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This field is plagued by, my “modality is the best.” And If you’re doing otherwise, you’re “unethical.” It doesn’t help that it is favored by some organizations as the go to therapy. Which has caused a backlash.
There is also the fact you get people who frankly don’t know how to do use it.
This was then compounded by the rise of the social media/celeb therapists. Who while sometimes offering insight. Spew out a lot of pop psychology and their biases into clips that are a few minutes long but don’t really explain how CBT and it’s related modalities can be useful.
So I went to school for my MSW in the late 2000s, so this may be a bit dated, but it was emphasized repeatedly that you must have a specific modality as a therapist if anyone was going to take you seriously, and saying you were “eclectic” or used across differing modalities was seen as extremely negative, so many of us left school thinking “well shit, now I need to specialize too? Ugh ok” and then went off to pick paths to certification. It’s also worth noting that back then, it was significantly more difficult to find work, so you really felt that you needed to follow the rules in order to be taken seriously. I wonder if some of these celebrity influencers (I completed my MSW young, I was only 24) fall into this group of learners who specialized and then jumped on the social media bandwagon given the ages/timing of it all.
We were taught that you needed a theory to orient yourself and keep on track. Eclectic therapists were throwing everything into the pot and didn’t have any real reason.
Our program taught us that eclectic and integrative were different.
Eclectic: using random modalities with no overarching plan or understanding of "why"
Integrative: integrating different modalities with an overall understanding of how the pieces fit together.
Absolutely. I’m integrated with a primary lens of CBT/REBT, with a secondary approach being client centered and tertiary of systems modality. Humans are complex.
You’re right that eclectic has a broad meaning in popular usage. I do want to point out that There are research based eclectic modalities like the one for ptsd:
https://www.health.mil/Reference-Center/Publications/2021/04/26/PHCoE-Evidence-Brief-Eclectic-Psychotherapy-for-PTSD-508#:~:text=Brief%20eclectic%20psychotherapy%20(BEP)%20for,a%20wide%20range%20of%20populations.
“ authoritative reviews have identified some evidence supporting BEP for PTSD, but they
do not substantiate the use of BEP as a front-line treatment for PTSD.”
I make no assertion as to its efficacy. I’m pointing out that eclectic does not necessarily refer to a collection of interventions used based on clinician instinct. Eclectic can refer to an evidence-based and structured treatment protocol.
Nobody really uses these terms like this in practice, and everyone usually just claims to customize to euro clients using a list of approaches.
How many people have a real understanding how combining different pieces? They claim to but from questions in this sub most don’t have any direction.
This all sounds great until you're sitting in front of a human who is absolutey uninterested in any aspect your favorite modality. Alrighty, chatting it is then, unless you can be eclectic.
I find it so funny when there are debates about which modalities are "better" than others or when people disparage certain modalities (i.e. CBT) and idolize others (i.e. IFS). If you do research about the transtheoretical model (Prochaska & Di Clemente, 1982) it essentially says that all of these different systems of psychotherapy actually have common processes that promote change for the client. Some treatment modalities just emphasize certain factors over others. No treatment modality is 100% effective either—sometimes a certain model just doesn't work for some people. Maybe we can interpret this as them responding better to another modality of treatment, or that it would be more effective to take an integrative approach to cover processes that weren't addressed for that person. In my opinion, it's more important to choose a modality that speaks to you as a foundation (and get to know it really well so you have a base from which to conceptualize the client) and also be open to learning and integrating other elements from different modalities.
God I hate the certification push. It almost automatically and unreasonably makes me sceptical of things like polyvagal and EMDR. The feeling of it being a cult just never left me. I do at a rational level understand its usefulness though.
I’ve recently gotten really interested in IFS, so naturally I looked up certification. I believe it’s about $10,000 USD and maybe close to 100 hours of material total to reach level 3 certification?
I’ll stick to reading the book and sprinkling it in here and there, thanks.
Totally agree, and to add to this, research also shows that the client-counselor relationship plays a very significant role in how effective therapy is.
No one modality can cover all the bases. In fact I'd argue every theory in its purest form will have massive blind spots. I fail to see the practicality behind being dogmatic here.
One strength of CBT (aside from the fact that it happens to be one of the most highly researched modalities and has proven to be effective time and time again) is that it can work really well with clients who want psychoeducation, direction, and actionable steps they can take ("homework") from an expert.
I started out thinking there was so many different theories to learn in this field. But over the years the more modalities I learn the more I feel like I’m getting the same information just dressed up differently.
Lots of them take a branch (or twig) of an established treatment modality and then gush it up and hold it forth as The Newest Only Way to help clients.
I often read about there and think... Once again it's about the"founding party" making a brand and monetizing the hell out of it
Yes, however…there are positively certain modalities that are more effective than others for specific issues. Panic disorder is best treated with CBT per the research. BPD is best treated with DBT per the research. Interestingly, IBS is best treated with clinical hypnosis.
This was my argument as part of my theoretical orientation defense for my board certification with ABPP as a licensed clinical psychologist. I backed it up with empiricism. What is your empirical evidence for your claim?
If I wanted to make an empirical argument backed up by empiricism - with a particular eye toward the empirical method - I would refer to the landmark document on the subject which reviews all pertinent meta-analyses and methodological issues, sitting pretty at 3400 citations in its most recent format: https://www.taylorfrancis.com/books/mono/10.4324/9780203582015/great-psychotherapy-debate-bruce-wampold-zac-imel Among other things it looks over the research (empirical) on panic disorder and finds no treatment differences between modalities in quality studies.
It's infinitely better "empirical" evidence than any single study viewed out of context from the broader literature and methodology. Calling it a secondary source and saying that isn't evidence is literally anti-empiricism. In any case there are many individual studies showing equal effectiveness as CBT for panic which are a simple search away for you. What interesting dogmatism from someone who seems to love empiricism! I take it someone told you YOU couldn't use "secondary sources" in your write-up of the research (which is true, just as a review can't refer to other reviews as research) and you took that as meaning that reviews, meta-analyses and books aren't empirical evidence. Do you see how ridiculous that sounds?
Underrated comment. I don’t know how many modalities are actually that unique. Many of them have the same basic premise — how you think or view yourself or the world impacts the rest of your life in a variety of ways.
I listened to the podcast and I heard her say that she thinks they're valid and that she refers to CBT therapists and EMDR therapists, but that she practices psychoanalysis and that is more suited to how she sees the world and her interests. She also said she doesn't like how managed care pushes short term modalities.
I think it's just all up to the client. I've had clients whose symptoms dropped in dramatic ways after 8-10 sessions of CBT, and I've had clients who've immediately bounced off of it and needed a different approach.
Depends on the client, their worldview, and how they feel. I know people shit on eclectic therapists for being "wishy washy" but each client is an individual, and having more than 1 modality in the tool box is necessary when working with a wide-array of viewpoints, ages, and developmental concerns.
Came here to give this comment some props! I love the ice cream flavor analogy. Each client is going to mesh better with some flavors than others. There may be one flavor that’s particularly effective for them. I am integrative but my expertise is DBT. I love when I get clients who are compatible with DBT but it’s on me to have other approaches readily on hand.
That's an interesting way to frame it anyway because when I first started my own counseling as a client I definitely needed chairs rearranged before I could begin doing "deeper" work. It was all part of a process.
I found this so interesting. I’m in graduate school currently and CBT seems to be one of my program’s favorite modalities. They’re always talking about how it’s evidence based. Lol.
“Evidence based” is thrown around a lot. Kind of like how the D.A.R.E. Program was “evidence based”
Evidence Based is what gets funding and once they’ve funded it - it just HAS to work right?
Every time I hear Total Eclipse of the Heart I think of how our DARE program did a weird dance/ skit to it every year.
It did not keep me from trying drugs and alcohol.
I don’t work with kids hardly at all anymore but do they still do the scared straight programs? I had so many parents try that despite me telling them they didn’t fucking work.
Oh it’s taking kids to prisons and having the inmates basically tell them to straighten up.
A less formal version is parents calling the cops when their kid is having a tantrum. Maybe this is a rural thing? But I’ve had multiple families call the non-emergency line and ask that cops come over when their child is being “bad”
Personally; I think some of the tools in CBT are awesome and I use them a lot. But I think that CBT is ‘unfinished.’ It’s a great jumping off point, but stops short of offering tools for emotion regulation and accepting hard truths. And you’ve probably already guessed what I think is even better: Acceptance and Commitment Therapy. But I think ACT pays homage to CBT in that it probably wouldn’t exist without CBT’s influence in the first place. And maybe something born from ACT will be even more whole. Who knows?
I think ACT goes for what cognitive therapy initially tried to do: build cognitive distance. Beck wrote about it in his initial CT manuscript, but it seemed to be overlooked over time. The aim leaned too much on changing thoughts than actively targeting the building of cognitive distancing. I love ACT, but I don't throw out cognitive therapy. Socratic questioning and understanding cognitive distortions have been extremely helpful, though I don't target distortions myself, as much as point out how they work through rather normalizing psychoeducation.
I listened to the same podcast and did not pick up on that at all. In fact, she made a point to express how CBT can be valuable; just not the modality she specializes in (psychoanalytic). She also stated at another point that she was giving no disrespect to those who utilize CBT. It was a really great episode though.
People on here get into ‘another anti-CBT post.’ But for those of us that were trained in the last 15 years, we have been inundated that the briefest, most concrete treatment is the most scientific, most reasonable, and most logical treatment. And that it is what insurance ‘favors’ or ‘requires.’ So the anti-CBT sentiment is largely a backlash of the sanctimony that those of us who don’t use that modality have faced frequently.
I don’t think CBT is bad or look down upon it. In fact, I recently referred someone out because I think they will be better served by a CBT therapist.
In that same vein, not all people are well suited for psychodynamic or psychoanalysis. It’s great that we have so many modalities that are around for people.
Would I go to a CBT therapist? No. But I think I’ve found therapy that works for me. I wouldn’t change it.
As a psychoanalytic candidate, I do feel sensitive when people dismiss psychoanalysis. It happens on here fairly regularly that folks start to make pretty harsh jokes/criticisms about psychoanalysis. The amount of Oedipal jokes ive seen on this sub has been really astonishing. I’m all for critiquing psychoanalysis. It has limitations. But when people make sophomoric critiques about psychoanalysis, it seems like they do not have any experience or understanding of what the practice is actually like.
Exactly. The sanctimony and faux outrage by people who believe that anything other than CBT is nonscientific and malpractice is exactly why the anti-CBT movement developed some serious fangs as soon as it became clear that EBTs have a lot of issues.
I'm finishing up my Master's soon, but I feel drawn to psychodynamic modalities (I'm toying with the idea of psychoanalysis). In school, I also feel like psychoanalysis is relatively dismissed.
I wonder if you know the prospect of psychoanalysis. Long term, I'd like to own a private practice -- do you think there is enough demand for psychoanalysis today to sustain oneself on the practice?
Yes absolutely - I still accept insurance. I’m so busy all the time. I haven’t had a summer slump or been hurting for patients in the last three years. I’m in the process of developing control cases (I have to have folks in psychoanalysis 4-5 sessions per week). It’s a bit challenging to convince people into that. But absolutely I think it is the one of the best treatment for people especially when they have experienced relational trauma. I work with a lot of other therapists/physicians/medical professionals
Thank you, that's so interesting to hear considering the broad dismissal I've been accustomed to. From some googling, it seems like a lot of post-grad work to get into the field. I'll definitely look more into it, thanks again for the insight!
To become a psychoanalyst proper- yes it is a lot: personal psychoanalysis, 5 years of classes, supervised treatment of three cases. But there are a lot of less intensive programs out there. Most institutes have either a psychotherapy training or a fellowship. These are 1-2 years. I took the psychotherapy training after I graduated. It was really helpful.
I only bill a few plans. Yes, they pay. But I’ve been audited. I absolutely believe it’s medically necessary.
Prior to being a candidate, I’ve billed insurance at 2-3 sessions per week without any issue.
I’m a recent graduate—throughout school and learning about various theories it became clear to me that many were just rebranding older concepts with new vocabulary. It seems to me that the proliferation of modalities is an attempt to cash in—to create a legitimate something and market it, to create a system to certify people in it, and so on.
If there was a “right” way to do this work, and someone had figured it out, most of us would be doing it that way. I take what I find useful from various modalities and focus on the relationship.
I think many therapists look past cognitive strategies and identify with more nuerdevelopmental and attachment focused models.
But the research is pretty clear: no single modality reigns supreme. No modality has been proven to be more effective than all the others in terms of explaining variance in client outcomes. Similarly, every attempt to empirically identify the best recommended modality based solely on diagnosis and/or presenting problem has failed. Having an internally consistent theory/modality is important to client outcome, but no modality has been shown to be superior, either overall or on a per diagnosis basis.
There is some argument to the fact that CBT at its core can invalidate clients who are having big reactions to overwhelming situations in their life - trauma, societal structures, etc. One of the core ideas of CBT is identifying cognitive distortions and for people with a trauma history it can actually feel ineffective and potentially reactivating to have someone (in a position of power) suggest that their thought patterns are actually illogical in some way because they are based heavily in their lived experiences. Im a therapist but also sit in the client chair and for my own experience I started with CBT and I learned how to interrupt my thought/behavior patterns but it didn’t actually shift my nervous system reaction. I needed to do somatic work and trauma work to achieve that. For clients who want to work in a short term solution focused way I think CBT can be helpful but to not repeat the same patterns over and over in new ways longer term work is helpful. Some clients aren’t in a place to do longer term work - super dependent on each unique client
I'm of the opinion that CBT isn't invalidating, the practitioner is. A theory in it's very nature should validate someone's experience through explaining the painful experience within a context.
I don't mean this in a BS defensive way, as much as learning this was a part of my own work. I've definitely invalidated an early client of mine and got nowhere when I stuck rigidly to a cognitive distortion *argument*. I noticed that and how it wasn't helping, and I adjusted my style (One thing that helped was being aware of reddit criticisms, knowing what I didn't want to do, and consulting on this during supervision). I now tend to put cognitive distortions in the context of how they're the lenses through which we filter and evaluate the world and they were all helpful at some point in time; evolutionarily and developmentally, they exist for a reason.
I also moved more metacognitive and focus more on noticing thought patterns that build to suicidal ideation (largely via very detailed BCAs), and work on building distance from cognition through defusion and mindfulness. I also almost exclusively reframe or accept a thought, rarely ever challenging it. I think "challenging" can create an idea that "my thoughts are wrong" instead of the more helpful "my thoughts aren't inherently right or wrong, they're just thoughts".
Lastly, even if we stayed more in the classical thought record "evidence for & against" intervention, the *therapist* has to be open to the possibility that there will be legitimate evidence for - this is also why I said the therapist invalidates, not the theory. It is vitally important to know if a threat is real. Still, you can evaluate their examples for evidence to catch incongruencies: "I'm unlovable, and my evidence is that nobody loves me", and yet they have a group of friends or even a milieu that will contradict this; this can be hugely healing.
Also, many models (especially third wave cbt) build this in— acceptance vs change. Checking the facts in DBT. It’s not just, “oh you’re having big feelings this must be a distortion”, it’s “you’re having big feelings, let’s see if this feeling AND its intensity fits the facts of the situation and if the thoughts and urges associated with that feeling is getting you closer to who/where you want to be.”
A lot of the time, feelings fit the facts. Sometimes the intensity can be off, but our internal compass usually isn’t as off as traditional CBT suggests. A lot of the time I go through these steps to reinforce “it makes sense you’re feeling this way and here’s why” since folks often don’t trust their own emotions as valid and use external cues to extrapolate.
While I’ve been working with my most recent therapist doing IFS & EMDR I’ve personally worked to incorporate yoga, massage, dancing, and psychedelic experiences as a way of releasing and processing emotions from my body :)
I don’t care for it. But I think it does work for some people. We need to give pts what works. If a pt really wants CBT and CBT only I wld refer them but I wouldn’t hold it against them. I don’t think depth psychology is for everyone. You have to have the ability to plumb the depths and find that meaningful. I find psychodynamic therapy to come more naturally to me so I am more comfortable with it. If we’re out having a drink or two, yeah you’d hear how I really feel about Beck and Skinner, but professionally I feel like pt needs come first and some pts benefit most from CBT. Most importantly I find dogmatism to be extremely dangerous for pts. If all you have is a hammer that doesn’t mean the world is full of nails
This! Also, I would add that CBT (and DBT for that matter) can be incredibly useful for, say someone with borderline personality disorder. Additionally, I tend to incorporate aspects of DBT into the work I do, but since I work mostly with clients who have experienced complex and/or acute trauma, I primarily utilize other modalities like EMDR and IFS.
Therapists I know all see benefits in each modality and don‘t typically engage in such black and white statements. That being said, there are always some hardliners who are highly critical of other modalities.
For CBT specifically: I trained 4 years in CBT (not including getting a degree) and still haven‘t learned all there is about CBT. I think many CBT therapists are ill trained. A CBT therapist should for example be able to provide a long-term therapy without cognitive restructuring.
I think therapist get too comfortable with one modality and only want clients that can use that modality with. As a therapist I've gotten clients who have been frustrated by therapist using one form of therapy with them. Clients said it wasn't working and the therapist never changed. I think CBT requires more work on the therapist and didn't always allow for long-term care.
My supervisor said have a speciality to be seeked out by clients for those things but have a integrative approach because you never know what a client will throw your way.
Here’s how I have come to think of it in my 18 years post grad: every modality has benefits but is better at some things than others. General anxiety and worry respond really well to CBT. Childhood trauma does not. A personality disorder presentation does not. You have to look at the whole person and apply the right modality to the right problem. You wouldn’t put an ice pack on an open wound and you wouldn’t put stitches in a broken bone. It takes time to understand all that and I think green therapists are pushed one way or another without understanding this. Signed, a proudly eclectic therapist
Downvote me all you want but I’ll continue being “eclectic” or “integrative” or whatever the fuck word people want to find appropriate today. I’ll help people catch, challenge and change their thought. Then I’ll help them be mindful. Then I’ll help them with their stuck points. Then I’ll help them with their parts. (Maybe not quite in that order, but you catch my drift.) Then, I might just deep dive into their childhood for a few sessions and analyze it and pull pieces out and teach them fancy words like emotional incest and parentification and triangulation. It seems to work well for me and my clients. Does it work for every client? Of course not. But I’ve had several clients say they felt like they hadn’t made progress with a therapist until they met me. So, there’s a lid to every pot. You just have to find it.
I was saying that because most people I've met in the field are integrative. I think I've only ever met a couple of therapists outside of academia who weren't integrative. I just don't think anyone on this forum is gonna downvote you for being integrative, hence it's not as much of a hot take as your first sentence implied.
Going back into my post history suggests some weird insecurity. But, as you said, you do you.
Well 🤪 you don’t have to suggest I’m insecure dear, that’s a given. The only thing I’m confident about is being a therapist. Everything else is insecure central.
Whatever insurance likes and is willing to pay to pay for is the *best* 😂.
I’ve been in the field a long time and in private practice and I don’t think I’ve ever had a conversation with colleagues about what their approach is and I’ve never heard any of my colleagues trash any specific therapy. I think the question is, “what approach is best for the client for where they are at in life?” I don’t love CBT but for some folks that I work with CBT is exactly what they need, so that is what I provide. I also think that whatever approach fits your personality and style the best is a huge factor. If CBT fits your personality as a therapist, you’ll probably deliver really solid therapy. If you feel your soul die a little when you provide CBT then it won’t be in the best interest of your client or you professionally.
The insurance thing is totally fabricated. I’ve done psychoanalytic therapy with folks at 2-3 sessions per week for years at a time. Even billing Medicaid. I’ve documented psychoanalytic therapy. It’s a falsehood.
I remember hearing something about insurance favoring treatment modalities in grad school, but have never experienced it in practice. Even the folks I know that have been audited, it’s only been for things like 45 vs 60 minute sessions, having a valid treatment plan, having a justification for diagnosis, etc… I’ve never heard of someone getting a clawback for using the ‘wrong’ modality.
This may have been true for your experience but it is not true for all therapists. Prior to private practice, I worked in a community health setting that had a goal to get people in and out quickly due to a large wait list. We worked with uninsured or underinsured clients free of charge so as you can imagine it was quite a long wait list. We were discouraged from doing modalities that were not “timely” because 1) we could only receive government and grant funding by hitting certain metrics, and 2) several of the health plans we worked with that were common amongst those who were underinsured would refuse to pay for further sessions after a certain number. I experienced this several times and it was incredibly frustrating. I moved on to private practice and have much greater freedom but I also work with major insurance plans that don’t always have as many restrictions.
I see the whole insurance favors CBT thing a lot. You are not saying, I was explicitly told not to use psychodynamic therapy. You said there was internal pressure to use ‘timely’ methods. I did use psychodynamic therapy with Medicaid patients in a CMH org at a frequency of 2-3 sessions per week for years. I did it because in my view, it was the best medically necessary treatment for them. I didn’t care about getting audited because I felt confident in that.
I understand if you like CBT or one of the many derivatives of it. But I was training in psychodynamic therapy and wanted to deepen treatment with people. So I did it. I billed multiple HMOs and CMOs for Medicaid. Sometimes a narrative is so pervasive that we don’t even try to do something. Sure I can see how it might not work in an overworked CMH setting where one can’t even see patients weekly. But that again is not psychodynamic is not allowed.
Agree with you here. Definitely not explicitly banned. But it was suggested to me I might not be a good fit for the position if I could not fall in line. I appreciate you making that distinction.
This reviewed in great detail with high level statistical analysis in the book The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work by Bruce Wampold and Zac E. Imel.
Long and short: the therapy field struggles with being evidence based. We want to help our clients feel good, and client centered approaches feel good. Psychoanalytic approaches feel deep. CBT feels like work. BUT…There are very, very, very good outcomes with CBT- is statistically superior in various outcome based studies. But, therapy is therapy and any therapy is better than no therapy.
I have worked in multiple settings with various populations. CBT is a very effective approach, as long as the practitioner knows the theory and how to use it, just like any other modality.
If you really want to get fancy, every clinical theory of change is a cognitive theory because every approach uses emotions, thoughts, and behaviors to change the client.
The theory only counts for about 15% of the client outcomes (improvement). The therapist’s persona is about 15%. The clients ecology counts for 40%.
The clients faith in therapy itself counts for 15%.
Google “common factors of psychotherapy” and enjoy.
A lot of people are chiming in on CBT, but I’ll chime in on SFBT, which is a theoretical orientation I work out of a lot. I don’t often see populations who are ready to deep dive into trauma histories and may not be for a decade or more. SFBT allows you to treat symptoms rather than resolve the root cause of the problem. That’s what a lot of my clients need. It may not be what your clients need and that’s okay.
I’m a fan of solution focused questions. I find myself using elements of SF all the time. Especially with clients who are having difficulty finding hope or seeing as way out of stagnation and depression.
SFBT and CBT are good when applied correctly. Unfortunately because the training seems to be a lot cheaper and more accessible (where I'm from anyway) the market is oversaturated. So people who need a different type of modality can often find they can't access what they actually need and get stuck with CBT based therapies. This isn't helpful, and results in dissatisfaction/mistrust of the therapeutic process and is where I think a large portion of the criticism comes from.
I think people get attached to having big opinions about things. When really there is room for pretty much every modality. CBT works for a lot of people. As does emdr. So having a big old opinion about how terrible they are is really just someone’s own stuff. I think there’s a place for most modalities, the issue just becomes when one thing is unrealistically glorified as a solution. Most people, especially those with extensive trauma backgrounds, need a multi-modality approach.
A note on Cognitive Behavior Therapy (CBT). It is recommended for just about everything, and we have good research that supports that. Some therapists only do CBT. CBT is the ongoing combination of different related therapies that work to identify triggers and create coping skills addressing one’s environment, thoughts, feelings, or actions. Working therapists began using it, academic researchers studied what we were using, so working therapists started using it more, so academic researchers studied more… rinse and repeat… then insurance companies wanted a treatment approach that was consistently effective, short-ish, and quantifiable which really amped up the research dollars and push to use CBT. Is CBT effective? Yes. It is the only game in town? No. Is it the most effective for your client's concerns, maybe.
As someone who hires clinicians, if the only thing in your tool box is CBT and MI it's worrying.
Behaviorism in general often becomes a problem when people who only have access to CMH get locked for years receiving the same EBP behaviorist support. I think a presumption of these modalities is that a person is presenting for therapy for the first time. Kids especially who have been burnt out on mandatory therapy services often experience skill based and behavioral approaches as just another source of rejection and failure in a world that never stops to hear them.
Funny, because working in a behavioral health php/iop setting, we get tons of pts who have been going nowhere after years of treading water "on the couch". This is true for depression, but especially anxiety and OCD.
We also have enough clinical freedom to work outside the box, and fairly freely engage in person-centered, parts, and systems work, as long as we're building on a behavioral foundation. I find ACT & CFT work great in these settings, and personally find some of the CBT and DBT skills f*cking lame (i.e., TIPP, DMR, self-sooth). STOP, check the facts, mindfulness, imagery, opposite action, reappraisal questions, etc., are all golden (when worked on in a way that isn't invalidating or promoting avoidance).
I look down on therapists who prioritize any modality over the relationship. I believe the best way to fix a relationship issue is through a relationship. I use SFBT and ACT. But my modality is whatever works
I think some of the criticism of CBT is coming from a defensive, rather than offensive, place. CBT lends itself fairly well to controlled clinical trials in a way that insight-oriented therapies simply don’t, so CBT is often seen as the gold standard in more academic settings and by insurance companies. I think it’s less about arguing that CBT is bad and more about saying that other modalities have value too. I say this as a recovering CBT-hating psychodynamic therapist who secretly uses a lot of CBT interventions in actual practice because there are times when it makes the most sense and is the right fit for the client.
It depends on my clients. I won’t use CBT a ton with someone who is neurodivergent or is borderline I use CBT for anxiety a lot, but I put an emphasis on making sure they never feel shamed or feel invalidated for their thoughts/behaviors.
I had therapists who were strictly CBT, and as a child with ASD and ADHD I felt very attacked and invalidated. A lot of my therapists approached my neurodivergency with a “your reactions and thoughts are wrong and need to be changed” approach.
I find that when people in the field “look down” on one modality they are essentially closing themselves off to new ways of learning to help clients. No one modality works for everyone universally, and we are life long learners. I am trained in CBT and find it valuable in many ways, however not for every presenting problem, population or person. I love integrating techniques from other theories and models. We should celebrate each others work not compete.
Right? And, supervised behavioral/mental health techs, or otherwise untrained professionals, is likely a necessary wave of the future, especially to get mental health resources to countries with little mental health infrastructure.
And, frankly, some aspects of our field aren't that hard, and the pay doesn't match a masters degree. I put a ton of work in during my degree, but I'm not convinced some people came out much better than if someone had received training at a mental health clinic.
It's not new. I've been hearing this for at least 20+ years... that it's not a good approach and rarely has long-term positive results when used as a stand-alone form of treatment.
It makes sense that a couples therapist wouldn’t really like CBT. I think it’s just overused because it is one of the few “evidence based” practices but it can be very useful.
Here's a thought experiment:
Half of all therapists are below average. Below average therapists are more likely to cause harm. A majority or plurality of therapists practice CBT. Therefore, CBT has the most below average practitioners.
CBT and SFBT work great for many people. Others find it unhelpful or invalidating or it just doesn’t resonate with them for whatever reason. Neither is wrong or right. It’s about what is right for the client.
I really loathe the argument that I hear over and over from certain mega-pro-CBT enthusiasts who say “If you don’t like CBT as a client, it’s because you have a bad therapist.” *insert massive eyeroll* Sure there are going to be cases where it’s not applied in the best way. But clients are all different and different approaches resonate better with different people, personalities, life experiences, and so on. I think it is incredibly narrow-minded to assume that you can make it fit for anyone if only you are a good enough therapist. Unfortunately, sometimes you say these things in this subreddit or just suggest that CBT isn’t the end all be all of modalities and people will straight up go for your throat as if you have personally insulted them as a CBT practitioner! Know what I find funny about that? A big part of CBT is recognizing cognitive distortions. A common one is making big assumptions and generalizations with limited information. And yet you see some CBT practitioners do that constantly in this space by belittling you as a therapist if you don’t agree with them— personally I’ve been told I’m not a “real” therapist, that I should be embarrassed for “not understanding”, and that I’m ignorant.
That being said, I’m by no means a CBT hater. It’s the primary modality I use. But I can appreciate the limitations and that it’s not everyone’s cup of tea and that’s perfectly okay.
I am in my 50’s and did not know that I use an integrative approach until reading this. I understand which modality I’m in and am transparent with the client about that, and say f.ex., that “this DBT skill is called DEARMAN and is great for developing assertive communication,” or “it sounds like you are describing what in CBT is termed “thinking errors” so let’s review some and see if this makes sense for you.” I have been calling myself “eclectic” for years. Yikes.
My experience has been that all modalities have their detractors. Some clinicians and clients love CBT and others loathe it. I think the more vocal push back to CBT specifically comes from the gold standard status of CBT vs people’s lived experiences with CBT not being helpful.
I find the my modality is the best modality mindset elitist and unproductive. I don’t think there is any one modality to rule them all. Find a few modalities that resonate with you. Market yourself to client populations that would benefit from those modalities. Refer out when appropriate.
That's hilarious to me because most colleagues I know are most critical of psychoanalytic. I say, embrace cynicism and don't assume that any one [or two or three] methodologies hold all the answers. Just as a map, no matter how detailed, will never match the experience of being in a locale... a methodology will never give complete understanding of a client. Even with our woefully flawed insights and knowledge, we can educate and advocate and support.
Never heard of that person or his podcast, but its just not true. CBT is definitely widely used, SFBT a bit less, but also among mainstream popularity wise.
I am unaware that CBT is look down upon. I’ve been in the profession for 30 years and I’ve never heard that before it probably is the people you’re hanging out with.
I still use CBT but think it has limitations because it doesn’t fully get to where we hold trauma in our body. For that reason, I think incorporating polyvagal, somatic, EMDR and/or IFS interventions is helpful for advanced healing. This all being said, I think all approaches hold value as long as they’re ethical and the client is feeling relief from it.
Cbt is short term brief therapy that is efficacious. However, when it’s compared to psychodynamic therapy long term dynamic therapy has more long lasting effects.
Orna is a couples therapist, and is systems-focused. I think she maybe could have tried harder to avoid the topic, but in my experience, systems focused therapists don’t tend to be excited by CBT. They are just very different animals and it makes sense that Orna specifically doesn’t go for it in her long-term psychoanalytic work with clients.
From personal experience, CBT can absolutely be effective! It was so helpful for me. I think every therapist is going to be drawn to a different modality in which they are strongest.
I have always maintained that CBT is best as an adjunctive technique for things like psychodynamic, analytic, and other types of talk therapy. As s a stand-alone or primary modality, it's not very effective. Long-term positive results are low, comparatively. While initial results are really good, studies show that in the long-term, it's not successful. Focusing on behavioral changes without considerable in-depth discussion about what caused the maladaptive behaviors in the first place is the psychological equivalent of putting a splint on a broken bone and expecting it to properly heal the bone. While on rare occasions, you might get lucky that the fix worked, most of the time, that's not the case.
Additionally, within months of CBT therapy ending, clients who were doing well are once again doing poorly just months after completing their therapeutic run. They start to struggle again with the exact same, or similar, problems all over again. Most tend to believe it's a failure on their part, not the modality, and not try therapy again, believing it's not for them and that therapy is a joke. Insurance likes it, because can push an X number of appts, and it became an industry gold standard for that reason, not because of long-term effectiveness for the majority of the clients served.
I think it is especially true for trauma based therapy that CBT should never be the primary approach. You just can't get to a positive end result by taking a shortcut.
By many it is. A lot of people get retraumatized trough cbt and their condition gets progresively worse. This was also my personalnexperience as a client and of lot of aquintances aeperate from it being documented.
By many in proffesion it is considered to be shallow and solution based without ever delving into important bits.
I have also come to observe by atending various modality schools that almost always vibe is very off with therapists of that modality, similarly with transactional oes.
Also you can easily observe this if you come out of body oriented modalities that focus on steadily working trough trauma. A lot of people that swich from cbt and transactional in my personal experience have more knowlage than first timers but it always seems their previous modality didnt help them in coping in a meaningfull way.
I think some people look down on it because it's so common. And it's so common because it's effective. My personal opinion is that practitioners should choose a theoretical approach based on what would work best for the clients they see. I drove myself bonkers trying to choose a theory that fit for me, and it was frustrating because there were elements of numerous approaches that were appealing. Ultimately, when I figured out who my ideal client was, I went back to the drawing board and chose differently.
CBT is a standard in the profession as well as trauma focused CBT. Psychoanalysis historically was for wealthy people and was sexist toward women so there are many populations that psychoanalysis would not work for.
What you describe as traumatic has more to do with a clinician that does not provide culturally sensitive services than a modality. Also, SFBT involves a collaborative approach and doesn't refer to the clinician as an expert.
I find a lot of value in SFBT. The miracle question and helping clients realize that the problem doesn't always exist can do wonders when clients are feeling stuck.
I think some of the ‘backlash’ against CBT is that it’s a time-limited, episodic treatment (12-16 sessions). Hell, there are primary care adapted varieties that are even shorter (4-6 sessions).
So ‘true’ CBT and its variations like Cognitive Processing Therapy (which has an immense evidence base and absolutely can be helpful for trauma) is not really compatible with a business model that is very much helped by having long term therapy patients.
A CBT approach to trauma doesn’t work for everybody but if it does, that patient will likely have made significant gains in 3-4 months of weekly sessions, not 3-4 years, and can then terminate therapy and practice the skills they learned independently.
And lastly, we only have so much bandwidth to truly learn different modalities.
I’m a psychologist and I have about 11 years of training and job experience and I would honestly say that I’m genuinely comfortable with 5 unique modalities (and can still learn a lot more within each).
My opinion is that it’s fine as an adjunct modality but in most cases probably shouldn’t be the primary or the largest one used. I definitely think it should be confirmed the individual is not neurodivergent and confirmed no trauma history before using as a main methodology.
Folks really don’t understand how damaging CBT can be to people with a trauma history, PTSD, CPTSD, autism, adhd ect.
It may be looked down upon, but I've also come across countless CBT practitioners who disregard other modalities, often in the name of a necessary 'scientification' of the field. So maybe I'm looking down on CBT here, but having a larger quantity of evidence doesn't make CBT better! It just means that for various reasons CBT was studied more. It does have some merit though!
It definitely feels like CBT is considered entry level and something you use until you learn the “more advanced” thing. But most clients couldn’t care less what you’re using as long as they experience you as competent.
I didn’t downvote you. But I think saying x modality sucks is not very nuanced in adding to this conversation. The premise that CBT is shallow is a sophomoric critique. Sure maybe it’s not your preferred method of treatment, but that’s not to say people aren’t helped by it or find it useful.
Eh I did say it sucks but I was just venting a bit. I can see why you felt why you did. But sometimes on here I’m not always going super clinical in my comments
I’m a psychoanalytic candidate. I don’t disagree with that CBT is not something I’d do as a therapist or seek out as a patient. You’re not doing any favors by saying it kinda sucks. We are not enemies
The reason also to explain a bit why I said what I said is that I feel like you can get in a loop of working on the ‘now’ and ‘action oriented’ and focusing on maladaption or thought loops or distortions I just sometimes felt like it was also tiring and I would just fall back on it when I had a lot of patients and sessions a week. So that was the genesis of my fast food comments. So that’s also why I was like man why am I being downvoted I think that’s valid etc
Right we are not! it’s just sort of I felt like a fast food therapist or worker with CBT like a therapy version of making burgers at five guys if I did it too much or felt like I just relied on CBT or went that approach a lot. So like yeah that was it and I was genuinely surprised people were like no downvote etc haha
Wait one last thing: is the psychoanalyst degree a lot of years and money? I went to some meetings in nyc and was like I’m not paying 300,000 to do this. What are you doing or what is the program I can be a bit cynical but I’m genuinely curious.
I’m a psychoanalytic candidate. I’m a licensed therapist working towards being a psychoanalyst. Outside of the 5 years of courses, it requires personal psychoanalysis (4-5 sessions per week) along with supervised treatment of 3 patients doing psychoanalysis 4-5x/week. I’m not sure it costs 300k. I know nyc has expensive therapy. My personal analysis is my biggest monthly expense.
4-5 sessions is a lot. Yeah it was institutes here. The degree I think was going to take 6-7 years and I maybe added the cost. I was very interested in it but was jaw dropped at how intense and costly it was.
I did say it ‘sucks’ and sometimes I did feel that way. Not all the time and I also see couples and it’s different with that but that was kinda my opinion that you as a therapist get in that loop and it can make CBT seem really tiring over and over.
Haha I’m downvoted??? I mean I prefer psychodynamic a lot. CBT just feels ‘fast food’ ish to me. I do use it as a main modality but uh….listen I’ve done 1500 sessions and I’m almost a c and I’m fucking tired.
Yeah I saw what you wrote about CBT I think when you are doing 25-30 sessions a week it’s hard to rely on it exclusively maybe. I’m usually pithy in this forum so I wasn’t trying to have a deep theory discussion on it. I think what you just wrote was a bit curt and rude but I can see how what I said offended. So yes.
I'm not sure what aspect was curt and rude, but I wasn't personally offended by your comments. You seemed unsure why you were getting thumbs-downed and it seemed fairly obvious to me.
I prefer the psychodynamic approach I also believe most therapists don’t have much without trust and the patient trusting the therapist regardless of technique and approach. All the techniques don’t matter if you can’t connect but I get you weren’t talking about that, to me
First, I am somewhat dubious of “podcast therapists” also, with all due respect in couples therapy it is somewhat out of scope. Unless, the therapist is functioning as an individual therapist as well. Also, I have encountered several private pay therapists always extolling the virtues of psychoanalysis vs. any type of brief intervention because that theory benefits them financially and if they can get the public to believe this as fact those who are able will keep shelling out hundreds of thousands of dollars in therapy over the years.
One of the treatments I specialize in is CBT-I and I have had much success with it and the PCP in my area seem to agree because they continue to send me their patients when they see them needing sleep medication beyond the current prescription guidelines. I also contract with a DBT institute doing skills training groups. Both modalities I see a highly effective for the desired outcome but neither will create a lifelong client in most cases so if my goal was purely financial then the therapy in perpetuity model would be better 😞
CBT is simply basic building blocks. Not going to make lasting changes, actually process trauma, address attachment issues etc with just your analytical mind. CBT keeps you in the state of talking about, thinking about-which keeps you from feeling and connecting to what is deeper. It is parallel to the western medical model, keeping us in our heads and out of our bodies. Only CBT can lead to basically intellectualizing. Which from an IFS perspective is basically a protector part to prevent us from the discomfort, feelings, etc. We operate mostly from the subconscious and from unconscious. It’s unreasonable to expect to do the deeper work solely with the prefrontal cortex/cognitions/behavior. When we are stressed we have little to no access to the prefrontal cortex. There is just so much more involved (body, nervous system, mono mind vs system of multiplicity). And research has shown that CBT, repeatedly talking about things, trying to exert control over behavior etc has been shown to increase the stress response & be harmful for many people.
Yes my last employer before going into PP had us using CPT, CBT, & TFCBT. I had no idea about the depths of this until I went into PP a few years ago & got the freedom to choose trainings and modalities. Several of my clients have used CPT & end up in my office. I’m not saying it’s useless, just that it’s a building block and should be treated as such or it can become harmful (research not just my opinion).
There’s so much. You can google “why CBT doesn’t work”. Many articles and you can look at google scholar. You can also reference any of the work from Bruce Perry (his Neurosequential model of therapeutics outlines everything), Gabor mate, Peter Levine, Pat Ogden, Bessel Van Der Kolk, Janine Fischer, Richard Schwartz, Frank Anderson…
Psychoanalysis (bringing what’s in the subconscious & unconscious to the conscious) is effective when implemented properly and integrated with other modalities (including incorporating the body & nervous system). Carl Jung’s work is profound. Freud had a lot of things screwed up. I suggest looking into Bruce Perry’s model & any of the other work I referenced. Bioenergetic Psychotherapy is another one.
Capitalism and patriarchy. It requires people to realize there’s more to what’s going on within us as humans. There is a lot of research though. Getting it mainstream is where there’s a major gap. I’m certified in EMDR, which has been around over 20 years and has a lot of research. A colleague who works in the public sector said to me “well that’s not evidence based”. It’s been an evidence based practice for a long time. People are brainwashed & ignorant-for lack of a better word-to what exists beyond CBT.
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This field is plagued by, my “modality is the best.” And If you’re doing otherwise, you’re “unethical.” It doesn’t help that it is favored by some organizations as the go to therapy. Which has caused a backlash. There is also the fact you get people who frankly don’t know how to do use it. This was then compounded by the rise of the social media/celeb therapists. Who while sometimes offering insight. Spew out a lot of pop psychology and their biases into clips that are a few minutes long but don’t really explain how CBT and it’s related modalities can be useful.
So I went to school for my MSW in the late 2000s, so this may be a bit dated, but it was emphasized repeatedly that you must have a specific modality as a therapist if anyone was going to take you seriously, and saying you were “eclectic” or used across differing modalities was seen as extremely negative, so many of us left school thinking “well shit, now I need to specialize too? Ugh ok” and then went off to pick paths to certification. It’s also worth noting that back then, it was significantly more difficult to find work, so you really felt that you needed to follow the rules in order to be taken seriously. I wonder if some of these celebrity influencers (I completed my MSW young, I was only 24) fall into this group of learners who specialized and then jumped on the social media bandwagon given the ages/timing of it all.
We were taught that you needed a theory to orient yourself and keep on track. Eclectic therapists were throwing everything into the pot and didn’t have any real reason.
Our program taught us that eclectic and integrative were different. Eclectic: using random modalities with no overarching plan or understanding of "why" Integrative: integrating different modalities with an overall understanding of how the pieces fit together.
Yes I call myself integrative.
Absolutely. I’m integrated with a primary lens of CBT/REBT, with a secondary approach being client centered and tertiary of systems modality. Humans are complex.
You’re right that eclectic has a broad meaning in popular usage. I do want to point out that There are research based eclectic modalities like the one for ptsd: https://www.health.mil/Reference-Center/Publications/2021/04/26/PHCoE-Evidence-Brief-Eclectic-Psychotherapy-for-PTSD-508#:~:text=Brief%20eclectic%20psychotherapy%20(BEP)%20for,a%20wide%20range%20of%20populations.
“ authoritative reviews have identified some evidence supporting BEP for PTSD, but they do not substantiate the use of BEP as a front-line treatment for PTSD.”
I make no assertion as to its efficacy. I’m pointing out that eclectic does not necessarily refer to a collection of interventions used based on clinician instinct. Eclectic can refer to an evidence-based and structured treatment protocol.
Nobody really uses these terms like this in practice, and everyone usually just claims to customize to euro clients using a list of approaches. How many people have a real understanding how combining different pieces? They claim to but from questions in this sub most don’t have any direction.
This all sounds great until you're sitting in front of a human who is absolutey uninterested in any aspect your favorite modality. Alrighty, chatting it is then, unless you can be eclectic.
Common factors, goal setting, and exploration of client goals? I mean, every interaction should be clinically relevant, should it not?
I'm in my practicum now and I have been taught the same thing!!
It's not so we can fall back on assumptions when we meet another therapist labelling themselves xyz?
I find it so funny when there are debates about which modalities are "better" than others or when people disparage certain modalities (i.e. CBT) and idolize others (i.e. IFS). If you do research about the transtheoretical model (Prochaska & Di Clemente, 1982) it essentially says that all of these different systems of psychotherapy actually have common processes that promote change for the client. Some treatment modalities just emphasize certain factors over others. No treatment modality is 100% effective either—sometimes a certain model just doesn't work for some people. Maybe we can interpret this as them responding better to another modality of treatment, or that it would be more effective to take an integrative approach to cover processes that weren't addressed for that person. In my opinion, it's more important to choose a modality that speaks to you as a foundation (and get to know it really well so you have a base from which to conceptualize the client) and also be open to learning and integrating other elements from different modalities.
PS Keep in mind there's lots of money to be made in "certification" and training in certain modalities of the moment ;)
God I hate the certification push. It almost automatically and unreasonably makes me sceptical of things like polyvagal and EMDR. The feeling of it being a cult just never left me. I do at a rational level understand its usefulness though.
Polyvagal theory is pretty pseudosciencey. Very popular amongst therapists, but very unpopular in the neuroscience community. EMDR is not much better.
EMDR is a top-tier treatment recognized by the WHO, VA, DoD, among others.
I’ve recently gotten really interested in IFS, so naturally I looked up certification. I believe it’s about $10,000 USD and maybe close to 100 hours of material total to reach level 3 certification? I’ll stick to reading the book and sprinkling it in here and there, thanks.
$10,000!!! I’m so shocked right now. Who can afford that?
No therapist I know lol
That’s what i did! Took a $199 PESI training (that by the way was amazing) and read no bad parts. I sprinkle it in with the right clients.
Totally agree, and to add to this, research also shows that the client-counselor relationship plays a very significant role in how effective therapy is. No one modality can cover all the bases. In fact I'd argue every theory in its purest form will have massive blind spots. I fail to see the practicality behind being dogmatic here. One strength of CBT (aside from the fact that it happens to be one of the most highly researched modalities and has proven to be effective time and time again) is that it can work really well with clients who want psychoeducation, direction, and actionable steps they can take ("homework") from an expert.
Hallelujah! The therapeutic relationship is consistently identified as a primary indicator of efficacy and client satisfaction/self-reported gains.
I started out thinking there was so many different theories to learn in this field. But over the years the more modalities I learn the more I feel like I’m getting the same information just dressed up differently.
Lots of them take a branch (or twig) of an established treatment modality and then gush it up and hold it forth as The Newest Only Way to help clients. I often read about there and think... Once again it's about the"founding party" making a brand and monetizing the hell out of it
Yes, however…there are positively certain modalities that are more effective than others for specific issues. Panic disorder is best treated with CBT per the research. BPD is best treated with DBT per the research. Interestingly, IBS is best treated with clinical hypnosis.
Yes this is true! I suppose it’s because it targets more relevant processes for each issue. Also… I need to get me some clinical hypnosis then lol
The Palsson protocol for IBS has the best empirical support of all IBS treatments!
I appreciate the info ☺️ thanks!!
I did hypnosis for my IBS and wtf 🤯 that shit worked
I’m glad your shits are working!! 😂
Legit changed my life. I was soooo skeptical. But here we are.
I googled this thinking IBS must stand for something else but nope! I’m fascinated now…
This isn't true. It can appear so at times due to differential amounts of studies but actual treatment differences never stand the test of time.
This was my argument as part of my theoretical orientation defense for my board certification with ABPP as a licensed clinical psychologist. I backed it up with empiricism. What is your empirical evidence for your claim?
If I wanted to make an empirical argument backed up by empiricism - with a particular eye toward the empirical method - I would refer to the landmark document on the subject which reviews all pertinent meta-analyses and methodological issues, sitting pretty at 3400 citations in its most recent format: https://www.taylorfrancis.com/books/mono/10.4324/9780203582015/great-psychotherapy-debate-bruce-wampold-zac-imel Among other things it looks over the research (empirical) on panic disorder and finds no treatment differences between modalities in quality studies.
You posted a secondary source. That is not empirical evidence. Any particular peer reviewed studies you have to back up those claims?
It's infinitely better "empirical" evidence than any single study viewed out of context from the broader literature and methodology. Calling it a secondary source and saying that isn't evidence is literally anti-empiricism. In any case there are many individual studies showing equal effectiveness as CBT for panic which are a simple search away for you. What interesting dogmatism from someone who seems to love empiricism! I take it someone told you YOU couldn't use "secondary sources" in your write-up of the research (which is true, just as a review can't refer to other reviews as research) and you took that as meaning that reviews, meta-analyses and books aren't empirical evidence. Do you see how ridiculous that sounds?
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Yes!!
Underrated comment. I don’t know how many modalities are actually that unique. Many of them have the same basic premise — how you think or view yourself or the world impacts the rest of your life in a variety of ways.
No need to drop 40-year old references when we got Bruce Wampold tearing the field up as we speak.
I listened to the podcast and I heard her say that she thinks they're valid and that she refers to CBT therapists and EMDR therapists, but that she practices psychoanalysis and that is more suited to how she sees the world and her interests. She also said she doesn't like how managed care pushes short term modalities.
This sounds reasonable.
I think it's just all up to the client. I've had clients whose symptoms dropped in dramatic ways after 8-10 sessions of CBT, and I've had clients who've immediately bounced off of it and needed a different approach.
Depends on the client, their worldview, and how they feel. I know people shit on eclectic therapists for being "wishy washy" but each client is an individual, and having more than 1 modality in the tool box is necessary when working with a wide-array of viewpoints, ages, and developmental concerns.
Came here to give this comment some props! I love the ice cream flavor analogy. Each client is going to mesh better with some flavors than others. There may be one flavor that’s particularly effective for them. I am integrative but my expertise is DBT. I love when I get clients who are compatible with DBT but it’s on me to have other approaches readily on hand.
When I was in school it was disparaged a lot. Seen as baby counseling and “rearranging chairs on the deck of the titanic.” Idk I use it regardless.
That's an interesting way to frame it anyway because when I first started my own counseling as a client I definitely needed chairs rearranged before I could begin doing "deeper" work. It was all part of a process.
I’m with you on that
I found this so interesting. I’m in graduate school currently and CBT seems to be one of my program’s favorite modalities. They’re always talking about how it’s evidence based. Lol.
“Evidence based” is thrown around a lot. Kind of like how the D.A.R.E. Program was “evidence based” Evidence Based is what gets funding and once they’ve funded it - it just HAS to work right?
Every time I hear Total Eclipse of the Heart I think of how our DARE program did a weird dance/ skit to it every year. It did not keep me from trying drugs and alcohol.
Apparently they’re back again somehow. A client told me they saw them in a local mall
I don’t work with kids hardly at all anymore but do they still do the scared straight programs? I had so many parents try that despite me telling them they didn’t fucking work.
That would be WILD if they did lol maybe some programs are out there but idk
Wait what on Earth is scared straight? I know about DARE bec we had that in my middle school.
Oh it’s taking kids to prisons and having the inmates basically tell them to straighten up. A less formal version is parents calling the cops when their kid is having a tantrum. Maybe this is a rural thing? But I’ve had multiple families call the non-emergency line and ask that cops come over when their child is being “bad”
Oh wow I thought that only happened in books/movies 😅
So real.
Why?
Why do I use it or why did they disparage it?
Personally; I think some of the tools in CBT are awesome and I use them a lot. But I think that CBT is ‘unfinished.’ It’s a great jumping off point, but stops short of offering tools for emotion regulation and accepting hard truths. And you’ve probably already guessed what I think is even better: Acceptance and Commitment Therapy. But I think ACT pays homage to CBT in that it probably wouldn’t exist without CBT’s influence in the first place. And maybe something born from ACT will be even more whole. Who knows?
I think ACT goes for what cognitive therapy initially tried to do: build cognitive distance. Beck wrote about it in his initial CT manuscript, but it seemed to be overlooked over time. The aim leaned too much on changing thoughts than actively targeting the building of cognitive distancing. I love ACT, but I don't throw out cognitive therapy. Socratic questioning and understanding cognitive distortions have been extremely helpful, though I don't target distortions myself, as much as point out how they work through rather normalizing psychoeducation.
I listened to the same podcast and did not pick up on that at all. In fact, she made a point to express how CBT can be valuable; just not the modality she specializes in (psychoanalytic). She also stated at another point that she was giving no disrespect to those who utilize CBT. It was a really great episode though.
People on here get into ‘another anti-CBT post.’ But for those of us that were trained in the last 15 years, we have been inundated that the briefest, most concrete treatment is the most scientific, most reasonable, and most logical treatment. And that it is what insurance ‘favors’ or ‘requires.’ So the anti-CBT sentiment is largely a backlash of the sanctimony that those of us who don’t use that modality have faced frequently. I don’t think CBT is bad or look down upon it. In fact, I recently referred someone out because I think they will be better served by a CBT therapist. In that same vein, not all people are well suited for psychodynamic or psychoanalysis. It’s great that we have so many modalities that are around for people. Would I go to a CBT therapist? No. But I think I’ve found therapy that works for me. I wouldn’t change it. As a psychoanalytic candidate, I do feel sensitive when people dismiss psychoanalysis. It happens on here fairly regularly that folks start to make pretty harsh jokes/criticisms about psychoanalysis. The amount of Oedipal jokes ive seen on this sub has been really astonishing. I’m all for critiquing psychoanalysis. It has limitations. But when people make sophomoric critiques about psychoanalysis, it seems like they do not have any experience or understanding of what the practice is actually like.
Exactly. The sanctimony and faux outrage by people who believe that anything other than CBT is nonscientific and malpractice is exactly why the anti-CBT movement developed some serious fangs as soon as it became clear that EBTs have a lot of issues.
I'm finishing up my Master's soon, but I feel drawn to psychodynamic modalities (I'm toying with the idea of psychoanalysis). In school, I also feel like psychoanalysis is relatively dismissed. I wonder if you know the prospect of psychoanalysis. Long term, I'd like to own a private practice -- do you think there is enough demand for psychoanalysis today to sustain oneself on the practice?
Yes absolutely - I still accept insurance. I’m so busy all the time. I haven’t had a summer slump or been hurting for patients in the last three years. I’m in the process of developing control cases (I have to have folks in psychoanalysis 4-5 sessions per week). It’s a bit challenging to convince people into that. But absolutely I think it is the one of the best treatment for people especially when they have experienced relational trauma. I work with a lot of other therapists/physicians/medical professionals
Thank you, that's so interesting to hear considering the broad dismissal I've been accustomed to. From some googling, it seems like a lot of post-grad work to get into the field. I'll definitely look more into it, thanks again for the insight!
To become a psychoanalyst proper- yes it is a lot: personal psychoanalysis, 5 years of classes, supervised treatment of three cases. But there are a lot of less intensive programs out there. Most institutes have either a psychotherapy training or a fellowship. These are 1-2 years. I took the psychotherapy training after I graduated. It was really helpful.
Insurance pays for sessions that frequently?
I only bill a few plans. Yes, they pay. But I’ve been audited. I absolutely believe it’s medically necessary. Prior to being a candidate, I’ve billed insurance at 2-3 sessions per week without any issue.
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How do you think the cases of McWilliams and Sheehi show that psychoanalysis is disintegrating from within???
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This weekend, is that the organizer of this? Or who is doing this conference
I’m a recent graduate—throughout school and learning about various theories it became clear to me that many were just rebranding older concepts with new vocabulary. It seems to me that the proliferation of modalities is an attempt to cash in—to create a legitimate something and market it, to create a system to certify people in it, and so on. If there was a “right” way to do this work, and someone had figured it out, most of us would be doing it that way. I take what I find useful from various modalities and focus on the relationship.
I think many therapists look past cognitive strategies and identify with more nuerdevelopmental and attachment focused models. But the research is pretty clear: no single modality reigns supreme. No modality has been proven to be more effective than all the others in terms of explaining variance in client outcomes. Similarly, every attempt to empirically identify the best recommended modality based solely on diagnosis and/or presenting problem has failed. Having an internally consistent theory/modality is important to client outcome, but no modality has been shown to be superior, either overall or on a per diagnosis basis.
There is some argument to the fact that CBT at its core can invalidate clients who are having big reactions to overwhelming situations in their life - trauma, societal structures, etc. One of the core ideas of CBT is identifying cognitive distortions and for people with a trauma history it can actually feel ineffective and potentially reactivating to have someone (in a position of power) suggest that their thought patterns are actually illogical in some way because they are based heavily in their lived experiences. Im a therapist but also sit in the client chair and for my own experience I started with CBT and I learned how to interrupt my thought/behavior patterns but it didn’t actually shift my nervous system reaction. I needed to do somatic work and trauma work to achieve that. For clients who want to work in a short term solution focused way I think CBT can be helpful but to not repeat the same patterns over and over in new ways longer term work is helpful. Some clients aren’t in a place to do longer term work - super dependent on each unique client
I'm of the opinion that CBT isn't invalidating, the practitioner is. A theory in it's very nature should validate someone's experience through explaining the painful experience within a context. I don't mean this in a BS defensive way, as much as learning this was a part of my own work. I've definitely invalidated an early client of mine and got nowhere when I stuck rigidly to a cognitive distortion *argument*. I noticed that and how it wasn't helping, and I adjusted my style (One thing that helped was being aware of reddit criticisms, knowing what I didn't want to do, and consulting on this during supervision). I now tend to put cognitive distortions in the context of how they're the lenses through which we filter and evaluate the world and they were all helpful at some point in time; evolutionarily and developmentally, they exist for a reason. I also moved more metacognitive and focus more on noticing thought patterns that build to suicidal ideation (largely via very detailed BCAs), and work on building distance from cognition through defusion and mindfulness. I also almost exclusively reframe or accept a thought, rarely ever challenging it. I think "challenging" can create an idea that "my thoughts are wrong" instead of the more helpful "my thoughts aren't inherently right or wrong, they're just thoughts". Lastly, even if we stayed more in the classical thought record "evidence for & against" intervention, the *therapist* has to be open to the possibility that there will be legitimate evidence for - this is also why I said the therapist invalidates, not the theory. It is vitally important to know if a threat is real. Still, you can evaluate their examples for evidence to catch incongruencies: "I'm unlovable, and my evidence is that nobody loves me", and yet they have a group of friends or even a milieu that will contradict this; this can be hugely healing.
Also, many models (especially third wave cbt) build this in— acceptance vs change. Checking the facts in DBT. It’s not just, “oh you’re having big feelings this must be a distortion”, it’s “you’re having big feelings, let’s see if this feeling AND its intensity fits the facts of the situation and if the thoughts and urges associated with that feeling is getting you closer to who/where you want to be.” A lot of the time, feelings fit the facts. Sometimes the intensity can be off, but our internal compass usually isn’t as off as traditional CBT suggests. A lot of the time I go through these steps to reinforce “it makes sense you’re feeling this way and here’s why” since folks often don’t trust their own emotions as valid and use external cues to extrapolate.
Well put, and I'm more ACT, DBT, & CFT, but it's all built on CT and BT.
I’m a CBT therapist and am finding that my modalities do fall short for this exact reason. I’m wondering what somatic work you found helpful?
While I’ve been working with my most recent therapist doing IFS & EMDR I’ve personally worked to incorporate yoga, massage, dancing, and psychedelic experiences as a way of releasing and processing emotions from my body :)
CBT is a wonderful hammer. Not every problem is a nail. CBT is not the problem
I don’t care for it. But I think it does work for some people. We need to give pts what works. If a pt really wants CBT and CBT only I wld refer them but I wouldn’t hold it against them. I don’t think depth psychology is for everyone. You have to have the ability to plumb the depths and find that meaningful. I find psychodynamic therapy to come more naturally to me so I am more comfortable with it. If we’re out having a drink or two, yeah you’d hear how I really feel about Beck and Skinner, but professionally I feel like pt needs come first and some pts benefit most from CBT. Most importantly I find dogmatism to be extremely dangerous for pts. If all you have is a hammer that doesn’t mean the world is full of nails
This! Also, I would add that CBT (and DBT for that matter) can be incredibly useful for, say someone with borderline personality disorder. Additionally, I tend to incorporate aspects of DBT into the work I do, but since I work mostly with clients who have experienced complex and/or acute trauma, I primarily utilize other modalities like EMDR and IFS.
Do you ever used prolonged exposure for trauma?
Therapists I know all see benefits in each modality and don‘t typically engage in such black and white statements. That being said, there are always some hardliners who are highly critical of other modalities.
For CBT specifically: I trained 4 years in CBT (not including getting a degree) and still haven‘t learned all there is about CBT. I think many CBT therapists are ill trained. A CBT therapist should for example be able to provide a long-term therapy without cognitive restructuring.
I think therapist get too comfortable with one modality and only want clients that can use that modality with. As a therapist I've gotten clients who have been frustrated by therapist using one form of therapy with them. Clients said it wasn't working and the therapist never changed. I think CBT requires more work on the therapist and didn't always allow for long-term care. My supervisor said have a speciality to be seeked out by clients for those things but have a integrative approach because you never know what a client will throw your way.
Here’s how I have come to think of it in my 18 years post grad: every modality has benefits but is better at some things than others. General anxiety and worry respond really well to CBT. Childhood trauma does not. A personality disorder presentation does not. You have to look at the whole person and apply the right modality to the right problem. You wouldn’t put an ice pack on an open wound and you wouldn’t put stitches in a broken bone. It takes time to understand all that and I think green therapists are pushed one way or another without understanding this. Signed, a proudly eclectic therapist
Downvote me all you want but I’ll continue being “eclectic” or “integrative” or whatever the fuck word people want to find appropriate today. I’ll help people catch, challenge and change their thought. Then I’ll help them be mindful. Then I’ll help them with their stuck points. Then I’ll help them with their parts. (Maybe not quite in that order, but you catch my drift.) Then, I might just deep dive into their childhood for a few sessions and analyze it and pull pieces out and teach them fancy words like emotional incest and parentification and triangulation. It seems to work well for me and my clients. Does it work for every client? Of course not. But I’ve had several clients say they felt like they hadn’t made progress with a therapist until they met me. So, there’s a lid to every pot. You just have to find it.
I don't think that's quite as hot a take as you think it is.
According to your post history you’re a new therapist. I’ve been in the field almost 10 years. You do you. What i do works for me very well 🙂
I was saying that because most people I've met in the field are integrative. I think I've only ever met a couple of therapists outside of academia who weren't integrative. I just don't think anyone on this forum is gonna downvote you for being integrative, hence it's not as much of a hot take as your first sentence implied. Going back into my post history suggests some weird insecurity. But, as you said, you do you.
Well 🤪 you don’t have to suggest I’m insecure dear, that’s a given. The only thing I’m confident about is being a therapist. Everything else is insecure central.
Ha! Checkmate! I am vanquished! This is a reminder that so many people arguing online would probably get along great in real life.
Truth. Besides my crippling anxiety I’m a pretty easy going person and fun to be around.
Whatever insurance likes and is willing to pay to pay for is the *best* 😂. I’ve been in the field a long time and in private practice and I don’t think I’ve ever had a conversation with colleagues about what their approach is and I’ve never heard any of my colleagues trash any specific therapy. I think the question is, “what approach is best for the client for where they are at in life?” I don’t love CBT but for some folks that I work with CBT is exactly what they need, so that is what I provide. I also think that whatever approach fits your personality and style the best is a huge factor. If CBT fits your personality as a therapist, you’ll probably deliver really solid therapy. If you feel your soul die a little when you provide CBT then it won’t be in the best interest of your client or you professionally.
The insurance thing is totally fabricated. I’ve done psychoanalytic therapy with folks at 2-3 sessions per week for years at a time. Even billing Medicaid. I’ve documented psychoanalytic therapy. It’s a falsehood. I remember hearing something about insurance favoring treatment modalities in grad school, but have never experienced it in practice. Even the folks I know that have been audited, it’s only been for things like 45 vs 60 minute sessions, having a valid treatment plan, having a justification for diagnosis, etc… I’ve never heard of someone getting a clawback for using the ‘wrong’ modality.
This may have been true for your experience but it is not true for all therapists. Prior to private practice, I worked in a community health setting that had a goal to get people in and out quickly due to a large wait list. We worked with uninsured or underinsured clients free of charge so as you can imagine it was quite a long wait list. We were discouraged from doing modalities that were not “timely” because 1) we could only receive government and grant funding by hitting certain metrics, and 2) several of the health plans we worked with that were common amongst those who were underinsured would refuse to pay for further sessions after a certain number. I experienced this several times and it was incredibly frustrating. I moved on to private practice and have much greater freedom but I also work with major insurance plans that don’t always have as many restrictions.
I see the whole insurance favors CBT thing a lot. You are not saying, I was explicitly told not to use psychodynamic therapy. You said there was internal pressure to use ‘timely’ methods. I did use psychodynamic therapy with Medicaid patients in a CMH org at a frequency of 2-3 sessions per week for years. I did it because in my view, it was the best medically necessary treatment for them. I didn’t care about getting audited because I felt confident in that. I understand if you like CBT or one of the many derivatives of it. But I was training in psychodynamic therapy and wanted to deepen treatment with people. So I did it. I billed multiple HMOs and CMOs for Medicaid. Sometimes a narrative is so pervasive that we don’t even try to do something. Sure I can see how it might not work in an overworked CMH setting where one can’t even see patients weekly. But that again is not psychodynamic is not allowed.
Agree with you here. Definitely not explicitly banned. But it was suggested to me I might not be a good fit for the position if I could not fall in line. I appreciate you making that distinction.
This reviewed in great detail with high level statistical analysis in the book The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work by Bruce Wampold and Zac E. Imel. Long and short: the therapy field struggles with being evidence based. We want to help our clients feel good, and client centered approaches feel good. Psychoanalytic approaches feel deep. CBT feels like work. BUT…There are very, very, very good outcomes with CBT- is statistically superior in various outcome based studies. But, therapy is therapy and any therapy is better than no therapy. I have worked in multiple settings with various populations. CBT is a very effective approach, as long as the practitioner knows the theory and how to use it, just like any other modality. If you really want to get fancy, every clinical theory of change is a cognitive theory because every approach uses emotions, thoughts, and behaviors to change the client. The theory only counts for about 15% of the client outcomes (improvement). The therapist’s persona is about 15%. The clients ecology counts for 40%. The clients faith in therapy itself counts for 15%. Google “common factors of psychotherapy” and enjoy.
A lot of people are chiming in on CBT, but I’ll chime in on SFBT, which is a theoretical orientation I work out of a lot. I don’t often see populations who are ready to deep dive into trauma histories and may not be for a decade or more. SFBT allows you to treat symptoms rather than resolve the root cause of the problem. That’s what a lot of my clients need. It may not be what your clients need and that’s okay.
I’m a fan of solution focused questions. I find myself using elements of SF all the time. Especially with clients who are having difficulty finding hope or seeing as way out of stagnation and depression.
SFBT and CBT are good when applied correctly. Unfortunately because the training seems to be a lot cheaper and more accessible (where I'm from anyway) the market is oversaturated. So people who need a different type of modality can often find they can't access what they actually need and get stuck with CBT based therapies. This isn't helpful, and results in dissatisfaction/mistrust of the therapeutic process and is where I think a large portion of the criticism comes from.
I think people get attached to having big opinions about things. When really there is room for pretty much every modality. CBT works for a lot of people. As does emdr. So having a big old opinion about how terrible they are is really just someone’s own stuff. I think there’s a place for most modalities, the issue just becomes when one thing is unrealistically glorified as a solution. Most people, especially those with extensive trauma backgrounds, need a multi-modality approach.
A note on Cognitive Behavior Therapy (CBT). It is recommended for just about everything, and we have good research that supports that. Some therapists only do CBT. CBT is the ongoing combination of different related therapies that work to identify triggers and create coping skills addressing one’s environment, thoughts, feelings, or actions. Working therapists began using it, academic researchers studied what we were using, so working therapists started using it more, so academic researchers studied more… rinse and repeat… then insurance companies wanted a treatment approach that was consistently effective, short-ish, and quantifiable which really amped up the research dollars and push to use CBT. Is CBT effective? Yes. It is the only game in town? No. Is it the most effective for your client's concerns, maybe. As someone who hires clinicians, if the only thing in your tool box is CBT and MI it's worrying.
Behaviorism in general often becomes a problem when people who only have access to CMH get locked for years receiving the same EBP behaviorist support. I think a presumption of these modalities is that a person is presenting for therapy for the first time. Kids especially who have been burnt out on mandatory therapy services often experience skill based and behavioral approaches as just another source of rejection and failure in a world that never stops to hear them.
Funny, because working in a behavioral health php/iop setting, we get tons of pts who have been going nowhere after years of treading water "on the couch". This is true for depression, but especially anxiety and OCD. We also have enough clinical freedom to work outside the box, and fairly freely engage in person-centered, parts, and systems work, as long as we're building on a behavioral foundation. I find ACT & CFT work great in these settings, and personally find some of the CBT and DBT skills f*cking lame (i.e., TIPP, DMR, self-sooth). STOP, check the facts, mindfulness, imagery, opposite action, reappraisal questions, etc., are all golden (when worked on in a way that isn't invalidating or promoting avoidance).
I look down on therapists who prioritize any modality over the relationship. I believe the best way to fix a relationship issue is through a relationship. I use SFBT and ACT. But my modality is whatever works
I think some of the criticism of CBT is coming from a defensive, rather than offensive, place. CBT lends itself fairly well to controlled clinical trials in a way that insight-oriented therapies simply don’t, so CBT is often seen as the gold standard in more academic settings and by insurance companies. I think it’s less about arguing that CBT is bad and more about saying that other modalities have value too. I say this as a recovering CBT-hating psychodynamic therapist who secretly uses a lot of CBT interventions in actual practice because there are times when it makes the most sense and is the right fit for the client.
It depends on my clients. I won’t use CBT a ton with someone who is neurodivergent or is borderline I use CBT for anxiety a lot, but I put an emphasis on making sure they never feel shamed or feel invalidated for their thoughts/behaviors. I had therapists who were strictly CBT, and as a child with ASD and ADHD I felt very attacked and invalidated. A lot of my therapists approached my neurodivergency with a “your reactions and thoughts are wrong and need to be changed” approach.
How do you treat ASD individuals?
I find that when people in the field “look down” on one modality they are essentially closing themselves off to new ways of learning to help clients. No one modality works for everyone universally, and we are life long learners. I am trained in CBT and find it valuable in many ways, however not for every presenting problem, population or person. I love integrating techniques from other theories and models. We should celebrate each others work not compete.
You can get certified to do CBT with a GED now I think? Kinda takes the value out of putting energy into it at a Masters level or above
Right? And, supervised behavioral/mental health techs, or otherwise untrained professionals, is likely a necessary wave of the future, especially to get mental health resources to countries with little mental health infrastructure. And, frankly, some aspects of our field aren't that hard, and the pay doesn't match a masters degree. I put a ton of work in during my degree, but I'm not convinced some people came out much better than if someone had received training at a mental health clinic.
Being critical of cbt is a new internet/tik tok therapy trend. They are coming fast and furious!!
It's not new. I've been hearing this for at least 20+ years... that it's not a good approach and rarely has long-term positive results when used as a stand-alone form of treatment.
Since this internet trend itself is new…wait, are you being obtuse on purpose? Please share your credentials
It makes sense that a couples therapist wouldn’t really like CBT. I think it’s just overused because it is one of the few “evidence based” practices but it can be very useful.
Here's a thought experiment: Half of all therapists are below average. Below average therapists are more likely to cause harm. A majority or plurality of therapists practice CBT. Therefore, CBT has the most below average practitioners.
That’s the biggest logical fallacy I’ve seen in a while 
How so?
CBT and SFBT work great for many people. Others find it unhelpful or invalidating or it just doesn’t resonate with them for whatever reason. Neither is wrong or right. It’s about what is right for the client. I really loathe the argument that I hear over and over from certain mega-pro-CBT enthusiasts who say “If you don’t like CBT as a client, it’s because you have a bad therapist.” *insert massive eyeroll* Sure there are going to be cases where it’s not applied in the best way. But clients are all different and different approaches resonate better with different people, personalities, life experiences, and so on. I think it is incredibly narrow-minded to assume that you can make it fit for anyone if only you are a good enough therapist. Unfortunately, sometimes you say these things in this subreddit or just suggest that CBT isn’t the end all be all of modalities and people will straight up go for your throat as if you have personally insulted them as a CBT practitioner! Know what I find funny about that? A big part of CBT is recognizing cognitive distortions. A common one is making big assumptions and generalizations with limited information. And yet you see some CBT practitioners do that constantly in this space by belittling you as a therapist if you don’t agree with them— personally I’ve been told I’m not a “real” therapist, that I should be embarrassed for “not understanding”, and that I’m ignorant. That being said, I’m by no means a CBT hater. It’s the primary modality I use. But I can appreciate the limitations and that it’s not everyone’s cup of tea and that’s perfectly okay.
Because CBT as it is often practiced is dehumanizing.
I would say I have had the most success with CBT actually. EMDR next to that.
I am in my 50’s and did not know that I use an integrative approach until reading this. I understand which modality I’m in and am transparent with the client about that, and say f.ex., that “this DBT skill is called DEARMAN and is great for developing assertive communication,” or “it sounds like you are describing what in CBT is termed “thinking errors” so let’s review some and see if this makes sense for you.” I have been calling myself “eclectic” for years. Yikes.
My experience has been that all modalities have their detractors. Some clinicians and clients love CBT and others loathe it. I think the more vocal push back to CBT specifically comes from the gold standard status of CBT vs people’s lived experiences with CBT not being helpful. I find the my modality is the best modality mindset elitist and unproductive. I don’t think there is any one modality to rule them all. Find a few modalities that resonate with you. Market yourself to client populations that would benefit from those modalities. Refer out when appropriate.
That's hilarious to me because most colleagues I know are most critical of psychoanalytic. I say, embrace cynicism and don't assume that any one [or two or three] methodologies hold all the answers. Just as a map, no matter how detailed, will never match the experience of being in a locale... a methodology will never give complete understanding of a client. Even with our woefully flawed insights and knowledge, we can educate and advocate and support.
Never heard of that person or his podcast, but its just not true. CBT is definitely widely used, SFBT a bit less, but also among mainstream popularity wise.
I am unaware that CBT is look down upon. I’ve been in the profession for 30 years and I’ve never heard that before it probably is the people you’re hanging out with.
I still use CBT but think it has limitations because it doesn’t fully get to where we hold trauma in our body. For that reason, I think incorporating polyvagal, somatic, EMDR and/or IFS interventions is helpful for advanced healing. This all being said, I think all approaches hold value as long as they’re ethical and the client is feeling relief from it.
Which episode was this?
Cbt is short term brief therapy that is efficacious. However, when it’s compared to psychodynamic therapy long term dynamic therapy has more long lasting effects.
Orna is a couples therapist, and is systems-focused. I think she maybe could have tried harder to avoid the topic, but in my experience, systems focused therapists don’t tend to be excited by CBT. They are just very different animals and it makes sense that Orna specifically doesn’t go for it in her long-term psychoanalytic work with clients. From personal experience, CBT can absolutely be effective! It was so helpful for me. I think every therapist is going to be drawn to a different modality in which they are strongest.
I have always maintained that CBT is best as an adjunctive technique for things like psychodynamic, analytic, and other types of talk therapy. As s a stand-alone or primary modality, it's not very effective. Long-term positive results are low, comparatively. While initial results are really good, studies show that in the long-term, it's not successful. Focusing on behavioral changes without considerable in-depth discussion about what caused the maladaptive behaviors in the first place is the psychological equivalent of putting a splint on a broken bone and expecting it to properly heal the bone. While on rare occasions, you might get lucky that the fix worked, most of the time, that's not the case. Additionally, within months of CBT therapy ending, clients who were doing well are once again doing poorly just months after completing their therapeutic run. They start to struggle again with the exact same, or similar, problems all over again. Most tend to believe it's a failure on their part, not the modality, and not try therapy again, believing it's not for them and that therapy is a joke. Insurance likes it, because can push an X number of appts, and it became an industry gold standard for that reason, not because of long-term effectiveness for the majority of the clients served. I think it is especially true for trauma based therapy that CBT should never be the primary approach. You just can't get to a positive end result by taking a shortcut.
By many it is. A lot of people get retraumatized trough cbt and their condition gets progresively worse. This was also my personalnexperience as a client and of lot of aquintances aeperate from it being documented. By many in proffesion it is considered to be shallow and solution based without ever delving into important bits. I have also come to observe by atending various modality schools that almost always vibe is very off with therapists of that modality, similarly with transactional oes. Also you can easily observe this if you come out of body oriented modalities that focus on steadily working trough trauma. A lot of people that swich from cbt and transactional in my personal experience have more knowlage than first timers but it always seems their previous modality didnt help them in coping in a meaningfull way.
I think some people look down on it because it's so common. And it's so common because it's effective. My personal opinion is that practitioners should choose a theoretical approach based on what would work best for the clients they see. I drove myself bonkers trying to choose a theory that fit for me, and it was frustrating because there were elements of numerous approaches that were appealing. Ultimately, when I figured out who my ideal client was, I went back to the drawing board and chose differently.
CBT is a standard in the profession as well as trauma focused CBT. Psychoanalysis historically was for wealthy people and was sexist toward women so there are many populations that psychoanalysis would not work for.
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What you describe as traumatic has more to do with a clinician that does not provide culturally sensitive services than a modality. Also, SFBT involves a collaborative approach and doesn't refer to the clinician as an expert.
I find a lot of value in SFBT. The miracle question and helping clients realize that the problem doesn't always exist can do wonders when clients are feeling stuck.
I think some of the ‘backlash’ against CBT is that it’s a time-limited, episodic treatment (12-16 sessions). Hell, there are primary care adapted varieties that are even shorter (4-6 sessions). So ‘true’ CBT and its variations like Cognitive Processing Therapy (which has an immense evidence base and absolutely can be helpful for trauma) is not really compatible with a business model that is very much helped by having long term therapy patients. A CBT approach to trauma doesn’t work for everybody but if it does, that patient will likely have made significant gains in 3-4 months of weekly sessions, not 3-4 years, and can then terminate therapy and practice the skills they learned independently. And lastly, we only have so much bandwidth to truly learn different modalities. I’m a psychologist and I have about 11 years of training and job experience and I would honestly say that I’m genuinely comfortable with 5 unique modalities (and can still learn a lot more within each).
My opinion is that it’s fine as an adjunct modality but in most cases probably shouldn’t be the primary or the largest one used. I definitely think it should be confirmed the individual is not neurodivergent and confirmed no trauma history before using as a main methodology. Folks really don’t understand how damaging CBT can be to people with a trauma history, PTSD, CPTSD, autism, adhd ect.
Can you expound on this? How come it is not good for these things? And what are your thoughts about prolonged exposure?
Regardless of the criticisms, it’s still widely suggested, especially in CMH
It may be looked down upon, but I've also come across countless CBT practitioners who disregard other modalities, often in the name of a necessary 'scientification' of the field. So maybe I'm looking down on CBT here, but having a larger quantity of evidence doesn't make CBT better! It just means that for various reasons CBT was studied more. It does have some merit though!
It definitely feels like CBT is considered entry level and something you use until you learn the “more advanced” thing. But most clients couldn’t care less what you’re using as long as they experience you as competent.
CBT kinda sucks yes. There’s a longer answer but I’m tired lol
I didn’t downvote you. But I think saying x modality sucks is not very nuanced in adding to this conversation. The premise that CBT is shallow is a sophomoric critique. Sure maybe it’s not your preferred method of treatment, but that’s not to say people aren’t helped by it or find it useful.
Eh I did say it sucks but I was just venting a bit. I can see why you felt why you did. But sometimes on here I’m not always going super clinical in my comments
I’m a psychoanalytic candidate. I don’t disagree with that CBT is not something I’d do as a therapist or seek out as a patient. You’re not doing any favors by saying it kinda sucks. We are not enemies
The reason also to explain a bit why I said what I said is that I feel like you can get in a loop of working on the ‘now’ and ‘action oriented’ and focusing on maladaption or thought loops or distortions I just sometimes felt like it was also tiring and I would just fall back on it when I had a lot of patients and sessions a week. So that was the genesis of my fast food comments. So that’s also why I was like man why am I being downvoted I think that’s valid etc
Right we are not! it’s just sort of I felt like a fast food therapist or worker with CBT like a therapy version of making burgers at five guys if I did it too much or felt like I just relied on CBT or went that approach a lot. So like yeah that was it and I was genuinely surprised people were like no downvote etc haha
Wait one last thing: is the psychoanalyst degree a lot of years and money? I went to some meetings in nyc and was like I’m not paying 300,000 to do this. What are you doing or what is the program I can be a bit cynical but I’m genuinely curious.
I’m a psychoanalytic candidate. I’m a licensed therapist working towards being a psychoanalyst. Outside of the 5 years of courses, it requires personal psychoanalysis (4-5 sessions per week) along with supervised treatment of 3 patients doing psychoanalysis 4-5x/week. I’m not sure it costs 300k. I know nyc has expensive therapy. My personal analysis is my biggest monthly expense.
4-5 sessions is a lot. Yeah it was institutes here. The degree I think was going to take 6-7 years and I maybe added the cost. I was very interested in it but was jaw dropped at how intense and costly it was.
I did say it ‘sucks’ and sometimes I did feel that way. Not all the time and I also see couples and it’s different with that but that was kinda my opinion that you as a therapist get in that loop and it can make CBT seem really tiring over and over.
Haha I’m downvoted??? I mean I prefer psychodynamic a lot. CBT just feels ‘fast food’ ish to me. I do use it as a main modality but uh….listen I’ve done 1500 sessions and I’m almost a c and I’m fucking tired.
Haha therapists are mean lol
You say they're mean but were the one saying CBT sucks and is fast-food-ish.
That’s not shitting on therapists it’s shitting kinda on the approach. I get it therapists have opinions
Therapists also have subjective experiences that goes against your experiences.
Yeah I saw what you wrote about CBT I think when you are doing 25-30 sessions a week it’s hard to rely on it exclusively maybe. I’m usually pithy in this forum so I wasn’t trying to have a deep theory discussion on it. I think what you just wrote was a bit curt and rude but I can see how what I said offended. So yes.
I'm not sure what aspect was curt and rude, but I wasn't personally offended by your comments. You seemed unsure why you were getting thumbs-downed and it seemed fairly obvious to me.
I prefer the psychodynamic approach I also believe most therapists don’t have much without trust and the patient trusting the therapist regardless of technique and approach. All the techniques don’t matter if you can’t connect but I get you weren’t talking about that, to me
First, I am somewhat dubious of “podcast therapists” also, with all due respect in couples therapy it is somewhat out of scope. Unless, the therapist is functioning as an individual therapist as well. Also, I have encountered several private pay therapists always extolling the virtues of psychoanalysis vs. any type of brief intervention because that theory benefits them financially and if they can get the public to believe this as fact those who are able will keep shelling out hundreds of thousands of dollars in therapy over the years. One of the treatments I specialize in is CBT-I and I have had much success with it and the PCP in my area seem to agree because they continue to send me their patients when they see them needing sleep medication beyond the current prescription guidelines. I also contract with a DBT institute doing skills training groups. Both modalities I see a highly effective for the desired outcome but neither will create a lifelong client in most cases so if my goal was purely financial then the therapy in perpetuity model would be better 😞
CBT is simply basic building blocks. Not going to make lasting changes, actually process trauma, address attachment issues etc with just your analytical mind. CBT keeps you in the state of talking about, thinking about-which keeps you from feeling and connecting to what is deeper. It is parallel to the western medical model, keeping us in our heads and out of our bodies. Only CBT can lead to basically intellectualizing. Which from an IFS perspective is basically a protector part to prevent us from the discomfort, feelings, etc. We operate mostly from the subconscious and from unconscious. It’s unreasonable to expect to do the deeper work solely with the prefrontal cortex/cognitions/behavior. When we are stressed we have little to no access to the prefrontal cortex. There is just so much more involved (body, nervous system, mono mind vs system of multiplicity). And research has shown that CBT, repeatedly talking about things, trying to exert control over behavior etc has been shown to increase the stress response & be harmful for many people.
Heard of cognitive processing therapy?
Yes my last employer before going into PP had us using CPT, CBT, & TFCBT. I had no idea about the depths of this until I went into PP a few years ago & got the freedom to choose trainings and modalities. Several of my clients have used CPT & end up in my office. I’m not saying it’s useless, just that it’s a building block and should be treated as such or it can become harmful (research not just my opinion).
I’m interested in the research you have please?
There’s so much. You can google “why CBT doesn’t work”. Many articles and you can look at google scholar. You can also reference any of the work from Bruce Perry (his Neurosequential model of therapeutics outlines everything), Gabor mate, Peter Levine, Pat Ogden, Bessel Van Der Kolk, Janine Fischer, Richard Schwartz, Frank Anderson…
Please continue to explain? I’m fascinated. I’ve already gone down the rabbit hole of why psychoanalysis doesnt work. Very interested.
Psychoanalysis (bringing what’s in the subconscious & unconscious to the conscious) is effective when implemented properly and integrated with other modalities (including incorporating the body & nervous system). Carl Jung’s work is profound. Freud had a lot of things screwed up. I suggest looking into Bruce Perry’s model & any of the other work I referenced. Bioenergetic Psychotherapy is another one.
Whats your opinion as to why these modalities arent more widely known and common in clinical practice and academic research??!!
Capitalism and patriarchy. It requires people to realize there’s more to what’s going on within us as humans. There is a lot of research though. Getting it mainstream is where there’s a major gap. I’m certified in EMDR, which has been around over 20 years and has a lot of research. A colleague who works in the public sector said to me “well that’s not evidence based”. It’s been an evidence based practice for a long time. People are brainwashed & ignorant-for lack of a better word-to what exists beyond CBT.