cognitive behavioral therapy

Journalist Sydney J. Harris said “Once we assuage our conscience by calling something a ‘necessary evil,’ it begins to look more and more necessary¬†and less and less evil.” I think that may be where we’re at with psychotropic medications for depression.

I found myself emailing this bit today, and realized that I have said it over and over to many patients. It’s probably worth setting down in print.


We (psychiatrists) are not smart enough to fix brains with medications. Psychotropic medications only mitigate symptoms. Why bother? Because if your symptoms are severe enough to prevent you from taking care of business, then you won’t get better. Think about putting a cast on a broken leg. The cast doesn’t fix the bone, it just holds everything in the right place so that your body can heal itself. Without the cast, you would re-injure the leg every time you tried to walk. Healing, if it took place at all, would be disturbed.

Yes, brains heal. You make new brain cells. Your brain is remodeling all the time. But it will only heal in a healthy way if it’s in a healthy environment. Call creating that healthy environment “therapy,” but that doesn’t necessarily mean lying on a couch talking about your mother. It can mean playing golf or writing a sonnet, but it mostly involves structuring your life in a healthy way and doing things that give your brain some relief and a healthy space in which to grow in a healthy way.

Feelings happen. We don’t choose them. “You shouldn’t feel that way!” is a meaningless thing to say to someone. (Of course, we do choose how we act on our feelings.) But there is a way, over the long term, to modify your feelings or at least develop some acumen in how to handle them.

Remember when you’ve learned to play a musical instrument or a sport? At first it’s very mechanical (“let’s see… F… A… C! that’s a C! it’s that white key that’s just to the left of the two black keys…”). So you press the C, and it makes a sound, but it ain’t music. You have to practice. So you practice until you can start stringing notes together fluently. Then you’ll notice that something suddenly feels wrong, you’re about to hit a wrong note (or throw the ball west of the backboard) and you know it, but it happens anyway.

So you keep practicing, and maybe you’ll get to where you can not play the note or not make the throw when you notice that it’s feeling wrong. You’ve still messed up, but perhaps a little less dramatically.

So you keep practicing, and now maybe you’ll correct the note or make a better throw, and your timing might be a little off but you’re definitely doing better.

So you keep practicing and you’ll feel that wrongness coming on but correct for it quickly enough that maybe nobody even notices.

And with more practice you can get through that bit of the piece (or make the shot) without even thinking about it.

CBT leverages that same kind of learning. The problem is that there isn’t the obvious feedback you get when missing a shot or hitting a sour note. Instead, after you recognize that you’ve engaged in destructive thought patterns, you generate that feedback by doing a written exercise.

Now, the cool thing about CBT is that it doesn’t require that you pay a therapist a boatload of money or sit in a group and bare your soul to a bunch of near strangers. You can get a good CBT workbook for cheap, here’s one…

If you are anything of a self-starter and are able to read, you can do the CBT on your own. What’s the catch?


You can read a library of books about playing piano and shooting hoop. They’ll help. Really. But you’ll still mightily suck the first time you sit down at the keyboard or throw a ball at the basket. You have to practice. And you have to write stuff down. You can daydream all you want about tickling the ivories or making that 3-point play at the buzzer and, yes, it will help a little. But you’ll still suck mightily unless you practice, and for CBT that means doing it in writing.

Did I mention practice?

So, no lie, it’s really a lot of hard work. But the reward is mastery over feelings that otherwise can overwhelm you. So there it is: “doctors HATE this one simple trick that can improve your moods without pills.” But it’s really not so easy, it’s just… practice.

Don’t get me wrong. If someone’s too depressed to open the book or even think about their feelings, some medications might be in order to help with the focus, cognition, drive, and motivation to do the work. But the healing comes with… practice.

Hope this is of some help.