There was a psychiatrist (now retired) whose referrals for psychotherapy would include helpful advice about how CBT treatment should proceed. Alas, this psychiatrist had only the vaguest idea about how CBT works, and the advice invariably missed the point.
I was reminded of this recently when I looked at the information leaflet Cognitive Behavioural Therapy (CBT) published online by The Royal College of Psychiatrists.
The leaflet describes what I now call lifestyle CBT — the false belief that by controlling your everyday thoughts you can cure yourself of mental illness. The reality is that while worrying about your own thoughts might take your mind off your other worries, it has no effect whatsoever on mental illness.
More extreme forms of lifestyle CBT tend to involve meditation and perhaps other thought-control techniques, but the Royal College does not seem to have heard about those yet.
Amongst the many silly and misleading statements in the leaflet, it is difficult to identify the silliest. Perhaps it is:
A therapist is like a personal trainer that [sic] advises and encourages…
On the contrary, a therapist who can only offer advice and encouragement is not a therapist at all. Therapy involves actively and intelligently listening, understanding and making sense of the origins of the things that trouble you.
It can be difficult to explain the relationship between CBT and common sense. The problem is that when you look back after successful CBT, things do make sense and it is hard to remember how confusing they once were. But before you have CBT is is equally hard to understand how your feelings could possibly make sense.
The difficulty is famously illustrated by the story of Columbus and the Egg (original emphasis):
Columbus…took an egg from a dish and said to the company, “Who among you, gentlemen, can make this egg stand on end?”
One by one those at the table tried the experiment. When the egg had gone entirely around and none had succeeded, all said that it could not be done.
Then Columbus took the egg and struck its small end gently upon the table so as to break the shell a little. After that there was no trouble in making it stand upright.
“Gentlemen,” said he, “what is easier than to do this which you said was impossible? It is the simplest thing in the world. Anybody can do it — after he has been shown how.”
The point of the story is not just that Columbus performed an after-dinner trick. The point is that he performed the same trick in the real world by making it obvious that anyone at all can travel between Europe and America, although for him to do that required real skill as a sailor.
In the same way, making your recovery seem like common sense requires real skill from your therapist, not just advice and encouragement.
Elsewhere in the New World — in Australia — blogger jeneli quite rightly pointed out recently that controlling your thoughts can do you harm, in Fibro fog, and more rambling about CBT:
Sometimes negative thoughts are TRUE. Sometimes people ARE staring at you because you’re ugly. Sometimes you have to accept that actually, you’re just not very good at something. And I actually think that part of CBT can be very dangerous for someone who is severely depressed.
I agree. The problem, generally, with lifestyle CBT is that it layers abnormal thought-control techniques on top of your existing abnormal patterns of thinking. Granted, that makes your existing problems harder to see, but it actually make your overall situation worse.
The example I often use is being bullied at work. Bullies at work are usually easy to deal with if your thoughts about being their victim are sufficiently negative. If you force yourself to have positive thoughts — sympathy for the bully, or you tell yourself that it’s OK really — then the bullying will only get worse. On the other hand, people who have strongly negative feelings about it, and who let their feelings be known in no uncertain terms, tend not to be bullied again.
A further example of the damage that ideas like lifestyle CBT can cause was illustrated in a recent article in New York magazine, All Joy and No Fun — Why Parents Hate Parenting. (Hat tip to vaughn at Mind Hacks for this one.) Examining whether being a parent makes people happy, they found that it mostly doesn’t at the time (page 1 online, original emphasis):
Daniel Kahneman, a Nobel Prize–winning behavioral economist…surveyed 909 working Texas women and found that child care ranked sixteenth in pleasurability out of nineteen activities. (Among the endeavors they preferred: preparing food, watching TV, exercising, talking on the phone, napping, shopping, housework.) This result also shows up regularly in relationship research, with children invariably reducing marital satisfaction.
But looking back, it’s the other way around — with hindsight, being a parent makes you much happier (page 6 online):
About twenty years ago, Tom Gilovich, a psychologist at Cornell, made a striking contribution to the field of psychology, showing that people are far more apt to regret things they haven’t done than things they have. In one instance, he followed up on the men and women from the Terman study, the famous collection of high-IQ students from California who were singled out in 1921 for a life of greatness. Not one told him of regretting having children, but ten told him they regretted not having a family.
So again, the philosophy of avoiding negative feelings in life, the basic philosophy of lifestyle CBT, makes people’s lives worse overall. There is much in life that is negative, including many of the day-to-day experiences of bringing up your children, but the appropriate and healthy response to those negative things is to have negative feelings about them, to be anxious, depressed, angry and downright miserable at times. Those are normal feelings and you do yourself harm by trying to avoid them.
People whose overall experience of life is the most positive have many negative experiences of life along the way, and they have not blocked their negative feelings about them.
I don’t even know whether a psychiatrist wrote that leaflet on CBT. It might have been cobbled together by a website designer or a PR company.
Regardless, psychiatrists’ expertise is limited to certain aspects of mental illness like diagnosis and prescribing. Psychiatrists are not generally experts on all forms of therapy or on life as a whole, and it is wrong to expect that of them. (The exception that proves the rule, perhaps, is Alone at The Last Psychiatrist, whose ruthless deconstruction of the article about parenting is a classic example of his insight.)
Even so, to see the Royal College of Psychiatrists publish that kind of drivel about CBT under the slogan:
Let wisdom guide
is very sad.