Side effects of Cognitive-Behavioral Therapy (CBT)

July 4, 2009 12:31 PM

Are there really no side effects to cognitive-behavioral therapy? Has anybody had a bad outcome or weird experience?

The reason I ask is that I discovered CBT in 2004. Rather than forking over money to a therapist, I just read how it worked and tried applying it to myself. I found that it made me over-think my anxieties and in one case, aided me in putting blinders on myself in a situation, thereby making it worse.

Fast forward to now, and I can see that there are many many studies showing that CBT is effective. I'm using computerized CBT, and I've been reading a lot about how it works (literature I couldn't find five years ago). Needless to say, I think I'm excited about it, and think that I won't run into the same abuses and mis-applications that I had before.

However, after a few initial sessions this time around, I did notice some anxieties crop up. For example, one of my "warped thoughts" is "I can't relax otherwise I'll get screwed up." I went through the process of disputing that, and afterwards I started to relax but I also felt nervous about my relaxation. It almost reminded me of how I feel when taking Xanax. It's like, "this feels good, I'm relaxed. Oh wait, relaxed means danger!"

So my question is, are there any bad side effects to CBT? Are there any ways to abuse it?

posted by pauldonato to health & fitness (20 comments total)

The surest way to abuse any therapy method is to practice it on yourself. That's guaranteed to distort the process out of recognition. You are your own moving target.

I can't imagine how computer-based therapy could work. Are you using it for financial reasons or because talking to someone directly is intimidating? If the latter, please make the jump.

A good shrink can have a galvanizing and normalizing effect on your life. The ideas can be very simple and obvious, but having someone you come to trust apply them directly to your life is immensely powerful.

Of course it can be abused. A bad therapist, one who's out of whack, can misuse your trust. It's unlikely, though. I suspect that right now you're searching for a reason why therapy of any reason is a bad idea — it's probably one of your layers of defense. Try to break through there.
posted by argybarg at 1:15 PM on July 4 [1 favorite has favorites]

I have done CBT for years, in the short-term with a therapist and now on my own. I have mild OCD and "double depression" (dysthymia with occasional major depression) and find that CBT works for me if 1) I continue to take my antidepressant; 2) if I write things down using structured exercises (as in David Burns' New Feel-Good Workbook) rather than trying to do it in my head. The antidepressant took down the anxiety level enough that I could actually pay attention to the cognitive distortions rather than counter-arguing them ("But what if I really DID screw up enough that they'll fire me?") and writing the exercises down in a structured way also helped me stick to the routine rather than hare off on an anxiety goose-chase.

I would suggest some short-term work with a therapist. It may be that there are some deeper control issues that are coming up that may make it harder to stick with the CBT on your own. This is strongly suggested by the "I can't relax otherwise I'll get screwed up". Many people with truly dysfunctional family backgrounds develop hypervigilance of this sort, where they feel they have to control things that are actually out of their control.
posted by lleachie at 1:16 PM on July 4

Any behaviour modification technique can be misused or misapplied. I was reading some new research yesterday about how "positive thinking" can actually have a negative impact on the mental health of some people (and this has been known for years in regard to trauma counselling and sexual assault counselling).

CBT, like many other tools, is not intended to be used in isolation. If it's being used as the only way to address an issue - whether by a "therapist" or as self-help - then the potential for unintended consequences is high.

In the situation you've described, the intention would be for you to learn when it is safe and appropriate for you to relax - in some situations, doing so would be dangerous. You're not trying to eliminate the "danger" response, you're trying to stop it from kicking in inappropriately.

My concern is that you're trying to be your own therapist. There are some amazing online CBT resources out there, but it still helps enormously to have someone else monitoring your progress objectively and suggesting additional tools and strategies - none of us are nearly as objective about our own behaviour as we'd like to think. I'm not a big fan of therapists, but it might be worthwhile hooking up with some other kind of mental health worker you can check in with occasionally and who can monitor your "treatment plan" - as a mentor to guide you rather than as someone directing you.
posted by Lolie at 1:16 PM on July 4

Argybarg > 'I can't imagine how computer-based therapy could work.'

I think in this context CBT means cognitive behavioural therapy, not computer-based therapy.
posted by plep at 1:23 PM on July 4

Are there any bad effects to thinking? Are there anyways to abuse it?
Are there any bad effects to analyzing things? Are there anyways to abuse it?

No, and yes.

One of the things I learned in my therapy with a real, live, therapist was that new experiences feel strange - even if they are healthy and positive.

Maybe the progress you've made via CBT has led you to a new place, where things feel different, and you're not used to that difference, so it worries you.
posted by Locochona at 1:24 PM on July 4

I can't imagine how computer-based therapy could work.

If the OP is using something like MoodGYM, it isn't meant to replace formal diagnosis and treatment - a lot of mental health resources here are online and the government funded ones are all credible - although online programmes will be the only mental health resources available to many people in remote areas here.
posted by Lolie at 1:27 PM on July 4

Yeah, the computerized CBT that I tried is MoodGYM.

Right now my regiment consists of two ABCDE exercises every other day.

ABCDE is where you write down the Adversity, then the warped Beliefs that it brings up, describe the Consequences, Dispute the belief, and then Energize yourself. Each exercise takes me about 5-10 minutes.
posted by pauldonato at 1:33 PM on July 4

If you're using MoodGYM, consider adding e-couch as well - there's a link on the Mood-GYM front page. Similar kind of format, but targeted at specific mental health issues like anxiety disorders and depression and not just CBT-focused.

For those unfamiliar with these programmes, they're operated by the Australian National University's Centre for Mental Health Research and the feedback sections are quite pushy about seeking "live" help when warranted.
posted by Lolie at 1:51 PM on July 4

plep> I think in this context CBT means cognitive behavioural therapy, not computer-based therapy.

The OP also wrote: "Fast forward to now ... I'm using computerized CBT."
posted by galaksit at 6:06 PM on July 4

Side effects for... a particular type of introspection? What could you mean by that?

The term "side effect" usually refers to unintended negative consequences of a medical intervention of a pathology. In the case of a pill, or surgery, it's not too hard to distinguish what qualifies. If I give you chemotherapy, and the cancer continues to progress, the treatment is simply ineffective. If it causes you to throw up, assuming you hadn't been before, that's a side effect.

So how would that notion apply to a the treatment of a mental disorder? Well, starting with the definition the DSM-IV gives mental disorder: a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual,...is associated with present distress...or disability...or with a significant increased risk of suffering. So there is some pattern of behavior that you (or a nominal expert) has decided is against your interests (which raises interesting questions about the nature of interests and their connection to behavior - how does one intend to do something you don't want to do?).

So CBT is essentially a body of recommended self-talk or mental exercises that is supposed to alter behavior to be more agreeable to the subject (you). If you're attempting to follow these instructions and find that this isn't happening, I'd say the suggestions as followed can safely be appraised as ineffective. This could be because you've misinterpreted the formulators of CBT or because CBT simply doesn't work for you.

You're raising the possibility that such mental exercises could additionally cause harm. I'm not sure if this makes sense. What kind of harm would occur exactly? The creation of new patterns of thought/behavior you find undesirable beyond the habit of CBT itself? If it's possible for thought patterns to have unintended consequences like that, couldn't in principle this very thought have unintended consequences we would find undesirable? Moreover what does it mean for a thought to have an unintended consequence? Do our thoughts have intended consequences? It seems to me that most of the time we just think them. If I can consider the consequences of a thought, I can consider the consider the consequences of said consideration - a regression looms.

I don't have an any answers, but this is an interesting question.
posted by phrontist at 6:50 PM on July 4

I can consider the consider the consequences of said consideration.
posted by phrontist at 6:53 PM on July 4

The surest way to abuse any therapy method is to practice it on yourself. That's guaranteed to distort the process out of recognition. You are your own moving target.

At the same time, isn't surrendering to another person's judgment of what aspects of you are desirable and how you should think a little suspect? Is it even possible? Lets say a therapist tells me believing women don't have souls and men do is bad for me... it seems they need to convince me first or I end up just parroting back to them. And what, exactly, do I need to be convinced of - the truth of the matter, the effect of the belief on me or both? Why is another person desirable, let alone necessary, in this process?

Can you really be utilitarian about your thoughts/beliefs? What if believe I should believe in god because I think it will make me happy? Can I really choose that? Justifications must end somwhere... there must be some thoughts whose "value" I'm not appraising.
posted by phrontist at 7:04 PM on July 4

You aren't actually believing your new effective thoughts if you are winding up with "Oh wait, relaxed means danger!".....at that point you need to begin with ferreting out why you think there is danger. You have to go through it all again. Example:

A (activating event) = I was doing the CBT exercises when I disputed my disputing B= (belief /what I said to myself) I am not getting this CBT stuff! Maybe there are side effects to it. I am stupid for not getting this! C= (consequences) I feel like I wasted tons of time and wrote to the people on Metafilter. I am mad at myself for spending so much time on this. D= (dispute) Why do I think there is danger? Where is the evidence of danger? There is absolutely no evidence that when I relax there will be danger. It is fortunetelling to predict that danger will happen. What is the worst that will happen if I relax and there IS danger?! I will deal with it when it happens! Additionally, I am not stupid at all, I am doing my best and challenging my irrational thoughts E= effective new thinking..I accept that I have some resistance to CBT but I have made improvements and I am going to stick with this for at least two more weeks, vigorously attacking my irrational thoughts! I won't give up!


The "trouble" with CBT, as you've learned, is that it does take quite a lot of time. But consider how much time making appointments with therapists, driving to therapists, talking to therapists all takes. CBT is MEANT to be self help (as you know). Ellis, Beck, Burns all agree that people can do this work themselves. However, obviously, a CBT therapist can and will help you if your realizing that you are very resistant and arguing with yourself about CBT instruction.

I understand what you are talking about by "over thinking"..but CBT is best for people in danger of being self absorbed because it teaches you to become aware of your automatic negative thoughts and to challenge them. Other therapies want you to DWELL on your inner child and things that put your mind in the past. CBT keeps you in the here and now. Don't give up on it..you are on a good track. CBT makes people take responsibility for themselves and if you stick with it, invest the time, you can improve in leaps and bounds.
posted by naplesyellow at 7:13 PM on July 4 [1 favorite has favorites]

You're raising the possibility that such mental exercises could additionally cause harm. I'm not sure if this makes sense. What kind of harm would occur exactly?

Pretty much every cult in existence uses well-established behaviour modification techniques to "programme" its members, so they can definitely be harmful if misapplied.

An unintended consequence would be a particular technique resulting in a lessening of a person's ability to cope with everyday life - and there is some evidence that this does happen, although it can be argued that where it does occur whoever has been overseeing the therapeutic process has been more focused on the technique than the outcome and was not monitoring the actual results and adjusting individual treatment plans accordingly.
posted by Lolie at 7:19 PM on July 4

Forgot to mention that one of the things I love about CBT is that it's not an either/or proposition. The times when I'm struggling with overcoming the thought and beating myself up for that, I can approach it from another angle - I tend to use a Zen attitude then and just observe and detach from the thought instead of fighting it, but my point is that you can combine CBT with other bits and pieces as needed.

Sometimes I just set myself a "wallowing" period. I honestly can't remember where I picked up that particular idea from, but I know that I've never yet been able to actually wallow in my negative thoughts for the full time I've allotted. That's the great thing about CBT, you don't have to do battle with every single negative thought and emotion - it's about recognising and changing your overall pattern of thought/emotion/behaviour and you don't "fail" if you haven't got mastery over every individual negative thought.
posted by Lolie at 8:06 PM on July 4

One of the great things about CBT is that it is an excellent tool that can be used on your own to handle maladaptive thoughts and troubling feelings. The problem is that trying to administer it to yourself as a first step is problematic because there's no one to help you contain the feelings of getting freaked out when you get X result or Y outcome that you weren't expecting, or that bring you some discomfort. That's why it's advisable to start CBT with a therapist, who can guide you in the process until you can successfully and confidently practice it on your own. It's not just a racket to get money out of you--it's to help you learn how to use this powerful tool so that it will actually work to its greatest potential for you, and to help you learn to use it safely and correctly. All that said, the only negative effect to speak of that you might get from CBT is, if a particular exercise triggers some distressing thoughts/feelings for you, there won't be a therapist there to help you manage that, because you are electing to do it totally on your own. I am actually pretty concerned about what you're saying happened to you when you tried it on your own, and it increased your anxiety repeatedly. This means that what you are currently doing is NOT WORKING. Please consider seeking out the help of a CBT-practicing therapist.
posted by so_gracefully at 8:24 PM on July 4 [2 favorites has favorites]

@Lolie it's amazing how often people, on their own, find solutions that eventually get codified into therapeutic policies. Your "wallowing" period is a well-established solution for Obsessional thinking, where you just set aside 30 minutes a day where you'll let all your worries come out... everything else gets deferred until then.
posted by pauldonato at 8:27 PM on July 4

Well, the reason I posted this today is that I initially intended to do two ABCDE exercises every other day, so as to gradualize myself into CBT. But on Friday, I was feeling particularly anxious, and so I went ahead and did more exercises. All day today I've felt really weird. I've been sleeping a lot, and just being generally moody. At the same time, I can feel that the CBT did change certain aspects of my thinking. Like I don't feel like I'm overly thinking and I don't hear really dark negative thoughts. At the same time, my head's been foggy all day, almost like I had just taken St. John's Wort.

So, I'm going to try to be more disciplined, maybe only doing one exercise every other day, and slowly work my way up. I think it's helping to correct my warped thoughts. However, I think a lot of my security comes from old habits of thinking, and so my personality has to find footing on the newer, more realistic/positive foundations that CBT is bringing me to.
posted by pauldonato at 8:41 PM on July 4

Even after years of using CBT, you'll still have "warpy thoughts" occasionally - but you'll be more likely to "test" those thoughts and see whether they are skewed. CBT doesn't mean you're going to wake up every morning bursting with optimism and full of energy, it's more about becoming aware of how your thoughts are influencing your mood at any given time and challenging distorted thinking than it is about never having negative thoughts.
posted by Lolie at 8:54 PM on July 4

I think I know how you feel. I've read a great deal of David Burns's work and am found recommending it quite a bit around Mefi. I've used it mainly for anxiety, and at my most anxious I've occasionally found myself feeling more anxious when I was supposed to be doing exercises to achieve the opposite. I think many times I was simply not applying myself in the right way, it's something that takes practice. As naplesyellow said, I've found that doing it correctly takes time. If you deal with one thought another one often pops up, such as you described. The way I understand CBT, that one has to be addressed as well if it's bugging you.

I'm no expert, and I've actually never used the exercises regularly for a period of time, instead clustering them around times that I've felt very off or when the anxiety was affecting my life, but I definitely feel that CBT has helped me. I obviously love Burns's books. And once again echoing what naplesyellow said, CBT is designed to be able to be done independently. Burns reiterates that time and time again.

I've heard of MoodGYM but haven't used it, I suppose if you feel you're not doing things "right" it would make sense to seek out a therapist to help guide you, another suggestion Burns makes.

Either way, I don't think there's a reason to stress out (haha). Sounds to me like you're on the right track.

Good luck!
posted by Defenestrator at 11:35 PM on July 9