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Understand the limits of CBT

November 17, 2011
by Nicholas A. Roes, PhD
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Cognitive-behavioral therapy (CBT) has been proven effective for treating substance abuse problems. When it is combined with pharmacologic interventions, the result is better than that that seen with either medication or CBT alone. The therapeutic effects also last longer compared to those from only medication, but there also are limitations to the cognitive approach that are important to consider.

Need for client matching

CBT works best with voluntary, motivated clients. It is really not very useful in resolving the ambivalence that most of our clients bring to treatment. If mandated clients chose treatment only to avoid prison, they often are not ready to share this with their assigned counselor. So a lot of time might be wasted as the counselor tries to help clients change thoughts that they don't really have in the first place.

Motivational Interviewing (MI) can help the clinician build the kind of therapeutic relationship that makes clients comfortable sharing what they really think. Then CBT (and many other research-based approaches) will be more likely to succeed.

So MI might be required for clients who enter treatment on the pre-contemplation (“I don't have a problem”) or contemplation (“I might have a problem, but I'm not sure what I want to do about it”) stage of change. Once clients have progressed to the preparation (“I'm committed to changing and want to make a plan”) or action (carrying out the plan) stage, CBT is much more helpful.

Possibility of backfiring

CBT can backfire with certain clients. Sometimes clients hear cognitive approaches as judgmental, and attribute their “inappropriate” or “distorted” thinking to a basic flaw in their humanity. CBT even could be confused by clients with a moral model, where clients conclude that bad things happen to them because they are bad people with bad thoughts and feelings.

CBT also can present a problem for clients with anxiety, especially if a focus on their thoughts is part of their troubles to begin with. It could give ruminators another thing to worry about, and could increase anxiety rather than alleviate it.

Likewise, CBT might keep depressed clients in their dark places for so long that it could feel like a punishment. Some clients might be at a point in their lives where they can't handle their most suppressed thoughts, and in these instances it is not wise to rip the lid off them.

Some cognitive techniques are not helpful when low self-efficacy (rather than low interest in change) constitutes the obstacle. For example, decisional balance sheets, which record the risks and rewards of client choices, can be helpful if a client's ambivalence is based on not really knowing which choice is best. But they can be counter-therapeutic when the client already knows which choice is best, but keeps having trouble making it. In these cases, the decisional balance sheet might reinforce clients' opinions of themselves as losers, or failures who are incapable of correctly making even the most obvious choices.

This is especially true with regard to behaviors such as smoking. All else being equal, very few people believe they are better off smoking cigarettes than quitting. The problem often is that they haven't yet devised an effective plan. In these cases, doing a decisional balance sheet can be very discouraging, as clients might feel even worse about not being able to quit. The unhelpful cognition here is not, “Smoking is a great idea,” but more likely, “I'll never be able to quit.” So rather than continue with discussing the benefits of quitting versus the risks of smoking, session time with these clients would be better devoted to building self-efficacy and collaborating on a workable plan.

A focus on experiences

There may be a better way to change thinking than addressing thoughts directly. Most of us agree that more helpful thoughts support high-quality, lasting sobriety. But sometimes thoughts can be changed more efficiently without addressing them directly, as new experiences often lead to new insights.

Most of us also agree that what we think affects what we feel and do, but the relationship among cognitions, emotions and behavior is circular rather than linear. Thoughts don't develop in a vacuum and then dictate our emotions and actions. Clients often succeed in acquiring more helpful thoughts because they first addressed unhelpful emotions or behavior. It would be great if having knowledge of the best course of action automatically translated into change. But we know this is not the case.

Nicholas A. Roes, PhD
Nicholas A. Roes, PhD

In the case of trauma that is pre-verbal, CBT may have a more limited chance for success. In these cases, art, music or movement therapy, or other body-centered techniques, might be helpful.

Time considerations

Finally, CBT takes longer than many other approaches. Depending on your modality and opportunity for face-to-face contact with your client, traditional cognitive therapy might not be practical.

In the long-term residential treatment program where I work, we have great results with cognitive approaches. We have the luxury of being able to observe how our clients behave in the 167 hours each week that are outside their individual counseling sessions. We know when self-reports of progress differ from objective measures of a client's situation. But with a single session, or a small number of visits, it is difficult to explain the principles and practices of CBT to clients, and even harder to confirm forward movement.