When we first set about planning this article, its working title was “The Most Evidence-Based Psychotherapies.” But as we scoured the literature, it became clear that there’s no scientific consensus about which techniques are best (one exception to this being techniques for OCD—see page 3). In fact, the latest official statement on the subject by the American Psychological Association concludes with two key points: “(1) most valid and structured psychotherapies are roughly equivalent in effectiveness and (2) patient and therapist characteristics, which are not usually captured by a patient’s diagnosis or by the therapist’s use of a specific psychotherapy, affect the results” (http://www.apa.org/about/policy/resolution-psychotherapy.aspx). In other words, all techniques are equally effective, and it’s likely that the skills of individual therapists are as important as the specific technique they choose.
This is all well and good, but meanwhile, in the real world, we need to make decisions about how to treat specific patients. If we wait for the definitive answers from research, we will be waiting for a very long time. Therefore, in this article, we will detail certain well-known techniques drawn from the broad umbrella of cognitive behavior therapy, or CBT. We choose these techniques because they have all been widely researched and found to be more effective than receiving no therapy. Does this mean that you should prefer these techniques to others, such as supportive psychotherapy or psychodynamic therapy? Not at all. You should develop a repertoire of techniques that you find intriguing enough to pursue expertise in. And you should have a systematic way of gathering feedback from your patients on whether they are responding to therapy.
In past issues of our newsletters, we have focused on psychoanalytic techniques (TCPR, June 2016), dialectic behavior therapy (CATR, August 2016), and the general characteristics of good therapists (TCPR, April 2015). We are an equal opportunity therapy critic. This article covers certain techniques without implying that they are more—or less— effective than others.
Behavioral activation therapy (BAT) is a subset of techniques derived from CBT for depression. CBT for depression is a more comprehensive approach requiring significant training and greater time commitment from patients—both of which limit the technique’s real-world usefulness. BAT is simpler to learn and is more easily integrated into the briefer sessions that most prescribers are likely to have with patients. A recent meta-analysis of 26 controlled studies found that BAT had a large effect size in comparison with control groups such as wait list and treatment as usual (Ekers D et al, PLoS ONE 2014;9(6):e100100. doi:10.1371/journal.pone.0100100).
BAT simply encourages depressed patients to engage in more general activity, physical movement, and social interaction. This counteracts the tendency of people with depression to withdraw, disconnect, and disengage from previously enjoyable involvements and outlets. Ask patients to describe their typical days and assess whether they are avoiding activity. Then teach them about the vicious cycle of depression, in which their lack of motivation and activity leads to withdrawal from potentially enjoyable experiences—thus inviting their depression to worsen. Instead of a vicious cycle, BAT helps create a “virtuous circle” of becoming more engaged in life, resulting in more positive experiences and, theoretically, better mood.
Many of us were taught in training that CBT is the most effective therapy for panic disorder. However, according to the latest Cochrane review, there is no good evidence that CBT is any more effective than psychodynamic therapy, and only marginal evidence that it has an advantage over supportive therapy (Pompoli A et al, Cochrane Database of Systematic Reviews 2016;(4):CD011004. doi:10.1002/14651858.CD011004.pub2).
As is true with CBT for other conditions, such as OCD and PTSD, CBT for panic entails some type of exposure to the source of anxiety. Since the idea of exposing oneself to an anxiety trigger frequently makes patients nervous, I will often help them buy into the treatment by using the analogy of how one treats an environmental allergy. I will explain that allergies are caused by an immune system that is overly sensitive to environmental triggers, or allergens. Instead of having little or no reaction when exposed to, say, pollen, an allergy sufferer’s immune system launches a dramatic response, resulting in the misery of an allergy attack.
In anxiety, the nervous system overreacts, rather than the immune system. Anxious people overreact to a “psychological allergen” (ie, a sense of risk, threat, or danger), and their nervous system’s response leads to the misery of an anxiety attack. Just as allergy sufferers can be successfully desensitized by exposure to gradually increasing doses of allergens, people who suffer from the psychological allergy of anxiety can be desensitized, too. This is accomplished by gradually exposing anxious patients to the very stimuli, situations, or events that evoke their anxiety. Over time, the anxious person’s nervous system calms down and, just as with allergy desensitization treatment, eventually stops overreacting to whatever used to set it off.
This allergy metaphor not only helps patients to accept the treatment, but also provides a preview for the different components of CBT. CBT for panic has three important elements: cognitive relabeling, corrective breathing, and exposure to the interoceptive feelings and sensations of panic itself.
Cognitive relabeling entails teaching the patient that the sensations of panic are not life-threatening, but instead are physiological responses to events that are falsely interpreted as catastrophic. Patients can learn to reinterpret actual life events as less threatening, typically by filling out automatic thought sheets after having a panic attack.