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.” [1]
This fact has been further confirmed by a number of meta-analyses [2] and by a large randomised controlled trial comparing behavioural therapy and cognitive therapy side by side with medication for depression [3].
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 [2]. 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.” [3] 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.” [1]
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.
References
[1] 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.
[2] Longmore RJ, Worrell M. Do we need to challenge thoughts in cognitive behavior therapy? Clinical psychology review 2007 Mar;27(2):173-87.
[3] 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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Dr C. Edward Pitt 