5 Reasons Cognitive Behavioral Therapy May Not Work for You
Maybe you are thinking about going to therapy. So you do a search on the Internet for information and you come across one of the more popular types of therapy, Cognitive Behavioral Therapy (CBT). During your search you find that much of the information is vague and non-descript. In frustration you find the same generic information either cut and pasted or rewritten for the masses on various mental health sites. You find the basics, however cognitive behavioral therapy (CBT) is a combination of two therapies including: cognitive therapy (focusing on helping the patient change their irrational or dysfunctional thought patterns) and behavioral therapy (focusing on changing maladaptive actions and behaviors). "Great," you may wonder. "So how does this help me?" You also find that the literature proclaims this type of therapy as effective for treating a multitude of mental health conditions. Yet in many cases you aren’t shown the studies or research to back up these claims.
Will CBT be an effective treatment for you? The answer is: It all depends. There are many factors which impact on the usefulness or functionality of any mental health treatment. In this post I am going to discuss why there is no clear consensus on what cognitive behavioral therapy entails. In addition, I will list some of the potential reasons why CBT or some variations of CBT may not be an effective treatment for some people.
When someone uses the term “CBT” can we be certain of what they mean?
One of the problems in assessing whether or not CBT is an effective treatment for you is the fact that when people write about this type of therapy they usually speak in very general terms. Thomas A. Richards, Ph.D.Director of the Social Anxiety Institute has this to say about CBT:
The specifics or details of CBT are not universally applicable. This has been a thorny issue for professionals who do not really understand what cognitive-behavioral therapy involves. With the advent of managed care, the insurance companies now want therapists who say they can do "cognitive-behavioral" or "solution-focused" therapy. So, in order to be included in these groups and panels, professionals now will usually say they do "cognitive-behavioral therapy".
The insurance companies like CBT so much so that quite often they will not pay for any other type of therapy. The reason they like it so much? CBT is usually short-term and costs less than psychodynamic or interpersonal type therapies. But what does it mean when a therapist says he or she does CBT? You may have to ask the individual therapist as there are a wide variety of ways this therapy may be interpreted and used.
For example, here are just some of the off-shoot varieties of cognitive behavioral therapies offered. If you read any of the descriptions you will see that these methodologies can be extremely different from one another but still under the umbrella of CBT.
The other thing to keep in mind is that CBT may look a lot different for patients who are being treated for vastly different mental conditions. For example, someone coming in to be treated for schizophrenia may have a totally different experience than someone seeking CBT for panic attacks. What happens during therapy, therapeutic technique, focus, and average length of treatment may be different for each patient. A therapist who says he or she does CBT really doesn’t tell us anything about the actual therapy or what it will be like for the patient.
If you really want to know what CBT may be like my suggestion is to ask other patients who have actually undergone this type of therapy. Everyone's experience is going to be different but at least you will get a better idea of what this therapy may be like from the patient perspective. My other suggestion is to ask questions from a qualified mental health professional who is currently in practice, utilizes this approach, and has stayed current in their knowledge of effective CBT techniques.
Reasons why CBT may not be an effective therapy for you
1. Your therapist may lack skill, experience and education about effective cognitive behavioral techniques.
Here the focus is not upon the methodology but upon the therapist’s skill set. One reason why CBT may get a bad rap in some cases is because of the overabundance of “therapists” who claim that they do this type of therapy so that insurance will pay them. Yet calling yourself a CBT therapist doesn’t always mean that you are an effective therapist by association. One of my worst therapy experiences was with a therapist who labeled himself as a cognitive behavioral therapist. He may have known some basic techniques but he failed to tailor his approach so that I could achieve my goals. In fact, it was such a frustrating experience that I had to terminate therapy early. This was my first experience with CBT and unfortunately my therapist’s ineptness colored some of my perceptions about this type of therapy. However, I do wish to say that some patients have wonderful experiences with therapists who use this approach and report that their CBT was very effective for treating their particular disorder. As with any type of treatment, everyone will have a unique response.
The main point I wish to make is that you cannot assume that just because a therapist says they are skilled at CBT does not automatically make them a good or effective therapist for you.
Always check your therapist’s credentials and don’t be afraid to ask questions about their training and experience. In some cases the definition of CBT is so vague that it loses all meaning and especially when someone does not have sufficient training to conduct this type of therapy or any type of therapy for that matter. The following are some examples of this.
CBT is so popular that someone thought it might be a good idea to train general practitioners to conduct brief CBT for patients who they otherwise might refer to a mental health professional. General practitioners are quickly becoming the Wallmarts of the medical world-your one stop shop for all your mental and medical needs. Guess what? Being trained for 4-half days in cognitive behavioral therapy isn’t enough training to make a difference. In a 2002 study published in the British Medical Journal (BMJ) researchers concluded that: Training general practitioners to treat depressed patients with brief cognitive behavioral therapy is ineffective. This conclusion doesn't seem surprising especially since their training was so inadequate.
There are also therapists who claim they can conduct CBT sessions on-line and that these sessions will be just as good as an in-office meeting. Some people greatly disagree with this view stating that the therapist is missing out on critical aspects of communication such as tone, body-language, and facial expression. Not to mention there are ethical concerns with on-line therapy as it relies upon email messaging which could be vulnerable to hackers. You may also be getting therapy from someone with little to no credentials.
The bottom line is that a medical professional or therapist who says he or she does cognitive behavioral therapy tells you nothing about their training, education, or ability to help you. Be wary.
2. In some cases cognitive behavior therapy stresses the therapy technique over the relationship between therapist and patient.
If you are an individual who is sensitive, emotional, and desires rapport with your therapist, CBT may not deliver in some cases. Again, the therapist is the critical element here. One of the stated roadblocks to effective CBT is that some therapists will hammer away at the patient’s dysfunctional thoughts but pay little attention to the fact that this is a multi-dimensional person affected by emotions, social interactions, and biology. It has been said that therapeutic technique is often less important to the overall outcome of therapy than the relationship one has with the therapist. If you do wish to try cognitive behavior therapy find a therapist who meshes with your personality.
3. CBT promotes assumptions which may be faulty.
One of the basic tenets of CBT is that your faulty or irrational thought patterns and cognitions are responsible for maladaptive behavior and mental health problems. If one accepts this premise then some practitioners may dismiss the other factors which play a part in mental illness such as genetics and biology. It assumes that the thoughts precede emotions, which isn’t always true. It also usually labels any “negative” thoughts as pathological or dysfunctional and again, this is not true.
Another faulty assumption is that changing one’s thinking patterns can improve one’s mood or decrease the symptoms of a mental disorder. Unfortunately this does not always happen. One cannot always “think” themselves better.
In a provocative article published in Time Magazine entitled “Yes, I Suck: Self-Help Through Negative Thinking” writer John Cloud cites studies which show that attempting to get people to think more positively can backfire and make them feel even more unhappy than before. Those positive affirmations of the positivity gurus don’t help much either. Research has found that most people feel worse and not better after self-infliction of inflated statements of their worthiness.
In addition, changing your thought patterns may not help you with the fact that you got fired from your job due to poor work performance, got a bad grade on a test because you didn't study, or got a D.U.I for driving while drunk. Sometimes “negative” thoughts such as “I really messed up” are true. As the Time article points out sometimes we do fail and instead of wasting time fighting negative thoughts maybe we should accept them, take ownership of our mistakes and move on.
4. CBT may not give you enough time to meet your goals.
As stated previously, insurance companies love CBT because it is generally considered brief therapy. And we are talking really brief here. In some cases CBT may be limited to as little as six to twelve sessions. As a patient I lift my brow in doubt. Really? Someone going in to be treated for depression who has early traumas, current social stressors, and a biological predisposition for a mood disorder is going to be all patched and ready to go in a few months? I would like to see that happen!
Nick Bolsover, consultant clinical psychologist for Community Health NHS Trust, wrote a detailed commentary on the lack of real data to show that brief therapies actually work in the long run. For example, he cited a study which showed that 6-12 sessions of cognitive behavior therapy produced better results than care from a general practitioner at four months but that this clinical gain was not maintained at 12 months. In other words, the studies which show CBT to be an effective treatment may have some flaws especially when it comes to showing long term gains.
5. Research shows that CBT or certain CBT techniques may be ineffective for many types of mental disorders.
I saved the big guns for last. Despite the popularity of CBT and the generalized statements that this type of therapy is effective for a multitude of mental health problems, there is also research to the contrary. In addition there are mental health experts who also agree that certain CBT techniques may be counterproductive or should be avoided altogether in treating certain mental disorders.
• In a landmark 2009 review published in the journal Psychological Medicine, the study authors concluded that: (CBT) is of no value in treating schizophrenia and has limited effect on depression. The authors also concluded that CBT is also ineffective in preventing relapses in bipolar disorder.
• In a 2009 study published in the British Journal of Psychiatry researchers compared depression treatment in adolescents over a period of 28 weeks. The study authors compared treatment with SSRI antidepressants vs. the use of a combination of SSRIs and CBT. At the end of the 28 weeks both groups showed improvement but there were no significant differences between them. It was found that CBT did not add any benefit to the antidepressant treatment.
• Dr. Thomas A Richards, director of the Social Anxiety Institute explains how telling the individual with social anxiety to stop thinking negative thoughts is not going to work. He also states that giving the socially anxious person positive affirmations to recite will do nothing. Instead, this practitioner advocates employing specific cognitive techniques such as helping the patient to be aware of their automatic negative thinking.
• Dr. Stephen Phillipson writes on OCD on-line that a critical element of good cognitive behavioral therapy is that the therapist be warm, understanding and compassionate. He also talks about how more traditional CBT techniques are ineffective for those patients with obsessive compulsive disorder (OCD). He stresses that OCD is not a thought disorder but an anxiety disorder which means that it is less likely a manifestation of irrational thoughts. He states that: “Helping OCD sufferers to see the irrational nature of their thought content is counterproductive.”
• The experts on PsychCentral agree that CBT has limited potential for helping those with Histrionic Personality Disorder. The authors state that: “…cognitive-oriented approaches are generally largely ineffective in treatment of this disorder and should be avoided. “ The reason, they share, is that people with this disorder are often incapable of examining their thoughts and motivations.
Although the first recommendation for someone who has a mental health condition including an anxiety related disorder may be to receive cognitive behavioral therapy, it may be wise to do a little research first. Has CBT been shown to be an effective treatment for your particular disorder? What does the research show? What type of credentials, training, and experience does your therapist have? Will brief therapy meet your needs or will you need more time? What types of techniques does your therapist actually use during the course of treatment? If possible I would fully recommend interviewing your chosen therapist before making the actual appointment.
Cognitive behavioral therapy includes a broad spectrum of therapeutic principles and techniques. Vague descriptions that CBT will be effective to treat your mental health disorder have little merit. Patients deserve and require more substantial information than generalizations. As with any type of treatment or therapy there will be plusses and minuses about using this approach. Look at CBT not as some end all or cure for what ails you but maybe as one tool you can choose from an array of treatment options. CBT just may help you but you won’t know unless you actually undergo treatment. In order for any therapy to work, your therapist will need to tailor their techniques to suit your goals, personality, and type of disorder.
CBT is not a one size fits all methodology and I think this is where we go wrong when we assume that this is a unified approach known to all. The details are very important in making any judgement about whether this approach may work for you.
We would love to hear from you now. Have you ever had CBT? How did it go? Was it effective to treat your condition? What sorts of therapeutic techniques did your therapist use? Would you recommend CBT to other patients? Let us hear your story. It may help someone going through the same thing.