CBT is not the only approach for Anxiety and Depression


depression, anxiety,

So Why are You Told That it is?

If you went to your GP and told them, you were depressed or suffering from anxiety they would likely suggest medication and CBT therapy. General Practitioners are not psychologists or mental health practitioners, so their knowledge is based on what the medical profession as a whole has come to understand. There is a lack of understanding about other therapeutic approaches and how they might apply to you.

I have to admit that this subject gets me worked up. I have a bias for sure. I am not a CBT therapist. However, I want to be clear that I am not interested in a for/or against CBT discussion. I do believe that every approach has something to offer and that you can learn something from CBT.

 What concerns me, is that you are informed, and realize that many options could work for you.

I want you to understand that a good outcome has less to do with an approach and more to do with your relationship with your therapist.

commonknowledge1) It has become common knowledge.

Everyone is passing it on as the truth, so by default, it becomes the truth. It’s human nature to want to feel like you have an answer to a problem. Passing on information makes you feel knowledgeable and helpful. 

So, you hear from someone that CBT is the therapy for depression. You might read it on the internet. You go to your GP for help, and because that’s what you have understood is effective, you may ask for a referral to someone who does CBT, or your doctor suggests it. You become confident that this is what you need to help your depression or anxiety. It is likely that neither you, your friend or your GP have investigated why CBT might be effective and how it compares to other approaches.

CBT is taught on all graduate counselling courses, whereas training into trauma and other approaches take in-depth training that therapists have to undertake after their degree. CBT is easy to research because it is short term and can be administered following a manual so doesn’t take long specialized training. Many other approaches aren’t as easily researched which gives an unbalanced view of what works and what doesn’t. 

Many organizations practice CBT because it is short term and has this approval of the medical profession. If therapists start up in private practice, they can feel the pressure of providing a therapy that is going to provide them with clients. These pressures can perpetuate the legitimization of CBT above other approaches.

So, from many positions, once you are on this train, you can see how it might be hard to jump off and say, ‘wait a minute I’m not so sure.’

evidence2) You have heard CBT is evidence based

This one, in particular, gets me. If someone told you that CBT is evidence-based, it would not be unusual to think ‘well that sounds legit.’ I mean if there is evidence, then it must work. That’s what it would say to me. So, what does CBT being evidence based mean?

Researchers have tried to apply science to a practice that most therapists understand as more art and relationship than science. The term evidence-based has been co-opted by psychology from the medical profession to medicalize psychology. 

However, there is a big difference, between researching a medical treatment and the effect on blood pressure or reduction in disease, where there is a clear, measurable outcome to successful treatment and a therapeutic method that has so many variables. Those variables include the; skill of the therapist, the motivation of the client, comfort of the client with the therapist, stresses in the client’s life, historical events and traumas and so on. So what are you measuring that is affecting the client?

A little side note here. To try and deal with these variables most of the studies disqualify you from taking part if you are dealing with ‘too many issues.’ In an attempt to make a clearer connection between the problem, and treatment. However, in my experience, the people who come through my door have many challenges, often in addition to, or part of, being depressed. 

The evidence is, therefore, not based on regular clients that walk through therapist’s doors, or at least, only a small proportion of them.

Another problem is that researchers refer to statistical significance as proof that CBT is effective. What this means is, that the results are better than the placebo effect. In real terms, this means that 75% of people in the study showed no improvement, plus improvements decrease over time for a significant proportion of the people. When you think about the term ‘evidence-based,’ I doubt that you would understand it in these term

So What Should You be Looking For?

Firstly, do not let the term ‘evidence-based’ be your guide

If like me, you understand the difficulty of researching a particular approach to proove it’s efficacy, it makes more sense to look at how human beings work and what is a healthy mind and body. As practitioners, we can use this information to develop skills and interventions that facilitate a movement towards health. There is a lot of research and experience that has helped us understand development, how you experience others and the world, how your brain develops and how various experiences interrupt and impact your emotional, mental and physical systems. There are a couple of things that this type of research points to.

The importance of Relationship

Your relationship with a therapist is not just about feeling comfortable and being able to be vulnerable, which is important, but it is crucial to our ability to integrate new information and process trauma. Developmental neurobiology, in particular, has highlighted the brain/body systems that are important in creating safety and how this is related to connection. The ability to self-sooth and be present with our experience relates to a connection with a safe, calm, and self-contained individual. Our safety mechanisms lie within a part of our nervous system that maintains relationships with others.

Working with the body

Working with the body (sensations, emotions, movement, self-regulation ) and not just thoughts, intellectual insight, and interpretation, are increasingly seen as important in the way in which we change unhealthy patterns and work through emotional difficulties.

Look for an approach that makes sense to you, here are some important distinctions to bear in mind

With all the focus these days on neuroscience and how that informs therapeutic approaches, I think a simple comparison is left brain vs. right brain approaches. Another distinction is between a technique or procedure and an overall therapeutic approach.

Techniques vs. Therapeutic Orientationmorequestions

Techniques focus on one aspect of experience such as reducing symptoms of anxiety. Whereas a Therapeutic Orientation is a way of working as a whole. Each Orientation takes into account human behaviour, development and a view of how we change in developing a therapeutic theory.

For example, EMDR (eye movement desensitization reprocessing) is a procedure (technique) to help facilitate a reduction in distress and promote a positive view of oneself. Whereas Gestalt Therapy is an experiential orientation that values self-awareness, present moment, and sees human beings as being driven to complete needs. Gestalt sees one of the main causes of common struggles in life resulting from interruptions to contact with yourself and others. Gestalt sees change as occurring through self-awareness, frustration and owning more of who we are.

Therapists incorporate Techniques into their general Orientation.

Right Brain vs. Left Brain Approaches

When we refer to the right and left brain these are different channels of our brain and body that process the flow of information about our experience. Each channel takes care of integrating various aspects of our experience; both are important and both are to some extent going on at the same time. 

Therapeutic approaches will have both types of processing to some degree but tend to highlight one over the other. What we tend to focus on creates more activity in that area of our brain.

Your Left Brain takes care of language, concepts, intellect where your higher cognitive processes live that plan, set goals, make conclusions about beliefs, values, and meanings in your life.  It is where you evaluate your experience and develop the rules for how you are to do things or live your life.

From this point of view approaches that focus on working things out intellectually and examine how we think about things, the way our thoughts might affect our decisions and actions, use interpretations and analysis, explore the meaning of our lives or goal setting fit into a left-brain process. These include; CBT, Solution Focused, Narrative and Analytic Approaches.

Your Right Brain functions are about being in your experience and describing your experience. When you are absorbed in an experiential awareness in the now moment, when you are focused on your sensations, movement, emotions, and sense of your body, are examples of right brain processes. The right brain is referred to as the emotional brain. It is the world of metaphor, empathy, and bodily wisdom. How we feel connected to others and bond to people.

From this point of view approaches that encourage an emotional, somatic(body) reflection and a focus on the therapeutic relationship, work in the present moment, focus on safety and regulation of our nervous system will fit into a right brain approach. The would include; Somatic Psychotherapies, Gestalt, Emotionally Focused Therapy, music/drama therapy, art therapy.

Both right brain approaches and left brain approaches have something to offer. In my view, there is no one way that is more effective than any other approach. The left brain approaches like CBT focus on your thinking and help you to deal with the way negative thoughts and perspectives are influencing your emotional world. Right brain approaches see depression and anxiety as the way your nervous system either has too much activation or too little and works through experiential means to promote a change. Also, the connection with the therapist is seen as an important condition for change.

In the end trust what feels right, and who feels right for you rather than a prescribed approach.