Can Cognitive Behavioral Therapy Change Our Minds?

The theory behind C.B.T. rests on an unlikely idea—that we can be rational after all.

Burns didn’t invent cognitive behavioral therapy, but he is connected to its founding lineage. He studied with the psychologist Aaron Beck, who created an approach known as cognitive therapy, or C.T., in the nineteen-sixties, and is often described as the “father” of C.B.T. Beck’s ideas dovetailed with the work of Albert Ellis, a psychologist who had invented rational-emotive behavior therapy, or R.E.B.T., the decade before. There are substantive differences between C.B.T. and R.E.B.T., but also essential commonalities. They all reflect the so-called cognitive revolution—a shift, which began in psychology during the mid-twentieth century, toward a more information-based view of the mind. Freudian thinkers had pictured our minds as hydraulic machines, with pressures rising against resistances and psychic forces that might get bottled up. The cognitive model, by contrast, imagined something more like a computer. Bad information, if it were stored in a crucial place, could cause system-wide problems; irrational or inaccurate thought patterns could shape feelings or behaviors in counterproductive ways, and vice versa. Coders get at a similar idea when they say, “Garbage in, garbage out.”

Ellis, who earned a Ph.D. in psychology in 1947, trained as a psychoanalyst but grew frustrated with the tradition’s approach to therapy, which he felt emphasized dwelling on one’s feelings and ultimately subordinated patients to their pasts. The “rational therapy” for which he became known in the sixties proposed that individuals had the power to reshape themselves willfully and deliberately, not by reinterpreting their life stories but by directly analyzing and modifying their own beliefs and behaviors. “We teach people that they upset themselves then and that they’re still doing it now,” Ellis said, in a 2001 interview. “We can’t change the past, so we change how people are thinking, feeling, and behaving today.” Ellis showed his patients how to avoid “catastrophic thinking,” and guided them toward “unconditional acceptance” of themselves—a rational position in which you acknowledge your weaknesses as well as your strengths.

Beck, like Ellis, trained in a Freudian tradition. “He was a psychoanalyst who had people lie on the couch and free-associate,” his daughter, the psychologist Judith Beck, who heads the Beck Institute for Cognitive Behavior Therapy and teaches at the University of Pennsylvania, told me. He switched from searching for repressed memories to identifying automatic thoughts after a client seemed anxious during her session and told him, “I’m afraid that I’m boring you.” Beck found that many of his patients had similar negative mental touchstones, and based cognitive therapy upon a model of the mind in which negative “core beliefs”—of being helpless, inferior, unlovable, or worthless—lead to a cascade of coping strategies and maladaptive behaviors. Someone “might have the underlying belief ‘If I try to do something difficult, I’ll just fail,’ ” Judith Beck told me. “And so we might see coping strategies flow from that—for example, avoiding challenges at work.” In C.T., patient and therapist joined in a kind of “collaborative empiricism,” examining thoughts together and investigating whether they were accurate and helpful. C.T. combined with elements from behavioral approaches, such as face-your-fear “exposure” therapy, to create C.B.T.

In the second half of the twentieth century, rational and cognitive therapies grew in prominence, their lingo sliding from psychology into culture in roughly the same way that Freudian language had. Ellen Kanner, a clinical psychologist who trained in the nineteen-seventies and has been in practice in New York since 1982, watched the rise of C.B.T. in her clinic. “I’ve seen psychology evolve from very Freudian, when I first did my training,” she told me. Cognitive behavioral therapy had an advantage, she recalled, because therapists and researchers liked its organized approach: exercises, worksheets, and even the flow of a therapy session were standardized. “You could more easily codify it and put it in a study with a control, and see whether it was effective,” she recalled. Patients, meanwhile, found the approach appealing because it was empowering. C.B.T. is openly pitched as a kind of self-help—“We tell people in the first session, ‘My goal is to make you your own therapist,’ ” Judith Beck told me—and patients were encouraged to practice its techniques between sessions, and to continue using them after therapy had ended. Compared with older approaches, C.B.T. was also unthreatening. “When they’re using it, therapists aren’t asking you about your sexuality or whether someone molested you,” Kanner said. “C.B.T. is more acceptable to more people. It’s more rational and less intrusive. The therapist doesn’t seem as powerful.”

The pivot that C.B.T. represented—from the unconscious to the conscious, and from idiosyncrasy to standardization—has enabled its broad adoption. In 2015, a study by Paulo Knapp, Christian Kieling, and Aaron Beck found that C.B.T. was the most widely used form of psychotherapy among therapists surveyed; in a paper published in 2018, titled “Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy,” the psychologist Daniel David and his collaborators concluded that it was the most studied psychotherapy technique. (“No other form of psychotherapy has been shown to be systematically superior to CBT,” they write. “If there are systematic differences between psychotherapies, they typically favor CBT.”) Meanwhile, the therapy keeps extending its reach. “I just got back from Japan, where they’re teaching C.B.T. in schools, and have used C.B.T. methods for people who were at risk for suicide,” Beck told me. In the U.S., many schools integrate aspects of C.B.T. into their curricula; the U.K.’s National Health Service has commissioned at least a hundred thousand C.B.T. sessions. Increasingly, C.B.T. is also delivered through apps or chat interfaces, by human therapists or bots; studies have shown that online C.B.T. can be as effective as therapy conducted in person. Even though C.B.T.’s central tenets are nearly half a century old, people who discover it today may still find that it feels au courant. It’s a serious therapeutic tool, but it’s also a little life-hacky; it’s well suited for an era in which we seek to optimize ourselves, clear our minds, and live more rationally.

Iasked Judson Brewer, a psychiatrist and neuroscientist and the director of research and innovation at Brown University’s Mindfulness Center, for his views on C.B.T., and he referred me to a comedy sketch, made in the early two-thousands, starring Bob Newhart as a therapist and Mo Collins as his patient. “I have this fear of being buried alive in a box,” Collins says. Newhart asks, rationally, “Has anyone ever tried to bury you alive in a box?” “No, no,” Collins replies. “But, truly, thinking about it does make my life horrible.”

“Well, I’m going to say two words to you right now,” Newhart explains. “I want you to take them out of the office with you and incorporate them into your life. . . . You ready?”

“Yes,” Collins says.

“Stop it!” Newhart screams. (...)

C.B.T. does contain a theory of change—and it’s not entirely convincing. If people could change just because rational thinking told them to, we wouldn’t live in such a crazy world. Yet the rationality of C.B.T. is aspirational. We can wish that we were the kinds of people who could solve our biggest problems simply by seeing them more clearly. Sometimes, by acting as though we are those people, we can become them.

by Joshua Rothman, New Yorker |  Read more:

Image: Evan Cohen
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