The aims of this essay are to critically evaluate the arguments for and against Cognitive Behavioural Therapy (CBT). I will explore the theory of CBT comparing it to other approaches and the strengths and limits of the approach. I will then focus on the therapeutic relationship and issues of power. I will then critically evaluate the evidence that supports the use of CBT, focusing on the methodology and bias of research in the NHS. In my conclusion after considering the theory and evidence that is for and against CBT, I will then give my opinion of CBT, what I have learned from doing this essay and how it will change my practise in future. The reason I have chosen to explore the arguments for and against CBT is because I am due to start working for the NHS as a Primary Care Counsellor and will have the opportunity to study a certificate in CBT. I hope that I will be able to gain knowledge to help me make my decision on whether or not to study a CBT certificate.
I also feel that IAPT is influencing counsellors to feel they need to value the scientific model of CBT because of the time limited advantage and cost saving attributes. I feel IAPT training is potentially exposing vulnerable people to harm, because of the brief IAPT training that does not focus on the quality of the relationship, awareness of the counsellor, and the lack of knowledge that some CBT and primary well-being practitioners have about counselling and psychotherapy. I hope that this essay will offer me the chance to explore my assumptions about CBT and thus influence my practise and views. Having introduced the essay, I will now explore the theory of CBT, against other approaches. The cognitive behavioural approach is the most scientific approach to counselling (McLeod, 1998), it is a scientific psychological approach (Gilbert & Leahy, 2007) that argues that what a human thinks directly effects how they behave and feel (Dobson, 2001), this includes physical reactions and can lead to changes in the social environment (Greenberger & Padesky,1995). The model is used to treat people who have psychological disorders such as depression and anxiety (Beck, 2002) and focuses on changing behaviour in the future, by changing the dysfunctional way a person thinks about things that occur in the environment (McLeod, 1998). CBT argues that humans are not created by biological influences and sensations but are actively involved in constructing their reality (Neenan & Dryden, 2004). The CBT model is similar to person-centred counselling in the way it does not put an emphasis on unconscious processes but works with what is conscious (Medcof & Roth, 1979) and Watson argued that actual, observable behaviour rather than unconscious processes should be focused on because this can be measured and controlled (McLeod, 1998). However the Person-centred and Psychodynamic model disagree with the assumption that thinking is central.
The person-centred approach argues that the actualising tendency, which is an innate drive, is central to change and this is accomplished through the valuing of a client in therapy (Rogers, 1951) and focuses on the here and now experiences of the client (McLeod, 1998). Carl Rogers who is one of the founders of person-centred counselling would argue that conditions in the therapeutic relationship of empathy, congruence and positive regard, promote trust which is important as it enables a person’s self-actualising ability, meaning there is a capacity for personal growth and change (Rogers, 1951).
The Psychodynamic approach argues it is unconscious issues from childhood often created by feelings of the environment, that cause clients problems and the focus is on exploring past experiences and transference in the relationship (McLeod, 1998). John Bowlby who is from a psychodynamic model, would argue that the quality of the therapeutic relationship provides a secure base from which humans feel safe and supported and can develop self-esteem (Bowlby, 1988). A book titled ‘The Therapeutic relationship in the Cognitive behavioural Psychotherapies’ (Gilbert & Leahy, 2007), refers to Rogers core conditions (1951) and Bowlby’s secure base (1988) and they are both regarded as essential in CBT to promote change, which shows me the importance of the therapeutic conditions in therapy. A further study in the book also found empathy as central to change in CBT (Gilbert & Leahy, 2007) which confirms to me again a limit of CBT is the value placed on the thinking that is connected to the feeling, and not the feelings themselves. Both person-centred and psychodynamic models therefore argue that the role of the therapist is to create an environment that feels safe to explore issues and has a strong focus on the therapeutic relationship (McLeod, 1998), as opposed to CBT which is to mutually agree a treatment plan and to teach the clients different problem solving models where they can explore the meaning they have attached to events in life (Neenan & Dryden, 2004). A Limit of CBT is that clients are persuaded away from feelings and towards thinking about how they feel.
This is confirmed by Greenberger & Padesky (1995) who state there is a gap in CBT between thinking and feeling and that empathy is essential to bridge the gap. Further evidence that thinking is not central is supported by Tudor who states that the human organism is inter-related and trying to separate thinking, feeling and behaviour is artificial and won’t work. Furthermore he felt that separating behaviour and thinking as irrational was not treating a client with unconditional positive regard (Tudor cited House & Lowenthal, 2008). Clarkson agrees with this and states that the focus of therapy should be to explore the client’s wholeness and to integrate all disparate parts to fully experience life (Clarkson, 1989), separation of mind and body or thoughts and feelings is also a western concept and limits other cultures whose beliefs are more spiritual and religious (McLeod, 1998). Another issue CBT raises is that it is trying to comply with the current government climate that dictates that therapists should tell clients what to think and re-programme them (Brazier cited House & Lowenthal, 2008) which is confirmed by Marshall and Turnbull who instruct therapists to sell the rationale, make suggestions in therapy and be persistent (Marshall & Turnbull, 1996). This tells me that the benefit of the client is not central and the focus is on performing to government guide lines. Strength of CBT is that it would be useful when working with clients who cannot bear the thought of thoughts coming to them or find it hard to describe feelings (Clarke cited House & Lowenthal, 2008) and it is also a straightforward approach that enables action. Counsellors will also feel competent with the approach because of the techniques and teaching of the model (McLeod, 1998) and clients often appreciate been given tools to help deal with their problems (Clarke cited House & Lowenthal, 2008).
Further strength of CBT is that it is a medical model that stands up to the assumption in mental health that medication is the only answer and it has put therapy in the NHS as a treatment (Clarke cited House & Lowenthal, 2008). The model can be integrated into other approaches and more recently CBT therapists are looking at different approaches to support their practise, such as mindfulness and person centred counselling, which helps to develop the therapeutic relationship (Westbrook & Kennerley & Kirk, 2007). However integrating the model of CBT tells me that it is not enough as a single approach and more focus on the quality of the relationship is needed. Evidence of this is in a book called ‘Introducing CBT’ where the authors state that CBT is not the optimum therapy for all psychological problems and is not accessible to all clients (Westbrook & Kennerley & Kirk, 2007) and further support is that CBT is not a standalone treatment (Mansell cited House & Lowenthal, 2008). CBT is also limited with different cultures because of its western view that is individualistic. Collectivist cultures, who work on group solutions would not benefit from the approach and would find it hard to break the rules and not conform to their cultural beliefs (D’Ardenne & Mahtani, 1999). This individualistic view is confirmed by Dryden and Neenan who state that it is important to help the individual recognise where culture has shaped an individual’s outlook but also to point out that the individual determines their own outlook (Dryden & Neenan, 2004).
Having compared CBT to other approaches and the strengths and limits, I will now explore the issues of the therapeutic relationship.
CBT views the therapeutic relationship as one that instils trust and reassurance and requires the therapist to make the client feel secure and valued. CBT draws on person-centred theory to create the relationship, but does not put as much emphasis on this as other therapeutic models (Marshall & Turnbull, 1996), which shows me that therapeutic relationship is central to all models and clients require a safe environment to explore issues. The strength of the CBT approach is that it attempts to understand life experiences and common beliefs, which help develop accurate empathy and the client feels understood, this will prevent ruptures in the therapeutic relationship occurring (Beck, 2002). One of the early goals of CBT is to create a good therapeutic alliance and this is done by demonstrating empathy to help the client engage (Beck, 2002), however it fails to require trainees to develop self-awareness in the counselling relationship with the use of personal therapy (McLeod, 1998) so it is limited in how much the therapeutic relationship can develop because of lack of self-awareness by the therapist. The rejection of unconscious feelings that get in the way of the therapeutic relationship developing (Medcof & Roth, 1979) prevents exploration of the therapeutic relationship.
Evidence of this is in a paper by Milton who says that “CBT practitioners are beginning to rediscover the same phenomena that psychoanalysts earlier faced” (House & Lowenthal, 2008, pg101) which is that unconscious transference could get in the way of the therapeutic relationship and the client engaging in therapy (House & Lowenthal, 2008). This shows me that CBT’s rejection of transference and the focus on analysing clients thinking does get in the way of the therapeutic relationship developing. This is confirmed by Teyber who says that clients can move towards, away and against unmet needs to reduce the anxiety it has created. Clients may be submissive and never assert their own wishes, be resistant or withdraw from therapy (Teyber, 1988). The consequence of what Teyber states is that CBT’s lack of focus on unconscious process would mean that clients complete and perform tasks and agree with therapist’s opinions rather than exploring their own meaning or they may even dis-engage in therapy. Approaches outside of the CBT tradition all argue that CBT does not pay enough attention to the therapeutic relationship and CBT therapists themselves feel there is a gap of knowledge in how to relate to clients causing them to drop out of treatment (Gilbert & Leahy, 2007).
Having explored the Therapeutic Relationship I will now explore power.
CBT argues that the power in the therapeutic relationship is equal and issues of power are attended to because the therapist and client work together to agree a treatment plan, which includes work in between sessions, and looking at medical models that illustrate patterns in a person’s behaviour (Simos, 2002). CBT teaches the client how to solve their own problems by teaching them different models of CBT, which means there is a subtle move of power from therapist to client and clients are able to self-maintain in future (Marshall & Turnbull, 1996) and fix their own problems (Greenberger & Padesky, 1995). Strength is that the client can assume their own power and become their own therapist, and the goals of therapy are realistic so the client feels empowered as they achieve goals (Marshall & Turnbull, 1996). The image that CBT therapists convey is that two scientists work together to explore the problem (Neenan & Dryden, 2004) and strength of CBT is that the therapist will encourage the client to self-direct and self-maintain to create their own solutions to problems and they will have this skill for life (Marshall & Turnbull, 1996). Gillian Proctor (cited House & Lowenthal, 2008) disagrees and argues that feelings of powerlessness are central to issues that clients bring to therapy, and clients often turn to counselling because of psychological distress and vulnerability that is associated with feeling powerless. It is important in therapy that counsellors respect a person’s autonomy and explore issues of power (Proctor, 2002) and the very fact CBT therapists dominate therapy by teaching and applying models and determining thoughts as irrational, means that the client is powerless.
The client is forced to be engaged in therapy and has to learn how to use the models, this means they cannot engage with their own internal power or leave therapy feeling more in control (Proctor cited House & Lowenthal, 2008). Evidence of the expectation that clients will perform in therapy is evident at the stage of assessment. The therapist decides whether the client will benefit from CBT and the client has no involvement with making this decision. Clients are expected to be able to identify their problems and they must be motivated in therapy and have the ability to understand CBT models (Curwen, Palmer & Ruddell, 2000). The consequence of this is that not all clients can access CBT and clients are disempowered at the stage of assessment. Further evidence of disempowerment is evident by Marshall & Turnbull, who state that clients sometimes need to be coerced into carrying out actions that may be unpleasant in order that progress is made (Marshall & Turnbull, 1996).
A further limit of CBT is that it does not respect a client’s autonomy as it tries to fit the client into the model rather than adapting the model to suit the client, and the view is also that the counsellor knows what is best for the client (Bond, 2000). The client has little option to disagree with the therapist when the scientific evidence supports the therapist’s views, and this disregards the clients autonomy (Proctor cited House & Lowenthal, 2008). Neenan & Dryden also present further evidence of the lack of autonomy, when they instruct therapists to offer suggestions and solutions when clients are stuck with a problem (Neenan & Dryden, 2004). Proctor suggests this is CBT valuing beneficence from the point of view that the therapist knows what will benefit the client, and this takes away the clients autonomy (Proctor cited House & Lowenthal, 2008). A further consequence of directive counselling is that it affects the process of actualising and gives the view that the therapist knows what is best; this places judgements on the values and beliefs of the client (Merry, 2002).
Having explored issues of power, I will now critically evaluate some of the research supporting CBT.
The strength of CBT is evident in the research that supports the effectiveness on clients. CBT outcomes can be measure quantitatively and the model has leant itself to research (Paul & Haugh, 2008), this means therapists are accountable for practise and that clients benefit from therapy (McLeod, 1998). Accountability of practise and the benefit for the client is important; the BACP states that, “ensuring that the client’s best interests are achieved requires systematic monitoring of practice and outcomes, by the best available means. It is considered important that research and systematic reflection inform practice” (BACP 2013, pg2). The scientific support and psychology of CBT therefore support the ethical principle beneficence. The strong representation of CBT in research based practise, show a transparency that supports the worth, trust, confidence, time, money and effectiveness of the approach (Dobson, 2001). Guilfoyle however argues that the evidence base itself, does not measure ethics and philosophical principles of therapy and discounts anything that cannot be proved by science (Lowenthal & House, 2008). CBT has conformed to pressures in academic life, to pursue science (McLeod, 1998). CBT regards the scientific research as fact, meaning clients may feel powerless to disagree and therefore this does not respect client’s autonomy (Proctor cited House & Lowenthal, 2008).
Limits to quantitative research by CBT are that it focuses on techniques of therapy and does not account for the therapeutic relationship. Furthermore some types of measures do not represent the intensity of feelings, while statistics can shape the answers to questions they can also shape the questions asked, it disregards statistics that do not fall within a certain scale, and it also does not often take into consideration the amount of people who would show a result by chance (McLeod, 1998). Randomised control trials which are often a method to collect quantitative research do not represent normal clinical practise, they are expensive, do not reflect difference in the practise of CBT, do not consider external variants, and do not collect information about negative outcomes or the views of the client (Hemmings cited House & Lowenthal, 2008). McLeod also states that in RCT’s “it is inconceivable that the two groups would be exactly equal” (McLeod, 1998, pg 53). Studies into different approaches have also shown evidence that outcomes are similar regardless of the model, because of the nature of therapy which is to provide a bond that works towards a helpful goal (Haugh & Paul, 2008), this is known as the Dodo bird verdict, after Alice in wonderland who declares all have won (Tudor cited House & Lowenthal, 2008).
The research is also bias towards CBT by the government, as it is the treatment of choice, because it saves time and money (House & Lowenthal, 2008). Hemming’s agrees and states a bias is present and that CBT was originally used to reduce incapacity and unemployment, saving the government money (House & Loewenthal, 2008). This bias means that the client’s needs are not central and the ability to be a low cost treatment is the focus. Tudor also felt that the research method is biased and states that the government privileges the quantitative research of randomised control trials, and this avoids the complexity of human suffering due to its design (House & Lowenthal, 2008) which shows again that client’s needs are not the focus of research. Furthermore RCT’s fit the behaviourist views of CBT and discount other models which is unfair. This shows the bias of the RCT and limitations of the research as it excludes comparisons to other models. Research is more concerned with governance and economics than integrity and open inquiry (House & Lowenthal, 2008). This view is also held by Winter, who says that the research is designed to favour CBT and certain diagnoses (pg 141, House & Lowenthal, 2008). The outcome of government bias has resulted in IAPT training, where CBT is often practised by practitioners who have completed 45 days of training and have little knowledge of psychotherapy.
CBT seems to be a fast track approach by the NHS to quickly fix a problem in society. The IAPT training given to NHS employees has resulted in bad practise of a model with little attention to the therapeutic relationship (House & Loewenthal, 2008) and in future CBT training Milton suggests that longer and more complex training may be required as CBT develops the use of other theories (cited House & Lowenthal, 2008). This confirms my fears that IAPT could potentially be exposing clients to risks and that the research is biased towards proving CBT works, as the government is more interested in getting people back to work and out of therapy to save money. Instead of collecting feedback, that could improve the therapy itself and the outcomes for the clients.
Having explored the research method of CBT I will now conclude the essay.
In completing this essay it would only be fair to point out the bias that was present from the beginning. I found it difficult to write this essay giving an equal balance of the strengths and limits of CBT and I do feel that this may be present throughout the essay. I was not convinced by the arguments provided by CBT therapists and feel this may be because of my values on autonomy and non-directive counselling which CBT neglects. I hold assumptions about CBT that it does not value the relationship, is a very practical approach, and I also have negative views about the NHS IAPT service that I am to become part of. The reason for my views is the long waiting list that has developed for clients who are waiting to see counsellors who are not CBT trained, because clients will not benefit or fit into the CBT model. This essay and research of CBT has reinforced my views, there is not enough focus of the therapeutic relationship which should be central and transference is rejected. Furthermore the therapist’s self-awareness is not a requirement and CBT therapists do not pay enough attention to power because of the directive, teaching methods adopted. I also do not agree with the assumption that thinking is central and as a relational counsellor, I hold the view that the self develops in relation to others.
The essay has also shown me that others hold the same assumptions about the potential harm to clients from inexperienced IAPT practitioners and that training needs to be more in-depth. It concerns me that so much money is invested into CBT by the government and that further damage to clients could be a result. Certain cultures will not benefit from CBT because of its individualistic approach and this is a concern to me, because of the multi-cultural society we live in. I realise throughout the literature I have read there is hatred towards CBT that is not present towards other approaches and I feel that this may be due to the government backing and bias of research. Lees confirms this with his comment that “I’ve never seen so much anxiety associated with receiving £170 million” (Lees cited House & Lowenthal, 2008, pg 79). This essay has shown me that the models used in CBT can have a positive effect when integrated into different models that do pay attention to the relationship and this is an option for me when working within a time limit. It seems that CBT is also developing theory to include more focus on the therapeutic relationship with mindfulness CBT and it is something that I am open to learning more about. This essay has not changed my opinions of CBT in a radical way, but I will remain open to learning the model so I can enhance my practise for those clients who want to learn how to take control and have a problem solving approach. I also feel that it is important as a counsellor to have different options and not expect clients to fit into my way of working. CBT is something that could enhance my current practise which focuses on the therapeutic relationship; however as a single approach I am not in support of CBT.
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