|
How should Christians
think about CBT?
Cognitive Behavioural Therapy (CBT) is a
- short-term,
- practical,
- client-based,
- collaborative,
- problem-solving,
- life-skill
learning
‘talking therapy’ which has had excellent and well documented
success in alleviating certain emotional problems. These problems include depression,
obsessive-compulsive disorders, anxiety disorders, panic attacks, phobias,
post-traumatic stress disorders, eating disorders and, in the last 10
years the therapy has even been used on the hallucinations and delusions
of schizophrenia sufferers. In general however the therapy works
best on less severe emotional problems where the client desires relief,
is relatively self-aware but is still not able to ‘cure’ themselves.
The theory and practice of CBT can perhaps best be seen if we
trace the history of its development.
We can discern three strands of thought feeding into what we now
call CBT. All three grew out of a
dissatisfaction with traditional psychoanalytic therapies which located
the problems in past traumas, family relations and an intangible,
inaccessible sub-conscious. First
came the behaviourists. Their rejection of consciousness
turned their attention to conditioning, education, the external
environment. B.F. Skinner,
perhaps its most famous proponent, said:
“The picture which emerges from a scientific
analysis is not of a body with a person inside, but of a body which is
a person in the sense that it displays a complex repertoire of
behaviour.”
Since a person is, at every level, conceived of as a
machine (though a very complex one),
personal problems are therefore problems of behaviour. The person, who is a function of his
make up and environment, needs to behave in a manner better suited to
smooth functioning. In this
system, the environment is the only variable we can alter and so
conditioning through negative reinforcement of bad behaviour (‘stick’)
and positive reinforcement of good behaviour (‘carrot’) is the
path to personal change.
Such stark materialism cannot be accepted by the Christian
counsellor either at the philosophical or practical level. However its methods proved very
successful with problems such as bed-wetting and stuttering. The behaviourists had demostrated that
‘the journey within’ is not always the route to change. Thus the Christian can learn that,
though we are more than bodily, it is not more spiritual to ignore
the material, the environmental, the somatic, in the
treatment of the person.
The second strand contributing to modern day CBT came from another
atheist, Albert Ellis, who developed Rational Emotive Therapy (RET) in
the 1970s. Again he did so as a
reaction to the psychoanoalytic tradition in which he had been
trained. He came to see that most
of the emotional problems that presented to him in counselling were not a
function of either material cause and effect (as with behaviourism) or a
sub-conscious, sub-rational struggle (e.g. between the id and the
super-ego, as in Freud.).
Instead, emotional problems were the rational (or, more usually,
irrational) reactions a person made to their situation.
A client may speak as though a situation (say, the break down of
their marriage) caused their depression. Antecedent event ‘A’ (the marriage break down) seems
like it automatically produces Consequent emotional state ‘C’ (the
depression). Yet, in counselling,
Ellis usually found that behind emotion ‘C’ is Belief ‘B’ (‘I must
be a good spouse or I’m worthless’).
This belief assesses the event ‘A’ and assigns to it a
significance which ‘A’ does not have in itself (marriage break
down does not make me worthless, my belief is what assigns that
meaning). Thus the significance
which has been assigned by belief ‘B’ is what causes the depressed
emotion ‘C’.
Antecedent
=> Belief => Consequent
emotion
The process of change becomes clear. Once it has occurred, I cannot alter ‘A’ and emotions (C)
are notoriously difficult to control, thus ‘B’ must be altered. If ‘B’ does not produce an emotional
state in which I can function properly, ‘B’ must be mal-adaptive. The counsellor therefore seeks to
un-earth, counter and replace faulty belief ‘B’, citing its empirical and
pragmatic limitations (i.e. ‘it doesn’t fit the facts, and it doesn’t
make you happy.’) Just as the behaviourist had sought to
alter behavioural habits, the RET therapist views “human beliefs as
mental habits that can be influenced in the same way.” The carrots and sticks of behaviourism
are then used to condition our cognitive habits rather than physical.
Ellis listed many maladaptive beliefs a person could hold which
would prove counter-productive in the world as we find it. Self-deification was one – the notion
that I always ought to be held in high regard by others and that life
always ought to go well for me. Yet Ellis warns us away from such a
view, not so much because of its falsehood but because it will cause
emotional problems in the world in which we live. As to other maladaptive beliefs he
writes in “The Case Against Religion” that “the concept of sin causes
virtually all psychopathology.”
and that self-interest and self-direction are emotionally healthy,
inferring from this that no Christian could be. All this warns us that the standards
for rationality will be crucial in any cognition-based therapy.
We now turn to the third strand contributing to CBT. Aaron Beck was developing his
Cognitive Therapy (CT) at about the same time as Ellis
and along similar lines. He
again challenged the older psychoanalytic theories which held that
negative thoughts and emotions “were symptomatic of other problems
(low self-esteem, projection of un-acceptable impulses). [Such older
theories saw] no benefit in directly changing the thoughts. In Beck’s mind [however], the
distorted thinking is not the symptom of the problem; it is the cause of
the problem.”
This seems to be Ellis’s
insight repeated. Yet we can
discern three ways in which Beck and the CT school bring improvements to
the actual process of change through cognitive restructuring:
Firstly, Beck identifies
the specific cognitive content involved in emotional disorders:
|
Cognitive Content, which leads to…
|
Emotional Disorder
|
|
Devaluation/loss
|
Depression
|
|
Danger/threat
|
Anxiety
|
|
Situationally-specific
dangers
|
Phobias
|
|
Unjustified intrustion
|
Paranoia
|
|
Transgression
|
Anger
|
Second, Beck and the CT
fraternity have developed tailored techniques for uncovering both the
negative automatic thoughts (NATs) and the underlying assumptions and
core beliefs (or schemas). We will discuss these techniques
below.
Thirdly, Beck puts a high
degree of value on the client’s own abilities to uncover and diagnose
faulty cognitions. There is
therefore an emphasis on homework outside counselling and, within it,
what Beck calls ‘collaborative empiricism’. This refers to the joint
efforts of counsellor and client in gathering information and
looking for patterns.
Between these three
strands – behaviourist, RET and CT – CBT has grown up as a practical
method of handling emotional problems.
It may be asked where
behaviour fits back into this process.
It certainly does not occupy the prime place that it did for
Skinner et al. With Ellis
and Beck we have a new confidence that factors within can be
altered, not only the environment without. Yet behaviour remains
important since the notion that ‘you feel the way you think’
is readily extended to the truth that you act the way you feel. In general there will be a flow of
causality from thoughts to feelings to behaviour. Yet it also cannot be denied that
causation often flows back in the other direction (think, for instance,
of the emotional effects of alcoholism or self-starvation). Thus behaviour has a deserved place in
cognitive therapy (the B belongs to CBT). This importance comes in two ways, firstly as new beliefs
are acted upon in the counsellees environment (this itself will be a part
of reinforcing the new beliefs).
Secondly, behavioural change is required to break out of Schema
Maintenance,
Schema Avoidance
and Schema Compensation
where certain behavioural patterns are bound up with faulty cognitions.
The same techniques applied to bad thought habits are applied to bad
behavioural habits. In this way the counsellee is freed not only from the
underlying beliefs that have dominated but also the behaviours which both
flow from and re-inforce such beliefs.
Thus CBT represents a
small number of different counselling schools which understand the
process of change to involve the re-habituation of thoughts and
(secondarily) behaviours. The
underlying assumption is that faulty emotions and behaviours flow from
faulty thinking. It could be
crudely diagrammed as follows:
Thoughts => Feelings =>
Behaviours
These thoughts are
themselves the result of faulty beliefs which underlie them and need to
be confronted and changed.
The process of change for
CBT happens in stages: (1) the rationale for therapy is explained, (2)
precipitating events are discerned (3) automatic thoughts are examined
then (4) underlying assumptions and beliefs (schemas) are uncovered, (5)
challenged, (6) replaced and (7) the new beliefs maintained.
We will now assess what we
see as the benefits of CBT before discussing some draw-backs which a
Christian practitioner would have to bear in mind.
Benefits of CBT
1)
Beliefs are foundational
Our problems (those not a
result of being victims of the curse) do indeed flow out of wrong
beliefs. Romans 14:23 states “whatever does not proceed from faith is
sin.” Jesus defines sin as the fact
that “men do not believe in me” (John 16:9). Wrong beliefs are foundational, not only to wrong
behaviour, but, more basically, wrong being. To believe rightly is the fundamental
issue of life.
2)
Our emotional state is clearly affected by our
thinking
Paul learns the
secret of contentment in all circumstances. (Phil 4:11) He
clearly frames his experience of life according to certain truths that
give him comfort no matter the environment.
Martin Luther has said:
“For the Holy
Spirit knows that a thing has only such meaning and value for a man as he
assigns to it in his thoughts.”
Luther is often quoted as
support for Christian CBT. See here for many examples of preaching to yourself
from his Galatians commentary.
See also Martin Lloyd Jones in his classic Spiritual Depression.
“…the ultimate
cause of all spiritual depression is unbelief… What about treatment? …
the first thing we have to learn is what the Psalmist learned [from Psalm
42-43] – we must learn to take ourselves in hand… we must talk to
ourselves instead of allowing ‘ourselves’ to talk to us!… I suggest that
the main trouble in this whole matter of spiritual depression in a sense
is this, that we allow our self to talk to us instead of talking to our
self… This is the very essence of wisdom in this matter. Have you realized that most of your
unhappiness in life is due to the fact that you are listening to yourself
instead of talking to yourself? …
The main art in this matter of spiritual living is to know how to handle
yourself. You have to take
yourself in hand, you have to address yourself, preach to yourself,
question yourself. You must say
to your soul ‘Why art thou cast down’ – what business have you to be
disquieted? You must turn on
yourself, upbraid yourself, condemn yourself, exhort yourself, and say to
yourself, ‘Hope thou in God’ instead of muttering in this depressed and
unhappy way. And then you must go
on to remind yourself of God, Who God is, and what God is and what God
has done and what God has pledged Himself to do.” Martin Lloyd Jones, Spiritual
Depression, Pickering & Ingliss, 1965, p20-21
It seems a Christian thing
to reframe our thoughts on better grounded beliefs and in this way to
address our feelings.
3)
Right behaviour must come from a right heart
A behaviourist model goes
with Aristotle’s ethics rather than Christ’s. Aristotle believed act
leads to being (I play the violin to become a violinist). Jesus said the opposite, “A good tree
produces good fruit.” (Matt 7:17).
This is to say: being leads to act (the one who is a
violinist will play the violin).
This is crucial for understanding grace – the indicatives precede
the imperatives. Without such an
understanding, a legalistic, earning, works mentality will pervade our
pastoral care and the grace of Christ will be lost.
CBT fits well with this
model of being-then-act. The
Christian counsellor can be true to the techniques of CBT when he/she
says ‘understand the truth of who you are, conform your thinking to that
reality and then act out of that centre.’
4)
CBT’s order of: beliefs => thinking =>
emotional state => action can be seen throughout the Scriptures.
Think of how Moses or Paul
tried to encourage generosity.
(Ex 25:2; 35:4-29; Deut 15:7-11; 2 Cor 8-9). Only those whose hearts had been
changed by the Lord’s prior goodness were to give. For those who were moved to give it is
not difficult to recontruct the stages of their discipleship along the
lines of: belief; changed thinking; a resultant (grateful, cheerful,
generous) emotional state; followed by the behavioural change.
5)
Scripture exhorts us to challenge our thinking.
Deut 9:4-6: “Do not say in
your heart… Know therefore… Remember and do not forget.”
Psalm 42:5,11; 43:5: Why
are you cast down, O my soul, and why are you in turmoil within me? Hope
in God
Romans
12:2: Do not be conformed to this world, but be transformed by the
renewal of your mind, that by testing you may discern what is the will of
God, what is good and acceptable and perfect.
6)
Our discipleship should be marked by such reformation of our minds
The New Testament word for
repentance, ‘meta,noia’, is literally a
word for changing of mind. The
word for discipleship ‘maqhth,j’ has clear
cognitive overtones (it is the word from which we get mathematics). Our repentance and discipleship is a
matter of continual cognitive challenge and conformity to God’s word.
7)
We ought to be challenged to live consistently with
our beliefs.
CBT works by drawing links
between what we think, what we feel and what we do. Any Christian will want to monitor
their integrity in this.
8)
The gospel of grace speaks into the very heart of
our core beliefs.
McMinn notes this as a
major reason why Christians ought to embrace much of CBT.
God’s unconditional love and acceptance in Christ addresses our deepest
needs for security, worth, acceptance and love which CBT uncovers but
cannot finally deal with.
9)
There is a clear place for the use of Scripture
Since the heart of the
therapy is challenging beliefs, the Bible can be used by the Christian
CBT practitioner as an integral tool. In fact one could argue that Christian
CBT can function more truly as CBT since the Bible provides an
authoritative standard far superior to the empirical or pragmatic
standards used in secular treatment.
10)
Feelings are given relative but (hopefully) not
absolute importance.
Emotions are neither all
powerful nor insignificant in CBT.
They are neither beyond all question nor beyond all control. Instead feelings are acknowledged as
reactions. Christians can agree
to this. There is a story
concerning Robert Murray McCheyne in which he counselled a woman who said
she needed more joy. McCheyne
replied that she did not need more joy, she needed more Christ. Joy will follow from the appreciation
of Christ. In this way feelings
are addressed (and addressed in the strongest possible way) yet priority
is given to gospel truth over subjective experience.
11)
CBT’s pragmatism makes it less wedded to
anti-Christian world-views
Since it is not so
interested in the deepest ‘why’s of emotional distress but rather the
‘how’ of recovery, there is far less humanistic baggage attached to CBT.
(Of course the pragmatism itself expresses an anthropology etc which
needs to be thought through). It
is much easier therefore to integrate CBT techniques into Christian
counselling than, say, Rogerian or Gestalt therapies!
12)
The counsellor-client collaboration is healthy
This is especially
important if a Christian sees a non-Christian CBT practitioner. Unlike some other psychotherapies, the
client is not submitting themselves wholesale to the counsellor’s
world-view. Yet also in Christian settings a more collaborative style
suits the mutuality of Christian life together and models that every
Christian is ‘competent to instruct one another.’ (Rom
15:14).
13)
The tools used to uncover faulty thought patterns
and beliefs are excellent
This is perhaps the chief
contribution which CBT makes to Christians offering pastoral care. We have always known that beliefs and
thought-patterns are life-altering, but three or four decades of clinical
practice at ‘digging down’ into the beliefs of counsellees has produced
very useful tools which can also be used by the Christian.
Identifying Negative Automatic Thoughts (NATs)
- Ask directly – What
are you telling yourself when you feel X…
- Guided discovery (ask
around the issues, get them to unearth)
- Note emotional change
as they speak – these are ‘hot cognitions’
- Worst consequence
scenarios – What would be so bad if…?
- Imagery (some NATs
are images) – Do you have a picture of yourself or of your
environment when this is happening?
- Exposure exercises –
go to uncomfortable situations either physically or in your mind.
How are you now thinking?
- Offer multiple
suggestions of what the NATs may be
- Offer suggestions
opposite to client’s expected response. They will usually say ‘No,
no, I’m telling myself X’
Question the
assumptions underlying the NATs:
- What would be so
terrible about X?
- What would it be like
for you not to do or feel X?
- What does it say
about you that you have done or felt X?
- Are there verdicts
being passed on you from God, the world and yourself associated with
X? What are they? Could you
put them in words?
- On what basis are
these verdicts being passed?
- On what basis are you
believing them?
At this stage, CBT
identifies the faultiness of such thinking as certain cognitive errors:
- Mind reading: e.g. ‘I know what
they’re all thinking…’
- Crystal ball: e.g. ‘I know what’s
going to happen now…’
- Catastrophizing: e.g. ‘It’s all over
now. X is out of the bag, all hell will break loose.’
- Emotional reasoning: e.g. ‘I feel X so
strongly, therefore it must be a fact.’
- Self-labelling / blame: e.g. ‘X
makes me an idiot!’ ‘X makes me ugly!’
Beneath these
faulty cognitions are the schemas or core beliefs that feed such
thinking. CBT also offers helpful techniques in bringing these to the
surface.
To identify core
beliefs, look for…
- ‘If…, then…’
statements: ‘If I’m X, then I’m a failure.’
- ‘Shoulds’ and ‘Musts’
- Themes in the NATs
- Family sayings,
mottoes, memories
The CBT
practitioner should then get the counsellee to put this core belief into
words. Make them identify it as a
rule: e.g. “I need everyone in my environment to be ok with me or else I
will be destroyed.” Simply the
process of articulating this rule – exposing it as the dominating force
in a person’s every decision, act and feeling – is incredibly
powerful. In Christian contexts
it should lead to heart-felt and deep confession.
Yet it is
precisely at this point that the Christian must part company with the
non-Christian CBT counsellor. For
at this point the non-Christian CBT counsellor is committed to changing beliefs
for the purpose of alleviating emotional distress. The false belief is jettisoned largely
because it is maladaptive for the person’s current environment. It would
feel better for the counsellee to do away with it. The Christian confronts this idolatrous
commitment and sorrows over the unbelief. A good outcome for the Christian
undergoing CBT may well not be the glad heart but rather the
broken and contrite heart. The Christian’s priority is not, primarily,
the alleviation of distress, but the uncovering of unbelief of which the
distress is a symptom.
This moves us
onto…
Draw-backs
of CBT in a Christian context
1)
What is the
motivation for change?
If the motivation for
change is the relief of emotional discomfort or the cessation of
behavioural compulsions, the entire process is set on a decidedly selfish
footing. So many of our core
beliefs are self-centred strategies for minimizing the pain of vulnerable
engagement with God and His people.
The question must be asked, ‘Will CBT simply substitute one
selfish strategy for a smoother running selfish strategy?’
This is an issue in any
counselling situation yet one that is a particular temptation with CBT’s
problem-solving focus. Christian
counsellors must repent of seeking such small goals with their
counsellees as ‘a smoother running emotional and behavioural life.’ Our goals must be to create a deeper
thirst for Jesus Christ, a deeper confession of sin and weakness, a
firmer trust in His blood and grace, a closer walk with Him day by
day. To focus on short-term,
practical relief from certain behaviours and feelings could simply
produce a white-washed tomb.
The pastor using CBT must
ask, Is the goal of therapy relief from certain feelings and compulsions
or is the goal a deeper repentance of idols, a firmer trust in the true
and living God, a heightened longing for Christ’s return and a greater
freedom for service. CBT by itself is inherently selfish
and pragmatic. CBT will not push Christian counselling in the direction
of other-centred submission to God and His people. The pastor will need
to be very clear that this is the priority.
2)
What are the
grounds used for assessing beliefs as rational/irrational,
valid/invalid?
The rationality of a
person’s thinking is generally judged on empirical and pragmatic grounds. That
is to say ‘Does it fit the facts?’ and ‘Does it work?’ On the first we must ask, What counts
as ‘the facts’, and how is a person to weigh the relative importance of
differing standards? (More on
this below). As to the second,
the Christian simply must not decide his/her beliefs according to ‘what
works for them’.
3)
If empirical
testing is used, how do the ‘facts’ of the Bible inter-relate with the
‘facts’ of experience (even if scientifically derived).
It might be that the process of empirical testing (using the
judgements of the world) work against the belief-level repentance
required by the word of God.
Imagine a person who presents with a performance anxiety and whose
NATs are along the line of ‘Everyone at work thinks I’m
incompetent.’ A CBT counsellor
may prescribe a long list of homework exercises examining the
counsellee’s past performance appraisals and interviewing co-workers
about their abilities. However it
is quite conceivable that the counsellee’s problem is itself this
obsession with the approval of others and the homework simply feeds this
obsession. In the end, the CBT
counsellor might well diagnose this underlying obsession as the problem.
Yet the route towards diagnosis has largely modelled a dependence on the
opinion of others. The testing
process could well foster an initial sense of walking by sight and
fearing men, before (under Christian direction) it eventually resolves
into walking by faith and fearing only the Lord.
The counsellor will have to use judgement as to when the testing
may exacerbate the problem.
4)
In Christian CBT the Bible can be used out of
context and against its intention.
The clear place for an
empirical standard against which to judge faulty cognition gives the
Bible a prominent place in Christian CBT. However, if this is the only way the Bible is used (to
‘bash’ faulty thinking and behaviour) its intention as testimony to
Christ is twisted into a simple behavioural manual. The Bible ought to have a prominent
place in heralding the new identity of the Christian who is clothed in
Christ. It is this prior
indicative, known only by faith and not by sight, which the word
proclaims and which ought to shape our core beliefs. The Christian CBT practitioner must
therefore ensure that the bible is not simply employed as law but, far
more, as gospel.
5)
On what grounds can the counsellor or client
determine that a particular emotion must be relieved (thus necessitating
a belief-change)?
Could there not be a case when an unpleasant emotion
ought to be endured precisely because it is produced by a true and
unalterable belief? Does CBT
provide reliable guidance on when emotions are truly problematic.
One wonders what a CBT
counsellor would have made of Luther’s Anfechtung (deep sense of
sin). Stanton and Jones wonder if
the question would come: “What evidence is there that God exists or that
he cares for your behaviour?”
“The goal would be to eradicate the thought because it bothers the
client.”
CBT itself cannot tell you
what levels of emotional distress are right and healthy. Again, the Christian sitting under the
word must use judgement.
6)
It is not wise
and persuasive words that are required but a demonstration of the Spirit’s
power.
At the core of CBT is the challenging of irrational beliefs with
logical standards. However the
deceitful and unfathomable heart
will take more than good reasoning to shake it from its madness. The truth of God’s gospel must be
driven home to the counsellee with living power by the Spirit. Faith does not come by reasoning but
by hearing and hearing through the word of Christ. Therefore there ought to be a healthy
dose of proclamation to pastoral counselling, a worshipping community to
surround it and the regular table fellowship of the Lord’s Supper. All
the means of grace ought to be employed by the Christian counsellor. This goes far beyond pointing out
faulty cognitions!
It is not our intellects that need changing but our hearts. The heart is the centre of a
person according to Jesus and the source of our thoughts and actions.
Our true hope is in the change of hearts. This means:
a)
we will not look
for non-rational means (the heart is not an anti-intellectual concept in
the Bible)
b)
we will
employ emotional, artistic, sensory means also
c)
true change is
ultimately the work of God.
7)
Mental rehabituation can be every bit as legalistic
as behavioural rehabituation
An internal rather than
external focus does not equate to a grace-based rather than works-based
focus. That is to say, CBT does
not save itself from the works charge of behaviourism simply because it
focusses on mental rather than behavioural habits. It is entirely
possible to perform behaviours which are faith-based and equally possible
to change mental habits on a works basis. A counsellee’s desire for a
righteousness of their own could well drive their mental re-habituation
(especially if they know that their pastor will hear all about their
mental habits the following week).
Again it must be clear
that being leads to act. The
Christian does not ‘change the tape’ in order to think their way to a new
mind-set. The Christian is new
and now thinks out of their new centre in Jesus.
It is significant that
Paul’s two great mind renewal verses (Rom 12:2 and Eph 4:23) both have
‘renewal’ in the passive. We
cannot think our way to renewal but are renewed as our minds are
acted on by a truth beyond us.
For this reason, the words we say to ourselves may be important,
but the words said to us are crucial.
That is our next point…
8)
Truth spoken to ourselves is important, but truth
spoken from beyond ourselves is even more vital.
The alien word of an alien
righteousness comes best from another.
As important as it is to ‘change the tape’ on your automatic
thoughts and ensure your self-talk is godly and true, God has ordained
that our beliefs are shaped from outside ourselves. Faith comes by hearing and God gives
us communities and preachers within them to proclaim a truth from beyond. It is often said that the gospel is
not in us – it is above and beyond us in Christ. Putting ourselves in the way of gospel
preaching and speaking the word to one another in community ought to be
our primary means of ‘changing the tape.’
9)
CBT is in danger of defining the problem so that
the solution is within my grasp
This is not simply a
problem for CBT but for all reactive counselling. However CBT is more problem-solving
focussed than most and so seems to promise easier answers than most.
Whenever the problem is
defined as less than the curse of all creation, my desperately fallen
flesh, the power and policy of hell and my wrath-deserving sin, then the
solution will be something less than Christ – His life, death,
resurrection and return. | 
