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CBT In The Water Supply

[Epistemic status: Very speculative, <50% confidence, thinking out loud. Don't let this turn you off therapy.]

Here’s a vignette from cognitive-behavioral therapy book When Panic Attacks, heavily edited for length:

A chronically anxious medical school professor named Nate suffered from low-self-esteem and feelings of inadequacy. One day, Nate brought me a copy of his CV. I was blown away. He’d listed over sixty pages of research publications, prestigious awards, and keynote addresses he’d given at major conferences around the world. I asked Nate how he reconciled his low self-esteem with all of his accomplishments. He said that every time he looked at his CV, he felt discouraged and told himself that his colleagues’ research studies were far more rigorous and important than his own. He said his paper seemed “soft” and consisted primarily of theoretical work, rather than hard-core laboratory research with real tissue. He said “Dr. Burns, no matter how much I accomplish, it never seems good enough.”

Perfectionism was clearly one of Nate’s self-defeating beliefs. I suggested that Nate use the Pleasure/Perfection Balance Worksheet to test this belief. I told him to write “If I can’t do something perfectly, it’s not worth doing at all” on the top of the sheet, and asked him to list several activities in the left-hand column. I told him to predict how satisfying and rewarding each activity would be, to record how satisfying and rewarding it was afterwards, and to rate how perfectly he did each activity. That way he could find out of it was true that he only enjoyed the things he did perfectly.

The next week, Nate had some interesting results to share with me. One of his activities was giving the welcoming lecture ot the incoming class of medical students. Nate gave this lecture every year because he was considered to be the most charismatic speaker at the medical school. Nate predicted this lecture would be 70% satisfying, but his actual satisfaction as only 20%. This was surprising, since he’d received a thirty-second standing obation, and he’d rated his perfection level for the talk at 90%.

I asked Nate why his satisfaction rating was so low. He explained that he always got standing ovations, so he routinely timed them. The previous year, the medical students had stood and cheered for more than a minute at the end of his talk. This year, the only stood and cheered for half a minute. Nate felt disappointed and started worrying that he was over the hill.

The second entry on Nate’s Pleasure/Perfection Balance Worksheet was that [he fixed a broken pipe in his bathroom]. He had to make several trips to the hardware story to buy tools and parts and to get tips on how to do it, so he didn’t get the pipe fixed until 10 PM. How explained that any plumber could have fixed the pipe in five minutes, so he rated his perfection as 5%. But his satisfaction level for this activity was 100%. In fact, he felt exhilarated. Nate said it was the most satisfying thing he’d done in years.

The result of Nate’s experiment was not consistent with his belief that things weren’t worth doing unless he did them perfectly. It dawned on him that there were many sources of satisfaction in his life that he’d overlooked, such as taking a walk through the woods with his wife, even though neither of them were world-class hikers, playing squash with his son, even though neither of them were champions, or just going out with his family for ice cream cones on a warm summer evening.

This experiment had a significant impact on Nate’s feelings of self-esteem and on his career. He told me that his feelings of anxiety and inferiority decreased, and his productivity actually increased because he was no longer so worried about having to do everything so perfectly.

At first I assumed this story was made up, but the book claims these are based on real patients, and even mentions how the writer showed videos of some of these therapy sessions to his classes. Interesting. How about another?

Several years ago, I did a three-day intensive workshop for a small group of psychotherapists in Florida. A marriage and family therapist named Walter explained that he’d been struggling with anxiety and depression for several months because Paul, the man he’d lived with for eight years, had found a new lover and left him. He put his hand on his chest and said: “It feels real heavy, right here. There’s just a sense of loneliness and emptiness about the whole experience. It feels so universal and final. I feel like this pain is going to go on forever, until the end of time.”

I asked Walter how he was thinking and feeling about the breakup with Paul. What was he telling himself? He saidL “I feel incredibly guilty and ashamed, and it seems like it must have been my fault. Maybe I wasn’t skillful enough, attractive enough, or dynamic enough. Maybe I wasn’t there for him emotionally. I feel like I must have screwed up. Sometimes I feel like a total fraud. Here I am, a marriage and family therapist, and my own relationship didn’t even work out. I feel like a loser. A really, really big loser.”

Walter recorded these five negative thoughts on his daily mood log:

1. I’ll never be in a loving relationship again
2. I must be impossible to live with and impossible to be in a relationship with
3. There must be something wrong with me
4. I totally screwed up and flushed my life down the toilet
5. I’ll end up as an old, fat, gray-haired, lonely gay man

He believed all of these thoughts very strongly.

You can see that most of Walter’s suffering results from the illogical way he’s thinking about the rejection. You could even say that Walter is treating himself far more harshly than Paul did. I thought the Double Standard Technique might help because Walter seemed to be a warm and compassionate individual. I asked wehat he’d say to a dear friend who’d been rejected by someone he’d been living with for eight years. I said “Would you tell him that there’s something wrong with him, that he screwed up his life and flushed it down the toilet for good?”

Walter looked shocked and said he’d never say something like that to a friend. I suggested we try a role-playing exercise so that he could tell me what he would say to a friend who was in the same predicament […]

Therapist (role-playing patient’s friend): Walter, there’s another angle I haven’t told you about. What you don’t understand is that I’m impossible to live with and be in a relationship with. That’s the real reason I feel so bad, and that’s why I’ll be alone for the rest of my life.

Patient (role-playing as if therapist is his friend who just had a bad breakup): Gosh, I’m surprised to hear you say that, because I’ve known you for a long time and never felt that way about you. In fact, you’ve always been warm and open, and a loyal friend. How in the world did you come to the conclusion that you were impossible to be in a relationship with?

Therapist (continuing role-play): Well, my relationship with [my boyfriend] fell apart. Doesn’t that prove I’m impossible to be in a relationship with?

Patient (continuing role-play): In all honesty, what your’e saying doesn’t make a lot of sense. In the first place, your boyfriend was also involved in the relationship. It takes two to tango. And in the second place, you were involved in a reasonably successful relationship with him for eight years. So how can you claim that you’re impossible to live with?

Therapist (continuing role-play:) Let me make sure I’ve got this right. You’re saying that I was in a reasonably successful relationship for eight years, so it doesn’t make much sense to say that I’m impossible to live with or impossible to be in a relationship with?

Patient (continuing-role-play:) You’ve got it. Crystal clear.

At that point, Walter’s face lit up, as if a lightbulb had suddenly turned on in his brain, and we both started laughing. His negative thoughts suddenly seemed absurd to him, and there was an immediate shift in his mood…after Walter put the lie to his negative thoughts, I asked him to rate how he was feeling again. His feeling of sadness fell all the way fromj 80% to 20%. His felings of guilt, shame, and anxiety fell all the way to 10%, and his feelings of hopelessness dropped to 5%. The feelings of loneliness, embarassment, frustration, and anger disappeared completely.

The book is quite long, and it’s full of stories like this. The author, who’s one of the top cognitive-behavioral psychiatrists in the world, describes his experience with the therapy as:

[When I first learned about this therapy, I thought] depression and anxiety seemed far too serious and severe for such a simplistic approach. But when I tried these methods with some of my more difficult patients, my perceptions changed. Patients who’d felt hopeless, worthless, and desperate began to recover. At first, it was hard to believe that the techniques were working, but I could not deny the fact that when my patients learned to put the lie to their negative thoughts, they began to improve. Sometimes they recovered right before my eyes during sessions. Patients who’d felt demoralized and hopeless for years suddenly turned the corner on their problems. I can still recall an elderly French woman who’d been bitterly depressed for more than fifty years, with three nearly-successful suicide attempts, who started shouting “Joie de vivre! Joie de vivre!” (“joy of living”) one day in my office. These experiences made such a strong impact on me that I decided my calling was in clinical work rather than brain research. After considerable soul-searching, I decided to give up my research career and become a full-time clinician. Over the years, I’ve had more than 35,000 psychotherapy sessions with depressed and anxious patients, and I’m every bit as enthusiastic about CBT as when I first began learning about it.

Okay. I am not one of the top cognitive-behavioral therapists in the world. I’ve been studying formal cognitive-behavioral therapy for about a week now, and been doing untrained ad hoc therapy on inpatients for a couple years. But I’ve also gotten to observe a lot of other people doing therapy, and talked to people who have had therapy, and treated patients who were simultaneously undergoing therapy, and the impression I got was very different.

Dr. Burns asks patients to question whether their anxiety and their negative thoughts are rational, and their faces light up and all of their psychiatric problems suddenly melt away.

The therapists I’ve seen ask patients to question whether their anxiety and their negative thoughts are rational, ever so tactfully, and the patients say “No shit, Sherlock, of course they aren’t, but just knowing that doesn’t help or make them go away, and I’ve been through this same spiel with like thirty people already. Now shut up and give me my Xanax.”

In my last post, someone asked what to do if they found cognitive-behavioral therapy hokey and patronizing. I said, only half joking, that “if you don’t like hokey patronizing things, CBT may not be for you.” I know it’s mean, and pessimistic, but everyone I’ve talked to has had pretty much the same experience. I used to attribute this to my friends being pretty smart, and maybe CBT was aimed as less intelligent people, but Nate The Genius Medical School Professor seems pretty smart. So does Walter The Therapist. Burns’ book includes a bunch of other vignettes about high-powered lawyers, graduate students, et cetera. They all find his suggestions of “Well, have you considered that your irrational negative thoughts might not be rational?” super life-changing.

You might have read the study this graph comes from: The Effects of Cognitive-Behavioral Therapy As An Anti-Depressive Treatment Is Falling: A Meta-Analysis. As you can see, the Hedges’ g declined from about 2.5 in 1980 to around 1 today. The latest embarrassing set of results now show CBT doing no better than its old nemesis psychoanalysis. Why?

There are a lot of possible explanations. The smart money is always on “it never worked very well, but we’re finally doing studies that aren’t hopelessly biased”, but the analysis doesn’t find a clear difference in study quality. Other suggestions are that therapists have gotten less committed over time, or that the patient populations has changed. All of these sound reasonable. But let me mention one more possibility.

Every so often, psychiatrists joke about how so many people are depressed we might as well put Prozac in the water supply. Sometimes we say the same thing about lithium, although in that case we’re not joking.

Nobody’s ever talked about putting cognitive-behavioral therapy in the water supply, but insofar as that’s meaningful at all I would say we’ve kind of done it. Cognitive-behavioral ideas, like perfectionism, excessive self-blame, conditional versus unconditional self-respect, deep breathing, goal-setting, et cetera have become basic parts of popular culture. The whole self-esteem movement isn’t exactly cognitive-behavioral, but it’s certainly allied, and it certainly represents a shift to a style of thinking about the self and about psychology in a way that’s much more fertile for cognitive-behavioral ideas. Inside Out was kind of “Cognitive Behavioral Therapy: The Movie”.

Although the particular book I’m reading is from 2006, Burns himself was one of Aaron Beck’s original students and one of the first cognitive-behavioral therapists ever. I wonder how many of these patients who seem absolutely shocked to realize that maybe their anxiety isn’t rational come from that very early period.

It’s very hard to track changes in people’s basic beliefs about psychology. I was flabbergasted to learn that until Dr. Benjamin Spock’s landmark 1940s book on child care, parents were told not to hug, kiss, or show affection to babies, because that would coddle them and make them weak, pampered adults. Before that, parents interacted with their kids much less, and it was assumed that siblings and nannies and friends would raise them, or they would raise themselves. It’s easy to read books about ancient Greece and not notice that they have a completely different view of the role of the self/individual than we do. So it wouldn’t surprise me if a lot of the psychology we consider “obvious” is CBT that has seeped out into the water supply over the past thirty years.

If that were true, it would explain why CBT is no longer as effective – it’s just telling people things they already know.

It could be fairly asked: then why isn’t everybody already better? Depression seems to be increasing, though there’s a lot of argument about exactly how much; that doesn’t sound like what would happen if everyone were automatically getting a background level of therapy.

Here’s a theory, though it’s on even shakier ground than the other one. The meta-analysis proposes that CBT may have lost some placebo effect over time because patients no longer think of it as The Exciting New Thing. I’m not sure I can go along with that – my own analysis of psychotropic medications suggests patients very much prefer the old ones for some reason. But a big part of psychotherapy is placebo effect, so they might be on to something.

What part of psychotherapy provides the placebo? Is it going to the clinic? Talking to the therapist? Hearing fancy words like “self-estimation”? Doing worksheets?

One thing a lot of therapies have in common is that they provide the feeling of insights. For example, psychoanalysts are very good at coming up with surprising-but-plausible ways that your current problems are linked to things that happened to you as a child; the usual result is a patient feeling enlightened, like “You’re right, the leg pain that’s been bothering me is in the same part of my leg that accidentally brushed up against my mother’s breast one time when I was seven, that’s pretty interesting.”

Suppose that in the old days, CBT was an insight a minute and you were constantly hearing surprising things you’d never thought about before. And nowadays, you’re kind of absorbing a lot of those things by osmosis without it seeming too insightful, and then the therapy itself is anticlimactic. Could that lessen the placebo effect enough to account for the data?

I don’t know. Maybe after I’ve been training in formal CBT for more than a week, I’ll have more data and can report back to you.

[EDIT: Sarah writes: “In a way, seeing CBT stuff in pop culture inoculates people, I think. People will get as far as noticing “this negative thought is an anxiety symptom”, but not as far as *actually reversing it*. When people hadn’t heard of CBT, they first got the “this negative thought is irrational” message in a context when they were actively working on their problems, so they followed through with the ‘hard’ step of actually reversing the thought. Now, people run into the revelation that the ‘inner critic’ is wrong just by browsing facebook, when they’re *not* actively trying to fight their anxiety problems, so the revelation loses its force.”]

[EDIT 2: Paul Crowley points out a very similar theory in The Guardian]

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310 Responses to CBT In The Water Supply

  1. Pku says:

    My personal experience with CBT was that most of the time it had a minor positive effect, but sometimes when dealing with hard situations it helped move me all the way from “I can’t deal with this, it’s crazy!” to being able to deal with it pragmatically. I also suspect that some of the benefit came from just taking five minutes to think about something thoroughly.
    I don’t know about the “intelligent people have trouble with CBT” thing – I know a couple of intelligent people who didn’t have that issue at all (I found the guy who wrote the book I tried to be somewhat patronizing, but I still liked the ideas – maybe it’s more “people who are sensitive to patronization?” But I’m generally pretty sensitive to patronizing tones. Maybe it’s about being willing to consider obvious solutions to hard problems? I know I have a tendency to miss simple answers, so maybe I’m more open than other people to giving them an honest try?)

    • Vilgot says:

      I don’t buy the “intelligent people have trouple with CBT” either. I’d expect CBT to work better on patients with heigher IQ since it’s about aquiring new skills and applying abstract knowledge to ones life. And, depending on what the author means by intelligent, shouldn’t intelligent people be expected to be more flexible or open to new ideas? I know intelligence doesn’t mean being positive or hopeful, but I’d expect a less intelligent person to be more likely to get stuck at “this is obvious, why are you telling me this”, and more likely to miss the finer points about the value of actually reflecting or actually doing exercises. CBT is supposed to be about more than insight-moments.

      • Marc Whipple says:

        Shouldn’t intelligent people be expected to be more flexible or open to new ideas?

        You’d think so, but this is not my experience after dealing with a relatively large number of them. In fact, many of them are even less inclined to accept new ideas than more neurotypical individuals, because they are so used to the idea that most other people (and their ideas) are stupid.

      • undermind says:

        I think it’s more “people knowledgeable about mental illness” than “intelligent people”; in my particular experience, the two have overlapped.

        The point of failure is people who know what the therapist is likely to say and have already come up with counter-arguments.

      • Sasha says:

        I agree. It takes a lot more intelligence to learn to apply new skills than to pop a pill. Especially since anti-depressants don’t work better than placebos, anyway.

  2. Steve Johnson says:

    Interesting idea and actually quite expected if you think about it (similar to hearing the solution to a riddle – once you hear an explanation that works well it seems obvious in retrospect).

    People have a pretty good psychology module and are quite interested in learning to use psychological tools to improve their own lives.

    (tongue in cheek) Maybe any future new therapy methods should require patients to sign NDAs so that the effectiveness of the new method can be evaluated over the long term with scientific rigor? (/tongue in cheek)

  3. Lumiere says:

    Lithium occurs naturally in some water supplies, and is suspected of having an antidepressant effect.

  4. oligopsony says:

    The impression I get from my girlfriend, who practices CBT, is that the practice is much more (supposed to be) about “homework” than “insights.” Things like the “put the hairdyer in the car” example from the trans-related post here – or, say, for biting your nails, getting yourself some worry beads or toy to play with – are the “behavioral” side of CBT, and the “cognitive”/”insight” side gets reinforced by encouraging you to do it on your own.

    This still seems consistent with a “water supply”-type explanation of declining effectiveness , but I thought it was worth mentioning that the repetoire of recommendations is a little wider than the post gives the impression of.

    Also (and unrelated to the above,) I don’t know if this is really a thing, but at least it’s a concept describing a thing.

    • Yes, I agree with this. I am by no means an expert, but I’ve practiced CBT, and in my experience, it doesn’t deliver remarkable insights about the illogic of anxiety and depression. As Scott pointed out, most people are capable of realizing that their neuroses are not logical. The problem is that applying logic to emotional states is usually not very effective, particularly “in the moment,” and particularly when done in an ad-hoc, unpracticed way. If you’re really anxious for no reason, just telling yourself that there’s no reason to be anxious is not going to do anything.

      What CBT does is provide a set of structured practices which allow you to more easily recognize and categorize irrational thoughts on a regular basis. It helps you notice unhealthy patterns of thought and counteract them before they turn into full-blown anxiety or depression. Practicing this regularly and proactively, even when you’re not feeling bad, seems to be effective at reducing anxiety and depression in a way that mere unpracticed positive thinking is not.

      Again, this is just based on my experience. CBT may well be a placebo; I readily admit that I don’t fully understand why the deliberate practice of CBT techniques is more effective… all I can say is that I did find CBT effective when I did it. Some therapists are much better than others at it, though.

      • Ruthan says:

        Edit: I see that Kaj already said what I had to say, but as regards relevant emotional states: Being a therapist seems hard not because it involves memorizing and synthesizing a bunch of symptoms and techniques, but because all the therapists I know spend day after day evoking enough empathy that their patients are able to use the therapist as a foil to help themselves.

      • Sigh says:

        Isn’t all psychotherapy placebo?

  5. lumenaide says:

    Is it possible that CBT is like antibiotics, in that you can build up a “psychological immunity”? Then, just like how putting penicillin in the water would make all the viruses immune, putting CBT “in the water supply” has kept us from using it effectively.

    This is very similar to what you just said, but here’s an anecdote to distract you: the self-esteem movement is pretty low status in a lot of cases, at least from what I’ve seen. That serves as a pretty effective antibody, where before it wasn’t well-known enough to even have a status.

    • onyomi says:

      This was my thought, as well, though it’s hard for me to know how miserable people really were in the 50s and earlier. My subjective impression is that they were *less* miserable then, but maybe that’s just an illusion created by Leave it to Beaver.

      Also, been reading Jonathan Haidt’s book on “The Righteous Mind” recently, and he really emphasizes a point I think most of us here are at least somewhat familiar with: that the rational mind often serves only as the “press secretary” or finder-of-evidence for whatever position the subconscious mind has already arrived at.

      Applying this idea to depression, we might say that if the subconscious mind has already decided to be unhappy, then the logical mind will start looking for good reasons to be unhappy. I think this is the real reason smart people seem more resistant to therapy: their rational minds can construct more elaborate and seemingly airtight cases to justify their subconscious feelings.

      But if it’s true that CBT concepts’ infiltration of our cultural “water supply” has not really resulted in people being more happy overall, it may be because we are misunderstanding how it worked in the first place.

      On the surface, it seems that good CBT defeats the logical justifications the mind creates for feeling the way it already wanted to feel. But if that were true, we would expect any improvements to be very fleeting, as the logical mind will simply find a new explanation for unhappiness so long as the underlying brain chemistry, etc. is unchanged.

      Instead, maybe it is the feeling of having insights, of attacking a problem at its source, of making progress and getting better, which itself helps change the underlying subconscious state. I know from experiencing these states in dreams that the sensation of “having a great idea/deep insight” is separable from actually having a great idea. And it wouldn’t surprise me if such states were inherently cathartic or antidepressive for the subconscious mind. I also know that hope, and the sense that I am taking positive action to fix a problem can themselves make me feel better for a while.

      To the extent CBT no longer sees like an exciting, new, insight-producing, progress-making modality, maybe it loses its efficacy. In other words, maybe we really have just succeeded in making more treatment-resistant depression…

      But then, seeing the mind for what it is may itself help us in the long run…

      • houseboatonstyx says:

        This was my thought, as well, though it’s hard for me to know how miserable people really were in the 50s and earlier. My subjective impression is that they were *less* miserable then, but maybe that’s just an illusion created by Leave it to Beaver.

        From my lower middle class view — respectable, possibly-irrational depression may have been a thing for Holden Caulfield, Sylvia Plath, Frannie Glass … people who lived in cities and had families that could afford psychiatrists. My class saw either real craziness (just beginning to be called ‘mental illness’) or malingering.

        Mass communications were different. People who could afford televisions had Leave it to Beaver, where Beaver’s world was everyone’s normal world, at least in the US. Steinbeck could get published writing about ‘Okies’, but the Okies and other ‘trashy people’ couldn’t. No blogs, no self-publishing, few magazines that would take anything like that. Very few people interested in helping or publcizing trashy problems.
        Therefore, Middle Class people were happier then (and if not, they were less desperate aboaut it). Whatever zie’s personal problem, it was in a sunlit, optomistic rising tide in a happy world (true financially etc, with GI bill, good post-WWII economy). Thinking one’s unique, rare, emotional suffering couldn’t get fixed, (“See a counselor! Join AA!”) was being irrational.
        Now, even Middle Class people who have no individual objective problems — see themselves as in a priviledged bubble in a sinking world beside a bottomless pit of suffering, and their could-be-happy condition is something to feel guilty about, and they need to solve the whole world’s problems. (And there isn’t much religion to cheer them up.)
        Of course this isn’t just otherwise-happy-MC people — the non-priviledged, when they look at the whole world, don’t see sunlit optomism either.

        • onyomi says:

          I do think it’s important to remember, whether judging happiness levels or the quality of writing, that the past 50 years, and especially the past 20 years of internet, have opened up the possibility of progressively poorer, less educated people making their voices heard.

          That is, if it seems like no one knows the difference between “its” and “it’s” nowadays, it’s probably not because fewer people know the distinction (probably the reverse, actually), but because more people who don’t know the distinction are writing in a place where many may read it. And the analogy to mental health here should be obvious.

          Considering how rapidly the total number of people capable of getting their writing read or their grievances heard by a therapist has expanded, perhaps we should be impressed things don’t seem worse.

      • Marc Whipple says:

        They weren’t less miserable, but they didn’t believe that every minute should be blissful and dynamic, so they were more satisfied, which means they were, in a real sense, happier.

        • Deiseach says:

          Yes, some of it is definitely a change in expectations. Again, quoting from work – we get people who think they’ll get a three-bedroom house because of course they need one bedroom for their five year old child and one for their three year old child, and we have to explain “Nuh-uh, doesn’t work like that”. Contrast that expectation (each child has their own room) which is very definitely a “within the last ten to fifteen years” expectation in Irish society with the experience of (at least some of) us older people working here, where not alone did siblings share rooms for years, they often shared beds (at least up until a particular age), and it’s a whole different world nowadays.

    • Pete says:

      Pedant alert, penicillin does nothing for viruses and doesn’t try to.

      • Randy M says:

        Well, if you want to be pedantic, penicillian should only be an object, not a subject.

        • Izaak Weiss says:

          Penicillin is the object of both the sentence you wrote, and of this sentence.

          Linguistic tricks aside, Penicillin can totally be the subject of a sentence! I can’t even think of a false reason why it couldn’t be.

          • Deiseach says:

            Linguistic tricks aside, Penicillin can totally be the subject of a sentence! I can’t even think of a false reason why it couldn’t be.

            Penicillin-as-subject where penicillin has goals, aims, objectives and things it is trying purposefully to do. Penicillin is not (so far as we know) self-aware or conscious and does not have ends it is trying to attain by doing X for these entities and not doing Y for those entities.

            Penicillin-as-subject where “Penicillin is the thing I am talking about”, sure 🙂

          • Jiro says:

            If you want to be pedantic, you still shouldn’t say that “penicillin” can’t be a subject because penicillin can’t do anything on its own. Phrasing the sentence by saying that penicillin does something is an example of metonymy. It is not incorrect and it does not imply that penicillin is doing things by itself any more than “the White House announced that…” means that a building got up and spoke to the press.

            Why do people on the Internet have trouble understanding figures of speech and anything nonliteral? It’s a plague.

          • Nick says:

            Even more pedantry: Deiseach is actually confusing agent with subject. The subject is just the first argument of a verb, but may be any one of a number of relations.

  6. Nick T says:

    A slightly-different, not-sure-how-likely, very-sad-if-true hypothesis that immediately comes to mind is that CBT has a non-placebo benefit in naive people, but prior exposure to pop-CBT inoculates against that benefit because people think they’ve heard this already.

    Unrelatedly, how plausible is it that the quality of formal CBT has gone down over time? How has the number of therapists changed over that time, and has how they’re trained changed? If what Burns is saying is true, one possible explanation is that he’s doing something right that hasn’t been communicated to other therapists and that he may not know about himself.

    • Douglas Knight says:

      If therapists have changed over time, worksheets written by those therapists have probably also changed. But we still have the old worksheets. It is still possible to give those worksheets and see how effective they are today. It would be a good exercise to take an existing meta-analysis of bibliotherapy, track down the original studies, and see if any used the same worksheets 10 or more years apart. But the answer is probably no.

  7. Siahsargus says:

    If what you say is true about CBT-type have seeped into a sufficient amount into the water of popular consciousness, then we may have raised the sanity waterline. Provided of course that CBT is strictly focused on demonstrating the irrationality of one’s automatic negative thoughts, and not just about feeling better through positive thinking.

  8. Unknowns says:

    I found CBT effective the same way anti-procrastination methods are effective: it works for a while, then you get tired of using it and go back to what you were doing before.

  9. Anaxagoras says:

    Therapist (pretending to be patient’s friend):

    There’s a statement that gets pretty amusing out of context.

    • suntzuanime says:

      Yeah, I found it amusing too. On the other hand, isn’t that hypothesized to be basically the active ingredient in therapy and the whole reason for the Dodo bird verdict?

  10. suntzuanime says:

    It seems plausible that the cognitive behavioral therapy that’s been leaking into the water supply has been helping, just not as much as the late capitalism that’s been leaking into the water supply has been hurting, and so on net depression goes up.

    There’s also the possibility that it’s not CBT itself that’s been leaking into the water supply, but something that binds to the same receptors and makes CBT ineffective. Call it “cynicism” or something.

    • onyomi says:

      I think that along with CBT’s entry into the water supply has come cynicism about CBT-like modalities themselves. When Freud first started treating PTSD with insight it was pretty revolutionary. Now Freud and his descendants are kind of a joke in the popular culture.

  11. Greg says:

    What about the practitioners? Could early adopters of interesting new approaches more likely self-recruit from the right side of the therapist IQ bell curve? If therapy truly requires surprising insights, maybe the average therapist doesn’t produce them in sufficient quantity, while the early-adopting, book-writing exceptional therapist does, regardless of theoretical framework.

    • Siahsargus says:

      I had a similar thought. Basically, schools of psychology are a lot like schools of art; they have virtuoso founders with unorthodox ideas and a central philosophy. The artists tended to have a central clique of other artists and protegés who followed the school closely, and a looser sphere of imitators who might just take one or two good ideas or techniques. As time continues and the original founders die/branch out, the original idea is either totally lost or absorbed into the artistic canon.

      For psychology, a good example would be Freudians and Neo-Freudians. Even though saying “psychologists are not freudians” in an article titled something like “common misconceptions about physcology” is definitely a cliché at this point, every knows about id-ego-superego. The public has a hard time keeping up with fashions in therapy, it seems. Freudian ideas are either accepted as common sense or rejected as ridiculous (talk about penis envy seriously, I dare you).

      I suspect the same thing will happen with CBT. It’ll be crazy good a first because it has a small school of experienced trailblazers. Then it’ll go maaaaainstream and be diminished in quality as it is mixed and diluted with other popular hypothesises/schools. Eventually, there will be a new “next big thing” and dumbed-down CBT will slowly enter the realm of obscure old pyschology, or worse – “common sense”.

      • Who wouldn't want to be anonymous says:

        talk about penis envy seriously, I dare you

        Do you mean “talk seriously about penis envy, I dare you” or “talk about penis envy, I seriously dare you” … ?


  12. youzicha says:

    I totally expected the first story to end “I met Nate again a year later. After realizing that his satisfaction was unrelated to the quality of his work, he found it impossible to motivate himself. His university had fired him for shoddy work performance and he was now divorced and living on the street”. I guess many of your stories and with a clever twist, so I subconsciously anticipate it.

    • DES3264 says:

      Someone with Nate’s background almost surely has tenure (if this story takes place in the US). Academic tenure is a wonderful machine for driving people like Nate to exhaust themselves for 15-20 years, and then catching them after they collapse.

  13. eqdw says:

    I have had several experiences with therapy. Being the good evidence-based rationalist I am, I have insisted on seeing ONLY therapists who provide CBT. With this in mind, here was my experience:

    * The vast majority of therapists I’ve seen who claim to provide CBT are full of complete horse shit. They spout hippie pseudoscience bullshit and feel-good quazi-spiritual bullshit, while halfassedly implementing CBT. This is what I get for trying to get medical help in a city that doesn’t believe in reality
    * Of the therapists who knew what they were doing, it all came across as extremely patronizing. Were you not listening to the part of my intake when I told you that I’ve had bad past experiences, have researched this shit to death, and already know all about it? Don’t treat me like I’m retarded
    * Of the therapists who remained, their entire CBT technique seemed to be to print out pages from websites containing basic explanations of CBT and giving them to me as homework. You think I haven’t already read all this? Even if I hadn’t, you’re charging me $150/hr out of pocket to give me printouts from the internet. You know I have that at home. I even (GASP!) have a printer, just in case the fact of it being on paper is relevant.

    Finally: Every single therapist I’ve ever seen has been less intelligent than me. They try to go through the motions of CBT, in ways similar to the anecdotes blockquoted from that book. And you know what happens? It makes it worse. Without fail, it actively makes it worse. Possibly because I am more skilled than the median human at rationalizing the things I believe. Or maybe because some things are legitimately shitty and ~*~feeling really good~*~ about them doesn’t make them stop being shitty.

    Therapists are useless. The only benefit they’ve *ever* given is that they take the pressure off my closest friends to listen to me being sad. They have only ever made me feel worse, not to mention poorer.

    Therapy is bullshit

    • Deiseach says:

      Or maybe because some things are legitimately shitty and ~*~feeling really good~*~ about them doesn’t make them stop being shitty.

      Yeah. That’s my major fear about accessing counselling (and why I asked for antidepressants in the first place): it’s all very well to say “We’ll investigate why you think the way you do, and demonstrate how your negative perceptions are based on unrealistic and excessively self-critical assessments, which we will then give you tools to counter those and inculcate a positive sense about yourself and your abilities”, but that’s not going to do much good if the assessment is not excessively self-critical and unrealistic but is actually a pretty accurate summing-up of my deficiencies.

      • CAE_Jones says:

        I keep finding myself tempted to share this article with everyone just for your comments, Deiseach.
        (I also find myself tempted to rant about how every piece of advice I can remember OTTOMH* is specifically useless. Especially since I just read a Reddit thread where someone did exactly that and got downvoted in spite of the subreddit’s “only downvote for rudeness, not disagreement” rule and feel attacked by proxy. But most of my examples would be off topic to CBT.)

        * You know, I’ve never seen anyone abbreviate “off the top of my head” before. I think this means I’m using it too much, lately.

        • anon says:

          The commonly used abbreviation is OTOH.

          • anoner says:

            That’s “on the other hand.”

          • anon says:

            That’s surprising, I had always thought it is “off the top of my head” and used it as such with no issue, but googling it, you’re right.

        • Deiseach says:

          Thank you for the very kind words, CAE. Before my head gets too swelled, I should remember the equivalent exchange in the Sherlock Holmes story 🙂 :

          “You have heard me speak of Professor Moriarty?”
          “The famous scientific criminal, as famous among crooks as – ”
          “My blushes, Watson!” Holmes murmured in a deprecating voice.
          “I was about to say, as he is unknown to the public.”

      • Shenpen says:

        Same. Basically nature does not want us all to win. It is perfectly possible to be a failure and die, and this seems rather frequent out there in the wildlife. In civilizaiton, we can be failures and live, and even have the outer markers of success like a decent career and sex life, but it is perfectly possible to suck, be aware for it, suffer until the kids grow up and then die of liver cirrhosis or something.

        There are really two options only. Either there is such a thing as unearned, undeserved happiness, the kind one is totally unworthy of and yet it feels good. Or else it will suck and then we die.

        • Sigh says:

          Basically nature does not want us all to win. It is perfectly possible to be a failure and die, and this seems rather frequent out there in the wildlife. In civilizaiton, we can be failures and live, and even have the outer markers of success like a decent career and sex life, but it is perfectly possible to suck, be aware for it, suffer until the kids grow up and then die of liver cirrhosis or something.

          My pet theory is that that’s the evolutionary purpose of depression (which seems to exist in other animals too). Instead of spending the rest of our defective lives sucking up resources we aren’t going to procreate with, evolution wants us to apathetically wander into a predator’s mouth to take some survival pressure off of our more fit siblings. Suicide wasn’t necessary until we killed off all of our predators and were no longer picked off from the herd for lethargically lagging behind.

          • maxikov says:

            Suicidal intent is never ever selected for. It may only be not selected against hard enough.

          • Marc Whipple says:

            Maybe it is, and maybe it isn’t. But it certainly could be selected for, although not directly. Perhaps it’s more accurate to say that suicidal tendencies could be selected for in the proper environment.

          • rsaarelm says:

            Suicidal intent is never ever selected for.

            There was a theory somewhere that the suicide rates you see in Greenland might be because of an adaptation where everyone gets suicidal if they don’t feel like they’re pulling their weight. If an extended family is stuck in a harsh environment, the uncle with the crippled leg who can’t go hunting killing himself might mean the difference between everybody starving and everybody else barely surviving.

          • Sniffnoy says:

            Hm — today I encountered this article (H/T Sark Julian, actual paper here) claiming that limited lifespan can in fact be selected for, contrary to what previous models have predicted. If that is indeed the case, it doesn’t seem too implausible that suicidal intent could be selected for. The octopus case described, which possibly could be selected for, could even be described as a “suicidal intent” of sorts.

            (…that said, I would be pretty surprised to learn that the human sort of suicidal intent, which doesn’t seem to much resemble the octopus case, actually is/was selected for.)

      • Adam says:

        Negative emotional responses that impede your ability to perform necessary tasks and enjoy life are themselves deficiencies.

        I don’t see that excessive self-criticism and realism has to lead to depression. I’m well aware I exist in the vast amorphous mass of averageness at just about everything, much like everyone else, my chronic pain and neverending stream of orthopedic injuries aren’t going away and will probably only get worse, most of what I ever wished to do in life I won’t do, and additionally the universe itself is a huge expanse of inert gas and rock without purpose or meaning and morality is mostly a crock of shit fairytale we convince ourselves of for the sake of maintaining a stable social order. There is no god, the singularity isn’t coming, and I’ll be in the dirt with everyone who came before me in another few decades, and the world won’t care.

        But none of this particularly bothers me. They’re value-neutral beliefs, best guesses, possibly facts, but there are still plenty of things to keep me busy that I enjoy doing and that seems to be more important than anything else. What these things are changes as I lose physical abilities I once had, and I’ll eventually lose mental abilities as well, but until then, as long as there is something, that is sufficient reason to keep going.

      • Nicholas says:

        My training was meant for psychological research, not therapy, so take this with a grain of salt but:
        My understanding is that the point is not to change the facts of your life, but to change your rules for evaluating those facts so that you feel better about them. If you have the mindset that your feelings about things need to flow from the facts of events in a straight line pragmatism sort of way, then you’re specifically going to fight this process.
        When I say your beliefs about how your deficiencies should make you sad are Wrong, I mean that they don’t have instrumental utility, not that they aren’t true.

        • Deiseach says:

          to change your rules for evaluating those facts so that you feel better about them

          Speaking for myself alone and nobody else, there are things I know I need to change, but I’m too comfortable in my rut to do so (and too lazy and selfish to put in the effort and suffer the discomfort of changing). I am also very good at self-deception and practicing “out of sight, out of mind” so as to keep uncomfortable truths swept under the carpet and enable me to tell myself a narrative where It’s Not My Fault I’m A Failure.

          Where this breaks down is when outside reality insists on obtruding inconvenient facts to burst the happy bubble of I’m Okay. For instance (did not happen to me – yet, anyway) if you are daydreaming your time away at work and not getting the job done, then eventually the boss will take notice, insist you do the work, and if you don’t/won’t change your behaviour, you lose your job.

          A string of “incapable of holding down a job” experiences means you either have to acknowledge that the negative assessment of your capabilities is true, or you engage in further self-deception, which is not much good when you have to report to the social welfare office as to why you’re still on the dole and not genuinely looking for work – the story “It’s Not My Fault” is not going to wash there.

          I’m very good at changing my evaluation of the facts to feel better about them; the depression is worsening now that I can’t keep my little self-deceptive denial of reality bubble going and have to face the real facts of my inadequacy.

          • Nicholas says:

            Oh no, the goal isn’t to change your beliefs on the object level. You should believe you are incapable of holding down a job. You just shouldn’t care.

          • Deiseach says:

            You will care when not being able to get and keep a job means no money means not alone no roof over your head but no food, no clothes, no heat or light.

            Yes, people live on the streets. No, it’s not great.

      • Sigh says:

        The patient represents his ego to us as worthless, incapable of any achievement and morally despicable; he reproaches himself, vilifies himself and expects to be cast out and punished…. It would be equally fruitless from a scientific and therapeutic point of view to contradict a patient who brings these accusations against his ego. He must surely be right in some way and be describing something that is as it seems to him to be. Indeed we must at once confirm some of his statements without reservation. He really is as lacking in interest and incapable of love and achievement as he says…. He also seems to us justified in certain other self-accusations; it is merely that he has a keener eye for the truth than other people who are not melancholic. When in his heightened self-criticism he describes himself as petty, egoistic, dishonest, lacking in independence, one whose sole aim has been to hide the weaknesses of his own nature, it may be so far as we know, that he has come pretty near to understanding himself; we only wonder why a man has to be ill before he can be accessible to truth of this kind.

        —SIGMUND FREUD, “Mourning and Melancholia”

        • houseboatonstyx says:

          The patient represents his ego to us as worthless, incapable of any achievement and morally despicable;

          A post-Oxford-comma translation, I presume?

      • eqdw says:

        Yeah. I’m not saying that I have it bad, and all my problems are real. I have a good understanding of my negative thought processes. I’ve sort of independently derived my own personalized cbt that works for some of those. But some of the things are just legitimately shitty stressors that make everything else that much harder, and therapy isn’t going to help anyone with those kinds of things

    • stillnotking says:

      Or maybe because some things are legitimately shitty and ~*~feeling really good~*~ about them doesn’t make them stop being shitty.

      This reminds me of what one of my psych professors remarked about the popularity of 19th-century patent medicines (“Good for man and beast”): “Whatever’s wrong with you or your horse, you’ll feel a hell of a lot better about it after a good slug of laudanum.”

    • Nicholas says:

      This is the short version of my reply below but basically: The goal isn’t to change the shitty thing. The goal was never to change the shitty thing. The goal was always just to get you to feel better about the shitty thing. We didn’t tell you that because then you wouldn’t have come in, and then you’d still feel bad about the shitty thing, which provides less utils than the alternative.
      [Standard caveat, I was trained for research, I don’t even work in research I’m a professor, YMMV, void where prohibited.]

      • Mary says:

        Yes, but if you can’t feel happy unless your life is a rose garden, you’re not going to be happy. Ever.

        I’ve read a woman writing about her therapy experience, and the first thing her second (and effective) therapist told her was that the problem was not anything that had happened to her, it was in her current day problems. Since they could not change the past, they were going to concentrate on what could be changed.

        • maxikov says:

          > Yes, but if you can’t feel happy unless your life is a rose garden, you’re not going to be happy. Ever.

          Unless you take opiates, in which case you probably are. In most cases, I suspect, even LSD will do. There may or may not be non-chemical means of achieving same effects.

      • eqdw says:

        I get this. The thing is, I already researched this to death before coming in in the first place. I know this.

        So, assuming that this actually works, I suppose my real problem is that there are a lot of therapists out there who aren’t very good at their jobs?

    • Sigh says:

      The vast majority of therapists I’ve seen who claim to provide CBT are full of complete horse shit. They spout hippie pseudoscience bullshit and feel-good quazi-spiritual bullshit, while halfassedly implementing CBT.

      Of the therapists who remained, their entire CBT technique seemed to be to print out pages from websites containing basic explanations of CBT and giving them to me as homework. You think I haven’t already read all this?

      I have only seen one therapist for CBT so far, but this describes my experience exactly.

    • Marc Whipple says:

      No, therapy is b******t for you.

      For some people, including some extremely intelligent people (I’m not trying to compare brainpans here) it is very helpful. That’s because it is not a science. It fails falsification and it doesn’t produce predictable or consistent results. So if it doesn’t work for you, stop doing it. Won’t criticize you or pull the Woody Allen “sleeper” joke. But it really does help some people a great deal, and disclaiming it across the board is not helpful.

  14. notes says:

    Arguably, novelty primes a different mode of thinking: more attention, less expectation or assumption. Perhaps the work being done primarily consists of provoking self-reflection while in that mode — that’s consistent with the observations of people suddenly reaching life-changing realizations about themselves. Things that they could have noticed earlier, but for their existing habits of thought.

    Mistaking the new thing for the newness is an easy error, and naturally leads to results which prompt the question about why therapies decline in effectiveness over time.

    Still leaves the question open of how best to prime that sort of attentive, open, mindset… beyond sincerely flitting from fad to fad.

  15. Anaxagoras says:

    Could it be possible to try basically “insight-porn therapy”? Giving the patient all sorts of cool, not necessarily true, insights about psychology and their life, which, for experimental purposes, have nothing actually to do with what’s wrong with them.

    Optimistically, I could see this producing a sense of awe and understanding that seems like it would have beneficial therapeutic effects. As you say, since CBT has entered the mainstream, it’s no longer surprising and insightful, and therefore loses some of its benefits.

  16. Dan says:

    This reminded me of one of my favorite pieces of dialogue in Catch 22:

    “Hasn’t it ever occurred to you that in your promiscuous pursuit of women you are merely trying to assuage your subconscious fears of sexual impotence?”
    “Yes, sir, it has.”
    “Then why do you do it?”
    “To assuage my fears of sexual impotence.”

    • Tracy W says:

      Wasn’t this George Orwell’s objection to Freudianism: that all his sexual fantasies were quite explicit?

      • Marc Whipple says:

        By definition, subconscious fantasies cannot be explicit or known to the conscious mind, so while ol’ George, as usual, got off a real zinger, it really isn’t a logical refutation.

  17. VIRSEN says:

    Long time Lurker, First Time commenter:

    Hmm…it’s a good thing I didn’t happen to come on this blog before I tried to alleviate my anxiety. I used the Burns book a bit. It was a starting point.

    Well I think there maybe something to CBT than just standard common sense. For example, I remember a study where people wrote out their argument for a particular belief (I believe political) that they held. After they did so they were less certain about their belief. A Cognitive behavioral therapist would probably argue that they are using the same effect. Most people, (I know I did), tend to ruminate without actually constructing their belief accurately.

    One useful technique for me was comparing probabilities of events that I was scared of to events that I wasn’t afraid of. I wasn’t scared of an asteroid hitting the earth, or even driving a car every day for a year. If the odds of death or harm were less than than driving a car it stopped a lot of the worry.

    Sometime obvious solutions aren’t very obvious I guess.

    But beyond that I kind of poured through book after book in the university library trying out technique after technique seeking to wipe out any trace of anxiety I had. I developed my own system that is theoretically coherent and works at least for me. I don’t spend much time using CBT. I was thinking of writing it out because I think I have some novel insights. Though this post makes me reconsider as there is a chance it’s all placebo and any real insights will be found out by folks smarter and more knowledgeable than I. (Though the fact that I’m not getting anxious in the slightest from this post itself is a good sign).

    This has been a very unusual two years for me. All my life I’ve had anxiety, and now little to none at all. I don’t know what to say Scott, other than I guess I’m glad to be noise :/

    I guess I’ll move on to procrastination now. Ha! 🙂

    • Ghatanathoah says:

      One useful technique for me was comparing probabilities of events that I was scared of to events that I wasn’t afraid of. I wasn’t scared of an asteroid hitting the earth, or even driving a car every day for a year. If the odds of death or harm were less than than driving a car it stopped a lot of the worry.

      When I did this it made me less afraid of improbable scary events, but also more afraid of cars. Fortunately the decrease in anxiety from worrying about improbable events was far greater than the increase in anxiety from worrying about car crashes. And it’s probably a good thing that I’m a more careful driver now.

      • Marc Whipple says:

        I am suddenly reminded of the line in Have Spacesuit, Will Travel wherein the protagonist reads the manual for a spacesuit he is restoring, including all the environmental parameters which the spacesuit must maintain to very tight tolerances.

        “When I was done [reading that manual,] I didn’t see how anybody stayed alive anywhere at all, much less in a spacesuit.”

  18. Kaj Sotala says:

    Dr. Burns asks patients whether their anxiety might not be rational, and their faces light up and all of their psychiatric problems suddenly melt away.

    That doesn’t sound like an accurate description of the excerpts you posted: rather than just asking whether their anxiety might not be rational, Dr. Burns makes his patients go through exercises that force the patients to really confront the irrationality of their beliefs. In none of the examples did the patients really get better after just being asked “is your anxiety rational” – e.g. Walter was asked whether he’d say something like that to a friend, and he said no, but that alone wasn’t enough to improve his condition. What did help was putting him in a position where he had to really think through the arguments for why this is irrational in order to convince his friend, and then, after having formulated the arguments once himself, get convinced by them himself.

    Like, it’s one thing to ask a phobia patient whether they really believe that harmless thing X would kill them, and it’s quite another to put them through gradual exposure therapy where they can experience the thing being harmless in a safe environment. This seems like a similar difference – yes, people know thing X on an intellectual level, but it’s only when they’re actually put through the experience that they internalize it on an emotional level.

    • Kaj Sotala says:

      To put it differently, CBT seems like a set of techniques for taking beliefs (“yeah, my anxiety is kinda irrational”) and turning them into aliefs (“huh, my anxiety IS irrational!”). If so, this seems like further evidence against the “only non-intelligent people benefit from CBT” model, because a lot of CFAR’s stuff – things like urge propagation, aversion factoring, and so on – is also explicitly about converting beliefs into aliefs and vice versa, and is quite CBTish in this respect. (I kind of feel that a lot of CFAR’s stuff is basically taking the idea behind CBT and then systematically applying it everywhere.) And the people hanging out at CFAR are generally pretty smart, he said understatingly.

      • onyomi says:

        I think this is a good point.

        In the examples above, it seems like the marriage therapist already knew he was being irrational on some logical level, but he couldn’t feel that way on a gut level. Forcing the patient to role-play, etc. may be a way of making them experience something on an intuitive level.

  19. PD says:

    I think it’s a mistake to think of CBT as primarily about generating insight, and if you do think of it this way, then it’s bound to appear hokey and patronizing.

    In my experience the point is rather to develop a habit of disrupting rumination. It’s true that irrational self-defeating thoughts form habitually and automatically and not because the patient is just too stupid to know better. The effect of CBT is to develop a reflex of inhibiting them. I.e. the next time the patient forms the thought, “I am a shitty person,” or whatever, he also thinks, “but I know that thought is stupid because reasons x,y,z that I’ve already beaten to death in therapy.” This heads off the rumination spiral. But you start to see the effect after this pattern repeats many times over (maybe several times a day, for weeks), not in a flash of dramatic how-could-I-have-been-so-dumb insight.

    This is why I would expect CBT and meditation to fit nicely together, since meditation trains the meta-cognitive awareness that you need to notice what you’re thinking about.

    • Steve Sailer says:

      “In my experience the point is rather to develop a habit of disrupting rumination.”

      Somewhat along those lines, golfers often find it helpful to repeat a single “swing thought” in their head while swinging. It’s usually a reminder to do something that particular golfer sometimes forget to do, but a major purpose for a stock swing thought is to crowd out other potential thoughts, so that the swing happens as close to automatically as possible.

  20. Last time I suggested to someone they might be going though some sort of manic/depressive state, they started screaming and then ran off.

    About a week later, I found the suicide note I’d accidentally missed.

    Luckily the story has a happy ending, because sometimes hobbies make people feel better even when the people in their lives are doing a shitty job of it.

  21. Anisha says:

    CBT works really well with intelligent people who have little to no understanding of themselves. Which is a descriptor that probably fit a lot more people then than does now (due to cultural changes as you mentioned and maybe partly the internet?). Otherwise, the idea that it works amazingly well for everything is pretty much just because it’s the easiest to study and thus there are loads of studies saying that it’s better than “business as usual”. Plus because it’s more straightforward than other types of therapy (like psychoanalytic), insurance companies love it. Otherwise, the most important factors are the relationship with the therapist and how much the client buys into what’s going on (which, unsurprisingly, is linked to their relationship with the therapist).

    Basically, yeah you’re likely right about this to some degree. Moreso if you take into account how wildly CBT was blown out of proportion. Plus I’m sure the whole “do this exercise and when we’re done you’ll feel better” effect has a huge impact — CBT assigns more homework than most therapies, which exactly the kind of thing that would have been awesome and great back then, but tedious now.

  22. paddybrown says:

    Some therapists are better at CBT than others. It’s not so much the technique, it’s how well the therapist is able to relate it to the patient and their issues, that’s what works. My experience of psychiatry is that it’s a very imprecise science anyway, and the malign influence of the DSM means that it’s often practiced by half-trained, half-skilled people from a checklist, one size fits all. That’s when you get patronised and not listened to.

    When I sought help for my chronic depression from the UK NHS, I beat my head off uninterested jobsworth psychiatric nurses and clinical psychologists for a couple of years – before I got so erratic at work that they referred me to a counsellor from the staff welfare department, and she was brilliant. The strategies we worked out over about nine weeks are still holding a decade later. The NHS people were definitely practicing CBT, albeit ham-fistedly. I’m pretty sure the staff welfare counsellor was too, but she did it rather more subtly and was able to relate it to me and my particular needs.

    One problem was, I had one issue that was foremost in my mind, that I was fixated on, that seemed to be the cause of all my unhappiness, but I knew wasn’t – there were more underlying things, and this issue was an effect of them. But it was so prominent in my mind, it felt so urgent, I couldn’t get past it to deal with the underlying things. I begged the NHS people, in as many ways as I could think of, to help me get past it, but all they could tell me was that it was irrational to focus on that and not the underlying issues. They treated the issue that filled my head as nothing and belittled me for taking it so seriously. The staff welfare counsellor was able to help me past it, in large part by starting where I was, listening, and understanding the distress it was causing me – as well as helping me think differently about it.

    I suspect if CBT didn’t exist and I’d seen the same people practising psychoanalysis or some other technique, the NHS people would have failed me and the staff welfare counsellor would have helped me. Because she was good at it, and the NHS people weren’t.

  23. Samuel Skinner says:

    “I was flabbergasted to learn that until Dr. Benjamin Spock’s landmark 1940s book on child care, parents were told not to hug, kiss, or show affection to babies, because that would coddle them and make them weak, pampered adults. It’s easy to read books about ancient Greece and not notice that they have a completely different view of the role of the self/individual than we do.”

    Modern society isn’t often referred to as WEIRD for nothing. I’m reading The Anthropology of Childhood (David Lancy) and none of the features we consider good parenting (and often parenting) are human universals. Things are simple as “parents interact with their children” are not common in traditional societies- older sisters, other relatives or peers are more common sources of interaction.

    Humorously “maternal grandmothers spoil their offspring” is nearly a human universal.

  24. Steve Sailer says:

    Speaking of figuring out when CBT-like techniques diffused into the pop culture so that people became aware of them before they visited a therapist, I’m trying to recall when CBT-like therapy was around long enough to be parodied on television. I can think of a couple of examples from about a quarter of a century ago.

    They’re basically the same joke: successful professional athletes, very non-self-defeating individuals, visiting a therapist:

    – Here’s Stuart Smalley (Senator Al Franken) on Saturday Night Live in 1991 helping Michael Jordan feel better about his not being the best basketball player with his daily affirmation.

    – And here’s Tracey Ullman in about 1988 playing Kiki the Australian golf pro whose problems, such as fear of flying, are cured by psychiatrist Dan Castellanata (the future Homer Simpson) with a single common-sensical sentence each (e.g., “Your chances of dying in a plane crash are as likely as being dealt two royal flushes in succession.)

    I didn’t see either skit on TV when they aired, but my wife called both of them to my attention as being quite striking to her, suggesting that in the 1987-1991 era they were relatively fresh ideas for comedy.

    These no doubt aren’t real CBT, but, darn it, they’re good enough.

  25. Deiseach says:

    Warning: rant ahead.

    This is why I cannot read self-help books, no matter how good they may be; this whole “frustrated novelist” style where they retail anecdotes from (for confidentiality’s sake we had better hope they do this) heavily redacted “actual real person” stories but all gussied up like some “Disease of the Week” movie with florid prose and talky set-pieces of “As you know, Bob – or Dr Burns, in this instance – I’m an incredibly successful person in my field, yet I have this vague sense of dissatisfaction as if something is missing”.

    It annoys me when I read it in American journalism, and I blame Tom Wolfe and the “New Journalism” style for this, but in a book which is supposed to be factual and didactic (after all, the reason I’m reading a self-help book is to learn (a) what is my problem (b) techniques for dealing with it) it absolutely drives me up the wall.

    If I wanted encouraging little stories about Bob and his ultimate triumph, I’d read a feckin’ novel. I don’t care about Bob, successful small-business owner, happy husband and father, pillar of the community and one day he finds the word “octopus” makes him turn blue, break out in orange lumps, and hop on one foot for ten minutes, which makes all his buddies at the golf club look at him funny when he’s playing a round with them. Even worse, Bob blows a big opportunity to open a franchise in Sao Paulo when this happens in front of the people who came all the way from Sao Paulo to discuss opening the franchise. But luckily, Bob comes to see Dr Bill (author of this very book what you are reading now) and although it’s tough, after a heart-warming account of ups and downs, eventually Bob beats Octupus Hopping Syndrome and is now even more successful and happy!

    Ack. Just give me plain unvarnished facts and discuss (a) the causes of Octopus Hopping Syndrome insofar as they are known (b) how it can be treated (c) if it can’t be treated, at least how it can be lived with.

    Telling me how blown away you are by Really Successful Guy’s amazing CV and how even this Really Successful Guy has problems too (just like you) and if he can crack them, so can you!

    I. Don’t. Care. In fact, instead of being encouraged, this discourages me: it may be meant to say “Somebody with this amount of hard work and talent needs help too, so you’re not a hopeless loser if you need help” but it comes across as sounding like “White People/First World Problems”: incredibly more successful than you guy suffers ennui about how he’s not feckin’ Superman or something, so even the best day you lived really sucks to be you, loser. (The man times his standing ovations? Really???? The amount of expletives deleted that went through my head reading that would require an entire decade of the Rosary the next time I go to confession. Oh how I weep for your hard, hard life of constant struggle, Professor Nate. Though the man really is struggling with psychic pain, so I should not sneer: but the examples this Dr Burns chooses to make us empathise with him – really do not work, at least not for me.)

    or just going out with his family for ice cream cones on a warm summer evening

    That is the kind of sentimental glop that brings me out on hives. How heart-warming. To borrow Dorothy Parker’s review of “The House at Pooh Corner”:

    And it is that word ‘hummy,’ my darlings, that marks the first place in The House at Pooh Corner at which Tonstant Weader fwowed up.

    Scott, the greatest service to mingling writing for a mass market audience and psychotherapy would be if you were to write a good, plain, non-treacly self-help book that stuck to a factual account of various patients without bathing everything in a rose-hued limelight and upping the sugar quotient till I need to go check my blood glucose levels after reading that touching narrative. All that is lacking is Nate romping through the woods with a six year old and a cute puppy in tow (are Labradors still a popular breed or what is the maximum cute one now?)

    Or maybe to have a successful book you need to write in that style; do Americans really like that “Success – temporary setback – invoke Mom and apple pie – even greater success” formula? I suppose they must do, seeing as how it seems to be the model for these books.

    • Shenpen says:

      North American culture is really that sentimental – I was living in the UK when some Canadian guy wanted to sell us something, and the amount of happy enthusiasm he felt about the product was sickening.

      I still don’t know if I was upset because other people dare to be happy, or because they seem to earn that happiness so cheaply.

      But it is not classy! Let’s all rather be unhappy with style like people in the really high-brow literature who have so important, deep and mystical things to be unhappy about!

      • Creutzer says:

        Let’s all rather be unhappy with style like people in the really high-brow literature who have so important, deep and mystical things to be unhappy about!

        I don’t know which works you have in mind, but in my experience, they’re often unhappy for very pathetic reasons – without detracting from the classiness.

      • Anonymous says:

        I still don’t know if I was upset because other people dare to be happy, or because they seem to earn that happiness so cheaply.

        A Buddhist (or any other religious person) might tell you this: “Happiness isn’t something you earn. It’s something you just sort of have. If you feel like happiness must be earned, and resent people for being happy without in your opinion deserving it, you’ll never have it yourself.”

    • onyomi says:

      What drives me crazy is the seemingly increasingly popular technique of starting out and framing an article with narrative descriptions of how the writer came to write the story in the first place: “It was raining the day I first met Henry Kissinger…”

      • Deiseach says:

        It drives me spare in American journalism, and you get it in legit news stories not just in editorials or opinion pieces or regular columnists.

        I really do blame Tom Wolfe and the New Journalism for reporters writing stories as though they’re penning short stories not a news article. I know the human interest angle sells, but I don’t want to read an extract from your unpublished novel, I want to know what the facts and the people involved are.

        It’s bad enough when it’s “Blonde, bubbly Janie stooped to pet Mangler, the family’s Shih-Tzu, that morning before getting into the car to drop off Preciosa (her six year old daughter who loves apple-raspberry organic ethically sourced boutique chocolatier cupcakes and neo-hip-hop modern ballet) and Fortesque (Preciosa’s eight year old brother who volunteers every Tuesday in the local ‘teaching the poor kids how to read gooder’ peer tutoring programme run by his school) off at their regular Saturday morning tae karate zen bo Wicca zumba speedreading intense burst session at WowKidz gym in their leafy Smallville suburb”. Do I need to know all this before getting to the story, which is “Local mother of two runs red light and has been summonsed to appear in the district court for non-payment of traffic fine”?

        But it’s even worse when it’s supposedly a factual piece of reportage and you get the reporter apparently possessed of both clairvoyance and telepathy as they are able to describe the thoughts and interior motivations of third parties to events where the reporter was not present, they are not going on what that third party said to them, and they’re not writing an extrapolation based on what the second-party told them. I recently read what is, for all intents and purposes, an extract from a Gothic romance bodice-ripper complete with “spiteful aunt” “hissing” into the ear of the heroine protagonist person the story is about. Now, the person in the story may have told the reporter “My aunt didn’t just whisper into my ear, she hissed the message to me” but I don’t know. And how can the reporter know the aunt was motivated by spite rather than some other emotion? It was a lovely piece of writing for telling us who the villains to boo and hero to cheer was, but as a news story with actual information and not “Amelia swayed before the coffin of her grandmother as eyes bored into her through the heavy gauze of her mourning veil*”, it wasn’t so great.

        *There was no Amelia, but there really was a Victorian-style mourning veil, swaying, and a grandmother’s coffin. For someone who hadn’t been next, nigh or near the place and was going on a second-hand account of what the subject of the story was allegedly feeling, including the thoughts, actions and motivations of third parties, the reporter produced a pippin of a tale! As to the actual facts of what happened, I have no idea other than “person shows up at grandmother’s funeral seemingly determined to make it All About Me and is disappointed when this appears to incur disapproval of immediate family”.

        • Creutzer says:

          Goodness, that third paragraph of yours was brilliant!

        • Protagoras says:

          A major pet peeve of mine is historians who write like this. I guess I don’t expect any better from reporters, but I do expect better from people who claim to be scholars, and so I’m often disappointed.

          • Deiseach says:

            Ah, I don’t mind a bit of imaginative reconstruction from historians, Protagoras, it helps bring the scene alive – I’m more likely there to throw my toys out of the pram about obvious personal bias for/against their subject (coughDavidStarkeyandtheTudorscough) – where this does not match up with my completely objective, neutral, factual, and in no way subjectively biased opinion.

            Alas, Creutzer, I will never be hired as a journalist, because I forgot to specify the make and model of car Janie was driving, not to mention the specific shade of paint – the entire story would be ruined if the readers never knew that her 2009 Hyundai Elanta was Stratos Blue, not Vivid Blue! 🙂

            Matt M – I get more exercised about Business English and the neologisms, mangling of the English language, and tendency to turn everything into High!Concept!Buzz!Word!

            Though “slurping” his coffee? Tsk, tsk, Mr Bezos, how low-class and unmannerly! And agreed, the opening/closing paragraphs read like bad pastiches of hard-boiled detective fiction.

        • Matt M says:

          Hah, I’m currently in business school where we do a ton of case studies – I joke with my classmates about how I want to get the job of being the guy who writes the first and last paragraph of every HBS case. Because they’re always the same.

          “Jeff Bezos sipped his Pike’s Place roast while looking out the window on another gray Seattle morning. As he reflected on the history of Amazon and how it grew from a small online book store operating out of his garage into a multi-media empire, he knew that his company faced another key turning point, and that his decision in the upcoming board meeting would affect the lives of himself, his employees, and his shareholders forever.”

          *actual content relevant to business students*

          “As he slurped out the last few drops of coffee, the taxi cab came to a halt. The rain had suddenly stopped and the sun could seen just peaking out behind Mount Rainier. He gathered his thoughts and proceeded to the board room…”

          They’re. All. Exactly. Like. This.

          Personally I’d write one where the CEO is stressed about the meeting so he goes home and does a few lines of coke off the nude body of the Guatemalan nanny.

        • Mountain Girl says:

          Tom Wolfe is an odd choice of villain here, IMHO. His journalism tended to cover the oddball beliefs of his subjects (Merry Pranksters, Lenny Bernstein, college students, etc.). Of course that’s going to require some subject’s-POV retelling.

          A just-the-facts recounting of the Furthur bus’s road trip would be – well, maybe not pointless, but pretty hard to follow.

          If you’re complaining about Wolfe’s INFLUENCE on journalism that shouldn’t use his techniques – of the kind you parody – well, okay, that’s a defensible point of view. I’m a bit of a nihilist when it comes to journalism’s claims to objectivity, so I’d much rather have some entertaining writing like Wolfe’s, or some self-aware and self-critical stuff like Janet Malcolm’s, than just the facts. But that’s a matter of taste.

          • Deiseach says:

            I think Wolfe was well able to do it, and I also think it’s telling that he turned to writing novels.

            The idea that EVERY news story needs to be framed in human-interest terms, and that we can’t or won’t care about it unless it’s presented to us as a story, complete with potted bio of ‘hair colour/eye colour/mood/pets’ of the people involved, sets my teeth on edge.

            We haven’t yet got to the stage where hard news reporting of the “President Obama today announced the signing of the new trade agreement with the EU” kind is festooned with this type of descriptive language, but I wonder is it far off?

            Will the notion of the attention spans and novelty seeking of the general public, plus the slow death of traditional news media, mean that in future we will get the economics pages producing stories like:

            Barack gazed out at the mass of upturned faces waiting breathlessly for his announcement. Although he wore his usual, carefully rehearsed until it was natural, expression of calm authority, inside he was bubbling over with a mixture of excitement and anticipation as well as a touch of nervousness. Steady, now he reminded himself, the voice sounding like that of his soulmate and support, the mother of his two beautiful and talented daughters, the woman who made his fifty-odd years of life on this planet complete. You’re the President. They have to wait for you, not the other way round.

            As ever, the thought of Michelle grounded and centred him. He shuffled his papers, more a nervous tic than a necessity, cleared his throat, and began.

            “Ladies, gentlemen, others, of the Press…”

    • Nicholas says:

      It’s the retelling of a popular fable in American culture using real people’s life events as props in the passion play. I *think* the source is Horatio Alger’s biography, but I can’t be bothered to do the research again.
      It doesn’t really stand out in the states, because it’s one of our universal plots that gets used in everything (With a few brilliant exceptions, it’s the only non-controversial plot in american PPRPGs).

    • Acheman says:

      I once read part of a book which relentlessly sent up these little stories. The couple of pages I read had an account of a guy’s miserable day, with an accompanying exercise to go through the story and rate the guy’s (a) enjoyment and (b) mastery at every point. It was very dry, and dark, and funny. You’ll notice I haven’t mentioned the title of the book, and that’s because I didn’t buy it – a massive error – didn’t remember the title, and haven’t been able to find it since despite hours and hours spent searching the internet. Every so often I go on a little binge search for about half a day. This has been happening for years. That book haunts me.

    • Tom says:

      in the same vein, it’s really striking that none of the patients in these books ever disagree with the therapist. Always the patient describes their woes then the therapist says “here is why they are irrational”, to which the patient replies “ah, yes”. If it was me, I would probably reply something like “no, I’m still correct and here are ten reasons why”.

      The fact that this never happens makes all the stories seem incredibly artificial. No-one I know is happy to let their fundamental view of the world change without at least a token resistance.

      • Mary says:

        For the same reason beneficient stepmother seldom feature in fairy tales — like, ONCE that I know of — it kinda ruins the story. (Leaves out the climax. 0:)

    • Deiseach says:

      Shenpen, I suppose my attitude is a bit like that which Chesterton attributes to Gower about Chaucer:

      One would not say that the graver poets disapprove of cheerfulness in the minor poets; but they mention it.

      Americans seem (or seemed) to be optimistic in a way that’s not really common over here; this idea of infinite perfectibility (which, excuse me dear sirs, but also seems to me to colour this notion of the Singularity and cryonics and what-have-you: all will be well and all will be well and all manner of thing will be well) in human and national affairs – ‘from the log cabin to the White House’ – so that working hard and a new therapy or new idea will make all the difference and you can have your best life now!

      So the peppy, upbeat “Bob had a good life but even that was not enough to make him happy but this was not because he became aware of the ultimate futility and meaningless of existence, no, it was because of bad thinking which simply needed to be sorted out and now Bob is even more successful and happier than ever” style of self-help books grates on me, but that’s not their fault.

      I mean, I recognise that obviously you can’t sell a book on “And here’s how I couldn’t help this patient or things became even worse or there was a minor improvement but they still felt relatively lousy or yeah, therapy is no use because they were in a situation where they had no realistic chance of getting out of”, so you need to include the anecdotes about Bob and Sue and how things got better for them when they used NuMethod.

      But the chirpiness does irritate the nerve-endings when you’re not feeling very sunshiny yourself.

  26. DiscoveredJoys says:

    How many narrative stories invoke the Guru who doesn’t fix ‘the problem’ itself or deliver a straightforward answer but encourages ‘Our Hero’ to find the answers by their own efforts – because it will mean so much more to them?

    If(!) there is any worth in this narrative then any methodology that ‘provides an insight’ and then provides a tool to quantify that (Guru revealed) insight is doing things in reverse order. Which might not work as well.

  27. Deiseach says:

    I asked Nate why his satisfaction rating was so low. He explained that he always got standing ovations, so he routinely timed them. The previous year, the medical students had stood and cheered for more than a minute at the end of his talk. This year, the only stood and cheered for half a minute. Nate felt disappointed and started worrying that he was over the hill.

    I have to wonder, how successful would a therapist or counsellor be considered as, if they treated patients like this in the following way?

    “Get over yourself. You’re asked to give these introductory talks because some poor hoor has to do it, and you’ve been stuck with it each year because you either haven’t realised or haven’t been able to dodge it. The other lecturers are fine and happy letting you do this because it means they’re free to head down the pub instead of babysitting the new intake while you’re stuck in a hall full of bored first years.

    Speaking of which, that standing ovation is not because they’ve been so moved by your inspirational words. They’re first years – they’re on their feet cheering because they’re thinking “Thank Christ he’s finally finished yapping so we can go get something to eat/hit the pubs which are all running half-price drink promotions for freshers’ week”.

    Get over yourself: it’s not that big a deal and you are not the centre of the universe, which means you can actually relax and the world will not stop spinning. Next year, try dodging the speech and let some other eejit give it while you go drinking or gossiping office politics with the rest of the team.”

    I also have to wonder: does Dr Burns realise the message he/she is actually sending out?

    “That high-status career and position you worked your brains out in school and college and afterwards to get? It’s not going to make you happy. In fact, it will make you unhappy. What will make you happy are things like eating an ice cream cone in summer with your family. So forget trying to get high grades, skip going to college and settle for a minimum wage job which will just about permit you to pay the bills but which will let you have time to go for walks in the park and eat ice cream.” 🙂

    • Tracy W says:

      They’re Americans. They don’t go to pubs. At least, not properly. (Only place in the world I’m regarded as an alcoholic.)

      • Deiseach says:

        You’re absolutely correct, Tracy W, I should have specified “coffee shop” 🙂

        Though I’m willing to bet 18-20 year old American first year university students are every bit as interested in going drinking as 18-20 year old first year university Irish students.

        • Vaniver says:

          Though I’m willing to bet 18-20 year old American first year university students are every bit as interested in going drinking as 18-20 year old first year university Irish students.

          I will take that bet. Consider this paper and then please send me all your money at your earliest convenience.

          • Deiseach says:

            Vaniver, that paper tells me Irish young people like drinking, which I knew already 🙂 I need to see a comparable study about American young people to be able to make a comparison. And who mentioned money? I might have been betting I’d say the Angelus every day for your intentions!

            University age is too old. They should be surveying them at Junior Certificate age (which is 15-16 years old) going by the annual stories in the papers about kids celebrating their Junior Cert results by getting passed-out drunk in ‘niteclubs’ and the other venues which cater to the post-exam events. And just to demonstrate that this is not a new problem, back in my day when I made my Confirmation (aged 12), we were also asked to take the Pioneer pledge to refrain from drinking alcohol until we were 18. The reasoning behind asking 12 year olds not to drink being that, by the time we were in secondary school, it’d be too late, we’d have started:

            Juvenile Pioneers are children aged eight to eleven years who, with the consent of their parents, take a pledge of total abstinence from alcoholic drink until an agreed age, typically 18. In addition they agree to wear the pioneer badge and to say the Juvenile pioneer prayer twice daily.

            The notion that American young adults only start drinking when they’re 21 is endlessly amusing to me; I’m pretty sure most of them have tried at least beer well before that, and that at university they are just as interested in getting smashed off their faces as Irish kids.

            Unless you’re trying to tell me Americans can’t hold their drink as well as the Irish? 😀

        • Shenpen says:

          Aren’t they bored by booze by 18-20? I mean do things like a legal drinking age really matter? If teenagers can routinely acquire entirely illegal pot, how hard it is to acquire something that is legal a few years later? It is the easiest simple arbitrage for any guy who had just hit legal age and does not yet earn a proper income… At least here in Budapest it was ridiculously easy to get drunk at 15.

          • Teresa says:

            American college students do like getting drunk. It’s still illegal until they’re 21 here, anyway.

          • Nicholas says:

            Easier, far easier, at least where I live, to get illegal drugs than to get alcohol while underage. Mainly because vendors of alcohol are held to certain standards via random sting, which are designed to make it hard to buy alcohol for minors. Drug dealers obviously have no such compunctions, and will send you your marijuana through the US post.

          • John Schilling says:

            Most under-21 college students will have at least one 21+ friend who will provide them with all the booze and/or beer they can drink. The problem is that they may not be able to enjoy it at any bar, pub, or formal party, because as Nicholas notes the people who run those have too much visibility and too much to lose. This leads to students who have extensive “experience” in drinking under very unhealthy conditions, e.g. consuming an evening’s worth of alcohol in private before going out to party with their friends.

            American colleges have very little in the way of Irish/UK style pub culture, partly as a result of this dynamic. And partly because pub culture was never as big a thing in the US as in the British Isles.

          • onyomi says:

            Drinking age of 21 is one of those obviously bad laws that never gets changed because who wants to run on a platform of “kids should be able to buy alcohol at a younger age.”?

          • Winter Shaker says:

            Drinking age of 21 is one of those obviously bad laws that never gets changed because who wants to run on a platform of “kids should be able to buy alcohol at a younger age.”?

            We are starting to see real progress, in some US states and some other countries on a comparably bad law, cannabis prohibition, with the forces of ‘who wants kids to be able to buy cannabis’ being under real pressure to defend their position. And yet progress on the legal regulation of most other currently-prohibited drugs remains slow.

            Perhaps there is room for a gradualist approach – allowing people between 18 and 21 to buy certain low-strength drinks, like beer and cider at 3%ABV and under – such that they can take part in drinking culture but would need to drink an uncomfortably large volume of fluid in order to get truly paralytic?

            Or then again, perhaps the answer is to plough a lot more resources than we are currently, into research to find a recreational drug that has the same sort of disinhibitory / anxiolytic effects as alcohol with much less of the health risks. David Nutt is the only person I know of trying to make serious progress with such a project.

          • John Schilling says:

            with the forces of ‘who wants kids to be able to buy cannabis’ being under real pressure to defend their position

            I haven’t seen the “no marijuana for kids” crowd been under the slightest pressure to defend their position. Quite the opposite; that position is absolutely unassailable, and at least here in California there’s frequent reference to research (never challenged) that while marjiuana might be OK for adults it does horrible, horrible things to adolescent brains. It is the proponents of legalization who are forced to defend their position by convincing skeptics that decriminalization or legalization will not make it easier for adolescents to obtain marijuana.

            Which, fortunately, is not terribly hard as the legal dispensaries are subject to strict scrutiny and their owners likely to be carted off on federal charges if they sell to kids. If every legal dispensary displaces a black-market dealer who will not discriminate by age, that’s a net “win” on the no-pot-for-kids front. But not a sign that society is ready to tolerate drinking at an earlier age, under any circumstances.

            Or anything else, for that matter. There seems to be an absolutely monotonous trend towards increasing the age at which the rights and privileges of adulthood are granted in the United States. Since the 26th amendment in 1971, has there been any significant instance of a legal right, privilege, or freedom being granted to Americans at a younger age than had previously been the case?

          • Shenpen says:

            @Onyomi: they need to run on that? Can’t they just lie in their election promises? People forget them by the next election anyway.

          • johnnycoconut says:

            @John Schilling’s last comment in this thread:

            Did you mean “monotonic” when you wrote “monotonous”?

            Also, I like your comments here

    • Sarah says:

      As a very achievement-oriented person, this is precisely what made Feeling Good unusable to me. I don’t want to lower my standards and give up on my dreams!

      It turned out my problem wasn’t actually *high* standards, it was *wrong* standards.

      • Mirzhan Irkegulov says:

        As a massive CBT advocate it’s always interesting to read people who are one way or another dissatisfied with CBT, because it gives me new perspective on how human psychology works. And I strongly believe that CBT’s biggest problem is not that it’s incorrect (at least its core ideas are definitely a step in a right direction), but because we as a humanity didn’t figure out a reliable way to present ourselves in such way, as to convey exactly our intent and message.

        2 different people read the same book and make absolutely contradicting conclusion. For example I’m an achievement-oriented person as well, I view myself as striving for excellence (at least in a certain sense) and I’m not satisfied in how everything in the world is broken at all.

        But what I take from Feeling Good is that when I accidentally woke up a few hours later than I planned the day before, scolding yourself for the rest of the day is stupid. It’s much more productive to tell yourself, that it’s alright, you’ve failed in this small regard, shit happens, mistakes happen and they are supposed to happen, so just admit that you can’t be perfect and continue working as if nothing bad happened.

        The least thing I’d expect from Burns is lowering standards and not trying achieve dreams, however audacious. Ditching perfectionism ≠ lowering standards, it’s allowing your strategy to be more effective and flexible. For example, if your goal is to vacuum the carpet, perfectionism would be unrealistically expecting there to not be even a single dust speck, while a better goal would be to clean only to a some, even if high, extent.

        • alaska3636 says:

          This is a very insightful post.

          I share a similar operating philosophy as you (it seems 🙂 ) and I have found that Zen and the Art of Motorcycle Maintenance is a good manual for this kind of benign, value-free trouble-shooting. Phil Jackson, of all people, also elucidates similar principles.

    • Aegeus says:

      Last I checked (and I was a student not two months ago), students don’t give *standing* ovations for “thank god he finished talking.” They give polite, seated applause for however long it takes you to walk off stage. Standing ovations show actual respect – “I liked it so much I’m going to stand up and clap instead of giving a bare minimum of politeness.”

      Especially since he apparently timed it and it went on for a whole minute. Unless the people in your country are a lot more enthusiastic than Americans, that’s quite a long time. Get a clock and try it yourself – do you really applaud boring speakers for a full 60 seconds?

      So I suppose the next question is, how often is a therapist going to give you a “nobody cares” speech and be *correct* about it, and how often are they going to be callously knocking down achievements that you should be proud of?

      • Deiseach says:

        Well, good grief, you lot in America really are as nice and polite (and excessively enthusiastic) as you’re made out to be.

        I feel like the troll living under the bridge in the “Three Billy Goats Gruff” by comparison. Standing ovation? Only if you’re Mozart returned from the dead with the seraphic choirs singing your music, mate! Standing ovation for lecturer giving standard address to first years? No, that’s ‘polite smatter of applause as we wonder can we finally go get something to eat after five hours of various bods talking at us about how wonderful this university is and how special our experience will be and oh yeah this is the first and last time in four years that we’ll ever see them’.

        I think that for people who are very highly wound about “I am the only person in the world who can do this job and it all depends on me!!!!!”, unless they really are the only person in the world who can do this job, then it might help them by pointing out that if they dropped dead in the morning the world would keep on turning, the business or university or organisation would hire a replacement, within about a fortnight it would be pretty much like they were never there as far as organisational life is concerned, so take the self-imposed pressure off themselves, it’s not that hugely huge a deal if some of the time they only hit 85% instead of 110%.

        And really, if you’re “routinely” getting standing ovations, then timing them is excessive – unless you feel they are only pro forma and not really sincere, and it’s been pointed out to me that people don’t give boring speakers spontaneous standing ovations.

        May I ask – are these standing ovations spontaneous, in your experience, or have they become part of what is expected? That where polite applause used to be sufficient, now the cultural expectation is “you must demonstrate woo! yeah! all right! by public exhibitions of enthusiasm”, because everyone knows the implicit bargain here is “The person giving the address will be Inspirational (whether or not they really are) and you in turn will be Enthused (whether or not you really are)”.

        What I am asking is, is it now simply Good Manners to give standing ovations in these situations, so that is why people like Nate time them, as duration is the only means they have of discerning the sincerity of them? “Yes, my speech really was good, since the ovation went on longer than the standard polite thirty-second limit!”

        • Marc Whipple says:

          Yes, yes we really are. Not so much as we once were, but out there in the wild, there’s still a lot of that sentiment in us.

          And no, standing ovations are not and have never been “required” or expected. We’re not that polite. If we get up, it means either you nailed it or you really impressed us in some related way. E.G., Americans would give a standing ovation to a mediocre speech from a certified Hero (Sully Sullenberger, say) or someone who has a huge obstacle to overcome to speak at all a la Helen Keller.

          • Deiseach says:

            Americans would give a standing ovation to a mediocre speech from a certified Hero (Sully Sullenberger, say)

            So it is politeness; we will applaud you simply for turning up, even if the speech is mediocre or trite, because you are the designated Heroic Overcomer of Adversity and we are the designated Inspired By Your Example?


          • Marc Whipple says:

            That’s not politeness, that’s respect, and it has to be earned. We’re still giving it to you for something you did – just not the speech you made. 🙂 If you haven’t earned it, you won’t get a standing ovation or anything beyond a smattering of polite applause unless your speech was ovation-worthy.

            It’s possible there was some of that in the doctor’s welcome-freshmen speech – he’s obviously an accomplished person – but I just have my doubts that enough of them knew enough about him to get him the ovation unless he worked for it.

    • Jiro says:

      Speaking of which, that standing ovation is not because they’ve been so moved by your inspirational words. They’re first years – they’re on their feet cheering because they’re thinking “Thank Christ he’s finally finished yapping so we can go get something to eat/hit the pubs which are all running half-price drink promotions for freshers’ week”.

      Isn’t that implicitly the reason he compares half minute ovations to one minute ovations and is unhappy with half-minute ones? A certain level of ovation indicates that everyone doesn’t really care about his lecture and just wants to leave, a higher level means they actually care.

    • Ghatanathoah says:

      I also have to wonder: does Dr Burns realise the message he/she is actually sending out?

      “That high-status career and position you worked your brains out in school and college and afterwards to get? It’s not going to make you happy. In fact, it will make you unhappy. What will make you happy are things like eating an ice cream cone in summer with your family. So forget trying to get high grades, skip going to college and settle for a minimum wage job which will just about permit you to pay the bills but which will let you have time to go for walks in the park and eat ice cream.”

      I don’t know if he realizes it or not, but it seems like a pretty good message to me.

      When I was little I saw all those movies featuring a parent (usually a dad) with a high-status high-paying high-pressure job that prevented him from enjoying life and spending time with his loved ones. I vowed that I would never, ever be like that when I grew up.

      So far it’s a vow I haven’t had much trouble keeping. I’ve deliberately avoided the kind of jobs that suck up so much of your time. I have lots of stuff to do and little time to do it, I can’t waste it working. I have books to read, SO’s to cuddle, movies to watch, friends to hang out with, etc. Why would I throw that away for a job? All a job is is a way to get enough money to pay for all the really important stuff.

      • Jiro says:

        This may fall under the category of advice that is good for some people, bad for others, and can’t be targeted. There are people who need less work when balancing life and work. There are also people for whom that would be a phenomenally bad idea.

        One wonders if the psychiatrist uses a one size fits all solution or actually targets his advice, and if he would be able to detect someone for whom this would be bad advice and tell him something different.

        • Ruthan says:

          It seems unlikely that someone who had already generated sixty pages worth of credentials, and did not find them happifying, would find more of them happifying.

        • Randy M says:

          I am dubious that the actual messages do much to change our inclinations, but you can put me into the category that could have used more along the lines of “Go do some thing big! Make lots of money!” as I am too accepting of being “just above average” I think in general.

    • Nicholas says:

      Well I’m not sure the data disagrees. It’s at what, 42,000 dollars American that the happiness benefit of wages becomes logarithmic? And maybe it’s just the Introvert in me, but isn’t job prestige a *burden* of important work? I’ll take an italian ice on a lazy Saturday every day of the month over a red carpet event.
      When I meet someone who’s forty with over two million in the bank, I wonder why they keep working at all.

      • Mary says:

        Studies differ on how much money it is. Some have concluded that actually, it’s not a constant level. It varies according to the person, the point at which money stops bringing more happiness.

        • houseboatonstyx says:

          Skirting around cliches, some Monks from Delhi told me that it’s not a symmetrical situation. Depending on where you started, money can remove some things that cause work and worry, leaving you free for real joy, which comes only from your own wire-heading, er, heart. Once free, adding more money can add complication, thus new things to worry about. If you win the lottery, the first million pays your debts, buys a home, etc. But the rest of the money at best buys toys and luxuries that don’t really bring much new happiness, and at worst gets into taxes, choosing accountants, worrying about investments, etc.

      • Tracy W says:

        With interest rates these days, there’s good reasons for that.

        • Who wouldn't want to be anonymous says:

          Well, I think the bigger issue is life style. If you have managed to amass $2m by the time you are in your forties, you are probably used to a multi-hundred thousand dollar budget. However, as a rule if thumb, two mill would only allow you to budget about one hundred thousand a year.

          Low interest rates only compound the problem because taking a big hit to principle up front would lower the long term income prospects from the rule if thumb. And the inclination is to spend big the first couple years while you are young enough to enjoy it.

          If you are somehow acclimated to less than a hundred grand a year (inheritance, maybe?), for shits sake retire already. But otherwise it probably isn’t a good move yet.

          Quality of life issues not withstanding. If, eg, Big Law is killing you it is a totally different issue.

          • ” If you have managed to amass $2m by the time you are in your forties, you are probably used to a multi-hundred thousand dollar budget. ”

            Alternatively, and I think more plausibly, the reason you accumulated that much was that you weren’t spending it. It is, after all, the difference between income and expenditure that provides for accumulation.

          • Who wouldn't want to be Anonymous says:

            You are absolutely correct that the difference between expenditure and income is the key to saving.

            But empirical evidence suggests that most people don’t save a lot. The rate in the US seems to hover around 5%.

            Suppose you are saving $10k a year with arbitrary 9% annual rate of return. (I.e., 5% of a 200k income, 10% of 100k, etc.) My TVM calculator seems to think it would take around 34 years to hit $2m. Not likely to make it while still in your forties.

            If you’re saving $20k a year instead, it would still take almost 27 years. You might be able to squeak that one while still in your forties. But you would be saving an insane 20% of a $100k income. Or much more likely you would be saving a more reasonable percentage of a multi-hundred thousand income.

            And this is before considering (a) taxes, (b) more taxes, and (c) what kind of student loans they took out.

            So I stand by my assertion that they are probably acclimated to a high income lifestyle, or are extremely lucky. (Inheritance, pre-IPO stock options, that sort of thing.)

          • Mary says:

            “But empirical evidence suggests that most people don’t save a lot.”

            But empirical evidence suggests that most people don’t amass $2m by the time they are in their mid-forties.

            Remember that saving rates is an average. There’s a large portion of the public with a negative net worth.

    • Marc Whipple says:

      What you have just described is what I call Schwitzer Therapy, after the brilliant but, alas, fictional therapist who pioneered it.

      (I showed that to a counselling psychologist I know and she about died laughing. She told me later she sent it to all her colleagues and they universally loved it.)

  28. Deiseach says:

    To be positive about Dr Burns’ book, seeing as how I’ve had a good laugh at his expense – it seems like his clients are all high-achievers and have got that way through constant effort. So they’ve been conditioned into thinking, since childhood probably and their first report card:

    (1) I must get the best result possible all the time. Second place and less than 100% aren’t enough [looking at how the US scores grades in class makes me go “Holy crap, I thought the Irish educational system was bad, but you lot are nuts. I couldn’t understand how in an episode of “The Simpsons” 59% was an F and a “fail” on an exam for Bart until I found out how you grade. Irish system]
    (2) Getting perfect scores in everything is achievable by hard work and effort on my part. I am perfectly capable of doing this if I only try hard enough.
    (3) Unless I am absolutely perfect and successful in everything, it is my fault because I did not try hard enough and/or I am lacking in talent, ability or capacity.

    So if, for the first time ever, someone in A Position Of Authority (like a therapist who’s a proper doctor with qualifications and everything) tells them “You’re good enough and it’s not your fault”, then it may indeed be an outside voice telling them that their anxiety is irrational, they are not to blame, they can take their foot off the pedal and ease off a bit and the world will not come to an end, and their little faces will light up and their problems fall away.

    This might also be why it doesn’t work so well on those of us who aren’t high-intellect, high-powered over-achievers; we have already experienced failure and disappointment and we know that certain things are down to us really not having the ability or capacity to overcome things, or being in a position where life is a bit crappy but we can’t really change it so we’re stuck, so our anxiety and depression has some rational roots and simply telling us not to beat ourselves up over it is like telling someone with a broken leg “But you can still use your hands!” Yes, and what good is that to me if I need to walk? CBT is not going to do me much good if the idea is “Change your unrealistic negative assessment of your personality/circumstances/ability to a realistic positive one”, if my assessment is fairly realistic in the first place.

    (Though I am chortling to myself at the helpful translation of joie de vivre, but I probably shouldn’t be – Dr Burns is not expecting that we’re all linguists or studied French in school).

    • Shenpen says:

      Irish grading seems really simple – in Hungary it differs per discipline and per level, college tougher than high school but it really depended on the school as good schools pride themselves on grading harder. However at the end of the day it does not matter because how students view grading depends on how it is graded i.e. when in high school 48% earned a 3 (C) and our teacher warned us in college that would be an 1(F), we valued a barely passed / 2 / E in college more than we valued that 3 (C) in high school. It was a shame in high school to do any worse than a 4 (B) while in college it was you barely passed? You’re good!

    • Nicholas says:

      You’ve basically just described Growth Mindset, the most popular terrible thing in American pop-psychology. People seem torn between accepting that some things are out of their reach and that’s okay, or believing that because anything is out of their reach that is terrible.

      • Marc Whipple says:

        It is not completely negative, far from it. That sense of possibility is one of the things that sets Americans apart from the citizenry of many other nations. “In America poor people see themselves not as downtrodden and oppressed, but as temporarily embarrassed millionaires.”

        The problem is that it’s gotten way out of hand, at much the same time that it has gotten harder to exercise significant social mobility. “Work hard and you can make something of yourself” is a great societal attitude to have. “If you aren’t Michael Jordan, Diddy, or Bill Gates you’re worthless” is not.

    • Randy M says:

      “Holy crap, I thought the Irish educational system was bad, but you lot are nuts. I couldn’t understand how in an episode of “The Simpsons” 59% was an F and a “fail”

      Ideally in this system exams don’t measure everything that is available to be learned in a course, but just the essentials. If you are missing a few percent of the fundamentals, it is okay to advance because you will probably pick them up; if you are not well above half, you should repeat the course before advancing.

      Whether that is how it is used in practice (or how applicable it is when none of it is really essential and I’m just babysitting overgrown children, erm, nevermind) is a different matter.

      • Deiseach says:

        Oh, I’m not saying that in Ireland a D would be a great result; it’s just about scraping a pass and signifies “You better pull your socks up and do some work, sonny”. But at least it is a pass and not a fail. (You will realise how abysmal I am at maths when I tell you I only managed a D in Pass Mathematics for my Leaving Certificate). People are only satisfied with D when it’s “Feck it, I hate this subject/I am useless at this subject anyway, I’m not going to bother/I am incapable of putting in more work at it, so a D is at least evidence I did some work”.

        If the expectation is that A is the only good grade, then either A must be really easy to get, or only a few people can get them (so what about the rest of the class)? Is this more of that growth mindset – work hard enough and you’ll make it? So what happens when you work work work and still don’t get As?

        • Anonymous says:

          This is my problem with the compete-and-blame mindset (the version of the growth mindset without any encouragement, only disappointment). Basically that mindset goes:

          1. Only 10% [or some other very small proportion < 0.1] can achieve [insert goal here; in your case, an A grade].

          2. If you're part of the 90% that didn't make it, it's your fault, and you should have tried harder.

          People who do this are literally setting up 90% of everybody for failure and blaming them for making a choice as if it were completely independent of everybody else whether they're in that 10% or not. Yes, it will get everybody to try harder, to the point of exhaustion and depression and burnout as everybody else does the same. It's a classic war-of-attrition scenario.

          To see an example of this in action, basically look at the Chinese school system, or even just the schooling attitudes of recently-immigrated Chinese parents to North America.

  29. John Sidles says:

    Scott remarks  “The therapists I’ve seen ask patients whether their anxiety might not be rational, ever so tactfully, and the patients say ‘No s**t, Sherlock, of course it isn’t, but just knowing that doesn’t help or make it go away, and I’ve been through this same spiel with like thirty people already. Now shut up and give me my Xanax.'”

    No physician is surprised when bacteria evolve resistance to antibiotics.

    So why should be be surprised, when we see that the behaviors associated to anxiety/depression/addiction are similarly evolving resistance to psychiatric treatments?

    Family members appreciate full well the adaptive mechanisms by which:

    • anxiety protects itself, and
    • depression protects itself, and
    • alcohol protects itself.

    To say nothing of the adaptive mechanisms by which pharmaceutical companies are fending off competition from behavioral therapies.

    When a patient dictates “shut up and give me my Xanax”, is that the patient speaking? Or is it the Xanax speaking?

    Conclusion The behaviors associated to anxiety/depression/addiction adaptively seek new resources to protect and sustain themselves … and both the internet and the pharmaceutical industries are serving-up an extraordinarily rich and ever-increasing smorgasbord of resources that distance patients from behavioral changes.

    • DavidS says:

      This is interesting. It’s not obvious that issues such as depression/anxiety should ‘protect themselves’ in that way – obviously there’s some survival effect in that a depression which actively resists therapy will survive longer, but to expect that sort of evolutionary survival instinct, it would need to propagate too, so you’d have to either assume that things like anxiety are contagious between individuals (and not just the symptoms but the underlying mechanics) or that major mental issues are somehow the survivors of lots of tiny mental issues, which is perhaps more plausible.

    • Scott Alexander says:

      Bacteria are entities that have incentives to evolve self-protective behaviors and enough “intelligence” (in the form of genes that have been optimized for quick evolutionary ability) to do so. I’m not sure it’s correct to think of anxiety or depression this way.

    • Have a theory– I’ve wondered about what the incentive for abuse is, and I’m inclined to think it’s status enforcement.

      It’s amazing how much work some people put into being abusive. Consider internet trolls. Consider parents who (at considerable cost of time and energy for themselves) impose a reign of terror on their children.)

      I think there’s a feedback mechanism, and what motivates abuse is signs of happiness and self-assurance and such in the target. (In the case of internet trolls, I think a lot of the feedback is generated by the troll.)

      In other words, abused people are trained out of being happy, having initiative, and various other traits. Feeling better *brings punishment*, which is a major reason why people who are anxious, depressed, etc. resist things that make them feel better.

      I’m not saying this the whole story– there are people with depression, anxiety, etc. where the cause is purely physical, and I think there’s an aspect of homeostasis where people are just trying to maintain their identities.

      Now that I think about it, identity might be an important piece of what’s going on– another reason for resisting improvements might be fear of not having the resources to sustain them.

      • Deiseach says:

        Some of the cases of abuse I’ve seen in my work, where it’s not because of neglect but because of parent(s) actively working at it, are because the abuser thinks it will bring them some benefit.

        “If my child is categorised as having special needs, either physical or mental, I will be able to demand special concessions/consideration from service providers/get more money” and never mind if it hurts the child. I know “psychopath” is a discredited term, but I have to say, it’s the best term I can think of to use for some people: they absolutely do not care about anyone other than themselves and they have no guilt or hesitation about inculcating a problem where none exists, or making an existing problem worse, in their own child, if it will get them even a minor advantage.

      • houseboatonstyx says:

        I think there’s a feedback mechanism, and what motivates abuse is signs of happiness and self-assurance and such in the target.

        In my milder experience, I would say it triggers a reflex of some sort of negativity that interrupts or punctures a child’s moment of happiness.

        In other words, abused people are trained out of being happy, having initiative, and various other traits. Feeling better *brings punishment*, which is a major reason why people who are anxious, depressed, etc. resist things that make them feel better.

        The parent’s motive is often concern, protectiveness.

        Tl;dr – Carefree = careless.

    • John Sidles says:

      The ecologies within us  Organismic biological entities that have “incentives” to “evolve” as “ecosystems”

      * viruses
      * bacteria
      * lymphocytes
      * tumor cells
      * neuronal connexions

      The evolution within us  The idea that brain mechanisms evolve day-by-day is as contemporary as Pixar’s Inside Out; as academically traditional as Marvin Minsky’s Society of Mind (1986); as ancient as dawn-of-history legends of spirit-possession.

      Clinical pearls

      * viruses:  intermittent/weak antiviral regimens are bad medical practice
      * bacteria:  intermittent/weak antibiotic regimens are bad medical practice
      * lymphocytes:  intermittent/weak steroid regimens are bad medical practice
      * tumor cells:  intermittent/weak chemotherapy/radiation regimens are bad medical practice
      * neuronal connexions:  (unknown?) ………

      The world wonders  There’s a lot we don’t know about the day-by-day evolution of our brain architecture. Perhaps coming decades will witness an increasing medical appreciation that intermittent/weak psychoactive medication regimens are bad medical practice? Ditto for intermittent/weak talk-therapies?

      Conclusion  Future medical best-practices may differ substantially from present best-practices (even if available treatments don’t change much).

  30. Murphy says:

    Perhaps it’s as simple as the possibility that in a mixed population with n potential therapies some portion of the population will react unusually well to any particular one.

    CBT is currently socially popular and has apparently seeped out into the culture to the extent that when my [CBT trained] girlfriend was feeling down and I ran through the kind of approach that I’d internally use with myself she replied with “gah, stop doing CBT on me!” to which I replied:”CBT? what?”

    I’m willing to bet that there are quite a lot of people who react well to many of the older styles even including the “Toughen up you panzy!” style of the 50’s. Some people react really really well to effectively being given a drill sergeant and ordered to get their life in order and to do what’s sensible.

    Back in the day those people wouldn’t have ended up in front of a therapist because they would get exactly what they needed from the culture around them.

    In a a world where everyone is receiving low level CBT and internalizing it the people who react really well to CBT approaches are going to end up not needing help while people who don’t are going to be the ones sitting in front of a therapist.

    Indeed to continue your analogy, some patients react really well to lithium treatment, if there really was lithium in the water supply you’re likely only going to meet patients who aren’t helped by lithium so using it as a first line treatment isn’t going to be much help.

  31. David Moss says:

    These two sets of cases (some smart competent people responding extremely well to CBT seemingly making them realise that their anxiety/depression was irrational and lots and lots of people going “No shit sherlock, of course it’s irrational) seem easily compatible if CBT only succeeds in producing these great changes in thought infrequently or if some cases of anxiety/depression aren’t contingent on a simple single irrational view of something, but some are.

  32. chaosmage says:

    I think you’re wrong about people not being already better.

    We don’t have good data on the mental health of the undiagnosed majority in the 1950s or 1900s, let alone before, but there are lots of reasons to think public mental health is getting better overall. You mentioned changes in child care, and you always talk about lead; both of these are historical changes with profound implications for mental health that went the right way.

    The decline in wars and violent crime adds a decline in PTSD, which leads to a decline of all sorts of pathological behavioral patterns inherited from affected parents. The decline in domestic violence is partly that. Mobbing in schools is down massively. Alcoholism is going down, by a lot if you compare the time of the Industrial Revolution. Lots of illnesses that we know cause psychiatric comorbidities, especially those with chronic pain, have become much easier to manage. So unsurprisingly, suicide is declining too.

    Depression is being diagnosed so much more readily any possible increase in its actual prevalence is impossible to assert with any confidence.

    I don’t deny some problems do seem to be increasing. ADHD seems to be going up – maybe that’s just what you get when you stop punishing your children with beatings and denied food. Autism might actually be going up, not just being overdiagnosed. And I do find it plausible that social isolation, which has been going up, has bad effects on mental health for most people.

    But overall, I really don’t think you can say people aren’t already getting better. Meaning you can’t use it as evidence against your CBT in the water supply idea.

    Personally I’d say the decline in religion might indicate a decline in subclinical psychosis, but of course I’m being snarky here.

    • Nicholas says:

      Likely balanced by the fact that in pretty much every earlier generation your priest would have been your front line therapist and you only would have sought a professional if that didn’t work.

    • Anonymous says:

      >The decline in wars and violent crime adds a decline in PTSD

      I thought PTSD rates for soldiers were higher than the past? (I may be confusing an increase in PTSD attention/diagnosis with an increase in PTSD.)

      >ADHD seems to be going up – maybe that’s just what you get when you stop punishing your children with beatings and denied food.

      ADHD is what you get when work becomes increasingly focused on maintaining attention on trivial tasks for long periods of time. ADHD is my favorite example of a “fake” condition — the brain state itself isn’t intrinsically bad, and wouldn’t even be recognized as a disorder centuries ago. It’s only a “disorder” in the sense that daily life has become increasingly hostile to such behaviors.

  33. Sarah says:

    Speaking personally —

    Just the other day I was looking through old emails I’d written, and I was surprised to realize that five years ago I had *literally believed* my badbrains. I was explaining patiently to my friend why it would be wrong for me ever to make a request of another person or to take credit for any of my accomplishments, and why I was a very bad person. These things weren’t flagged as “irrational thoughts,” they were just things I thought were true. People had to tell me “actually, no, that’s not true.”

    I still have mood problems, though, and I suspect that part of the issue is that recognizing “my thoughts are irrational” is only a small part of the battle. It’s easy to say “when I think ‘I am worthless’, that’s an anxiety symptom.” It is significantly harder to say “I am worthy.” And it’s harder still to say it regularly enough that you internalize it.

    In a way, seeing CBT stuff in pop culture inoculates people, I think. People will get as far as noticing “this negative thought is an anxiety symptom”, but not as far as *actually reversing it*. When people hadn’t heard of CBT, they first got the “this negative thought is irrational” message in a context when they were actively working on their problems, so they followed through with the ‘hard’ step of actually reversing the thought. Now, people run into the revelation that the ‘inner critic’ is wrong just by browsing facebook, when they’re *not* actively trying to fight their anxiety problems, so the revelation loses its force.

    • Sonata Green says:

      This makes me wonder if it might be a good idea to actively suppress CBT-ish ideas in pop culture, so that CBT proper can hit in full force, like a mystery cult initiation.

      • David Moss says:

        The anecdote as a whole makes me think we would just benefit from *more* CBT, in the culture at large and applied directly. The idea that background CBT innoculates you seems entirely speculative, whereas in the actual case described it seems like the problem was simply that one hadn’t yet been brought to recognise one’s views as irrational: hence, more CBT needed.

        • FullMetaRationalist says:

          Maybe we can start celebrating a big coming of age ritual about CBT. Like a quinceañera.

    • Sniffnoy says:

      These things weren’t flagged as “irrational thoughts,” they were just things I thought were true. People had to tell me “actually, no, that’s not true.”

      Also even if you recognize that something is off, social validation helps quite a bit! (As does having somebody actually address your arguments for your irrational thoughts.)

    • Jimmy says:


      When I talk people out of “irrational” fears/whatnot, typically one of the first things I have to do is just about the opposite: “have you ever considered that maybe your fear is *rational*?”.

      That’s not to say that crippling fear is the *best* way to respond, of course, but when your default response is “it’s just irrational”, then it’s hard to actually make the decision about whether the fear is rational or not, since you’re not in a mood to listen to the other side of the argument.

      In my experience, it’s almost never one sided. An “irrational” fear of needles turns into “hm… okay, I guess I *shouldn’t* be sticking needles into my arm willy nilly… but I guess I can make an exception for the doctor”. An “irrational” fear of sharks turns into “well, I guess I *don’t* know much about when its safe and when its not, and if I just stopped being afraid altogether, I might do something dumb like go swimming when great whites are around, but I know I can go swimming at my local beach tomorrow so I’m gonna do that”. Neither of them were comfortable dropping the fear until the benefit was made explicit and dealt with (though that can work too if you bring awareness to *that* question while being fully open to it going either way: “is it worth dropping this without knowing what I get out of it?”)

  34. QDSH says:

    In my own therapy sessions, what seems to be the active ingredient is that people stop and look at their thoughts and feelings that are happing right in that moment. Not just talk about them and judge them (as irrational or anything else). No really stop and really look. Find the source of the unhelpful impulse, see what it wants, and focus on it so much you become able to hold it rather than let it go its usual course into something unhelpful. Because when you hold it you can find a new place for it to go.

  35. My Story says:

    Let’s suppose that, as suggested by Jaak Panksepp’s research, you’ve got different circuits in your brain that correspond to different emotions. And let’s suppose that using any given emotion tends to sort of wear a groove in that part of the brain, so by default you sort of feel the way you’ve been feeling lately, and the longer you’ve been feeling that way, the stronger the tendency for you to feel that way is.

    There’s not necessarily always a logical reason your brain feels a certain way. Sometimes a chance event will knock you in to a new groove, like having a certain thought, meeting a certain person, etc. etc.

    According to this story, CBT worked by giving people a bunch of insights and temporarily knocking them in to a new groove (the “seeking” or “play” groove of Panksepp’s, say). Nowadays the insights of CBT aren’t forthcoming. But you could still get nearly as good an effect by knocking yourself in to a new groove using some other method: smoke marijuana for insights, talk to a stimulating friend, travel to a new place, rearrange your house, etc. etc. And just don’t think too hard about whatever groove you are trying to get out of. By default your strategies for getting out of that groove are going to be the kind of strategies you come up with while you are in that groove, so you tend to just dig yourself deeper (since grooves are self-perpetuating). Instead of worrying about how to stop worrying, step away for a minute and have some fun. You can always get back to worrying about your worrying later.

    youtube video

  36. anodognosic says:

    Which brings me to my favorite pet insight of late:


  37. dlr says:

    Try drawing the trend line without the first data point or two. I bet that will eliminate a lot of the regression to the mean. You may not have ‘declining effectiveness’. You may have ‘publication bias’. The first data point or two should be thrown out because of publication bias: if a radical new idea is tried and it’s effect size is zero, it won’t get published. So, the first study is ALWAYS positive. Or rather, the first study that gets published is always positive. And probably performed by a true believer. That something DOESN’T work isn’t news until there are a fair number of people who think that it does.

    And, of course, publication bias works both ways. By 2010, it’s news that it DOESN’T work, or doesn’t work anywhere near as well as advertised. A lot of the people who are publishing the studies are debunkers, not true believers. Practitioners whose results are in line with expected results aren’t motivated to do a study to show ‘yes, look, this works just as well as everyone says it does!!!’

    • Douglas Knight says:

      Eyeballing it, I say no.

      Eliminating the first two points (both 1977) reduces the (population-weighted) coefficient by 9%. Even arbitrarily eliminating the two highest points (1977,1986) only reduces it by 20%. (Unweighted, eliminating the first two reduces by 6% and eliminating the two highest 23%.)

      Too many choices. Just stick with loess. It falls for 20 years and then is steady for another 20 years. csv

  38. stillnotking says:

    My theory is that almost all the work of therapy is done by simply getting the patient to consciously pay attention to his problems. One of my Zen teachers used to say “Your negative voices just want to be heard”; the entire point of mindfulness meditation is to attenuate subjective attachment to emotions by noticing them. Similarly, the main benefit of having a budget is to be aware of what you’re spending money on. What you do with that information, or how surprising/interesting/insightful it seems to you, is of secondary concern.

    • Shenpen says:

      Or calorie counting. It is not like 4000 kcal a day does not make one fat when it is counted, the point is more like at around 1800 kcal people feel ashamed to open another beer.

  39. Shenpen says:

    >Cognitive-behavioral ideas, like perfectionism, excessive self-blame, conditional versus unconditional self-respect, deep breathing, goal-setting, et cetera have become basic parts of popular culture.

    For a subset of people that apparently includes nobody I know. I find this perfection / satisfaction worksheet novel, interesting, will try it, will recommend to friends. For reference, it never even occured to me to watch Inside Out before EY recommended it. (Me watching Pixar? I wouldn’t even show my child Pixars, the older Disneys were so much more artistic.)

    >Cognitive-behavioral ideas, like perfectionism, excessive self-blame, conditional versus unconditional self-respect, deep breathing, goal-setting, et cetera have become basic parts of popular culture. The whole self-esteem movement isn’t exactly cognitive-behavioral, but it’s certainly allied, and it certainly represents a shift to a style of thinking about the self and about psychology in a way that’s much more fertile for cognitive-behavioral ideas.

    But that is the point. The whole self-esteem movement is something nobody serious really believes because you might then as well join Fat Acceptance, point at your double chin and yell “I am beautiful!” It is something the shallow, uncritical and narcissistic do. (For reference: it goes without saying I hate my fat face and I would not want to change that hate: why should I want to believe something false, such as fat is handsome?)

    I am not saying hating yourself makes you automatically more high-brow and classy, but, well, shucks, it does. People pretty much automatically gain more respect and acceptance in the eyes of the serious if they recognize and dislike their own faults. Perfectionism is a lie everybody gives in job interviews. Self-blame and conditional self-respect is a basic common way to signal you are not lazy and happy with mediocrity.

    I don’t know where exactly to draw the line but the people I know and hang out with don’t do pop-CBT on themselves at all, if anything the opposite. If they would meet someone from the self-esteem movement their reaction would be an incredulous laugh and mocking.

    • Nick T says:

      I am not saying hating yourself makes you automatically more high-brow and classy, but, well, shucks, it does. People pretty much automatically gain more respect and acceptance in the eyes of the serious if they recognize and dislike their own faults.

      Equating these things seems like a serious mistake, and like a lot of the reason that excessively anti-self-critical philosophies (assuming for the sake of argument that those are bad) exist. (“Hating yourself” makes me think of things like: not having a sense of scale about your faults, not recognizing your virtues, obsessing over your faults and having useless compulsive thoughts about them, thinking that you can’t change, incorrectly expecting others to hate you on net.)

    • Doug S. says:

      (Me watching Pixar? I wouldn’t even show my child Pixars, the older Disneys were so much more artistic.)

      But the writing is way better.

    • Randy M says:

      “The whole self-esteem movement is something nobody serious really believes”

      hmmm…. true to some level of serious I suppose, but it is nonetheless dogma, at least in terms of pop-culture (and establishment) child-rearing and educational advice. If that poor-performing kid only knew he was worth the effort, he would get top marks; if that bully only knew deep down how special she was, she would befriend the new student, and so it is incombent on parents, teachers, educators, social workers et al to make sure that they are at all times as affirming as possible.
      For example, teachers using red ink to mark papers is frowned upon because it’ll make student feel bad about their errors. Not making that up.

      For “grown-ups” it might be a different story, I know self-help books and therapy are popular.

  40. Could it be that CBT is “in the water supply,” has succeeded in making us on average happier and less anxious but as we compare our emotional state to that of the (moving) average we don’t perceive ourselves to be happier and less anxious?

  41. Ornithopter says:

    I too am a university professor who just today fixed a plumbing problem with my own hands and feel very satisfied about it. And I, too, realize that I am not at all skillful at this sort of thing. Why does this feel so good?

    • anodognosic says:

      Not a professor, but of a profession that’s similar enough in the right ways.

      My take is that it’s two things: 1. a physical, concrete connection to the work and 2. clearly verifiable criteria for success.

      • Parker says:

        I really thought you were going to say something about both professors and plumbers having to deal with little shits.

      • Marc Whipple says:

        Both important. To this I would add that when you are good at something, nothing less than perfection will impress or inspire. When you aren’t good at something, and you have no reason to expect yourself to be good at something, the Waltzing Bear effect kicks in, and you’re happy and gratified to have gotten it to work at all.

        For those of us who expect ourselves to be good at everything, this makes the world a bit bleak. Not only are we not good at everything – no one is – and thus are doomed to disappointment, when we do accomplish something, it’s hard to take any pride or pleasure in it.

    • Deiseach says:

      Because it’s a small (depending on the job), physical, concrete, positive achievement. Before, that tap was dripping; now, it’s not.

      I myself fixed it with my own hands! I am a successfully functioning adult who can look after myself! I need not be dependent on the skills of others! And as long as the tap is fixed and not dripping, nobody is going to critique my plumbing or grade me on it or peg my pay to it (as I’m not doing this for a living) and I won’t have to sit through a performance review on it etc.

      And it’s a small practical skill you can teach your kids e.g. my father taught me how to wire a plug, I can change plugs if I need to now, if I had kids I could teach them the same: it is an accomplishment of life that affects our physical well-being and comfort (if I couldn’t wire a plug then when the fuse blew on the kettle or the toaster or the washing machine, I’d be inconvenienced).

      It is very satisfying when you are able to complete successfully a task outside your general area(s) of competence, something that’s not your ‘day job’ and that you haven’t been trained to do professionally. So for people who work in clerical/academic/using your brain professions, doing manual labour gives that virtuous glow of achievement.

      • It’s also linked to the idea that a wide range of competence is admirable.

        “A human being should be able to change a diaper, plan an invasion, butcher a hog, conn a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, die gallantly. Specialization is for insects.” (Robert Heinlein)

        You don’t have to do all of those things at an expert level.

        • Anonymous says:

          I’m somewhat torn on this. To what extent do you think that specialization is inherently good, versus having a wide range of skills being inherently good? The advantages of the latter are obvious. But the former means that every job gets done by someone who is a master of that kind of work, someone who by spending all their time on that kind of problem, can do it better than anyone else (other than other people who have specialized in it).

          You could imagine a future in which every single human can do only one thing, and is totally reliant on trade for everything else. A world of no amateurs, no DIY. Is this a better world? A more peaceful one, maybe? Interdependence between countries certainly seems to have made the world a more peaceful place. A world in which every country is attempting to be an autarky is a dangerous one, because when you’re independent, there is no point in trade, other countries are just wasting resources you could better use yourself. Since specialization has such obvious economic benefits on a geopolitical scale, how far do you think it can be taken before these benefits no longer outweigh the disadvantages?

          I will add that I am not happy about this line of thought. It’s one of those disturbing ideas that I hope isn’t true but can’t dislodge from my mind. Can you offer me some convincing reason why we wouldn’t all be better off as totally specialized individuals, utterly dependent on others for every need outside of the single skill we each possess – or if not that far then much more specialized than we are today? Is anyone attempting to learn a wide range of skills a dangerous maverick that needs to be stopped in order to secure peaceful interdependence?

          • Jiro says:

            For the same reason that a world in which everyone is independent is dangerous, your enemies benefit from you becoming dependent. So becoming dependent is like unilateral disarmament.

            (Also, becoming too dependent can be dangerous too if you are still independent with respect to violence–if your life depends on something that someone has, you may be willing to use force to take it.)

          • Anonymous says:

            @Jiro: I specified interdependence, not just you becoming dependent on someone else while they are not dependent on you.

            Incidentally, your name is shared by a guy who is a model of the kind of extreme specialization I had in mind when I wrote that post:


          • I find it interesting that, as an economist, I regard specialization as a good thing, for the reasons you mention, and yet at the same time am moved by the Heinlein quote. I think the reason I am moved has to do not with the best way of getting the things done I want done but with something more like what sort of person I want to be.

            At only a slight tangent… . One of my hobbies, for the past forty some years, has been the Society for Creative Anachronism, a group that does historical recreation, mostly medieval and renaissance, for fun. In the early years, anything you wanted–clothing, shoes, jewelry, armor—for the hobby you pretty much had to make for yourself or get a friend to make for you. Nowadays, if you go to the Pennsic War, the SCA’s big annual event (ten thousand plus people—we’re on our way there at the moment) with enough cash, you can get yourself better equipped than any of us were then without making anything yourself.

            That means that people can do a better job of medieval recreation. It also means that the specialists can carry their arts to a higher level than we could as generalists. On the other hand, in the old days it was a way of getting people to do and learn interesting things—because they had to in order to accomplish what they wanted to. So the change strikes me as both good and bad.

          • CJB says:

            My first question is- is this even remotely likely?

            It’d require a fundamental shift in what humans are, for one thing. There are cases of people who specialize obsessively about one skill, to the detriment of all others- but that doesn’t make them happier, typically (The examples that come to mind are artists and composers, primarily)

            I suspect even Yo Yo Ma does other things for fun besides play the cello, for example.

            Further, most jobs aren’t tending towards “master craftsman with expertise in one specific area”. Consider, for example, one of the most rapidly growing career paths- IT support. A jack of all trades who can futz around in a number of different protocols, systems, etc, is, it seems to me, better off and more useful for a job like that that the guy who knows C++ better than anyone.

            And a lot of jobs top out rather quickly- I’m pretty sure that the range between the best avacado farmer god ever made and a pretty good avacado farmer is fairly limited.

            So I think we’ll continue as we are, barring some sort of Singularity. Most people have an area of focus with a wide band of knowledge, some people just have a wide band of knowledge, and some people have intensely focused specialties.

            Didn’t the soviets try something like this? Assigning people one job to focus on? IIRC, part of the problems they had on subs was that the entire crew was so overspecialized, lacking in any cross training, and worked so hard that it greatly decreased their efficiency.

          • Shenpen says:

            @David Friedman

            Specialization is obviously for safe and predictable environments like Adam Smith’s London smith who makes only nails as a big city will surely always need a lot of them. Heinlein was writing about adventure i.e. the opposite.

            Specialization requires exchange means it requires trust. Also exchanges are far too easy to tax. This why we in countries like Hungary do not specialize and do a lot DIY, because we don’t trust a contractor not screw us over for painting our house and if we pay him under the table we could get busted for tax evasion but when investing time not money, DIY then not. This is also why we are fricking poor.

            Finally, specialization kills fun. Anna the accountant goes home after work and relaxes by watering her plants. Bob the plant shop worker who watered plants for 8 hours a day would hate to do it again, maybe he relaxes by playing a videogame with accounting aspects as well like running a corp in EVE online. Both feel the difference between work and play is doing something else. Variety is what differentiates work you don’t like to do from play you like.

            Ideal but unethical setup: I would be a Reneissance Man doing many different things, all financed by my serfs who specialize. There is a reason that from Aristotle to the Reneissance you need financial indepence to do interesting stuff which reduced to living someone else’s labor. The laborers specialized, Aristotle didn’t. Replace serfs with robots for better ethics.

  42. Adam says:

    So I’m actually studying to become a therapist. CBT is not my favorite counseling theory. It’s a really popular theory but it doesn’t fit my understanding of how humans work.

    One of the frustrating parts of counseling is the vast number of theories there are. Psychodynamic, Object-relations, Gestalt, REBT, Behavioral, CBT, DBT, ACT, Existential, Interpersonal, Solutions Focused, Person Centered, and on, and on, and on. All of these are unique and distinctive theories that have all been “scientifically proven” to be effective and equally effective to all the others. Some of these theories are contradictory to other theories so how are they equally effective?

    I don’t have access to the study at the moment (its at home), but research has been done to show that 40% of therapy success is due to client factors (motivation, social support), 40% is due to common factors (empathy, therapeutic alliance), 5% to environmental factors (soft lighting, quiet room), and 15% due to expertise of therapist and technique used. This kind of information strongly suggests that CBT or any other technique just isn’t all that important.

    The real point of therapy is not to fix people. Therapy is not about applying the correct technique to the correct problem. Therapists who do this are bad therapists. Therapy is about providing an empathic space for people to work out their own solutions to their own problems.

    On some level this sounds like therapists are just professional nice people. That’s not entirely untrue. I sometimes think of therapy as emotional prostitution. For a fee, a person will listen to you, validate you, and encourage you while you try to make change in your life. This does work. When people are allowed to simply voice the things that are bothering them, they get better. CBT calls this an insight into wrong thinking but in reality it has more to do with being validated in vulnerability. I think most people recognize their weird thoughts are wrong. I also think a lot of people try to not pay attention to it because it bothers them or scares them. Therapy allows people to actually talk about it and process it so it stops hanging over them.

    However, this stuff isn’t all that different from what a good friend would do for you, just professionalized and mildly regulated. On one hand, it’s absurd that you would pay someone to be your friend for a few weeks. On the other hand, for people whose friends are failing at doing this, it’s good to have an option to get that. I also, strongly believe that our social connections are breaking down. Therapy is becoming more important because friendships are becoming less important / harder.

    Further reading in this area can come from:
    Brene Brown – shame researcher in Houston Texas.
    John Cacioppo – loneliness researcher in Chicago.
    John Arden – neuropsychology researcher in San Francisco.

    • LTP says:

      “I also, strongly believe that our social connections are breaking down. ”

      I kinda agree with this. How often do people say “your friend/romantic partner is not your therapist” as if you should only spend time with your friends and partners when you’re not having issues.

      ETA: On the other hand, maybe you’re idealizing that past a bit? A lot of the social connections in the past were pretty shallow, arbitrary, and weren’t non-judgmental havens of emotional support but actually judgmental and enforcing of conformity.

    • Deiseach says:

      To be fair to therapy and therapists, while I agree that there are so many competing theories and practices out there and many of them are mutually contradictory, it’s not simply about having someone who will listen to you; it’s giving you a tool or method once you’ve identified the problem.

      Most people are stuck: I know what’s wrong, I’ve tried doing this or that, it hasn’t worked, what do I do now? Giving them “Have you tried this?” or “That method is useful” is like handing them “You’ve been using the wrong screwdriver, you need one with a Phillips head” 🙂

    • Sigh says:

      The real point of therapy is not to fix people. Therapy is not about applying the correct technique to the correct problem. Therapists who do this are bad therapists. Therapy is about providing an empathic space for people to work out their own solutions to their own problems.

      On some level this sounds like therapists are just professional nice people. That’s not entirely untrue. I sometimes think of therapy as emotional prostitution. For a fee, a person will listen to you, validate you, and encourage you while you try to make change in your life.

      As a patient, I disagree with this on every point. I hope this attitude isn’t common, though if it is, that would explain a lot. A “professional nice person” who listens to me and validates me and encourages me while taking my money is a very bad therapist, since the whole point of therapy is to fix people, not to coddle them, and a good therapist would apply the correct technique to the correct problem to achieve this goal.

      • Adam says:

        The thing is, that’s not possible. It’s kind of like learning. A good teacher recognizes that they can’t actually teach you. You are responsible for the learning, the teacher can only facilitate your learning. A therapist can not solve your problems, you are responsible for solving your problems. The therapist can facilitate your growth and provide you with information, but ultimately you have to own that growth and do it yourself.

        The actual technique used in counseling is largely irrelevant. The measured effectiveness of any technique is incredibly low. It is the therapeutic alliance and the client’s contributing factors that determine the success of therapy, not the technique or theory used.

  43. TMK says:

    >“if you don’t like hokey patronizing things, CBT may not be for you.”

    I had the same feeling people mentioned had (No shit sherlock). But it still is not hopeless, the way is through patronizing oneself.

    By which i mean: I know my emotions are not rational, at least anymore, but i am going to do all that behavioral stuff, and the dude called therapist here is for me to use as a source of tips and tricks that i might or might not use. A servant.

    • Mirzhan Irkegulov says:

      Hey, that’s cool! That’s exactly the CBT approach at things that one doesn’t like. For example, I quite often read something with an knee-jerk reaction “this guy is bullshitting me, it’s not gonna work”. And it takes me some time and mental effort to realize I’m just rationalizing away out of fear or disagreement. So to save face I think to myself: “Who cares who this guy is and what his agenda is. If there’s some grain of truth in his writing, I wanna know it. And I don’t give 2 shits what this guy or anyone else think, and I don’t even have to identify with that guy, I’m gonna use him for my own benefit”.

      I often think that the reason people don’t want to read CBT books, or self-help books in general, even if they actually work, is because it contradicts their identity. The thought that goes thru their mind is something like: “I’m a scientifically-minded person, I respect myself highly because I’m such a skeptic and rationalist, I won’t read this pseudo-scientific mystical shit, because I’m not a person who reads this shit, I’ll leave it to New Age idiots”. I may be projecting, but that’s what often happened in my mind, when I was younger, I thought: “Pff, I’m not a person, who reads X”.

      • TMK says:

        Yes, exactly this. I didnt want to say that negative reaction (antipathy?) towards CBT is rationalization caused by fear of change, because that would only strenghten that fear, but since you said it, yeah.

        I have the same reaction, to be honest. I guess thats why i had to come up with that solution. (not that i put it to work myself, lol)

  44. TMK says:

    >It could be fairly asked: then why isn’t everybody already better? Depression seems to be increasing, though there’s a lot of argument about exactly how much; that doesn’t sound like what would happen if everyone were automatically getting a background level of therapy.

    My wild guess: Depression is not increasing. Anxiety is, and long-term anxiety is similar, if not causes depression. And we live in a much more unpredictable world compared to the past.

    • Marc Whipple says:

      The world we live in is actually much more predictable than almost all human societies have dared to dream. The problem is that we have lost our sense of optimism in that we have fewer and fewer things to be optimistic about. What we had in the past (religion, belief in various kinds of progress, etc.) we are now told is actively bad and its comfort has been negated.

      Since we are constantly being screamed at about how much everything sucks and is getting worse (which isn’t a new thing, but now we have the Internet to make sure we never ever get away from it) and have nothing offset that with, I agree that anxiety should reasonably be expected to be on the increase.

      • TMK says:

        Predictable? Not only we are getting overwhelmed with information, including information about threats, we also live in much more economically volatile world. And economic security and predictability is very important, thats the reason communism was/is generally fondly remembered by (east) Europeans.

        • Marc Whipple says:

          On a day-to-day, normal experience basis, the world is more predictable than it ever has been. We are constantly told that it is not, and likewise that it is much more dangerous than it ever has been (also not true.) Those are different things.

          • Creutzer says:

            Well, was spontaneous job-loss such a ubiquitous phenomenon in the past?

          • Matt M says:

            Depends. Does being eaten by a lion count as losing your job?

          • Matt M says:

            Also – no, spontaneous job loss was not a thing in the past – because for about 95% of the population, having a “job” was not a thing. Your “job” was “subsistence farmer,” and it consisted of raising as much of the locally popular crops as you could to survive. Having a sufficiently developed division of labor such that a majority of the population could specialize to a degree greater than “produce enough food to feed their own family” is a relatively modern phenomenon.

          • Creutzer says:

            When people talk about life in present times being more unpredictable than in the past, the point of comparison they have in mind is hardly the distant times when being eaten by a lion was still an issue…

          • TMK says:

            > the world is more predictable than it ever has been. We are constantly told that it is no

            Perception is all that matters (in this case). Obviously.

          • Marc Whipple says:

            TMK: Yep. Not disputing that the perception is the problem. However, obfuscating it by purposefully or inadvertently implying that the perception is accurate makes the problem harder to address.

    • “And we live in a much more unpredictable world compared to the past.”

      I don’t think I agree. Randomly changing weather makes the world much more unpredictable if you don’t have insulation, heating, and cooling. Going back further, random crop failures used to mean famine—now they might mean that the price of your favorite variety of something goes up. Back when measles was a lethal disease, life was quite a lot less predictable.

      It’s true that people nowadays enjoy fantasies of global warming wiping out human civilization if not the human race—but in the old days there were more conventional religious movements with a similar message. And for a considerable part of my life there was the very real possibility of a full scale thermonuclear war, which might have come close.

      • Who wouldn't want to be Anonymous says:

        And depending what kind of time horizon into the past we are talking about, there was the very real and constant threat of an army stealing all your food so you starve to death, or raping/murdering you on the spot if you resist (or just raping/murdering you for the hell of it) foraging off of your land.

      • TMK says:

        Unexpected famine happens once per year, tops. Nowadays, every day you go out of your house you encounter multi-quintal bullets that can smear you on the pavement if you are uncautious.

        I half-jest, obviously, but i think you are wrong.

  45. Mirzhan Irkegulov says:

    I wanna make a few points, and as CBT dragged me out of an extreme misery, I’m naturally gonna be biased. Also I’m not a therapist and my journey to superhumanship through CBT is far from finished, so take everything with grain of salt, and if it reads like I know more than Scott, remember that I’m just a random Internet guy.

    1. The essense of CBT is a so-called “cognitive model”: thoughts (cognitions) influence emotions and behaviors — first a thought crosses your mind, then you feel and act certain way. Cognitions in this context include beliefs, attitudes, assumptions, rules etc. Different cognitions evoke different emotions. E.g. feelings of anger stem from the belief that other people or the world itself is “unfair” to you: if you believe that the car in front of you impertinently just cut you in line, you will feel angry, to an extent proportional to how much you believe the whole situation is unfair and how much “this guy is being a jerk” to you. Emotions and behaviors however reinforce cognitions back, so if you use CBT to overcome procrastination-inducing thoughts but continue procrastinating, the thoughts will going to reappear in your mind soon.

    CBT practice looks like this. Something made you feel bad (depressed, panicked, insecure, insulted, betrayed, etc) or act in an irrational way (binge drinking, arguing, procrastinating, etc). You sit down and try to understand, what thoughts and beliefs are going through your mind right now. As you try to fish out the relevant thoughts, in whatever form, you write them down. Then you try to classify each of the thoughts as an example of one or few of 10 cognitive distortions. After that you come up with rational (not just positive even if untrue) explanations why the thought might be incorrect, meaningless, or at least imprecise. You continue this process until you run out of arguments. This is what therapists mean by “homework” and you are supposed to do this every day for weeks.

    Sometimes you can’t pinpoint a cognitive distortion in a thought and honestly believe the thought is rational and justified. Sometimes your rational explanations are not 100% convincing, only 50%. It’s OK and it’s part of the process.

    2. I agree with Kaj Sotala, the descriptions don’t look like patients were given a simple insight and they were suddenly cured. Instead they were going through the motions I described above — meticulously rebutting all your passing thoughts and deeply entrenched beliefs. Nate had to prove himself the correctness of new rational beliefs with behavioral experiments (giving lectures, plumbing), Walter had to go back and forth via the role-playing method. If cognitive model is correct (and I believe it largely is), then the only way to overcome depression, anxiety, insecurities, and many other forms of akrasia is to convince yourself through reason into a correct and justified belief, instead of a distorted one that was there before, the same way you convince yourself that, yeah, relativity theory is correct. Cognitive part of CBT is persuading yourself using logic and rationality, behavioral part is proving correctness of something by doing it in practice.

    I repeat, CBT is not just about telling a patient they are being irrational. It’s pointing out exactly what belief they hold is irrational, exactly how it is irrational, and convincing them of a refutation through reasoning and argument until they finally believe it as if they always believed it. This is called cognitive restructuring.

    3. Some beliefs and attitudes are so deeply ingrained, so integrally part of the person’s self-identity and everyday behavior, that they consider these beliefs and attitudes as something that goes without saying. Sometimes they don’t even realize they believe that, because they never experienced how it is to believe otherwise. Judith Beck calls it “core beliefs” and while they are still cognitions, when they are invoked, they flash through the mind so quickly, they are practically part of System 1. And that’s why to really restructure you as a person, you have to diligently do homework, until this System 1 belief is fully replaced by another one through constant reinforcement.

    4. I predict CBT effectiveness to correlate heavily with person’s intelligence. Many (not all) of CBT ideas are watered down insights from LessWrong. E.g. “labeling” is wrong because words like “loser” are observationally meaningless (see A Human’s Guide to Words); “perfectionism” is wrong because what matters is not how much you conform to your arbitrary ideal of a person, but how much you optimize your utility in any given circumstance; “overgeneralization” is admitting that availability heuristic makes you biased, so instead of thinking that X always happens, you start to come up with examples where X didn’t happen. CBT is to some extent applying LW-style epistemology to everyday beliefs about your abilities, virtues, men and women, love and friendship and so on. But CBT is not a strict subset of LW, and reading just LW can’t help with overcoming akrasia.

    However, there are factors against this correlation. Intelligent people happen to feel self-important, like “I’m too smart for this self-help crap, have you mistaken me for some stoopid low-IQ New Agey overenthusiastic philistine?” This is a rationalization, because the whole reason people are depressed (or anxious, or lonely) is because they believe they are horrible (or in danger, or unlovable), so why would they read something that tells them they are wrong in a first place? Also, intelligent people are extremely good at rationalizing away whatever they find unpleasant for their beliefs. E.g. when I asked various people why don’t they quit smoking, less smart people just shrugged and said “I tried but couldn’t”, while smart ones came up with fantastically convoluted excuses why smoking is actually a very good idea. Burns writes non-fiction self-help books for the lowest common denominator, so of course there will be cheesy one-line wisdoms, simplistic explanations and unrealistic dialog. But for a smart person, who already has a preconception against him, his self-help style will be an easy excuse to dismiss him.

    5. eqdw is largely right too. There is an unbelievable amount of hocus-pocus that is sold as CBT. CBT is not about positive thinking. CBT is not about self-esteem movement. CBT is not about Zen/Tao bullshit. CBT is not about affirmations, and lying to yourself, and rationalizing away. CBT is only about rational thinking, believing what is true, believing it only to an extent it is true, and not believing whatever is false, meaningless, vague, blown out of proportion, overgeneralizing, simplistic, emotionally-charged and so on. I’m so confident in that because Beck, Burns and Ellis repeatedly state in their books one way or another that positive thinking, self-esteem movement and all that New Agey stuff is crap. Just by telling yourself that you are awesome, without providing watertight arguments why this thought is supposed to be convincing doesn’t work, and Burns points this out several times.

    Suppose your hypothesis of water supply is correct, and superficial understanding of CBT insights is widely disseminated now. Well, Dale Carnegie is known for almost a century, but how many people you know who diligently apply his method in every day-to-day interaction, instead of just believing on a System 2 level, that “you are supposed to be nice to people”? I, however, question the water supply hypothesis itself: when I actually explain CBT core ideas to people, like 10 cognitive distortions, or necessity of doing written homework, they respond as if it’s something they never heard before.

    As I said, CBT succeeds when you literally convince the patient that they’re wrong and you’re right. Have you ever convinced somebody that your beliefs are superior to theirs? Now you understand why therapists all over the world fail miserably at applying CBT, because convincing someone is still a poorly-understood Art of Rationality. If whatever Yudkowsky did is punching, and combating akrasia is kicking, then CBT is a step in the right direction in kicking, just like LW is a step in punching, but it’s but one step. In other words, the key to destroying akrasia is somewhere through CBT, but we as a humanity haven’t figured a shitload of nitty-gritty details and small factors, which curb our success. One such factor is how to not repel the person and not effectively close their mind even before therapy starts.

    Burns himself quoted in the video Motivation Revolution a study, showing that CBT helped improve (not even cure completely) only 46% of patients. While the core idea of CBT is, I believe, correct, we still as a humanity don’t know how to reliably convince people of rational cognitions. Burns himself isn’t satisfied with CBT and calls the results of the study “unimpressive”, currently working on some new approaches to therapy. I hope he’s not washed up and will come up with something brilliant.

    6. If you want to learn CBT properly and maybe even help some people get out of their misery and mentally-induced torture, I recommend Burns’s original Feeling Good and Judith Beck’s Cognitive Therapy: Basics and Beyond. If you have lots of free time and wanna see CBT done right, I definitely recommend reading Allen Carr‘s 2 books: The Easy Way to Stop Smoking and The Only Way to Stop Smoking Permanently (the latter is the same method but with Carr trying to attack smoking with the help of as many analogies and arguments possible, to ensure the message actually gets across). Carr is a fantastic example of how you hammer an idea into a person from as many angles as possible, refute any possible feeble rationalizations one after the other, until the smoker is left without any supporting arguments for smoking and is practically forced to admit Carr is right. Then quitting smoking is suddenly a matter of closing the book, putting out your last cigarette and never picking it up again. I know many smokers who read the book, suddenly realized they don’t even want to smoke, and never started again after years, as if they never were smokers in the first place. And Allen Carr is pure cognitive restructuring, but highly narrowed down to just smoking, so it doesn’t even require written homework.

    7. I’m interested in going back and forth with this argument, so anyone, feel free to comment, criticize, doubt and so on.

    • Max says:

      Hey could you please elaborate why Zen/Tao is “bullshit” for you?

      Regarding CBT I think it has many truths and useful techniques, however for them to be effective person has to be willing to apply and work them. I know when I initially tried the psychotherapy/CBT it didnt work at all. However years later as part of the process of learning more about myself and life I opened my mind and found that many “cbt” techniques are useful.

      • Mirzhan Irkegulov says:

        I don’t claim all of Zen and Taoism is bullshit, because I never studied them except reading Tao Te Ching years ago. I’m currently halfway thru Smullyan‘s The Tao is Silent, and I love Smullyan, but I can’t comprehend at all, where is he heading with it.

        Every time I ask somebody to explain Zen or Tao, they hand-wave, babble and can’t explain shit, but get incredibly insulted, if you just call out bullshit. It’s like an elaborate game of beads, where everybody is supposed to nod in agreement, seem Deep, but if you dare to doubt, everybody gasps, shake heads and smugly smile. Just like in postmodernism.

        Maybe Zen or Tao are the best thing since sliced bread. But I’ve never seen them as basis for useful advice or method. Koans and one-liner wisdoms contradict the spirit of CBT anyway, which doesn’t ask you to contemplate on some vague fable or aphorism, but instead provides you with a highly detailed instruction of what to actually do, with an extremely reductionistic theory behind.

        Now I agree that a person should be willing to actually apply CBT for it work, and that’s exactly what Burns shows in the video Motivation Revolution i linked above. He references a study that showed that willingness to just at least try a technique is the best predictor of curing depression, while patients’ beliefs on how frequent they plan to use technique or how hopeful they are about the technique don’t matter much.

        That’s what is currently an open question in psychotherapy: how to consistently motivate people to at least try a technique, how to increase their willingness, and that’s what Burns working on in his new T.E.A.M. therapy. Maybe it’s complete crap, maybe it’s revolutionary, too soon to know.

        I disagree however that we can’t make people willing at all, and their willingness should come from “within”. Sometimes the person is extremely hostile and disbelieving, but then you say something, and they go “you know what, you changed my mind, I wanna try it out know”.

        • stillnotking says:

          Allow me to recommend Hubert Benoit’s Zen and the Psychology of Transformation for a more Western-oriented, “analytic” approach to Zen than you may be used to. Charlotte Joko Beck’s Nothing Special and Everyday Zen also do an admirable job of laying out the foundations of Zen practice in common-sense terms.

          • PD says:

            I always recommend Alan Watts (particularly The Way of Zen) to people with this attitude, even though a lot of serious Zen-types consider him to drop the ball in a few places. I think his basic insight that Zen is a system of unlearning the social conditioning acquired in collectivist cultures is valid and makes a lot of sense, and he’s pretty great at giving a simple “reductive” explanation of Zen for a popular audience that is more or less free of woo and hand-waving.

            It’s also worth noting that the main game of Buddhist traditions is observing the total philosophical vapidity of the commonsense concept of self, which aligns surprisingly well with contemporary philosophy of mind and brain science.

        • Christopher says:

          I can’t explain Tao as theology or practice, but the stories in, say, the Liezi are well-told, thought-provoking and not at all what I would call wand-wavey or woo.

          I mean, I can’t explain to you how the Trinity works or what it means that we’re saved by grace and not works, and I don’t go to church, but that doesn’t mean that the Gospels are just incomprehensible gibberish to me.

          As much as the Tao Te Ching itself is, um… difficult, that’s not at all true of all Taoist writing.

        • ChristianKl says:

          But I’ve never seen them as basis for useful advice or method. Koans and one-liner wisdoms contradict the spirit of CBT anyway, which doesn’t ask you to contemplate on some vague fable or aphorism

          When given useful advice it’s best to speak in the language that the person you are speaking with understands, regardless where one got one’s own insights.

          A lot of actual Zen practice is also not about contemplating one-liners.

          how to consistently motivate people to at least try a technique, how to increase their willingness, and that’s what Burns working on in his new T.E.A.M. therapy.

          But it’s not the only thing he’s doing. The empathy training and feedback mechanisms where a patient rates the empathy of their therapist is also likely to be highly valuable.

        • Deiseach says:

          I don’t know if this is any use to you (I still can’t really make heads nor tails of it, and I doubt it’s the classical Eastern understanding) but C.S. Lewis’ notion of the Tao from “The Abolition of Man”:

          In early Hinduism that conduct in men which can be called good consists in conformity to, or almost participation in, the Rta — that great ritual or pattern of nature and supernature which is revealed alike in the cosmic order, the moral virtues, and the ceremonial of the temple. Righteousness, correctness, order, the Rta, is constantly identified with satya or truth, correspondence to reality. As Plato said that the Good was ‘beyond existence’ and Wordsworth that through virtue the stars were strong, so the Indian masters say that the gods themselves are born of the Rta and obey it.

          The Chinese also speak of a great thing (the greatest thing) called the Tao. It is the reality beyond all predicates, the abyss that was before the Creator Himself. It is Nature, it is the Way, the Road. It is the Way in which the universe goes on, the Way in which things everlastingly emerge, stilly and tranquilly, into space and time. It is also the Way which every man should tread in imitation of that cosmic and supercosmic progression, conforming all activities to that great exemplar. ‘In ritual’, say the Analects, ‘it is harmony with Nature that is prized.’ The ancient Jews likewise praise the Law as being ‘true’.

          This conception in all its forms, Platonic, Aristotelian, Stoic, Christian, and Oriental alike, I shall henceforth refer to for brevity simply as ‘the Tao‘. Some of the accounts of it which I have quoted will seem, perhaps, to many of you merely quaint or even magical. But what is common to them all is something we cannot neglect. It is the doctrine of objective value, the belief that certain attitudes are really true, and others really false, to the kind of thing the universe is and the kind of things we are. Those who know the Tao can hold that to call children delightful or old men venerable is not simply to record a psychological fact about our own parental or filial emotions at the moment, but to recognize a quality which demands a certain response from us whether we make it or not. I myself do not enjoy the society of small children: because I speak from within the Tao I recognize this as a defect in myself—just as a man may have to recognize that he is tone deaf or colour blind. And because our approvals and disapprovals are thus recognitions of objective value or responses to an objective order, therefore emotional states can be in harmony with reason (when we feel liking for what ought to be approved) or out of harmony with reason (when we perceive that liking is due but cannot feel it). No emotion is, in itself, a judgement; in that sense all emotions and sentiments are alogical. But they can be reasonable or unreasonable as they conform to Reason or fail to conform. The heart never takes the place of the head: but it can, and should, obey it.

          • houseboatonstyx says:

            @ Deiseach

            I get lost in the R__ and the Tao stuff there, but I’m fascinated by Lewis’s subject headers, General Beneficience and such … do you know where he got them?

            And I see an elegant pattern they make, like the rim of a circular billiard table. Go too far in any one direction, and it bounces the ball back toward center. “Put your own family/tribe first — but don’t be unfair to strangers” … “Feed the populace — but don’t make anyone cry” (Communists take note).

            Lewis says loud and clear, that systems that choose one of the Do’s and set it as the highest priority and throw all the others under the bus for its sake — become evil systems. He says the same thing about an individual in MC, then talks about a ‘thing that tells you which note to play when’. That’s what I see the Do’s and But Don’ts doing — and by contexts it’s probably his Rta or Tao.

        • Furrfu says:

          I am not in any way an expert on Buddhism, but my understanding is that the basic tenets of Buddhism are the Four Noble Truths, which can be expressed in an obscurantist way (as the Wikipedia page kind of does), or you can express the Four Noble Truths in simple language that anyone can understand, and with everyday examples like this:

          I know one young man who suffered terribly because of a wrong perception. His father had been away, and when he returned home, he learned that his wife was pregnant. His neighbor had been visiting regularly and been very helpful, and the father was sure that the child was not his but his neighbor’s, and this wrong perception settled in so deeply that he became icy and distant from his wife. She had no idea why he had become so cold, and she suffered a lot. And of course, the baby within her also suffered. All three of them suffered, as did other members of their family seeing them like that. One wrong perception made many people suffer for many years.

          The child was born and grew in that atmosphere of suspicion and wrong perceptions. When he was twelve, his uncle, who was visiting, commented on how much the boy looked like his father and only then did the boy’s father accept him as a son. Much damage had been done in twelve years to the whole family, and now, many years later, the extent of the damage continues to reveal itself.

          (This is part of Thich Nhat Hahn’s explanation of sammā-diṭṭhi or “right view”, which is one of the eight parts of ariyo aṭṭhaṅgiko maggo, the Noble Eightfold Path, which is the fourth of the Four Noble Truths, and the one that people usually write books about.)

          The stuff about meditation is sometimes hard to understand because it’s describing experiences that people don’t share, don’t have in childhood, and many haven’t had at all, and therefore don’t have shared referents for. So they end up using metaphorical language and whatnot to try to give you some of the flavor. And so you go from this, which you have probably been prepared for by years of Eliezer and Scott:

          In Buddhist literature, ditthi (Sanskrit: drsti, views) always means wrong views. Your view is from just one point. That is why it is called a point of view. If you go to another point, you will see other things. The first view was not complete and therefore not entirely a Right View. In the sutras the word “view” always means Wrong View. That is why we hear the expression, “All views are wrong views.” Our practice is to eliminate more and more the elements that are wrong from our views. If you have a view of something, be aware that if you look more deeply and practice more mindfulness, attention, and concentration, you will discover that the quality of your view can be improved.

          Nuclear scientists have a view concerning electrons that they are pleased with, but they are careful. They continue to develop better accelerators, because they know that there is more to be discovered. They know that all views about the electrons are wrong views. We practitioners must do the same. We can never be sure of our views. Attachment to views is the greatest obstacle in the practice. We should be patient and careful, never too sure of our perceptions.

          directly to metaphorical stuff like this in the next paragraph:

          In each of us there is a river of perceptions flowing day and night. To meditate means to sit on the bank of the river and observe all perceptions. With the energy of mindfulness, we can see the nature of our perceptions and untie the knots that bind us to our wrong perceptions. All our suffering has its roots in our wrong perceptions, so please practice the mantra, “Are you sure?” Always refer to it, and try to look more and more deeply. Our views can be more or less wrong. When we have true understanding, we transcend all kinds of views, even our views of the Four Noble Truths.

          which you may have a metaphorical allergic reaction to. Hopefully it’s not as enigmatic as a kung-an. You can see that it’s describing a discipline for letting go of false beliefs, and that it’s not the same as the discipline of empirical experiments with statistical analysis, but you may not be able to see what it is, or whether it is in practice more or less effective than empiricism at curing the irrational beliefs (or other mental states) that cause depression or procrastination or whatever.

          As I’ve said, this is just Thich Nhat Hahn’s interpretation of sammā-diṭṭhi, and although he is widely respected, other Buddhists have different interpretations.

          Thank you very much for explaining CBT! Your comment is the best explanation of CBT that I have come across so far.

      • Publius Varinius says:

        Zen Buddhism and Taoism are religions. They are about as insightful as any other religion, and they have similar problems. The differences are superficial. Instead of the usual “sin”; “desire” and “attachment” are the favourite scapegoat of buddhists, taoists and the like.

        A priori, zen and tao are bullshit. Do you have any evidence at all that might suggest otherwise?

        • Mirzhan Irkegulov says:

          To support the spirit of charitable reading, I wanna point out that Max didn’t claim Zen and Tao are or aren’t bullshit, he just asked.

          • Publius Varinius says:

            You’re right. As such, my last question-demand was clearly an overreaction, which I would replace with a more neutral one, if I could still edit the post.

        • onyomi says:

          The differences really aren’t superficial.

          • Publius Varinius says:

            I am willing to be convinced that the differences are substantial, if you are willing to substantiate your claim.

            But that in itself is not enough to establish that Zen Buddhism isn’t bullshit. Homeopathy and moon-landing-denial make deeply different claims, even though both are bullshit.

            And there are many claims to justify, e.g. that death is unavoidable, that you’ll be reincarnated as a wild fox for answering the wrong question, etc.

          • Protagoras says:

            That death is unavoidable may not be completely uncontroversial, but it seems a little bit less silly than homeopathy. And many Zen Buddhists deny that reincarnation is part of their doctrine (Dogen, perhaps the most prominent Zen teacher, does not seem to have believed in it).

          • onyomi says:

            This is more of a Hindu advaita philosophy, but I think it is broadly consonant with Zen:


            This doesn’t sound like any Christian sermon or homily I’ve ever heard, and I’ve heard quite a few.

            Abrahamic religions do start to look more like Eastern religions when you look at the mystical traditions within them, i. e. Kabbalah, Sufism, etc., but even then, the differences strike me as more than just window dressing.

            That said, I think all religions derive from a similar impulse, and many believers would say that they are all different paths to one truth, but the differences in the paths aren’t superficial, any more than the differences between Indian and French food are superficial.

          • Publius Varinius says:


            You compared Zen Buddhism to homeopathy. I compared homeopathy to moon-hoaxing, but I merely compared Zen to the claims of other religions!

            Prima facie, rebirth and resurrection of the dead are claims of about equal depth.

        • ChristianKl says:

          Paul Ekman is one of the most respected psychologists when it comes to understanding human emotions. He’s in the top 100 most cited psychologists of the twentieth century.

          He credits the Dalei Lama a lot in his book “Emotions Revealed: Recognizing Faces and Feelings to Improve Communication and Emotional Life” and says that an audience with the Dalei Lama strongly influenced his thinking on emotions.

          Dalei Lama isn’t a Zen Buddhist but a Tibetian Buddhist, but I see no reason why the Zen tradition should produce less knowledge than than Tibetian Buddhism.

          I haven’t heard of any respected scientists who publicly states that an audience with the pope helped him substantially in understanding the scientific domain of the the scientist.

          • Mirzhan Irkegulov says:

            See, that’s exactly the problem I have. You haven’t reduced Buddhism or Zen to atomic observable phenomena. Buddhism is still a black box, but now I’m supposed to revere this black box because Dalai Lama.

            Although scientific method is the best thing since agriculture, an actual process of science is full of dishonest people. Maybe Paul Ekman pays lip-service to Eastern religions because nobody understands them anyway, but it allows him to sound Deeper and sell more books.

          • houseboatonstyx says:

            Although scientific method is the best thing since agriculture

            Imo, the scientific method pre-dated agriculture. Without experimenting to find out which berries, at what stage of ripeness, prepared by what method, were edible, the foragers would not have survived for enough centuries to invent agriculture.

          • ChristianKl says:

            The public image of Paul Ekman is not about Buddhism. Neither the word Buddhism nor Zen appear on his Wikipedia page. Ekman is not New Age.

            You are also engaging in a strawman. I don’t argue in favor of revering Buddhism. I’m not even a Buddhist. Thinking that a practice is either bullshit or you have to revere it is bad binary thinking. Don’t be like the fox with the sour grapes.

            As far as revering goes even the Dalai Lama isn’t advocating that everyone should revere Buddhism.

            Buddhism isn’t a framework that reduces phenomena to atomic units. That’s simply not how it’s structured.

            At the same time experienced Buddhist have stronger abilities to observe and manipulate their own state of mind than 99% of the academic scientists. That makes the Dalei Lama a useful person to talk to for someone like Ekman who ran many studies but has less self awareness about his mental state.

            Paul Ekman did run his studies of how different facial muscles get used in different emotions.

            Publius Varinius claimed that differences between Buddhism and other religions like Christianity are just superficial. That’s simply not true.

            If you are interested on the atomic breakdown of how emotions work Emotions Revealed is a good book to read. It’s the book if you have trouble with reading the emotional states of other people and that breaks the task down in a way that should be able to be applied by analytic people.

          • Mirzhan Irkegulov says:


            You still didn’t give any argument for Zen. I’m not even sure what should I agree with. That Zen isn’t bullshit? Or that it might help with overcoming depression?

            I never studied Zen and Tao as a scholar, but I see people being completely unable to explain even the most basic tenets without confusing self-contradicting aphorisms and non-sequitur fables. Which should be an immediate red flag, because I can explain basics of CBT easily.

            That makes me quite suspicious that nobody understands Zen anyway, i.e. it’s bullshit. OTOH, in certain circles it’s good manners to nod along every time mentions Zen or Taoism in a positive light, while just calling out bullshit yields condescending: “you’re too young, you don’t understand”. Just like postmodernism.

            I don’t care about Zen, the space of all possible ideas is so vastly big, why should I give disproportionate attention to it anyway? However I really hate the pervasive anti-intellectualism in the form of silently assuming truth of certain things, Zen being an example. I don’t want people to have this desire to talk about Zen when they don’t understand it (or understand how exactly it applies to the topic at hand) and get angry every time you tell them: “I think you don’t know what you’re talking about”.

          • PD says:

            @Mirzhan Irkegulov:

            >in certain circles it’s good manners to nod along every time mentions Zen or Taoism in a positive light, while just calling out bullshit yields condescending: “you’re too young, you don’t understand”. Just like postmodernism.

            Yes, true enough. Meanwhile in certain other circles it’s good manners to display a posture of aggressive skepticism and shout “bullshit” at things that one has invested no or minimal effort into understanding, and the applause lights come on at that point as well.

            The latter attitude may have the advantage of making you less gullible in the long run, but both seem pretty insipid to me. If you don’t know and don’t care, well and fine, then leave at that. There aren’t any Zen monks knocking on your door trying to sell you copies of the Shobogenzo. It’s hard to imagine a school of thought less suited to winning converts and less desirous of them.

            The truth is that Zen is just plain hard to understand and to explain, and most of the understanding that you get comes from doing it.

            As an aside, I think similar remarks might be made about postmodernism, where the people loudly crying “bullshit” derive all of their understanding from reading profoundly biased secondary sources.

          • Douglas Knight says:

            The latter attitude may have the advantage of making you less gullible in the long run


          • FullMetaRationalist says:

            The latter attitude may have the advantage of making you less gullible in the long run


    • houseboatonstyx says:

      Burns writes non-fiction self-help books for the lowest common denominator, so of course there will be cheesy one-line wisdoms, simplistic explanations and unrealistic dialog.

      I have been meaning to say something like this about Claire Weekes. At some point in her first book she explains that she is writing to people who, however intelligent and critical normally, are in such bad state that overly simple is the only thing that can get through. When reading all the way through a page of normal text is difficult because of distraction, brain fatigue, etc, two or three big bold typeface summaries per page are useful footholds. Some of the later books may address us in our normal states.

      Wikipedia says:
      She is considered by some as the Pioneer of modern Anxiety treatment via Cognitive Therapy. [….] She explained that so much nervous illness is no more than severe sensitization kept alive by bewilderment and fear. [3] Dr. Weekes analyzed fear as two separate fears; the first fear and the second fear. She explained that first fear is the fear that comes reflexively, almost automatically. The patient usually immediately recoils from it, and as he/she does, he/she adds a second fear to the first. Second fear is the fear the patient adds to the first fear. Examples of second fear are “Oh, my goodness! Here it is again! I can’t stand it!” It is the second fear that is keeping the first fear alive, keeping the sufferer sensitized, keeping them nervously ill.[4

    • Creutzer says:

      How does this relate to the fundamental problem that many of us have with this approach: what to do when your (negative) assessment of your situation is actually correct? You’d have to change your values and not care about these things anymore, which seems to be outside the scope of CBT as you (very helpfully, by the way!) describe it.

      • houseboatonstyx says:

        I wonder if all CBT cases being quoted are quite that extreme, one way or the other. What about Madeline Middle, who really is getting too old to model bathing suits, but was pretty good at math till she moved to France. By losing some of her old ambitions and her old discouragements, she could learn the Metric System and start a more realistic career.

    • Adam says:

      It looks to me like you have a good handle on what CBT is.

      My biggest problem with CBT is it’s total disregard for the unconscious. Current understanding of the brain says that we have 5 different memory systems broken down into implicit and explicit memory. CBT only works with explicit memory and ignores (some people deny) the existence of implicit memory. Emotions are primarily implicit and logic is primarily explicit. You’re going to have a really hard time changing a person’s implicit memory structure with purely logical techniques. Behavioral, Gestalt, and psychodynamic techniques are better equipped to address the implicit memory problems.

      The phenomenon you point out about CBT working with intelligent people, rides this line as well. There is a strong cultural idea that intelligence is not emotional. Some of this is the straw vulcan phenomenon. Some of this is that emotions are not rational and really do make us choose un-intelligent choices. And some of this is that the brain uses competing resources to be empathetic or logical. On some level, our brains can’t do both.

      Additionally, proper CBT requires a formal diagnosis. CBT needs a disease to cure. Diagnosis in the therapy world is highly contentious. This is called the disease model and a great many therapists do not like this model of human distress.

      This diagnosis model is partly why CBT is so popular these days. Insurance operates on the disease model and CBT has provided insurance a clear path for labeling dysfunction. Whether the labels are correct or even helpful is entirely unknown, but insurance companies find them easy so they use it. This means that CBT gets more funding from insurance where other therapies would not, even though they have similar outcomes.

      CBT also has bad outcomes on the long term scale. It’s almost guaranteed that you will relapse with CBT.

      A lot of that result has to do with poor etiology in the therapeutic world. All of these theories and treatments address symptoms and fail to understand causes.

    • DensityDuck says:

      “the only way to overcome depression, anxiety, insecurities, and many other forms of akrasia is to convince yourself through reason into a correct and justified belief”

      So the old joke is right, and the lightbulb has to really want to change.

      And the question is, how do we convince the lightbulb that change is possible and desirable?

      “Have you ever convinced somebody that your beliefs are superior to theirs?”

      Hell, just look at how hard it is to convince people that 9/11 was an inside job. (Ha ha ha, gotcha there, didn’t I?) But seriously, breaking people loose of a position that they have, by their lights, reasoned themselves into? Unbelievably difficult.

  46. Sigivald says:

    Sometimes we say the same thing about lithium, although in that case we’re not joking.

    Makes me wonder: Has anyone done a comparative study of auto/truck mechanics with other vaguely similar skilled-manual trades (say, plumbers, welders, carpenters) on depression rates?

    The hypothesis that came to mind is that long-term bare-handed exposure to lithium-base greases – ubiquitous in the mechanical fields, but not used in e.g. plumbing and carpentry to any significant degree – might make them detectably less depressed than the control?

    • Jacob H. says:

      Interesting idea, but the work conditions of mechanics are so different from carpenters/plumbers in ways potentially correlated with depression– ie, they are more likely to be regular employees rather than independent contractors, less likely to work with family members, more likely to socialize at work, and so on. Also, the different selection processes seems likely to select for different characteristics.

      I think you’d want a within-mechanics design that differentiated those more or less likely to be exposed to lithium-based grease…

  47. J Thomas says:

    1. Maybe over the years people have gotten less of a fetish toward rationality. Maybe it used to be “What? My fears are irrational? I’d better find out what’s rational and do it. I can’t be irrational!” And maybe now it’s more “Ah, rationality is overrated. It doesn’t solve the real problems, and anyway being too hung up on logic and all that is dull, square, patriarchal, etc etc etc. My fears are irrational, so what? Life is irrational. Somebody wants me to do these stupid exercises that can’t work, I won’t even bother. In an insane world my symptoms are appropriate. The hell with it all.”

    2. Maybe what people want and expect from psychotherapy is voodoo, revelation, the sense that there is a luminal meaning to their lives that they did not realize before, transcendence, etc. Maybe when CBT worked, it was therapists presenting it as transcendence — not the details but the attitude — and patients accepted the techniques which worked, as a side effect of that transcendence. But now when it usually gets presented without that attitude, the methods get dismissed as obviously useless and unworkable.

  48. Jacob H. says:

    Possibly relevant research ( )

    Although researchers often assume their participants are naive to experimental materials, this is not always the case. We investigated how prior exposure to a task affects subsequent experimental results. Participants in this study completed the same set of 12 experimental tasks at two points in time, first as a part of the Many Labs replication project and again a few days, a week, or a month later. Effect sizes were markedly lower in the second wave than in the first. The reduction was most pronounced when participants were assigned to a different condition in the second wave. We discuss the methodological implications of these findings.

  49. Jeremy says:

    I think it’s funny but at the same time sad how many people in these comments are completely unaware of how they are expressing depressive thoughts about themselves under the guise of criticism of therapy. I don’t think any of these people would consider the observations they were making to be true/necessary/insightful if they were talking about others. It’s just through the filter of depression they see themselves differently.

    • Nicholas says:

      That’s the constant drumbeat of madness, that makes the occasional attempt to just stop checking the fucking deadbolt frightening instead of annoying.

  50. Bramble says:

    CBT seems like a good therapy for helping people change bad habits of behavior. Changing bad habits is really just a matter of applying hokey cliches to your life. Start small and work up! If you first done succeed, try, try again. But helping people feel less sad or think fewer self-defeating thoughts is much harder. CTB claims to be able to do this, but does it really? Do we have control of our moods? We can influence them in the long run maybe, but we can’t control them as they arise. How much control do we have over which thoughts arise in our minds? Almost none at all. Trying to control thoughts and feelings has the paradoxical effect of keeping them in consciousness longer, and this is where CBT fails, I suspect. Therapists should be teaching their clients how to accept uncomfortable thoughts and feelings as a normal part of life. That is to say, they should be doing what parents have traditionally done for children. As with learning a new language, it is much harder to do as an adult. Can it even be done in five or six 50 minute sessions? I don’t know.

    • Mirzhan Irkegulov says:

      You should definitely read an actual CBT book :). You will be surprised with how much it actually agrees with you. For example, David Burns, whom Scott referenced in this post, writes about an “acceptance paradox” in his book The Feeling Good Handbook, that once you accept yourself, your feelings, your beliefs and your life as something natural, something that is not “ought not to be there”, something not reprehensible and uniquely catastrophic, suddenly it becomes much easier to actually change. In other words, unconditionally accept yourself for who you are and only then see how you can achieve whatever goals you’ve set.

      (Note: this sounds extremely vague, and many people would readily disagree, e.g. “but Burns asks you to accept mediocrity and not strive for better lives!!!11”, which is why there is a whole book on applying CBT, where Burns actually elaborates what exactly does he mean and how to achieve it.)

      Burns, for example, asks you to never try to control your thoughts or feelings, and he also asks you to override all “should” thoughts with his techniques, such as “I shouldn’t think this thought” or “I shouldn’t feel depressed”. His techniques are one way to eliminate all shoulds, musts, oughts, and replace them with more scientifically meaningful “if I do X, then I would be Y, and I want to be Y”.

      • Bramble says:

        I actually have the Feeling Good Handbook, but haven’t read it. Personally, I’m more attracted to Acceptance and Commitment Therapy and other mindfulness-based therapies. I’m of the opinion that it’s not helpful to think in a rational type way about my occasional bouts with depression (I associate this with CBT). I already think too much as it is. Instead, I try to focus my attention on the sensations I’m having in my body when uncomfortable feelings arise. I suppose there can be a CBT-type element to this. For example, you can tell yourself things like, “This anxiety is just a sensation in my gut, and it in no way prevents me from leaving the house.” And of course those types of thoughts will arise automatically if you’ve ever read a self-hope book or blog. But for me, the insight is not helpful. It’s the exercise of paying attention to what the sensation is in the moment that helps me.

  51. TomA says:

    For most of our evolutionary history, our species was confronted with daily hardship and harsh conditions that threatened our survival. We are the descendants of those that met this daily challenge with perseverance and success. Today, we live in a world of extraordinary affluence and a near total lack of existential hardship. The psychological maladies that you reference are probably a side effect of a lifetime devoid of primal hardship. Look in that direction for a new treatment scheme.

    • stillnotking says:

      Extremely convincing VR simulations of being chased by Smilodon?

      • John Schilling says:

        I’d prefer velociraptors myself. Or we could just figure out what really happened to make US violent crime rates drop by a factor of four, and apply the inverse. We don’t need any imaginary non-human predators when we have each other in the real world.

        Hmm, lead and testosterone in the water supply, to promote general contentment and mental heath?

    • alaska3636 says:

      I think there is a lot to be said about a lack of acute hardship in peoples lives. A persistent hardship seems to lend itself to neuroses whereas acute hardship forces people into their primal problem-solving wheelhouse.

    • Psmith says:

      In “My Age of Anxiety,” Scott Stossel mentions that Londoners who suffered from anxiety during peacetime experienced fewer and less severe symptoms during the Blitz.

      Also, see the “exercise” component of “diet and exercise.”

    • TomA says:

      Depression and anxiety could be habitual behaviors acquired as a result of a deficiency of opportunity to solve primal problems. Perhaps a new paradigm of treatment could include instituting a long term regimen of basic survival skill exercises in which the patient learns to substitute problem solving effort for episodes of despair or worry.

      • Adam says:

        Soldiers still seem to suffer from high rates of depression, but I don’t know, maybe mountaineers don’t?

        • That’s related to what I was thinking– the modern world doesn’t have the challenges of the early environment, and it’s also sensorarily drab by comparison.

          • TomA says:

            The flip side of depression and anxiety is vigor and confidence. These are feelings that you acquire by doing, and not something that can be instilled with mere words of analysis or encouragement. Remedy requires activity, repetition, and feedback of success or failure.

  52. Julia says:

    I wonder if it’s more effective in people who didn’t grow up with these ideas in their cultural “water”? For example, I think of it as obvious that dreams come from our thoughts, memories, and wishes rather than being portents of the future. It took me a while to realize that apparently this bit of Freud hasn’t made it into the culture of a lot of my clients, and they genuinely believe their dreams tell the future.

  53. alaska3636 says:

    I browsed the comments and did not see my thoughts mentioned so I will drop off my two cents.

    It sounds to me, and in my own experience, that a common fallacy in psychology is mistaking a person’s means for their ends. By definition, a person’s choice of means can be rationally analysed in terms of it’s success in achieving or moving towards an end. A person’s ultimate end, however, is beyond rational analysis. Whether the thing which somebody believes will relieve themselves of unease is a matter of subjective value. Thus, a buddhist denies himself the accumulation of material objects for he believes it will bring him peace or joy or release from Samsara; a Christian practices an ethical system which he believes will grant him access to the Kingdom of heaven; and an atheist adjusts his actions to remove unease in the immediate future in the belief of only a temporary and material existence.

    A person’s means can be rationally analysed as progress towards a specific end; but, whether that end will bring about a satisfactory feeling is individually subjective. When a perfectionist visits a therapist for feelings of unease, their actions may be unsuitable to the end of perfectionism or the end may be an unsatisfactory one but awareness of the the former item does nothing to reconcile feelings about the latter.

    In my own experience, most people seem somewhat detached from an awareness of their own ends, or, rather, they take them for granted. We act in ways because we expect to achieve certain results; we have no guarantee that those ends will bring us what we sought even if we choose successful means. There is the old cliche about riches not bringing happiness and this could be applied to a million scenarios where what we thought would make us happy, once achieved, brings only more feelings of unease.

    To conclude from running overly long, the ideas of perfectionism needs to be taken in context of it’s ultimate end. Does the person believe that God requires perfection; or that the meaningless of life is augmented by it; or that by a kind ascetic, mental immolation a person brings themselves closer to release from Samsara?

    Humans are purposive creatures and it must be asked how CBT is effective in analyzing purpose; it seems to me that the culture of the day is important in assessing whether those ideas are effectively manipulated by the processes of CBT.

    • Christopher says:

      My current therapist, who practices CBT, spends a lot of time asking me to be aware of what I’m trying to accomplish and what goals or needs I’m trying to serve with my actions.

      • alaska3636 says:

        Not to unnecessarily confuse things, I opted not to use the phrase “ultimate end”, especially to avoid confusion with Weber’s Ultimate end terminology. Essentially, your actions aim at goals, but the ultimate end is what causes you to perceive as valuable some goals over others.

        I guess I see a lot of psychology trying to explain why people do what they do without regard for the ultimate ends they aim at or by taking for granted that removing feelings of unease is a subjective valuation based upon a person’s definite ideas (i.e. deeply held beliefs) regarding life, the universe and everything.

        Ultimately, I’m skeptical that a therapist is little more than a proxy for a spiritual guide with the dogma of psychology replacing that of revealed or unrevealed religion. And I don’t think that this is a bad thing, I just wonder about the methodology of the human sciences trying to skirt around the issue of purposive consciousness.

        In short, you have actions and you have goals, but what are your beliefs regarding values? It may be that what is bothering somebody unaffected by CBT does not require a reassessment of their actions but of their values. I’m not sure CBT is equipped to have that conversation. Or another question might be: How can a therapist help a patient find solutions when their value systems are different?

        But maybe I’m just overthinking it. I was reading that Victorian era neuroses among “ladies” were as extravagant as their lifestyles (if Michael Crichton can be believed in the Great Train Robbery) and I have often wondered whether many anxieties reflect a kind of dissonance between a person’s values and the values of their culture.

  54. Calvin says:

    I tend to be fairly integrationist in my practice, with a slight bent towards CBT. But I think this article does fixate on the C part of it a little more than the field has trended towards in recent years. A lot of good CBT therapists I know tend more to describe themselves as “little C, big B” therapists (obvious sexual jokes abound), emphasizing behavioral shifts as the driver of change. And where I’m integrationist, I agree with the premise that there’s limited utility in all insight coming from the sort of cognitive tropes Burns discusses, and perhaps more value in weaving in some interpersonal and/or dynamic ideas to supplement behavioral principles.

  55. Douglas Knight says:

    Doesn’t the efficacy of all methods of treating depression fall over time? Thus, shouldn’t we look for more general explanations? eg, the patients included in the studies are less depressed than they used to be. (That is compatible with Scott’s claim that people in general are more depressed.)

    Ideally, there would be multiple RCTs, decades apart, comparing SSRIs to CBT.

  56. Haven’t read the comments; this will probably be similar to some of them, but hey, it’s more anecdata.

    My first experience with CBT (specifically Rational Emotive Behavior Therapy) was pretty helpful, and it only happened a few years ago. The reason it was helpful was that my anxious thoughts tend to present themselves — somewhat plausibly — as correctives to things like confirmation bias and Dunning-Kruger (and did so before I specifically knew terms like those). Essentially, the thoughts say, “people delude themselves all the time (true), often in ways that reconcile them to objectively bad situations or let them ignore their flaws (true), and you need to listen to us so you don’t make some horrible mistake as a result of these self-deceptions (not obviously false).”

    Of course I had already picked up the idea that anxious thoughts are often irrational. But I didn’t have a clear way of separating out the irrational parts of my own thoughts from the parts that were actively useful, nor a sense that this was especially important. Thinking about this kind of stuff really did (and does) help me make better decisions, and I felt like questioning it at any point was “just making excuses for myself,” and I didn’t see alternatives besides basically trusting these thoughts (in their worse moments as in their better ones) and ignoring them entirely.

    So it was useful to sit down with someone, and describe specific thoughts, and have them say (effectively) “you know that really doesn’t make any sense, right?” And to have to say, “yeah, you’re right,” and then realize that this little “voice of reason” I have is a very unreliable instrument and that it’s actually feeding me garbage some nontrivial fraction of the time. This was not obvious because it isn’t always feeding me garbage, and feels continuous with habits of thought that are actually useful. The dividing line was never clear, but therapy led me to realize it needed to be drawn, because it showed me that at least sometimes the “voice of reason” was pretty staggeringly irrational, and that I needed to re-evaluate my relationship with it.

  57. LCL says:

    I read the meta-analysis and was impressed with their thoroughness at anticipating and ruling out potential explanations. The diminishing effectiveness remains a mystery.

    I did find one minor piece of evidence against the “CBT in the water supply” hypothesis. If it was true, we might expect that control groups have better effect sizes in recent times than they used to, on the theory that control subjects are somewhat successfully self-treating their depressive episodes with pop CBT methods. Which would indeed reduce effect sizes in an RCT, which are based on treatment group gains relative to the control group. But: “The waiting list control group condition exhibited no significant changes in effect sizes across time (p = .48)”

    I’ll posit – hesitantly – an alternate hypothesis based on selection effect. The meta-analysis says that “newer studies also include more patients with higher initial BDI scores” (p = .04). So you’ve got people living in a time with much more widespread CBT (including some water-supply CBT), and they’re more seriously depressed. Selecting people who are seriously depressed in a time of widespread CBT is, to some degree, selecting for CBT resistance. In both treatment and control.

    This aligns with your perception – i.e. “I’ve been through this same spiel with like thirty people already!” And while you’d presume that study authors would check that their subjects haven’t previously had formal CBT before including them in a CBT study (right? wouldn’t they?), they’re pretty likely to have had at least some water-supply CBT. And, I’d speculate, to have previously had some form of therapy somewhere that at least incorporated CBT elements.

    The counter, I guess, is that study samples of CBT-resistant depressives may in fact accurately represent the population; that anyone with depression these days has CBT-resistant depression to some extent. CBT as a victim of its own success?

    • Douglas Knight says:

      No, the effect of CBT in the water supply on the control group would not be give them a bigger effect size. It would, most likely, make them healthier at the start of the experiment. Why would the CBT in the water supply just happen to hit them during the experiment?

      • LCL says:

        Because the control group is selected for being in a depressive episode, and that’s what CBT treats. You’d expect modern control groups to improve faster than control groups in the 70s and 80s by virtue of pervasive pop CBT.

        In other words it’s a control group contamination – it’s no longer possible to compare CBT vs. no CBT. Now it’s only possible to compare CBT vs. water-supply CBT. You’d expect the (modern) water-supply CBT group to show more/faster improvement than the (1980s) no CBT group.

        But it doesn’t. Which I see as a minor point against the water-supply CBT theory.

  58. Doctor Mist says:

    This is very interesting. I ran across CBT thirty years ago, when a friend of a friend described it enthusiastically as “arguing with yourself about whether your depressed thoughts make sense”. I later pursued it individually, learned of course that there was more to it than that, and found it surprisingly helpful. Many years later I wrestled with more profound depression (though, I should add, nothing like as bad as I’ve heard from other commenters here) and found that it didn’t do much for me at all, and my feeling at the time was that “I knew what was coming”, which lends anecdotal support to the “insight rush” you’re talking about.

    I am no longer depressed (or in remission if you like), and recently read A Guide to the Good Life: The Ancient Art of Stoic Joy by William Irvine. He is a philosopher who noted that these days academic philosophy no longer seems to be about “how to live life” and looked around for alternatives. (Isn’t tenure grand?) Zen was close, but he found a better match in the classical Greek and Roman Stoics. To his surprise (and mine) Stoicism wasn’t about suppressing emotion, but about accepting that life has both good and bad in it. He ties together the classical greats and modern researchers like Haidt and Kahneman and comes up with a few concrete techniques that he has found helpful.

    The most interesting such technique is “Stoic meditation”, taking a few minutes out of the day to imagine, deeply, losing various things you value — your family, your health, your possessions. This is so counter to everything in the popular culture today about visualizing success that it took me a while to even make sense of it. But I’ve tried it and — perhaps simply because it is so different — I have found that it really does help me appreciate more what I have, and lets me react more stoically to setbacks and petty annoyances.

    Perhaps as this starts to wear a groove in my mind I will find that it wears off just as CBT did. But I do recommend the book and would be interested to know if anybody else has run across it.

  59. Alsadius says:

    I heard the same comment made about Freud once – he worked really well when dealing with repressed Victorians, and it tailed off as the patients got less repressed and his theories got better-known. (Heck, I think I read that comment here). It rang true to me, as does this.

  60. Sigh says:

    So I went to a CBT therapist for social anxiety because I’d heard it was scientifically proven to work, etc. She gave me a few worksheets to do on my own but mostly didn’t ever talk about it in 1.5 years of seeing her. So maybe the problem is that therapists aren’t excited about it or taking it seriously anymore?

    Also reading Burns’ Feeling Good for depression. I’m not sure if it’s doing any good. What other scientifically-supported therapies are there, though?

    Fluoride naturally occurs in some water, preventing cavities, which is where the idea came from in the first place. Maybe we’re all depressed because our bodies are evolved for water with more naturally-occurring lithium in it.

  61. Lila says:

    I thought people didn’t like CBT because it told them their problems weren’t real. I did a CBT exercise in which I evaluated the evidence for my beliefs about a thing that has caused horrible pain and feelings of inadequacy for years… and when I finished, I thought, “Wow, things are even worse than they seemed when I look at it objectively!” It made me completely fall apart. Doesn’t explain why CBT would become less effective over time though.

    Anyone else have this experience?

  62. Marc Whipple says:

    Obviously,the stories in the book are going to be cherry-picked, but even if this guy has a ridiculous success ratio all the time… well, good for that guy, and double-plus good for his patients. But remember what I was saying about Erickson in that last post? Erickson’s therapies were magical because Erickson was a f*****g wizard. No, seriously, he was. And the thing is, most of us, even people bright enough and dedicated enough to go to medical school and finish residency and be more than competent psychiatrists are not wizards.

    If you prefer, you can use the “two types of genius” distinction usually used by somebody talking about Richard Feynman. There are two kinds of genius: the first is the kind that we would be just as good as, if only we were many times better. Once we see how they do what they do, how they arrived at a solution to a complex problem, we realize that we could have done it ourselves, if we only had the intellectual gifts they did. There is no magic there. The second kind are the magicians, the kind whose minds can look at a plate spinning in the air and unlock one of the fundamental mysteries of quantum physics or feel that fluttery sensation when the elevator starts to move and realize that acceleration and gravity are the same thing. Where they go, we cannot follow: we can only listen to their reports from that far place and try to use them to improve the world the rest of us live in.

    So my first response to a book full of people being cured by having something blindingly obvious pointed out to them is suspicion that there may be an eensy bit of selection bias going on. My second response, assuming that my first response is not appropriate, is to wonder if we’re dealing with a magician. (Not literally. That’s like my sixth or seventh response. I mean the metaphorical kind I was just talking about.) And if we are, great, and as I said double-plus good for their patients, but knowing that wizards exist and can work wonders of the Will and the Word is not helpful to the rest of us, and thinking that it is is actively detrimental to progress.

    • Furrfu says:

      If Erickson and Satir were wizards and their theories and beliefs were incidental, then maybe we should be teaching ritual magick, instead of theories and beliefs, to would-be therapists. (Not the Will and the Word; that’s just sorcery, and it doesn’t work in this universe.) Your implicit hypothesis seems to be that ritual magick is inherent in the wizard, like midichlorians, but it seems very likely that it can be taught. And if ritual magick, rather than rational argument, is what is effective in producing changes in consciousness, then maybe we should make the effort to train people in it, instead of hoping they’ll make it up on their own despite being misdirected with theories of psychotherapy.

      Then you just need to come up with some kind of measure with reasonable inter-rater reliability for how good the therapist is at ritual magick, and you can start readying your between-patients randomized clinical trial design.

      • It’s possible that being a wizard can be learned through apprenticeship, but it can’t be taught in a simple reproducible way.

        • Marc Whipple says:


          I think that this is true of many things, including many forms of mechanical operation and maintenance. E.G., the “knowing where to kick” joke. If we followed that guy around for ten years, we could probably figure out what cues he’s picking up on to tell him where to kick. But then we’d basically be… apprentices. Just apprentices with clipboards.

          Although I don’t know – and doubt – that it can be learned, this is closely related to my go-to theory for explaining psychic powers and supernatural phenomena, to the extent that they may need explaining beyond superstition and mistake. I think it’s quite possible that some phenomena either aren’t consistently reproducible, or the factors involved in making them occur are so complex that they literally can’t be purposefully reproduced consistently.

          While I’m carping on hypnosis, the Stanford studies which are still a major influence on the study of hypnosis purport to prove, among other things, that a relatively fixed percentage of the population can be hypnotized. The hypnotic inductions were standardized (Yay, Science!) and consisted of experimenters reading preprinted induction scripts to the subjects. Of those subjects, after the script was read, a certain percentage passed certain tests which measure various levels of depth of trance. And Bob’s your uncle, Fanny’s your aunt, we “know” what percentage of the population can be hypnotized and to what extent.

          No we do not. We know what percentage of the population can be hypnotized whilst sitting in a laboratory being read that script by an authority figure in a lab coat. This is very useful information: It gives us a minimum percentage of hypnotizability. But it doesn’t tell us anything more than that. If, for instance, a certain percentage of the population doesn’t respond well to authoritative hypnotic inductions (which turns out to be the case) it will make us think that they are not hypnotizable when in fact some or all of them may be eminiently hypnotizable, just not like that. The way you’d find that out is to follow a master hypnotist around and watch how she approaches people individually. Eventually, assuming you have the minimum level of talent necessary, you may start to pick up how it’s done yourself. Unless you have a vast amount of natural talent just waiting to leap forth, you will not pick that up through a simple reproducible course of study.

          If you want a more parapsychological example, take Rhine’s “What card am I holding?” experiment. Some people could do way better than chance – sometimes. And in the opinion of people who believe in ESP, the results aren’t consistent with “lucky streaks” such as one might expect in any large enough experiment – even accounting for the chance of luck, you get strings that the math says just shouldn’t happen.

          Well, maybe that day, the solar wind was low, the stars were right, and/or whatever other physical phenomena interfere with ESP wasn’t working. Maybe the experimenter and the subject were mentally compatible that day and the latter was able to pick up the transmissions of the former. But the next day it was a different experimenter and sunspots were more active and the subject didn’t eat the same thing for breakfast and the experimenter had a fight with her girlfriend and was mentally closed. With potential confounding factors that many, varied, and subtle, you’ll never convince any scientist that there’s any scientific plausibility to ESP. (And that’s entirely reasonable.) But that doesn’t mean it doesn’t exist and, in fact, inconsistently functioning ESP is the simplest explanation for those “the math says that shouldn’t have happened” lucky strings.

      • Marc Whipple says:

        The distinction between (metaphorical) wizards and ordinary people isn’t that they know things the rest of us don’t, it’s that their minds can go places the rest of ours can’t. To keep using Erickson (he won’t mind, he was an egotistical so-and-so) think about that cactus story. It’s in My Voice Will Go With You, and you can read a summary about it and some of his other wizardry here:

        Any bright person with a gift for metaphor could have come up with that story. But not only did Erickson do it, he did it with a person whom that story would profoundly effect. How did he do that? He was a magician. His intuition was incredibly powerful, beyond the ken of we mere mortals. You can’t teach that, either theoretically or empirically. Attempts to do so produce watered-down imitations at best or become cargo-cult pseudoscience at worst.*

        And in this case, we have direct evidence of this. What is now called “NLP” began as, literally, the attempts of Bandler and Grinder to do just that – turn Erickson’s approach to psychotherapy (hypnotherapy) into a set of principles that other therapists could use. After years and years of work and God only knows how many books and articles and blog posts and send-me-money-and-I’ll-teach-you-to-talk-anybody-into-anything scams… It works great for a few people, it works somewhat for a few more people, and most people who try to learn it end up sounding like a much less successful Mister Subliminal. (If you’re not familiar with Mister Subliminal:

        Why? Because while you can introduce talented people to areas they didn’t realize they were talented in, you can’t introduce talent to people who don’t have it. A lot of things we think of as “talent” can be learned, but this is not one of them. You can get better at interacting with people, absolutely. But you are born a magician: either you are one or you aren’t.

        So while I’m actually sympathetic to your view about magic (SWITD?) in this case I don’t think it would work much better than what we have now. In the words of a hapless engineer, “I’m not Tony Stark.” And telling other people that Tony Stark exists and does a lot of cool stuff will not produce a legion of Iron Men.

        *The alternate explanation – that the legend of Erickson’s prowess is a result of selection bias – is even less helpful in making a case that this is ritual magick which can be learned even by would-be wizards who don’t know why it works. If he really just walked around trying to hypnotize everybody he met and only told stories about the ones it went well with… well, Hell, I can do that.

        • Furrfu says:

          I don’t think this is metaphorical wizardry; we’re talking about exactly the kind of changes in consciousness that are the stock in trade of, say, shamans. Insofar as our cultural myths of Merlin or Circe are based on a real social role that was played by real people, they are people like that.

          I agree that NLP was claimed to be able to train you to be such a person, and it does not seem to have been successful. But there are also, for example, many MFA programs in creative writing with poor success records. This is only very weak evidence that either creative writing or hypnosis is unteachable, just that we don’t have effective systems for teaching them yet. But that’s not at all surprising — we don’t even have effective systems for measuring them yet, so we’re flying totally blind when it comes to measuring the effectiveness of changes in a teaching program!

          I do think, though, that an NLP seminar has very little resemblance to the traditional means of teaching ritual magick. Maye we could try those.

  63. Izaak Weiss says:

    Alternate theory: the population that got anxiety and depression in 1980 is vastly different than who gets depression now. The people who got it back then were cured by CBT, but the people who would be cured by whatever cultural memes were actually cured and never went to doctors. The people who get it now are exactly the opposite; they need different cultural memes, and the ones who would be cured by CBT are pre-cured by society before they get to the Doctor’s office.

  64. Anr-X says:

    The obvious possible reason to me is that it’s a selection thing. Like, different things work (and don’t) for different people, and different people need different things. If there’s CBT in the water supply so to speak, then a lot of the people for whom it’s the thing that works for them already *get* it, so that leaves a higher proportion of people for whom CBT is not a thing that helps them or helps them much in ‘people who still need things’.

    (Basically like if your society had a major problem with Important Vitamin Or Something That Actually Works This Way X deficiency, then if people came to the hospital giving people X might have a huge effect on pretty many people pretty routinely. On the other hand, if you put X in the water supply, then that will probably stop being the case).

    The question this leaves is ‘why don’t we have less people in the ‘people who still need things’ category then’? To which the best answer I can think of offhand is that due to social changes etc many people are having problems for different reasons/kinds of reasons, which changes the category numbers?

    • J Thomas says:

      The question this leaves is ‘why don’t we have less people in the ‘people who still need things’ category then’? To which the best answer I can think of offhand is that due to social changes etc many people are having problems for different reasons/kinds of reasons, which changes the category numbers?

      Maybe today’s society is inherently scarier.

      I’ve seen the claim that in my children’s high school, 20% of the students are on antidepressants, and rising. Maybe it’s just a lot harder to be a high school student than it used to.

  65. ChristianKl says:

    It doesn’t seem to me that sitting down with pen&paper to write down thoughts to debug them is in the cultural water supply.

  66. undermind says:


    Therapy is an information war. Therapists are, unknowingly and unintentionally, engaged in an arms race of insights, which have to be (or seem?) meaningful to patients, and they simultaneously have to keep these methods secret as long as possible to ensure their effectiveness.

    What’s next in the therapy development pipeline? How will we use it without letting it into the water supply?

    • Matt M says:

      Scientology has done a pretty good job of managing to charge people for insights for several decades now. Perhaps they would be the case study.

  67. onyomi says:

    On the question of why people don’t seem to be a lot happier, even with CBT in the water and technological improvements, I wonder if people don’t have more chronic, undertreated ailments, even as life expectancy has continued to improve?

    I was recently thinking about how hard it is to be cheerful when in pain. The pain need not be constant or severe–though obviously that is worse–but may be as simple as minor, nagging back pain, neck pain, constipation, etc.

    I could be wrong, but given how much more obese we are now, and how much more time people spend in office chairs, etc., as well as the growth in autoimmune problems, I wonder if there aren’t a larger number of people whose mental health is being sapped by a variety of chronic, low-grade ailments?

  68. “I’ve been studying formal cognitive-behavioral therapy for about a week now, and been doing untrained ad hoc therapy on inpatients for a couple years.”

    My mouth hung open when I read that. “Untrained ad-hoc therapy”? Um…

    “Everyone I’ve talked to…”, “a lot of people tell me…”, “psychiatrists joke that…” Again, the mind boggles. Confirmation bias, anyone?

    A lot of therapists (I can say general things too) are incompetent, untrained, and lazy. This is not the fault of CBT. A lot of magazines (“Psychology Today” comes to mind) and books distort CBT as being some kind of “feel-good” self-esteem magic that works without any insight or life-changes made by the client (the “behavioral” component) – that’s a disservice to skilled therapists and patients/clients alike.

    CBT, when done properly, is very effective. But it has to actually BE done, the patient/client has to actually DO the therapeutic assignments, and other aspects of the patient’s/client’s life have to be incorporated – such as the family/partner, the diagnosis and general health (if applicable), and day-to-day living. In short, it’s a lot more complicated and a lot more work than you indicate.

    IF. DONE. PROPERLY. In this “patient care vs profit” mental healthcare system of ours, that is a huge “if”.

    Therapists whose patients/clients get better are few and far between, because the effective ones get fired. There is no profit in “curing” people. There is, however, a lot of profit in having patients/clients return to their “therapists”, day after day, month after month, year after year, and having them do nothing more than vent, have conversations as if their therapist was their friend, and/or repeat their mental health history over and over again (ad nauseum) but refuse to do anything to change any patterns that might be there.

    Couple that with a therapist who doesn’t conduct therapy, but who has high patient satisfaction scores, and you’ve got high, sustainable profits for the institution. And if the therapist isn’t trained, you can pay them less! If you can get it across to the therapist that challenging Johnny’s mommy and daddy to be better parents will make them angry, and therefore lose the hospital money, and in turn endanger the therapist’s livelihood – well, is it any wonder therapists get a bad rap? Is it any wonder people not only do not like CBT, but don’t know what it is, even?

    As a therapist who is now on (I hope) temporary disability, who has lost jobs due to coming down quite clearly on the side of patient care (vs profit), and who now authors a blog that addresses these very issues, I am appalled by this article and its flippant tone. So many good therapists have been sacrificed in lieu of untrained “mental healthcare workers” in order to make more money, and to read articles like this….I don’t even know how to end that sentence, quite frankly.

    Being able to sleep at night should not come at the expense of one’s career, but in this field is it perhaps inevitable – until people start really caring about the patients.

    • Scott’s ~halfway into his residency, and is just now switching from inpatient to outpatient work. (Take a look at this post.) I’m reasonably certain that the ad-hoc therapy he refers to is probably more conscientiously delivered than that of many professionals; my guess is that he’s doing it in addition to his regular duties, in an attempt to help patients that goes above and beyond what is asked of him.

      Though I have no locus standi in this, I’m still offended at what you’re insinuating about Scott and his character. Please take the time to read his other posts, specially on psychiatry, before implying-but-not-stating accusations like the ones you’re hinting at.

      And if you want brilliant insight into the very issues you appear to be concerned about, and which have apparently affected your life (how incentives affect things, profit and competition being merely one of the incentives), with a depth and clarity that I think you haven’t encountered before, take a look at Scott’s Meditations on Moloch.

  69. Sasha says:

    It’s also possible that your feelings about CBT have to do as much with how it challenges what you believe about yourself and the value of what you do as it does about the value of CBT itself.

  70. Asterix says:

    I believe the appeal of CBT is primarily its philosophic basis. It sees us as computers; well, we see ourselves as computers. It emphasizes rationality; so do we. It identifies thought as crucial and emotion as an epiphenomenon; so do we. By contrast, Freud is creepy and weird, and Jung is as irrational as, well, these emotions we don’t like.

    Which I think is why I always found psychodrama powerful and CBT useless. Besides Scott’s point that if a CBT thought was useful (and some are), I could think it w/o needing to look it up in Burns or hear it from a counselor.

    I was clinically depressed for 10 years. Almost every therapist I had was cognitive, and they did me little good. In particular, when it was really black and I had repeating suicidal thoughts, I could mentally yell “STOP” at them all I wanted, and they were undeterred. When I felt better, I didn’t need to yell STOP or argue that they were irrational, because they were gone. The thoughts didn’t cause the feelings. Either the feelings caused the thoughts, or both were caused by something else.

    • Here’s something I’ve been doing which seems to be putting a dent in self-hatred. What I’m up against is frequent, irrational, and nasty– for example, I turn towards going downstairs to take out the garbage and the voice in my head says “You fucking stupid incompetent piece of shit”. It seems to largely be activated by my taking action, especially anything that useful for me, and by my thinking I’ve done something right.

      I did not grow up with that sort of language and the voice (except for the content) sounds like my usual internal monologue– it’s not the voice of anyone I’ve known. Sometimes it goes around the theme of “If you were any goddamn good, you’d kill yourself.” (I’ve tried telling it that if I die, it dies. It doesn’t care.)

      After a lot of observation, I found that there’s a mood of irritation that precedes the voice. (Think of irritation as being ready to be angry.) Also, reaching (say, for getting food at a buffet) can set it off. I believe that habitual thoughts of all sorts come with habitual physical patterns. That’s why, sometimes if you know someone well, you can tell what they’re thinking by looking at their face.

      Anyway, the I noticed that I could actually feel tension in by upper back when the voice was attacking, and what I’ve been doing is, after a sentence of attack, I relax my upper back. Then I repeat the sentence to see whether it feels like an easy pattern of behavior. If it still feels easy, I relax my back again. It usually takes several repetitions for the attack to feel like something that doesn’t have any habitual pull. I’ve been trying paying attention to what’s around me as well as my back tension to see whether an external focus helps. Next project, if I can manage it, is relaxing back tension before an attack sentence is completed. Or even observing back tension while the attack is going on.

      I’ve been trying to do this (and mostly succeeding) every time there’s an attack– I think it’s important for me to not pass off those attacks as just one of those things that aren’t bad enough to bother trying to deal with.

      I’ve only been doing this for a couple of weeks, but the attacks are less frequent and I’m finding it easier to get things done.

      If your negative thoughts are initiated by high stress levels (it was quite helpful for me when a friend pointed out that I was especially having problems with my attack voice after I’d been anxious for a while), then yelling at them might be a bad strategy.

      I’m cautious about offering this as advice in general. Partly, it’s that I’m not sure that re-initiating attacks to see whether I’ve actually defused them is safe. The other is that I’m not sure how feasible the approach is for people in general– I’ve done a lot with self-observation and body work, and a lot of people might need to do preliminary work to be able to notice muscle tension, relax it, and track whether an attack has been defused. I’ve gotten cautious about giving advice in a tone which implies that everyone ought to be able to follow it.

      I do recommend doing something gentle for yourself after an attack. Aside from the value of self-calming, it’s a way of you saying that you value yourself.

      I’m using a neutral tone, but really, the attacks have been going on for years and it’s pretty awful.

      • houseboatonstyx says:

        Drat, I just lost a long post about kinesthetic people, the James-Lange Theory of the Emotions, and baggy pants at the YWCA yoga poses.

        • Deiseach says:

          You say baggy pants, that makes me think of Baggy Trousers 🙂

          • houseboatonstyx says:

            Well, the index card notices on the YWCA bulletin board said “Wear loose comfortable clothing” and what we wore was sweat pants, but they were old and loose and comfortable and baggy, as were the teachers. And we learned some classic poses to hold and relax and breathe normally in.

            Then along came the yoga teachers who advertised Iyengar and made us wear tight leotards and corrected our postures to look good in glossy four-color photos with unfocused background in their shiny studios, and then their next generation said “Hey, we do yoga aerobically!”

      • Leo says:

        I grew up with such a voice. It berated non-stop me for years, and it was certainly convinced of its own invulnerability. I was quite surprised how easy it was when I told it to stop existing and it did.

    • Asterix says:

      Hey, that sounds helpful!
      Something I tried that helped on some issues (not suicidal thoughts) is to personify a cluster of thoughts and have a conversation with it. So, Internal Accuser, what do you want? What are you doing to achieve it? Are you satisfied with how it’s going? Inner Child, what about you? Recurrent Anger, what about you? This is developed further in Hal and Sidra Stone’s book Embracing Our Selves.
      I generally find the persona wants to help in some way, but it’s doing it in a way that causes problems. Sometimes it’s offering challenge: I tell you what a piece of s*** you are to see if you’re ever going to develop a backbone and shut me up!
      This is definitely not CBT! Making up characters, interviewing “people” that don’t exist, negotiating agreements between them? But I find it an effective way to make changes happen relatively quickly — for some things.

  71. CJB says:

    My answer- it works fine for people like the people in the examples.

    The people in the examples don’t actually have problems. They just think they have problems. The first guy is ACTUALLY massively accomplished- you just have to sell him on it. The second guy is ACTUALLY good at relationships- you just have to sell him on it.

    Joe Schmoe with depression because his life sucks…..actually has a sucky life. He’s not The Greatest Of All the Doctors. He’s not even an above average CPA. He’s some dude with some crappy life, and the reason he’s depressed/anxious is he thinks he’s some dude with some crappy life. And yes, his friends would describe his life and their lives and all the lives of people like him as “crappy.”

    • onyomi says:

      I kind of agree with you, but I think this points to a strongly relativistic aspect of human happiness which, may, unfortunately, make unhappiness highly resilient even as living standards get even better.

      For example, the living standard of the guy who finds his life to be “crappy” in 21st century US would probably be a dream for most people in most of history. But he naturally judges his life not by historical and world standards, but by the lives of the people around him. And it is hard to be happy with a comparatively crappy life, even if it is a great life in absolute terms.

      That said, there may be a few ways in which our lives tend to be crappier in absolute terms, most of them probably having to do with lack of social cohesion and not being in touch with nature.

      • CJB says:

        I think you’re looking at it backwards. This actually ties into a deeply rooted part of my personal philosophy that boils down to “suffering is necessary.” Joe Schmoe isn’t unhappier despite higher standards of living, but because of them.

        Seriously- people want to eliminate suffering from their lives, but all that a lack of suffering produces is whiny, dilettante people. We can talk about Tumblr or the Tea Party or Bronies or MRAs or whatever group pushes your “whiny dillettante” button- but overwhelmingly, those groups consist of people who, famously, are so well off they MANUFACTURE grievance, or social transgression, as a sort of suffering methadone. No, I don’t really get to Stand Up To The Man For What I Believe- but I get to stand up to trolls, and that feels the same.

        People- honestly, people in the modern world WANT to suffer. They just call it other things. Like “I want adventure” or “I want meaning in my life”, or “I want to fight for something” or “I just wish I could throw everything away and go out into the wild and live on berries haha please help I’m living a life of quiet desperation under fluorescent lights”.

        (And now I’m about to get twenty responses going “MYYY suffering hasn’t helped any!” and “the best guy I ever know was born with a whole silver cutlery set”- yes, there’s exceptions. It’s a general trend, not a physical law)

        Happy people and people who don’t suffer are not often the same people. One too many rich girl burnouts coupled with one to many happy old men with gnarled hands and no money has sold me on this.

        Or to put it briefly:

        Homo Sapiens doesn’t want to be fed. He wants to HUNT.

        • Creutzer says:

          What’s the definition of “suffering” behind this theory? The psychological pain that the person “in quiet desperation under fluorescent lights” experiences seems like real suffering to me.

          I have a feeling that you may be conflating two things. First, the phenomenon that you’re actually talking about; and second, effects of social isolation and large numbers of people being irredeemably low status in contemporary society. Perhaps you’re trying to explain the latter as “manufactured grievances” because of the first; but I really don’t think that’s right.

  72. Faradn says:

    @Sigh and Deiseach

    You have both touched on an assumption in CBT that I’ve noticed. The assumption, which seems central to the philosophy of CBT, is that the world is a fundamentally nice place and that there is a clear universal standard by which everyone is awesome. Treating the patient is a matter of getting them to see the World of Awesome; this is treated as a trivial task because any failure to believe in the World of Awesome is an obvious logical error.

    Therapists do sometimes acknowledge that there are some painful realities that can’t be changed. Their solution tends to be a pat “don’t worry about things you can’t change” without offering any more sophisticated strategies for accepting these realities. The assumption seems to be that if something can’t be changed, it wasn’t that important in the first place. CBT thrives on trivializing patients’ feelings.

    Or maybe the mind simply doesn’t have a good mechanism for acceptance other than putting its attention elsewhere. Hence the Behavioral portion of CBT. For someone who is introspective enough to have thought of a lot of most therapists’ objections to their negative thoughts, it’s possible that behavioral advice might be the most useful thing a CBT therapist has to offer.

    • Deiseach says:

      That’s the problem with The Story of Nathan. By any objective measure, Nathan had a successful life with real achievement. He was good at his job, he could easily get another. We didn’t hear anything about problems in his marriage/family life, debts, illness, etc. (which may have been there as well, we don’t know) so all we are left to go on is that Nathan was being too hard on himself and was a perfectionist, and once he was shown a way to stop focussing on trying to be impossibly perfect, his problem was solved.

      Would Dr Burns have been so successful with Nathan who said “I have an ordinary office job, not very high-paying, not much in the way of savings; I’ve already gotten three warnings about my work performance and I’m worried I’m going to lose this job. At my age, and with my mediocre qualifications, I don’t think I’m able to get a new one, and on top of that my wife is undergoing treatment for breast cancer, my son is drinking too much, and the landlord won’t renew our lease once it’s up because he wants to sell the property to developers”?

      • Leo says:

        Well, the point isn’t to make the guy happy. It’s to make him not depressed; i.e., to allow him to try to fix parts of his sucky life, rather than get overwhelmed and collapse.

        Why is therapy that makes you unconditionally happy better than therapy that just stops your misery spiraling out of control, while meds that make you unconditionally happy are evil and we have to swear up and down that they just stop your misery spiraling out of control?

  73. Esquire says:

    There’s an explanation from Steve Sailer’s writing on motivational speakers that might be right here. Maybe Dr. Burns is an extremely charismatic guy, and personally interacting with him has great placebo properties or maybe even actually does help people heal. Maybe the early CBT practitioners were all sexy rebels or, more plausibly, were ones who tried it and found it worked really well.

    Basically, if there is a small subset of therapists who can apply CBT to great effect, either due to their personal healing halos or due to having personalities/approaches that are synergistic with CBT, you would expect to see its effects decline as it becomes mainstream and your median therapist starts trotting it out as part of the standard menu of treatment options.

  74. Ant says:

    There is at least 2 countries in which it is psychoanalysis which is the dominant therapy: France and Argentine. At least in France, psychoanalysis is completely integrated to the culture and is dominating (for instance, when a book against psychoanalysis come out, it is often reviewed in newspaper by a psychoanalyst or a devout follower).

    From what I know, the mental health of French people seems to be one of the worst in the world (most depressed people of the world, most consumption of anti depressor of the world, high rate of suicide for a developed country). While they are other reason than the lack of efficiency of psychoanalysis for these factor (few people can afford psychoanalysis, job market that predisposed for this problem), I think that the psychoanalyst angle is a cause of that (for instance their treatment of autistic people worsen the problem).

  75. Azure says:

    Given the way LSD makes your brain go “BANG! FEELING OF INSIGHT!” even when you’re coming up with ideas you’ve had before, I wouldn’t be surprised if this is behind a lot of the effects people give it credit for.

    But now you make me imagine some super-theatrical psychotherapy with flash paper and music where the therapist talks to you and recasts every therapeutic instruction in the form of a reading of whatever Tarot cards are drawn. Or derives it from the an I Ching casting, just to try and cash in on as much new, novel experience and off the wall insight as possible.

  76. It wouldn’t surprise me if a lot of modern people have more background fear than people in the past, even though life is objectively better in a lot of ways. It may also be objectively worse for the majority in some ways– insufficient sleep and sunlight are more common than they used to be, for example.

    The big difference is that now there’s cultural pressure to never relax. I imagine that when hunter-gatherers had a big kill, they had a big meal and enjoyed it. No one was telling them to worry about possibly running out of mammoths. They didn’t have bureaucracies causing complicated problems which might take years to resolve. They didn’t think their culture might collapse because they just couldn’t get things right.

  77. locrian says:

    Are you only talking about the Cognitive part of CBT? Because in my experience it was the combination of the (very formalized) Cognitive component WITH THE BEHAVIORAL COMPONENT (which seems to be left out a lot) that had a major effect on decreasing my social anxiety symptoms. I had tried multiple meds, regular talk therapy, etc. and nothing (not even alcohol which is supposed to make you less inhibited!) to no effect but it was really doing the exposures that got me 1. comfortable feeling anxious, and 2. decreased my anxiety in social situations so that i was able to function like a regular shy person and NOT fail out of school. Note that this DID take a huge amount of effort on my part, it was basically like adding another class to my schedule, i went to therapy every week, did homework daily, did all the exposures, recorded everything. Writing down stuff and doing the stupid patronizing cognitive part was helpful too, because while I KNEW that my thoughts were completely irrational, if i replaced my worrying with the formalized CBT “worrying” I could avoid hours long rumination session and actually get on with things. The results were lasting, unlike medication, and no side effects such as the mild anterograde amnesia you get with benzos.

    However I will say that I found CBT to be completely useless for depression. But I think this is due to my depression not being a behavioral or cognitive problem.

    CBT works for anxiety, IF it is formalized, IF it includes the full behavioral component WITH EXPOSURES, and IF the patient puts in the work. There is no reason that the exposure part shouldn’t work – if you can be trained to have the anxiety, if you can be trained to have any response to anything, why would you not be able to be trained to have a different response? But this component is often left out of CBT for whatever reason and people focus on the cognitive restructuring. The exposures component is the most important IMO. It is just like training a dog.

    My advice to people looking for real, actual CBT: get enrolled in a research study if you can. The clinicians administering the CBT will be motivated to make it the real deal or risk compromising their results.