Why Cognitive Behavioural Therapy (CBT) Doesn't Work

What is CBT and how does it work?

Cognitive behavioral therapy (CBT) is one of the most common methods of psychotherapy used to treat complex psychological problems and illnesses, such as complex anxiety disorder and post-traumatic stress disorder (PTSD). It is based on the combination of two approaches: cognitive and behavioral. In the 1980s and 1990s, cognitive and behavioral methods were combined into cognitive behavioral therapy. The key moment in this fusion was the successful development of treatments for panic disorder by David M. Clark in the UK and David H. Barlow in the US.

In this case, three waves of CBT development are distinguished. The first wave includes behaviorism (1920s). In the 1950s, a personality with individual reactions to external stimuli appears in CBT. It was at this time that A. Beck introduced the concept of “automatic thoughts” and deep beliefs. Classical CBT works with them. By changing automatic thoughts, a person's sensations (feelings) change in response to an external stimulus, and as a result, deep attitudes can change. At this stage, cognitive and behavioral therapy are combined.

During this period, key concepts of CBT and schemes for their application are formed. The basic logical concept of the connection between thoughts, actions and feelings is presented in Fig. 1.

Fig. 1. Interrelation of key concepts of CBT

The third wave focuses on developing awareness and acceptance. Third wave CBT helps the client accept themselves and their characteristics.

It would seem that the second wave of CBT, working with the client through the correction of automatic thoughts, that the third one – aimed at self-acceptance and the formation of personal awareness and values, have working schemes and mechanisms of psychological work with the client. However, all these methods are aimed at correcting the client's behavior and reducing the impact of traumatic events in the past on the current state and, first of all, the client's behavior. At the same time, self-acceptance includes acceptance of the client's characteristics that do not allow him to become a full-fledged member of society. It is assumed that it is necessary to reduce expectations and accept one's characteristics, instead of striving for achievements, including overcoming severe chronic diseases.

One of the problems that CBT helps to cope with is frustration caused by failure to achieve one's goals. For example, psychological assistance to a client who is unable to get a high-paying job due to the labor market situation, even with a higher education. Such assistance is aimed at reducing frustration and maintaining self-esteem, despite external circumstances. However, with this approach, the client's level of strength to solve his actual problems does not increase. This therapy can be called “humility therapy.” Instead of forming an internal resource to overcome problems, a person is made more adaptive to negative external events and facts. A certain Christian ethic of humility is read here.

Moving on to a discussion of CBT as it applies to trauma and PTSD, it is important to note that the outcome of therapy is symptom reduction, not the client’s return to normal life. These outcomes are the easiest to measure, which allows us to justify the high effectiveness of CBT. It is believed that symptom relief is already an excellent outcome of such therapy, which is not always achieved.

Moreover, even the proven effectiveness of CBT, according to scientific research, has been significantly declining since 2008.

Fig. 2. Average effectiveness of CBT according to various published studies

Figure 2 shows the average values ​​of the CBT effectiveness indicators published in the corresponding years in various scientific sources. Thus, we can confidently conclude that the effectiveness of CBT is not only decreasing, but is currently at an extremely low level. It is slightly higher than 20% for the group of anxiety disorders. At the same time, disorders of this type affect about 30% of young people who do not have serious traumatic experience in the past, and more than 40% of young people with trauma.

Why doesn't CBT work?

In many ways, this dynamic is explained by the fact that people both in everyday life and in professional circles pay more attention to the quality of life, opportunities for self-realization and achievements. In other words, we can make a logical conclusion that treatment aimed at reducing the symptoms of psychological problems does not treat their sources. In essence, there is no deep solution to the problems, and the modern world has a large number of external triggers that affect people to a greater extent than before.

According to the definition of poverty introduced by Nobel laureate D. Kahneman and his co-author A. Tversky, poverty is a feeling of loss that people feel when they have to give up some goods in favor of others. We are not talking about choosing between cake and ice cream. Here we mean the need to deny yourself the purchase of quality food to pay for housing, including a mortgage. Thus, a person with a normal level of income, buying something, feels a pleasant joy from the purchase made. While a poor person feels and understands that he will have to deny himself something else, which leads to frustration. Considering the level of housing prices and its dynamics in Russia and developed countries, as well as its inaccessibility for young people, the level of poverty is growing significantly in this age group, which leads to the development of psychological problems and the formation of various diseases, including depression and various types of anxiety disorders.

When talking about working with trauma using CBT, it is important to understand that trauma radically changes the self-concept of the individual, creates a feeling of vulnerability, insecurity, and the insignificance of personal boundaries. This is what subsequently leads to the development of psychiatric illnesses. At the same time, treating the symptoms of illnesses does not lead to significant changes in the personality. In other words, the deep response to external triggers remains deeply negative and the person is easily retraumatized.

The situation is even more complicated in cases where the trauma occurred at an early age. In this case, there are two problems at the same time. The first of which is a possible “stuck” at a certain age, which interferes with recovery. CBT methods can make a person’s reactions to external stimuli more adult, but this does not mean that he will feel like an adult. Moreover, cognitive methods involve working with a fairly adult person and his mental state in order to correct his psycho-emotional state by performing mental exercises in situations with a negative external stimulus. Thus, the psyche must be healthy enough to perform these exercises, and the client must have enough internal resources to perform them. In this case, you can try to correct the self-concept, within the framework of which it is reasonable to use CBT techniques and methods, but you cannot limit yourself to them alone. In addition, in the case of trauma at an early age, it may not be formalized in words at all, often clients do not even remember it. As, for example, A. Lowen, the creator of the bioenergetic analysis method. In his book “Joy. How to fill the body with energy and life with happiness”, the author talks about a traumatic experience that happened to him when he was only 8 months old and which later affected his perception of himself as an adult. Such traumas are difficult to describe in words, which will only reflect them. They lie in the realm of feelings, which is why it is better to work with them using other methods, for example, in a psychodynamic approach.

Thus, to sum up, the main criticism of CBT can be summed up in the following theses:

· This type of therapy is aimed at reducing the symptoms of mental illness, rather than treating trauma;

· it is a therapy aimed at reducing the level of frustration, rather than increasing the level of satisfaction with life;

· this therapy requires mental effort from clients, including in situations with a complex external stimulus, while there are no mechanisms for the formation of an internal resource that ensures the operation of this mechanism;

· Over the past few years, the effectiveness of this type of therapy for complex mental illnesses has dropped to just above 20%;

· it is only partially applicable to situations where the formalization of any thoughts is limited.

In other words, it is safe to say that the popular opinion about the effectiveness of CBT is overestimated, which is due to two factors: the choice of the measurement scale (both symptom reduction) and the conditions for the development of this method. It was developed mainly in the USA, where science is developed on state and private grants. Grantors most often pursue their own interests in future research results. At the same time, there is no need to talk about the socio-economic benefit for both the state and corporations from reducing the level of frustration of citizens without increasing their internal resource for improving their lives.