Dr Robert London

CBT, underused, undervalued

Clinical Psychiatry News - July 26, 2013

Recently, I conducted a rather unscientific survey. I asked a few psychotherapists how they would treat a patient with whom I had worked and treated successfully in the past.

The patient is a 39-year-old single woman who is a successful attorney. Despite her career success, the patient’s personal and social life had been replete with conflicts, especially surrounding her relationships with men. In our work together, these issues resolved when I used a cognitive-behavioral approach with her. But just as we were wrapping things up, an unexpected issue surfaced.

She told me that at age 20, she had studied abroad for a year in Europe with her closest female friend. It seems that my patient’s friend was successfully married and the mother of four children – all under age 10. She also was an attorney but was now working part time. And now, years later, the patient reported despair and unhappiness about “not seeing her anymore.”

My survey began by asking numerous therapists what their approach would be to this woman’s dilemma. All of them knew about cognitive-behavioral therapy (CBT), reported using it, and endorsed using the technique to help this patient. However, the more we talked, it became clear that they were discussing traditional psychodynamic psychotherapy rather than the type of therapy started by Albert Ellis, Ph.D., in the 1950s as rational emotive behavior therapy, and later refined and codified as CBT by Dr. Aaron T. Beck in the 1960s and 1970s. In other words, my colleagues were not viewing this patient’s fears, distress, and even anger about losing her longtime friend in “here and now” terms.

They told me that they would ask questions like “how does that make you feel,” “what memories came to mind,” and the usual series of exploratory, open-ended questions and interpretations. “You need to discuss this with her and ‘get it out there,’ ” one of the therapists suggested. Wrong.

Admittedly, my patient’s past was marked by perceived abandonment, including a parental divorce; the loss of an older sister; and the constant switching of schools, because her mother moved several times. I agree that a psychodynamic style in this particular case might indeed have gotten to the root of the problem – at some point. But this approach is different from CBT, which circumscribes the problem, challenges faulty beliefs, and develops avenues for change in a reasonably short period of time.

I was able to make quick progress with this patient by asking her a simple question: “When did you last see your friend?” The answer, not surprising for “all or nothing” responders, was that she had seen her the previous week – but only for a quick 45-minute lunch. And the week before that, the two had met up at the local gym and taken a class together, but “we didn’t talk much,” my patient observed. My response to the patient was that she did indeed see and spend time with her friend, but not as much«Dr. L asks that we set this off because these words illustrate therapeutic breakthroughs» as she had when the friend was single and childless. Isn’t this the case, I asked. “Yes, yes that’s the case, I do see her, but, but, but…”

As the patient and I proceeded through the thinking therapy of CBT, she was able to recognize that she did see her friend but not as much. It became easier for the patient to understand that her friend’s life had changed dramatically and that her availability was limited because her friend’s family and work responsibilities kept her busy. The patient also began to realize that her own availability also had become more limited since she was 20.

The process of working with this patient using CBT involved more than one question and answer. The approach starts out as homing in on the “all or nothing” negative type generalized thinking, and is clearly aimed at resolving the patient’s distortions, and focusing on developing a new perspective and new way of thinking about this particular issue. Changing the thought process in this particular context is aimed at getting the patient to extrapolate to better processing in other contexts.

In addition, it is important to note that a psychodynamic approach can be incorporated into CBT as a teaching model. In this case, I found that bringing into the picture past events that had influenced the patient’s current distorted thinking helped the patient get a more honest picture of this long friendship. Her newfound perspective on that relationship spilled over into other aspects of my patient’s life in a positive way.

CBT is not only helpful for patients dealing with anxiety, depression, or lifetime personality styles and behaviors that cause them some form of distress in everyday living. A study soon to be published in the Journal of Behavior Therapy and Experimental Psychiatry suggests that CBT also might prove beneficial for negative symptoms in outpatients with disorders on the schizophrenia spectrum.

After 20 sessions of CBT over a period of 6 months, the investigators found that patients reported a decrease in the number of dysfunctional beliefs about their own “cognitive abilities, performance, emotional experience, and social exclusion” (J. Behav. Ther. Exp. Psychiatry 2013;44:300-6). This was a small study (n=21), and as the investigators noted, randomized, controlled trials are needed. Still, this study is a reminder that focusing on problem resolution in a few highly focused sessions also can help patients with serious mental illness.

Those findings notwithstanding, CBT is certainly no panacea for numerous psychotic disorders. But in light of its superb track record of resolving many emotional problems, I believe that it should be used more as a mainstay of treatment and that anyone coming out of a mental health training program – be it psychiatry, psychology, mental health social work, or psychiatric nurse practitioners – should be just as adept at using it as they are in using psychodynamic psychotherapy or medication management.