What is CBT and why is it so widely offered?
Cognitive Behavioural Therapy (CBT) developed as a combination of behaviourism, which considered responses to our environments, and cognitive theories which concerned themselves with the meanings that we ascribe to events as opposed to the responses to the events themselves (Corrie and Lane, 2021). Together, these ideas merged to consider the link between behaviour and thoughts, feelings and beliefs, and how such thoughts can be challenged, allowing for new responses.
CBT has continued to grow and has been adopted by the NHS as the primary treatment for moderate to severe depression, amongst other mental health conditions, due to its structured and time-limited nature (which is deemed to be cost-effective) and the findings of multiple meta-analyses of randomised controlled trials which have highlighted its effectiveness (Beltman, Voshaar and Speckens, 2010; van Straten et al., 2010). When compared to other therapies, however, CBT has not consistently been found to be any more effective (Cuijpers et al., 2021), raising the question of whether it is just the most researched method (David, Cristea and Hofmann, 2018). This has possible implications for the exclusion of other treatments and the elimination of choice, and potentially entails treating the issue rather than the individual.
The National Institute for Health and Care Excellence (NICE, 2022) state that there is ‘good evidence for the effectiveness of a combination of CBT with antidepressants, individual CBT and individual behavioural therapies’ (NICE, 2022) for the treatment of depression, for example, and these approaches are noted to be ‘cost effective’ (NICE, 2022). There is said to be ‘some evidence’ for the effectiveness of interpersonal psychotherapy and psychodynamic psychotherapy but these are also noted to be more expensive. Leichsenring (2001), for example, found psychodynamic therapy to be equally as effective as CBT in treating depression. Hiltunen, Kocys and Perrin‐Wallqvist (2013), however, found that CBT could be used effectively by trainee therapists, resulting in symptom reduction and satisfaction from both clients and therapists. The UK has utilised this in what is now referred to as its Talking Therapies (previously known as IAPT, NHS, n.d.) which enables trainees, under professional supervision, to provide therapy at a reduced cost to the NHS. Structure and techniques, in CBT, could be preferable to a trainee therapist, although there is a risk that they may gain the tools but lack the experience to use them as effectively as a trained psychotherapist. Whilst it is inevitable that cost is a crucial factor, it is equally important that the therapy is effective, in the short term and the long term, both ethically and economically.
How has CBT evolved?
CBT emerged from Ellis’ (1962, cited in Ellis and Dryden, 2007, p.8) ABC model, standing for ‘Activating event,’ Belief,’ and ‘Consequences.’ Ellis and Dryden (2007, p.2) state that ‘rigid absolutism is one of the main cores of human disturbance’ so CBT involves testing hypotheses to challenge each individual’s unhelpful beliefs. Beck et al. (1979, p.11), meanwhile, focused on a cognitive model of treating depression, by understanding the ‘cognitive triad’ of how a person views themselves, the world and the future, considering that these were likely to be ‘negative’ and that these interpretations would essentially then become self-fulfilling.
Modern day CBT is structured, goal focused and directive (Kennerley, Kirk and Westbrook, 2017); it involves identifying specific issues and taking small steps towards a considered goal, working on ‘automatic thoughts’, ‘core beliefs’ and ‘underlying assumptions’ (Kennerley, Kirk and Westbrook, 2017, pp.9-11) which are identified and challenged through therapy. The role of the therapist is, therefore, also more active and possibly more questioning than a person-centred approach. Kennerley, Kirk and Westbrook (2017) state that CBT treatment for depression may include identifying specific problems that the client is facing, considering thought patterns, and working on reducing symptoms through behavioural experiments and thought records to adapt any ‘core beliefs’ (Kennerley, Kirk and Westbrook, 2017, p.283).
Critique of CBT
What may be challenging for a person with depression, however, is defining ‘core beliefs’ (Kennerley, Kirk and Westbrook, 2017, pp.9-11) and this not only has the potential for the client to feel judged in terms of their thoughts but also misunderstood. The use of evidence and the concept of a balanced thought, however, has the potential to be eye-opening and, with the client able to consider the evidence themselves, this could remove the feeling of judgment and the imbalance of power which can emerge from such a directive approach.
CBT can be viewed as potentially confrontational, in terms of trying to change the client’s thinking, and Josefowitz and Myran (2005) noted that: ‘at its worst, CBT can feel like a debate between the therapist and client, where the client’s affect is ignored in favour of their thoughts.’ CBT’s practical and systematic approach could, however, be helpful for someone who may struggle to find a way forward themselves and, therefore, welcome a more structured approach. If problem-solving is particularly challenging for a person, it would potentially take far longer to treat them with a person-centred approach. Techniques such as scheduling, and the motivation to try activities such as exercise or engagement with others, for example, could, however, be too challenging in the short number of weeks that the NHS is likely to offer clients. Goals and work between sessions may, therefore, need to be small and incremental to ensure that tasks are achievable.
CBT can also be criticised by psychodynamic therapists for focusing purely on conscious thoughts, in the present (Moorey, 2014, cited in Cooper, 2019), although CBT recognises that not all thoughts are at the forefront of awareness (Kennerley, Kirk and Westbrook, 2017). Part of the reason for the brevity of therapy is also due to the focus on the present, so CBT has been criticised for not necessarily getting to the root of a presenting issue but rather treating symptoms alone (Cooper, 2019). Corrie and Lane (2021) state that it is a myth that CBT focuses only on the present; they argue that there is an interest in the past but that this knowledge is used to understand a client in terms of ‘predisposing factors’ (Corrie and Lane, 2021, p.14) which supports the medical model of treating a condition rather than an individual. Cooper (2019) notes that modern variants of CBT, such as Acceptance and Commitment Therapy, do, however, consider values of individuals more fully.
According to the NHS (2022), advantages of CBT as a treatment option are; that it is often shorter than alternative therapies; the structure allows for it to be used in groups and self-help exercises; it offers techniques that can be taken forward beyond therapy; it empowers people to change themselves, and it is effective. They state that the disadvantages include that; it needs full ‘co-operation,’ including work between sessions; ‘it involves confronting your emotions and anxieties’ (NHS, 2022); and it cannot address a client’s wider context. Corrie and Lane (2021) suggest that CBT can be empowering to clients, by enabling them to see how they have shaped their own understanding, allowing for new ways of seeing the world.
What does the evidence say?
Ardito and Rabellino (2011) discovered, in their review of psychotherapeutic outcomes, that the therapist’s relationship with the client, which is key to the person-centred approach, is a ‘reliable predictor of positive clinical outcome independent of the variety of psychotherapy,’ and Asay and Lambert (1999) also found that the relationship was the biggest factor in terms of a client’s progress, therefore Josefowitz and Myran (2005) suggest that CBT must be delivered with consideration of Rogers’ (1957) core conditions of empathy, congruence and Unconditional Positive Regard. Norcross and Wampold (2018), like others, highlighted that the ‘alliance’ was the greatest indicator of successful therapy across all modalities but also noted the collaboration of goals as ‘demonstrably effective’ which is key to CBT.
- King et al. (2000) compared CBT with non-directive therapy. At 12 months, all patients had improved, however patients who had received non-directive counselling were the most satisfied, suggesting, perhaps, that there was more of a tendency for ongoing growth with a person-centred model.
- Cuijpers et al.’s (2021) meta-analysis of therapies suggested that CBT was no more effective than all other tested therapies.
- Stiles et al.’s (2007) study compared psychodynamic therapy, person-centred therapy and CBT, delivered through primary care in the UK, and did not find any difference in success rate between the therapies.
- Ilardi and Craighead (1994) discovered, in an analysis of eight studies, that improvement in clients having CBT often occurred before the CBT techniques began, suggesting that other factors should be considered, like the relationship.
- Hofmann et al.’s (2012) meta-analysis of the efficacy of CBT, in research since 2000, found mixed results in the use of CBT as a treatment for depression, with some studies suggesting that it was equal to other psychological therapies and with others suggesting that CBT offered superior results.
- Tolin (2010) found CBT to be more effective than psychodynamic therapy, both initially and after six months.
- Vos et al. (2004) found that CBT had a similar level of effectiveness to medication for depression, but Chan (2006) found that medication and CBT combined was more effective than CBT alone.
David, Cristea and Hofmann (2018) argue that CBT is viewed as ‘the gold standard’ because it has been so heavily researched and because research has not yet shown that another form of psychotherapy is more effective, however they argue that ‘there is clearly room for further improvement, both in terms of CBT’s efficacy/effectiveness and its underlying theories/mechanisms of change’ and suggest that it should be used integratively rather than solely. They also note that, in many trials, the effect sizes are quite small but, when looking at so many clients, as the NHS would be, any effect size is considerable as any reduction in waiting times per patient has the potential to bring the overall waiting times down considerably.
Gonzalez-Blanch and Corral-Fernandez (2017) suggest that ‘only a few therapeutic models, of the hundreds that exist, have been put to the test. In addition, the studies that support the efficacy of the psychotherapies are subject to significant limitations […] that inflate the chances of finding positive results.’ David, Cristea and Hofmann (2018) state that CBT was the first fully researched form of psychotherapy and it has now been so thoroughly researched that any modern research on other therapies that shows a similarity in effect will not alter the use of CBT as it would now be costly to change. It would, therefore, take several studies and several years, showing repeated patterns of evidence that another method was more beneficial than CBT, to change guidelines. David, Cristea and Hofmann (2018) are, however, clear that empirical evidence does show the effectiveness of CBT, therefore they see the future of psychotherapy being based on this whilst also recognising that it is not necessarily effective for everyone and is not always effective long-term, thus the need for integration.
Where does therapy go from here?
CBT’s structure and techniques lend themselves far more to scientific analysis than other modalities of therapy and allow for a shorter period of treatment, thus making CBT a cheaper choice for the NHS. Whilst it has been shown to be effective, it cannot be usefully compared to other forms of therapy as there are so many more randomised controlled trials focusing on CBT rather than other therapies.
If CBT is utilised in an individualised manner, with the relationship at its heart, its structure and problem-solution focus may be effective, but it may not work for everyone due to its need for motivation and the potential for it to seem judgmental. Its brevity may also mean that it is not sufficient for all, therefore it seems that further research into other therapies and the length of treatment should continue, to ensure that those who are most likely to need NHS support have access to the best care, rather than the cheapest care.
Integrative Therapy
Integrative and pluralistic therapies offer the ability to engage with evidence-based CBT techniques, as part of a wider, more individualised plan, enabling each therapy to be tailored to each client, with an empathetic relationship as the key foundation and focus. Such integration allows for the utilisation of successful CBT techniques, alongside other evidence-based methods, within a safe, solid and secure therapeutic relationship.
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