There’s plenty of research evidence for the effectiveness of cognitive behavioural therapy (CBT), but for some reason it doesn’t always seem to work so well in real-life settings. In what many psychologists will surely find a readable and helpful paper, CBT expert Glenn Waller outlines why this is often the case, providing solutions along the way.
The biggest single problem, according to Waller, is that real life clinicians often fail to deliver proper CBT with all its active ingredients. For example, one of the most important aspects of CBT is behavioural change, yet clinicians often shy away from encouraging clients to adopt the changes they need to make, especially when such changes are likely to provoke increased anxiety in the short term.
“Many clinicians make the effort to reduce or to avoid immediate patient distress (and hence their own anxiety about whether they are doing the right thing) by being ‘nice’ to the patient,” Waller explained. “However, this short-term strategy means that we do not press for critical therapy tasks to be done, thus leading to long-term therapeutic immobility”.
Waller reminds clinicians they need to work with their clients to agree on a formulation, and an agreed plan of action, with both parties recognising that this plan, while bringing long-term benefit, might well be difficult in the short term.
Clinicians also need to be assertive in bringing structure to sessions. Many clients may well arrive at therapy sessions keen to discuss immediate crises in their life – but spending each session reacting to these crises rather than working through the long-term goals of CBT will prevent any progress being made.
It’s a similar story with so-called “therapy interfering” behaviours – many clinicians find themselves complicit in a client’s avoidance of homework even though this is a crucial part of CBT. Clinicians should remind clients of the rationale for the home-work and how vital it is for lasting change to be achieved.
Waller says one reason clinicians will often avoid challenging their client’s avoidant behaviours, especially if this is stressful for the client, is because they fear being negatively judged. “The clinician needs to know that he or she is not being judged by short-term, necessary negative transitions (e.g. increased patient anxiety),” Waller said. “Rather he or she needs to be helped in supervision to focus on the value of long-term outcomes that probably depend on those negative short-term steps.”
Other advice in the paper includes recognising when therapy isn’t working and bringing it to an end, and resisting switching, without a clear rationale, to so-called “third-wave” therapies, such as schema therapy, which often lack a behavioural change element.
Waller, G. (2009). Evidence-based treatment and therapist drift. Behaviour Research and Therapy, 47 (2), 119-127 DOI: 10.1016/j.brat.2008.10.018