Updated: Mar 23
The field of psychotherapy has undergone several transformations since mid 1900s. The field of psychological treatment, once under the purview of psychiatry, heralded psychoanalysis as the 'talking cure' for mental health conditions. Freud, and his contemporaries, asserted that if you can bring into awareness our unconscious drives we can alter the very structure of the ego thereby reducing psychological distress and psychopathology.
Nevertheless, psychoanalysis is a lengthy and in-depth process that does not yield imitate results, but for those of whom benefit report enduring psychological changes. The developing fields of psychology and social work expounded on the practice of psychotherapy throughout the 1960s onward. The models such as cognitive and behavioural therapy, gestalt, humanistic, and existential therapies argued that people are agentic and growth oriented, thus all behaviours serve a function and are helpful in certain contexts. The idea that all behaviour serves a purpose in service of agency was departure from classical psychoanalysis.
Nevertheless, cognitive-behavioural therapy seemed to rise to stardom from the 1970s onward because of well funded clinical trials that seemingly established CBT as an evidence-based practice because it's outcomes are 'measurable.' Because of it's focus on behavioural (i.e. objective) targets, CBT is able to substantiate behavioural and psychological change. The adage I have heard time again is that behaviours are observable whereas inner emotional structures can not be easily evaluated. People may not be 'happy,' but they're preforming better. The rehabilitation model of psychological treatment then became cemented with the rise of CBT.
Whilst CBT researchers continued to research the applicability of CBT protocols to various mental disorders, another school of thought was also conducting research on clinical outcomes in psychotherapy that empirically established that the quality of attunement and rapport in treatment is a far superior indicator of positive treatment outcomes then any one model it's self. Whilst there is great debate about what contributes to the quality of the therapeutic relationship, most agree that empathy on part of the therapist and a sense of expectancy of change on part of the client are essential ingredients.
Despite this growing body of research on the therapeutic relationship, CBT continues to be the preferred, if not the expected course of treatment. Why? Many argue that because it is a protocol-driven therapy with specific targets and instructions around troubleshooting problems in treatment that it is more efficient to administer through supervisory oversight. For example, CBT offers uniformity in care based on the protocols tailored for each disorder. Whilst the evidence for CBT is compelling, the trials are also it's downfall. What I mean by this is, the evidence on the effectiveness of CBT is clear that it works well for only certain clinical presentations like: Major Depression, Generalized Anxiety, Obsessive-Compulsive Disorder, Social Anxiety, Specific-Phobias, and PTSD.
CBT's formulation of psychological disorder rests on the symptoms of the above disorders because that's how the researchers designed the trials. Therefore, in settings were CBT is the preferred modality of treatment accurate and reliable diagnoses are essential, because the response to treatment relies heavily on symptomology. Further, if there is a poor response to treatment both the clinician and client suffer due to a decrease in confidence, attunement, and expectancy. If a client has a diagnosis of Persistent Depressive Disorder and the clinician treats them using the protocol for Major Depression, the treatment may be ineffectual at worst or marginal improvement at best.
Whilst I'm not advocating the need for psychiatric diagnosis to deliver effective treatment, we do need to have a sense of the mechanisms that contribute to distress and suffering. In CBT, for example, there is an emphasis on the interactions between cognition and behaviour in producing unhealthy coping behaviours that maintain distress. The clinician's focus on thoughts and behaviours may include the adverse emotional and interpersonal side-effects of avoidance and safety behaviours, but the mechanism of change is modifying thoughts and behaviours. However, in Persistent Depressive Disorder the primary mechanism of distress is a sense of interpersonal alienation and unrelenting apathy resulting from problems with emotional discernment.
Research shows that in cases of PDD cognitive and behavioural modification does little to shift feelings of emotional and interpersonal detachment. How then do we facilitate change in this case using CBT if the model's central concern is with thoughts and behaviours? In the cases of PDD, the focus shifts from thoughts and behaviours to what is happening in the immediacy of the therapeutic encounter through disciplined self-disclosure of the clinician to provide real time feedback on interpersonal relatedness whilst supporting the client discern their emotions to support a felt sense of interpersonal contact. Therefore, the therapeutic encounter moves from protocol driven techniques to process oriented engagement. Not matter the approach to psychotherapy, modifications to thoughts and cognitions remain great indicators of change.
Therefore, a well-rounded clinician needs to be prepared to shift or modify their approach to psychotherapy to meet the needs of the client and the particulars of their presenting concerns. Hence, the clinician must acknowledge the strengths and limitations of their therapeutic models. If a clinician is trained prominently in one model a referral may be needed to ensure good clinical outcomes. To assume CBT is good everyone is not only a clinical problem, but is theoretically and empirically inaccurate. I call on mental health professionals to be real with themselves about their specific practices whilst urging clients to be sure they ask their clinicians how they are conceptualizing their case and why they've chosen the course of treatment they have. Moreover, when seeking referral for mental health care by your family physician be sure to ask them what the current evidence is for the treatment they're recommending and does it redress the concern you're presenting with.