When I was doing Exposure & Response Prevention (ERP) therapy for OCD, it was very behavior-focused. It was all about progressively cutting out compulsions, starting from the easiest and working up to the most difficult. Although ERP is a form of Cognitive Behavioral Therapy (CBT), it’s generally heavier on the B than the C. But it’s not uncommon for a therapist to incorporate cognitive techniques as well, like adding up the evidence for or against a thought and trying to see, “rationally”, that the intrusive thought or worry isn’t “true” or “real” or particularly likely to happen. My therapist tried to help me with that a couple of times, especially with compulsions I had around preventing fire. But that only ever made me more convinced that my anxieties were true. If I had any doubt that laptops didn’t spontaneously combust and burn houses down, all I had to do was go online and I could find multiple stories to back up my fears. I didn’t even need to search for the stories. Visiting any news site or scrolling through Facebook ensured my brain was fed on a steady stream of terribly improbable but terribly real terrible events.
The Internet makes everything possible. You’re sucking on a fire hose of real evidence for every imaginable fear. Have an unusual pain in your gut? You can send yourself to the hospital armed with support from Dr. Google that it’s probably cancer, maybe you need your appendix out, and you’ve got a parasite living inside of you. Feel the flu coming on? You’ve got HIV now (maybe ebola). Left your laptop plugged in and worry it’ll catch on fire and burn your home down? You can spend the rest of the day reading about that, like this story: Charger catches fire! Or this one about a Macbook that caught fire and sent a guy to the ER with burned hands: My Macbook caught fire (note that the story says the original owner is now deceased… Coincidence? I think not.) And this one would have sent me into a compulsion spiral back in the day because the laptop wasn’t even plugged in when it caught on fire and melted a hole in the laundry basket: Macbook caught fire — with happy ending! And let’s not forget about that iPhone that caught fire on an Alaska Airlines flight in March earlier this year: Girl’s iPhone bursts into flames mid-flight: ‘I thought we were going down’ When “eight inch flames” started shooting out of the phone, she wisely tossed it under another passenger’s seat. Not my problem now… EVERYBODY PANIC.
When CBT was being developed back in the 80s, and even as it gained in popularity in the 90s, patients simply did not have the data available to them that they can gather today.
In the 90s, if a patient came in and said, “Everybody hates me,” the therapist could try to help them see that’s a “distorted” thought. They could add up the evidence to show them that everybody doesn’t really hate them. They could help them change that thought to change how they feel — a basic practice of traditional CBT. But now, if a patient comes in and says, “Everybody hates me,” and the therapist tries to help them see that’s not rational, the patient can pull out their phone, bring up Instagram, and show their therapist a selfie under which every member of their class has said far worse things than “I hate you.” That patient could be under a constant barrage of cyberbullying. That’s data. To an anxious brain, that’s deadly data.
Objectively, those cyberbullies are jerks and that patient probably isn’t hated by everybody. But my point is, doing CBT will be significantly more difficult because of the context in which that patient operates. Old-school CBT wasn’t designed for the Internet Age. The patient and the therapist need to be aware of that. Newer forms of CBT, the so-called “third wave” of behavioral and cognitive therapies, like Acceptance & Commitment Therapy, Dialectical Behavior Therapy, Mindfulness Based Cognitive Therapy, etc, are arguably more equipped to handle a world of infinite possibilities because they emphasize accepting experiences rather than trying to categorize them into tiny rational and irrational boxes.
Like many tools that haven’t survived the last 20 years, traditional CBT doesn’t scale well. It doesn’t equip people to handle the data available to them.
In the summer of 2015, a paper published in the Psychological Bulletin, analyzed 70 studies on CBT conducted between 1977 and 2014, and found that CBT was decreasing in effectiveness. There are likely multiple reasons for this — placebo effect, incompetent therapists, etc — but into that mix of factors, we also need to consider that the environment has changed drastically. In the past, before the Internet, if you went to your therapist and said, “I’m afraid my electronics are going to catch fire if I leave them plugged in,” she could have helped you see that’s not something that’s happened to anybody you know. It’s extremely unlikely. There’s no evidence that it happens. She might have suggested you label that as an “irrational thought” or an “OCD thought”. It’s false. But now, you can go back up to some of those links I posted earlier — they’re on forums — and you can reach out to the people to whom it actually happened. You can get to “know” them. And then, when you go into your therapist’s office, and she asks you how likely this is, you can say, “It’s happened to a couple of people I know.”