What it is, and why it works better than traditional therapy or drugs.
Many people suffer from the experience of being suddenly overwhelmed as they are gripped by an overwhelming emotion and their thoughts take them to dark places. For some it may be panic attacks; for others it may be episodes of crippling insecurity; for yet others a variety of phobias cause them to restrict their lives in order to avoid the triggering phenomenon.
Before we examine what Cognitive Behavioral Therapy (CBT) is, we need some context.
When we think of talk therapy we usually imagine a situation where the therapist works with the client over a long period of time to try to understand the cause of the client’s problem. This psychoanalytic approach was pioneered by people like Sigmund Freud and Carl Jung. Their general approach was adopted by most therapists thereafter, despite having no empirical evidence to support its efficacy.
Furthermore, although Freud’s case studies tend to feature patients who were “cured” as a result of psychoanalysis, Freud himself believed that the most important thing for patients was to understand why they were suffering; any cure was merely an incidental outcome and not at all the goal of the analysis.
Unfortunately, the amusingly baroque theories Freud and Jung variously constructed were entirely incompatible with evolution, not to mention (in Jung’s case) basic physics. Neither Freud nor Jung ever seems to have read Darwin or any of the later books explaining evolutionary theory. The constructs of psychoanalysis therefore were merely fantastical “just so” stories, akin to religious mythologies, and served only to obfuscate rather than to aid true understanding of the underlying phenomena they purported to explain. Not surprisingly as their explanations were wildly wrong their approach to treatment was also wildly wrong.
So it’s rather sad that for over a century no one thought much about the dubious basis of talk therapy. Many clients remained in therapy for decades; it was an expensive substitute for unburdening oneself to one’s close friends. Although therapy provided an excellent source of income for therapists, the medical value of therapy was extremely limited.
It’s not surprising that the big drug companies also sought to benefit from the fact so many people were struggling with emotional issues. First utilized in psychiatric hospitals where “a docile patient is a good patient,” psychoactive drugs soon spread throughout society. Tens of millions were prescribed depressants, stimulants, selective serotonin reuptake inhibitors, and a wide variety of other psychotropic compounds. The fact that these drugs usually had awful side-effects was ignored.
So it is that today, especially in the USA, we have the most over-medicated society in history. It’s good business for the pharmaceutical companies but not so great for the rest of us.
The really sad thing is that empirical evidence shows in most cases neither therapy nor drugs actually improve patient outcomes. For every one example of a “success” there are thousands of cases where no gain in function is achieved. The rare success, in other words, is a statistical artifact. If you have enough patients, a few will get better by random chance alone.
(NOTE: this observation does not apply to a very narrow range of neurological deficits such as bipolar disorder, where lithium salts do act to moderate the patient’s mood swings even though the underlying mechanism is not properly understood at this time.)
Furthermore, an increasing body of evidence shows that traditional talk therapy usually reinforces the trauma, and drugs create dependency. So standard treatments can be worse than simply doing nothing at all.
Fortunately, as knowledge of neuroscience improved, a few clinicians were willing to study this new understanding of the brain and attempt to create more plausible approaches to treating certain types of disorder. Cognitive Behavioral Therapy (CBT) was largely pioneered by Judith S. Beck and Aaron T. Beck. It was so effective that today a growing number of therapists are advocating this approach.
CBT recognizes that going over the supposed cause of a trauma serves to reinforce it and makes it worse. This is because the brain operates by creating connections between neurons. This is how memory works and it’s how we all acquire skills and knowledge. The more often something is repeated the more connections are made between neurons. So the very worst way of trying to overcome a trauma is by reliving it in talk therapy sessions.
Instead, CBT basically says “ignore what you believe to be the cause of the problem and focus instead on creating new helpful neural connections.”
So when a person is overwhelmed by a panic attack or an attack of deep insecurity or a fear of being out-of-doors or any similar sudden experience of being overwhelmed by one’s emotions, that person consciously focuses their attention on so-called safety signs. This, over time, creates a new set of pathways in the brain that eventually become more dominant than the pathways that are activated during the attack.
While the basic idea is simple, reality is of course more challenging. The brain wants to make sense of events, and so when a person is overwhelmed by emotion it’s natural for the brain to seek a reason and focus on that reason. Over time, the person becomes convinced that the reason is why these traumatic overwhelming emotions keep knocking them over. While the reasons may or may not be true, they are in fact irrelevant. Focusing on the nominal cause merely reinforces the neural pathways, thus strengthening the force of the occurrences and possibly also their frequency. It is very, very hard for us to pull away from our internal narrative and instead focus our attention elsewhere. But it’s essential if we’re to lessen the strength of our trauma and decrease the frequency with which it strikes.
So what are safety signs? Some examples include looking around and seeing that one is not under immediate threat, that one is in a safe place, that one is warm and dry, that there is food nearby, perhaps that there are friends nearby or within reach of a phone call. If we’re suffering from a phobia we can note that the object of our phobia isn’t present. If we’re suffering from a panic attack we can note that we’re actually alive, not under threat, and not exposed to any potential source of present harm. If we’re suffering an insecurity attack we can likewise note that our surroundings are stable and we can look for visible signs, or memories, to indicate that people close to us care about us. We have to resist the temptation to slip back into our old narrative, because that will simply amplify the attack just as previously.
Additionally, we focus on controlling our breathing, slowing our heart rate, and being peaceful. We look to reduce and eventually eliminate unhelpful actions like talking to ourselves about our fears, pacing, crying, panting, and so forth. By focusing on minimizing physical stress, we enable ourselves to calm down and continue to focus on safety signals. We do so for as long as necessary, perhaps for twenty or thirty minutes until we’re sure the attack has passed. Over time we grow in confidence as we learn to trust our ability to get our physical response under conscious control. This confidence makes us less vulnerable to the attacks, and more able to keep a clear head during them.
Not surprisingly, this takes a lot of practice and nobody gets it right the first few times. But with diligent practice we start to remember what we should be doing, we begin to do it, and over time we do it more and more automatically as new neural pathways are laid down and gradually become as strong as, and then stronger than, the old pathways that were activated when an attack struck.
Several studies have indicated that CBT is the most empirically effective form of therapy currently available and surpasses both traditional talk therapy and pharmacological approaches, without imposing unwanted side-effects nor locking us into potentially years of treatment.
I’ve written this article because I believe that it is important for people to learn that CBT is an option. We waste far too much time and money on ineffective therapy and we are far too dependent on drugs that rob us of agency and create all manner of harmful metabolic effects.
No treatment is ever going to be perfect and no treatment will ever be suitable for everyone. But today, CBT offers the best hope of truly minimizing otherwise intractable problems that millions of people struggle with every day of their lives.
Below is a list of references that provide an understanding of what CBT is and how it works.
Cognitive Behavior Therapy by Judith S. Beck & Aaron T. Beck
Cognitive Behavioral Therapy In 7 Weeks by Seth J. Gillihan
Cognitive Behavioral Therapy by Brandon Cooper
The Comprehensive Clinician’s Guide to Cognitive Behavioral Therapy by Leslie Sokol and Marci Fox
Evidence-Based Practice of Cognitive Behavioral Therapy by Deborah Dobson and Keith S. Dobson