CBT
Article
CBT is a recurring concept in the Astral Codex Ten archive, appearing 4 times across 4 issues between May 25, 2021 and January 03, 2024. The archive places it in contexts such as “If there’s some other therapy you’re more excited about than CBT, go for it”; “try CBT”; “wouldn’t be some kind of very formal therapy like CBT”. It most often appears alongside depression, FDA, Lorien Psychiatry.
Metadata
- Category: Concepts
- Mention count: 4
- Issue count: 4
- First seen: May 25, 2021
- Last seen: January 03, 2024
Appears In
- Peer Review Request: Depression
- Peer Review Request: Ketamine
- Your Book Review: Exhaustion
- Singing The Blues
Related Pages
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- depression (2 shared issues)
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- FDA (2 shared issues)
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- Lorien Psychiatry (2 shared issues)
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- Substack (2 shared issues)
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- 2002 meta-analysis by Cochrane Collaboration (1 shared issues)
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- 5-HTP (1 shared issues)
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- 5-HTP (1 shared issues)
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- acedia (1 shared issues)
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- Adderall (1 shared issues)
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- Against Nature (1 shared issues)
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- alcohol (1 shared issues)
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- amitriptyline (1 shared issues)
External Links
Source Context
Recovered passages from the original issue text. When the raw archive preserved outbound links inside the source passage, they are listed directly under the quote.
Every part of cognitive behavioral therapy sounds and feels obvious. Partly this is because CBT is the ancestor of most of today’s psycho-babble and self-help, so its advice has become cliched. But another part of it is that knowing things isn’t enough. I know that if I lifted weights every day I could become very strong, I even know some more complicated body-building advice, but the advice itself is nothing; the practice is everything. Cognitive behavioral therapy blurs the line between knowledge and practice; it involves practicing knowing things and thinking things. The number one misstep people make is believing that since they already know the thing, they don’t need to practice. This is wrong, and a good CBT therapy or course will be as much about building a routine to practice the skills as it is teaching you what you need to know.
David Burns is one of the gurus of cognitive behavioral therapy. His book Feeling Good: The New Mood Therapy is the canonical guide for do-it-yourself-CBT. I understand he has just put out an updated book, Feeling Great – I have not read this one and can’t confirm it is as good, but the title seems promising.
Inline links: Feeling Good: The New Mood Therapy, Feeling Great
Other forms of therapy for depression are harder to find and of more variable quality, but if you really want them, you should go for it. Studies show that how excited a patient is about a therapy, and how much they believe in it, is an important factor in how well it works. If there’s some other therapy you’re more excited about than CBT, go for it. But if it fails, CBT is a nice dependable workhorse.
This has been surprisingly poorly studied. A few very weak studies have shown weak positive effects from following up ketamine with cognitive behavioral therapy or transcranial magnetic stimulation. This studies are very preliminary and I don’t think it’s worth taking them too seriously at this stage. I’m also not sure whether the idea is that these have some sort of special interaction with ketamine, or whether these are just generally good treatments for depression, and doing any good treatment for depression will keep you non-depressed longer than not doing it.
Inline links: cognitive behavioral therapy, transcranial magnetic stimulation
In a typical KAP session, the patient would take a high dose of ketamine – usually significantly higher than in normal ketamine treatment. Then they would lie down in a comfortable position and “form an intention” (eg “I want to understand why I feel so stuck in my job”). While on the ketamine, they would watch the flow of thoughts that came to them, holding the intention very lightly (ie not worrying or beating themselves up too much if their train of thought goes somewhere else). A therapist would sit with them, guide them, and gently ask them questions. This usually wouldn’t be some kind of very formal therapy like CBT – the goal would just be to sit with the patient as they explore their own thoughts for a few hours. This might be preceded by a few “getting to know you sessions” and followed by a few “integrating the material” sessions.
No direct inline source block was recovered for this mention.
In depression, you are dangerously sad, but instead of trying to cheer up, you feel “driven” to perform behaviors that make you even sadder. IV. In anorexia, some psychosocial event (like criticism from a ballet coach and subsequent voluntary self-starvation) causes a shock to the lipostat. Instead of correctly activating regulatory processes to get body weight back to normal, it accepts the new level as its new set point, and tries to defend it. Depression is often precipitated by some psychosocial event (like loss of a job, or the death of a loved one). It’s natural to feel sad for a little while after this. But instead of correctly activating regulatory processes to get mood back to normal, the body accepts the new level as its new set point, and tries to defend it. By “defend it”, I mean that healthy people have a variety of mechanisms to stop being sad and get their mood back to a normal level. In depression, the patient appears to fight very hard to prevent mood getting back to a normal level. They stay in a dark room and avoid their friends. They even deliberately listen to sad music! The feverish person feels too cold, and the anorexic person feels too fat, so we might expect the depressed person to feel too happy. I think something like this is true, if we put strong emphasis on the “too”. One of the official DSM symptoms of depression is “feelings of guilt/worthlessness”. A depressed person will frequently think things like “I don’t deserve my friends / job / money / talents.” In other words, they believe they’re too happy! They think they deserve to be sadder! Depressed people seem to purposefully seek out the most depressing thoughts they can. They find that, unbidden, they are forced to think about the most humiliating thing they ever did, dwell on their worst failures, consider all the things that could go wrong in the future. They’ll be trying to cook dinner, and their brain will tell them “Consider the possibility that you could die alone and unloved.” Why is their brain so insistent that they spend time considering this possibility? Maybe it’s for the same reason that a feverish person’s brain makes them shiver: it’s trying to maintain an extreme state, and it needs to pull out all the stops. We know that if we make depressed people stop doing these things, they feel happier. This is the principle behind behavioral activation, opposite action, and cognitive behavioral therapy, three of the most powerful therapies for depression. If you depression tells you to do something, do the opposite. Go on a nice walk in the park! Listen to happy music! Spend time with your friends! If you do these things, your depression is pretty likely to go away. The problem isn’t that they don’t work, the problem is that it’s like a feverish person trying to take an ice bath, or an anorexic trying to eat a big meal - all their instincts are telling them not to do it. And if your depression tries to get you to think in a specific way, think in a different way. When it tells you that you should still feel bad for that embarrassing thing you did in third grade, tell it that makes no sense, and that you’ve done plenty of things you’re proud of since then. Again, this often works if you do it. It’s just really hard. Psychologists already suspect the existence of a happiness set point (thymostat?); this is the principle behind ideas like the "hedonic treadmill". So my theory here is that at least some cases of depression involve recalibrated happiness set points. A set point can either recalibrate randomly (ie for poorly understood biological reasons) or after a specific shock (ie interpreting a prolonged period of sadness as "the new normal"). Once a patient has a new, lower, happiness set point, their control system works to defend it. It enlists both biological systems (possibly changing the levels of various neurotransmitters?) and behavioral systems to defend the new set point. If it "succeeds", the person maintains an abnormally low mood. Taking this theory seriously would suggest a research program focusing on some of the following points: Which other conditions seem like cases of miscalibrated set points? Some of these are obvious, eg primary polydipsia. Others are more questionable; can hypertension be considered a recalibration of blood pressure set point? Opiate addiction a recalibration of endorphin set point? I'm not sure. What would it mean, philosophically, to answer yes vs. no to these questions?