Common Myths about CBT

This section is to give an overview of different models, different therapeutic orientations and techniques
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baa
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Common Myths about CBT

Post by baa » Wed Mar 09, 2011 8:21 pm

Common Myths about Cognitive Therapy (from Chapter 2 of An Introduction to Cognitive Behavioural Therapy: Skills and Applications (2007) by David Westbrook, Helen Kennerley and Joan Kirk):

The therapeutic relationship is not important in CBT

CBT regards the core conditions of empathy, warmth, genuineness and positive unconditional regard as essential to the therapeutic process. Collaboration between therapist and client is one of the cornerstones of CBT; after all, a client may be asked to test out their worst fears to see if their worst case scenario comes true. They will need to have trust in both the therapist and the techniques for them to even contemplate this! CBT does not see the relationship between client and therapist as therapeutic in itself, but still essential for effective therapy. CBT can provide a basis for the formulation of therapeutic ruptures, both predicting and effectively working through them with a focus on client and therapists beliefs and behaviours and how this impacts on treatment.

With clients who have more complex interpersonal difficulties, more difficulties in the therapeutic relationship are expected and of course the therapist's own beliefs and assumptions will be activated, impacting on their emotional and behavioural responses to the client. A cognitive therapist assumes that such difficulties can be conceptualised collaboratively and worked with in the same way that other problems are worked with in CBT. Indeed, the therapeutic relationship itself can provide the arena for behavioural experiments and the development of new beliefs and assumptions about interpersonal relaitonships. In cognitive therapy for personality disorders, the therapeutic relationship has been likened to a "relationship laboratory" (Davidson, 2008).

CBT is mechanistic, just apply solution X to problem Y

CBT is a very explicit way of working with clients, clearly linking cognitions, emotions, physical sensations and behaviour. There are disorder specific formulations, that clearly link to detailed protocols for treating specific problems. However, CBT stresses that the models and protocols alone do not drive therapy, but how they relate to the client's distress, how they can be used to understand what processes are maintaining the client's problem, and how the relationship between cognitions, emotions and behaviour is important in the client's situation. Therefore, CBT looks to fit the model to the client, not the other way around.


CBT is just about positive thinking

CBT is often thought to be a therapy where the therapist is trying to get the client to think positively about their situation or their problem. The actual focus of CBT is to enable the client to think differently about the world, themselves and the future,. After all, if a client is thinking negatively about a situation, they may actually be right! Their job might be awful, and their manager may well be a bully. CBT also emphasises that some thoughts may have been realistic and very helpful in the past; if a client grew up in an abusive home, then the rule “If I do everything perfectly, then I won't be punished” may have served them well. However, this thought may no longer be functional or helpful in the present day. CBT looks to understand and resolve problems, not to point out that the client is wrong.


CBT does not deal with the past

Most CBT sessions focus on the here and now as the emphasis in therapy is on the client's current difficulties and what is maintaining them. However, that is not to say that CBT cannot work with a client's past when necessary. Schema Therapy (Young) has a focus on how a person's core beliefs and rules for living have been formed, the evidence for and against them, and looks at new ways for the person to interpret themselves, the world, and the future as well as the past. CBT also looks to early experiences to understand how a problem has developed. The processes that maintain a problem in the here and now may be very different to those that contributed towards it's development, therefore CBT emphasises a greater focus on the maintaining factors than those contributing towards problem development.


CBT deal with superficial symptoms, not the root of the problem, so other symptoms are likely to occur.

CBT is often criticised for simply removing symptoms, however there are a number of studies suggesting that clients are protected from relapse following a course of CBT, not at higher risk of developing further problems. CBT focuses on the psychological processes underlying distress, therefore addresses fundamental maintaining processes. CBT teaches skills that are generalisable to other difficulties and problems, with the hope that the client can become their own therapist and continue with recovery following sessions with a therapist. Blueprinting is an essential part of therapy, reviewing the therapeutic process and skilling the client in preparing for relapse and continuing recovery.


CBT is adversarial

Ellis' REBT (Rational Emotive Behaviour Therapy) is perhaps more directive, and Ellis had a reputation for being confrontational, which may be the basis for this myth. However, CBT is more about guided discovery than simply telling a client that they are irrational and thinking incorrectly. CBT aims to guide the client to discover their own problems for themselves and to come to a potential new perspective.


CBT is for simple problems, you need something else for complex problems. People with personality disorders/psychosis/multiple difficulties etc are too complex to benefit from a standard approach to CBT.

CBT has been shown to work with a wide variety of Axis 1 problems, including those clients who have severe and chronic difficulties as a result. CBT has been shown to be effective with clients experiencing psychosis. It is also being used with clients with personality difficulties with excellent results in RCTs.The client needs to be engaged in the process, and the two of you need a good overarching formulation that fits for the client as well as meaningful goals that the client really wants to accomplish.

Reinventing your life is a self help guide that is invaluable in treatment of those with personality disorders.


CBT is interested in thoughts, not emotions.

CBT is interested in clients being able to identify, reflect on and come up with alternatives for unhelpful thinking. But as a means to an end, not as an end in itself. Cognitive change is a means of enabling people to change other systems – so their emotions and behavioural reactions. CBT shouldn't be used as an intellectual exercise of “debating” a client's thoughts, experiential learning plays a huge part in cementing change. Also, if a client is not experiencing a level of emotion during the process, change is less likely to happen in respect of their emotions and behaviour.


CBT is only for clients who are psychologically minded

CBT usually needs clients to be able to recognise and talk about emotions, thoughts and behaviours and to be able to distinguish between them. It is also helpful if a client can relate to and reflect on psychological models; such as a basic formulation or maintenance cycle. If they have difficulties with these, there is always scope to offer some initial sessions to develop the client's capacity to do so, rather than discharging them prematurely.


CBT is quick to learn and easy to practice

CBT has some basic techniques that are relatively easy to learn and apply, however, it is still as complex as any other therapy when used creatively and flexibly. Therefore, you do need substantial training and regular supervision to practice CBT appropriately.


CBT is not interested in the unconscious

Not in the Freudian sense. However, CBT does recognise that some processes are outside of the client's conscious awareness. This is not interpreted as repressed information, but information that is difficult to access, but available on reflection. Clients often need assistance in accessing and interpreting NATs and assumptions as they often occur at a pre-conscious level. Socratic questioning is used to increase the client's awareness to these. The CBT therpists acts as a guide and does not offer interpretations of their own, but enables the client to make sense of their own experiences as an expert in their own life. Sometimes, a client may be actively blocking thoughts or emotions through cognitive/emotional avoidance. e.g. in OCD or in PTSD. The therapist's role is to help the client to uncover and make sense of these. CBT also recognises that certain behaviours may be outside of the client's conscious control but would see these as conditioned responses that can be understood. DBT in particular provides a framework in which clients and therapists can carry out a functional analysis of particular behaviours (e.g. self-harm) in a way that helps both the client and therapist make more sense of things. The important thing in CBT is that everything is conducted in an atmosphere of collaborative empiricism where both client and therapist are partners in the process.


CBT demands high intelligence

CBT demands no more intelligence than any other therapy, and in fact has been adapted for use with children and individuals with learning disabilities.


Clients don't like agenda setting - it is harsh, rigid and comes across as critical

Agendas provide a structure to CBT sessions, the client is actively encouraged to add items to the agenda. Although the therapist may provide the majority of agenda items at the outset of therapy, the client is encouraged to take responsibility and control over the agenda items as therapy progresses. Again, the agenda is a very collaborative effort! The structure that an agenda provides can be reassuring for clients; they are aware that the issues that they want to discuss will be discussed and sufficient time will be allowed for that. Agendas ensure that the therapy continues to have momentum and has a focus on change.


Homework is a chore for clients

Research shows that clients who complete homework tasks recover faster and stay well for longer. There are 168 hours in a week, so CBT uses the 167 hours and 10 minutes per week where the client is not in therapy to continue to test out the old and new hypotheses around their cognitions and behaviours. It also gives plenty of time for the client to collect information on their current difficulties and to test out new skills and to perfect the tools in their CBT toolbox. Homework should be set collaboratively and should lead on naturally from the previous session. Well planned homework can mean that time limited treatment can be extremely effective – not something to be sniffed at in the current climate!

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Content checked by qualified Clinical Psychologist on 12/02/2018
Last modified on 12/02/2018
At least I'm not as mad as that one!

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