Does Cognitive-Behavioral Therapy Apply to Campus Politics?

Note: Usually, when I write about any remotely politically-charged topic, I make sure my arguments are very clear in my mind and supported by 9000 citations first. This isn’t the case with this topic, which I’m still forming ideas about. I’m posting this because I’d love to hear feedback/counterpoints from cognitive-behavioral therapy (CBT) and social justice perspectives: kathrynhgordon@gmail.com.

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I was recently on Jesse Singal’s podcast, and he asked thoughtful questions about the applications of CBT to campus culture war issues. Apparently, a side effect of asking me good questions on a podcast is that follow-up blog posts occur (well, it’s happened twice so far, anyway).

Here are my current, still-forming thoughts about whether CBT should be applied to college students making claims about politically-related offenses and psychological harm. My points are based on a variety of different arguments I’ve heard and are not directed at particular people/texts, though I believe this is the original article applying CBT in this way.

1. CBT is excellent and improves the lives of a lot (but not all) people struggling withBurns.jpg mental health issues. I’d love for all college students to read David Burns’ self-help CBT book, Feeling Good: The New Mood Therapy (which is referenced in the original article on this topic). I read it in college, found it eye-opening, and then proceeded to recommend it and loan it to countless people since — including undergraduate students who I taught when I was a professor. Seriously, ask anyone who knows me — I have probably recommended that book to them. Not all students find it helpful (which is consistent with research on any treatment modality), but some really do. However, it’s important to recognize that CBT is designed and scientifically-tested as a treatment for people who are having mental illness-related distorted cognitions and thinking errors. It does not focus on societal stressors related to healthcare access, income inequality, rights, or prejudice, and it doesn’t offer solutions to those issues either. My concern is that placing thoughts related to these issues in a CBT framework reinforces some individuals’ default position that people talking about experiencing prejudice or feeling upset about political issues are exaggerating. Within a therapeutic context, these complexities can be addressed with nuance. Outside of that context, I worry that it bolsters notions that people can and should just think their way out of these types of stressors. This NYT article is about an illustrative real life example of how this kind of disbelief or minimizing default can lead to negative consequences.

2. Relatedly, I’m wary of using CBT as a method for ‘correcting’ other people’s thoughts and feelings about offense or harm unless I’m the person’s therapist (and even then I’m cautious) for the following reasons:

Humility & AccuracyIf you think someone is overreacting to a politically-related incident, you can just plainly state that as your appraisal of the situation instead of using CBT language (e.g., calling it catastrophizing or emotional reasoning). When you say someone’s thinking is distorted, the assumption is that you know for sure that they’re overreacting and also that you know why they are (and that is mindreading). I don’t see the incremental value of using CBT terms in situations where you don’t know much of the context, unless it’s to tone down the fact that you’re making a judgment about the accuracy of a person’s thought by framing it as a concern about their mental health.

EffectivenessIn the self-help version of CBT, a person learns tools for investigating their own distortions and thoughts. In therapy, it’s a collaborative process, where the therapist hears the person’s point of view and guides them through the steps of evaluating their thoughts in a compassionate, contextualized process. By design, CBT helps people arrive at reframed thoughts that ring true for them. It can be hard to get to that place in therapy — it seems much harder to get to that place through some of the other methods I’ve observed (articles/posts referring to students’ behavior as evidence of their fragility). To be clear, I’m not saying that thought errors don’t happen in certain college campus situations — I’m just saying I don’t see how motivated the average college student would be to evaluate thinking errors when presented with them as a sign of their fragility.

Ignoring Real Problems Where They ExistAs I wrote about before, I think that disproportionate focus on students’ purported lack of resilience ignores the valid reasons for their actions. If students get painted with too broad of a brush and are characterized as simply being unable to tolerate opinion differences, then it distracts from points of legitimate concern about the spread of ideas that perpetuate social inequities. When therapists disagree with their clients’ approaches to situations, they motivate change by looking for and validating the truth in what the client is saying and collaboratively generating ideas about adaptively achieving their objectives.

Furthermore, there’s a long history of people from marginalized groups being misdiagnosed and poorly treated within mental health fields (e.g., 12). Broadly applying cognitive distortion framework in a public way doesn’t allow for a culturally appropriate framework that therapists are trained to use in treatment. Without that context and training, people might minimize or deny others’ valid experiences–which could be harmful to their health.

In conclusion, there are helpful elements in cognitive-behavioral therapy that apply to particular types of problems — especially when depression- or anxiety-related thinking errors are present. I have reasons to doubt it would generalize beyond what it’s been tested on and designed for, but could be convinced otherwise with empirical data.

A Short Guide to Everything You Need to Know About Eating Disorders

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In honor of National Eating Disorders Awareness Week, I will attempt to create a post that links to everything you need to know about eating disorders.*, **

*Or at least gets you within a couple of clicks of a lot of things that are good to know.

**Scientists and clinicians don’t actually know everything we need to know about eating disorders yet, but I’ll share what we do.

Definitions

The Diagnostic and Statistical Manual of Mental Disorders includes formal definitions of eating disorders, such as anorexia nervosa, bulimia nervosa, binge eating disorder, and others. Even if someone does not meet full diagnostic criteria for an eating disorder, they may still struggle with eating disorder symptoms such as body dissatisfaction, loss-of-control overeating or undereating, preoccupation with food, weight, or shape, or unhealthy weight loss behaviors (e.g., abusing laxatives, self-induced vomiting, compulsive exercise). If you’re curious about your own eating behavior, you can take an online screening here.

Causes

There are a variety of different factors that increase the risk for eating disorder symptoms. You can read about them here or see the biopsychosocial model below for some of the main factors associated with eating disorders.

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Treatments

Current research-supported eating disorder treatments include: family-based or Maudsley treatment, cognitive-behavioral therapy, integrative cognitive-affective therapy, and interpersonal psychotherapy.

There are also some scientifically-informed self-help books available:

Help Your Teenager Beat an Eating Disorder

Overcoming Binge Eating

The Body Image Workbook

Additional Eating Disorder-Related Topics

Activism

Emotion Regulation

How to Help A Loved One

The Marginalized Voices Project

Statistics

Suicide

Warning Signs

Weight Stigma

More Eating Disorder Resources

Association for Behavioral and Cognitive Therapies

Academy for Eating Disorders

Find Treatment

Helpline

Maudsley Parents

Mirror-Mirror

National Eating Disorders Association

Podcast Episodes on Eating Disorders (1, 2, 3)

How Psychologists Capture the Complexities of Mental Illness

When it comes to understanding and treating mental illness, clinical psychologists must strike a balance between grouping people with shared characteristics together and recognizing people’s individual paths, circumstances, and needs. Below I’ve described some of the models that clinical psychologists use to reflect these complexities.

1) Biopsychosocial Model

Most modern psychologists understand that mental illness is the result of both nature and nurture. Accordingly, biopsychosocial models map out biological, psychological, and social risk factors for mental health outcomes and highlight potential intervention points. This model is so prominent that clinical psychology graduate programs require education in human development, individual differences, and biological, cognitive, affective, and social aspects of behavior, and you can’t become a licensed psychologist without passing a formal test on these topics. The idea is that mental health outcomes result from the interplay of biological, psychological, and sociocultural factors and that different people arrive at outcomes through different combinations of factors. Here’s a sample I constructed from some suicide risk factors:

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2) Diathesis-Stress Model

People with identical genetics (i.e., monozygotic twins) and people with shared stressful events (e.g., witnessing the same violent act) can have different mental health outcomes. For example, many people with family histories of eating disorders will not develop eating disorders. Likewise, many people who have been bullied about their weight will not develop eating disorders. A diathesis-stress model of eating disorders explains this by saying that a person must have both a vulnerability (e.g., a genetic predisposition) and a significant stressor (e.g., weight-related bullying) to develop an eating disorder.

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3) Multifinality and Equifinality

People who experience a similar event (e.g., trauma) can have disparate outcomes that depend on other factors (e.g., financial resources, societal views of survivors). This is called multifinality. Meanwhile, people with similar outcomes (e.g., posttraumatic stress disorder) can arrive there via distinct pathways (e.g., surviving sexual assault, a car accident, being the victim of gun violence). This is captured with the term equifinality.

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4) Distal vs. Proximal Factors

Most research on mental illness focuses on a few risk factors per study. Organizing findings across studies can feel like fitting puzzle pieces together to create a holistic picture. One way to do this is by grouping risk factors in terms of how far in time (distal) and how close in time (proximal) they are to the onset of mental illness. For example, strategies for reducing distal risk factors for adult depression may include public policy efforts to prevent childhood maltreatmentincrease access to quality health care, and decrease discrimination. Meanwhile, therapy for individuals with depression may focus on more proximal factors (e.g., enhancing coping skills, increasing social support, behavioral activation).

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5) Nomothetic vs. Idiographic

I highly recommend this article by Beltz, Wright, Sprague, and Molenaar (2016) for detailed definitions of these terms:nom idioFor example, imagine that a client gets diagnosed with obsessive-compulsive disorder (OCD). In order to figure out the best way to help, a therapist begins with nomothetic information (e.g., the diagnosis) to select a treatment. A randomized clinical trial suggests that a type of cognitive-behavioral therapy called exposure and response prevention (EX/RP) leads to significant improvement among 80% of people with OCD after 17 sessions. Based on available information, EX/RP is a good place to start. However, it’s possible that the client will be among the 20% of people who don’t respond to EX/RP. Therefore, therapists must also pay attention to idiographic information after initiating treatment (e.g., by regularly assessing the client’s OCD symptoms over time). If the client’s not responding to therapy, the idiographic data signal that the therapist must figure out why and make appropriate changes.

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For more information on nomothetic and idiographic approaches, check out:

Clinical Practice as Natural Laboratory for Psychotherapy Research: A Guide to Case-Based Time-Series Analysis

Clinical Versus Actuarial Judgment

Single-Case Experimental Designs for the Evaluation of Treatments for Self-Injurious and Suicidal Behaviors

What Can the Clinician Do Well?

I’ve described frameworks that clinical psychologists use to understand people’s mental health needs at multiple levels while respecting their individuality. The dedicated people working hard to alleviate suffering in the face of these challenges give me hope for the future of the field.

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10 Star Wars Quotes for Therapists

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In anticipation of The Force Awakens, I rewatched all of the Star Wars movies over the last few months. I noticed a number of quotes that I believe exemplify therapeutic concepts and have listed my top 10 below. If you’re trying to build rapport with a Star Wars-loving client, engage students with pop culture examples, or just love psychotherapy and Star Wars, this post is for you. If you’re not interested in any of the above, stay tuned for the next post, which will focus on tips for becoming a disciplined writer!

1. Acceptance

Anakin Skywalker: I don’t want things to change.

Shmi Skywalker: But you can’t stop change any more than you can stop the suns from setting.

2. All-or-Nothing Thinking (Cognitive-Behavioral Therapy)

Darth Vader: If you’re not with me, then you’re my enemy.

3. Autonomy (Self-Determination Theory)

Princess Leia: He’s got to follow his own path. No one can choose it for him.

4. Doing What Works (Dialectical Behavior Therapy)

Anakin Skywalker: Sometimes we must let go of our pride and do what is requested of us.

5. Easy Manner (Dialectical Behavior Therapy)

Han Solo: Fly casual.

6. Mental Filter, Jumping to Conclusions (Cognitive-Behavioral Therapy)

Anakin Skywalker: She hardly even recognized me. I’ve thought about her every day since we parted. And she’s forgotten me completely.

Obi-Wan Kenobi: You’re focusing on the negative, Anakin. Be mindful of your thoughts. She was pleased to see us.

7. Mindfulness

Qui-Gon Jinn: Don’t center on your anxieties, Obi-Wan. Keep your concentration here and now, where it belongs.

Obi-Wan Kenobi: But Master Yoda said I should be mindful of the future.

Qui-Gon Jinn: But not at the expense of the moment.

8. Normalizing Difficult Emotions (Acceptance and Commitment Therapy)

Padmé Amidala: To be angry is to be human.

9. Reframing (Motivational Interviewing)

Padmé Amidala: All mentors have a way of seeing more of our faults than we would like. It’s the only way we grow.

10. Wise Mind (Dialectical Behavior Therapy)

Luke Skywalker: How am I to know the good side from the bad?

Yoda: You will know when you are calm. At peace, passive.