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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.
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 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.
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