Cognitive Behavioral Therapy: What the Critics Get Right (and Wrong) w/ Dr. Ellen Hendriksen

0:07Forrest Hanson: Hello and welcome to Being Well. I'm Forrest Hanson. If you're new to the show, thanks for joining us today. And if you've listened before, welcome back. Today we're going to be talking about cognitive behavioral therapy or CBT. I cannot believe that we have been doing the show for seven years, eight years, depending on when you want to count from, and we somehow have not done a formal CBT episode. If you're listening to this, you've probably heard of CBT. It's the most researched and probably most commonly recommended form of therapy in the world. We have a lot of evidence that it works at least pretty well for a number of different problems.

0:42Forrest Hanson: But it also tends to get a lot of criticism on social media. If you spend 10 minutes in most online mental health communities, you will find plenty of people saying that it teaches you to gaslight yourself, or describing it as a band-aid loved by insurance companies, or most frequently that they went and saw a CBT therapist and just didn't have a great experience. So what's going on here? Today, we're going to cover what CBT actually is, its strengths, some of those criticisms, and then talk about how to apply those strengths to common problems like anxiety, self-criticism, and perfectionism. So today, I'm joined by a very special guest, Dr.

1:19Ellen Hendrickson. So Ellen, how are you doing today? Great. Thank you so much for having me. I really enjoy the show, and I'm delighted to be on. I was so happy when you said yes. So to tell you a little bit more about her, Dr. Hendrickson is a clinical psychologist. She serves on the faculty at Boston University's Center for Anxiety and Related Disorders. And she is the author of, I believe, two books, How to Be Yourself and her newest book, How to Be Enough, Self-Acceptance for Self-Critics and Perfectionists. And it probably goes without saying, but Ellen uses approaches based on CBT in her work.

1:51So I'd like to start kind of concrete here. What is a session that uses CBT actually like? Like what are some of the big ideas you're playing with and how do you use those big ideas to maybe help somebody? Sure. So if you were a fly on the wall of a CBT session, you would see, well, it would actually start in the waiting room. You would see some kind of measurement. You'd probably see a client filling out some kind of self-report form on their symptoms. And then as we moved to the room, you'd see it start with a collaborative, this is what I think we should cover. What do you want to add? I always ask the client what they want to add.

2:34If there's, you know, this is a very flexible agenda. If there's something pressing they want to talk about, something happened that week. You know, the agenda is certainly not carved in a stone tablet. We can throw it out and do something else. We would review homework. and then for the bulk of the session, I, the therapist, would teach some kind of skills, do an exposure, maybe do some Socratic questioning, all driven by patient goals. So this is all driven by the particular problem that the patient comes in for. And then we'd wrap up with some kind of collaborative negotiation of homework. So this all sounds kind of dry and sounds sort of like a visit to the doctor.

3:12It sounds a little more doctor's office than typically what we talk about on the show. That's for sure. Yeah, exactly. Just a collaborative agenda. Oh, like what, what is happening here? CBT is goal directed. It's working on a defined problem to reduce suffering, improve functioning, teach skills. And it is designed to eventually make the client their own therapist. I like to say that CBT practitioners have the world's worst business model because they are trying to not be needed anymore. They're trying to make themselves obsolete. The second big idea is that it's structured. So there's an agenda.

3:45There's not a couch to be seen. There's no free association. It is kind of more like a meeting. Next, it's collaborative. So we'll talk more about Aaron Beck, the originator of cognitive therapy later. but he really built cognitive therapy on a collaborative, curious therapist-client relationship. It's more like two scientists side by side testing beliefs together. And while the therapist is the expert in teaching the skills, the client is the expert in their own thoughts and experiences. And this might seem silly, but there's homework. And homework was revolutionary too, because it expands therapy from that one hour in the therapy room to the other 167 hours.

4:27of the week. So it really brings it out of the room and into the world. CBT is grounded in learning theory. And so that, we'll get into that when we talk about the history of CBT, but classical conditioning, operant conditioning, social learning theory. It really is based on the idea that how we act and how we think is attainable by our experience in the world, that we learn these things. It is based in an empirical or scientific approach. So things are measurable and testable and observable, which again, revolutionary, and it is present focused. So CBT clinicians are interested in how problems from your past or currently are affecting your life now.

5:18So it's not that we're not interested in the past at all, but we want to know how is this affecting you today? So those are some of the bigger ideas and tenets. Awesome. It's a great setup. And the part of CBT that the average person might is, my guess, is the most familiar with is probably the thought, behavior, feeling triangle, the diagram. You'll see it on people's office or stuff like that. And the basic idea, as far as I'm aware, and please, you know, brighten this up for me here, is that thoughts, feelings and behaviors all influence each other. Feelings are really difficult for us to change on command.

5:56We have feelings about all kinds of things for all kinds of reasons. So CBT tries to kind of go through the other doors, right? Your thoughts and your behaviors. Is that more or less right? And would you like to add any color to that? Absolutely. No, I think if we think about CBD, cognitive behavioral therapy, literally, that is exactly right. It posits that our cognitions, so how we think, and that could be how we talk to ourselves, the words that we say to ourselves, or it could be images. So what we picture, the movie in our mind, affects how we feel. And that are our behaviors. So our actions, how we move through the world, what you might see us doing observably, or honestly, inactions, like procrastination, for example, is a behavior.

6:37And that also affects, our behaviors affect how we feel. And these all interact, absolutely. And we can also think of CBT both as sort of a standalone therapy, what we traditionally think of as CBT, sort of that Beckian cognitive therapy, but it's also, and we'll get into this later, an umbrella term. So DBT, so Dialectical Behavior Therapy, ACT, Acceptance and Commitment Therapy, Mindfulness, CBT, like they all, they go on. What dits them all together is that foundation in learning theories and the present focus and the idea that there is an empirical scientific approach. I'm going to ask you maybe a funny question very early on in this conversation.

7:19Do you find CBT warm? Oh, interesting. I think that CBT can be anywhere on the spectrum of cold to warm. I think therapists are warm. I think this is totally the point. Yeah. Yeah. You know, CBT can come across as sort of like data entry with some worksheets, or it can come across. I was like, let's look analytically at this, at a sort of a detached scientific view. But it's also fundamentally built on that idea that was brought to us by Carl Rogers and humanistic therapy of collaboration and empathy, active listening. And it's really necessary to have that therapeutic alliance to be able to like and trust your therapist.

8:10And so I'd say no matter what orientation you're working with, whether it's CBT or something else, if we don't have that fundamental liking and trusting, the therapy is not going to be warm. I think there's a real question about the kind of person who is drawn to working inside of a particular sort of modality, and both because CBT is probably still these days the baseline approach that people get funneled into, particularly as a client for a whole bunch of different reasons that we'll talk about later on. But also if you think about just the disposition of the therapist, what kind of a person is drawn to more relational work or more depth psychology or more psychoanalysis or more, we could use all the terms here, right?

8:52Versus the kind of person who is drawn to working in a CBT-ish style. But I think it's really important here to separate the tools that are used by an approach from the person who's applying those tools. And just like you're saying, I think that CBT has wonderful tools and they can be applied either skillfully or unskillfully and warmly or not warmly, just purely based on the person doing the applying. And I don't think that's necessarily commentary on the tools themselves. And I think it's more about the way in which those tools are delivered. And that changed a lot through time. And maybe this is a way for us to kind of slide into talking about the history a little bit here.

9:30Where did CBT come from? And particularly, what kinds of problems was it trying to solve that maybe other approaches were struggling with? Sure. Yeah. So that umbrella, the high-level form of CBT, arose over the course of the 20th century in three waves. And I like to think of these waves as a series of rebellions that really add up to this iterative moving forward of the field of psychotherapy. And before any of these waves, there was Freud, our pioneer in modern psychotherapy. Our main man. Our main man. And Freud, I think, got some things wrong, but he also did some really important things right.

10:13So foremost amongst them was the concept of the talking cure. So he didn't originate, but he did popularize that we can relieve suffering through talking to another human, which is extraordinary. and again he got some things wrong which is where we get the first wave so the b came first behaviorism in the 1920s then gets applied and developed into behavior therapy in the 50s and 60s so this is this is the first rebellion and i can talk about some the groundbreaking if often ethically dubious ideas that are being developed but they all take issue with a number of tenets of psychoanalysis. So behaviorists said the analysis was unobservable, that they couldn't reliably access fundamental psychoanalytical ideas, in part because they were unconscious.

11:05Our motivations and biases and defenses were like the bottom of the iceberg. They were all not accessible to us. And so the behaviorists really swung that pendulum to entirely observable, measurable. If you couldn't see it, it didn't exist. Didn't count. Yeah. Didn't count. Next, the behaviorist said analysis was untestable. So they decided to measure and test and taken together this observe, measure, test idea was revolutionary because it introduced the idea that psychology is scientific, that there are data and measurement and outcomes. So a lot of the ideas that were being worked out at this time are probably familiar to a lot of your listeners.

11:49There's Pavlov's classical conditioning that gets applied to humans with John B. Watson. B.F. Skinner is hanging out developing operant conditioning. Joseph Volpe is coming up with systematic desensitization. These are all the foundations of that B, that first wave of behaviorism. And so with your permission, if I could get into the weeds a little bit with some classical conditioning. Totally. Yeah, I think that that would be great. And to set you up a little bit here, maybe the big gift of the behaviorists, in my opinion, at least is exposure. We talk about exposure all the time on the podcast, you know, you approach the feared thing gradually.

12:28And hopefully over time, not just your fear of it fades, but your relationship to that fear transforms. Yes. And it's worth noting that it's hard for me to imagine changing just about anything without some form of exposure, if we interpret that word pretty broadly. Forms of relating to your thoughts differently could be a kind of internal exposure, if you want to think about it that way. So even though behaviorism, again, like all of these things, has its own problems, like you were saying, some of the experiments that they were doing were very, you know, fuzzy at best, both in terms of the ethics and in terms of what they were actually trying to get at.

13:06But this lasting takeaway still has an enormous impact on the field. Absolutely. And I work with exposures every day in the clinic. So this is a long, really important legacy. It all starts with Pavlov's dogs. So even if we haven't taken psychology 101, we are probably familiar with that concept of Pavlov taking the unconditioned stimulus of food and pairing it with the, naturally it's paired with the unconditioned response of salivation in the dogs. And then when you pair the food with the conditioned stimulus of the bell, through enough repetitions, dogs will salivate when they hear the bell, even if there's no food in sight.

13:44So you get this conditioned response. Okay, so that's in animals. And then later, John B. Watson and his graduate student, Rosalie Rayner, apply this to humans with the Little Albert experiment. And this is published in 1920, just to give us a date, just to ground us in time here. With this little Albert experiment, they let 11-month-old Albert hang out with a white rat. And he could look at it. He could be delighted by it. He could play with it. But every time Albert touched the rat, one of the researchers standing behind him would hit a steel bar with a hammer, which made a really loud noise and made Albert cry.

14:27This is such 100-year-old science here. This is crazy stuff. You can never get away with this. But okay, go ahead, Ellen. Never. Oh, my gosh. So, yeah, no, I'm absolutely not defending this, but telling the story. But hey, this is what happens. So after, oh, my gosh, after seven pairings, as you would when Albert saw the rat, he would cry and try to crawl away. Of course, rightfully so, because he had learned to associate this rat with a really scary, distressing noise. And so subsequently, Watson and Rainer showed that Albert's fear had also generalized to all fuzzy white objects. So a rabbit, a dog, a fur coat, even like a researcher wearing a Santa Claus beard.

15:10And so this was extremely problematic ethically. Of course, there was no consent. This was arguably cruel. The researchers didn't even treat him afterwards. They didn't mitigate the fear. It's unclear where they even acquired Albert. lore has it that he was either a patient in the hospital or was the child of one of the hospital workers. But there was no consent anyway. Okay. So that's a problem. It's also problematic scientifically. So there's one subject, there's no control group, and absolutely the ends do not justify the means. And it showed that fear can be learned. So there was a takeaway from this, despite all the ethical horrors.

15:49And then what happened next, I specialize in anxiety, so what happened next is important to me in my practice. So Watson goes on a lecture circuit to talk about little Albert. And a young woman named Mary Cover Jones attends one of his lectures. She thinks this is the coolest thing ever. And it inspires her to go to grad school in psychology. mind you as a woman in 19 in the 1920s which i thought was pretty cool and there she decides to try the opposite rather than conditioning fear she wondered can you decondition fear so mary cover jones finds a little boy named peter who was just shy of three years old who was already afraid of furry white creatures and at the beginning he would cry whenever there was a rabbit even in the room with him, even if it was in a cage.

16:42And she did two things. So first, she had him observe white rabbits over ever shrinking distances. So 12 feet, four feet, three feet, running free in the room, and eventually in his playpen.

16:55Forrest Hanson: Very great at exposure. Yes, exactly. And second, she had Peter observe and interact with kids who weren't afraid of white fuzzy animals. So she saw some modeled behaviors. So some like early, you know, pre-Albert Bandura social learning theory going on here. And so, yeah, long story short, over a number of trials, Peter goes from crying when the rabbit is in the room to letting the rabbit nibble his finger and just hanging out with the rabbit. So Mary Carver Jones was the first to decondition a fear response through learning and essentially invented the precursor to exposure therapy. That's really Oh, I actually hadn't heard that story before.

17:33Yeah. Yeah. That slips through cracks for me. It was fun to learn that myself. Just to flag what you're saying here, this is a kind of pendulum swinging. So we had this big swing initially in the direction of Freud and Jung and the psychoanalysts. Deep, fuzzy, immaterial stuff, the layers of the consciousness, and oh, I can't even look at the person while I'm talking to them, so my free association is truly liberated. All of that out there stuff. And then the behaviorists come in, they're like, no, no, no, no, no. That's too fuzzy. We got to turn this into a science, kids. And so pendulum swings back the other way.

18:09And I think that in some ways, like the cognitive revolution is also a sort of a pendulum swing toward, okay, everything doesn't have to be directly observable in this kind of way. We can appreciate that there is at least some formlessness about stuff and then, and so on and so on and so on. So go on ahead. Yeah, the cognitive part of this. No, I really like how you paved the way there. because, yeah, if the first wave of CBT, the B, focused on external observable actions, behaviors, the second wave added internal cognitive processes, added thoughts, particularly the idea that we can identify and change our thoughts.

18:48And I'm torturing this metaphor, but maybe the pendulum is swinging several different ways because not only are we adding internal processes, but we're still reacting against Freud because, you know, enter Dr. Aaron Beck in the 1960s. So he is a psychiatrist at the University of Pennsylvania. And in line with this idea that psychology is measurable and observable and scientific, he expected that his research in depression would fall in line with underlying theories of psychoanalysis. But instead, that's not what he observed at all. He found that depression was really more rooted in negative beliefs having to do with loss or failure, rather than these widely accepted analytic ideas that depression was anger turned inward, or that people with depression have like an unconscious desire to suffer.

19:37So Beck developed this groundbreaking idea that how we think, so whether that's about ourselves, the world, the past, the future, how we think affects how we feel. And if we can change our thoughts, we might feel different. The big landmark that happened was in 1977, Beck and his colleagues published the results of a randomized control trial. So the ultimate in testable scientific methods that found that CBT was as effective as medication for the treatment of depression and twice as effective at preventing relapse. So we've got this big trial making a splash. And just as the cherry on top, in 1981, a UK-based group achieved the holy grail of replication.

20:26So not only can you do this in Philadelphia, you can take this across the pond and do this elsewhere, which means that you can standardize and manualize therapy. You can have a standardized manual and you can teach therapists how to do this and check to make sure that there was fidelity to the manual, CBT was off to the races. So that is our second wave where we add the C to CBT. I want to add a little comment on something that you're saying here about replicability, because this is a really important idea in general. And there's been follow-up research, not just finding that CBT is pretty good in general, particularly for the treatment of depression, and maybe particularly, particularly for relapse related to depression.

21:08That's been one of the really consistent findings about it, but also this idea of can we teach people to do this thing, which for me has become increasingly a thing that I'm thinking about when I'm talking to people. You see these individuals, some of whom come on the show, who just seem to be very gifted clinicians. They've got a feel, they understand what they're doing, they've got the pixie dust, whatever the pixie dust is. But you take what they're doing in their individual work with people where they have great responses inside of their practice. But you try to teach somebody else how to do that thing.

21:43And for whatever reason, and there are a whole bunch of different complicated reasons, but for whatever reason, it doesn't seem like it's as generalizable. For whatever reason, we can't teach somebody to do fill-in-the-blank approach to therapy as, and I'm just selecting randomly, as well as this expert person, as well as Stephen Hayes. And I'm picking that because ACT actually replicates really well, as well as like Stephen Hayes does ACT or as well as Sue Johnson does, you know, more relationally informed approaches or things like that. And it's really gotten me thinking about this whole thing because CBT is very teachable.

22:16That's one of the benefits of it as an approach. Absolutely. Yeah. I think with some of the more relational approaches, it relies more on the relationship. It might be more improvisational. It might rely more on the personality of the therapist. and you can rate whether or not the therapist is staying true to those as well. So it drives the point home that therapy can be made scientific. That's another big one, what you just said, like, are they sticking to the outline? This is something that, again, gets studied a lot. And I'm forgetting this exact study that I read, but basically it was a really interesting article from a guy who was basically saying that outcomes were not as good as they could be in clinical practice because therapists tended to avoid the parts of therapy that were the most disruptive both for themselves and for the client.

23:07So people were getting on average a kind of watered down version of CBT in session because therapists didn't want to do like the exposure piece of it or the more uncomfortable parts of it or like, oh, the client's kind of withdrawing from that for understandable reasons. These are hard things to do. And it's another piece of it to kind of think about here in terms of how we both approach this as like a broad method and how clinicians think about practicing. Yeah, absolutely. So I have the privilege of supervising and teaching new therapists, like second-year graduate students who are just starting their journey on becoming psychotherapists.

23:42And I love that their questions are at the level of like, where do I sit? What do I do with my hands? Do I take notes? And for somebody who is just starting out, it can be really a big ask to expect them to make a client go through something that might be sort of aversive, i.e. exposure. And so at least I certainly know that I have walked in those shoes and I was like, you want me to tell them to do what? And I have seen it work so many times that now it's much easier to sell because I believe in it. But yes, I could see that if you're just a new CBT therapist or you're just reading a manual, I would probably back away from some of the techniques as well.

24:24It makes sense. Yeah.

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28:49and they hate it. CBT feels so invalidating to them, and they drop out of therapy. So, you know, you can smell it. Here comes the next rebellion, and here comes the third wave of CBT. The first wave, let's review, focused on external, measurable, observable behaviors. Second wave, added internal processes. And our third wave shifts from change to acceptance. So rather than trying to change the content of one's thoughts, et cetera. The aim is to change your relationship to your thoughts, your emotions, your physiology, and to use Buddhist mindfulness and acceptance concepts to do so. And this is where the umbrella starts to get a lot bigger.

29:32So DBT, dialectical behavior therapy, ACT, acceptance and commitment therapy, mindfulness-based cognitive therapy, compassion therapy, et cetera, the list goes on. We get increasing differentiation, but they are still all grounded in this idea of learning theory, collaboration, testable, observable. And let's use DBT just as an example, rather than get into all the different ideas. But Linehan develops DBT, debuting it in a book in 1993, which I think, interestingly, is titled Cognitive Behavioral Treatment for Borderline Personality Disorder. She doesn't even call it DBT. That catches up later.

30:09So she sells it as CBT, called eventually dialectical behavior therapy, because it holds two seemingly opposing truths at once, where clients get that validation and acceptance of exactly where they are at the present moment that they need, particularly in, here, let me, as a side quest, DBT has four modules. So there's mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, and they get that validation acceptance, particularly in mindfulness and distress tolerance. And they also get actionable tools for change, particularly in emotion regulation and interpersonal effectiveness.

30:45So that brings us to today where CBT is both this collection of interrelated therapies. And when we say CBT, or as we'll talk about later, when insurance companies talk about CBT, they usually mean sort of that second wave, more cognitive standalone therapy. One of the things I really want to emphasize here is that the third wave and these waves in general, but the third wave in particular, essentially came out of CBT people criticizing CBT and trying to find ways to make it better. And that's a kind of self-awareness and responsiveness to criticism inside of the field that I actually think is quite uncommon.

31:24Most approaches are a lot more defensive about their particular toolkit than CBT has demonstrated it to be historically, where people, in part because it was kind of this dominant model, it felt maybe strong enough in its little beachhead to be able to criticize itself without just collapsing under the weight of that. And I actually think here's kind of a demonstration of this. So you work at BU. If I remember right, David Barlow started the center that you work at, and he's as OG CBT as it gets. He's also one of the most awarded living psychologists. But the toolkit that you talk about in the book is almost entirely third wave.

32:02And in my kind of reading of it, there's a lot of radically open DBT in it. So CBT-ish is everywhere. And a lot of the time, people don't realize it, where they'll say something like, oh, I hate CBT, but I love ACT. And I'm like, well, yes, I see what you're saying. I see what you mean. You know, I know what you mean, but there's actually like a lot of similarity between these approaches, which takes us to some of my thinking about it. A, I think that people don't really love the vibes of like old school CBT. It does feel a little homework, worksheets, you know, intake form in the office, that kind of thing.

32:38And the second piece of it is I think that Dr. Linehan was, for starters, just a absolute, you know, G in how she did all of this and was so smart in her observations. and really nailed it in terms of patient experience. Like, do I feel like I am now at fault for the thoughts that I'm having or the feelings that I'm having and the intense shame and distress that can accompany that? And so the movement into more of an acceptance framework held alongside all of these change strategies really just creates so much more space in people in terms of being able to be like, okay, yeah, I could think about that.

33:16Absolutely. I mean, even Aaron Beck developed old school CBT as this is not for everything, that sometimes you do have to supplement with other approaches. And I think he would be happy to see the evolution of the field to include so many different approaches that can really ultimately do what we're all trying to do, which is relieve suffering. So I would love to make this kind of pragmatic for people here. You have a specialization, you know, anxiety, perfectionism, all of the work that you do there, whether you want to use that as our example here, use something else, go to town. I'm wondering how you feel like the same problem would be handled by these different approaches.

33:56That's a great question. One of my super specialties is social anxiety. All right, let's think about how the three different waves would handle one example. So let's say we've got somebody who has trouble introducing themselves to a group. So everybody hates the let's all go around and say our name and a fun fact about ourselves. But let's think about how each of the waves might handle this. So if we time traveled, we might see a first wave behaviorist doing some kind of like, I don't think we would call it systematic desensitization anymore, but we might help our client learn like some relaxation technique and then ask them to practice to do some exposures and introduce themselves again and again, maybe at first in front of, or at first maybe in their imagination to a group, and then maybe to a video of a group, and then a small actual group, and then a bigger group, all while using their skills to try to maintain some relaxation.

34:53I mean, we wouldn't, I don't think we would do it the sort of orthodox way that I just described. That's how a first wave, you know, if you're a cosplay and a first wave behaviorist, that's what we would do. Okay, Okay, second way of cognitive therapist might validate the fear and then use some Socratic questioning to inquire about the beliefs driving that fear. So like, hey, what are you afraid is going to happen? What are you worried that people might see and judge? Or like, let's separate possibility from probability. Like, yeah, your feared outcome, maybe people laugh at you or think you're super awkward could happen.

35:28That is possible in this world. What are some, what's probably going to happen? What are some likely outcomes? or like, tell me more. Has there been a time when like this feared outcome has actually happened? Like, let's riff on that. So I think we could see a cognitive therapist really using questioning to identify and challenge the beliefs and the assumptions around that fear. A third wave therapist might label emotions. This is anxiety. I'm having the thought that people are going to judge me. I can have this thought and feel these sensations of anxiety and still take valued action of introducing myself because building community and being friendly is important to me.

36:11So there might be some values work, some cognitive diffusion, trying to separate, trying to change our relationship to the thought, change our relationship to our physiology. And if we put it all together, a CBT therapist of today might encourage some combination of all of these, always grounded in all those things we got from human-centered psychotherapy, like empathy, genuineness, positive regard, active listening. That is the foundation, no matter what techniques you're using. I think that's a great description, and I really appreciate it because it's very clarifying for people to understand, what are the actual differences here?

36:48Particularly if I am a client seeking out a therapist, what do I want to have emphasized in this session? Which gets to issues of fit, which I think are really important for us to talk about a little bit here. Because CBT is so widely recommended to people, and because it is the predominant form of therapy that an insurance company is going to nudge you toward if you're trying to get coverage, what this means is it creates fit issues for people. Somebody who might not be a CBT-ish client gets nudged toward a CBT therapist. And we know again and again and again, and study after study that's been done on this, that if not the number one, then certainly a top five determiner of outcome in therapy is fit between the client and the clinician.

37:36And so this is a modality that I think is suffering that fit problem more than any other modality, just by virtue of the fact that it is the majority designation of where you go for therapy. So you're just running into more of those fit problems than something that a client has deliberately seeking out. Somebody who goes to do somatic experiencing work or something like that is seeking out somatic experiencing work. They're saying, I want to go do that thing. With CBT, it's not always so clear. That's fair. Yeah. No, I mean, CBT is loved by insurance companies, and there are certainly issues that come attached to that because, honestly, follow the money.

38:18CBT is designed to be short-term, which makes total costs easier to predict, easier to cap. CBT is designed to make people not need therapy anymore. And I think because it's been shown to be effective for a lot of problems, insurance companies can kind of have this Wizard of Oz curtain up of like, it's empirically validated. And they can sort of hide behind that curtain, pretend that that's the true driver when really, I think a lot of insurance companies might really just use it as a cost cutting tool. Yeah. Related to that, there could be a frame of like, if you don't get better in six to eight sessions, it's kind of your fault.

38:56You got the treatment that was supposed to work, buddy. Why didn't it work for you? And so again, there's that displacement. To add on maybe one more thing, I think that it's important here to separate out, again, another separating out we're doing, the set of ideas used by CBT and the medical model, or and the nature of insurance companies or whatever it is. The fact that insurance companies are only willing to pay for six to 10 sessions of CBT for most people is not CBT's fault. This is not like a thing that CBT created where they were like, you know what we're going to do? We're going to get into bed with these insurance companies.

39:29This is just the way it's going to be, man. That is not what's happening here. This is a genuinely good tool that is sometimes not used in the most genuinely good ways by virtue of the fact that, you know, to do the meme, we're living in a society here, right? Like this is the way things are set up. And I think that you actually do a good job also in your own work and in your books and talking about the relationship between like perfectionism and related social forces like that. Thanks. Yeah. I think there is often a complaint. I'm getting into the social media critiques of CBT here. Of that CBT, yeah, is reductive or that it's turning being a messy human into to data entry or a bunch of worksheets.

40:17And I totally get that critique. I get that thought records or like ABC worksheets, activating event, belief consequences, mood ratings, you know, can feel like data entry. And sometimes I will, I find myself sort of being an apologist for that in sessions where I'll say, I know this is really hard to quantify, but zero to a hundred, where is your anxiety with that. I do acknowledge for sure that it can feel a little weird to put a number on something that is so amorphous. And I think that the spreadsheet therapy critique also lands hardest when CBT is applied rigidly or is applied as a one-size-fits-all default rather than matched, as we're talking about fit, to the person or the problem.

41:00But I would also say that I think any therapy would struggle under those circumstances of trying to be one-size-fits-all. Because just in defense of CBT, I think that the structure is what makes CBT therapists able to work with the complexity of being human. That granular process of like, let's identify that thought. Let's try a different behavioral approach. Let's get some distance between our thought and what we can move our hands and feet to go do. It can give clients clarity in the overwhelming messiness and humanness of whatever problem they're dealing with. Because I think two things can be true at once.

41:42Standardized, sometimes manualized even, CBT is well-designed for what it targets. And what it targets is not everything about a person.

41:51Forrest Hanson: Yeah, yeah. So maybe related to that, are there particular problems or particular vulnerabilities that a person might have that you think that particularly like version 2 CBT is not a great fit for, or even some of the third wave approaches might not be a great fit for? Yeah, for sure. I think a lot of it depends on the therapist, honestly. Again, I don't want to say that the technique is pure and it's the therapist's fault. But okay, but I do think that if somebody expresses, like in my case, the clinic I work at, an anxiety, and the first response is, well, remember we talked about that list of thinking errors?

42:30Which one do you think you're making here? Like, it implies that you're wrong.

42:33Forrest Hanson: That could be a bit of a skill issue. Oh my gosh, that is definitely a skill issue. And that implication that you're thinking wrong, you're making, it's literally called a cognitive error, is just a pivot or two away from any number of insults that get thrown at people, especially women. You're not being logical. That doesn't even make sense. You know, this is really insulting. It's extremely invalidating. But I think that even thinking errors, and I try to honestly stay away from thinking errors for that very reason, but they can be made validating. So like, let's take catastrophizing. So the classic example is like, oh, I made a small mistake at work and now I'm going to get fired.

43:13So we take something small and we blow it up into a huge catastrophe. Okay. We can turn that into something validating. It makes sense that you're worried. You know, you don't want to get blindsided by the worst case scenario. You know, like the worst case scenario could happen. That is possible in this universe. But here, you know, you know your boss and your team really well. You know, what do you think is going to happen? What's most what's a more likely outcome? So I think I think you can, even with thinking errors, which are the most problematic in terms of making people feel invalidated, I think done well, or with a heavy dose of validation, that makes sense.

43:48If I thought that way, I would feel that way, too. Then I think you can still make a lot of progress. You can say this is so common, it has a name. So many people do this. It is called catastrophizing, universal Oh, humanity, all of that good stuff. Totally. Exactly. One thing that I do want to flag, and I would also be curious to get your take on, is the one we hear over and over again from just people who listen to the show, like emails I get, comments I see on YouTube, people I've randomly talked to related to this stuff for whatever reason, is trauma. And particularly forms of trauma recovery.

44:19We've had people like Dr. Bruce Perry on the show. He's a child trauma specialist. He wrote The Boy Who Was Raised as a Dog. He's a brilliant guy. And they've talked about how CBT can be a poor fit for trauma work because significant childhood trauma can actually affect the development of the brain. So if you're trying to rely on these kind of prefrontal cortex capabilities, but for whatever reason a person sort of struggles to apply those tools, then CBT may not be a great fit for them. Also, traumatic experiences are almost entirely by their nature grounded in the past. You talked about how CBT is kind of present focused.

44:52We care about what happened to you, but we're really caring about how what happened to you is showing up right now today. So if you need to do more coherent narrative formation or like those kinds of softer skills, personal history, all of that, the tools of CBT could be applied to them in some ways, but it's not really what the approach is built to do. So again, you have people who are kind of like dealing with these experiences or these problems in the moment, and they're getting kind of funneled into this modality that may or may not be a great fit for it. And they're saying, I had a bad experience.

45:26Yes, it makes sense that you had a bad experience. Do you have any takes on this? Yeah, absolutely. I'm actually thinking of a client I have who has complex PTSD, and I had proposed doing some rescripting with her. And she really blanched at it and said, you know, I don't really want to go back and like change what happens. So rescripting is where it's sort of like a kinder, gentler version of exposure, of prolonged exposure, where you go back and you revisit the event and you tell the story with a lot of sensory detail. But then right before the traumatic event happens, you intervene and you change and finish the story however you want.

46:05And so I was describing this technique to her and she's like, you know, I really don't want to do that because I think it's going to feel for me like gaslighting, like self-gaslighting. I was like, cool, we're not going to do that. No problem. We have a lot of other techniques in our toolbox. We've got two toolboxes, actually. We've got change and we've got acceptance. And so we can dig around in both of these and see what fits better. So I think as long as it's collaborative and as long as we listen to our clients and don't try to shove something down their throat that they don't want to do, then absolutely.

46:36You were asking about groups that sometimes CBT is not great at. I think, yeah, I have found that cognitive therapy, at least, is not great for, honestly, either end of that normal distribution of intelligence, like folks with maybe some cognitive impairment or some dementia or some brain injuries. But also what I run into more is folks who tend to intellectualize, who sort of talk about their emotions or - Oh, you're kind of playing into the tendency.

47:07Forrest Hanson: Yeah, totally. into the thoughts on social media. You sometimes see this as people saying, well, you know, I'm too self-aware for therapy or I'm too advanced for CBT. And in, and that, that can, sure, we can just roll with that. That's okay. And in my experience with, with folks who are, yeah, too intellectualizing or yeah, again, talk about the emotion without getting into the emotion. In those cases, you just go straight behavioral. So I was like, all right, let's do some exposures. Let's go try some new behaviors. Let's go do the thing. And that you can get through the back door and not have to go through the sea of CBT at all.

47:47Yeah, I think that's a really interesting one because I had not thought about that. But you're totally right that any approach to therapy can play into a person's tendencies to some extent. For sure. And this is a half-baked idea here, Ellen, so go with me here. There's a part of me that sometimes wonders if people would be best served by selecting the approach that feels the least like them. So you're talking about somebody who's very intellectual. I'm so self-aware. I really know what's going on, man. Maybe CPT isn't such a good fit because you're just doodling with your thoughts even more. And you really need to move, like you were saying, into more of a behavioral framework of, hey, we just got to get out there and affect change more in the world.

48:32I think about myself. I had Terry Reel on the podcast once, and he had a good little intervention with me where he was like, bro, you're kind of avoidant. You're a little bit of an emotional avoidant in a funny little way. And I was like, damn, Terry, way to come from me, buddy. But he was good about it. We have good rapport. I know Terry. We've talked a few times in the past. And he delivered it in a really wonderful way, and it ended up being extremely helpful for me. But that kind of warm and fuzzy relational approach, although Terry is a funny, I would call him warm and fuzzy. I I don't know if other people would describe him that way, but he is such a loving person.

49:06That's not what I would default to as my, like the therapy that I sought out. I might seek out something that's more thought driven because I'm an intellectual person and all of that. But I got so much value out of that. And so I kind of wonder if, I don't know, there could be some underlying benefit in seeking out approaches that feel less like you in a funny way. But I guess you got to balance that against fit. I don't know. How do you think about this? Yeah, no, 100%. So just real quick, that story tracks. Yeah, he is hardcore and just says it like it is. He's very direct. Yeah, yeah, yeah.

49:37Yes, very direct. Yeah, in a warm way. Personal disclosure, when I went to therapy, my first thought was I do not want a traditional, you know, see the cognitive CBT therapist because like I, this is what I do every day. I'm going to feel like I'm at work. This is not helpful. I want somebody who can see my blind spots, who is going to call me out a little bit, but in a supportive way. And so I went to an ACT therapist. And so I realized that's still under the CBT umbrella, but it was different than how I generally approach. I do ACT as well, but it was different than how I approach my work. I wanted something different.

50:13And so I think that speaks to, should we pick what might not feel natural for us? Like if I'm sort of fiery, the last thing I need is more fire. I need some water. And so that's what I'm going to search out. I feel like we could just keep on talking about this for at least another 30 minutes, if not another three hours. But I think that we've mostly hit the four big online complaints that I see about CBT. So to just list them out as a summary for people. You talked about the spreadsheet therapy. Have you tried just thinking different thoughts, bro, part of it? That, again, unskillful CBT can sometimes look or feel like.

50:51The second one was facts don't care about your feelings. You're learning how to self-gaslight that aspect of it. And yes, clumsy forms of thought restructuring, what's the evidence for that, like you were talking about, or oh, that's a catastrophizing thought, can definitely feel this way. And also, this is in part what DBT was trying to deal with, like you were talking about historically. You draw a distinction in one of the books, Valid vs. Justified, about different kinds of feelings. Like all emotions are valid. They come from somewhere. But we can also look at the things that led to those emotions or those feelings and go, huh, you know, maybe I'm feeling a bigger feeling than the evidence would kind of suggest to me here.

51:32And that's about living in reality. Gaslighting is about the opposite of that. Gaslighting is about lying to yourself about what reality is, right? So third one, we talked about insurance and insurance companies and how that can create the fourth one, which is I tried CBT and had a bad experience, which for me gets to those issues of fit that we were talking about. Is there anything under any of those that you feel like you haven't mentioned that you wanted to get in here at some point? Sure. I think I see this sometimes, but there are sometimes there's a complaint of CBT is just positive thinking.

52:05I can do that with myself or a good friend, just think positively. And CBT is It's really not about replacing the metaphorical gray-colored glasses with rose-colored glasses. Instead, it's really about replacing them with clear glasses. It's about thinking clearly and seeing things. And we could get acaty about this, too, seeing things as they are without judgment. But that's also without positive judgment. So I want to just throw that in there, that it's not just trying to change your thoughts to be positive or toxically positive either. And that's also, I think, a good response to the gaslighting yourself comment, basically.

52:44It's not so much that you're trying to build this fake reality. You're trying to live in reality and hopefully build an emotional structure alongside it that helps you live in reality in that way, that helps you self-buffer and deal with the normal stuff that comes with being human. You know, you're in a therapeutic frame with somebody where you're working with your therapist and you really want them to be a perfect receiver of your thoughts and your feelings and your emotions. And, you know, we talk to people like Dr. Jacob Palm on the podcast. He's a trauma therapist, works in New York and does very, very cool work with complex PTSD.

53:22And he talks a lot about rupture and repair, how one of the normal parts and best parts of therapy is when some bump happens between you and the clinician, and you got to iron it out. And you learn that this is not a perfect person in front of you. And they're just a person too. And guess what? Humans make mistakes. We mess up all the time. And it's okay. Can we deal with that reality that everybody's a person and everybody makes mistakes? And so these are all just like the cool aspects of therapy that I really love talking about with people. And I want to turn more towards your area of expertise here a little bit.

53:53And particularly, how do we apply like some of the good parts of CBT to the stuff that you are really an expert on, like you were talking about social anxiety and also perfectionism. One of the things that I bumped into in your work that I hadn't seen before that I thought was a really interesting way in around perfectionism was this idea that the behavior stays, but the motivation changes. Could you explain what that means? I think I can explain this best with an example. Okay, So say somebody with perfectionism, people with perfectionism live by a lot of rules. There are a lot of have tos, a lot of shoulds.

54:29So let's, for example, say that somebody with perfectionism thinks they have to be a good friend. And to be a good friend, they have to follow certain rules. They have to remember their friend's birthday. They have to tell entertaining stories when they see each other. And they have to remember their coffee orders so they can surprise them with it when they get together. Okay. So these are all rules-based and they might go through the motions and do that, but it's really a conflation of our performance with our worth. So when we work on our perfectionism and we try to roll back some of that overcompensation, try to separate out our worth from our performance, we might actually end up doing exactly the same behaviors.

55:14So we might still remember our friend's birthday. We might still tell entertaining stories when we're with them. We might still remember their coffee order and pick up some coffee for them when we get together. But the driver underneath that has changed. And we're doing that because not because we have to or we should, but because we choose to. and that element of choice and living through our values. Maybe we value a connection, or we value being friendly, or we value being generous, and we can start to separate out our performance from our worth. The tough part of perfectionism for people a lot of the time isn't that you have a strong work ethic.

55:55It's not that you have high standards. It's not that you're a really responsive person in all of these different domains. It's not that you achieve at a high level. It's that it feels shitty the whole time you're doing it. You know, it feels like not feeling good enough. It feels like you're constantly running. It feels, I have some of these tendencies myself. It feels like you're procrastinating because you feel like you need to write a bestseller if you're going to bother writing a book. And that's a darn hype. I don't know anything about that. Yeah, that's what I'm talking about, you know? Like it feels bad.

56:26And we see all of these behaviors associated with perfectionism that look good, which is part of the reason that people move toward them. They see other people being high achievers or whatever, so they go, yeah, I want me some of that. But most of the time, these kinds of impulses are different forms of defense against criticism. You're trying to launch a preemptive strike against people telling you that you messed up or even more so, you telling yourself that you messed up. And so I think that that's what's really great about how you frame this here, which also I think is probably more acceptable to most perfectionists who might be listening, where, oh, I still get to have all of these good behaviors, but maybe I have less suffering associated with them.

57:06And that's a very cool flip of it. Thanks. Yeah. No, I think, okay. So I, I find it endlessly amusing that perfectionism researchers can't agree on a perfect definition of perfectionism. And so the one, the one that I like the most is that perfectionism is a tendency to demand more of ourselves than the situation requires. And I like that because it does go two ways. It can be really good. Like, please keep demanding of yourself more than the situation requires. That's what makes the world go around. That's what makes good work. That's what helps us hit it out of the park. Cool. It's when we start to conflate our performance with our worth.

57:43It's a phenomenon called over-evaluation. It's when we over-prepare, over-practice, over-rehearse, over-work, show up overdressed. We think that doing those things, that over-compensation is what's keeping us safe from criticism and is what's keeping us worthy. And it's entirely possible that we were actually safe all along, but overdoing these things is stealing the credit. And so I like that tendency to demand more of ourselves in the situation requires can go two ways. So you can keep all those surface behaviors, but yes, the driver underneath them can change. And just because we were talking about therapy and therapeutic practice, I like that you said that we get to have all these high standards.

58:26Trying to change that does not work if we're trying to treat people with perfectionism. Really? That's really interesting. So lower your standards is not an intervention. No, not an intervention because it gets, well, I mean, okay, so it gets a lot of affect because there's a lot of fear if I lower my standards. Like that's, I'm unsafe. And so I find it's much easier to work around that and say, keep your high standards, but let's look at what's driving that. Let's look at the thoughts and the beliefs that might be driving your need to have those high standards. When I first started learning how to treat perfectionism, I did try to do some like, well, let's try to have an 80 % productive day or let's try to do anyway.

59:10And never, it always fell flat. So just for any therapist listening out there, I think trying to convince people with perfectionism to lower their standards is a losing battle. So let's go for what's underneath that. So in the what's underneath that part, one of my favorite psychology questions is what's the function? So why do people develop these tendencies if we are living in a world of motivated behavior? So the idea there is that we don't do stuff that's totally random. And this is kind of classic CBT-ishness, but behavior is motivated in some way. we're trying to avoid something or approach something or get something or solve some kind of problem.

59:50That's the frame on it that I really like, that we're trying to engage in problem solving. So what's the problem solving of perfectionism? Yeah, for sure. Yeah. Perfectionism is interpersonal. It's interpersonally motivated. So meaning we do it to try to earn belonging and acceptance. But perfectionism tells us a lie, and that's that we can earn that belonging and acceptance by being good at things. So forgive my grammar, but perfectionism says, well, when I do good, I am good. And when I do bad, I am bad. But then our worth is never a settled question because every performance, and I say performance very broadly, however we define performance, every performance becomes a referendum on our character.

1:00:33And it also backfires because then when we perform superbly, we might earn admiration, but that's different than acceptance. And also it backfires because when we're admired, we're on a pedestal. But that means we're different and we're alone. Because when we're singular, we're separate. When really people with perfectionism really just kind of want to be like everybody else, just be accepted and belong. But there's this idea that we have to perform as superbly as possible to be sufficient as a person. And that ends up backfiring and doing the very thing that we're not trying to aim for.

1:01:14Forrest Hanson: Back to the show after a quick break. This episode is sponsored by Huel. Out of every sponsor we have ever had on the show, I think that Huel is the one that Elizabeth and I have used the most. It's always been tough for Elizabeth to eat enough protein, and she's been trying to build some muscle recently. And, well, we're both busy during the day. It often feels easier to just grab something rather than taking the time to make something that's actually healthy. But what if you could do both? Huel, that's spelled H-U-E-L, has solved that problem for us. Their Black Edition powder is a complete meal you have instead of food, not a shake on top of food.

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1:02:37Forrest Hanson: Now, back to the show. in the clinical model that you share in your book about what perfectionism is it has two ingredients a hypercritical relationship with yourself which you also talk about having a kind of zero tolerance policy if you had one cookie in a day you did not eat healthy if there was one awkward silence when you were on a date with somebody it wasn't a good date my example from earlier if i didn't write a best-selling book it doesn't count it wasn't good enough okay so that's the first one hypercritical in this. Second one, over-identification with meeting personally demanding standards.

1:03:12And this is what you were talking about. Your worth as a person rides on your performance. A mistake is evidence about who you are. And guess what, buddy?

1:03:21Forrest Hanson: Who you are kind of sucks. So we've got these good parts of perfectionism, which you really tie also to conscientiousness, which is one of the big five personality traits. But then we've got these bad parts of perfectionism, and to use some loaded language, that hypercriticalness and over-identification. And I'm wondering if we're not going to just lower our standards a little bit, how do you help people work on those two tendencies, maybe using some of these CBT-ish tools that we've been talking about? We can do a number of things. So just to tie back to our discussion about the waves of CBT, I think we can take a lot, honestly, from the first wave of just classic behavioral experiment, classic exposures for social anxiety.

1:04:09You know, go forth and do, to quote Rich Heimberg, the father of American social anxiety research, going out and doing the things we're afraid of is the best thing we can do. In perfectionism, we can drop the safety behaviors that we think are keeping us safe. let's take over preparation. So let's pretend I'm going to be on a podcast and I perhaps over prepare, for example. So what we can do is we're not going to do a 180. I'm not going to not prepare and just say, I'm going to wing it and it'll be fine. But what we can do is try to roll it back from over preparation to just preparation. And therefore we're still being prepared, but we're going to drop that overcompensation that is getting the credit.

1:04:52So first wave perfectionism treatment, social anxiety treatment, highly applicable. Let's do some exposures and drop those safety behaviors. Something I also like is that sort of some newer ideas like self-compassion, some ideas we think of third wave, can still fit into like these first wave principles. Self-compassion can be actions. Self-compassion can be behaviors. We can be kind to ourselves by giving ourselves time to drink our coffee in the morning. Taking care of ourselves can put behaviors first. And when we see ourselves doing it, we start to think we deserve it or start to think we can.

1:05:31So we can fit some of those third wave principles even into straight behavioral work. Second wave, good old cognitive work. You mentioned function. Yeah. What does that buy you? What does that cost you? So let's say we're working with a client with perfectionism who doesn't ask for help or like does not admit mistakes. We could look at some feared outcomes, say, you know, well, how, you know, your feared outcome is possible. What's probably going to happen. We could do some decatastrophizing. We could do lots of work with intermediate beliefs, which side quest with Becky and cognitive therapy, there are automatic thoughts.

1:06:07Those are our surface thoughts. There's intermediate beliefs, which are often contingent rules, if X, then Y. And then there are core beliefs. So like maybe I am bad, I am inadequate, I am unlovable. And so we can work with some of those, especially the contingent rules, those intermediate beliefs. If I make a mistake, people will think less of me. If I perform perfectly, I will be accepted. And then getting back to our conversation about keeping standards high, we can keep our standards high, but maybe we can make some room for mistakes. When a natural mistake happens, we can do some cognitive cleanup work after the fact to allow it.

1:06:41So rather than having to work really hard to hide these mistakes, maybe we can see, maybe we can allow ourselves some room to make them.

1:06:52Forrest Hanson: The safety behaviors part of this I thought was really interesting. So you said going not from over-preparing to not preparing, just dropping the overcompensation that's giving you the credit. And so that idea of giving you the credit is really interesting. So why was I safe when I did the test? Well, it was because I studied for whatever, 50 hours to prep for this test. Okay, so it wasn't because I studied for 40 hours or 30 hours or 20 hours. It was because I studied for 50 hours. That's what allowed me to feel safe. And so we can see how we're not giving ourselves the credit, we're giving the work the credit.

1:07:36It's not because I was smart and capable and knew what I was doing so I could study efficiently and so on and so forth. It's because I just grounded out, man, until I was ready to go. I'm wondering when you're working with somebody, how do you help them figure out what the right amount of fill in the blank is? Yeah, this is where we need the client and they are the expert in their lives and experiences. So I will really rely on the client to say like, okay, so you can tell me when the seesaw sort of shifts and you are less preparing because like the preparing moves you forward. Like you're adding new knowledge.

1:08:17If you're studying for a test that this helps you remember, you have a new mnemonic and you're really just studying to reduce your anxiety. Like, let's look at where that shift happens and try to, like, say, maybe you can overstudy a little bit, but let's do less than you normally would. And then I really rely on them to tell me when the studying stops moving them forward and just becomes anxiety management. I'm not going to take it away from them, for sure. I'll let them take the lead in how they're going to try to reduce that from overstudying to studying. You have a line about procrastination that I really liked, in part because I was a habitual procrastinator when I was moving through school and still can fall into those tendencies occasionally.

1:09:08Procrastination isn't about time management. It's about emotion management and connecting to our future selves. Could you explain what you mean by that? For sure. Yeah. So aversive tasks require quite a bit of self-regulation and self-regulation deteriorates under emotional distress. So especially for people with perfectionism, if we feel distressed and overwhelmed because our standards are unrealistic, or we feel like we have to do the whole thing in one go, or we feel like we can't struggle or make mistakes, that's just not allowed, then And procrastination often steps in as a coping mechanism because it is a double reinforcer.

1:09:49You know, we with perfectionism are not going to do things one way. We'll do it two ways. So procrastination allows us both to avoid the task that's making us feel bad and immediately replace it with something that makes us feel bad. And I get to watch baby whales on TikTok. Cool. Double whammy. And so what we can do with that, I find a behavioral practice is to just break it down into steps so small, you feel no resistance. So I have a rising high school senior who is studying for the SAT. And he was procrastinating and feeling really overwhelmed about studying for the SAT. And I was like, well, OK, how long would you want to study?

1:10:33or like if what's the amount of time where you were like, yeah, I could do that. That's fine. Like 20 minutes, 15 minutes, 10 minutes. And he's like, oh, I was going to try to study for three hours. I was like, oh, okay. Well there, that's why you're feeling overwhelmed. And he's like, okay, yeah, I could do 20 minutes. So like, I think, so trying to break it down into steps so small that you feel no resistance is really helpful. And then, like you said, connecting with your future self, I find this fascinating. Okay. So apparently people who procrastinate feel more disconnected on average from our future selves.

1:11:06We tend to think of our future self as this other person who will feel better than we do now and will happily take care of the task that we're procrastinating. Our future self will feel like writing this paper or washing these dishes or going to the gym. So simply trying to connect with a more realistic version of our future self can help increase like empathy and connection for this mythical future self rather than expecting them to cash the checks our current self is writing when we procrastinate. We don't have to picture our future self like having done the task or like or done the opposite.

1:11:46We don't have to picture them procrastinating. Just simply picturing our future self and really imagining our future self in rich sensory detail can be enough to realize, you know, like, I don't know if my future self is going to be this eager beaver, and maybe I can just get started now. So just picturing our future self is helpful in getting us out of the rut. Yeah, there were two stories you told in the book that I thought were really interesting. First about a client that you named Noah, all of the names, of course, have been changed, I'm sure in this book, Noah couldn't fill out a application for a coffee shop job.

1:12:22And this was not because they were not a capable person. It's because the bar was so low that if you can't clear it, it's kind of terrifying. You know, like this is not supposed to be a complicated, elaborate task. And the person knows it. It's well within their capabilities. They're very qualified individual for this job. But there's that fear. Like, what if I don't get it? Or like, what if I can't fill out this application? That implies things about you as a person, like we were talking about before, in a way that's just really scary. The second part with this emotion management piece, you gave this study that they had done,

1:12:57Forrest Hanson: I think it was, about an aromatherapy candle, where people were told that the candle would freeze their mood. And when they were told that, they didn't procrastinate as much, because there was no point in procrastinating anymore, because the whole point of procrastinating was to help them feel better. So when that was taken off the table, the procrastination went away, which I think is really interesting because we tend to think of procrastination, like you were saying, as more of a time management thing, like the person has an issue with designating the proper amount of time for this task. No, it's an emotional management tool.

1:13:30And so what can we do to change the emotional management part of procrastination to make it not something that is as desirable for us to move toward? And I'd be curious about that. Yeah, I think so. One way we can approach procrastination, which is sort of a tough ask, but it gets to your point about the aromatherapy candle. If we think that like procrastination is not going to change our mood, that our mood is frozen, then we can apply that to like, well, I can just do this task while I feel crappy. Like I don't have to repair my mood. That's that is a tough ask because mood repair always comes first.

1:14:09Like it's, I would not use that as a go-to, but theoretically it is absolutely possible to move our hands and feet and do the task, even if it makes us feel stupid or bored or whatever. You tied together these two different areas of your expertise that until I read your book, I thought of as being different things, which was social anxiety and perfectionism. And you said that the heart of social anxiety is perfectionism. Could you kind of connect the dots for me here? Sure, yeah, in both. We think there's some fatal flaw that we need to hide or some inadequacy that we need to compensate for so people don't judge or reject us.

1:14:47We think we have to perform as superbly as possible for people to like us. So perfectionism and social anxiety share the sort of perceived inadequacy that can be made up for through hard work. When I was reading it, I was thinking a lot about Sonia Lubomirsky, who I recently spoke to on the podcast. She wrote a book with a co-author on love and being more lovable, and also on self-love to some extent. And she, in the book, really drew this distinction between competence and love. Like, are we wearing a mask that allows us to display competence, or are we taking off the mask in a way that allows us to be known and therefore to be loved?

1:15:30and it was extremely similar to what you were talking about in your book related to social anxiety when you're talking about this kind of like sense of performance that the person needs to put on inside of a group and if the performance drops then oh my god i feel so bad about whatever happened yeah i just thought this was a really interesting parallel there this like warmth versus competence thing absolutely yes well so the the analogy i like to make about that is think about why your friends are your friends. Are your friends because of how they perform? Because they are good at things? Are you friends with them because, I don't know, they're good at skiing?

1:16:09Or because they always pick a good restaurant? Or because they tell highly competent, funny stories? No, probably not. I mean, that might be part of it. Maybe you're friends with your friends because they speak three languages. But probably you're friends with your friends. because of how you feel when you're with them, that warmth, that love aspect. And the fact that when you're with your friends, I'm with my friends, I feel like I don't have to perform at all. Social anxiety and perfectionism both tell us this lie that if we perform well enough, then people will, then we'll earn that love and belonging.

1:16:47And it does, or it can earn admiration, but that's qualitatively different than love, belonging, and acceptance. If you're working with somebody related to social anxiety, which includes these other things that we've been talking about, as you've been saying, you've already mapped some things here in our broad conversation about CBT that feels like it would make sense to me. We've talked about various forms of exposure, kind of graded exposure. This could be figuring out different kinds of situations. What are your low anxiety situations? What are your higher anxiety situations? How do we help you approach those lower anxiety situations first so you can establish more comfort in them?

1:17:26At what point does a group start to become big enough to activate your social anxiety? Do you have one-on-one social anxiety? Or do you have, I'm at a party with 30 people with social anxiety, and wow, there's a lot going on. That would also be a lot going on for me. Can we find a healthy middle ploy where we try to set up these kinds of situations for people? You've also talked about looking at our internal thoughts, the assumptions that we have about what makes us be lovable or what makes us be likable or friendly or perceived as valuable by other people? Do we have a frame of warmth or do we have a frame of competence?

1:17:59We can work on those internal beliefs that we have about what makes somebody a desirable person to be around. From there, I'm sure there's an awful lot that I'm not thinking of. Are there other things that you would want to name here that are in part of the mix when you're working around this kind of stuff with people? Or if you want to finesse anything I've said so far, because I am not a social anxiety therapist. No, no, no, no, No, this is great. I think maybe the one thing I would add, so let's circle back because we had started to talk about CBT-ish approaches to perfectionism and anxiety.

1:18:28And so we got through first wave, we got through second wave. And so let's cap it off with some third wave stuff. A lot of folks who come in for social anxiety and or perfectionism are surprised when I posit that we don't actually have to have less anxiety or less self-criticism to move forward, that using those third wave principles, we can change our relationship to anxiety or self-criticism. And honestly, with self-criticism, that is going to be impossible to get rid of entirely anyway. So we criticize ourselves in order to check ourselves and to make sure our behavior stays in line, to make sure we stay part of this group.

1:19:08So it's hardwired within us. We're going to criticize ourselves. But what we can do, rather than trying to get to zero on social anxiety, try to get to zero on self-criticism, is to kind of think of it as just part of a script. So what I mean by that is, you mentioned like going to a group or going to a 30-person party invokes some dread. I have learned over the years that that can just be part of the script. I get invited to something. I'm excited. It draws near. Maybe a couple of days before I'm like, oh, I don't know if I want to do that. And my brain finds every excuse in the book, like, oh, it's cold out.

1:19:49Or I don't know, the parking's going to be hard. Or I don't know if I want to go. But then ultimately what always happens is that I will go and it'll be fine. And so I've learned over the years that this is just part of the script. Let me back up. At a restaurant, there is a script. You walk in, you get seated, you look at the menu, the waiter comes and takes your order, you get your food, you eat, you pay, you leave. And then we can apply this like a similar script. This is just what happens to my example of going to a party for self-criticism. Maybe here, I'll use myself as an example again.

1:20:28After being on a podcast, I have discovered that when I, you know, close Zoom, that my brain will start going back, oh, why did I say it that way? Or like, oh, you know, like that, that part was very inarticulate or, you know, just other, that's just what happens. But I don't, that doesn't mean that I have to listen to it. I don't have to listen to my brain self-criticisms after an interview. It's just part of the script and I can treat it to mix my metaphors, sort of like the music at a coffee shop. I can hear it. I can hear those lyrics, but I don't have to dance along. I don't have to take those lyrics literally.

1:21:09It's just what happens. So we can really try to change our relationship to our anxiety or our self-criticism rather than trying to press it down to zero.

1:21:20Forrest Hanson: Yeah. And man, I don't know if I want to generalize quite this much. But if I look back over the 200 conversations I've had with really smart people about this stuff, over and over again, one of the themes has been some version of we have the order backwards. We think that we start feeling good, and then we go do the things. When in reality, most of the time it's the opposite. We don't feel great. It feels complicated. We need to deal with our emotions about something. And we start doing the things anyway. The things are small, the things are approachable, the things are reasonable, but we're doing the things.

1:22:05And then over time, our motivation toward those things or our feelings about those things tends to naturally change. Of course, if you're somebody who has tried doing things over and over and over again, and you have not experienced that, something else is going on. And it's good for you to pay attention to that. I'm not saying that this is like a blanket prescription for everybody. I can't prescribe anything, nor should I. But as a theme, this has really come up over and over again. It relates to a lot of the behavioral activation parts of cognitive behavioral therapy, right? That there is a get out and doing aspect of the whole thing that is often the hardest part for people.

1:22:43And so that's something that I would just give people encouragement toward. Yeah, sometimes, man, to use a line that Rick likes, the mind is a cave of bats. There's a lot of stuff going on in there, but we can kind of shift our relationship with that cave of bats over time. If I could distill all of CBT or my entire job down to one phrase, it would be to lead with behavior because if we put that first, then motivation catches up. Confidence catches up. Our thoughts catch up. Like just when we see ourselves doing something, all these beliefs in this big fishing net behind us catch up and are brought along for the ride.

1:23:30I really appreciate everything that you've talked with me about today, Ellen. This has been really, really great. This was a really wide-ranging conversation. This was one of the more wide-ranging ones we've had in a good way, where we're going all the way back through time talking about the history of CBT, the different waves, and then applying some of the good tools to your area of expertise. And I just thank you so much for also for the prep that you did for this conversation, you know, having the stories and having the history. And you're such an expert about this. Is there anything else you would like people to know about your work, where to find you, your books, anything you want to talk about?

1:24:02Sure. You can find me, I publish most often on Substack and it's called How to Be Good to Yourself When You're Hard on Yourself, which brings together the social anxiety, the perfectionism. We really talk about the connection and the overlap between anxiety and connecting with each other as humans. So find me on Substack. Yeah. And then the two books are How to Be Yourself. That's the social anxiety book, subtitle Quiet Your Inner Critic and Rise Above Social Anxiety. and then the perfectionism book is How to Be Enough, self-acceptance for self-critics and perfectionists. Again, thanks so much for doing this with me today.

1:24:40I really enjoyed it. Thank you. This was a delight. You asked great questions and I really appreciate being able to be on the show.

1:24:46Forrest Hanson: Thank you, Ellen. It was great talking with you.

1:24:56Forrest Hanson: Really appreciate Dr. Ellen Hendrickson taking the time to talk to me today about CBT and probably my favorite part of the conversation was Ellen's willingness to say, yeah, totally, when I raised a complaint that people have about CBT or talked about people having bad experiences related to it. And she was very willing to engage with all of those questions in a very open-minded way and clearly had thought about many of these things herself as well. And I think that that really ties to the history of CBT and something that I just want to like really make sure that I say at the end of this episode, I already said it during the episode, but I want to double down on it, that most of the transformation in CBT over time came from CBT.

1:25:41Forrest Hanson: It came from people who practiced in a cognitive or a behavioral way, taking a look at their own way of doing therapy, the whole school of it that they were bought into and going, wait a second here, what are the experiences that clients are having that are bad experiences? What are the things that we are doing in the room that are not getting the results that we want? How can we polish this approach to be more effective for a wider range of people dealing with a wider range of problems? And I think that we should commend that because there are so many approaches, so many people in the world of psychology, the world of therapy broadly, who are frankly quite defensive about whatever approach it is that they are bought into.

1:26:31Forrest Hanson: They do not take criticism well. They are not responsive to feedback. For whatever CBT's faults might be, you cannot say that it is not a responsive approach to therapy. And I think that this is the value of an approach that really cares about evidence, that really cares about reality, that really cares about finding the right scientific-ish way to approach a problem. Because the whole point of the scientific method, the whole point of what we're doing here is I come up with a theory and I test it and I see what happens. And I let what happened inform what I do in the future. And so I would just really ask if you are into a different approach to therapy, if you perhaps have fired some shots at CBT in the past, that frankly, you take a little look in the mirror here and you ask yourself, would my fiefdom, would my approach be as responsive to criticism as CBT has historically been?

1:27:31Forrest Hanson: And I think that this is a place where we can all take a look. To go all the way back to the beginning, Ellen started by talking about what a session of CBT is like. She talked about the intake, what happens when you're sitting in the waiting room, what initially interacting with the clinician is probably going to be like. And this gets to a phrase that comes from Aaron Beck, collaborative empiricism. The therapist and the client are two scientists testing guesses. And the core idea of the approach is that a thought is a hypothesis. It is not a fact. So when we have a thought, we can start to peel back the layers and see how that thought is typically an assumption.

1:28:11Forrest Hanson: I think that person doesn't like me. I think that if I go to the party, I will have a bad time. I think that if I say this to that person, something bad will happen. A lot of those thoughts are accurate. Many of them are accurate. Maybe most of them are accurate. But they're probably not all perfectly accurate all of the time. And the other thing we talked about was the CBT triangle, how thoughts, feelings, and behaviors all influence each other. It's really hard for us to directly influence our feelings. It is really hard when I'm working, even just in a coaching context with somebody, for me to make them feel better or to take their fear away or take their sadness away or something like that.

1:28:53Forrest Hanson: If you're working with a therapist, your therapist cannot change how you feel. They cannot remove the negative experience that you're having from you. The feeling is the feeling. It's very difficult to influence. They might be able to soothe. They might be able to do some stuff around it. They can do things, but they can't remove your feelings. What they can do is help you with your thoughts and help you with your behaviors. That's the premise of CBT. We then talked about the history of CBT, how it first came about as a kind of response to psychoanalysis with behaviorism in general. Ellen talked about a couple of different experiments, which she emphasized many of these experiments would not pass today's ethical standards for work.

1:29:34Forrest Hanson: But hey, still, there were findings from them that were interesting or that led to transformations inside of the field. Then there was the swinging back to the cognitive revolution, the cognitive model that was really introduced and created and popularized by this guy, Aaron Beck. And then other people came along who said, huh, CBT has got this pretty darn good toolkit, but here are these kind of issues in it, like I was talking about at the beginning of the outro here. Here are these different problems with it, huh? What do we do to improve it and maybe to remove some of those problems or to make CBT better for certain kinds of problems or certain kinds of clients?

1:30:09And this gets to DBT and ACT and all of the many approaches that have spawned

1:30:16Forrest Hanson: off of cognitive behavioral therapy. Cognitive behavioral therapy for insomnia, for chronic pain, for many different things that we talk about on the podcast or will be discussing in the future. We then talked about some of the strengths and some of the vulnerabilities of CBT. It is very good for depression and particularly for the relapse of depression, or at least there are many studies that have come along that say it is very good at that. It's also very good for anxiety, which is Ellen's area of focus. I mentioned insomnia a second ago. CBT-I is probably the first-line treatment for insomnia right now.

1:30:48Forrest Hanson: There's some research that suggests that it beats sleeping pills over the long term, which is obviously a fantastic result for any approach to therapy. And we also talked about some of the vulnerabilities. Ellen mentioned how for people who are on either side of the cognitive spectrum, CBT might not be the best fit, including for people who tend to really overthink. And this led us into a bit of a conversation about how maybe people get more out of therapy when there's something about it that isn't their natural inclination as a person. This then took us to some of the common criticisms of CBT that you will see online.

1:31:23Forrest Hanson: I mentioned four in particular. First, people don't like the vibes. You know, you're being very reductive. It's spreadsheet therapy. You're trying to reduce all of this messy complexity of being human into an intake form. Second, that therapy is self-gaslighting. Third, that CBT is in bed with the insurance companies. and fourth, that I tried a session of CBT and I really had a bad experience myself. That last one is the one I wanna talk about a little bit more in the outro. I mentioned it a few times throughout the episode, but I think so much of this gets down to fit. And it also overlaps with the insurance company question, where if people are just getting funneled into one approach to therapy over and over again, but that's not a great approach to therapy for them or their problem or their temperament or for whatever reason, then that approach is gonna have a higher rate of bad fit, obviously.

1:32:14Forrest Hanson: People are not like selecting it themselves. They're just getting nudged into it. So I think any therapy that became the default option would probably get a lot of the criticism that CBT has. And particularly any therapy that became the default option for insurance companies, it would get this kind of criticism. This then leads to some questions about the format that therapy is being delivered in. Is the provider overloaded? Are there session caps? Is this happening virtually? Do those sessions, do those virtual sessions work as well as in-person sessions for this particular modality? I'm not sure.

1:32:49Forrest Hanson: Even inside of just my own coaching experience, which again, to be clear, is not therapy. I feel like the good stuff often starts six to eight sessions in. That's when we are really getting into whatever the heart of the problem is for the person who's coming into the room. It's where we've been able to build enough rapport to get to the good stuff. So if you're only prescribing six to 10 sessions of therapy, well, are you able to get there? And yes, the structure of CBT lends itself to being delivered in a tighter format, but still, can you really affect that kind of positive, meaningful, lasting change for somebody in that period of time?

1:33:27Forrest Hanson: Maybe there's some evidence that you can. There's evidence for various brief therapies, including briefer courses of CBT. But I'm inclined to believe that it's a little bit more difficult. During the last third of the episode, we talked about applying tools from CBT to Ellen's areas of expertise, particularly social anxiety and perfectionism, which she talked about being closely related to each other. I really appreciate her frame of perfectionism as we're not trying to purge you of these tendencies. Perfectionism is closely related to conscientiousness, and there's a lot of evidence that if you're going to be high in any personality trait, you want it to be conscientiousness.

1:34:05Forrest Hanson: It is good to be high in conscientiousness, generally speaking. You don't want it to get totally out of control, but in general, it's a good tendency for a person to have. So how do we get the good parts of perfectionism, high standards, high quality of work, real focus on doing in a good way out in the world, without having to deal with the problems that come with it? Most specifically, a hypercritical relationship with yourself, and over-identification with meeting personally demanding standards. We talked about the function of perfectionism, the kinds of experiences it's defending against. Ellen mentioned go forth and do a couple of times for social anxiety, and she talked about dropping the different safety behaviors that we are attributing credit to.

1:34:50Forrest Hanson: So we're not able to attribute credit to ourself, to our own work, to our good nature, our good thoughts, or good actions in the world, we're attributing it to, oh, I stayed up all night studying, or oh, I did 30 hours of work on this project that other people did five hours of work on. I hope you enjoyed today's episode. I had a great time talking with Ellen. I'm very curious to see the thoughts and feelings and feedback from people on this episode. If you would like to send us an email, you can reach us at contact at beingwellpodcast.com. Did you think I was too hard? Did you think I was too soft?

1:35:23Forrest Hanson: What's your take on this whole thing? I would love to see the comments on YouTube. I'm sure that those are going to be a really interesting time. And if you've made it this far without subscribing to the podcast, if you could take a moment to subscribe, I would really appreciate it. Maybe that's on Spotify or Apple or YouTube or wherever you get your podcasts from. Ellen mentioned her sub stack. Check that out if you're interested in learning more about her work. You could also check out my sub stack. I'm writing over there. It is very occasional. It's just kind of when I move to write something.

1:35:52Forrest Hanson: But I'm trying to do that a little bit more regularly these days. Until next time, thanks again for listening, and I'll talk to you soon.