Why CBT doesn’t work

Why CBT doesn’t work

Why doesn’t CBT work? The title of this blog post is deliberately provocative, and I chose it to flag a certain issue, public discussion of which is long overdue. As someone on an educational mission I want to raise awareness and help people make more informed choices when seeking therapy. 

CBT (Cognitive Behavioural Therapy) is at present a number one therapy, “on prescription” and promoted by the NHS for treating all kinds of mental health issues, including anxiety and depression. CBT is a short-term (6-12 sessions) solution-focused therapy that aims at modifying certain behaviours and thought patterns. It is easy to see why it presents an attractive option for both employers and medical services that are interested in quickly getting people back to the production line. It is also frequently appealing to people struggling with emotional challenges and desperate to obtain relief from their suffering. 

Then what is wrong with CBT, and what prompts me to say that CBT doesn’t work? It’s time for me to qualify my statement. I have nothing against CBT as such. CBT offers a valuable array of techniques that can be very helpful. I have them within my own therapeutic toolbox and use them as a part of my practice. My issue is not with CBT as such but with the way it is being marketed and sold as some sort of a “happiness pill” that would purportedly fix all our life problems. I perceive this trend as seriously misleading and potentially damaging for some people. It may leave people disillusioned with the idea of therapy in general, once they have discovered that CBT didn’t hold its promise. It also engenders the feelings of failure and hopelessness when people realise that after all those CBT sessions their problems still persist. I hear similar accounts over and over again from those who decided to give therapy another go, and who tried a different approach and found the way to my door: after an initial excitement and seeming success with CBT, they quickly realise that very little has changed. 

Let me now say a few words about CBT to try to explain why it is not effective as a stand-alone treatment for resolving deep-seated complex issues. 

The explanation is simple and is based on a few basic facts from neuroscience. Cognitive Behavioural Therapy techniques appeal to our so-called “rational brain” or the ‘thinking brain” located in the prefrontal cortex. It is the most recently evolved part of our brain and it is responsible for planning, decision making and controlling impulses. On the surface it seems that to engage and reason with our “rational brain” should be enough to make it “see” where it has gone wrong and how it can put things straight. 

However, it doesn’t work like this because our “rational brain” doesn’t rule autonomously. It operates in interaction with and is profoundly impacted by other regions of our brain that constitute the “emotional brain.” These are much more ancient structures situated deeper in the brain and they include the hypothalamus, the amygdala, the hippocampus, and the cingulate cortex. These areas of our brain are concerned with our survival. They control our fight or flight responses, the release of stress hormones such as cortisol and adrenaline as well as the formation of long-term memories that help us navigate this complex world and identify the situations of potential threat.  

From this short exposition you may begin to see the complication. If as a result of some previous adverse experiences our “emotional brain” came to associate certain life situations with danger, it will sound an alarm and trigger defence responses (whether it is fighting, withdrawal or shutting down) within a fraction of a second. What chance does our “rational brain” have of overpowering a system hard-wired for survival?! It might be compared to a man-made dam pitched against a tsunami wave: it will be smashed and swept away within moments, overwhelmed by the raging sea of turbulent emotions.  

This is why CBT doesn’t work as a stand-alone therapy for resolving deep-seated, trauma-based behaviours and ways of thinking. It is, however, a very effective tool that can be successfully used within a comprehensive therapeutic treatment that combines work on rewiring the deeper structures along with coaching our “rational brain”, and enabling it to assume more control. As our “emotional brain” becomes calmer and our nervous system lowers the flag of a permanent high alert, the “rational brain” acquires more leverage and its persuasive power increases. 

We can say that, in terms of neuroscience, the aim of therapy is to make the two brains talk to each other, to hear each other and to work in partnership. It is at this point that we begin to see real changes in ourselves and profound shifts occur.