Is Cognitive-Behavioral Therapy the “Gold Standard” for Psychotherapy?

CBT treatment involves efforts to change thinking and behavioral patterns and patterns, which usually leads to emotional changes and feeling better. 

APA Division 12 also offers an informative summary of cognitive-behavioral therapy’s approach to treatment:

CBT is based on several core principles, including:

1. Psychological problems are based, in part, on faulty or unhelpful ways of thinking.
2. Psychological problems are based, in part, on learned patterns of unhelpful behavior.
3. People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives. 

CBT treatment usually involves efforts to change thinking patterns. These strategies might include:

• Learning to recognize one’s distortions in thinking that are creating problems, and then to reevaluate them in light of reality.
• Gaining a better understanding of the behavior and motivation of others.
• Using problem-solving skills to cope with difficult situations.
• Learning to develop a greater sense of confidence is one’s own abilities.

CBT treatment also usually involves efforts to change behavioral patterns. These strategies might include:

• Facing one’s fears instead of avoiding them.
  • Using role playing to prepare for potentially problematic interactions with others.
  • Learning to calm one’ s mind and relax one’ s body.

There is no one way to do CBT.  The following is a brief example of one way to approach CBT, and an example of how I use CBT.  So as not to share confidential client information, this is a fictional example based on my many years of clinical experience. 

Bill, a 32-year-old, single male presenting for treatment of depression.  His symptoms include depressed mood, lack of energy, insomnia, poor self-esteem, difficulty enjoying activities he formerly took pleasure in, social withdrawal and loneliness, and a sense of hopelessness about his life improving.  Together he and his therapist came up with a treatment plan that included  recording his thoughts in a thought diary when he felt depressed, getting to bed at an earlier and more regular time, practicing healthier sleep hygiene, exercise 5 days or more a week in the form of walks or working out at the gym, and attending one or two social gatherings each week.  In the therapy sessions, Bill and his therapist went over the thought diaries and identified several unhelpful beliefs that characterized Bill’s thinking, including:

          Other people don’t like me.
          I am not competent at anything. 
          My future is bleak, and I will never get better. 
          No woman will ever want to marry me. 

Bill’s therapist proceeded to gently deconstruct these beliefs, helping Bill to appreciate examples from his life that contradicted these beliefs, and helping Bill to recognize the possibility that these mistaken beliefs were narrowing and limiting his life and his happiness.  The therapist also taught Bill mindfulness meditation, which he found helped him to observe his thoughts more objectively and discern which thoughts were overly negative and contributing to his depression. 

Bill and the therapist also worked on Bill’s social skills, including how to make and sustain better eye contact, and how to talk to others more comfortably in social situations. 

Typically, this type of therapy yields improvement within six months, although the full course of treatment can take longer.  In cases of moderate to severe depression, CBT can take much longer and is sometimes augmented with antidepressant medication, prescribed by a physician or nurse practitioner. 

Cognitive-behavioral therapy can be done on yourself, although it will work best with the guidance of a trained and experienced therapist.  The research that shows CBT to be most effective involved individuals working with trained therapists.  However, CBT involves doing “homework” exercises outside of therapy sessions and places an emphasis on teaching the client to become his or her own therapist once therapy is over. 

If you would like to try CBT on your own, there are some excellent CBT self-help books, including Feeling Good: The New Mood Therapy by David D. Burns, M.D. and The Anxiety & Worry Workbook: The Cognitive Behavioral Solution by David A. Clark, Ph.D. and Aaron T. Beck, M.D. 

CBT is a highly effective approach to psychotherapy, but the evidence that it is superior to other approaches to therapy is weak at best.  

CBT is the most researched type of psychotherapy.  According to APA Division 12:

Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications.

Research clearly shows CBT to be effective psychotherapy.  Some studies find CBT to more effective than other types of therapy, while other studies simply find it to be equally as effective.  In my opinion, the evidence for the superiority of CBT is limited and weak.  For example, one study critically examined three large meta-analyses of cognitive behavioral therapy, and found the meta-analytic evidence for the superiority of CBT to be “nonexistent or weak” due to factors such as the inclusion of problematic trials, problems accurately classifying treatments, an excessive focus on disorder-specific symptom measures while ignoring other important indicators of psychological functioning, and the reliance on small, clinically unimportant (and often not even statistically significant) effects. 

To sum it up, CBT is definitely effective psychotherapy, but the evidence that it is superior to other approaches to therapy is not convincing in my opinion.  

Yes.  CBT is an excellent and useful approach to therapy, but it has limitations, as all approaches to therapy have.  

All approaches to psychotherapy are based on theories about human nature and the human mind that are useful but inherently limited.  Psychology and psychiatry have developed many theories to understand the human mind, and no theory has proven so useful and effective that it has crowded out the others and taken a dominant role in the field. 

Regarding CBT, its theory emphasizes thinking and behavior as fundamental to human change and treats emotion as secondary.  I believe that this approach gives short shrift to the emotional side of human nature and is a weakness of the theory.  Focusing is a different, humanistic approach to psychotherapy that gives much more weight to emotions and the way we experience emotions in the body.  Focusing works to help the client gain awareness of a bodily felt sense, by holding an open, spacious, and nonjudgmental attention that helps the client clarify and understand his or her emotions.  Many clients have found Focusing to be profoundly helpful in ways that are quite different from CBT. 

CBT also operates in a very logical manner, which is both a strength and a weakness; the approach will appeal to some and will alienate others. 

Another way we can look at the limitations of a particular theory is to consider what the theory leaves out.  CBT does not address the unconscious mind, i.e. the contents of the mind that we are not conscious of, nor does it address defense mechanisms like repression and denial, which are means by which we lose awareness of the painful contents of the mind, or the inner critic, the inner voice that criticizes and condemns us (the inner critic is usually very prominent in depression).  The unconscious mind, defense, mechanisms, and the inner critic (or superego) are all parts of the psychodynamic theory of the mind, dating back to the work of Freud and Jung.  I often find these concepts helpful in my work as a therapist. 

CBT also does not address differences in personality type and development, which I consider a major limitation of the theory.  There are many approaches to psychotherapy that recognize the existence of qualitatively different personality types, and tailor their approach to the client based on which interventions are most effective with the client’s particular personality type.  Many theories also recognize differences in personality development or maturity, utilizing the rich knowledge of developmental psychology, which is important to take into account in working effectively with an individual client.  Psychodynamic psychotherapy takes into account both personality type and personality development, and the DSM-5 explicitly takes personality into account.  My favorite approach to working with personality is the Enneagram.  The Enneagram covers the whole range of human personality, from severe psychological disturbance to self-actualization, and also addresses the spiritual side of human nature in a way that is inclusive across spiritual traditions.  As a therapist, I find the Enneagram helps me understand my clients more quickly and more deeply, and helps my clients better understand themselves in a way that Cognitive-Behavioral Therapy does not. 

To sum up, CBT is an excellent and useful approach to therapy, but it has limitations, as all approaches to therapy have.