Is CBT (cognitive behavioural therapy) really “the gold standard” ?

The term “Gold Standard” evolved from a time when the value of gold was used to standardize the value of paper currency across the world. Gold was stable, reliable and the constant. That CBT is “the gold standard” in psychotherapy is an oft-repeated statement. A statement repeated enough times , with or without corroboration, can stay alive as long as it is repeated. The claim that CBT is the “gold standard” - implying that it is THE fix to ALL problems - is a heavy claim that , in my experience , is repeated with far too much lightness. The problem is with the dark underbelly of this statement - what then of the other ways of practising? Does this statement leave any room in the tool box or is CBT the only tool we need? What is the effect of this statement on a young, new aspiring clinician? Is the implication that CBT will “fix” all problems? I thought I would take a moment to examine and wonder about the various aspects of this increasingly unquestioned statement in North America.

Theories, Models and Strategies

Many years ago, as a new Social Work student but also a woman in my 40s and a mother of two young boys, I happened to encounter the various ‘theories’ in psychology as I was learning the art of being a Clinician. I encountered CBT and DBT, Bowenian Family Systems, Attachment theory, EMDR, Integrated Body Psychotherapy, Mindfulness, EFT, EFFT and on and on. As I read Daniel Siegel’s “The Developing Mind” I came across the idea of ‘integration’ and ‘coherence’. I was excited by Dan Siegel pointing out, as does Gabor Mate, the separation among disciplines and the need for integration. Integration of disciplines, integration of theories and integration of thinking in the clinician’s mind. And an integrated sense of self for the client.However, Dr. Gordon Neufeld will tell us, as will the Buddhist mindfulness teachers , that the “capacity to hold complex ideas without fragmenting” (falling apart, losing track ) is a matter of having a mind that is not only intelligent but housed in a body that has a calm nervous system. A mind that has the freedom to entertain curiosity and integrate the knowledge it acquires because it is not vigilant about safety. (We shall return to this point later.) The opposite of integrated thinking is compartmentalized thinking. A failing of compartmentalized thinking is , often and sometimes, mistaking a part for the whole. Like the proverbial blind men, the trunk IS the elephant. As I learned the various ‘theories’ , I began to see their purpose and connection. I also saw them as beads on a necklace, each having its place. But most of all, I recognized that there is a difference between theories, models and strategies.

The significance of Context - In my first job interview, I was asked a brilliant question by an older clinician. What is the importance of context?

The idea that one can treat just the symptom is too simplistic for human problems. On one end of the spectrum , we have scientists paying attention to epigenetics, the idea that nature is affected and changed by nurture and on the other end of the spectrum , we have psychologists believing that we simply need to teach a client to think positive thoughts. Funnily enough, context plays a role even in CBT. The client spends time in a room, with a therapist , talking about themselves and cultivating a relationship. What is attributed to CBT is probably the effect of the co-regulation that a client experiences in that time together. Since little attention is paid to the context in the pursuit of giving all credit to the methodology, this is not accounted for.

Compartmentalized thinking in the clinician is equal to black and white thinking in a client.

Theories, Models, Strategies and Practice Wisdom

It might be important to start with the point that in a person’s narrative is text, subtext and context. Text and context are the easier components. The subtext is a little more complex. Text is simply what a person tells us. The spoken narrative. “ I think my husband is going to leave me”. The context of an individual includes all the parts of the individual’s current life ( work, social relationships, current familial relationships) as well as the details of their “formative or developmental” past. This involves a genogram as well as many questions about how the individual navigates their current life. The subtext is what lies beneath the spoken text. “ I am the daughter of a father who cheated on my mother. I became my mother’s buddy and I don’t trust men. I suspect my husband every time he looks away or doesn’t respond to my text. I am fairly convinced I am not good enough for him as my mother was not good enough for my father and I know he will leave me”.

A theory is primarily a broad way of thinking, an idea, a way of seeing things, a frame. A collection of hypotheses. The underlying landscape. While philosophy may search for the right question, theories are propositions of answers. Theories can be operationalized and researched. And research can be qualitative or quantitative. Attachment theory examines and explores the significance and implications of the mother-child bond and relationship. From birth. From before birth. To understand the nature of this bond and its significance, one has to stretch one’s mind, remember stories and feelings and be willing to wade into the vulnerabilities of one’s own life narrative including perhaps , the narratives of one’s parents. Embracing attachment theory can be difficult and painful for clinicians and theorists because this bond with our own parents is powerful, complex and leaves a deep imprint in all of us. Mothers are supposed to be safe, knowledgeable, selfless and concerned. Fathers are supposed to be available and protective.This is not always the case. And that makes Attachment Theory a most inconvenient one. Family systems theory , both structural and strategic , talks about the roles we play, the interpersonal dynamics and the powerful inter-dependent patterns that exist in a family system. We all influence each other by our presence and actions. Again, complex, broad and deeply evocative. Both Attachment theory and Family Systems theory apply to all of us as we are all children of families and we all have mothers and fathers. While we would like to assume that all children are wanted and all parents love their children, we all know this is not the case. The word “Love” is often used to encompass or gloss over reality. The truth is that parenting a child is a complicated task for which most parents have no training. Folded into this experience is often frustration, guilt, anger, resentment and unexpected feelings of rejection and shame. It makes therapists and clients alike not want to talk about the experience. The problem is that these powerful dynamics that craft and shape our very foundation of existence are in play whether we talk about them or not. Not talking about them is not really an option when one is seeking sustainable change.

Why are theories important? They are the soil of the garden where the trees and plants grow. They are the foundation beneath interventions. One has to know the nature of the land before planning the type of plants to plant or buidings to build. These theories give language to the knowledge of procedural patterns and memories deeply ingrained and operating in our lives. Some conscious, many unconscious. We do not know ourselves as well as we think we do. We simply know the best story we have from the seats we got in the arena. These theories give us an aerial view of the whole arena, our whole family system taken a couple of generations back. Many a client will ask me why we have to talk about the past. Can we not just deal with the present? The operative word is “deal”. It is like asking why I cannot just use a chain-saw without any training. For the therapist, a theoretical framework provides the map which shows the way. Therapy at best, is a dance between therapist and client. From the map, the therapist derives a “formulation” - the compass - a broad understanding of this particular client’s difficulty navigating their life in the context of their family system. The therapist then proposes a line of action - the Pathway. Every formulation is creative and subjective. The theory is the objective roadmap. The formulation is the subjective roadmap. The therapist is constantly referring to the map, plotting new points, exploring new pathways and co-creating progress with feedback from the client. It is imperative that the therapist stays curious, nimble and creative. Complicating the process is the fact that the therapist ALSO has an internal map. Every encounter is between the map of the therapist and the client. Sometimes an encounter does not need to go so deep but the therapist must be prepared for the ones that do. These theories are not “optional”, they exist and are at play whether a therapist acknowledges them or not. It is a mistake to ignore them.

Out of theories are evolved Models of Intervention. A Model is a practical manual of a course of action. A Model tells the therapist what “to do”. Models are made up of numerous Strategies. Strategies are little steps of action - when this happens, do this. A therapist who is trained in a model or two and dispenses strategies without the larger map of a theory and a broad formulation will lose their footing when the strategies do not “work”. The therapist will ask the client to “try harder”, turning the same screw tighter. Often clients tell me they know all the strategies but it does not work in the moment they need it when they are dysregulated or “activated”. The client will gradually be classified as “stuck, difficult or chronic” without a formulation that tells them why. I don’t need to go into how disheartening it feels to a client when they are told they are “treatment-resistant” or “just not motivated”. This is untherapeutic language that is extremely condescending and serves no purpose. It is a fact that there are people who are not customers for therapy. For the most part, these people will tell you so. The therapist must always have a formulation that makes sense, EVEN when this is the case.

It is a fact that institutions - hospitals, universities and community organisations - are increasingly driven by quantitative, outcome-based funding. Instead of explaining the qualitative nature of human mental health, management often succumbs to the number game. There are things that can be quantified and things that exist qualitatively. One can attempt to quantify emotions but one must be honest about one’s limitations. The absence of honesty leads to reports of success that choose to eliminate key parts of a human being. CBT results slice and parse a human being to only the parts that can be measured. This leads to systems of revolving doors where people receive band-aid interventions or “strategies” that require that they get “fixed” quickly on a time-line or join the line again. Therapists and clients who do not fit into the number game just fall off the conveyor belt.

While theoretical knowledge and formulations are indispensable to treatment, they are time consuming and qualitative. In a world that relies on marketing, it is much easier to market Models and Strategies as magical fixes. I notice that clients have also learned the language of “strategies and scripts” and “tips and tricks” from pop psychology and arrive asking for them. It is a disservice to lead a parent down the garden-path of scripts to talk to their child. While scripts are helpful to an extent as conversation starters, it is more helpful and effective if the parent understands the landscape of the conversation and can find the words to communicate in their own “language” once they understand what they are hoping to achieve, instead of using a ready-made script that does not sound like themselves at all. Often the script sounds like the therapist and very soon , the child rolls their eyes at the apparent helplessness of the parent. There is an absence of respect for the power of family history , dynamics and emotions in this quick-fix way of convenient therapy. A hurry to “move on”.

And “Practice Wisdom” - Finally we have Practice Wisdom, simply put - the wisdom that one gains through the experience of practice. While practice wisdom is anecdotal and subjective, it is an informal asset in the therapist’s pocket. I am careful to not use the word “intuition” here. I have found that intuition is often understood to be an inspiration that has no structural accountability. In my world, intuition is a fast-forward response from a well-practiced place well grounded in theory. It can seem and feel magical but it is not. John Gottman talks about being able to predict the possibility of a couple divorcing after just a few minutes into an interview. It is a good example of practice wisdom. He has simply learned the “tell” of these couples’ dynamics from years of working with the same topic over and over. Practice wisdom is the result of verifying theory with the results derived from practice, over and over and sharpening one’s skills to simply be quicker at the process without losing accuracy. Practice wisdom also, unfortunately, cannot be quantified. It can be verified with patient observation. '“Patient” being the key word here. The proof of the pudding is in the eating.

The world of “Convenient therapy” - Manualized models - Over time, people trained in older, broader theories created manualized models. A “How-to” book. Nothing wrong with a how-to book in general. It is one tool among many for a therapist. There is a problem however, when a therapist sees the tool as the theory. It is a problem when the Manual is sold as “The Gold Standard” by the institutions we work for. When a young therapist is trained with the tool and it is implied that the older theories are not important or required, the young therapist is missing the mobility of the broad foundational ground. In the absence of theory, the Model HAS to work. So the young therapist uses their hammer to hit the nail harder and harder. When it doesn’t work for the odd client, the client is told they “lack motivation, that they are treatment - resistant and stuck.” Both therapist and client are stuck and frustrated.

We are trained in a culture that starts talking very quickly about “fixing the problem”. Young people who are eager to “help”, train to become clinicians. It is mostly overlooked or lightly noted that we all come from imperfect family systems that have influenced us, that we all have biases and that that the process of therapy comes with a lot of performance anxiety. Therapists and clients are equally eager about strategies and tools. But human problems are broad and deep. Therapists also have anxiety and a manual is more comforting to a therapist than the client. Therapists swear by the manual and hold on to it while clients throw their manuals in a forgotten corner and tell me that the strategies don’t work when they need them the most. Therapists forget that the client is not looking to be fit into yet another box. In this manner, the manual is more a therapist-oriented intervention than a client-oriented one. The client has to “fit into” the therapist’s preferred manual. When the strategy fails, the therapist is left without an alternate “tool”. So , like a frustrated carpenter, the therapist hammers harder with the same hammer. The bewildered client internalizes that he is absolutely flawed. Not even therapy can fix him.

The stance of a therapist has to be broad, nimble and creative. A person who promises to help others figure out their problems has to be an ongoing learner with their feet firmly planted in a broad theoretical framework that helps with the ‘formulation’ or the working model of the case. Ultimately, theory keeps the process from overlapping with the personal. A therapist’s lack of knowledge, narrow view of therapy and naiivete are deeply costly for the client. Emotions cannot be quantified, tabulated and repeated. However, they can be felt and anticipated. Emotions are powerful and require space to show up. And, contrary to reputation, they do have a logic to them. If one chooses to work in the qualitative field of emotions, memories and experiences, one has to find tolerance for the nature of them as they are.