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, The Washington Post, September 03, 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."
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."
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."