CBT is Like Shopping at 7-11 for Your Mental Health Needs
One of the things that drives me crazier than usual is this notion that anxiety is in overwhelming proportion amenable to rational thought on the part of the person suffering from the anxiety disorder. It's a persistent idea. It's also wrong.
Cognitive behavioral therapy: What they don't tell you, why you should find out
Large segments of society and government sit in the somewhat jaded but still pro-positive thinking/CBT camp. (CBT essentially being the idea that rational interventions can identify and mitigate harmful cognitive feedback loops.)
The problem? This has increasingly led to the use of CBT as a catch-all for people with mental health issues with the expectation that it will make them well and do it darn quickly.
CBT seems like a tailored, streamlined mental health treatment that should work sufficiently well for most. Plus insurance companies love it. The underlying premise is, however, not so much brain-centered as it is economically and emotionally motivated.
I'm the last person to suggest either of those motivations are inherently bad. They're not. But when it comes to things like treating anxiety and depression, emotional and economic efficiency shouldn't be top of the list. Making them so endangers lives but nobody wants to think about that much, 'k.
Brains require more than brief, 'rational' interventions. If you don't believe me, please watch this amusing and informative TED talk by a cognitive neuroscientist:
After you've watched that. You did watch it? I know it's long. Think about how many years we spend learning apparently simple skills like:
- How to relate to each other;
- How not to freak out and think the world is ending when someone leaves;
- How to answer questions in our own lives whilst feeling confident about that and possibly creating our own small miracles of nature in the process.
How to tell your mental illness really does exist
Suppose one day, in your 20s, or when you pop out one of those small miracles of nature, a whole bunch of those skills get wiped out. Without warning, or preparation. "And there's no manual", as Ruby Wax would say.
You didn't have a stroke but in terms of your ability to function mental illness can have similar effects. A stroke might be easier; Nobody would tell you to "perk up".
In any event, you've crashed and now you get to pick up the pieces. Most people do not know how to do this. Again, no guidebook. Maybe they keep quiet, until it turns into 'I seem to be in the hospital. Er, maybe there's really something wrong?'. It's about that time someone offers 6 to 8 sessions of CBT with a side of medication.
CBT is not the magic bullet of mental health recovery
What isn't often mentioned is that to work well, and not remain simply a semi-functional bandaid that comes off when wet, CBT needs continual reinforcement over the long-term. That 6-8 therapy sessions with some dude you've never seen before but to whom you're supposed to reveal your innermost thoughts, no matter how terrible they may seem, probably won't fix mental illness.
Regardless of efficacy or efficiency the government, my neighbor, my family have no right to tell me that 6-8 sessions should be quite sufficient to undo the damage. It's unlikely I'll begin to understand the magnitude of what I've lost in 6-8 sessions, let alone fix anything. Can I pick up a few helpful tools? Sure but it's still the equivalent of shopping at the 7-Eleven for all your mental health needs.
White, K. (2011, June 11). CBT is Like Shopping at 7-11 for Your Mental Health Needs, HealthyPlace. Retrieved on 2020, December 4 from https://www.healthyplace.com/blogs/treatinganxiety/2011/06/cbt-is-like-shopping-at-7-11-for-your-mental-health-needs
Author: Kate White
I agree that some therapists are not being trained as well as they might. I think there is also a perception now by the public that cbt can cure all in 6 sessions. However, I feel for longstanding or recurrent problems cbt on its own is not enough.
I can see and understand both sides of the argument. As a cbt therapist starting out thirteen years ago, I came to realize that cbt wasn't the answer to all people and all illnesses. I then started using schema focused cbt in conjunction with standard cbt. I find that the combination works really well. I use schema therapy for longer term problems and have had good success using it briefly as well. Another problem which I see in the private sector is people buying into the hype surrounding cbt. They have high expectations of success in relatively few sessions and it doesn't matter how severe there illness is.
I see your point. 6-8 sessions probably won't cut it. But I'd say that's not an indictment of CBT, but of cost-cutting insurance companies.
When I was suffering from depression and anxiety, I underwent two years of CBT from an outstanding psychologist, and it changed my life. I gained a measure of control over my thoughts, and thus my emotions, I never dreamed possible. Before this therapy, I thought emotions were a roller-coaster ride we have no control over--that all we can do is enjoy the good times, hang on for dear life during the bad times, and more or less muddle through the rest. I was 56 when I started CBT. I'm so grateful for it and for my wonderful therapist. It was a lot of hard work, pretty much every hour of everyday for two years, but I quickly started to see progress and that motivated me to trust it and keep at it. It's still work, often hard work, but using CBT I can choose my thoughts, keep perspective, alleviate anxiety, maintain much better control over my emotions, and avoid falling back into the dark pits of depression. I doubt there is actually a cure for depression, but CBT keeps it at bay and lets me live my life.
I am more than willing to help out in anyway I can. I'm going to leave you my work email for you to access me with any questions. It is public information so I don't worry about people accessing it. firstname.lastname@example.org
Thank you for that acknowledgement. And judging by your following, my clinical experience, and feedback from clients they are all very valid concerns. I also want to state a point that I saw titled in another entry about anxiety work and it being hard. That is exactly what I tell everyone. IT IS HARD WORK! If it were easy a person would have figured it out on their own.
I wish I could say that there are more therapists out there that use techniques, theories, and evidence based practices that work, however that seems to be the exception not the rule. However I will say that insurance/government entities are forcing people to actually train and be competent in such areas. There are some basics that you can tell about a therapist if they are doing actual CBT.
1) Do they set an agenda each session at the beginning?
2) Do they stay focused on one problem to master or come to resolution in that area?
3) Do they assign homework or home practice between sessions?
4) Are they using psychometric measures (rating scales, self-report forms, etc) to track how clients are doing?
5) Do they ask for feedback on sessions and check with client on how they are doing?
6) Most important: are these done collaboratively?
If a person can't answer yes to all of the above, more than likely they are not getting true CBT. If you ever want more feedback or information do not hesistate to ask :) This is a great blog!
hi again Zach,
what a great comment!
I really like that you couch (excuse the pun) your approach in that final question: are these done collaboratively? Yes! And thank you. It's where so much can just fall down, no matter how experienced, intelligent or well-intentioned the folks in the room may be. It takes two to tango and then some with so much of the work there really is to do in therapy.
Would you mind if I used some of your ideas here in a future post? I think it could be really valuable for my readers to see (with appropriate credit of course).
As to the insurance carriers it seems to vary by geography. There is a big push towards low-cost, severely condensed CBT training of GPs outside of the USA. In theory to reduce the eventual burden on the health care industry/public sector but it's a bit of a joke in reality.
I noticed that the CBT referenced in the article only speaks about the "C" part...meaning cognitive aspect of therapy. If you want real change and treatment for anxiety, you will need the behavioral or "B" part. Meaning exposure therapy, or other related exercises. Strict only cognitive or "talking/processing/rational thinking" techniques rarely promote change in anxiety disorders. The exposure or experience of a situation, object, or place is what makes the "B" part the most crucial due to experiencing a perceived catastrophic situation in a new way (meaning it didn't happen the way your mind predicted it to happen) over and over. Then it becomes habitual and poof, anxiety is changed! If you don't believe me check out all of the research. Confirms that people seeking change in anxiety disorders can anticipate 60% of symptoms reduced. None of this was referenced in the article which makes me believe that the author is not really talking about CBT or hasn't experienced competent or "real" cognitive behavioral therapy.
PS: I'm a therapist and an expert in treating anxiety disorders.
thanks for your comment.
sounds like your approach is sensible and in-depth. i'm glad to hear it! :)
the B part was indeed put to one side for purposes of this article but not because i'm unaware or unappreciative of its benefits for some people; largely because i have a word limit and was making a point about the way CBT is all too often distorted and used as a quick-fix bandaid solution by undertrained, underresourced therapists who miss the big picture and the potential benefits of a multidisciplinary long-term approach. that seems to be due to government/insurance restrictions in most cases but in the experience of many clients i've spoken to it's due to general incompetence [yes i'm aware of how anecdotal that is nevertheless it's relevant to many of my readers].
WELL SAID. i always said CBT for myself was useless because, in my own terms--"i KNOW why i do the things i do and think the things i think; but that doesn't stop me from doing and thinking them."
you can put a bandage on a wound, but if the patient has a bleeding disorder, he's still going to bleed out.
You might want to chime in on my post regarding affirmations; I think it ties in nicely with this article: http://www.healthyplace.com/blogs/breakingbipolar/2011/06/i-am-good-enough-and-people-lik…
thanks for your comment on this one. i'll have a look at your article.
I just discovered this site and hoorraaayyy.... the pic of a mental stroke combined with what Robin shares strike home. I am so tired of trying to articulate my emotional state (with lay and mental health professionals) and getting little or no results. Generating energy takes all my energy. Often find I am in analysis paralysis......... think about "stuff" but nothing changes.
I like the picture you paint about having a mental stroke. I have been searching for ways to express what depression feels like to one of the "get over it crowd". I can't explain it- they don't get it.
it is terribly difficult to communicate what it's like, isn't it?
i suspect a lot of people who fall into the "get over it crowd" don't really want to get it, either. just because they're uncomfortable with the thought of it. for whatever reason. that's why i do advocacy work -to try to break the stigma of mental illness, or at least get people willing to engage.
Very interesting article and as a therapist practising CBT with clients, 6-8 is pretty short but seems to work well with individuals with adjustment problems. however Beck definitely advocated 18-24 sessions (minimum) for depression. so it is a challenge but it's also the clinician's choice to extend therapy. I'm not sure if there's any specific magic bullet for mental health recovery but with so many various options/psychotherapies for our clients, I'm sure there's one that can help them feel better :)
thanks for your comment. yeah, this post is in large part a response to listening to a lot of stories from folks who struggle with health coverage/national health services that restrict them to that (imo, unreasonable) 6-8 session limit, give or take. for those that are able to take advantage of private therapeutic services it makes a world of difference. as you say, there are a world of options, with a willing clinician and a good therapeutic alliance.
great words and so true...as many of us who have been through this all our lives have tried to tell professionals. Like a Slurpee it get's you through the moment
Hi Kate. Great piece. Encapsulates the frustration many people have with CBT.
CBT is great, and I'm a big believer in it, but it just doesn't touch severe, biological mental illness. It just doesn't. And much as you mention, 6-8 sure ain't gonna help matters either.
Again as you mention, CBT is a set of tools and sometimes that set of tools is exactly what a person needs to fix their house, but it can't really build a house from the ground up.
On the upside, when people are doing better, CBT often works better. (If you're already healthy, shopping at a 7-11 isn't so bad.)
New research suggests that with severe mental illness only neurobiological treatments have any real success. (This doesn't necessarily mean medication but often does.) But the same research indicates that CBT is more successful on less severe symptoms.
So... I feel you. Totally. But don't give up on CBT, it has it's place.
Who doesn't have a hankering for a Slurpee now and then?
- Natasha (from Breaking Bipolar)