How modern therapy is like learning to play the piano

When learning how to play piano, or engaging in modern therapy, the best ways to make improvements are to listen closely to your lessons, practice in-between them, and learn how to read the notes while studying the theories behind them.

Not all therapy is created equal. The archetype of therapy – laying on the couch, endlessly talking about dreams and your mother, is but one form – most closely resembling psychoanalytic psychotherapy. However, more recent approaches have turned this model on it’s head.

In particular, Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) are data-driven, time-limited, and evidence based. They focus on what you are doing, thinking, and feeling, in the moment and on a daily basis, not what happened in your childhood. They require active engagement and practice between sessions, and how good you feel is directly and proportionately related to how much work you put in.

Based on the idea that our thoughts create our reality, CBT teaches us to critically examine how we’re are thinking, and to rewrite the script. Imagine I’ve just bombed in a recent performance review at work. That event objectively happened, and it’s totally rational to feel negatively towards that, but it’s actually what I tell myself about that event that shapes my mood. If I tell myself that “I’m such a loser”, “everyone hates me”, or “I’m going to lose my job and not be able to provide for my family”, those feelings are the things that create the depression that I feel, not the event itself.

This graphic explains the cycle that your thoughts, feelings, and reactions create and CBT wants to help interrupt – when I feel like this, I am debilitated (I’m a loser, why bother trying); disconnected (because everyone hates me); and panicked (because I’m about to lose my job).

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Under stress like this our ability to deal with situations is diminished, and we tend to spiral downwards. Turns out that it’s not that easy to fix our emotions, so CBT is aimed at an easier target - our thinking. This process would teach us that these cognitions (i.e., thoughts) are distorted in very common ways, in this case; “I’m such a loser” is an example of labelling and black & white thinking; the thought that “everyone hates me” is both mind-reading and black & white thinking; and “I’m going to lose my job...” is fortune telling.

In addition to identifying the distortions in our thoughts, the final task is to re-write the thoughts without those distortions. This is SUCH a deceivingly simple, yet powerful, exercise. This doesn’t mean pretending everything is fine – we adjust the interpretation of the event so it’s more realistic, but we don’t ignore the situation itself. In this case; “I’m such a loser” can become “I’m disappointed, but it’s not the end of the world, I’ve had many positive performance reviews in the past”, “everyone hates me” can become “I know that my manager and I haven’t seen eye to eye, but I get on great with most of my colleagues”, and “I’m going to lose my job” can become “I really thought I did well this quarter, I’ll seek clarity and more frequent feedback to demonstrate that I want to do well here.”

This process needs to be repeated again and again to lead to lasting improvements in mood. Just like piano lessons, the more you do in between sessions, the faster you’ll improve and the better you’ll get. Practicing thought challenging is a skill that ultimately will shift how your brain is thinking about situations. In essence, challenging your thinking is the same as practicing scales. The more you do it, the better you’ll get, and it’s tough to make real improvements without putting in the work.

When you learn piano, you also have to learn music theory alongside the basic skill set. Similarly, there is psychoeducation in CBT, alongside the actual skills themselves. Psychoeducation explains how our minds deal with information, and in some cases, it can be immensely powerful and lead to change in and of itself. One powerful example – someone who suffers with panic attacks can perceive that they’re having a heart attack, which can in turn make their heart rate increase and be misinterpreted as evidence of a cardiac event. Practicing psychoeducation can be one of the best tools to fight the delusions your brain is creating to cause a situation like that.

So, that’s practice and learning. The final piece of CBT is tracking, which involves tracking metrics that improve our mood, and the improvements we can make simply by following and being aware of them. But we’ll save that for our next piece.