The CBT Path Out of Depression

Two Perspectives on How It Works

Magazine Issue
November/December 2014
A figure walking on a path of stones through water and reaches as fork

Cognitive behavioral therapy (CBT) is arguably the most successful therapy ever developed. In only about 40 years, it’s gone from the almost accidental innovations of two disenchanted psychoanalysts to the most widely practiced and promulgated approach in the world. For space aliens who’ve never heard of CBT, a quick and dirty definition may be in order. CBT—not a single model, but a constellation of short-term, pragmatic, goal-oriented clinical techniques, used in varying ways in different circumstances with people suffering from different conditions—is based on a simple axiom about human experience: how we think and perceive hugely influences how we feel. Independently coinvented by Aaron Beck and Albert Ellis, the clinical method rests on a kind of Socratic questioning (with lots of homework!), which helps clients identify and correct the inaccurate, defeatist assumptions and distorted thinking patterns that keep them stuck in a perpetual round of self-reinforcing unhappiness.

Taught in almost every clinical psychology and psychiatry program in the United States, CBT dominates the field in North America, much of Europe, and increasingly, Asia and Latin America. It’s essentially the “official” therapy of the healthcare arm of the US Department of Veterans Affairs, which has in place a national staff-training program for treating depression—the largest such program in the country. Managed care and insurance companies love CBT for obvious reasons: it’s brief, usually 16 sessions or fewer, thus much cheaper than that once-famous other brand, psychodynamic therapy. It’s also reassuringly protocol-driven, sticking to a plan without wandering all over the place for years at a time. But what really stands behind its extraordinary rise is, and always has been, its claim to be far and away the most empirically supported therapy out there.

For a psychotherapy approach, the sheer numbers of studies of CBT are astonishing. A 2012 review of CBT research published in Cognitive Therapy and Research reported that at least 1,163 studies had been done on it since 2000, 84 percent of them after 2004. After winnowing down this bumper crop and separating the wheat from the chaff, the reviewers had 16 quantitative reviews of 269 clinical trials. Even though they found the sum results of depression studies “mixed”—not a slam dunk in favor of CBT—overall, the authors (no doubt themselves CBT therapists) were impressed: “In general, the evidence base of CBT is very strong,” which is researcher-speak for “Hot damn, this stuff works great!”

The imprimatur of science, or Science, not only boosted CBT’s reputation as empirically “truer” than other therapies, it gave therapists a life raft in the rising sea of medicalized psychiatry. CBT therapists touted their research to demonstrate that, indeed, not only was their version of talk therapy as good as psychotropic drugs, it could, in various trials, show itself to be even better! Today, it’s considered the preeminent “evidence-based practice” or “empirically supported treatment,” and has become virtually synonymous with those terms.

Where did this streamlined, efficient, practical therapy come from that would prove such a good match for our fast-paced, high-tech civilization? CBT’s founders, Beck and Ellis, began their careers as true believers in the great 19th-century Church of Psychoanalysis, but they lost their faith and became radical dissenters. Both came to believe that whether the causes of emotional suffering did or didn’t lie in buried unconscious impulses and repressed motives was irrelevant. What sustained unhappiness and turned it into an unshakeable habit, they hypothesized, was a pattern of distorted thinking and false, self-defeating beliefs. Ellis’s version of CBT, which he called Rational Emotional Behavior Therapy, was more a tough-minded philosophy of life than a clinical intervention. Combining the wisecracking persona of a Zen stand-up comedian with the attitude of the Greek Stoic Epictetus (maxim: “Men are disturbed not by things, but by the views which they take of them”), Ellis argued that we’re largely responsible for our own unhappiness because we cling to irrational beliefs, which prevent us from accepting life as it comes and ourselves as we are.

Beck was more a clinician-scientist than a philosopher-sage, and certainly a far more modest presence than Ellis, but he, too, came to embrace the belief that by working hard at thinking about their own thinking, people could figuratively pull themselves up from despair by their own mental bootstraps. As Beck tells it, he more or less accidentally stumbled upon his own revolution. In a now-legendary story, he was analyzing a young woman who spent her sessions describing in lurid detail her action-packed sex life while Beck sat quietly behind her taking notes. At the end of the session, he asked her in good, neutral analytic style how she felt.

“Very anxious, Doctor,” she said.

Beck gave her the standard formula: she felt anxious because she believed her sex life was unacceptable and feared disapproval from him, the community, her family, and so forth.

“No, no, not really,” she replied.

Well then, what? As Beck probed, she finally admitted that she wasn’t anxious about her reputation, but about whether she was boring him; in fact, she worried continually about boring everybody in her life. It wasn’t the sexual material, but her mistaken thoughts about how tedious a person she was that stirred up her anxiety.

Once Beck began helping her examine the belief and the entire lack of evidence for it, her anxiety rapidly diminished. From this small acorn of revelation, a mighty forest began to sprout. He began asking other patients, while they sat up in front of him rather than lying down on the couch, about their thoughts, uncovering poisonous streams of transitory, barely conscious self-talk—negative, pessimistic, self-disparaging, distorted, even including blatant misinterpretations of what he had said to them—that lavishly fed their anxiety and depression. Borrowing some techniques from Ellis, he began systematically helping patients “explore, investigate, and evaluate,” and quite soon, resist these negative thinking patterns. Amazingly, his patients rapidly improved. People he’d been seeing for years would get drastically better after only 10 to 12 so-called cognitive sessions and leave analysis.

Beck went on to become one of the most influential figures in modern psychotherapy. Behaviorists loved him: he was a scientist of psychology, just like them, but lent chilly behaviorism a certain human warmth, drawn from the psychodynamic tradition. Young psychological researchers loved him: his was a way to demonstrate empirically that psychotherapy worked at a time, during the 1970s, when psychotropic drugs were beginning their relentless ascendancy.

According to its proponents, CBT came, challenged, and conquered, triumphing over all the world of talk therapy by virtue of its clear and empirically supported clinical superiority. So it’s safe to assume that anybody who doesn’t believe that mental healthcare begins and ends with a psychotropic prescription now belongs to the new Church of CBT, right?

Not exactly! For all its mantle of scientific rigor and official approval, many therapists find CBT hard to love, if not downright dislikable. Ask the average therapist what he or she thinks about CBT and you’ll likely get several predictable responses. They don’t really believe that “lab therapy,” with its strictly exclusionary criteria limiting samples only to the “purest” cases, has much relevance to the heterogeneous clients they see every day, each with multiple diagnoses and a jumble of symptoms. These critics are usually inclined to see therapy more as art than science anyway, regarding therapy as a special kind of relationship, requiring the kind of people skills they assume aren’t really necessary for following a protocol. In fact, most therapists like exploring feelings with their clients, delving into family history, helping them achieve emotional growth, going deep—and taking their time doing it. That’s why they got into therapy in the first place.

They enjoy letting the client lead the way, rather than—in their view—foisting a preset agenda on the process. The objections of many therapists to CBT ring like a litany of unattractive clinical features: the approach is rigid, inflexible, reductionist, shallow, unresponsive, overly didactic (schoolmarmish). Sure, some aspects of CBT may be useful—occasionally asking about clients’ negative thoughts seems like a sensible clinical step—but as an overall approach, they insist it’s more like a soulless anti-therapy than what any self-respecting, compassionate, emotionally open, people-hugging clinician would choose as a career!

Well, in the interviews below, Judith Beck and Michael Yapko are here to tell you that CBT has gotten a bum rap. Judith Beck, the Great Man’s daughter, is herself a leading CBT clinician, researcher, author, and president of the Beck Institute for Cognitive Behavior Therapy, a nonprofit organization that provides training to mental health professionals worldwide. And Michael Yapko is an internationally recognized psychologist, teacher, and author, who combines CBT with clinical hypnosis and specializes in treating depression. Here, they each argue that far from being a kind of ersatz therapy by automatons for automatons, CBT at its best is a humane, compassionate, and rational approach, which both accepts and validates people’s emotional pain, while gently showing them what else is in their brains. Further, in a psychological climate of opinion that’s perhaps overvalued emotionality and a touchy-feely approach to relieving suffering, they both offer a precise, step-by-step method that zeroes in on what sorts of thoughts keep human misery well fueled, while demonstrating that even the most depressed, anxious, and otherwise unhappy people maintain their capacity for reason, for acquiring the mental tools to free themselves from their own suffering. Certainly it might be worth 10 to 16 sessions to try out. After all, the meds will still be there if it doesn’t succeed.


Photo © Thomas Barwick / Getty Images

Mary Sykes Wylie

Mary Sykes Wylie, PhD, is a former senior editor of the Psychotherapy Networker.