Does Cognitive Behavioral Therapy (CBT) really work?
Each year, it is estimated that one in every 5 adults (20%) around the world suffer from a mind-brain disorder like depression or anxiety.1 The cost of these disorders can be substantial, not just in financial terms but also in loss of human potential.
The two main lines of treatment for these disorders are antidepressant drugs and psychotherapy.
Interesting side note: When patients themselves are surveyed about their preference between the two, about 75% of them prefer psychotherapy.2 In spite of this, the use of psychotherapy has declined in the United States while the use of antidepressant drugs has increased.3
Cognitive Behavioral Therapy is the most extensively studied among several psychotherapy methods used for these disorders. In Part 1, I explained that psychiatrist Aaron T. Beck and his colleagues developed CBT because psychoanalytic techniques had not performed well in carefully designed research studies.
Has CBT done any better?
This is an important question to answer before we get into the nuts and bolts of the whole thing. Otherwise, we’re just wasting our time.
Pim Cuijpers, Professor of Clinical Psychology at the University of Amsterdam, has headed up efforts to collect and analyze clinical trial data for depression and anxiety disorders. In a recent meta-analysis of 144 clinical trials involving over 11,000 patients, Cuijpers and his colleagues reported that CBT was effective in treating major depressive disorder (MDD), generalized anxiety disorder (GAD), panic disorder (PAD) and social anxiety disorder (SAD).4
It’s embarrassing to admit this, but before starting my own psychotherapy I really didn’t know that my thinking was distorted. I just assumed that the way I thought about things was the way everyone thought about things.
Now that I know better, I want to share that good news with you, too. Neither you nor I have to stay trapped in old patterns of thinking – it is possible to re-train our brains to think balanced, healthy thoughts.
Let’s take a closer look at the first of ten main types of cognitive distortions. You will also find all ten described in the classic book by Dr. David Burns: Feeling Good: The New Mood Therapy.5
Cognitive Distortion #1: “All-or-Nothing” Thinking
People who use “all-or-nothing” thinking view themselves and the rest of the world in extreme, “all-or-nothing” terms. Psychologists call this “polarized” or “dichotomous” thinking because everything is simplified down to basically two categories: black or white, up or down, good or bad, positive or negative, right or wrong.6
Here are some all-or-nothing thoughts:
- “I got a B on that test. That means I failed.”
- “She forgot to change the towels when she cleaned the bathroom. What a terrible job she did!”
- “That typo just ruins the whole paper.”
- “My husband forgot to fold the socks the way I told him to. He made a complete mess of folding the laundry.”
- That pimple makes me look so ugly. I wonder how people can stand looking at me.”
I don’t know what world we believe we’re living in when we think in these extreme terms. It’s certainly not this one, where no one is 100% beautiful, brilliant, successful, or perfect 100% of the time.
The problem with all-or-nothing thinking is, “I have to be perfect.”
This cognitive distortion used to be a big problem for me – it is for most of us who struggle with perfectionism.7 This is because there is no room for “good enough” in all-or-nothing thinking. If something is not done 100% successfully, then we perfectionists automatically move it to the only other category that exists in our minds: failure.
But expecting perfection just sets us up for depression and disappointment because we will constantly fail to reach such unrealistic expectations.
My experience with perfectionism may be different from yours. But I think what drove my own perfectionistic impulse was fear. I used to be afraid of letting other people down, and I was also afraid of criticism. Living perfectly in a perfectly organized home, performing all my work with a perfectly executed flourish sounded…well, safe.
So perfectionism was the armor I wore to try to shield myself from disappointment or disapproval.
Well, that was just plain stupid.
Sorry – that is how the old, dichotomous me would have put it. Let’s see…That was not very smart.
I finally realized that there were two major flaws in my armor. 1) Try as I might, there were and always would be chinks here and there, because I am not a perfect human being. 2) What I think is perfect is not everyone else’s idea of perfect. So try as I might, disappointment and disapproval were and always would be sure to come.
That’s when I understood that I could either try harder to maintain a perfect façade, or I could accept my imperfections and learn how to deal with others’ criticism. Since the first way was bound to fail, I decided the second way is the way to go.
I still struggle with perfectionism, but minor flaws and failures don’t throw me the way they used to. I like this quote by writer Anne Lamott:
Perfectionism is the voice of the oppressor, the enemy of the people. It will keep you cramped and insane your whole life… I think perfectionism is based on the obsessive belief that if you run carefully enough, hitting each stepping-stone just right, you won’t have to die. The truth is that you will die anyway and that a lot of people who aren’t even looking at their feet are going to do a whole lot better than you, and have a lot more fun while they’re doing it.”8
Do you have the cognitive distortion of All-or-Nothing Thinking?
If you answer “yes” to any of the following questions, then you probably have this cognitive distortion:9
- Do you have trouble accepting anything less than perfection or the best?
- Do you or others ever think that your expectations are unrealistically high?
- If you don’t reach your expectations, do you completely give up (“I blew my diet today, so I guess I’ll take the rest of the week off and go whole-hog.”)?
- Do you have trouble admitting your mistakes?
- Do you have trouble admitting your character flaws?
- Do you believe that you are either a success or failure?
- Do you use a lot of the following “all-or-nothing” words in your thinking and conversations?
Keep in mind that words in BOTH columns can be problematic if they skew our version of reality in either direction.
Now, some believe that dichotomous thinking is a virtue rather than a vice. And it is true that dichotomous individuals tend to be strong, decisive thinkers – after all, boiling everything down to only two options does simplify things.
However, dichotomous thinking has a dark side. It has been linked to self-centeredness (narcissism), manipulation and cynicism (Machiavelli-ism), callous social attitudes and impulsive, exploitive behavior.10
Dichotomous thinkers see the world only in black and white. They do not see the many shades of gray in between. Their focus on perfectionism does not allow for error in themselves or anyone else. This can result in inordinate lack of compassion toward themselves and others.
Such coldness turned inward creates feelings of low self-worth, discouragement, and at its worst, suicidal thoughts. Coldness turned outward destroys concern and goodwill. Any relationship caught in such a draft is likely to freeze to death.
What is the solution to All-or-Nothing Thinking?
As a recovering perfectionist/dichotomous thinker myself, I offer the following tips:
- Journal your thoughts. Look for “All-or-Nothing” words.
- Don’t try to be perfect.
- Accept partial successes.
- Focus on the lessons learned.
Journal your thoughts.
I know what you are probably thinking because I thought the same thing: “I don’t have to write anything down in order to understand what is going on. I can keep track of my distortions in my head.”
I’ve said this before, but I’ll say it again here: writing things down will make a huge difference in your recovery.
One reason is, even one thought can relay multiple distortions (you’ll see what I mean as we talk about more of them). It’s not until you write your thoughts down and ponder over them that you begin to see specific patterns of distortions starting to develop.
The specific pattern you are looking for here is a high volume of “all-or-nothing” words (see them listed above).
After you have identified these words, you can go one step further and re-write your thoughts, replacing the black-or-white word with something a bit more grayish. For example,
“That typo just ruins the whole paper,” can be changed to
“That typo blemishes the paper. Oh, well. No use crying over it now.”
Don’t try to be perfect.
“Perfectionism” is a perversion of a much better goal: “Do your best.”
Not some fixed and absolute version of best.
No. Your best.
The best that you, with your current resources and knowledge, can do. And when you reach your limitations in each, then you need to cut yourself some slack.
By extension, this also means hoping for the same sort of “best” from others, while recognizing that they too will have limitations in resources and knowledge. You can think of this as “loving your neighbor as yourself.”11
Here is another quote from Anne Lamott:
If you don’t believe in God, it may help to remember this great line of Geneen Roth’s: that awareness is learning to keep yourself company. And then learn to be more compassionate company, as if you were somebody you are fond of and wish to encourage. I doubt that you would read a close friend’s early efforts and, in his or her presence, roll your eyes and snicker. I doubt that you would pantomime sticking your finger down your throat. I think you might say something along the lines of, ‘Good for you. We can work out some of the problems later, but for now, full steam ahead!’ (italics mine)”12
Accept partial success.
In the real world, there are many levels of success.
It may help to reframe our thoughts by acknowledging the successes in every situation, even if they were incomplete. Here are a couple examples:
“I got a B on that test. It is not as good as I would have liked, but it is enough to keep me in the graduate program. That is what matters.”
“My husband forgot to fold the socks the way I told him to. But he remembered to fold the shirts and pants the right way. Good for him! After I thank him for doing those things, I will remind him about the socks.”
Focus on the lessons learned.
There’s actually nothing wrong with pursuing perfection, provided the effort is properly motivated.
We should never be motivated by fear, or by a need to control, or by a drive to be “number one.”13
The best motives for working toward any goal are enthusiasm, sharing success with others, and enjoying the process. When we enjoy the process, it becomes much easier to understand that mistakes along the way are just opportunities for growth and improvement.
Here are a few examples of turning mistakes into lessons learned:
“I blew my diet today. But I know where I went wrong: those leftover brownies were just too tempting for me. Next time, I’ll tell my husband to take leftover treats to work so they won’t be in the house. Tomorrow, I’ll go right back to my healthy eating plan.”
“I got a B on that test. What can I do next time to improve my chances for an A?”
Conclusion and Action Steps
All-or-nothing thinking can be a real stumbling block to thinking about our flaws and failures in a healthy, productive way.
To overcome this stumbling block:
- Continue your daily thought journal.
- Review your thoughts for the all-or-nothing cognitive distortion. If you find it, revise the thought using the tips above.
- Read the next part of this 101 series. Or you can read the whole series from the beginning here.
1 Steel, Z., Marnane, C., Iranpour, C., Chey, T., Jackson, J. W., Patel, V., & Silove, D. (2014). The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013. International Journal of Epidemiology, 43(2), 476–493. https://doi.org/10.1093/ije/dyu038
2 McHugh, R. K., Whitton, S. W., Peckham, A. D., Welge, J. A., & Otto, M. W. (2013). Patient Preference for Psychological vs. Pharmacological Treatment of Psychiatric Disorders: A Meta-Analytic Review. The Journal of Clinical Psychiatry, 74(6), 595–602. https://doi.org/10.4088/JCP.12r07757
3 Olfson, M., & Marcus, S. C. (2010). National trends in outpatient psychotherapy. American Journal of Psychiatry, 167(12), 1456-1463.
4 Cuijpers, P., Cristea, I. A., Karyotaki, E., Reijnders, M., & Huibers, M. J. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta‐analytic update of the evidence. World Psychiatry, 15(3), 245-258.
5 Burns, D. D. (2009). Feeling good: the new mood therapy. New York: Harper Publishing. pp.32-33.
Note: This book was originally published in 1981. The reference above is for the first paperback edition by Harper (an imprint of HarperCollins Publishing).
6Beck, A. T. (2002). Cognitive models of depression. Clinical advances in cognitive psychotherapy: Theory and application, 14(1), 29-61.
7 Egan, S. J., Piek, J. P., Dyck, M. J., & Rees, C. S. (2007). The role of dichotomous thinking and rigidity in perfectionism. Behaviour Research and Therapy, 45(8), 1813-1822.
8 Lamott, A. (1995). Bird by Bird: Some Instructions on Writing and Life. Anchor.
9 Nedley, N. A. (2011). The lost art of thinking: How to improve emotional intelligence and achieve peak mental performance. Oklahoma: Nedley Publishing. pp.25-33.
10 Jonason, P. K., Oshio, A., Shimotsukasa, T., Mieda, T., Csatho, A., & Sitnikova, M. (2018). Seeing the world in black or white: The Dark Triad traits and dichotomous thinking. Personality and Individual Differences, 120, 102-106.
11 Matthew 22:36-40 (New International Version) 36 “Teacher, which is the greatest commandment in the Law?” 37 Jesus replied: “‘Love the Lord your God with all your heart and with all your soul and with all your mind.’ 38 This is the first and greatest commandment. 39 And the second is like it: ‘Love your neighbor as yourself.’ 40 All the Law and the Prophets hang on these two commandments.”
12 Lamott, A. (1995). Bird by Bird: Some Instructions on Writing and Life. Anchor.
13 Burns, D. D. (2009). Feeling good: the new mood therapy. New York: Harper Publishing.
Dr. Pamela Coburn-Litvak has published research articles on exercise and stress in Neuroscience and Neurobiology of Learning and Behavior. Her latest book, Leaving the Shadowland of Stress, Anxiety, and Depression, was published in 2020.
After receiving a Ph.D. in Neurobiology and Behavior from the State University of New York at Stony Brook, she served as both Assistant Professor of Physiology & Pharmacology and Special Assistant to the Vice President for Research Affairs at Loma Linda University in Loma Linda, California. She then joined the Biology department at Andrews University and developed courses in human physiology as well as the neurobiology of mental illness. She also founded Rock @ Science LLC, a company that specializes in health and science education and web development. She co-developed the brain and body physiology segment of the Stress: Beyond Coping seminar with its creator, Dr. William “Skip” MacCarty, DMin.
Dr. Coburn-Litvak currently lives in California with her husband. Their two daughters are mostly grown and attending school elsewhere.
When she’s not studying or teaching about stress, she enjoys stress-relieving activities like puttering around the garden, taking nature walks with her family, knitting, cooking, and reading.
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