Cognitive Behavioral Therapy, Revisited

CBT Isn't as Manualized as You Think, Says Judith Beck

Mary Sykes Wylie

Cognitive behavioral therapy (CBT) is arguably the most successful therapy ever developed. In only about 40 years, it’s gone from the almost accidental innovations of two disenchanted psychoanalysts to the most widely practiced and promulgated approach in the world. For space aliens who’ve never heard of CBT, a quick and dirty definition may be in order. CBT—not a single model, but a constellation of short-term, pragmatic, goal-oriented clinical techniques, used in varying ways in different circumstances with people suffering from different conditions—is based on a simple axiom about human experience: how we think and perceive hugely influences how we feel. Independently coinvented by Aaron Beck and Albert Ellis, the clinical method rests on a kind of Socratic questioning (with lots of homework!), which helps clients identify and correct the inaccurate, defeatist assumptions and distorted thinking patterns that keep them stuck in a perpetual round of self-reinforcing unhappiness.

Taught in almost every clinical psychology and psychiatry program in the United States, CBT dominates the field in North America, much of Europe, and increasingly, Asia and Latin America. It’s essentially the “official” therapy of the healthcare arm of the US Department of Veterans Affairs, which has in place a national staff-training program for treating depression—the largest such program in the country. Managed care and insurance companies love CBT for obvious reasons: it’s brief, usually 16 sessions or fewer, thus much cheaper than that once-famous other brand, psychodynamic therapy. It’s also reassuringly protocol-driven, sticking to a plan without wandering all over the place for years at a time. But what really stands behind its extraordinary rise is, and always has been, its claim to be far and away the most empirically supported therapy out there.

But for all its mantle of scientific rigor and official approval, many therapists find CBT hard to love, if not downright dislikable. They don’t really believe that “lab therapy,” with its strictly exclusionary criteria limiting samples only to the “purest” cases, has much relevance to the heterogeneous clients they see every day, each with multiple diagnoses and a jumble of symptoms. These critics are usually inclined to see therapy more as art than science anyway, regarding therapy as a special kind of relationship, requiring the kind of people skills they assume aren’t really necessary for following a protocol.

In the interview below, Judith Beck is here to tell you that CBT has gotten a bum rap. Judith Beck, the Great Man’s daughter, is herself a leading CBT clinician, researcher, author, and president of the Beck Institute for Cognitive Behavior Therapy, a nonprofit organization that provides training to mental health professionals worldwide.

What are the defining characteristics of the cognitive therapy approach to depression?

Judith Beck: The hallmark of cognitive therapy is understanding clients’ reactions—emotional and behavioral—in terms of how they interpret situations. For example, currently I’m treating a severely depressed client I’ll call Mary, who basically sits on the couch for most of the day, feeling hopeless and sad. Even though she understands that she’d be better off if she were to become more active, she can’t overcome her profound lethargy. She continually has thoughts like This apartment is so messy. Nothing’s put away. What’s wrong with me? I should get up and do something, but it’ll just be a drop in the bucket. What’s the point? No wonder she feels so depressed and hopeless and just stays on the couch.

The repeated themes in people’s thinking and behavior always make sense once we understand the basic way they view themselves, their world, and other people. Mary, for example, sees herself as helpless and incompetent, a “complete failure,” and that pervades her moment-to-moment experience. Not only does she feel unable to get off the couch, but she also believes that she won’t be able to solve any of her problems and that nothing, including therapy, can help.

That kind of outlook is one of the biggest problems in working with depressed clients. How do you begin trying to work with someone who seems so hopeless?

Beck: First, I reinforced her for being open about her skepticism: “Mary, it’s good you told me that.” Then I reinforced the cognitive model by saying, “That’s an interesting thought. You don’t think that therapy can help. How much do you believe that?” Then I proposed we test the thought: “Mary, I’d like us to figure out whether that thought is likely to be 100 percent true or 0 percent true or someplace in the middle.

Is it okay if we take a look at it?”

I asked Mary several questions. What evidence did she have that the thought was true? What evidence did she have that the thought wasn’t true or not completely true? Was there another way of looking at this situation? What was the effect of telling herself this over and over? If her best friend had this thought, what would she tell her? Following our discussion, I asked Mary what she thought would be important to remember. She verbalized a good summary, which I suggested we should write down: “Just because other therapy didn’t help much in the past doesn’t mean that this therapy won’t. It sounds different, and it makes sense. I would want Joyce [Mary’s best friend] to give it a try. I should do that, too.”

And finally, I asked Mary whether she’d be willing to let me know in the future if she again became skeptical that therapy would help. She agreed.

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Is that how you usually handle negative feedback?

Beck: Clients should always be positively reinforced for expressing their doubts and concerns about therapy or the therapist. So the first thing we generally say is something like “It’s good you told me that.” Then we need to understand why the problem arose. If I think I’ve made a mistake, I apologize and figure out with the client what we need to do to address the problem and prevent it in the future. For example, I remember another depressed client, named Lori, who got quite upset one day when I pulled out a Thought Record to help her learn how she could evaluate her own thoughts at home.

“I hate worksheets!” she said. “They never help!”

“I’m sorry,” I said. “I made a mistake. This was obviously the wrong thing to do.”

So I tore the Thought Record in half and threw it away to demonstrate to her that I wanted to make treatment right for her. I also asked, “Would you be willing to let me know the next time I make a mistake?” When she said she was, I asked, “Can we go back for a minute? What do you think of the idea of trying to answer back some of these thoughts we were talking about before that are so upsetting when you’re at home?” She agreed with that idea in principle, and we figured out another way for her to do this without a worksheet.

Cognitive therapy is often criticized as not attending to the therapeutic alliance. Yet here it sounds as if you’re addressing it quite directly.

Beck: I’m not sure how this view started, but it certainly isn’t true. The earliest textbooks in cognitive therapy, written over three decades ago, discuss its importance. A strong therapeutic alliance is essential to treatment. It’s just not sufficient in itself to help clients get better as soon as possible. Therapists also need expertise in cognitive conceptualization, treatment planning, and the technical aspects of carrying out treatment.

As a therapist, you always need to adapt your style so it meshes with the client’s preferences. You need to be attuned to changes in the client’s mood during sessions to pick up when he or she is having important automatic thoughts. You need to be highly collaborative and elicit feedback. You need to use all the basic Rogerian counseling skills. In other words, you need to be a nice human being in the room with the client and treat every client the way you’d like to be treated. And of course, therapists need to work on their own negative reactions to clients.

I think part of the misperception people have about cognitive therapy comes from the fact that research studies use manuals. But there’s a huge difference between how cognitive therapy is conducted in randomized controlled trials—which require standardized procedures—and clinical practice, in which it’s crucial to fit the therapy to the client’s cultural and educational background, stage of life, personal preferences, and many other things.

While cognitive therapy is the most researched therapy model, it still hasn’t achieved widespread acceptance among many clinicians in private practice, who complain that it’s too structured and restrictive. Why so much emphasis on structure?

Beck: Why do we structure the session in the first place? Every minute in a session is precious, and we want to maximize the time we have to help clients learn to deal with the issues that are most important to them. At the beginning of sessions, we do a mood check (so we can make sure that clients are improving), get an update (including a review of their action plan from the previous session), and find out what problem or problems they most want help in solving. Then we help clients prioritize their issues and ask them which one they’d like to start with.

In the middle of sessions, we discuss their most pressing problems and collaboratively decide where to start working. For example, should we do problem-solving? Should we help them evaluate their thinking? Should we teach them emotional-regulation skills, or other cognitive and behavioral techniques? After discussing the problem and working at one or more of these levels, we ask clients, “What do you think would be important for you to remember this week? What do you want to do about this problem this week?” We give them the choice of writing down this important summary or having us write it down for them.

At the end of sessions, we ask clients for feedback. What did they think of the session? Was there anything they thought we didn’t understand? Is there anything they want to do differently next time?

Toward the end of treatment, we ask clients to write a list of early warning signals they’ll use to detect if they’re starting to get depressed again. Then we help them develop a written plan of what they should do if that happens. We also teach them how to hold a self-therapy session with themselves. We try to taper sessions so clients gradually end treatment, and if possible, we schedule booster sessions after treatment is over. Overall, the research shows that clients who’ve had cognitive therapy have about half the relapse rate as those who only take medication.

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Mary Sykes Wylie, PhD, is a senior editor of the Psychotherapy Networker.

This blog is excerpted from "The CBT Path Out of Depression" by Mary Sykes Wylie. The full version is available in the November/December 2014 issue, Depression Unmasked: Exposing a Hidden Epidemic.

Photo © Filo/Getty Images

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Topic: Anxiety/Depression | Professional Development

Tags: Aaron Beck | Albert Ellis | Carl Rogers | cbt | client feedback | cognitive behavioral therapist | cognitive behavioral therapy | cognitive behavioral therapy cbt | cognitive therapy | Judith Beck | negativity bias | psychology as a science | relapse prevention | therapeutic alliance

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2 Comments

Tuesday, August 30, 2016 7:49:32 AM | posted by indu chhibber
I have full faith in the efficacy of this therapy and I practice it too.Both medication and CNT have their own distinct uses. A client of mine was hospitalised for ten days without any improvement and then he was given counseling which cured him completely. http://jeeteraho.blogspot.in/2016/05/post-traumatic-stress-disorder-or.html

Saturday, April 13, 2019 1:22:23 PM | posted by Glenda - UK
While there is no doubt that CBT has it's place as a tool in any psychotherapeutic tool box, I agree that it is ONLY ARGUABLE as to its therapeutic success. A tool is not a therapy, just like a hammer alone cannot build a home. If we accept that humans are relational beings made up of both cognition and emotion, then cognitive therapy alone is not the answer. I have lost count of the number of clients who have come to me distraught that CBT, at best, offered them no relief or, at best, for a very short time. As a response to the previous commenter, there is enough evidence out there to suggest that no one is cured of their psychological challenges, but that many learn to manage those challenges more comfortably and less overwhelmingly.