Friday, 17 February 2012

CBT and me (TW: discussion of depression)

AnnalyticaPosted by Annalytica
As I may have mentioned, I suffer from depression. Like many people with depression (and increasingly, like many people with any kind of mental health problem), I have at various points been recommended cognitive behavioural therapy. CBT is extremely helpful for a lot of people, but it isn't the magical panacea that many mental health professionals and policy-makers seem to think. In this post I want to explain why it has been particularly unhelpful for me.

To begin with I'll briefly explain what CBT is, for the uninitiated.
It's based on the idea that thoughts (cognitions), feelings, behaviour and physiology all interact and affect each other. If someone is depressed, there can be a sort of feedback loop. For example, the thought "I'm useless" leads to feeling demotivated, which leads to the behaviour of staying in bed, which leads to the physiological effect of feeling lethargic and tired, and then having done nothing all day reinforces the original thought. All of these things can reinforce each other, leading to a vicious circle, or rather a vicious downward spiral. CBT works by intervening in the parts of this loop that the person has the power to change - their cognitions and their behaviour. By identifying and challenging negative thoughts, and choosing certain behaviours even when they don't feel like doing that (for example, going out and socialising), the person can change their emotional state, and even reverse some of the physiological effects of depression. CBT also involves rating your mood at various points, so you can see how certain activities affect your mood. The rating also gives a convenient way to assess the effectiveness of the therapy: one of the reasons CBT is so popular with healthcare funders is that its effects are measurable, insofar as rating your mood on a scale of 1 - 10 counts as a measurement.

Now, as I said, a lot of people find CBT extremely helpful. I don't want to deny the good it can do in some cases. But I am concerned by the way it is prescribed for everyone, all the time, when it isn't always appropriate.

When I first came across it (about 7 years ago) I thought it was great - I could use all these skills I already had for logically picking stuff apart to help me do the thing that seemed most important at that time, which was recovering from depression. I spent quite a long time engaging with CBT and thinking it was basically the answer to all my problems. These days I react very strongly against any suggestion that I should try CBT, and it's taken me a while to fully understand why. Indeed, it's taken me a while to realise that my feelings towards CBT are grounded in genuine problems with the approach, and not just my own resistance to self-care. My unwillingness to speak up about the fact that it is not right for me and I don't want to try it again is itself a symptom of the kinds of problems CBT exacerbated.

One of the things I've come to realise through counselling is that a lot of my problems stem from the way I have grown up believing that my intellectual abilities are my sole source of worth, and that other parts of myself and my experience need to be suppressed. Emotions, desires, bodily experiences, my sense of fun - all of these are things that I expect to be either mocked or dismissed or ignored if I express them, so I ignore them myself in favour of only expressing what seems rational. Thank you, kyriarchy. So I'm starting from a position where I enforce within myself a sharp separation between rationality and everything else, and the idea that my rational mind is good and everything else about me is bad.

CBT encourages me to separate the "sick" part of my mind that produces "dysfunctional" attitudes from the rational part of my mind that can assess how appropriate my reactions are, and while there are situations when that can be helpful, for me it reinforces the existing problem. I have great difficulty with spontaneity, and in part that comes from the feeling that everything has to be filtered and processed through my conscious, analytical mind, because I can't trust any impulse or intuition that I haven't yet had time to examine logically. To a certain extent that tendency was already there, and my practice of CBT gave it the extra force of the fear of depression. I came to see my proneness to depression as being due to my subconscious basically being out to get me, and thought I had to be constantly vigilant against whatever poison it might produce, to stop myself from becoming depressed again.

I find that vigilance exhausting, and it leaves me feeling like I'm at war with myself. When I started using CBT, I thought the best way to ensure that I didn't become depressed again was to keep using it even when I was well, to ward off negative thoughts before they turned into depression. After a while that just became unbearable, and I felt like I'd rather just allow myself to slip into depression than be constantly questioning my every thought and feeling. I went through a phase of thinking, "Screw this, if my brain wants to be depressed I'm just going to let it," which at one time would have been an utterly unimaginable thing for me to think, but I was too tired of fighting it.

In the depths of a severe depressive episode, understanding the depression to be separate from the self can be very helpful. For someone in my situation, with depression so chronic that it's no longer possible to separate out what is me and what is the illness, parcelling off a part of myself and labelling it as diseased only exacerbates the problem. I want to learn to acknowledge and accept those parts of myself which I have buried. For me, that has to involve loosening my grip on cognitive approaches to everything, and trusting in other kinds of knowledge.

7 comments:

  1. Thanks for sharing, this was really interesting, and helpful for me. I definitely agree that CBT is often pushed on people as a sort of cure-all without any recognition of what they actually need.

    Recently I sought NHS counselling on my doctor's recommendation and was sent for CBT even though it wasn't what I'd asked for and I felt that the person who assessed me tried to make my answers skew towards what ticked their boxes.

    Fortunately when I actually met the CBT therapist, she agreed that it was the wrong choice for me, but it does seem that there's a tendency to just send everyone for CBT first regardless of their individual needs.

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    1. Wow, that's really interesting that the CBT therapist (who you'd expect to be more immersed in the CBT worldview) could see it wasn't right for you, while the person who assessed you (who presumably ought to have an overview of a range of approaches) was pushing you into CBT. I hope you find an approach that suits you better.

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  2. Thank you so much for sharing your experiences. I have also been pushed towards CBT for my depression and found myself very uncomfortable with the process for vague-reason-that-I-can't-really-describe-but-you-sum-up-perfectly-here. Thank you for making me feel less alone in my journey, and I wish you all the best in yours.

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    1. I'm glad you found it helpful. I felt this as a vague reason I couldn't quite describe for a long time and it's only recently dawned on me that this is what's going on for me.

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  3. Thank you for sharing.

    I've had an eating disorder for 10 years. I went for CBT treatment 4 years ago and was told that this would be the answer for me. It did actually improve my mental health (although feminism/social justice has done far more for me than it ever did) but the eating disorder remains. It was far too simple a system for something so complex. They'd say "You have to eat regular meals and do CBT around these meals - here is your plan" and I'd have a million questions, none of which they could answer. People are complex creatures and one size certainly doesn't fit all!

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  4. Hi there! Thank you so much for sharing your knowledge about cognitive behavioral therapy. You have such a very interesting and informative page. I am looking forward to visit your page again and for your other posts as well. I am so glad to drop by and to have an additional knowledge about this topic through your blog. Keep it up!
    In addition to that, based on what I have read online, there are different protocols for delivering cognitive behavioral therapy, with important similarities among them. Use of the term CBT may refer to different interventions, including "self-instructions (e.g. distraction, imagery, motivational self-talk), relaxation and/or biofeedback, development of adaptive coping strategies (e.g. minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting". Treatment is sometimes manualized, with brief, direct, and time-limited treatments for individual psychological disorders that are specific technique-driven. CBT is used in both individual and group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are cognitively oriented (e.g. cognitive restructuring), while others are more behaviorally oriented (e.g. in vivo exposure therapy). Interventions such as imaginal exposure therapy combine both approaches.

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  5. maggie.danhakl@healthline.com30 October 2014 at 09:10

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