![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by Dr. Bob on January 25, 2002, at 15:58:27
[reposted from http://www.dr-bob.org/babble/20020124/msgs/91575.html]
> Good for you.
>
> I read about CBT years ago, and with time, I keep doing some of the stuff that helps. I simply forgot what got on my nerves. Indeed, the "homeworks" are sometimes weird and I once fought with a therapist not to do an assignment that I found pointless and a sheer waste of time. Each person needs to adapt depending on their personality, as in anything else in life.
>
> Indeed, CBT can be a good complement to meds.
Posted by Dr. Bob on January 27, 2002, at 3:03:46
In reply to Re: in defense of CBT « sid, posted by Dr. Bob on January 25, 2002, at 15:58:27
[Posted by Rick on January 26, 2002, at 0:39:43
In reply to http://www.dr-bob.org/babble/20020124/msgs/91528.html]
> > Anyone out there had luck with CBT for SP?
>
> Haven't tried it, but CBT generally works best for SP that is specific to, or heavily weighted towards, performance anxiety. Which is not to imply that it's always ineffective for generalized SP.
Posted by Dr. Bob on January 27, 2002, at 3:05:58
In reply to Re: David Burns » Lisa01 « Rick, posted by Dr. Bob on January 27, 2002, at 3:03:46
[Posted by sid on January 26, 2002, at 12:12:56
In reply to http://www.dr-bob.org/babble/20020124/msgs/91422.html]
> > Personally I've never heard of *anyone* with serious depression who was cured by CBT.
> >
> > -elizabeth
>
> You heard of me a couple of months ago. Of, and acupuncture too, along with CBT. Selectve memory serving your personal beliefs, it seems to me. Blatant need of CBT right there.
>
> Now I suppose you'll tell me my depression was not *serious*.
>
> And who gives a **** about Burns? Does CBT work? For some people, yes, that's all that matters.
>
> - Sid
Posted by Dr. Bob on January 27, 2002, at 3:07:33
In reply to Re: David Burns » Elizabeth « sid, posted by Dr. Bob on January 27, 2002, at 3:05:58
[Posted by sid on January 26, 2002, at 18:47:09]
> I am sorry for being rude to you in my previous message. I took the *anyone* too personally - like most people I don't like to be discarded as "no one".
> You can choose to ignore my success story of CBT and acupuncture if you want. I should not get upset by that. I just hope other people hear me and can be helped by CBT as a complement to meds.
>
> - Sid
Posted by Dr. Bob on January 28, 2002, at 1:00:44
In reply to Re: in defense of CBT « sid, posted by Dr. Bob on January 25, 2002, at 15:58:27
[Posted by Adam on January 27, 2002, at 19:01:30
In reply to http://www.dr-bob.org/babble/20020124/msgs/91422.html]
> Ahh, the old debate.
>
> FWIW, one can scan the literature and look at CBT's track record. It's been been tested in numerous nicely-designed studies, has shown efficacy on par with meds in many of them, and is generally regarded as having at least the effectiveness of any other psychotherapeutic modality. This is simply a fact.
>
> Most certainly, it doesn't work for everyone. No particular treatment works for everyone, sadly.
>
> I found both straight behavioral therapy (for an OCD-spectrum disorder) and CBT (for depression, etc.) far, FAR more helpful than psychodynamic therapy, and for a long time was convinced that PDT was complete horseshit, based on those experiences.
>
> I've changed my mind: Whatever works, use it. Different people are different. They need different things. Nobody really knows why. If one thinks David Burns, MD is an idiot, try something else, and best of luck. Whatever one thinks of Burns, though, one should keep in mind that, as an advocate of CBT, there's a lot of good reasearch to back up his convictions. If he has different ideas about the etiology of depressive disorders, he is in good company. IMHO, "depression" is too broad a term, so asking "what causes depression" is bit like asking "what causes cancer"? Well, lots of things, some of them heritable, some of them environmental, with different ratios of either depending on the particular disease. Appropriately, there are different surgical and pharmacuetical treatments one ought to use, depending on the characteristics of the neoplasia, and the person with it. Lots of new technologies are making the choosing of appropriate treatment strategies easier for cancers. I can only hope some similar progress is made on "depressions" before too long.
>
> I personally have come to regard Burns as a bit of a showboat, but I can't blame him for making money. If his going on Oprah and shamelessly plugging himself is what it takes to help a few people out, so be it. He makes a buck, somebody maybe gets a little better, tries CBT on for size with a therapist because of what they've read...worse things could happen, I suppose.
>
> > Out of curiosity, have you tried CBT or other talk therapy, and if so what did you think of it? (My experience with CBT was much like Cecilia's.)
> >
> > > He also admits bipolar disorder is heavily biological and genetic, but denies depression is biological. LOL
> >
> > So he buys the idea of a biological basis for some mental disorders, but denies that depression is one of them, huh? Personally I've never heard of *anyone* with serious depression who was cured by CBT.
> >
> > Yes, the brain gets sensory input from external experiences, and in the long term these experiences affect what we call "personality," but whether or not a major depressive episode will occur is largely predetermined, probably at least in part by genetics. (There may be other factors, such as autoimmune conditions.) So I don't think that people with depression that has recurred for more than a couple times are likely to benefit from personality or behavior modification (the supposed effect of CBT).
> >
> > -elizabeth
Posted by Dr. Bob on January 30, 2002, at 19:01:29
In reply to Re: in defense of CBT « sid, posted by Dr. Bob on January 25, 2002, at 15:58:27
[Posted by Elizabeth on January 30, 2002, at 8:19:11
In reply to http://www.dr-bob.org/babble/20020124/msgs/91533.html]
> [Dr. Bob: This post concerns both medications and talk therapies and doesn't necessarily belong in one forum or the other. I prefer to post here in part simply because I don't generally read PSB. I'm not willing to say that one board is better than the other, but the attitudes expressed on PSB seem to me to be more intuitive or emotional than those here, so I feel more comfortable here on PB. I hope you'll respect this. TIA.]
Well, let me try something new: part I left there and part I'm moving here (reposted below). You don't need to read all of PSB, you know, you can just read these particular threads. :-)
Bob
> > Behavior and thoughts affect brain chemistry. CBT does not pretend that depression is not a brain chemistry problem.
>
> CBT isn't an individual. I have encountered some psychotherapists (some of whom favored CBT) who did seem to have a dualistic "brain vs. mind" view, seeing mental disorders as being one or the other (a simplistic and archaic world view, IMO). I have also encountered psychopharmacologists (and plenty of psychoanalytic therapists!) who also had this sort of attitude. It's a world view that really doesn't belong in the third-millenium world, but is nonetheless ubiquitous.
>
> > It can be used, as well as meds to treat depression. It does not have a 100% rate of success, and meds don't either. Acupuncture can help too, and it does not have a 100% success rate either.
>
> YMMV -- everybody needs to find a treatment regimen that works for them. I think talk therapy (not necessarily CBT only) can be worth trying as an aid in the treatment of serious mental disorders, but it's not always successful, and even when it does help, it often is not sufficient.
>
> It is possible for people who are in talk therapy to recognize why it may not be working for them (often, as has been mentioned, because they're just too depressed) and decide to pursue other forms of talk therapy (e.g., psychodynamic psychotherapy instead of CBT) or that talk therapy in general isn't likely to help them (or that they need to wait until they're less depressed, for example). In contrast, we can't see what's going on in our brains at the molecular level, so we don't have a way of evaluating what medication is most likely to yield success, or whether medication is likely to help at all. I hope this illustrates why people feel justified in making a decision to pursue psychotherapy or not but can't be certain that medications will or will not work for them without trying them (it's a mixed blessing that there are so many of them to try these days). I also think there are things that we don't understand about how talk therapy works (although in this regard CBT is probably the most simplistic type of talk therapy), so it's not necessarily a good idea to rule it out altogether.
>
> I've heard it said that all talk therapies (regardless of the therapeutic modality or the problem they're trying to treat) have about the same success rate -- about a third get better, a third stay the same, and a third get worse. I don't know if there's any solid evidence to back this up, but it seems about right to me. There seems to be an element of randomness in the success of psychotherapy. I also think that much of the success attributed to specific psychotherapeutic techniques (such as CBT) may be due to characteristics of psychotherapy in general (such as therapist-client match), and not to the particular technique used.
>
> > I did have success with CBT and acupuncture to get rid of a major depression, and I think CBT helps me everyday of my life now. It is some kind of emotional/psychological education that everybody should have in my opinion.
>
> I agree -- just about everyone could benefit from therapy, including CBT. I think that CBT might be particularly beneficial for adolescents, helping them to learn adult attitudes and improve their awareness of their behavior. It would fit nicely into a classroom setting, too.
>
> But CBT is *not* a cure for any disease. Just about everybody has some bad attitudes or habits that they could stand to unlearn. I think that most of us understand that that's not the same as a mood or anxiety disorder.
>
> > But some people are not open to learning.
>
> This is where some people start feeling like they're being put on the defensive: the implication, whether intended or not, is that when people say that CBT didn't work for them, it's because they're not open to learning. (Ironically, rigidity and lack of openness are among the "bad attitudes" that CBT is supposed to correct.)
>
> The "blame the patient" strategy is sometimes invoked in order to rationalize the failure of medication, too. This is done by changing the diagnosis to "personality disorder" (or adding a personality disorder diagnosis). Indeed, there are some psychiatrists who seem to equate treatment resistance with personality disorder, regardless of the symptomatic presentation!
>
> > I think it's another tool that can help, and I don't see why people don't use it more.
>
> I think that many people try it, but some find that it doesn't live up to its claims. As you say, it's a tool that *can* help. That's no guarantee that it will help everybody. (The above applies to medication too, of course.) It also doesn't mean that people who aren't helped by it simply aren't trying, or that they're lazy and expect the meds to do everything for them without any effort on their part (as you seem to imply -- again, perhaps unintentionally).> > I am not sure if different CBT techniques could help, I just got tired of making efforts and decided to rely on meds at this time. CBT does require efforts indeed, that's the downside: no free lunch.
>
> Again, this is the kind of attitude that can make people feel bad or defensive if they aren't helped by talk therapy. Many people assume that people who don't find talk therapy helpful are simply not trying hard enough. This is probably true in some cases, but I see no reason to assume that it is always (or usually) the case. I also think that the idea that people who take medication are not putting forth effort is mistaken: medications have side effects that need to be endured or managed. Many people are willing to endure these side effects because their response to medication is rapid and dramatic (let's not forget that many people need medication simply to function). For a lot of people, talk therapy produces little benefit rapidly enough to permit them to continue with their lives uninterrupted, and the effects, when they do finally begin to show, aren't that impressive. I suspect that there are people who might be helped a little bit by CBT or other talk therapy, but not enough for it to be worth the time and expense to them. Self-help books like Burns's are useful for people who can't afford to see a therapist, but this approach isn't useful for people whose problems require therapies that are more complicated and can't be written into a manual like CBT can.
>
> > However, it does help for the rest of your life, even if it is not a panacea.
>
> CBT advocates have for some time been trying to prove that it has lasting effects. To date, these efforts haven't shown much success.
>
> There is no panacea for mood and anxiety disorders; we just have to do whatever we can. And we're all individuals -- there's a *lot* of variation among human brains -- so making generalizations doesn't pay off (generally :-) ).
>
> BTW, "johnhill"'s post expresses, better than you or I ever could :-), the extremist (and unsupported) attitudes and assumptions that some people have about psych meds and talk therapy.
>
> -elizabeth
Posted by Dr. Bob on January 30, 2002, at 19:03:43
In reply to Re: David Burns » Elizabeth « sid, posted by Dr. Bob on January 27, 2002, at 3:05:58
[Posted by therese desqueroux on January 30, 2002, at 13:18:38
In reply to http://www.dr-bob.org/babble/20020124/msgs/91517.html]
> In response to the David Burns' thread:
>
> Several years ago, I read David Burns' books as requested by my CBT. (I have not read any more recent editions). I told him that Burns was an idiot. The therapist, who had some of the smugness that Burns displays on his book jackets, acknowledged that at least one other patient had had a similar response. All Burns does is present a diluted, dumbed-down version of Beck perpetrated -- not written -- in an extremely irritating condescending style.
>
> Some years ago, I also read Beck's main book and some books by E.P. Seligson at the University of Pennsylvania, another CBT proponent.
>
> I am someone who does not take an aspirin if it is not necessary.
>
> Let me say, I hope for the last time:
>
>
> Cognitive Behavioral Therapy is NOT, NOT, NOT APPROPRIATE for individuals with severe forms of OCD, depression or anxiety.
>
>
> You can't just "learn optimism" (to paraphrase the title of one of Seligson's books) if you feel awful to begin with and your therapy is only making you worse, in part because of the massive amounts of money you are wasting, in my case, thousands.
>
> And if you have any verbal ability and mental capacity at all you'll find yourself arguing against yourself and getting nowhere. All the time. Then when you don't improve it's your fault, of course. As I believe Cecilia said, the therapy does not teach the individual to translate supposedly more objective thoughts to the emotional level. Words do not change deeply experienced emotions, and I like words. As far as I'm concerned, it's Coue-ism ("Every day in every way I am getting better and better") in modern dress with a little pseudo argumentation added.
>
> And don't get me started on those insulting exercises --
>
> 1. Rate your mood from 1 to 10.
>
> 2. What is your negative belief? blah blah blah
>
> 3. What's the evidence for that? (there was
> plenty)
>
> 4. How would you refute that? (could never come up with anything for which felt strong conviction; sometimes the dark side looks dark because it is)
>
> 5. Rate your mood again. -- same score. (Sometimes I'd pretend to have improved a little, although I don't usually feel it necessary to appease in a situtation like this.)
>
> 6. The same score?
>
> 7. Yes, the same.
>
> The book "Stop Obsessing" also is not effective for someone with a severe form of ruminative OCD.
>
> I am not saying that CBT is worthless to all individuals, but rather that for people trapped in painful,seemingly endless ruminations, it is not effective. It does not teach you to interrupt the thought. CBT may be helpful as an ancillary form of therapy once an individual is not channeling all of his or her energy into ruminations because of the successful administration of medication. It may also be helpful to people who have relatively minor problems, but that is true of most any therapy.
>
> My cynical theory is that CBT has been so heavily promoted because it's supposed to be fast and effective and the managed care folks like that.
>
>
>
>
>
>
>
>
>
>
> > > Hi Folks,
> > >
> > > Funny this thread should come up. I'm partway through the book. I personally find a lot that's objectionable and a lot that's good (besides the thorough medicine listing at the end). First of all, I don't think we should disregard the usefulness of CBT. *Every* human being, mood disordered or not, can use a reality check now and then. To me, CBT is just a formalized system of being aware of how your thoughts and reactions relate to what may or may not actually be going on. When I look at his descriptions of cognitive distortions, I see myself so clearly in some of them. While I'm not big into writing it all down, it doesn't hurt to have my awareness raised. My therapists have used some aspects of CBT (though not in the rigid cultlike manner as Burns prescribes). Although it's certainly not enough to manage my illness without meds, I can't say it hasn't been helpful.
> > >
> > > Do I think CBT has or can "cure" my serious mood disorder? No! I *know* that I need careful psychopharmacologic management. Do I think there's a genetic component to my illness? My family history says absolutely. And I can't process any CBT while severly depressed - the meds have to bring me up a bit. I suspect my illness is more "biologically" based than "psychologically" (if we're gonna draw a line between the brain and the mind). But hey, any adjunct tool that can help me manage better can't hurt. I just don't expect CBT to be the magic key.
> > >
> > > On the negative side: I do agree the book and techniques have an almost cultlike feel to them. I totally agree that it's ridiculous that he says bipolar is genetic and depression is not. It also sounds a bit hard to believe when he says he has cured suicidal patients in incredibly short periods of time. And that he's rarely had a patient need onoging drug treatment beyond a year or so. I also worry that all his glowing stories might make people who've had CBT feel like failures if they haven't had resounding success with CBT. I worry that the book might encourage folks to abandon their medicine without appropriate discussions and oversight from their doctors, or to not recognize when they need to really think about starting meds. Yeah, I know he puts in caveats about when to call in a professional and all that. But I think his anti-drug stance poses possible dangers.
> > >
> > > Oh, and the guy's way too long winded (unlike this post :) He could've made his points in a quarter of the space and his writing style irritates me - he writes as if his audience is a bunch of third-graders. How annoying.
> > >
> > > Emme
> >
> > I see Dr. Burn's as more of an opportunist than anything else. Essentially, he took the ideas of Aaron Beck, M.D. (father of congitive therapy) and ran with them. He did his psychiatry residency at the Philadelphia VAMC and gave the hospital an undeserved black eye when he described (in his preface if memory serves me) a patient he passed on the elevator there who was returning from his 18th shock treatment, and was yelling "I want to die." I haven't looked at "Feeling Good" since it was first published, but I think he claimed that it was at this point when he decided there 'must be another way' (to treat depression). In any case, I know psychiatrists who remember him well, and he routinely used drugs in his practice.
> >
> > I don't care about his drug recommendations since he's not a psychopharmacologist.
> >
> > I've tried manualized CT/CBT before, but it's of no value if you're in a state of depression that makes it impossible to carry out the "homework assignments" that are part of the therapy. For those who are experiencing mild to moderate depression, I think it's an excellent adjunct to medications.
> >
> > Blue
Posted by Dr. Bob on January 30, 2002, at 19:06:13
In reply to Re: David Burns « therese desqueroux, posted by Dr. Bob on January 30, 2002, at 19:03:43
> problem I had with with David Burns'-style therapy and CBT in general (I also can't abide Albert Ellis and his usually hectoring tone) is that it has often been observed that depressed people are not necessarily unobjective. In fact at times they are more accurate in assessing situations than individuals who are not clinically depressed. This topic came up again in the most recent Harvard Mental Health Letter.
>
> So it is really hard to talk yourself out of a so-called negative perception if your perception is in fact accurate. Of course the perception becomes a problem when it is endlessly repeated, sometimes creating almost paralyzing anxiety. But as I noted before, in my experience, CBT does zilch for people with serious ruminative problems. The therapist I was seeing at one time kept characterizing thoughts as "behaviors" that can be changed in the same way that a person with a germ phobia can be desensitized to the point where he or she can touch a doorknob without a handkerchief. I firmly believe that the ruminative thoughts are symptoms, not behaviors.
>
> I just hate to see so many people berating themselves as I did for not trying hard enough or being frustrated because of their lack of improvement. And many times they are shelling out large amounts of money they can ill afford.
>
> As said before, I'm not drug-happy, but there really are some conditions so severe as to be treatable only by medications. At least initially, and perhaps permanently.
>
> > In response to the David Burns' thread:
> >
> > Several years ago, I read David Burns' books as requested by my CBT. (I have not read any more recent editions). I told him that Burns was an idiot. The therapist, who had some of the smugness that Burns displays on his book jackets, acknowledged that at least one other patient had had a similar response. All Burns does is present a diluted, dumbed-down version of Beck perpetrated -- not written -- in an extremely irritating condescending style.
> >
> > Some years ago, I also read Beck's main book and some books by E.P. Seligson at the University of Pennsylvania, another CBT proponent.
> >
> > I am someone who does not take an aspirin if it is not necessary.
> >
> > Let me say, I hope for the last time:
> >
> >
> > Cognitive Behavioral Therapy is NOT, NOT, NOT APPROPRIATE for individuals with severe forms of OCD, depression or anxiety.
> >
> >
> > You can't just "learn optimism" (to paraphrase the title of one of Seligson's books) if you feel awful to begin with and your therapy is only making you worse, in part because of the massive amounts of money you are wasting, in my case, thousands.
> >
> > And if you have any verbal ability and mental capacity at all you'll find yourself arguing against yourself and getting nowhere. All the time. Then when you don't improve it's your fault, of course. As I believe Cecilia said, the therapy does not teach the individual to translate supposedly more objective thoughts to the emotional level. Words do not change deeply experienced emotions, and I like words. As far as I'm concerned, it's Coue-ism ("Every day in every way I am getting better and better") in modern dress with a little pseudo argumentation added.
> >
> > And don't get me started on those insulting exercises --
> >
> > 1. Rate your mood from 1 to 10.
> >
> > 2. What is your negative belief? blah blah blah
> >
> > 3. What's the evidence for that? (there was
> > plenty)
> >
> > 4. How would you refute that? (could never come up with anything for which felt strong conviction; sometimes the dark side looks dark because it is)
> >
> > 5. Rate your mood again. -- same score. (Sometimes I'd pretend to have improved a little, although I don't usually feel it necessary to appease in a situtation like this.)
> >
> > 6. The same score?
> >
> > 7. Yes, the same.
> >
> > The book "Stop Obsessing" also is not effective for someone with a severe form of ruminative OCD.
> >
> > I am not saying that CBT is worthless to all individuals, but rather that for people trapped in painful,seemingly endless ruminations, it is not effective. It does not teach you to interrupt the thought. CBT may be helpful as an ancillary form of therapy once an individual is not channeling all of his or her energy into ruminations because of the successful administration of medication. It may also be helpful to people who have relatively minor problems, but that is true of most any therapy.
> >
> > My cynical theory is that CBT has been so heavily promoted because it's supposed to be fast and effective and the managed care folks like that.
> >
> >
> >
> >
> >
> >
> >
> >
> >
> >
> > > > Hi Folks,
> > > >
> > > > Funny this thread should come up. I'm partway through the book. I personally find a lot that's objectionable and a lot that's good (besides the thorough medicine listing at the end). First of all, I don't think we should disregard the usefulness of CBT. *Every* human being, mood disordered or not, can use a reality check now and then. To me, CBT is just a formalized system of being aware of how your thoughts and reactions relate to what may or may not actually be going on. When I look at his descriptions of cognitive distortions, I see myself so clearly in some of them. While I'm not big into writing it all down, it doesn't hurt to have my awareness raised. My therapists have used some aspects of CBT (though not in the rigid cultlike manner as Burns prescribes). Although it's certainly not enough to manage my illness without meds, I can't say it hasn't been helpful.
> > > >
> > > > Do I think CBT has or can "cure" my serious mood disorder? No! I *know* that I need careful psychopharmacologic management. Do I think there's a genetic component to my illness? My family history says absolutely. And I can't process any CBT while severly depressed - the meds have to bring me up a bit. I suspect my illness is more "biologically" based than "psychologically" (if we're gonna draw a line between the brain and the mind). But hey, any adjunct tool that can help me manage better can't hurt. I just don't expect CBT to be the magic key.
> > > >
> > > > On the negative side: I do agree the book and techniques have an almost cultlike feel to them. I totally agree that it's ridiculous that he says bipolar is genetic and depression is not. It also sounds a bit hard to believe when he says he has cured suicidal patients in incredibly short periods of time. And that he's rarely had a patient need onoging drug treatment beyond a year or so. I also worry that all his glowing stories might make people who've had CBT feel like failures if they haven't had resounding success with CBT. I worry that the book might encourage folks to abandon their medicine without appropriate discussions and oversight from their doctors, or to not recognize when they need to really think about starting meds. Yeah, I know he puts in caveats about when to call in a professional and all that. But I think his anti-drug stance poses possible dangers.
> > > >
> > > > Oh, and the guy's way too long winded (unlike this post :) He could've made his points in a quarter of the space and his writing style irritates me - he writes as if his audience is a bunch of third-graders. How annoying.
> > > >
> > > > Emme
> > >
> > > I see Dr. Burn's as more of an opportunist than anything else. Essentially, he took the ideas of Aaron Beck, M.D. (father of congitive therapy) and ran with them. He did his psychiatry residency at the Philadelphia VAMC and gave the hospital an undeserved black eye when he described (in his preface if memory serves me) a patient he passed on the elevator there who was returning from his 18th shock treatment, and was yelling "I want to die." I haven't looked at "Feeling Good" since it was first published, but I think he claimed that it was at this point when he decided there 'must be another way' (to treat depression). In any case, I know psychiatrists who remember him well, and he routinely used drugs in his practice.
> > >
> > > I don't care about his drug recommendations since he's not a psychopharmacologist.
> > >
> > > I've tried manualized CT/CBT before, but it's of no value if you're in a state of depression that makes it impossible to carry out the "homework assignments" that are part of the therapy. For those who are experiencing mild to moderate depression, I think it's an excellent adjunct to medications.
> > >
> > > Blue
Posted by sid on January 31, 2002, at 0:21:58
In reply to Re: assumptions « elizabeth, posted by Dr. Bob on January 30, 2002, at 19:01:29
In response to Elizabeth...
> > But CBT is *not* a cure for any disease. Just about everybody has some bad attitudes or habits that they could stand to unlearn. I think that most of us understand that that's not the same as a mood or anxiety disorder.
Right, but depression distorts our thoughts and possibly our behavior too, as a consequence of distorted thoughts. So CBT can help realize that and actively work on changing those. I think that's what happened in my case. I was sooo incredibly irrationally negative. CBT did help with that.
> > > But some people are not open to learning.
> >
> > This is where some people start feeling like they're being put on the defensive: the implication, whether intended or not, is that when people say that CBT didn't work for them, it's because they're not open to learning. (Ironically, rigidity and lack of openness are among the "bad attitudes" that CBT is supposed to correct.)
> >
> > The "blame the patient" strategy is sometimes invoked in order to rationalize the failure of medication, too. This is done by changing the diagnosis to "personality disorder" (or adding a personality disorder diagnosis). Indeed, there are some psychiatrists who seem to equate treatment resistance with personality disorder, regardless of the symptomatic presentation!Well, I've seen it mentioned on PB and PSB many times. I personally did not feel guilty. I just wanted to get better and worked at it every way I felt comfortable with, one being CBT. I did learn things that helped and stil do in my everyday life. When I get stressed, I have a tendency to have negative thoughts. I catch them immediately and move on to better things. Had I not learned about CBT, I would be in danger or sliding towards another major episode every time my stress level is high. I don't think there should be any guilt. Guilt is one of the symptoms of depression, that may be why so many people seem to be feeling it in relation to therapy. I had lots of guilt, about other stuff.
> > > I think it's another tool that can help, and I don't see why people don't use it more.
> >
> > I think that many people try it, but some find that it doesn't live up to its claims. As you say, it's a tool that *can* help. That's no guarantee that it will help everybody. (The above applies to medication too, of course.) It also doesn't mean that people who aren't helped by it simply aren't trying, or that they're lazy and expect the meds to do everything for them without any effort on their part (as you seem to imply -- again, perhaps unintentionally).I seemed to imply that because that's the impression I sometimes have from reading different posts. My impression may be wrong. On thing I did notice is that people insist on the diabetes-insulin example to explain, rationalize, justify (to themselves and their loved ones) taking meds for depression. But I never read about exercise and diet against diabetes being similar to therapy, relaxation techniques, etc... To me, IME, it becomes a better analogy when all is included. But again, my experience, and the fact that many things have worked for me, is what generates this opinion.
> > > I am not sure if different CBT techniques could help, I just got tired of making efforts and decided to rely on meds at this time. CBT does require efforts indeed, that's the downside: no free lunch.
> >
> > Again, this is the kind of attitude that can make people feel bad or defensive if they aren't helped by talk therapy. Many people assume that people who don't find talk therapy helpful are simply not trying hard enough. This is probably true in some cases, but I see no reason to assume that it is always (or usually) the case. I also think that the idea that people who take medication are not putting forth effort is mistaken: medications have side effects that need to be endured or managed. Many people are willing to endure these side effects because their response to medication is rapid and dramatic (let's not forget that many people need medication simply to function). For a lot of people, talk therapy produces little benefit rapidly enough to permit them to continue with their lives uninterrupted, and the effects, when they do finally begin to show, aren't that impressive. I suspect that there are people who might be helped a little bit by CBT or other talk therapy, but not enough for it to be worth the time and expense to them. Self-help books like Burns's are useful for people who can't afford to see a therapist, but this approach isn't useful for people whose problems require therapies that are more complicated and can't be written into a manual like CBT can.Right. No guilt or juggment form me on that. I preferred not to take meds for the longest time, but therapy was not working for the dysthymia, and I had spent a lot of time on it, needed to work more and spend less time trying to get better. I am still making efforts (side effect: it's 1AM and I can't sleep, so I am writing instead; have to be at the office at 8AM tomorrow), but spending less time on it. I work a lot more now and I don't think about the depression so much. I write and read about it here, but my day otherwise is depresion-free. Stressful, but depression-free. Cross my fingers.
> > > However, it does help for the rest of your life, even if it is not a panacea.
> >
> > CBT advocates have for some time been trying to prove that it has lasting effects. To date, these efforts haven't shown much success.Well, for me, as I explained above, it helps. I see some situations (high stress) that could lead to another episode and I have managed to avoid them so far, using what I learned in therapy, mostly CBT.
I have not read many studies overall since I do research in another field for a living (that's enough reading studies and writing them for me), but that's what my experience has been so far.
> > There is no panacea for mood and anxiety disorders; we just have to do whatever we can. And we're all individuals -- there's a *lot* of variation among human brains -- so making generalizations doesn't pay off (generally :-) ).
Indeed.
> > BTW, "johnhill"'s post expresses, better than you or I ever could :-), the extremist (and unsupported) attitudes and assumptions that some people have about psych meds and talk therapy.
> >
> > -elizabeth- Sid
Posted by sid on January 31, 2002, at 0:32:47
In reply to Re: David Burns « therese desqueroux, posted by Dr. Bob on January 30, 2002, at 19:03:43
> > I am not saying that CBT is worthless to all individuals, but rather that for people trapped in painful,seemingly endless ruminations, it is not effective. It does not teach you to interrupt the thought.
Well, I don't know how it happened (as it tells you to stop the thought but not how), but I've learned to do it. It took time, but now I do it all the time.
I can understand your frustration with CBT, I was frustrated at times too, but I think it helped me during my major depression. I guess we're not all the same. I did choose the exercises or therapist's homeworks I would do. Some of it got on my nerves or I'd go: OK, I get the point, no need to do this first grader homework, what's next? I did fight with a therapist about a homework that I did not want to do and did not do. I had gotten the point and that was sufficient for me. He would not accept that and kept coming back with this idea. But I resisted. It was nothing fantastic, just cost money and would have used too much of my time while the benefits were mostly obtained just by getting the point as I had already. So yeah, there was frustration at times.
Oh well...
Posted by Elizabeth on February 1, 2002, at 17:53:45
In reply to Re: David Burns » Elizabeth « sid, posted by Dr. Bob on January 27, 2002, at 3:05:58
I said:
> > > Personally I've never heard of *anyone* with serious depression who was cured by CBT.I'm sorry if you felt excluded by this remark, Sid. I should have elaborated rather than just sticking it out there as a generalization for the reader to interpret.
I've certainly heard of people with serious depression who were *helped* by CBT. I've met people who say they were very depressed and got better on a combination of medication and CBT. Some have said that CBT was an essential part of their recovery. A few even say they got better with CBT and without medication.
What I haven't heard of is anyone with serious depression being successfully *cured* with CBT. By "cured" I mean that the CBT eliminated the depression and there was no further need for talk therapy or for any other kind of treatment: the patient was able to stop the therapy without becoming depressed again. A cure is permanent: for example, we have *treatments* for AIDS, but at present there is no *cure*. Similarly, I don't believe that any of the present approaches to serious depression is a cure.
I don't know much about your case, or how "serious" your depression is, but my impression is that you've improved a great deal but are not fully recovered, and that CBT wasn't the only treatment that you received. I'd be interested to hear the details of how you got to where you are now. You did say that your doctor now thinks that you have an anxiety disorder and not depression. I think the distinction between depression and anxiety is a fuzzy one in many, or even most, cases; they often go together and probably have common or related etiologies. In any case, CBT is supposed to help with both.
I believe that all depression is serious in a sense, but obviously, there's mild depression and there's severe depression, and the latter was what I was referring to (I should have said "severe" instead). The scenario I was imagining was a patient with a "long term" depressive illness (i.e., one that was either chronic or recurrent and had been present long enough that the chances of spontaneous recovery were very slim) who starts seeing a cognitive-behavioral therapist and gets well (never becoming depressed again) from that therapy alone. That didn't seem too realistic to me.
I'm sorry if it sounded like I was saying that therapy is worthless, because I certainly don't think that (I know I've said this on a number of occasions). When I was living in Boston, I saw a psychotherapist (psychodynamic, not cognitive-behavioral) on a weekly basis for four or five years, and if I go back there I will definitely start seeing him again if he's accepting new patients.
But I do think that therapy has its limits -- just like medication, it's not a panacea.
I have plenty of experience with talk therapy, incuding CBT, so I'm not just talking out of my ass here. You seemed to think that I had never tried CBT when you accused me of some sort of distorted thinking, and I wanted to clear that up. I have tried CBT twice, with two different therapists. Although I liked both therapists and felt they were good at their job, I eventually concluded that CBT wasn't for me. Like many people, I really wasn't able to get much out of CBT when I was acutely depressed (even if I could do the exercises, I was only "going through the motions"); when I wasn't depressed (due to medication or to partial remission -- my depression is more or less episodic) but had residual symptoms, the therapy wasn't useful because CBT doesn't address the type of problems that I have. (The second cognitive-behavioral therapist I saw agreed, and I decided to quit after discussing it with him. The first one mostly saw me only when I was depressed.)
I also found CBT a little bit intellectually stifling; it didn't seem to encourage individual expression or original thought. It had a "one-size-fits-all" quality to it. (In the group, I often felt like I was in a remedial coping skills class. :-) )
I found the insight-oriented therapy with my therapist in Boston more appealing. There weren't any assumptions about what my problems were; instead, the therapy was an attempt to identify and understand (on a "psychological" level) those problems and how they affected me. Although this therapy didn't relieve my depression either, I think the self-understanding I gained has been useful in my attempts to treat and manage my depression. I've also been in interpersonal therapy groups which I think were useful in some respects.
There are a lot of different kinds of depression, probably with a lot of different kinds of causes: bad life circumstances or events, distorted thinking, mysterious neurological glitches, etc. We don't have a way to determine the exact cause in any particular case, but it's good to recognize that not every treatment will be right for every person, in part because of varying symptoms, but also because of varying etiologies. (BTW, I think that what cognitive-behavioral psychologists like to call "cognitive distortions" are more often a result of depression than a cause of it.)
Anyway, I hope this clears things up. I really do agree with you about a lot of things; I'm just presenting my point of view.
-elizabeth
Posted by sid on February 2, 2002, at 12:30:39
In reply to Re: David Burns, posted by Elizabeth on February 1, 2002, at 17:53:45
>(BTW, I think that what cognitive-behavioral psychologists like to call "cognitive distortions" are more often a result of depression than a cause of it.)
I agree with you on this. My therapists did not stick to CBT liek a recipe book. Unfortunately, that's a lot of what people's experience has been, from what I read here.
> Anyway, I hope this clears things up. I really do agree with you about a lot of things; I'm just presenting my point of view.Yes, that and all the other exchanges we've had. I'm sorry for reacting so fiercely last week. I believe I was angry for a couple days and reacted too strongly to many things. Some people around me are still pushing my buttons and I need to find a way to better cope with them. Cutting them off my life would be ideal for me, but I need to consider other people around us that would be affected by it. Relationships are tough.
To answer some of your questions (perhaps they were rethorical, I am not sure, so I'll answer anyway)... I've had dysthymia for what I think is 21 years (since I was 13). I had a major depression in 1995 (at 27), which either lasted long or reccured in 1996. I got somewhat better and then worse again, with school pressures. I should have stopped grad school for a year or two, but I felt that's all I had going for me and could not let go of it. So it took longer to heal the depression. After that, I believe I had what you call residual depression - I was bitter, emotionally dulled, had no fun in life for some years. And in the past year, I got better: back to dysthymia only, which is kind of my "normal" state. In the past few months, I've been even better and it seems like the dysthymia is clearing. Some days not so much, but some days I feel lucky to be alive, and that has not happened since I was 13.
I think that my major depression was prompted by delayed grief (undelt with grief). However it did happen at a good time in my life: I was finishing my MS, had been accepted to the PhD program of my choice, with funding, I was inthe best physical shape I'd been in ages. And all of a sudden, I was in bed for a week, barely showering, crying and sleeping most of the time. I probably have the genetics for it too; my father had one major depression at 61 and he had all sorts of anxiety-related diseases (ulcers, insomnia, diarrhea, alcoholism), and most of his 7 bros and sis had depression, some of them most of their lives. Some had ECTs because nothing else would work.
All this to say that yes, my major depression was severe and that the probability of recurrence is very high, unless I fight it very hard with whatever works and feels comfortable to me. Acupunture has worked beautifully at one point, but since moving back home, I have not found an acupuncturist that can treat me as well as the one I first had. I think that's what led me to meds... I do miss her terribly! Acupuncture is also service-provider-dependent, just like psychotherapy. :-(
-sid
Posted by sid on February 2, 2002, at 13:48:44
In reply to severe depression » Elizabeth, posted by sid on February 2, 2002, at 12:30:39
> >(BTW, I think that what cognitive-behavioral psychologists like to call "cognitive distortions" are more often a result of depression than a cause of it.)
>
> I agree with you on this. My therapists did not stick to CBT liek a recipe book. Unfortunately, that's a lot of what people's experience has been, from what I read here.Oooops; these are 2 different things and should have been written in 2 paragraphs.
1- I agree with you about the distortions possibly being a result more than a cause. Although I think it may be different for different people. For example, my sister has completely distorted thinking but she does not seem to be in depression. She is definitely over anxious though. Could it cause depression at some point? I am not sure. I almost hope so, so it gives her an opportunity to correct it. Right now she does not feel miserable enough to do talk therapy or CBT. Depression increses those distorted thoughts in those who have them. And creates them in those who are initially rational (apart for 1 issue, I am pretty rational (mathematically-oriented mind) but depression made me a mess of guilt and distorted thoughts and behavior).2- My therapists did not stick to CBT like a recipe book. Unfortunately, that's a lot of what people's experience has been, from what I read here. I guess I was lucky in finding some balance there too.
- sid
Posted by Elizabeth on February 2, 2002, at 21:12:01
In reply to Re: assumptions « elizabeth, posted by sid on January 31, 2002, at 0:21:58
> > > But CBT is *not* a cure for any disease. Just about everybody has some bad attitudes or habits that they could stand to unlearn. I think that most of us understand that that's not the same as a mood or anxiety disorder.
>
> Right, but depression distorts our thoughts and possibly our behavior too, as a consequence of distorted thoughts. So CBT can help realize that and actively work on changing those. I think that's what happened in my case. I was sooo incredibly irrationally negative. CBT did help with that.That's cool. Unfortunately, a lot of people in the acute phase of depression are too impaired to benefit from CBT. I think it might help more in the residual phase, although I didn't find it relevant. I think I've told you about my residual symptoms of anergia and anhedonia -- not really amenable to CBT. In general, depression, for me, seems to be more about core feelings than about beliefs.
re blame-the-patient attitudes:
> Well, I've seen it mentioned on PB and PSB many times. I personally did not feel guilty. I just wanted to get better and worked at it every way I felt comfortable with, one being CBT.I think that people are often made to feel that if talk therapy simply doesn't work for them, it's their fault. This is, no doubt, amplified by depressive tendencies to feel guilty about everything.
> When I get stressed, I have a tendency to have negative thoughts. I catch them immediately and move on to better things. Had I not learned about CBT, I would be in danger or sliding towards another major episode every time my stress level is high.
So stress can lead to depression for you? I've found that depression (including residual symptoms), if already present, makes it harder to cope with stress, but when I'm not depressed I'm generally pretty good at coping.
> I don't think there should be any guilt. Guilt is one of the symptoms of depression, that may be why so many people seem to be feeling it in relation to therapy.
Sure, but I think the attitude that some therapists and others express contributes to these guilty feelings. When someone's doing their best, they shouldn't be made to feel that it's their fault that the therapy isn't helping, which it often doesn't.
I've heard people being told, in relation to therapy, things like "You need to work harder," "You don't really want to get better," "You can't expect the medication to do everything for you," etc. For that matter, you interpreted my remarks (in a moment of anger -- no hard feelings, I'm just using it as an example) as "selective memory serving your personal beliefs" and suggested that I needed CBT to correct this. The implication is that CBT is for people who are irrational or have other intellectual or personal flaws. (Irrational beliefs that are due to depression or depressive temperament are different from a general inability to think rationally.) A depressed person, or a person with a depressive temperament, isn't necessarily a stupid or bad person, but such a person is more vulnerable to being encouraged to believe that he is stupid or bad.
> I had lots of guilt, about other stuff.
Me too. I pretty much felt guilty for existing. I felt I was worthless and that my life was a mistake, and I could come up with a million reasons. Of course, all the reasons in the world don't change the fact that I have family and friends who care about me (regardless of my "objective" worth -- a major guilt focus was my inability to work) and would be devastated if something happened to me. I knew that, intellectually. It didn't change how I felt.
> I seemed to imply that because that's the impression I sometimes have from reading different posts. My impression may be wrong.
I think it's worthwhile to give people the benefit of the doubt.
> On thing I did notice is that people insist on the diabetes-insulin example to explain, rationalize, justify (to themselves and their loved ones) taking meds for depression.
I think they feel the need to justify it because they so often feel attacked by people who accuse them of laziness or wantint a "free lunch" (to use your words) -- I don't get the impression that they need to "rationalize" it to themselves. I'm not convinced the analogy is all that great; it's just the standard one (a lot of doctors use it). It obviously refers to type I diabetes, since type II diabetics don't necessarily need insulin. AFAIK, exercise isn't really a form of treatment for type I diabetes; the important thing is to keep your diet *regular* (as opposed to dieting to lose weight) and to be especially careful to monitor glucose levels and adjust insulin dose accordingly. There's a lot of effort that needs to be put into *monitoring* diabetes: you need to check glucose levels constantly, and there are all kinds of things that can alter the need for insulin which you need to be aware of. I don't think there's anything comparable in depression.
> I am still making efforts (side effect: it's 1AM and I can't sleep, so I am writing instead; have to be at the office at 8AM tomorrow), but spending less time on it. I work a lot more now and I don't think about the depression so much.
Working can be good for the recovering depressive, I think.
> I write and read about it here, but my day otherwise is depresion-free. Stressful, but depression-free. Cross my fingers.
I've got mine crossed for you.
> I have not read many studies overall since I do research in another field for a living (that's enough reading studies and writing them for me), but that's what my experience has been so far.
Going with what works for you is important, more important for your own life than the results of clinical trials or FDA labeling or whatever. (But try explaining that to some of these doctors here in NC who want to force me to stop taking buprenorphine even though it's been working for me for over a year. Jeez.)
-elizabeth
Posted by sid on February 3, 2002, at 11:25:34
In reply to Re: assumptions » sid, posted by Elizabeth on February 2, 2002, at 21:12:01
> In general, depression, for me, seems to be more about core feelings than about beliefs.
That's what's left for me I think: core beliefs. Meds may help; I think they are already helping. I'm less rigid about certain things. I've had those core beliefs since adolescence, that's why I think it's only dysthymia I have left, as it started during adolescence.
> So stress can lead to depression for you? I've found that depression (including residual symptoms), if already present, makes it harder to cope with stress, but when I'm not depressed I'm generally pretty good at coping.
Yes. I have an anxiety disorder, and when stressed, I can "loose it" and become very negative. I have to watch for that, as it's a slippery slope. That's what I've observed over time. Clearly, the less depressed I am to start with, the more easily I can deal with stress, but I think that both depression and stress can affect each other in me; it's not a one-way relation.
> I've heard people being told, in relation to therapy, things like "You need to work harder," "You don't really want to get better,"
A therapist once told me that. I got up in the middle of the session, paid him and left. I had found someone better the next week. I guess being stubborn and having a strong temper have helped me during depression. I told him that he was out of ideas on how to help me and that's why he started blaming me (which I still believe) - that was the last thing I needed from him, thanked him for his services and left.
> I think they feel the need to justify it because they so often feel attacked by people who accuse them of laziness or wantint a "free lunch" (to use your words)
I'm an economist and that's a basic things for us. "No free lunch" comes back all the time in my work, that's why I used it.
> -- I don't get the impression that they need to "rationalize" it to themselves. I'm not convinced the analogy is all that great; it's just the standard one (a lot of doctors use it). It obviously refers to type I diabetes, since type II diabetics don't necessarily need insulin. AFAIK, exercise isn't really a form of treatment for type I diabetes; the important thing is to keep your diet *regular* (as opposed to dieting to lose weight) and to be especially careful to monitor glucose levels and adjust insulin dose accordingly. There's a lot of effort that needs to be put into *monitoring* diabetes: you need to check glucose levels constantly, and there are all kinds of things that can alter the need for insulin which you need to be aware of. I don't think there's anything comparable in depression.
Well, I agree that it's not a great analogy for depression. I continue to believe that any one approach used alone to heal depression is weaker than many - at once or one after the other. It's been my experience and many other people's. Again, there is unfortunately not one answer for all with depression. That would be so nice.
> (But try explaining that to some of these doctors here in NC who want to force me to stop taking buprenorphine even though it's been working for me for over a year. Jeez.)I hope you can continue doing better and find a way to convince them that you are. Take care.
> -elizabeth
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