Mindful Cognitive Behavioral Therapy: A Simple Path to Healing, Hope, and Peace

Dedication

For Marcia Lynn Leithauser

Epigraph

If you want to discover the truth about God,

don’t strive for things that lie beyond you.

Draw your thoughts inward to the center, and

seek to become one and simple in your soul.

Let go of all that distracts you, all you desire,

and come home to yourself, and when you do,

you’ll become the truth you first sought.

—Meister Eckhart (1260–1328)¹

Contents

Cover

Title Page

Dedication

Epigraph

1. Hear the Call

2. Connect with Yourself

3. Find Leverage

4. Say Yes

5. Practice Mindful Awareness

6. Connect with Your World

7. Offer Thanks

8. Find Rest

9. Love Your Body

10. Love Others

11. Work in Alignment

12. Live with Purpose

13. Come Home

Acknowledgments

Notes

About the Author

Copyright

About the Publisher

1

Hear the Call

If there’s a common longing among the hundreds of people I’ve treated in therapy as a clinical psychologist, it’s for an end to their pain. But my own journey through depression taught me that relieving symptoms is not enough. More than finding a cure for suffering, our deepest longing is for peace. That distinction is what this book is about.

Most people who come to see me are dealing with some form of overwhelming anxiety: panic, constant worry, obsessive-compulsive disorder (OCD), social fears. Many are healing from trauma, sometimes recent, sometimes from their childhood. Some are fighting through daily depression or chronic illness or are wondering if their marriage can be saved. Others are desperate for a good night’s sleep. In one way or another, they’re yearning for relief from the stress and strain of life.

People seek out my services because they believe I can help them find relief and peace through cognitive behavioral therapy (CBT), the most scientifically tested therapeutic method practiced today. CBT is a straightforward approach that integrates two components:

Cognitive therapy for practicing healthy patterns of thought

Behavioral therapy for helping us choose actions that lead us toward our goals

Treatment tends to be brief, typically eight to fifteen sessions, and addresses current problems rather than focusing on a person’s childhood and relationship with their parents. I was drawn to this approach early in my graduate training because I wanted to relieve suffering, and CBT seemed like the most efficient path to healing.

But after a number of years helping others as a CBT therapist, I discovered that I needed help as well. I had slowly dropped into a deep depression, and despite all my training, I was struggling to find my way out. Eventually, as I groped my way forward, I discovered something surprising and significant. I learned that CBT could be more than a means for eliminating symptoms, which was how I had been using it. When combined with mindfulness practices, it could also address questions of meaning, purpose, and even spiritual peace.

That is quite a claim, I know. But be assured this is not one of those books by some self-designated guru who claims to have finally figured out the secret of the universe and wants people to follow behind. I am by no means the first person to walk this road.

My goal, instead, is to simplify the process that I found to be so incredibly helpful so that as many people as possible can experience it for themselves. This life-changing approach can be summarized in three words, making it easy to remember on the fly when you need it: Think Act Be.

Descent

I was motivated to become a psychologist in part by what I knew of my grandfather’s emotional struggles and his suicide eight years before I was born. Frank Rollin Gillihan was haunted by horrific memories of naval combat in the South Pacific during World War II; I wondered what his life would have been like if he had gotten effective psychological treatment. Maybe he would have lived to meet his grandchildren. His only child—my father—would have been spared the pain of losing his dad to suicide. That pain was a felt presence throughout my childhood, often apparent in my dad’s irritability and temper. At other times it was raw grief, such as when I was eight and walked in on my parents in our laundry room. My mom had her arm around my dad as he sobbed, a stack of old family photos in his hand.

I did my training at the University of Pennsylvania, the birthplace of many CBT treatment programs. The faculty were deeply engaged in developing short-term, effective treatments and testing them in rigorous clinical trials, and my faith in the power of CBT deepened as I witnessed its effects firsthand. I saw the power of thoughts to affect our emotions. I learned how simple changes in our actions can boost mood and bring greater fulfillment.

I continued at Penn after I graduated and took a faculty position in an anxiety research center, where I oversaw a treatment study of CBT for post-traumatic stress disorder (PTSD). Participants came from the surrounding community and the local Veterans Affairs hospital, men and women haunted by traumatic memories of violence and pain. After the twelve-session protocol, many were transformed, freed from nightmares and flashbacks and ready to live their lives again. I often thought of my grandfather.

When I left Penn and opened a solo private practice, I continued to offer CBT. It was exhilarating to see the dramatic effects that a few sessions—sometimes just five or six—could have on a person’s life. The grip of anxiety would loosen, depression would lift, sleep would improve. My schedule quickly filled with people who wanted an action-focused way to feel better.

But as I continued to practice, I was often struck by changes my patients were experiencing that seemed to transcend simple symptom reduction. People described feeling lighter, freer, more connected to a version of themselves that they liked. Their family members told me with tears in their eyes that they finally had their loved ones back.

I wasn’t sure what to make of these changes, since they didn’t fit neatly with my CBT view of therapy that focused on measurable outcomes. At times, I even envied the deep work they were doing and the new levels of peace and happiness that they’d found.

I was especially struck by the deep changes I saw with Paul, a young dad who was out of work.¹ His childhood had been tough, and Paul had hated himself for as long as he could remember. His father had left the family when Paul was five, and Paul always felt that he was his mom’s least favorite child. He had battled alcohol addiction early in his life and had struggled in his closest relationships.

Paul’s biggest challenge was feeling like a failure to his young daughter and son. He’d been deeply wounded by his dad’s departure and had always vowed he’d be a father his children could be proud of. With his job loss and the depression that followed, he thought they must see him as a pathetic disappointment. He choked on the words every time he tried to talk about disappointing his kids but would wave off the tissue I offered. His shame would quickly turn to anger at himself for being a crybaby as he roughly brushed away the tears with the heel of his hand. Paul denied being an imminent threat to himself but said he often imagined ending his life.

We had worked together for many months—longer than a textbook course of CBT—and he had made slow but steady progress. He had gradually and consistently started doing more activities that brought him enjoyment and a sense of accomplishment, which dramatically improved his mood. Paul also learned to recognize the lie in his horrible thoughts about himself, such as I’m worthless and everyone would be better off without me. And yet there remained a deeper undercurrent of self-hatred that seemed to resist the efforts he was making in therapy.

But one day Paul shocked me. The tears came, and he let them. Only this time, he wasn’t crying about being a lousy father. He was crying for his five-year-old self who had lost his dad and had never known love until he had kids of his own. Through his tears, he told me he was starting to feel love for himself. I was wiping away tears of my own. I had hoped for this day as long as I’d known Paul, who in truth was easy to love.

But when Paul’s relationship with himself finally shifted, it caught me by surprise. Our self-directed thoughts and feelings are stubbornly hard to change. I was used to seeing patients make incremental changes in these areas but often somewhat begrudgingly and with a lingering sense of self-loathing. Paul’s transformation was of a different kind. It was as if a barrier had been torn down between his heart and himself, releasing a wave of self-love that he had held back for decades. He could finally see that his wounds and suffering called for compassion, not disgust.

Paul didn’t just stop hating himself or simply stop being depressed. Paul was transformed. He became the father and husband he’d always wanted to be. How did our therapy help to bring that about? I wasn’t sure I knew.

Discovery

It was only later that evening after our breakthrough session that the irony hit me. Just that week, I’d been torn up inside about being a disappointment to my own wife and kids. I’d been struggling with health issues for a couple of years. It started with persistent problems with my voice—laryngitis, a burning sensation in my throat, difficulty making myself heard. I struggled to meet the vocal demands of therapy and the teaching I was doing at a local college. Over time, I was plagued by a long and growing list of nonspecific symptoms: poor sleep, physical exhaustion, mental confusion, body pain, heat intolerance, and digestive problems, among many others. Frequent visits to many specialists and alternative therapists brought few answers and little relief and a growing stack of medical bills.

My world shrank as my struggles continued. I had to stop most forms of exercise because of the fatigue, and I no longer got together with friends, since it was so hard to talk. Even at home I rarely spoke, having exhausted my limited vocal reserve by the time I was done with work. I was forced to reduce my clinical hours because of my voice limitations and low energy, which led to serious financial strain for my family.

In hindsight, I realize that depression was nearly inevitable, given my circumstances: chronic stress, social isolation, lack of exercise, poor sleep. I’d witnessed this pattern countless times in my clinical work, and now I was experiencing it myself. It took me awhile to recognize that I had sunk into a deep depression, wanting to die and thinking my family would be better off without me. My wife, Marcia, was incredibly supportive, but she couldn’t take away the lows or the self-loathing. She would reassure me when I bottomed out: Seth, you’re doing the best you can. It’s not your fault that you’re sick. Meanwhile, I was silently shouting in my head, over and over, "I fucking hate myself!"

My depression dragged on for months. In its depths I felt lost, bewildered, and alone. I didn’t know what had brought me to this place and felt too exhausted and confused to escape from it. I was crying all the time. I cried on my walk to work, having no idea how I would make it through my day. I cried on the way home, struggling up tiny hills and feeling as if I were wearing lead boots. I cried on the couch in my office, where I napped between patients, careful about my head placement so I wouldn’t start my next session with the pillow pattern imprinted on my face.

After dinner, I would often lie on the couch in our living room, desperate, dispirited, and praying for help. I felt defeated as I climbed into bed every night and dreaded the day to come. I kept feeling that I’d reached the end of myself. And yet something kept me going, drawing me back to life when all I wanted to do was give up and fade away.

I was where so many people I had treated had been when they first came to my office. They were beaten down by depression or strung out by anxiety, and a big part of them was ready to throw in the towel. But a bigger part of them was determined to go on. At the core of their being was a fundamental wholeness that had compelled them to seek help in spite of their hopelessness.

They might have felt nothing but darkness inside, but I could see clearly a light that hadn’t been dimmed, as if through a crack in their obvious struggles and pain. No matter how they were feeling, seeing that light always gave me hope and even made me smile inside. I knew their suffering did not have to be the end of the story. And I knew that their path to healing had started well before they walked through my door, because the power to heal doesn’t start with finding the right treatment. It comes from a place deep inside us.

One night, I finally recognized in myself what I had seen in so many people I had treated. Everything seemed especially hopeless as I lay on the couch after dinner, feeling as if I were dying. I kept saying in my head, I’ve come to the end of myself. I’ve come to the end of myself. And then, in that moment, I realized: the end of myself wasn’t the end—it was the beginning of something else, something beyond my physical and mental limitations, beyond illness and depression. With my body feeling broken and my mind in a haze, my spirit was laid bare.

This experience brought me back to the most meaningful dream I had ever had. I had woken up crying. My wife, a light sleeper since our kids were born, stirred beside me. What’s wrong? she asked.

I dreamed I died, I replied.

I’m sorry, she said sleepily, reaching out to pat me.

No, I said, the scene still fresh in my mind. It was beautiful.

In the dream, the pilot had badly botched our plane’s landing. We were off kilter as we approached the runway, the left wing higher than the right. One wheel touched down before the others, throwing the plane off-balance and causing us to skid across the runway. The plane started twisting and shearing and then tearing apart from the front to the back, where I was seated in the last row. Seats and luggage and the passengers in front of me were flying through the air. I was terrified, expecting the plane to explode at any second, extinguishing my life.

But before it did, I decided to accept my imminent death. I wanted to open to it if it was unavoidable, rather than dying afraid. Clouds of dust and debris washed over me as I leaned back and closed my eyes. I brought to mind the faces of my children so I could die thinking about what I love. Their images filled my mind and heart as I waited for death like waiting for sleep. I was euphoric, knowing implicitly that I was going to join everything I love.

When death came, I felt no pain and no break in consciousness. The color behind my eyelids seamlessly became the purplish space in the night sky, which I was passing through into the stars. I sensed that the spirits of everyone I loved, dead and alive, were there, and I was joining them.

And then I woke up, beside my wife, our kids asleep down the hall. I was crying not because dying was sad but because it was glorious. Experiencing my greatest fear led to the realization of an eternal connection to all that I cared about. There was no place left for fear. More than anything, it was an experience of deep peace.

Remembering this dream, I realized that I had come to the end of myself, but this end meant the beginning of something new and transcendent, as in the dream. I felt a powerful sense of peace that night on the couch and a healing presence within myself. I’d woken up to the fundamental truth of who I am: a spiritual being connected to the divine. And I knew that divine spirit was what I had seen and felt so many times in my patients. That spirit within had kept calling me back to life, in the same way that my patients’ spirits had called them to keep going and had called them to the work of therapy.

I had discovered firsthand the constant call of our spirits—a call to thoughts and actions that lead us to wholeness. I have nothing left, we say. And our spirit answers, I know. I see your struggles every day, the ones nobody else knows about. It’s okay. Come as you are. Life doesn’t have to be so hard.

My religious understanding was shaped by Christianity and secular Buddhism, but when I use the word spirit, I am not assuming a particular religious meaning. Spirit is simply the best term I’ve found for the inner presence I have encountered with people in therapy and in myself, which guides us toward wholeness. Most of us have deep intuitions about this part of ourselves that is neither mind nor body and that is central to who we are. In a way, it is the you-iest part of you because it has always been with you and isn’t tied to your changing roles, your passing emotions, or your thoughts or actions.

This revelation on the couch was far from the end of my struggle, and it certainly wasn’t the last time I would need to hear that call from within. But it was the beginning of hope. It also marked the beginning of a profound shift in how I thought about therapy. For the past several months I had found the practice of CBT to be limiting and considered abandoning it in favor of an unspecified deeper approach. But CBT is a powerful method, and I recognized what a loss it would be to give it up. I couldn’t forget the faces of the women and men whose lives had been changed through their efforts in CBT.

And yet I knew that I had to go beyond understanding principles and applying techniques. To realize the full potential of CBT, I would need to integrate my training with deeper spiritual truths.

Co-creating Our Lives

Years before my personal crisis, I sat in my office at Penn, looking out my window at the Philadelphia skyline. A red-tailed hawk flew into view, circling higher and higher over the city with only an occasional flap of its wings. I stopped writing whatever grant or paper I was working on and watched until it was nearly out of sight, mesmerized by its effortless flight. Later, I learned from my bird-loving wife that the hawk was riding thermals, powerful updrafts of warm air.

Many birds use thermals to save energy, especially during long migrations. The broad-winged hawk relies on them to travel over four thousand miles as it migrates from the United States and Canada to Mexico and Central America, averaging about seventy miles per day. Without these currents of air, the trip would be quite a slog, taking vastly more time and energy. The hawks would feel every mile. Every day would be a struggle. They might long for rest. And maybe they would despair, in a bird sort of way, of ever making it. Many probably wouldn’t survive the journey.

That’s what our lives can feel like at times, when everything is hard and every day exhausting. We feel every bump in the road. We’re giving all we have, and still it seems it’s not enough. We fear for our lives. We’re tempted to give up. And then there are those moments when everything stops feeling like such a struggle. We feel buoyed, inspired, uplifted. Life feels more like a dance than a wrestling match. We find flow. That’s what our spirits offer us. They are thermals that lift us up when we’re overwhelmed and exhausted. Through that spiritual connection, we can find grace and ease.

Hawks and eagles and other birds don’t just fall out of their nests into thermals or happen upon them by chance, because the stakes are too high. Birds actively seek them out as collaborators with the air currents. Scientists aren’t sure how birds locate thermals, but we know birds are highly attuned to them, as if their lives depend on them. Once they find a thermal, they skillfully navigate the current to stay in it as long as possible.

The same is true for our spiritual connection:

Our spirits provide the will.

Our efforts provide the means.

We need both spirit and effort to live the lives we know are waiting for us. Through our thoughts and actions, we join our spirits in co-creation of our lives. Our spirits can lift us up. We allow ourselves to be lifted. Our spirits continually call to us. We choose how we answer.

The practice of listening for the call of our inner voice, or spirit, is what many call mindfulness, and effective therapy is a way of answering that call. Through mindfulness-centered CBT, we can remove the habits that disconnect us from who we are and replace them with thoughts, actions, and mindful awareness that nourish our