If you’ve ever been to therapy, you’ve likely heard of CBT. Even if you haven’t, you’ve probably experienced some form of it in the media, in self-help books, and through word of mouth. While CBT is highly researched and useful in many situations, every theory has its limits. In my practice I use CBT as a foundational place on which to build, while recognizing the importance of being holistic in our approach with clients.
The Prevalence and History of CBT
You’d be hard pressed to find a therapist in today’s world that isn’t well-acquainted with Cognitive Behavioural Therapy. I would wager to guess that it is the most prevalent system of therapy that exists, and for good reason. Created by Dr. Aaron Beck in the 1960’s, CBT was a radical shift away from the classic therapeutic modalities of psychoanalytical work, led by the likes of Freud and Jung. Before CBT, there was great emphasis placed on our past experiences, our subconscious, and our biological desires and drives. While there is merit still in the world of psychoanalytic therapy, CBT set us on a new path, one where therapy became focused on the present moment, on our present cognitions, and on behaviours that can be changed and adapted in the here and now.
CBT’s Approach to Thoughts, Feelings, and Behaviours
The basic premise of CBT is this: your thoughts, feelings, and behaviours are intrinsically connected, at all times. Thoughts produce emotions, and emotions lead to behaviour, and this process cycles through us constantly. But, thoughts are tricky and they don’t always reflect reality like we think they do. Here’s an example. Let’s imagine that you get anxious at parties. You might think “I hate how I look, I’m going to stand out like a sore thumb and people will think I’m weird and won’t want to talk with me”. This thought is quite anxiety producing (we call them negative automatic thoughts, or AT’s), and it leads to emotions (anxiety, fear, shame, etc.), and consequential behaviour (maybe you skip the party to avoid the fear). Seems simple enough. The part of this example that CBT wants to zoom in on is the initial thought. We like to assume that our thoughts are accurate, but that’s often not the case. In that previous example, is there really evidence to support the thought that you ‘look bad’ and that you will ‘stand out’? When we go through therapy and break down those negative automatic thoughts, we begin to see that thoughts are unreliable. In therapy, CBT can help to examine thoughts objectively, decide how ‘real’ they are, and then create new, adaptive thoughts to replace ones that produce anxiety and fear. In doing so, we break down the cycle and allow ourselves to live with a more positive view of self. This is a simplified explanation, but you get the point. Thoughts affect mood and behaviour; therefore, to change feelings you must change your thoughts.
CBT’s Limitations in Addressing Trauma
But, there’s a problem here. As therapists and researchers have learned more about mental health conditions there has been more emphasis on the effects of Trauma. Trauma, from a therapeutic standpoint, consists of large-T traumas (for example, sexual assault, war, serious accidents, abuse) and small-T traumas (bullying, harsh parenting, death of a loved one, relationship betrayal, and more). Many clients come to therapy with varying degrees of trauma that exist from their past. The hard part about trauma though, which research is still discovering, is that it lives in our body; meaning, trauma directly affects our brain, biology, and nervous system. Because of that, those of us who have experienced trauma in our past have different ‘wiring’ in our body. The way we are post-trauma does not allow us to easily shift our thoughts in the way CBT would want us to. It’s not that simple. This is where CBT may hit a bit of a wall.
Holistic Approaches in Therapy Beyond CBT
In therapy, I approach clients with the understanding that everyone coming in may have trauma in their past that lives in their body today. Really, this is the definition of what it means to be trauma-informed as a therapist. For those clients, CBT can get them part of the way, but it would be unwise to rely on it fully and completely. That is why in my practice I use CBT as more of a foundational modality. It allows us to understand the relationship between thoughts, emotions, and behaviours, but it doesn’t mean it gives us the full picture. For those who present with traumas, we need to add other elements into play like inner child work, body regulation, skills like emotional regulation and distress tolerance, somatic healing, amongst others. Being a holistic therapist requires you to do what is best for the client, based on their unique context and goals for therapy. Often, this means therapy will have to go off in many different directions outside of CBT. This is a good thing.
The Value of CBT and Its Role in a Comprehensive Therapeutic Approach
CBT will always have value, and it does a really good job giving us the psychoeducation piece around thoughts, feelings, and behaviour. It is a great place to start, and it undoubtedly lays a great foundation from which to work. But, it’s just the beginning. People are highly unique and beautiful in their own way. Therapy needs to adapt and truly understand the need to expand and draw in other types of therapy to best serve the client.