At seventeen years old, I got sick. It started on my first morning back to high school. It was a bright and warm September day, but when I entered the air-conditioned school, everything suddenly appeared murky and grey.

I was experiencing a feeling that I couldn’t touch or name yet but which many others have characterized with clichés and worn-out metaphors: the black dog, a rain cloud, a shadow passing across the sun. Headaches, stomachaches, irritable bowel syndrome, insomnia, panic attacks: all these physical symptoms crept into my life one at a time. My initial blue feelings turned into anxious thoughts and eventually became daily panic attacks. I couldn’t get on buses or trains or go into any other place where I felt confined, because my panic revolved around feelings of nausea and a fear of vomiting.

On an ill-fated family trip, my parents finally realized this wouldn’t go away on its own. Back in Canada, they booked the first appointment they could get with our family doctor. My dad did most of the talking, describing the change in my moods, sleep, and eating habits. The doctor asked me a few questions about how I was feeling and then heaved a big sigh, shaking his head. “Why are so many girls dealing with things like this?” he said to no one in particular. This was how I first became aware of the fact that I wasn’t alone in my suffering.

Iwas referred to a child psychologist at the local hospital. Jeff’s voice was gentle but confident, and I immediately felt at ease. The ideas I had about therapy—a Freudian chaise longue and dream analysis—had been shaped by television and movies. I was about to discover a new world of talk therapy, one that focused entirely on the present and my everyday challenges.

In particular, cognitive behavioural therapy (CBT) worked well for my high-strung personality, encouraging me to challenge unrealistic beliefs and pull myself from spiralling panic. First, I would lay out my fears in a long list, and together Jeff and I would examine the thoughts behind my worries.

Situation: Boarding a packed train with friends for a night out on the town.
Thought #1: I will be trapped. (Emotions: fear, panic)
Thought #2: People will see I’m having a panic attack. (Emotions: shame, embarrassment)

Jeff would jot down my thoughts, then pass his notebook to me to write down my counter thoughts:

Counter thought #1: I’m not trapped, because I can get off the train at any stop.
Counter thought #2: My friends care about me. If they see me struggling, they will be there to help.

The thoughts that dominated my mind could be packaged up into neat little thinking styles— most of which were fuelling my anxiety, Jeff proposed—and these needed to be challenged for me to develop a healthier thought process. My thinking pattern was also fuelling extreme perfectionism as I fought to maintain high grades, participate in multiple extracurriculars, be a reliable employee, and maintain a busy social life. For many years, I had pushed myself to the limits of what I could achieve and felt unrelenting pressure to meet (what I imagined were) the very high expectations of me.

Widespread adoption of CBT and years of research have proven that the approach holds significant value in the treatment of mental illness. In a large overview, in 2012, of 269 meta analyses examining the efficacy of CBT, the authors concluded that “the evidence-base of CBT is very strong.” However, they did caution that more randomized controlled trials were needed and that evidence was lacking for racialized groups and people of low socio-economic status.

The premise for most talk therapy is simple: the patient and therapist talk, thought patterns and behaviours are explored (and sometimes challenged), and the patient comes out of the process with better “thinking tools” for coping with adversity. “CBT is more of a foundational approach to therapy, where the therapist is the expert and you teach the client strategies, skills, and coping mechanisms,” says Lindsey Boes, a marriage and family therapist. “It’s very formulated, and there’s a reason that there are so many studies over the decades showing that CBT works—because it’s manualized.” This provides consistency, and scientific study of a therapy that can be applied in the same way in any setting generally gives more solid and dependable evidence.

CBT doesn’t ignore physical feelings, but the therapist helps to break down problems into separate parts: the anxious thought (“I’m scared that I’ll faint”), the physical sensations (“My heart pounds and my hands get sweaty”), and the action (“I leave the situation as quickly as possible”). The goal is to change the thought, which creates a domino effect of changing the physical sensations and behaviours. CBT is very much focused on the here and now, so there’s no exploration of past relationships, trauma, or family dynamics (with the exception of CBT therapies that have been adapted to focus on trauma). It also doesn’t address wider societal or environmental problems that may be affecting a person’s well-being.

In a meta analysis of CBT for treating substance use, the authors found only a few studies that were able to engage and retain Black and Hispanic participants—which is consistent with existing research looking at the effectiveness of CBT for non-white participants. Dropouts in trials happen for a variety of reasons, but this study suggested that there could be a conflict between the needs of some Black or Hispanic populations and the way that CBT plays out in practice. The researchers also stated that “the limited inclusion of women in clinical trials is alarming” and could indicate specific barriers that prevent racialized women from accessing CBT for substance use (which was the focus of their analysis). Possible explanations include a lack of transportation or child care, distrust of the medical system, fear and shame, the belief they can recover without help, and a general lack of knowledge about the services that are available.

There is also evidence that CBT might not lead to longer-term improvement in some mental disorders. A meta analysis from 2021 looked at the efficacy of CBT and psychodynamic-interpersonal therapy (PIT), another talk therapy, for individuals with eating disorders (the majority of whom were female). They found that CBT was the most effective, with about one-third of the included patients, and one half of those with bulimia, in remission after going through therapy. But based on their analysis, the authors suggested that the therapy itself (changing eating-disorder thoughts and behaviours) might not have led to remission. It appeared that other factors, including personal motivation, better cognitive ability, and lower rates of pre-existing depression, played a greater role in remission than the talk therapy itself.

Research on the efficacy of CBT for those who are neurodivergent is also lacking. One study that examined CBT for younger individuals diagnosed with autism spectrum disorders (ASD) and co-occurring obsessive-compulsive disorders (OCD) showed promising results, though individuals with ASD often require modifications for CBT, including the use of visuals, positive reinforcement, and clear language and instructions. In the adult population, a few randomized controlled trials have been conducted looking at CBT alone or with medication to treat people diagnosed with attention deficit hyperactivity disorder (ADHD), and these have shown positive results.

One of the moderators here is the length of treatment—most trials are analysing the short-term efficacy of CBT (over eight to twelve weeks of therapy). One review found positive outcomes over the long term, but a substantial number of participants in their sample did not improve following treatment and a smaller number experienced worsening symptoms.

For Boes, CBT is helpful when she has a client who’s having a hard time understanding their actions. They want a very tangible answer for their behaviour—to identify the thought that triggered a reaction. But with many clients, Boes prefers narrative therapy, an approach that aims to reduce the restraints of unhelpful stories about ourselves created by dominant power structures. “Narrative therapy is very postmodern, in terms of believing the client is the expert in their own life, not the therapist,” she says. “There are steps to make CBT more culturally sound, but addressing someone’s socio-cultural environment is not inherent in the philosophy behind the therapy itself.”

After doing a full year of CBT with Jeff, I felt cautious and hopeful that I could leave my problems back in high school, along with bad boyfriends and questionable life choices. During my last appointment, Jeff congratulated me on all my hard work and then said in his gentle voice: “Many people who deal with these issues as teens go on to deal with them again in adulthood. It’s something you should prepare for.” I nodded in agreement but secretly didn’t believe him. I had mastered my thoughts! Overcome my panic! I almost wanted a therapy certificate with a shiny A for “amazing.”

But I soon discovered that Jeff was right. Despite my significant achievements in tackling the thought processes behind my panic attacks, stable mental health was not something that would come easily to me. My anxiety and depression symptoms did indeed rear their ugly heads at various times throughout early adulthood; and when they did, CBT became less and less effective for me.

Theories have surfaced in the past few decades that the way humans heal from adversity is not typically by thinking our way out but primarily within and through our bodies. This relates to growing scientific understanding of the mind–body connection. Neurological research has proven that there are networks in the cerebral cortex (the largest area of your brain) that connect to the adrenal medulla, the inner part of the adrenal gland located above each kidney. The adrenal medullas are responsible for the body’s stress response—our pounding heart, sweaty palms, and dilated pupils—which prepares our body to fight or hightail it out of a stressful situation.

In ScienceDaily, Peter Strick, the author of a published study, says that this connection “raises the possibility that activity in these cortical areas when you re-imagine an error, or beat yourself up over a mistake, or think about a traumatic event, results in descending signals that influence the adrenal medulla in just the same way as the actual event.”

“We can all create more room, and more opportunities for growth, in our nervous system. But we do this primarily through what our bodies experience and do—not through what we think or realize or cognitively figure out,” writes Resmaa Menakem in his groundbreaking book on racialized trauma. People who have experienced trauma or other repeated stressors may at times feel almost entirely disconnected from their bodily experience, but they can also report severe physical symptoms. Research shows that among survivors of interpersonal violence, women report physical symptoms more frequently than men. These symptoms might include chronic pain, gastrointestinal issues, or heart problems. While some might say that trauma is “stored” or “trapped” within the body, I suspect that a more scientifically correct phrasing would be that trauma “manifests” in the body, sometimes as a numbed-out feeling and other times as intense physical sensations.

Girls and women are at a much greater risk of experiencing trauma and a dysregulated stress response—which makes it imperative that we better understand the mind–body connection and the interventions that could interrupt a stress response. While I don’t necessarily place myself in the category of a person with trauma, I do see that the ways I had been experiencing and coping with stress since early childhood had elements of a traumatic response. Looking back, I realize that there have been very few times in my life when I was not afraid; I was incessantly on high alert, my body likely flooded with cortisol, my heart hammering.

Trauma is not always related to a single catastrophic event, like a car crash or natural disaster; it can accrue over time and be caused by a series of smaller events that disrupt the ways in which our bodies respond to stress. This is called complex post-traumatic stress disorder (PTSD), which the DSM-5 does not recognize, but the International Classification of Diseases 11 (ICD-11) names the condition and its impact on emotional regulation, self-identity, and relationship with others.

Most treatments for PTSD and trauma rely primarily on CBT and exposure-based methods. Exposure therapy aims to help an individual overcome their fears by confronting the thing that makes them scared—but this is done in small increments, with the support of a safe person. However, people who suffer from trauma show impaired cognitive functioning, which means they are sometimes unable to think their way through their trauma responses. As well, exposure can often be terrifying and confrontational, and it can exacerbate symptoms rather than making them better.

Body-based practices such as massage, occupational therapy, or yoga—which we can do on our own or with trained practitioners—target the body directly. Narrative-based approaches like talk therapy use language to better understand our thoughts and mental landscape. A relatively new approach gaining traction within therapeutic communities combines both of these strategies in a framework called somatic reappraisal, which deals with both levels of emotion processing—the body and the mind—to help a person heal from mental distress. This framework offers an alternative technique for women who have not responded well to traditional CBT methods. The first part of the practice involves bringing our attention to our inner-body experience—the beat of our heart, the tightness in our muscles, our stomach gurgling, and the rise and fall of our breath—which is known as interoception. By building up our awareness of these sensations, we can learn to better understand the granularity of emotion—which allows us to expand beyond the narrow definition of “good” or “bad” that we often use to describe our feelings.

Once we’ve learned to observe our bodily sensations and attend to them, the second part of somatic reappraisal has us become aware of the story we tell ourselves about what these sensations mean. This is the narrative part of the process. The stories our brain tells and the language we use about our bodies can shape the way we’re feeling. A flutter in the stomach might be labelled as “excitement” by one person and “anxiety” by another. Maladaptive narratives about sensory information happen when we interpret a sensation as negative, and then we repeat this process over and over until we are stuck in a negative pattern of feeling and thinking. Somatic reappraisal helps us learn to tell ourselves a new story.

Somatic experiencing is a similar therapeutic approach developed to meet the needs of people for whom CBT has a limited effect; it’s also considered a complement to the CBT- and exposure-based methods already proven to work for many individuals. This trademarked therapy uses a technique called “bottom-up processing,” which guides an individual’s attention toward our internal, bodily landscape, including our sensations, movements, and actions within the body and within the space around us. One review of somatic experiencing found promising results, but the overall quality of the included studies was mixed. As is usually the case when evaluating alternative treatment options, there is a need for more trials that are properly conducted to meet quality standards.

There is evidence that the process of looking inward and practising mindful awareness of the body creates measurable changes in the brain. “The main principle of neuroplasticity is that the brain is constantly changing based on experience,” says Cortland Dahl, a research scientist with the Center for Healthy Minds at the University of Wisconsin–Madison and an expert on mindfulness. “Over time, those brain networks can be strengthened or weakened depending on what you do.” By focusing our attention on breathing or other internal bodily sensations, over time, we can induce changes in the brain that may propel us toward more adaptive coping strategies as well as a better understanding of ourselves and of the socio-cultural forces working on and around us. Somatic reappraisal isn’t just fanciful thinking—it’s changing our brains and our minds—which eventually changes how we experience and manage emotions.

The consensus among cognitive and psychological researchers up until about a decade ago was that emotions depend on a trigger, or “stimulus.” Something happens in the world (for example, you see someone crying), which triggers a specific emotion (sadness) in one area of your brain. This earlier research is based on the belief that there are commonalities in emotional expression that all humans recognize. Anger is shown in a grimace, sadness as a frown, and happiness is a smile. But new research has called into question the idea of universal emotions.

What some neuroscientists now propose is that emotions are constructed through our brain’s complex network of neurons, and they happen because our brain is trying to keep us alive, not because something has triggered us to feel them.

“Every thought, memory, perception, or emotion that you construct includes something about the state of your body: a little piece of interoception,” writes neuroscientist Lisa Feldman Barrett. Our brain must do something with these sensations and makes meanings from them.

Our brains are perceiving moment-by-moment signals from the body, and it’s at this point that the cognitive mind kicks in—it’s not the simple thought–feeling–action sequence that CBT proposes. The awareness of all these internal sensory signals allows women to subjectively figure out what their bodies are trying to tell them, and—no surprise to those of you who have experienced panic attacks or anxiety—the mind can be a poor judge of sensory character. People with anxiety, depression, and panic often have poor body literacy skills—which means they find it hard to accurately interpret sensory signals.

Physical sensations in the body and our understanding of what they mean are shaped in large part by our culture. Kristen Lindquist, a professor of psychology and neuroscience at the University of North Carolina, uses the example of hunger. “Evidence is mounting that women have a unique experience of hunger, caused by how we filter our own biology through gendered concepts about the body,” write Lindquist and colleague Mallory Feldman in an article for Aeon. They reference mounting evidence that women can be poor evaluators of changes in our physiology—which means that we either ignore bodily sensations (a numbed-out feeling, which is more common in women who have experienced trauma) or we mistake a sensation for something else.

This mistake is also the result of self-objectification, which is when women view their bodies as objects separate from themselves. Internalized misogyny means we understand that our bodies are primarily valued for their outward appearance. “There is a huge focus on girls’ bodies, but it’s completely external, and not internal,” says Lindquist. “There’s so little focus on their own experiences and their own appraisals of the world.” The more we experience self-objectification, the less capable we are of detecting our own internal physiological cues. This is likely linked to the higher incidence of dieting and eating disorders among girls and women and in the LGBTQ+ community.

Neuroimaging studies of the brain have found that a region known as the insula is responsible for creating meaning about our body’s condition. The rear and middle insula receive messages of physical sensation from the nervous system and spinal cord; these messages are then projected forward to the front of the insula, where we become conscious of the sensation. Insula activation is associated with greater interoceptive sensitivity—which is how skilled we are at recognizing and understanding our physiological cues. When our culture applies its own meaning and strict rules to our bodies, it becomes much harder for us to successfully detect these inner bodily changes and apply an appropriate meaning to the sensations that we do notice.

This is why it’s so important for girls and women to become detectives of their own bodily experience. Healing from anxiety, depression, and trauma largely depends on how we reframe emotional experiences, but in a way that taps into the body–mind connection rather than simply replacing “bad” thoughts with more helpful ones.

Adapted, with permission of the publisher, from All in Her Head: How Gender Bias Harms Women’s Mental Health, written by Misty Pratt and published by Greystone Books in May 2024.

Misty Pratt
Misty Pratt is a medical researcher who has written for publications including Broadview, Mindful, and Today’s Parent. All in Her Head is her first book. She lives in Ottawa.