Is that old-school approach to CBT giving you a chronic problem?

Cognitive Behavioral Therapy has evolved and changed significantly over the years. CBT is a category of therapies that include cognitive and behavioral components. It’s a category in the same way that “cardio” is a category of exercise. What a person does within that category, can lead to profoundly different outcomes. And the exercises evolve over time–we find more effective ways to reach the outcomes we’re pursuing. Group fitness in 1988 looked like this:

30 years later, group fitness looks a bit different:

CBT has evolved in the same way that group fitness has. That doesn’t mean you can’t do the old exercises. It just means we’ve developed better, more effective tools that can take you further than those earlier exercises could. However, it’s not uncommon that patients still run into outdated tools and approaches. It’s like they’re walking into a gym to do a HIIT class and instead being handed an aerobics VHS tape from 1988. Except in this scenario, that VHS tape is something called a “Thought Record”.

As a tool, a Thought Record might be in the form of a piece of paper with several columns for a patient to write about her situation, her mood, the automatic negative thoughts she had, evidence supporting the thought, evidence against the thought, and then a more balanced, rational thought. This reflects a general concept in old-school CBT: that you engage with thoughts and rationalize your way out of them. The patient is supposed to see the thought as irrational or less-likely. They can reassure themselves it’s not true. At first, this can actually be very reassuring to the patient. Their mood might lift as well. The therapist might also be happier and feel reassured about the effectiveness of the techniques they shared because the patient is leaving their office happier than when they came in. But this approach, although it might seem like it’s helping in the short-term, can actually make things worse in the long-term. As one former patient, Sarah, explained: “…in the short term my anxiety went down, because I was using CBT techniques ritualistically. I used to painstaking dissect and label all the thoughts I didn’t want, like some sort of deranged butterfly collector.”

Older tools, like a Thought Record, are rooted in the belief that you shouldn’t be having these thoughts or feelings. You’ll get rid of that anxiety! You’ll quiet those intrusive thoughts! This can seem appealing to people when they’re struggling, not realizing that it’s all of the attempts to control and avoid thoughts and feelings that lead us into these struggles.

More recent forms of CBT, like ACT or DBT, recognize experiential avoidance as the problem, not the solution. That’s because chasing certainty and relief from feelings or thoughts doesn’t lead to having them less (except in the short-term). What we’re really doing is taking short-term relief at the expense of our long-term health. As with any compulsion that gives us relief, we’re only teaching our brains to give us even worse withdrawal, as another former old-school CBT patient explains: “There was one exercise they taught where you draw a pie chart and add a slice for each possibility explaining why you might be nervous. It was really a ‘add up the evidence why you’ll be okay’ approach… But during the last year when new events in my life put me down a new path of struggle with OCD, I became addicted to proving why I’ll be okay. My brain evolved in tandem with this and found even more slippery ways to convince me I was doomed.”

That really hits on why I caution people (patients and practitioners) against this approach: it’s creating a framework for your brain to sink you. And it will, at ever increasing levels of complexity and severity, because it wants you to get that relief again. If you felt relieved by proving those simple uncertainties wrong in the past, then you’re going to feel so much more relief when you solve this next set of even more complex uncertainties or unwanted feelings. And it runs off into disaster, like any addiction–we chase the high of rational certainty, and our brains respond with the withdrawal of more experiences we hate and need to solve.

As a society and within the mental health system, there are so many people bought into the myth that mental illnesses are chronic. If a professional believes your mental illness is chronic, then giving you tools that require you to fight and manage your brain the rest of your life probably doesn’t seem strange. If somebody is doing an exercise like a Thought Record, and their struggles persist or return after awhile, they’re likely to blame themselves or blame some problem they believe they’ve got in their brain, rather than see the exercise as part of the problem. So we need to talk about our experiences and talk about what works better, in the same way we do in physical fitness. It’s only through openly sharing about experiences that we see there are better ways to take care of our health.

If you did months of 1980s-era aerobics classes and didn’t reach your strength goals, it doesn’t mean that exercise won’t work for you and you just don’t have the body type to be strong. It doesn’t mean you have a genetic defect or some chemical imbalance that’s getting in your way. You weren’t doing the exercises that would actually help you reach your goals. If you’re still doing CBT exercises from the 80s and you’re not reaching your mental health goals, maybe it’s time for some new exercises.