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Why Traditional Psychotherapy Led to CBT, Which Spawned DBT

Therapies that are not based on science are, well, unscientific.

Key points

  • Behavior therapy was a reaction to the idea of the unconscious mind being the singular target for therapeutic intervention.
  • According to traditional psychotherapy dogma, if one treated only symptoms, “symptom substitution“ would result.
  • Evidence shows scientifically based, symptom-focused treatments produce significantly beneficial and durable results.

Since its inception in the 1950s and 1960s, and systemization in the 1970s and 1980s, cognitive behavioral therapy (CBT) has been the gold standard in non-medical, psychological treatment and behavioral health care. Indeed, CBT and its progenitor, behavior therapy (BT), were the first scientifically based and empirically supported forms of “psychotherapy.“

I put the term “psychotherapy“ in quotation marks because the very origin of behavior therapy was a reaction to the idea that the ineffable “black box” of the unconscious mind or psyche—literally the soul—was the singular target for therapeutic intervention. According to traditional psychotherapy dogma, if one treated only symptoms, “symptom substitution“ would be the inevitable result. The rationale is that, without addressing the deep, underlying intrapsychic conflicts and repressed memories laid down in childhood that are thought to give rise to the current symptoms, others would simply fill the void if the presenting symptoms were the successful focus of treatment. In essence, traditional “psychotherapy” is backward-looking because its core principle is to resolve historical and childhood conflicts that are believed to produce current problems.

Alternatively, BT’s central tenet states that in most cases, the symptoms are the problems, not merely “smoke“ resulting from some deeper, unconscious, psychodynamic conflagration that must be extinguished to produce a cure. Therefore, according to BT, a symptom-focused treatment that does not require a deep dig, or psychological excavation, into the inner recesses of the mind and the past is the way to go. Following the evolution of BT into CBT, beyond maladaptive behaviors, issues including irrational beliefs, dysfunctional ideas, misinformation, and missing information are now also seen as crucial foci of treatment (e.g., A. Lazarus, 1971). Thus, with its symptom-focused, goal-directed and active stance, unlike traditional psychotherapy, CBT is forward-looking.

Evidence supports symptom-focused treatments

Despite traditional psychotherapists’ insistence that treating symptoms will merely produce symptom substitution, the actual evidence—accumulated during the past 50 years of extensive research—suggests that scientifically based, symptom-focused treatments produce significantly beneficial and durable results, much more than traditional psychoanalytic and psychodynamic therapy for the majority of conditions and people.

Perhaps this is why the last 30 years have spawned a wide array of new-generation, symptom-focused, active and directive, goal-oriented psychological treatments. These approaches focus on the here-and-now—in fact, the only actionable time there is—instead of emphasizing the heretofore. It includes methods like eye-movement desensitization and reprocessing therapy (EMDR), acceptance and commitment therapy (ACT), and dialectical behavior therapy (DBT), all of which are firmly rooted in the soil of CBT (e.g., C. Lazarus, 2019).

Dialectical behavior therapy (DBT)

In my opinion, DBT is of special interest because its originator, Marsha Linehan (1993), was able to distill the pillars of adaptive, functional psychosocial skills (viz., CBT) into a wonderfully elegant, highly effective, and client-friendly approach. Linehan‘s groundbreaking and original book on DBT is actually called Cognitive-Behavioral Treatment of Borderline Personality Disorder and credits CBT as the theoretical foundation on which it rests.

As an interesting aside, very few people, whether they're clinicians or clients, understand the relevance of the term “dialectical“ in DBT. In CBT, “cognitive“ is essentially self-explanatory. Most people have an intuitive understanding of what cognition is—thinking, planning, interpreting, reasoning, etc. But “dialectical“ tends to confuse people. The actual definition of the term is “of or pertaining to a diameter” — that is, bisecting something into equal and complementary opposites. Also, dialectical means any systematic reasoning, exposition, or argument that juxtaposes opposing or contradictory ideas and usually seeks to resolve their conflict through an intellectual exchange of ideas and acting through opposing forces.

Ultimately, dialectical thinking refers to the ability to view issues from multiple perspectives, often opposite extremes, and arrive at the most economical and reasonable reconciliation of seemingly contradictory information. Thus, dialectical refers to a synthesis of opposites into an integrated and functional whole. For example, a generally good day can have some crummy moments and a seemingly crummy day can have some pleasant times. And someone with significant suicidal ideation can have an equally strong will to live. This is why what Linehan refers to as “opposite to emotion action“ or simply “opposite action“ is seen as one of the core treatment methods of DBT and explains the use of the term “dialectical.“ (A simple example of opposite action is approaching a fear rather than avoiding it.)

Yet far beyond semantics, DBT emphasizes the four essential targets that effective therapy needs to address better than almost any other system of psychological treatment. (One exception is multimodal therapy—MMT—which routinely incorporates methods like DBT into its approach, yet due to the unique aspects of MMT, the converse is not possible; DBT cannot subsume MMT. The interested reader might want to examine the essence of MMT here.)

Most importantly, however, the four crucial aspects of psychological functioning that DBT does an excellent job of addressing are distress tolerance, emotional regulation, interpersonal effectiveness, and mindfulness. Obviously, if a person can achieve a degree of proficiency with these four pillars of mental and behavioral health, they will feel and function as well as possible. This is why a psychological treatment that hones in on these four zones of functioning is currently seen as the way to go.

To be truly effective, psychological treatment needs to focus on these four essential zones of psychological, social, and behavioral functioning — not the purported unconscious motivations or deep, repressed psychological antecedents that traditional psychotherapy aims to uncover but rather the corrective thinking and corrective action of methods like CBT and DBT. Science tells us these methods are necessary to produce desirable outcomes and durable emotional shifts.

Thanks to the increasing popularity of effective methods like DBT and its progenitor CBT, perhaps traditional psychotherapy might finally be moving into the display case at the Smithsonian Museum where it belongs with many other obsolete relics of the past.

Remember: Think well, act well, feel well, be well!

Copyright 2022 Clifford N. Lazarus, Ph.D. This post is for informational purposes only. It is not intended to be a substitute for help from a qualified health professional. The advertisements in this post do not necessarily reflect my opinions, nor are they endorsed by me.

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References

Lazarus, A.A. (1989). The Practice of Multimodal Therapy. Baltimore: Johns Hopkins University Press.

Lazarus, C. N. & Lazarus, A. A. (2019). Multimodal Therapy. In J. Norcross (Ed.) Handbook of Psychotherapy Integration, Third Edition. Oxford: NY.

Linehan, M. (1993). Cognitive–Behavioral Treatment of Borderline Personality Disorder. Guilford publications.

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