CBT: The ‘gold standard’ for therapy?

Cognitive behavioural therapy (CBT) is like Marmite for many therapists. Some emphasize the research results which arguably show that it’s the “gold standard of the psychotherapy field” (David, Cristea and Hofmann, 2018). Others, like Richard House, see it as a “therapeutic technology” backed by a research regime that misses vital aspects of therapeutic practice; “subtlety, intuition, discernment and ‘the tacit’ in human relational experience” (2010).

Given that my original therapeutic training was with two of the most vehement critics of CBT – Richard House and Del Loewenthal – it seemed odd to some colleagues that I completed a Professional Certificate in CBT. One jokingly suggested that I’d “gone to the Dark side”!

At first CBT didn’t sit well with my existing approach, which is very much grounded in those qualities Richard extolled; subtlety, intuition and tacit embodied knowing. But I sensed that there was something of value here, notably because I’d unwittingly used CBT techniques to tackle my own anxiety in the past. Several years ago I started getting anxious about whether I’d locked the front door. I’d be about to cycle off to work when the thought would come: ‘Did I lock the door properly?’ My rational mind knew very well that I had: I’d  been successfully locking my front door every day for years! But the doubt nagged at me. The first couple of times I went back to check and it was, of course, fine. But I knew this wasn’t right because I was pandering to my irrational concerns. So I stopped checking. Sometimes it was quite hard. That voice in my head said: ‘It’ll only take a second to check, and then you won’t have to worry any more.’ I countered that with reason: ‘There’s no need to check. I already know it’s fine’. That’s a classic CBT approach and it worked very well: The worry went away instead of growing into full blown OCD!

But CBT doesn’t work for everyone. I’ve had several clients tell me that they tried CBT and it just didn’t work for them. Typically their CBT was provided on the NHS and the therapist didn’t know any other way of working. Why bother to learn anything else when CBT is the “gold standard”? This is part of the reason why CBT has such a bad name amongst some therapists: CBT is presented as the solution in a ‘one size fits all’ approach.

There’s some evidence that CBT is becoming less effective. A paper from 2015 looked at 70 CBT trials and found that the impact of the treatment for depression was falling (Johnsen and Friborg). The authors suggest several possible reasons for this decline, with the most likely being a reduction in therapist competence. What made CBT so attractive to the NHS was that it can be done by the book. In theory anyone who knows how to follow a step-by-step guide and can demonstrate the exercises to a client can be CBT therapist. But we know from extensive research that technique contributes no more than about 20% to the outcome of therapy. Those vital elements that Richard House highlighted above – subtlety, intuition, discernment and tacit knowing – are much more important.

I’m pleased I persevered with CBT. My trainer – a therapist with many years of experience – emphasized that CBT works best when it’s used creatively by an empathic, open minded therapist. It also opens the door to further training with the ‘third wave’ of CBT that integrates it with mindfulness.

CBT isn’t just one more technique in my ‘tool box’: It’s more like another pattern to weave into the rich tapestry of my therapeutic practice. As Richard House points out, the key to good therapy is how it’s practised, not which techniques are used (ibid.). To put it more crudely, it’s not what you do, it’s the way that you do it!

The Neuroscience of Walk and Talk Therapy

Susan Greenfield is a leading thinker on the neuroscience of consciousness, so I was curious to learn that she believes walking can help us think. Do her ideas help illuminate how ‘walk and talk’ ecotherapy works? Walk and talk therapy is much like conventional counselling but takes place outdoors. Therapist and client walk side by side exploring issues just as they would in the consulting room. Walking and talking in the park feels familiar to most people and being alongside the therapist avoids the potentially uncomfortable feeling of sitting opposite them.

Walk and talk therapy is increasingly popular and Susan Greenfield’s work suggests that it might also be very effective. Walking in natural environments has been shown to boost cognitive capacity, improve working memory and enhance recall. Susan describes other benefits:

“It is you who decides to examine a plant more closely or to focus on the far-flung horizon one moment, then perhaps to lean up against the tree the next: this internally driven sequence of events will then have the additional benefit of restoring a sense of control, of giving you a longer time frame in which to develop and deepen your thoughts”

(Greenfield, 2016)

Although Susan is writing about walking in nature, she has perfectly described a typical ecotherapy session.

Follow the path …

Susan suggests that as thinking is basically a series of steps, it can be seen as “a kind of movement: the longer the journey, the ‘deeper’ the thought”. She adds:

“the actual physical act of walking could amplify and thereby perhaps enhance this inner process: by reflecting in external movement what is happening in the brain, by having a clear causal link between one step and the next, with the mental being enforced by the physical, the repetitive contraction of muscles could help insure against the mind ‘wandering’, going, literally, off-track”

(Greenfield, 2016)

Everything that Susan Greenfield says about walking in nature suggests that walk and talk ecotherapy will enable clients to think more deeply and powerfully. Furthermore, the therapist will benefit in the same way, so we can do our job better. Susan Greenfield may have never heard of walk and talk outdoor therapy, but the fact that her neuroscience research unintentionally supports what we’re doing is exciting news.

Focusing and the Cognitive Iceberg

Focusing is a simple technique that helps you to become aware of what’s called a ‘felt sense’ – a feeling in the body that has a meaning. Focusing has myriad applications including personal growth, creativity and psychotherapy. I’m nearly halfway thorough my two-year Focusing Oriented Therapist training and it’s deepening my work in all kinds of ways.

For example, it’s opening new insights into how the cognitive iceberg might be applied to psychotherapy. First, let me outline how the cognitive iceberg can be used to illustrate the Focusing process. Gendlin, who first identified the felt sense, writes that it “comes between the usual conscious person and the deep, universal reaches of human nature, where we are no longer ourselves ” (Gendlin, 1984). On my cognitive iceberg the felt sense is represented by the dotted area just below awareness. Focusing is the process that enables the felt sense to emerge into awareness, as illustrated by the vertical arrows.

Focusing and the cognitive iceberg diagram
Focusing and the cognitive iceberg diagram

Now, what happens when a client and therapist are working together? The therapist is paying careful attention to whole situation; the client/therapist relationship, their own processes and what is going on for the client. A Focusing Oriented Therapist will be ‘listening’ with their whole body and be in touch with their felt sense.

Therapist and client Focusing diagram
Therapist and client Focusing

The arrows on this diagram schematically illustrate something of the process – note that I haven’t included the verbal exchanges which will also be going on. There is an exchange of ‘information’ between the therapist and client below awareness at the level I call the ‘deep body’. Both the client and therapist are also Focusing, becoming aware of material arising from felt senses.

There are many therapeutic processes going on here. The client will often be working through something difficult and the presence of the therapist can facilitate that: It’s as if the feeling is shared between them and the therapist’s embodied engagement processes some of the pain. Sometimes the therapist’s felt sense will alert them to something going on for the client and their embodied empathy can help the client. It’s also possible for the therapist to have a felt sense of something that comes from outside the client’s awareness and, with care, they can help it emerge.

I’ve covered a lot in this short post and I hope it’s reasonably clear. Please do ask me for clarification if not. I’ll add that this is all very speculative, but I hope that’s what makes this blog interesting!