TThe first time I was introduced to cognitive behavioral therapy (CBT), I felt the pleasure of recognition and superiority. I was in high school and it would be years before I saw a therapist of any kind, but from what I gathered online, CBT consisted of what I was already doing.
The modality grew out of the core belief that irrational thoughts are responsible for emotional suffering, according to Rachael Rosner, a historian writing a biography of Aaron Beck, the father of CBT. It followed that changing these thoughts could alleviate distress.
You may be concerned that your headaches are a sign of a brain tumor. The CBT “thought registration‘ technique might advise you to gather the facts for and against this fear. Is there a family history of brain tumors? Could the headache be caused by dehydration? Then you rephrase it into a more realistic and probably less panicky position.
This back and forth volley already described my inner monologue. Years later, I chose as my first therapist someone who practiced an old-fashioned form of cognitive behavioral therapy that reinforced these habits.
It was easy to find such a therapist. Although exact statistics are scarce, CBT is a common form of therapy. Many practitioners consider it the Golden standard of psychotherapy and use it for conditions such as anxiety and depression. In 2002, the Washington Post claimed: “Be that as it may, cognitive therapy is quickly becoming what people mean when they say they are ‘getting therapy’.”
Its concepts “are now very mainstream,” says Sahanika Ratnayake, a philosopher of medicine and psychiatry. “You hear people talk about ‘cognitive distortions’ and ‘reframing your thoughts’ and the idea that the way you think about something changes how you think about it.”
But despite my fluency in these techniques, I remained trapped in rumination. Knowing all cognitive distortions – types of negative biases or irrational thinking – did not reduce concerns. No matter how much evidence I gathered to show that a concern was unlikely, I couldn’t forget that unlikely things happen. People goods struck by lightning, planes crashed, headaches turned out to be tumors. Eventually I switched to psychodynamic therapy (more focused on feelings, more useful for me), but continued my inner debate tournament.
In my 30s, I was diagnosed with obsessive-compulsive disorder (OCD), a condition characterized by intrusive thoughts and physical or mental compulsions to get rid of those thoughts. This delay was not unusual: diagnosing OCD can take time up to 14 to 17 yearspartly because it is possible difficult to distinguish of other disorders such as anxiety. During that time, these thought-challenging techniques can backfire. They did that for me.
TThe story of modern cognitive behavioral therapy is partly the story of being in the right place at the right time: the US in the 1980s. After the Diagnostic and Statistical Manual of Disorders III was released in 1980, the National Institute of Mental Health began requiring researchers to randomized controlled trials for therapy if they wanted financing. By then, Rosner says, Beck had already done that created a manual for CBT so that it could be standardized and studied in this way. This meant that CBT therapists were able to quickly adapt to the new rules, and the techniques took off.
As insurance companies became increasingly interested in CBT, therapists developing new modalities were also eager to join CBT, in part so that these forms could also be covered by insurance, Ratnayake said. Today, CBT is a broad label that can include, for example, mindfulness skills and anxiety tolerance skills.
Yet it is the original ideas around modifying irrational thoughts – the ‘cognitive’ part of cognitive behavioral therapy – that seem to have penetrated the most into the mainstream. Behavioral and exposure-based CBT techniques are effective, but therapists may be less likely Unpleasant use these methodssays Dean McKay, professor of psychology at Fordham University. Article mentioning CBT tend to to emphasize the aspect of ‘distorted thinking’, like most free worksheets – all of which contributes to the mistaken idea that cognitive behavioral therapy is primarily about being rational.
Cognitive techniques work for many. But “the typical OCD patient already knows the evidence,” adds McKay, who has researched it the potential harms of CBT-type interventions. For them, gathering evidence becomes just “another form of reassurance.” Reassurance (“of course you won’t die if you eat food off the ground”) makes people with OCD feel better in the short term, but increases anxiety in the long term (“what if I’m the strange exception who shall die?”), so that in the end they need more and more comfort.
Katie O’Dunne, a pastor and interfaith chaplain with OCD, experienced a compulsive cycle of reassurance related to intrusive fears of hurting others. Her therapist asked O’Dunne to list all the great things she had done and to remember that she was a kind person. It worked, briefly. Then her brain started circling the same questions again: “It made the intrusive thoughts stronger because they came back and found new ways to poke holes in the logic.”
OCoincidentally enough, the first-line treatment for OCD is a form of cognitive behavioral therapy – just not the type that many would associate with the label. The difference in approach becomes clear in these practice sentences from a manual for people with OCD: There is no way I can guarantee that I won’t stab my husband. Despite my best efforts, my neglect could start a fire at work. I’m not sure if my partner will remain faithful to me.
This type of treatment, called exposure and response prevention (ERP), tries not to challenge thoughts. It encourages patients to expose themselves to fears, both real and real imagined situationAccept that it can happen and do nothing to take away the fear. Instead of reaching for the piles of evidence that you won’t stab your husband, live with the possibility that you will.
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For me, this approach was more useful. As someone who would be obsessed with the 0.0001% chance, that might be me struck by lightningrecognizing that coincidence feels like facing reality.
When I stopped trying to think rationally, my mind felt liberated. I no longer had to constantly remind myself to stop catastrophizing. I had permission to stop sifting through piles of research looking for certainty. Instead, I started practicing ERP as soon as the fears started. I can never be 100% sure I won’t get my mother’s diseaseI would think, despite ‘knowing’ that her illness was (almost certainly) due to bad luck.
At first I cringed at the idea and the pressure in my chest grew. But with time and repetition, my mind became less prone to these repetitive thoughts. And I started thinking about how this approach could help beyond OCD.
O‘Dunne, the chaplain, leads online groups for people seeking faith and obsessive-compulsive disorder, but the community now includes people without the disorder. “A lot of people who have dealt with religious trauma, spiritual abuse, or really rigid spiritual communities have been told for so long that they need to have security,” she says. “It’s been such a damaging dynamic.” For her, ERP is not just a treatment, but rather “a beautiful, healthy lifestyle full of uncertainty”.
In fact, “intolerance of uncertainty” is correlated with many conditions, including generalized anxiety, OCD, social anxiety and eating disorders, according to Mark Freeston, a psychologist at Newcastle University who has been studying the concept since the 1990s. Rather than focusing on cognitive distortions, Freeston and associates help patients accept physical cues of uncertainty.
For example, patients play a child’s game in which they pass a spring-loaded toy. Because people know the outcome – the toy will show up – but not when it will happen, they learn to identify “temporary uncertainty” and realize that the feeling does not mean a situation is dangerous. They can experience uncertainty and still be okay. In a group treatment study that Freeston and his collaborators plan to submit for publication, they found that “making friends with uncertainty” helps reduce anxiety, even if the treatment never addresses a specific concern.
Ultimately, it’s not that challenging your thoughts doesn’t work (it can) or that behavioral strategies work for everyone (they won’t). Some people respond to evidence; they feel its rational power and are comforted. Others may prefer art therapy or internal family systems, a protocol that asks clients to work with different “parts” of their psyche. Approaches that analyze the past may provide insights for some; for others, including people with OCD, focusing on the origins of intrusive thoughts can distract from getting better.
There are many reasons why we might suffer, and no one approach works for everyone – but for me and many, with and without OCD, the cognitive form of CBT was most often seen as clear and generally helpful. For me, this led to simplistic and misleading insights, both about CBT itself and about what I needed. I liked the cognitive strategies of cognitive behavioral therapy because the self-exploration came naturally, but for that very reason I needed a treatment that did the opposite. I just wish it hadn’t taken so long.