CBT-plus: Going further with/ than cognitive behavioral therapy

CBT-plus

For a time, I received supervision at the American Cognitive Behavior Institute in NYC, one of the pioneering training centers for the wildly-popular therapy approach of cognitive behavioral therapy. I learned a lot about this method and utilized it in my practice. When I moved to a new NYC therapy practice, Tribeca Therapy, we created our own tailored method of CBT, which for now I’ll call CBT-plus.

CBT-Plus: Cognitive behavior therapy + relational therapy

Cognitive behavioral therapy is a systematic approach to changing thoughts, feelings and behaviors by developing new practices. CBT gained popularity in the 80's and 90's and was seen as a notable counterpoint to the predominant therapy of the previous decades, psychoanalysis. Unlike psychoanalytic psychotherapy, which places particular importance on the therapist's "analysis" of the past, particularly childhood, CBT is problem-focused and, in its purer forms, stubbornly uninterested in the past.

Like most forms of therapy, CBT's practitioners tend to be orthodox in their application. The notion of CBT-plus is a break from this orthodoxy. I'm a rebel.

I found CBT training helpful but cold. Cold when my supervisor would not and did not look backwards. It felt limited. When we limit a relationship to one problem it felt results driven instead of process driven. So as in any creative activity, I took the helpful pieces of CBT, the results-driven techniques, and made a new arrangement. Cognitive Behavioral techniques plus learning about a patients past, and acknowledging that they and I are now in a therapeutic relationship that is a process not a one-off fix.

Lets start at the beginning:

CBT begins with identifying the “problem” and restructuring thinking and re-organizing the behavior. It is terribly easy to track the outcome of CBT interventions and therefore it is the most popular of the so-called emperically-based practices. Insurance companies and the researchers they fund love to know that you can gather information, make a conclusion and find results. And you can. This is an affective method. However, adding the person within the exercises of behavior change makes a big difference. CBT is structured process: typically 12-13 sessions, therapist and patient come together with strict agenda for each session, you do not stray from this, with a specific end goal. You evaluate weekly progress in a measured way, set up check in's and homework to keep the therapy not just in the room but outside.  All in my option successful methods. But so strict!

My love/hate relationship with CBT

I utilize the structure and worksheets, and homework to help organize the therapy and the sessions. I find value in goal setting and monitoring progress. But I want some conversations to take us to new places of discovery--the creative process needs us to be able to stray from the worksheets and even the very structure of the goals we create. There is often complexity behind an emotional experience--that is information needed to help us re-structure our interventions. The past does matter, a great deal. We also havea  very real relationship, me and the patient, that is more than data. It that can help us understand why certain homework is not working or how to slow down the process and not expect problem to be solved in three months.

Does it take longer?

It depends on what you're trying to accomplish. We want to change feelings and reduce anxiety but there is so much more. It takes longer to create a meaningful process as opposed to borrowing a preexisting  structure. Structures come in a box ready-made. That is why CBT is easy to learn and easy stick with for a short time. But long term it seems there are usually deeper issues a foot. Therapy for anxiety, therapy for eating disorders, therapy for post-partum depression, all might be related to others issues: Issues of trauma, of relationships, sexuality, family relationships and beyond. The CBT frame? It's too small.

Do we have to go into the past?

Yes, it helps. How did you develop a habit? Where did it come from? What made self doubt so full in your mind? Why do you beat yourself up? What was the dialog when you lived with your parents? What happened when you were 20 that you suddenly felt anxious? Is it your dad’s voice or your mom’s voice or your brothers voice that you hear questioning your direction? All questions that help us gather information so we can work on restructuring both behavior and cognition.