I was surprised. My first blog received so many responses, that I thought I would address a few concerns that were expressed. (They mirror the misconceptions I uncover when I give workshops on CBT to therapists who have not read the major CBT books or received formal training and supervision in CBT or watched DVDs of CBT therapy sessions).
Q: Doesn't Cognitive Behavior Therapy downplay the importance of the therapeutic relationship?
A: No! CBT requires a good therapeutic relationship. Therapists do many things to build a strong alliance. For example, they work collaboratively with clients (making joint decisions such as how to spend the therapy hour), ask for feedback ("What did you think of the session? Anything you want to do differently next time?"), and conduct themselves as genuine, warm, empathic, interested, caring human beings. They also work hard to reduce patients' suffering as quickly as possible. Interestingly, research shows that the alliance becomes significantly strengthened when clients see that their therapist is helpful, that is, when clients see themselves solving their problems and feeling better.
Q: Doesn't Cognitive Behavior Therapy require clients to be motivated?
A: No. Many clients are unmotivated when they first come to treatment. One essential part of therapy is helping clients set goals they want to reach, which often boosts motivation. If it doesn't, it is the responsibility of therapists to help patients build motivation. They need to gently question clients to discover whether the problem is due to a practical concern (e.g., that therapy is too expensive), to the clients' thoughts (e.g., that others are to blame and they shouldn't be in treatment themselves), and/or to mistakes they (the therapists) have made (e.g., interrupting clients too much). It is also helpful to record in writing what clients see as the advantages and disadvantages of coming for treatment and the advantages and disadvantages of not coming for treatment.
Q: How do I know if my therapist is really practicing CBT?
A: You can download a document from www.beckinstitue.org entitled "Q and A about Cognitive Therapy" for a description of CBT. You can also visit the Academy of Cognitive Therapy website to find a certified cognitive therapist. Unfortunately, many people call themselves CBT therapists when they are not employing even the most fundamental elements of this kind of treatment. I frequently discover this when I give workshops. Often 80 percent of attendees self-identify as CBT therapists, yet only about 20 percent raise their hands when I ask who sets an agenda, discusses homework, sends clients home with notes (with what clients need to remember during the week) and asks for feedback, at virtually every session.
Q: Is it true that CBT isn't deep, doesn't help clients gain insight, and helps people only superficially?
A: No! For clients to improve, they need to understand themselves well. They need to know why it is that they are feeling upset and/or behaving in an unhelpful way (i.e., contrary to their goals). The answers are related to what they are thinking at the moment. Gaining this insight is essential but insufficient. Clients need to know what to do with this insight this week to make their lives better.
The next step is to help clients evaluate their thinking, which allows them to appraise situations and problems more realistically. When they do this, they are able to behave in a more functional way and move toward their goals in life.
Clients also need insight into why they think the way they do, which is related to their underlying beliefs, that is, the basic way they see themselves, others and their worlds. These beliefs begin developing in childhood but usually it is not necessary to spend much time uncovering the roots of these beliefs unless clients have personality disorders. Again, insight alone is necessary but insufficient, and clients need to evaluate and modify their unhelpful, unrealistic beliefs.
Therapists often work at deeper levels, too, when, for example, clients' goals are related to finding more meaning in life, living according to their most deeply held values, or coming to an acceptance of problems that can't be changed. However, this work is done (if it is still needed, and often it is not) after clients have recovered from their psychiatric disorder (if they had one).
As for superficiality, if it were valid, then one would expect that people who have recovered from a disorder would soon relapse. The opposite is true. In depression, for example, clients successfully treated with CBT have half the relapse rate as people treated with medication alone.
Q: How do I know if therapy is working?
A: You should be feeling better, behaving in a more functional way, solving your problems and making progress towards your goals.
Judith S. Beck, Ph.D.
President, Beck Institute for Cognitive Therapy and Research
Clinical Associate Professor of Psychology in Psychiatry,
University of Pennsylvania
www.beckinstitute.org and www.beckinstituteblog.org
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