TCPR: In your 2010 book, High Yield Cognitive Behavior Therapy for Brief Sessions (American Psychiatric Publishing, Inc, 2010), you discuss how psychiatrists and other prescribing professionals have slipped away from using psychotherapy, and you offer some tactics for fitting it back into a psychopharmacology practice. Is there a certain type of patient that you think CBT works best for?
Dr. Wright: I think every session to some extent has psychotherapeutic qualities if one is interested in paying attention to the therapeutic relationship, having people manage stressors in their lives, and solving problems. In CBT, there is a fair amount of teamwork—this is called “collaborative empiricism.” I often liken the therapist in CBT to a really good coach or a teacher. You are trying to help people gain skills and build knowledge about how to examine their thinking and behavioral patterns, and then use CBT techniques to turn those around. So someone who can participate as a member of the team, and is motivated to do that, is a reasonably good candidate for CBT. Some illnesses respond better to CBT, such as mood and anxiety disorders, than others. But CBT can be useful for a broad range of problems.
TCPR: Let’s discuss CBT techniques for people with anxiety disorders—in particular, panic disorder.
Dr. Wright: Some of the techniques that have proven effective for panic disorder include breathing retraining, cognitive restructuring, and relaxation training.
TCPR: Tell us about breathing retraining.
Dr. Wright: This method is usually easy to teach and often is effective for people who hyperventilate as part of a panic attack (Clark DM et al, J Behav Ther Exp Psychiatry 1985;16(1):23–30). The goal is to help your patients bring breathing patterns from irregular back to a normal pattern, and to use positive imagery to further calm their cognitions.
TCPR: Walk us through how you would actually do this.
Dr. Wright: First, I ask patients to watch me breathe normally, and I say, “Do I look nervous or anxious right now?”And they say, “No, you look pretty calm.” Then I ask them to explain what my breathing looks like. When people are calm and not in a panic attack their breathing is fairly slow and it is hardly noticeable. So I ask them what they think a panic attack looks like. And they will usually say, “Well it is obviously not calm like that. I struggle with my breathing.” Then I will role-play what a panic attack looks like, and the anxiety responses that one might see in a person’s face and body. So I will perform a hyper pattern of breathing, and the patient will usually say, “Yeah that’s it. That is exactly what it is like for me.” And I will say, “Well if I kept going with this, I could probably feel like I am in a panic attack myself because I get sort of dizzy and I might have funny feelings in my hands or my feet and I will feel like I am out of control.” Sometimes, if a patient is willing, I will ask him or her to over breathe in a panicky way. If they don’t want to, that’s fine; we just go on to the next step.
TCPR: So you first get them to notice the difference between normal breathing and panicked breathing. Then what?
Dr. Wright: I will give them a simple technique that can really help if they find themselves getting into this pattern of breathing that goes along with panic attacks. Here’s how it works: If a patient can just simply recognize that he is having this panicked type of breathing, all he has to do is look at a watch with a second hand and use that to try to reduce the pattern of breathing down to the normal of about 15 breaths or so per minute, which is roughly one breath every four seconds.
TCPR: And where does the positive imagery come in?
Dr. Wright: I will suggest that once a patient has started slowing his breathing down and getting into a calm state, then he can let his mind go to a place that is very calming and peaceful; a place where there is really no worry or anxiety. So for me that might be walking along the beach with my feet sort of in and out of the waves on a warm day. But it’s different for everyone, so the patient needs to decide. This mix of breathing training coupled with positive calming imagery can help lots of people begin to get some control of panic attacks.
TCPR: Great tips. Next, what is cognitive restructuring?
Dr. Wright: This technique works by helping people spot, and then change, the catastrophic thoughts they are having during panic attacks. Some classic automatic thoughts would be, “I’m going to have a stroke. I’m going to have a heart attack. I’m going to lose control.” Those kinds of thoughts, when added to the physical sensations of a panic attack, create a vicious cycle and worsen the panic.
TCPR: And how do you teach people to restructure these thoughts?
Dr. Wright: First, I ask the patient to write those fears down on a “thought record,” and then take a look at how realistic they are. Next, we come up with some alternate thoughts that the patient can write down on a piece of paper or an index card and keep with him or her to look at when a panic attack is starting. Examples of these thoughts might be, “This is just a panic attack. I can control it by breathing regularly at about one cycle every four seconds.” “I have seen my doctor and there is no evidence of heart disease. I’m misinterpreting a fast heart beat. I can calm my thoughts, and I’ll be okay.”
TCPR: While these sound like extremely helpful techniques, is it really possible to accomplish all this within the time constraints of short psychiatric office visits?
Dr. Wright: I have found that if I can get someone going on a “thought change record” or some of the other methods that we discussed earlier, he or she can work with this self-help exercise for homework between visits, and this skill-building method often is quite beneficial. Some patients with uncomplicated disorders can be treated just with brief CBT sessions combined with pharmacotherapy. But, of course, there are others who may need more extensive psychotherapy. One option to consider is “front loading” of CBT. This means that in the early phase of treatment, a patient might have more frequent and/or intensive sessions to learn the techniques. They might see a psychiatrist or another psychotherapist for six to 10 sessions, and then the rest of the treatment is done by a psychiatrist with brief sessions only. This method may be particularly useful for patients with illnesses such as chronic depression or bipolar disorder that may require long-term management by a psychiatrist.
TCPR: So once a patient knows how to do CBT, it is possible to do maintenance therapy during short visits.
Dr. Wright: Yes. The brief session format can work quite well for patients who require ongoing treatment. Another method that can help clinicians and patients make good use of brief sessions is computer-assisted cognitive therapy. It’s a great way for people to build basic knowledge and skills so that the therapist doesn’t have to spend a whole session teaching how to do a thought record or what an automatic thought is. I also strongly suggest having a stack of handouts or suggesting workbooks to give patients for home study.
TCPR: Now, please tell us about relaxation training.
Dr. Wright: A psychiatrist can teach relaxation training in the office or recommend a digital recording or a website where the patient can learn how to use this calming exercise. Relaxation techniques are easy, effective, and can be implemented in the space of five to 10 minutes in a session. Relaxation training typically involves teaching patients how to systematically control the muscle tension in major muscle groups throughout the body. Often it is coupled with positive imagery. This method was introduced by Jacobsen in the 1930s and has been used extensively as part of CBT methods for anxiety disorders for many years.
TCPR: How do you think medication fits with CBT in treating panic?
Dr. Wright: Therapy and serotonin-active antidepressants can work well together, although benzodiazepines can interfere with the effectiveness of CBT, particularly alprazolam (Xanax) (Marks IM et al, Brit J Psychiatry 1993;162(6):776–787). There is some thought that longer acting benzodiazepines may not have that problem. So if I am using combined pharmacotherapy and CBT for panic disorder, I would typically choose an SSRI and would try to avoid a benzodiazepine if possible. If a benzodiazepine seems to be necessary, lorazepam (Ativan) or clonazepam (Klonopin) might be a better choice than alprazolam.
TCPR: Thank you, Dr. Wright.