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Thanks to Managed Care, Evidence-Based Medical
Practice and Changing Ideas about Behavior, Cognitive Therapy Is the
Talking Cure of the Moment
By Cecilia Capuzzi Simon
Special to The Washington Post
Tuesday, September 3, 2002
Woody Allen is still making movies, but the kind of psychotherapy he
made famous -- lying on a couch, endlessly talking about your mother and
your lousy childhood -- is losing its audience. Those who find
themselves in a therapist's office these days are likely to encounter a
very different form of treatment, one that's short-term, goal-oriented
and evidence-based. It will probably involve sitting upright in a chair.
And it will probably be
some form of cognitive therapy. Cognitive psychotherapy is the fastest
growing and most rigorously studied kind of talk therapy, the subject of
at least 325 clinical trials evaluating its efficacy in treating
everything from depression to schizophrenia. For reasons both economic
and cultural, it has begun to unseat neo-Freudian psychodynamic therapy
as the dominant form of treatment in private and institutional practices
around the country. For better or worse, cognitive therapy is fast
becoming what people mean when they say they are "getting
therapy."
As its name implies, cognitive therapy (CT) focuses on a patient's
thoughts. It is based on the idea that our beliefs and perceptions shape
our emotional responses to the world. In the world according to
cognitive therapy, negative thinking patterns -- not unconscious
conflicts or early life traumas -- cause depression, anxiety and some
other mental disorders. CT attempts to make patients aware of the
effects of these dysfunctional thoughts and then helps to change them.
For cases of minor to moderate depression, CT usually lasts from a few
weeks to a few months -- far less time than other talk therapies usually
require. This makes cost-conscious managed care companies happy.
Insurers are more likely to cover care by practitioners who use (or say
they use) cognitive therapy than by those who do not. Therapists, who
find that, on average, just seven of a patient's sessions are covered by
insurance (if any are covered), increasingly appreciate the ability of
CT to produce results in such a short time.
The public, knowingly or not, is also supporting the ascent of CT.
Perhaps it's a reaction to the overindulgent ethos of the '80s and '90s,
says John Riskind, a cognitive therapist and professor at George Mason
University, but Americans are now living in "a very pragmatic
time," seeking evidence to verify everything from automobile
reliability to school quality and now treatments for mental health.
Unlike most other forms of talk therapy, he says, CT has plenty of
evidence demonstrating its effectiveness. Medications such as Prozac and
Zoloft are still the frontline treatment for depression: 80 percent of
the 14 million Americans treated every year for depression take
antidepressants.
But there are signs of a growing backlash. The plethora of ads for these
drugs don't mention that 60 percent of people who take them don't find
adequate relief and often move from drug to drug seeking better results.
Or that some studies show patients receiving placebos do just as well as
those taking antidepressants. Or that when you stop taking the drugs,
you have a 60 to 70 percent chance of relapse. Or that side effects,
especially loss of sexual interest, discourage many people from staying
with the drugs.
Meantime, since few academics or private psychiatrists have the ad
budgets of, say, Eli Lilly, the public remains largely unaware of the
research supporting the efficacy of CT or other talking cures. But
numerous studies show cognitive therapy is as effective as medication at
treating depression, and often better than drugs for conditions like
anxiety and obsessive-compulsive disorder. In the latest and largest
study to date, presented at the American Psychiatric Association's
annual meeting in May, CT held its own with medication in treating even
severe depression – and the
relapse rate for those receiving therapy was lower. Among patients who
were followed for a year, those who had had 16 weeks of CT and up to
three "booster" sessions during the year had a relapse rate of
25 percent. Patients who took Paxil all year long had a relapse rate of
40 percent. Other studies show that combining CT with antidepressants is
the best treatment of all. Research published in the New England Journal
of Medicine two years ago showed that 85 percent of patients with
chronic major depression who were treated with CT and drugs had
significant relief of their depression or went into remission, compared
with 55 percent who took drugs only and 52 percent who were treated with
psychotherapy only. There is also published evidence that, like drugs,
CT can change brain chemistry and function in people suffering from
obsessive-compulsive disorder and social anxiety.
All of which makes a convincing case that cognitive therapy is a
legitimate alternative or adjunct to other treatment for a variety of
mental disorders. And one whose benefits can persist and enhance one's
life in other ways.
"Pills don't give you skills," says
Robert Leahy, a psychologist who heads the American Institute for
Cognitive Therapy in New York. "Prozac might make your mood better,
but it's not going to teach you how to communicate better at work."
By helping people develop successful strategies for living, CT appeals
to many people. Cognitive therapy, he says, is "practical,
here-and-now, and it empowers patients, even outside the session."
Beyond Freud Aaron Beck, known as the father of cognitive therapy, is 80
years old and a professor of psychiatry at the University of
Pennsylvania. His theory of cognitive therapy revolutionized the way
depression is conceptualized, assessed and treated. In 1989 he was given
the Distinguished Scientific Award from the American Psychological
Association for his contributions to the field. Last year, he was
presented the Heinz Award for the Human Condition for his
"pioneering breakthroughs" in psychopathology. This afternoon
he is sitting in his home in suburban Philadelphia, lunching with his
protégé daughter and a reporter, discussing his work.
Beck began his career under the sway of Sigmund Freud. As a psychiatrist
at Penn in 1959, he set out to find evidence to support Freud's theories
about depression. He began by analyzing his patients' dreams, seeking
signs that their depression was caused by deep-seated "introverted
hostility." Under Freudian theory, depression results when a person
tries to block what he considers inappropriate anger -- toward a
deceased loved one, for example. Instead of a son's accepting that his
beloved mother was in reality a selfish harridan -- that would make him
feel too guilty -- he will block that hostility and blame himself for
being a bad son. This is all unconscious, of course.
Beck figured that if Freud had it right, this would all be apparent in a
depressed person's dream state. So he studied his patients' dreams,
seeking evidence of the inward hostility.
What he found instead was that his patients' dreams were a reflection of
their conscious thinking -- or "replicas of how they saw themselves
in reality," he says. A person who dreamed of failing an exam saw
himself as destitute, for example. Another who felt he was a loser in
life dreamed of losing something of great value.
Additionally, Beck says, he noticed that the more he let his patients
"free associate" during sessions -- that is, lie on the couch
reporting their thoughts as they occurred, as psychoanalysts encourage
-- the worse they felt. But when he intervened and helped them
understand practical problems, he says, his patients made quick
progress.
Beck found no empirical validation for Freud's theories. But he did find
evidence that other interventions were effective at controlling and
eliminating symptoms of depression and other mental disorders. He
concluded that practicing as a psychoanalyst meant accepting Freudian
doctrine on faith. "For me, it was faith versus science," he
says. "I took the science route."
Face to Face
And so Beck began to break ranks with
psychoanalysis. He got his patients off the couch, interviewed them
face-to-face and worked with them on immediate thoughts and problems.
Through the 1960s and '70s, Beck developed his ideas and honed his
techniques, primarily through work with patients at his Mood Clinic at
Philadelphia General Hospital. He standardized and wrote down his
treatment so he could teach it to other therapists.
At first cognitive therapy was not taken seriously,
Beck recalls. In the '60s and '70s, psychiatry was dominated by those
studying the biological basis of depression; in the arena of talk
therapy, psychoanalysis alone ruled. Cognitive therapy was considered
"superficial and feel-good," he says. "One colleague told
me it was like treating malaria with an electric fan."
In 1973, Beck and his team from Penn conducted the first of many studies
comparing the efficacy of CT to that of antidepressant drugs. (No other
psychotherapies had been standardized for comparative study, he
explains, or he would have included them, too.) That trial and others to
follow showed that CT was successful at reducing depression and other
mental ills. When Beck published his seminal "Cognitive Therapy of
Depression" in 1979, the book launched cognitive therapy by giving
psychotherapists a precise guide to treatment.
CT is a collaborative process between therapist and patient that
ultimately teaches patients how to identify and manage their negative
thoughts. These habitual distortions in thinking -- or "automatic
thoughts," as cognitive therapists call them -- are of several
common types, including mind reading (assuming the thoughts of another,
as in, "He thinks I'm stupid"), labeling ("I'm a
failure"), catastrophic thinking ("My career is over if I'm
rejected") and all-or-nothing thinking ("Nothing ever works
out for me"). Such thoughts
play like a loop of bad background music as a depressed person makes his
way through life, clouding mood and influencing behavior.
"We look at these" statements in therapy, says Rob Leahy,
"and we get the patient to examine how accurate they really
are." What follows is a kind of Socratic dialogue questioning the
patient's negative beliefs and testing whether they are based in
reality. Often they are not. People do pick it up very quickly,"
says Beck. "For example, you might say to a patient, 'What is it
that got you really sad today?' And she says, 'Well, I realize what a
terrible mother I am. The kids were fighting at the table, throwing
things around.' You say, 'Well, I can see how that might upset you. Do
you see anywhere else where this happens?' And she says, 'Yes, it
happens to my sister and my neighbor.' And you say, 'Well, do you think
they're terrible mothers?' And she says, 'No.' You say, 'Is there any
other explanation of why kids fight at the table?' And she says, 'Well,
I guess all kids fight at the table.' "Now she's got a little
perspective and has distanced herself from her interpretation,"
Beck says.
Patients learn to question such beliefs long after therapy is completed,
Beck says, and the results endure.
"It's like the old adage 'Give a person a fish and you feed him for
a day; teach him to fish and you feed him for a lifetime,' " says
Steven Hollon, a professor of psychology at Vanderbilt University and a
leading CT researcher.
In its pure form, CT involves a set of standard therapeutic procedures.
Before therapy starts, a patient fills out a self-report and completes a
depression index, most likely the Beck Depression Inventory (BDI), a
series of 21 statements that ask a patient to rate feelings like sadness
("I feel sad most of the time") or suicidal thoughts ("I
don't have any thoughts of killing myself"). The diagnostic
instrument then calculates a level of depression.
The therapist explains cognitive therapy to the patient and they define
goals for treatment. Medication is discussed and often encouraged. The
patient leaves each session with "homework."
This homework is a hallmark of cognitive therapy
and of behavioral therapy, and
it is one of the reasons CT is often called cognitive behavioral
therapy. If a patient feels isolated and unloved, the homework might be
to call a friend to go to a movie, and then rate the experience. Unlike
pure behavioral therapy, which theorizes that an activity itself can
change behavior and reduce depression, CT uses an activity to
demonstrate to the depressed person that he is not helpless. The
evidence that he can do the activity is meant to prove that his negative
thoughts are unjustified.
Patients are also asked to write down negative
automatic thoughts, and then to write out challenges to them, or
evidence that they are incorrect. Homework includes reading about
cognitive therapy, such as David Burns's popular "Feeling
Good," a self-help book.
Not Just Purists
Not all who say they are cognitive therapists
practice a pure form of treatment as Beck conceived it. There are 350
accredited cognitive therapists in the United States, trained and
certified through the Academy of Cognitive Therapy (ACT), which operates
through the Beck Institute for Cognitive Therapy and Research.
The institute, located in Bala Cynwyd, Pa., near Beck's home, was
started eight years ago by Beck and his daughter, Judith Beck, a
psychologist and the institute's director. The institute trains mental
health professionals from around the world and treats patients. Aaron
Beck continues to do research
and evaluate patients there.
Judith Beck says "tens of thousands" of mental health
providers use cognitive therapy's techniques, or say they do (not always
accurately, she adds). Some have received training at other CT centers,
including ones in Atlanta, New York and San Francisco, but have not
taken ACT's competence exams. Of 197 accredited clinical psychology
programs around the country, about 20 offer strong coursework in
cognitive therapy, including Penn, the University of Chicago and Boston
University. Many therapists have been informally exposed to the
techniques and employ them along with others in clinical practice.
But it is difficult to quantify how many therapists actually practice
CT. A 1990 survey published in the journal Professional Psychology:
Research and Practice found that 68 percent of respondents identified
themselves as "eclectic" or "integrative"
therapists, meaning that they draw on a variety of orientations in
treatment. Of those, 72 percent included psychodynamic methods in their
approach, 54 percent included cognitive and 49 percent included
behavioral. Of those who listed an exclusive approach, 17 percent
endorsed psychodynamic, and 5 percent cognitive.
In a more recent survey of a different therapist population, the ongoing
Mental Health Provider Opinion Survey, 42 percent identified their
"theoretical orientation" as cognitive-behavioral; 18.8
percent reported psychoanalytic/dynamic, the next largest group. The
Wave of Cognition Cognitive therapy is practiced around the world,
taking hold in places from the Middle East to Japan. The technique has
had its greatest acceptance in Great Britain, where it is widely used as
a first-line treatment for depression, panic and obsessive-compulsive
disorders, and in conjunction with medication to relieve symptoms of
schizophrenia and manic depression.
In the United States, adoption has been slower,
though CT is being pushed along now by the convergence of its growing
body of research and managed care's spare allowances for psychotherapy.
In the Washington area, practitioners say there is growing interest in
CT.
Catholic University, American University, George Mason University and
the University of Maryland all offer coursework in CT. American and
George Mason do clinical training. There is even an attempt to formally
integrate CT and psychoanalysis at a clinic in McLean, the Institute for
Cognitive Analytic Studies. Still, Steve Holland, a cognitive therapist
in private practice in the District, says Washington is historically a
center for psychoanalytic training and remains "psychoanalytically
bound." There are about 20 cognitive therapists accredited by ACT
in the area. As is the case elsewhere in the country, many providers in
Washington, whether trained in CT or not, are drawing on its techniques.
Holland says participants who come to CT workshops he leads consistently
say they attend because they do not have the tools to treat people who
are allowed only a limited number of sessions by their insurers. Many
have learned to play the managed-care game.
Bruce Pickle, chairman of the clinical program at the Washington School
of Psychiatry, a postgraduate school for mental health professionals
that also treats patients, calls CT the "lingua franca" of
mental health managed care. A trained cognitive therapist, he practices
integrative psychotherapy and has, like others, explained treatment in
CT terms when communicating with managed care organizations.
"I understand cost is a factor," he says, frustrated.
"But instead of approving just 'cognitive therapy,' how about
approving therapy that works?"
But in an era of evidence-based medicine, managed care companies – and
the medical community as a whole -- are looking to standardize medical
treatment across the board. And they want to use treatments that have
been proven effective by studies. Behavioral therapy and another
treatment called interpersonal psychotherapy have empirical data that
show they work, but the bulk of research showing positive outcomes has
been done with cognitive therapy.
"You can't say you're doing evidence-based medicine without doing
cognitive therapy," says Cathy Frank, director of psychiatric
education at the Henry Ford Behavioral Health Clinic in Detroit.
To hear managed care officials tell it, psychotherapies including CT are
integral to treatment for depression. "We believe that medication
and talk therapy is the best treatment," says Jodi Aronson, vice
president for clinical operations at Cigna Behavioral Health. Cigna
refers depressed clients to a psychiatrist and a psychotherapist at the
same time. Providers, she says, must be "comfortable with
evidence-based treatments, such as cognitive therapy." Insured
patients get eight sessions upfront, but can request more.
Hyong Un, national medical director for behavioral health at Aetna,
trained with Aaron Beck and admits a bias toward CT. "We're not
having discussions about whether psychotherapy works anymore," he
says. "It's not a question of which therapy to advocate. But the
push will be for therapies which have empirical evidence to demonstrate
outcomes." A Sellout? With the ascent of CT in managed care, many
mental health providers with psychodynamic inclinations don't even
bother signing on with insurers. They resent questions about their
treatment, their methods often require more time than CT and
reimbursement is usually so low it's not worth their time.
"It is a problem when an outside entity comes between psychiatrist
and patient," says Daniel Boorenstein, a clinical professor of
psychiatry at UCLA and past president of the American Psychiatric
Association (APA) who practices psychodynamic therapy. "I don't
belong to any managed care panel. I couldn't do it. I would rather have
fewer patients."
What will be the ultimate effect of managed care's push for
quantifiable, short-term results and the mental health profession's
struggle to meet patients' needs? Psychotherapies that may be as
effective as CT but take longer and have little if any data to show they
work will be screened out, says Lloyd Sederer, who worked on managed
care issues at APA before becoming New York City's commissioner for
mental hygiene.
And that has caused resentment in the field.
Therapists feel they are being railroaded into a single school of
therapeutic thinking -- the one supported by managed care companies,
which care less about patients than about holding costs down.
Aaron Beck sees some humor in the situation. "In this country,
psychoanalysts pretty much equate cognitive therapy with managed
care," he says with a laugh. "They feel that cognitive therapy
is a betrayal because we've played into the hands of the enemy.
"Cognitive therapy was developed first! But they see this as a
sellout."*
Cecilia Capuzzi Simon is a Bethesda-based writer and editor.
© 2002 The Washington Post Company
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