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What Cognitive Behavioural Therapy Is Missing

Cognitive Behavioural Therapy or CBT is probably the most prevalent form of psychological therapy for issues such as anxiety and depression in use in the UK today. It's recommended by NICE, on the basis that it seems to be the best supported psychological therapy in terms of research evidence. I suspect there's a widespread view that if only the government would properly invest in making CBT available through the NHS then we would to a large extent solve the problem of widespread and economically damaging poor mental health (for example see the LSE Depression Report 2006).

Personally, I think that while CBT is undoubtedly a useful tool it's rather over-egged, and that it misses or at least under-values certain truths. In this article I'm going to explain why I think so, what's missing, and how CBT can be made more complete and more effective.

What Is CBT?

Cognitive Therapy was first developed by Aaron Beck back in the 1960's. His basic insight was that negative emotions such as anxiety and despair arise in dependence on aberrant or unhelpful thinking patterns. An example: you're feeling anxious about giving a presentation to the bosses at work. You believe the bosses will think you're not up to the job, so you feel anxious (i.e. the anxiety is caused by your belief).

So to gain relief from anxiety or depression etc. you should target the relevant thoughts and beliefs: if you can see that the bosses don't really think you're stupid the anxiety will start to evaporate.

Cognitive Behavioural Therapy adds behaviour patterns to the picture. Behaviour patterns are also conditioning factors for difficult emotions, and likewise are targets for change. For example if you tend to decline every opportunity to give presentations, then that will maintain your belief that you're really bad at them and thus the anxiety. What you need to do is stop avoiding and start giving presentations so that you can find out you're actually ok.

Here's a short YouTube video that summarises CBT.

Something Missing?

Is the CBT account of how emotions arise really true? Well, it's hard to deny the logic of the above examples, but I don't think it's the whole story.

What I think is missing (or not sufficiently emphasised) is that what you believe is conditioned by how you feel, or putting it more concretely, by the state of your body physiology.

If you believe everyone thinks you're stupid, just as you stand up to speak, then yes of course you're going to be anxious. But it's quite likely you only believe it in the heat of the moment, because you're already anxious. Three hours later when you've calmed down again, do you still believe everyone thinks you're stupid? Probably not. The belief is conditioned in part by the feeling, or the over-aroused ("fight-or-flight") physiology. Change the physiology and you change the belief.

So it seems that thoughts and feelings condition each other (here I'm defining feelings as the perception of body states). 

thoughts feelings connection

What comes first? What starts off the chain reaction? To an extent it's a matter of chicken-and-egg. But for a fuller understanding we can bring in the concept of pattern matching. What happens is that the mind can recognise or classify any given situation as just another example of such-and-such, and this unthinking, automatic recognition kicks off a patterned or conditioned response such as getting anxious (just like Pavlov's dogs salivated when they heard their dinner bell).

Here's this fuller picture in diagramtic form.

thoughts feelings connection

Implications for Therapy

I've seen plenty of clients for whom CBT hasn't really worked. (Don't get me wrong, it works for a lot of people, just not everyone, and it for those it does help, it's not necessarily a full and perfect solution). These clients often have the impression that CBT is telling them their thoughts aren't true and they should just stop believing them. But that's actually very hard to do. Sometimes you just can't help believing in what you've always thought.

But with the more complete picture, we have two possible points of attack, or opportunities to change the response:

  • change the thoughts (the CBT way)
  • change the physiology that is the basis of anxiety, depression, etc.

An example of the second way: suppose when you're anxious, your muscles tighten up (e.g. shoulders, brow). Maybe this tightness is part of what conditions your negative beliefs and thoughts. Learning to release tension effectively can help you let go of the negative thought.

Third Wave of CBT

New forms of psychotherapy see themselves as new (and presumably better) forms of CBT, or extensions of CBT. Examples are Mindfulness-Based Cognitive Therapy (MBCT) and ACT or Acceptance and Commitment Therapy. They hold that it's not necessary to actually change problematic beliefs such as that you're stupid, but merely to "hang loose" to them, stop taking them so seriously, not getting so caught up in them,  and to start relating to thoughts as like a radio playing in the background of your mind, that you just don't have to pay attention to. In other words, you only need to open up some space between you and your belief (a process sometimes called cognitive defusion).

How Biofeedback Can Help

What actually happens when you step apart from your own thinking process like this? I think a really key aspect of the process is that your physiology changes. When you "let go" of a negative thought, you literally let go - your muscles loosen.

Using biofeedback you can develop your skill in letting go of muscle tension. And that can make it much easier to step apart from negative thoughts.

Of course muscle tension is not the only factor in the physiology of anxiety, and it's not the only useful biofeedback parameter, but you get the idea.

My Stress Resilient Mind Programme focuses on developing mind-body regulation skills in this way, but it doesn't ignore the insights and techniques of CBT. Both methods together are a powerful combination.

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