Life after CBT

March 7, 2018 5:20 PM

I've reached the limits of what CBT can do for me. If you did too, or it didn't work for you, what next?

I've been in and out of therapy for the past 15 years. My primary problems are:
- Depression. Medication takes care of the worst of it, but I'm still prone to becoming overwhelmed and hopeless. My natural inclinations in thought are always negative. I look back and feel like I've spent my whole life low-level unhappy, chasing something, looking for something - a boyfriend, a new job, a different city, money, more friends, different friends, traveling, a better apartment. Always something.
- Terrible self-esteem.

There are some secondary problems, but I believe they are tied to the first two:
- Procrastination on big life issues. I've been trying some ADD medications, and I believe there are some genuine physical issues there, but I know some of it is tied to thinking that certain things are overwhelming and hopeless or that I'm not capable of doing them.
- Anxiety. I get anxious about certain situations or things, but I don't believe it's really anxiety. It's more my pessimism (yes, it's terribly unlikely this thing will happen to me, but it's possible, and why not me?) and my scarcity mindset (if I lose my job I'll never get another one...) and low self-esteem (...because I'm stupid).

I feel like I'm in a cage.

Why I need to move beyond CBT:
- I sometimes use it to convince myself that feelings I'm having that bother me are invalid. If I'm unhappy about a situation, I try to talk myself into being happy about it. Not in a temporary way (here are the positives until I can change things), but in a way that keeps me from taking action and that beats up on myself (look at all these positive aspects, you're so ungrateful for feeling this way).
- My behavior isn't actually changing. For example, I'm still letting people railroad me and not speaking up about my feelings or thoughts in some circumstances. I just beat up on myself after for doing so and for the thought patterns that were behind it (you know your feelings are just as valid as everybody else's you fucking idiot so just fucking speak up already).
- I'd like my default thoughts to not be negative. I don't know if that will ever be possible. I can look at some of my thoughts a few seconds after having them and see all the distortions, and self-correct to something more positive and genuinely believe it. That's great progress, but I'd really like to not have that negative thought pop into my head in the first place. I know there are some negative thoughts I'm not even seeing.
- I'm not opposed to a different kind of therapy, but the once a week format doesn't really do it for me anymore. I'm often dredging up things I've already processed or managed to forget and often don't get any additional insight from doing so. Additional rumination or self-examination beyond what I already do is just not helpful sometimes. I really need something in the moment. (I looked into text based therapy but got very mixed reviews. I'm also not sure it would be helpful if the person didn't actually know me or spend any time with me in person to get to know me and my history.)

Some things I've found helpful in the past, therapy-wise:
- A therapist who suggested once that instead of trying to convince myself that my negative or troubling thought was wrong, that I just exist with it and see if it eventually floats away.
- The therapist that pointed out that I was trying to CBT my feelings away. ("Just because you are depressed doesn't mean you're not allowed to dislike something.")

Any and all suggestions welcome, go nuts, don't feel restricted to books and therapies despite the two things I said were helpful. Thanks.

posted by unannihilated to Health & Fitness (17 answers total)

CBT did not work for me either, and it doesn't work for a lot of people. It's not a sign that you weren't trying hard enough or that your issues were "too big." You recognize this, which is good but I want to give you additional support there.

I have found EMDR (to heal trauma) and a low-dose of Zoloft (for anxiety) to work wonders. In fact, my life and outlook and self-image have radically changed for the better: it's the little things but also those little things that count and make my day-to-day better. Not a panacea but they made it possible for me to make so much progress after so much hard work on myself. Admittedly, things felt worse before they starting feeling better, which is why I added medication to the mix; I'm so glad I did both. Your situation and background are different but they're only one option of many beyond CBT. Good luck!
posted by smorgasbord at 5:25 PM on March 7, 2018 [4 favorites]

You could look into ECT (electroconvulsive therapy), ketamine infusions (experimental, not covered by insurance in the US generally), EMDR (the eyeball movement therapy), or TMS (transcranial magnetic stimulation.)
posted by xyzzy at 5:34 PM on March 7, 2018 [2 favorites]

A therapist who suggested once that instead of trying to convince myself that my negative or troubling thought was wrong, that I just exist with it and see if it eventually floats away.

Your therapist was likely approaching part of Dialectical Behavior Therapy (DBT), a common alternative for folks who have trouble with CBT. If you know this helps you, it is worth investigating and finding a therapist who specializes in it.
posted by furnace.heart at 6:12 PM on March 7, 2018 [3 favorites]

Look into Acceptance and Commitment therapy.
posted by SyraCarol at 6:44 PM on March 7, 2018 [7 favorites]

You are me. After decades of constant low-grade depression with occasional deep dives into the pit of despair, I did three weeks of full-time intensive DBT group therapy, and that coupled with meds has been life-changing. The big take-home idea is that feelings aren't inherently good or bad, they just are, it's how you respond to them that matters and you can learn to retrain your responses. This worked way better for me than CBT, which always just felt like lying to myself - with DBT you aren't trying to talk yourself out of negative thoughts or feelings, more acknowledging "I am having this troubling thought, is it objectively true or not, and what am I going to do with it?" We worked on a lot of mindfulness techniques and stress management and ways to re-engage the rational side of the brain during strong emotions or triggering events. Search for "intensive outpatient" or "partial hospitalization" and look for a program that focuses on DBT. If you have a current therapist or health insurance, they can probably recommend something.
posted by Flannery Culp at 6:47 PM on March 7, 2018 [10 favorites]

Seriously, there are so many other good options, many mentioned above. DBT is often-recommended. I hated CBT with a fiery passion, found real help with an eclectic ACT/other modalities therapist. If I were you I might try DBT first as the most highly recommended alternative. Not knowing better, I went to my PCP and told them how much I hated the CBT, and they recommended I see the head of psychiatry at their hospital, who listened to the things that Did work for me (like your list) and then recommended the practice that worked for me (also Prozac, but I never filled that script). So if you have a good local personalized recommendation, try that. Otherwise, look at DBT practitioners on Psychology Today in your area, or practitioners who mention things other than CBT in your insurance list of covered therapists.
posted by ldthomps at 6:57 PM on March 7, 2018

I also did a few weeks of DBT groups in an intensive outpatient setting and found it life-changing. Something about working with other mentally ill people, connecting with them, and helping each other through the program was really, really powerful for me.

Therapy groups are a lot different from drop-in support groups. They tend to want you to commit to a chunk of time (which could be "three weeks of intensive outpatient all-day" or "an hour a week for at least a few months" depending on the group), so you see the same people session after session and can form connections. And... then you can also try and debug those connections. If there's a problem with how you relate to people, it'll probably show up in group, and then you can try other ways of interacting.
posted by nebulawindphone at 7:03 PM on March 7, 2018 [2 favorites]

I'm a therapist who was trained in CBT and often uses it. This:

- The therapist that pointed out that I was trying to CBT my feelings away. ("Just because you are depressed doesn't mean you're not allowed to dislike something.")

is exactly why I think CBT has enormous limitations and is especially ill suited for people who tend to minimize their emotions. I believe that's a limitation/blind-spot of CBT, not a limitation/blind-spot of my clients. If you're running into that, you may want to look for therapists who focus a bit more on emotional processing. I don't know much about ACT, but I've heard good things about it. Psychodynamic therapists, somatic therapists, and DBT therapists might also be good fits.

You're not broken or too much. The therapy modality is just not all cure-all as it's hyped to be.
posted by lazuli at 7:20 PM on March 7, 2018 [15 favorites]

Humanist/Existential therapy might also be a fit, though those therapists tend to call themselves "eclectic" because existentialism is out of fashion.
posted by lazuli at 7:22 PM on March 7, 2018 [1 favorite]

It can be so difficult to find a therapy that works for you. It can be really hard but so worth it when you finally find it. I went through CBT for a while and found some of the same issues that you had, especially the "beating myself up for feeling this way don't I know that I should know better by now" type of thoughts.

I would also recommend EMDR. It didn't quite work for me, but the process of it is definitely worth looking into.

I didn't see it mentioned in your ask, but I'd recommend getting a journal and writing in it if you don't do so already. I've found that it does two big things for me: it helps me to express feelings in the moment so they don't stay bottled up; and to make notes of things I'd like to talk to my counselor about so they aren't forgotten before my next appointment.
posted by Halimede at 8:07 PM on March 7, 2018

I have never, ever understood how CBT could ever work for anyone at all, so you're not alone.
posted by Violet Hour at 9:52 PM on March 7, 2018 [3 favorites]

You need to find a psychodynamic focus or DBT focused therapist - I'm actually switching to a therapist focusing on CBT/DBT because I've reached the limits of psychodynamic therapy after nearly 4 years of it. I've processed my past and trauma to the point where I just need help thinking through thought patterns.
posted by yueliang at 10:39 PM on March 7, 2018

I deal with anxiety and a tendency toward depression, and have been through a lot of therapy. (Something I'm happy about and grateful for and that I consider part of keeping myself healthy and growing.) I've done a mix of therapeutic approaches over the course of my life and each technique was helpful in certain ways.

I did some CBT awhile back and at the time really appreciated the way it honed in on action; it made a big difference for dealing with acute depression, at least for me, because it was a way I could get some amount of relief relatively quickly. And it gave me some skills in recognizing that while there certainly were important underlying things that I needed to work on over time (which I did at the same time) , the behaviors themselves had an effect and could make me feel better or worse right there in the moment, so it gave me an important sense of control over my emotional state, at least somewhat, rather than feeling entirely beholden to my mood and like it was out of my control in the moment.

I can be really goal-oriented though, and to the point of being really hard on myself and holding myself to overly high standards. I definitely held onto the mentality that I had to "fix" myself and I would get caught up in being down on myself for still having bad feelings or anxiety or... anything less than perfectly healthy/stable. (What does that even mean, anyway?) So that wasn't helpful, for me, because here I was not only feeling bad, but feeling bad about feeling bad. So at that point in my life, Acceptance and Commitment Therapy (ACT) had a big impact for me. (It still does.) The focus on mindfulness and compassion was a big game changer for me and how I treat myself and live with myself.

After doing that for awhile, now I've started working with a psychodynamic therapist in the last year and although I was a bit skeptical at first that it would just become a series of sessions where she just lets me talk with no direction, I've started to really see how she is helping me unpack layers of stuff deep down by being there to catch it and talk through it as things come up over the course of my life. I'm seeing how my brain tries to protect me from uncomfortable experiences and feelings, via habits that it thinks are helpful but actually aren't :). (Such as being hard on myself, or not letting myself feel sad, or...) It feels like we're getting down to the roots of things and that as I sort some of that stuff out the behaviors that are trying to protect me, but actually hurting me, will change accordingly, because they're coping mechanisms and I won't need them as much anymore.

I share all that to try to explain I see it as something of a balance, like has been said above... each method brings with it certain strengths and certain weaknesses and each one has its way of addressing things. It can come down to where you're at right now or what you need at this point in your life. I have definitely experienced "maxing out" the benefits of a particular therapy method, and being ready for a different approach. Not one is necessarily better or worse although each of us probably has some that work better for us. That can change over the course of your life though, too, and depend on where you're at and what you need -- and I imagine that I will return to some of the methods I previously "maxed out", over the course of my life. I think I carry with me pieces of things I've learned from all the methods I've worked with, they combine to form my own personal mix of helpful skills and habits and perspectives that help me take better care of myself and be stronger and healthier and more at peace with myself.

It sounds like a new method might help shake things loose in a good way for you, get you trying some new things and offering some different perspectives that you can add to your repertoire of how you take care of yourself. It can be nerve-wracking to try out new things but there's also a lot of potential for big leaps when you find the right person and do it for awhile. Cheering you on!
posted by inatizzy at 1:14 AM on March 8, 2018 [2 favorites]

Meditation.
posted by Mr. Fig at 3:02 AM on March 8, 2018

REBT.
posted by dissolvedgirl22 at 9:07 AM on March 8, 2018

EMDR helped me deal with a lot of obsessive thoughts. A therapist trained in this will have you make your eyes move while you go deep into your past traumas. EMDR is a legitimate and well-accepted therapy for PTSD.

Secondly, MDMA (ecstasy) is also being tested for treating persistent depression and anxiety. Depending on where you live, you may be eligible for participation as a test subject.

I'm sure that sounds a little weird, but my few experiences with ecstasy when I was much younger, were absolutely transformative. I was able to think about a lot of the abuse and trauma I had experienced without having an anxiety attack, and what was amazing to me, have some compassion for and forgive my abusers. And the effects lasted for months. I was a calmer, happier person.

NOTE!! Do NOT use street ecstasy. It is laced and compounded with who-knows-what. I was able to get pure ecstasy from a lab because it was the early 1980s and not very well known yet.
posted by jfwlucy at 5:44 AM on March 9, 2018

Another option is Mindfulness-Based Cognitive Therapy. It combines aspects of meditation, ACT, and CBT approaches. In the UK, courses are often offered by buddhist centres and are relatively inexpensive.

Personally, for my ongoing depression, I've had many years of CBT-based therapy, and some MBCT. I've recently started psychodynamic therapy, and am finding it helpful especially from the self-esteem perspective.
posted by yesbut at 2:29 PM on March 9, 2018