Why Cognitive Behavioural Therapy (CBT) is Not Enough
Practitioners need to take seriously the social contexts aggravating mental health
Cognitive Behavioural Therapy, or CBT, is everywhere these days — and for good reason. But the popular practice is far from perfect.
As the name suggests, CBT works by helping a person to change their thoughts (cognition) and behaviours in order to cultivate a practical, task-oriented approach that can target everyday problems. Instead of emphasizing childhood events or past traumas, CBT focuses on negative thoughts a person is having about themselves, and how this affects their view of the world.
In doing so, it can help to improve emotional regulation and aide in the development of personal coping strategies that replace self-destructive habits with more positive and constructive attitudes and practices. Considered a ‘solutions-oriented’ form of talk and text-based therapy, CBT rests on the central idea that knowledge is empowering — the more someone knows about their disorder and how it is maintained, the better equipped they will be to recognize its symptoms and do something proactive to manage them.
A digital health revolution?
In the age of COVID-19, psychological approaches to the treatment of mental health problems are undergoing a fundamental change as practitioners around the world speed up their transition to online delivery models.
While increasing in popularity for a number of years, electronically-delivered CBT (eCBT) has exploded during the pandemic for a few reasons. For starters, it is proving more effective. A 2020 systematic review of 17 CBT studies found that eCBT repeatedly outperformed face-to-face CBT treatments in reducing the severity of patient depression. What’s more, eCBT eliminates the risk of workplace transmission of COVID-19 and reduces childcare and transport concerns, which can create a more relaxed and comforting experience.
An added bonus of eCBT is that therapists can engage directly with clients from the comfort of their own living spaces. As a result, practitioners can provide greater access to treatment, specifically for those in remote areas, and also help control costs. This is because while eCBT doesn’t necessarily reduce a client’s time in treatment — they have homework tasks outside of face-to-face contact with the therapist — it can cut back on therapist contact time.
Most eCBT populating the myriad of mental health apps is derived from existing face-to-face treatments or from self-help books based upon them. Many, as clinical psychologist Gerhard Andersson points out, are greatly simplified versions of the original treatments and are little more than collections of ‘tools’.
Yet others retain the treatment’s procedures and strategies. In general, eCBT makes more use of behavioural than cognitive procedures, and often there is a central educational aspect to the process. Indeed, some apps present themselves as self-taught programs rather than treatments and deliver CBT-based interventions in ‘lessons’ and ‘tasks’ as opposed to ‘sessions’.
The selection of the apps themselves is astounding. From mood, pulse, sleep and heart rate monitoring to alcohol and food intake, brain wave and muscle tracking, there are programs for quantifying and regulating almost every aspect of everyday life. This process of health and wellness appification (by which apps become the user primary interface) is projected to generate revenues upwards of 4 billion USD by 2027 — a growth rate of 23.7 percent.
Enticed by the promises of this burgeoning market, much of the writing on digital health today takes as a given that such apps have vast, untapped potentials. But the promises of the technology are also at risk of moving faster than the science. While there is indeed evidence that empirically based, well-designed eCBT-focused apps can improve outcomes for patients, a recent expose in Nature highlights that the vast majority remain understudied.
Research is often limited to pilot studies, randomized trials are small and unreplicated, and many studies tend to be conducted by the apps’ own developers rather than by independent researchers. Trials that account for the well-documented ‘digital placebo effect’ are few and far between, increasing the probability that at least some of the positive outcomes claimed by eCBT are inflated by the strong attachments people have to their personal devices.
What’s more, some apps reserve the right to cull and sell ‘anonymized’ data portraits of their users and have been shown to cut corners by relying on bots and unlicensed therapists as substitutes for more personalized and thus more costly care. In the face of ongoing pandemic pressures and potentials, what can be said for certain is that mental health practitioners, scientists and government officials are starting to appreciate the underlying challenges in effectively delivering e-wellness technologies and treatments.
Cognitive-behaviour therapy roots
While the modern roots of CBT can be traced to the development of behaviour and cognitive therapies in the mid 20th century, the philosophical precursors of CBT are drawn from the ancient philosophical tradition of Stoicism.
As Donald Robertson highlights in The Philosophy of Cognitive-Behavioural Therapy, stoic thinkers like Epicurus — who believed that logic could be used to identify and discard false beliefs that lead to destructive emotions—have come to deeply influence the way modern CBT practitioners identify cognitive distortions that contribute to depression and anxiety. For example, CBT’s self-focused approach is based on the assumption that it is irrational or negative cognitive beliefs about the self, rather than negative externalized experiences, that engender negative emotional states and dysfunctional behaviours.
In his treatment manual for depression, Aaron T. Beck, the ‘father of cognitive behavioural therapy’, claimed the philosophical origins of cognitive therapy could be traced back to the Stoic philosophers. The treatment mechanisms of CBT mirror the foundational tenet of stoic ethics: one cannot control their external circumstances, but they can regulate their internal thoughts and feelings. For Beck, our thoughts and beliefs (schema) determine the course of our actions, which means that the causal mechanisms for dysfunctional behaviour are reduced to the negative effects of dysfunctional thinking.
The stoics, in this regard, ascribe fundamental significance to the notion of determinism — that all events in the universe are predetermined, and people have little power over the course of those events. The ethics of Stoicism, and of CBT, follow logically from this premise.
After all, both face-to-face and eCBT techniques are based on a process of challenging beliefs and patterns in people by replacing errors in thinking — known as ‘cognitive distortions’ — including magnifying negatives, overgeneralizing and catastrophizing with more effective, calming, positive thoughts that decrease emotional distress and self-defeating behaviours.
In his book ‘Illusion and Reality: The Meaning of Anxiety,’ clinical psychologist David Smail traces out the ways in which the mantra first coined by former UK Prime Minister Margaret Thatcher — “there’s no such thing as society, only individuals” — finds an unacknowledged echo in the behavioural roots of therapy. And indeed, while the self-corrective focus of CBT has proven more effective than medication and other chemical interventions in treating symptoms of depression and anxiety, its’ underlying reliance on the existence of a so-called ‘autonomous ego’ also gives way to a number of challenges.
What happens when peoples’ cognitive distortions — that is, their experiences of negativity and catastrophe — become so widespread and validated that it would appear ‘irrational’ to ignore them? Is the stoic, in their focused self-containment, meant to presume that everyone else has lost their minds? In a world where external factors such as a destabilizing climate, a global pandemic, and increased economic insecurity have been directly linked to the intensification of stress and ill-health within individuals, at what point does irrational panic, anxiety, and fear become a rational course of action?
The problem, as psychologist Key Sun traces out, is that the emphasis on mitigating and regulating negative cognitive distortions risks confusing symptoms (i.e., negative self-concepts and self-images) with their cognitive causes. This begs the question: are anxiety and depression a cause of negative cognition permeating one’s internal self-evaluation or a symptom? After all, research has shown that people’s appraisals of their negative or distressful feelings and experiences tend to be more rational, realistic, and accurate than reports of positive ones, which are often coloured by inaccuracy and bias.
In other words, a self-focused cognitive-behavioural model imports the stoics’ strong association between negative thoughts and mental dysfunction. Yet this fails to adequately address the question of why individuals fixate on and seek validation for negative experiences. Poverty, xenophobia, racism, sexual violence, conflict, and systemic climate and health shocks —under such circumstances, cognitive-restructuring exercises, with their emphasis on re-framing reality but not changing it, are ill-equipped to recognize these factors.
Rethinking our thinking
In 2015, a meta-analysis by researchers Tom Johnsen and Oddgeir Friborg published in Psychological Bulletin shook the world of CBT by finding that cognitive-behavioural treatments were becoming less effective over time.
Like the digital placebo effect discussed above — where attachment to our devices can inflate the positive outcomes of app-based eCBT — the authors posit that as CBT grows more popular, the proportion of chat-bots, as well as inexperienced or incompetent therapists increases. While early research on CBT reported full and lasting recoveries, today we are all connected to someone who has tried CBT in earnest and just wasn’t able to effectively redirect their negative thoughts. As people’s expectations have become more realistic, so Johnsen and Friborg argue CBT’s effectiveness has fallen.
Since the paper’s release, there has been much discussion in psychotherapy communities about the findings. Some insist the results can be invalidated, others argue there was indeed a decline in CBT effectiveness between 1977 and 1995, but this levelled off from 1995 onward. First and foremost, such tensions between researchers highlight the challenges both clinicians and patients face trying to engage and also improve evidence-based care.
Writing in The Guardian, journalist Oliver Burkeman points to an argument made by influential psychoanalyst Allen Wheelis in the late 1950s, who posited Freudian analysis had become less effective because the character of patients had changed over time. It was for similar reasons CBT pioneers like Beck steered away from studying the unconscious to focus on how certain types of cognate thinking or ‘automatic thoughts’ could be more closely linked to emotional distress.
In his work on the social, historical, and ethical implications of CBT, writer and group analyst Farhad Dalal takes things a step further, situating this shifting character of patients’ automatic thoughts within the particular social, historical, and economic contexts they inhabit. The issue is not with cognitive therapies per se, which have proven effective in aiding recovery from obsessive and phobic behaviours. Problems become apparent when CBT’s focus on cultivating logical, self-regulating individuals is retreaded as a catch-all solution to large-scale sources of psychological distress and suffering. The result, as Dalal reiterates, is the production of a powerful polarization:
“…at one pole happiness and health, at the other, mental illness and mental disorder. The dichotomy is so powerful that it makes it seem that the only available territory resides at one or other of the poles, leaving no place to stand anywhere between mental illness and mental health.” (p.6)
Either you are happy and ‘have’ mental health, or you are not happy and therefore ‘have’ a mental disorder. Yet if happiness is hard to find, maybe that’s because the criteria is always changing. In the context of COVID-19 and the very real fears it has enlivened, more people are looking for support managing their depression and anxiety about the future. This combination of increased social dysfunction and the lack of accounting for distressing structural inequalities are feeding a growing crisis of mental health but also an opportunity to experiment with new approaches to treatment and care.
There are new strategies for more effectively situating rational practices of self-care and self-regulation in their relational contexts of widespread stress and insecurity. In terms of accessible tools, biometric sensors offer the potential for practitioners to supplement the self-reporting component of eCBT with real-time biofeedback data that reveals where and when patients have problems, linking symptoms with triggers. Importantly, these potentials could be bolstered through the further democratization of mental health data, which is regarded as one of the most challenging hurdles in strengthening patient service, hospital operations, and the entire medical field.
Beyond the tools, accounting for what is often overlooked and internalized in mental health care requires new ways of thinking. For instance, the ‘liberation health model’ — a holistic behavioural theory for situating individuals’ problems within their full matrix of personal, structural, institutional and ideological determinants—can help clients and analysts to rethink the belief that resilience can only come from the personal acceptance of overarching conditions as inevitable and thus outside of one’s power to effect.
One visualization of this is the ‘unrecovery star’, which focuses not on the ways someone should be expected to ‘recover’, but on factors that can hinder people’s recovery and sustain high levels of distress. As a teaching tool, the star demonstrates we need to pay attention to internalized distresses while also contending with the problems that currently exist in communities and wider society — that mental health is a profoundly social issue.
Think of it in terms of co-morbidity. Many mental-health disorders share the same processes, including avoidance, suppression, dwelling and self-focused attention. Rather than treat a single one and hope the others resolve, we need to start thinking trans-diagnostically—addressing common processes across populations to develop more parsimonious and accessible ways of helping people to get well.