Updated: Sep 7
The utilization of psychotherapy services is increasing tremendously. As more and more people reach out for help, I've noticed that awareness of psychotherapy approaches is increasing too. More specifically, there is one approach that many if not most of the clients walking into my office have heard of: CBT. I've found myself wondering, CBT is just one of the hundreds of psychotherapeutic approaches out there - why is this the one approach clients have heard about? If you're curious about the increasing popularity and seeming dominance that CBT holds over the world of psychotherapy read on! In this short article, we'll take a look at what CBT is about, some common misconceptions and essential bits of knowledge, and consider whether CBT truly deserves the attention it has been getting.
Origins and definitions
Cognitive-Behavioral Therapy or CBT for short was developed in the 1960s by the late psychiatrist Dr. Aaron T. Beck. At the time of its development, CBT represented a shift from some traditional models of psychotherapy, which emphasized the resolution of psychic conflicts and the development of insight. Often this would be achieved through facilitative discussions - sometimes over a course of years -between client and therapist and could lead to reduced client distress and improved life functioning. Cognitive-Behavioral Therapy also aimed to resolve client distress and life problems. However, a key focus of CBT was on helping clients change their behaviours and thoughts in the present moment often leading to a more practically-focused and shorter-term counselling approach. Within CBT, clients would be taught how to clients better identify the specific thoughts, feelings, and behaviors that were contributing to their present difficulties and on changing these to more adaptive thoughts and behaviors.
While the term CBT is often used to refer to the therapy created by Dr. Beck, his therapy was originally called Cognitive Therapy or CT. Today, Cognitive-Behavioral Therapy and Cognitive Therapy are terms often used interchangeably to refer to the same psychotherapy approach developed by Dr. Beck. Although when people use the words Cognitive-Behavioral Therapy they are often referring to the specific approach originally developed by Dr. Beck, Cognitive-Behavioral Therapy is also used as an umbrella term to describe a range of psychotherapeutic approaches that fall under the wider cognitive-behavioral therapeutic orientation. These include approaches such as Acceptance and Commitment Therapy (ACT), Compassion Focused Therapy (CFT), Dialectical Behavior Therapy (DBT), Mindfulness-Based Cognitive Therapy (MBCT), Functional Analytic Psychotherapy (FAP), Exposure Therapy, and many other approaches. Common threads drawing these approaches together are that they are action-oriented, emphasize understanding and working with the thought-feeling-action connection, aim to understand the function of client behaviors, and help clients learn skills, strategies, and tools for moving their lives in a more positive and less stuck direction. In addition, many cognitive-behavioral approaches place the primary emphasis of therapy on changing the present moment context rather than exploring past history in-depth (although this may be done for the sake of informing and facilitating present-focused work).
What are the strengths and benefits of CBT?
CBT and other cognitive-behavioral approaches have gained increasing popularity in recent years. Part of the reason for this is that CBT approaches tend to be highly research-backed and display some of the strongest evidence-base for helping clients with varying mental health concerns. Although, it should be noted that one reason that CBT approaches display such a robust evidence-base is that the structure, manualization, and time limitations of some forms of CBT are particularly well-suited to research. In other words, CBT is a type of therapy that is highly suitable for research projects and so is more likely to be researched than other, often equally qualified therapy approaches. Notwithstanding this point, CBT has been tremendously well studied and evaluated as an effective psychotherapy for many common mental health issues including anxiety and depressive disorders, attention-deficit-hyperactivity-disorder, obsessive-compulsive disorders, anger, trauma, and more making it easy to recommend. Another reason for the success of CBT is its highly action-oriented nature which enables clients to almost immediately start putting into practice knowledge, skills, and tools that can have a very practical real-world impact on their lives. The CBT emphasis on skills-building also allows clients to in a way become their own therapists, learning skills and tools that are helpful to them that they can keep using in their lives even outside therapy sessions. Thus, CBT often does not require a significant long-term commitment to attending therapy sessions for years at a time, making it cost-effective and less burdensome than some approaches. Many clients like cognitive-behavioral counselling and find it be an engaging, practical, and sensible way to do therapy.
What are some limitations of CBT?
Cognitive behavioral therapy is not without its critics, however. Some clients can find the structure of CBT confining and the goal and time-focused nature of the approach as unwelcoming, almost as if there is a particular deadline by which they need to 'get better.' To some extent, these concerns are particularly present in Beck's CBT but often less relevant in sister approaches such as Acceptance and Commitment Therapy (ACT) or Compassion Focused Therapy (CFT). In these related approaches which are similarly rooted in cognitive-behavioural principles, counselling tends towards a more client and context-centered style of therapy that can feel more flexible and open than traditional CBT. Additionally, these concerns may be more heightened in particular settings where resources are limited (i.e. agencies, hospitals, or government-funded programs) but less of a concern in private practice therapy settings where it is the client, rather than an external body who can more explicitly define and direct the focus of therapy.
For better or for worse, CBT has also been associated with extensive homework use. Clients are often given prompts, worksheets, resources, or exercises to contemplate or complete outside of therapy sessions. Many clients appreciate the additional resources which can deepen and reinforce their therapeutic progress. However, critics of CBT may argue that such tasks can be tremendously burdensome to clients, cause therapists to rely on highly motivated clients (i.e. those who will complete all the worksheets!) for progress, or cause shame and self-criticism for clients who don't follow through on home tasks. While it is true that all these points can be valid concerns, they are not a reflection of properly implemented CBT. Skilled CBT therapists will break down and tailor tasks to the readiness and receptiveness of their clients, will use homework to augment - not replace - therapy sessions, and will anticipate client difficulties and barriers in home task completion to address these barriers and associated, natural, self-critical thinking. In much the same way that a middle-school teacher can unskillfully replace their act of didactic and instructional teaching with the introduction of copious amounts of worksheets, any therapist can be unskillful in how they implement the principles of any approach. Challenges in these areas then are more likely a reflection of therapist skill rather than the quality and integrity of a therapeutic approach.
Too Surface Level?
CBT has also been criticized by some therapists and clients as not going deep enough, to the root of client problems. Some criticize the top-down nature of the approach as being too cognitive, brainy, heady, or logical, and missing deeper emotional conflicts, relationship or attachment histories, or failing to address past traumatic material that precipitates present-moment difficulties. In some cases, these criticisms are provided by people who have possibly only had a passing encounter with cognitive-behavioral approaches. In fact, exploring and addressing the role of emotions, attachment, trauma, and somatic experiences is generally a part of all cognitive-behavioral approaches. In some cognitive behavioral approaches, such as Compassion Focused Therapy, exploring attachment and relational history may in fact be a primary focus of therapy. It is true, however, that in settings where CBT is offered and resources are limited that a deeper exploration of issues is often not possible. This is more a limitation of settings associated with CBT approaches rather than cognitive-behavioral approaches per se. It is also true that other therapies may have a greater bottom-up focus and more explicitly prioritize and explore these issues, even if they are addressed to an extent within many cognitive-behavioral approaches.
So is CBT for me?
There are many good reasons for the rising popularity of cognitive-behavioral approaches. These approaches are often heavily science-based, goal-oriented, and skills-focused. CBT approaches have many strengths and are a fit for many client problems. At the same time, the rising popularity of these approaches does not indicate that they are the best approaches at all times for all clients. CBT is not the 'one approach to rule them all.' Hundreds of psychotherapeutic approaches are in use today that have earned the title of evidence-based. Hundreds of approaches beyond those considered strictly cognitive-behavioral have helped thousands of clients experience tremendous therapeutic growth and significant and meaningful life change. Whether a specific psychotherapeutic approach is right for you depends on a confluence of factors including your goals, past experiences with therapy, resources available to you, life circumstances, and preferences. Learning more about specific approaches and what they offer can better help you decide what is right for you. If the descriptions and aims of cognitive-behavioral approaches described in this article resonated with you, you may indeed find that CBT is an approach worth trying.