Beyond CBT

You have likely heard about Cognitive-Behavioural Therapy (“CBT”). CBT helps people to challenge their own thinking patterns (which may be distorted or irrational) and behavioural patterns (which may be unhealthy or maladaptive) in order to help people overcome their psychological symptoms. It is by far the most researched psychotherapeutic modality and as such, it has become the treatment model of choice for many people and third party payers. Insurance companies for instance, have a preference for paying for CBT. One reason CBT has become so popular is that it focuses on symptom reduction, which makes sense for a lot of people. For example, suppose you are having panic attacks and they interfere with your ability to work or to enjoy your social life. CBT for Panic Disorder has been demonstrated to be effective and efficient for reducing the severity and frequency of panic attacks relatively quickly. We at InnerQore Health employ CBT approaches regularly, as we believe it has a very important place in mental health recovery.

That said, CBT is not the be-all and end-all of psychotherapy for everybody, for a number of reasons:

1. There are theories of personality and of psychopathology that understand psychological symptoms as a reflection of deeper underlying dynamics, feelings, fears, or impulses that you may not be aware of. Therapists that subscribe to psychodynamic theories believe that we all have feelings, wishes, impulses, fears, and even fantasies that lie below the surface of our conscious awareness. Furthermore, these impact our conscious thoughts, feelings and behaviours in a manner that can make it difficult for us to feel our feelings freely, which can result in emotional distress and psychological symptoms. From this perspective, a psychological symptom might provide important clues into what is troubling you on a deeper level, such that rather than “getting rid of them” with symptom-reduction approaches, a therapist might help by focusing on what a client is “keeping below the surface” and how this strategy does not work for the client. This is a difficult concept to understand, and so an example would be helpful. I (Dr. Frank) recall working with a woman who, immediately after giving birth to her second child, developed extreme anxiety about her older son becoming ill. She recognized her fear was irrational and out proportion to actual risk but she nevertheless could not shake her feelings of panic and dread. Over the course of a few sessions, she offered small clues about how she felt anger toward her husband for working long hours when she was home alone with the children, and about how she could not allow herself to fully feel her anger as she felt that this was not permissible in her family and based on her own values. Through an inviting and curious approach, psychotherapy allowed her to feel her anger and to embrace it – as it was genuine and honest – and to recognize that anger is not the same thing as aggression; one can feel angry and yet control it effectively and act assertively rather than aggressively. Importantly, her acceptance and processing of her anger did not only result in her feeling more free to have honest conversations with her husband, it also resulted (and without any concurrent anxiety-reduction strategies) in a very significant reduction in her anxiety about her son.
2. There are models of psychotherapy that are based on the assumption that 1) life will always have moments of suffering and angst at different points in our lives and 2) that we can grow personally, experience improved overall emotional functioning, and buffer ourselves from such suffering when we create meaning in our lives. From this perspective, therapy should focus on 1) figuring out what is truly meaningful for a given individual, 2) helping the individual to create meaning based on this exploration, and 3) helping the individual to create meaning through building authentic relationships by encouraging vulnerability, transparency and a present-focused stance. Sometimes our interpersonal styles and patterns that developed in the past become “alive” in the relationship with the therapist, allowing for a “here and now” exploration of how an individual relates to others and allowing an opportunity for relational growth. Notice that I did not use the phrase “find meaning”, which is commonly used. Meaning is not something we “find under a rock”, it is something that we are all responsible (to ourselves) for creating as we live our days.
3. There are certain modes of human suffering that respond well to emotion-focused and experiential therapies. The death of a loved one, for instance, can sometimes result in a profound grief reaction that does not relieve easily on its own. In these cases, emotion focused therapy can be very powerful in helping an individual to resolve “unfinished business” or to find closure so that they can go on with life with a sense of purpose and meaning.

It should be noted that some of the clinicians at InnerQore are more CBT-focused, some subscribe to psychodynamic or emotion focused and process-focused approaches, and some draw equally from different modalities of psychotherapy. One of the strengths of our practice is that we are a close knit group who can consult with and refer to each other as needed so that we can ensure that our clients are receiving the best possible care to meet their individual needs.