The Gospels of Private Practice and Resistance to Full CBT
The gospels of private practice say full CBT cannot or should not be done.
Posted Mar 30, 2019
Full CBT is the faithful implementation of a whole protocol of cognitive behavioral therapy (CBT). In contrast, CBT-Lite is an unstructured, pick-and-choose method of using a few but not all of the elements of a CBT protocol. Research has documented that CBT-Lite is the dominant practice of CBT in private practice, although one cannot justifiably call it CBT. CBT-Lite is analogous to a surgeon saying he’s going to remove your appendix, and he makes an incision on your stomach, but opts not to give you anesthesia. Or sew you back up. Or take out your appendix. He’ll do one part of the operation, but not all the parts.
Practitioners of CBT-Lite support their manner of practice by criticizing full CBT. They would have you believe that the academic CBT researchers have bulldozed the world of private practice with randomized clinical trials and official practice guidelines, to the point that the little private practice clinician has to fight like David versus Goliath to keep eclecticism and psychodynamic treatment alive in the world (Shedler, 2018). The truth is, the fight has gone entirely the other direction.
Full CBT Is Relatively Rare
Despite numerous, expensive dissemination and implementation projects to train clinicians to adopt CBT, the effort to implement full CBT in the world generally has failed. These previous implementation projects used the voluntary “train and hope” method (Stokes & Baer 1977), in which trainers would train clinicians in full CBT and then hope the clinicians would use it in their practices. The hope part has never fully materialized. While there does not seem to be any well-organized effort against CBT, there has not been a need for one. There has been a resounding act of populist democracy by clinicians, and most clinicians have voted with their behavior and simply refused to adopt full CBT.
Criticisms of Full CBT
The critics of full CBT, however, have been vocal individually as presenters at conferences, as audience members at conferences, on the internet, and as supervisors in training programs. They say CBT cannot be done in the real world, or, if it can be done, it should not be done. Their objections to full CBT are virtually unchanged since Aaron Beck first unveiled CBT in the 1960s: My patients aren’t like the ones in research studies; my patients are too complicated; many private practice patients do not have full-blown disorders; CBT works only for simple problems; CBT is inflexible and can’t compare with the flexibility of an eclectic therapist; CBT doesn’t fix everything; CBT only helps superficially; there are flaws in the randomized studies of CBT; it only addresses thoughts, not emotions; CBT is just about positive thinking; the therapeutic relationship is not important; CBT is too mechanical; it only treats symptoms, not the whole person; many patients do not stick around for 10-15 sessions; or, it requires patients to be super-motivated.
The list of objections for why CBT cannot or should not be done are like a gospel of teachings handed down through the ages of private practitioners. I call these criticisms the gospels, because they are belief systems, in the absence of data, about the ways in which a group of professionals in an industry believe they should practice. The critics do not have data to support their criticisms, because according to them, either what they do in private practice is too complicated for research, or they are too busy practicing to do their own research. We all have our belief systems, and we need them, and they are valuable. There is nothing wrong with belief systems, as long as you aren’t bothered by data.
Nevertheless, Full CBT Is Feasible and Effective
Despite the gospels of private practice saying CBT cannot be done, we manage to do it at my private practice clinics, and it works. The therapists follow a structured protocol for approximately 12 sessions.
How do I know the full CBT works in private practice? We collect pre- and post-treatment data and calculate the improvements in symptoms. I post the results on our website at ccanola.com. PTSD symptoms improve by over 50 percent on average, and anxiety symptoms improve over 30 percent on average.
How do I know my therapists are following a protocol and really doing full CBT? I meet with the therapists, and we follow the protocols step-by-step. We used to track their fidelity to the protocols more systematically with structured forms, but it was too easy, so we stopped the extra paperwork, and now we just talk through the protocols on individual patients in our regular meetings.
The point for consumers is this. When you have a problem that is treatable by CBT, you potentially have choices of full CBT, an evidence-based treatment, or CBT-Lite, which is not an evidence-based treatment. It is not impossible to conduct full CBT in private practice, even with complicated situations. In fact, it’s not even very difficult. But full CBT is not what you will be routinely offered, and if you want it, unfortunately you’re going to have to shop around until the mental health field gets serious about providing it.
Shedler S (2018). Where is the evidence for “evidence-based” therapy? Psychiatric Clinics of North America 41:319-329, doi 10.1016/j.psc.2018.02.001
Stokes TF & Baer DM (1977). An implicit technology of generalization. Journal of Applied Behavior Analysis 10(2):349-367.
A longer rejoinder to the CBT critics is available in my book They’ll Never Be the Same: A Parents Guide to PTSD in Youth (Las Vegas, NV: Central Recovery Press, 2018).