CBT: it’s terrible, except when it’s not
Like many of my clients, I have had some PTSD-inducing experiences with CBT.
Like many of my colleagues, I do occasionally use CBT techniques with my clients.
What the hell, man? You may justifiably be asking at this point. Gimme five minutes, and hopefully this will make a little more sense.
First off, what the heck is CBT anyway? You probably know it’s Cognitive Behavioral Therapy on its driver’s license, but beyond that, most people would be hard-pressed to define it in a sentence. For a lot of people, myself sometimes included, CBT has become a cipher for “everything I hate about the western medical model of mental health.” And not without reason, although I would argue that as with most things, the nuance is where the good stuff is.
So, let’s start with those first two words: Cognitive and Behavioral. They’re both in the name because CBT is a hybrid of two theoretical lineages: Cognitive Therapy and Behavioral Therapy. A labradoodle of therapy techniques, if you will.
Cognitive Therapy was developed by a USAian psychiatrist named Alan Beck in the 1960s, and he based it in (stole it shamelessly from?) the ancient Greek philosophy of Stoicism. Stoics were the OG “fake it ‘till you make it” guys—basically they believed that if you lived according to a set of culturally-bound virtues (faked it) you would achieve wellness and success in all areas of life (make it). Dr. Beck’s model focuses this philosophy on a client’s thoughts—“testing” them, identifying “distorted thinking,” and changing those thoughts to something more “positive” (faking it) to achieve relief from anxiety and depression (making it). Already you can probably see how this might be put to use in gaslighting a patient, or encouraging some industrial-strength neurodivergent masking. You might also see how it could be supportive in helping someone confront un-examined thoughts that are sabotaging their quality of life (an example might be thinking “my partner is looking for a reason to leave me” when said partner is giving every indication that they are ride or die—is this you talking, or an attachment wound?).
Behavioral Therapy got its start rather earlier, in the 1920s, with Ivan Petrovich Pavlov and that experiment, you know, with the meat powder and the bell and the dog and the drool? You remember. Over time, Pavlov’s “classical conditioning” (linking a reaction with an unrelated stimulus) formed the foundation of Behavioral theory, and eventually Behavioral techniques for working with humans. Behavioral interventions often rely on desensitization (reducing reaction to a stimulus over time) and have informed modern specialized techniques like ERP, which can help people work through crippling phobias and OCD. Behavioral techniques are also the methods of choice for modern-day “conversion” or “reparative” “therapists,” who often use classical conditioning to try and torture the gay or trans out of their victims (just to be clear: this is unethical, impossible, and the only long term effect is psychological harm)
Cognitive Therapy and Behavioral Therapy began their slow-burn toxic relationship in the 1970s. That was, to put it mildly, a Bad Time to be eljibbity. Although homosexuality was removed as a disorder from the DSM in 1973, it would take another 30 years before it was decriminalized in the USA. In that time, many therapists continued to view any kind of queerness or transness as a shameful disease to be cured, and had no problem torturing people to do it. The earliest mention I could find of the unholy union of cognitive and behavioral theories for conversion torture (in an admittedly very low-effort search) is an article in the fall 1972 issue of the journal Psychotherapy: Theory, Research, and Practice titled “Combining behavior therapy and cognitive therapy in treating homosexuality.” In it, a man I cannot have kind thoughts about, Allen E. Shealy, waxes on for about a page and a half about how innovative he believes himself to be for using both cognitive AND behavioral “therapies” to “treat” the homos. For a little context: until fairly recently, we didn’t have any of this newfangled integrative psychology—people usually learned one (1) theory, defended it tooth and nail while disparaging all other modalities, and then practiced it until they died (mad, probably). Combining theories was Simply Not Done. So, Shealy was being an edgelord by doing it and then (gasp!) publishing about it. (I’m being a little bit hyperbolic and facetious here, but only a little. The history of psychology as a discipline is absolutely bonkers)
I’m not sure if Shealy was the first to have slapped the two together, but he certainly wasn’t the last. In the 1980s and 90s, combining cognitive and behavioral techniques went from gauche to de rigueur, and CBT rapidly became the golden child of psychotherapy. Because of its relatively early rise to fame and glory, during a time when psychology was trying its best to be a hard science (it’s not, I’m sorry, it just isn’t), CBT is now the modality we have the largest research base for in western medical lore. This presents us with two very different sets of data:
A fairly large body of well-designed, ethical, repeatable science showing how CBT can be effectively applied to help certain specific issues (like insomnia)
A whole lot more shamefully bad science trying to apply CBT to everything under the sun, often cherrypicking clients or using other unethical methods to skew the numbers in favor of a certain desired result (particularly in PTSD research)
Unfortunately, both of these categories are considered equally part of the “evidence base” from which insurance companies, hospitals, and clinicians derive their “evidence-based protocols.” Sadly, publishing something—even with peer review—is not very difficult to do if you have enough funding, the favor of certain people, or a fashionable subject.
Given its long and sordid history as a “treatment” for being gay, modern CBT is often the modality of choice for what I call “stealth conversion torture”—practitioners who don’t advertise as conversion/reparative “therapists” but who are effectively conversion torturers in all but ad copy. They let their biases, ignorance, fear, or outright malice take the wheel when clients present with queer or trans identities, and use their CBT training to attempt to gaslight clients into a different orientation or gender. Anything related to one’s actual orientation or identity is labeled a “distorted thought,” and replaced with something the torturer prefers. While overt conversion torture is (finally) being outlawed in many places, this stealth version remains entirely legal and alarmingly commonplace.
However, it’s also worth noting that the vast majority of therapists in the USA are trained primarily in CBT. It’s a requirement of many accrediting and licensing boards, meaning in many areas there literally are no credentialed therapists without at least some CBT training, if not an entire degree program based in it. Even I had to take one unit of CBT in my otherwise excessively woo-woo graduate program. If you train every mental health practitioner in the same modality, that means some people are using it as they help, and some people are using it as they do harm.
One of the few things we actually know for sure about therapy* (from a western medical culture perspective) is that the most influential factor in whether or not therapy works is the “therapeutic alliance”—basically, the rapport you build with your therapist. If you dig into the research, you’ll hear this referred to as part of the “common factors,” the things that are common across all talk therapy types, and the medium through which various therapeutic modalities are theorized to work in “common factors theory.” According to that theory, the modality that therapist uses once a rapport is established is almost immaterial. Theoretically, a therapist who is skilled at creating a therapeutic alliance could pick a different modality out of a hat every day, and their clients would still have pretty consistent good results. Including with CBT.
So, how do I, an integrative therapist who usually gives CBT some pretty heavy side eye, incorporate CBT into my practice?
Mostly, I do not.
Bit of a let down after this whole lead up, I know, but bear with me.
This is partly because I’m not a huge fan of it, partly because my clients often explicitly request non-CBT therapy, and partly because I don’t feel I have any business practicing (let alone advertising) a modality I have so little training in. That’s an ethical and legal issue. However, there are some techniques, apps, books, or worksheets I might offer in certain situations when a client has requestesd help changing a behavior. Not in changing an orientation, or an identity, or an attraction, but a behavior. Examples might include “I want to spend less time on social media” or “I want to go to bed earlier.” CBT does what it says on the tin, ethically, for certain targeted applications like these. As I mentioned above, CBT for insomnia (I-CBT) is a whole branch of CBT that is a safe, effective, medication-free option for treating chronic difficulties with falling asleep, staying asleep, and getting good quality sleep. I am not certified in this modality, but may refer a client out to someone who is, or encourage my client to read I-CBT resources or download the I-CBT app if sleep is something they want to work on.
I won’t ever rely entirely on CBT, however. Want to spend less time on social media? Let’s look into what social media is/does/can be for you. What is the story you tell about it? Let’s look at other ways that need can be met, or build new skills for overwhelm if TikTok is how you take a break when you’re overstimulated. There are a dozen ways to approach each behavior change, and CBT doesn’t have to be one of them.
I will let you go with a metaphor: a hammer can do a lot of useful things (hammer in a nail, knock down an old wall for renovation). It can’t do a lot of other things, and it would be silly to try to use it for those (stand-up comedy, certified professional accounting). It can also, in certain hands, be used for acts of mild to extreme violence and destruction (breaking a window, breaking a bone).
CBT is a hammer.
*LOL you thought we know things? About how therapy works? We don’t. We know nothing, Jon Snow. Therapy is squishy. ¯\_ (ツ)_/¯
