CBT works by correcting the negative bias of depression, not by teaching positive thinking, and it grew out of analytic ideas. It is limited for patients below the healthy neurotic range, and OCD needs ERP rather than cognitive work.
What it is
Depression does not make people more realistic. It is a huge negative bias, rose-colored glasses of negativity, and that bias is what CBT works on.
“And what I see, especially as a clinician, is depression isn't that you're more realistic. Depression is a huge negative bias. And when you hear patients talk about things, There's a rose-colored glasses of negativity”
49:05What Patients Should Know When Diagnosed With DepressionSep 2026 CBT grew from an analytically trained therapist, and time-limited therapies draw on those earlier insights.
“Where you see it the most baked in is our psychotherapy concepts. So time-limited modalities are really drawing on the earlier insights. You know, CBT itself grows from an analytically trained therapist”
15:52Is Psychoanalysis Still Relevant in Modern Psychiatry?Oct 2025 CBT that aims to identify problems, bring insight and teach skills is, we would argue, a form of ego psychology.
“a lot of what people just consider to be psychotherapy today i would argue is really a form of ego psychology because cbt uh cognitive behavioral therapies for the most part especially ones that aim to identify bring insight into and teach various quote skills it's ego psychology”
44:55Is Psychoanalysis Still Relevant in Modern Psychiatry?Oct 2025
When we use it
If a patient can engage in therapy, therapy should come before medication. Medication goes first when they are too symptomatic to engage in therapy, or when that is their choice.
“If a patient can engage in therapy, I think that they should be engaged in therapy before medications. When do I use medications first? First, if they're too symptomatic, that they're not able to engage in therapy. And second, patient autonomy”
8:05Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025 For self-directed work, The Happiness Trap is a lighter option: ACT is a lighter, easier, breezier form of CBT.
“The Happiness Trap is a little bit lighter. It's acceptance and commitment therapy, which to me is like a lighter, easier, breezier form of CBT”
11:51Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026
How we use it
Follow up on homework the basic CBT way: what was it like when they tried, what got in the way, did they schedule it, do they keep a calendar at all.
“You should follow up with the patient's experience of the mindfulness, what it was like for them when they tried, or what happened that caused them not to try, even if they remembered, or did they not schedule at all, do they keep a calendar at all, all the basic CBT homework stuff”
45:54Mindfulness in Psychiatry: How to Teach It as a Clinical Treatment SkillMay 2026 Use natural behavioral experiments to negotiate a plan. Instead of arguing that this or that is true, say let's find out, for example how risky it really is for this patient to stay up until two and have a couple of beers with friends.
“You negotiate a plan based on not this is true or that is true, but well, let's find out. So you You can you have your natural behavioral experiments that will show you how risky is it for you to stay up until two and have a couple of beers with your friends”
1:09:27How to Stabilize Mood without Medications: Social Rhythm Therapy Anyone Can Use with Dr. Jim PhelpsNov 2026Guest episode
Limits
It works, but it is limited, and it is not suitable for most people anywhere even slightly below the healthy neurotic range of personality functioning.
“it works you know and it may be limited in some places i think it's not suitable for most people who are anywhere even slightly below healthy neurotic range of personality functioning”
45:28Is Psychoanalysis Still Relevant in Modern Psychiatry?Oct 2025 OCD is not a thinking problem; the issue is how the brain responds to the thoughts, which is why ERP differs from CBT. Patients should not enjoy ERP, and calming skills such as breathing techniques do not treat the OCD.
“ERP differs from CBT because OCD is not a thinking problem because the issue isn't what the person's thinking. The issue is how the brain is responding to the thoughts”
40:26What Is OCD? How to Understand It, Recognize It, and Treat ItJul 2025 Also said in 1 more episode
“Patients should not enjoy ERP because it involves slow and deliberate exposure to the distress and tolerating and accepting discomfort. And what we're saying is... coping or calming skills don't treat the OCD like breathing techniques”
38:45What Is OCD? How to Understand It, Recognize It, and Treat ItJul 2025
It also comes up on
- InsomniaWhen there is no more than a mild Axis I condition, insomnia is more likely psychological, and CBT-I and sleep hygiene are the appropriate treatment. In practice CBT-I usually means an app or teaching it piecemeal in sessions; it is not complicated, getting it done is.
- Acceptance and commitment therapyThird-wave CBT, especially ACT, is in large part founded on mindfulness.
- CBT-IPart of CBT-I is reducing the metacognitive anxiety about sleep itself. Having distress about your distress does not help your distress.
- InsomniaA strict waking time, CBT-I and sleep hygiene may work less reliably when the circadian rhythm is disrupted for endogenous reasons.
- OCDInference-based CBT identifies the incorrect thoughts that generate the obsession and the deeper assumptions and biases behind them.
- PsychoanalysisAs the neurotic conditions went to biological treatments and CBT, the purview of psychoanalytic treatment has become more and more the personality disorders.
- Sleep hygieneCBT-I and sleep hygiene are the appropriate intervention when no more than a mild Axis I condition can be identified and the insomnia is likely psychological.
- Sleep hygieneStrict wake times, CBT-I and sleep hygiene may have variable efficacy when the circadian rhythm is disrupted for reasonably endogenous reasons.
From these episodes
- How to Stabilize Mood without Medications: Social Rhythm Therapy Anyone Can Use with Dr. Jim PhelpsNov 2026 · 1 point
- What Patients Should Know When Diagnosed With DepressionSep 2026 · 1 point
- Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 · 1 point
- Mindfulness in Psychiatry: How to Teach It as a Clinical Treatment SkillMay 2026 · 1 point
- Is Psychoanalysis Still Relevant in Modern Psychiatry?Oct 2025 · 3 points
- What Is OCD? How to Understand It, Recognize It, and Treat ItJul 2025 · 2 points
- Psychiatrist's Guide to Anxiety Medications: First Line to Last ResortJun 2025 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.