Questions about Psychotherapy

A recent editorial in the Journal of Psychopharmacology by David J. Nutt and Michael Sharpe raises questions about the efficacy and safety of psychotherapy. It's currently available free of charge, but will be placed behind a pay wall 90 days after initial publication.

Clearly, an editorial in a psychopharmacology journal is not going to be sympathetic to psychotherapy and this article does not disappoint. I'm going to discuss four of their points.

1. Is Psychotherapy Effective?

Nutt and Sharpe begin by questioning the effectiveness of psychotherapy. They say, "few psychotherapy trials have complied with the standard regulations that are required of all drug treatments." This is both true and not true. Psychotherapy cannot be evaluated in the same way as drug therapy. It's a different treatment and there are different issues in evaluating it. Psychotherapy is a procedure, and as such, it is more akin to surgery, than it is to pharmacotherapy.

Nevertheless, psychotherapy has a rich and diverse research base, going back over 50 years. In particular, cognitive behavior therapy (CBT), always grudgingly acknowledged as an empirically based therapy, is based on a large body of literature involving operant conditioning, classical conditioning, rational emotive behavior therapy, self control and self-management. There are large numbers of outcome studies available. While few are large-scale studies, the accumulation of the data through meta analysis still shows fairly robust and positive results.

This research base has given us a good understanding of how CBT works. See the Handbook of Psychotherapy and Behavior Change for some excellent reviews of the research. In fact, we have a better idea of how CBT works than how drug therapy works. We have a pretty good idea about how changing thoughts change mood, and how exposure changes anxiety. In contrast, we still haven't been able to define that "biochemical imbalance" that allegedly causes depression. If you think we have, ask a psychopharmacologist what the balance is, or ask why one SSRI works and another doesn't.

Nutt and Sharpe also raise the issue of whether or not psychotherapy has been evaluated with double blind studies and placebo controls. I'm going to leave that issue for another day. I think they're wrong, but that's going to require more research than I have time for tonight.

Is Psychotherapy Safe?

Nutt and Sharpe question the safety of psychotherapy. They begin by arguing that psychotherapy can, in some cases, worsen outcomes. In particular, they identify suicidal patients and manic patients as being at risk. However, any treatment can cause problems in these patients. We have all heard of the worsening of suicidal ideation in adolescents on SSRI's (Nutt and Sharpe minimize this, but the black box is still there). Less well known is that SSRI's can also cause a manic episode in people with bipolar disorder. One advantage of psychotherapy is that the individual is seen more frequently and can be managed if they deteriorate. In contrast, people receiving drug therapy may not have any contact with their physician for a month or longer.

Another issue they raise involves an old technique called flooding. In exposure therapy, we deliberately expose people to feared stimuli, but in gradual steps. Flooding therapy involves fully immersing the subject in the feared situation all at once. Here is what Nutt and Sharp say about it:

When taken to its logical extreme [exposure therapy] becomes flooding therapy, which was once popular. The anxiety induced by flooding can be extraordinarily distressing and there are well recognised examples of patients escaping in fear from their treatment andrefusing further sessions. David Nutt runs a specialist anxiety disorders clinic in which we have seen a number of patients who could be considered as suffering from a PTSD-like syndrome as a consequence of failed flooding treatment for phobias and OCD. (p.4)

I can believe that a "PTSD-like syndrome" could occur as a result of premature termination of flooding. In fact, I never thought I would have the intestinal fortitude to keep a client in a feared situation long enough to make the procedure work. So, I never did any flooding, and, in fact, I've never met a therapist who ever did any flooding. They must have been out there, but I never traveled in their circles. So, I can't believe it was "popular."

Besides, isn't this an example of the pot calling the kettle black? Shall I now list the now-rejected medical procedures that have hurt people? Ever read the book, The Lobotomist? We who help those in pain often feel the need to "do something," to help people and we often wind up hurting instead of helping.

Nutt and Sharpe then raise the "false memory syndrome" canard. According to advocates of this syndrome, questioning people about past trauma can cause people to develop false memories of events. In reality, experimental evidence for false memory syndrome is weak. Ken Pope has a good discussion of the problems with false memory syndrome here.

Nutt and Sharpe unwittingly provide an excellent example of how badly false memory syndrome is abused. They say:

One young adult patient of David Nutt’s with severe OCD (obsessive-compulsive disorder--F.O.) was quizzed by a therapist about the possibility that she had suffered sexual abuse by family members. This led to her developing chronic ruminations about the possibility that she might have been abused by her father, even though she knew this had not happened. As a consequence for years she was unable to tolerate being in the same room as him, which markedly exacerbated her problems and caused great distress to the family. (emphasis added; p.4)

The section I italicized is the key. The patient knew full well that her father never abused her, so this could never have been an issue of false memories. Instead, this woman was struggling with an obsession. No big surprise. She had OCD. The woman obsessed over the possibility of her father abusing her.

There have clearly been some therapeutic abuses in the name of uncovering a history of trauma. This ain't one of them. A therapist who doesn't consider the possibility of trauma in a severely ill patient isn't doing his or her job.

Are Effective Treatments Withheld?

Moving on, Nutt and Sharpe argue, "Another proven potential risk of psychotherapeutic treatment is that effective drug treatments are withheld either because the therapist does not believe in their efficacy or because the patients are not introduced to the possibility of their being useful in their condition (Klerman, 1991)." True, but this is not a risk of psychotherapy. It's a risk of being a true believer. How many times have patients not been referred to psychotherapists because the physician doesn't believe in it?

Therapist Misconduct

Finally, Nutt and Sharpe bring up the risk of sexual misconduct. They site a 1986 study showing 7% of male psychiatrists and 3% of female psychiatrists have engaged in sexual contact with their patients. I am assuming these are psychiatrists who are providing psychotherapy. But this data is over 20 years old and since then, laws have been enacted, and licensing boards have been aggressive in enforcing a ban on so-called dual relationships. In Pennsylvania, it's a felony to sleep with a client. Yes, I know it still happens. But overall, this isn't a problem with psychotherapy. It's a problem with power relationships. Professors sleep with their students. Business people sleep with their secretaries. This kind of sexual misconduct occurs everywhere there's a power imbalance between men and women. Thankfully, my profession has been aggressive about stopping this.

Conclusions

After all this, I'm not willing to just write off Nutt and Sharpe as a pair of physicians with an axe to grind. I agree that psychotherapy is not as closely regulated as pharmacotherapy and I'd like to see greater quality control over psychotherapeutic services. But like other hands-on treatments, such as surgery, physical therapy, occupational therapy, and others, much of the effectiveness of treatment relies on the skills of the provider. This comes from training. One of the great disappointments to me has been the unwillingness of the leadership in psychology to improve training and accountability.

Psychology defines itself as the science of behavior, and we often research psychotherapy. But, when it comes time to say, "Yes, I believe the data. We should do A and not B to treat depression," we back down and run away. Too many people view any effort to develop treatment guidelines as an attack on psychotherapy. It's a shame that papers like this are so poorly drawn that they reinforce this belief.

Treating Depression in the Elderly: Medication, Psychotherapy, or Both?

An article in Psychiatric Times discusses the status of treatment for elderly people who are depressed. Written by Mark Miller, it opens with this observation:

There are hundreds of studies that show that pharmacotherapy is used to treat depression in adult and geriatric populations. There are far fewer studies that test the efficacy of psychotherapies and even fewer studies that focus on combined treatment for older patients. This discrepancy is largely a consequence of industry support of research in the former and the dependence on NIMH funding in the latter two. The sober lesson we have learned from STAR*D is that there are no pharmacological treatments that work for everyone.

STAR*D (Sequenced Treatment Alternatives to Relieve Depression) was a massive set of studies, conducted under grants from NIMH, in which they attempted to replicate real world treatment of depression. In the real world, depression often--if not usually--coexists with another disorder, such as anxiety. In most studies, the subjects have uncomplicated depression. That makes it easier to interpret the results, but raises questions about applicability of the results to the real world. In most studies, the subjects were given one medication and evaluated for depression after a set period. In the real world, if the patient isn't responding to treatment, the treatment is changed.

In STAR*D, the subjects were more heterogeneous and they were given sequenced treatment. Hence, the treatment was more applicable to the real world. The results, which Miller summarizes in one sentence above, are, I think, consistent with what all of us practitioners know. Treatment effects are significant, but there is no
predictability in response to treatment. Not everyone gets better easily.

In the real world, psychotherapy is often added to medication management. In STAR*D, there were a number of studies of psychotherapy. Here is one report of adding cognitive therapy to the mix. NIMH summarizes the results as follows:

Switching to or adding cognitive therapy (CT) after a first unsuccessful attempt at treating depression with an antidepressant medication is generally as effective as switching to or adding another medication, but remission may take longer to achieve.

I believe also, that either this study or another study had evidence that showed that the subjects, when given a choice of medication change or psychotherapy, often opt for medication change. There are two reasons for this. First, taking medication is easier and less anxiety-provoking than going once a week for psychotherapy. Second, all of the television ads for drugs give the impression that they are the way to go. Yet several types of psychotherapy, most notably cognitive therapy and interpersonal therapy, have very good track records.

All of this is equally true with the elderly. Miller argues that psychotherapy is particularly important for the elderly:

Every depression is expressed in an interpersonal context and thus its effects in the patient cause ripples that sometimes damage relationships that need to be addressed for potential repair work. The goals of combination treatment in late life are to:

• Be able to restore a state of homeostasis or balance by lessening the severity of the depression (and any comorbid anxiety).
• Maximize the coping ability of the patient.
  
• Foster a more positive outlook of remaining strengths and opportunities.
  
• Solicit external supports to foster not only a sense of being "backed up" but also a sense of having valued and purposeful integration into a social network.

Working with the elderly is different from other types of psychotherapy, because there is more emphasis on coping with problems in the real world. Therapists often worry that elderly clients will be too rigid to benefit from therapy. However, that rigidity is often outweighed by a strength not possessed by younger clients. Elderly persons have been through a lifetime of problems and usually have a well-developed repertoire of coping skills. The trick in therapy is to identify them and encourage the client to use them again.

So, the answer to the question, medication, psychotherapy, or both? is "It depends." It's frustrating that mental health professionals have not been able to identify who will profit from what kind of treatment. It's still very much a trial-and-error process, despite a significant amount of science in both medicine and psychology. By combining psychotherapy and medication, we can often bring out the best of both treatments. Miller illustrates this by paraphrasing Kay Redfield Jamison (An Unquiet Mind): "Lithium diminishes my depression, but psychotherapy heals."

More Complaining about Evidence-Based Treatment

The most recent edition of the National Psychologist contains two articles concerning evidence-based treatment. Unfortunately, the online edition hasn't been updated yet and the articles are only out in hard copy.

For those of you who are not of the cognoscenti, evidence-based treatment is simply treatment with a clear research base. The research establishes that certain procedures are helpful for certain types of problems. My previous post describes an evidence-based treatment for OCD.

The first article, by Thomas Habib, opens with a bizarre story. Apparently a managed care network, Managed Health Network, wants to establish a category of, what Habib calls, an "elite clinician." I'm not sure if it's Habib's words or theirs'; I couldn't find it on their web site. Essentially, this elite clinician would be someone who has been trained in and practices evidence-based treatment. I assume that these elite clinicians would be given priority in referrals.

Habib is worried about the perceived deadly combination of managed care and evidence-based treatment. He states,

No one is against evidenced based practices. As mentioned above, how this goal was pursued and the disregard of how this might strait jacket psychology and be misused by mangled care is the problem.

"Mangled care" is an obvious shot at managed care. Certainly somewhat deserved, but then, our hands aren't entirely clean, either. There have been far too many clinicians who weren't good at getting change, but were very good at keeping clients in therapy for extended periods of time.

Managed care credentialing for clinicians doing evidence-based treatment is silly. From experience, I know this will fail, because it won't save MHN any money. Back in the 1980's, when managed care blew into Pennsylvania, I spent an incredible amount of time on the phone with "care managers," who would authorize treatment for my clients. Once I learned what they wanted to hear, it was no problem to get sessions authorized. I got to know a lot of care managers by name and we'd chat about our families before getting down to business. But, eventually, telephone authorizations became too expensive, and most of my telephone friends had to get other jobs. Now, my secretary fills out a page, I add the diagnosis, and sign it. Bingo! Another 10 sessions.

So, let me assure you, Dr. Habib. This will end with a whimper, and you'll be left with a mild bit of bureaucracy. Nothing to get excited about. Managed care isn't going to hurt you with evidence-based treatment requirements because it's too expensive to do so.

But, is evidence-based treatment a "strait jacket?" Absolutely not, and the second article illustrates my point clearly. Surprisingly the author, Frank Dattilio, also thinks he's attacking evidence-based treatment. He should really know better, as he has extensive training and publication in cognitive-behavior therapy. In his article, he tells the story of Corey, a young psychiatrist completing his fellowship. Corey brought him a tape of a therapy session, of which he was very proud. Dattilio viewed the tape and said,

Much to my dismay, the same things kept cropping up repeatedly during the course of the session--a dry, robotic type of interaction that almost appeared as though it was scripted.

At the end, Corey said to me, "So what do you think?" I was speechless. Before I had a chance to say anything, he interrupted me by saying, "I think it's classic cognitive-behavior therapy. I don't believe I left one thing out."

"Well, there is one thing that is missing," I replied. Corey looked at me perplexed, "What did I forget?" "You!" I exclaimed, "You, the therapist is missing."

It's a wonderful story, and a great cautionary tale to young therapists, who, unsure of themselves, want to retreat into "techniques." Since the 1950's, we've known the quality of the therapeutic relationship has a strong effect on therapeutic outcomes. Wampold (2001) has a good review of the data. Maintaining a good relationship with the client, being empathic and supportive, is part of any evidence-based treatment. Just look at Beck, Rush, Shaw, and Emery (1979).

The sad thing is that we continue to argue about evidence-based treatment even though we consider psychology to be a science. If psychology is a science, we believe the data. If psychology is a science, we opt first for treatments that the data shows are worthwhile. No one expects us to give up our clinical judgment and our empathy in the process. Being empathic and supportive is just another evidence-based therapy.

All psychotherapies are like seeds. They cannot grow into a beautiful flower without the fertile soil that the humanity of a good therapist provides. Clinicians do not need to fear evidence-based therapies.

References

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford.

Dattilio, F. M. (2006). Evidence based treatment may be too confining. National Psychologist, 15(5), 23.

Habib, T. A. (2006). A profession in search of legitimacy. National Psychologist, 15(5), 14.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Lawrence Earlbaum Associates.