It’s a treatment that can relieve depression, calm anxiety, improve sleep quality and reduce chronic pain. It can also ease symptoms of bulimia, bipolar disorder, chronic fatigue syndrome and schizophrenia. And because it’s not a prescription drug, there are no side effects. As health officials around the world debate the risks of antidepressant drugs, doctors are re-evaluating standard treatments for conditions from depression to obsessive compulsive disorder to panic attacks. Largely ignored amid the controversy is one alternative that has proven itself as versatile and effective against mental illness as any antidepressant.
Cognitive behavior therapy, a short-term talking cure, helps people make small, seemingly mundane changes in the way they think (the cognitive) and act (the behavioral) that can produce profound and lasting recovery.
Although it came of age in the 1980s as a treatment for depression, the therapy has proved itself effective in recent years against more than a dozen illnesses in which mental distress plays some part. Between 50 percent and 60 percent of people diagnosed with depression who complete a course of the therapy show significant improvement–a success rate that’s at least as good as that seen among patients on drug regimens.
The treatment would be much more widely known and used, experts say, if not for a shortage of trained specialists, spotty insurance coverage and patients’ preference for the ease and convenience of pills.
“We really have become a Prozac nation, in the sense that drug prescribing is going up, and the use of talk therapy is declining,” said Mark Reinecke, chief of the psychology division at Northwestern University Medical School in Chicago. “The fact is that most people don’t realize how effective this therapy can be and still associate it with traditional psychoanalysis.”
As first formulated in the 1960s by Dr. Aaron Beck, a psychiatrist, and psychologist Albert Ellis, cognitive therapy was an open rejection of psychoanalysis. Whereas Sigmund Freud probed the depths of the unconscious to explain behavior and mental illness, Beck and Ellis stayed in the shallows.
The two argued that depression was not the result of cryptic, unconscious forces but rather of conscious, seemingly trivial negative assumptions and thinking. Maybe, they reasoned, these patterns of self-critical, pessimistic thinking are the disease, not merely symptoms. Cognitive techniques are meant to help people recognize those habits and provide tools to break them.
First, people learn to identify thought patterns, dark assumptions that often become self-fulfilling (“I’m a terrible parent”; “I don’t do well on tests”; “I’m unlucky in love”).
They then begin disputing these assumptions, using logic and evidence, engaging in a sort of internal debate with themselves. (For example: “Hold on, I’ve had several long-term, loving relationships.”)
Ideally, this Socratic dialogue helps people develop alternate explanations for future difficulties. (“I’m not a bad parent, I’m merely impatient when I’m trying to work.”)
They’re also taught ways to distract themselves from brooding over loss, betrayal, humiliation or other disquieting memories–the kind of rumination that can be paralyzing in everyday life.
Activity by itself can be distracting. A walk to the post office can lift one’s spirit. So can having lunch with a friend or going for a jog. As most people know through experience (but often forget), the simple act of starting work on a challenging project can quickly ease the dread of failure, said Kenneth Reinhard, director of the anxiety disorders clinic at the Hudson Valley Veterans Administration medical center in Montrose, N.Y.
By engaging in various activities with the purpose of interrupting harmful rumination or inertia, people can learn in therapy to complement their thought management with behavior, their thinking with action, Reinhard said.
The unexamined beliefs that drag people into chronic depression often are rooted in childhood, and therapists have to explore early memories, as in more traditional analysis. Any effective therapy can stir sensations or emotions that are initially upsetting or disruptive.
But for many people with stubborn mental problems, recent research suggests that cognitive therapy is worth a try:
In a study of 187 hypochondriacs, Harvard researchers reported recently that six weekly sessions of cognitive behavior therapy significantly eased patients’ anxieties over daily aches and pains and allowed them to live more normal lives.
Dutch researchers reported in March that patients suffering from chronic fatigue syndrome were about three times more likely to improve using cognitive behavior counseling than with standard group-therapy sessions. After eight months of weekly cognitive sessions, about a third of patients reported more energy and lower medical costs.
In a study published last month among 131 cancer patients, researchers at the University of North Carolina tested a five-session cognitive behavior program tailored to address pain and individuals’ psychological needs. All the patients were taking prescription painkillers. Compared with standard care, which included some counseling, the individualized therapy reduced pain intensity during the first month and allowed people to walk, socialize and sleep more comfortably, the doctors said.
Given its track record against depression in particular and its minimal side effects compared with drugs, cognitive behavior therapy should be more widely used as a first-line treatment, many psychologists and psychiatrists believe.
Yet such therapy typically costs from $50 to more than $100 a session. And a full course of the therapy may require 12 hourlong sessions, including at-home assignments, such as keeping a diary of daily difficulties and the thoughts they prompt. By contrast, a daily dose of generic Prozac can cost less than $50 a month, there’s no homework, and it is often covered by health insurance.
