The CBT is awesome post

Disclaimer:  I did CBT 20 years ago at a research university that is/was known for CBT research, and this post had been sitting unfinished in drafts since 2016.  A lot of stuff may have changed since then!

Another one of those comments I’m always leaving.

CBT is amazeballs. It’s also what they use in Bradley class for natural childbirth. It takes practice but it totally changed my life even more than just the test anxiety I was getting it for. I’m so much of a calmer person now. Every time I start getting anxious my deep breathing automatically starts up. Personally I think everybody should get trained in it starting in high school!

It also has the benefit that it’s a set of specific techniques and once you’ve learned them, or learned even a set of them, you can stop going to therapy* for the specific anxiety. The one I did was a 6 week program, IIRC. (They graduated me a little early because I responded really well to the early techniques, which makes sense as they teach the most effective ones first.) I went to a university program, which was nice, though I had to wait a few months before they could see me. A private practitioner might not be as systematic, but may have less of a wait.  (DH tried it locally as a professor and it was not as focused or as good.)

The CBT place I went to recommended Mind Over Mood and Thoughts and Feelings while I waited to be seen. They were also helpful.

The main idea behind CBT is that anxiety causes a physical response that makes you more anxious.  If you can interrupt that physical response, you have a chance at letting your rational brain take over.  Ditto negative repeated thoughts (what my therapist called “ticker tape”).  It is NOT about getting to the root of your problems.  It’s only about getting tools to treat the symptoms of anxiety and anxiety-related disorders.

The first lesson for me was breathing.  When you’re in fight or flight your breathing changes and that gets you more anxious.  So we spent a lot of time practicing breathing in through the nose two three four, out through the mouth two three four.  I had to practice this at home too in a relaxed state, so I started identifying the breathing with being relaxed.  Eventually taking a deep breath became an immediate unconscious response every time I got anxious.

Cognitive restructuring was another important lesson.  With my anxiety I had these negative repeated thoughts, “you’re so stupid, you’re going to flunk out of graduate school, you’re a failure etc.”  In this step, the therapist folded a piece of paper in half length-wise and on the left wrote each negative thought down.  On the right we came up with something that was *true*.  It’s really important here for it not to be aspirational or unbelievable, but for the response to be completely believable and true.  Stuart Smalley-style affirmations don’t work.  But replacing incorrect negative thoughts with neutral or positive true things does work (on average, in RCT).  (And I decided what was true, not the therapist.)  So “You’re so stupid” would be replaced with “I’m not stupid.”  “You’re going to flunk out of graduate school” with “[Grad School] doesn’t flunk anybody out, they just give people consolation PhDs and make sure they work in industry instead of academia where they make more money.”  “Even if I leave graduate school I’m not a failure, I can still get a real job making money.” and so on.  I kept that original list on our refrigerator through several moves and really only didn’t put it back after our last sabbatical.

Progressive muscle relaxation was another interesting one.  With this one, you start at your toes and clench them super hard and focus on how they feel while clenched.  Then you unclench them and ponder how different they feel when unclenched.  Then you go up your feet and legs and so on.  I fell asleep in the therapist’s chair doing this and we decided maybe it was a bit overkill for test anxiety.  But it does help me get to sleep sometimes.

There were more lessons after this, I think positive visualization for which the science wasn’t really there yet was one.  I don’t remember what else.  Breathing and cognitive restructuring really helped me.  If they hadn’t worked so well, we might have done some aversion therapy which is NOT just throwing someone into a pit of their fears without support.

Anyhow, that’s my CBT post and now maybe instead of typing this all out each time it comes up in a chat I can just refer to this post.

*YOUR MILEAGE MAY HEAVILY VARY.  CBT didn’t do jack squat for #2, although she recommends it to most people.  Please don’t feel bad if 8 sessions of manualized CBT doesn’t fix your decade-long problems.  It’s not designed for that.  It works well for, say, test anxiety, or a first-time depressive episode.  It works less well for relational trauma and complex interactions of problems.

Have you done CBT?  What were your experiences with it?

30 Responses to “The CBT is awesome post”

  1. Anonymath Says:

    I was trained in CBT when I was a grad student in Counseling Psychology. Managed to use it successfully with a university student in our clinic who was having panic attacks during my practicum so I’ve been positively disposed to CBT for years now. Not perfect, and as you stated, doesn’t get to the root of many problems, but it was great for anxiety issues.

    • nicoleandmaggie Says:

      I started because I had a panic attack during a final exam in the class I was doing best in and couldn’t breathe. CBT was instrumental to me getting through grad school. Also helped with natural childbirth! (Since we didn’t address my irrational fear of anesthesiologists in my sessions…)

  2. Steph Says:

    I’ve had some therapists use CBT and I didn’t like it. It feels like toxic positivity to me, like my therapist was ignoring my negative feelings by always trying to put a positive spin on the situation. Just acknowledging my feelings and naming them was a big step for me, so it hurt to have that acknowledgement ignored. Maybe it would have been different with some different methods like the ones you describe, but honestly I stay away from CBT now.

    I’ve had some success with DBT, and what I guess is “interpersonal therapy”. It’s really hard to find a therapist where I live now, but someday I would like to get back to someone who works with those.

    This is a tumblr post that compares some common therapy styles, which was helpful for me to understand differences in style

    • mnitabach Says:

      Altho I never engaged w CBT, what you aren’t referring to as “cognitive restructuring” is exactly what I figured out on my own to do to interrupt catastrophizing thought spirals. The intensive therapy that I did for years in twice weekly sessions in my mid-late twenties was basically that my therapist guided me to embrace my thoughts & feelings without intellectualizing them AND she herself engaged in mostly-tacit total acceptance of me. She never asked me to explain myself or justify anything, she just let me do whatever I wanted in our sessions, only pointing out when I was intellectualizing instead of embracing myself.

      There were many sessions where I just laid there on the couch silently for the entire hour & she sat there silently with me, fully accepting my silence. This was all key for me, as I had never been fully accepted as myself by anyone before in my life nor by myself. We never discussed what theoretical & methodological framework for therapy she was working within, so I have no idea what this would be called.

      If you think I’m an obnoxious dickehole NOW, try imagining me without all that therapy!!! 😹 😹 😹

    • nicoleandmaggie Says:

      The literature is really clear that positivity does not work—it has to be believable and believed. The Stuart Smalley stuff does not work in RCT. That’s not actually CBT. And acknowledging the feelings is a big first step of cognitive restructuring!

    • nicoleandmaggie Says:

      It’s cold in wonderland is wrong though. CBT doesn’t work for most things and it’s not designed to! The research and books are really clear about this. It is designed to help anxiety SYMPTOMS so that your rational mind can work. It is very similar to Beta Blockers in terms of its use except that (again according to RCTs) it continues working for many people after stopping CBT therapy but beta blockers stop working when people stop using them.

      CBT is often used in conjunction with other therapies because if you’re constantly in fight or flight it can be difficult for the other therapies to help.

  3. First Gen American Says:

    I went through a phase of repeatedly needing to tell myself “shut up brain” until the ticker tape thoughts would stop. Simple yet effective. Not sure what the medical term is for what I did but it works.

    The other thing I found super helpful was telling myself “what actions are in my control that will make these thoughts of inadequacy go away”. Then when the thought happens, cue action. Make a plan to reverse some bad thing that is going on at work. Eat something healthy, go for a walk. Sometimes when I am really in a funk even starting a load of laundry is enough to make me feel like I’m “doing something”.

    Sometimes it’s okay to give yourself permission to do nothing for a while until you are in a place where you can start and not fail. Walk away and clear your brain so you can start fresh.

    I can’t really say that I suffer from the kinds of serious mental health issues that some of my friends battle every day but I think you’re right. Stopping that death spiral of thoughts before they get out of control is super important no matter where you are in the recovery process.

    I always love to hear people’s coping mechanisms and looking forward to seeing your reader comments.

  4. nicoleandmaggie Says:

    In case we have any millennials or Gen Zrs watching, Stuart Smalley is an SNL character played by Al Franken who took positive affirmations to a really stupid level, making it clear why they Do Not Work (tag phrase: “I’m good enough, I’m smart enough, and Gosh Darn It, people like me”). Cognitive restructuring is NOT positive affirmations even though some people think it is. 20 years ago when I read all that I could on CBT, there were RCTs that showed how important it is that the restructuring be true and believable to the the participant.

  5. middle_class Says:

    A therapist taught me CBT although I am not sure if it goes deeper than what I learned. I had a handout with 4-5 questions to ask self once the death spiral of thoughts begin. It helped me a lot! I once made a big mistake at work and immediately thought I would be fired. I used that worksheet to rationalize and step back. The questions I asked myself then (and now) is “what is worse that can happen? I will ne fired.” followed by “How likely is that going to happen?” “Unlikely because I have a good track record at the company and good boss.” I can’t remember the exact questions but I wrote down other possible, less drastic scenarios like “Boss will have a talk with me to discuss how to better next time” or “Boss will be more hands-on with my projects for a while.” Etc..

    • nicoleandmaggie Says:

      Yes! What is the worst that can happen is also one of the things (though it’s one I did before CBT because that’s how my brain works…). Obviously if the worst is terrible (ex. people die), it’s not a great question, but if the worst is that I drop out of graduate school and get a real job making a reasonable salary… that’s not so bad. Great point!

  6. CG Says:

    Just to add that CBT can work on trauma, too, depending on the circumstances. I had some really scary birth and postpartum experiences with my oldest and it made a big difference when the therapist helped me switch from thinking, “I almost died and I failed my baby” to “I noticed something was wrong and got help for my baby. I took good care of him.” I’m actually tearing up a little writing about this, almost 15 years later, but it’s more in gratitude for that therapist who was so kind and encouraged me to be kind to myself. She helped me restore my sense of agency in the whole mess.

    Anecdotally, I think CBT works especially well for science-y people.

    Also, thanks @Steph for that informative thread above.

    • nicoleandmaggie Says:

      OMG, yes, it is true though. You did notice something was wrong and got help. That’s amazing.

      CBT is a lot about agency. It helped me get back into control of my body, and not being in control– not being able to breathe because of a stupid TEST– was one of the scariest experiences of my life (and at the time was probably the scariest experience I’d had). And I agree with your anecdotally for me too.

  7. xykademiqz Says:

    My experiences with therapy have been a mixed bag. The longest-term and likely most successful therapeutic relationship for me has been with an analyst (Jungian, if case anyone cares). We had good interpersonal chemistry, which I think is very important — if I sense I annoy them (and I believe I am pretty annoying and I know I grate on a lot of people when they first meet me), I am out of there. With this analyst I never got that; either she never disliked me or was very good at hiding emotions from her patients. Paying also helped, to be honest. I felt that because I was paying I was allowed to impose on her for the hour, that because she was compensated I wasn’t actually burdening her with my crap, which is something I always worry about whenever I open up even a little bit to people IRL (maybe that’s why I blog). Anyway, unrelated to this, when I read some CBT books, the technique did make sense, and I do apply cognitive restructuring in life (and when working with students) to get rid of irrational thoughts. I’ve become better at this with age.

    • nicoleandmaggie Says:

      The first therapist I tried (from my grad Uni) didn’t believe me when I told the truth so I would make up lies she would believe before each session just to get through it. But she did get me a referral to CBT which actually helped and I was able to get brave enough to dump her (“CBT is helping so much I think we can stop this talk therapy now, but thank you”).

      I’m annoying to a lot of people too. *Shrugs* I’ve given up trying to fix it and just try to present myself in small doses. I’ve heard I am delightful in small doses.

      I am glad you blog! And I get feeling the need to give something in exchange. Paying helps. There’s probably something there from our childhoods causing us to not want to impose, but … enh.

  8. omdg Says:

    I’ve had some therapists be like, “OMG what a horrible toxic place you go to school/work at. Do yourself a favor and find someplace else to go to school/work. I’ve had others be like, “All you have to do is be perfect! It’s just behavior, so I don’t see what your issue is. You should be able to have perfect control over all behaviors. Just make sure your face and tone of voice in no way give away what you’re really thinking. What, you think that’s impossible? Well, it will be if you have a fixed mindset.”

    I did order the CBT book. I recently realized that I start to have a mini-panic attack when I think someone may be upset with something I said (or… a facial expression, or my voice) because nursing staff has weaponized physician write-ups. Having a mini-panic attack just makes it more likely that I will lose control of my face or voice and say something wrong. I think I need to learn to give fewer fucks, and maybe the CBT book will help me do that.

    • nicoleandmaggie Says:

      I don’t know that it helps to give fewer f*** but it does help keep control and to recover from mini-panic attacks. There’s a lot to be said for being able to get a racing heart rate back down for the ability to rationally respond to something.

    • xykademiqz Says:

      I need to befriend you and N&M IRL. I think we’d get along swimmingly. We could be super intense, overly facially expressive, and annoying together, and not upset the civilians.

      Btw, FWIW, years of teaching (and inane questions that I can’t reveal are inane) have helped me cultivate a good poker face.

      • nicoleandmaggie Says:

        ROFL Back to the Midwest!

      • omdg Says:

        Maybe I need to botox my forehead. It’s those damn eyebrows and the squinty face, and now I have permanent 11 lines between my eyes that I swear makes people think I’m scowling all the time. I’m just concentrating on what you’re saying, people! I swear I’m not angry!

  9. Debbie+M Says:

    I’ve been super lucky to not have many mental health issues and all of them mild. Nowadays, I’m having anxiety, but it’s not about me. It’s about climate change and politicizing every little thing and losing our democracy and just basically living in some crazy opposite land. Literally yesterday I read in the news ‘Georgia Gov. Brian Kemp, a Republican, said in a Twitter message that the ruling [blocking Biden’s vaccine mandate] will provide relief to workers “who were in fear of being forced to choose between this vaccine and their livelihood.”’ How can anyone possibly believe that’s a scary decision? Oh, no, my job is requiring me to get a huge protection against an often horrifying disease, for free. Oh, no, my job is also giving me a paycheck. Not only are we not coming together to fight common enemies (covid, climate change) like we did with WWII, a bunch of us are actually helping these enemies, and *they* manage to call the *rest of us* traitors and suckers and morons.

    I know it’s a minority of people. And I know some of those people aren’t morons and have good reasons for things. And I know that one person *can* make a difference.

    But that person isn’t me. And it takes forever; we don’t have time. And huge minorities of morons and/or evildoers have ruined loads of things in the past (other pandemics, cutting down that last tree on Easter Island or whatever, Nazi Germany).

    On the other hand, lots of things I never thought could be improved actually have. Many species have been saved from the brink of extinction, pollution has actually been greatly reduced in lots of places, MADD (Mothers Against Drunk Driving) actually made “designated drivers” a thing, and there’s so much less smoking than there used to be (even my mom quit). So I know there’s hope, even when I can’t feel it.

    And I know that my sometimes feeling stressed enough to affect my sleep and even my health is not helpful at all. But did a bunch of people in Nazi Germany really tell themselves to just take a break from the news, etc? Surely I should be doing something. (By the way, I love that you do recommend actual things to do like calling our reps, and then also advise it’s also okay to take a break and then jump back in later when we can. I love all that.)

    So, maybe this is a different topic. Anxiety feels like a thing that therapy could help with, but I don’t see it for this kind of anxiety. But probably I’m wrong.

    • nicoleandmaggie Says:

      Yeah, if what’s going on now isn’t anxiety making, likely one is either not paying attention or one is part of the problem.

      Cognitive restructuring doesn’t help when the truth is bad. :/ But doing something does help me. I just wish it felt like more people were doing things, you know? It was really nice when we were all working towards a goal. Right now I’ve been mostly giving money and getting people to vote in our local elections/run-offs.

      Those are excellent reminders about how much progress we’ve made even in our lifetimes. It’s amazing going to restaurants and nobody smoking– so different from when I was a kid. And Gay Marriage is legal! We can’t let the bad guys beat us down.

      Thank you so much for the pep talk!

      • Debbie+M Says:

        Yes, gay marriage is STILL legal! Even in Texas!

        Yes, when I was a kid, it was considered rude if you in any way even implied that you didn’t enjoy people smoking in your presence. (At best, they let us open a window, and then in the car my long hair would blow all over the place.) Now smokers actually expect to be kicked out of other people’s houses to smoke.

        And the drinking! When I was in college, I couldn’t imagine anyone agreeing that they shouldn’t be allowed to drive if they got drunk. This is America–we need our cars!

        And people (even me!) are learning to say “they.” It helps that every single teenager I know (well, I know their parents) goes by “they.”

  10. revanche @ a gai shan life Says:

    Yay the CBT post! (Sorry if I said it before, I’m fuzzy today: I don’t know what I did to make your posts get emailed to me but I like it. Only for your blog though.)

    xykademiqz’s comment made me laugh because I feel the same about being ok with talking to my therapist because I pay her. But at the same time I discount certain things she says that are positive about me BECAUSE I pay her. I feel like it’s a bit of a double edged thing: I pay her so I’m not imposing and I won’t waste my time on pretending everything is fine so I’ll be open with her. But that’s not representative of how I am with everyone else. I don’t trust most of them to like me for me.

    But I very much like the use of CBT for anxiety specific things. I tried the listing of things that I cannot control recently and I think that particular exercise did help me break the cycle of the panicky physical reactions I was having around the Big Scary Terrible Things anxiety spiral I was getting stuck in.

    • nicoleandmaggie Says:

      There’s really something about writing things down that makes them more I dunno mentally attended to so they can stop cycling. Like I wrote it down so I can think about it later when I want to.

  11. Alice Says:

    I haven’t done CBT, but did do several years of more basic talk therapy. I started it because I was having daily physical stress symptoms and a doctor recommended that I try counseling.

    It was helpful to eventually get the stress symptoms to be less frequent. And gave me the push to work on some things that were holding up big parts of my life. But once I’d dealt with the big issues and those parts of my life weren’t held up anymore, it began to feel like I was treading water in the sessions. I think I kept going for a good 2 years after I was ready to be done because I didn’t know how to say, “thanks, been seeing you weekly for years now, you’ve been really helpful, I think I’m done.”

    I stopped when the pandemic hit. I know that she resumed with phone sessions about a month in… and I just never called to be put on the schedule. To be honest, I feel like I’m doing better with the things I was treading water on now that I’m on my own. I was using talking about various issues during sessions as a way of avoiding actually doing anything about them in reality. It’s not that seeing her wasn’t incredibly helpful at one time in my life– it was, and it got me to change my life for the better. It’s more that once a lot of those changes were made, there didn’t seem to be another level and there wasn’t an offramp.

    • nicoleandmaggie Says:

      #2 is really good at taking that step but I so was not. #2 is always telling people that good therapists understand and they want you to do what is right for you at the appropriate time and place. That is one of the things I loved about CBT though—at the beginning they were like this is eight weeks and then you’re done. Love that end point. Obviously with talk therapy that endpoint isn’t going to be obvious or the same for everyone.

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