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Meghan Beier , Neuropsychologist
Managing Invisible Symptoms: Fatigue, Mood, and Cognition
Sponsored By Sanofi
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6 May 2026 | ~07:53 Engagement Time
Mental health is an essential part of living well with MS. Depression affects approximately 50% of people with MS, and a third of people with MS will experience clinical levels of anxiety in their lifetime. Few people know all the types of therapy that exist and which one may be best for their individual needs. Here we will break down the most common types so you can decide what type of therapy is best for you.
CBT is based on the idea that our thoughts, feelings, and behaviors are connected. By learning to identify and modify unhelpful thinking patterns, people can change how they feel and act. It is structured and skills based. Depending on the therapist, it can be time-limited (often 8 to 16 sessions).
CBT has the strongest evidence in psychology. In MS, evidence shows it can reduce depression and anxiety symptoms. Digital or virtual CBT formats show comparable results to in-person therapy, which is helpful for people managing fatigue and mobility challenges.
Therapist: “You mentioned feeling like a burden to your family.”
Client: “I can’t do as much as I used to. They have to pick up the slack.”
Therapist: “Let’s test that thought together. Have you talked with your family directly? And what do you contribute? Are there tasks you take off their plate?”
Client: “I handle all the scheduling and calls with the insurance company. And I haven’t asked them if they feel frustrated about taking on more tasks.”
Therapist: “It might be worth having that conversation. I also wonder if you’re not counting what you do contribute. How would it feel to track those tasks this week?”
Because CBT is a flexible framework, it has been adapted to a number of symptoms and challenges. One example includes CBT-I, a specialized form of CBT designed for insomnia or chronic sleep problems. CBT-I improves insomnia severity, sleep quality, and daytime fatigue. It is considered a first-line treatment for chronic insomnia and is available in-person and online.
Other targeted applications include CBT for chronic pain, health anxiety, and needle phobia (especially helpful if you experience anxiety around infusions or injections). A series of books called “Treatments That Work” cover many of these specific interventions in workbooks you can use at home.
CBT has been the go-to therapeutic intervention for decades. Over time, clinicians recognized that for people with challenges that cannot be “fixed,” like MS, focusing only on changing unhelpful thoughts was not enough. Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) grew out of this recognition. They retain CBT’s core strengths while adding tools for accepting what cannot be changed, regulating intense emotions, and building a meaningful life alongside difficulty.
Rather than working to change or eliminate difficult thoughts and feelings, ACT focuses on building the ability to move toward what matters to you even when things are hard. It teaches people to make room for difficult experiences rather than fighting or avoiding them.
In MS, this distinction matters. The hardest parts of living with a chronic illness cannot simply be reasoned away: uncertainty about the future, losses both real and anticipated, fatigue. ACT does not ask you to challenge negative thoughts and feelings about those things. It asks what kind of life you want to build alongside them.
ACT has a large and growing evidence base. In MS, it has been shown to reduce stress, and improve psychological flexibility, anxiety, and depression.
Therapist: “Imagine you’re driving a bus. The destination is your choice. Some passengers on that bus are loud and unpleasant. They are telling you to stop the bus, to turn around, or that you should pick a different destination. You could listen to them. Stop and try to kick them off the bus or yell back. Or you could keep driving where you want to go, even when they are loud.”
Client: “So what you’re saying is that I don’t have to wait for the scared thoughts to go away before I try something new.”
Therapist: “Exactly. The goal isn’t a quieter bus. It’s learning that you’re always the one driving it. You can still drive even when the passengers on the bus are loud.”
DBT was originally developed for people with intense emotional experiences. However, its core skills including distress tolerance, emotion regulation, mindfulness, and interpersonal effectiveness are now being used in a multitude of medical and mental health conditions. It is useful to understand the difference between traditional DBT and DBT skills training:
Full DBT: The program includes individual therapy, a skills training group, phone coaching, and therapist consultation. This is especially effective for intense emotional distress that is not being improved by weekly therapy.
DBT Skills Training: A program that teaches the same DBT skill set without the full DBT structure. DBT skills training is widely available, including online.
Emerging. A pilot randomized controlled trial found that remotely delivered DBT skills training produced significant reductions in anxiety and depression compared to a peer support group. The study included both people with MS and their care partners. Both groups showed benefit.
Therapist: “You mentioned that when you get bad news about your MRI, the rest of the week falls apart. Let’s talk about some distress tolerance tools for those moments, things that can help you get through without the situation getting worse.”
Client: “I’d really like that. I feel like I just go into survival mode and say or do things I regret.”
Therapist: “That makes sense. Let’s start by making a list of distracting and comforting activities you can use when emotions are getting too intense.”
MBSR is an eight-week structured program combining meditation, body awareness, and gentle movement. Mindfulness is often woven into other therapies, including CBT, ACT, and DBT.
Moderate. Studies show meaningful improvements in anxiety, depression, fatigue, and quality of life. Online and app-based mindfulness programs are available.
There are other types of therapy you may come across including EMDR, somatic therapy, psychodynamic therapy, interpersonal therapy, and emotionally focused therapy, among others. Some of these have meaningful evidence in the general population, but research in MS is limited.
If you are drawn to body-based approaches, it is worth knowing that many techniques such as relaxation training, diaphragmatic breathing, progressive muscle relaxation, self-hypnosis, and more are often woven into CBT, DBT, and ACT. Consider asking potential therapists whether they incorporate these relaxation techniques into their work.
Finally, this article is not a comprehensive guide to every form of therapy that exists, it focuses on the approaches with the strongest evidence and the most relevance for people living with MS. If you are curious about a type of therapy not mentioned here, a mental health professional can help you think through whether it is a good fit for your needs and goals.
*No MS-specific RCT data; evidence from general populations.
Standard outpatient therapy is one hour per week. However, sometimes that is not enough. If your symptoms are not improving with standard therapy, more intensive options exist and can be extremely helpful for some people and situations:
No single therapy is right for everyone. A few things to consider:
If you are not sure where to start, your neurologist, MS care team, or primary care provider can be a good first resource. The National MS Society also offers an online directory to help connect people living with MS with mental health support.
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