What is CBT and how does it work?

Cognitive behavioral therapy (CBT) is one of the most common forms of psychotherapy used to treat complex psychological problems and illnesses, such as complex anxiety disorder and post-traumatic stress disorder (PTSD). It is based on a combination of two approaches: cognitive and behavioral. In the 1980s and 1990s, cognitive and behavioral methods were combined into cognitive behavioral therapy. A key point in this merger was the successful development of panic disorder treatments by David M. Clarke in Great Britain and David H. Barlow in the United States.

At the same time, three waves of CBT development are distinguished. Behaviorism (1920s) belongs to the first wave. In the 1950s, CBT introduced a personality that has individual reactions in response to external stimuli. It was at this time that A. Beck introduced the concept of “automatic thoughts”, as well as deep convictions. It is with them that classic CBT works. By changing automatic thoughts, a person’s feeling (feeling) changes in response to an external stimulus, as a result, a change in deep attitudes is possible. At this stage, there is a combination of cognitive and behavioral therapy.

During this period, the key concepts of CBT and schemes of their application are formed. The main logical concept of connection of thoughts, actions and feelings is presented in Fig. 1.

The third wave focuses on developing awareness and acceptance. Third wave CBT helps the client to accept himself and his peculiarities.

It would seem that the second wave of CBT, which works with the client through the correction of automatic thoughts, that the third is aimed at self-acceptance and the formation of personal awareness and values, have working schemes and mechanisms of psychological work with the client. However, all of these methods are aimed at correcting the client’s behavior and reducing the impact of traumatic events in the past on the client’s current state and, primarily, the client’s behavior. At the same time, self-acceptance includes acceptance of the client’s characteristics that prevent him from becoming a full member of society. It is assumed that it is necessary to lower expectations and accept one’s peculiarities, instead striving for achievements, including overcoming serious chronic diseases.

One of the problems that CBT helps to deal with is the frustration of not achieving one’s goals. For example, psychological assistance to a client who is unable to get a high-paying job due to the labor market situation, even with a higher education. Such help is aimed at reducing frustration and maintaining self-esteem, despite external circumstances. However, with this approach, the client’s ability to solve his actual problems does not increase. You can call this therapy the therapy of humility. Instead of forming an internal resource to overcome problems, a person is made more adaptable to negative external events and facts. Here we read some Christian ethics of humility.

Moving on to the discussion of CBT in relation to working with trauma and PTSD, it is important to note that the results of therapy are reduction of symptoms, not a return of the client to a normal life. Such results are the easiest to measure, which makes it possible to justify the high effectiveness of CBT. It is believed that the relief of the symptoms of the disease is already an excellent result of such therapy, which is not always achieved.

At the same time, even the proven effectiveness of CBT, according to scientific research, has been significantly declining since 2008.

Figure 2 presents the average values ​​of indicators of the effectiveness of the use of CPP, published in the corresponding years, in various scientific sources. Thus, we can confidently come to the disappointing conclusion that the effectiveness of CBT is not only decreasing, but is currently at a very low level. It slightly exceeds 20% for the group of anxiety disorders. At the same time, disorders of this type suffer from about 30% of young people who do not have a serious traumatic experience in the past, and more than 40% of young people with trauma.

Why does CBT not work?

In many ways, this dynamic is explained by the fact that people, both in everyday life and in professional circles, pay more attention to the quality of life, opportunities for self-realization and achievements. In other words, it is logical to conclude that treatment aimed at reducing the symptoms of psychological problems does not treat their source. Basically, there is no deep problem solving, and the modern world has a lot of external triggers that affect people to a greater extent than before.

According to the definition of poverty introduced by the Nobel Laureate D. Kahneman and his co-author A. Tversky, poverty is a sense of loss that people feel when they have to give up some benefits in favor of others. It’s not about choosing between cake and ice cream. Here they mean the need to deny oneself the purchase of quality food in order to pay for housing, including the mortgage. Yes, a person with a normal level of prosperity, when acquiring something, feels the pleasant joy of a perfect purchase. Whereas a poor person feels and understands that he will be forced to deny himself something else, which leads to frustration. Considering the level of housing prices and its dynamics in Russia and developed countries, as well as its inaccessibility for purchase by young people, the level of poverty increases significantly in this age group, which leads to the development of psychological problems and the formation of various diseases, including depression and various types of anxiety . disorders

Speaking about work with trauma using CBT, it is necessary to understand that trauma radically changes the concept of the individual, creates a sense of vulnerability, danger, insignificance of personal boundaries. This is what leads to the development of psychiatric diseases. At the same time, treatment of disease symptoms does not lead to significant changes in personality. In other words, the deep response to external triggers remains deeply negative and the person is easily retraumatized.

It is even more difficult in cases where the injury occurred at an early age. In this case, there are two problems at the same time. The first of which is the probable “stuckness” at a certain age, which hinders recovery. CBT methods can make a person’s reactions to external stimuli more mature, but this does not mean that he will feel like an adult at all. Moreover, cognitive methods involve working with a sufficiently mature person and their mental state to correct their psycho-emotional state by performing mental exercises in situations with a negative external stimulus. Thus, at the same time, the psyche must be healthy enough to perform these exercises, and the client must also have enough internal resources to perform them. In this case, you can try to adjust the self-concept, within the framework of which it is reasonable to use techniques and methods of CBT, but you cannot limit yourself to them. In addition, in the case of trauma at an early age, it may not be formalized in words at all, often clients do not even remember it. Like, for example, A. Lowen, the creator of the method of bioenergetic analysis. In his book “Joy. How to fill the body with energy and life with happiness”, the author talks about the traumatic experience that happened to him when he was only 8 months old and later affected his perception of himself in adulthood. Such injuries are difficult to describe in words that will only reflect them. They lie in the area of ​​feelings, which leads to the fact that working with them is better than other methods, for example, in the psychodynamic approach.

Thus, summing up, the following theses can be attributed to the main criticism of CBT:

• this type of therapy is aimed at reducing the symptoms of mental illnesses, rather than treating trauma;

• it is a therapy aimed at reducing the level of frustration, rather than increasing the level of satisfaction with life;

• this therapy requires imaginary efforts from clients, including in situations with a complex external stimulus, while the mechanisms of internal resource formation that ensure the operation of this mechanism are not provided for;

• in the last few years, the level of effectiveness of this type of therapy for complex mental illnesses has decreased to a level slightly above 20%;

• it is limitedly applicable to situations where the formalization of any thoughts is limited.

In other words, we can safely say that the popular opinion about the effectiveness of CBT is overestimated, which is due to two factors: the choice of measurement scale (both symptom reduction) and the conditions of development of this method. It developed mainly in the USA, where science develops on state and private grants. Grant donors often pursue their interests from future research results. At the same time, there is no need to talk about the socio-economic benefit for both the state and corporations from reducing the level of frustration of citizens without increasing their internal resources to improve their lives.