“There is nothing either good or bad but thinking makes it so,” Shakespeare
If you could capture the essence of Cognitive Behaviour Therapy (CBT) in one quote, this might be it! Although CBT was conceived centuries after the era of Shakespeare its creators shared a similar perspective on the human mind; it’s not what what happens to us that determines our emotional wellbeing but rather how we think about what happens. So what is CBT?
The Beck Institute defines CBT as “a time-sensitive, structured, present-oriented psychotherapy directed toward solving current problems and teaching clients skills to modify dysfunctional thinking and behaviour.” Unlike psychoanalysis, which focuses on the past, the unconscious mind and family history, CBT focuses more on the present; patterns of thinking, emotion and behaviour as they are unfolding in the client’s life.
CBT emerged in the 1950s and has since grown to become one of the most popular first line treatments for depression and anxiety today. It has an extensive body of evidence-based research behind it and you’d be hard pressed to find any therapist who isn’t familiar with it. In a nutshell it’s mainstream psychology 101. But does it work?
This question was the topic of much heated debate during CBT’s early years. The approach was slow to gain traction and was often met with hostility and skepticism by conventional psychologists and therapists of the day. It was an unwelcome rebellion against the trusted Freudian and Jungian approaches revered at the time.
One of the key catalysts in the development of CBT, was Dr Aaron Beck, a passionate psychiatrist who was initially quite loyal to psychoanalytic theory in his early career. After conducting research into psychoanalysis, expecting to find strong evidence to support it, he was shocked to discover quite the opposite; his approach wasn’t actually helping his patients feel better! As such he was driven to innovate and create new processes that would make a greater impact.
Another key player in the emergence of CBT was Albert Ellis who developed Rational Emotive Behaviour Therapy (REBT), a precursor to CBT which shared many common elements. A fundamental premise of REBT is that humans do not get emotionally disturbed by circumstances, but by how they construct their views of these circumstances through their language, beliefs, meanings and philosophies about the world, themselves and others. Sound familiar? Hint… Shakespeare… scroll up 🙂
Ellis challenged his patients to evaluate their thoughts and cultivate more rational ways of thinking about themselves and the world at large. He was by no means the first person to use “rational thinking” as a therapeutic tool. Stoics, for example, were doing this back in ancient Greece but Ellis developed a modern user-friendly framework that he was able explore and test through empirical studies.
When Ellis declared “Freud was full of horse shit,” at a psychology conference in 1960s a war between therapeutic approaches was born. One camp loyal to diving deep into the patient’s childhood and the other looking for a quicker solution grounded in the present. Tensions between these ideas continued over the decades, but CBT gradually gained favour appealing to a culture enthused by the idea of a quicker fix.
It’s quite amusing to consider how mainstream CBT is today when it began with just a few rogue thinkers challenging the status quo. Regardless of whether or not they were right, Beck and Ellis shared a truth-seeking spirit and a willingness to admit their own shortcomings as therapists. They created something new because the old way didn’t seem to be working for them.
Now another wave of rebellion is emerging; this time against CBT and back to psychoanalysis! In this fascinating article Oliver Burkeman explores the new research that might see Freud and Jung making a comeback!
In one recent study researches from Norway concluded that CBT’s effect size (a technical measure of its usefulness) has fallen by half since 1977. If that trend were to continue, CBT could be entirely useless in a few decades! How can this be?
Coinciding with that researches from London’s Tavistock clinic published results on the first rigorous NHS study of long-term psychoanalysis as a treatment for chronic depression. They concluded that 18 months of analysis worked far better, and with much longer-lasting effects, than CBT style “treatment as usual.”
These studies are not isolated, there are others beyond the scope of this blog but what I’ve touched on here raises a number of interesting questions about the nature of “evidence-based” medicine and the need for more long-term studies.
I wouldn’t want to dismiss decades of research into CBT, surely there’s some element of truth in it, at the very least as a helpful tool for short-term relief. But my guess is that its strong evidence base is partly due to how quickly results can be seen when applying this method, and this fits in better with society’s 10-minute-medicine model. Everyone loves a quick fix!
However, as many of us are learning some of the best medicine is slow and perhaps the truth takes longer to uncover. Did Beck lack patience in his earlier psychoanalysis approach? Should he have waited longer before giving up on Freud, or was it about time someone created a faster process, a handy modern tool to add to the therapy tool box? Certainly, looking back at the history of any therapeutic style does provide insight! (Yes irony noted!)
So answering my earlier question, does CBT work? Well my “rational emotive” brain is telling me yes but my unconscious mind is encouraging me to explore a deeper question… could both approaches have a valuable role to play in healing? Only if thinking makes it so!