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.
Corrective breathing consists of diaphragmatic breathing methods. One way to teach this is to say to your patient, “First, get as comfortable as possible within your current surroundings. Then, close your eyes and begin to breathe deeply through your nose or mouth, whichever feels better for you. Take in deep breaths, and during each exhalation, let yourself unwind; notice your muscles loosening and tension draining away. Now, see if you can notice your belly rising as you inhale and falling as you exhale. This ‘belly breathing’ is what is meant by ‘diaphragmatic breathing.’ By doing this for just a few minutes, your physiology can return to a more balanced state, helping your body relax and your mind grow calm.”
Finally, in the interoceptive exposure phase, you help the patient induce the feelings of having a panic attack. You can do this in various ways. The most common technique is to have a patient spin in a swivel chair for about 30 seconds while hyperventilating into a paper bag. This often produces some of the sensations of panic, such as dizziness and increased heart rate. Usually, demonstrating this method before having the patient do it is most beneficial (partly because watching the therapist deliberately induce generally unpleasant sensations causes a degree of anticipatory anxiety in the patient, thus “priming the pump”). I also find it helpful to model a few moments of diaphragmatic breathing after the interoceptive demonstration.
According to continued expert consensus, the most evidence-based method for treating OCD is a form of CBT that includes exposure and response (or ritual) prevention (ERP). (See, for example, Lack CW, World J Psychiatry 2012;2(6):86–90. doi:10.5498/wjp. v2.i6.86.) Other therapies might also be effective but have not yet been adequately tested in controlled trials.
ERP is based on the idea that OCD behaviors are counterproductive efforts to prevent anxiety. It’s helpful to break down the patient’s anxiety prevention efforts into three categories: avoidance, escape, and reassurance-seeking. Avoidance means simply not exposing oneself to the anxiety-producing situation (for example, not using public restrooms). Escape is performing a ritual, which is a behavior done to neutralize the anxiety, such as washing, checking, or arranging. Reassurance-seeking involves repeatedly asking questions to confirm that nothing bad has happened (for example, a patient calling his parents multiple times a day to make sure they are alive, due to his fear that he had left the stove on the last time he visited).
The ERP technique involves encouraging patients to expose themselves to the trigger, and to learn how to neutralize the anxiety without resorting to rituals. For example, if a patient has contamination fears, the therapist might first model desirable responses by touching something the patient avoids and then not washing (eg, a doorknob, toilet flusher, rim of a trash can, etc). After modeling the nonavoidant and nonritualistic behavior, the patient is encouraged to perform it. Once the patient reports feeling “contaminated” and the patient’s subjective distress is gauged (usually on a 10-point SUDS—subjective units of distress—scale), the therapist asks the patient to periodically reassess the SUDS score until the anxiety has significantly diminished or completely resolved.
Conducting this type of therapy well usually requires significant experience and expertise, meaning you will likely need to refer patients to therapists for this treatment. Two websites that can help you locate such therapists are the sites for the Association for Behavioral and Cognitive Therapies (http://ABCT.org) and the International OCD Foundation (https://iocdf.org).
According to the latest Cochrane review, the three most evidence-based therapies for PTSD are exposure therapy, eye movement desensitization and reprocessing therapy (EMDR), and cognitive processing therapy (Bisson JI et al, Cochrane Database of Systematic Reviews 2013;12(CD003388). doi:10.1002/14651858.CD003388.pub4).
Exposure therapy is the most well-established technique. You start by teaching patients some basic relaxation exercises, then you have them recount the traumatic experience out loud several times. Often, patients record the sessions so they can listen to the narrative later as homework. This repetition gradually extinguishes the fear response triggered by the memories. The technique is highly effective if patients can stick to it, but there’s a fairly high dropout rate since the process is emotionally painful and not everyone can tolerate it.
EMDR involves having patients move their eyes back and forth while recounting the traumatic event and repeating various functional or dysfunctional beliefs, images, sensations, and emotions. The theory is that eye movements (or hand taps or sounds in lieu of eye movements) activate and facilitate the brain’s information processing system. However, there’s controversy about whether the eye movements are a necessary part of the therapy.
In cognitive reprocessing therapy, you help patients identify how a traumatic event has affected their view of the world, and how this view may be negatively affecting their life. For example, patients may believe that the world is a dangerous place and therefore avoid work or other activities. Other patients may blame themselves for the trauma, leading to depression. The therapist helps patients evaluate these beliefs and replace them with more accurate and functional ones.
The best psychological treatment for insomnia is an approach called cognitive behavior therapy for insomnia, or CBT-I. See this month’s Q&A with one of CBTI’s major innovators, Michael Perlis, for more information on this technique.
Although medications are the mainstay of treatment for bipolar disorder, a recent review found that several bipolar-specific therapies are helpful as an adjunct (Swartz HA and Swanson J, Focus (Am Psychiatr Publ) 2014 Summer;12(3):251–266. doi:10.1176/ appi.focus.12.3.251). Psychoeducation, for example, is useful for any phase of the disorder. Talk to your patient about factors that tend to trigger an episode, such as increased work stress, less sleep, arguments with family members, substance abuse, and so forth. Then, based on that discussion, come up with a relapse prevention plan, which should be put in writing.
Typical CBT can be very effective for treating depression in bipolar disorder. This involves behavioral activation (as described previously); activity scheduling and pleasure predicting; thought journaling; and reevaluation of irrational beliefs (eg, overgeneralizing, catastrophizing, all-or-none thinking, and so on.). Another type of psychosocial treatment is interpersonal and social rhythm therapy (IPSRT). The premise is that recurrences of mood episodes are often triggered by changes in routines, changes that are frequently caused by interpersonal conflicts. These changes in routine (called “rhythm dysregulation”) can then disrupt the sleep cycle, and sleep problems are often linked to mood issues. Your job as the therapist is to help patients identify connections between times when their days are thrown off kilter and mood episodes. Then, you coach your patients in how to manage their life in a somewhat regimented way to maintain a consistent sleep, meal, work, and exercise schedule.
Finding the right therapist for your patient
A helpful referral resource is the Association for Behavioral and Cognitive Therapies (ABCT); it has a useful “Find a CBT Therapist” function on its website (http://ABCT.org). Most of ABCT’s members are trained and experienced cognitive behavior therapists, which can help in making reasonably confident referrals.