life

When CBT doesn’t cut it.

I’m not a psychologist, but I’ve been through some stuff — including several attempts at cognitive behavioral therapy. Here’s why it didn’t work for me, and what I did to get to where I wanted to be.

Cognitive behavioral therapy is considered the gold standard for treating anxiety disorders. It’s a reputation that isn’t entirely undeserved — there’s a load of research demonstrating its effectiveness, both combined with medication and on its own. It’s often the first thing that a doctor will suggest when a patient presents with anxiety problems.

CBT relies on recognizing thought patterns that we have that don’t line up with reality. The underlying concept is that, when we can identify distortions in our thinking, we can prevent or intervene in those distortions and keep them from negatively impacting our feelings and behavior.

But what do you do when CBT doesn’t work for you?

If you’re me, that means feeling like a failure and going into a deeper anxiety spiral first.

I first tried CBT through a workbook. It was helpful, but definitely not a substitute for going through it with an actual therapist. So, when that opportunity presented itself, I jumped on it.
And left feeling like my anxiety was entirely my fault.

I was able to identify distortions in my thinking, that wasn’t the problem. The problem was that identifying and reframing them didn’t actually seem to have much of an effect. My first therapist eventually cut me loose when I failed to make substantial progress after a few weeks, and oh boy did I feel like a lost cause.

There’s definitely something wrong with the messaging surrounding CBT. Because so much of it relies on the patient identifying and reframing cognitive distortions outside of therapy sessions, CBT comes packaged with a hearty side of moralizing — if it isn’t successful, it’s because the patient wasn’t willing to “put in the work.”

That’s not true.

When medication doesn’t work, you try a different one. When other modalities don’t work, you try another therapist or another type of therapy. When CBT doesn’t work, it might not have anything to do with your level of effort, willingness, or ability to get better.

Why CBT Wasn’t the Answer for Me

Don’t get me wrong, cognitive behavioral therapy has been enormously helpful for tons of people. I suggest that everyone at least try it, because it can be great for reducing some anxiety symptoms. There are two big reasons why I didn’t achieve the results I hoped for:

  1. It offered behavioral strategies for what might be a chemical and genetic issue.
  2. It didn’t help my specific worries.

Panic disorder can look like anxiety, but it definitely doesn’t feel like it. Panic attacks show up seemingly out of nowhere, and the idea behind treating them with CBT is that a panic attack happens when we catastrophize a sensation — like shortness of breath, or palpitations. This might be the case for some people with panic disorder, but may not be for all. Unfortunately, accepting the premise behind this treatment is what leads to some of the “victim blaming” mentality surrounding CBT.

If I’m bopping along, feeling perfectly fine, and suddenly get hit with a full-blown, unable-to-breathe-or-move panic attack, there’s no time. That overwhelming, unprovoked rush of adrenaline isn’t mitigated by identifying and reframing my thoughts. While cognitive behavioral therapy was helpful for reducing some manifestations of my anxiety, it wasn’t helpful for my panic attacks — the whole reason I was pursuing CBT in the first place. If I didn’t think my way into them, how was I going to think my way out of them? CBT gave me something to do for the twenty-odd minutes it takes for a panic attack to resolve anyway, but it didn’t actually seem to change anything. I couldn’t just think myself better. Knowing it was “just” a panic attack didn’t stop the chest pain, shortness of breath, terror, or inability to move.

It also didn’t help my obsessive-compulsive behaviors. Yes, I know that it isn’t logical or helpful to check the stove burners exactly five times each before leaving the house. I know that it doesn’t make sense to smell my hallway every hour to make sure there isn’t a gas leak. Even forcing myself to not do these things so I could achieve “mastery” over them did nothing to reduce the torment.

(I’m not alone, either. The NIH says that, “Unfortunately, CBT doesn’t work for up to half of people with OCD.” As it turns out, spotting activity in different areas of the brain may be a helpful predictor of what therapy might be the most effective for a specific patient. Not everyone with OCD has the same level of activity in the same areas.)

It didn’t help my cyclical bouts of minor depression, either. This was largely because they’re another thing I don’t think my way into, they just happen. I already recognized that they don’t last forever, but they were still as frequent and as soul-sucking after CBT as they were before it. Womp-womp.

My other problem with CBT was that there are some outcomes that just are catastrophic. If I’m afraid of performing in front of a crowd, it’s relatively easy for me to say, “What’s the worst that can happen? What am I afraid of? I’m afraid of bombing and embarrassing myself. That probably won’t happen, but what would be the outcome if I did? It won’t kill me. Nobody’s going to physically attack me. I’ll probably never even see these people again, so, if the worst actually did happen, its impact on my life would be momentary, at best. The people in the audience might go home with a funny story to tell about me, and that wouldn’t be so bad. I can defang the situation by being willing to laugh at myself.” It helps!

This was less helpful for me for, say, health anxiety. “What’s the worst that can happen? I die and it hurts the entire time. That probably won’t happen, but what would be the outcome if I did? I die, it hurts the entire time, and my loved ones suffer in the process. If I’m wrong, I’m fine, but if I’m not, it’s literally the worst possible outcome.” There’s only a slight chance that I have some potentially fatal undiagnosed health issue (something that I’ve actually experienced), but, if I do, I’m still 100% dead if I don’t act on it.

It wasn’t helpful for the anxiety surrounding a past sexual assault, either. I’ve been through that. I know how awful it was. The feelings are a product of experience, not catastrophizing. My reframed thoughts felt like lies.

In short, it wasn’t a great fit for me.

There are other issues with CBT, too. A big one is that it’s a bit of a darling for insurance companies. They love it because it doesn’t take long (a few weeks, as opposed to months or years for other therapies) and doesn’t cost much to cover. For this reason, your insurance company is likely far more willing to pay for CBT… and not much else. For a patient with significant trauma, a genetic predisposition to mental illness, neurotransmitter imbalances, chronic illness, life stress, or any number of other contributing factors, a couple of sessions and some homework probably isn’t going to cut it.

Another is that, even though CBT puts the patient in the driver’s seat, the therapist is still important. If you’re working with someone who comes off as uncaring, off-putting, or smug, you might not be in a great environment for you to learn and implement the therapy. This can be especially difficult if you’re working with someone who emphasizes the techniques over everything else — there were definitely times when I felt more like a collection of behaviors, and not like a human being with my own traumas, genetics, and brain chemistry.

The underlying premise of cognitive behavioral therapy is that your thoughts influence your behavior and mental health. If your therapist hammers at that to the exclusion of other factors, you could be missing a big part of the picture.

I’ve read some other interesting theories on why CBT doesn’t work for some forms of anxiety. One of them proposes that executive function shuts down when anxiety gets too high. Some people are able to engage their cognitive techniques before this occurs. If you already have trouble with executive function, or your arousal ramps up too quickly, this can’t happen in time. In those cases, your brain needs to rely on automatic self-soothing mechanisms that trigger relaxation via the parasympathetic nervous system and the release of oxytocin. I can’t speak to this personally, but it would explain a lot.

What I Did Instead

So, cognitive behavioral therapy didn’t work. What’s next?

After feeling like I needed more therapy to overcome my feelings about “failing” at CBT, I looked at other options. I still had medication, so that was helpful, but not as helpful as it could be combined with therapy. I knew that part of my problem was that my ex-therapist’s approach seemed very inflexible — there was no room to consider what other factors could be contributing to the problem. Every negative feeling had to be proceeded by a thought, and, if I couldn’t identify and “fix” that thought, I was doing it wrong.

So, I read over the “About” pages of a number of psychologists, eventually settling on one who mentioned methods other than CBT. And I lucked out.

The therapist I ended up seeing — with whom I’ve been very happy — uses CBT as part of a larger collection of therapies. We’ve worked on my past trauma. We’ve worked on my self-esteem. I get things to read and homework to do that have helped me grow, not feel like a failure for being unable to think my way out of a panic attack. We’ve explored everything from my diet (did you know that fenugreek could contribute to depression? I didn’t!) to physical relaxation techniques like progressive muscle relaxation. I feel like a person, not like a disjointed cloud of thoughts that need to be corrected. My panic attacks are less frequent and easier to deal with, and I can recognize the signs of an impending bout of depression and take steps to make it less disruptive to my life.

CBT doesn’t work for me. It’s the go-to treatment for anxiety because it’s very focused and able to produce results in a relatively short period of time, but the same things that make it work so quickly also force it to exclude other factors that can contribute to a patient’s mood. If you haven’t tried CBT, at least give it a shot — it teaches valuable skills. If you have tried it and you’re feeling disheartened, that’s natural. You aren’t a failure. There are plenty of other therapies out there that can help. They might take longer, you might have to try a few different things out, but they work. You’re worth the time and effort.

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