Does Cognitive-Behavioral Therapy Lack Compassion? It Depends Upon the Therapistby Monica A. Frank, Ph.D.
A complaint often heard about cognitive-behavioral therapy (CBT) is that clients may experience it as harsh and demanding. People turn to therapy for a sympathetic ear, reassurance, and help with addressing an overwhelming problem. Unfortunately, many people report that their experience with CBT and its focus on changing irrational thinking and maladaptive behavior is offensive, belittling, and impersonal (patient forums on the internet).
1) The therapist's approach. In my opinion, as a CBT therapist, the problem is not CBT itself but how it is presented by the therapist. Although CBT has been consistently shown in laboratory experiments to be an effective, if not superior, treatment for depression and anxiety, the story is more murky when examining real-world psychotherapy outcomes (Beutler et al., 2012; Nathan et al., 2000). In particular, laboratory studies involve very specific protocols for treatment whereas real-world studies are dependent upon the decisions of the individual therapist. As a result, real-world treatment depends more upon the qualities of the therapist such as warmth and empathy and how the therapist presents the treatment.
2) Demands by healthcare companies. A complicating factor has been that CBT is often considered a treatment of choice by managed care insurance companies because it can be conducted from a manual, and thus, is considered simpler to provide. Such a feature has been attractive to these companies because their provider panels tend to use less experienced and less educated mental health professionals which keeps their costs down (Seligman and Levant, 1998). However, research consistently shows that the experience of the therapist is related to the effectiveness of the treatment even more so than the type of therapy (Hubbert, et al., 2001).
As a result of the manualized approach encouraged by the insurance companies and implemented by less experienced therapists, many clients are on the receiving end of a step-by-step procedural CBT that is lacking. CBT is anything but simple when implemented correctly! Personally, I believe that because CBT can be implemented in such a non-personal fashion, it is even more important for the therapist to be attuned to what is often referred to as the “non-specific factors” of therapy: compassion, empathy, positive regard, and other relationship factors. Such factors can be a critical component of helping clients to accept the often uncomfortable methods of CBT.
Everything is context. For example, although I tell my clients to watch the word choice they use when talking to themselves, word choice doesn't matter as much depending upon if it is in the context of acceptance. For instance, if I don't accept myself and tend to blame myself, saying to myself “That was really stupid, Monica” can have a profound negative impact on me. However, I can use the same words in a state of acceptance and I don't take it in the same way.
Similarly, if my client makes a mistake and I say “Well, that was silly, wasn't it?” how it impacts my client is based on the relationship I have with that client. If my client feels accepted by me, flaws and all, such a statement allows us to laugh about the situation, learn from it, and move on. However, if my client does not feel accepted by me, such a statement can contribute to feelings of blame and low self-esteem. Therefore, it is important for the therapist to be aware of the relationship with each client.
Even subtle rejection by the therapist can have profound effects (Lambert, 2013) making this an area where it is easy for even an experienced therapist to make mistakes. I know I certainly have. At times when I say something that I believe is in the context of a warm and accepting relationship, the client will hear me based upon their inner voice. Since I come from a family where we tease and can argue and disagree but still accept and love one another, I need to be aware that not everyone will interpret my statements as they are intended.
I once had a client who was extremely terrified due to severe sexual abuse as a child as well as neglect and emotional abuse. She believed the lies she was taught by her abusers so thoroughly that whenever I brought up her critical thinking about herself she would immediately have a panic attack. It was impossible for her to understand that I could be accepting of her and not blame her for what had happened in her childhood. Therefore, I needed to be especially careful initially and the focus of treatment had to be on the relationship until she could trust me enough to look at what she had been taught to think about herself, how it was inaccurate, and how to challenge it. If I had been a therapist with a rigid policy that clients have to be ready to do whatever I say (as some CBT therapists do), she probably would not only have left therapy but would have felt inadequate and may not have tried therapy again. Instead, she is now able to be a productive adult in a healthy relationship.
In such situations, I need to be very careful of how I interact with the client. My natural tendency to use humor needs to be suppressed initially until that person feels accepted in the relationship. In addition, compassion and empathy allows me to know when someone is ready for certain therapeutic methods. By fully understanding the perspective of the client, I can gently move them toward the more effective, but more intense, methods of CBT. This allows the client to feel understood and increases the responsiveness to CBT.
Certainly, with less severe problems this may not be an important factor. A person who has reasonably good self-esteem and is experiencing normal life problems can respond quite well to a more manualized approach. Unfortunately, most research has been conducted with such higher functioning individuals so that the emphasis has been more on the treatment method than on the therapeutic relationship (Lambert, 2013).
Hopefully, we will see more of a change in the future as to the importance of implementing CBT with a focus on compassion and empathy. A recent book by Cory Newman (2013) teaching therapists the methods of CBT spends several chapters discussing the therapist factors and the impact on therapy outcome. In particular, he discusses the importance of the therapeutic alliance and having patience by recognizing that what we are asking of our clients can be quite demanding. This is a departure from most books on CBT which focus only on the methods. However, he asserts that “accurate empathy, warmth, good listening skills, and clarity of communication” is a starting point that needs to be “combined with the organizational, conceptual, and technical skills that are well-tied to CBT theory and principles.”
1) Comfort with the therapist. Part of the therapist's job is to help you feel comfortable. You will be discussing and confronting unpleasant and uncomfortable topics. Therefore, you need to feel compassion, warmth, acceptance, and empathy from the therapist which should allow you to feel comfortable in therapy. If you don't, you can discuss this with the therapist or seek another therapist. Do not assume that all CBT therapists are the same. If CBT did not work for you and you were not comfortable with the therapist, it is more likely due to the therapist's approach, not the CBT itself.
2) Individualized approach. Although there are certain methods that help certain kinds of problems, your treatment plan should be based upon an evaluation of your situation and what is most likely to help. Therefore, even though reading and assignments are often a part of CBT, it is not a one-size-fits-all therapy. Your assignments should be determined based upon your goals for therapy.
3) Flexibility. CBT is ultimately flexible when applied with expertise and not following a formula. Some clients feel blamed when they do not respond to certain methods. However, it is the method that didn't work, not the individual. Even if the issue is inability to follow the plan, the plan needs to be reassessed rather than blaming the individual. CBT has many methods so that when one doesn't work, another might.
4) Therapist's experience. Experience isn't just the number of years someone has been practicing but it is also how the therapist was trained and the intensity of the training. For instance, a semester course in CBT is not likely to provide the same level of training as a year-long supervised fellowship. A therapist more fully trained in CBT is likely to take a much more active, directive approach with emphasis on the specific goals of treatment than someone with less experience. In an initial session, the therapist should be able to comfortably provide an overview of therapy and what to expect.
Beutler, L.E., Forrester, B., Gallagher-Thompson, D., Thompson, L. and Tomlins, J.B. (2012). Common, Speciﬁc, and Treatment Fit Variables in Psychotherapy Outcome. Journal of Psychotherapy Integration, 22, 255–281. DOI: 10.1037/a0029695
Huppert, J.D., Bufka, L.F., Barlow, D.H., Gorman, J.M., Shear, M.K. And Woods, S.W. (2001). Therapists, Therapist Variables, and Cognitive-Behavioral Therapy utcome in a Multicenter Trial for Panic Disorder. Journal of Consulting and Clinical Psychology, 69, 747-755. DOI: 10.1037//0022-006X.69.5.747
Lambert, M. J. (2013). Outcome in Psychotherapy: The Past and Important Advances. Psychotherapy, 50, 42–51. DOI: 10.1037/a0030682
Nathn, P.E., Stuart, S.P. and Dolan, S.L. (2000). Research on Psychotherapy Efficacy and Effectiveness: Between Scylla and Charybdis? Psychological Bulletin, 126, 964-981. DOI: I0.1037/0033-2909.126.&.9S4
Newman, C.F. (2013). Core Competencies in Cognitive-Behavioral Therapy: Becoming a Highly Effective and Competent Cognitive-Behavioral Therapist. New York, NY: Routledge/Taylor & Francis Group. DOI: 10.1037/a0033780
Seligman, M.E.P. and Levant, R.F. (1998). Managed Care Policies Rely on Inadequate Science. Professional Psychology: Research and Practice, 29, 211-212. DOI: 10.1037/0735-7028.29.3.211