A Catholic Evaluation of Cognitive-Behavior Therapy
Every approach to therapy is based on a particular theoretical interpretation of empirical evidence and experiences, it seems to me one should approach such theory much the same way the Catholic Church understands other religious frameworks and science. Namely, “The Catholic Church rejects nothing true and holy in these religions. She regards with sincere reverence those ways of conduct and of life, those precepts and teachings which, though differing in many aspects from the ones she holds and sets forth, nonetheless often reflect a ray of that Truth which enlightens all men.”[1] Similarly, my practice and evaluation of Cognitive-Behavioral Therapy (and its variants), or any other form of therapy, does not claim that it alone is true while others are false. Rather, it acknowledges the truth found in the diverse anthropological perspectives within psychological theories. Together, these provide a cohesive and yet multifaceted understanding of human nature: recognizing man as broken and sinful while also being open to his ultimate purpose and destiny, exemplified in Mary and united to Divinity in Christ. Every therapy recognizes part of the truth of man, but the best will incorporate the most truth, and the others will address the particular things they concern themselves with, from belief in self to conditioned response. Nevertheless, to look at psychotherapy with Catholic eyes is to see the human as a singular confluence of his aspects: biological, psychological/logical, free/moral, sociological/moral, anthropological/teleological, eschatological/spiritual, corrupt, and destined for salvation and everlasting life with God. When integrated with the Catholic understanding of the human person as a unity of the aforementioned aspects, cognitive-behavioral therapy (CBT) can effectively aid individuals in addressing inner conflicts rooted in a world marked by contra-human tendencies and spiritual antagonism, fostering growth toward their ultimate good, and cooperating with grace on a more fundamental, wholistic level.
In the US, Albert Ellis founded rational emotive therapy to help clients modify their irrational thoughts when encountering problematic events, and Aaron Beck employed cognitive therapy for depressed clients using [Ellis’s] model. Behavioral therapy and cognitive therapy were later integrated in terms of theory and practice, leading to the emergence of “second-wave” CBT in the 1960s. The first- and second-wave forms of CBT arose via attempts to develop well-specified and rigorous techniques based on empirically validated basic principles. From the 1960s onward, the dominant psychotherapies worldwide have been second-wave forms of CBT.[5]
Second, any treatment of the person, to be effective, must
cooperate with and improve human nature in statu quo. This improvement can only be accomplished if it indicates something true
of the current condition as well as the destination of human nature in terms of
one’s present health/journey and future eternal destination. Catholicism seems
to reliably/consistently describe both the nature of man’s condition and the
matter of his destination.
“As the Scriptures suggest, there is an unbreakable link between authentic freedom and truth (cf. Jn. 10:47); indeed, "freedom attains its full development only by accepting the truth" (John Paul II, Centesimus annus, 46) It follows that no genuine therapy or treatment for psychic disturbances can ever conflict with the moral obligation of the patient to pursue the truth and to grow in virtue.[6]The above quote seems to imply, by mention of human virtue and truth, the existence of human volition and reason. Humans are rational i.e. bound to find and follow what is true. Further, the quote above also implies it is both possible for human reason and volition to fall short of virtue and truth, i.e. sin and error which both undermine salvation and health (as described in the latin word “salute” in the Nicene Creed), bringing the necessity of psychological, philosophical, and theological help.7 This next quote will further assist our derivation of the Church’s interpretation of man:
The dignity of human life flows from creation in the image of God (Gn 1:26), from redemption by Jesus Christ (Eph 1:10; 1 Tm 2:4-6), and from our common destiny to share a life with God beyond all corruption (1 Cor 15:42-57) Catholic health care has the responsibility to treat those in need in a way that respects the human dignity and eternal destiny of all. The words of Christ have provided inspiration for Catholic health care: “I was ill and you cared for me” (Mt 25:36).[8]The quote calls to mind our being made children of God, unfolding three truths: our source, our nature, and our destiny. Humans are created good, in the image of God (Genesis 1:26-27). Each of us is made to be a single, unified, and yet relational self (John 17:21-24, John 13:34-35). Humans are called to membership in the Body of Christ through faith and baptism; i.e. communion (John 17:21-24, John 15:1-17). The Catholic understanding of the human person is that of a substantially unified creature of body and soul, made in the image and likeness of God, endowed with reason to govern free will (matter and form), yet corrupted if reason is neglected or misused—acting against this nature (contra-efficient and contra-final cause)—and thereby weakened in sin and error, but called, through grace in faith and baptism, to salvation from both sin and error, and restored to the communion for which humanity was created and longs (efficient and final cause).[9] In brief, man is, at once, 1) biological, 2) psychological/logical, 3)free/moral, 4) sociological/moral, 5) anthropological/teleological, 6) eschatological/spiritual, 7) corrupt, and 8) destined for salvation and everlasting life with God.
Third, given the antecedents, CBT is very compatible with
Christianity, and therefore, is potentially very effective in improving the
human condition. 1) Humans are bodily/biological. CBT recognizes the logical
circuitry of behavior, namely that there is a logically discernible and
dialogical cause-and-effect with any given behavior that results from both
willed and unwilled beliefs, both of which form circuitry, i.e. conditioning is
possible. 2) Humans are rational/logical. CBT recognizes that reason is the
primary efficient cause of behavior, but reason is influenced by other factors
as well. This is perhaps even more true for the standard behavior therapy.
Successful CBT involves understanding the "middle premise in the old
circuitry," recognizing how one's past and present reality is connected to
a negative self-perspective and maladaptive behavior. Effective CBT aims to
place good logic or “new circuitry” back in control of the will in place of the
“old circuitry” by reprogramming this “middle premise”. 3) Humans have
volition/will and thus a moral aspect. CBT recognizes the human has a will and
is responsible for their behavior. This suggests that our emotions, influencing
instinctual patterns, can impact our behavior in an unwilled fashion, thereby
taking the helm of our will, reducing but not eliminating our freedom of will.
4) Humans are relational, social, and communion-bound. CBT accounts for social
context, recognizing the human as a part of a social environment and thus
relational, in that it considers behavior which always affects others. 5)
Humans are substantially unified beings i.e. finite, singular entities. CBT
breaks from psychoanalysis, which posits the human as a confluence of separate entities, rather than aspects.[10] It does not necessarily completely exclude this concept, but it does seem to
suggest a human is substantially unified. 6) Humans are created in the image of
God. CBT, naturally, makes no reference to this, but does not exclude it, and
it even suggests that there is a discernible cause for any defect, thus
implying we are inherently and otherwise good. 7) Humans are weakened by sin.
If by sin one means maladaptive behaviors caused by preceding related, faulty
beliefs, then behavior therapy does account for this. CBT does not in itself
define right belief, but still recognizes the effect of error and sin against
us i.e. our health. 8) Humans are called to membership in the body of Christ
through faith and baptism. CBT makes no direct reference to divine filiation,
but it does not exclude it. It does hold that our behaviors, inspired by faulty
beliefs, can disintegrate us interiorly and from communion with others, thereby
it does suggest that we have an objective integration of parts to which we are
best directed and destined. Destination is what Catholics/Christians understand
to be Life in Christ. No therapy would/could perfectly embrace all truths of
the human person, nor subsequently, in itself detect and aim to cure the whole
condition of the human person. Even so, it is reasonable to focus on a
particular aspect of the person and work intelligibly with that aspect
(eventually integrating other therapies). CBT addresses the content of one’s
reason and how they act upon it, which naturally embraces much of the human
reality.
Fourth, let us observe an example situation. It is
reasonable to suspect a therapist would apply this theory and therapy in the
case of addiction, as later to be shown. Let us take the case of Patrick, who
now struggles with alcoholism and suicidal thoughts. He had a largely normal
childhood, with the exception that his father gave himself more to hobbies of
solitude and work than family time. This behavior left Patrick questioning
himself and developing rebellious tendencies in his adolescence, creating perpetual
openness to whatever temptations came from resisting authority by indulging in
behaviors considered taboo, most prominently among them (at one point underage)
drinking. We may note the nature of the problem being, from a therapist’s
perspective, a faulty means of coping with the belief “authority is always illegitimate, because it imagines itself good, while not truly knowing and working toward the common good” and “I don’t deserve good things especially if difficult”. In applying CBT, a therapist would begin by investigating the logical flow from the childhood context to the current behavior of acting out, treating alcohol at certain moments as a necessary good, as if believing that the prior parts of his life had alcohol sustaining him. The therapist would address the fallacious beliefs by introducing a broader perspective, replacing maladapted conclusions and behaviors ("old circuitry") with more effective ones ("new circuitry") to improve reasoning and acceptance of the current situation. Subsequently, they would consider what undoing the hard-wired aspect of holding and acting upon said framework for years may require.11 The therapist may consider having the client repeat truths to himself or recognize how other behaviors affirm or assume the old framework and rather suggest that he do his best to act as if the new framework is true, because it is. Here is an example of what Patrick may believe: All children rely on parental love, attention, and guidance to develop a sense of self-worth and security (Premise 1.1, natural assumption). However, Patrick’s father prioritized hobbies of
solitude and work over family time, failing to demonstrate consistent
affection, care, and attention (Premise 1.2, father’s behavior). When a child
does not receive consistent affection, care, and attention from a parent, they
may conclude that they are unworthy of love or inherently flawed (Premise 1.3,
therapist rationalization/client wound). Consequently, Patrick interpreted his
father’s neglect as evidence that he was unworthy of love, undermining his
sense of self-worth (Conclusion 1, father’s love to self-worth). Furthermore,
all children who perceive themselves as unworthy of love seek ways to cope,
often through rebellion or external affirmation (Premise 2.1, therapist’s
rationalization/client’s actions). In Patrick’s case, his perception of being
unworthy of love led him to question the legitimacy of authority, particularly
that of his father (Premise 2.2, Patrick’s response to Conclusion 1
extrapolating a particular situation). When authority is seen as illegitimate,
rebellion becomes a tempting outlet, including engaging in taboo behaviors like
underage drinking (Premise 2.3, correlated assumption overthrowing the
conscience). Therefore, Patrick’s feelings of neglect and unworthiness fostered
a rebellious attitude and openness to temptations like underage drinking as a
form of self-soothing and defiance (Conclusion 2, permission to override
conscience). Behaviors initially adopted as a form of rebellion or coping can
become habitual and escalate into addictions when the underlying emotional pain
is unresolved (Premise 3.1, effect of Conclusion 2). Patrick used drinking to
cope with his feelings of unworthiness and distrust of authority, but this
behavior failed to address the root emotional issues (Premise 3.2, effect of
Conclusion 2 and Premise 3.1). As drinking became habitual, it reinforced
Patrick’s negative self-perception and created a cycle of dependence, deepening
his despair (Premise 3.3, circular logic/negative feedback loop originating in
Premise 2.3 and 3.2). Consequently, Patrick’s drinking escalated into problem
drinking, as it both numbed his emotional pain and perpetuated his belief that
he was unworthy of love and incapable of breaking free from his struggles
(Conclusion 3, “justified” destructive behavior). After determining the status
of the logic and conclusions, the therapist identifies the logical issue
present (which due to being unconscious logic, the client will likely see the
fallacy involved once presented with it, and the degree to which they don’t can
be an indicator of the severity of struggle), noting when it binds behavior and
emotion in order to work against it. For instance: Premises 1.1 and 1.2
describe reality, although Premise 1.1 can be applied by degree (as one should
be able to qualify their expectations of parents by seeking identity and safety
first in God (or themselves if atheist)) Premise 1.3 is necessary in fostering
Conclusion 1. The therapist must help the client correct the logic by
acknowledging that the father’s behavior is more an indicator of his values,
which may be maligned, but that has no bearing on the client’s own goodness.
Indeed, a parent should ascribe the full meaning of a person to a child and
recognize that persons deserve more good than hobbies. The client can learn
from this error and, when appropriate, advocate for change, perhaps even
directly in reconciliatory conversation. The client may also recognize that his
father might have thought he was showing love by providing rather than being
present, believing it was his role or that he was socially inexperienced or
perceived Patrick as always disgruntled in his presence. The therapist can help
the client address these emotions as they arise with better conclusions and
premises to repeat and act upon, such as: they are loved at least by God (when
others seem to fail in this effort and often will, given our depravity); they
are safe in Him; feelings can be converted into logical claims to share and
enhance communion rather than suppress them; and they can be invited to new
opportunities for love, which may clarify similar situations. Although the
successive conclusions are dependent on those prior, it can be helpful to
extend this process to all problematic permutations and applications of
Conclusion 1, i.e. dismantling the “old circuitry” of implicative reasoning to
prevent adverse behavioral outcomes. It is well worth noting that no good
conclusion can come from the idea that one is “unloved and justly so,” and if
that conclusion is ever felt to be true, then the “old circuitry” will be
reinforced. In the second syllogism of the “old circuitry,” the assumptions or
fallacies include responding to pain with a need to numb it, while neglecting
its role as a signal of something wrong, extrapolating a particular to the
general, defining authority solely as human and not accountable to Divine
authority, and engaging in self-destruction to express the absurdity of
apparent reality. Pain should be understood as a sign of a problem improper to
one’s nature, indicating that the matter or form of a person is being
undermined; thus, that understanding and mitigating the problem is worthwhile.
Authority is meant to protect, guide, steward, and assist in the perfection or
implementation of virtue in the governed. To the extent that authorities fail
in this, they become tyrants, abusing power or neglecting responsibility for
personal gain or convenience. If the system is well-ordered, authoritative
personnel can be confronted or held accountable, either in time or at Divine
judgment. Even though others may bear blame for damage done to us and the degree
of its effect on us, one should not justify nor perpetuate self-destructive
actions as testimony to such damage. Instead, the individual should address it
with God and, if possible or appropriate, with the relevant persons to the
extent they appear blameworthy. Broken parts of ourselves should neither be
ignored nor exclusively lived out. In the third syllogism of the “old
circuitry,” assumptions or fallacies include the belief that if a method and
its extent seem insufficient, then the method itself should not be questioned
and the conclusion that “this is what I deserve” remains unchallenged. A
therapist may point out, if appropriate, that taking a depressant to mitigate
depression is illogical and destructive. No one is worthy of receiving
destructive behavior from within or without, as such self-pity leads nowhere
helpful. Through this analysis, Patrick may learn how to love himself, give
himself room to confront and forgive his father by seeing the offense as
external to his identity, and take on the difficult task of loving himself
rightly. Beyond the cognitive, narrative, and reasonable aspects of a person’s
struggle lies the behavioral, and for Patrick, the behavioral transformation is
accomplished ultimately by himself and those who support him. However, he
begins this process by habitually changing his beliefs and using reason to
follow up on true beliefs.
Fifth, given that each therapy has a specific focus, it will
inevitably have a corresponding application that ensures its
effectiveness/ideal impact. As can be seen in the example above and in its
connection to the truth of a person as understood by the Catholic Church, CBT
can have a positive effect across many situations. CBT dialogues with the whole
person's body and mind so that the soul may be well, and in this way, CBT is at
least a generalized help. If one is to claim the title Christian meritoriously rather than associatively, truly there must
be a noteworthy change in the person, even if from generally moral to holy rather than debaucherous to holy (Romans 12:2, 2 Corinthians 5:17, Ezekiel 36:26-27). CBT can reveal alignment, or lack thereof, to the “new circuitry” or new heart in Christ. CBT has also been shown to be effective for particular symptoms. CBT has been shown helpful in cases of “Compulsive sexual behavior disorder (CSBD) which includes problematic pornography use (PPU)”.[12] In children and adolescents, CBT has been shown to help with “internalizing disorders including anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder” in both efficacy studies and in routine clinical care.[13] CBT is shown to have efficacy in both university and clinical applications in externalizing disorders, especially Attention Deficit Hyperactivity Disorder (ADHD), Conduct Disorder (CD), Oppositional Defiant Disorder (ODD), and Internet Addiction/Internet Gaming Disorder (IGD).[14] CBT has also been shown to be effective in reducing the frequency and magnitude of psychosomatic symptoms such as migraine headaches and insomnia.[15] CBT has also been shown to be efficacious in cases of co-morbidity in psychosomatic symptoms, internalizing disorders, and externalizing disorder combinations/permutations.[16] CBT works in combination with other therapies in the treatment of substance use disorders.[17] Mindfulness-based Cognitive Therapy (MBCT), a derivation of the original cognitive therapy, has been shown effective in treating anxiety.[18] In summary, it seems CBT is effective anywhere a faulty life narrative is bringing negative effect, whether a reduction of life to a particular good (addiction) and/or to a particular struggle (emotional disorders).
Sixth, due to the aforementioned fact that a given therapy has its particular applications, it will certainly also have its particular limitations. However, there is a very particular set of limitations which are due more to its specificity of application than its effectiveness, since as stated above, CBT dialogues with a significant portion of man’s aspects and yet not all and not perfectly.[19] The most fundamental limitation exists in the extent of CBT application by the client, not unlike the old adage, “one can lead a horse to water, but may still not be able to get the horse to drink.” CBT cannot be effective without the client following through, it is likely that the “old circuitry” will remain a struggle for the client to varying extents, and the clients will vary (individually and moment to moment) in their desire to follow through. It is necessary for the client to form a “new circuitry,” ideally on what is true and virtuous, lest a new problem develop or the “old circuity” still persists, given man’s nature. Disorders which merit the use of CBT signal a need for total, internal, belief-framework adjustment, which can be done only by therapy follow-up via a client’s consistent, affirmative choice and action. Follow-up (or follow through) by the client requires genuinely putting effort forth outside of counseling sessions to alter habitual faulty beliefs, and living a narrative which does not hold the problematic behavior or emotion as necessary. Addictions are not usually solved only by therapy alone but also by a context of love and self-improvement, twelve-step groups often apply principles from CBT in a loving accountability, mitigating motivational issues concerning follow through.[20] Often, CBT requires knowledge of self in ways that may make clients uncomfortable, so they have to be willing to choose what is difficult, but this is a universal requirement to all forms of recovery (and often growth), even physical. Sometimes emotional conditions persist, even if improved, in spite of the client’s best efforts and keenness of self-knowledge, due to complexity or the subconscious nature of conditions, but again, this is the nature of all forms of recovery (also in light of man’s nature). Ultimately it is up to the client whether the therapy will be properly tailored to them by way of self-knowledge and communication, and whether it will be effective given that it is not a pill or surgery. The client alone can work with their own neurological reality, even if aided by pharmacology, counseling, support, etc.
In conclusion, cognitive-behavior therapy is the most compatible with Catholic anthropology, and as such, it is no surprise that it is the fundamental methodology of the twelve-step process, because the twelve-step framework is based on the Catholic understanding of man and conversion/salvation. A given therapy cannot have broadly positive efficaciousness unless it is united to more than one aspect of man. Since cognitive behavior therapy holds humanity is moral, biological, autonomous, and reasonable without opposing the spiritual, teleological, and eschatological aspects, it can bring positive healing in those areas. The limitations of CBT stem from the same human struggles it seeks to address, such as the stability of choices and diligence. CBT helps clients take action, guided by their therapist, to change harmful patterns of thought and behavior. These harmful patterns largely originate from one’s social and spiritual environment, and thus to recover with CBT, one must refute the error given to them. CBT does this by improving the matter and form of reasoning, challenging faulty assumptions and thereby replacing unhealthy habits with healthier habits. This effort opens the way for God’s grace—His intimate help in our journey toward healing and salvation. The Latin word salute in the Nicene Creed highlights this purpose of Christ’s Incarnation, Suffering, Death, and Resurrection.
- Second Vatican Council, Dogmatic Constitution on the Relation of the Church to Non-Christian Religions Nostra aetate (28 October 1965), §10.
- Mutsuhiro Nakao, Kentaro Shirotsuki, and Nagisa Sugaya, "Cognitive–Behavioral Therapy for Management of Mental Health and Stress-Related Disorders: Recent Advances in Techniques and Technologies," Biopsychosocial Medicine 15, no. 1 (3 October 2021), 1
- Nakao, Shirotsuki, and Sugaya, "Cognitive–Behavioral Therapy for Management," 1.
- Nakao, Shirotsuki, and Sugaya, "Cognitive–Behavioral Therapy for Management," 1.
- Nakao, Shirotsuki, and Sugaya, "Cognitive–Behavioral Therapy for Management," 1-2.
- John Paul II, Address to the members of the "American Psychiatric Association" and the "World Psychiatric Association" (4 January 1993).
- Catechism of the Catholic Church, 2nd ed. (Washington, DC: United States Catholic Conference, 2000), 1849.
- United States Conference of Catholic Bishops, Church Document on the Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition (1 June 2018), 10.
- E. Christian Brugger, "Psychology and Christian Anthropology," Edification: Journal of the Society for Christian Psychology 3, no. 1 (2009), 5.
- Gerald Corey, Theory and Practice of Counseling and Psychotherapy, Enhanced, 10th ed. (Brooks/Cole, 2020), 280.
- Gerald Corey, Theory and Practice of Counseling and Psychotherapy, 294.
- Sebastian Antons, Jana Engel, Peer Briken, Tillmann Krüger, Matthias Brand, and Robert Stark, "Treatments and Interventions for Compulsive Sexual Behavior Disorder with a Focus on Problematic Pornography Use: A Preregistered Systematic Review," Journal of Behavioral Addictions 11, no. 3 (2022), 662.
- Gro Janne Wergeland, Eili Riise, and Lars-Göran Öst, "Cognitive Behavior Therapy for Internalizing Disorders in Children and Adolescents in Routine Clinical Care: A Systematic Review and Meta-Analysis," Clinical Psychology Review 83, no. 1 (2021), 12-14.
- Eili Riise, Gro Janne Wergeland, Urdur Njardvik, and Lars-Göran Öst, "Cognitive Behavior Therapy for Externalizing Disorders in Children and Adolescents in Routine Clinical Care: A Systematic Review and Meta-Analysis," Clinical Psychology Review 83 (2021), 13.; Chuan-Hsin Chang, Yue-Cune Chang, Luke Yang, and Ruu-Fen Tzang, "The Comparative Efficacy of Treatments for Children and Young Adults with Internet Addiction/Internet Gaming Disorder: An Updated Meta-Analysis," International Journal of Environmental Research and Public Health 19, no. 5 (2022), 2.
- Riise et al., "Cognitive Behavior Therapy for Externalizing Disorders," 13.; Elisabeth Hertenstein et al., "Cognitive Behavioral Therapy for Insomnia in Patients with Mental Disorders and Comorbid Insomnia: A Systematic Review and Meta-Analysis," Sleep Medicine Reviews 62, no. 1(2022), 12.
- Elisabeth Hertenstein et al., "Cognitive Behavioral Therapy for Insomnia in Patients with Mental Disorders and Comorbid Insomnia: A Systematic Review and Meta-Analysis," 12.
- Lara Ray, Lindsay Meredith, Brian Kiluk, Justin Walthers, Kathleen Carroll, and Molly Magill, "Combined Pharmacotherapy and Cognitive Behavioral Therapy for Adults With Alcohol or Substance Use Disorders: A Systematic Review and Meta-analysis," JAMA Network Open 3, no. 6 (2020), 11.
- S. Ghahari et al., "Mindfulness-Based Cognitive Therapy for Generalised Anxiety Disorder: A Systematic Review and Meta-Analysis," East Asian Archives of Psychiatry 30, no. 2 (2020), 52.
- Molly Magill, Brian D. Kiluk, and Lara A. Ray, "Efficacy of Cognitive Behavioral Therapy for Alcohol and Other Drug Use Disorders: Is a One-Size-Fits-All Approach Appropriate?" Substance Abuse and Rehabilitation 14, no.1 (2023), 2.
- Lorenzo Zamboni, Francesco Centoni, Francesca Fusina, Elisa Mantovani, Francesca Rubino, Fabio Lugoboni, and Angela Federico, "The Effectiveness of Cognitive Behavioral Therapy Techniques for the Treatment of Substance Use Disorders: A Narrative Review of Evidence," The Journal of Nervous and Mental Disease 209, no. 11 (2021): 835.
