CBT Harmed Me: The Interview That the New York Times Erased
disabilityvisibilityproject.com
disabilityvisibilityproject.com
Pain distracts me. It makes me highly anxious about my health. It ruins my mood. No surprise.
I've been suffering from a throat condition that has made me unwilling to eat many days for almost two months. We are not quite sure what's wrong yet. Maybe it's because I don't have chronic pain, but it seems clear to me how the pain interweaves with my thinking. It triggers thought loops. It is an automatic excuse to stop self-care. I can't eat it hurts. (Not eating and getting sicker will hurt more.) When it flairs up, i want that to lead to "go take care of yourself!" thoughts not a loop of "is it resistant to all antibiotics?" which is of no use to me.
That's an insight I learned from CBT not even for pain. In my case, this is mostly about anxiety at its core. I'm not sure I would expect too much benefit otherwise.
It specifically says “Psychological problems are based, in part, on faulty or unhelpful ways of thinking.”
That is in no way saying that all pain is psychological. It also goes out of its way to add “in part”, to show that it isn’t everything even for psychological problems.
I can totally understand that she wasn’t helped by CBT because her problems were not psychological. That doesn’t mean CBT is not effective for actual psychological problems, it means she was misdiagnosed.
This is like writing an essay about how chemo is not an effective treatment and is a scam just because you tried chemo for a toothache and it didn’t work at all.
Was gonna come around and talk about it but you hit the nail on the head. I don't trust the account mainly due to the more flippant (sorry i can't think of a better word) treatment of what CBT actually is. I understand why NYT didn't want to use it.
There's no evidence that she was misdiagnosed. There's some evidence that she holds deeply stigmatizing discriminatory attitudes around mental health.
* Because the therapy is asking the patient to do something that, at some level they don't want to do and think is going to be painful, therapists generally have to exert significant effort to persuade the patient to continue to the point where they benefit.
* Most (all?) Psychological therapies have a high failure rate. A significant fraction of the patients won't be helped, and so the persuasion above is harming a large fraction of patients (the opportunity cost of a failed therapy, which generally takes months, is huge)
I have not seen this problem acknowledged at all by the psychological professions. There ought to be a good deal of research into how to decide the optimal stopping point, and making sure that the operation of a therapy causes the least possible harm to those is doesn't help. But my impression is that the cognitive dissonance of delivering an intervention that will help some, but expensively fail many, is too much for most therapists. They generally continue to believe that the patient would be helped if they held on for long enough, and don't provide any support for a rational process for deciding when to give up on a given approach, resulting in the kind of gaslighting and blaming described here.
It is done because otherwise in the 9/10 cases where things do not improve, you feel you have failed. Much easier if the client fails you instead.
You can tell yourself, "well, maybe next time they'll get better -- after all, it takes many relapses before people kick a drug habit!"
This is a lot easier to swallow than "Oh god this stuff barely is working at all, I'm mostly just a gigantic resource suck and the money I'm paid would be much better spent getting this person stable housing and other support--but that's a lot less attractive to tax payers."
I got out of social work when I had that realization. Initially I coped by saying I was a "Good Person" in a helping profession, so I never looked too deeply into whether any of this horse shit actually was "evidence-based."
Every Psych 101 class should cover the current findings on efficacy of psychotherapies. But they never do, for obvious reasons.
To say that someone is harmed by finding out what doesn't work is a bit of a stretch. You can only talk about opportunity costs meaningfully if the costs of each opportunity (those taken and those not taken) are known beforehand. To say the opportunity cost of a failed therapy is part of an intrinsic dilemma is to say that not knowing what will work is an intrinsic flaw to all decision making. While it may be true, it is neither meaningful to point out, nor exclusive to therapy.
Many people go through several different programs before they find one that works for them. The fact that you might have to narrow down which one works for you is not "harm".
Conversion therapy
Bloodletting
Rydalin
12 step / AA
Every quak remedy that ever existed
Good grief there's an infinity of things that are more harmful than doing nothing at all, and cost a lot in real harm just "to find out what doesn't work", and yes of course even mere conversation vs drilling holes in your skull can be harmful all the way up to death and even collateral death other people when someone they love is essentially killed or abused.
The dilemma I am talking about is an emotional one, not a dilemma of decision. The therapist must persuade the patient that the treatment could work, but they know that it is quite likely not to work. They should be emotionally committed to the the therapy, and persuade the patient to be emotionally committed to the therapy, while at the same time recognising that there should come a point at which the therapist should recommend stopping and trying something else.
And while it isn't working the patient is suffering. A patient isn't in a state of stasis, like a computer program being debugged. While they have a chronic illness, it uses up their resources, of energy, time, money, social and professional capital, and ultimately, will to live. and it's very hard for the therapist to be rational about when to stop. Because giving up on the therapy requires recognising that the therapy they chose to deliver, and advocated for, may have caused the patient to suffer for longer than some alternative. And if the patient's resources are depleted enough, they may not now have a good shot at getting the alternative to work.
If people could be coldly rational about this, you'd be right, it's just a question of trying one thing after another until something works. But therapists have emotions, and those emotions cause them to commit to a therapy long past the time when rationally the patient would be better off trying something else. And that is harm.
There is extensive evidence that pain is significantly modulated by psychological factors. If that wasn't the case then opioids wouldn't work, as they rely on the descending pain pathway.
While CBT tries to substitute dysfunctional thinking with a different narrative, ACT is about realizing that any narrative you're telling yourself is just a narrative, and any feelings are just feelings. As such they are not all that serious or meaningful. We don't need to try to push away, ignore, or try to change the thoughts and feelings. People weren't meant to feel happy all the time and we shouldn't try to. Instead we should find out what truly matters to us and focus on that. I'm probably not doing it justice but that's the gist of it.
A good book on it is A Liberated Mind by Steven Hayes.
CBT is no use for schizophrenia. ACT is no use for schizophrenia.
Abled people don't want to accept that disabled people might require care beyond exercise and a change of mindset. It's disturbing to them that somebody (potentially them one day) could be in such a vulnerable position, and it potentially calls for costly support beyond these minimalist interventions.
The insurance companies choose which therapists administer the CBT program.
The therapists that are more likely to drive their patient through to the end of the return to work program, and have their patient answer "I feel more ready to return to work" during sessions, is more likely to keep their job.
Source: Worked at CBT company.
If you look at a longitudinal, high-quality trial (or meta-analysis, since you'd be very lucky to find any of these) of ANY psychotherapy for a specific problem, they are all pretty underwhelming in terms of efficacy.
Even CBT for conditions like anxiety in youth is poorly supported. This one, for example, shows that it is no more effective than a self-help book:
https://www.cochrane.org/CD004690/DEPRESSN_cognitive-behavio...
You can also see the similar conclusions in these meta-analysis:
https://www.cochrane.org/CD008712/SCHIZ_cognitive-behavioura...
https://www.cochrane.org/CD012614/ENT_cognitive-behavioural-...
I think it is important to realize that medications and therapies for most psychological illnesses are not particularly effective.
We try them because they are still better than doing nothing at all.
There also seems to be decent evidence that receiving empathy and compassion from therapists is more effective than their mode of therapy (See: https://en.wikipedia.org/wiki/Common_factors_theory).
I have often seen in the mental health industry, people overstating the efficacy of treatments. CBT and anti-depressants are particularly bad offenders.
>CBT is significantly more effective than no therapy in reducing symptoms of anxiety in children and young people.
>No clear evidence indicates that one way of providing CBT is more effective than another (e.g. in a group, individually, with parents).
>CBT is no more effective than other 'active therapies' such as self-help books.
The thing about therapy, is that you usually want benefits to last for a duration that makes the effort put in worthwhile.
>Only four studies looked at longer-term outcomes after CBT.
>No clear evidence showed maintained improvement in symptoms of anxiety among children and young people.
If you take a look at the results further they conclude:
>The few controlled follow-up studies (n = 4) indicate that treatment gains in the remission of anxiety diagnosis are not statistically significant.
I'd like to remind you that "significant" in the context of a meta-analysis means "statistically significant." If something performs at the level of a self-help book, most lay people would agree that is not a very effective treatment, even if it has a statistically significant impact.
Food for thought: https://www.theguardian.com/science/2016/jan/07/therapy-wars...
> CBT as a modality is based around gaslighting. It’s all about telling a patient that the world is safe, bad feelings are temporary, and that pain (emotional or physical) is a “faulty or unhelpful” distortion of thinking. That’s literally in CBT’s definition on the APA website.
I wonder whether there will ever be a mode of therapy that doesn't seem to lose favor after a decade.
I don't want to move into Ad Hominem attacks, but the article really reads like the author is setting out to mischaracterize CBT because of their own bitter experiences.
But that's just the 'feeling' I get from it and I'm biased already having had a positive CBT experience :-)
https://dictionary.apa.org/cognitive-behavior-therapy
It seems they deleted that definition from their site. And having been through CBT as part of treatment a couple times over (now) almost twenty years, I've never been told that "pain is a 'faulty or unhelpful' distortion of thinking." It's the response to things that have always been the focus (that is, the pain is real, but the response is what's "maladaptive" to use the term in the current APA definition).
CBT doesn't really stand up against severe mental illness, so why should we expect that it's good for the average person who's suffering from some mild depression and anxiety? We have gold standards that can help people who suffer from some of the most treatment resistant forms of mental illness. Someone with severe CBT who responds to say, IFS after 20 years, you know that's not a placebo. This stuff needs to be studied more drawing from what we know about the populations who suffer the most, because we know that's not a placebo effect or a one off when we see people go into remission.
Because the two are very different things!
So very different!
Our society doesn't value teaching children soft skills like healthy communication, or understanding what emotions are and distress tolerance around them. These are very basic things that a lot of people only learn after they get into therapy. And they help everyone if applied correctly. The skills you learn in DBT are skills that can help EVERYONE. When you learn how to communicate better at a gold standard you help yourself and the people around you.
If we have a gold standard that can be applied to the most severe cases and help, and this isn't based on anything specific to those disorders but rather taps into some very core "how to be human and deal with weird lizard brain hurty emotions" stuff we need to start using that. Using our brains to rationalize our way out of emotions got us to where we are as a society now and it's pretty unhealthy.
CBT tells you to look at the situation rationally and evaluate if you’re falling into one of many cognitive distortions humans are prone to. If you should be angry and you have the appropriate level of anger at the situation, good.
He specifically warns that using CBT to make everything good is actively harmful.
It absolutely doesn’t work for mania or depression. My therapist was very clear that CBT only works on “normal people problems”.
I've seen a therapist, ostensibly for depression, that used CBT techniques.
My experience has been a positive one!
I take issue with the article in the way it cuts a path from the very broad overview statements on the APA website to asserting that CBT is "built to be dismissive and invalidating".
There is so much to take issue with in that article:
"CBT is based on the premise that any patient coming into therapy is experiencing distorted, “faulty,” “catastrophizing” thinking. CBT therapists are trained to convince patients that they’re overreacting and that they’ll feel better when they realize they’re overreacting."
IMHO that is a totally unreasonable way to characterise CBT. The use of the word "overreacting" suggests that a therapist is seeking to invalidate the patients experience. That invalidating approach is not built into CBT, and if the author has experienced that, then I'd say that was rather unfortunate and the therapist is at fault, not the practice of CBT.
CBT aims to get people functioning and coping by equipping them with strategies that work, for them. It's an individual approach that takes time and discovery.
Anyway....
On the APA website, they do provide some more background:
CBT treatment usually involves efforts to change thinking patterns. These strategies might include:
Learning to recognize one’s distortions in thinking that are creating problems, and then to reevaluate them in light of reality.Gaining a better understanding of the behavior and motivation of others.Using problem-solving skills to cope with difficult situations.Learning to develop a greater sense of confidence in one’s own abilities. CBT treatment also usually involves efforts to change behavioral patterns. These strategies might include:
Facing one’s fears instead of avoiding them.Using role playing to prepare for potentially problematic interactions with others.Learning to calm one’s mind and relax one’s body. Not all CBT will use all of these strategies. Rather, the psychologist and patient/client work together, in a collaborative fashion, to develop an understanding of the problem and to develop a treatment strategy.
CBT places an emphasis on helping individuals learn to be their own therapists. Through exercises in the session as well as “homework” exercises outside of sessions, patients/clients are helped to develop coping skills, whereby they can learn to change their own thinking, problematic emotions, and behavior.
CBT therapists emphasize what is going on in the person’s current life, rather than what has led up to their difficulties. A certain amount of information about one’s history is needed, but the focus is primarily on moving forward in time to develop more effective ways of coping with life.
Apart from that, my son suffers from medically undetectable problems. His symptoms are real. Medical science acknowledges that but the doctors say they don’t know what to do. We’re all frustrated but we don’t whine about it.
However it's my opinion that CBT even if used exactly to gold standards is very unhealthy, overprescribed in a lot of situations it shouldn't be, and is based on some really faulty assumptions.
Number one, a lot of people with mental health issues have undergone trauma. CBT is completely useless in this case but yet gets overprescribed like everything else. The ABC model in CBT (Activating Event, Belief, Consequences) sounds like on the surface that it makes sense but it's a very very basic view of how the brain and body works. Here's how it's supposed to work. A) You see a spider. B) You think spiders are gross and scary and the scary could bite you. C) You are scared and run away. In reality, trauma and fear work at the speed of light through your sympathetic nervous system and hit your lizard brain before you are making any conscious thought whatsoever. Feelings like fear, disgust, and so forth are very primal and lizard brainy and it really doesn't do any good to dissect them with our Big Simian Brains. It just causes more problems because the solution is acceptance and understanding the nature of emotions.
100% agree by this statement by the pt: "CBT as a modality is based around gaslighting" That's exactly WHY it works so well and you see that great effect in the studies. Gaslighting works as a means to control people. For a while, until their world falls apart worse because you're programming yourself to tell you a different delusional reality, just in this case since it's "positive" it's supposed to be OK. News flash, if you can't get your basic needs met, you shouldn't be using CBT. Use all the CBT you want, it's not going to change the fact that you don't have enough to eat, you're about to be homeless, you're in an abusive relationship, and so on. In this case CBT was inappropriately prescribed to someone with chronic pain and trauma and big Psych is terrified to let this narrative out - that CBT is routinely used on people who don't have cognitive distortions. To get an idea of how ridiculously overprescibed this is, check out this video, where an actual MD with a vitamin deficiency was pressured by his sleep doctor to try CBT for his insomnia https://www.youtube.com/watch?v=d_qKA6KTvs8
Thankfully he knew, AS A DOCTOR, that the advice he was given was full of crap. But people who have already been marginalized, and are often women, people of color, and so on? God forbid we're questioning CBT and have valid reasoning behind it, that just means that you're resisting treatment and it's something further to put under the microscope.
If you push your problems down it makes it worse. The therapies we should be using should be about acceptance, distress tolerance, communication skills, and things like inner child work such as internal family systems therapy or somatic work. Things like DBT which have a mindfulness component, is about acceptance and dialectics - two things can be true rather than overanalyzing the crap out of everything, and IFS as well as EMDR and other body based work are evidence based to work against trauma as it exists biologically. CBT does not. Everyone has trauma from childhood and even if you don't have mental illness there are weird things around from that time which make you regress and feel bad about yourself. The key is working with that stuff and actually accepting those parts of yourself and loving them which CBT DOES NOT DO. It pushes things down.
Props to this author. We need more people speaking out against CBT. It causes people to give up on therapy and think it's a sham. This kind of disgusting behavior where the patient's experience is invalidated because god forbid that further puts cracks in the wall in the CBT model which we've invested so much in!
For me, that is too broad a statement!
Having had CBT therapy here in Australia from experienced qualified Doctors, I can say it's been excellent.
But I was being treated for a "Nervous Breakdown", and CBT helped me get my life back on track and functioning again before I burnt my life down!
However, I can't see how it would work for everything and chronic pain seems like a bad fit. ANAD.
I'm glad that you were able to get good treatment - I think also the clinical standards here are pretty abysmal, so in the US if you're getting CBT you're most likely dealing with serious insurance issues that limit the quality of care. In addition post pandemic even paying out of pocket it's harder and harder to find therapists with any spots :( All bets on quality are off if your only options are one of the larger clinics in a big city. At least that's been my experience.
CBT does show efficacy in the short term, no one is contesting that. But I think that's also kind of why it's "awful" - because people get so excited about it that it's touted as some magic bullet, or cure all. The effects from CBT were so strong that a whole industry popped up around it and we're seeing it increasingly applied to things that it shouldn't be applied to and people silencing the narrative from those who are trying to speak out against it.
CBT is a tool and it's appropriate for certain situations. But the issue with CBT being overused and in the hands of untrained professionals who are overeger to apply it to a variety of situations it's completely inappropriate in is very, very problematic. I'd guess that's a bigger issue here in the US. For example you're absolutely not supposed to use CBT if you're homeless, can't get enough to eat, and so on, and this is in the training manuals. You need to have your basic needs met. But it's routinely used anyway.
A tool this powerful and with this evangelical of a base behind it is dangerous. It's the same problem we were seeing with the sugar and alcohol industry getting involved in clinical studies. We're losing sight of the science behind it because it turned into an industry that's being threatened.
But thanks, it is good to hear it's helping people and get a data point there. Anecdotally I've only heard negative/neutral personal experiences with it, and although the majority of those experiences were from people with more serious mental health challenges I did hear from people who were dealing with transient issues who had no luck from it - again could be quality issues and some of them could have fared well with CBT at gold standard. I feel like increasingly we're hearing the industry champion CBT rather than the patients so as a patient your story is important too.
I’m around 18 months in.
The AU gov are amazing in this regard - under a mental health plan from your GP, you can get 10 free appointments with a qualified Dr per year!
No cost!
I totally take your point about long term efficacy!
My Doctor has said they now realise they need not only to get patients heads above water, but they need to get them well above water!
All cases are different, and I’m fortunate in many ways.
Im diagnosed with ADHD. My nervous breakdown is likely a result in part by me trying to fit myself into the corporate word and burning out!
Im fortunate because my ADHD makes me very fearless and confident to take control of my own destiny. And I have a strong introspective ability - says my Therapist!
And I’m a relatively wealthy middle class good looking white man with an amazing wife and a stable home life.
Now anyway. I almost burned it all down with self destructive behaviours.
The world is kinda on my side.
And I get for many, they don’t have the backup networks that I did.
I have zero qualifications and came from a very poor family in the UK. But by virtue of being smart and sounding posh, being white and good looking in a suit, I’ve gotten ahead in this world.
Not bragging - I say that as recognition of my good luck and my empathy for those who are not so lucky.
And I do mean luck. I didn’t get here by grit and street smarts and believe it’s your fault if you don’t….
Anyway.
I guard my mental health now like the Crown Jewels!
I can easily see how others would fall backwards.
I don’t need to get time off work. Or make excuses. If I’m feeling bad I can just go to the gym in the middle of the day. Or do yoga. Or meditate with the Smiling Mind app for half an hour.
I have everything. Others are not so lucky!
So glad you've found the support you've needed and things that worked for you. That's one of the biggest components of therapy working and I'd say that often that connection with the therapist and humanistic element is missing here in the US, especially if you need to use the larger clinics on Medicaid. It sucks when therapists try to circumvent things before a trusting relationship has been made.
Thank you so much for the Smiling Mind app meditation, it looks like it's based in AU which may be why I didn't hear of it! Another one I like is Buddify, and there's another app called FocusMate that I use as a life hack when I'm having problems completing tasks.