What's So Great About CBT?
Does CBT Actually Work?
Deciding it's a good idea to get therapy is like deciding it's a good idea to eat lunch. Sure, eating lunch is helpful - essential even - but did you mean a PB&J with milk? A microwave burrito? A four-course meal at a five-star restaurant? Every therapy experience is different because every therapist is unique, and therapists all approach the job from different foundations.
Therapists disagree about what’s helpful.
Therapists don't *really* learn how to practice effective therapy in grad school. You would think we would, but we don't. When I graduated, I had learned about diagnosis and a few basic listening skills but knew very little that would be useful to help someone recover from depression, for example.
This is a field in its infancy.
Compared to medicine, we agree so little on how things work, what causes things like anxiety and depression, and *what precisely to do* when we sit down with someone who's suffering.
Because there's so little agreement, only a handful of graduate programs can offer a specific approach. If most schools did, they'd alienate most of their students and faculty. CBT sounds inhumane to most folks in the Somatic and Psychoanalytic worlds, and conversely, those approaches feel too wishy-washy to someone in a Reality-Based or Solutions-Focused mindset.
Empathy and compassion are necessary but aren’t enough.
As a result of our undecided education, many therapists have little to offer beyond empathy and compassion. They may have learned what is "wrong with you" in grad school but didn't learn how to do anything about it.
Those particular tools (empathy + compassion) are essential. It takes tremendous effort to offer them well, and they go some distance toward helping people feel better. My first experience in therapy was with a mostly-empathy therapist, and I benefitted from that.
The truth is, though, that therapy can have so much more to offer than compassionate listening. For me, that's where TEAM-CBT comes in. I want to talk about how amazing it is, but first, here are the criticisms I've heard most.
Why It Makes Sense to Hate CBT
There’s background on Cognitive Behavioral Therapy (CBT) elsewhere on Bit by Bit Counseling, and here and here. Some people love it, but I’ve felt weird about adopting it for a long time. When I’m around other therapists, I’m usually hesitant to say exactly what I do and why I love it. Here are some of the critiques that run through my mind when I’m self-conscious about its pitfalls.
Critique #1: CBT is a Tool for Capitalism to Quantify and Commodify Therapy
CBT is supported by a lot of research, making it popular with hospitals and insurance companies. That very backing brings it critique from a lot of therapists.
While I am a big fan of science, skepticism about the big-money support makes sense. I remember nodding along in classes where a longtime therapist told us that CBT is crap sold to us by insurance companies who only care about the bottom line. In truth, he said, the practice of therapy is ineffable. It works because of the facial expression on your therapist's face, the gentle reminder or suggestion that brings a sudden shift or insight, and the safety you feel in simply having a place to share your scariest, most vulnerable, most painful feelings.
There's truth to that. Psychological and emotional well-being is complex! It's mostly invisible, hard to pin down, and challenging to describe.
It makes intuitive sense that it feels inhumane to dole out a precise number of sessions at an unvarying pace - mobilize X units at Y cost to limit the liability for insurance companies. It sounds gross when you describe it that way.
Critique #2: CBT Is Gaslighting You So You'll Pretend to Be Happy
Another common criticism of CBT is that it is just a way to induce fake happiness. Positive Vibes culture makes it challenging to be open and honest about the fact that we're struggling.
On top of that, specific people in our lives often pressure us to get treatment. A parent, partner, friend, or boss wants us to get therapy, and it's supportive, but also... makes it feel like they want us to pretend to feel better for their sake.
That would mean denying the truth of our suffering. Look around! Is there not plenty of reason for despair? Isn't it possible that rage and devastation are the only rational ways to feel?
When I feel like someone else wants me to be in a good mood for their own purposes, I feel more inclined than ever toward anger, sorrow, and resentment.
Even your therapist might give you the impression that they want you to be happy so they can feel good about themselves. Is CBT just about telling yourself some pretty bullshit so you can be a compliant worker bee?
Critique #3: It Feels Impossible
Okay, assuming it's not just about faking happiness to please other people, how could "changing your thoughts" and "transforming your life" possibly work?
I work with lots of brilliant, high-insight people. My clients are typically very self-aware and highly rational. They'll say things like, "I can already tell that my anxious or depressed thoughts are irrational. I just can't change them." It feels impossible that anyone could ever change them.
For others, it doesn't even feel true that feelings are connected to thoughts. Sometimes emotions hit with such intensity that they feel entirely independent, like a weather system that touches down and hangs out as long as it wants to - strong winds and high waters testing your limits - both unpredictable and beyond anyone's influence.
Does it even sound serious to say that writing down some words and then writing down new words could have any bearing on that?
What could CBT (or maybe even any therapy) bring to bear in the face of heart-pounding, tunnel-vision-inducing, overwhelming anxiety? Or the complete despair and anguish of depression?
Critique #4: CBT Will Only Touch the Surface - It Can't Deal with Deep Issues
And finally, the critique I hear most often is that CBT can only skate on top of things.
CBT must be a band-aid. Because it's designed to be a short-term treatment (usually about 8-20 sessions), it makes sense to conclude that we could only work at a superficial level. How could you address the full complexity of a human life in that amount of time?
Sure, it looks good to insurance companies because it can be researched, but it can only be studied because it's uniform. Because it's uniform, it must not be powerful or complex enough to do any real good.
So Why Do I Use CBT?
Given all those critiques, why would I devote my life to practicing and spreading the word about TEAM-CBT? Moreover, this skepticism makes sense because I used to believe it too!
I was taught that CBT existed to shortchange the value of genuine human relationships to maximize the bottom line of HMOs. It was also portrayed as a "masculine" approach that was all about orderly lines and numbers and would naturally dismiss the chaotic curviness of hearts and feelings.
Despite all that, I've come to love TEAM-CBT for three big reasons:
1. It made sense.
2. I saw it work.
3. I felt it work. I experience it myself, over and over.
It made sense.
It made sense to me in a way that other approaches didn't. You've probably had this experience: there's some problem in your life that you don't know how to begin solving. A medical issue, a parenting concern, a life management question, etc. You google it, you read a bunch of stuff, maybe listen to some podcasts, consult an expert, and then finally, you hear someone explain their understanding of it, and it clicks: their explanations of the world, of physics, human behavior or biology, it sounds reasonable in a way that other explanations haven't. That's how it was for me with TEAM-CBT.
Knowing that thoughts create feelings didn't always make intuitive sense, but it did offer hope. If it were true that thoughts did create our feelings and if it were possible to change our thoughts, then we wouldn't be at the mercy of these emotional tsunamis that seem to rise up unpredictably. Thankfully, I've seen it play out hundreds and thousands of times - our feelings about a situation are generated by our interpretations. Even when I feel certain that it’s not applicable in a particular situation, I turn out to be wrong.
Furthermore, I saw the approach to motivation, resistance, and autonomy as a revelation. TEAM expects us all to be wary of change. In my earliest days of learning TEAM, it felt like a magic trick, like you could fool people into thinking you weren't trying to get them to change, but you really were. My understanding today is more profound, transparent, and genuine: change always comes at a price. My job is to tell you what's possible, then tell you what it would take to get there. Then it's up to you to decide whether it's worth it.
I saw it work.
I've seen it work. Seeing and hearing other people work through a problem using TEAM-CBT convinced me that it was powerful. Thankfully, there are session recordings that demonstrate profound transformations in real-time. There are recordings of people struggling with depression, social anxiety, feeling inadequate as a parent, or angry about world events.
In addition, I’m in weekly consultations with colleagues and friends, and I’ve been lucky enough to be present as some of them worked through problems that made them sad, anxious, or overwhelmed.
Finally, I have seen my own patients make huge, exciting turnarounds! It is incredibly gratifying to witness the changes and know what it means for my clients to experience life in a new way.
I felt it work.
If I ever waver in my convictions about TEAM-CBT, I can look at my own life. Since discovering it in 2017, so many things have improved: my enjoyment of life, my relationships, my ability to appreciate myself and not take myself seriously, my physical health, my alcohol use, and my sex life. An accurate list would be much longer than that, but it would get tedious. I know TEAM-CBT works because I live it.
But What About the Critiques?
Let's take them one at a time.
CBT is Just a Tool for Capitalism to Quantify and Commodify Therapy
I'm sure it's true that CBT is appealing to insurance companies. It is conducive to research and often shows benefits after short-term treatment.
I actually like the idea of short-term treatment because it feels compassionate and ethical to use the least possible amount of clients' time and money. I'm not paneled with insurance companies, so their opinions don't have much bearing on my practice, but it does make sense to me to be wary of the potential motivations and even of the likelihood of success from short-term treatment.
I typically work with people for about 8-16 weeks on the first problem they want to tackle. That's relatively short-term in for therapy, but it's not a quick fix from clients' perspectives. They're still devoting themselves to 2-4 months of sessions and homework and living with an unresolved issue during the process.
My primary goal with every patient is to teach the skills you need to become your own therapist. Challenges will come up throughout every life; you will learn the steps to respond so that you don't necessarily need to return to therapy.
That said, sometimes it takes working through more than one issue before you feel confident in your skills. For example, if you'd like help with OCD and you also have social anxiety and want to improve your close relationships, we would start with one and keep going until you feel ready to stop. That would mean a much longer stretch of sessions.
So: is it short-term? Maybe - sometimes. It’s a challenging process and works best when we are both aiming to be done as soon as possible and not adding pressure for instant success.
CBT Is Gaslighting You So You'll Pretend to Be Happy
I honestly don't know what classical CBT is like or what the CBT therapist one zip code over is doing, but TEAM-CBT is the least gaslighting therapy around.
One of the cornerstone features of TEAM-CBT is the "A," which has a couple of different words associated with it (in some places, it's called "agenda-setting," in others, it's "assessment of resistance"). Let's think of it here as "agency" or "autonomy."
In TEAM, as I mentioned above, we never assume that someone wants the change we can offer. In fact, we assume the opposite. Every offer we have, while potentially glorious and life-transforming, is also costly. It demands your time, effort, and, most importantly, the death of your ego, which can be intensely painful. You might not want to feel any less angry at your boss or happier about your circumstances. You very well might despise the very notion of feeling closer to your parents or your partner.
In TEAM, you decide how much better, if at all, you want to feel. You may want to be even angrier than you already are, and we can get behind that.
It Seems Impossible
Yes! It does seem impossible. This critique is tricky because it does seem impossible. How can I feel this much better in this many ways because of words and some grids on a piece of paper? It's hard to wrap your mind around.
That said, we don't just write down words and then edit them into different words. We use dynamic, powerful methods to move from "I could maybe believe that intellectually" to "I feel that in my bones and know it to be true."
CBT Will Only Touch the Surface - It Can't Deal with Deep Issues
Sometimes clients are surprised about how we focus our work. It feels silly to spend weeks working through the thoughts they had while driving to work in the morning. But if they’re big and upsetting, those thoughts are inevitably about the most profound issues in their lives.
CBT helped me grieve
I’ve been grateful to notice the effects of TEAM-CBT on my mood and my life for years. Recently, though, I had an experience that heightened my gratitude for the skills I’ve learned. After a few frantic days of realizing something was wrong with him and trying to get treatment, we had to euthanize our four-year-old dog on Christmas Eve.
Four years is a lot less time than we thought we'd have with him.
This problem probably isn’t as big as the ones you're currently facing, but it was meaningful to me.
It eased my guilt and regret.
I second-guessed our decisions in caring for him and pursuing treatment. My skills made it possible for me to notice that I was doing this. Noticing is small but significant - it means I wasn’t just plunged into guilt and regret but could be aware of where those feelings were coming from.
Moreover, I could recognize it as an expression of my love and the responsibility I felt to take good care of him. I could almost look at my guilt and regret from a distance. I could see they were there because I wished things could be different. They were also a caring fantasy that I could have more control than I do.
It helped me make sense of feeling strange and separated from “normal life.”
I felt the strangeness of being in a bubble so set apart from everyone else's 'regular day.' Previous versions of me might have been angry or felt more alienated or needy, but I could notice that it felt odd and still see that it made sense.
Of course, they're just going about their days. And, of course, I feel like curling up in a ball and wailing.
It made it easier to feel okay about the emotional roller coaster.
I had every emotion one after the next and would have been confused or judged myself for that in the past. Instead of judging myself for laughing or focusing on other things, I could remind myself (and my kids) that this is how grief works. Hell, it's how emotions work in general. Grief isn't days, weeks, or months of uninterrupted sadness. It's a big jumble of snot and hugs, goofiness and mundane tasks, and doubling over when a new realization hits you in the gut.
It made communication and connection possible.
I could also talk to my husband about all the complexities of my thoughts and feelings because I have spent so much time learning how to name and describe them. I had access to the comfort of that relationship because it's grown stronger as I've gotten more skilled.
It gave my sadness meaning and even beauty.
I also saw that this loss, while heart-wrenching, is a built-in part of love. As I told my son last week, anything you care about has the potential to break your heart. You may have heard Buddhist teachings about how attachment is the root of all suffering - well, it's also the root of much joy! I'm grateful for his time in my life and my connection to a living being who was affectionate, reliable, cuddly, and trusting. I miss him and am glad that I miss him, even as I am heartbroken and sad, tearing up as I write these words.
Is That All?
There are so many other examples, but it's important to note that earlier versions of me would've handled all of this much differently. I would have felt jealous that other people were happy. I would have had impossible expectations for them to acknowledge my hurt or reach out with care. I would have felt intense regret, guilt, and anger, not simply the loving sadness of missing my dog but the suffering caused by other painful emotions. And I would have found the whole experience overwhelming and confusing.
But Couldn't Other Therapies Do That Too?
A lot of the growth I've come to is growth that others have spoken about coming from all kinds of other approaches to therapy. Some of what I described above sounds like mindfulness, and some may sound like Attachment Theory or IFS. People reach their goals through a variety of paths.
The one that has been the most dependable, repeatable, all-encompassing (whatever problem I'm facing, I know TEAM-CBT has a path for it), the most effective, and most comforting is TEAM-CBT.
I've tried mindfulness meditation, for example, but I couldn't sit still long enough to make it helpful. I developed the state of mindfulness by going through the TEAM steps over and over, practicing, and gradually changing my understanding of my emotions and thoughts. Oddly enough, I can stand to meditate now that my thoughts and emotions work differently!
Is It Too Good to Be True?
TEAM is rigorous and demanding of both the therapist and client - a fact I sometimes resent but which makes the rest of it more believable. If I told you something was this powerful and easy, you'd be wise to be skeptical.
I'm still making a big claim, though - if you are anxious, depressed, or feel distant or frustrated in your relationships, if you can't figure out why you can't get yourself to make seemingly simple changes in your life, TEAM can show you how to create happiness and peace. That's a huge claim! I know it seems unreasonable, and I stand by it.
Get in touch if you want to talk about what it could do for your life. If you live outside of Georgia, I’ll do my best to point you to a skilled TEAM clinician.
Note: This post is part of a comprehensive blog by Cheryl Delaney, MS, LPC. Cheryl owns Bit by Bit Counseling, LLC, and is affiliated with the Feeling Good Institute. She’s a Level 3 TEAM Certified therapist who is passionate about spreading the word about the power of TEAM-CBT and specializes in working with perfectionists. The original article is published here.