When Cognitive-Behavioral Therapy Fails: The Five Most Common Reasons

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Aldo R. Pucci, Psy.D.

Psychotherapy outcome research over the years has established that cognitive-behavioral psychotherapies, when utilized properly, are effective at helping people to achieve their emotional and behavioral goals.

However, this fact does not always translate into success for the individual therapist.  My experience with supervising many therapists throughout the United States has revealed to me the following five most common reasons they sometimes are not as successful with implementing CBT as they would like to be.

1. The Therapist Has No Coherent System

Many therapists believe that the practice of cognitive-behavioral therapy consists simply of reaching into their toolbox and pulling out the technique that seems most appropriate at the time.  They do not have a systematic approach to CBT that serves as a therapeutic roadmap for them.

When the therapist utilizes a systematic approach to CBT, there is a point to each session that is consistent with the system, and each session builds on the client’s previous learning. For example, with both Maultsby’s Rational Behavior Therapy and my Rational Living Therapy (http://www.rational-living-therapy.org), the next step after teaching the client the ABCs of Emotions is to teach the client the Rational Questions.  The Rational Questions help the client to determine whether his or her thinking is rational, but there is no point to teaching the client those questions if the therapist first has not established that our thoughts cause our feelings and behaviors.  The client will wonder, “Why are we talking about my thoughts?  I want to talk about my situation!”

2. The Therapist Has Not Established Accurate Empathy

The term accurate empathy refers to developing an accurate understanding of what the client is explaining to the therapist, and then sharing that understanding with the client.  When the therapist has established accurate empathy, the client comes to the conclusion, “My therapist understands me.”

One mistake many therapists make is that they begin disputing thoughts before they have established in the client’s mind that accurate empathy has been established.  Therefore, when the therapist offers a more rational way of thinking that is contrary to the client’s, the client immediately thinks, “My therapist doesn’t understand me.  If he did, he wouldn’t be saying this.”

3. The Therapist Does Not Recognize the Client’s Irrational Thoughts

Usually, therapists are raised in the same society as their clients.  Therefore, it is not surprising when a therapists has some of the same irrational beliefs their clients hold.  When this is the case, it is difficult for the therapist to diagnose a client’s thoughts as being irrational.

For example, most cognitive-behavioral therapies encourage people to replace the words “awful, terrible, and horrible” with “unfortunate”.  However, sometimes therapists will ask me, “That’s fine, but what if a person’s situation really is terrible?”

4. The Therapist Does Not Help the Client Develop a New Rational Replacement Thought

Therapists often say to me, “I told the client that her thought was irrational, but that didn’t change her behavior.” 

The human brain does not like a vacuum.  If the therapist does not help the client develop a new rational replacement thought, the client will revert back to the only explanation he or she has had for their situation.  It is analogous to a client who lives in Washington, DC, wanting to drive to Maine, but is driving toward Florida.  The therapist tells the client, “The way to get to Maine is not to drive to Florida.”  What the therapist failed to mention is how to travel to Maine.

5. Therapist Practices CBT Superficially

Some cognitive-behavioral therapists practice CBT very superficially.  They focus on thoughts rather than underlying assumptions.  For example, a person walks past a group of people and they begin laughing.  Most people’s thought about the situation would be, “They are laughing at me.”  Good therapy sounds something like this, “There is no evidence that they were laughing at you, and there are other possible explanations.  They might have been laughing at a joke as you were walking by.  Therefore, there is no point in thinking they were laughing at you.”  True therapy, though, would address the underlying assumption, “it is terrible when people laugh at me.”  When the underlying assumption is corrected, the person will not be nearly as concerned with whether he or she is being ridiculed.

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