Valerie is a 25-year-old graduate student. She is compassionate, giving, and devoted to local volunteer work with refugees. She always seems to have a smile on her face. But since she was a teenager, Valerie has experienced excruciating periods of depression. When depressed, she is plagued by self-critical thoughts, and struggles to get out of bed. In these moments, she sometimes thinks of her troubled childhood – a time when her mother had also been bedridden with depression. Forced to become the ‘parent’ of the family, Valerie had to emotionally care for her mother and look after her younger sister. This upbringing affected the entire course of Valerie’s emotional development. By the time she had become an adult, she had a feeling of emptiness that was hard to shake. She felt that she had lost herself when she was young. Searching for help, Valerie decided to visit her university’s mental health centre and, after several sessions of cognitive behavioural therapy (CBT), learned new ways of thinking about her mood. But she still felt lost. Something was missing. For her, CBT couldn’t develop the submerged aspects of herself that had been pushed aside when she was young.
Valerie is not a real person, but I have seen many patients like her in my practice who have found that CBT doesn’t resonate with them. Yes, research consistently shows that patients who receive this form of therapy are more likely to experience an improvement in symptoms than those receiving no treatment at all (or receiving placebos). And yes, CBT is one of the most widely used, well-researched and well-funded forms of therapy in the world, accessible through mental health clinics, online therapists, or even apps. But it is not perfect.
Patients like Valerie come looking for an alternative, but often they can’t pinpoint what went wrong. I believe their concerns can be best understood if we acknowledge that not all adult emotional problems ultimately stem from failures in thinking and reasoning, as CBT maintains. Not all problems can be solved quickly through what CBT practitioners call ‘cognitive restructuring’. Understanding the limits of this popular form of therapy requires us to ask a difficult question: can CBT ever help us to fully develop psychologically?
To answer this question, we need to consider the conceptual scaffolding of CBT. Its philosophical roots go all the way back to ancient Greece, to the age of the Stoics. A faith in the power of reason can be found in most ancient Greek philosophy – and in much philosophy since. When we suffer, the logic goes, it’s because we’re letting our emotions get the better of us, pulling us away from seeing reality. Reason, these early philosophers argued, allows us to learn about things that truly matter, including how to be happy, live a good life, and free ourselves from negative emotions including depression, worry, anger, envy and jealousy.
If the patient’s faulty reasoning makes them depressed, they can avoid being depressed by learning to correct this and other failures in reasoning
One of CBT’s founders, the American psychiatrist Aaron Beck, acknowledged this intellectual inheritance in his influential book Cognitive Therapy and the Emotional Disorders (1976) – an early manual for CBT therapists. Beck wrote that the philosophical underpinnings of CBT ‘go back thousands of years, certainly to the time of the Stoics, who considered man’s conceptions (or misconceptions) of events rather than the events themselves as the key to his emotional upsets.’
Learning to think differently about events is what CBT therapists call ‘cognitive restructuring’. Changing thinking patterns is what CBT therapists do when they teach their patients to avoid errors in reasoning and to view reality more accurately. In one of Beck’s clinical examples from his co-authored 1979 book on depression, he presents material from a session with a depressed patient. The patient is a student who has just failed a university exam. The therapist questions him about why failing would make him depressed. Failing, according to the student, means he’ll never get into law school. It means he’s ‘just not smart enough’ and ‘can never be happy’. After discussing this, the therapist provides the take-home message for the patient:
So it is the meaning of failing a test that makes you very unhappy. In fact, believing that you can never be happy is a powerful factor in producing unhappiness. So, you get yourself into a trap – by definition, failure to get into law school equals ‘I can never be happy.’
According to Beck, the student’s problem is an error in reasoning: it’s illogical to believe that being rejected by law schools means a person can never be happy. If the patient’s faulty reasoning makes them depressed, they can avoid being depressed by learning to correct this and other failures in reasoning. Even today, according to the CBT model, psychological disorders generally fit this mould: the patient is committing cognitive errors that lead to negative emotional states. Helping the patient reason more accurately is key to helping them feel better.
CBT has also relied on behavioural methods, including ‘exposure’. This happens, for example, when someone with a fear of dogs attempts to conquer their fear by spending increasing amounts of time around dogs. From the point of view of CBT therapists like Beck, the point of exposure is to teach the patient to think more rationally by giving them direct evidence that shows why their thoughts don’t align with reality.
Attempting to explain a person’s psychological suffering as stemming entirely from how they think isn’t always useful
The world of CBT has developed since Beck wrote those books in the 1970s. A suite of new techniques has been added, including mindfulness and acceptance. But, ultimately, CBT is still based on the idea that psychological disorders are rooted in problems of thinking. For CBT advocates, this is a virtue – a unified explanation of psychological problems. The psychologist Leslie Sokol is one such advocate. Her widely used manual for CBT therapists, The Comprehensive Clinician’s Guide to Cognitive Behavioral Therapy (2019), co-authored with Marci Fox, tells us:
Remember, all psychological problems involve problems in thinking, so cognitive restructuring can help clients evaluate their thought processes. Use the process of guided questioning to help clients modify distorted or unhelpful thoughts so they can see situations in a less biased and more helpful way.
It is no exaggeration to say that, if you go to see a CBT therapist who is practising according to the core tenets of the therapy, there is a strong likelihood that your psychological problems will be conceptualised as thinking problems. It’s also likely your therapist will view the underlying solution to your problems as a matter of helping you to develop habits of thinking that allow you to interpret the events in your life more accurately.
This idea of mental problems as thinking problems is based on the Stoics’ highly plausible insight: we must learn to see reality. Most of the patients I have seen in my practice – and indeed most human beings – can benefit from cultivating clearer thinking. It’s not helpful to falsely interpret situations in our lives as highly threatening or catastrophic when they are not. We can find happiness if we stop attending only to the negative aspects of situations, and understand life as a combination of good and bad. This shift in thinking happens to some degree even in most non-CBT therapies as patients engage in dialogue with a neutral listener. But attempting to explain a person’s psychological suffering as stemming entirely from how they think isn’t always useful. Most people are complex, and this reductive view of mental problems doesn’t meet everyone’s needs.
Before CBT’s rise, there was another leading psychotherapeutic treatment: psychoanalysis. Psychoanalytic therapies are what many people still think of when they conjure up the idea of talk therapy; and, even today, this family of therapies remains one of the key alternatives to CBT. Classical psychoanalysis normally occurs several times per week, typically with the patient lying on a couch. Psychodynamic therapy is a less intensive form of therapy derived from psychoanalysis. Unlike CBT, which will often be just a few weekly sessions, psychoanalytic or psychodynamic therapies can last several months to several years. Unfortunately, publicly funded mental health programmes don’t often incorporate these treatments, which means that those who want to pursue psychoanalysis must make a greater financial commitment than those using CBT. For many people, this can make the cost of treatment prohibitive. (Psychoanalytic training institutes are often the best places to seek out treatment at a reduced fee.)
CBT failed to bring about remission in roughly half of patients – roughly half were not helped in the long term
The differences between CBT and psychoanalysis are striking. Whereas the structure of CBT sessions is meant to be directed by the therapist – who will assign homework at the end of the session – the structure of a psychoanalytic session is left open-ended by the therapist. The patient is encouraged to gain comfort over time speaking whatever comes to mind. Whereas CBT emphasises using a set of tools to form new habits of thinking and behaving, psychoanalysis involves an ongoing, collaborative and transformative process involving therapist and patient. During this process, the therapist notes ways in which the patient might, in the here-and-now of the therapy itself, unconsciously experience repetitions of situations from the past. These repetitions, known as ‘transference’, can indicate core psychological conflicts from childhood or adolescence – often moments when needs went unmet while growing up. But perhaps the major difference between CBT and psychoanalysis is that psychoanalytic therapy does not view all psychological problems as problems of thinking. There is no expectation that these problems can be resolved merely by helping the patient think more carefully and accurately.
This does not mean that CBT is not effective – just look at the article ‘Why Cognitive Behavioral Therapy is the Current Gold Standard of Psychotherapy’ (2018) published in the journal Frontiers in Psychiatry. It is true to say that CBT is an evidence-based therapy and that it is effective. But it is also true that many people are not helped by CBT. For example, a 2018 study in Clinical Psychology Review examined 100 previous studies on CBT used to treat adult anxiety disorders. The aim was to understand the true remission rate in CBT. Remission can be said to occur when the patient no longer meets the criteria for an anxiety disorder diagnosis, or at least when the patient’s symptoms have significantly improved. The study found the overall mean remission rate was 51 per cent. That means that CBT failed to bring about remission in roughly half of patients – roughly half were not helped in the long term.
Another study, published in 2017 in Behaviour Research and Therapy, looked at whether the remission of depressive and anxious symptoms following CBT was lasting or fleeting. This study focused on low-intensity CBT, which involves guided self-help supported by learning materials (a cost-effective method of delivering CBT, which is becoming more widespread). The study found that roughly half of the patients whose symptoms went into remission suffered a clinically significant deterioration within 12 months of completing treatment. For many patients suffering from depression and anxiety, undergoing CBT treatment is not a lasting cure.
But CBT continues to dominate. Seeking to increase access to mental health care, many publicly funded services now focus on providing CBT at the expense of other therapies. Clinicians and public health administrators worldwide are understandably excited by the promise of a treatment that can be delivered so efficiently. And many patients will find CBT appealing right from the first session, recognising it as offering plausible explanations of their problems. But for patients like Valerie, the approach is too structured and educational to foster the kind of maturation and development they desire. It would be heartbreaking if these patients were made to feel like failures just because their concerns do not fit the CBT model. Not all psychological problems are thinking problems, and not all problems require correcting through cognitive restructuring. Given the chance, people like Valerie can learn to address their submerged selves, forgotten or ignored by therapies that focus on cognitive tools for viewing reality more accurately. Given the chance, these people can learn, instead, to empathise with their earlier selves in nuanced ways. They can begin finding themselves.