Cognitive behavioural therapy (CBT) is often thought of as the gold treatment standard for mental health issues. This is because CBT is evidence-based, meaning that research has consistently supported the benefits of treatment. Moreover, most hospital-settings prefer CBT as the primary psychological treatment because it is short-term (to reduce wait times to receive services) and structured (making it easy to train mental health professionals to provide CBT).
However, despite CBT’s strengths, there are limitations to this dominant treatment modality. This post describes some of the pitfalls of CBT and ways to address them.
1. Too much focus on change (and not enough validation)
CBT is about changing our thoughts and behaviours to improve our mental health. For example, challenging the belief that “I’m a failure” or “the world is dangerous” to improve mood or reduce anxiety.
However, when we jump the gun and only focus on change, we might invalidate the client’s experience. Yes, it would be helpful to think of the world a little differently than viewing it as totally dangerous, but there was probably a reason for this person to think of the world as dangerous in the first place. For example, a traumatic car accident or a losing a family member to violence. Asking them to immediately change this view can belittle their very real concerns.
Therefore, there is a need to slow down and validate that there is a reason why a person feels a certain way. We need to first recognize and show understanding of the client’s perspective before working together to build more adaptive thoughts and behaviours that support them towards their goals.
2. Too much focus on structure
In working within hospital-settings, I found that CBT treatments can be highly manualized. There is a set agenda for each session with a specific time limit to discuss each component, for each disorder. A 12-week manual for anxiety, a 16-week manual for depression – so on and so forth.
Although this makes sense to ensure consistency in care for all clients, the problem is that a manualized treatment makes it hard to flexibly work with each person’s unique needs. It feels like a shotgun approach to see what sticks. While this works for some folks, other people do not benefit nearly as much – whether because they feel overwhelmed or because they are not able to really soak in the information.
Instead of providing all the possible skills, I sometimes it helpful to give a couple tools and lessons that a client can hold on to and really cultivate to support their lives. The chosen skills are based on what we think may be most relevant to how their mental health challenges are maintained (and what the client prefers). This helps them to be a master of one skill, rather than a beginner of many.
3. Prioritizing only the content, and not the relationship
CBT therapists sometimes get caught up in all the content, education, and skills, that we sometimes forget about important qualities that make or break any type of therapy. For example, being genuine and warm, learning about the person, and developing a strong relationship. These common factors have been observed in the research to be incredibly important part of the process. As Irvin Yalom once said: “It is the relationship that heals.”
Therefore, I believe it is important balance the content with developing the relationship. To take time to learn about the human in front of you and cultivate an alliance built on trust, respect, and cooperation.
4. Thinking that CBT is a good fit for everyone
Research finds that CBT works. Research does not find that CBT works for everyone. Some folks do not vibe with changing our thoughts or behaviours. In some cases, clients prefer to work on acceptance and changing our relationship with experiences, rather than changing the experience itself.
A good example is a person who notices that they have a lot of depressive thoughts, such as “I’m worthless”, “things are always going to be like this,” and “there’s no point.” Although a CBT approach might try to change the thought itself, more acceptance-based strategies try to help us notice the thoughts, but recognize that it is just a thought. Thoughts are thoughts. Thoughts are not facts. This realization can lead to reductions in our reactivity to negative thoughts without having to outright challenge them.
5. Being too focused on the present
CBT emphasizes what’s going on in the present – the ‘here and now.’ This can be helpful to work on current goals, which leads to more specific and actionable steps that can be taken. For example, taking a 10-minute walk twice a week if you are working on increasing physical activity. However, much of the lessons we learn and reasons we behave in certain ways is because of past events, such as childhood experiences. For example, thinking we are a burden because our parents consistently dismissed us when we were young. Gaining awareness of where these feelings come from can in and of itself can be freeing – because it separates our past traumas from the here and now. The client can then make a distinction between their past and present, and begin to heal and change.
6. Not enough focus on the emotion
One last pitfall is that CBT, as the name suggests, primarily focuses on thoughts and behaviours. In my practice, I have found that honing-in on the emotion can be very deep and meaningful. It provides so much insight into the inner experience.
Moreover, in other therapies (like dialectical behaviour therapy), a client’s behaviours are understood by the way they react to aversive emotions. Ineffective behaviours (e.g., alcohol use, shouting at other people) are made sensical by their benefit of getting away from uncomfortable emotions. Therefore, learning to work with a client’s emotions and learning to respond to them in a more effective manner can lead to important changes in their lives.
Best wishes,
P
Simply mental health 