Treatment

COGNITIVE THERAPY

 

SAYS HAMLET:

There is nothing either good or bad, but thinking makes it so.

And researchers can see the results, thanks to brain scans - there along the left prefrontal lobe, an ominous blotch signifying the mind in crisis, and again in the paralimbic regions of the brain. And, reassuringly, researchers can also view that very same dark cloud being lifted, of one's brain being restored to working order.

But what's the connection? How does one's thinking relate to the digital shadows on a PET scan? Can the way you think REALLY bring on a depression? Or flip you into mania? And, if so, can the reverse apply? Can you actually THINK your way out of the deep dark pits of despair? Or back to a soft landing?

Consider this case:

In 1976, David Burns MD became a father. The birth was normal, but the boy was blue and gasping for air, and sent into intensive care. Despite the obstetrician's reassurances, Dr Burns visualized the worst. He imagined a severely brain-damaged son and everything that implied. Feeling his own mental well-being slipping away, Dr Burns turned to the therapeutic techniques pioneered by his colleague, Aaron Beck MD.

It didn't take the new father long to identify his negative thoughts and realize he had jumped to some fairly wild conclusions. Soon his son was breathing just fine, and Dr Burns was on his way to becoming a leading advocate of Dr Beck's technique, one we know of as cognitive (or cognitive behavioral) therapy.

Cognitive Therapy

Cognitive therapy is fairly new to the mental health field, but we can actually trace its development back in time 2,600 years to the Buddha and the great emphasis his followers place on watching - and eventually taming - one's thoughts. (SeeMindfulness.) There, the long-term goal is eventual enlightenment. The short-term goal - perfectly suited to our situation - is skillful living, involving hyper-awareness of your thoughts and feelings, and making the appropriate adjustments.

Cognitive therapy is not a cure for depression orbipolar disorder. Unlike traditional psychoanalysis and its variants, it does not purport to get to and root out the underlying causes of one's problem. But if it can help you change your thinking, then maybe you won't have depression or mania to think about. These days it is typically used in combination with drug treatment, and generally involves from ten to twenty sessions. You should not feel you have to reveal private details of your life in cognitive therapy, but do expect to have your thinking challenged.

We All Do It

Once our brains start running away from us, the mind throws out all kinds of negative thoughts that can keep us trapped in a vicious cycle of depression and anxiety and other states:

All-or-nothing thinking is one. Blowing negative events out of proportion is another, and blaming ourselves, no matter what, still another. Typically we filter out positive feedback and assume the worst based on little or no evidence.

We've all done it: We get stuck in traffic and our day is naturally ruined. We win some praise from the boss, but somehow it doesn't count. It rains on the family picnic and we're the ones who apologize instead of God.

Sometimes it gets personal: We misplace our keys and assume we're jerks. We forget a person's name and automatically we're stupid.

And sometimes it can get very serious, especially when we don't see life going according to our expectations. Now, single incidents become part of an unending flow that stands for everything that is wrong with the world or ourselves. Here the mind is working overtime, indiscriminately processing outside information and stamping out negative thoughts on a production-line basis.

Things Get Out of Control

You're stuck in traffic. But now, instead of you thinking that your day is ruined, you see this as a situation that never should have happened had there been no such thing as Fox News (or white Zinfandel, for that matter), this in a culture that gave us Louis Armstrong and Saran Wrap. What has gone wrong with the world? you can only wonder, midway between your cubicle at work and the soccer game you're supposed to be driving your kids to, and your husband doesn't give a shit, and, well, there's gotta more to life than this ...

Bring on the depression (or a screaming raging manic fit).

In cognitive therapy, your therapist is likely to ask you to recall what you were thinking as you plunged down into your last depression or flipped into mania - all those stuck in traffic thoughts, if you like - and work with you in recognizing them and nipping them in the bud before they can cause future damage.

 

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In essence, you are being asked to become a detached observer of your own nearly automatic worst thoughts. Once you've established breathing room, you can turn these thoughts around and substitute new ones. To stick with the stuck in traffic example, the car can become your peaceful inner sanctum rather than your personal torture chamber.

And how does it FEEL being in your inner private sanctum? A hell of a lot better than your personal torture chamber, thank you very much, which is precisely the point of the whole cognitive therapy exercise.

Yes, But Does Cognitive Therapy Work?

At ground zero in the teeth of a force nine depression or raging mania - perhaps not. As a tool for long-term recovery, almost certainly, not to mention as an early warning system against future depressions, manic episodes, and anxiety attacks.

According to Monica Basco PhD of the University of Texas Southwestern Medical Center and a leading proponent of cognitive behavioral therapy, responding to my question at the 2000 DBSA conference: "I do not believe you should be a passive recipient of care."

And this, perhaps, is cognitive therapy's greatest asset: The simple knowledge that we are not helpless bystanders, that in the unending battle for control of our own brains there is still an "I" that can put up a fight. And where there is "I" there is hope.

Dr Basco's Book

Cognitive therapy is being increasingly applied to bipolar disorder, especially in catching the swings up toward mania and down into depression before they take on a life of their own, while they are still manageable.

The first section to her "The Bipolar Workbook: Tools for Controlling Your Moodswings" sets the tone: "See It Coming," says the heading.

Emotions such as sadness or euphoria change the type of things you think about, as well as the quality of your thinking (such as trouble concentrating), which affects behavior.

A sad mood brought on by depression, for example, can lead one to think, "There is nothing I can do about my problem," causing one to give up on a project. By contrast, the euphoria of mania can bring on the perception of a bright idea and the impetus to foolishly take on a new enterprise.

But there is more to it than that. The ultimate path to Buddhahood, world peace, and getting rich quick - which came to you in a flash from watching Flipper advance to the next round of Dancing With the Stars - may set the scene for speaking in tongues to Vlad in Bucharest till three in the morning, then showing up at one’s day job a few hours later exhausted and with racing thoughts.

"The problem was not the project," Dr Basco writes. "The problem was the timing … Emotions can set you up to overreact to internal or external events."

Such as magnifying a situation (and minimizing its positives or negatives). If mania can turn a simple insight into divine revelation, depression can transform a routine minor annoyance into the impending apocalypse.

"Walk away from the situation," Dr Basco advises. Take time to evaluate it. Sleep on it, get the advice of your friends. Count to ten.

Often easier said than done. Self-knowledge is the key. Most of us have learned the hard way. We don’t want to go there again. From our bitter experience we can take stock, spot patterns, recognize triggers. Dr Basco uses various terms, but what she is driving at is mindfulness, the ability to recognize when the brain is starting to play tricks on us. We may personalize, catastrophize, engage in mind-reading and fortune-telling, think in absolutes, and on and on.

Catch the distortions in thinking as they occur, Dr Basco advises, Control then by keeping them from influencing your behavior. Correct any errors in your logic.

Dr Basco gives the example of Amanda, whose nursing license came up for yearly review. Amanda was legitimately concerned that truthfully answering the questions on the forms would unmask her illness. "I will be out of work," she started thinking. "We are not going to be able to pay our bills."

That’s Amanda’s fear talking, says Dr Basco. In no time flat, Amanda became her own personal prophet of doom. Ironically, her fear posed a greater risk to her privacy than filling out any forms. Left unattended, her inner fears and thoughts stood to manifest as behavior that even the people in Accounts Receivable would have noticed.

One of the things Amanda did was ask herself what someone else would say in the same situation. Then, with a better handle on her thoughts, she was able to form an action plan, which involved making discreet enquiries. Now Amanda had a sense of control. Those who have been through cognitive behavioral therapy can pick it up from there: How does it FEEL to be in control? A lot better than being in a panic, thank you very much.

Amanda was able to safely jump off the depression-mania bullet train before it left the station.

Yes, there will be setbacks – it’s a fact of life with this illness. But Dr Basco has faith in our own personal power, namely that mindfulness coupled with action can keep us well longer and reduce the time we spend unwell. Even when our illness has the upper hand, we are not helpless bystanders. It’s a reassuring thought.

Update July 5, 2016

A 2015 study review published in Psychological Bulletin showed less impressive patient outcomes than studies conducted in the 70s and 80s. My interpretation ...

Cognitive therapy requires both motivated patients and clinicians. You don't sit back waiting for things to happen. But the success of CBT suggests it is now being administered on a much wider populations - to indifferent patients by disengaged clinicians. For instance, if you’re too depressed to get out of the house to even keep your appointment with your therapist, let alone do your homework, CBT is not going to work. Neither are things going to happen with a therapist who is just going through the motions.

The takeaway …

If you tried CBT before and weren’t happy with it, it may have been because you went into it when your weren’t ready or when various circumstances were conspiring against you. Your situation may be a lot different now.

Revised July 5, 2016

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