Cognitive behavioural therapy (CBT) is often cited as the gold standard treatment for many psychological difficulties, mostly because of the number of research studies demonstrating its effectiveness. It is a “here and now approach” that focuses on how to improve your mental health now and prides itself in not focusing on the past. It tends to promise that psychological disorders can be treated within 12 sessions, 20 at a maximum by changing thinking and behavioural patterns. However, it doesn’t work for everyone.
Those are the people I work with. And those people are also me. Some people who come to me in therapy have had up to 5 rounds of CBT over 20 years. Sometimes it worked temporarily, sometimes not at all. Sometimes they dropped out because they felt invalidated by the thought techniques and there by invalidated by the therapist.
The unfortunate part of this is that people often draw their own conclusions about why the gold standard treatment didn’t work for them that are self-blaming. Such as there is something really wrong with me, therapy doesn’t work for me or I failed at therapy, or I didn’t work hard enough at my relapse prevention strategies. The conclusion some CBT therapists come to is that the CBT wasn’t done properly by the previous therapist and so when the person re-enters therapy they begin another round of CBT.
But the truth is, as we are starting to see in research, the impact CBT quite often doesn’t maintain over a longer period. When CBT is compared at longer time frames to other therapies that go beyond the here and now, it is less effective.
The deeper I have delved into trauma, as a clinical psychologist focused on treating trauma and also my ongoing efforts to heal my own trauma patterns, I understand why CBT doesn’t work over the longer term for many people. It’s the reason I now choose to work with people in long-term therapy models that do focus on the past and present and only integrate those parts of CBT that are part of the schema therapy model into my approach.
The way that I think of it now as a former CBT therapist, is that CBT provides the coping mode/everyday self part of the person skills to feel better and keep going. This is often much desired by clients, including myself when I entered into therapy. “I can’t be like this, I can’t have all these feelings, I need to get back to how I normally am”. (I am pretty sure I said exactly that, and not just once in the early months of therapy). However, by ignoring the childhood memories and relational patterns that were formed based on attachment relationships and childhood trauma, the emotional needs of the part of the person that was wounded in childhood are not met in therapy. (In schema therapy, this wounded part is called the vulnerable child mode). Rather the emotional needs remain unacknowledged or at best they are band-aided over with strategies and different ways to think.
The bandaids will hold for a while until the needs of the wounded part can no longer be suppressed and the person’s system breaks down. And so, there is another series of symptoms, panic attacks, episodes of depression or waves of nightmares and flashbacks or maybe even some new symptoms this time around. Another round of feeling broken, dysfunctional, somehow less able to manage than other people.
For me personally, CBT strategies had the impact of allowing me to avoid my past. It stopped me from delving into why recurrent difficulties would arise and left me feeling that my personality was 100% responsible for these difficulties. I would tell myself I just needed to talk to myself differently, adjust my thinking, defuse from my thoughts, do more mindfulness, expose myself more to situations I avoided. Underneath it all was a complicated childhood that I needed to acknowledge, make sense of and (the hardest part for me) allow myself to feel the pain of that childhood, if I was going to really be healed.
If CBT hasn’t worked for you, you are not alone. You are not a failure, too hopeless for therapy or any of the other things your critic might be telling you.
You just need a different approach.
A longer-term approach that understands that early wounding and attachment relationships must be part of the therapy process and a model that works with parts of self. You need an approach that isn’t manualised but is based around your needs and doesn’t just focus on skills to cope.
You need an approach that will allow you time to discover and rebuild yourself to be the person you were always meant to be. Schema therapy and EMDR are two such approaches but there are also other long term therapy options that may work for you.