Cognitive behavioral therapy (CBT)
Preliminary studies of CBT showed impressive improvements in symptoms of conditions ranging from depression to personality disorders, leading to a surge in therapists who offered CBT. This type of therapy continues to be one of the most widely used evidence-based treatments available.
According to famed British psychologist Oliver James, though, CBT is a “scam” that does little to address underlying psychological issues. James, a psychodynamic therapist, argues that until people understand what led to their psychological troubles, those troubles are likely to reoccur.
GoodTherapy.org CEO and founder Noah Rubinstein, LMFT, LMHC, takes a similar stance with regards to addressing underlying issues in therapy.
“I am certainly not an expert on what research has shown about the efficacy of CBT, and I certainly don’t want to throw the baby out with the bathwater. CBT is an evidence-based, short-term therapy that has helped many people. However, on a theoretical level, I’ve always considered CBT to be a surface-level treatment rather than a method for lasting changes,” Rubinstein said. “In my experience, the only way to make lasting change is to help people tend compassionately to the more vulnerable feelings that protective functions, or defense mechanisms—such as depression, anxiety, self-criticism, anger, or addiction—are shielding us from.”
There’s no question about CBT’s short-term effectiveness; even James admits that people receiving CBT can see remarkable improvements in a short period of time. So effective is CBT in the short term, in fact, that CBT self-help manuals such as David Burns’s The Feeling Good Handbook have become bestsellers. Because CBT teaches people how to detect and stop automatic negative thoughts, it’s especially popular for treating depression and anxiety. Some therapists, regardless of therapeutic modality, even insist that their clients use CBT principles to treat these conditions.
When researchers evaluate the long-term effects of CBT, the treatment looks less promising. James points out that psychodynamic psychotherapy yields better results in the long term because it helps people address the root causes of their distress. Several studies support this claim. For example, a 2003 meta-analysis that compared CBT and psychodynamic therapy for depression across several studies found that people who used psychodynamic therapy had larger improvements. Another study of marriage therapy evaluated the effects of behavioral versus insight-oriented marital interventions. CBT relies on behavioral interventions, while psychodynamic therapy is built on insight. Thirty-eight percent of couples who used the behavioral strategies were divorced four years later, compared to just 3% of couples who relied on insight-based approaches.
Rubinstein takes the view that conditions such as depression and anxiety protect us from the vulnerable feelings associated with the true source of our distress.
“For example,” Rubinstein said, “the man with depression who’s shut down, can’t get out of the bed in the morning, and has given up might be protecting himself from trying, failing, and once again feeling that terrible worthlessness he’s felt in the past.” Like James, Rubinstein sees CBT as a short-term fix that “helps to eliminate the problematic, surface-level protective behavior.”
Indeed, one of the selling points of CBT is that it doesn’t require a long-term commitment to therapy. Many CBT programs take only a few months, and some promise near-immediate results. A study published in Psychological Medicine in 2008, though, found that long-term approaches may be preferable. That study compared long-term psychodynamic therapy to two short-term therapies: short-term psychodynamic therapy and solution-focused therapy. While the short-term approaches produced more immediate results, those results faded over time. At the three-year mark, people who had undergone long-term therapy saw more improvements. Although this study didn’t evaluate CBT, it does suggest that dedicating more time to gaining insight can be valuable.
Laura Reagan, LCSW-C, a GoodTherapy.org Topic Expert on trauma and posttraumatic stress, blends CBT with a variety of other techniques. She sees CBT techniques as effective and essential, though she acknowledges that CBT may not be best for addressing long-term issues.
“In my practice with trauma survivors, focusing only on changing thoughts and behaviors through CBT without using a more depth-oriented approach will result in only temporary improvement of symptoms which are likely to return, as the underlying problem has not been addressed. I use CBT skills as part of my work with clients to challenge negative cognitions about the traumatic events experienced.”
Rubinstein agrees that underlying problems need to be addressed for lasting change, “I don’t agree with everything Freud postulated, but he did believe that if you eliminate a defense mechanism, another will take its place, and I think that is the problem with CBT in terms of its long-term effectiveness. Therapies that help people to resolve the deeper and more vulnerable feelings that fuel defense mechanisms offer potential for long-lasting change.”
While CBT doesn’t work for everyone, it’s far from a scam. James is a well-respected therapist, but he’s also a practitioner of psychodynamic therapy, so his opinion is by no means free of bias. While some studies have shown that psychodynamic therapy is more effective in the long term, others show that the two approaches are equally effective. Few studies show that CBT doesn’t work at all, and several studies suggest that CBT can work in the long term. A study that evaluated people who had been treated with CBT for social anxiety found that, even three years later, they were able to use what they had learned in CBT to more effectively cope with anxiety. A 2006 review of recent studies found that CBT may help reduce depression relapse rates, particularly when researchers compare the effects of CBT to the effects of medication alone.
Carey Heller, PsyD, a GoodTherapy.org ADHD Topic Expert who uses CBT as well as other forms of therapy in his practice, highlights the importance of a strong therapeutic alliance. He explains, “Many studies have shown that the quality of the relationship between the therapist and the patient/client is one of the best predictors of treatment outcome. Thus, the specific type of treatment, whether it is CBT, psychodynamic, or an integrative approach, is not the only determining factor in whether treatment will be successful for a specific individual. I feel it is more important to find a clinician who you feel comfortable with and can look at your unique needs in determining the best treatment approach to help you rather than just seeking out a specific type of treatment on your own.”
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