Man talking to therapist over video chatTwo new studies suggest online therapy may be effective for treating mental health issues. Online therapy is increasingly popular, particularly among people who live in rural areas and cannot easily get to a therapist’s office or who are concerned about the costs of in-person therapy. New technology may pose some concerns, and the security of online therapy continues to be an issue, but research suggests the benefits may be significant.

The Benefits of Online Cognitive Behavioral Therapy

The first study, published in the Canadian Medical Association Journal, reviewed studies of online cognitive behavioral therapy (CBT) conducted between 2000 and 2012. CBT is a widely used and well-researched form of therapy, with most studies saying in-person forms of this treatment are highly effective. CBT focuses on reducing negative thoughts, thereby changing behavior and alleviating symptoms.

Most of the studies tracked participants for a relatively short period of time after undergoing therapy—ranging from eight weeks to about two years. Researchers found online CBT could effectively reduce symptoms of depression and other mental health issues. In some cases, online CBT was even more effective than traditional in-person therapy.

[fat_widget_right]Most online CBT sessions focused on short-term goals and symptom relief. Because the studies did not track participants for an extended period of time, the researchers do not know if the symptoms were permanently alleviated. The team that conducted the analysis cautions that some human connection is lost with online therapy, but they also say the evidence supporting online therapy’s effectiveness is significant.

Reducing Suicidal Feelings in Doctors

Another study, published in JAMA Psychiatry, looked at how online therapy affects the well-being of new doctors. Young doctors often work long hours, including nights and weekends, and the stress of those long shifts can lead to mental health issues such as depression and suicidal thoughts. One previous study found that suicidal thoughts increase four-fold during a medical residency.

Researchers looked at 200 first-year medical residents working 80-hour weeks and overnight shifts. Compared to doctors who received no online therapy, doctors who received four 30-minute online sessions before beginning their residency had fewer suicidal thoughts. Because the sessions were delivered online, researchers say it might be possible to provide such treatment to other doctors while still keeping costs low.

References:

  1. Mozes, A. (2015, November 3). Online therapy may help some with emotional problems. Retrieved from http://health.usnews.com/health-news/articles/2015/11/03/online-psychotherapy-may-help-some-with-emotional-problems
  2. Online cognitive behavioral therapy benefits people with depression, anxiety. (2015, November 2). Retrieved from http://www.sciencedaily.com/releases/2015/11/151102125440.htm
  3. Study: Online therapy eases new doctors’ suicidal thoughts. (2015, November 4). Retrieved from http://news.wabe.org/post/study-online-therapy-eases-new-doctors-suicidal-thoughts

person crouching, hidingA seizure is a sudden and unexpected loss of control accompanied by abnormal body movements or convulsions, a loss of consciousness, or both. Though epileptic seizures are caused by sudden, rapid, and chaotic electrical discharges in the brain, not all seizures are epileptic.

Psychogenic nonepileptic seizures (PNES) are not caused by abnormal discharge of electrical brain signals, but instead are emotional in nature and usually triggered by stress or anxiety. Although these seizures are rarely discussed, they are not rare. PNES have a prevalence similar to that of multiple sclerosis.

Statistically, one in five people sent to epilepsy centers experience PNES rather than epilepsy. In fact, a team of physicians and psychologists at Johns Hopkins Hospital reported that more than one third of patients admitted to the inpatient epilepsy monitoring unit were experiencing stress-triggered seizures rather than true epileptic seizures.

Diagnosing Psychogenic Nonepileptic Seizures

Because PNES can mimic epileptic attacks, they are often misdiagnosed. At least 80% of patients experiencing PNES are treated with antiepileptic drugs for several years before a correct diagnosis is made.

[fat_widget_right]The source of this dilemma is multifaceted. Most physicians do not have access to electroencephalogram (EEG) video monitoring, and even those who do can easily misread an abnormal EEG without video if they have not been specifically trained in epileptology. A 2005 study of 46 patients published in the Neurology journal revealed that 54% of EEG readouts were misinterpreted as epilepsy.

Epileptic seizures tend to be more serious than PNES. If there is any doubt, a neurologist will usually treat the more serious condition. If medication fails to treat seizures, a patient is then referred to an epileptic center, and it is often there that the diagnosis of PNES is made.

With proper equipment and specialized knowledge, an epileptologist can easily distinguish between epilepsy and PNES. An EEG-video monitoring system monitors a patient for several hours and sometimes days until a seizure occurs, though there are techniques that can be used to trigger a seizure to speed up the monitoring process if necessary or desired. By analyzing the video of the seizure, a diagnosis of PNES can be made with 100% certainty.

Causes and Risk Factors

PNES is a somatoform illness, meaning that emotional stress creates physical illness in the body. These seizures are emotional in nature—induced by stress—and often result from traumatic experiences, some of which may have been repressed or forgotten. Such traumas may include divorce, physical or sexual abuse, death of a loved one, incest, or any other great loss or sudden upheaval in one’s life.

Individuals without developed coping skills may be more susceptible to PNES than those with a high level of resiliency to stress. A team of neuropsychologists and neurologists at Johns Hopkins University School of Medicine found that people with PNES don’t necessarily have a higher frequency of stress and/or trauma than others, but they seem to lack effective coping mechanisms to deal with stress and are thus more affected by it.

Coping with Diagnosis and Stigma

Psychosomatic illnesses like PNES are often misunderstood by family members and even by physicians and other health care professionals. A person may be reluctant to accept the diagnosis and become upset when told the seizures are psychological. Some people completely refuse to accept the diagnosis and continue to take antiepileptic drugs even as symptoms continue. This places responsibility on the physician to stop administering the drugs.

A lack of public knowledge and awareness of PNES only increases the misconceptions, misdiagnoses, and stigmatization of the illness. Somatoform illnesses like PNES are real—resulting from real stressors and traumas—and should be treated as such.

Treatment and Outcomes of PNES

Overall, PNES can be treated if properly diagnosed. The earlier the diagnosis, the better the outcome may be. About 70% of people who receive adequate treatment for PNES eventually experience a complete disappearance in seizures. The recovery time will vary from patient to patient depending on the severity of the traumas and stressors involved, as well as the person’s established coping mechanisms and resiliency to stress.

While a neurologist typically treats epileptic seizures, PNES tends to be treated by a psychologist or other mental health professional. Someone who has been newly diagnosed and has been taking antiepileptic drugs will need to work with a neurologist to gradually come off the drugs rather than stopping use abruptly.

About 70% of people who receive adequate treatment for PNES eventually experience a complete disappearance in seizures.Treatment for PNES typically involves various types of psychotherapy. Cognitive behavioral therapy (CBT) may be used to help people develop adequate coping skills to deal with life stressors. Relaxation techniques and biofeedback are also used to help manage and cope with stress.

For those whose seizures are a manifestation of past trauma, PNES is typically treated as posttraumatic stress. In this case a physical seizure may be the body’s way of expressing what the mind cannot. Some physicians have also found eye movement desensitization and reprocessing (EMDR) to be an effective treatment for PNES.

EMDR is a synthesis of many different therapeutic approaches including CBT, psychodynamic, interpersonal, body-centered, and experiential therapies. This information-processing therapy occurs in eight phases—attending to past traumas that contribute to the pathology being treated; the current situations, beliefs, and sensations that are triggering the dysfunctional emotions; and the positive experiences needed to improve mental health and well-being in the future.

The costs of being treated for misdiagnosed epilepsy are high and should not be ignored. As the incidence of misdiagnosed PNES continues, it is important for neurologists, psychiatrists, and psychologists to work in collaboration to raise public awareness, remove the stigma, and provide proper diagnosis, treatment, and support.

References:

  1. Benbadis, S.R. and Heriaud, L. Psychogenic (Non-Epileptic) Seizures: A Guide for Patients and Families. (n.d.). Comprehensive Epilepsy Program: Tampa General Hospital & University of South Florida College of Medicine. Retrieved from: http://hsc.usf.edu/COM/epilepsy/PNESbrochure.pdf
  2. Desmon, S. (2012, April 10). Symptoms that Mimic Epilepsy Linked to Stress, Poor Coping Skills: Patients with “Pseudo-Seizures” Often Misdiagnosed. Johns Hopkins Medicine. Retrieved from: http://www.hopkinsmedicine.org/news/media/releases/symptoms_that_mimic_epilepsy_linked_to_stress_poor_coping_skills
  3. The Truth about Psychogenic NonEpileptic Seizures. (n.d.). Epilepsy Foundation. Retrieved from: http://www.epilepsy.com/article/2014/3/truth-about-psychogenic-nonepileptic-seizures
  4. What is the actual EMDR session like? – EMDR International Association. (n.d.). Retrieved from http://www.emdria.org/?120

DepressionPortrait of a sad woman can make people feel like a dark cloud hovers over them, while the sun shines brightly on the rest of the world. According to the U.S. Department of Health and Human Services, major depression affects approximately 14.8 million American adults each year, and as many as 1 in 33 children and 1 in 8 adolescents experiences clinical depression.

When people feel like they don’t have the strength to pull themselves out from under the shadow of depression, there are many therapeutic options to choose from. Depression is a highly treatable mental health condition with 80% to 90% of those who seek treatment reporting relief.

One of the most popular forms of behavioral therapy used to treat depression is cognitive behavioral therapy (CBT). Cognitive behavioral therapy techniques are routinely used to treat depression by focusing on a person’s internal dialogue and how it affects his or her behavior.

What Is Cognitive Behavioral Therapy (CBT)?

CBT is a blend of two types of therapies: cognitive therapy and behavioral therapy. Cognitive behavioral therapy has proven to be effective for a wide range of mental health conditions including anxiety, eating disorders, and depression. Cognitive therapy focuses on how our thought patterns and belief systems affect our mood and actions, while behavioral therapy aims to transform unhealthy habits and behavior patterns.

How Do CBT Techniques Help with Depression?

Cognitive behavioral therapy focuses on the present moment, concerned more with the thoughts and behaviors themselves rather than their origins. A therapist using CBT techniques might assist a person in therapy for depression by first educating him or her about automatic thoughts, known as cognitive distortions, and then by teaching the person to monitor themselves for such thoughts.

Cognitive distortions are irrational or inflated thoughts and beliefs that cause a person to have a distorted and often negative view of reality. These distortions often reinforce negative thought patterns and perpetuate mental states like anxiety and depression. Some common dysfunctional thinking patterns include all-or-nothing thinking, over-generalization, “should” statements (ruminating about the way things should be or how you expect them to be, not as they are), and personalization.

Negative thinking and behaviors often precipitate depression. CBT techniques can help people in therapy restructure their thought patterns and alter their behavior to alleviate depressive symptoms.

For example, a person experiencing depression may have an automatic thought such as “I am worthless and things are hopeless.” A cognitive behavioral therapist would help this person reframe the thought to something more realistic like, “I may have made some mistakes, but I am learning. I do have value as a person regardless of my imperfections.”

Another CBT technique for depression is pleasant activity scheduling. This involves scheduling healthy activities into your life that you enjoy—perhaps for 30 minutes a day, 3 hours a week, or whatever your schedule allows. You might read a book, ride a bike, or go for coffee with your friends. Whatever yours may be, pleasant activities create more positive feelings of joy and well-being in your life.

Is CBT Effective for Treating Depression?

Studies have shown that psychotherapy is at least as effective as antidepressants for individuals experiencing mild to moderate depression. In fact, varying degrees of depression can often be treated with psychotherapy alone, without the use of psychotropic medication. However, individuals experiencing severe depression may have a more difficult time utilizing cognitive behavioral therapy techniques alone and may require medication in addition to therapy to transform debilitating symptoms.

Therapeutic outcomes are improved by people’s capacity for self-motivation, introspection, and recognition that they have the power to change their lives—conditions which may not be met depending on the severity and root cause of a person’s depression.

Limitations of Cognitive Behavioral Therapy for Treating Depression

Some therapists don’t see CBT as the most effective method for treating depression because they believe deep-seated trauma and other circumstances may require a more long-term approach to treat effectively. California-based psychotherapist Cynthia W. Lubow, MS, MFT, for example, is one of many who share this opinion. “While there are cognitive elements of the work that I or any therapist does, I find that they are mostly helpful at the end of therapy when people are mostly resolved and doing well, or when people really are very psychologically healthy and just need a little guidance,” she said.

Lubow believes that CBT techniques are difficult to administer in those dealing with severe depression and that other therapies should be utilized first until the person is stabilized. “Trying to do [CBT] with people who are depressed or severely depressed because of trauma, abuse, or chemical issues is pointless. … They need intervention with their emotional state, including reprocessing trauma and resource building and strengthening before they can get to the cognitive and behavioral changes,” she said.

Therapy Is a Great First Step in Treating Depression

Just as depression is multifaceted, so is its treatment. If you are experiencing symptoms of depression, a great first step to take is to find a therapist you’re comfortable with who can help you understand your depression. [fat_widget_right]

Cognitive behavioral therapy is just one of many options for helping an individual experiencing depression, and it may or may not be the best one for you. Regardless of modality, therapy can help you reduce stress, gain perspective, learn to talk about your feelings, and change your thought and behavior patterns. Regardless of what type of therapy you and your therapist choose, there is much to be gained from seeking help and learning more about the mental health issues affecting your quality of life.

References:

  1. Depression Statistics. Retrieved from Depression and Bipolar Support Alliance. http://www.dbsalliance.org/site/PageServer?pagename=education_statistics_depression
  2. Duckworth, Ken M.D. & Freeman, Jacob M.D. (2012).Cognitive Behavioral Therapy. National Alliance on Mental Illness. Retrieved from http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Mental_Illness/About_Treatments_and_Supports/Cognitive_Behavioral_Therapy1.htm
  3. Facts on access to medications for people with depressive, bipolar and anxiety illnesses: The policymaker’s resource. (n.d.). National Alliance on Mental Illness. Retrieved December 8, 2014, from http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Public_Policy/Policy_Research_Institute/Policymakers_Toolkit/Facts_on_Access_to_Medications_Policymakers_Res
  4. Goldberg, Joseph. (2012). Cognitive Behavioral Therapy for Depression. WebMD. Retrieved from http://www.webmd.com/depression/guide/cognitive-behavioral-therapy-for-depression

Cognitive behavioral therapy (CBT)A therapist listens to his client seeks to help people identify negative or unhealthy thoughts, replace those thoughts with healthier thoughts, and in so doing, change their behavior and feelings. People don’t have to spend endless sessions discussing painful childhood memories, and the formulaic nature of CBT offers some people reassurance.

Preliminary studies of CBT showed impressive improvements in symptoms of conditions ranging from depression to personality disorders, leading to a surge in therapists who offered CBT. This type of therapy continues to be one of the most widely used evidence-based treatments available.

According to famed British psychologist Oliver James, though, CBT is a “scam” that does little to address underlying psychological issues. James, a psychodynamic therapist, argues that until people understand what led to their psychological troubles, those troubles are likely to reoccur.

GoodTherapy.org CEO and founder Noah Rubinstein, LMFT, LMHC, takes a similar stance with regards to addressing underlying issues in therapy.

“I am certainly not an expert on what research has shown about the efficacy of CBT, and I certainly don’t want to throw the baby out with the bathwater. CBT is an evidence-based, short-term therapy that has helped many people. However, on a theoretical level, I’ve always considered CBT to be a surface-level treatment rather than a method for lasting changes,” Rubinstein said. “In my experience, the only way to make lasting change is to help people tend compassionately to the more vulnerable feelings that protective functions, or defense mechanisms—such as depression, anxiety, self-criticism, anger, or addiction—are shielding us from.”

CBT’s Short-Term Effectiveness

There’s no question about CBT’s short-term effectiveness; even James admits that people receiving CBT can see remarkable improvements in a short period of time. So effective is CBT in the short term, in fact, that CBT self-help manuals such as David Burns’s The Feeling Good Handbook have become bestsellers. Because CBT teaches people how to detect and stop automatic negative thoughts, it’s especially popular for treating depression and anxiety. Some therapists, regardless of therapeutic modality, even insist that their clients use CBT principles to treat these conditions. 

Can Short-Term Behavioral Interventions Provide Lasting Results?

When researchers evaluate the long-term effects of CBT, the treatment looks less promising. James points out that psychodynamic psychotherapy yields better results in the long term because it helps people address the root causes of their distress. Several studies support this claim. For example, a 2003 meta-analysis that compared CBT and psychodynamic therapy for depression across several studies found that people who used psychodynamic therapy had larger improvements. Another study of marriage therapy evaluated the effects of behavioral versus insight-oriented marital interventions. CBT relies on behavioral interventions, while psychodynamic therapy is built on insight. Thirty-eight percent of couples who used the behavioral strategies were divorced four years later, compared to just 3% of couples who relied on insight-based approaches.

Rubinstein takes the view that conditions such as depression and anxiety protect us from the vulnerable feelings associated with the true source of our distress.

“For example,” Rubinstein said, “the man with depression who’s shut down, can’t get out of the bed in the morning, and has given up might be protecting himself from trying, failing, and once again feeling that terrible worthlessness he’s felt in the past.” Like James, Rubinstein sees CBT as a short-term fix that “helps to eliminate the problematic, surface-level protective behavior.”

Indeed, one of the selling points of CBT is that it doesn’t require a long-term commitment to therapy. Many CBT programs take only a few months, and some promise near-immediate results. A study published in Psychological Medicine in 2008, though, found that long-term approaches may be preferable. That study compared long-term psychodynamic therapy to two short-term therapies: short-term psychodynamic therapy and solution-focused therapy. While the short-term approaches produced more immediate results, those results faded over time. At the three-year mark, people who had undergone long-term therapy saw more improvements. Although this study didn’t evaluate CBT, it does suggest that dedicating more time to gaining insight can be valuable. [fat_widget_left]

Laura Reagan, LCSW-C, a GoodTherapy.org Topic Expert on trauma and posttraumatic stress, blends CBT with a variety of other techniques. She sees CBT techniques as effective and essential, though she acknowledges that CBT may not be best for addressing long-term issues.

“In my practice with trauma survivors, focusing only on changing thoughts and behaviors through CBT without using a more depth-oriented approach will result in only temporary improvement of symptoms which are likely to return, as the underlying problem has not been addressed. I use CBT skills as part of my work with clients to challenge negative cognitions about the traumatic events experienced.”

Rubinstein agrees that underlying problems need to be addressed for lasting change, “I don’t agree with everything Freud postulated, but he did believe that if you eliminate a defense mechanism, another will take its place, and I think that is the problem with CBT in terms of its long-term effectiveness. Therapies that help people to resolve the deeper and more vulnerable feelings that fuel defense mechanisms offer potential for long-lasting change.”

Is It a Scam?

While CBT doesn’t work for everyone, it’s far from a scam. James is a well-respected therapist, but he’s also a practitioner of psychodynamic therapy, so his opinion is by no means free of bias. While some studies have shown that psychodynamic therapy is more effective in the long term, others show that the two approaches are equally effective. Few studies show that CBT doesn’t work at all, and several studies suggest that CBT can work in the long term. A study that evaluated people who had been treated with CBT for social anxiety found that, even three years later, they were able to use what they had learned in CBT to more effectively cope with anxiety. A 2006 review of recent studies found that CBT may help reduce depression relapse rates, particularly when researchers compare the effects of CBT to the effects of medication alone.

Carey Heller, PsyD, a GoodTherapy.org ADHD Topic Expert who uses CBT as well as other forms of therapy in his practice, highlights the importance of a strong therapeutic alliance. He explains, “Many studies have shown that the quality of the relationship between the therapist and the patient/client is one of the best predictors of treatment outcome. Thus, the specific type of treatment, whether it is CBT, psychodynamic, or an integrative approach, is not the only determining factor in whether treatment will be successful for a specific individual. I feel it is more important to find a clinician who you feel comfortable with and can look at your unique needs in determining the best treatment approach to help you rather than just seeking out a specific type of treatment on your own.”

References:

  1. Hope, Jenny. (2014, November 10). ‘CBT is a scam and a waste of money’: Popular talking therapy is not a long-term solution, says leading psychologist. Retrieved from http://www.dailymail.co.uk/health/article-2828509/CBT-scam-waste-money-Popular-talking-therapy-not-long-term-solution-says-leading-psychologist.html
  2. Kendall, P. C., & Southam-Gerow, M. A. (1996). Long-term follow-up of a cognitive–behavioral therapy for anxiety-disordered youth. Journal of Consulting and Clinical Psychology, 64. Retrieved from http://dx.doi.org/10.1037/0022-006X.64.4.724
  3. Knekt, P., Lindfors, O., Härkänen, T., Välikoski, M., Virtala, E., Laaksonen, M., . . . Renlund, C. (2008). Randomized trial on the effectiveness of long-and short-term psychodynamic psychotherapy and solution-focused therapy on psychiatric symptoms during a 3-year follow-up. Psychological Medicine, 38(05). doi: 10.1017/S003329170700164X
  4. Leichsenring, F. (2003). The Effectiveness of Psychodynamic Therapy and Cognitive Behavior Therapy in the Treatment of Personality Disorders: A Meta-Analysis. American Journal of Psychiatry, 160(7), 1223-1232. doi: 10.1176/appi.ajp.160.7.1223
  5. Snyder, D. K., Wills, R. M., & Grady-Fletcher, A. (1991). Long-term effectiveness of behavioral versus insight-oriented marital therapy: A 4-year follow-up study. Journal of Consulting and Clinical Psychology,59(1), 138-141. doi: 10.1037//0022-006X.59.1.138

cory f newmanEditor’s note: Cory F. Newman, PhD, ABPP, is a psychology professor at the University of Pennsylvania and the author or co-author of several books. His continuing education presentation for GoodTherapy.org, titled Core Competencies in Cognitive Behavioral Therapy: Becoming an Effective and Competent Cognitive Behavioral Therapist, is scheduled for 9 a.m. PDT on May 16. This event, free to GoodTherapy.org members, is good for two CE credits. For details, or to register, please click here.

Much has been written about the methods that comprise cognitive behavioral therapy (CBT). There is an abundance of research supporting CBT’s efficacy in treating a range of psychological maladies across a variety of groups (age, gender, ethnicity, etc.). As such, CBT is more accurately described as an entire set of psychotherapies, with key features in common but also demonstrating differences depending on the problem and person being treated, that have been designed and tested to meet the highest standards of care.

Over the past few decades, great strides have been made in developing CBT so that it helps people even when they demonstrate psychological difficulties on the more serious side of the spectrum, such as chronic mood issues, suicidality, debilitating anxiety, addictions, posttraumatic stress, eating disorders, and many other areas of mental health concern. Furthermore, the field is always improving, owing to the CBT tradition of refining and researching new ways of delivering care. Although CBT is not a magic “cure,” it is a powerful psychological technology that is helping more and more people, providing ever-increasing hope for even better outcomes in the future.

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It is easy to think of CBT as comprising a set of “techniques,” mainly because there is indeed a set of core methods that are most often associated with this modality that have been identified as being key components in helping people to cope and live more effectively. The list below is just a sample of such techniques, all of which have been described in great detail in CBT texts and CBT treatment research protocols:

These are just some of the CBT methods that can be used effectively, not only in the therapist’s office but also as part of homework assignments—another powerful part of treatment that improves people’s sense of self-efficacy, consolidating their memories for the interventions and their skills in performing them, and leading to good maintenance of therapeutic gains.

Additionally, the CBT literature is clear that the therapeutic relationship is an indispensible part of a positive, efficacious intervention, as is a well-conceived cognitive behavioral case formulation. This is where CBT begins to go beyond techniques and into the realm of the therapist’s personal qualities, thinking style, interpersonal manner, and skills in listening, understanding, and communicating. CBT is not delivered by machines, and it does not come in prepackaged “doses” that are passively “taken.” It is delivered by fellow humans called “therapists,” a rather diverse lot of individuals with varying years of clinical experience and training histories, as well as individual personality characteristics that naturally play a role in their competency and expertise in conducting CBT. What are the qualities of therapists who are most likely to be highly competent? What should people look for in a therapist so as to be confident that the CBT they are receiving is top-notch care?

Most people think of competency and expertise as being related to training and experience, and there is more than a kernel of truth to this assumption. When a therapist is licensed, board certified in cognitive behavioral therapy (e.g., via the American Board of Professional Psychology and/or the Academy of Cognitive Therapy), has a substantial history of treating people and supervising trainees, and has a track record of publishing and lecturing on CBT, there is a good chance that this therapist will be knowledgeable and effective in the clinical sphere. However, there is evidence that even novice practitioners can deliver CBT very competently if they are well-supervised. Therefore, there is more to competency than repetition of methods and recognition of patterns over time.

What are some of the habits, attitudes, and personal qualities of therapists that amplify their competency and help get the best clinical results, whether they practice CBT or any other evidence-based treatment? The following may seem obvious, but they warrant more discussion and attention than they typically get. If the information below simply validates and reinforces what you already do as a therapist, I will have accomplished my goal with this post. Here is a sample list of suggestions, with some accompanying commentary:

Show respect for a person’s time: Make a concerted effort to be on time for sessions, to stay focused on the person in the session (e.g., rarely attending to your incoming calls, messages, or other distractions), to give them their full allotment of session time, and to try to see them as soon as your schedule will allow. Return their phone calls as promptly as you can, and be understanding when their legitimate life demands make it difficult for them to attend sessions and/or to do their therapy homework as regularly as would be optimal.

Do your homework and be organized: Be a good role model for taking care of business, being prepared, and being up to date on a person’s situation. This includes taking good therapy session notes, reviewing those notes so you are aware of and conversant in the matters that are on the person’s agenda, following through with extra-session tasks such as consulting with the person’s other practitioners and releasing records when requested, and being willing to review the person’s homework assignments as part of your own homework. Anything you can do to facilitate your memory of the details of the person’s current life and history (including the names of family members, important events in their lives, and noteworthy things they said in previous sessions) is very powerful in conveying the message, “I value you as an individual and I am providing a treatment that is focused on you, not just your diagnosis.”

Be professional, ethical, and respect cross-cultural issues: This covers a broad area, including speaking to people in a caring, supportive, confident tone, maintaining professional boundaries while still being friendly, attentive, and personable, going over the details of informed consent, explaining both your role and the person’s role in treatment, handling uncomfortable requests in a calm way that is not sanctimonious, speaking in a way that shows self-respect and respect for the other person, and being sensitive and responsive to his or her cultural identity and related issues.

Don’t just provide instructions; provide hope and inspiration: In thinking back to our school days, most of us can remember at least one teacher who was particularly adept at inspiring us to learn and to get the best out of ourselves as students. Be like that teacher when you treat people. Many people feel lethargic, distracted, helpless, and hopeless. It is not enough for us simply to provide instructions in a neutral tone. We need to “lean in” and speak in a way that gets their attention, promotes hope, and that expresses confidence in them. Express a commitment to help the person even when he or she has difficulty making a commitment to treatment. Give positive feedback even when people can’t believe it themselves. Be a role model for persevering in the face of obstacles and adversity, and for not giving up. Share some appropriate humor at the right time to make people smile and laugh, and to add some positive energy to the therapeutic dialogue.

Be open and eager to learning: One of the most rewarding aspects of being a therapist is meeting so many people who have so much to teach us. We can provide people with an education about using CBT effectively in their lives, but they provide us with lessons about life itself. Don’t just be aware of and open to the idea that people are often our teachers, embrace the idea. It is very empowering for people when their therapists thank them for sharing their knowledge and wisdom, and it enriches the therapist—both in his or her personal life, but also in terms of being that much more aware and sensitive toward a diversity of people in the future. It also demonstrates a respectful humility that amplifies the validity and meaningfulness of what therapists communicate when they do show confidence and authority in teaching CBT methods to people.

Find the “picture that is worth a thousand words”: A little bit of creativity can go a long way in therapy, especially if it makes a positive impression on people and helps them remember important concepts for the long term. Using metaphors, analogies, images, hypothetical questions, and stories with which people can personally relate are powerful learning vehicles. When therapists make it a point to pay attention to the things that matter to people most (and that define them as individuals), such as their hobbies, their profession, their cultural practices and beliefs, their most important relationships and memories, and their views about life and the world, the therapists are in a position to give feedback that deeply resonates. Brief examples include:

In sum, CBT is a powerful technology for psychological change, but the human element is part and parcel of CBT methods. Competent CBT practitioners know how to use the core techniques that have been demonstrated to be efficacious, but they magnify the positive impact of these methods via their personal qualities, habits, and attitudes that communicate care, convey accurate understanding and respect, and inspire people to remember and use the most important aspects of treatment for the long run.

References:

  1. Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York: Guilford.
  2. Butler, A. C., Chapman, J. E., Forman, E. M., and Beck, A. T. (2006). The empirical status of cognitive behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17-31.
  3. Dobson, D., and Dobson, K. S. (2009). Evidence-based practice of cognitive behavioral therapy. New York: Guilford.
  4. Gilbert, P., and Leahy, R. L. (Eds.). (2007). The therapeutic relationship in the cognitive behavioral therapies (pp. 106-142). New York, NY: Routledge.  
  5. Greenberger, D., and Padesky, C. A. (1995). Mind over mood. New York, NY: Guilford.
  6. Hays, P. A., and Iwamasa, G. Y. (Eds.). (2006). Culturally responsive cognitive behavioral therapy: Assessment, practice, and supervision. Washington, D.C.: American Psychological Association.
  7. Kazantzis, N., Whittington, C., and Dattilio, F. (2010). Meta-analysis of homework effects in cognitive and behavior therapy: A replication and extension. Clinical Psychology: Science and Practice, 17, 144-156.
  8. Knapp, S. J., and VandeCreek, L. D. (2006). Practical ethics for psychologists: A positive approach. Washington, D.C.: American Psychological Association.
  9. Kuyken, W., Padesky, C. A., and Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. New York: Guilford.
  10. Newman, C. F. (2012). Core competencies in cognitive-behavioral therapy: Becoming a highly effective and competent cognitive-behavioral therapist. London: Routledge.
  11. Newman, C. F. (2011). Cognitive behavior therapy for depressed adults. In D. W. Springer, A. Rubin, and C. G. Beevers (Eds.), Clinician’s guide to evidence-based practice: Treatment of depression in adolescents and adults (pp. 69-111). Hoboken, NJ: Wiley.
  12. Nezu, A. M., Nezu, C. M., and D’Zurilla, T. J. (2013). Problem-solving therapy: A treatment manual. New York: Springer.
  13. O’Donohue, W. T., and Fisher, J. E. (Eds.). (2009). General principles and empirically supported techniques of cognitive behavior therapy. Hoboken, NJ: Wiley.

Man in small space hugging selfMost people have experienced brief periods of anxiety while riding in an elevator, stuck in the midst of a large and tight crowd, or even while playing hide-and-seek. But for people with claustrophobia, the fear of being trapped in a small space can be so debilitating that it interferes with regular life activities.

In fact, the distinction between “normal” anxiety about enclosed spaces and phobic-level fear is the fact claustrophobia tends to interfere with life activities such as climbing a stairwell or riding in an elevator for work, playing with one’s children, or going to certain locations.

What Is It?
Claustrophobia is categorized by a chronic and unreasonable fear of being trapped in a small or enclosed space with no hope of escape, and it is classified as an anxiety disorder. People with claustrophobia also frequently experience a related fear of suffocation. Being in a small space can cause people with the issue to fear that they won’t be able to breathe, and for this reason, people with claustrophobia sometimes experience fear in settings that don’t seem enclosed or frightening. For example, a person with claustrophobia sitting in a dentist’s chair might be so afraid of confinement that the person becomes convinced that he or she will suffocate if he/she remains in the chair. People with the issue may experience extreme anxiety, panic attacks, difficulty breathing, profuse sweating, and difficulty concentrating when they are in a small space.

People with claustrophobia tend to experience anxious reactions in a variety of settings rather than just one particularly frightening setting. For this reason, claustrophobia tends to become generalized and may worsen over time. A person who was once afraid of elevators might generalize his or her fears to closets, apartments, doctor’s offices, and small stores. In extreme cases, people with claustrophobia may be so afraid of confinement that they refuse to leave their homes or travel to unfamiliar locations.

What Causes It?
Claustrophobia is one of the most common phobias, with about 5% of the population experiencing it to one degree or another. Some scientists believe that this indicates an evolved, genetic fear of closed spaces. The reasoning for this explanation is that being trapped in a small space can be dangerous, so the brain has evolved a special fear of these situations to prevent people from taking potentially life-threatening risks. However, there is also evidence that claustrophobia is learned. People who have been trapped in a small space—such as people who were trapped in an elevator or who were locked in their bedrooms as children—are more likely to become claustrophobic, and children of people with claustrophobia are more likely to become claustrophobic. This is probably due to a combination of genetics and parental modeling.

How Is It Treated?
Although phobias can be debilitating, they are generally fairly easy to treat. Counter-conditioning and exposure therapy work by gradually exposing people with claustrophobia to triggering circumstances to help them build a tolerance and learn coping mechanisms for their fears. People with mild claustrophobia sometimes benefit from deep-breathing techniques and distracting thoughts, and people with severe claustrophobia may take anti-anxiety medications to help them function until therapy can help them address the underlying causes of the phobia. Some people with claustrophobia also benefit from cognitive behavioral therapy, which helps them identify the negative thoughts that lead to fear-based reactions and to slowly adjust these thoughts to more positive, less fear-inducing ones.

References:

  1. Claustrophobia. (n.d.). Epigee. Retrieved from http://www.epigee.org/mental_health/claustrophobia.html
  2. Kahn, A. P., & Doctor, R. M. (2000). Facing fears: The sourcebook for phobias, fears, and anxieties. New York, NY: Checkmark Books.

Childhood anxiety is a serious but often undiagnosed condition. Separation anxiety, social phobia and generalized anxiety are among the most common mental health issues affecting children and adolescents. Anxiety in childhood often predicts the occurrence of such problems later in life.

Identifying and treating anxiety and other mood disorders at early as possible is therefore an important goal of psychiatric research. Undiagnosed mood issues represent a large public health burden and result in a poor quality of life of those affected. The standard treatments for childhood anxiety are antidepressant medications and cognitive behavioral therapy.

Zoloft (sertraline) belongs to the class of antidepressant medications known as selective serotonin reuptake inhibitors (SSRIs), and researchers have identified it as the medication of choice for treating most instances of childhood anxiety. Compared with similar medications, Zoloft offers the greatest benefit to anxiety sufferers with the lowest incidence of adverse side effects. However, as with many antidepressant medications, there is a small risk of suicide or self-harm in children and young adults at the start of a new drug regimen. Those with anxiety rather than depression are less likely to experience these effects. Children and adolescents should be assessed for suicide risk before beginning any antidepressant medication.

Several clinical trials have offered strong evidence that a combination treatment including Zoloft and cognitive behavioral therapy offers the most substantial improvement for children who have been diagnosed with anxiety issues. In one such study, 80% of participants receiving combination treatment saw significant improvement after 12 weeks. Researchers theorize that therapy and medication have a synergistic effect with one enhancing the effects of the other.

Regular therapy sessions also provide an opportunity for children and parents to report side effects from the children’s medication. In the previously mentioned study, both therapy and Zoloft alone also led to improvements on an anxiety rating scale that far outperformed placebo. Most importantly, participants receiving Zoloft did not report more adverse side effects than participants receiving placebo did, and none considered or attempted suicide.

When considering childhood anxiety, the rewards of effective treatment for outweigh the potential risks of medication. A combination of weekly cognitive behavioral therapy sessions and prescription of the antidepressant medication Zoloft seems to promise the best results for the greatest number of patients. As always, attending physicians must prescribe drugs like Zoloft cautiously, especially to children and adolescents.

References:

  1. Sertraline – PubMed Health. (n.d.). National Center for Biotechnology Information. Retrieved April 6, 2012, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001017/
  2. Walkup, J.T., Albano, A.M., Piacentini, J., Birhamer, B., Compton, S.N., Sherrill, J.T., Ginsburg, G.S. et al. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359, (26), 2753-2766.

Close up of hands being washed

Most people experience some form of irrational fear or anxiety, and many are concerned about germs and disease in particular. Amid a flurry of films and media reports about antibiotic-resistant infections and life-threatening flu strains, it’s easy to understand why some people actively worry about what they touch and breathe.

While concern about germs can motivate people to make health-conscious decisions such as frequently washing their hands, a serious germ phobia can drastically alter how a person functions and engages with society. Even actor and television host Howie Mandel concedes he has been unable to shake the grip of mysophobia—the technical term for fear of germs. Phobias are differentiated from general fears by degree. A person who is concerned about germs might wash his or her hands or get a flu shot, but a germ phobia can interfere with every area of life. Phobias are treatable, and people experiencing them should seek medical or psychological assistance.

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Symptoms
The primary symptom of mysophobia is an irrational fear of germs. This can manifest differently in different people. One person, for example, might be fixated on a specific germ or disease, while another person might be afraid of germs and dirt in general. Common behaviors associated with mysophobia include:

Effects
Mysophobia doesn’t simply inspire fear and avoidance. The phobia can be all-encompassing and life-altering. While people with mysophobia often recognize that their reactions are irrational, they can’t control them. They may avoid going out in public, developing intimate relationships, or eating food they did not cook. Because mysophobia affects so much of a person’s life, it can lead to other mental health issues such as depression, social isolation, and anxiety. Complete avoidance of germs can actually contribute to the development of health problems. Overuse of antibacterial and disinfectant products has been implicated in the spread of new, resistant infections, and children who are not exposed to germs are more likely to develop allergies.

Causes
No one knows exactly why people develop phobias, but mental health experts have developed a few theories. Some believe that people are more likely to develop phobias that protect from danger. These phobias include germ phobias, fear of large animals, and fear of heights. People who develop phobias may take these natural fears too far and react with extreme anxiety, placing them in danger they are believed to be trying to avoid.

Early experiences also can make a person more likely to develop a phobia. Childhood illness, the death of a parent, or painful medical procedures can condition a person to be extremely fearful of germs and to take extreme measures to avoid them. Phobias also tend to run in families; they may be genetic or simply learned from parents.

Treatment
Phobias are highly treatable and often require only a few sessions with a qualified mental health professional. Cognitive behavioral therapy, which helps people to reframe intrusive and phobic thoughts, can be extremely beneficial. Desensitization, a process whereby a person is slowly exposed to a frightening stimulus, also is highly effective. Some doctors may prescribe anti-anxiety medications to help people with mysophobia cope with their fears during treatment or to enable them to function in public. Some clients also experience success with hypnotherapy, often in only two or three sessions.

References:

  1. Audesirk, T., Audesirk, G., Byers, B. E. (2008). Biology: Life on earth with physiology. Upper Saddle River, NJ: Pearson Prentice Hall.
  2. Overcoming your Fear of Germs. (n.d.). Fear of Germs. Retrieved from http://www.fearofgerms.com/
  3. Kring, A. M., Johnson, S. L., Davison, G. C., Neale, J. M. (2010). Abnormal psychology. Hoboken, NJ: John Wiley & Sons.
  4. Phobias. (n.d.). U.S. National Library of Medicine. Retrieved from http://www.nlm.nih.gov/medlineplus/phobias.html

 

A client that drops out of therapy is one who does not complete the recommended course of treatment. Many therapeutic approaches, such as cognitive behavioral therapy, do not have a specific treatment deadline, and clients are considered dropouts when they have voluntarily stopped therapy prior to resolving the issues and symptoms that brought them there to begin with. Dropout is a serious concern for the medical community and the general population. Individuals who drop out of therapy are more likely to have future psychological complications and seek services multiple times, which places an economic burden on society. Because they do not learn adaptive coping strategies and fail to address the issues that plague them most seriously, they are likely to be less than productive in their careers, families, and communities. Additionally, therapists who experience client dropout may begin to question their ability to help clients and their own adequacy.

Understanding the factors that contribute to dropout can provide clinicians with the information they need to address the problem. Joshua K. Swift of the Department of Psychology at the University of Alaska in Anchorage wanted to explore this problem further and made it the focus of his most recent study. Swift analyzed over 650 studies that included more than 83,000 clients and looked at factors such as client age, therapy setting, therapist experience, type of therapy, issues addressed in therapy, and clinician definition of dropout.

Swift found that nearly 20% of all the clients in the studies ended their treatment early. He found that some variables, such as therapy setting, influenced the rates of dropout. He also discovered that rates of dropout were highest among the youngest participants and those seeking treatment for personality or eating problems. Swift believes that more work is needed to determine specific nuances that effect retention. He hopes efforts will be aimed at isolating psychological issues, such as anxiety or depression, and approaches, such as psychodynamic or behavioral therapy, in order to get a clearer idea of the different dimensions affecting treatment completion. Swift said, “By paying attention to these variables and making adaptations where needed, clinicians may be able to reduce rates of premature discontinuation in their work with clients.”

Reference:
Swift, J. K., Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology80.4: 547-559.

Close up of person meditatingI first met Albert Ellis, the founder of Rational Emotive Behavior Therapy (REBT), about 35 years ago. Soon after I became an Associate Fellow and a Supervisor with the Albert Ellis Institute in New York City, and was a died-in-the-wool devotee for decades.

Al was open to all of us adding or subtracting a variety of techniques, whether meditation, homeopathy, yoga philosophy, or anything else, as he had already incorporated disparate ideas from areas as diverse as Buddhism and behaviorism. He wanted each therapist to put his or her own stamp on their ways of working, although I believe he assumed we would all keep the REBT skeleton beneath whatever robes we draped it in.

Rigid, dogmatic thinking was not the coin of his realm. In fact, he loved to engage in lively discussions of all therapeutic techniques and was happy to incorporate anything he believed would help shift a client to becoming more unconditionally self-accepting.

Of course, like any parent, he was proud and delighted when his baby, REBT (the precursor of cognitive behavioral therapy [CBT]), would be “proven” to be effective in alleviating depression, anxiety, anger issues, or anything else, as it was with 40-plus years’ worth of studies.

This plethora of evidence-based practice studies that have lauded the effects of REBT and CBT is what led to the Swedish government’s decision to invest heavily in training clinicians to provide CBT to people with depression and anxiety and spend no money on training or treatment in other modalities. Naturally, the Swedish government was a bit shocked when a recent study showed that training therapists in and treating clients with CBT had little or no effect.

In response to these findings, Scott D. Miller, Ph.D. wrote: “The widespread adoption of the method has had no effect whatsoever on the outcome of people disabled by depression and anxiety.  Moreover, a significant number of people who were not disabled at the time they were treated with CBT became disabled.”

Apparently, this has not deterred the American Psychological Association from resurrecting its plan to draft and promulgate a series of guidelines pushing specific treatments for different mental health issues.

Dr. Miller and his colleagues at the International Center for Clinical Excellence have analyzed many studies showing little difference between treatment approaches in terms of outcome. They argue that all approaches work almost as well, and efforts to target specific treatments for each psychiatric diagnosis are not an effective use of time and money.

Dr. Miller recently talked about what works in behavioral health and recommended shifting the focus to designing client-tailored services rather than spending so much energy on examining specific treatment models and techniques. Meanwhile, Sweden has decided to end the exclusive use of CBT for the treatment of anxiety and depression, realizing that people need to have therapy choices.

As a holistic psychotherapist for almost 40 years, I think it is obvious when treatment is working: people self-report feeling better. They engage in life more fully, sleep better, take better care of themselves, and have more satisfying relationships and more meaningful life experiences.

As much as it can be wonderfully useful to study psychological modalities, theories, and philosophies, at the end of the day it all boils down to whether the person has been helped or not. Using evidence-based practice studies as a Procrustean bed will only cause pain and prolong suffering, just as the original one tried to stretch or shrink people to fit its specifications.

Source:
Miller, S. D. (May 13, 2012). Revolution in Swedish mental health practice: The cognitive behavioral therapy monopoly gives way. Retrieved from http://www.scottdmiller.com/?q=node%2F160&goback=%2Egde_53475_member_125725759

Related articles:
What is CBT?
Deep Breathing and Guided Imagery
When Someone Really Listens, We Heal

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