Does cognitive behavioral therapy (CBT) work?
The short answer to this question is “yes”, but the longer and perhaps more accurate answer is, “it depends”. We know that it works because research tells us it does. Now, I recognize the somewhat circular argument here (i.e., “we know it works because we know it works”), so I’m going to shed some light on the fundamental principles and mechanisms underlying CBT as a way of hopefully explaining why CBT is often so effective for many psychological problems.
Answer #1: Yes.
One reason CBT works is because it positively modifies the strategies and skills we use to solve or manage our problems. In other words, it changes how we experience and approach our lives. This point is important because the psychological difficulties, emotional distress, and functional life interference that many people experience often stem from unhelpful or maladaptive patterns in thinking (e.g., accurate beliefs, perceptions, assumptions) and behavior (e.g., avoiding problems, anger mismanagement), and these unhelpful patterns are precisely the targets of cognitive behavioral therapy. This doesn’t necessarily mean that unhelpful thoughts and behaviors are inaccurate or illogical (although that is sometimes the case); it simply means they are no longer working for that individual and are interfering with desired outcomes. These desired outcomes might be reduced stress, anger management, enhanced performance in a particular domain, or improving the quality of interpersonal relationships. Often these strategies were working for the individual at some point in the past, but no longer are, and therefore require modifying.
Another reason why CBT works is because it physically changes structures in the brain and the body. CBT focuses on learning new information about oneself and the world, and on modifying one’s behavior. As a function of this learning and modifying of behavior, both the brain and body change how they are neurologically “wired”. In other words, CBT helps clients physically change the way their brains and bodies function. This process is virtually identical to how the body physically changes as a result of it repeatedly engaging in a particular physical exercise or activity. If you started swimming everyday, for example, your muscles, nervous system, cardiovascular system, and so forth would physically change in order to accommodate the way your body is now interacting with the environment. This is no different than when you learn to think and behave differently, since these psychological changes also change the physical structure and function of the body. Research tells us that psychological functioning either directly or indirectly impacts cardiovascular, gastrointestinal (i.e., digestion), and immune system functioning (and vice versa). By learning adaptive mental health strategies, then, we are simultaneously boosting our physical health. (The topic of the mind and body being inextricable, or two sides of the same coin, is one I will likely revisit in more detail in future blog entries.)
Importantly, because these physical changes in the brain and body are a result of CBT’s purposeful, active training, they tend to stick around longer than if they were induced by more passive treatments like medication. The lasting effects of CBT are important because they tend to reflect a personal mastery over or improved management of the original problem, which then leads to lower rates of relapse compared to passive treatments. This also translates to a lower probability of needing treatment in the future and reduces the financial burden of treatment in the long run, both for the individual and for the economy.
CBT also works because it doesn’t apply a “one size fits all” approach to treatment. CBT is based on well-established psychological mechanisms that apply to all humans. This is called a “nomothetic” perspective because it draws on general rules and principles that apply to all people. At the same time, CBT involves gathering knowledge about each individual client so that an effective, uniquely tailored treatment can be developed and delivered. This second perspective, called an “idiographic” perspective, is concerned with the understanding of how the general principles vary across individuals. In this way, CBT integrates nomothetic and idiographic perspectives. In practice, this means a well-trained cognitive behavior therapist will both (a) understand principles underlying human behavior and (b) work with the client in order to understand his or her unique difficulties so that an accurate “conceptualization” of the problem can be derived.
Answer #2: It depends.
Whether cognitive behavioral therapy is effective for any one client depends on a number of factors, such as the characteristics of that client (e.g., motivation, readiness, social support, cognitive abilities), the characteristics of the therapist (e.g., training, experience, personal qualities), the alliance between the client and therapist, and the nature of the client’s problem, among other things. As highlighted above, CBT is considered an active therapy, which means it wouldn’t be very helpful for a person who isn’t prepared to put in some degree of effort. Unlike passive treatments such as surgery, medication, acupuncture, or therapeutic massage, a passive recipient of CBT would not benefit much from it. The effectiveness of CBT requires more on the part of the client than simply attending the treatment session; it requires engagement, dedication, and effort. Completing CBT assignments in the real world, between treatment sessions, is often crucial to CBT treatment success because the real world is where change is most relevant for, applicable to, and desired by the client. One of the responsibilities of the cognitive behavioral therapist is to work with the client in order to structure and pace the CBT work in a way that is manageable and sustainable for him or her. The client’s job is to do their best to complete the work. If factors arise that interfere with completing assignments (this often occurs and is perfectly normal), then those barriers or obstacles are identified, strategies are collaboratively developed, and the plan is modified as needed.
(As a side note, this CBT treatment model is in many ways analogous to exercise programs that one might receive from a personal trainer or physiotherapist. Strength building and/or stretching exercises are often prescribed as a part of these programs, and it is the responsibility of the client to complete those exercises between sessions since functional improvement hinges heavily, if not entirely, on the client doing so. Another analogy is to imagine CBT assignments as doses of effective medication for a stubborn cough. If I don’t take the medication and I’m still coughing next week, I shouldn’t be perplexed as to why this is the case.)
CBT’s effectiveness also depends on the knowledge, expertise, and emotional warmth of the therapist. While the process of “changing unhelpful thought and behavior patterns” might sound simple enough theoretically, in practice it is not. As noted earlier, effective cognitive behavioral therapy requires on the part of the therapist a sound understanding of what the problem is, as well as when and how it originated. This understanding in turn informs treatment. Effective CBT also requires the therapist having a good understanding of the client’s “barriers to change” (i.e., factors that might interfere with making the changes they wish to make), as well as strategies for overcoming those barriers. Having a psychologically skilled and empathic clinician is an asset to this process because effective treatment hinges on conceptualizing what the principal difficulty is. This requires a therapist who can take all the nuances and complexities of human behavior and conceptualize the problem accurately for each client. Effective CBT also depends on having a therapist that is emotionally warm, patient, empathic, and supportive. CBT may be structured, but it should never be cold or mechanical. A caring therapist underlies all effective forms of therapy, and CBT is no exception.
CBT’s effectiveness also depends on the nature of the problem itself. Changing unhelpful thought and behavior patterns can be helpful, but of course this won’t solve all mental health problems. There are many cases where physical or organic factors are contributing to, or are the source of, the client’s mental health difficulties. Schizophrenia, bipolar disorder, dementia, tic disorders, severe and recurrent depression, and severe obsessive-compulsive disorder (OCD), to name a few, are all known to have some organic, biological contributors. In these cases, biological treatments (e.g., medication, electroconvulsive therapy, transcranial magnetic stimulation, surgery) are sometimes required in conjunction with psychological strategies for their management. CBT-type learning might still be an integral aspect of effectively managing these conditions, but this learning should be combined with one or more biological interventions. Also, in cases where the client has cognitive limitations as a result of developmental issues, such as with severe mental retardation or autism spectrum disorder (ASD), CBT would not be effective or appropriate. In these cases, treatment would focus more (or entirely) on modifying behavior than on modifying thoughts. (As one might logically deduce, when there is no “cognitive” component to cognitive behavior therapy, it is simply called “behavior therapy”.)
So that was a brief synopsis on whether and why CBT works. If you have any thoughts or questions about this topic or think I should write more on a certain aspect of this or any other topic, feel free to contact me. I’ve also listed below a number of possible topics for future blog entries, so if you’d like me to write on one of these in particular, let me know!
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