Post via the The New Yorker:
“Can Cognitive Behavioral Therapy Change Our Minds?”
By Joshua Rothman
“I’ve had only one panic attack. It happened in the fall of 2008, during a period when my wife and I were graduate students in English. I was walking across a sunny quad, wearing an actual tweed jacket, thinking about all the papers that I had to grade, when suddenly a wave of fear washed over me. Its origin wasn’t at all mysterious: I had no workable plan for my life. There were almost no jobs for new English professors, and the search for work would likely send me and my wife to different parts of the country. How would we ever build a life together, or start a family? Intellectually, I had known for years that we were approaching our future in an unrealistic way—but now the problem registered as a physical assault, contained in the brightness of the sun and the stirring of the air. Oh, my God, I thought. What am I going to do? Breathing hard, I paced up and down the path, preparing to throw up. It took a few minutes for these sensations to pass; eventually, the sound of the chapel bell steadied me, and I sat on a bench, drained and disturbed.
One thing that dismayed me about the panic attack was its accuracy: my life really did need a major course correction, which I had no idea how to effect. But I was also unsettled by what the attack said about my personality. Having grown up in a tumultuous family, with a mother beset by alcoholism, I had worked hard to master my feelings through homegrown strategies of self-regulation. I had, at various times, felt guilty, angry, paralyzed, worthless, incompetent, or ashamed, in ways that I knew made no sense, and over the years I’d figured out how to stop, or at least attenuate, those feelings. In many respects, overcoming my childhood was my life story; I took pride in not being ‘messed up.’ Now it appeared that I was out of control after all.
I was far from the only troubled grad student. For reasons personal or professional, about half of my classmates seemed anxious, depressed, or otherwise at wit’s end. When I told one of them about my panic attack, she mentioned cognitive behavioral therapy, or C.B.T.—a rational kind of therapy, she explained, that focussed on influencing your emotions by inspecting and adjusting your thought patterns. I didn’t think that I needed to see a therapist, since panic attacks weren’t a regular part of my life. But I did read ‘Feeling Good: The New Mood Therapy,’ a perennially popular self-help book about C.B.T., published in 1980 by David D. Burns, a psychiatrist at Stanford. Cognitive behavioral therapy, Burns wrote, was based on the idea that ‘your feelings result from the messages you give yourself.’ This was an old and familiar notion (we are disturbed ‘not by things, but by the views we take of things,’ the Greek philosopher Epictetus wrote), but C.B.T. systematized it through exercises designed to identify problematic emotions and trace them back to the thoughts that had authored them. ‘Your thoughts often have much more to do with how you feel than what is actually happening in your life,’ Burns wrote. By confronting and adjusting those thoughts, he argued, you could change your mood and behavior.
I was skeptical about C.B.T.; I’d read ‘The Interpretation of Dreams‘ and ‘Civilization and Its Discontents,’ and doubted that our irrational moods and feelings could be brought under such rational control. But, when I got to Burns’s list of ‘cognitive distortions’—bad mental habits that cause us to react inappropriately to life’s difficulties—I started to change my view. I recognized myself vividly in the list. I had certainly engaged in ‘all-or-nothing thinking’—assuming, for instance, that, after disappointing my parents in some way, I must be an altogether bad son. I had practiced ‘emotional reasoning,’ in which a feeling is taken to be, in itself, ‘evidence for the truth’—a mental spiral that allows an inaccurate emotion to get a grip. (Feeling like an idiot, you might think, Only idiots feel this way.) I’d been particularly fond of ‘personalization’—the tendency to ‘assume responsibility for a negative event when there is no basis for doing so.’ On some level, personalization had been the reigning condition of my teen-age years: emerging from a disorganized and confusing childhood, I had imagined that I’d created it.
Reading Burns’s list of cognitive distortions, I recalled how I’d wrestled with them in my own life. I’d kept diaries and taken photographs; I’d written fiction about thinly disguised versions of myself. I’d simply been unhappy, then found ways of ending that unhappiness a little sooner—workouts, Martinis, incredibly loud music. A key strategy involved a kind of internal mental effort that seemed vaguely telepathic, like something out of the sci-fi novel ‘Dune.’ I’d just control my feelings, holding them carefully, as though I were walking through a house while carrying a bowl brimming with water; when I sensed a bad feeling unbalancing me—anxiety, stress, guilt—I’d wrinkle my brow and hold my mind steady, pushing the bad feeling away with a kind of brain work that registered as physical. And, on top of all this, I was constantly thinking about my life, trying to decide, in an almost philosophical way, whether I was a decent person.
Burns’s approach, I found, differed from mine to a nearly comical degree. After a difficult experience, he’d simply use ‘the double-column technique.’ This involved drawing a line down the middle of a sheet of paper, then recording his ‘automatic thoughts’—fears, dissatisfactions, grumblings, confessions, and so on—on the left, and his ‘rational responses’ to those thoughts on the right. Faced with an unreasonably angry patient who calls him incompetent and moneygrubbing, Burns’s automatic thought is, ‘He should at least treat me with respect!’ But his rational response resists all-or-nothing thinking: he asks himself, ‘Do you expect him to show respect all the time, or part of the time?’ (In fact, the man is sometimes respectful: ‘If you don’t expect perfection, you won’t feel frustrated,’ Burns notes.) When another patient is pointedly unappreciative of Burns’s help—’Your methods are no damn good,’ she says—his automatic thought is, ‘She should admit I helped her! She should be grateful!’ But, more rationally, he thinks, ‘Why ‘should’ she? That’s a fairy tale. If she could she probably would, but she can’t yet.’ His distress, he concludes, is the product of an irrational belief that, when he helps people, ‘they are duty-bound to feel grateful and reward me for it.’ ‘It would be nice if things worked like this,’ he writes, ‘but it’s simply not the case.’
It was impossible for me not to admire Burns and his levelheaded methods. Mine were almost medieval by comparison. I felt foolish. To deal with my problems, I’d written dozens of unpublishable short stories; not once had it occurred to me to try using two columns on a single page. I’d taken classes on Freud and thought about my own unconscious; I’d never considered subjecting myself to a rational point-counterpoint. C.B.T. seemed understandable, powerful, and enjoyably straightforward. Had I been wasting my time? Could it really be that simple?
Burns didn’t invent cognitive behavioral therapy, but he is connected to its founding lineage. He studied with the psychologist Aaron Beck, who created an approach known as cognitive therapy, or C.T., in the nineteen-sixties, and is often described as the ‘father’ of C.B.T. Beck’s ideas dovetailed with the work of Albert Ellis, a psychologist who had invented rational-emotive behavior therapy, or R.E.B.T., the decade before. There are substantive differences between C.B.T. and R.E.B.T., but also essential commonalities. They all reflect the so-called cognitive revolution—a shift, which began in psychology during the mid-twentieth century, toward a more information-based view of the mind. Freudian thinkers had pictured our minds as hydraulic machines, with pressures rising against resistances and psychic forces that might get bottled up. The cognitive model, by contrast, imagined something more like a computer. Bad information, if it were stored in a crucial place, could cause system-wide problems; irrational or inaccurate thought patterns could shape feelings or behaviors in counterproductive ways, and vice versa. Coders get at a similar idea when they say, ‘Garbage in, garbage out.’
Ellis, who earned a Ph.D. in psychology in 1947, trained as a psychoanalyst but grew frustrated with the tradition’s approach to therapy, which he felt emphasized dwelling on one’s feelings and ultimately subordinated patients to their pasts. The ‘rational therapy’ for which he became known in the sixties proposed that individuals had the power to reshape themselves willfully and deliberately, not by reinterpreting their life stories but by directly analyzing and modifying their own beliefs and behaviors. ‘We teach people that they upset themselves then and that they’re still doing it now,’ Ellis said, in a 2001 interview. ‘We can’t change the past, so we change how people are thinking, feeling, and behaving today.’ Ellis showed his patients how to avoid ‘catastrophic thinking,’ and guided them toward ‘unconditional acceptance’ of themselves—a rational position in which you acknowledge your weaknesses as well as your strengths.
Beck, like Ellis, trained in a Freudian tradition. ‘He was a psychoanalyst who had people lie on the couch and free-associate,’ his daughter, the psychologist Judith Beck, who heads the Beck Institute for Cognitive Behavior Therapy and teaches at the University of Pennsylvania, told me. He switched from searching for repressed memories to identifying automatic thoughts after a client seemed anxious during her session and told him, ‘I’m afraid that I’m boring you.’ Beck found that many of his patients had similar negative mental touchstones, and based cognitive therapy upon a model of the mind in which negative ‘core beliefs’—of being helpless, inferior, unlovable, or worthless—lead to a cascade of coping strategies and maladaptive behaviors. Someone ‘might have the underlying belief ‘If I try to do something difficult, I’ll just fail,’ ’ Judith Beck told me. ‘And so we might see coping strategies flow from that—for example, avoiding challenges at work.’ In C.T., patient and therapist joined in a kind of ‘collaborative empiricism,’ examining thoughts together and investigating whether they were accurate and helpful. C.T. combined with elements from behavioral approaches, such as face-your-fear ‘exposure’ therapy, to create C.B.T.
In the second half of the twentieth century, rational and cognitive therapies grew in prominence, their lingo sliding from psychology into culture in roughly the same way that Freudian language had. Ellen Kanner, a clinical psychologist who trained in the nineteen-seventies and has been in practice in New York since 1982, watched the rise of C.B.T. in her clinic. ‘I’ve seen psychology evolve from very Freudian, when I first did my training,’ she told me. Cognitive behavioral therapy had an advantage, she recalled, because therapists and researchers liked its organized approach: exercises, worksheets, and even the flow of a therapy session were standardized. ‘You could more easily codify it and put it in a study with a control, and see whether it was effective,’ she recalled. Patients, meanwhile, found the approach appealing because it was empowering. C.B.T. is openly pitched as a kind of self-help—’We tell people in the first session, ‘My goal is to make you your own therapist,’ ’ Judith Beck told me—and patients were encouraged to practice its techniques between sessions, and to continue using them after therapy had ended. Compared with older approaches, C.B.T. was also unthreatening. ‘When they’re using it, therapists aren’t asking you about your sexuality or whether someone molested you,’ Kanner said. ‘C.B.T. is more acceptable to more people. It’s more rational and less intrusive. The therapist doesn’t seem as powerful.’
The pivot that C.B.T. represented—from the unconscious to the conscious, and from idiosyncrasy to standardization—has enabled its broad adoption. In 2015, a study by Paulo Knapp, Christian Kieling, and Aaron Beck found that C.B.T. was the most widely used form of psychotherapy among therapists surveyed; in a paper published in 2018, titled ‘Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy,’ the psychologist Daniel David and his collaborators concluded that it was the most studied psychotherapy technique. (‘No other form of psychotherapy has been shown to be systematically superior to CBT,’ they write. ‘If there are systematic differences between psychotherapies, they typically favor CBT.’) Meanwhile, the therapy keeps extending its reach. ‘I just got back from Japan, where they’re teaching C.B.T. in schools, and have used C.B.T. methods for people who were at risk for suicide,’ Beck told me. In the U.S., many schools integrate aspects of C.B.T. into their curricula; the U.K.’s National Health Service has commissioned at least a hundred thousand C.B.T. sessions. Increasingly, C.B.T. is also delivered through apps or chat interfaces, by human therapists or bots; studies have shown that online C.B.T. can be as effective as therapy conducted in person. Even though C.B.T.’s central tenets are nearly half a century old, people who discover it today may still find that it feels au courant. It’s a serious therapeutic tool, but it’s also a little life-hacky; it’s well suited for an era in which we seek to optimize ourselves, clear our minds, and live more rationally.
I asked Judson Brewer, a psychiatrist and neuroscientist and the director of research and innovation at Brown University’s Mindfulness Center, for his views on C.B.T., and he referred me to a comedy sketch, made in the early two-thousands, starring Bob Newhart as a therapist and Mo Collins as his patient. ‘I have this fear of being buried alive in a box,’ Collins says. Newhart asks, rationally, ‘Has anyone ever tried to bury you alive in a box?’ ‘No, no,’ Collins replies. ‘But, truly, thinking about it does make my life horrible.’
‘Well, I’m going to say two words to you right now,’ Newhart explains. ‘I want you to take them out of the office with you and incorporate them into your life. . . . You ready?’
‘Yes,’ Collins says.
‘Stop it!’ Newhart screams.
Brewer has been trained in cognitive behavioral therapy, has used it clinically, and still refers some patients to C.B.T. specialists. But, he told me, he has come to believe that the therapy’s emphasis on rationality can be limiting. ‘Maybe you’ve heard this characterization of C.B.T.—‘Catch it, check it, change it,’ ’ he said. ‘It’s about thinking your way out of your situation. You’re literally changing your cognition.’ But thinking differently, in his view, isn’t always the right approach. The idea that we can challenge and adjust our automatic thoughts ‘makes us feel like we’re in control,’ Brewer went on, but constantly wrestling with our thinking can itself become a bad mental habit: if you feel anxious, the best approach might not be to interrogate your anxious feelings or mount a rational counterattack, but simply to notice the anxiety and then let it pass. ‘It’ll go away on its own,’ Brewer said. ‘If you push it away, or engage with it, or tussle with it, it’ll grow.’ Brewer has explained his mindfulness-inflected theory of personal change, which has its roots in what he calls Buddhist psychology, in books such as ‘Unwinding Anxiety,’ from 2021. ‘With mindfulness, it’s about changing the relationship to cognition,’ he said. ‘The thought is already there. It’s not something we have a lot of control over. It’s going to come up. But you can observe it, and, by observing it, you can change your relationship to it.’
I gave Brewer a capsule version of my own story, explaining how I’d spent years wrestling with my emotions and thoughts. It had taken a lot of work, I said, to get myself straightened out. ‘I just want to call attention to that word you used, ‘work,’ ’ he said. ‘We’ve been trained, as part of our culture, and as part of C.B.T., to think, I have to work to change myself.’ This attitude, he continued, could be counterproductive. ‘People get in their own way. They say, ‘I’m not working hard enough. I don’t have enough will power.’ But curiosity and kindness don’t take work. They take practice and recognition.’
If Brewer thought that C.B.T. was too work-intensive, Kanner had the opposite concern. ‘If I have someone, and they have a lot of negative self-talk, and I can get them to see that, and they can change, then I’m golden,’ she said, of using C.B.T. with patients. ‘But my experience is that, if you can use logic to solve your problems, and say, ‘Oh, I’m speaking to myself in too harsh a way, I’m catastrophizing,’ and that’s enough, then you probably don’t have trauma. Sometimes there’s an unconscious process that has to be addressed when there’s resistance to conscious interventions. If your mother told you that you were ‘worthless,’ or you had parents who were narcissistic or alcoholic or who didn’t build you up, then we have to go back and talk about your history. That’s more of a psychodynamic approach.’
Beck, when we spoke, told me that cognitive behavioral therapy is less exclusively cerebral than is often supposed. Burns’s manual ‘Feeling Good,’ she said, had been written during ‘an era in which there was much more of an emphasis on rationality’; although the cognitive side of the therapy remains fundamental, the Beck Institute now incorporates mindfulness, ‘compassion-based therapy,’ and techniques from other evidence-based therapies. ‘You have to change your ideas both at the intellectual level and emotionally, at the gut level,’ she told me. She asked me to imagine a patient who had experienced trauma at the hands of a parent with alcoholism. ‘It’s not the events themselves—it’s the conclusions they reach, such as ‘I’m unlovable, I’m worthless,’ ’ she said. ‘We first help someone understand why these things happened on an intellectual basis. ‘These things happened because my mother was often drunk, not because I was a bad kid.’ Sometimes those realizations will filter down to the emotional level. But sometimes they’ll say, ‘I still feel like I’m a bad person.’ In which case what they’re saying is that the intellectual techniques were necessary but not sufficient.’
Beck walked me through a hypothetical C.B.T. session for such a patient. ‘For example, we might have the client recall in detail one specific incident that she really remembers well,’ she said. ‘We work through that first at the intellectual level. But then we might ask the client to visualize it, as though it’s happening right now. She’s a seven-year-old child coming home from school, and the mother hits and hits her for waking her up when she comes in, even though the child didn’t do anything wrong—all she did was come home. And then we can kind of do C.B.T. with the seven-year-old child. We can ask, What is that child feeling? What is she thinking? And we can ask the client, Do you believe that thought a little bit, or a medium amount, or a lot? And then we might have the child continue the image until she’s in a safe place—maybe tucked into bed. And then we might ask the client to have her older self come into the room, too. The younger one says, ‘Mommy hit me because I’m bad.’ And the older one answers her back.’
Each year, the Beck Institute delivers C.B.T. training to more than seven thousand clinicians around the world. And yet C.B.T. is practiced so widely, and in so many different ways, that a patient might not encounter what is now the official version. A typical therapist might employ C.B.T. as one of many techniques, using a particular exercise when she believes it will help a particular patient. Beck thinks that C.B.T.’s rational approach is most effective when the therapy is ‘delivered in the context of a warm, compassionate therapeutic relationship,’ and that C.B.T. ‘must be adapted for each individual client. It isn’t one size fits all.’ But large numbers of people administer C.B.T. to themselves, using workbooks (‘Cognitive Behavioral Therapy: Simple Techniques to Instantly Be Happier, Find Inner Peace, and Improve Your Life‘) and even decks of cards (‘CBT Deck for Kids and Teens: 58 Practices to Quiet Anxiety, Overcome Negative Thinking and Find Peace‘). A person coming to C.B.T. in this way might be forgiven for thinking that the worksheets and exercises embody, in themselves, a complete theory of how we change, and mistake their limitations for her own.
C.B.T. does contain a theory of change—and it’s not entirely convincing. If people could change just because rational thinking told them to, we wouldn’t live in such a crazy world. Yet the rationality of C.B.T. is aspirational. We can wish that we were the kinds of people who could solve our biggest problems simply by seeing them more clearly. Sometimes, by acting as though we are those people, we can become them.
The mind is an alien place; it’s impossible to describe anyone’s completely and accurately. This only makes it more powerful when a therapeutic model offers you a way of describing yourself to yourself. Do we really have ‘core beliefs’? Are we really shaped by our ‘automatic thoughts’? Simply by proposing such ideas, we can make them almost true. It’s by believing in descriptions that we allow therapy to slide from theory into practice. Scaling the rock face of our own problems, we can carve the rock in fresh ways, inventing handholds; we can create new routes where none seemed to exist. In the years leading up to my panic attack, I wanted to be the sort of person who dealt with his problems through roundabout, artistic means. I didn’t particularly want to be a rational person. C.B.T. helped me notice this, and ask, Why not?”