Does CBT work?
Cognitive Behavioural Therapy (CBT) is considered by most accademics and clinicians to be the best long-term solution for people with severe social anxiety. So what is CBT and does it really work? Academic reasearch says that, yes, for most people CBT does lead to significant improvements, but there is a lot more to the phrase ‘does CBT work?’ than first meets the eye.
Firstly, CBT is an evolving therapy. This means that CBT today is not what CBT was 15 years ago. CBT for social anxiety used to mostly be about learning relaxation through controlled breathing, visualisation techniques, simple exposure, and replacing negative self-talk with cognitive coping strategies. These may still be used today, but through research CBT has moved on. Today, if you visit a well trained CBT practitioner your therapy might well be more focused on using behavioural experiments to gather evidence to counter negative beliefs, eliminating the use of safety behaviours, focusing outwardly to reduce self-focused attention, video feedback, and even exposure through virtual-reality.
The basic premises of CBT have continued to be the same; we can change our feelings and increase our quality of life through changing our thoughts and behaviour, but how we do that has changed over time. This is an important point to make for those who may have tried CBT a good few years ago or have been unlucky enough to visit a therapist who has not updated their training. If CBT has not helped you much in the past then it is quite possible that it could be more beneficial if you tried it again with more up-to-date techniques.
Much of the help I offer people resembles CBT and I may even use CBT terminology from time to time. In many respects it is CBT because I focus on helping people change the way they think and behave to overcome their social anxiety, but some of the theory and techniques I employ are unique and would not commonly be found in a typical course of CBT (although I hope that they will be in the future). So when answering the question, ‘does CBT work?’, the answer is not so straight forward. It really depends on what that CBT consists of. Not all CBT is the same.
A second point to make regards the relationship between therapist and client. In CBT this is commonly called the therapeutic alliance. It is important that you get on well with your therapist and feel like they are someone who can understand and help you. If you do not gel well together then it could be a significant barrier to progress. The idea of the therapeutic alliance is not so much that the therapist is there to help you, but rather that together, as a team, you can work through your difficulties. If you wanted to visualise this then you might like to see you and the therapist sitting together facing the problem as opposed to you sitting opposite each other with the therapist looking at you with the problem. If your therapist is not someone you can feel understood by, trust and cooperate with then sooner or later it will get in the way of the therapeutic process, so another answer to the question, ‘does CBT work?’ is that it depends on your relationship with your therapist.
Some personalities fit together better than others and it is not necessarily a failing of your therapist or yourself if you do not connect. If you do not get on well with your therapist then be brave and bring up the matter with them, it could lead to a major break-through in your progress. If things still are not working out, ask to see someone else. It is possible that they can refer you to a colleague who will be a better match. I understand that this can be difficult to do when you have social anxiety, but it might be a key step towards you making significant progress.
Finally, CBT never works for anyone. What I mean by this is that CBT is just a set of theories and techniques. It has to be you who puts in the time and effort to turn those theories and techniques into changes in your life. Although most people understand this, and it can seem patronising to state the obvious, the unfortunate truth is that a lot of people still stand back and take a passive approach to therapy in the hope that change will happen to them. Fear of failure is a big reason for this, but it is important to remember that if we do nothing, then nothing will change, and worse, our situation could even deteriorate.
As you can see, when someone asks the question, ‘does CBT work?’, the answer is not as straight forward as a simple yes and no. CBT does help many people overcome their social anxiety, but your success will depend greatly on what exactly your CBT consists of, how good your relationship is with your therapist and whether or not you are ready to make the commitment of time and effort that is required by it.
What have your experiences of CBT been?
Tags: CBT, CBT for Social Anxiety Disorder, CBT for Social Phobia, CBT Techniques, Cognitive Behavioural Therapy, Cognitive Therapy, Social Anxiety Therapy, Therapeutic Alliance, Therapeutic Relationship
December 21st, 2008 at 9:40 pm
I think it can work but due to the nature of my anxiety I never complete the therapy b/c I’m to anxious to even go to the sessions. So I wind up always starting from the beginning with a new therapist and going over the same mundane start that I already know like the back of my hand.
http://diaryofashyblackwoman.blogspot.com/
January 14th, 2009 at 4:02 pm
You bring up something that I am sure affects a lot of people with social anxiety when they are in therapy. It is hard starting again with someone new and expensive if you have to pay for it. It takes time to build up trust and tell someone your story and I think this is another reason why it is so important to choose a therapist well from the start. If you start with someone new it would probably be helpful to tell them from the start that you can end up getting too anxious to go to sessions and are prone to moving on to another therapist. You can then work together to put something in place to prevent or resolve this when it happens.
August 1st, 2009 at 7:07 am
Hi Nick. I think it’s great CBT has helped you so much. I was just wondering how long it took for CBT to begin reducing your symptoms, as I am beginning a course of CBT myself?
August 1st, 2009 at 12:36 pm
Hi John, Everyone starts from a different place and is unique, so it’s almost impossible to say how long it will take for different people. CBT is very much a thing where you get out as much as you put in, so if you really give it your all then you’ll have a good chance of making progress quickly. I worked through a program of CBT when I was starting out. I’d already done some self-taught exposure therapy at quite a basic level, but it was the first thing I tried that had any structure to it. I really worked hard at it and did my best to follow it to the letter, putting in the time and effort every day. If I remember rightly, much of my social anxiety had gone within 3 months and by 6 months things were much better and I got a temping job and did that for a month with hardly any anxiety at all. It wasn’t all the CBT though, within that time I also work really hard on some other self-help/personal development programs. I’d say the CBT really took the edge off my SA, and then working on other things and developing my own understanding of social anxiety really helped me leave it behind. I think CBT can be really helpful and I would recommend it to people as the best option that’s currently available, but what I’m putting together now I hope will be a big step forward and really help people achieve above average levels of confidence in a shortest time possible. People will still have to work hard at it to achieve the results, but that’s always going to be the case.
August 26th, 2009 at 2:22 pm
Try computerised CBT? Could this be an option for shy black woman? Good luck. Josh
August 26th, 2009 at 9:38 pm
People can access a free computerised CBT course for people with Social Anxiety through this Australian site, http://ecouch.anu.edu.au I’d be interested to know how people get on with it…
September 8th, 2010 at 11:56 pm
There’s one problem with CBT which most people, if not all people I’ve ever heard, have not picked up yet: confronting and challenging negative automatic thoughts is the bread and butter of CBT.
My point is that the problem with challenging your negative thoughts is that the only way you can do that is to continue thinking about the same thoughts which were bothering you in the first place: and the longer you do that for, the longer you’re behaviour will be influenced (either subtly or obviously) by your negative thoughts.
The reason this is a problem is that not all negative thoughts ARE entirely unrealistic, or if it is possible to challenge and disprove them, then the person using CBT might run out of plausible or realistic explanations for their negative thoughts. When compared to simply occupying your mind with other thoughts, it seems to me that attemtping to disprove the negative ones is really just a longer route to the same destination: lack of concern/anxiety/insecurity.
How can you confront and then disprove challenging thoughts without thinking about them in the first place? I think that this problem holds the key to the next stage in evolving CBT from from where it is now, to where it could be eventually.
September 9th, 2010 at 12:49 am
Many thanks for your comment, Simon, and you are absolutely correct. One of the flaws in CBT (as it is commonly practiced) is that it can keep you focused on those negative thoughts and engaged with them. As a response to this, some of the newer mindfulness based behaviour therapies recommend accepting and just observing negative thoughts (and feelings), not challenging them and then taking positive steps in the direction you want to travel in life.
My personal opinion is that this is a step too far in the other direction. I believe, and have experienced, that it is extremely helpful to replace those negative thoughts, but replace is the word I’d use rather than challenge. As you point out, challenging keeps you engaged in the thoughts.
Just straight switching to unrelated more helpful thoughts can be difficult for people when they fully feel their negative thoughts are the whole truth, but they rarely are. They could be a part truth, though, or very true but an incomplete truth, which makes challenging them confusing for people.
As a first step it can be helpful for people to just make a small dent in their line of thinking and just start to doubt its usefulness a little while still acknowledging any negative circumstances they are faced with. I talk about this in this video, http://www.youtube.com/watch?v=6sGRyZUIVzM. Once doubt is established, then it is easier for someone to ‘replace’ their thoughts with something more positive (but preferably unrelated to the original negative thought in my opinion).
That said, standard CBT can still be very helpful for people if they persist with it, even if it’s not perfect. Standard CBT is a massive improvement on no CBT, or some other therapy options, when it comes to social anxiety. There are improvements to be made though.
October 15th, 2010 at 3:06 pm
Those are some interesting ideas you have described here Nick. I can see your point about “incomplete truths”. Certainly CBT is not perfect – the main question, however, which I think we need to ask is: how much better could CBT be? With that, I now have some additional points to present.
Firstly, why is it that cbt is (most of the time) not practiced by those who preach it, i.e. the psychotherapists who prescribe it to their clients/patients. For example, even though psychotherapists train their clients in how to dispute negative thoughts and identify faulty thinking patterns (such as distortion, mind reading and black and white thinking), why do these same psychotherapists not use the same techniques in their own personal lives? Surely, patients would benefit most from using the same strategies used by people who are NOT diagnosed with depression or anxiety.
Secondly, CBT involves critical thinking, which is mentally fatiguing for people when practiced in large volumes. CBT virtually relies on a person to use critical thinking in order to replace their negative thoughts. It seems problematic that disputing negative thoughts in order to “replace” them is the only way to use CBT. Critically thinking about negative thoughts is also time consuming and is therefore impractical in the long run.
Thirdly, CBT is only useful for fixing the symptoms, not the problem. This is because CBT involves “replacing” each and every individual negative thought which ever arises. This is also why it only works when the person using it is committed to the process. Yet I am questioning the effectiveness of a form of therapy which continues throughout a person’s life.
I am arguing that a truly effective form of therapy is like an effective teacher: when a teacher performs their job properly, they leave the student better off, even to the extent that the student can now continue learning without the teacher; a student taught successfully becomes an independant learner. Hence, a good teacher is constantly working on making themselves obsolete to the student – when the student no longer requires the teacher’s assistance, this indicates that the teacher has successfully taught the student. Likewise, when the client no longer requires psychotherapy (in this case, CBT) they can consider themselves successfully treated for whatever problem they suffered from.
If we apply this analogy to the psychotherapist training their clients in CBT, then CBT as a system or method of therapy fails the test of being an effective teacher. In other words, it fails to properly teach clients how to NATURALLY think positively about the world around them. If CBT only needed to be practiced for a few months in order to have its positive effects, then I would think differently of CBT. However, the reality is that CBT only works as long as the client actually uses it. This is because the underlying causes of the person’s anxiety are not directly addressed by CBT. In this respect, hypnotherapy might have a more positive and lasting impact on a client – after a client has received hypnotherapy from an expert practitioner, they are not required to constantly engage in “identifying their automatic thoughts” and then finding an alternative explanation for those thoughts.
Nor are the person’s behavioural habits successfully improved (despite the name Cognitive Behavioural Therapy). The name Cognitive Behavioural Therapy was chosen mainly because of an “assumed” link between cognition and behaviour. This link DOES exist, however proponents of CBT seem to have this misconception that training clients to replace negative thoughts automatically equas less negative behaviour.
The reason this does not work consistently is that the only way to form a habit out of a certain behaviour is the repeat that behaviour many times. The only way to become more comfortable and less anxious about public speaking is to actually DO public speaking lots of times; the only way to become more confident and less hesitant about initiating a conversation with a stranger is to DO that lots of times; the only way to become more relaxed when asking someone out on a date or for their phone number is DO it lots of times. And each time a person does that, they are guaranteed to lose some of their fear and anxiety. The only way to achieve real results in the area of social anxiety is through “exposure”.
Why have I now shifted the focus onto improving behaviours? The answer is because behaviours, in the end, are the what really shape our relationships, our careers, our social lives, our diets and every other aspect of our own environment. The ultimate goal of any form of therapy, I think, should be to equip the client with new, more helpful (and healthy) patterns of behaviour.
September 8th, 2011 at 8:37 pm
I had problems with practicing meditation up until recently. I kinda couldn’t focus. I guess staying focused is the key and that’s why doing meditation doesn’t work for everyone. I made a relaxed little place for me in my apartment and that gave me the extra focus I needed. It’s way easier now!
September 29th, 2011 at 9:45 pm
Simon, with all my respect, but your way of looking at CBT is crazy. I mean, of course you need to keep your thinking positive for the rest of your life. But you don’t need to do 3 hours of self talk every day anymore. At some moment systematic exposure is enough. And the fact that systematic exposure is needed, doesn’t mean the therapy is not good. If you take a socially confident person and put him in the basement for 5 years without letting him speak to anyone, once he gets out of the basement he will have social anxiety. You can’t expect to simply do CBT, avoid many social settings and afterwards still be confident. Practice makes confidence.
November 15th, 2011 at 1:20 am
I’m on my 6th session of cbt, I have a constant tight chest caused by hypercondriasis. at the minute im not really feeling any different, do you think it will work for my symptoms
November 16th, 2011 at 1:20 am
I’m also on my 6th session of cbt this morning. I take propanalol, diazepam and sertraline to help those feelings of tight chest and anxiety Hennessey. Those meds work for me, but my cbt therapy is there to replace it (I guess). Or at least eventually get me off the meds.
I’m currently trying to “Notice” the spaces between thoughts. Or be just aware of them, without all the negative thoughts. And then carry on with that space and just check it out.
No idea if that answers your question as I’m in the same point maybe, does make me think I’m not the only one who thinks this way. I hope it will work and I can see that it could work.
Long way to go yet. Stick with the cbt and try it.
It might help us yet!
x