Why it’s not a one-size-fits-all solution, and what might be a better alternative
CBT (Cognitive Behavioural Therapy) may seem like a relatively modern form of psychotherapeutic treatment, but it’s been around in some form since the work of behaviourist John B. Watson in 1913 and became popular through advances made by Albert Ellis (with REBT in the 1950’s) and Aaron T. Beck in the 1960’s.
CBT is still extremely prevalent and is certainly shorter and more solution-focused than the more ‘traditional’ forms of therapy (such as the Humanistic and Psychodynamic approaches that dwell on and analyse the past). It also encourages the client to take some responsibility for making changes in their life, thereby giving them the tools to be self-sufficient once their therapy is over.
However, a large meta-analysis of the effectiveness of CBT from the 1970’s to 2014 by Johnson and Friborg (1), shows a steady decline in its efficacy and has actually lost about 50% of its ‘power’ as a treatment. It is thought that the early success was partly down to placebo effect and that any form of treatment or therapy that can inject a powerful element of hope or expectation into a client, which will have a positive effect on them.
When might CBT not work?
In a nutshell, CBT aims to change the patterns of thinking or behaviour that are behind people’s difficulties and in doing so change the way they feel. This sounds fair enough. It focusses on thoughts, images, beliefs and attitudes and looks to make some positive strategic change to any negative patterns within them.
The problems with this are:
- Focusing on negative and unhelpful thoughts in therapy can give them power and anchor them, even if the intention is to replace them with healthy alternatives. If I tell you not to think about a pink elephant, what do you do?
- Prolonged stress, anxiety and depression physically impairs the part of the brain (the prefrontal cortex) which controls our ability to think and plan strategically and to see the bigger picture. As a result, our mind become foggy and we are prone to black-or-white thinking and we lose the ability to make long term decisions. It won’t matter what changes we agree to make in a CBT session if we lack the capacity to visualise them, let alone to make them. Don’t panic though, these changes to the brain are reversible.
- The basic premise that our thoughts come before our feelings has been proven to be flawed with advances in neuroscience. It is now known that our emotional brain gets to process all the stimuli that we experience for our environment before our rational thinking brain has a look in. Not only that, but the emotional brain can filter what the rational brain sees, it can act like a dimmer switch to it, or even turn it off. When we are in a high state of emotional arousal, we are dominated by the more primitive instinctive part of our brain and we lack the cognitive capability to make changes in our lives
When might CBT not work?
In a nutshell, CBT aims to change the patterns of thinking or behaviour that are behind people’s difficulties and in doing so change the way they feel. This sounds fair enough. It focuses on thoughts, images, beliefs and attitudes and looks to make some positive strategic change to any negative patterns within them.
The problems with this are:
- Focusing on negative and unhelpful thoughts in therapy can give them power and anchor them, even if the intention is to replace them with healthy alternatives. If I tell you not to think about a pink elephant, what do you do?
- Prolonged stress, anxiety and depression physically impairs the part of the brain (the prefrontal cortex) which controls our ability to think and plan strategically and to see the bigger picture. As a result, our mind become foggy and we are prone to black-or-white thinking and we lose the ability to make long term decisions. It won’t matter what changes we agree to make in a CBT session if we lack the capacity to visualise them, let alone to make them. Don’t panic though, these changes to the brain are reversible.
- The basic premise that our thoughts come before our feelings has been proven to be flawed with advances in neuroscience. It is now known that our emotional brain gets to process all the stimuli that we experience for our environment before our rational thinking brain has a look in. Not only that, but the emotional brain can filter what the rational brain sees, it can act like a dimmer switch to it, or even turn it off. When we are in a high state of emotional arousal, we are dominated by the more primitive instinctive part of our brain and we lack the cognitive capability to make changes in our lives.
What is the alternative?
Nobody can function well in a high state of emotional arousal. If you are depressed you might not feel particularly ‘aroused’, but you will have high levels of cortisol in your system and you are highly emotionally charged, even if you don’t feel that way.
Relaxation is so important. Once we can get those cortisol levels down, we can begin to see things more clearly and to think straight – even positively. It can’t be stressed enough how vital relaxation is to people who suffer with mental health conditions. Once the fog has lifted, you can have a whole new outlook.
Also once relaxed, you can start to address any primal emotional needs that aren’t being met and start working on changes to help you meet them and build up your emotional resilience.
In summary
The effect of long-term stress is like a stranglehold on the brain. And therefore, it’s hard and often ineffective to do cognitive therapy with someone who is depressed, until their brains are free from these effects of stress.
However, the good news is that all these long-term effects of stress can be reversed. Studies show that after only 8 weeks of relaxation training, subjects have measurably reversed the effects of stress on a cellular level in their brains. Stressed clients can visibly alter after just one deeply relaxing experience in therapy.
If you have had CBT and it didn’t help, don’t hesitate get in touch if you would like to try something different.
References
- Tom J Johnson and Oddgeir Friborg (2015) – The Effects of Cognitive Behavioral Therapy as an Anti-Depressive Treatment is Falling: A Meta-Analysis, Psychological Bulletin https://uit.no/Content/418448/The%20effect%20of%20CBT%20is%20falling.pdf