SPENCER: Christine, welcome to the Clearer Thinking Podcast.

CHRISTINE: Thank you for inviting me, Spencer. I'm looking forward to our conversation.

SPENCER: Now, some of our listeners may have heard of cognitive behavioral therapy, often abbreviated CBT, and one of the things I think is most important to know about it is that it has an incredible body of evidence supporting it as a treatment for anxiety and depression. I would say probably the most evidence of any therapy. Would you say that's right?

CHRISTINE: I think that's probably right. We're a very evidence-based therapy.

SPENCER: So, what is CBT fundamentally?

CHRISTINE: CBT stands for cognitive, as you said, and cognitive means thinking, behavioral, which is what we're doing, and it's a type of therapy that really started out by looking at how our thinking and our behavior affect our moods, particularly in the early days, depression and anxiety. Although over time, the therapy has really morphed and expanded, and now it deals with all kinds of human issues.

SPENCER: Yeah, almost anything about humans that you could test, it's probably been tested for that at this point, whether it's chronic pain or all kinds of disorders.

CHRISTINE: Exactly, everything from psychosis to perinatal depression to now many like myself are also turning our attention to staying well and just normal everyday human experiences.

SPENCER: Because usually CBT is thought of as a way to treat a problem. It's not typically used as a kind of self-improvement. Do you think it has much potential for self-improvement?

CHRISTINE: Actually, I think CBT, at its core, is self-help. In fact, that's what attracted me to it. We've just met today, Spencer, so you don't know that much about me, but I actually grew up in the Midwest in the 1950s and 60s, and back then self-help was assumed. When I was growing up, our parents would say in the afternoon, "Go outside and play, and come back at dinner time." It was kind of up to you to sort out what that meant, and if you got into problems with your friends, figure it out. I grew up in a culture where I didn't even know therapy existed. In fact, when I tell people, they're kind of amazed, but when I started graduate school in clinical psychology at my PhD program, I really didn't know much about what therapy was. I was even at that time very interested in self-help. I was curious, why don't more people get depressed and anxious, given everything going on in the world? How do people stay well? Those are the questions that interested me, but unfortunately they didn't interest the faculty back at that time in the 1970s. Everyone was into studying depression, anxiety, et cetera.

SPENCER: So, did you end up having to pivot into studying mental health because of that?

CHRISTINE: I did, but luckily around that time CBT came along. It was just being developed in the mid to late 70s when I was in graduate school, and I was immediately attracted to it because it was all about teaching people what skills they can use themselves with full knowledge of why they're using it and when they're supposed to use it, so that they don't need therapy. How can we teach people skills that will not only help them feel better, but keep them well the rest of their lives? Over the decades, I really expanded that in my own work too. How can we use the same CBT principles to help people lead more positive and fulfilling lives?

SPENCER: With some types of therapy, it seems that there's an expectation change will happen in the therapist's office. You're going to get some insight into your childhood, and then you're suddenly going to be different. But it seems to me that CBT, a lot of the change is expected to happen outside the therapist's office. Could you elaborate on that?

CHRISTINE: Absolutely, one of the things that's interesting is in CBT, really, what we try to teach therapists to do, and a lot of my career has been teaching therapists to do CBT well, is to figure out what skills would really help this person at this point in their life. We practice them and introduce them in session, but then we give clients learning assignments to do in between appointments, and it's those learning assignments that, the more clients do them, the more quickly they tend to feel better if they're depressed or anxious or having other kinds of issues.

SPENCER: People sometimes ask me, "How do I know if I'm going to a good therapist, or how do I find a good therapist?" One test I suggest to them is, does the person give you assignments between sessions? Do they give you things to work on? Is that unfair to use that criterion?

CHRISTINE: Well, I would actually agree with you. I'm sure there are some therapists who don't give assignments that may be very helpful to people, but certainly from a CBT perspective, if the therapist isn't giving things to do in between, they're not doing CBT, because it's such a core central feature of CBT.

SPENCER: The irony is, I have definitely seen CBT therapists that don't give assignments, which made me quite worried.

CHRISTINE: Well, I think because the evidence showed that CBT was more effective than a lot of other therapies, insurance companies in the United States started reimbursing CBT more than other types of therapy, and so then pretty soon 80% of therapists in the United States started saying, "I do CBT," even if they hadn't been trained in it or really didn't know how to do it.

SPENCER: If you go on these websites like Psychology Today, you'll often find that not only do most people do CBT, they also do 40 other things as well, slightly, but it's this long list of all the things that they're allegedly doing with you.

CHRISTINE: That's one of the rules I have. If somebody lists 30 types of therapy that they do, I would assume they probably aren't in-depth experts at any of them, because it really takes a lot of skill, practice, and experience to become good at any type of therapy.

SPENCER: So what does CBT look like when you're doing it yourself? Because usually you're doing it with a therapist, but what is self-guided CBT?

CHRISTINE: I was interested in self-help, and that attracted me to CBT. After I'd been practicing CBT for a decade or so, a colleague, Dennis Greenberger, approached me because he and I had set up a hospital program for people who were severely depressed. People were getting better in this hospital program at the time, and one of the things we had done was write a workbook for them to use while they were in the hospital setting. A funny thing happened. We had this workbook, and all of a sudden people from the substance abuse sections of the hospital and other sections started saying, "I'm depressed, I want to transfer to the depression unit." The staff were really confused; they were saying, "Why is everyone all of a sudden wanting to transfer to the depression unit?" It turned out the patients were using this workbook, and the word got around the hospital that this workbook was actually helping them feel better. Eventually, we were approached by Guilford Press, and we changed it into a self-help book for the general public called Mind Over Mood. What that looks like is we put in that book the same sorts of skills that people were learning in CBT therapy, but we said, "This isn't rocket science; people with some guidance and practice can learn to practice these skills in their life." That kind of started the whole success of our book, Mind Over Mood. We think it's helped a lot of people. When I go around the country speaking, people come up to me and say, "I live in a rural community, and don't have access to therapy. I've used this book, and it's helped."

SPENCER: Oh, it must be very gratifying. People come up to me and say, "Hey, I disagreed with you about this thing you said on episode 83."

CHRISTINE: Well, I'm sure there's that too.

SPENCER: I'm half joking. Okay, before we get into some of the details of how people can apply these methods and what's useful. When do you think it's important to have a therapist versus when is it appropriate to use something like CBT for self-help?

CHRISTINE: I think that all of us should have self-awareness every day. It's not just self-help; it's also self-awareness. We should be paying attention to our moods, because moods fluctuate. They go up and down throughout the day and across the weeks, and if we're starting to feel down or anxious much of the time, or even most of the time, then we might want to move from self-awareness to self-help and actually do some reading online or whatever, and learn what are some of the things I can do to boost my mood, improve my mood. If you're doing those things and they're just not working, and your mood is getting worse, and it's really starting to interfere with your day-to-day functioning, then I think that's a good time to seek out a therapist, get some help, support, and make sure you're applying things in the right way.

SPENCER: So you think of the more self-help element as really the first step, and then if that doesn't work, you can kind of stage it.

CHRISTINE: Yeah, exactly.

SPENCER: Are there certain conditions where you would say if someone has them, you really should see a therapist, like bipolar, for example, or schizophrenia, that kind of thing?

CHRISTINE: Yeah, I think for bipolar and schizophrenia, it's really very helpful to have a therapist, because you may also find it helpful with bipolar disorder to have some medication, so that can be important. Even with those kinds of conditions, though, I think self-help is also really important. A colleague of mine, Aaron Brinen, has written an excellent book called Living Well with Psychosis, and it's really helpful. It teaches people who hear voices, who see things that other people don't see, to identify what's important for them to live a good life and feel happy and fulfilled, and what skills they can practice. So I always think of self-help and seeing a therapist, when it's necessary to see a therapist, you still want to be learning self-help skills as well.

SPENCER: Sometimes people argue that a lot of the benefit of therapy comes from the therapeutic alliance, that relationship between patient and therapist. With self-help, you don't have that, so if it were really true that a substantial amount of the benefit came from that alliance, it makes it seem like maybe self-help wouldn't be that useful relative to going to therapy. What do you think about that?

CHRISTINE: Well, I think that's true. I think self-help is a very good example of this point. I do think that therapeutic alliance is important if you're seeing a therapist most of the time, although for some issues, probably therapeutic alliance isn't that important. Say, you have a blood phobia, one of the things with blood phobia is that it's pretty easy to treat. It sounds complicated, but it's easy to treat, because it really has to do with some people having a natural drop in blood pressure at the sight of blood or injury, and so they faint. You can just teach people to raise their blood pressure by pumping their fists, tensing their muscles, that sort of thing. Therapeutic alliance probably isn't important if it's just a very narrow skill that you're being taught, but most people, when they go to therapy, need to have at least a good alliance with their therapist to be willing to do some of the things that can be kind of difficult, and you might need some encouragement to take the steps that are being recommended. However, I personally don't believe that for many issues, therapeutic alliance is enough. I think it's sufficient if you have a pretty wise, mature therapist, and you're just dealing with life issues, and maybe therapeutic alliance would be enough, but if you're in serious clinical depression, feeling suicidal, or have obsessive-compulsive disorder, therapeutic alliance isn't going to get you better necessarily. You need a therapist who really knows what skills and methods are going to be most likely to be helpful, and having a more expert, skilled therapist will make your treatment happen a lot faster and be more likely to be effective, anyway.

SPENCER: So the alliance then is more about helping you learn the techniques that you need to learn, trust the therapist and what they tell you, that kind of thing, rather than being sort of the change agent in and of itself.

CHRISTINE: Yes, I think it's a necessary condition, but not the total package for many issues. For some issues, if you have relationship issues, it may be that having a good alliance with a therapist who knows about relationship factors may be a central issue, because you might be using the therapy relationship to help you learn more about what a good relationship is and how to set boundaries and that sort of thing. But for many things, particularly panic disorder, obsessive-compulsive disorder, and severe depression, I don't think the treatment alliance is enough.

SPENCER: Some people argue that you actually just need enough therapeutic alliance; it doesn't even have to be that good, because often it will improve if you're making progress. Obviously, if it's really bad, then maybe you just have a dysfunctional relationship with the therapist. Do you think that's true?

CHRISTINE: There's actually evidence to support that. It turns out that with some of the research that's been done, they found that the therapy alliance, which, by the way, for listeners, if they don't know what therapy alliance means, therapy alliance has been measured usually by looking at a sense of warmth and connection between you and the therapist. That's what you would think of an alliance, but it also means you and the therapist are pulling in the same direction, that you have an agreement on the goals of therapy, and you agree on what method you're going to use for therapy. So, for example, if you're going to therapy and you really want medication, you're sure medication is the thing that's going to fix you, and you're not going to be happy until you get medication, and your therapist is trying to teach skills or things that you could do in your behavior and your thinking to improve, you're not going to be happy. That's going to be a bad alliance because you're not aiming for the same things. So those three things — a sense of warmth and connection, agreement on the tasks of therapy, and agreement on the goals of therapy — are really important; that's what therapy alliance is. But the research does show that if you have a good enough alliance in the beginning and you start to make progress and feel better, your alliance definitely improves. You start to feel good about your therapist because your therapist is being effective.

SPENCER: That reminds me of another thing that I sometimes say to people when they ask about how to think about a good therapist, this idea of having goals for therapy, things you're actually trying to achieve, because surprisingly often people go to therapy for a long time, and it's not that clear what they're trying to achieve with the therapist, which also means they can't tell if it's working.

CHRISTINE: Yes, and that does go back to your original question of how do I know if therapy is helping me. It's really important to have goals, and ideally those goals should be measurable. They don't have to be measurable on a zero to 10 point scale, but it might be I want to have better relationships, and I'll know that I've achieved that if I can walk into a coffee shop and hold a conversation with strangers, and if I start to a couple of times a month, get together with people I know, and do things socially. Then I'll know I'm making progress, because I'm not currently doing those things. So, having some clear goals and some signposts that you're reaching those goals, that's a very important and helpful thing for evaluating if therapy is helping me or not.

SPENCER: So, let's talk about depression. Suppose someone's depressed, what kind of self-help technique might they use?

CHRISTINE: Well, there are really two big classes of things that a lot of research shows help depression. The first of those is getting more active, and the second is changing negative thinking patterns. Those, I think, are important because those are hallmarks of depression. When we get depressed, we naturally stop doing as many things, and we also start having thousands of negative thoughts every day, once we become depressed.

SPENCER: It's fascinating that changing behavior can work for depression. Because I think often people who are depressed feel the world is hopeless, that they themselves are worthless. You're like, "Well, what do pleasurable activities have to do with anything?" Yet, as I understand it, evidence suggests that it actually can help.

CHRISTINE: It actually does. I mean, there is a ton of evidence over the last 50 years showing that if people do more things, they will feel better. Ironically, though, when we're depressed, doing things is the hardest thing to do because we don't have much motivation. We have a lot of inertia to just stay sitting down, or lying down, or watching TV, or scrolling our phone, and we don't feel like doing anything. As you just said, we don't see the point of it. We're hopeless; what's the point of getting up and washing the dishes? What is that going to do for my depression? I understand that. I think those are understandable thoughts to have. One of the things that I found really helpful, and that my depressed clients told me was most helpful, is I came up with this idea of what I called the five-minute rule when I was working with depression a lot early in my career. It was designed as an experiment. We do a lot of experiments in CBT to test ideas. It's not like I'm going to tell you something and I expect you to believe it as gospel. It's more, let's experiment and find out if activity makes a difference. The five-minute rule was a way to overcome inertia, and I would just say to my clients, look, let's make a list of things you can do during the day. You can wash the dishes, you could take a walk, you could call someone, call a friend, whatever it is that you want to be doing. If you don't have the energy to do it, if you do it for five minutes, you get full credit. So let's take washing the dishes. If you go over to the sink, you set a timer for five minutes. You go over to the sink, you put some water in the sink and some soap, maybe get one or two dishes washed. When that timer goes off at the end of five minutes, you can stop and get full credit for doing the dishes. My depressed clients would be a little skeptical. They'd say, "Well, what do I do with the rest of the dishes?" I said, "Just leave them there. That's okay, you get credit. If you want to go on, you can, but you don't have to." The five-minute rule was so helpful for people when they're depressed because they could imagine getting the energy to do something for five minutes, and then they often found they had a sense of accomplishment. It's like, "Okay, I did this," and they discovered that doing something, even for five minutes, boosts your mood a little bit, and that can, of course, then chain into doing things longer and doing more things during the day.

SPENCER: I wonder how often do you think that they end up doing it for much longer than five minutes once they've gotten some momentum going?

CHRISTINE: Well, most of the time they do because inertia, as people know from science, works both ways. A body at rest wants to stay at rest, but a body in motion wants to stay in motion. In fact, a lot of times people would do things for more than five minutes, maybe six minutes, seven minutes, 10 minutes, and then they feel kind of double good. I think this is the really helpful part about the five-minute rule. If you do it for five minutes, you do get full credit, but oftentimes you'll be able to do things a little bit longer, and then we feel even better. It's like, "Okay, I'm capable of more than I thought I was. I got something done, and I feel good about that." I'll tell you, I've written a number of books, and almost all my books were written according to the five-minute rule because I'm not someone who wakes up and gets excited about sitting down and writing. I would often say to myself, "Okay, just work on something for five minutes," and often I would end up writing for 20 or 30 minutes, sometimes even a little bit longer, and bit by bit, books got written.

SPENCER: Yeah, it seems a useful role for almost anything that we're having trouble motivating ourselves to do.

CHRISTINE: Yeah.

SPENCER: And there's actually habit research that's related to this idea of tiny habits, where on days when you can't do a habit, if you just commit to doing some mini version of it, like, "Okay, today I don't have time to go to the gym, I'm just gonna do three push-ups," or whatever it is, people tend to be more successful in their habit change as well, so that's kind of another use case of that.

CHRISTINE: Yeah, and I do that as well, because I try to walk a certain number of steps a day, and some days I just don't feel like taking a long walk, but I'll at least get out of the house, take a short walk, and that counts, makes me feel good, I'm not letting myself down.

SPENCER: I once wrote an essay that was about effective forecasting, and people kept correcting it, saying, "You mean effective forecasting?" I said, "No, effective forecasting." "Can you tell us, do you think that effective forecasting, what it is, and how does that help explain what's going on with depression?"

CHRISTINE: Well, what did you mean in your article by effective forecasting?

SPENCER: So we were talking about this idea of predicting how you're going to feel about things in the future. The idea being that depressed people may anticipate, "Oh yeah, I could do this thing that people might enjoy, maybe I would normally enjoy it, but when I do it, I'm not going to have a good time, or it's not going to be worth it."

CHRISTINE: Okay, yeah, that's perfect. Exactly. I would get my clients all the time to make predictions about, okay, if you do this activity, how much are you going to feel better or not? They would make their prediction, and then I would have them do their experiment, do the experiment of doing the activity, and then rating how well they felt doing it. What happened almost all the time with depression is that people ended up enjoying things more than they predicted they would. It's not just pleasurable activities that help depression; it's also mastery, accomplishment activities, getting things done that you've maybe been avoiding or that have been nagging you. I have a friend who's going through a real tough time right now, and he said the other day he went out and mowed the lawn, and he said, "Oh my god, I felt so much better after I mowed the lawn. It's like, at least I'd gotten something done, even though I was in a rotten mood." I think doing things like making a prediction, but not believing your prediction, testing your prediction out, that's what's important. We all make predictions; we all do affect forecasting. I like that phrase. We all do that, but the thing is, don't believe your affect forecasting until you go out and check the weather.

SPENCER: Do you think that that's a really deep part of depression? This idea that we mispredict how rewarding things will be, and therefore we stop doing them because we don't think they're rewarding?

CHRISTINE: Yeah, that is part of depression, for sure. We make negative predictions, we have negative thoughts about ourselves, we have negative thoughts about the world and the effect of things we could be doing in the world, and we also have negative thoughts about the future. I always characterize that as when we're depressed, our natural thought processes are, "My life's a mess, it's all my fault, and I'll never get better." Each of those negative things are testable, and what happens when you start to test out those beliefs is you usually end up feeling better, because if you can look at all the evidence, and that's the tricky part in depression, because in depression, what comes to mind is all the negative evidence that backs up these negative thoughts. We really have to teach ourselves to look at the other side of the coin.

SPENCER: What would you say makes depression fundamentally different than anxiety?

CHRISTINE: So many things. Depression is, first of all, looking at the present and the past. Usually, there is future hopelessness as well, but it's a very present-focused kind of problem, whereas anxiety is very future-oriented.

SPENCER: Where anxiety is very future-oriented.

CHRISTINE: Anxiety is very future-oriented. The themes in depression are loss, failure, that sort of thing, whereas the themes in anxiety are danger, catastrophe, inability to cope. So they're really quite different, even though oftentimes people can have both, and there's a huge overlap in people's experience. Just to say one more thing about the negative thinking in depression: when Aaron T. Beck originally came up with cognitive therapy for depression in the late 70s, I had the benefit of being good friends with him throughout his lifetime from that point forward. He developed really the cognitive therapy for depression very close in model to what we would use today. One of the things he did is he developed something he called a thought record. It was five columns, and it identified negative thoughts and had people come up with a rational response. For instance, they would say, "I'm no good," and then their rational response was, "Well, I'm probably good for some things." When I was learning this therapy soon after he developed it, I would work with my clients, and they gave me feedback and said, "Yeah, well, I can come up with an alternative response; I just don't believe it. I can write it on the paper, but I don't believe it." With my clients, I developed what I called the seven-column thought record. That's the one we teach people to use in the Mind Over Mood book. The seven-column thought record came about because my clients said these thought records help me when I'm with you in therapy, but they don't help me when I do them at home. People were depressed, but not stupid, so they could come up with an alternative thought that wasn't depressive, but it had no credibility to them. We added in two columns: evidence that supports my hot thought, the thought that was really driving me to feel so bad, and evidence that didn't support it. Over the decades, I would ask clients questions to look for this evidence that didn't support their negative thinking, and I would send clients home with lists of all the questions I asked in a therapy session, asking them to put a little circle or check mark by the ones they used at home that helped them a lot. We came up with a list of really helpful questions for when we're depressed, things like, "If my friend said this, what would I say to my friend?" When we're depressed, we see ourselves in a negative light, but we don't see other people in a negative light. Other questions included, "If my friend knew I was thinking this, what would my friend say to me? If I was feeling happy instead of depressed, how would I think about this event differently five years from now, looking back on it?" Anything that shifts perspective. My clients really helped me develop and fine-tune this list of good questions to ask to look for evidence that doesn't support our negative thinking. Those early clients who helped me with that have helped maybe even hundreds of thousands of people since, because we published all these questions that people could ask themselves.

SPENCER: That's wonderful. When I was younger, I had some depression, and thankfully I haven't had it in many years, but I remember it feeling like everything was so meaningless and hopeless. It was almost like living in a cloud of despair, and it sounds like the kind of questions you're using are trying to get people to shift out of that despair and let another perspective in.

CHRISTINE: Yes. Our brain filters information based on the mood we're currently experiencing. This is why we can get in trouble when we're falling in love with someone, because we can ignore warning signs. When we're falling in love, everything seems wonderful. Similarly, when we're depressed, everything is doom and gloom and failure and insurmountable. What's interesting is that by asking ourselves good questions, we can actually shift the information and data that our brain pays attention to. When people practice using the seven-column thought record, at first it's a little difficult because they're not used to asking themselves these kinds of questions. However, after filling out 15 to 20 thought records, it's like their brain learns new software. Your experience, Spencer, which I'm glad to hear you're not struggling so much with depression anymore, illustrates this. People who learn to ask themselves these questions and think about the evidence that both supports and doesn't support negative thoughts eventually don't need to fill out thought records anymore, because their brain starts to naturally do that when they have a negative thought. Their brain says, "Well, what about this or this? Is there another way of looking at it?" Right now it seems like you can't solve this, but is it possible that if you talk to someone else or waited a few days, a solution would come to you? That's what's exciting to me. It's a little harder to change our thoughts than it is to change our behavior, but once we learn how to do it, it's a skill that we carry with us for the rest of our lives.

SPENCER: It's intriguing to me that having people generate evidence on both sides actually works, because you might think, if you're depressed and trying to gather evidence on both sides, are you going to be really biased in your evidence? Or, okay, maybe you put the evidence on both sides, you're going to interpret it, but it's almost like it kicks them into a different way of thinking that's not aligned with the depressed way of thinking.

CHRISTINE: The thing I always found interesting in therapy is sometimes we'd have to work five minutes to find the first little bit of evidence that didn't support a depressed thought, but once we found that first bit of evidence, it opened up a whole new way of thinking. The second bit of evidence might come in two or three minutes, the third bit of evidence in one minute, and then in the next minute we get three more bits of evidence. It's like there's this wellspring of information in our brains, but in certain mood states we just can't access it. Once we access it, then it starts to flow a little bit more easily.

SPENCER: Sometimes I think people misinterpret what's happening in cognitive therapy, where they think of it as you're doing positive thinking or something like that. How is it different from positive thinking?

CHRISTINE: It's different because positive thinking can be just as distorted and troublesome as negative thinking. Someone who's highly narcissistic thinks everything they do is wonderful, and even if other people are getting hurt, it doesn't really matter. That's positive thinking, but not in a helpful way. What I like to think of it as on the seven-column thought record, I ended up calling it alternative balanced or balanced thinking, one or the other, because you want to pay attention to negative things in our life. If there are things you're struggling with, you don't want to ignore those things. We want to go open-eyed into looking at our experience so that we can come up with some kind of sense of, "Okay, what am I good at, what am I not good at, what do I need to learn more of?" I really think of it more as balanced thinking, or I haven't used this term before, but it's almost like functional thinking. What thinking is going to serve me well and move me closer to my goals and help me fulfill the purpose and meanings that are important to me in my life?

SPENCER: I love this technique, and I try to use it a lot in my life. I'm having a thought, "Oh, this project's going to fail, and then I try to respond to it." The way I think about what I'm doing is I'm trying to come up with a new thought that's more helpful and at least as true as the original. I'm wondering if you endorse that way of thinking about it. I might think of another thought, "Well, I don't know that it's going to fail, and actually there are some good signs and some bad signs, or something like that." It's at least as true, probably more true, and it's more helpful than the original.

CHRISTINE: Yeah, I think that's a really good way of thinking about it, Spencer. You do want to come up with a thought that is at least as true, if not more true than your original thought, but one that's going to move you forward. If a thought is just derailing you from what's important in your life, that's not a helpful thought to cling to.

SPENCER: It's strange, though, the nature of our thoughts is they often feel inherently true, and we have them. You have to take this step back to be like, wait, oh no, I know it feels completely true, but there's another perspective I can adopt. It's just funny how true a thought feels.

CHRISTINE: Yeah, when you say that, it reminds me that thoughts are not all words, they're not all sentences. An additional kind of thought that we're getting much more research on in the last decade or so is images. It turns out that many times throughout the day, it's not just words that are going through our head, but we're having images. We're having images of ourselves failing, feeling embarrassed, images of things going wrong, images of what we look like to other people, images of what other people are saying about us. We have these kinds of images. They can be visual, they can be auditory, and images, by their very nature, feel real. If I say to you, "Apples don't fall far from the tree," you have a certain reaction to that. But if you actively visualize an apple falling and you see it falling at the base of a tree, that has a lot more credibility to you. Well, images, just like thoughts that we have, are not always necessarily grounded in reality, but when we have an image of ourselves getting up and making a fool of ourselves when we're giving a report in class or something, that image seems very real to us, and that can convince us that it's true. Once we have an image of something, it really has a lot more believability.

SPENCER: There's interesting individual variation. A couple of my friends never have verbal thoughts; they only seem to think in images and concepts. Other people can't form mental images at all; they literally seem unable to form an image in their mind. It's just fascinating, and I don't know that there's any research on this, but it'd be really interesting to know how people's differences in ability to form images or not, or ability to have verbal thoughts or not, impacts their mental health.

CHRISTINE: Well, there actually is a lot of research on this.

SPENCER: Oh, I didn't know that.

CHRISTINE: So, I could say, first of all, virtually everyone thinks in images. A lot of people think they don't, but I think it's less than 2%. It may be even less than 1% of the population. And the way to test that, I have many people tell me in therapy, "Well, I don't think in images," and I say to them, "What did you have for breakfast today? Can you imagine your plate? What did it look like, or your bowl, or whatever, your wrapper on the granola bar that you ate?" If they can say "Yes, I can see that," then they do have images; they just may not be aware of it. Images happen so quickly that we have to really teach people to stop and catch their imagery, because it turns out imagery is really real. We have always known it's really important with anxiety, but it turns out it's also really important with anger and depression and all the other moods as well.

SPENCER: Yeah, that's really interesting. Some people, though, are genuinely aphantasic. I think you're right, it's very less than 2% of people. Is anything known about how their mental health is different that you're aware of?

CHRISTINE: I'm not aware of how their mental health might be different.

SPENCER: That would be an interesting research program. So, we've talked about one kind of behavioral approach to depression. You have this idea of taking a walk. Can you tell us about that?

CHRISTINE: Yeah, amazingly enough, walking is one of the things that has robustly been shown to be antidepressant, and it seems like a simple thing. It can be hard to get people to get up and take a walk, and you're in New York, so it's a lot colder in New York, so sometimes that's less pleasant than in California, where I live, but walking is one of the things that we can do that does almost guarantee to lift our mood. It's really important how you walk, and you can actually improve the antidepressant nature of walking by walking in ways that build on your own natural values and interests. For example, I really like nature; you put me out in the woods or even a grassy lawn, and my mood immediately improves. So, for me, walking outside, especially if there's some nature around, is going to be much more antidepressant than walking on a treadmill. It may not be just a walking process, but it might be what you're doing while you're walking, and what you're doing while you're walking is really important because you could be walking and obsessing about all the ways you've screwed up and all the things going on in your life, and you're going to say, "Walking doesn't serve as an antidepressant for me." It's really important that people walk in ways that build on what you are aware of helps you. If you are people-oriented, if you could get a friend to walk with and have a conversation while you're walking, that would probably be a better antidepressant for you than just walking by yourself. Walking by yourself would probably be preferable, especially if you made eye contact with people and said hello to people when you were passing them. I do that when I walk around my neighborhood; I see people, I try to smile, say hello. Sometimes I've actually had nice conversations with strangers doing that, and that can make it a better experience. You want to pay attention. A lot of people nowadays walk staring at their phones, and I think that would take away for most people from the antidepressant nature of walking.

SPENCER: I've heard that sunlight may even be helpful with depression, taking a morning walk in the sun. Is there some support for that in evidence?

CHRISTINE: Yeah, there is biologically. There's support that sunlight, especially for people who have seasonal affective disorder, depression that comes in the wintertime when we have less sun. For all of us, I think the sun can really help boost our mood. If you think about it, if you go outside on a super cloudy day, you get one kind of mood. If you think about it, if you go outside on a super sunny day, and maybe add some birds chirping in there, that often feels a lot more positive to us.

SPENCER: So, we've talked about both cognitive methods and behavioral methods. How would one decide which to use? The cognitive methods involve grappling with your thoughts, doing thought records. The behavioral methods include taking a walk, planning pleasurable activities, or activities where you have a sense of accomplishment.

CHRISTINE: When I teach therapists, I teach that the more severe the depression, the more you want to lean into the behavioral methods initially. That's because if you're in the midst of a really severe depression, it's really hard to think more flexibly. It just is. Doing the more behavioral things until your mood improves a bit, and then beginning to test out your negative thoughts is probably a good way to go. If you're doing this for self-help and you're not in a super serious clinical depression, but you're feeling down, you've been feeling down for a few days, then I think you could really do either. It's often good to start by doing something behavioral, like maybe take a walk, and then sit down and look at your thoughts, because the walk will kind of get you activated in a little bit better mood state. The better our mood state, the easier it is to ask yourself those questions, to look at the other side of the coin, and to begin to see evidence that doesn't support your most negative thoughts.

SPENCER: As I understand the research history, and please correct me if I'm wrong, but back in the day, when there was cognitive therapy for depression, there was a study that, to many people's shock, found that just behavior change could have a really huge effect on depression, essentially as big an effect as the cognitive side. This wasn't really what people would expect to find, and now it's sort of thought of as maybe behavioral activation, the kind of behavioral stuff, is even superior. Where do you land on that? What's your read on the evidence there?

CHRISTINE: Where I land on that is, I know some of the people involved in those studies. Science is not always neutral, and the first study, the one that found that behavior was as good or better than cognitive, was a little bit of a false study because they were purportedly comparing behavioral activation therapy with cognitive therapy for depression, but what they did is they stripped out the behavioral activation parts of cognitive therapy, which cognitive therapy has always really been cognitive behavioral. Back in the early days, it always had people doing activities, and that was always the first phase of treatment. They kind of took out the behavioral part, and so they were just comparing behavior alone to thinking focus alone.

SPENCER: Right.

CHRISTINE: I think it's kind of a false study because, in my view, I can't think of a single therapy session I've done in my life where I wasn't doing both behavioral and cognitive things at the same time.

SPENCER: It's not realistic to the way it's...

CHRISTINE: I don't think it was a realistic study; it was more of a theoretical kind of study.

SPENCER: I guess it's still interesting, though, because it tells us

CHRISTINE: It's very interesting, and I liked it because I think therapists have a bias toward wanting to talk just about thinking, and many therapists really underestimate the value of focusing with people on what they're doing, because what we do during our days has a huge impact on our mood. I am very much a behavioral cognitive therapist. In fact, I've spent 40 years teaching therapists to do therapy, and one of my most recent workshops that I taught in many countries around the world was called Action Packed Cognitive Behavioral Therapy. It was Action Packed because I'm trying to get — I called it More Walk, Less Talk — and I was trying to get therapists, even in the therapy session itself, to not just sit in chairs talking at each other, but to get up and do experiments in the office and really try things out. The reason for that, Spencer, is that we really do believe our experience of doing is easier for testing out ideas than just sitting in a chair thinking about stuff. I think the behavior part of CBT is really very powerful, and it works hand in glove with the cognitive part, because if we want to test a belief, like "I can't do anything right," we could talk about that for 20 minutes or 30 minutes, or we could actually do something for a few minutes and see if you're able to do it right. That's going to have more potency for you than a 20-minute discussion about whether it's true that you really can't do anything right.

SPENCER: So, how do you think about the cognitive and the behavioral working now? Do you think of it as you don't need them both, or do you think of it as they provide flexibility, maybe some clients prefer one or the other, or do you view them as complementary, where using them both is actually more effective?

CHRISTINE: I think using them both is actually more effective. I think you're weakening the effectiveness if you just look at behavior or just look at thinking, because both are powerful in their own right, and both can change together.

SPENCER: Let's talk about anxiety. One thing that is baffling about anxiety is that it's so linked to depression. You describe very well how they're really different in many ways, and yet, for example, in one study we ran, we found the correlation between the standard anxiety scale and the standard depression scale was over 0.7. The kind of correlation you almost never find in social sciences, over 0.7. How could they be so correlated if they're so different at a fundamental level?

CHRISTINE: It's true too, when people come to therapy and they're depressed or anxious, more than half the time they probably are both, so they do really go together.

SPENCER: People have even suggested merging them into one diagnosis.

CHRISTINE: Yeah, I think that would be a mistake personally, or based on my clinical experience. But I think it kind of makes sense, because let's look at the origins. I don't think they necessarily start out together, but I think they often end up being together. So let's take someone who's really anxious. What's the hallmark of anxiety? It's avoidance. You stop doing things because you're trying to avoid triggering the anxiety, and as you stop doing things, you start getting into a more and more restricted world where you're doing less and less, and you get more and more anxious the less you do, and so the anxiety grows. When you stop doing things, what are you doing? You're mimicking one of the key segments of depression. Many people, after they've been anxious for a period of time, start feeling really depressed for two reasons. One is they start getting a negative view of themselves: "What's wrong with me? I'm weak compared to other people. Why can't I do things?" That sounds a lot like depression. It may not be that people develop anxiety and depression at the same time, but one leads to another. Similarly, with depression, if you have this negative view of yourself and you think you can't do things, and everything you do, you mess up, then when you're asked to do things in life, it makes sense you might start to feel anxious, like, "Oh my gosh, my boss has asked me to do this task, but I'm such a stupid person, I'm not going to be able to do it well. And then, what's going to happen? Oh my gosh, the boss is going to get mad at me. I might even lose my job." Then you start to get anxious, so I think depression and anxiety trigger each other much more than they grow up together at the same time.

SPENCER: That makes a lot of sense. I would also imagine that there are some risk factors for both, so you could end up with people having elevated risk for both simultaneously, such as maybe mistreatment during childhood or poverty, or things like that for sure.

CHRISTINE: Yeah, there can certainly be factors, trauma. We've become much more sensitized over the years to how many people in society experience trauma, and both depression and anxiety are common reactions to traumatic life experiences.

SPENCER: Because people with anxiety disorders often have what seems like excessive fear of things that are not that dangerous. It can be natural to focus a lot on getting anxious people to reduce their sense of how dangerous things are. But you have a really interesting perspective on this. If there's another way to look at it, I think you have a cool visual too.

CHRISTINE: I'll describe it for those who are listening to the audio and not looking at the video. A colleague of mine, Dr. Kathleen Mooney, is a really good anxiety specialist, and many years ago she came up with this really neat equation. For those of you who aren't able to see it, you can have a big A for anxiety and an equal sign, anxiety equals, and there's a ratio here. On the top of the line is danger with an arrow going up, and on the bottom is coping and resources with an arrow going down. The idea is that anxiety is danger divided by our coping and resources. The more we think danger is greater than our coping ability and the resources we have available to us, the more anxious we're going to be. We could see something as dangerous, but if we think, "Oh well, there are safety mechanisms, those would be the resources, and I can cope because I enjoy riding on roller coasters. I know I enjoy it." So, the coping and resources are greater than the danger that exists. Then we can feel excited by the danger rather than anxious. What's nice about this equation is it incorporates almost everything we know about anxiety from a theoretical perspective. One thing we know is that when we get anxious, we tend to overestimate dangers. We tend to see danger everywhere and actively seek it. Also, once we get anxious, we tend to underestimate our ability to cope with things. What this equation does is I show this to clients because I'll ask them, "What would be most helpful to you: to reduce the danger or to increase your coping and resources?" Most people, when they're anxious, want to eliminate the danger, but life is life, and we really can't eliminate danger. People often see that if we could increase our confidence in our coping, then we'd feel anxious a whole lot less. I think this equation highlights one of the weaknesses in how CBT has been practiced with some anxiety disorders. A lot of therapists have focused more on reducing dangerous beliefs. I'll give you an example. I used to work a lot with flying phobia. People would be afraid of flying, and they might be afraid the airplane was going to crash. At one point, I had the statistics on how rare airplane crashes were, much safer than a car, etc. But my clients were very good at saying to me, "You know, it really doesn't matter if it's one in a billion, if it's me, it's 100%." So talking about dangerous beliefs doesn't really help many of the anxieties, as well as working with people on coping. First of all, what do you think of that equation, Spencer? Does that fit your own anxiety experiences?

SPENCER: I think so. I tend to be more prone to anxiety than depression, and I think it's really helpful because there are many things in life where you can't control the danger. For example, I can't control whether I get cancer. I can do healthy behaviors to reduce my chance somewhat, but past that, it's just a complete luck of the draw. I can't control the fact that people I love will eventually die. But I could get better at coping and managing my feelings. It seems really powerful to me.

CHRISTINE: Yeah, I think it is. The area of psychotherapy and CBT, where people have missed the boat a lot is in social anxiety, which is very common. People feel anxious speaking or going into social situations, and psychologists pretty much agree that social anxiety is often rooted in a fear of criticism and rejection, afraid people are going to see them as stupid or inept or not cool, and they're just not going to want to be around them. CBT, though, has tended to, for the most part, train therapists to talk to people about how most people aren't going to be critical of you, even if you make a mistake. People are really tolerant. Research studies have shown that if you make mistakes, people actually like you a little bit better because you're not seen as perfect and out of reach. The problem, I think, is that especially in the last decade or so, we all know now that people are in fact critical; they're very critical and harsh on people. We see that on social media to the nth degree. One of the things years ago, I was working with clients who were socially anxious, and they weren't getting better with me focusing on how likely it is that people are going to think critically of you. Most people are going to be understanding when you make mistakes. People weren't getting better, so I started trying to think about that. Why aren't they getting better? It occurred to me that we weren't really testing out the central fear, and part of anxiety treatment is you have to put people in situations where they're exposed to what they're afraid of so they can learn to cope with it, and we weren't really exposing people to criticism and rejection. I developed a therapy approach for social anxiety, which I called assertive defense of the self, in which I would ask the client, "What are all the things you think people will criticize about you? You're stupid, you don't dress well, your haircut's silly," whatever. Then I would, in session, ask them to come up with an assertive defense to that criticism, "What could you say if somebody says your haircut is stupid?" Some people might say, "Well, you know, it may look stupid, but I like my haircut this way." Other people might say, "Yeah, you're probably right, it's probably stupid, but haircuts aren't important to me," whatever the person could say with some legitimacy. We would have a list on one side of the page, like a script of negative criticisms, and the other side was assertive defenses of themselves. Then we would do a sort of defense of the self practice, where I would literally criticize them, starting with mild criticism and moving to vicious criticism, and they would end up having to assertively defend themselves. What really surprised me is how quickly people with social anxiety got better because once they learned they could defend against the criticism. A curious thing happened, we'd start with a very short practice, but then it would get longer and longer as they got better at defending themselves, and eventually, after a few minutes of being persistently criticized, they would say, "My God, there's something wrong with you, you're such a critical person," and it shifted their view that maybe it's not me that's the problem; maybe somebody who goes around being so critical of people, maybe they're the person with the problem, and it was really helpful. That still has taken on in some of the research studies. They now include this approach, but I think it's still not used as often as it could be for social anxiety.

SPENCER: I'm just imagining the neighbor across the wall from your office, thinking, "Oh my god, that's a terrible therapist, they're just constantly criticizing their patient."

CHRISTINE: Yeah, that's why it's important to have a soundproof office. Can't hear you doing some of these things.

SPENCER: It seems to me this could be more robust in a way because if you convince yourself that the world is not as dangerous as you thought, which, as you point out, anxious people often think it's more dangerous than it is, but if you convince yourself it's not as dangerous, then the bad thing does happen, it's like you're freaked out because you have no resilience to the bad thing.

CHRISTINE: That's why I think for most anxiety, working on making your confidence and your coping more robust is important. One of the cognitive features of anxiety is catastrophizing. People say, "Oh my gosh, I made a mistake here, and I'm going to lose my job and end up homeless on the streets." There are all kinds of techniques therapists use to help people see that catastrophizing is too extreme. But I actually think instead of downplaying catastrophizing, it can be more powerful for people who are anxious to say, "Okay, how could you cope when you're homeless on the street? What would you do? How would you handle that?" If people can cope with their most catastrophic thoughts, that's very empowering. If I could handle that, I can probably handle my boss chewing me out for the mistake I made on the report. I think it turns anxiety a bit on its head when it's less about disproving the anxious thought and more about, "Okay, well, let's imagine that happens. How will you cope when that happens?"

SPENCER: How do you think about something like someone's definitely afraid of an airplane crashing? You might think, "Well, if you were in an airplane crash, there really is nothing you can do about it."

CHRISTINE: With that, I then go a little bit deeper with people, and I say, "Okay, what's the worst part about being in an airplane crash?" Most people say, "I'll die." Now, I could take the strategy of saying that a large number of people do survive airplane crashes, and I did that early in my career, but nowadays what I would do is say, "Okay, what would be the worst thing about dying?"

SPENCER: That's such a good question.

CHRISTINE: Now, I don't mean that in a glib way, because it turns out there are really three common answers to that. One is, who will take care of my kids or other family members I love? I'm so concerned about that. A second one is, it'll be painful, and I'll be afraid, and it'll be an awful experience, focusing on the self-experience of dying. The third thing that comes up sometimes is people say, "Well, I haven't led the best life, and I'm going to end up in hell." And so then what we would do is say, okay, let's come up with a coping plan for those things. It turns out that people had a fear of flying, and they were worried about their kids. One of their learning assignments was to go home and talk to whoever was relevant in the family, their partner, and actually make a plan of who will look after the kids if we get killed or if we die for whatever reason, and their anxiety went down significantly once they made that plan. So that's really what the fear of death was about.

SPENCER: That's amazing, because you think the field of justice is so primal that you wouldn't think it would be about something like that. I find that so cool. It is,

CHRISTINE: It is very interesting. Now, your listeners might be very curious about the people who were afraid of going to hell.

SPENCER: I'm curious, because I kind of thought most people talk themselves into tears. "Oh, well, somehow it worked itself out."

CHRISTINE: That's what the client said. The client said, "Oh, well, I don't really believe in hell. We don't have to talk about that." Avoidance is the highlight of anxiety. So, whenever a client says, "We don't have to talk about that," that's where I'm going. You may not believe in it, but that's where your mind goes, that's where your imagination goes, that's the image you have, so you have to come up with a coping plan for that. How will you handle that? And they looked at me like I was daft. "What are you doing?" I was actually silent for quite a long time, and they would say, "Well, how would you cope?" I'd say, "Hey, this isn't my fear, this is your fear. You got to figure it out. How would you cope?" They did actually come up with a plan for how they would cope with being in hell, and it doesn't, in a sense, matter what it was for them. They had a lot of creative energy, and they talked about how they would mentally create and paint and do all these things. They were able to relate it to a book they were reading about people in a gulag in Siberia. There were certain artists who were imprisoned there, and how they coped with freezing conditions and being put in solitary, etc. They actually came up with quite an elaborate plan of how they would cope if they did end up in hell, and it brought them a tremendous amount of peace, and their fear of flying went away.

SPENCER: That surprised me. See, I thought you were gonna say they then were like, "Okay, I'm gonna hedge my bets, I'm gonna become a Christian, or whatever."

CHRISTINE: No, it's more about coping with your catastrophe, Spencer. I should probably write a book called Coping with Catastrophe, because I really think that is the heart of much anxiety treatment. If people feel they can cope with catastrophe, they're not going to be so anxious.

SPENCER: Could you explain what exposure is and where that fits into the treatment?

CHRISTINE: Well, in a way, by asking people to imagine their catastrophe and come up with a coping plan, I am doing some cognitive exposure. But in general, exposure means facing up to whatever your fear is about. That's why with social anxiety I realized people should be exposed to criticism, because if that's what their social anxiety central fear is, then the more you can be exposed to that. Exposure does two things: one is it often surprises you because the things you're afraid are going to happen don't, or when bad things do happen, you often cope better than you imagine. That's the learning that you hope happens with exposure. It's not just throwing someone into a snake pit if they have a fear of snakes, but it's more gradually exposing them to snakes, so they can test out their beliefs and their fears more specifically, and practice coping if coping is relevant to their fear.

SPENCER: Would it work, though? Obviously, it would be unethical, but would it work if someone who is deathly afraid of snakes was in a pit of non-deadly snakes, right, harmless snakes, and they just got put in the pit, and they just had to be there for two days, or whatever? Would they be cured by the end?

CHRISTINE: Possibly. But there'd be a more humane way of doing it, which is with phobias. You might have a pit of snakes, that's okay. With phobia treatment, classically, what we would do is have a pit of snakes and have people standing 20 feet away, and then we would say to them, as you feel comfortable, I want you to gradually approach the pit of snakes, and then eventually encourage them to reach their hand and pick up a snake, and maybe learn about snakes a little bit. I don't know if anyone actually has to go into the pit of snakes, because we try not to do things that most... I don't particularly have a snake phobia, but I wouldn't want to be in a pit of snakes.

SPENCER: In terms of mechanism of action, do you think what's going on there is that somehow the brain has learned this association, like, snake incredibly dangerous? Obviously, some snakes are dangerous. It's understandable, but it's sort of like it's over-learned it in some sense, even for harmless snakes. If you put yourself near snakes and nothing bad happens, essentially the brain learns that prediction is not coming true, so it eventually stops making the prediction.

CHRISTINE: Yeah, I do think that's a big part of what happens. It's interesting for phobias; a lot of phobias are probably innate or inborn. We're probably born with phobias. It turns out almost all children have certain phobias, and often they grow out of them over time. But certain phobias, like I grew up with a terrible fear of heights. A lot of times we don't do anything about our phobias because it doesn't really affect us; we don't encounter it. In my 20s, I started backpacking a lot, and one time I was backpacking up in the Sierra Mountains. I got on a ledge, and the fear of heights just overtook me. I looked down and literally froze; I couldn't move. I was up quite high, at an elevation of about 11,000 feet. The ledge I was on was not a drop-off of 11,000 feet, but it was a significant drop-off. I realized it was dangerous for me to be standing on this ledge and frozen because I needed to get off the ledge and keep moving to get on the flatter part of the trail. When I came home from that camping trip, I literally got a ladder, climbed on the roof of my house, and stayed up there, approached the edge, looked down, and I was up there for an hour and a half until I was no longer feeling afraid.

SPENCER: You went in the pit of snakes.

CHRISTINE: Yeah, and after that, the rest of my life, every time there's a height, I go for it because I want to keep reminding myself that I'm okay. I did overcome my fear of heights. I think the exposure is being in the presence of it and staying in the presence of it long enough that your anxiety has a chance to go down, and then you can learn something different.

SPENCER: Something that people find baffling is that they'll say, "Well, but I'm already doing this thing that I'm afraid of." Like, let's say they have social anxiety. "Well, I go to parties regularly, and I socialize regularly, so why isn't that an exposure? Why am I not cured?" Or to give an example of someone I know, they had a severe fear of flying, and they would kind of impulsively check the weather up until the moment of the flight, but then they would go on the flight, and they're like, "Well, why am I not cured? I fly regularly, so why am I so anxious all the time?"

CHRISTINE: Well, a common thing with anxiety is that we're not dealing with coming up with a coping plan for the catastrophe. Just because you go to a place where catastrophe doesn't happen, it doesn't resolve your anxiety. You say, "I skated through this time, but next time the catastrophe will happen." So this flight went okay, but I'm still doomed to die in a plane crash. Or, yeah, I went to this party. The other thing is, when you think about the person going to lots of parties, are they going to parties and doing the things that potentially expose them to criticism, or are they going to parties and staying on the edges, staying with people that they know, doing the safe thing all night, and then walking home and saying, "Thank God, I kept my mouth shut and didn't say something stupid and look like a fool"? Because a lot of times when we're anxious, most of the time when we're anxious, we go into situations that relate to our anxiety, and we do what are called safety behaviors. If we have social anxiety, we ask people questions and get them talking about themselves so we don't have to reveal anything about ourselves that might get judged, or we stay very quiet, hang on the edge of groups, or we bring a friend with us and just follow that friend around all night. Those are safety behaviors, and safety behaviors really undermine the learning of exposure because we think to ourselves, "Well, that went okay because I was with my friend Frank, and if I hadn't been with Frank, it would have been a disaster." So we don't really learn anything positive when we're exposing ourselves to things and at the same time practicing these safety behaviors because we think the only reason we survived is because of the safety behavior, not because we don't really learn that the situation isn't dangerous or that when danger occurs, we can cope with it.

SPENCER: It's almost like the brain learns the wrong rule. Instead of learning flying is safe, it learns flying is safe as long as you obsessively check the weather, right?

CHRISTINE: Exactly, flying is safe because I chose a flight on a day the weather was okay.

SPENCER: Right, yeah.

CHRISTINE: Yeah.

SPENCER: Before we wrap up, I just wanted to ask you quickly, what is strength-based CBT? How is that different from regular CBT?

CHRISTINE: Kathleen Mooney, Dr. Kathleen Mooney, the colleague I mentioned earlier, and I developed something we called Strengths-Based CBT. It really has three levels to it, and maybe at some point we could have another conversation when we talk about it. The first level means when people come to me for whatever issues they have, I'm going to try to ask about the strengths and what's going well in their lives and build on that. A lot of times people think when they come to therapy all they're going to be doing is talking about their problems, but actually learning about people's strengths, passions, and interests often can make the route of therapy a lot quicker, because people have a lot of good qualities and knowledge in areas of positive interest, and we can often apply those. For example, someone who's a marathon runner and is having trouble in the workplace with big projects has learned a lot about marathon running and not getting hung up on the challenges of any given mile of the 26 and how to get through the more difficult miles. They've learned a lot of things that they may never think of applying at work when they're working on a long project, so it means accessing, identifying, and bringing into people's awareness the strengths they have, and thinking, how can we apply these strengths to problems in their lives. That's one thing. The second thing it means is we developed a model for helping people build, enhance, and broaden their resilience to life difficulties, and we called that a strengths-based CBT approach to building resilience. The third thing it means is we gave a lot of thought to chronic difficulties that people have, people who've been depressed their whole lives or anxious their whole lives. Oftentimes in CBT and other therapies, we try to unravel a problem, but we've come up with this idea that with more chronic difficulties and lifelong difficulties, maybe relationship patterns you've had your whole life, maybe unraveling it isn't the best way to go. Instead of focusing on the problem and trying to figure out all the roots of it and change all those roots, maybe it would be a lot better to help the person envision how they would like to be instead and build a positive alternative, so that's a third strengths-based approach. Strengths-based CBT is something that Dr. Kathleen Mooney and I developed, and we have a lot of different levels to it. Unless we have quite a bit of time today, maybe we should have another conversation about that at some point.

SPENCER: Sounds great. Where's the best place for people to learn about your work?

CHRISTINE: You can learn about my work through my books. For the public, Mind Over Mood is the main book, but I also have a YouTube channel, Christine Padesky, and I have a lot of short videos there that teach some of the common techniques people can use for depression, anxiety, guilt, shame, and some of them are quite fun. We've also made humorous shorts about some of our books, and those are probably the best places to learn about my work. If you're a therapist watching this, I've written quite a few books for therapists, Dialogues for Discovery, which talks about the Socratic dialog process in therapy, and The Clinician's Guide to CBT Using Mind Over Mood, and a variety of other books too.

SPENCER: Fantastic. We'll put links in the show notes. Christine, thanks so much for coming on the Clearer Thinking Podcast.

CHRISTINE: Thank you, Spencer. It's been great talking with you, and I really enjoyed myself.