Why Does Cognitive Behavioral Therapy Work?
Remembering is more important than knowing.
Posted Jan 29, 2015
Modern cognitive-behavioral treatments weren’t available just a few decades ago. Early versions of behavior therapy were developed in the 1950s and '60s, with refinements of the treatments continuing into the present. Aaron Beck wrote his groundbreaking book on cognitive therapy for depression in 1979. Sixty years ago the Association for Behavioral and Cognitive Therapies, the leading professional group for CBT clinicians and researchers, didn't exist.
Thanks to the development of these treatment programs, countless women, men, and children have been able to reclaim their lives.
At the same time, the principles of CBT are hardly new. At least since the time of Greek philosopher Epictetus nearly 2000 years ago we've known that "People are not disturbed by things but by the view they take of them." Is that idea any different from 20th-century cognitive therapy?
Long before Emerson said to "Always do what you are afraid to do," humans have known that the best way to overcome our fears is to face them.
The history of mindfulness goes back thousands of years to Buddhism and Hinduism, a long time before it was popularized as a non-religious Western practice. Before there was MindfulnessTM there was the common realization that staying in the present and accepting what is can quiet our troubled minds.
If many of the basic tenets of modern CBT have been around for hundreds or thousands of years, what does CBT add?
For one thing, CBT programs tend to be very structured and systematic, which makes it more likely that a person gets an adequate “dose” of thinking and acting in healthful ways. It’s no different from being on an exercise program that turns knowledge about the benefits of physical activity into action.
For example, CBT for depression asks a person to write down the thoughts he has when something upsetting happens, and then to work with the therapist to test how helpful and accurate those thoughts are. Repeated and focused practice is an integral part of CBT.
Another big advance of CBT is its contribution to a clinical science. Once we’ve created treatment packages, we can test those packages in rigorous studies to find out how long treatment may take for a given condition, and how likely a person is to benefit from it.
Perhaps the most important part of CBT is not that it teaches us things we didn’t know, but that it reminds us of what we need to do. Most of the time we flourish not by learning new things but by remembering what we already know.
Do we not already know that we need to exercise and eat well to feel our best? Have we never heard that building healthier relationships is good for us? Is it news to us that allowing our minds to be cluttered with distractions doesn’t lead to emotional health? CBT is less about imparting information and more about building new habits.
Cognitive therapy helps by repeatedly showing us where our thinking leads us astray, and offering better alternatives.
Exposure therapy helps by encouraging us to gradually and repeatedly face the things we’re afraid of, not by having someone tell us, “You know your fears don’t make sense.”
Programs like Mindfulness Based Stress Reduction (MBSR) are powerful not because they invented age-old activities like yoga and sitting meditation, but because they packaged well-tested techniques into a focused program that encourages consistent practice.
Even exposure and response prevention (ERP) for OCD, arguably the most counter-intuitive CBT program, relies on repetition and a systematic approach. The basics of ERP are to face the things that trigger obsessions and not do compulsions. Understanding what a person needs to do in ERP is not the key to healing; consistent and progressive practice is what gets a person there.
Sometimes I tell a person I’m treating in CBT that I’m going to ask her to do some “stupidly obvious” things. For example, if a person is avoiding everything she enjoys, we’ll work to … (wait for it) build back into her life the things she enjoys. This is not rocket science. And it’s at least as good as the latest medications in helping a person get her life back.
Countless studies have been conducted to understand if and how CBT programs work, and for the most part, the programs boil down to a few basic principles that we’ve known all along. We just needed reminding.