Why isn't CBT working for me?

"My therapist is keen to keep utilising CBT, but I am not feeling it. Do you think I can ask her to try something else?"

Cognitive Behavioural Therapy (CBT), the "gold standard" treatment modality for almost all psychological difficulties, is something that since I started my training has intrigued me with a mixture of professional interest and growing concern. While its proponents tout it as the "gold standard," a closer examination reveals limitations, particularly when dealing with complex concerns.

CBT has its place

For short-term, targeted interventions, particularly for specific behavioural issues, it can be effective. Its emphasis on identifying and providing individuals with tangible strategies for managing symptoms can be effective. For example, accepting minor discomfort and using behavioural activation to step into the world and gain a sense of mastery, can be highly effective in increasing short-term motivation. However, what happens over the long term?

The revolving door

Clients may find relief from a specific presenting problem using these strategies, only to return later with a different issue, as the underlying, deeper issues remain unaddressed. For example, presenting to the clinic with panic attacks, treating them with exposure, only to return a year later with depression. This suggests a focus on symptom management rather than true, lasting healing.   

Research flaws

The claim that CBT is the "gold standard" rests heavily on research, but this research is far from flawless. Many studies rely on tightly controlled protocols, often excluding individuals with comorbidities or complex presentations. This limits the generalizability of findings to real-world clinical settings. Furthermore, there's a tendency to prioritize easily quantifiable outcomes, neglecting the subjective experience of the patient and the nuances of the therapeutic relationship. The sheer volume of CBT research doesn't necessarily equate to superior efficacy, but rather to a research bias driven by funding and a focus on easily measured outcomes.

CBT and trauma treatment

Perhaps the most glaring shortcoming of CBT lies in its treatment of trauma, particularly complex trauma. While CBT may offer some relief for single-incident PTSD (e.g. exposure to driving after a car crash), it often falls short in addressing the often pervasive and multifaceted impact of prolonged or repeated trauma (complex trauma). Complex trauma, with its presentation as a sense of lacking safety, hypervigilance, dissociation, emotional dysregulation, and somatic symptoms, requires a more nuanced and integrative approach. 

CBT's emphasis on logic and rationality can inadvertently invalidate the lived experience of trauma survivors, whose responses are often rooted in deeply ingrained survival mechanisms. A great example of this is a senior lecturer once told me "doing breathing exercises is avoidance". I could not believe my ears. The brains of people who are experiencing panic attacks are telling them they are not safe and they need to run. Deep breathing, particularly the biological sigh (two breaths in, one out), can assist in regulating our nervous system, bringing more of a sense of safety, potentially allowing them to remain where they are and battle through the moment. To tell someone they aren't able to utilise this healthy and scientifically rigorous strategy, is lunacy.

What are the alternatives?

So, what are the alternatives? As therapists, we may seek to move away from the single modality approach, and align our approach to the specific needs of the client. I've found that a combination of modalities offers a more comprehensive and effective approach. Janina Fisher's parts work, which draws from Internal Family Systems (IFS), provides a powerful framework for understanding and working with the fragmented self that often results from trauma. It acknowledges the protective functions of different "parts" and fosters self-compassion, crucial for healing.   

Integrating parts work with modern psychodynamic therapies allows us to delve into the underlying relational patterns, defences, and attachment wounds that contribute to trauma-related difficulties. Psychodynamic therapy emphasises the importance of the therapeutic relationship as a vehicle for healing, providing a safe and supportive space for exploring deeply held emotions and experiences.   

Furthermore, Eye Movement Desensitization and Reprocessing (EMDR) can be invaluable in processing traumatic memories and reducing their emotional charge. EMDR's ability to access and integrate implicit memory networks offers a powerful tool for addressing the somatic and emotional aspects of trauma that often remain untouched by purely cognitive interventions. None of these modalities are perfect alone, however they acknowledge the individual experiences of the client, and key role previous experiences play in ones current presentation.

Take home message

In conclusion, while CBT may have a role to play in specific situations, its limitations, particularly in the treatment of complex trauma, are evident. As clinicians, we have a responsibility to move beyond the limitations of a single modality and embrace a more integrative and holistic approach. This requires a willingness to challenge the prevailing orthodoxy and prioritise the individual needs of our clients. We must prioritise the patient's lived experience, and the bodies response, and move with the client to a more lead more meaningful lives.