When Cognitive Behavioural Therapy doesn't work - Is it just me?
CBT is commonly referred to as a “top down” approach as it relies on creating change through the client’s cognitions (“thinking brain”). This approach relies on the belief that a client’s unhelpful or biased ways of thinking are causing them distress. Altering these ways of thinking to more helpful, adaptive ways of thinking will resolve their symptoms. For example, if the client has social anxiety, a CBT therapist would help a client understand how their beliefs and thoughts about their ability to participate in social settings may be inaccurate, misrepresented, and/or negatively biased, which may be impacting their ability to perform the way they would want to in a social setting. Thus, CBT looks at how the brain is interpreting information and believes if we change the thoughts that any difficulties with emotions and behaviours will resolve with it. However, this approach may not be as effective in creating change for those who are highly activated emotionally.
We can think of our brain being sectioned into three different major parts – ‘’the instinctual brain’’, the “emotional brain” and our “thinking brain”. Our instinctual (unconscious) and emotional (subconscious) brains are highly responsive to stressors. For example, if you are walking across the street and you see a car driving towards you, your instinctual and emotional brain will activate to get you to safety. It will override your thinking brain so that you don’t consider the pros and cons of moving as it knows it needs to react fast to keep you safe. This is called our fight-flight-freeze response. This response is highly useful and can be very functional when there is a direct threat to our safety, but sometimes this response can be triggered even when there is no direct threat to our safety. When this happens, we can feel that this response is unhelpful and when this response happens constantly we can feel overwhelmed and stuck with no ability to change our reactions or behaviours.
When an individual is constantly overwhelmed instinctually and emotionally, this often makes accessing this logical part of the brain difficult. Since CBT relies on accessing the thinking brain to make change, it can be hard to make change because if the individual is too overwhelmed in their emotional brain by this constant feeling of being in the fight, flight, or freeze mode from the instinctual brain response. This can look like: depression, anxiety, panic attacks, body aches and pains, headaches, mood changes, etc. The individual will not be able to effectively challenge and change their thought processes because the emotions from this response overpower this ability to think logically. This is where some individuals who undergo CBT treatment get stuck – they want to change their thought processes but their emotional and instinctual brain are taking up most of their energy!
We often call this high activation of the emotional brain “emotional dysregulation”. This dysregulation means that an individual often has a decreased ability to manage their emotions, especially negative emotions such as sadness, anger, irritability and frustration. An individual will often feel like their emotional response is intense relative to the situation that triggered it. They may feel that it is difficult to calm down or control the intensity of the emotion they are feeling, often leading to the individual avoiding their emotions or reacting in a way that feels impulsive. A person with emotional dysregulation may also have difficulty recognizing and identifying their emotions, which may make the individual confused or overwhelmed and unable to make decisions or control their actions.
An individual may become dysregulated for a number of reasons, including:
Concussion or brain injury
Trauma (from an adverse event or accumulative)
Sensory difficulties (including ADHD, ADD)
Constant exposure to stressors that take them outside their window of tolerance
When a client is dysregulated, we have to help the client become more regulated before we can do CBT. This is often done through approaches and interventions that are more attuned to regulating the emotional brain, such as mindfulness, Emotionally Focused Individual Therapy, and somatic therapy. However, even once an individual becomes more regulated, CBT may not be an effective approach for them. CBT sometimes labels emotions and thoughts as irrational – however from a humanistic perspective, emotions can be thought of as providing us insight into our experiences. Believing that a thought or emotion is irrational can feel invalidating as these thoughts and emotions are representative of our current experience, whether we feel they are “rational” or not. For example, labeling our terrified feeling of driving a car after an accident as exaggerated may not feel helpful to resolving our fear because it may not change how real that fear feels for us in our current experience. In these cases, it may be more beneficial to use emotional processing treatment approaches in these cases to investigate the underlying causes about why someone feels stuck in their current emotional holding pattern. Both approaches can be beneficial and deciding which approach to use often relies on what the individual feels is the origin of their main difficulties.