Hill or Everest? Photo by Ascent Media/Getty


Psychology’s power tools

Cognitive behavioural therapy has created interventions that truly help people to change. Here are the best of them

by David A Sbarra + BIO

Hill or Everest? Photo by Ascent Media/Getty

A few years ago, while attending a conference in Berlin, I went out one evening to catch up with a friend I hadn’t seen in years. James lives in the United States and works in the field of psychology, but Berlin was the first time we’d been together in a good while. It was a beautiful evening and the city felt so alive, but James looked nervous. I knew he had something to tell me.

He started: ‘Brian is Briana.’


‘My son is my daughter. He is really a she.’

I didn’t need any more explanation to know what James was saying. His 18-year-old, formerly Brian, identified as a woman, and he was breaking the news to me.


‘I know. I know. He’s going to… I mean, she’s having sex-reassignment surgery in Singapore in December, and we’ve been doing hormone treatments for months. It’s been a wild ride.’

When James used the word ‘we’ to describe the hormone treatments, I knew everything would be OK. The ‘we’ in his sentence was a clue that that their family was not split apart by this news. Learning that your son is really your daughter is, for most people, life-changing news, and the few clients I had worked with in therapy around their gender identity were torn apart by how their families had responded.

James had learned so much in the past year about how to connect with his daughter as a trans-woman. Briana’s brother was turning his back on her, and James and his wife felt alone, as if they were walking on quicksand. Throughout the conversation, though, he kept saying: ‘It is what it is.’ James must have said the phrase 10 times, and it dawned on me that he was getting at something profound. With this aphorism, he could avoid getting sucked into potentially painful emotions and instead be present and available to help his daughter.

When I returned from Berlin, I was primed to hear the phrase everywhere I went. I am convinced I hear it at least once a day, and not only from my clients. I hear it from my wife, my friends, my colleagues, my students and, a few days ago, I heard it from the woman working the register at the gas station. I hear myself and others saying these words, but I hardly ever stop to reflect on their meaning. When it finally dawned on me to ask why everyone keeps using this phrase, the answer appeared quickly and with force: the phrase is a way to psychologically disarm powerful negative emotions. It’s an efficient means of distancing ourselves from difficult experiences, to create mental space and, potentially, to ignore – in a good way – percolating negative emotions. In short, this phrase represents what psychologists call an emotion-regulatory strategy.

Research in clinical psychology suggests that a key aspect of maintaining our emotional health is not deepening our connection to painful thoughts – that is, not getting ‘sucked into’ thoughts about inferiority, impossibility, or seeing the potential for bad outcomes around every corner. ‘It is what it is’ reflects the decision not to go down this road and, when we use it, we’re practising one of the best therapies around. Although there are many routes to emotional equanimity, it is the thoughts in our heads, and the words we choose to express them, that are the gatekeepers of our psychological wellbeing.

This notion is at the heart of cognitive behavioural therapy, or CBT, a proven collection of techniques that help us realign our thoughts so our emotions stay in balance and we successfully navigate life.

Imagine you’re strolling across a lovely college campus on your way to grab lunch with a friend. You’re stopped by two students.

‘Could you spare a minute? We’re running a research study on how people perceive the natural environment. Would you like to participate?’

‘Sure, why not?’

This is when things get a little weird. The researchers have you don a backpack that weighs about 20 per cent as much as you do. Then they ask you to estimate the slant of the hill in front of you from completely flat to a vertical cliff. Can you zip up this hill with your backpack on, or did this small hill just become Mount Everest in your mind? Although I’ve glamorised it a bit, this is a real research study. Developed by the psychologist Dennis Proffitt and his colleagues at the University of Virginia, the ‘hill slant’ study is well-known, and has garnered an impressive set of findings about visual perception. It makes sense that people perceive the hill to be steeper when they are wearing a heavy backpack, relative to when they’re not wearing one (That hill with this backpack? No way!), and that they perceive the hill to be steeper if they’re tired.

A more surprising finding emerged in 2008, when psychologist Simone Schnall, director of the Mind, Body, and Behaviour Laboratory at the University of Cambridge, found that people perceive hills to be less steep when they’re with other people or when they imagine a supportive significant other alongside them. Schnall reasoned that the availability of social resources might keep people from ‘being depleted’ when they donned the heavy backpack. It is hard to overstate the significance of these findings: social support alters how we perceive the demands of the physical world.

In fact, the hill-slant study illustrates one of the most important topics in contemporary psychological science: our evaluations of situations, events and people shape how we perceive, or appraise, the world around us. These psychological evaluations are often referred to as cognitive appraisals. When we’re with others we appraise the slant of the hill differently; we evaluate that mound of dirt as less foreboding.

We’re constantly taking our own psychological temperature and evaluating whether we need to conserve our resources or spring into action

How do you feel about work or school tomorrow? Smooth sailing or another headache? What about that weird look a colleague gave you this morning? Your kid is talking back and being a total pain. Why does it bother you so much after dinner compared with after breakfast?

These questions capture the essence of the calculus we engage in every second of the day. We’re constantly taking our own psychological temperature and evaluating whether we need to rest or spring into action. Our emotional lives hinge in large part on this appraisal process. Whether we feel happy, engaged and full of energy is derived from the belief that we are in harmony with the world around us.

We maintain this sense of harmony by viewing ourselves, others and the events around us in a relatively benign light: things are fine, we’re safe. When we perceive the slings and arrows of life as non-events – when we can say: ‘It is what it is’ – we can face difficult circumstances and effectively disarm potential emotional landmines.

When anxiety makes our thinking disordered, on the other hand, quite the opposite happens. Hills seem insurmountable, and the world becomes a scary and impossible place. As a brief example of appraisals gone awry, stop for a moment and think about what it would feel like to believe that you are absolutely worthless. You contribute nothing to this planet. Zilch! What if you were as certain of these thoughts as you were of the fact that you need light in order to read this article? Now you have an idea about what it’s like to be depressed.

Most of the time, however, these negative appraisals are distortions; they are misappraisals of the world around us based on automatic habits of thought that have rooted themselves deep inside our minds. CBT was designed to help people break these habits, to learn new ways to evaluate the reality of their appraisals and, in general, to think more flexibly about their lives.

Judith Guest’s novel Ordinary People (1976) is, arguably, one of the richest literary explorations of grief. Guest shows us how reactions to loss can insidiously gnaw at the foundation of our psychological health, and explores how the same events can impact people in different ways. In one of the book’s best exchanges, Conrad Jarrett talks with his psychiatrist, Tyrone Berger, about the massive emotional pain he has kept under wraps since the tragic death by drowning of his oldest brother and his own unsuccessful attempt at suicide. Conrad’s mother, Beth, meanwhile, shuts down completely and is totally disconnected from Conrad’s pain. His father, Cal, tries with all his might to protect his son from the throes of depression, and it’s clear that these efforts are in large part to protect himself from the pain of losing his elder son. The Jarretts were just ordinary people, just trying to make sense of their lives. When tragedy struck, they became ordinary people dealing with an extraordinary set of emotions that set them adrift.

Understanding and improving our mental health often hinges on demystifying emotional experience, and any therapist worth a dime should begin his or her treatments with a review of some basic lessons learned from the research on emotions. For starters, emotions are feelings – the conscious experience of pleasure or pain. We experience our emotions along a continuum from good to bad, at intensities from relatively neutral to downright explosive. Thus, we can sit happily on our couches or jump and scream for joy at our favourite sporting events.

Importantly, emotions communicate information, prepare us for action, and have incredible survival value. Without a signalling system to warn us about potential threats in the natural world – that is, without emotions to provide information – humans and other animals would be toast. Quite often, our emotions become disordered when they are out of proportion to the demands of a given situation. Just think of someone who has a panic attack at the idea of being at Costco on a Saturday; it can be overwhelming for anyone, but it is not an emergency that should elicit an immediate and overwhelming fear response. Given the importance of emotions to our survival and the myriad ways in which they can become disordered, the goal of most psychotherapies is to recalibrate our emotional response system.

Over the course of my career, I have worked with many clients who just wanted to figure out how to eliminate every single one of their emotional reactions. Doc, if you had a pill that would stop me from feeling, I’d take it in a heartbeat. There’s a simple and poignant response for such statements: if we eliminated the experience of physical pain, we’d burn our hands off on a hot stove by dinnertime. The same goes for our emotions. Our goal should never be to eliminate our emotions, but rather to regulate or coexist with them better.

Change how you view your circumstance, and you can change how you feel

Perhaps no psychologist has contributed more to the study of emotion-regulation than James Gross at Stanford University. In one of his earliest studies, Gross showed research participants three silent videos: one of an abstract shape like you might see on a computer screensaver, one of a burn victim receiving treatment, and one of a close-up amputation of an arm. At any point, participants were allowed to ask that a film be stopped. Gross then evaluated participants’ felt experiences and physiological and behavioural responses under one of three conditions: watching as usual; actively trying to suppress emerging emotions; or using techniques of cognitive reappraisal, in which they were asked to think about what they were seeing objectively and technically, and then reappraise the images in those terms.

The big finding from this study was that reappraisal lead to ‘decreases in both behavioural and subjective signs of emotion’, with no hint of elevations in physiological stress. A particularly interesting aspect of the findings was that seven of the participants in the ‘watch’ and ‘suppress’ groups asked for the upsetting films to be stopped, compared with none in the ‘reappraise’ group, suggesting that asking people to view upsetting material from a more detached perspective does indeed alter the nature of the emotional experience.

This fact is a foundational element of CBT: change how you view your circumstance, and you can change how you feel. Gross’s research provided empirical backbone for the link between our thoughts and our emotions. I have long felt this research captures the essence of what most cognitive behavioural therapists do on a daily basis: we help people come to view the hurdles of life less like perilous threats that will slowly eat them alive and more like challenges to be managed and overcome. In many ways, this too was the perspective that Berger offered to Conrad in Ordinary People. Although few experts would call him a cognitive behavioural therapist, he provided Conrad with the tools to think more flexibly about his life and helped him stop viewing his emotional world as an overwhelming threat.

‘A cop without a badge and a gun is about as useless as tits on a bull,’ Mark told me. ‘Total waste… I am an empty fuck, and I just fill that fucking hole with booze.’

This exchange, from our first meeting together, signalled Mark as one of the saddest men I’ve ever worked with in therapy. He was depressed through-and-through, and this was not his first bout with major depressive disorder. As he described it to me, becoming a cop saved his life, and receiving an indefinite disciplinary suspension would likely end his life. Mark was drinking more than ever, his wife had left him two weeks before, taking the dog and the kids, and he was spinning recklessly out of control.

A month earlier, Mark had been arresting a small-time drug dealer who put up a fight. Something inside him snapped, and instead of following procedure, Mark got scared and overreacted, using his baton on the suspect’s temple. Now the 20-year-old was, as Mark put it, ‘a complete vegetable’.

One of the biggest challenges for a clinical psychologist is helping people when their situations are deeply messed-up. What would you do if you almost killed someone? How would you react? I think it would be reasonable to become depressed, especially if you have a history of other depressive episodes. But what about punishing yourself and everyone in your life? Mark was making a terrible situation even worse, and he knew he was going under; his last hope was to figure out some way to stop punishing himself and make peace with what happened.

CBT emerged in the early 1960s as an answer to radical behaviourism and strict psychoanalysis, both of which shared the stage as the dominant psychotherapies of their day. Rather than viewing psychological problems as emerging from our family of origin (as done in psychoanalysis and psychodynamic forms of therapy) or as a function of our immediate potential for reward (as done in the behavioural therapies), the architects of CBT argued that we should look at people’s thoughts (behaviours that occur in the mind) and the events in their lives to understand the underpinnings of emotional disturbance. The idea is that when people change their thoughts (or, what psychologists call cognitions) they can also change how they feel and behave.

A core tenet of CBT is that the thoughts underlying most forms of emotional distress are dysfunctional and distorted. When his depression came crashing down on him, every situation Mark encountered was viewed through a lens of distorted badness. One morning Mark saw his lieutenant’s office phone number come up on his cellphone. Then he locked himself in his room all day to escape the possibility – or, in his view, the certainty – that he would be fired. But when Mark spoke to his lieutenant about the call, he learned that the lieutenant simply wanted to clarify a detail of Mark’s arrest report. Mark was sure, he later told me, that the lieutenant’s need to clarify this detail represented the true beginning of the end of his career.

Another core feature of CBT is the finding that these distorted thoughts are automatic and very deep-seated. When Mark described himself as a ‘total waste’ he was describing one of his core beliefs, which are the foundational or bedrock thoughts we hold about ourselves. In practice, CBT therapists work with their clients to help them notice and modify their automatic thoughts on a moment-to-moment basis while at the same time helping them to revise their core beliefs of unlovability, worthlessness and inability. When done well, the process of evaluating evidence for or against a client’s particular thoughts is highly collaborative and very action-oriented. Many clients challenge their strong beliefs that they can’t succeed by going out into the world and behaving in ways that force them to alter their beliefs.

If you can live in the grey zone of multiple outcomes, you no longer need to challenge every negative thought

One CBT idea that I particularly like is that of cognitive flexibility. To see how this might play out, consider the ways I think about my own research. When I go to write a new paper, I am scared that the work is going to stink. Over and over again, I catch myself saying: ‘This sucks,’ or, worse: ‘You suck, stop doing this.’ Here, I have a few choices. I can let these thoughts overwhelm me and cripple me from writing the next sentence. Or, I can tell myself: ‘I don’t suck and the work will be great.’ That is, I can delude myself into being too positive. I can also challenge my negative thoughts and revise them in such a way that makes me feel better. This would not be the worst thing in the world, especially if I was depressed or really anxious to begin with, but I choose instead to go a fourth route: ‘The work could suck… it might suck… but I just don’t know yet. And when I learn what happens, I’ll deal with that reality as it comes up.’

Cognitive flexibility represents the ability to entertain multiple thoughts about what is and what can be. If you can learn to live in the grey zone of multiple possible outcomes then you no longer need to vehemently challenge every negative thought that gets you down.

Like many people, Mark had difficulty distinguishing between his thoughts and his feelings, and this can sometimes be a big stumbling block in CBT. On 21 April 2008, Mark presented me with the following record of a situation he wished to discuss in treatment:

Situation: My wife called. She told me she’s thinking of moving the kids to California.
Thoughts: What the fuck? This will kill me for sure. She’s getting back at me for being such an asshole.
Feelings: She can’t do this! No way!
Behaviours: Called her, screaming and cursing. She told me I have a choice to make, but she won’t come home until I stop drinking. I cried and begged her to come home. Then I yelled more.

In this particular exchange, Mark was incredibly angry, largely because he was catastrophising about the worst possible outcomes, and demonising his wife about moving. Mark also felt incredibly sad. He cried, he told me, because he was hopeless. Once he exposed this sadness, Mark gave me further insight into his core beliefs: ‘I cried because I don’t deserve them. I don’t deserve anything good.’

Despite his pain, Mark was actually a quick study, and he took to the CBT readily: he considered himself a ‘wounded warrior’, and viewed the treatment as central to becoming whole again. We hammered on his automatic thoughts, and he quickly became skilled at evaluating the evidence for/against his thoughts, then identifying a ‘rational response’, which is the revised (and less distressing) thought. In his thought record on 12 May 2008, Mark wrote:

Situation: On light duty. Two dickheads in office walk by and one ‘mimes’ hitting motion, then winks at me.
Thoughts: Everyone hates me. I will never live this down. Everyone is watching me. Everyone knows I am a shitty cop.
Feelings: Worry. Frustrated. Nauseous.
Evidence for painful thoughts: It’s true, everyone knows.
Evidence against painful thoughts: Everyone is too busy to worry about me. Most people thought I was a good cop. People forget.
Rational response (revised thoughts): Fuck him. He can say what he wants, I am getting my life back together. It’s gonna be OK.
Feelings (again): Slightly angry. Nothing really. Who cares anyway!

Mark was improving by the day and once he got rolling, he learned that he could stop pounding on himself by simply slowing down to check and revise his automatic thoughts. But these proved much more amendable to treatment than his core beliefs. Mark’s father, he told me, was: ‘A first-class SOB.’ His dad was the kind of person who never had a good word for anyone, and often referred to Mark as a ‘complete failure’ because it was clear even when Mark was a boy of 10 or 12 that he was prone to being down on himself. Mark’s dad preyed on this weakness and left a big scar. This history is unique to Mark, of course, but in many ways plays itself out in all of our lives. The ideas we carry about ourselves today have roots that go a long, long way back.

‘I don’t know if I’ll ever shake the feeling of being no good,’ Mark explained.

I replied, testing out two different metaphors: is it time, perhaps, to rewrite that script or change that song playing in your head?

Over 22 sessions, he made the leap from belligerent to someone who could handle the range of his emotions well

‘Easy for you to say, doc. I don’t have a new song, and it’s not simply about changing songs. I gotta go from vinyl to cassette, if you know what I mean,’ Mark said, and that became his winning idea. Mark’s drinking was largely secondary to his depression, an escape and a means of avoidance. By the time we started ‘replacing the vinyl’, he was hardly drinking at all, and I attributed this largely to the fact that he had learned to handle his emotions differently. Mark had recalibrated his emotional response system, and the final step was revising his most deeply held beliefs of self-worth and value. This wasn’t merely about going back into the deep past. Mark had to figure out a way to live with what he had done. How can you reconcile being a good person with using your baton on someone’s head? We figured it out together and Mark relied heavily on his ‘wounded warrior’ idea.

I asked Mark if he could forgive that old self for what happened.

‘It takes so much energy to be depressed all the time. I choose to forgive myself,’ he said.

Within three weeks of stopping his drinking, Mark’s wife was talking to him again regularly, and within five weeks, his family had moved back into their home. Over the course of 22 sessions, Mark had made the leap from a belligerent, out-of-control man to someone who could handle the full range of his emotions quite well. He had upgraded his sound system, and although he was quick to note that having a cassette system still put him ‘back in the 1980s’, it was way better than what he’d been working with before.

Eventually, Mark got his badge and gun back, too, and with it came a revised sense of his identity as a husband, father and cop. We ended our treatment, and I haven’t heard from him since.

From Mark, who almost killed a man, to the Jarretts, whose brother and child died, to my friend, making sense of his daughter’s gender identity, life throws brickbats, and none of us pass unscathed. What should we do when things get hard? Where do we turn for answers? Although it’s an imperfect enterprise, psychological science has contributed much to our understanding of emotion regulation through the techniques of CBT. From basic science to clinical practice, we now see the logic behind ‘It is what it is’: these words are not escapist, but instead part of the sophisticated way in which the mind operates. In many ways, these words can reflect the essence of psychological health.