Cognitive Behavioural Therapy (CBT) is the darling of mental health treatments. Nearly every therapist I have had has in some way promoted CBT. They tout that study after study has scientifically proven its effectiveness. It’s as if they expect skepticism on the patient’s part, and they are desperate you understand that it is not some wibbly wobbly, cat poster, pseudoscience; that it’s a legitimate treatment. They want you to buy in immediately.
At its core, it is really just thinking about your thinking, about stepping back and observing your own assumptions and reactions to them, separating fact from your “cognitive distortions.” They use bigger words to make it seem more impressive.
The therapy is based on paper worksheets, some of which were photocopied and recopied so many times the hand-out was faded and flawed. As I mention in my therapist chapter, a course of therapy typically lasts 4 to 6 weeks. Some therapists’ whole spiel was just working through CBT questionnaires. They would give me homework to read and thought charts to fill in. It was not very helpful. In the end, I was left with pages and pages of proof that I had been therapized, but I still didn’t feel any better. I was told to review the worksheets again on my own and to keep working on them. I was left feeling that it was my fault it didn’t work.
I never really understood CBT until I was put into a 14-week group therapy series, where each session lasted two hours. It was part of the outpatient services offered by the Psyche Hospital, where I was an inpatient for six weeks.
Instead of worksheets, we were given a comprehensive workbook that provided a detailed overview as well as deep insights into CBT. It highlighted the interconnectivity between your thoughts, behaviour, mood, and physical sensations. In other words, if your mood is severely depressed, your behaviour, thoughts, and body will follow that lead. The darkness would then take hold, and your inner critic would have free reign to berate and destroy your self-esteem. The theory goes that if you can improve one of the four, you can lift all four. It encourages you to become your own therapist and use self-talk to calm your own thoughts. The idea is to rewrite your brain, which they confidently declare can be done. Again, they demonstrate more scientific proof that it works. Brain scans have shown changes in brain function before and after treatment.
At first, I was not impressed with the idea of a group session. I’m an introvert. I’m shy and anxious. Why would I want to share my deepest thoughts with strangers? In the end, though, it was actually helpful. It turned out that all 7 of us were depressed, anxious introverts.
The first class was painful. There were no extraverts to carry the introductions. We all gave the simplest responses possible, keeping our heads down as we talked. Noone felt their lives were interesting enough to elaborate on. Besides, we didn’t want to be judged. Happily, the two therapists had a great deal of experience with people like us. They carried the mail that first class but left us with homework for the next week.
Our first assignment was to create a record of thoughts and events that produced distress or anxiety and rank them from 1 to 10 in intensity. For those not in therapy, these triggers are non-events or inconsequential, but for us they were challenging. These included being nervous about using a drive-thru, going to Costco on a Saturday, wearing a shirt with a logo of some kind on it, checking out with a cashier, and talking on the telephone. All produced a high level of anxiety, often leading us to catastrophize the situation (i.e. expecting the absolute worst outcome, such as driving into the drive-thru speaker, not only breaking the sign but getting the car stuck in place so severely that a tow truck had to be called. Catastrophe!)
At our next session, we started to break down those negative thoughts and try to get at the root cause of our anxiety, so we could understand the underlying emotions. It was comforting to hear that others had the same distorted thoughts. There was no judgment. I remember one of the patients bursting into tears in the middle of class. She quickly explained she had never felt so accepted and understood before. We all had the same sentiment.
We then had to come up with three SMART goals for the coming week. (Mental health care is full of acronyms. The idea is that as a mnemonic device, you’ll remember the details, but after three or four, they tend to lose their effectiveness.) At any rate, in this case, SMART stands for Specific goal, Measurable (you know when it is completed), Attainable (it is within reach), Realistic (it is doable) and Timely (has a deadline). The purpose was you had a plan to follow that could not be derailed by your mood. In other words, you couldn’t just say I don’t feel like it. If, for some reason, you were unable to achieve your SMART goal, there were no consequences. The instructors just encouraged us to set a more attainable goal, such as making your bed or brushing your teeth for three days in a row.
Each week we also had to fill in a WAS - Weekly Activity Schedule (yet another acronym) where we rated our mood throughout the day. It helped to dismiss the erroneous belief that the whole day was terrible and to identify triggers that distorted our thoughts.
As a class, we reviewed 10 different Cognitive Distortions. I still struggle with all of them in varying degrees however, now, with the help of CBT, I can manage them better. The key is identifying the distortion and then recognizing the evidence that brings the dark thoughts into question.
All or nothing. - There is no middle ground. If I am on a diet and eat a cookie, it does not mean my diet for the day is blown, so I might as well polish off the whole bag of cookies and binge on chocolate-covered almonds or whatever else is in the house. Show moderation. You ate one cookie. That is OK. You can have one or two, which will not dramatically change your weight loss progress. By not eating anything more, you are respecting your diet.
Overgeneralizing - This always happens. This never happens. I am trying a new recipe for mushroom fried rice. I mess up. My thought jumps to the conclusion that I can’t cook anything right, ignoring the fact that I make a mean chocolate chip cookie. Hot from the oven, they don’t last long.
Minimizing positive compliments. Compliments are spontaneous words of praise or admiration, but for me, they are much more complicated than that. My self-esteem has never been strong. I often overthink someone’s words and intentions to the point where my anxiety is spun into a tight knot. I am either scared of a new perceived expectation, or I dismiss someone’s words as unfounded.
When I was a child, I hated going to the dentist. Not because it hurt or because I was scared but because I had never had a cavity, and the dentist, after initially looking over my chart, always called me his “superstar.” I was terrified I would let him down, and he would find out his praise was unfounded. If I wasn’t his superstar every time, I was a failure.
Other types of compliments also ring hollow. I once had a manager in a grocery store who was very upbeat and positive. He always said, “Great work!” numerous times throughout a shift. I never believed I was worthy of all that praise, definitely not that much in one shift. His words were baseless. He didn’t see me struggle with the apple display just moments before, so I dismissed his compliments. On the flip side, though, if he didn’t compliment me the same number of times on another day, I interpreted it to mean I had let him down. I know it does not make sense to think his words are not sincere but then miss them when he remains quiet, but that is how my mind works. I am either unworthy or a disappointment.
CBT encouraged me to recognize that a compliment is often just a spontaneous comment, a nice thing to say. It is not a future expectation of performance or unfounded praise with some ulterior motive. It is just a kind word shared between two people. It’s not meant to define who I am or gauge my value. It’s just a smile that someone wants to share.
Jumping to conclusions - I sometimes believe I can read people’s minds or can predict the future and thereby react to situations as if I have a deeper insight. A full-time teacher walks by the classroom I am supplying in just as the students get a little loud. I immediately believe the teacher is judging my classroom management skills and does not think I am very good at my job. She will then tell other teachers how bad I am, that I am a disaster. Of course, if I stepped back, more likely than not, she found my situation relatable and expected that the class would settle soon after she passed. Which, of course, it did.
At university, during my graduate degree, I had a professor return one of my essays with the comments “naive and unsophisticated,” which, even for the U of T standards, was particularly harsh. I immediately put the label on all of my papers, future and past. It didn’t matter if I got an 80% or better; they were now all rubbish. That was a major blow to my academic career.
Catastrophizing - Everything is the worst possible scenario. If I tell you who I really am and show you my true personality, you will hate me and never talk to me. Or I could destroy a whole McDonald’s drive-thru if I try to place an order.
Should have statements. - My inner critic hounds me with this one, constantly heaping more “should haves” on top of me. I skip through my life from one (e.g. I should have stood up to Mike Coldorella in grade 5) to another (I should have accepted the new Stats Can position when it was offered) to now, (I should be losing weight. I should be eating healthier).
Emotional reasoning. Going by your gut feeling rather than looking at the evidence. My ability to predict sporting outcomes should be proof enough that my intuition is not very accurate. Sometimes I feel guilty for no apparent reason, like when a conversation goes silent, I assume I’ve done something wrong, that people disagree with what I’ve said or just don’t want to be around me.
Personalization and Blame - accept too much personal responsibility. It is my job to absorb all the stress, to be calm, to be everyone else’s deep breath, patient in the face of crisis. If there is a challenge, it is my fault and my job alone to fix it.
Labelling/Mislabeling - When I made a mistake at the grocery store, such as being reminded by my manager to check Asian Fresh, my self-talk, my critic was corrosive, “I’m stupid,” “I’m a loser.” The worst part of depression is that it steals all your confidence and leaves you full of doubt and despair.
Double Standard - My critic, my negative self-talk, is far more understanding of others’ actions than my own. You took the wrong turn; that’s OK. We will circle back. I made the wrong turn: I am useless as a driver and stupid.
I hear their thoughts,
I hear their chatter,
their opinions and complaints.
I know they’re only in my mind
I know that is a fact
but they don’t stop... ever.
While all this theory was helpful, the real CBT success came from the exposures. The four to six-week therapy sessions never progressed to this point of CBT, so I could never make the great leap forward where I would quell the distorted thoughts and actually live a happier and healthier life. An exposure is basically putting yourself in harm’s way. For example, I was terrified of drive-thrus, so they encouraged me to use one at least three times over the upcoming week. When we agreed to an exposure in class, it became a promise we each made to each other. It seemed like a good idea until it came time to do it.
I was very nervous, thinking about everything that could possibly go wrong. I took my 14-year-old daughter in the car so I could not back out. I never told anyone about my drive-thru phobia. I was embarrassed, so with her with me, I was committed as soon as I told her where we were going. She had no idea of my skyrocketing anxiety.
I carefully selected which fast food we would go to, based on how narrow the drive-thru lanes were and how many there were to choose from. I picked the middle of the afternoon, hoping it would be less busy. I decided on Dairy Queen. As I approached the point of no return, when you have to drive through, regardless of whether you order something, I took a deep breath and focused on driving up close to the speaker. You have to get close but not too tight. The car had to stop so the driver’s window was at the right place to order. I inched along, repeating a mantra in my head, “not too close but close enough,” and “watch the driver’s side mirror.” I managed to aim the car directly and pulled up to just the right spot.
I took my daughter’s order ahead of time - an M&M Blizzard - and to keep it simple, I decided to order the same even though I probably would have ordered a Mocha Moolatte if I had my choice. I wanted to keep it simple for my first time through. I repeated the order over and over in my head, “Two M&M Blizzards.”
As soon as we pulled up, the cashier said, “Just a minute please.”
My breathing was erratic. This pause wasn’t planned. “OK.” I replied, “not a problem.” What a dumb thing to say! I should have just left it at “OK.”
And then my daughter changed her mind. “No. Wait. I want a dipped cone.”
My mind chattered. An ice cream cone could fall over. I could drop it outside the car as she gave it to me. I could spill it as I passed it to my daughter. What a mess. And now I thought, what was I going to order. The same? Two cones would be even harder to manage, especially as I drove out of the drive-thru. I couldn’t put them down on the seat or in the cup holder.
The helpful voice broke my spiral. “Hello, welcome to Dairy Queen, how can I help you today?”
“Umm,” I replied, then realized I was holding everyone else in the drive-thru lineup. I was sure it wouldn’t be long before they began honking their horns and swearing at me. I finally stammered, “Can I have a dipped ice cream cone and an M&M Blizzard, please?”
Unfortunately, I mumbled too fast, so she had to extend our conversation. “Pardon me, could you repeat that, please.”
“What a fucking idiot,” I thought. I felt like abandoning the whole thing and just driving through without ordering, even though I knew that would only make matters worse. If you don’t live with anxiety, this will all seem silly but for those who do, I’m sure you will relate to all this excessive thinking.
I took a deep breath and reassured myself, you can do it, then repeated my order at a more pedestrian pace.
To which she replied, “What size of cone?”
What? Why was she doing this to me? I had not anticipated her question and was about to ask the most ridiculous of questions, “What sizes are there?” when my daughter spoke up, “Small, please.”
That’s right, I thought. I forgot to say please.
“What size Blizzard do you want?”
At this point, I didn’t really care. I was about to say, “Whatever’s easiest is fine.” but that would have been a silly answer, as would have been, “I don’t care.” or “Surprise me.” I paused for a moment until she was just about to repeat her question, then said, “Um. The same. Please..”
“Great. Drive on up.”
She mentioned the cost as well, but I forget what it was. It could have been $100, and I would have paid just to get this ordeal over with.
Next, my anxiety focused on payment. What if my debit card didn’t work? What if the tap didn’t work? What if I forgot my pin number? I would look so stupid. By the way, I had my card already out of my wallet and in the door handle. I put it there when we were still in our driveway at home.
I slowly pulled up to the window, again making sure I positioned the car just right. I desperately hoped there was nothing stuck in my teeth. I couldn’t remember if I brushed just before we headed out. I didn’t think so. That’s when I noticed black scrap marks on the drive-up window. Someone had hit it with their mirror before me. I found comfort in another’s mistake. My mirror was clear by about 30 cm.
A teenage girl with a complete set of braces held out the machine for me to tap. I tapped, and nothing happened. Oh my god, what’s wrong? Now what am I going to do? Just as I was about to apologize and speed off, she pleasantly suggested I tap more toward the top. I did, and it beeped immediately. Should have known to tap up above. She must think of me like some sort of fool. What an idiot!
She passed me the cone first, which I immediately passed to my daughter. I then took my blizzard and put it into the cup holder. I said, “Thank you.” and rolled up my window as I pulled away. Once we were out of the drive-thru, I immediately pulled into a nearby parking lot to assess what had happened. In hindsight, I congratulated myself. It had actually gone relatively smoothly. I had done it. My daughter and I enjoyed our treats.
I repeated the exposure two more times that week. My daughter was the unexpected beneficiary of my therapy. And so I went through the DQ drive-thru, and each time the anxious chatter settled more. By the third time I ordered a Mocha Moolatte. I proudly reported my success at my next CBT class. I could even laugh at my own anxiety. I have since gone through a variety of drive-thrus, even the McDonald’s double drive-thru. I still run through the same distorted thoughts when I am in line, but I can now quickly identify them as distorted and dismiss their impact. My heart still races, but I can do it.
Another exposure had me dropping change at the check-out. I do not like checking out of a store. Like the drive-thru, I catastrophize the exchange, where I drop all the coins on the floor. To avoid this possibility, I usually use the self-check-out and my debit card. I never use cash. The possibility of disaster it too great. The purpose of CBT is to confront a distorted thought and identify it as baseless. It’s not so much the staged situation but instead recognizing reality.
So I dropped the coins, which was a disaster; the coins went in every direction, rolling and spinning. I thought for sure something “bad” would happen. That someone would yell or sigh at my clumsiness, but surprisingly, the cashier, a middle-aged woman, didn’t even react, and the person behind me didn’t shout or swear. She actually helped me gather them back together. Contrary to my distorted beliefs, people were not just waiting to judge me and call me stupid. If anything, they were willing to be patient and helpful, something I thought only I did.
Another exposure was logo shirts. I used to avoid wearing anything with logos on them when I went out in public. I didn’t want to attract attention to myself. I was worried about someone jumping to the wrong conclusion, that they would judge me by the logo and in some way be offended. Just to be clear, the logos I am talking about are not political. Most of them are related to sports teams. For my exposure, I wore a bright red Chicago Blackhawk jersey. I was worried everyone would know I liked the Hawks. I didn’t know why that mattered, but with my distorted cognition, it couldn’t be anything but bad.
As the day wore on, though, I noticed that no one seemed to really care, that is, until a man behind me in an ATM line said, “I like the hawk’s too.”
I wanted to hide but was trapped between the person entering his pin number and the man smiling behind me. I actually made eye contact which for me was a challenge. He continued, “My son is the manager of media relations in Chicago.” He quickly produced a business card from his wallet to prove it. It looked genuine with the logo that matched my shirt. It’s funny because the worst-case scenario I could imagine, that someone would talk to me based on the logo I was wearing, was not bad at all. In fact, it was downright bizarre. What are the odds that the father of the manager of media relations for the Chicago Blackhawks would line up behind me in an ATM line when I happened to be wearing my brightest Chicago jersey? As I related my encounter in therapy, we all laughed at the interaction. My fear was unfounded. Even being signaled out wasn’t all that bad. I am still a little nervous about logos but I can wear them out if the laundry basket is full.
CBT has been beneficial for my anxiety. I still get anxious, but it is not as debilitating. This breakthrough, however, did not come from a few worksheets filled out over 4 weeks. It only worked when it was long-term, intensive and shared. Group therapy was probably the most significant factor in its success. I hate to admit it, but they were right; we encouraged each other to success.
While all of this was great news and my greatest therapeutic triumph, it did nothing to temper my chronic suicide ideation. My brain still wanted to kill me. I may have rewritten neurological pathways to calm my worst anxiety, but the critic, the narrator of my depression, still remains.
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