She shifted uncomfortably in her seat, her uneasy hands fidgeting together, her eyes flitting around as she tried to focus on the wall across from her, unable to find a target for her empty gaze.
“But … I’m normally a rational person,” she said, finally putting words to the thought that had been evading her for half a minute.
She was a woman in her mid thirties, with a comfortable job, a family and a mortgage in the suburbs. We were halfway through a standard GP consult, and we had already discussed and resolved something trivial before she finally plucked up the courage to change tack and reveal the hidden agenda she’d hoped to discuss all along.
“I’m anxious all the time. I try so hard, but I can’t seem to stop thinking about all the things that could go wrong.”
I empathised. I’ve been there too – I’ve lived through times when my anxiety disorder was so debilitating that I wouldn’t call someone on the phone for fear of dialling the wrong number. Or when I was so depressed that I couldn’t see anything positive for the future, when nearly every thought I had was saturated with moribund darkness.
I was anxious as a teenager, but I was depressed as an adult. I’d been through medical school and I had attained by GP fellowship when my depression took hold. During the four years or so that I spent with the black dog, I was constantly haunted by the same narrative that now haunted my patient … “I’m a rational person, why am I thinking like this?”
The fact I had fellowship level medical training intensified my mental self-flagellation, “I know all about depression. I understand CBT. I know I’m ruminating on catastrophic thoughts. So why can’t I stop them? If only I could think more positively, I’d be so much better.”
I found myself in a self-defeating spiral, often called the struggle switch, where I thought I knew how to climb out of my psychological mire, but all I achieved in trying to climb out was to sink further in, making me feel more defeated, even more of a failure. It was a very difficult time which I thought would never end.
Eventually it lifted, like a heavy fog thinning in the morning sunlight, but it certainly wasn’t the result of anything clever I did. So why did my rational brain keep filling my mind with irrational thoughts?
The answer lay in a paradigm shift away from the long held beliefs that we were taught at medical school and in our general practice training. We’ve been lead to believe for so many years that our thoughts were the key driver of our behaviour, but it turns out that it’s actually the other way around, our behaviour is but one of a number of key driver of our thoughts.
The foundation of CBT is the notion that challenging maladaptive thoughts helps to empower behavioural change. Except that research suggests that cognitive therapy specifically targeting problem thoughts offers no extra improvement over behavioural therapy alone.
Herbert and Forman confirm this when they point out that, “proponents of behavioral activation point to the results of component control studies of CT, in which behavioral activation or exposure alone is compared to behavioral activation (or exposure) plus cognitive restructuring. The majority of these studies have failed to demonstrate incremental effects of cognitive restructuring strategies.” 
This fact has been further confirmed by a number of meta-analyses  and by a large randomised controlled trial comparing behavioural therapy and cognitive therapy side by side with medication for depression .
So therapies aimed at fixing thinking works equally as well as therapies aimed only at promoting therapeutic action. However, when thinking therapies are added to behaviour therapies, they add no extra benefit over and above the behaviour therapies alone . This suggests that action is the driver of the therapeutic effects of psychological therapy. If thinking were the driving force of psychological change, the addition of cognitive therapy to behaviour therapy should have an incremental effect.
That cognitive therapy works equally well as behavioural therapy may be related to their fundamental similarities. Dobson et al explains, “Behavioural Activation is implemented in a manner that is intended to both teach coping skills and to reduce future risk. The same is true for Cognitive Therapy, which adds an emphasis on cognitive change, but otherwise takes a similar skills-training approach.”  In other words, cognitive behavioural therapy is just behavioural therapy with bling.
Herbert and Forman summarise it nicely, “The ideas that thoughts and beliefs lead directly to feelings and behavior, and that to change one’s maladaptive behavior and subjective sense of well-being one must first change one’s cognitions, are central themes of Western folk psychology. We encourage friends to ‘look on the bright side’ of difficult situations in order to improve their distress. We seek to cultivate ‘positive attitudes’ in our children in the belief that this will lead to better academic or athletic performance. Traditional cognitively-oriented models of CBT (e.g., CT, stress inoculation training, and rational emotive behavior therapy) build on these culturally sanctioned ideas by describing causal effects of cognitions on affect and behavior, and by interventions targeting distorted, dysfunctional, or otherwise maladaptive cognitions.” 
I understand this is going to ruffle some feathers, and not everyone is going to be keen to dispense with CBT just yet, but I hope this gets us thinking about thinking at the very least.
For me, coming to an understanding that my thoughts were just the dashboard and not the engine helped me to pay less attention to them and to focus my healing energies on what was really important, taking values based action rather than just fighting with my stream of thoughts.
And it’s helped me to empathise differently with my patients and reassure them that you can still be a rational person even if your thoughts don’t always seem to follow suit.
 Herbert JD, Forman EM. The Evolution of Cognitive Behavior Therapy: The Rise of Psychological Acceptance and Mindfulness. Acceptance and Mindfulness in Cognitive Behavior Therapy: John Wiley & Sons, Inc., 2011;1-25.
 Longmore RJ, Worrell M. Do we need to challenge thoughts in cognitive behavior therapy? Clinical psychology review 2007 Mar;27(2):173-87.
 Dobson KS, Hollon SD, Dimidjian S, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. Journal of consulting and clinical psychology 2008 Jun;76(3):468-77.
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Have a look at Human Givens psychotherapy , Mindfulness and Acceptance and Commitment Therapy.
Mindfulness- recognises the difficulty of suppressing experience or avoiding it and teaches acceptance whilst focusing on the moment etc
The founders of Human Givens Therapy were challenging the effectiveness of CBT for the same reasons stated above on courses that I attended over 10 years ago
Acceptance and Commitment Therapy is building a strong evidence base using mindfulness techniques in combination with committed action based on values .
Hi Jenny, thanks for your comment. I agree, and I’m a big fan of ACT – dedicated a full chapter to it in my book!
All the best to you 🙂
I understand and respect that you personally don’t have much time for the C part of CBT, but “cognitive behavioural therapy is just behavioural therapy with bling.” is a bit harsh, perhaps?
I think it is matter of horses for courses. I don’t believe that one type of evidence-based psychological therapy is better than another, empirically, for everyone. They are all valuable tools to be used with discretion, in the right circumstance. And they don’t have been to administered by a psychologist and are not just for those who are unwell.
Personally? I think cognitive strategies can be incredibly powerful for some, in the right circumstances. I know they have helped me. A lot. And the ones that have helped best are the cognitive re-framing ones, for things like coping with pain and for work stress. Expressing gratitude is one of my top helpers – and this is very much a cognitive process for me – turning “poor me” thoughts into “lucky me” thoughts. The key to my coping is (generally but not exclusively) with cognitive therapies. Getting my thoughts in order allows the other things (eg feelings, actions) to follow. That is me. For others, the same approach might make them feel worse. We are all different.
And I rush to add that I’m not talking about treating depression, but looking at mental wellness overall. I’m certainly not saying that the mind controls everything or that medication is not warranted in depression. Absolutely not. I’m a big fan of medication when indicated. And I think ACT and Mindfulness are wonderful. All great tools to have in one’s toolbox. Let’s just be in a rush to through out the screwdriver just because we have a new electric drill.
Hi Genevieve, Many thanks for your comment 🙂
I appreciate your perspective, and perhaps I was using a little bit too much poetic licence by cognitive therapy / bling analogy. But the evidence overall, at least the evidence I’ve seen, is that cognitive therapy is a lot weaker than we like to think (Jakobsen JC, Lindschou Hansen J, Storebo OJ, Simonsen E, Gluud C. The effects of cognitive therapy versus ‘treatment as usual’ in patients with major depressive disorder. PloS one 2011;6(8):e22890 – for example).
The truth is probably more nuanced than a few studies might indicate. I am certainly a fan of gratitude along with mindfulness and a number of other psychological tools (all of which I wrote about in my book, Kintsukuroi Christians – fb.me/KintsukuroiChristians).
But the danger in promoting cognitive therapies as powerful tools then suggests to people that they should be able to fix all of their issues but just thinking right, which over the years since Beck, has blossomed into the multi-billion dollar positive thinking movement, which is great for Tony Robbins, Deepak Chopra, Caroline Leaf and their ilk, but which hasn’t done a whole lot for society as a whole.
I see it all too often in my consulting room where patients are suffering twice over, because of their illness, and because other people (and they, themselves) just expect they can think their way out of it, and feel bad because they can’t stop the flow of distressing thoughts that constantly haunt them.
Anyway, that’s my personal view. I acknowledge that I might have a bias against screwdrivers, though I do always try to use the best tool for the job.
Many thanks for your excellent comment, and all the best to you 🙂
Please don’t confuse evidence based cognitive therapies such as structured problem solving and gratitude practice with the pop psychology promoted by people like Anthony Robbins. Moving away from the tool box analogy, it’s like equating the health benefits of Weetbix with Coco Pops. I’m not saying people can “think their way out of depression” nor that cognitive strategies should be used exclusively. Weetbix is a wonderful source of nutrition but one needs to have a varied diet for full health. And if you have coeliac disease, Weetbix are very unhelpful. 🙂
Yes, thanks. I agree. My point was more that structured cognitive therapy has been misrepresented for generations and, like Chinese Whispers, the message has morphed into something unrecognisable, which to my mind, is counterproductive. It’s not that true cognitive therapy is unhelpful across the board, but people see it as a magical incantation that they need to focus on or recite to make their life perfect again.
Like I said, I’m happy to promote some predominantly cognitive strategies where there’s likely to be some benefit, but I feel like we need to be more realistic about its prominence in our toolbox (or pantry …).