Beautiful Blends of Therapy: The Benefits of Mixing and Merging Modalities

The digital health world is so abuzz with hype about Cognitive Behavioral Therapy (CBT), you’d think it was a brand new, end-all solution. Nope to both counts! To the first, CBT is hardly new; dedicated researchers and health professionals have spent years pioneering and refining it. Second, it’s not a panacea – though it is one of the most broadly effective evidence-based practices (and arguably the most easily digitized and scaled). Therapy tends to be most effective when it blends different approaches and techniques to suit different client’s needs…a beautiful blend if you will! One that is curated by the skill of the therapist, the curriculum provided, and increasingly, the technologies used to deliver it.

In the wise words of our Director of Counseling, Chrissy: "Individuals and their situations vary greatly and it would be a disservice to only have one method to use with them. Even for an individual there can be variance between what works well depending on the particular issue. Using only one methodology would be like only having a screwdriver in your toolkit - sometimes it is exactly what you need but it doesn't work well as a hammer."

Here's an example of a simple beautiful blend in action: how Narrative Therapy (NT) and Cognitive Behavioral Therapy (CBT) have complementary strengths.

How does each type of therapy frame the issue/presenting problem?

CBT: Cognitive distortions – distorted patterns of thinking automatically intrude people’s  lives, causing unwanted emotions and behavior. Cognitive behavioral theory identifies various types of these unwanted thoughts specifically, such as "overgeneralization, "jumping to conclusions", or "mind-reading".3

NT: Problem-saturated life stories – negative and or disturbing narratives people have about their lives.4 “Impoverished” narratives ignore crucial aspects of one’s life, and “disorganized” narratives are uncoherent and or do not produce meaning.5

What’s the goal of therapeutic intervention?

CBT: To replace negative cognitive distortions with patterns of thinking that lead to the client’s desired feeling and behavior; specific goals are closely defined by client.1 NT: To reauthor personal narratives to reduce negative feelings regarding the past, and to engender new meaning, purpose, and identity.4

How is it achieved? 

 CBT: In a highly structured, present-focused process, the client and therapist work together to identify cognitive distortions, challenge their validity, replace them with alternatives, and continue this process outside of therapy and after it ends.6

NT: Skillful, extensive questioning helps the client explore the past to become aware of problematic life stories and collaboratively re-author them. Taking a critical stance on the outside world and language used in narratives facilitates change.7 How might the two orientations complement each other to meet client's unique needs?

CBT offers a clear and simple framework for transforming insights into action, demystifies the therapeutic process, and offers a clear avenue to improvement in the present. The downside of this present-focused, “power of the positive” philosophy is that it risks ignoring or invalidating client’s feelings as well as personal history. In this regard, narrative therapy can fill the void because, as a social constructionist perspective, it encourages empathic exploration of a client’s past and inner frame of reference, which can help them address feelings on a deeper level and provide cathartic release.

Furthermore, CBT centers around disputing “irrational” cognition, but doesn’t generally address how to deal with problems caused by a sociocultural context, such as the very real and painful effects of things like racism or poverty. The narrative therapy process gives clients room to acknowledge and critique how external factors have impacted their perspectives, ultimately to create a more empowering view of themselves and their strengths.

Still, NT can present its own set of both class and culture related barriers to clients.For example, people struggling with day-to-day survival issues of living in poverty may benefit more from CBT’s immediate, concrete action plans, as opposed to NT’s lofty goals of changing their life narratives and critiquing societal influences. Moreover, NT depends heavily on comfort and ability to extensively verbalize a narrative and self-disclose, which not everyone has. In fact, the notion of exploring personal narratives with a therapist is one that is quite outside the norms of most world cultures.8

Comparing CBT and NT is a simple example, but in practice, the interplay between how different therapeutic approaches merge to meet an individual's needs is far more complex; Workit's program was designed to better understand and manage this complexity as it impacts interventions across individuals and populations.

1 Beck, A. T. (1963). Thinking and depression: Idiosyncratic content and cognitive distortions. Archives of General Psychiatry, 9, 324-333.
2 Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York: Harper & Row.
3 Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International University Press.
4 White, M. & Epston, D. (1990). Narrative means to therapeutic ends. New York: WW Norton.
5 Dimaggio, G., & Semerari, A. (2001). Psychopathological narrative forms. Journal of Constructivist Psychology, 14, 1–23.
6 Alford, B. A., & Beck, A. T. (1994). Cognitive therapy of delusional beliefs. Behavior Research and Therapy, 32 369-380.
7 Besley, T. (2002). Foucault and the turn to narrative therapy. British Journal of Guidance & Counselling, 30(2), 125-143.
8 Hays, P.A. (1995). Multicultural applications of cognitive-behavioral therapy. Professional Psychology: Research and Practice, 26, 309-315.