by Scott Mehl
“Cognitive Behavioral Therapy changes people, and we can prove it.” This implicit claim has propelled Cognitive Behavioral Therapy (CBT) to become one of the most widely practiced therapies in the world. No other form of therapy has the scientific validation and popular support currently enjoyed by CBT. In the first week of May 2016 alone, news outlets across the United States published stories touting the power of CBT in treating chronic pain, insomnia, depression, OCD, opioid abuse, suicidal thoughts, and even memory loss from chemotherapy. In addition, the empirical evidence supporting CBT is unparalleled in the world of psychotherapy. As one researcher puts it, “CBT is arguably the most widely studied form of psychotherapy…. Despite weaknesses in some areas, it is clear that the evidence-base of CBT is enormous. Given the high cost-effectiveness of the intervention, it is surprising that many countries, including many developed nations, have not yet adopted CBT as the first-line intervention for mental disorders.” For these reasons CBT has become the go-to intervention for most mental disorders in the United States. Being trained and competent in CBT is now one of the accreditation criteria for all psychiatry residency programs in the US. What’s more, the psychiatry practice guidelines for almost every mental disorder include CBT as a first-line therapy.
CBT is also popular among many Christians who believe that it is able to be effectively integrated into a Christian worldview. As Stanton Jones and Richard Butman summarize, “Perhaps no other therapy approach so closely mirrors a biblical balance of cognitive and action orientation as cognitive-behavioral therapy. Even a superficial reading of the pastoral exhortations of the New Testament epistles yields a clear theme of obedience in actions and in thoughts as the way to maturity.” CBT can appear to be the ideal psychotherapy for the Christian. It hits the trifecta of being (a) scientifically demonstrated, (b) anecdotally effective, and (c) consistent with biblical principles. But is CBT actually consistent with Scripture’s understanding of motivation and change? Before we can answer that question we need to understand what CBT actually is.
To understand CBT we must first recognize where it came from. CBT was birthed out of two previously separate forms of therapy: behavioral therapy and cognitive therapy. Behavioral therapy was developed, most famously, by B.F. Skinner and was propelled into wide use by the needs of soldiers returning from World War II. Cognitive therapy was developed by Albert Ellis and Aaron Beck. They identified irrational thoughts and beliefs as the greatest cause of psychological problems. Beginning in the late 1970s, those who practiced behavioral therapy (behaviorists), recognizing the overly simplistic nature of their theories, began incorporating cognitive approaches into their therapeutic repertoire. This gave rise to Cognitive Behavioral Therapy in the early 1980s. In observing CBT today, the legacies of Skinner, Ellis, and Beck are still readily apparent. CBT recognizes that, just as thoughts must be addressed in order to change behavior, changing behavior inevitably helps in the process of changing thoughts. “Part of the inheritance from [behavioral therapy] is that CBT considers behaviour (what we do) as crucial in maintaining – or in changing – psychological states.” For the CBT therapist this dual legacy is reflected in equal emphasis given to behavioral and cognitive techniques.
But recognizing the roles these “grandfathers” of the movement played does not take us back quite far enough. While the theoretical underpinnings of Skinners’ behaviorism are well-known among psychologists and can be traced back to the famous experiments of Pavlov and his dogs, the philosophical underpinnings of Ellis and Beck are less commonly recognized. Donald Robertson explores this philosophical backdrop in his book, The Philosophy of Cognitive Behavioral Therapy. He writes:
“It is important to emphasize that both Aaron Beck and Albert Ellis, often regarded as the main pioneers of CBT, have stressed the role of Stoicism as a philosophical precursor of their respective approaches. There is only a relatively vague appreciation of this fact among many therapists, however, so it is worth drawing attention to the key passages in their writings.”
Robertson points out that both Stoicism and CBT assume that thoughts determine emotions and both see changing our thoughts as the greatest way to change our emotions. In both Stoicism and CBT “cognitions are central to both the cause and the cure of emotional disturbance.”
Or put more simply, “[Ellis’] own approach was based on the ancient Stoic philosophy…[which] stated that facts do not upset people, but rather people upset themselves with the view that they take of those facts.” This is the assumption that is at the core of Cognitive Behavioral Therapy. 2,300 years after the first Stoics and 20 years after Ellis and Beck, David Burns, who popularized CBT (selling over 4 million copies of his landmark bestseller), summarized CBT in a way that is undeniably Stoic in nature: “You can learn to change the way you think about things, and you can also change your basic values and beliefs. And when you do, you will often experience profound and lasting changes in your mood, outlook, and productivity. That, in a nutshell, is what cognitive therapy is all about.”
So what exactly is Cognitive Behavioral Therapy, then? David Burns says that CBT is essentially about changing the way you think in order to change your mood, outlook, and productivity. Michelle Craske (director of the UCLA Anxiety Disorder Research Center) agrees: “The primary assumption of cognitive therapy, whether in accordance with Ellis or Beck, is that dysfunctional thinking can be changed and, in turn, lead to symptomatic relief and improvement in functioning.” In short, Cognitive Behavioral Therapy is the application of behavioral and cognitive interventions to address an undesirable psychological problem. But what are these behavioral and cognitive interventions?
Behavioral interventions are developed reactively from classical conditioning or proactively from instrumental conditioning. Classical conditioning observes that there are certain innate, involuntary responses that follow certain stimuli. But it also recognizes that these involuntary responses can be changed. If anxiety is the involuntary response to a nurse walking into the room — because you associate nurses with getting shots — all you have to do is repeatedly introduce a nurse into the room without giving you a shot to change the involuntary response from anxiety to calm. This is at the root of exposure therapy, a classic behavioral intervention.
Instrumental conditioning, on the other hand, is not aimed at reacting to involuntary responses but at eliciting certain desirable responses by means of reinforcement or punishment. Simply put, behavior can be altered through a systematic and consistent application of positive and negative reinforcements that encourage adaptive behavior and discourage maladaptive behavior. Craske observes that, “the challenge for treatment is to make the reinforcement for the adaptive behavior more influential than the reinforcement for maladaptive behavior” (an observation that any parent of a 3 year-old can readily attest to).
Cognitive interventions differ from behavioral interventions in that they are aimed at the more complex cognitive process of how life is interpreted and discerned. Whereas a behaviorist would simply observe that a certain event produces a certain behavior or emotion, the cognitive therapist observes that, in fact, a certain event produces a certain cognition, which in turn produces a certain behavior or emotion. When these “cognitions” are maladaptive or problematic they are sometimes called “negative automatic thoughts.” But these automatic thoughts don’t spring from thin air. If they did, they might be easier to change. However, cognitive therapists observe that these negative automatic thoughts are the natural byproduct of dysfunctional assumptions and that these dysfunctional assumptions stem from problematic “core beliefs.” Cognitive interventions are developed to help someone with problematic “core beliefs” identify those beliefs and replace them with more “healthy” beliefs that will naturally produce more helpful assumptions and, eventually, more constructive automatic thoughts.
If the last two sections left you scrambling for your dictionary, I can assure you that you are not alone. While filled with astute observations, the theory of CBT can get a little convoluted, especially for those not steeped in its history and terminology. For this reason I find the most helpful way to understand CBT is by identifying some of the specific skills and interventions it employs in seeking to help people change. While there is great diversity between behavioral and cognitive interventions, the CBT therapist employs them all, not necessarily because they all stem from one coherent theory of humanity, but simply because they all work in certain situations. CBT is eclectic at its core, providing a smorgasbord of different behavioral and cognitive interventions for the therapist to choose from depending on the person, the situation, and the issue. In order to get a sense for exactly what this entails, let me give you a sampling of some of the most common interventions.
There are two main types of behavioral interventions: exposure-based interventions (as applications of classical conditioning) and skills-based interventions (as applications of instrumental conditioning). Exposure-based interventions involve repeatedly and progressively introducing certain stimulus for the sake of addressing either fear or craving. For example, if someone has an irrational fear of water, repeated and gradual exposure to a swimming pool without harm coming to the person will gradually reduce the unwanted fear. Similarly, if someone has a destructive craving for dessert every night when their kids go to bed, repeated exposure to their kids going to bed without eating desert (because it has been removed from the house) will, over time, reduce the undesirable craving.
Skills-based interventions involve teaching the counselee certain skills that help to produce the desired behaviors or emotions. Examples include:
Relaxation. Counselees are taught techniques of muscle relaxation or breathing training as tools to combat anxiety or fear and to use moments of anxiety as reminders to engage in intentional relaxation. Eastern meditation and yoga (in their popular forms) have also become prevalent manifestations of this intervention.
Problem Solving. Many behavioral and emotional issues can be helped significantly by providing counselees with simple problem solving skills. This often takes the form of teaching a counselee how to identify a problem, brainstorm possible solutions, evaluate those solutions, enact a solution, and evaluate the result afterwards.
Behavioral Rehearsal. Role playing and modeling by the counselor are ways to help produce desirable social skills or social confidence that may be lacking. By practicing the desired behaviors in a safe setting, the counselee will be better prepared to manifest those behaviors in the desired contexts.
Systems of Reinforcement. Developing various systems of reinforcement are a key strategy in CBT interventions. These may include systems of positive reinforcement: using activity logs, praise from the counselor, or identification of the ongoing benefits of particular behaviors. These may also include systems of negative reinforcement: removing certain privileges or positive reinforcements, if goals are not met.
Increased Activity. Many CBT therapists have also observed (as demonstrated in numerous scientific studies) that simply increasing one’s activity level (through exercise or some other form of physical exertion) can oftentimes contribute to the production of desirable emotions or even behaviors. Setting up plans to increase a counselee’s activity level is a common behavioral intervention.
Cognitive interventions, as discussed above, seek to address deeper beliefs and assumptions. In order to do this, most cognitive therapy first involves instructing the counselee on the theory of cognitive therapy in order to gain their buy-in moving forward. From there the counselor and the counselee embark on a journey of identifying and confronting dysfunctional thought patterns through a process of “collaborative empiricism.” The two collaboratively seek to study the thought patterns of the counselee and, together, make observations regarding what should be regarded as “dysfunctional.” Those problematic thought patterns are then addressed with “truth” that is more helpful or healthy for the individual. The most straight-forward example of this can be found in David Burns’ 10 cognitive distortions. He summarizes the most common cognitive problems into 10 categories, only a few of which can be mentioned here for the sake of space.
Jumping to Conclusions. “You make a negative interpretation even though there are not definite facts that convincingly support your conclusion.”
Emotional Reasoning. “You assume your negative emotions necessarily reflect the way things really are.”
Disqualifying the Positive. “You reject positive experiences by insisting they ‘don’t count’ for some reason or other.”
Burns’ entire book is a perfect example of how the cognitive therapist would confront these dysfunctional types of thinking. He takes them head-on and uses evidence from the person’s life to demonstrate how and why their thinking is untrue and replaces the untrue thoughts with healthier, more helpful thoughts such as: “The evidence of my life suggests that I’m not a total failure, but have experienced success in certain areas.” Or, “My emotions don’t determine reality, and even though I feel unloved, there are actually plenty of people who love me very much.” Or, “The promotion I got at work really does show that I am a good worker and valued by my boss, it’s not just the natural result of the person ahead of me leaving the company.” These are all examples of the truth statements involved in confronting someone’s core beliefs, and replacing their negative automatic thoughts with positive ones.
Before we evaluate all of this from a biblical perspective, there’s one last question that is important to address. It’s the question that helps us to understand why any of this matters for the Christian today. In addition to asking, “What is CBT?” and “Where did it come from?” we also need to ask, “Why is CBT so popular?” Although there are many complicated factors that contribute to its popularity, there are four reasons that rise above the rest.
First, CBT is popular because it just makes sense. Many of the “interventions” utilized in CBT are similar (if not identical) to the common sense parenting that many mothers have provided to their kids for centuries. “If you talk to me that way again you will have to be disciplined.” “Let’s think about other ways you could have handled this situation.” “Don’t let anyone tell you that you’re stupid, it’s just not true!” “Go outside and play.” These are all simple, common sense applications of cognitive-behavioral therapy.
Second, CBT is popular because it has been empirically demonstrated to be effective. No form of therapy has been studied more than CBT. And the result of all of those studies has been a great deal of confidence that CBT really can help people change how they act and feel. In fact, a 2012 comprehensive review which analyzed 106 meta-analyses (studies of studies) concluded that, “In general, the evidence-base of CBT is very strong.” This is the reason for the high level of respect it currently enjoys in the medical community.
Third, CBT is popular because the interventions are reproducible and easy to learn. When CBT is compared to other forms of psychotherapy, the simplicity of many of its interventions stands out. Psychoanalysis, hypnosis, existential therapy, and many others can be difficult to learn with concepts that take years to grasp. In contrast, while CBT can always be improved, its interventions are far more accessible and can be quite easily handed to counselees to apply on their own.
A final reason CBT is popular is because it is so cost effective. CBT is known for being time-limited (especially in comparison to psychoanalysis), applicable in groups, and able to be self-directed. This makes CBT the most cost-effective form of treatment available for mental disorders. In a world of managed healthcare, the impact of this on CBT’s current popularity cannot be overstated.
Having identified where CBT came from, what it is, and why it’s so popular, let’s revisit the key question for us as Christians: “Is CBT actually consistent with Scripture’s understanding of motivation and change?” It may appear that there are a lot of similarities between CBT and the biblical process of change. As you read through the list of behavioral interventions, many of them look very similar to strategies Christians engage in to “put off” sinful actions. Behavioral rehearsal is oftentimes used to prepare someone for a future moment of temptation, problem-solving skills are used when helping someone identify alternative responses to temptation, and systems of reinforcement are utilized in almost every accountability group. Think of the Bible study group that does pushups for every word they get incorrect when memorizing Scripture. Or the “cheat day” granted as a reward to Christians who are trying to get control of their eating habits. All of these are strategies of habituation, which even the biblical counseling movement has utilized extensively. After all, Paul instructs the Thessalonians that, “If anyone is not willing to work, let him not eat” (2 Thes 3:10). CBT can sound a lot like the common-sense approaches to change many Christians utilize every day.
Similarly, the emphasis CBT places on identifying faulty core beliefs and irrational thinking, confronting them with truth statements, and altering behavior by changing one’s thoughts, all sounds downright biblical. After all, in one of the clearest passages on human motivation and change, Paul instructs believers to, “not be conformed to this world, but be transformed by the renewal of your mind” (Rom 12:2). CBT seems like a simple, empirically demonstrated tool for renewing one’s mind. All we need to do is use Scripture as the content of those truths, and Christianized CBT is essentially biblical counseling, right?
While it may look similar on the surface, CBT and the biblical process of change are, in fact, very different. This is not to say that there are not components of the biblical process of change that are echoed in the efforts of CBT therapists. There undeniably are. Ancient Stoics, Skinnerian behaviorists, Ellis-inspired cognitivists, and modern-day cognitive-behavioral therapists have all stumbled upon practical strategies that have been in God’s Word all along and utilized by Christians for centuries. But that does not mean that we need to integrate their systems with biblical truth in order to more-effectively help people. As Lambert writes in his essay on Reparative Therapy, “Once you realize that the effective elements of [CBT] are the instances when the therapists are unwittingly biblical it drives you away from that therapy to the Scriptures which authoritatively declares what will help people.” When an employee for a tire company approaches GM with a design for a new tire, but it’s essentially the same design GM already uses, they don’t hire the guy and ask him to oversee their entire R&D department. His expertise is limited to one rubber part of an incredibly complex machine, and all he did was recognize something they had already known. Talk about reinventing the wheel.
So what are the fundamental differences between CBT and the biblical process of change? While both CBT and the biblical process of change involve identifying untrue thinking and renewing one’s mind with truth, the content of that truth is completely different. In CBT, the counselor can only affirm that which is helpful, while the biblical counselor can affirm that which is true. All of the truth statements of CBT are utilized because they have been shown to be helpful in combatting automatic thoughts and core beliefs that produce undesirable behavioral and emotional patterns. The problem is, the emperor has no clothes. Just because something is helpful to produce desirable behavioral and emotional patterns does not mean that it is actually true. In contrast, the biblical process of change reminds us of what the God of the universe has declared to be true about himself, what he has done, and who we are in him. He reminds us that he is our Creator (Gen 1), our Savior (1 Pet 1:17-19), our Father (John 1:12), and our Lord (Eph 4:1-6). He reminds us that our real “cognitive distortions” stem from the fact that we have forgotten who he has made us to be in Christ (for those that are in Christ). He reminds us that:
In him we have redemption through his blood, the forgiveness of our trespasses, according to the riches of his grace, which he lavished upon us, in all wisdom and insight making known to us the mystery of his will, according to his purpose, which he set forth in Christ as a plan for the fullness of time, to unite all things in him, things in heaven and things on earth. In him we have obtained an inheritance, having been predestined according to the purpose of him who works all things according to the counsel of his will, so that we who were the first to hope in Christ might be to the praise of his glory. In him you also, when you heard the word of truth, the gospel of your salvation, and believed in him, were sealed with the promised Holy Spirit, who is the guarantee of our inheritance until we acquire possession of it, to the praise of his glory. (Eph 1:7-14)
In doing this, the biblical process doesn’t settle for surface-level change, but seeks to draw everyone into Christ himself. Scripture teaches us that even if you have identified and addressed every one of Burns’ cognitive distortions, you are still not any closer to becoming who you were created to be in Christ.
Some might say that this is a perfect example of how we can integrate CBT and the biblical process of change. If you switch out the truth statements of secular CBT with truth statements from the Bible, can’t you integrate the two seamlessly? Unfortunately, there are more differences between CBT and biblical change than simply the truth statements. The biblical process of change utilizes different means as well.
While practical strategies for changing our behavior and addressing untrue thought patterns are absolutely a part of the biblical change process, Scripture offers us so much more. Stanton Jones and Richard Butman provide a candid summary: “It seems likely that we are what cognitive-behavioral therapy depicts us as being: thinking and acting creatures of habit who act upon and are acted upon by our environments for the purpose of obtaining that which we value. But it also seems clear to the Christian that we are more than this.”
At its core, CBT denies the fundamental spiritual component of humanity. It sees us as beings whose actions and emotions can be manipulated through training or intervention. There is no place in CBT for the reality of the heart as Scripture conceptualizes it. CBT tells us that what comes out of us proceeds from our habits. Scripture tells us that what comes out of us proceeds from our heart (Matt 15:18).
More than all of this, in CBT the answer to our problems is found in the right “truth statements.” But, for the Christian, the answer to our problems is not only found in “truth statements,” but in the person who is Truth. God himself is the means of our transformation through the work of Christ on the cross and the ongoing work of the Holy Spirit in our hearts. God offers us more than certain truths, he offers us himself. He offers us more than truth statements, he offers us a relationship. This is why, leading into behavioral instructions, Paul exhorts the Colossians:
If then you have been raised with Christ, seek the things that are above, where Christ is, seated at the right hand of God. Set your minds on things that are above, not on things that are on earth. For you have died, and your life is hidden with Christ in God. When Christ who is your life appears, then you also will appear with him in glory. (Col 3:1-4)
This is different from “addressing maladaptive core beliefs.” This is coming home to the One we were created for. In Christ we don’t have to settle for change through behavior management, we can be transformed through the gospel. Again, some might point out that if we align both our means and truth with Scripture we still should be able to integrate CBT and the biblical process of change, utilizing the best that both have to offer. But, even if we were to align the truth of CBT and the means of CBT with the biblical process of change we would still have to reconcile the fact that the two have distinctly different goals.
In CBT the goal of change is determined by the counselee and the counselor collaboratively. Together they determine what is “healthy.” This means that the goal of CBT ends up simply being a compilation of the desires of the fallen hearts of these two people. Their own systems of ethics and morality inform what they are working toward and, usually, the goals center on happiness, individuality, freedom, self-interest, or some variation thereof. As such, CBT is fundamentally a philosophy based on culturally defined morality and ethics. It may be the best system for achieving those goals, but that does not mean that it’s the best system for achieving what God wants to achieve.
God’s goal for our lives is different than these narrow and subjectively defined goals. God is, most basically, interested in making us more like Christ. He desires for us to be reconciled to him through Christ, and having been reconciled he is in the process of transforming us more and more into his image. As Scripture communicates so clearly:
“For this is the will of God, your sanctification” (1 Thes 4:3)
“For we are his workmanship, created in Christ Jesus for good works, which God prepared beforehand, that we should walk in them.” (Eph 2:10)
Even if you were to “Christianize” CBT by making the goal biblically-defined morality, while CBT may be helpful at achieving self-defined goals, it is unable to produce the God-defined goals of sanctification and Christlikeness. CBT may have a large body of scientific evidence to support it, but it has never, in any study, been empirically demonstrated to be effective at producing godliness. Scripture is unequivocal on this point. “Let me ask you only this: Did you receive the Spirit by works of the law or by hearing with faith? Are you so foolish? Having begun by the Spirit, are you now being perfected by the flesh?” (Gal 3:2-3) CBT may be a compassionate stop-gap for people who don’t know Jesus, but we must recognize that it is impotent to address their greatest needs or to fulfill their greatest desires.
It’s not that the CBT therapist isn’t on the right track, it’s just that they stop far too early on that track, thinking they have arrived. This was true of the Stoics, it was true of the original cognitive therapists, and it’s true of CBT therapists today. Robertson connects the Stoic’s goal of happiness to Ellis’ same goal:
“As the Stoics put it, the basic, common sense, preconception that we should seek happiness and well-being (eudaemonia) is correct, but we frequently fall into error when applying this to specific cases in our daily lives….Albert Ellis made a similar distinction in his philosophy between short-range and long-range hedonism, which he derives explicitly from Stoicism. He observed that people often suffer because they irrationally sacrifice their long-term happiness for the lure of short-term pleasure.”
Read that last sentence again. Doesn’t a Christian worldview declare that exact same thing? We can heartily affirm that our greatest problem is our choice to “irrationally sacrifice long-term happiness for the lure of short-term pleasure.” This was Eve’s problem, and it’s yours and mine as well.
As John Piper has asserted throughout his entire ministry, the problem isn’t our hedonism but our refusal to acknowledge that God himself is the source of our greatest long-term happiness. Piper defines what he calls “Christian hedonism” by acknowledging five specific truths. Here are the first three
1. The longing to be happy is a universal human experience, and it is good, not sinful.
2. We should never try to deny or resist our longing to be happy…we should seek to intensify this longing and nourish it with whatever will provide the deepest and most enduring satisfaction.
3. The deepest and most enduring happiness is found only in God. Not from God, but in God.
Both the Stoic and the CBT therapist would heartily affirm #1 and #2. But by settling for simple cognitive or behavioral modifications to achieve satisfaction and happiness they stop far too early on the track. For it is only in recognizing and embracing #3 that God’s goal for humanity can truly be pursued. To truly be happy we must find our satisfaction in him.
Even in light of all of these differences, the counselor committed to integration may still assert that CBT and the biblical process of change can (or even should) be integrated as long as the Christian CBT therapist adopts the biblical truth, means, and goal discussed above. But if the CBT therapist were to integrate their approach that fully with biblical truth it would raise the question, “In what ways are they still a CBT therapist?” In fact, they would no longer be practicing CBT, but biblical counseling. This isn’t integration but assimilation. The therapist has become a biblical counselor.
This distinction is important because it will determine where the counselor turns most often for additional wisdom, insight, and tools in their ministry to others. If they believe they are fundamentally practicing CBT, they will turn to expert CBT practitioners to learn and grow. However, if the Christian recognizes that what they are practicing is, in fact, biblical counseling, they will turn to Scripture and to the wealth of wisdom provided both in the local church and the biblical counseling movement. If you were to take your car, remove the wheels and build a hull underneath it, remove the engine and replace it with an outboard motor on the back, and remove the dash instruments in order to install sea navigation instruments, I guess you could still call it a car if you wanted to, but it would probably be more accurate to call it a boat. And if you wanted to improve your new vehicle the best place to take it to would probably be a boat shop, as the only help your auto mechanic would have to offer would be cosmetic at best.
Having established the significant differences between CBT and the biblical process of change, the biblical counselor may be tempted to walk away from this article secure in their commitment to biblical counseling and content to never think about CBT again. However, I believe that would be a mistake. First of all, there are many astute observations about human functioning that CBT practitioners have made throughout the years that can remind us to consider factors we might otherwise miss or downplay. Listening to other observers of humanity (regardless of their theoretical commitments) always has benefits for the Christian whether it be in identifying helpful observations or simply better understanding how others think and make sense of the world without Christ. But probably the most helpful fruit of evaluating CBT for the Christian is the opportunity it provides to evaluate how much of our own counseling utilizes CBT-style behavior management and how much is truly dependent on God and his Word to transform hearts.
If we’re honest with ourselves, we will find that we all minister as CBT therapists far more often than we would care to admit. In fact, the history of biblical counseling has shown a subtle propensity for Bible-loving God-glorifying Christians to be drawn to the interventions promoted by CBT over gospel-motivated heart change. Let me provide three examples.
First, we can all be tempted to equate behavior modification with sanctification. When we do this, we declare “Success!” when we see certain emotions or behaviors change without taking the time to evaluate the reason they changed and whether or not God is actually transforming the person’s heart. What is it that has produced this change? A certain plan put in place by a counselor, or the truth of the gospel, delivered through the counselor, and empowered by the Spirit?
Second, giving homework to a counselee is one of the trademark features of CBT. Giving specific and realistic instructions (homework) is an undeniably helpful tool in a Christian’s process of sanctification. But we may be tempted to neglect the many other tools in the biblical counselor’s toolbox (generosity, a loving community, patient listening, prayer, etc.) when we, like the CBT therapist, see homework as the single most helpful thing we can offer a counselee.
Finally, the simplicity of many CBT interventions can tempt us to take their “common-sense approach” to change instead of prioritizing the counselee’s relationship with God. I know that far too much of my own counseling has been spent finding practical solutions to people’s immediate problems as opposed to helping the counselee remember God’s call to “seek first the kingdom of God, and all these things will be added to you” (Matt 6:33). Far more important than the counselee’s relationship with the counselor is his or her relationship with their Creator.
When we gently and consistently lead counselees back to the grace and glory of the gospel they will have all the truth they will ever need. When we gently and consistently lead counselees back to the person of Christ they will find their deepest satisfaction and richest joy. When we gently and consistently remind counselees of God’s call upon their lives to live humbly and sacrificially, confusion will dissipate. This is what it means to be a biblical counselor.
CBT changes people. That’s what it claims. And while there is plenty of evidence to demonstrate the fact that it can change certain behaviors and emotions, that doesn’t mean it can actually change people. Hurting and struggling people need more than just surface level change; they need transformation. And what can bring that about? As the old hymn says: nothing but the blood of Jesus.
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 Leah Harris, “A Radical New Direction for Suicide Prevention and Care” [on-line], accesed 3 May 2016, http://www.huffingtonpost.com/leah-harris/a-radical-new-direction-f_b_9838932.html; Internet.
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 Stefan Hofmann, et. al., “The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses,” Cognit Ther Res 36(5) (2012): 436.
 ACGME Program Requirements for Graduate Medical Education in Psychiatry [on-line], accessed 3 May 2016, https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/400_psychiatry_2016.pdf; Internet.
 Stanton L. Jones and Richard E. Butman, Modern Psychotherapies (Downers Grove, IL: IVP Academic, 1991), 218-19. These authors provide a helpful summary of CBT, but their analysis of the theory differs from what is presented here. Jones and Butman express enthusiasm about the Christian ability to incorporate CBT in a biblical model, where this article expresses concern.
 David Westbrook, et. al., An Introduction to Cognitive Behaviour Therapy, 2nd Ed. (London: SAGE Publications, 2011), 5.
 Donald Robertson, The Philosophy of Cognitive Behavioral Therapy (London: Karnac Books, 2010), 5.
 Ibid., 73.
 Michelle Craske, Cognitive-Behavioral Therapy (Washington, DC: American Psychological Association, 2010), 40.
 David Burns, Feeling Good (New York: Harper, 1980), xix.
 Craske, Cognitive-Behavioral Therapy, 49.
 Ibid., 35.
 Westbrook, An Introduction to Cognitive Behaviour Therapy, 8.
 “Core beliefs represent a person’s ‘bottom line’, their fundamental beliefs about themselves, other people, or the world in general.” Ibid., 9.
 Craske, Cognitive-Behavioral Therapy, 87.
 Burns, Feeling Good, 32-49.
 Hofmann, “The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses,” 436.
 Heath Lambert, “Oil and Water: The Impossible Relationship between Evangelical and Reparative Therapy” [on-line], accessed 10 May 2016, https://biblicalcounseling.com/resources/acbc-essays/oil-and-water-the-impossible-relationship-between-evangelical-and-reparative-therapy/; Internet. “Reparative therapy” exchanged for “CBT” in quote.
 Jones and Butman. Modern Psychotherapies, 223.
 Robertson, The Philosophy of Cognitive Behavioral Therapy, 82-85.
 John Piper, Desiring God (Sisters, OR: Multnomah Books, 1986), 23.