Why This Therapist (Kinda) Hates CBT

maybe it's me, maybe it's evangelical ptsd

A little context before diving into the meat of this post: CBT, or cognitive behavioral therapy, is a so-called “gold standard” of therapeutic treatment. It involves recognizing how your thoughts impact your emotions and behaviors, and deliberately challenging or changing negative thought patterns so that you can change how you feel and act.

Image sourced from https://hudsontherapygroup.com/blog/cognitive-triangle

I’ll caveat that in my graduate program, I was trained in the psychodynamic tradition. This pays particular attention to one’s unconscious drives and impulses (Freudian theories), and gives a lot of weight to one’s early attachment experiences (object relations). It also frequently uses the therapeutic relationship as a way of healing earlier wounding, because people show up to therapy with the same patterns that they have in real life — giving you an opportunity to work on those issues “in the lab,” so to speak. I learned to do therapy in-depth, patiently, and meaningfully. We weren’t just trying to change exterior behaviors — we wanted people to transform their internal experience of themself.

It was a rude awakening after graduation when I went to work in community health agencies, where CBT was touted as the solution for every affliction. Mind you, the populations coming to these agencies were often deeply traumatized and sometimes with some pretty severe mental health issues. I worked with children in schools, and we were given scripts and worksheets for how to help kids deal with their anxiety and their ADHD and anger issues. It was extremely formulaic.

I’m not saying there’s no place for a good coping skill like some deep breathing, journaling, or externalizing the worry monster… but it seemed insane to me that we were expecting a totally dysregulated child to remember to “stop and think” and “take a deep breath!” when they were mid-meltdown. The agency’s goal seemed to be trying to bandaid up a scratch when we actually needed to be recognizing there were broken bones underneath that needed to be set and healed.

Needless to say, I kind of hated it. I loved the kids I worked with, but I hated how every note I wrote needed to reflect some concrete progress we’d made or skill we built, when in reality, sometimes sessions looked like sitting in nonjudgmental near-silence with a child whose trust had been broken by nearly every caretaker in his life thus far. (But we were discouraged to do “rapport building” for more than just a couple sessions before moving on to the “meat” of therapy…. well guess what; rapport-building sometimes [always, if by rapport we mean the therapeutic relationship!] is the meat of therapy). I hated how it felt clients were problems to be solved and progress to be measured (for the sake of continuing our Medicaid funding — it’s a whole system in play here!) instead of people with unique hopes, dreams, and individualized paths.

The ironic part is that my understanding of trauma was still in its infancy — as it was for the whole field. And this isn’t even that long ago! 2016-2018¹! I felt strongly that CBT was missing the point, but my psychodynamic training also hadn’t adequately prepared me for directly treating trauma, nor had it given me a sufficient framework for understanding what happens to the brain when it has adverse early experiences, and how to work with the brain’s innate capacities to heal from early trauma.

If you are a person for whom CBT has been immensely effective, I love that for you²! Perhaps I am just too filled with unconscious drives and unresolved traumas, or too stubborn to have someone else suggest that I modify my thought patterns to feel better. In the past, I have worked round and round on the same problems and gotten nowhere by just thinking about it… but once I experienced alternate healing modalities (EMDR, energy psychology, somatic methods), a giant shift was able to occur.

There have been occasions when I have a near-violent internal reaction to CBT. Curious, right? I began to wonder what was going on, and I had the realization:

the CBT strategy of “changing your thoughts to change your behavior” sounds wayyyyy too close to evangelicalism’s “hold captive every thought” in the quest for sanctification…

Huh. Well, no wonder I find myself chafing against the very essence of CBT. I spent my entire existence in evangelicalism convinced that if I just change myself through sheer willpower, or by “submitting to the will of Christ” which somehow also felt like sheer willpower… then I’d be truly loved by God. If only I could make myself think the proper thoughts about myself, my religion, my god…then I’d surely have the proper feelings and behaviors follow. If only I could turn off the feelings and desires evangelicalism told me were so sinful … if I could shut down my doubts about the Bible … if I could conjure never-ending feelings of love and affection for g/God.

As much as evangelicalism promises grace for every sinner, it’s a bait-and-switch tactic in actual practice, and we end up feeling the need to constantly strive to prove ourselves and feel good enough — and always come up short in the process. And no amount of cognitive reframing is going to change the underlying message of evangelicalism that if you don’t believe the right way, God will — even if reluctantly — have to send you to hell.

The second irony of today’s post is that religious trauma causes a kind of wounding that I don’t think CBT techniques have a shot at truly resolving. I see religious trauma clients who “know” they don’t believe in a vengeful, angry god… yet a deeply ingrained part of them truly fears the wrath they might experience if they step out of line. We could spend our time talking out the issue ad nauseum, presenting alternate viewpoints, noticing catastrophic thinking. But why do that when we could do some actual healing work using trauma modalities like EMDR or IFS?

Of course, learning EMDR and IFS and other trauma modalities is a lot harder than handing a new counseling grad a packet of worksheets and a CBT triangle that explains what people need to do to fix their problems. The inner work required to do good trauma treatment is a lot more intensive, too, because a lot of your own stuff can get stirred up when doing depth-full work with clients.

Effective treatment of trauma requires getting a processes that are usually sub- or unconscious for people. CBT remains at the conscious, cognitive level, which is fine if you have a problem that needs a conscious, cognitive resolution. But my preferred work is with trauma clients, including the ones who come to me saying they’ve seen other therapists but felt like therapy didn’t go deep enough. It probably didn’t.

I may not shout my rage at CBT much anymore³, which I’m sure is helped by gaining a lot of confidence in my therapeutic skills by using other modalities. And it helps that I can recognize that both CBT and evangelicalism trigger the same self-shaming button of why I struggle to “fix” my problems of my own conscious accord. I’m letting go of all of that and sinking into the lovely, intuitive, somatic, soulful complexity that is really good therapeutic and inner work, and I don’t miss the other stuff one bit.

1. Is that not WILD?? This is less than a decade ago, but our understanding of trauma and neuroscience has grown exponentially. I remember my first play therapy conference in 2018 learning about the neuroscience of trauma and polyvagal theory. These concepts existed before then, of course, but even the mental health field was not super well versed in them. And here we are today with “trauma” as a part of our general public’s lexicon!

2. Also, I will semi-begrudgingly admit that there’s some really help ideas in CBT. For instance, I’m fond of concepts like catastrophizing: realizing that you’ve begun assuming that the worst outcome is going to happen, instead of recognizing that it might not be as bad as you think. And I often use cognitive challenging and reframing in sessions to help provide another perspective that clients seem to be missing. I’m not against every tool in the box; I’m protesting the oversimplification of our complex beings.

3. Ask my spouse; I would come home raging after work about the stupid ways my agency expected me to be treating and “fixing” my severely traumatized child clients.