July 19, 2010


As you might imagine, people often tell me about the health issues of their friends and family -- and a recurring theme is the types of problems that donít show up in a blood test or on an x-ray. I am talking about people who face emotional struggles but are reluctant to seek psychotherapy... and this story is about some new research that may help change their minds.

There are many who believe that problems like depression, anxiety and other mood disorders represent character flaws that should be overcome, not illnesses that can be effectively treated. The attitude is sometimes generational -- older folks often look at therapy as an indulgence or a sign of weakness. Sometimes it reflects a sense of hopelessness, as with my neighborís long-unemployed brother, who has gained so much weight that he now has diabetes and two stents but is too depressed to try to improve his health. And sometimes it concerns compulsions, phobias or problems that hold such sway that people believe there is nothing therapy could do to help.


All too often these days, the recommended fix for such problems is to take a pill -- and in truth, some people really do need medication. But, while psycho-pharmaceuticals have come a long way in terms of helping to alleviate symptoms, and they are sometimes a necessary and reasonable first step, patients need to address their underlying issues as well. Thatís what psychotherapy is for -- healing the cause of the disturbance. However, itís no longer acceptable for "therapy" to amble aimlessly along as in a Woody Allen movie -- evidence-based standards have now crept into the practice of psychotherapy. This may bode well for treatment of emotional issues.


Just like with orthopedic issues, heart disease and other medical problems, researchers now evaluate which types of psychotherapeutic treatment offer the best outcomes for which types of patients. This will never be black and white, mind you -- experts argue that in the right therapistsí hands, all styles of psychotherapy are helpful, since it is the dynamic between the therapist and the patient that brings results. Even so, researchers recently evaluated the purpose and success rates of two of todayís most popular approaches to therapy -- cognitive behavioral therapy (CBT) and psychodynamic therapy -- affirming that each can be very effective. Their compelling results may help convince some people who are suffering that therapists have more to offer then just a sympathetic ear -- they really can help.


Developed in the 1960s, CBT refers to a style of counseling that is relatively short-term (typically 20 sessions or less over five to six months). CBT does not dwell on the past but instead is intently focused on how you think, behave and communicate in your daily life. This research was reviewed by Timothy B. Baker, PhD, of the University of Wisconsin School of Medicine and Public Health, Madison, and published in Psychological Science in the Public Interest.

In CBT, patients learn to identify the thoughts, images and beliefs that are causing problems in their lives and then to reframe them in order to get better results. Therapy sessions help them see how their thoughts shape their behavior, which in turn affects what happens in their lives. Example: CBT is particularly helpful for post-traumatic stress disorder, not only for soldiers returning from war but also for people who have been victims of violence or accidents and even those who have witnessed terrifying events. Patients learn how the body reacts to trauma by storing emotional reactions and producing physical symptoms instead, even long after the triggering event. They practice different ways of thinking and learn relaxation techniques to use in certain types of situations. In a process called systemic desensitization, some are then gradually exposed to anxiety-producing situations so that they can practice responding more appropriately. CBT often involves homework, such as keeping a journal and practicing techniques learned during therapy sessions.

Dr. Bakerís research found that after a number of sessions (up to 15), 40% to 87% of patients show significant improvement, meaning that they have less anxiety and are able to cope better with the anxiety that they do have. According to Dr. Baker, patients with anxiety disorders including panic disorder or PTSD who undergo CBT more than double the likelihood that theyíll get better.


The second method, psychodynamic therapy, has been around lots longer than CBT and has its roots in Freudian psychoanalysis. It considers how past experience -- often from long ago -- shapes people and their lives, not only in ways that are readily apparent, but also on a more subtle level. Therapy sessions usually take place once a week and focus on the psychological roots of patientsí emotional suffering. The treatment may extend over five or six months, or it could be open-ended, lasting a year or more. Patientsí goals include...

Jonathan Shedler, PhD, from the University of Colorado School of Medicine, reviewed a large number of meta-analyses (compilations of research studies) that involved many thousands of patients to write this report. It was published in the February-March 2010 issue of American Psychologist.

Dr. Shedlerís study evaluated a range of common mental disorders, including depression, anxiety and somatic conditions (physical symptoms that can be rooted in psychological causes), noting that these were often mixed with personality problems and relationship difficulties. Not only was the psychodynamic therapy successful in the short run for all types of problems, but his report found that nine months after they had completed therapy, patients were still reporting improvement in every problem area (including depression, anxiety and physical symptoms) even though they were no longer seeing their therapists.

Especially intriguing: Dr. Shedler told me that among studies in the analysis that included data on health-care utilization, 77.8% reported significant reductions in medical treatment. It seemed that for these patients, learning to address their emotional difficulties helped bring about physical well-being as well.


While these reports describe two approaches to psychotherapy, in actual practice many therapists use both methods and others, too. Good psychotherapists need skills and tools -- not one or the other. Emotional problems are both painful and real, and these studies offer concrete evidence that may help convince some doubters that psychotherapy can be good medicine.


Timothy B. Baker, PhD, professor of medicine, University of Wisconsin School of Medicine and Public Health, Madison.

Jonathan Shedler, PhD, associate professor of psychiatry, University of Colorado School of Medicine, and director of psychology, University of Colorado Outpatient Psychiatry Service, Aurora, Colorado.