Talking In Circles

We’ve all had the experience of leaving a therapist’s office and thinking: “I paid all my hard-earned money for that!”. No? Well, at least I have. In any case, reflecting on my negative and positive experiences with psychotherapy, I wanted to consider which modalities have proven most successful and why. Now, the four most common modalities of psychotherapy are psychodynamic, cognitive-behavioral (CBT), humanistic, and eclectic. Today, I want to hone in on CBT in order to determine which elements of this modality to preserve and which to leave behind. By the end of this piece, I hope to briefly sketch a new CBT modality which preserves its own successes and eliminates its own weaknesses. 

Within CBT, there are a plethora of different modalities implemented by therapists. Today, I want to focus on three of them: acceptance-and-commitment therapy (ACT), dialectical behavioral therapy (DBT), and exposure and response prevention (ERP). ACT was devised by Steven C. Hayes and later explicated by Russ Harris as a modality intended to provide us the tools to move towards our values despite negative feelings, thoughts, and life events. ACT’s ultimate goal is psychological flexibility and consists of six core tenets: acceptance; cognitive defusion; being present; self-as-context; values; and, finally, committed action. Meanwhile, DBT was devised by Marsha Linehan and incorporates mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness so that we are able to, again, cope with negative feelings, thoughts, and life events. Finally, ERP was pioneered by Victor Meyer and is usually implemented for patients suffering from obsessive-compulsive disorder (OCD). ERP forces patients to confront their fears and not allow their anxiety to dictate their behavior. 

Unlike generic CBT talk therapy which focuses on reframing negative thoughts and feelings, these three modalities are focused on value-based living despite inevitable negative feelings, thoughts, and life events. Perhaps I am just more of a behaviorist than a cognitivist, but it seems that we possess far more control over our behavior than our thoughts and, as such, should focus on modifying our behavior rather than changing our thought patterns. Oftentimes, I find that people are discouraged because the first-line of therapy involves generic CBT and co-rumination rather than specialized ACT, DBT, and ERP. An honest reckoning with contemporary therapeutic practices would, in my opinion, necessarily involve moving away from co-rumination and, instead, towards evidence-based treatments which prioritize values-based living in spite of life’s curveballs. 

Now, I’m no therapist. I’m not even sure what this new therapeutic approach would look like. However, by trying to combine the successful elements of ACT, DBT, and ERP with insights from Eastern and Western philosophy, I believe therapists and patients could achieve better results. It’s time for us to stop talking in circles and start living in spite of our anxiety.