When set in the very midst of troubles one should say: Perchance some day the memory of this sorrow will even bring delight.
Seneca, Letters From a Stoic.
Cognitive Behavioural Therapy (CBT) is a form of psychotherapy that began in the 1950s and 60s, based on the work psychotherapists like Aaron T. Beck and Albert Ellis. CBT has gained traction through the decades since. One of the most studied forms of psychotherapy, CBT remains a standard treatment for many clients facing a variety of issues, from grief to anxiety, depression to low self-esteem. The principles of CBT have permeated counselling therapy, such that many other modalities cohere with approaches found in CBT. It is not unusual for many therapist to use CBT techniques and approaches in combination with other therapies. Although many psychologists now consider CBT an effective treatment, trace the roots of CBT and we find the same principles in Stoicism, which aims to cultivated wisdom through ongoing reflection. The process of inner dialogue and rational examination forms the basis of CBT.
CBT begins with the premise that our thoughts and behaviours are interlinked. By changing one, we affect the other. Negative thought patterns induce negative behaviours and moods. If we intervene in the negative thought patterns, behaviour and mood will follow. Conversely, maladaptive behaviours lead to afflictive thoughts and moods (disappointment, guilt, harsh judgements on oneself). CBT aims to change negative thoughts and behaviours by replacing afflictive patterns with healthier ones. The preceding quote from Seneca instantiates an arc of self-dialogue that coheres with CBT principles. When confronted with adversity, wise people offer themselves encouragements that strengthen their resilience; their minds are oriented toward adaptive self-management rather than withering negativity.
Jane is a 27 year old woman who recently started a graduate program in nursing. On the first day of the semester, she attends a social gathering to meet her classmates, many of whom have excelled in other careers, attained other degrees and distinctions. Jane feels inadequate by comparison. She questions whether she is qualified to study with such an accomplished cohort. This bruise on her confidence makes her shy away from social contact. She becomes quiet in class, fearing judgement from classmates. As the weeks pass, her silence and reticence takes hold. She feels smaller, more invisible. Classmates come to see Jane as a quiet mouse. They do not want to make her uncomfortable, so they avoid putting her in the spotlight, thus reinforcing her invisibility. Without a chance to share her excellent insights, Jane’s confidence shrinks further. Her feelings of inadequacy have become a self-fulfilling prophesy.
A CBT therapist begin by identifying afflictive thoughts and their accompanying emotions. In Jane’s case, the thoughts start with “my classmates are so impressive; I am not in their league.” These thoughts come with a cluster of emotions: awe, intimidation, nervousness and a bubbling anxiety. In a safe therapeutic space, Jane sees that her thoughts are associated with valences that undermine her confidence. The therapist then suggests that she generate a response to her initial thought. In response to “My classmates are so impressive; I am not in their league,” Jane ventures a follow-up: “I have also done some impressive things; I deserve to be here.” When asked by the therapist whether she can respond in another way, Jane says: “My classmates are so impressive; I can learn much from them.” The therapist then asks Jane to identify the emotions associated with these alternate responses. Jane says that there is more self-assurance, positivity, and hope. In both these responses, Jane identifies the negative thought, intervenes in the cycle by steering her inner dialogue in a positive direction. The adaptive thoughts bring along a suite of emotions that allow Jane to thrive in her program.
Eric is a 35 year old man who has been feeling down for the past 6 months. He had been unhappy at work for many years. Then, his mother passed away. Eric quit his job to give himself time to grieve. He spent many days alone in his apartment, watching Netflix and playing video games. Anguish over his mother’s death, coupled with the long, dark winter days, kept him in seclusion. His previously healthy diet was replaced by processed, sugary comfort foods. Soon, he found himself without vitality, powerless to move out of the darkness that engulfed him. He wants to get his life back on track, but he cannot find the motivation to take the next steps. Eric is reluctant to apply for jobs, fearing that his next job will be as unsatisfying as his previous one. Without confidence in his future, Eric remains cloistered in his home, which he sees as a fortress against the uncertainty of his future.
In session, the therapist asks Eric to describe the thoughts and emotions associated with disruptive life-events. Eric says the past 6 months has been a train wreck; one thing led to another, and now he doesn’t know how to extract himself from this mess. The difficulty lies in the disjuncture between what Eric knows and what he is able to do. He knows that he should eat healthy, but simply can’t find the motivation to cook a good meal. He knows that he should go out and do something, but feels weighed down by a dark cloud, which prevents him from leaving his apartment. Through discussion with the therapist, Eric learns that if action always follows mood, then he is always at the mercy of his mood. Conversely, if action and mood are interlinked, then he can affect his mood by electing certain actions. Since we cannot choose our moods the way we choose our actions, we claim our agency by opting for behaviours that lead to health, and let our moods to follow. By deciding to go out for a bike ride, for example, Eric is opting for fresh air and physical activity. As he is out on his bike ride, he is pleasantly surprised to feel his mood lifting. In regards to his job prospects, disappointment over his previous employment darkens his expectations of his future employment. Further, Eric learns that a dim view of his next job exacerbates discouragement and doubt. Worse, the thoughts impairs his ability to act. In dialogue with the therapist, Eric realizes that his grim view of his future is a way to project the disappointment of his past employment, a way to reinforce his disdain for other people’s shortcomings. The therapist encourages Eric to dispute the maladaptive thoughts. Instead of “my next job will be equally terrible as the previous one,” Eric posits: “I have learned a lot in my previous work experience. I will apply what I know and find a more suitable job for me.” This thought redirects him toward brighter possibilities. Having worked himself out of oppressive thoughts, Eric puts together an updated CV for his next application.
CBT aims to alter negative patterns by negative thoughts and behaviours, then encouraging a more intentional course of thinking and acting. Some may argue that this is a superficial treatment that does not get to the root of psychological issues, such as past traumas and childhood hardships. This objection is valid and incisive. CBT is not deep psychological treatment, and therein lies its strength. CBT eschews prolonged psychoanalytic treatment, preferring a briefer intervention. It aims to restore function rather than extract psychoanalytic insight. Some CBT therapists will examine thought patterns and extrapolate core beliefs. For example, Jane’s reluctance to engage her classmates may stem from a foundational view of herself as unworthy, and the world as threatening place from which she must take shelter. CBT uncovers core beliefs without reference to the unconscious, that mysterious domain of the psyche that psychoanalysts are keen to explore. CBT prefers a practical, solution-based approach to immediate issues. For clients with limited resources, or who only need immediate support with acute situations, CBT may prove an effective intervention.
There are worksheets and tables that clients can fill out as they try to understand how their thoughts affect their world-view. Although such exercises are effective in highlighting the link between thoughts and moods, they often feel like homework. I believe that the best therapy should feel like a lively and engaging conversation. A skilled therapist will be able to draw out a client’s prevailing thought-patterns and their accompanying beliefs through dialogue and encouragement.
For more information on CBT, please see “Mind over Mood” by Dennis Greenberger and Christine Padesky. For more on Stoic philosophy, one of the primary influences that helped form CBT, please see the works of Epictetus and Seneca.