tim: text: "I'm not offended, I'm defiant" (defiant)
Tim Chevalier ([personal profile] tim) wrote2017-02-14 09:02 am
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Why CBT Is Bad

Cognitive-behavioral therapy often gets pushed, to the exclusion of all other therapy modalities, for a range of mental health issues: depression, anxiety, insomnia, phobias, addiction.

I can't speak to how well it works for all of those issues, but one of the things wrong with it -- not with it, rather, but with the privileged place it's been given in the current medical model of mental health issues -- is that it's close to useless for people with a trauma history, and trauma is the underlying cause of all five issues I mentioned for many people. (I could write a separate post on why it's been given that privileged place, but I'll leave that to your imagination for now.) I am not a medical or mental health professional, just someone with a lifetime of personal experience.

[personal profile] azurelunatic's post about being prescribed a CBT workshop for insomnia is a great example. When I read it, I thought about my own sleep issues and how useless every behavioral approach -- both CBT-type approaches, and "sleep hygiene"-style approaches -- have been for it.

I have obstructive sleep apnea, so no behavioral approach can address the fact that untreated, I wake up more tired than I was when I went to bed, because I wake up many times an hour unable to breathe. But the main issue is that my body learned when I was a child that sleep was dangerous, and neither cognitive nor behavioral approaches can make my body unlearn that -- it's something I learned before I was developmentally able to use cognition or to reflect on my behavior.

As a child, I had an abusive parent who would force me to go to bed hours before I was actually ready to go to sleep, because she thought it was good for children to be on a regular sleep schedule. (Or because she wanted to control somebody and doing things to children that are generally believed to be for their own good is a socially acceptable way to do it. I don't really know.) So I learned that sleep meant lying in bed for hours, awake and intensely bored but not allowed to get up and do anything. When I got a little older I would get up and night and go into a walk-in closet in our apartment and read for as long as I could get away with it. When my mother figured out I was doing this, she unscrewed the light bulb. I learned to associate sleep, as well as going to bed early, both with an abusive parent who I knew was incapable of knowing what was good for me, and with hours of boredom and anxiety.

Therapists (and others) who apply CBT simplistically would tell me that the lasting, physical residue of these years are "cognitive distortions" that I need to reason my way out of. They would be wrong, because there's nothing distorted about mechanisms I learned in order to keep myself safe. Being awake is safer than being asleep in an environment that is dangerous for you, and for a child, there's nothing more dangerous than an environment that contains an alternately intrusive and inattentive caregiver and nobody else.

It's safe for me to relax now, and has been for the past twenty years, but because trauma changes your body in chemical and physical ways, just telling myself that won't make me go to sleep. I use chemical solutions to a chemical problem: medication. Maybe someday, I'll have had enough trauma therapy that I won't need it as often. But in the meantime, I'll be able to get enough rest and avoid some of the constant physical stress that arises from inadequate sleep.

CBT is politically attractive because it individualizes responsibility . Better to blame people's suffering on their own cognitive distortions, and teach them that they need to do work to overcome them (under capitalism, any solution that gives already-overworked people more work to do gets conferred with near-religious levels of praise), than to recognize that abuse culture harms people in long-lasting ways. If we recognized that many parenting practices widely considered to be non-abusive, or even helpful, in this culture are actually traumatic, we'd have to rethink a lot. Better to avoid confronting that by privatizing trauma and recasting it as individual pathology, ignoring the patterns in front of us.

Mental health is (I suspect) not the default state of human existence in the first place -- our brains are complicated and have too many failure modes for that. But in a society that depends on denial -- of the lasting effects of slavery (denial of the effects on white people, mostly), of the violence done by income inequality, and of the corrosiveness of toxic masculinity -- self-awareness is rebellion, and thus it's not surprising that to find therapies that foster it rather than providing a few tools to be economically productive while hurting inside, we often have to look outside the mainstream.
redbird: closeup of me drinking tea (Default)

I think the causes of my symptoms are different from yours

[personal profile] redbird 2017-02-14 06:08 pm (UTC)(link)
I found CBT useful for anxiety, because my anxiety was such that being able to look at the situation and remind myself "the worst that will happen is that you're late for the eye doctor, and they either see you anyway or reschedule" and "yes, you went to the wrong bus stop, but you also allowed enough time that you caught the bus anyway" actually helped.

But in addition to individualizing responsibility, I suspect there's a certain amount of "there are a lot of problems that are kind of vaguely the same thing (i.e., they fall under mental health), and here's a tool that has actually been proven to work sometimes, so let's try using this hammer to fasten a nut, and do some wood carving."

I will also note here that CBT wasn't the only approach my therapist used; some of it was discussing details of the situation, recognizing that it bothered me, and having a safe place to be unhappy about things that weren't going to change barring major medical breakthroughs. (Being angry at something that a person or group of people have done is different, in my experience, from being angry at what my own immune system has done: there's no volition in the latter case, and no independent consciousness to try to persuade.)
azurelunatic: A glittery black pin badge with a blue holographic star in the middle. (Default)

Notes: abusive parents, suicidal ideation

[personal profile] azurelunatic 2017-02-14 09:02 pm (UTC)(link)
It's not actually a cognitive distortion if you're reacting like you could die, and one of the strong risks of what you're doing is in fact death! But it can be used to shift the blame back where it belongs.

My internet daughter (who was raised by an abuser and an enabler) viewed difficult homework assignments as an existential threat. That was because she had realized that she would probably in fact attempt or complete suicide if she had to go through college with her abusive mother in direct control of her education. Her best route to independence at college was a full scholarship, which depended on academic performance. Which meant that difficult homework assignments that could affect her grades were an indirect existential threat.

So we worked to try and get her to college in a way that her mother had no control over, and meanwhile she continued to panic over difficult homework because it could decrease her chances of escape. But identifying the distortions and re-framing them meant that she was panicking with an increased awareness that she wasn't having a hard time because she was stupid, it was because her mother was an abusive snotrag.

And now that she is in college as an independent student (thank you, youth shelter and technical homelessness), it's safe for her to take anxiolytics when she panics around tough homework, because we know where the panic is coming from, it's no longer a concern, and there's no reason for her to suffer through it and give it more of a hold on her.

Anxiolytics would probably also have helped her spend more time on what she wanted to do in high school (which was mostly studying and reading, rather than panicking and crying and struggling to find time to study or do anything fun), but the gatekeepers there were not going to be inclined to help out. Unfortunately.
Edited 2017-02-14 21:03 (UTC)
siderea: (Default)

Re: Notes: abusive parents, suicidal ideation

[personal profile] siderea 2017-02-15 05:16 am (UTC)(link)
What you're describing in this case are not cognitive distortions.

One of the things I despise about the CBT cultural hegemony our host decries is how it has resulted in this crude, bastardized form of Cognitive Therapy becoming the jargon that lay people use. It's as bad as, back in the Freudian days, everyone calling everything a "complex".

When somebody has an unlikely and extreme emotional reaction to something apparently relatively benign, and it is remedied by realizing that the reaction is actually perfectly reasonable given some specific, unobvious circumstance (present and true or past and remembered), that form of clinical intervention is called insight.

Insight based therapies are ones predicated on the idea that understanding one's self results in the remission of symptoms. The classic example of an insight based therapy is Freudian psychanalysis; there are others. I gather Gestalt is similar. I'm a Rogerian, and played at a high enough level that becomes an insight based therapy too.

Historically, CBT snobs have made much of their contempt for insight and insight based therapies. CBT was held out as the opposite of insight-based therapies, and, indeed, did not require insight. Insight requires time-consuming investigation of each case; insight-based treatment is always bespoke, customized to the patient. Insight requires intense listening and attention to a patient over a long time, getting to know them deeply.

CBT was sold as the BigMac of therapies: eight sessions, out of a standardized workbook, and you're cured. Or you're resistent to treatment and it's all your fault you're ill. CBT partisans bragged that they didn't need to "waste" huge amounts of time listening to patients to figure out what was wrong with them. CBT already knows all the answers, and they have "Evidence" to prove it.

Of course, that's rarely how CBT is practiced in the wild, today. Turns out insight – and spending time listening to the patient – aren't optional in psychotherapy.
sasha_feather: Retro-style poster of skier on pluto.   (Default)

[personal profile] sasha_feather 2017-02-15 07:58 am (UTC)(link)
under capitalism, any solution that gives already-overworked people more work to do gets conferred with near-religious levels of praise

*thumbs up*
jesse_the_k: ACD Lucy holds two blue racketballs in her mouth, side by side; captioned "I did it!" (LUCY absurd success surprise)

[personal profile] jesse_the_k 2017-02-15 07:30 pm (UTC)(link)
CBT is politically attractive because it individualizes responsibility


This explains so much. My recent experience with EMDR is the first time I haven't felt guilted by my therapist.
Edited 2017-02-15 19:30 (UTC)