<p>I came across this question whilst researching CBT for a course I am studying.</p>
<h2>The short answer</h2>
<p>As I will cover in the long answer, there has been a lot of articles stating that CBT is very effective, and there are articles which have stated that it is not as effective as has been claimed.</p>
<blockquote>
<p>CBT is not a single model of therapy, applicable to all clients in all situations.  This has been one of the criticisms levelled at CBT, that its 'one size fits all' approach to the complex nature of human problems will, inevitably, fail to meet the needs of many, or (at best), simply focus on symptom reduction. (Reeves, 2013)</p>
</blockquote>
<p>There are a fair few factors which can prevent CBT from becoming effective, and a trained and certified CBT practitioner will be able to assess the suitability of CBT.  If they operate ethically, they will not go ahead with providing CBT to someone who it would not benefit.</p>
<p>One of the biggest factors which doesn't allow CBT to work is that if the client is not willing <strong>or able</strong> to challenge their thoughts and behaviours, then CBT will not be effective.</p>
<h2>Long answer</h2>
<p>For the long answer, which will help to explain <strong>some</strong> of the reasons why CBT may not work with some people, I will be using a lot of the work I put into an essay I had to write for my psychotherapy course which covered Cognitive Behavioural Therapy (CBT) and <a href="https://www.counselling-directory.org.uk/integrative-therapy.html" rel="nofollow noreferrer">integrative approaches to therapy</a>.</p>
<p>CBT is an integrative model of approach and we had to look at how an integrative approach may be used to support the client within a case study provided.</p>
<hr>
<h3>Case study provided</h3>
Hassan has been referred to you for work-related stress and anxiety.  He has a management position and is finding it difficult to cope.  At present the information you have is that he is a 42 years old Muslim man, married with 2 children.  He has lived in the UK since the age of 5 when his parents travelled here.  His father died two years later and Hassan, as the eldest son, has felt responsible for the wellbeing of his mother and sisters as well as his own family.
<p>Your referral is through an employee assistance scheme.  Hassan’s assessment shows high level of anxiety without depression.  He is otherwise fit and healthy.  You may offer him six sessions with a further six sessions if appropriate.</p>
<hr>
<p>An article (<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071164" rel="nofollow noreferrer">Dhami &amp; Sheikh, 2000</a>) adapted from a chapter in <em>Caring for Muslim Patients</em>, published by Radcliffe Medical Press, Oxford, England; provides key insights needed to allow Muslim clients' concerns to be adequately heard.  The vignettes section of the article gives a few sayings of Muhammad regarding relationships with parents and one of them points out that you should “strive to serve them”.</p>
<p>If the client has had the opportunity to fully integrate with the western culture they are living in, they may be more open to challenging their thoughts and beliefs, however we need to be mindful that as therapists, just like we are not here to judge, for an example, on sexuality (<a href="https://pinktherapyblog.com/2016/02/17/why-i-am-resigning-from-the-british-association-for-counselling-and-psychotherapy/" rel="nofollow noreferrer">Pink Therapy, 2016</a>) (<a href="https://www.psychotherapy.org.uk/wp-content/uploads/2016/09/Memorandum-of-understanding-on-conversion-therapy.pdf" rel="nofollow noreferrer">UKCP, 2015</a>), we are not in a position to judge whether a cultural or religious belief is right or wrong, especially when we are not priests, vicars, rabbis, imams or the like.  Not only that, if the client is devout in their religious beliefs, then we are not going to change those beliefs very easily, if at all. (<a href="http://churchandstate.org.uk/2015/10/the-problem-with-faith-11-ways-religion-is-destroying-humanity/" rel="nofollow noreferrer">Babilonia, 2015</a>)</p>
<p>The only time when we can intervene in any religious or cultural beliefs is when it is believed that laws may be broken such as the FGM Act (<a href="https://www.gov.uk/government/publications/mandatory-reporting-of-female-genital-mutilation-procedural-information" rel="nofollow noreferrer">Home Office, 2016</a>) (<a href="http://www.cps.gov.uk/legal/d_to_g/female_genital_mutilation/#a02" rel="nofollow noreferrer">Crown Prosecution Service, n.d.</a>), in which case, we would refer the legal case to the necessary authorities and it would be down to the legal profession and not the therapist.</p>
<h3>Strengths and Limitations of integrative approaches to counselling</h3>
**Strengths**
<p>Integrative counselling and psychotherapy can be seen as one of the most effective approaches within counselling. (<a href="http://www.counselling-directory.org.uk/counsellor-articles/integrative-psychotherapy-is-the-best-approach" rel="nofollow noreferrer">The Counselling Directory, 2013</a>)  The idea behind the integrative approach is that no single approach suits every client and therefore you use different approaches and models of therapy to suit the situation and client.  The article within The Counselling Directory cited also states that integrative therapy has four different categories:</p>
<ul>
<li><strong>common factors</strong><br>Looking at the common tools available in each approach that can be useful in the therapy.  Therapist/Client rapport, therapist qualities – <a href="https://en.wikipedia.org/wiki/Unconditional_positive_regard" rel="nofollow noreferrer">positive regard</a>, and <a href="https://en.wikipedia.org/wiki/Carl_Rogers#Incongruence" rel="nofollow noreferrer">congruence</a> etc. – emotional release, and clarification etc.</li>
<li><strong>technical eclecticism</strong><br>The therapist looks at and selects the best interventions by relying on experience and knowledge of what has worked in the past for others, through theories and research literature.</li>
<li><strong>theoretical integration</strong><br>The combination of two approaches with a common philosophy.  The combined ideas are theoretically the same as each other.  For example, cognitive behavioural therapy (CBT) is part of the theoretical integration category, as it is a combination of behaviourism and behaviour therapy, and cognitive theories and their application in therapeutic settings (Reeves, 2013), plus, cognitive analytical therapy is also a theoretical integration of psychodynamic therapy and cognitive therapy.</li>
<li><strong>assimilative integration</strong><br>The therapist primarily sticks to one therapeutic approach, for example Humanistic or psychodynamic, but the therapist will use strategies and models from other therapeutic approaches as well.  The combination of ideas will assimilate the pure form of the primary therapeutic approach.</li>
</ul>
<p><strong>Limitations</strong></p>
<p>The limitations of any integrative therapy depend on the category of integration.</p>
<p><em><strong>Theoretical integration</strong></em></p>
<p>One problem identified in theoretical integration is that it is difficult to integrate some theories; for example, it is difficult to integrate psychodynamic theory and behavioural theory.  The psychodynamic approach suggests that our early experiences from birth onwards and their impacts lead to our psychological problems, where behaviour theory sees problems as much more agreeable to change (Reeves, 2013).  These differences result in incompatibilities between these theories.</p>
<p><em><strong>Assimilative integration</strong></em></p>
<p>With this kind of integration, there is no balance compared to the other forms of integration.  Where the therapist is primarily psychodynamic or humanistic, for example, they will pick and choose ideas from other approaches which may not be put forward by their primary approach, but can work very effectively and contribute to the treatment or treatment plan.</p>
<p><em><strong>Technical eclecticism</strong></em></p>
<p>This shares similarities and differences with assimilative integration, but it has no theoretical underpinning to the approach. (<a href="http://www.counselling-directory.org.uk/counsellor-articles/integrative-psychotherapy-is-the-best-approach" rel="nofollow noreferrer">The Counselling Directory, 2013</a>)</p>
<p>As CBT is a theoretical integrative model, and it is difficult to integrate some theories, CBT cannot and does not incorporate any psychodynamic theories.  However, if you are going to work in a fully integrative manner, you need to bear in mind the theories within the psychodynamic approach too.  If therapy seems to need some psychodynamic interventions, then you may need to drop CBT sessions sometimes and concentrate on the psychodynamic interventions, maybe through Cognitive Analytical Therapy instead, before continuing with CBT.</p>
<h3>The basic concept of CBT</h3>
Cognitive Behavioural Therapy (CBT) was developed by [Aaron Temkin Beck][11], and as mentioned before, CBT is a combination of behaviourism and behaviour therapy, and cognitive theories and their application in therapeutic settings (Reeves, 2013).  CBT helps to change how you think, hence the word *Cognitive*, and what you do, hence the word *Behaviour*.
<p>A difficult life situation, relationship or practical problem can lead to:</p>
<ul>
<li>Altered thinking</li>
<li>Altered emotions and feelings</li>
<li>Altered behaviour</li>
<li>Altered physical feelings or symptoms</li>
</ul>
<p>Things can happen the other way too.  Any of the above alterations can lead to a difficult life situation, relationship or practical problem (<a href="https://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/cbt/5areas.aspx" rel="nofollow noreferrer">Royal College of Psychiatrists, n.d.</a>).</p>
<p>CBT works by trying to get the client to think about a situation in a more helpful way in order to move forward using more helpful behaviours.</p>
<h3>The basic concept of REBT</h3>
Rational Emotive Behaviour Therapy (REBT) has generally been put under the same umbrella as CBT, however although it has similarities, REBT is different.  Where CBT was developed by [Aaron Beck][11], REBT was developed by [Albert Ellis][13] when he started to lose faith in the type of psychoanalysis he was using.
<p>REBT is a practical and action-led model of therapy and personal growth.  It doesn’t just focus on the client’s behaviours, but also allows the client to understand the behaviours of others and provide techniques that will help to solve future problems.</p>
<p>Although REBT looks primarily at our current beliefs and behaviours, it also looks at the cause and effect of past experiences and beliefs which create our present beliefs and behaviours.  It does this whilst aiming to change irrational beliefs into rational ones quickly rather than slowly, however, one key point to note is that the therapist does not impose rational beliefs on the client, but accepts there are non-rational beliefs that may help people achieve happiness.  That way, the therapist is accepting the client’s value system.</p>
<p>REBT, uses an A-B-C-D-E formula.</p>
<ul>
<li><strong>A</strong>ctivating Experience<br>Also referred to by some as the Initial Sensitising Event (ISE), this is the root cause of our unhappiness</li>
<li><strong>B</strong>eliefs<br>Irrational self-defeating beliefs that are the source of our unhappiness, or come about as a result of the ISE</li>
<li><strong>C</strong>onsequences<br>The neurotic symptoms and negative feelings and emotions that result from the ISE and/or Beliefs</li>
<li><strong>D</strong>ispute<br>We must dispute and challenge these irrational beliefs in order for the client to enjoy a balanced outlook in life</li>
<li><strong>E</strong>ffects<br>The client must learn to enjoy the effects of the new rational beliefs and get used to the changes, letting them become the new norm.</li>
</ul>
<h3>The shortfalls of CBT</h3>
As mentioned before, One of the ideas put forward about CBT is that it is a suitable form of therapy for all human problems.  This idea can be damaging in some respects, as CBT is not suitable for all psychological conditions.
<p>Interestingly, whilst researching the overall efficacy of CBT, I came across a few items of note.</p>
<ul>
<li>Carl Rogers emphasised the quality of the therapeutic relationship as a necessary and sufficient condition for successful therapy (<a href="http://www.shoreline.edu/dchris/psych236/Documents/Rogers.pdf" rel="nofollow noreferrer">Rogers, 1957</a>) whereas CBT therapists tend to see the alliance as more instrumental in ensuring the patient’s adherence to the treatment protocol (e.g. <a href="https://doi.org/10.1002/cpp.481" rel="nofollow noreferrer">Dunn, et al., 2006</a>) (<a href="https://doi.org/10.1017/S003329171500032X" rel="nofollow noreferrer">Goldsmith, et al., 2015</a>)</li>
<li>The Countess of Mar in the House of Lords suggested the results of a trial into the effectiveness of CBT and GET (graded exercise therapy) had been artificially inflated (BACP, 2013)<br></li>
</ul>
<blockquote>
<p>The fact is that, as opposed to the spin that accompanied the publication of selective results, only 15% of patients improved with CBT and GET, leaving 85% with no benefit from those interventions. Furthermore, of the combined CBT/GET groups of 321 people, 91% experienced adverse events<br><strong>[...]</strong><br>[The UK Medical Research Council] PACE trial PIs [Principal Investigators] changed the primary outcome measures with the intention of artificially inflating the success of CBT and GET—treatments they promoted for more than 20 years—and that, consequently, they are guilty of scientific misconduct. (<a href="https://hansard.parliament.uk/lords/2013-02-06/debates/130206114000195/PACETrialChronicFatigueSyndromeMyalgicEncephalomyelitis" rel="nofollow noreferrer">UK Parliament, 2013</a>)</p>
</blockquote>
<ul>
<li>An international team of researchers (<a href="https://doi.org/10.1002/wps.20346" rel="nofollow noreferrer">Cuijpers, et al., 2016</a>) concludes that<br></li>
</ul>
<blockquote>
<p>…CBT is ‘probably effective’ with major depression, general anxiety disorder, panic disorder and social anxiety disorder, but not as effective as has been claimed, due to publication bias, poor quality of studies, and the use of waiting list control groups as a comparator. (BACP, 2016)</p>
</blockquote>
<ul>
<li>CBT is as much based on the development of a therapeutic alliance as it is in a psychodynamic and humanistic approach.  The success of therapy will be, at least partly, informed by the nature of the therapeutic process, and not simply the application of particular theoretical ideas, as some suggest (Reeves, 2013)</li>
<li>Recent literature provides fairly strong evidence that CBT in addition to antipsychotic medication is effective in the management of acute as well as chronic schizophrenia (<a href="https://doi.org/10.1097/00001504-200503000-00009" rel="nofollow noreferrer">Rathod &amp; Turkington, 2005</a>).  However, I would stress that CBT was not used alone in any of these studies from what I have seen.  It was used carefully in conjunction with psychiatric help and antipsychotic medication.</li>
</ul>
<p>An alternative to CBT called Metacognitive Therapy (MCT) has been touted to be better than CBT. But it was developed by Manchester University (<a href="https://medicalxpress.com/news/2020-05-therapy-effective-cognitive-behavioral-depression.html" rel="nofollow noreferrer">Addelman, 2020</a>) and studied by Manchester University (<a href="https://doi.org/10.3389/fpsyg.2019.02621" rel="nofollow noreferrer">Wells, 2019</a>) so more independent studies are needed.</p>
<p>Either way, if the client is not able or willing to challenge their thoughts and behaviours, then CBT will not be effective.</p>
<hr>
<h2>References</h2>
Addelman, M. (2020). *New therapy more effective than cognitive behavioral therapy for depression.*
Retrieved from: https://medicalxpress.com/news/2020-05-therapy-effective-cognitive-behavioral-depression.html
<p>Babilonia, S. (2015). <em>Challenging religious privilege in public life</em>.
Retrieved from: <a href="http://churchandstate.org.uk/2015/10/the-problem-with-faith-11-ways-religion-is-destroying-humanity/" rel="nofollow noreferrer">http://churchandstate.org.uk/2015/10/the-problem-with-faith-11-ways-religion-is-destroying-humanity/</a></p>
<p>BACP. (2013). Policy. <em>Therapy Today, 24</em>(2), p. 52.</p>
<p>BACP. (2016). News. <em>Therapy Today, 27</em>(8), p. 6.</p>
<p>Crown Prosecution Service. (n.d). <em>Female Genital Mutilation Legal Guidance.</em>
Retrieved from: <a href="http://www.cps.gov.uk/legal/d_to_g/female_genital_mutilation/#a02" rel="nofollow noreferrer">http://www.cps.gov.uk/legal/d_to_g/female_genital_mutilation/#a02</a></p>
<p>Cuijpers, P. et al. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. <em>World Psychiatry, 15</em>(3), pp. 245-258. <a href="https://doi.org/10.1002/wps.20346" rel="nofollow noreferrer">https://doi.org/10.1002/wps.20346</a></p>
<p>Dhami, S. &amp; Sheikh, A. (2000). The Muslim family: predciament and promise. <em>The Western Journal of Medicine, 173</em>(5), pp. 352-356. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071164" rel="nofollow noreferrer">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071164</a></p>
<p>Dunn, H., Morrison, A. P. &amp; Bentall, R. P.  (2006). The relationship between patient suitability, therapeutic alliance, homework compliance and outcome in cognitive therapy for psychosis. Clinical <em>Psychology &amp; Psychotherapy, 13</em>(3), pp. 145-152. <a href="https://doi.org/10.1002/cpp.481" rel="nofollow noreferrer">https://doi.org/10.1002/cpp.481</a></p>
<p>Goldsmith, L. P., Lewis, S. W., Dunn, G. &amp; Bentall, R. P. (2015). Psychological treatments for early psychosis can be beneficial or harmful, depending on the therapeutic alliance: an instrumental variable analysis. <em>Psychological Medicine, 45</em>(11), pp. 2365-2373. <a href="https://doi.org/10.1017/S003329171500032X" rel="nofollow noreferrer">https://doi.org/10.1017/S003329171500032X</a></p>
<p>Home Office. (2016). <em>Mandatory reporting of female genital mutilation: procedural information.</em>
Retrieved from: <a href="https://www.gov.uk/government/publications/mandatory-reporting-of-female-genital-mutilation-procedural-information" rel="nofollow noreferrer">https://www.gov.uk/government/publications/mandatory-reporting-of-female-genital-mutilation-procedural-information</a></p>
<p>Pink Therapy. (2016). <em>Why I am resigning from the British Association for Counselling and Psychotherapy.</em> Retrieved from: <a href="https://pinktherapyblog.com/2016/02/17/why-i-am-resigning-from-the-british-association-for-counselling-and-psychotherapy/" rel="nofollow noreferrer">https://pinktherapyblog.com/2016/02/17/why-i-am-resigning-from-the-british-association-for-counselling-and-psychotherapy/</a></p>
<p>Rathod, S. &amp; Turkington, D. (2005). Cognitive behaviour therapy for schizophrenia: a review. <em>Current Opinion in Psychiatry, 18</em>(2), pp. 159-163. <a href="https://doi.org/10.1097/00001504-200503000-00009" rel="nofollow noreferrer">https://doi.org/10.1097/00001504-200503000-00009</a></p>
<p>Reeves, A. (2013). <em>An Introduction to Counselling and Psychotherapy: From Theory to Practice</em>. London: SAGE Publications Ltd..</p>
<p>Rogers, C. (1957). <em>The Necessary and Sufficient Conditions of Therapeutic Personality Change.</em>
Retrieved from: <a href="http://www.shoreline.edu/dchris/psych236/Documents/Rogers.pdf" rel="nofollow noreferrer">http://www.shoreline.edu/dchris/psych236/Documents/Rogers.pdf</a></p>
<p>Royal College of Psychiatrists. (n.d.) <em>5 Areas Assessment.</em>
Retrieved from: <a href="https://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/cbt/5areas.aspx" rel="nofollow noreferrer">https://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/cbt/5areas.aspx</a></p>
<p>The Counselling Directory. (2013). <em>Integrative Psychotherapy as an Effective Form of Counselling.</em>
Retrieved from: <a href="http://www.counselling-directory.org.uk/counsellor-articles/integrative-psychotherapy-is-the-best-approach" rel="nofollow noreferrer">http://www.counselling-directory.org.uk/counsellor-articles/integrative-psychotherapy-is-the-best-approach</a></p>
<p>UKCP. (2015). <em>Memorandum of Understanding (MoU) on Conversion Therapy in the UK.</em>
Available at: <a href="https://www.psychotherapy.org.uk/wp-content/uploads/2016/09/Memorandum-of-understanding-on-conversion-therapy.pdf" rel="nofollow noreferrer">https://www.psychotherapy.org.uk/wp-content/uploads/2016/09/Memorandum-of-understanding-on-conversion-therapy.pdf</a></p>
<p>UK Parliament (2013). <em>PACE Trial: Chronic Fatigue Syndrome/Myalgic Encephalomyelitis - House of Lords Grand Committee</em>
Available at: <a href="https://hansard.parliament.uk/lords/2013-02-06/debates/130206114000195/PACETrialChronicFatigueSyndromeMyalgicEncephalomyelitis" rel="nofollow noreferrer">https://hansard.parliament.uk/lords/2013-02-06/debates/130206114000195/PACETrialChronicFatigueSyndromeMyalgicEncephalomyelitis</a></p>
<p>Wells A (2019) Breaking the Cybernetic Code: Understanding and Treating the Human Metacognitive Control System to Enhance Mental Health. <em>Frontiers in Psychology, 10</em>(2621). <a href="https://doi.org/10.3389/fpsyg.2019.02621" rel="nofollow noreferrer">https://doi.org/10.3389/fpsyg.2019.02621</a></p>

CC BY-SA 3.0
2017-06-01T07:13:15.680Z
Wow! Jaw-dropping answer
Robin Kramer-ten Have
CC BY-SA 4.0
2020-01-15T12:07:54.290Z
Could you please tell in a sentence what's essential about "psychatric help" as opposed to cognitive and/or behavioural therapy? In which respect is psychatric therapy *not* cognitive and/or behavioural and goes beyond it?
Hans-Peter Stricker
CC BY-SA 4.0
2020-01-15T12:41:45.297Z
@Hans-PeterStricker - Therapists trained in talking based therapies such as CBT are not necessarily trained in the psychiatric help required to deal with psychotic mental health disorders such as Schizophrenia. These kind of psychotic disorders require the help of psychiatrists who can support their therapy and prescribe the necessary medication which will help to mediate the hallucinatory aspect of the problem. Psychotherapists cannot prescribe medications whereas psychiatrists can.
Chris Rogers
CC BY-SA 4.0
2020-01-15T12:48:39.700Z
So the main role of psychatrists is to prescribe medication? I haven't been aware of this. But I stumbled over your formulation "psychatric help and antipsychotic medication" which I understood to be two different things.
Hans-Peter Stricker
CC BY-SA 4.0
2020-01-15T12:57:11.493Z
@Hans-PeterStricker - Prescribing is not the main role of psychiatrists, but one of the roles they can fulfill. https://www.nhs.uk/conditions/psychiatry/ may help to define what a psychiatrist does. Low level psychiatry for PTSD etc. can be provided by a general practitioner or primary care physician, but if there is a severe disconnect from reality in any way, more specialised help is required, hence the need for a psychiatrist.
Chris Rogers
CC BY-SA 4.0
2020-01-15T13:05:37.533Z
Thanks - and quite interesting a criterion: "if there is a severe disconnect from reality". Is this "official" or just your phrase? Another criterion might be: "if there is a severe deviation from normality" - both reality and normality not well-defined and unequivocal.
Hans-Peter Stricker
CC BY-SA 4.0
2017-05-17T16:56:12.660Z
2021-12-19T07:48:08.657Z
2021-12-19T07:48:08.657Z
Chris Rogers
<p>In treating people with Cognitive-Behavioral Therapy:</p>

<ul>
<li><p>Which people <strong>can't be helped</strong> by therapy?</p></li>
<li><p>How are some people <em>more treatable</em> than others? </p></li>
</ul>

<hr>

<h1>Additional Info</h1>

<p>In the comments of a blog post analyzing male seducers, a psychotherapist explained the effect of narcissistic mothers on their sons. She said that some people have a <strong>greater capacity</strong> for benefiting from therapy than others. Some people can't be helped by therapy.</p>

<p>What makes a person unable to benefit from therapy?</p>

CC BY-SA 4.0
2020-01-15T15:28:23.587Z
Could you please provide a link to the "comments of a blog post analyzing male seducers". Thanks in advance.
Hans-Peter Stricker
CC BY-SA 4.0
2020-05-15T15:34:42.287Z
I have noticed that CBT might be good to reframe one's negative world views due to that person either having had repetitive bad experiences, or due to their brain chemistry not being "healthy". Example, lacking Seratonin. I however posit that most therapists that recommend CBT take into consideration the patient's ability to come up on their own with the "more realistic" possibility or alternative thought to whatever dissonance they have about a certain situation or person. I would love to see therapists be more directive.
user26008
CC BY-SA 4.0
2020-05-15T18:38:44.867Z
**An even shorter answer** Some people just need to understand to get resolution and closure. Others are vigilant to the injustices in the world and have moral issues with society, or even difficult permanent situations in life. These are obviously far more difficult subjects to help.
agiopnl
CC BY-SA 3.0
2012-12-07T06:42:22.953Z
It's an interesting question, but you'll probably need to refine your scope: (a) what kind of therapy are you talking about? (b) what class of symptoms or disorders are you covering?
Jeromy Anglim
CC BY-SA 3.0
2012-12-08T04:59:36.093Z
Some people can be stubborn and stick to noncompliance. If a patient isn't willing to "try" or "listen", therapy will not be beneficial... working with patients with BPD can be difficult (for example) but could you elaborate on what you mean by "more treatable"? I mean, you're right, CBT is not the befitting form/orientation of therapy for everyone, but do you want to focus on the mentioned narcissistic mothers?
PheonixEnder
CC BY-SA 3.0
2012-12-08T05:07:51.570Z
So people really need to want therapy. They must feel like cooperating for the therapy to be successful. Yes, PheonixEnder. I'd like to focus on people with narcissistic mothers for this question. If you can provide any additional info on psychological mental illness, instances where illness is not caused by phisiology such as chemical imbalances in the brain but rather is the result of experience or destructive thinking, I'd love to hear it. In cases where the illness is "purely mental," what makes a person more, or less, treatable? We can focus on narcissistic mothers if that keeps the
Tyler Langan
<abnormal-psychology><clinical-psychology>
Cognitive-Behavioral Therapy Limitations
Tyler Langan
# Cognitive-Behavioral Therapy Limitations

(Asked by: username_0 on 2012-12-07)

In treating people with Cognitive-Behavioral Therapy:

* Which people **can't be helped** by therapy?
* How are some people *more treatable* than others?

---

# Additional Info

In the comments of a blog post analyzing male seducers, a psychotherapist explained the effect of narcissistic mothers on their sons. She said that some people have a **greater capacity** for benefiting from therapy than others. Some people can't be helped by therapy.

What makes a person unable to benefit from therapy?

**Tags:** abnormal-psychology, clinical-psychology

> **Comments:**
> **username_4**: It's an interesting question, but you'll probably need to refine your scope: (a) what kind of therapy are you talking about? (b) what class of symptoms or disorders are you covering?  
> **username_5**: Some people can be stubborn and stick to noncompliance. If a patient isn't willing to "try" or "listen", therapy will not be beneficial... working with patients with BPD can be difficult (for example) but could you elaborate on what you mean by "more treatable"? I mean, you're right, CBT is not the befitting form/orientation of therapy for everyone, but do you want to focus on the mentioned narcissistic mothers?  
> **username_0**: So people really need to want therapy. They must feel like cooperating for the therapy to be successful. Yes, username_5. I'd like to focus on people with narcissistic mothers for this question. If you can provide any additional info on psychological mental illness, instances where illness is not caused by phisiology such as chemical imbalances in the brain but rather is the result of experience or destructive thinking, I'd love to hear it. In cases where the illness is "purely mental," what makes a person more, or less, treatable? We can focus on narcissistic mothers if that keeps the  
> **username_1**: Could you please provide a link to the "comments of a blog post analyzing male seducers". Thanks in advance.  
> **username_2**: I have noticed that CBT might be good to reframe one's negative world views due to that person either having had repetitive bad experiences, or due to their brain chemistry not being "healthy". Example, lacking Seratonin. I however posit that most therapists that recommend CBT take into consideration the patient's ability to come up on their own with the "more realistic" possibility or alternative thought to whatever dissonance they have about a certain situation or person. I would love to see therapists be more directive.  
> **username_3**: **An even shorter answer** Some people just need to understand to get resolution and closure. Others are vigilant to the injustices in the world and have moral issues with society, or even difficult permanent situations in life. These are obviously far more difficult subjects to help.  

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## 1 answers

### Answer by username_6 on 2017-05-17. Score: 8

I came across this question whilst researching CBT for a course I am studying.

## The short answer

As I will cover in the long answer, there has been a lot of articles stating that CBT is very effective, and there are articles which have stated that it is not as effective as has been claimed.

> CBT is not a single model of therapy, applicable to all clients in all situations. This has been one of the criticisms levelled at CBT, that its 'one size fits all' approach to the complex nature of human problems will, inevitably, fail to meet the needs of many, or (at best), simply focus on symptom reduction. (Reeves, 2013)

There are a fair few factors which can prevent CBT from becoming effective, and a trained and certified CBT practitioner will be able to assess the suitability of CBT. If they operate ethically, they will not go ahead with providing CBT to someone who it would not benefit.

One of the biggest factors which doesn't allow CBT to work is that if the client is not willing **or able** to challenge their thoughts and behaviours, then CBT will not be effective.

## Long answer

For the long answer, which will help to explain **some** of the reasons why CBT may not work with some people, I will be using a lot of the work I put into an essay I had to write for my psychotherapy course which covered Cognitive Behavioural Therapy (CBT) and [integrative approaches to therapy](https://www.counselling-directory.org.uk/integrative-therapy.html).

CBT is an integrative model of approach and we had to look at how an integrative approach may be used to support the client within a case study provided.

---

### Case study provided

Hassan has been referred to you for work-related stress and anxiety. He has a management position and is finding it difficult to cope. At present the information you have is that he is a 42 years old Muslim man, married with 2 children. He has lived in the UK since the age of 5 when his parents travelled here. His father died two years later and Hassan, as the eldest son, has felt responsible for the wellbeing of his mother and sisters as well as his own family.

Your referral is through an employee assistance scheme. Hassan’s assessment shows high level of anxiety without depression. He is otherwise fit and healthy. You may offer him six sessions with a further six sessions if appropriate.

---

An article ([Dhami & Sheikh, 2000](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071164)) adapted from a chapter in *Caring for Muslim Patients*, published by Radcliffe Medical Press, Oxford, England; provides key insights needed to allow Muslim clients' concerns to be adequately heard. The vignettes section of the article gives a few sayings of Muhammad regarding relationships with parents and one of them points out that you should “strive to serve them”.

If the client has had the opportunity to fully integrate with the western culture they are living in, they may be more open to challenging their thoughts and beliefs, however we need to be mindful that as therapists, just like we are not here to judge, for an example, on sexuality ([Pink Therapy, 2016](https://pinktherapyblog.com/2016/02/17/why-i-am-resigning-from-the-british-association-for-counselling-and-psychotherapy/)) ([UKCP, 2015](https://www.psychotherapy.org.uk/wp-content/uploads/2016/09/Memorandum-of-understanding-on-conversion-therapy.pdf)), we are not in a position to judge whether a cultural or religious belief is right or wrong, especially when we are not priests, vicars, rabbis, imams or the like. Not only that, if the client is devout in their religious beliefs, then we are not going to change those beliefs very easily, if at all. ([Babilonia, 2015](http://churchandstate.org.uk/2015/10/the-problem-with-faith-11-ways-religion-is-destroying-humanity/))

The only time when we can intervene in any religious or cultural beliefs is when it is believed that laws may be broken such as the FGM Act ([Home Office, 2016](https://www.gov.uk/government/publications/mandatory-reporting-of-female-genital-mutilation-procedural-information)) ([Crown Prosecution Service, n.d.](http://www.cps.gov.uk/legal/d_to_g/female_genital_mutilation/#a02)), in which case, we would refer the legal case to the necessary authorities and it would be down to the legal profession and not the therapist.

### Strengths and Limitations of integrative approaches to counselling

\*\*Strengths\*\*

Integrative counselling and psychotherapy can be seen as one of the most effective approaches within counselling. ([The Counselling Directory, 2013](http://www.counselling-directory.org.uk/counsellor-articles/integrative-psychotherapy-is-the-best-approach)) The idea behind the integrative approach is that no single approach suits every client and therefore you use different approaches and models of therapy to suit the situation and client. The article within The Counselling Directory cited also states that integrative therapy has four different categories:

* **common factors**  
  Looking at the common tools available in each approach that can be useful in the therapy. Therapist/Client rapport, therapist qualities – [positive regard](https://en.wikipedia.org/wiki/Unconditional_positive_regard), and [congruence](https://en.wikipedia.org/wiki/Carl_Rogers#Incongruence) etc. – emotional release, and clarification etc.
* **technical eclecticism**  
  The therapist looks at and selects the best interventions by relying on experience and knowledge of what has worked in the past for others, through theories and research literature.
* **theoretical integration**  
  The combination of two approaches with a common philosophy. The combined ideas are theoretically the same as each other. For example, cognitive behavioural therapy (CBT) is part of the theoretical integration category, as it is a combination of behaviourism and behaviour therapy, and cognitive theories and their application in therapeutic settings (Reeves, 2013), plus, cognitive analytical therapy is also a theoretical integration of psychodynamic therapy and cognitive therapy.
* **assimilative integration**  
  The therapist primarily sticks to one therapeutic approach, for example Humanistic or psychodynamic, but the therapist will use strategies and models from other therapeutic approaches as well. The combination of ideas will assimilate the pure form of the primary therapeutic approach.

**Limitations**

The limitations of any integrative therapy depend on the category of integration.

***Theoretical integration***

One problem identified in theoretical integration is that it is difficult to integrate some theories; for example, it is difficult to integrate psychodynamic theory and behavioural theory. The psychodynamic approach suggests that our early experiences from birth onwards and their impacts lead to our psychological problems, where behaviour theory sees problems as much more agreeable to change (Reeves, 2013). These differences result in incompatibilities between these theories.

***Assimilative integration***

With this kind of integration, there is no balance compared to the other forms of integration. Where the therapist is primarily psychodynamic or humanistic, for example, they will pick and choose ideas from other approaches which may not be put forward by their primary approach, but can work very effectively and contribute to the treatment or treatment plan.

***Technical eclecticism***

This shares similarities and differences with assimilative integration, but it has no theoretical underpinning to the approach. ([The Counselling Directory, 2013](http://www.counselling-directory.org.uk/counsellor-articles/integrative-psychotherapy-is-the-best-approach))

As CBT is a theoretical integrative model, and it is difficult to integrate some theories, CBT cannot and does not incorporate any psychodynamic theories. However, if you are going to work in a fully integrative manner, you need to bear in mind the theories within the psychodynamic approach too. If therapy seems to need some psychodynamic interventions, then you may need to drop CBT sessions sometimes and concentrate on the psychodynamic interventions, maybe through Cognitive Analytical Therapy instead, before continuing with CBT.

### The basic concept of CBT

Cognitive Behavioural Therapy (CBT) was developed by [Aaron Temkin Beck][11], and as mentioned before, CBT is a combination of behaviourism and behaviour therapy, and cognitive theories and their application in therapeutic settings (Reeves, 2013). CBT helps to change how you think, hence the word \*Cognitive\*, and what you do, hence the word \*Behaviour\*.

A difficult life situation, relationship or practical problem can lead to:

* Altered thinking
* Altered emotions and feelings
* Altered behaviour
* Altered physical feelings or symptoms

Things can happen the other way too. Any of the above alterations can lead to a difficult life situation, relationship or practical problem ([Royal College of Psychiatrists, n.d.](https://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/cbt/5areas.aspx)).

CBT works by trying to get the client to think about a situation in a more helpful way in order to move forward using more helpful behaviours.

### The basic concept of REBT

Rational Emotive Behaviour Therapy (REBT) has generally been put under the same umbrella as CBT, however although it has similarities, REBT is different. Where CBT was developed by [Aaron Beck][11], REBT was developed by [Albert Ellis][13] when he started to lose faith in the type of psychoanalysis he was using.

REBT is a practical and action-led model of therapy and personal growth. It doesn’t just focus on the client’s behaviours, but also allows the client to understand the behaviours of others and provide techniques that will help to solve future problems.

Although REBT looks primarily at our current beliefs and behaviours, it also looks at the cause and effect of past experiences and beliefs which create our present beliefs and behaviours. It does this whilst aiming to change irrational beliefs into rational ones quickly rather than slowly, however, one key point to note is that the therapist does not impose rational beliefs on the client, but accepts there are non-rational beliefs that may help people achieve happiness. That way, the therapist is accepting the client’s value system.

REBT, uses an A-B-C-D-E formula.

* **A**ctivating Experience  
  Also referred to by some as the Initial Sensitising Event (ISE), this is the root cause of our unhappiness
* **B**eliefs  
  Irrational self-defeating beliefs that are the source of our unhappiness, or come about as a result of the ISE
* **C**onsequences  
  The neurotic symptoms and negative feelings and emotions that result from the ISE and/or Beliefs
* **D**ispute  
  We must dispute and challenge these irrational beliefs in order for the client to enjoy a balanced outlook in life
* **E**ffects  
  The client must learn to enjoy the effects of the new rational beliefs and get used to the changes, letting them become the new norm.

### The shortfalls of CBT

As mentioned before, One of the ideas put forward about CBT is that it is a suitable form of therapy for all human problems. This idea can be damaging in some respects, as CBT is not suitable for all psychological conditions.

Interestingly, whilst researching the overall efficacy of CBT, I came across a few items of note.

* Carl Rogers emphasised the quality of the therapeutic relationship as a necessary and sufficient condition for successful therapy ([Rogers, 1957](http://www.shoreline.edu/dchris/psych236/Documents/Rogers.pdf)) whereas CBT therapists tend to see the alliance as more instrumental in ensuring the patient’s adherence to the treatment protocol (e.g. [Dunn, et al., 2006](https://doi.org/10.1002/cpp.481)) ([Goldsmith, et al., 2015](https://doi.org/10.1017/S003329171500032X))
* The Countess of Mar in the House of Lords suggested the results of a trial into the effectiveness of CBT and GET (graded exercise therapy) had been artificially inflated (BACP, 2013)

> The fact is that, as opposed to the spin that accompanied the publication of selective results, only 15% of patients improved with CBT and GET, leaving 85% with no benefit from those interventions. Furthermore, of the combined CBT/GET groups of 321 people, 91% experienced adverse events  
> **[...]**  
> [The UK Medical Research Council] PACE trial PIs [Principal Investigators] changed the primary outcome measures with the intention of artificially inflating the success of CBT and GET—treatments they promoted for more than 20 years—and that, consequently, they are guilty of scientific misconduct. ([UK Parliament, 2013](https://hansard.parliament.uk/lords/2013-02-06/debates/130206114000195/PACETrialChronicFatigueSyndromeMyalgicEncephalomyelitis))

* An international team of researchers ([Cuijpers, et al., 2016](https://doi.org/10.1002/wps.20346)) concludes that

> …CBT is ‘probably effective’ with major depression, general anxiety disorder, panic disorder and social anxiety disorder, but not as effective as has been claimed, due to publication bias, poor quality of studies, and the use of waiting list control groups as a comparator. (BACP, 2016)

* CBT is as much based on the development of a therapeutic alliance as it is in a psychodynamic and humanistic approach. The success of therapy will be, at least partly, informed by the nature of the therapeutic process, and not simply the application of particular theoretical ideas, as some suggest (Reeves, 2013)
* Recent literature provides fairly strong evidence that CBT in addition to antipsychotic medication is effective in the management of acute as well as chronic schizophrenia ([Rathod & Turkington, 2005](https://doi.org/10.1097/00001504-200503000-00009)). However, I would stress that CBT was not used alone in any of these studies from what I have seen. It was used carefully in conjunction with psychiatric help and antipsychotic medication.

An alternative to CBT called Metacognitive Therapy (MCT) has been touted to be better than CBT. But it was developed by Manchester University ([Addelman, 2020](https://medicalxpress.com/news/2020-05-therapy-effective-cognitive-behavioral-depression.html)) and studied by Manchester University ([Wells, 2019](https://doi.org/10.3389/fpsyg.2019.02621)) so more independent studies are needed.

Either way, if the client is not able or willing to challenge their thoughts and behaviours, then CBT will not be effective.

---

## References

Addelman, M. (2020). \*New therapy more effective than cognitive behavioral therapy for depression.\*
Retrieved from: https://medicalxpress.com/news/2020-05-therapy-effective-cognitive-behavioral-depression.html

Babilonia, S. (2015). *Challenging religious privilege in public life*.
Retrieved from: <http://churchandstate.org.uk/2015/10/the-problem-with-faith-11-ways-religion-is-destroying-humanity/>

BACP. (2013). Policy. *Therapy Today, 24*(2), p. 52.

BACP. (2016). News. *Therapy Today, 27*(8), p. 6.

Crown Prosecution Service. (n.d). *Female Genital Mutilation Legal Guidance.*
Retrieved from: <http://www.cps.gov.uk/legal/d_to_g/female_genital_mutilation/#a02>

Cuijpers, P. et al. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. *World Psychiatry, 15*(3), pp. 245-258. <https://doi.org/10.1002/wps.20346>

Dhami, S. & Sheikh, A. (2000). The Muslim family: predciament and promise. *The Western Journal of Medicine, 173*(5), pp. 352-356. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071164>

Dunn, H., Morrison, A. P. & Bentall, R. P. (2006). The relationship between patient suitability, therapeutic alliance, homework compliance and outcome in cognitive therapy for psychosis. Clinical *Psychology & Psychotherapy, 13*(3), pp. 145-152. <https://doi.org/10.1002/cpp.481>

Goldsmith, L. P., Lewis, S. W., Dunn, G. & Bentall, R. P. (2015). Psychological treatments for early psychosis can be beneficial or harmful, depending on the therapeutic alliance: an instrumental variable analysis. *Psychological Medicine, 45*(11), pp. 2365-2373. <https://doi.org/10.1017/S003329171500032X>

Home Office. (2016). *Mandatory reporting of female genital mutilation: procedural information.*
Retrieved from: <https://www.gov.uk/government/publications/mandatory-reporting-of-female-genital-mutilation-procedural-information>

Pink Therapy. (2016). *Why I am resigning from the British Association for Counselling and Psychotherapy.* Retrieved from: <https://pinktherapyblog.com/2016/02/17/why-i-am-resigning-from-the-british-association-for-counselling-and-psychotherapy/>

Rathod, S. & Turkington, D. (2005). Cognitive behaviour therapy for schizophrenia: a review. *Current Opinion in Psychiatry, 18*(2), pp. 159-163. <https://doi.org/10.1097/00001504-200503000-00009>

Reeves, A. (2013). *An Introduction to Counselling and Psychotherapy: From Theory to Practice*. London: SAGE Publications Ltd..

Rogers, C. (1957). *The Necessary and Sufficient Conditions of Therapeutic Personality Change.*
Retrieved from: <http://www.shoreline.edu/dchris/psych236/Documents/Rogers.pdf>

Royal College of Psychiatrists. (n.d.) *5 Areas Assessment.*
Retrieved from: <https://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/cbt/5areas.aspx>

The Counselling Directory. (2013). *Integrative Psychotherapy as an Effective Form of Counselling.*
Retrieved from: <http://www.counselling-directory.org.uk/counsellor-articles/integrative-psychotherapy-is-the-best-approach>

UKCP. (2015). *Memorandum of Understanding (MoU) on Conversion Therapy in the UK.*
Available at: <https://www.psychotherapy.org.uk/wp-content/uploads/2016/09/Memorandum-of-understanding-on-conversion-therapy.pdf>

UK Parliament (2013). *PACE Trial: Chronic Fatigue Syndrome/Myalgic Encephalomyelitis - House of Lords Grand Committee*
Available at: <https://hansard.parliament.uk/lords/2013-02-06/debates/130206114000195/PACETrialChronicFatigueSyndromeMyalgicEncephalomyelitis>

Wells A (2019) Breaking the Cybernetic Code: Understanding and Treating the Human Metacognitive Control System to Enhance Mental Health. *Frontiers in Psychology, 10*(2621). <https://doi.org/10.3389/fpsyg.2019.02621>

> **Comments:**
> **username_7**: Wow! Jaw-dropping answer  
> **username_1**: Could you please tell in a sentence what's essential about "psychatric help" as opposed to cognitive and/or behavioural therapy? In which respect is psychatric therapy *not* cognitive and/or behavioural and goes beyond it?  
> **username_6**: @Hans-PeterStricker - Therapists trained in talking based therapies such as CBT are not necessarily trained in the psychiatric help required to deal with psychotic mental health disorders such as Schizophrenia. These kind of psychotic disorders require the help of psychiatrists who can support their therapy and prescribe the necessary medication which will help to mediate the hallucinatory aspect of the problem. Psychotherapists cannot prescribe medications whereas psychiatrists can.  
> **username_1**: So the main role of psychatrists is to prescribe medication? I haven't been aware of this. But I stumbled over your formulation "psychatric help and antipsychotic medication" which I understood to be two different things.  
> **username_6**: @Hans-PeterStricker - Prescribing is not the main role of psychiatrists, but one of the roles they can fulfill. https://www.nhs.uk/conditions/psychiatry/ may help to define what a psychiatrist does. Low level psychiatry for PTSD etc. can be provided by a general practitioner or primary care physician, but if there is a severe disconnect from reality in any way, more specialised help is required, hence the need for a psychiatrist.  
> **username_1**: Thanks - and quite interesting a criterion: "if there is a severe disconnect from reality". Is this "official" or just your phrase? Another criterion might be: "if there is a severe deviation from normality" - both reality and normality not well-defined and unequivocal.  

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