Biblical Counseling is not Cognitive Behavioral Therapy (CBT) - A Biblical Critique

Introduction

Is there a significant difference between truly biblical counseling and Cognitive-Behavioral Therapy (CBT)? Some suggest the differences are negligible enough to equate the two. For instance, Jones, Clinton and Ohlschlager suggest that “whether they recognize it or not, many nouthetic counselors are essentially practicing a form of cognitive-behavior therapy in the name of biblical counseling” (Ian F. Jones, Tim Clinton and George Ohlschlager, Christian Counseling and Essential Biblical Principles). This suggestion demands careful evaluation. Our evaluation here will be a biblical critique of Cognitive Therapy: Basics and Beyond, a standard work of secular CBT practioner, Judith S. Beck. We must recognize that this evaluation and critique is of a version of CBT which is decidedly secular and does not attempt to integrate biblical truth or biblical methodology. As such, this article will be limited in its usefulness for interacting with integrationists. A fuller analysis of how CBT principles have been understood, modified and integrated with biblical principles would be helpful, but is beyond the scope of this article.

Our critique of CBT will be focused under two headings. First, we will offer a basic definition of CBT, note the similarities with biblical counseling, and consider its positive contribution to the ever-evolving psychotherapeutic landscape. Second, we will critique CBT from a biblical point of view, noting its weaknesses in the assumptions, goals and practices of its adherents.

Definition and Description of Cognitive-Behavioral Therapy

The basic approach of CBT involves changing a person’s thinking as a means of changing their behavior and feelings. Beck provides the best descriptions of CBT.

Cognitive therapy was developed…as a structured, short-term, present-oriented psychotherapy for depression, directed toward solving current problems and modifying dysfunctional thinking and behavior…evaluation and modification of thinking produce an improvement in mood and behavior…The therapist seeks in a variety of ways to produce cognitive change—change in the patient’s thinking and belief system—in order to bring about enduring emotional and behavioral change (Judith S. Beck, Cognitive Therapy: Basics and Beyond, p. 1-2).

Many forms of psychotherapy and counseling developed with secular assumptions contain glimmers of truth in their philosophy and approach. CBT is no exception. Perhaps the most obvious reason nouthetic counseling has been associated with (or equated with) CBT is that the Bible also teaches that changed thinking is part of the growth and change process. One must “renew the mind” (Rom. 12:2; Eph. 4:23; Col. 3:10) in order to live a life of acceptable worship to God. CBT has located a biblical element of genuine change (and therefore, a true element of genuine change) through a scientific approach of hypothesis and testing, and has defined its system of therapy around this necessary element of change.

Another similarity between CBT and nouthetic counseling is in the degree of responsibility placed on the counselee, both for their present problems and for effectively seeking a solution to those problems. While careful not to minimize the contribution of past experiences in the development of psychological difficulties, CBT recognizes that it is one’s interpretation or response to past or present circumstances that are the largest contributor to behavior and feelings. While the specifics between CBT and biblical counseling regarding how to correct the interpretation and response to circumstances might be different, the basic premise of taking personal responsibility for one’s thoughts and responses is similar.

This emphasis on personal responsibility is also evident in how both CBT and biblical counseling seek to help counselees move toward change. Both strongly advocate the use of “homework” as a method of gathering data, securing commitment and taking personal responsibility for change. We see this as another similarity with biblical counseling, and one that is a positive aspect of CBT.

In terms of the ever-widening landscape of counseling theories and methodologies, CBT offers an advance on the pure environmental determinism of behaviorism. With its emphasis on personal responsibility and the need for changed thinking as an element of change in behavior and feelings, it moves secular psychological theory away from purely physiological mechanisms and toward a more reasonable and wholistic consideration of man’s nature. However, CBT still falls glaringly short of dealing fully with all aspects of man’s fallen human nature.

Biblical Critique of Cognitive-Behavioral Therapy

While CBT contains some similarities to biblical counseling, and even reflects a “glimmer of truth” by advocating changed thinking as a means to changing behavior, it must still be rejected as a system of counseling based on the following biblical critiques of its assumptions, goals and practices.

Critiquing the Assumptions of Cognitive-Behavioral Therapy

The first critique that must be offered is the standard critique of every secular counseling theory. It is based on atheistic and humanistic assumptions concerning the nature of man. As a natural consequence of this assumption CBT does not deal adequately with issues related to man’s depravity. It seems throughout the work that there is an overarching notion that anyone who comes for counseling will have a desire to act “right,” “proper,” or “normal.” While most people who seek counseling do so in order to better function in society, the model as a whole offers little help in explaining how to redirect or alter the thinking of someone who has evil thoughts and intentions, or even why this redirection must take place. This method would be insufficient for addressing critical issues in the life of anyone unwilling to resist evil desires or ambitions. The heart of man is inherently evil and will commit evil when he knows it is wrong, and perhaps even when he hates such actions (Rom. 1:32; 7:15). CBT does not adequately address sinful desires and sinful choices, which manifest themselves even in those who are cognitively correct. As Adams points out, “[there are] many Christians who know perfectly well what they ought to do and how to do it but who disobey God anyway. They are led astray not by poor thinking, but by sinful desires…A person must be willing to submit to God and the Spirit’s work, in spite of conflicting aspirations, ambitions, or desires” (Jay Adams, How to Help People Change, p. 64-65). If such a characteristic exists even among the regenerate, how much more does it exist among the spiritually dead.

This leads to a second critique concerning CBT assumptions. The CBT model contains no universal standard of truth (like the Bible) to define the terms used. This produces a vague understanding of its aims, goals or practices. How do we define a “normal” emotional response? What if the patient’s definition of “normal” is different than the therapist? While an emotion is said to be “dysfunctional if it interferes with a patient’s capacity to think clearly, solve problems, act effectively or gain satisfaction” (Beck, p. 94), even this definition must be evaluated subjectively. It is unclear how a CBT practitioner would deal with someone if their “core belief” was that they could only “gain satisfaction” if they fornicated with as many people as possible. There are many other difficult to define terms used in the book that could be substituted here with the same critique (e.g., excessive, inappropriate, advantageous, right, wrong, proper, etc.).

A third critique relates to CBT’s dependence on the medical model of therapy. While not pharmacological in nature (i.e., it is not psychiatry, or based primarily on “medical” treatment), it certainly advocates an underlying belief in a physiological basis for many “dysfunctions” and diagnoses. Throughout the book the term “patient” is used instead of “client” or “counselee.” Beck’s explanation is that this term reflects the designation that predominates in her medically oriented work setting. We believe this setting likely influences other treatment assumptions within CBT structures, as well as reflecting the overall bias of CBT toward adopting and supporting the physiological bias of the “medical model.”

Critiquing the Goals of Cognitive-Behavioral Therapy

The first major critique of the goals of CBT relate to the motivation for change. Why does a patient want to change? Beck repeatedly, and almost exclusively, suggests self-centered and pragmatic motivations for change. This is in direct contrast to the motivation for growth and change in the Christian life, which is to be pleasing to God (i.e., to know and worship God) by bringing one’s thoughts and actions into obedience to Christ so that you might reflect the glory of God (2 Cor. 5:9; 10:5; 1 Pet. 1:2; Heb. 4:12; John 14:15; 1 Cor. 6:20; 10:31). In contrast to these motives, CBT discourages the maintenance of any belief that is not “advantageous” for the patient. For instance, Beck says, “Often it is useful for patients to examine the advantages and disadvantages of continuing to hold a given belief” (Beck, p. 149). If holding a belief is not advantageous then, “He asks himself, ‘What belief would be more functional for the patient?’” (Beck, p. 150). The motivations are almost always self-focused. If your thoughts, beliefs actions affect you in any negative way, then you are generally encouraged to change those thoughts so that you feel and act in a more positive way. Again, these terms are often left vague and undefined (for instance, what does “functional for the patient” really mean?) but stated in such a way that it is easy for most people who want to live in peaceful relationships with others to agree with. It is easy to see how integrationists take the concepts and baptize them with biblical standards and motivations. Even so, the secular model critiqued here is clearly deficient in establishing any biblically acceptable motivation for change and is thus an unacceptable model for growth and change.

Not only are the motivations for change unbiblical, there are also no clearly defined goals established. In other words, what is the patient trying to change into; who or what are they trying to become? To be an acceptable model of biblical counseling, the goal for counseling must be to see the counselee conformed into the image of Christ through thinking and living in conformity to God’s Word. The goals for CBT are varied, but clearly not biblical. One stated goal is, “symptom relief, a reduction in a patient’s level of distress” (Beck, p. 94). Once again we are faced with the problem of definitions. “Negative” emotions like guilt, sadness and anxiety are generally assumed to be the result of “misinterpreting a situation” or not properly evaluating “the validity of your automatic thoughts.” While care is admittedly taken to not leave the impression that all negative emotions are bad, the clear emphasis of the methodology is that steps should always be taken to help the patient feel better. Increasing positive feelings and decreasing negative feelings is not an adequate biblical goal for change.

Changed emotions are not the only goal of CBT. “Modification of thinking [produces] an improvement in mood and behavior” (Beck, p. 1; emphasis mine). Once again we are confronted with the total lack of an absolute moral standard for what is acceptable behavior. In the case-study followed in the text, the therapist is trying to help a college student decrease anxiety and increase her ability to maintain friendships (among other things). As a tool to help the patient see how “different beliefs” effect attitudes about grades, the counselor asks her if she knows anyone who has a lower personal standard for grades, but who seems to have a “happier” attitude about life in general. The example the patient gives is her cousin Emily, who is “more interested in having a good time” than in getting good grades. The therapist is quick to point out that the patient’s new belief ought to be “somewhere in between hers and yours” in order for the patient to have more functional emotions and responses (Beck, p. 148-149). However, there is little room in this system for defining why that must be the case. It is conceivable that a patient could decide that a C-average with a lot of “good times” in college would be more “adaptive” for them in the long run than the A-average with the pressures and stresses of studying hard in the short-term. Without a moral standard for what acceptable study habits should be, or proper motivations for having them, the CBT model is inadequate. It cannot define a universally acceptable goal that people should be striving for.

It would be unfair to assert that CBT never works toward altering beliefs that are wrong or behavior that is sinful. This is often the case, and we would expect people created by God with a conscience to pursue some measure of righteousness, even if only for self-centered reasons (Rom. 2:14-15). However, without a standard by which to measure these “beliefs,” therapists could potentially encourage a patient to pursue wrongs standards. The case-study patient in the text is one such example. The patient is encouraged to shed the belief that she “should always work hard and do my best” (which seems to be a reasonable ethical standard), and replace it with the “more functional belief” that, “I should put in a reasonable amount of effort much of the time” (Beck, p. 151). The deficient ethical standard is a clear weakness of the system, and potentially could be exploited and carried to drastic extremes—even to point of convincing someone to “feel good” about living in a pattern of sin. Certainly most responsible therapists (even unsaved ones) would not pursue such goals, but there is no ethical standard within the system itself to prevent this possibility.

The fundamental point is clear. Because CBT does not have a universal standard of truth, it cannot define or encourage any consistent motivations or goals for counseling. As a system it is morally bankrupt. At best the goals will be shaped by some vague conception of social acceptability. At worst, they could be grossly immoral.

Critiquing the Practices of Cognitive-Behavioral Therapy

In addition to faulty assumptions and faulty goals, CBT also contains a few practices and principles which are erroneous or inconsistent. One such practice is categorizing all thoughts and beliefs according to the man-made categories of the cognitive model (Beck, p. 95). The purpose of this process is to help the patient distinguish between their thoughts and emotions so that they can see more clearly how they relate and how they can be changed. The categories are not entirely un-commendable. However, they are clearly not exhaustive either. Some desires, motivations and “thoughts and intentions of the heart” (Heb. 4:12) may be very difficult to locate within these categories, but clearly play a vital role in overcoming sinful behavior.

Later the readers are instructed that all “negative core beliefs” can be categorized in either the helplessness realm, the unlovability realm, or both. Again, these categories are extremely reductionistic and unbiblical. Even if we could squeeze all negative beliefs about the self into one or both of these categories, it isn’t entirely clear what a patient or therapist should do if these beliefs are true! What if the patient is unlovable or helpless? Only one page is devoted to the topic of “problem solving” and this section says little about how to deal with the truly unlovable or helpless patient.

A third weakness in the practices of CBT is the standard for what degree of change is to be sought for the patient. Biblically the aim is to be perfection (Matt. 5:48; 1 Pet. 1:15-16) and the image of Christ (Rom. 8:29). Christians recognize the impossibility of fully attaining to this standard, but in obedience to Christ they press on toward this goal of perfection (Phil. 3:12-14). In contrast, CBT is not interested in establishing or seeking to meet any such standard. When considering the need to change a patient’s belief we are told, “It is usually neither possible nor necessarily desirable to reduce the degree of belief to 0%...Generally a belief has been sufficiently attenuated when the patient endorses it less than 30% and when she is likely to continue to modify her dysfunctional behavior despite still holding onto a remnant of the belief” (Beck, p. 151). God’s standard, attainable by the grace of Christ, is 100% adherence to the truth concerning one’s own heart, life and behavior. Every thought must be taken “captive to the obedience of Christ,” (2 Cor. 10:5) including thoughts and beliefs about the self (Rom. 12:3; cf. Gal. 6:3; 1 Cor. 4:7). The standard in place throughout the book is vague and focuses on helping patients establish thinking and behavior that does not tend toward any extreme. Rather than working toward “right” thinking and behavior, the standard is usually presented as “more balanced,” “more functional,” “more socially adaptable,” and the like. You may recall the example earlier where the extreme view of Emily, the partying cousin, is discouraged. A whole list of “un-extreme” beliefs that should be encouraged is listed in one location. This practice of encouraging “balanced” beliefs about one’s weaknesses and actions enables people to “feel better” even when they are failing. When one’s failures relate to obeying and honoring Christ, the belief becomes nothing less than a justification for being content with sin.

Another example of an unbiblical practice is the encouraging of role-play and alternate realities. While role-plays are not bad in and of themselves, the versions that are encouraged in the text, which are modeled after Rational-Emotive Therapy, border on emotional manipulation. While not advocating dishonesty, suggesting alternate realities in an emotional setting designed to help someone “re-live” an experience could be potentially harmful. A patient might project untrue motives or actions upon others, and treat them accordingly. In an extreme case someone might even convince themselves that others pose no threat to their well-being, when this is potentially not the case.

Conclusion

We believe these are the major concerns and objections to CBT from a biblical perspective. There are other less critical observations that could be made, but in most of those instances the objections relate to the particular therapist’s understanding and practice. This critique focused on three main concerns. The motivations of the counselee are principally self-focused in nature, rather than God-focused in nature (pleasing self rather than pleasing God). Similarly, the aims and goals of counseling are humanistic and focus primarily on helping people “feel good” because they think and act in a way that is socially reasonable and acceptable. This leads to the third major concern, which is that in all regards there is no absolute standard of truth to evaluate what constitutes acceptable thinking, goals or motivations for counseling.