Cognitive therapy typically views disorders such as anxiety and depression as arising from clients’ cognitive distortions or biases. A main goal of cognitive therapy is to help clients replace those distortions with more rational thinking. This general approach, particularly cognitive behavioral therapy (CBT), is among the most effective treatments for those disorders and can change lives (Rogers, 2022).
Among potential challenges, therapists may be at risk of a number of biases of their own (Yager et al., 2021). Training helps therapists steer clear of some classic biases, but I describe five types of bias or irrational thinking to which a cognitive therapist could still be prone. Addressing such biases can lead to even better outcomes for the client.
A common theme in advice to clients seems to be that they won’t die if they undertake a difficult task or let a scary thing unfold. Specifically, therapists have advised that you will “survive,” or the “world won’t end,” if you “leave work at work” (Johnson, 2019), “don’t answer that email” (Fredericks, 2019), “have a difficult conversation with somebody” (Spector, 2019), have a child who “gets a sore throat” (Burns, 1999), have a drawer where “the socks aren’t folded properly” (Henry Ford Health, 2024), or just “do something that is anxiety provoking” (Wilson, 2023).
Some clients appreciate this approach to put things in perspective. But unless the client shares in some way that they think they won’t survive (or they say something like “I’ll just die if that happens”), which they sometimes do, taking the world-won’t-end approach seems to exaggerate the client’s concerns and may reflect at least two cognitive distortions: all-or-nothing thinking and the straw man fallacy (Stalder, 2016).
The general idea, explicitly stated by some cognitive therapists, is that either the world ends or “life goes on” as usual (Burns, 1999). For the sensitive client who sees the false dichotomy, this approach, though well-intended, can feel patronizing and may inadvertently disparage and discourage the client’s disclosure of even realistic concerns. Trying to influence a client’s thinking in this way may, therefore, represent an inadvertent form of the straw man fallacy, where the client’s position is exaggerated or distorted, which makes it easier to counter.
A cognitive distortion by a therapist can fall under “do as I say and not as I do,” which is not necessarily an invalid approach to helping people. Though not ideal, parents may commonly have to resort to it (Catana, 2014). In the television series Ted Lasso, British football star Roy Kent encourages his young niece not to swear, claiming it is okay for him to swear because he is a footballer—but Kent pays his niece a small amount every time he swears in her presence (reaching over a thousand pounds at some point).
Therapists may not always recognize their own distortions. There could be some form of an actor-observer bias in play, where therapists may interpret some client statements as arising from irrational thoughts while seeing their own sometimes exaggerated statements as being driven by the situation and their training.
As a potential example, a client may say they’ll “look like an idiot” if they’re brushed off while flirting with a romantic interest. This statement is interpreted by some therapists as a cognitive distortion called “magnification” because the client is “using overly colorful language and blowing things out of proportion” (Burns, 1999).
A therapist's response of assuring the client the world won’t end is arguably also out of proportion because the most the client may be doing is underestimating their intelligence. Hypothetically, a therapist could attribute their world-won’t-end approach to the client’s exaggerated behavior, to a general therapeutic approach, or to the therapist’s previous successful use of the phrase. Of course, therapists do have more therapy training than most clients and may regularly have to make judgment calls on whether the client is overreacting.
In a field that sees anxiety and depression as arising from cognitive distortions in the client, victim-blaming might be hard to avoid. Some critics of CBT suggest that, despite therapists’ good intentions, victim-blaming is built into the therapy as some kind of occupational hazard (Barton, 2014; Lyddon and Weill, 1997; Miller, 2021). At the least, there’s a fine line between empowering a client and blaming the client for their mental illness. Being openly careful not to cross this line can avoid the negative consequences of victim-blaming for the client (Stalder, 2018).
Depressed individuals can engage in cognitive distortions, whatever the cause. However, according to research on depressive realism, the average (moderately) depressed individual sees the world more accurately than non-depressed individuals (Moore and Fresco, 2012). The positive illusions research shows that (positively) biased thinking is typically part of good mental health (Taylor, 1989; Taylor et al., 2003).
Those who teach or administer CBT, whom I’ve asked, say they haven’t heard of this research. CBT articles and manuals rarely mention them. My small sphere of acquaintances and colleagues and what I’ve read hardly represent the field at large, but perhaps there’s some form of confirmation bias whereby CBT training programs tend to avoid the research that contradicts CBT’s tenets (not that this research is without limitations). So far, I’ve found two attempts to resolve these contradictions (Haaga and Beck, 1995; Ratnayake, 2022), and those authors contended that CBT and depressive realism don’t have to be at odds.
Although CBT may have one of the best success rates, “best” doesn’t necessarily mean good in an absolute sense. The latest meta-analysis reports success at under 50 percent (Cuijpers et al., 2023). Even for clients who are helped, the process of CBT, specifically the exposure treatment, can have a number of negative side effects. According to Schermuly‑Haupt and colleagues (2018), these side effects are unnoticed or underrecognized by most therapists as part of a “non-recognition bias.”
Some negative side effects are unavoidable and even intended, but they still represent a burden to the patient. The open acknowledgment of this issue can “reduce attrition,” “help to avoid unnecessary distress,” and allow “for the development of treatment alternatives that are better tolerated” (Schermuly‑Haupt et al., 2018).
I admire therapists for their efforts to help those with chronic and debilitating mental illness. If the therapy helps clients, it may not matter if any of its approaches technically reflect irrational thinking. But at least based on the success rates, there’s room for improvement. Cognitive therapists’ continued acknowledgment of their risk of bias can result in stronger therapist-client relationships and the best outcomes for the client (DeAngelis, 2019; Firestone, 2013; Yager et al., 2021).
References
John Barton, “The Great CBT Debate,” John Barton Therapy (blog), November 18, 2014, http://www.johnbartontherapy.com/blog/the-great-cbt-debate.
David D. Burns, The Feeling Good Handbook (New York: Plume, 1999).
Kelli Catana, “Have We Taken the Common Sense Out of Parenting?” HuffPost, May 26, 2014.
Pim Cuijpers et al., “Cognitive Behavior Therapy vs. Control Conditions, Other Psychotherapies, Pharmacotherapies and Combined Treatment for Depression: A Comprehensive Meta-Analysis Including 409 Trials with 52,702 Patients,” World Psychiatry 22 (2023): 105–15.
Tori DeAngelis, “Better Relationships with Patients Lead to Better Outcomes,” APA Monitor 50 (2019): 38–43.
Robert W. Firestone, “The Ideal Therapist,” Psychology Today, April 8, 2013, https://www.psychologytoday.com/gb/blog/the-human-experience/201304/the-ideal-therapist.
Madissyn Fredericks, “Prioritizing Time to Unplug,” Symmetry Counseling, March 11, 2019, https://www.symmetrycounseling.com/therapy-chicago/prioritizing-time-to-unplug/.
David A. F. Haaga and Aaron T. Beck, “Perspectives on Depressive Realism: Implications for Cognitive Theory of Depression,” Behaviour Research and Therapy 33 (1995): 41–48.
Henry Ford Health Staff, “How to Share the Mental Load in a Relationship,” Henry Ford Health (blog), February 13, 2024, https://www.henryford.com/blog/2024/02/how-to-share-the-mental-load-in-a-relationship.
Robert Johnson, “STOP—10 Things to Quit Tolerating,” A New Outlook, May 8, 2019, https://coloradocounselor.org/stop-10-things-to-quit-tolerating/.
William J. Lyddon and Robin Weill, “Cognitive Psychotherapy and Postmodernism: Emerging Themes and Challenges,” Journal of Cognitive Psychotherapy 11 (1997): 75–90.
Kenneth E. Miller, “The Subtle Art of Blaming the Victim,” Psychology Today, March 22, 2021, https://www.psychologytoday.com/us/blog/the-refugee-experience/202103/the-subtle-art-blaming-the-victim.
Michael T. Moore and David M. Fresco, “Depressive Realism: A Meta-Analytic Review,” Clinical Psychology Review 32 (2012): 496–509.
Sahanika Ratnayake, “It's Been Utility All Along: An Alternate Understanding of Cognitive Behavioral Therapy and the Depressive Realism Hypothesis,” Philosophy, Psychiatry, and Psychology 29 (2022): 75–89.
Kristen Rogers, “After Years of Debilitating Social Anxiety, a Special Tool Changed My Life,” CNN, April 1, 2022.
Marie‑Luise Schermuly‑Haupt et al., “Unwanted Events and Side Effects in Cognitive Behavior Therapy,” Cognitive Therapy and Research 42 (2018): 219–29.
Nicole Spector, “How to Break Up With Your Therapist (and Learn Something from It),” NBC News, March 7, 2019.
Daniel R. Stalder, “It’s Not the End of the World: Comforting but Illogical,” PARBs Anonymous (blog), February 21, 2016, https://parbsanonymous.wordpress.com/2016/02/21/its-not-the-end-of-the-world-comforting-but-illogical/.
Daniel R. Stalder, The Power of Context: How to Manage Our Bias and Improve Our Understanding of Others (Amherst, NY: Prometheus Books, 2018).
Shelley E. Taylor, Positive Illusions: Creative Self-Deception and the Healthy Mind (New York: Basic Books, 1989).
Shelley E. Taylor et al., “Portrait of the Self-Enhancer: Well Adjusted and Well Liked or Maladjusted and Friendless?” Journal of Personality and Social Psychology 84 (2003): 165–76.
Jillian Wilson, “Therapists Say These 6 Common Habits Are Fueling Your Anxiety,” HuffPost, September 14, 2023.
Joel Yager et al., “Clinicians’ Cognitive and Affective Biases and the Practice of Psychotherapy,” American Journal of Psychotherapy 74 (2021): 119–26.
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