Thoughts on Cognitive Behavioral Therapy (CBT)

Greg Thorkelson, MD with Ryan Reagan, PhD(c), LPC

This week we will be covering cognitive behavioral therapy.  CBT remains one of the most popular and widely practiced therapies.  In some cases, it has been modified and repackaged to target specific disorders, e.g., trauma, eating disorders.  At the time of its arrival it was arguing against the two giant paradigms that had occupied Psychology for much of the early 20th century—the psychoanalytic school and the behavioral school.  

Psychoanalysis was initiated and dominated by two thinkers Sigmund Freud and Carl Jung.  Their names are so closely associated with psychoanalytic theory that practitioners still often describe themselves as Freudian or Jungian. There were second and third waves of theoreticians who made valuable contributions to the field and are occasionally labeled as psychodynamic.  Regardless of the label, the central tenet remains consistent—psychological disturbances are the result of psychic forces, psychic meaning of the psyche (not fortune tellers).

Behaviorism was the second dominant school of psychology and peaked in the post war era of the 1940’s and 50’s.  Behaviorism is mostly closely related to B. F. Skinner and Ivan Pavlov, who contributed operant and classical conditioning respectively.  The guiding philosophy of behaviorism was that psychological problems emerge from maladaptive behavior patterns that have emerged as a result of reinforcement.  We repeat behavior that is associated with a pleasurable response. We avoid behavior associated with an unpleasurable response.  

By the 60’s and 70’s there was an emerging consensus that both schools of thought were inadequate.  The notion that behavior could be explained solely by unconscious drives was as inadequate as the notion that all behavior could be reduced to a schedule of reinforcements.  Now, here is an important thing to keep in mind, it is not that either school was wrong per se, as much as they were inadequate.  It is true that we have biological drives that motivate our mental lives.  It is also true that we repeat behavior if it is rewarding.  The problem for psychology emerged as these schools ossified into ideologies.  

The literature on the history of psychology will sometimes refer to the “cognitive revolution.” The word revolution can sound a bit hyperbolic, but sometimes stating the obvious is revolutionary in that it irreversibly undermines the prevailing paradigm.  So, what was so revolutionary about what Aaron Beck and other cognitive theorists were proposing?  That a person’s conscious thoughts mattered as much to the presentation of the problem.  

It is so obvious that you might be asking, that’s it?  That’s the cognitive revolution?  Indeed, it is, to understand it you would have to appreciate how deeply radical and revolutionary psychoanalytic theory was when Freud proposed it.  It was a cultural phenomenon that far exceeded the reach of the field in which it was situated. Suddenly, a great amount of our mental life was explicable and attributed to the mysterious human unconscious.  When behaviorism emerges decades later with its neat, clean, efficient experiments, it again seemed so obvious that nobody questioned the underpinnings for some time.

The flaw inherent in both psychoanalytic and behaviorist theory was that it situated human beings in a condition devoid of control.  Your suffering was either the product of drives that were unconscious, or it had merely been shaped by external reinforcement that must be unlearned.  In this mix, there is no room for thoughts and feelings of which you are consciously aware.  Without conscious awareness we have no agency.  A lack of agency means that you have no control over your circumstances, and when taken to it’s logical extreme this is the condition of helplessness.  In laymen’s terms: if you have no agency, you cannot be an “agent of change.”

Beck’s key insight was to work directly with what was in conscious awareness.  Consider this quote from the preface of his classic Cognitive Therapy And the Emotional Disorders:

Moreover, let us suppose that the patient has at his disposal various rational techniques he can use, with proper instruction, to deal with these disturbing elements in his consciousness.  If these suppositions are correct, then emotional disorders may be approached from an entirely different route: man has the key to understanding and solving his psychological disturbance within the scope of his own awareness (1979).”

We should emphasize awareness in the preceding passage.  We do not want to throw Freud and the Behaviorists under the bus. There is a place for work on unconscious motivation, attachment, and family of origin issues.  Likewise, there is a place for positive reinforcement.  A skilled therapist knows the general terrain of human problems even if it can present a thousand different ways. Counseling is an art as much as a science. Part of the art of counseling is to know when and where to shift through various schools of thought, it’s how the picture gets “colored in,” (if you want to stick with the art analogy).  

To summarize—CBT was developed in response to shortcomings within the psychoanalytic and behaviorist approaches to psychology, specifically a refocusing on conscious awareness as opposed to unconscious. It also resituated the concept of agency which is the seat of empowerment.  We also want to stress that CBT is just one approach.  There is no one-size-fits-all method.

To bring this point home, a bit of humor:

A guy walks into a therapist office…

The psychoanalyst says “can you tell me about your relationship with your Mother?”

The behaviorist says “can you tell me how your Mother used positive praise?”

The CBT therapist says “can you tell about how you presently think and feel toward your Mother?”

This may not be funny if you aren’t into this stuff, or if you don’t care much for Dad jokes of the “guy walks into a bar” type.  If you’re a psychologist and into Dad jokes, God bless you.  Joking aside, each of the above are important.  Your relationship with your Mother matters or mattered.  Ditto for your Father. Likewise, the messages that were sent had an impact on your behavior.  Third, how you think and feel toward anyone who holds a significant place in your life matters, because you matter.  

All Blog Posts

November 4, 2021

The Cognitive Triad

October 26, 2021

Thoughts on Cognitive Behavioral Therapy (CBT)

September 21, 2021

The Therapeutic Potential of Ketamine

September 21, 2021

Psychedelics in Mental Health

September 8, 2021

Are You Meditating?

August 13, 2021

Are We There Yet? (Post-Covid Anxiety)

July 22, 2021

Languishing—The Mood State of the Pandemic

July 6, 2021

Neurofeedback—New Hope for ADHD?

June 24, 2021

Finding The Right Therapist

June 16, 2021

Living with OCD

June 9, 2021

CBD and Anxiety

June 1, 2021

Demystifying Bipolar Disorder

May 25, 2021

When to Ask for Help?

May 18, 2021

Good News on Difficult to Treat Anxiety and Depression—TMS.

May 11, 2021

The Nexus Group Announces Deep Transcranial Magnetic Stimulation (Deep TMS) Available for Pittsburgh Community

Press Release- The Nexus Group now offering Brainsway TMS Treatment

May 11, 2021

What do we know about post-Covid?

How is Post-Covid Syndrome affecting the Mental Health community

March 5, 2021

4 Commonly Asked Questions About Transcranial Magnetic Stimulation

Nexus answers a few commonly asked questions about TMS Therapy.

February 26, 2021

Things to Know About Seasonal Affective Disorder

Are you experiencing SAD this season? What you can do to improve your mood!

February 18, 2021

TMS Therapy at the Nexus Group

TMS Therapy is now available at the Nexus Group.

December 16, 2020

Coping with your ADHD and COVID19

Effectively handling the current situation can be a scary task to take on...

December 16, 2020

Mental Hygiene During COVID19: Recommendations from (WHO)

With a global pandemic spreading, many of us are bound to be anxious and distressed.

December 16, 2020

Find the Silver Lining: Ways to Remain Positive this Weekend

The week has come to a close and we are left to spend yet another weekend sitting on the couch

December 16, 2020

The Ever-Blurring Lines of O.C.D. During COVID-19

As the weeks press on in quarantine, we are urged take extra precautions.

December 16, 2020

Victims of Domestic Violence: Who to Turn to?

Stuck inside, it is easy to feel trapped as we wait for cases of COVID-19 to dwindle.

December 16, 2020

Date Night Plans, Anyone?

Date nights don’t have to be dull just because you’re stuck inside.

December 16, 2020

A Few Questions to Ask Yourself Daily:

It’s important to clear your head regularly in order to alleviate stress or tension.

December 16, 2020

Parents Helping Children with Autism: Coping with Transitions and Change

A strategical approach to help your Autistic children cope with transitions and change.

December 16, 2020

How Helping Others Can Help You

Giving does not have to be overly complicated. See how helping others can help you!

July 2, 2020

Safely Entering Phase Yellow

Phase yellow shows a positive step in the right direction.

July 2, 2020

Managing Bipolar Disorder Amid the Pandemic

A few helpful tips on how to manage your Bipolar disorder during the pandemic.

July 2, 2020

How to Journal for Your Mental Health

Journaling can benefit your mental health. Here are some practical steps on how to approach it.

July 2, 2020

Experiencing Grief During COVID-19

Some practical steps on how to overcome grief during COVID.

July 2, 2020

Waiting Out Another Weekend at Home

How to keep your brain active at home during the pandemic!