First of all, I’d say that schema therapy (ST) and CFT ( to some extent) are part of the mainstream. (It’s fair to say that IFS is not part of mainstream medicine. This is also a major reason for why we wrote this post: To introduce readers to more “mainstream” therapy approaches that work with inner multiplicity.)
CFT and ST are taught in many CBT schools. For example, Ewelina learned about these CFT and ST in her 4-year CBT training (accredited by The European Association for Behavioural and Cognitive Therapies, probably the largest and most mainstream CBT organization in Europe).
As we write in the post, schema therapy was developed by a CBT therapist (Young) in close collaboration with Aaron Beck, the founder of CBT (see also Beck’s review of this standard ST book). Paul Gilbert, the founder of CFT, also collaborated with Aaron Beck who was supportive of his work.
Generally, there isn’t a “clash” between ST, CBT and CFT and many other often called “third-wave” CBT schools (like, e.g., ACT and DBT). ~No expert in this area thinks that CBT is the only therapy school that is “evidence-based” and that there is no reason to explore or work with other therapy modalities.
My sense is that most CBT scholars respect CFT and ST and other CBT-affiliated schools and view them as complimentary (more on this below). It’s very common that major CBT figures recommend CFT and ST and incorporate techniques from these (and other!) schools. Just as an example, Judith Beck, the daughter of Aaron Beck and perhaps one of the most respected and well-known living CBT therapists had this to say about the standard CFT book for clinicians:
This excellent and comprehensive volume contains a biopsychosocial model, informed by evolutionary theory. It is an important resource, systematically exploring compassion from many vantage points. It has certainly motivated me to put an increased focus on incorporating principles of compassion-focused therapy into my cognitive behavior therapy practice. I highly recommend this book!
Second, as we mention in the post, there is (tentative) evidence that CFT and ST work as effectively as CBT and for certain problems more effectively. For example, ST seems to work better for personality disorders (Bamelis et al., 2014), particularly borderline personality disorder (Jacob & Arntz, 2013, p.175 −178) than standard CBT. [1]This is not too surprising because ST was developed particularly for clients with long-standing emotional problems and personality disorders, for whom CBT doesn’t seem to work so well.
Likewise, there is tentative evidence that CFT works better for patients high on self-criticism and shame (Leaviss & Uttley, 2015). Again, this makes sense because Gilbert developed CFT when he realized that standard CBT therapy doesn’t work that well for such clients.
Of course, the evidence base isn’t as strong as one might like (it never is). Kaj discusses some of the reasons for this.
It should be mentioned that for borderline in particular, the evidence base for DBT is probably even stronger (Lynch et al., 2007); we mention DBT briefly in the last section.
This might get us off track but it’s easy to not sufficiently understand the nature and importance of interindividual variability in this area. Most effectiveness studies can only show you how effective a therapy (or drug) is for the average individual suffering from a given syndrome. (More sophisticated studies and meta analyses include moderator analyses; they might look at personality variables such as high self-criticism, personality variables, and so on. More on this below.)
This is all good and informative. If you suffer from a mental health problem, say, depression, you should just try the therapy or antidepressant that works the best for the average person. You should just go with the prior that you are like the average person (unless you have evidence to the contrary).
However, once you tried out the first line treatment (be it a drug or a therapy) and it didn’t work for you, you can either i) give up or ii) try other treatments or drugs. I generally recommend step ii). This post was written, as mentioned in the summary, primarily for people who are interested in therapy (and inner multiplicity) but have had disappointing experiences with IFS and/or CBT. What is your advice? That they try the same approach repeatedly even if it hasn’t worked for them in the past?
I’d like to explain in more detail how it is possible that i) most studies find that CFT, ST and CBT are comparatively effective and ii) some people might see bigger therapeutic improvements from seeing a CFT or ST therapist than from a CBT therapist—and the reverse!
For the sake of illustration, let’s use a completely hypothetical and unrealistic scenario: Assume that all clients suffer from depression but only differ in two aspects: Some are high on self-criticism, some are low; some are good at mental imagery, some are poor. 50% of clients are low on self-criticism and poor at mental imagery, 25% high on self-criticism and good at mental imagery, and 25% fall in the other two categories. Researchers run a perfectly designed and administered RCT that tests the effectiveness of two different therapies on this sample: therapy A and therapy B. The results are as follows.
Average reduction in depression score
Low self-criticism & poor mental imagery (50%)
High self-criticism & good mental imagery (25%)
Remaining population (25%)
Overall
Therapy A
-4
0
0
-2
Therapy B
0
-8
0
-2
If you average across all people, therapy A and B are equally effective. They both reduce depression scores by 2 points, on average.
A person that doesn’t know whether she is high or low on self-criticism or mental imagery, should be indifferent between the two therapies or go with the therapy that is cheaper, easier, or more widely used. BUT, if you have tried therapy A and it didn’t work for you, you should try therapy B (and vice versa). Likewise, if you know that you are high on self-criticism, you should try out therapy B, and vice versa.
Coming back to the real world. More and more studies start to include such moderator analyses (e.g., the study by Leaviss & Uttley (2015) mentioned above). However, in reality, people differ in hundreds of potentially therapy-relevant aspects, not all of which can be studied. For example, a therapist might work well for most people but doesn’t work well for committed atheists who are high on conscientiousness, low on neuroticism and extraversion, high on self-criticism, low on mental imagery, have a family history of schizophrenia and bipolar disorder, like Bayesianism, and who were bullied early in their lives.
I think there are actually good reasons to expect such relevant interindividual differences. One can already observe them in the case of antidepressants, for example. Generally, there is enormous variability between humans in all sorts of psychological and physiological traits. A few individuals do perfectly fine with 5 hours of sleep, some need 9 or more hours (I think Bostrom and Brian Tomasik are among those). For most people, whole grain bread is probably fine and even healthy. But some have Coeliac disease. Some people swear to benefit from meditation, others claim to have suffered enormous negative consequences. The list goes on.
Of course, I’m not saying one should now totally give up on evidence-based medicine. If you start out and haven’t done a lot of self-experimentation, go with the first-line treatment and recommendations that work for the majority of people (e.g., CBT, SSRIs, 8 hours of sleep, etc.). But if a therapy, food, lifestyle choice or antidepressant isn’t working for you, take an empirical approach, and try out alternatives that might work better for you.
I acknowledge that there is a failure mode here of trusting your own experience and experiments too much and, e.g., start swearing on the effectiveness of energy crystals, tarot cards, and so on. I’d say that trying out CFT and ST (and IFS) is still far removed from this failure mode; for the reasons listed in the post and my above comment.
To me, this post sounds like individual differences of the patient and the mode of therapy are the only key ingredients. Therapists who practice the same mode of therapy differ widely.
If two doctors both give me Bupropion that’s going to have a similar effect. If two therapists both do CBT or CFT the effectiveness will be different depending on their empathy and the relationship I have with them.
To me, this post sounds like individual differences of the patient and the mode of therapy are the only key ingredients.
We definitely did not want to suggest that. I strongly agree that the individual skills, traits and “general style” of therapists vary widely even within a single therapy school and that these variables are extremely important. Research has shown that the individual relationship between a client and a therapist (the ‘therapeutic alliance’) is one of the most important variables in predicting therapy success. (One of the reasons I like ST and CFT is the strong emphasis they put on the therapeutic alliance.)
One can probably rank therapists in terms of overall skill/empathy, and this matters perhaps even more than to which therapy school they belong to. (That being said, people vary in their preferences so there isn’t a therapist that is optimal for everyone.)
First of all, I’d say that schema therapy (ST) and CFT ( to some extent) are part of the mainstream. (It’s fair to say that IFS is not part of mainstream medicine. This is also a major reason for why we wrote this post: To introduce readers to more “mainstream” therapy approaches that work with inner multiplicity.)
You can find dozens of articles about CFT and ST published in mainstream psychology and psychotherapy journals, often with hundreds of citations.
CFT and ST are taught in many CBT schools. For example, Ewelina learned about these CFT and ST in her 4-year CBT training (accredited by The European Association for Behavioural and Cognitive Therapies, probably the largest and most mainstream CBT organization in Europe).
As we write in the post, schema therapy was developed by a CBT therapist (Young) in close collaboration with Aaron Beck, the founder of CBT (see also Beck’s review of this standard ST book). Paul Gilbert, the founder of CFT, also collaborated with Aaron Beck who was supportive of his work.
Generally, there isn’t a “clash” between ST, CBT and CFT and many other often called “third-wave” CBT schools (like, e.g., ACT and DBT). ~No expert in this area thinks that CBT is the only therapy school that is “evidence-based” and that there is no reason to explore or work with other therapy modalities.
My sense is that most CBT scholars respect CFT and ST and other CBT-affiliated schools and view them as complimentary (more on this below). It’s very common that major CBT figures recommend CFT and ST and incorporate techniques from these (and other!) schools. Just as an example, Judith Beck, the daughter of Aaron Beck and perhaps one of the most respected and well-known living CBT therapists had this to say about the standard CFT book for clinicians:
Second, as we mention in the post, there is (tentative) evidence that CFT and ST work as effectively as CBT and for certain problems more effectively. For example, ST seems to work better for personality disorders (Bamelis et al., 2014), particularly borderline personality disorder (Jacob & Arntz, 2013, p.175 −178) than standard CBT. [1]This is not too surprising because ST was developed particularly for clients with long-standing emotional problems and personality disorders, for whom CBT doesn’t seem to work so well.
Likewise, there is tentative evidence that CFT works better for patients high on self-criticism and shame (Leaviss & Uttley, 2015). Again, this makes sense because Gilbert developed CFT when he realized that standard CBT therapy doesn’t work that well for such clients.
Of course, the evidence base isn’t as strong as one might like (it never is). Kaj discusses some of the reasons for this.
It should be mentioned that for borderline in particular, the evidence base for DBT is probably even stronger (Lynch et al., 2007); we mention DBT briefly in the last section.
This might get us off track but it’s easy to not sufficiently understand the nature and importance of interindividual variability in this area. Most effectiveness studies can only show you how effective a therapy (or drug) is for the average individual suffering from a given syndrome. (More sophisticated studies and meta analyses include moderator analyses; they might look at personality variables such as high self-criticism, personality variables, and so on. More on this below.)
This is all good and informative. If you suffer from a mental health problem, say, depression, you should just try the therapy or antidepressant that works the best for the average person. You should just go with the prior that you are like the average person (unless you have evidence to the contrary).
However, once you tried out the first line treatment (be it a drug or a therapy) and it didn’t work for you, you can either i) give up or ii) try other treatments or drugs. I generally recommend step ii). This post was written, as mentioned in the summary, primarily for people who are interested in therapy (and inner multiplicity) but have had disappointing experiences with IFS and/or CBT. What is your advice? That they try the same approach repeatedly even if it hasn’t worked for them in the past?
I’d like to explain in more detail how it is possible that i) most studies find that CFT, ST and CBT are comparatively effective and ii) some people might see bigger therapeutic improvements from seeing a CFT or ST therapist than from a CBT therapist—and the reverse!
For the sake of illustration, let’s use a completely hypothetical and unrealistic scenario: Assume that all clients suffer from depression but only differ in two aspects: Some are high on self-criticism, some are low; some are good at mental imagery, some are poor. 50% of clients are low on self-criticism and poor at mental imagery, 25% high on self-criticism and good at mental imagery, and 25% fall in the other two categories. Researchers run a perfectly designed and administered RCT that tests the effectiveness of two different therapies on this sample: therapy A and therapy B. The results are as follows.
If you average across all people, therapy A and B are equally effective. They both reduce depression scores by 2 points, on average.
A person that doesn’t know whether she is high or low on self-criticism or mental imagery, should be indifferent between the two therapies or go with the therapy that is cheaper, easier, or more widely used. BUT, if you have tried therapy A and it didn’t work for you, you should try therapy B (and vice versa). Likewise, if you know that you are high on self-criticism, you should try out therapy B, and vice versa.
Coming back to the real world. More and more studies start to include such moderator analyses (e.g., the study by Leaviss & Uttley (2015) mentioned above). However, in reality, people differ in hundreds of potentially therapy-relevant aspects, not all of which can be studied. For example, a therapist might work well for most people but doesn’t work well for committed atheists who are high on conscientiousness, low on neuroticism and extraversion, high on self-criticism, low on mental imagery, have a family history of schizophrenia and bipolar disorder, like Bayesianism, and who were bullied early in their lives.
I think there are actually good reasons to expect such relevant interindividual differences. One can already observe them in the case of antidepressants, for example. Generally, there is enormous variability between humans in all sorts of psychological and physiological traits. A few individuals do perfectly fine with 5 hours of sleep, some need 9 or more hours (I think Bostrom and Brian Tomasik are among those). For most people, whole grain bread is probably fine and even healthy. But some have Coeliac disease. Some people swear to benefit from meditation, others claim to have suffered enormous negative consequences. The list goes on.
Of course, I’m not saying one should now totally give up on evidence-based medicine. If you start out and haven’t done a lot of self-experimentation, go with the first-line treatment and recommendations that work for the majority of people (e.g., CBT, SSRIs, 8 hours of sleep, etc.). But if a therapy, food, lifestyle choice or antidepressant isn’t working for you, take an empirical approach, and try out alternatives that might work better for you.
I acknowledge that there is a failure mode here of trusting your own experience and experiments too much and, e.g., start swearing on the effectiveness of energy crystals, tarot cards, and so on. I’d say that trying out CFT and ST (and IFS) is still far removed from this failure mode; for the reasons listed in the post and my above comment.
To me, this post sounds like individual differences of the patient and the mode of therapy are the only key ingredients. Therapists who practice the same mode of therapy differ widely.
If two doctors both give me Bupropion that’s going to have a similar effect. If two therapists both do CBT or CFT the effectiveness will be different depending on their empathy and the relationship I have with them.
We definitely did not want to suggest that. I strongly agree that the individual skills, traits and “general style” of therapists vary widely even within a single therapy school and that these variables are extremely important. Research has shown that the individual relationship between a client and a therapist (the ‘therapeutic alliance’) is one of the most important variables in predicting therapy success. (One of the reasons I like ST and CFT is the strong emphasis they put on the therapeutic alliance.)
One can probably rank therapists in terms of overall skill/empathy, and this matters perhaps even more than to which therapy school they belong to. (That being said, people vary in their preferences so there isn’t a therapist that is optimal for everyone.)