Cognitive Behavioral Therapy: Some New Thoughts

Patient Expert

Is cognitive behavioral therapy not what it used to be? This is the strong suggestion from a Norwegian study published in Psychological Bulletin.

The study amounts to 17 pages of impenetrable statistical gobbledygook. Sample sentence: “The metaregressions examining the temporal trends indicated that the effects of CBT have declined linearly and steadily since its introduction …”

In plain English, recent studies of cognitive behavioral therapy (CBT) show less impressive patient outcomes than studies conducted during the 1970s and 80s.

Does this mean we should give cognitive therapy a miss? Not at all. Let’s investigate …

CBT is a manual-based talking therapy designed to provide patients with the necessary skills to avoid the cognitive and emotional traps that make us sitting ducks for depression. The therapy has also been adopted for PTSD and other conditions.

For instance, if you’re stuck in traffic your default response might be to ruminate how you’re going to be late for your meeting, which in turn is sure to get you fired, which in turn means you will wind up homeless.

With practice, though, you can change your reaction to something like, “Great, I get seventeen extra minutes of uninterrupted opera time.”

CBT does not equate to positive thinking. The therapy only works when we discipline our brains to reject the mindless negative chatter that sets us up for depression. This frees us to implement more constructive thinking. In essence, we learn to replace “it’s the end of the world” with “let’s work on finding a solution.”

And how does it FEEL when you’re working on a solution, with a sense of control? As opposed to freaking out and being helpless? Precisely.

So if cognitive therapy works so well, why are we seeing diminishing returns? Here is my theory:

Our treatments and therapies for depression and other mental illnesses fall into the trap of one-size-fits all. Antidepressants don’t work for everyone who has depression. Neither would any form of talking therapy. Especially CBT.

CBT is not about lying on a couch waiting for your therapist to make a penetrating insight about your childhood. It’s all about the here and now. You’re learning new skills for navigating life and there’s homework involved. No effort, no result.

My guess is that CBT could be a victim of its own success. Those first clinical trials were most likely done on a willing patient population, with equally motivated clinicians. Since the 1990s, though, CBT has been routinely recommended for all and sundry.

Perhaps you can see the problem. For instance, if you’re too depressed to get out of the house to even keep your appointment with your therapist, let alone do your homework, CBT is not going to work. The same is true for those with personality issues, such as having problems dealing with authority figures.

Throw into the mix a much wider pool of clinicians, and we find ourselves dealing with average-on-average rather than motivated-on-motivated.

Finally, contrary to what its proponents may tell us, CBT may not be a therapy for all seasons. In my experience, I have found that the skills I learned from CBT work best in avoiding or lessening the impact of impending depressions rather than getting me out of my current one.

The takeaway …

The skills you learn from CBT can be enormously useful in managing your depressions. But you need to be sufficiently motivated and disciplined to put in the work. If you tried CBT before and weren’t happy with it, it may have been because you went into it when your weren’t ready, when your depression and other circumstances were conspiring against you.

Your situation may be a lot different now. You’re the one who knows yourself best. Are you ready this time?