The Logic Behind Cognitive Behavioral Therapy and Its Widespread Use
Roughly 2,000 years ago, the emperor of the Roman Empire sat in his tent to clear his head. He had plenty of reasons to decompress: ugly border disputes threatened his legacy, untrustworthy warlords schemed behind his back, and unrelenting family issues from the premature passing of his wife and a difficult relationship with his only surviving son brought on constant loneliness. Yet this emperor, Marcus Aurelius, remained mentally strong and became one of the most successful leaders in history. The secret to his achievements is distilled in the personal writings made in his tent far from home while de-stressing in the calm of night.
A classic figure of stoic philosophy, Marcus Aurelius promotes the development of mental self-control and fortitude by explaining, “the things that you think about determine the quality of your mind. Your soul takes on the color of your thoughts” (Aurelius, p. 67). In a world of intractable and fickle external circumstances, Marcus Aurelius highlights the significance of training our controllable thought patterns to overcome adversity.
Despite the rapid increase in knowledge of the natural sciences and specifically of mental health in the two millennia after Marcus Aurelius’ death, his stoic philosophy of using logic to identify and reconsider toxic beliefs and behaviors is more prevalent now than ever. This legacy lives on through cognitive behavioral therapy, or CBT. CBT is a pervasive evidence-based psychotherapy that assumes many of life’s problems derive from corrigible cognitions, feelings and behaviors. By recognizing the distress caused by maladaptive patterns in these three areas, one can work towards applying healthier, more practical responses to difficulties. Unlike in many forms of therapy, a CBT therapist works collaboratively with clients to set goals, identify problems and check progress, often through assignments between sessions. Clients learn to proactively break down problems into conquerable steps. Rather than dwell on the past, CBT focuses on specific, solvable issues in the present.
Also unlike many forms of therapy, CBT has extensive scientific research verifying its effectiveness. CBT facilitates research on patient outcomes by aiming to make quick, clear, measurable changes in thoughts and behaviors through fairly consistent procedures. One study examined 269 meta-analyses reviewing the overall effectiveness of CBT (Hoffman et al., 2012). Meta-analyses allow researchers to compile a range of studies, weigh their results based on the size and thoroughness of the research conducted, and draw comprehensive conclusions utilizing multiple data sources. This study went one step further by surveying many meta-analyses, thus providing a broad survey of contemporary evidence for the efficacy of CBT. The authors filtered results by quantitative analyses so that numerical comparisons between studies could be calculated, then filtered by recent results published after 2000. Last, the authors only included studies using randomized control trials, leaving 11 relevant meta-analyses. Randomized control trials are considered the gold standard in research because they meticulously determine whether a cause-effect relationship exists between treatment and outcome. The 11 studies showed better responses to CBT than comparison conditions in seven reviews, and a slightly lower response in only one review. Thus, CBT is generally associated with positive outcomes. However, despite the vast literature on CBT, many meta-analytic reviews include studies with small sample sizes, inadequate control groups, and lack representativeness of particular subgroups such as ethnic minorities and low-income individuals. Thus, the conclusions are insightful but complex.
Not everyone benefits from CBT, which assumes that changing the processing of information leads to better behaviors. If a child has anxiety and ruminates about past experiences, jumps to extreme conclusions, or labels themselves in negative ways, they are likely candidates to benefit. But what if the problem is not so specific? What if the child has more complex issues like severe autism, and is unable to cooperate in therapy? Further research must be conducted to fully answer these questions.
Some scientists argue that CBT focuses on obvious surface-level symptoms instead of the symptom’s deeper roots and consider this shortsighted since it reduces complex psychological and emotional states to simple, solvable problems. Can that reduction truly capture the subjective distress and complexity of the individual’s internal world? Perhaps not, but if therapy aspires to alleviate distressing symptoms, is it more helpful to understand the roots of patient’s internal world, or to focus on overcoming specific issues causing daily distress? Marcus Aurelius provided a simple metaphor to answer this question two centuries ago; “the cucumber is bitter? Then throw it out. There are brambles in the path? Then go around them. That’s all you need to know. Nothing more. Don’t demand to know why such things exist,” (Aurelius, p. 130).
CBT relies on parallel logic by concentrating on helpful and direct solutions to issues, rather than investigating their origins; perhaps this efficacy is why its lessons appear timeless. How to solve a problem overrides why the problem exists in the first place. Whether this is truly the best solution to mental health issues has yet to be determined. Nevertheless, the practical application of CBT, which originates in ancient philosophical rationality, continues to pervade.