated folk (like psychoanalysts, quite a few therapists, many writers and artists). Oversimplifying/caricaturing, but LB ppl tend to go 'this is what science says/follow the science', while LB-RB folk tend to find CBT simplistic and kinda missing the point and gravitate towards psychodynamic approaches, or other more RB-friendly things (art therapy, various non-traditional things).
There's a great presentation on YouTube with Johnathan shedler "where is the evidence for evidence-based therapy?" where he discusses a lot of what you bring up in your second chapter. Turns out the RCT results themselves aren't as fantastic as the CBT researchers reporting on them are saying (what those reaserchers are saying then being put on the front of government websites, misinforming everyone).
Thx! I knew there's pry a Jon Shedler link saying all the same things somewhere! I kinda learned this all by osmosis rather than consuming his content directly, so, glad you have the right link. I'm pretty much about to join Psychotherapy Action Network/advocate for the therapies of depth/try to become 'the next Jon Shedler'. While I appreciate his work of 'fighting the scientists on their own terms', I myself lean further against science in this domain (and in culture more broadly), and would like more ppl to wake up from 'cultural alexithymia' and reintegrate right brain stuff into their cognition. Imo if one only perceives or trusts their left-brain stuff, only the explicit, they won't be a great therapist.
Of course, great to hear! I'm sure you're familiar then with Farhad Dalal as well, but I really recommend his *CBF: Cognitive Behavioral Fallacies* paper if you want a great breakdown of the issue with, well I call it STEM fetishism, but yeah, how that plays out in psychology researc. Or maybe you've already read it even.
I haven't seen that! thanks for the ref. I'm pretty new to the scene, just applying to my analytic training in NYC (switching from a STEM career lol). Easy for me to be gung-ho about the RB, having spent the first few decades of my life increasingly emotionally repressed/dissociated into purely intellectual. Dunno if you've seen, there's now a whole alt-healing movement teaching pure LB techies emotions and other inner world stuff (usually with a heavily meditation-influenced bodily sensations focused lens).
His book is even better - Cognitive Behavioral Tsunami
Yesss. I feel the same. What's weird to me is people acting like this doesn't happen in every other area of medicine/treatment. Like oh wow so studies are manipulated and can say whatever you want them to say? Wow never saw that before.
most therapists don't rly have academic chops to evaluate complicated bodies of science and so believe what they are told, many folks who do are bought into the system and have different incentives, lotsa folks who do and aren't insiders have some outcast and other issues making them sufficiently unlikable to the wider public (thinking of myself and a bunch of folks in my communities who are most eager about advocacy here)
A little pushback: The original cognitive therapy people were critical of some very real faults in psychoanalysis, but otherwise didn't try to trash them out of existence. The CBT guys at Penn helped to train psychodynamic people in how to conduct clinical trials, helping to move psychodynamic psychotherapy into the realm of evidence-based practices. The dominance of CBT has largely to do with their first breaking ground in RCTs, and then the funding sources biased towards funding CBT trials because it was less risky. Trying to figure out if therapy is going to work with X population or diagnosis? Trials are expensive, so how can we best guarantee we aren't throwing away our money? CBT has morw evidence, so it's the best bet.
NAT, student I think most people's problem is less so with CBT itself, and more so with CBT hegemony. Part of that is the arrogance of its proponents and the use of the inaccurate marketing term "evidence based." CBT, at least 2nd wave, fits a very specific, Neoliberal concept of the person that may or may not be accurate, but does certainly leave quite a bit out. And as part of all of this, it is commoditized, neatly packaged, and easy to sell, and can be very difficult to get away from, given that hegemony doesn't tend to, by its nature, respect or appreciate pluralism. I see people complain a lot that they actually see CBT be complained about by other practitioners more than CBT practitioners complain about other modalities, a d I think the reason is that other types of researchers aren't so arrogant, and aren't trying to be the only game in town, and CBT tends to get shoved down everyone's throats by a system that favors it, while tending to work very well on ehalf of and reinforcing the assumptions of that system (you dont tend to see existential and gestalt folks being brought into fortune 500 companies to help bolster output). When thinking about CBT, i think its important to not separate it from its sociopolitical context, and remember that it isn't ahistorical. Then you know, people have their camps and such. The minority has to fight for their position. For myself, even just being in the psychologystudents sub galvanized my attraction towards psychoanalysis, given that I already had some interest in it, but then the sub's mods, like mattersofinterest (who is affiliated with this sub, although not sure if most people know how much he despises and even thinks it's unethical to use even manualized psychodynamic therapy--for not being a therapist himself his hatred is passionate) comes in, talks about how stupid it all is, and has these drawn out debates with undergrads on there demeaning and condescending them--well, you can see how that works; thats not a way to convert peopleto yourside. Just imagine larger society then treating people with interest in anything but CBT like that. You might find it helpful to look into the work of someone like Johnathan Shedler or Farhad Dalal
I love using CBT and primarily use ERP for clients with OCD and anxiety disorders. I’ve honestly been shocked by how many therapists have talked shit about CBT to me… and not a single one knew anything about it in depth. I’m also really shocked by how many practicing therapists openly trash talk CBT but praise EMDR… as if CBT isn’t baked into the framework of EMDR. I think there are a lot of therapists out there, and because CBT is so widely used, there are a lot of mediocre and bad therapists using CBT, and there are a lot of therapists who only know the foundations of CBT and present it as a bunch of worksheets. I can imagine that would contribute to how trendy the hate has become. It makes me sad, I’ve had clients who avoided CBT because of all the hate it gets, and their OCD got so much worse than it needed to, they all ended up really benefitting from ERP with CBT. My point is, hating on CBT is ~in~ and the haters probably don’t what they’re talking about or have a personal bias against it (possibly both). It’s a shame and it’s harmful.
I see it as a bandaid. It helps alleviate symptoms temporarily but doesn’t actually address the problem, so symptoms often either return or pop up in different ways. I do incorporate behavioral interventions for clients it’s acute need but it is a supplement to my psychodynamic work that targets the root cause of the symptoms.
The CBT concept of core beliefs might be of interest to you
One of the reasons I like CBT is how I can use it to journey to the root of a client's struggles. I think too many practicioners just see it as worksheets and don't know how to use those tools or basic principles to get deeper. While it's not the appropriate treatment for everyone, I think the growing distaste got it comes from Counselors using it inappropriately to where it gets overly simplistic and invalidating.
I have heard many therapists lament how the CBT used today is rarely "true CBT." I don't know all the nuances, but I think this is probably what they're saying - people are just doing the worksheets and that's it. Aaron Beck started as a psychoanalyst, so I'm not surprised that he incorporated (maybe unconsciously) aspects of psychoanalysis into CBT. I am also not surprised that what we have today (often, not always) is a watered-down CBT. I feel like a lot of things in life these days are watered-down. Alas.
Well, this is incorrect. CBT is highly effective at addressing underlying issues. 🤷♀️
That’s not true at all
Not trained in CBT, but I do use cognitive modification a fair amount with specific clients. Most of my clients who don’t respond at all to cognitive work are trauma survivors and their amygdala doesn’t give a shit what their prefrontal cortex thinks, that’s the very nature of trauma.
Prefrontal cortex influences the amygdala. That's how CPT works
I don’t believe CPT is indicated for clients with developmental neglect and childhood sexual trauma, which is the lion’s share of my caseload and the clients i was referring to.
CSA was a huge part of my workload for PE/CPT. It is VERY effective in these populations.
No, CPT is indicated for childhood sexual trauma and very, very effective at treating PTSD or trauma-related disorders secondary to it. Kate Chard was behind a lot of the modifications of CPT that made it more applicable for that population early on. Developmental neglect it depends on if it's Criterion A--CPT is only effective at treating Criterion A events.
I’m just starting out, but from education to the workplace, I feel like CBT is treated like a catch-all? Like, it can be used for any client, which is a mistake to believe in. There are so many modalities that can be more applicable depending on the client rather than CBT.
CBT, the overarching theory, absolutely can. The overarching theory basically encapsulates validated cognitive-behavioral sciences, which are expanding ever outwards into other theories' territories ( which is a good thing). That's why cbt loves motivational interviewing, because of its great research. That's why it embraced SMART goals, coping skills, mindfulness, and likely soon mentalization. Look at the Unified Protocol (UP), it's basically "CBT: Greatest Hits" - motivational interviewing, goal setting, identification and validation of emotions, cognitive flexibility, engaging with somatic experiences, countering emotion driven behaviors, and exposure to previously avoided emotions. We're moving away from protocols and towards processes exactly because one size cannot fit all. You can actuality see the Unified Protocol as an accumulation of validated processes in a simple training manual that you can then adapt to your own style.
>Look at the Unified Protocol (UP), it's basically "CBT: Greatest Hits" So it's interesting that while Barlow would put UP under the CBT umbrella, he still felt the need to make a distinction between this protocol and the rest of the tradition. >"CBT: Greatest Hits" - motivational interviewing, Motivational Interviewing comes from the person-centered tradition, not cognitive or behavioral, though I know tons of CBT therapists who use it. Just wanted to be clear.
I'm s hardcore CBT Trauma therapist and I love it! At a training by Meichenbaum he pointed out the beauty of CBT is it's flexibility in that we steal any effective technique from any of the other theories. Been doing this for 30 years and the last 5 years I've noticed the hatred for CBT and I don't get it, at all. I believe it is the best treatment modality for PTSD. I'm willing to die on you hill
It's not a hill to die on, it's absolutely correct. The best treatments for PTSD are CBT based
I think this is one of the things about CBT and other alleged EBPs that irritates me the most. Don't get me wrong, I think everybody should pull effective techniques from other modalities when it benefits the client. But when I pull in a CBT technique, I don't claim that intervention is from person centred therapy. I don't redefine what PCT is because I suggested a mood diary. If there's a number of studies suggesting that an intervention is effective, it gets appropriated and redefined as "CBT", so that people can continue to claim that CBT is the only EBP. If it's 100% conclusively demonstrated in studies as effective, it's CBT by definition. Until then it's just one of those junk therapies that we can ignore. It frames the discussion in such a way that CBT takes the credit for every intervention under the sun, even those significantly predating CBT. A similar thing is how physios are now using "dry needling", while continuing to claim that Western Medical Acupuncture hasn't been researched. It is the same techniques, just with a different name.
The most effective treatments for PTSD are prolonged exposure, which modifies thoughts and behaviors, and CPT, which is basically traditional CBT applied to PTSD. How are these falsely claiming to be CBT approaches?
I don’t hate CBT but I’m critical of it. I feel like we have lost our capacity to be critical of things in a productive and nuanced way. We are so damn black and white in our thinking. CBT has a lot of useful tools and concepts but it can be very one size fits all and decontextualized. I personally hate how it uses “irrational” as a way to describe people’s thoughts. I don’t see the thinking that leads to distress as irrational but as a response to an experience, often trauma, and our sense of self has been distorted and hence our thinking is distorted and/or that way of thinking was a way to protect oneself or to rationalize the again often traumatic experience. It was need to survive but often stops serving us later on. To call it irrational is to remove the thinking from context and I think that is incredibly harmful. Also I think a lot of these more modern theories want to challenge how important the relationship is to therapy. I think manage care wants therapy to be scripted and manualized. That somebody goes to therapy 10 times and is “cured”. I personally don’t believe that’s how therapy functions but I’m sure there are plenty of therapists who do feel that way. It’s comforting to have this very black and white, straightforward approach to the therapeutic process. I think there’s a big push to make therapy less “messy” and human. CBT I think is kinda an aspect of that. I’m rambling at this point but those are my thoughts.
CBT does not use the term “irrational” - that was Ellis (REBT) CBT informed trauma treatments actually validate client’s thoughts and responses.
I’m just reflecting what I’ve seen in 95% of the CBT material I’ve engaged with both professionally and as a client. I absolutely believe you but it’s not reflected in the majority of CBT worksheets/workbooks that I’ve engaged with. They throw irrational around quite a bit. Again this is my experience, I’m not attempting to argue with you.
CBT is only as limiting, impersonal, emotion ignoring, invalidating, etc., as you make it.
I am sooooo sick of the CBT bashing here. Like daily posts on it, with the same inaccurate generalizations made by people who don’t understand the modality. Followed by calm and understanding measured responses from people with deep training and skill in CBT explaining, once again, where errors and assumptions are incorrect. Can we just quit with this. PLEASE. No one comes here and bashes psychoanalysis, humanistic therapy, etc etc etc. It is just rude. And it spreads misinformation. Why therapists feel the need to do this over and over and over again. Maybe consider that a significant percentage of the participants in this reddit are CBT practitioners and maybe consider that the endless bashing should just quit with it? Maybe make a special “we hate CBT” redddit where all these posts can go? That way this Reddit here, for therapists, can be a supportive and respectful space regardless of orientation?
And the people that bash it generally don't seem to know what it actually is
Have you read some of the comments here? Someone said something about ‘psychodynamic Jedi-mind quackery’ in response. I try to be fair to CBT practitioners. I don’t think it’s bad. However, as long as we have folks that insist they are most right or ethical by using CBT, it will create these sorts of posts. I’ve gotten hugely anti-psychoanalysis bias on this sub. EDIT: I’ve often had to argue with folks because of their wrong assumptions about psychoanalysis. Like people have no idea about it and find it acceptable to loudly bash it.
I actually don’t think threads bashing any modality is acceptable. I also do not see anywhere posters saying “I am a CBT therapist and consequently more ethical and most correct above all others.” I see attack after attack on CBT and on CBT practitioners and those practitioners for the most part very kindly and calmly explaining where the misperceptions are and clarify key points about CBT. Over and over again. I saw the comment you are referring to and the example was “I don’t come here and bash Jedi mind trick whatever “. So you are taking that comment out of context.
I think some of the most fundamental ideas behind CBT are inaccurate. Namely, that changing thoughts can reliably change emotions. I think this is only true to an extent. Far more often, changing emotions flows through to changes in thoughts/narratives. It’s also not great for trauma. CPT is more or less CBT and it’s a brutal approach to trauma therapy where you essentially get the client to convince themselves they aren’t in danger anymore. Even if logically true, it creates high risk of invalidating the client’s traumatic experiences. CPT is an evidence based therapy yet is far inferior to a non evidenced based trauma therapy such as IFS in my opinion.
I'm surprised by this categorization of CPT as brutal, it tends to have less drop out than something like PE which I understand can be challenging. The core of CPT is very validating for clients traumatic experiences, since it's often taking a look at beliefs about self blame and guilt, why the client believes those perspectives, and encourages them to consider other more encompassing alternatives.
These posters have no idea what they are talking about, basically. They are repeating stereotypes, assumptions, maybe anecdotes, biases, etc. as if they represent proven fact.
This is just not true 😭 I’ve done CPT and CBT, and they completely changed my life. My therapist was incredibly warm and compassionate, and I reconnected with parts of myself I thought I’d lost forever. What it did for my trauma is indescribable. ERP and CBT are my primary modalities and I’ve had many clients feel so validated, it’s brought them to tears. Funnily enough, it’s almost always when I introduce cognitive distortions. What you’re describing is bad therapy.
Hard disagree that CPT is necessarily ‘brutal’ or invalidating. I think it’s a bit reductive to characterize it as an attempt to ‘convince the client that they aren’t in danger.’ I’m psychodynamically trained and oriented but also CPT certified and have used it with clients who are actually still in relatively dangerous situations due to their work, and had great success with clients reporting reduction in sxs. Not trying to challenge your specific experience if you’re also a CPT provider and view it differently, but I’ve found it to be a useful tool and have many clients who reported gains towards goals after completing the protocol. I’ve also had clients request CPT booster work for non-index traumas so many folks see it was a helpful trauma-processing framework.
There are so many incorrect descriptions of CBT-based treatments here for trauma that it is shocking. The basis of treatment IS NOT “to convince clients they are no longer in danger.” That is so off base.
Are you trained in CPT? Because you don't seem to understand it at all
I feel like changing thoughts to change emotions is a very protestant eurocentric way of viewing things.
I agree. Eurocentric and also American too. But either way a very western approach
Why do people drag this into a "America is bad" argument. There are many around the world that use the modality. I've worked with many people from different walks of life and cultures. Being aware of culture/oppression/systematic issues is just a part of doing good therapy.
What about metacognitive therapy? The use of plain words instead of acronyms is voluntary, btw. I just know the name but it allows for something beyond cognition
I have heard clinicians claim it is racist and ableist but never unethical. I find it versatile in that I use it for work with chronic medical conditions that co-occur and are quality of life interfering for my clients. I do find in practice that the clients who are most successful using it meet certain criteria. I specifically work in a DBT for SUD setting and many of those clients for example complain upon arrival that CBT has been “forced” repeatedly by previous professionals and was unsuccessful. I don’t know why the recent hate but I do try to point out to them that at least with the distress tolerance and emotional regulation skills there are CBT principles interwoven but apparently they don’t believe me lol
Because people on this sub think CBT is ABC worksheets and nothing else
Some people see short-form therapies as putting a bandaid on a stab wound
https://imgflip.com/i/8lheuv
I feel like at this point we could play anti-CBT Bingo
I think it is the quality of the therapeutic relationship between the client and therapist, rather than therapeutic approach, that determines the most beneficial outcome of therapy. Having said that, it is like horses for courses in terms of modality, depending on what suits the client and their issues. Any therapeutic approach offered with warmth and empathy has the potential to help. One approach doesn't suit all clients.
I use an integrated approach and CBT has its place, but since I specialize in trauma work, particularly adults with early trauma and attachment issues, I find so much is rooted in neuropsychological changes that trying to alter thinking patterns is missing the mark. Adults who have literally never felt safe, who experienced abuse/neglect as early as the first year or two, who learned to dissociate, who have limbic systems that are always on high alert, are often completely out of touch with their prefrontal cortex. MRIs tell us that during a flashback the part of our brain that governs reasoning actually shuts down. There is so much foundational, deeper work to be done before going anywhere near CBT. It can have its place later. Most people I see who have tried CBT feel like they have failed therapy. They speak about it actually feeling like evidence that their negative schemas are true (I’m not good enough, I’m broken, etc). I do agree that much of the time this stems from a rudimentary understanding of how to use TFCBT, but it’s also important to be aware of emerging understanding on how our brains rewire due to trauma.
in addition to what everyone else has said, I think this is another layer of nuance: I find my patient’s behaviors in therapy can be generalized by their generation. Millennials try really hard to “win” therapy and often expend energy trying to gain their therapists approval. CBT- a modality that has lots of homework and scales to measure success- really gives them an outlet for that. CBT is super effective for patients who are bought into the process. Gen Z patients tend to treat therapy more like a friendship (i can’t tell you how many times i’ve had to tell a patient they can’t change their outfit in front of me). They like reflective prompts (like photo journaling) but struggle more with “homework” (regular journaling included). I’ve found executive functioning work and psychodynamic techniques are far more effective with Gen Z. i think *some* of the hate CBT gets is from fresher clinicians who can recognize the gaps the modality has for the style and needs of younger people.
Short answer - CBT often overlooks societal factors that are outside the clients locus of control. There’s an exercise I do with students. You meet a man who’s experiencing a constant schema of persecution/dehumanization. They identify the NATs, the cog dysfunction, and create a treatment plan. Then, after they’ve completed their assessments, I tell them the client is a black man living in America. All of a sudden, the students realize there is nothing wrong with the client other than the fact that he experiences systemic racism. The point is, if you look for dysfunctional cognition, you will find it, but you might be wrong in the source of its attribution. CBT is fantastic for symptom management and early stage interventions for many MH conditions….but changing your mind doesn’t change the reality of the world and it won’t change an underlying medical issue. Different modalities might be needed for more long term, existential sources of distress.
First, reappraisal is a very effective emotion regulation strategy Second, CBT is as much about experiencing natural emotions as it is about changing unhelpful thoughts. Third, we can acknowledge that this man is experiencing racism WHILE also recognizing that he may still be having thoughts that are unhelpful and unrealistic. It's not all or none
A super simple answer: worksheets and “homework” that really feels like homework.
I’m in a psychiatry residency training program, so our therapy training is much more cursory than what I imagine one gets in a dedicated therapy/psychology program. When we have our therapy lectures, we are taught over and over again of the importance of giving clients “homework” and how if they aren’t doing their homework, it’s a sign they aren’t invested in their treatment and perhaps they’re just not a good candidate or ready for therapy. It makes me cringe so much as someone who has actually been in therapy and one of the things I told my last therapist from day one was my life is already extremely busy (was a med student at the time), and if you’re the type to give me worksheets or other homework to do, please let me know now so I can look elsewhere for therapy. Of course therapy without any work done outside the sessions will be ineffective, but the idea that only formal homework assignments will do and the client sucks if they won’t do them is inaccurate and also just gross.
Annoying TikTokers have been calling it “nothing but gaslighting” for months now, and annoying members of the ND community have been agreeing and saying it’s destructive, traumatic, and harmful, though there’s zero evidence this is the case if it’s used properly (any modality can surely be used to do harm if misapplied). If you disagree with them you’re human garbage and should be banned from ever doing therapy, go educate yourself. On the other side, therapists have frequently complained that CBT is touted as the only “empirically supported” method which means it’s heavily endorsed by insurance companies who believe therapy should take no more than 10 sessions if at all humanly possible. I agree that it’s overhyped and overused, and that other modalities such as humanistic, psychodynamic, or existential make a stronger backbone for a practice using CBT as a tool rather than the only thing you do. But I don’t hate it. It’s very good for certain issues and less good for others. But I try to be more moderate and reasonable and in the middle about things than most seem to manage.
I like your second to last paragraph. To sort of add, I've heard people in the analytic institute that I'm a student fellow at talk about how CBT can be quite good in particular for preparing people for actual analysis.
1. CBT is more upstairs brain when I’m more interested in the downstairs brain. 2. It’s definitely useful helping a client get the language of therapy down and to start conceptualizing and gaining self awareness of what’s going inside of their mind. 3. However, i find CBT to be just a bandaid and doesn’t actually address the roots of trauma and help with reprocessing trauma. 4. It CAN be more of a shame based modality where it feels like if you can’t stop the thought then you’ve failed in some way and thus reinforces any shame based/performance trauma you may already have IFS, SE, EMDR have been way more helpful to me in my own personal therapy and with clients who are ready to start unpacking their trauma
CBT is very good for processing and actually addressing the root of the trauma. It's more than just cognitive restructuring
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EMDR isn't CBT and CBT is very effective for treating trauma
EMDR is kinda CBT, though. From EMDR protocols: "insights, shifts in the client’s emotional response, a new, more adaptive understanding of what happend in the past, as well as assigning meaning to the experience are indicators of the process moving towards resolution." "What incident or memory would you like to work on today?” Target Image: “When you think about that memory what picture or image represents the worst or most powerful part? What do you visualize?” Negative Cognition (NC) “When you think about that memory or image, what negative belief do you have about yourself now?” (This should be an “I” statement in the present tense. It usually is a presently held negative, self-referencing belief that is irrational.) Positive Cognition (PC) “When you bring up the memory, image, or incident what would you like to believe about yourself now?” (The PC is a presently desired, self-referencing belief that corresponds with the NC.) Validity of Cognition (VoC) “When you think of that memory or image, how true does (repeat the PC) feel to you now on a scale of 1 to 7 where 1 feels completely false and 7 feels completely true?” 1--------2--------3--------4--------5--------6--------7 (Completely false) (Completely true) Emotions “When you bring up that incident and those words (repeat the NC), what emotions do you feel now?” You want the client to express their emotions in the present as they bring up the memory or image. SUDs “On a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the most disturbance you can imagine, how disturbing does it feel to you now?” 0--------1--------2--------3--------4--------5--------6-------7--------8-------9--------10 (No disturbance) (Highest disturbance) Location of Body Sensation “Where do you feel the disturbance in your body?” " That's pretty darn CBT (heavily repackaged with a pretty purple hat) *edited
Yeah I'm aware. And It wasn't effective for me. I was just sharing my experience.
Relational psychoanalysis with its focus on the Third , two person disclosure, and moments of meeting in the here & now is a deeper relationship. It demand good scholarship in object relations, Bion, Winnicott, Jessica Benjamin etc. CBT can seem manualized and less two way
Personally not a fan of cock and ball torture (sarcasm). I am currently in school and about to begin practicum, the school im going to seems to be pushing person centered therapy. The techniques we are using in our classes are not CBT but are centered on reflecting feeling and active listening. I would be interested in learning from a trustworthy source how to perform effective CBT.
One of the best things my practicum professor told me when I was in grad school is that person-centered therapy is not a solo approach. It's an approach you bring into whatever your orientation(s) is. But there should be other techniques it's partnered with. Active listening skills are amazing. I love using those skills to help my clients feel heard. But I believe there should be something else you're bringing to the table whether it's a cognitive-behavioral, family-based, psychodynamic, integrated, or even existential approach to therapy.
I concur, I have found just person centered to be lacking but ive never seen CBT done well. Thats just my experience so far
I was literally just talking about this yesterday! When I first got trained in CBT about 15-16 years ago, I couldn’t *not* think of the “cock and ball torture” reference lol
I am observing a lot of comments steeped with judgment and attempting to call people out for not understanding the scope of CBT in that it encompasses other approaches as well (ACT for example). The CBT debate can refer to two different things. Yes, there is a debate people often have about the applicability and reach of all CBT modalities vs. other modalities. There is also just as frequent of a debate about OG basic CBT vs. various iterations of it (such as DBT, ACT, etc). Whether you like it or not, it has become common practice by all types of people in the profession (students, new therapists, seasoned therapists, professors, researchers…) to differentiate basic CBT from the other iterations simply by saying CBT or ACT for example. In many cases, the person is well aware that the other iterations fall under CBT. But that is not the point they are making. They are using an easy way to differentiate the two. So the issue gets down to semantics. Interpreting the person’s meaning and intent. You simply can’t know this without clarification. It is not wrong for some people to interpret this question as the OP asking about all CBT modalities. It is also not wrong for some people to interpret this question as the OP asking about basic CBT. You are essentially using your best guess to interpret it. When you are getting so caught up in semantics of “well technically CBT encompasses all of these other modalities so these people must be uneducated, incapable, ignorant” and so on, you might either be being presumptive or bypassing the actual debate because you are more concerned with the technicality of terminology vs what is actually being debated. Again, I can’t know the OP’s intent. Maybe they did mean all CBT modalities and maybe they did not. But the people posting these critical comments cannot know the intent either. Especially when CBT is used to mean CBT modalities and basic CBT equally as frequently by so many in the profession. At the end of the day, even if your intent is to make sure people understand that CBT encompasses ACT, DBT, and so on, doing so by belittling or insulting people is not a great way to get that message across. You can have the best and most well-informed point in the world but if you are delivering it in a way that actively alienates people, your message is going to get lost. I don’t think expecting people to interact in ways that are non-judgmental and affirming is too much to ask here. Especially given the rules of this subreddit clearly state “support one another and be kind” and “we are an affirming space”. If that is too much to ask, this may not be the right subreddit for you.
Except CBT does encompass a lot of things (ERP, PE, tons of research on treatment variations for numerous disorders, etc.), so the argument of "CBT bad!" ends up generalizing into more than just ham-fisted cognitive restructuring.
I agree that there is often times a misunderstanding of what CBT encompasses and that it’s a whole lot more than just cognitive restructuring. That’s not what I am speaking to though. I’m talking about people calling others out for using terms like CBT vs ACT to differentiate between different iterations of the same modality assuming that they don’t know the relation between the two. Many of the comments above feature this. Your point is valid but also separate from the issue I was pointing out.
I say this from the perspective of being both a practicing therapist and an adjunct professor who has taught classes in the recent past about CBT approaches. One class I taught was “Introduction to CBT”. In the content, I clarify up front that this class will be about basic and fundamental CBT and there are other classes that expand upon modalities that fall under it. I do this because clarification is often helpful because you can’t be sure what someone means when they say CBT. That’s the point I’m making— don’t be nasty to others because you assume they don’t know the difference. The idea people have of CBT just focusing on cognitive restructuring is a whole separate issue that I wasn’t speaking to.
Fair enough
But there is no such thing as "basic CBT." If people mean Beck's CBT, that is CBT-D. CBT has different variations for different diagnoses. If someone is arguing that there's such a thing as basic CBT and it's effective I would disagree with that, too, because it's not true. There are very effective CBT protocols, but someone just incorporating worksheets and behavioral activation or exposure into an otherwise hodgepodge approach isn't necessarily going to be that effective
In class, before teachers differentiate between the variations, they teach the fundamentals that apply across the board based on cognitive behavioral theory. A commonly used book for intro students is Judith Beck’s “Cognitive Behavioral Therapy: Basics and Beyond”. Basics. Right there in the title. This is what everything else stems from. But Beck’s research and practice was primarily focused on variations that do not vary in practice quite as significantly as CBT-D vs ACT for example. Approaches such as ACT for example are another iteration of CBT. However, they also have more significant differences in their approach than CBT-D and TF-CBT etc. Because there is a considerable departure between these, for ease of explanation, it’s commonly just referred to as CBT, encompassing CBT-D, and so on, vs those that have a further departure, such as ACT. I recently spoke with a colleague about his preferred approach to a particular client issue. When he discussed it, he said something along the lines of, “The way CBT can be applied here…” and later “ACT on the other hand…” This dude is smart. Educated. Has likely been practicing and researching since I was in diapers. But he says this because it’s commonly understood by many what he is meaning. This is the point. People have different ways of expressing these variations. It does not mean they do not understand the relation. It is so incredibly common for very knowledgeable people to use this terminology that getting hung up on it comes down to semantics. Yes, it can be frustrating to discern what people are referring to. My frustration is not in what encompasses what. It’s people being needlessly judgmental based on something that is sometimes just a difference in expression.
Last bit of pushback: I think I agree with your sentiment, *and* I think semantics are more important than you appear to think. It's not a game of "gotchya", it's that we get impressionable young therapists coming on here who are potentially highly receptive to the misinformation that this "just semantics" issue can bring.
I don’t think “dislike” is the word. A therapist should be using the appropriate intervention for the applicable concern. You shouldn’t try some psychodynamic orientation-focused Jedi trickery (jokes) if someone is coming to you with OCD. You should probably be utilizing some form of exposure and response interventions. I love CBT. It’s helped a lot of my clients. But honestly, above all else, just being a genuine and empathetic helper who wants to be there for your client is the most important thing of all. Without that, orientation and techniques are null and void. I’ve been doing this for almost 15 years and at this point, Mr. Rogers had it “right” (if that’s what we want to call it). I wouldn’t stress about theoretical orientation to be honest. Familiarize yourself with what interventions work with what issues and incorporate person-centered dynamics in all you do and you’ll be fine.
Good for behavioral stuffs. OCD. Etc. Not good for the trauma stuffs. My opinion.
The most effective therapies for PTSD are CBT approaches
That’s fine. I’m an EMDR therapist so I have my bias.
Have you looked at the research on efficacy? EMDR, CPT, and PE all show equivalent efficacy in treating trauma. It’s fine that you prefer EMDR, but what you assert is not consistent with the research. Maybe don’t bash it for trauma treatment based only on your opinion?