by Aldo R. Pucci, Psy.D.
(c) Copyright, 2009 by Aldo R.
Pucci. All Rights Reserved.
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 road map 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.