There's the classic joke where someone goes to the doctor and says "it hurts when I do this", and the doctor says "well don't do that then".
Cognitive behavioral therapy is basically the same thing but it boils down to: "it feels bad when I think about this" / "well don't think about that then".
It's more like a thing gives a patient unbearable anxiety and makes them feel like they have no control. CBT helps them put that thing in perspective, and actively control how they respond to it before it winds out of control.
Is it really about never thinking those things, or is it about training yourself to have the ability to turn those thoughts off when you want to?
Like meditation is about not thinking, but it doesn't mean you try to never have a though again... it just means you have a degree of control over when you put gas on that fire and when you let it burn down.
I read about how beneficial CBT is on HN only a couple days ago
https://news.ycombinator.com/item?id=12298898
(Disturbing trend of people with no medical experience making critical medical recommendations.)
> 1. scientific method is not a good fit for 'mental health' research
What exactly is a good basis for mental health research then in your opinion? twisi the scientific method is basically all you've got even if it doesn't work as well as it does in other types of research. Yet what other options do you have besides anecdotes and woo?
Alright then let me clarify my opinion. I don't think anecdotes and intuition are useless. They're appropriate for every day decision making where stopping to do a controlled study isn't an option. When it comes to actually looking for broader truth though all they can do is point you in potential directions to study. Theres no better option than scientific method for that so far as I know.
So if you want to know broadly of CBT works then science is your only realistic option.
So if I spent an afternoon each talking to five people who all had done CBT, your expectation is that I would have learned nothing about the "broader truth" about CBT's effects?
Not zero, but what you learned is highly subject to bias and error from your small sample of individuals. You are likely to have drawn conclusions from your conversation that are not broadly applicable or possibly even true for those individuals because in 5 informal conversations likely:
* you didn't interview enough people from different backgrounds
* you didn't control for the specific psychological conditions of your interviewees or what treatments/medications were in play at the same time or before / after the program
* you didn't test your question set to ensure that it doesn't have leading questions or questions can otherwise influence the results
* and so on.
I could go on, but the point is anecdotes are not _nothing_ but they pale in comparison to a well built scientific study. If you want to really know if a type of treatment works well and who it works well for with a minimum of bias then science is by far the best option. It's normal and fine to use anecdotes to guide personal day to day decisions in life, but if you want to make broad claims that are taken seriously by professionals trying to say help folks manage mental health issues then we have a higher standard than anecdote and rightly so.
I realized that I unnecessarily came off like I was getting on your case specifically about this. It's just a concept that's crossed my mind in general lately about people's views on the place of science.
no worries! i can see how what i said originally could be read that way and suspect we may agree that there's a bit of an unhealthy tendency amongst some of our peers to overstate how well science works and underestimate everyday reasoning that we all must do. Science is messy too. The world we're measuring is messy.
I say - use the best method that you reasonably can use and see where it gets you. If that's science then great, but often you need to get by with a lesser method and that is ok.
The odd thing about the linked post, is that the book in question is aimed at people who don't have a depression, and it explicitly asks readers with a depression to hold off the book until that depression has been dealt with.
It is part of a type of psychology called "Positive psychology", that works with how to be happier and how not to fall into depressions. This is in contrast to the traditional "disease model", which is only about curing psychological problems, or as the Author states "Making miserable people, less miserable".
People aren't depressed because they want to be, CBT relies upon the false assumption that people are able to change their mood if they will it enough.
If we wish to treat depression, we should focus on life not being so depressing to begin with, not persuading people that actually it isn't once they have already spiraled into despair.
I have been through three courses of CBT. On the third I was dismissed after six weeks because "I already knew it all" and the pediatrician thanked me as I had helped them "gain a better understanding". I found that it was only after receiving medication that I returned to mental stability.
I resent that you make a false assumption, having been through CBT so many times I feel I might even have a better knowledge of it than professionals whose only experience is from a text-book.
Now it's clear that in addition to knowing nothing about CBT, you also know nothing about what it takes to become a licensed therapist. My fiancé just became one, so I can help educate you: it goes far, far beyond textbook learning. After you get your Masters, you have to accumulate 3000 hours of supervised professional therapy under the guidance of another therapist who is licensed, and then after that you must pass an ethics exam and a clinical exam as well. Therapists are rigorously trained.
4mg of Fluoxetine daily for a little over two years.
Additional: Occassionally I may forget to take it and I won't feel any different however those around me pick up on it straight away as I become reclused and start constantly sweating.
Nobody in this thread (at time of writing) seems to have the slightest idea about what CBT is.
It is not about denying thoughts. It is not about telling yourself that you are happy, when you are not.
It can't treat severe depressions, but it can treat mild ones, and it can lower the amount of medication needed to treat severe ones.
You can think about it as "good posture for your mind". Nobody wants a bad posture, but lots of people have it, and some have it so bad, that they get pains so severe they cannot work. Some people with back pain take pain medication, and never solve the problem, but can go on with their lives.
For some people, there are external influences on their posture that cannot be negated by exercise and they do need to change their environment.
Some do need an operation with everything that entails, but most just need to fix their posture: Do the right exercises and stretches and they won't need medication or operations.
If you are depressed because of your abusive boyfriend, then CBT's answer is not "stop thinking about it" or "just think happy thoughts when you're being beaten" it is "get the fuck out of it".
> In the case of a fever, that might be enough, but for psychological disorders it is not so likely.
That might actually likely be enough. The reason why you have psychologist using CBT as therapy and not just self-help books is to identify if it is enough.
They're using CBT to see whether CBT is enough? I don't understand your statement.
My point was that there are typically unconscious thoughts that lead to disorders, and fixing those disorders at the surface without finding the root is likely to cause them to reappear later, in the same or different form. E.g. aspirin will not cure malaria.
I think they meant that the psychologist would tell the patient when a condition wouldn't benefit from CBT. As opppsed to relying on your own judgement and using self help books.
CBT goes a bit deeper than you think. Not as deep as psychoanalysis, but that's not really saying much. CBT does not dwell on how things came to be, but it does care about why things persist. CBT is in part about finding the flaws in your thinking that fucks you up.
> It seems to be enough only in the more benign cases.
you're assuming a false relationship between level of consciousness and severity. Case in point: war veteran with PTSD. His PTSD is from getting shot at, not from a disrupted relationship with his mother when he was 5.
case 2: patient has a phobia of flying. therapist gradually deconstructs the phobia using CBT methods, until the patient finally gets in a plane and flies.
Subconscious issues are not correlated to severity.
Your claim is that one's depression, anxiety, paranoia, etc., caused by post-traumatic stress, is purely the result of conscious thoughts, even though the individual knows, consciously, that they are no longer in immediate danger?
As for the second case, the "deconstruction" of a phobia is more characteristic of psychoanalysis than CBT.
Can CBT help with finding and addressing why one can't seem to find motivation and satisfaction from (most areas of) life? A state where almost everything feels boring, dull and lukewarm at best?
CBT can treat severe depression, but the problem is that all those deep-seated underlying mental patterns don't just change because you want them too.
Most people don't seem to realise that the celebrated prefrontal cortex is the youngest and in a way weakest part of the brain. It surrounds older structures that don't work much different than in reptiles.
Changing your thoughts is easy, changing the attached emotions, fight/flight responses etc., who might even trigger the thoughts in the first place is incredibly hard.
It takes time, the right corrective and endless patience and iterative practise.
I agree that CBT falls short with severe issues. I was going to CBT therapy and it caused the relationship issues with my wife (who suffers from borderline personality disorder) to be amplified greatly. My CBT therapist would constantly show me how my wife is irrational and manipulative. It caused huge amounts of distress to the relationship. I am now going to a therapist who does DBT and understands borderline personality disorder. CBT is still applied where it is useful but these issues require deep self-introspection and looking into the past. I've been so much better at communicating with my wife and have discovered my own codependency issues I need to work on. I no longer see my wife as someone who is evil and manipulative but understand that what she does and says is out of fear of abandonment.
I am the founder of a behavioral health practice management SAAS company and my cofounder is a therapist. So we actually get into those very discussions. I have enough mental health clinical knowledge to be dangerous and she knows enough code to make the discussion interesting.
As a side note we have a moderately successful CBT app so I have definitely spent plenty of time in the 'source code' of CBT methodology. It isn't bad or good anymore that C is bad or good. It's a tool that's useful when applied to the problem for which it is best suited.
Unfortunately, given the realities of health insurance payments, it's a tool often overused due to its 'promise' of fast results (compared to psychotherapy for instance.)
The real problem isn't CBT, it's an attitude by payers that mental health treatment can be quantified as easily as physical health. That leads to writing webpages in C so to speak.
In the psych community though the CBT vs. Psychotherapy debate reaches similar passions as debating PHP versus Rails. (Fix my analogies as appropriate, but you get the idea.)
A doctor I spoke to about CBT said he thought CBT was effective for the relatively intelligent, introspective people they might have had in early trials. Rolling it out further beyond that group had lower success rates.
The additional the article raises about lower standards of training as it scales is also an interesting one, and could possibly apply further to other fashionable "therapies" in things such as fitness and project management.
> A doctor I spoke to about CBT said he thought CBT was effective for the relatively intelligent, introspective people they might have had in early trials. Rolling it out further beyond that group had lower success rates.
That would seem to be a testable hypothesis that would make for a great finding if it was seen to be true.
>> A doctor I spoke to about CBT said he thought CBT was effective for the relatively intelligent, introspective people
That makes sense to me. From my experience you have to be willing to take small events in your life and read into them/pull them apart in great detail. If you can't understand the root issue (the reason you react to your thoughts/feelings in a certain way) by examining your thoughts in that way then you can't really put into practice the basic tenets of CBT. Maybe it depends on the therapist but from my perspective it seemed like quite an intellectual way of dealing with your problems.
This is completely unsurprising. Like all other disciplines, behavioral health is subject to trends and the glitter of the "new things". We've seen this regarding initial enthusiasm for new medical procedures or medications, after practitioners gain experience with new tools the limitations prompt more sober reanalysis, and the enthusiasm becomes more restrained.
Recent studies have called into question the initial reports of effectiveness of psychotherapies, CBT included, or perhaps in particular. I won't go into detail here, but in a phrase all kinds of established therapies tend to eventually be observed to follow the classic "rule of thirds". More or less about a third of the treatment cohort will get better, a third remain the same and a third are worse. Proportions vary of course, but that's the idea.
What it comes down to is that CBT, interpersonal therapy, psychodynamic therapy and a thousand variants can be helpful for certain problems, but quite often a combination of approaches is needed for optimum outcome.
It's not unlike software development, a "team" of tools is necessary to actually get from initial concept to production release. It's a complex non-linear process, at least as much art as technology must be applied to get there.
I can attest after decades in the trenches that treatment for behavioral conditions runs in a parallel form, the art and science of applying relational and medical tools is distinctly complex, as it's necessary to tailor the approach to each individual. The salient point is no two people ever have the same illness.
CBT can be no more effective than the skill and talent possessed by the therapist and patient working as a team .
I've heard about this correlation before as well. When I went through CBT therapy I saw how logic could be used to re-frame issues to not assume the worst in a situation, i.e.: my boss doesn't hate me, he very well could be having a bad day today. However, I think CBT lacks the negative visualization aspect of Stoicism where you think pessimistically about the future in order to be prepared for the worst. This is definitely useful for someone strong enough to handle that and not get depressed, but to the average person with depression it probably won't help much if they aren't ready for it. I personally feel like the Stoics were on to something that is more helpful as a long-term solution rather than just getting by battling the current day's depression.
I had a session of it for OCD. I had personal issues with the therapist and I didn't care for all the writing things down (seemed like bureaucratic busywork, it seemed meaningless). And yet from the few times he talked me through doing things that made me uncomfortable, it improved things then, and also taught me how to do it for myself. I wasn't 100% afterwards, but I slowly improved myself over time.
Bottom line: sometimes half-assing it can still have decent results.
I once knew a clinical therapy student who was studying in the psychodynamic school and heavily anti-CBT. Is that what the state of the field is really like, there's a rivalry between the two schools?
Masters in Counseling Psych here. The short answer is yes.
Basically people who practice CBT think that people who practice psychodynamic/existential-humanistic spend too much time analyzing things that may not matter with less direct evidence that it works. The other half(myself included) think that CBT is too much of a quick fix, and that yeah, you may want to have 6 sessions of skill building to solve your problems, but that will only provide a short term solution.
The reality is probably somewhere in the middle, and the skills taught by CBT are probably important. And if you have poor coping mechanisms or antagonistic thought patterns CBT is important, but it won't touch the underlying issues.
The funny thing about this article and the talk about the "placebo affect" is that to a certain extent many types of therapy are about integrating experiences: coming to an understanding about events in your life and the context in which they take place. The other thing that is linked most highly to success in therapy is the strength of the relationship between therapist and client(with a few caveats. The research shows this relationship should embody a few things and obviously it could be strog and unhealthy if there's something unethical going on).
But basically, talking about the placebo affect in mental health is kind of a funny thing. There are studies that look at placebo affects to certain therapies, but in general, since the goal is to feel better, if you think it worked and your supposed to feel better, should I come back and say don't feel better?(barring concerns about it being a short term effect). When the goal is to think you feel better, how(and why) do you suss out the difference. What I've always wondered, is do we think about the placebo affect the wrong way? Instead of seeing as something that disapproves efficacy, should we think about it as a power we should try and harness?
> linked most highly to success in therapy is the strength of the relationship between therapist and client
Have there been many studies looking at how the client-therapist relationship itself effects the client? Wouldn't having a non-judgmental person with whom you can comfortably confide it, whom you know is making a concerted effort to help you improve your well being, have some noticeable improvement on your condition, regardless of whether they were a trained professional?
Or put another way, is there anyone who finds themselves in therapy largely because they have no close friends?
It's worth noting the study was specifically about CBT for depression, which may not indicate similar effects for CBT for other disorders. As always it's worth reading the actual study and not just the headlines. From the study:
"The present meta-analysis is not without limitations. First, this study only included depression, thus, excluding CBT trials aimed at treating other diagnosis, such as anxiety, posttraumatic stress, eating, schizophrenia, and sleep disorders. There is no reason to expect the present findings to generalize to these disorders. In particular, anxiety disorders, which include a heterogeneous group of disorders that probably yield different time trends, have been subjected to the CBT approach. The clinical presentations of, for example, panic, obsessive– compulsive, and posttraumatic stress disorders are very different, as are the CBT approaches used. A meta-analysis of five trials comparing cognitive therapy with exposure therapy to treat obsessive– compulsive disorder (Ougrin, 2011) did not indicate a decline for the newer trials."
Given the slightly less than rigorous reputation psychology has lately, what are the chances the initial measurements that determined CBT were woo to begin with? There are certainly enough incentives on the part of the practitioners to give the benefit of the doubt to the efficacy of expensive new techniques.
CBT is much cheaper than other forms of psychotherapy. It's a short form therapy, that takes between 8 to 14 sessions, of about an hour each, as oppose to the sometimes years long therapy of other systems.
EDIT: Its cheapness is one reason it's been pushed so heavily in the UK.
"What’s going on? One theory is that, as any therapy grows more popular, the proportion of inexperienced or incompetent therapists grows bigger. But the paper raises a more intriguing idea: the placebo effect."
The placebo effect, and effects like it, happen everywhere. Everything given with a good or bad attitude will have some beneficial or detrimental effect. In that sense this article isn't that interesting.
What I think is more interesting is combining the interaction between inexperienced therapists and the placebo effect. Well trained psychologists have a stronger -- and I'd guess more nuanced -- belief of when CBT is useful and how it is useful. Since they have that belief, it has the potential to create a positive placebo. I always have to think of the Pygmallion effect and similar effects.
People who treat patients CBT but are inexperienced do not have that enthusiasm and have a weaker belief that it will work. Maybe they only think intellectually that it would work, but don't feel an emotional tsunami of conviction -- in particular cases -- that it will work. It's easier to have that when you know that in 7 out of 10 particular cases it worked really well (i.e., having experience).
That would be my guess anyways.
---
Now I read a couple of comments with people giving the sentiment that they think CBT is nonsense. Allow me to address that.
When I looked into CBT (@ 17/18 yo) and its pseudoscientific brother -- reframing in NLP -- I noticed that it was all about changing perspective. Learning to see that multiple emotional perspectives can be equally true was mind blowing for me. I came to the conclusion that I might as well pick the most positive one. I learned a couple of nuances on the way. For example, for some goals it's useful to hold multiple positive and negative perspectives at the same time.
I used it even today, now that I think of it. I was learning Django and it took me 4 hours to write simple custom email validation. I had a bug, a very simple one if you know the framework, but I don't. I was pissed after 4 hours, I felt like I wasted my time. I found the bug though :)
Since I didn't want to feel pissed I looked for a reframe. The reframe was: it's the first time that I learned to debug in Python with pdb, read source code from a framework so intensely, have a better understanding in transferable skills since I have experience with gdb and have the guts to debug the framework and understand it, for the first time. While I didn't progress much in writing actual code, my confidence in tackling issues in Python has grown tremendously. After thinking this I felt pretty good and figured that tomorrow it would be another day. So yea, I didn't progress in my initial goal (completing a tutorial) but I got something way more cooler for it in return. Now, if I hadn't known CBT I would've stopped at my first thought and stayed pissed, I'd then enter a lot of thought trains that would go to destructive places.
So yes, changing perspectives works. I also call it 'simple CBT'.
And when heavy stuff happens, then it doesn't completely cure you (perhaps reduces the pain by 5 to 20% IME, got no scientific sources). In many ways that's because the pain from the problem does not only stem from cognitive distortions -- e.g. generalizing the slightest thing to a negative epic scale -- which is the main assumption that CBT makes. If you lose a person (breakup, passing away, etc.), for example, you also need to be reconditioned since a lot of habits are still there that are only applicable to the other person which may trigger an immediate pain. You can't just think your way out of that, and the "behavioral" part of CBT will take a longer time and may not work (habit formation and destruction is a difficult topic).
Disclaimer: studied psych., I know a lot more about reframing than CBT (I skimmed a couple of texts and was like "hey that looks like reframing"). So my know...
Your story is spot on with my experiences dabbling with reframing lately (the kind presented in Learned Optimism, where the practitioner is aware of their beliefs and debates internally to install new beliefs. Negative things are reframed to be temporary or impersonal while positives are permanent general traits about the individual)
I've known some people who have seemingly indestructible self confidence, bordering on delusional, and this seems to be how they do it. I don't particularly want to be delusional, but I'd rather be happy than right.
This article discards the boring, plausible thesis in the first paragraph. The rest of the article is given over to speculation.
CBT requires a lot more work from both the patient and the therapist. I can easily believe that as it's become more popular, it's being applied less well or to populations where it's less appropriate.
Anecdotally, in my experience, there are enormous differences between therapists. I have had very ineffective treatment which did seem a lot like "just get happy, stop thinking bad thoughts". And I've had effective treatment where a perceptive person cut straight through to reveal my self-defeating patterns and gave me skills to do better. It's a constant battle but I'm glad I did it this way.
CBT isn't for everyone or every problem. But I would be surprised if the main insights were totally wrong.
I think the immense amount of constant work is the biggest challenge. It may be that the use case for CBT is a lot narrower than current practice is selling it as. For mild to moderate anxiety though, it's pretty amazing if you stick with it, especially since the alternatives are all basically chemical.
I wish I could site the study, but I read it many years ago. It was one of the major studies being touted at the time for showing the effectiveness of CBT. They actually stopped the study at one point to retrain the therapists on CBT. After retraining them they started the study from scratch and through the term of the study constantly evaluated the therapists and provided additional guidance to ensure they were properly applying CBT. What I gathered from the study was that proper application of CBT in the wild was likely to be rare and therefore the effectiveness of CBT in the wild would be limited.
I've had a severe double down depression for most of my life. It started at around 10~11, after my father died and it peaked at 26 where I could not get out of bed without extreme amounts of stress or sleep deprivation. This ruined relationships, friendships and left me with practically all of my teenage years and most of my twenties lost to self-hatred and self-denial.
Medication was the life preserver for me when I finally got myself to accept that I would never be able to deal with this alone. Medication gave my brain some well deserved rest, let me take stock from a more balanced point of view.
CBT was my ladder to climb out of hell. Without CBT I would be still where I was those years ago, just less affected by it. Sitting in a room that was on fire, but just not caring about it that much, that's still a shitty place to be in.
The important thing about CBT was for me that it gave me tools to work with. A chisel for my mind so to speak. It is not at all about talking oneself into happiness, for me it was about NOT talking oneself into sadness. About giving me the logical framework to force myself to see good things where they were, instead of focusing on the bad things. It gave me ways to correctly differentiate between tackling bad situations and just glooming about non-issues.
I'm pretty sure without CBT my life would be nowhere where it is right now, so i'm very glad for its existance and would recommend anyone in a similar situation to try it with a GOOD therapist (mine was a guardian angel, battling the worst parts of my reasoning when I wasn't strong enough to do so).
Similar story here, from the POV of someone with moderate anxiety, and very mild depression (probably as a result of the anxiety). Medication made me feel less, which was preferable to anxiety, but CBT was a set of tools I've continued to use. I had so little insight into my own thought processes, and the ways in which I was unintentionally reinforcing my own anxieties. It's taken a lot of effort, over a lot of years, but with that basic set of tools I don't need medication and I don't have anxiety or panic attacks. Ever.
Still, if you did have that set of tools going in, but for whatever biological reason it didn't matter, then I would guess that CBT would be dust in the wind for you.
> for me it was about NOT talking oneself into sadness.
Exactly. one tool you learn is how your thoughts/feelings/actions interact:
You cannot control your feelings, but they do influence your thoughts. You can control your actions, but they can influence at least some of your feelings. You can control some of your thoughts, which will influence your feelings.
(I may not have stated this exactly correctly, but the gist is the same ). So basically you learn that if you begin "investing" in healthier actions and thoughts (i.e. not sulking or self-pity or rumination), it will slowly pay off in less negative feelings.
No it doesnt' solve every single problem in your life, but a big part of depression is "learned helplessness" [1], and learning about thoughts/feelings/actions can be the first tool to counter this.
I found this last week on HN, but there was a great book that's short and hands-on called Learned Optimism: https://en.wikipedia.org/wiki/Learned_optimism which was written by one of the researchers on Learned Helplessness
I tried SSRIs and SNRIs, both worked slightly differently and were a great help at the start, but NaSSAs actually helped with my sleeping issues, which became even stronger on SSRIs. I paid for better and deeper sleep with a slight hangover in the morning, but that was much better than what I had experienced from my depression so I was able to handle it. I took the SSRIs about 3 months and then switched to NaSSAs for the next two years until i was able to fade the medication out without much issues.
It seems a like a different possible explanation is a variation in publication bias (and perhaps researcher bias) over time in response to the changing status of CBT.
Studies saying "this new thing works" have an obvious appeal, particularly in a field searching for something beyond classic psychotherapy. So when CBT first appeared, studies with strong, positive results may have been favoured.
Studies saying "the mainstream thing doesn't work", or "this mainstream thing doesn't work as well as we thought" also have obvious appeal. Now that CBT is mainstream, research showing that it is less effective that thought, or not effective in particular types of cases, may be more likely to be published.
I've tried cbt in conjunction with other mindfullness techniques: they required me to work a lot on myself and my thoughts (but this is right: you, the patient, is the one that does the work on itself, not the doctor) but it was one of the greatest help and valuable resource i discovered in my life. Really, can't even understand what they meant when they are talking about placebo effect. There is no placebo effect in cbt.
I've tried cbt in conjunction with other mindfullness techniques: they required me to work a lot on myself and my thoughts (but this is right: you, the patient, is the one that does the work on itself, not the doctor) but it was one of the greatest help and valuable resource i discovered in my life. Really, can't even understand what they meant when they are talking about placebo effect. There is no placebo effect in cbt.
Having experienced CBT as a patient, I thought it was a useful, but limited. I had two specific critiques:
1. If you're reasonably intelligent, it's easy to see how CBT "works" within a few sessions, and afterwards you can fall into a trap of telling the therapist what you "should" say according to CBT. Because there's a very specific goal of avoiding negative thoughts and thinking patterns, it's easy to exaggerate your level of success in order to "please" the therapist, rather than admitting that you've not make any progress.
2. My larger problem is that CBT puts a primacy on thoughts over emotions that I'm not sure is warranted. The thesis is that you have a established negative thought, such as "social situations make me nervous", which becomes a self-fulfilling prophecy, and so you are always nervous in social situations.
However, I am not sure that this is truly the order of things, at least for me. I observed that, even when I studiously avoided negative thoughts like this, the underlying emotions were still often present. Being confronted with a social situation produced a physiological response that included anxiety. I might consciously rationalise that response with a thought like "this is a social situation, and social situations make me nervous", but the underlying response existed regardless.
Freudian psychotherapy has a lot of wacky ideas about unconscious desires and whatnot, but it does at least acknowledge the idea that there is something within people beyond the rational, conscious mind, and that it it can be the stronger force. In contrast, CBT seems to be a therapy born from the opposite viewpoint: that the primal, subconscious, animal brain is entirely subordinate to the rational, conscious mind. Perhaps that's true for the people who developed the therapy, but it isn't true for me.
Right, but isn't it about coping with that response, not eliminating it? That was the impression I had of what it is. The goal isn't to eliminate sadness or anxiety, but to limit the negative impact it has on your life. So you don't get into these cycles were depression prevents you from moving forward, which makes you more depressed and so on. That's why it supposedly works so well with people with bpd, right? Because bpd is all about fear of people leaving you, while you behave in ways that absolutely ensure that people will.
My wife has BPD. CBT never worked for her (and it never worked for me either), her therapist switched from CBT to DBT & EMDR instead and it has better results. The problem with CBT is that it tries re-frame situations using a logical explanation to people who don't know how to talk in logical terms to see things from a different perspective. The problem is that people with BPD don't express things in logical terms, so it is easy to mis-diagnose or misrepresent and cause an invalidating statement. Borderlines are great at reading between the lines and trying to understand things in an emotional way. They can easily misinterpret your re-framing to be invalidation. So instead, DBT and a question-based approach that helps them to think through the problem themselves is so much better. My CBT therapist told me to tell my wife "that being out of town for her birthday wasn't abandonment", yeah right that'd go over like hell. BPD requires deeper introspection and CBT therapy will usually cause the client to feel invalidated
>> "The problem with CBT is that it tries re-frame situations using a logical explanation to people who don't know how to talk in logical terms to see things from a different perspective."
Not BPD but my experience with CBT and anxiety was that I could see my response was illogical but I didn't believe myself it at the same time. So when the therapist asked about this assumption I had that influenced my thinking he was able to show me it was illogical, I was able to say 'I know in my head', but at the same time - I don't believe you in my gut. His solution to this was exposure. If you are put in the situation and you personal assumption is proven to be untrue or it's is sufficiently challenged enough times then you can start to believe it's illogical.
My experience is with OCD, but the way I see things, if you feel anxiety about something, and you've concluded that it's irrational, and you then decide to just ignore the feeling as useless information, eventually it sort of just fades away.
> However, I am not sure that this is truly the order of things, at least for me. I observed that, even when I studiously avoided negative thoughts like this, the underlying emotions were still often present. Being confronted with a social situation produced a physiological response that included anxiety. I might consciously rationalise that response with a thought like "this is a social situation, and social situations make me nervous", but the underlying response existed regardless.
This was an issue for me and I asked about it. Will I ever be able to experience the situation without having to use CBT to deal with it. The response was you need to practice. Using CBT makes it easier for you to confront the situation and makes you less likely to excuse yourself from it. And over time the situation will become more normalised and those emotions will go away. Personally I have found that to be true. If I ensure I regularly engage socially the emotions are rarely bad. If I fall out of practice for a month or two it is a struggle at the beginning again but eventually with enough practice I'm fine again. So the CBT isn't a cure but a tool to help you engage in the situation instead of avoiding it and then over time the emotionally response improves. Just like if you start a new challenging job you might be nervous you don't know enough but you learn and slowly it becomes easier until you reach a point where you have no 'negative' emotions going to work everyday.
>you have a established negative thought, such as "social situations make me nervous", which becomes a self-fulfilling prophecy
My understanding of how CBT works is not like that. If you think about the mechanics work, to know it's a social situation you get sensory input which turns to nerve impulses which go into your neural network which figures it's a social situation which then activates many neural pattern recognition circuits in parallel - for it being scary based on instinct or past experiences or imagination. That all happens unconsciously - you're probably setting off thousands of pattern recognisers and the conscious bit of your brain is only fast enough to really be aware of one or two at a time.
CBT works by rewiring that at your leisure so you can rubbish the unfortunate pattern recognisers maybe relating to some bad experience and enhancing positive ones by say recalling when things went well in reality (or imagination). But if it works you should just feel better in social situations without active thinking required at the time.
Meta-analysis: the non-study, study that says, well, anything you want it to say.
I am so tired of second rate journals running rehashes of other researcher's work and pawning it off as a "ground breaking examination of the data". Anyone in the field of medicine will tell you that meta-analysis is the least credible form of "research".
I find the Guardian author's first hypothesis most credible. There are a lot of bad therapists out there. It is well established in surgical studies that results for a procedure will be less positive in study sites that are not centers of excellence as the surgeons are less practiced and less skilled. Surgeons and therapists are not stamped from a machine. As the commercial says, "your mileage may vary". Put another way, what do they call the person who graduates last in their class in med school? Doctor.
For any medical ailment of any consequence you might face you will be well served to find the best and most experienced provider available to you.
On what basis do you say that meta-analysis is not credible? From my stats background, (but without any direct experience in meta-analysis) I would say that they could be problematic because the N is very small and so have a lot less to work with, and more temptation to use fancy statistical techniques with hidden assumptions. On the other hand, what do you do when you have 50 studies of varying quality, no one of which is has such a compelling methodology as to eclipse the others? In that case it seems like meta-analysis is the least bad option.
Your point is a good one but in medicine the issue tends to be that a lot of studies with varying controls and endpoints are being lumped together and presented as a coherent whole. In reality the distortions (and in some cases biases of the researcher) that are introduced leave the data often untenable. You are absolutely right that powering medical studies correctly is a critical issue. It is also critical that when making pronouncements about important treatment modalities that the research be of the highest quality.
Meta-analyses are often used in so creating so called evidence based medicine standards which are sometimes cost cutting efforts dressed up like research.
As a trauma surgeon recently said to me recently, "They said they designed it using evidence based medicine. They didn't say whose evidence".
One if the issues I have with CBT is the same that I have with 12 step programs. In both if they aren't effective often the person is blamed, "They didn't do the process right." or "They weren't willing to do the hard work needed.", allowing avoidance of questions regarding the limitations or flaws of the therapy.
I feel like CBT can be counterproductive because it encourages you to ruminate on negative thoughts instead of just not thinking them. You have to examine them and put them into categories like "mindreading" or "catastrophizing", but giving them time in your mind just reinforces that you should be thinking them.
I much prefer mindfulness methods where you immediately think "is this thought useful to me at all?" and if it isn't, you put it out of your mind. Meditation helps with this, as it trains your brain to be able to let go of thoughts.
Ideally they won't be negative after working on them using CBT. In CBT, you have to be aware of your thoughts too, but instead of thinking "is this thought useful to me", you think "is this thought an accurate representation of my current situation". You then work on changing your thoughts until it is an accurate representation of your current situation. Categories like "mindreading" and "catastrophizing" mean that you are assessing a situation with incomplete information, and training your brain to not make snap judgments can be immensely more helpful than training your brain to just ignore those snap judgments. It does take a lot of work, but a lot of the time the thoughts you need CBT or mindfulness to work through, you get because there's an unresolved conflict in your life that you can't find a resolution for. It's better to train your brain to find a resolution for problems than to ignore them.
There are developments towards approaches that put less emphasis on the negative thoughts and which are more in line with mindfulness. From what I've read, they're at least as effective as CBT, and might well be more effective for people who already ruminate too much (autism, for one). But AFAIK it's too new a 'field' to be too confident about these things. Worth looking into though.
As a fan of zen/mindfulness and as I'm going through CBT currently, I definitely feel some friction between the two approaches.
92 comments
[ 3.2 ms ] story [ 158 ms ] threadCognitive behavioral therapy is basically the same thing but it boils down to: "it feels bad when I think about this" / "well don't think about that then".
Like meditation is about not thinking, but it doesn't mean you try to never have a though again... it just means you have a degree of control over when you put gas on that fire and when you let it burn down.
Anything that has been researched is immediately accepted as truth https://news.ycombinator.com/item?id=12300577
What exactly is a good basis for mental health research then in your opinion? twisi the scientific method is basically all you've got even if it doesn't work as well as it does in other types of research. Yet what other options do you have besides anecdotes and woo?
So if you want to know broadly of CBT works then science is your only realistic option.
* you didn't interview enough people from different backgrounds * you didn't control for the specific psychological conditions of your interviewees or what treatments/medications were in play at the same time or before / after the program * you didn't test your question set to ensure that it doesn't have leading questions or questions can otherwise influence the results * and so on.
I could go on, but the point is anecdotes are not _nothing_ but they pale in comparison to a well built scientific study. If you want to really know if a type of treatment works well and who it works well for with a minimum of bias then science is by far the best option. It's normal and fine to use anecdotes to guide personal day to day decisions in life, but if you want to make broad claims that are taken seriously by professionals trying to say help folks manage mental health issues then we have a higher standard than anecdote and rightly so.
I say - use the best method that you reasonably can use and see where it gets you. If that's science then great, but often you need to get by with a lesser method and that is ok.
It is part of a type of psychology called "Positive psychology", that works with how to be happier and how not to fall into depressions. This is in contrast to the traditional "disease model", which is only about curing psychological problems, or as the Author states "Making miserable people, less miserable".
See the authors TED talk: http://www.ted.com/talks/martin_seligman_on_the_state_of_psy...
He's a very prominent doctor and at one point was President of the APA. You can read more about his credentials here: https://en.wikipedia.org/wiki/Martin_Seligman
If we wish to treat depression, we should focus on life not being so depressing to begin with, not persuading people that actually it isn't once they have already spiraled into despair.
I resent that you make a false assumption, having been through CBT so many times I feel I might even have a better knowledge of it than professionals whose only experience is from a text-book.
Additional: Occassionally I may forget to take it and I won't feel any different however those around me pick up on it straight away as I become reclused and start constantly sweating.
It is not about denying thoughts. It is not about telling yourself that you are happy, when you are not.
It can't treat severe depressions, but it can treat mild ones, and it can lower the amount of medication needed to treat severe ones.
You can think about it as "good posture for your mind". Nobody wants a bad posture, but lots of people have it, and some have it so bad, that they get pains so severe they cannot work. Some people with back pain take pain medication, and never solve the problem, but can go on with their lives.
For some people, there are external influences on their posture that cannot be negated by exercise and they do need to change their environment.
Some do need an operation with everything that entails, but most just need to fix their posture: Do the right exercises and stretches and they won't need medication or operations.
If you are depressed because of your abusive boyfriend, then CBT's answer is not "stop thinking about it" or "just think happy thoughts when you're being beaten" it is "get the fuck out of it".
In the case of a fever, that might be enough, but for psychological disorders it is not so likely.
That might actually likely be enough. The reason why you have psychologist using CBT as therapy and not just self-help books is to identify if it is enough.
My point was that there are typically unconscious thoughts that lead to disorders, and fixing those disorders at the surface without finding the root is likely to cause them to reappear later, in the same or different form. E.g. aspirin will not cure malaria.
> CBT is in part about finding the flaws in your thinking that fucks you up.
That is, it focuses on conscious thought rather than unconscious. It seems to be enough only in the more benign cases.
you're assuming a false relationship between level of consciousness and severity. Case in point: war veteran with PTSD. His PTSD is from getting shot at, not from a disrupted relationship with his mother when he was 5.
case 2: patient has a phobia of flying. therapist gradually deconstructs the phobia using CBT methods, until the patient finally gets in a plane and flies.
Subconscious issues are not correlated to severity.
As for the second case, the "deconstruction" of a phobia is more characteristic of psychoanalysis than CBT.
Most people don't seem to realise that the celebrated prefrontal cortex is the youngest and in a way weakest part of the brain. It surrounds older structures that don't work much different than in reptiles.
Changing your thoughts is easy, changing the attached emotions, fight/flight responses etc., who might even trigger the thoughts in the first place is incredibly hard.
It takes time, the right corrective and endless patience and iterative practise.
Or that it has several meanings in internet lingo, not all savoury.
I like to think that somewhere there's a discussion board for psychologists and they're talking about, say, using R and how it sucks or not.
As a side note we have a moderately successful CBT app so I have definitely spent plenty of time in the 'source code' of CBT methodology. It isn't bad or good anymore that C is bad or good. It's a tool that's useful when applied to the problem for which it is best suited.
Unfortunately, given the realities of health insurance payments, it's a tool often overused due to its 'promise' of fast results (compared to psychotherapy for instance.)
The real problem isn't CBT, it's an attitude by payers that mental health treatment can be quantified as easily as physical health. That leads to writing webpages in C so to speak.
In the psych community though the CBT vs. Psychotherapy debate reaches similar passions as debating PHP versus Rails. (Fix my analogies as appropriate, but you get the idea.)
The additional the article raises about lower standards of training as it scales is also an interesting one, and could possibly apply further to other fashionable "therapies" in things such as fitness and project management.
That would seem to be a testable hypothesis that would make for a great finding if it was seen to be true.
That makes sense to me. From my experience you have to be willing to take small events in your life and read into them/pull them apart in great detail. If you can't understand the root issue (the reason you react to your thoughts/feelings in a certain way) by examining your thoughts in that way then you can't really put into practice the basic tenets of CBT. Maybe it depends on the therapist but from my perspective it seemed like quite an intellectual way of dealing with your problems.
Recent studies have called into question the initial reports of effectiveness of psychotherapies, CBT included, or perhaps in particular. I won't go into detail here, but in a phrase all kinds of established therapies tend to eventually be observed to follow the classic "rule of thirds". More or less about a third of the treatment cohort will get better, a third remain the same and a third are worse. Proportions vary of course, but that's the idea.
What it comes down to is that CBT, interpersonal therapy, psychodynamic therapy and a thousand variants can be helpful for certain problems, but quite often a combination of approaches is needed for optimum outcome.
It's not unlike software development, a "team" of tools is necessary to actually get from initial concept to production release. It's a complex non-linear process, at least as much art as technology must be applied to get there.
I can attest after decades in the trenches that treatment for behavioral conditions runs in a parallel form, the art and science of applying relational and medical tools is distinctly complex, as it's necessary to tailor the approach to each individual. The salient point is no two people ever have the same illness.
CBT can be no more effective than the skill and talent possessed by the therapist and patient working as a team .
It's not a simple bandage over a cut. It's the sort of thing that a parent or religion might teach to a child over years of growing up.
Bottom line: sometimes half-assing it can still have decent results.
Basically people who practice CBT think that people who practice psychodynamic/existential-humanistic spend too much time analyzing things that may not matter with less direct evidence that it works. The other half(myself included) think that CBT is too much of a quick fix, and that yeah, you may want to have 6 sessions of skill building to solve your problems, but that will only provide a short term solution.
The reality is probably somewhere in the middle, and the skills taught by CBT are probably important. And if you have poor coping mechanisms or antagonistic thought patterns CBT is important, but it won't touch the underlying issues.
The funny thing about this article and the talk about the "placebo affect" is that to a certain extent many types of therapy are about integrating experiences: coming to an understanding about events in your life and the context in which they take place. The other thing that is linked most highly to success in therapy is the strength of the relationship between therapist and client(with a few caveats. The research shows this relationship should embody a few things and obviously it could be strog and unhealthy if there's something unethical going on).
But basically, talking about the placebo affect in mental health is kind of a funny thing. There are studies that look at placebo affects to certain therapies, but in general, since the goal is to feel better, if you think it worked and your supposed to feel better, should I come back and say don't feel better?(barring concerns about it being a short term effect). When the goal is to think you feel better, how(and why) do you suss out the difference. What I've always wondered, is do we think about the placebo affect the wrong way? Instead of seeing as something that disapproves efficacy, should we think about it as a power we should try and harness?
Have there been many studies looking at how the client-therapist relationship itself effects the client? Wouldn't having a non-judgmental person with whom you can comfortably confide it, whom you know is making a concerted effort to help you improve your well being, have some noticeable improvement on your condition, regardless of whether they were a trained professional?
Or put another way, is there anyone who finds themselves in therapy largely because they have no close friends?
"The present meta-analysis is not without limitations. First, this study only included depression, thus, excluding CBT trials aimed at treating other diagnosis, such as anxiety, posttraumatic stress, eating, schizophrenia, and sleep disorders. There is no reason to expect the present findings to generalize to these disorders. In particular, anxiety disorders, which include a heterogeneous group of disorders that probably yield different time trends, have been subjected to the CBT approach. The clinical presentations of, for example, panic, obsessive– compulsive, and posttraumatic stress disorders are very different, as are the CBT approaches used. A meta-analysis of five trials comparing cognitive therapy with exposure therapy to treat obsessive– compulsive disorder (Ougrin, 2011) did not indicate a decline for the newer trials."
The paper (linked to in the article): https://uit.no/Content/418448/The%20effect%20of%20CBT%20is%2...
EDIT: Its cheapness is one reason it's been pushed so heavily in the UK.
The placebo effect, and effects like it, happen everywhere. Everything given with a good or bad attitude will have some beneficial or detrimental effect. In that sense this article isn't that interesting.
What I think is more interesting is combining the interaction between inexperienced therapists and the placebo effect. Well trained psychologists have a stronger -- and I'd guess more nuanced -- belief of when CBT is useful and how it is useful. Since they have that belief, it has the potential to create a positive placebo. I always have to think of the Pygmallion effect and similar effects.
People who treat patients CBT but are inexperienced do not have that enthusiasm and have a weaker belief that it will work. Maybe they only think intellectually that it would work, but don't feel an emotional tsunami of conviction -- in particular cases -- that it will work. It's easier to have that when you know that in 7 out of 10 particular cases it worked really well (i.e., having experience).
That would be my guess anyways.
---
Now I read a couple of comments with people giving the sentiment that they think CBT is nonsense. Allow me to address that.
When I looked into CBT (@ 17/18 yo) and its pseudoscientific brother -- reframing in NLP -- I noticed that it was all about changing perspective. Learning to see that multiple emotional perspectives can be equally true was mind blowing for me. I came to the conclusion that I might as well pick the most positive one. I learned a couple of nuances on the way. For example, for some goals it's useful to hold multiple positive and negative perspectives at the same time.
I used it even today, now that I think of it. I was learning Django and it took me 4 hours to write simple custom email validation. I had a bug, a very simple one if you know the framework, but I don't. I was pissed after 4 hours, I felt like I wasted my time. I found the bug though :)
Since I didn't want to feel pissed I looked for a reframe. The reframe was: it's the first time that I learned to debug in Python with pdb, read source code from a framework so intensely, have a better understanding in transferable skills since I have experience with gdb and have the guts to debug the framework and understand it, for the first time. While I didn't progress much in writing actual code, my confidence in tackling issues in Python has grown tremendously. After thinking this I felt pretty good and figured that tomorrow it would be another day. So yea, I didn't progress in my initial goal (completing a tutorial) but I got something way more cooler for it in return. Now, if I hadn't known CBT I would've stopped at my first thought and stayed pissed, I'd then enter a lot of thought trains that would go to destructive places.
So yes, changing perspectives works. I also call it 'simple CBT'.
And when heavy stuff happens, then it doesn't completely cure you (perhaps reduces the pain by 5 to 20% IME, got no scientific sources). In many ways that's because the pain from the problem does not only stem from cognitive distortions -- e.g. generalizing the slightest thing to a negative epic scale -- which is the main assumption that CBT makes. If you lose a person (breakup, passing away, etc.), for example, you also need to be reconditioned since a lot of habits are still there that are only applicable to the other person which may trigger an immediate pain. You can't just think your way out of that, and the "behavioral" part of CBT will take a longer time and may not work (habit formation and destruction is a difficult topic).
Disclaimer: studied psych., I know a lot more about reframing than CBT (I skimmed a couple of texts and was like "hey that looks like reframing"). So my know...
I've known some people who have seemingly indestructible self confidence, bordering on delusional, and this seems to be how they do it. I don't particularly want to be delusional, but I'd rather be happy than right.
Me too, to add: I'd rather be both ;)
CBT requires a lot more work from both the patient and the therapist. I can easily believe that as it's become more popular, it's being applied less well or to populations where it's less appropriate.
Anecdotally, in my experience, there are enormous differences between therapists. I have had very ineffective treatment which did seem a lot like "just get happy, stop thinking bad thoughts". And I've had effective treatment where a perceptive person cut straight through to reveal my self-defeating patterns and gave me skills to do better. It's a constant battle but I'm glad I did it this way.
CBT isn't for everyone or every problem. But I would be surprised if the main insights were totally wrong.
Medication was the life preserver for me when I finally got myself to accept that I would never be able to deal with this alone. Medication gave my brain some well deserved rest, let me take stock from a more balanced point of view.
CBT was my ladder to climb out of hell. Without CBT I would be still where I was those years ago, just less affected by it. Sitting in a room that was on fire, but just not caring about it that much, that's still a shitty place to be in.
The important thing about CBT was for me that it gave me tools to work with. A chisel for my mind so to speak. It is not at all about talking oneself into happiness, for me it was about NOT talking oneself into sadness. About giving me the logical framework to force myself to see good things where they were, instead of focusing on the bad things. It gave me ways to correctly differentiate between tackling bad situations and just glooming about non-issues.
I'm pretty sure without CBT my life would be nowhere where it is right now, so i'm very glad for its existance and would recommend anyone in a similar situation to try it with a GOOD therapist (mine was a guardian angel, battling the worst parts of my reasoning when I wasn't strong enough to do so).
Still, if you did have that set of tools going in, but for whatever biological reason it didn't matter, then I would guess that CBT would be dust in the wind for you.
Exactly. one tool you learn is how your thoughts/feelings/actions interact:
You cannot control your feelings, but they do influence your thoughts. You can control your actions, but they can influence at least some of your feelings. You can control some of your thoughts, which will influence your feelings.
(I may not have stated this exactly correctly, but the gist is the same ). So basically you learn that if you begin "investing" in healthier actions and thoughts (i.e. not sulking or self-pity or rumination), it will slowly pay off in less negative feelings.
No it doesnt' solve every single problem in your life, but a big part of depression is "learned helplessness" [1], and learning about thoughts/feelings/actions can be the first tool to counter this.
[1]. https://www.youtube.com/watch?v=NOAgplgTxfc
Studies saying "this new thing works" have an obvious appeal, particularly in a field searching for something beyond classic psychotherapy. So when CBT first appeared, studies with strong, positive results may have been favoured.
Studies saying "the mainstream thing doesn't work", or "this mainstream thing doesn't work as well as we thought" also have obvious appeal. Now that CBT is mainstream, research showing that it is less effective that thought, or not effective in particular types of cases, may be more likely to be published.
1. If you're reasonably intelligent, it's easy to see how CBT "works" within a few sessions, and afterwards you can fall into a trap of telling the therapist what you "should" say according to CBT. Because there's a very specific goal of avoiding negative thoughts and thinking patterns, it's easy to exaggerate your level of success in order to "please" the therapist, rather than admitting that you've not make any progress.
2. My larger problem is that CBT puts a primacy on thoughts over emotions that I'm not sure is warranted. The thesis is that you have a established negative thought, such as "social situations make me nervous", which becomes a self-fulfilling prophecy, and so you are always nervous in social situations.
However, I am not sure that this is truly the order of things, at least for me. I observed that, even when I studiously avoided negative thoughts like this, the underlying emotions were still often present. Being confronted with a social situation produced a physiological response that included anxiety. I might consciously rationalise that response with a thought like "this is a social situation, and social situations make me nervous", but the underlying response existed regardless.
Freudian psychotherapy has a lot of wacky ideas about unconscious desires and whatnot, but it does at least acknowledge the idea that there is something within people beyond the rational, conscious mind, and that it it can be the stronger force. In contrast, CBT seems to be a therapy born from the opposite viewpoint: that the primal, subconscious, animal brain is entirely subordinate to the rational, conscious mind. Perhaps that's true for the people who developed the therapy, but it isn't true for me.
Not BPD but my experience with CBT and anxiety was that I could see my response was illogical but I didn't believe myself it at the same time. So when the therapist asked about this assumption I had that influenced my thinking he was able to show me it was illogical, I was able to say 'I know in my head', but at the same time - I don't believe you in my gut. His solution to this was exposure. If you are put in the situation and you personal assumption is proven to be untrue or it's is sufficiently challenged enough times then you can start to believe it's illogical.
This was an issue for me and I asked about it. Will I ever be able to experience the situation without having to use CBT to deal with it. The response was you need to practice. Using CBT makes it easier for you to confront the situation and makes you less likely to excuse yourself from it. And over time the situation will become more normalised and those emotions will go away. Personally I have found that to be true. If I ensure I regularly engage socially the emotions are rarely bad. If I fall out of practice for a month or two it is a struggle at the beginning again but eventually with enough practice I'm fine again. So the CBT isn't a cure but a tool to help you engage in the situation instead of avoiding it and then over time the emotionally response improves. Just like if you start a new challenging job you might be nervous you don't know enough but you learn and slowly it becomes easier until you reach a point where you have no 'negative' emotions going to work everyday.
My understanding of how CBT works is not like that. If you think about the mechanics work, to know it's a social situation you get sensory input which turns to nerve impulses which go into your neural network which figures it's a social situation which then activates many neural pattern recognition circuits in parallel - for it being scary based on instinct or past experiences or imagination. That all happens unconsciously - you're probably setting off thousands of pattern recognisers and the conscious bit of your brain is only fast enough to really be aware of one or two at a time.
CBT works by rewiring that at your leisure so you can rubbish the unfortunate pattern recognisers maybe relating to some bad experience and enhancing positive ones by say recalling when things went well in reality (or imagination). But if it works you should just feel better in social situations without active thinking required at the time.
I am so tired of second rate journals running rehashes of other researcher's work and pawning it off as a "ground breaking examination of the data". Anyone in the field of medicine will tell you that meta-analysis is the least credible form of "research".
I find the Guardian author's first hypothesis most credible. There are a lot of bad therapists out there. It is well established in surgical studies that results for a procedure will be less positive in study sites that are not centers of excellence as the surgeons are less practiced and less skilled. Surgeons and therapists are not stamped from a machine. As the commercial says, "your mileage may vary". Put another way, what do they call the person who graduates last in their class in med school? Doctor.
For any medical ailment of any consequence you might face you will be well served to find the best and most experienced provider available to you.
Meta-analyses are often used in so creating so called evidence based medicine standards which are sometimes cost cutting efforts dressed up like research.
As a trauma surgeon recently said to me recently, "They said they designed it using evidence based medicine. They didn't say whose evidence".
I much prefer mindfulness methods where you immediately think "is this thought useful to me at all?" and if it isn't, you put it out of your mind. Meditation helps with this, as it trains your brain to be able to let go of thoughts.
As a fan of zen/mindfulness and as I'm going through CBT currently, I definitely feel some friction between the two approaches.