In the Room

Is CBT Just a Load of B?

What if you could just forget about all that complex cognitive challenging, understanding of logical fallacies and the mental demand this asks of the clinician working in the room? A new paper out in the latest Clinical Psychology Review suggests that maybe you can. Richard Longmore and Michael Worrell have a provocative paper (can't make a link) entitled: Do we need to challenge thoughts in cognitive therapy?

..... is the direct, explicit modification of maladaptive cognitions a necessary or sufficient intervention in CBT? Hayes (2004) identified three empirical anomalies in the CBT outcome literature. First, component analyzes do not show that cognitive interventions provide added value to the therapy. Second, CBT treatment is often associated with a rapid, early improvement in symptoms that most likely occurs before the implementation of any distinctive cognitive techniques. Third, measured changes in cognitive mediators (the thoughts and beliefs held by the cognitive model to underpin disorder) do not seem to precede changes in symptoms.

Longmore and Worrell take us through a range of depressive and anxiety disorders including OCD and provide research showing that behavioural components are as effective if not more effective than the CT component. In other words leaving out cognitive challenging doesn’t make a lot of difference to outcome. I would have to say the paper appears pretty convincing and it will be interesting to see what scholarly refutation to this is raised. Studies on behavioural activation by Jacobson et al in the mid nineties raise some interesting questions.

Jacobson et al. (1996) study has potentially serious implications for both the theory and practice of CBT for depression. In practical terms, behavioral activation is simpler and more cost effective, both in the training of therapists and delivery to patients. Further, they suggest that efficacy of behavioral interventions in the trial must lead to doubt regarding the significance of cognitive factors in the etiology and maintenance of depression.

This study is currently being replicated and preliminary results suggest:

Here, it is stated that Behavioural Activation proved as effective as antidepressant medication, and that both produced superior outcomes to cognitive therapy, which was no more effective than the pill placebo condition. Given that the Washington University study purports to be the largest outpatient therapy trial for depression yet undertaken, these would appear to be perplexing results for the proponents of cognitive therapy as a treatment for depression. However, putting aside the comparison with BA, the Washington results would seem to contradict many previous studies which have shown CT to be equally effective as pharmacotherapy as a treatment for moderate depression and severe depression. Therefore, it will be necessary to wait for the publication of the study's data before its full implications can be assessed.

More on Working with Borderline Clients

A plug for this book, just out from one of my clinical colleagues in Sydney.

Guidelines for the Management and Treatment of Borderline Personality Disorder.

This is a very practical hands on book focussing on what to do and how to respond to this complex client group.  It promotes a strong  Linehan model (dialectical behaviour therapy).  The newer Transference Focussed and Schema Focussed don’t get much of a mention. It has good chapters on working with other health profession and managing risk.  I definitely recommend it. If you are in Australia or even if you are not in Australia and want to know about this book contact Julia Shearsby at Bankstown Mental Health.

What if you had to Pass an Empathy Test?

How long before we are doing therapy with our clients in an MRI scan. Interesting news just out today on neurophysiological measures of empathy in both clients and clinicians. Hat tip: Eureka. As a total aside Eureka is one of the best news feeders I have found for keeping up to date with breaking science news.

There is now converging evidence that, during moments of empathic connection, humans reflect or mirror each other’s emotions, and their physiologies move on the same wavelength.

I suppose it is not surprise really to think that we mirror physiologically as much as psychologically with our patients but this seems to be a first step in actually beginning to be able to measure it. Actually measuring empathy is something new. Is this yet another of the clinician’s arts falling to science. The idea of therapists having to pass an “empathy test” to practice in the future is an interesting and scary thought.

Empathy is well known to be an important component of the patient-therapist relationship, and a new study has revealed the biology behind how patients and therapists “connect” during a clinical encounter. In the February Journal of Nervous and Mental Diseases, researchers from Massachusetts General Hospital (MGH) report the first physiologic evidence of shared emotions underlying the experience of empathy during live psychotherapy sessions. The researchers found that, during moments of high positive emotion, both patients and therapists had similar physiologic responses and that greater levels of similarity were related to higher ratings of therapist empathy by patients.

As part of an ongoing study of the role of empathy in psychotherapy, the MGH researchers videotaped therapeutic sessions of 20 unique patient-therapist pairs. The patients were being treated as outpatients for common mood and anxiety disorders in established therapeutic relationships. The participating therapists practiced psychodynamic therapy, an approach that uses the therapeutic relationship to help patients develop insight into their emotions.

Throughout the therapy sessions, patients and therapists were “wired up” to record their physiologic responses using skin conductance recordings. Skin conductance is a commonly used measure of the activity of the sympathetic nervous system, which controls human arousal and provides a physiologic context for emotional experiences. Following the sessions, the videotapes were edited to focus on moments of high and low physiologic concordance – that is, when patients’ and therapists’ levels of nervous system activity were most and least similar. Independent observers, blinded to the study’s goals and methods, reviewed randomly presented video segments to identify the types of emotions being expressed by both patients and therapists.

The observers' data showed that both patients and therapists expressed significantly more positive emotions during moments of high physiologic concordance than during low concordance. In addition, patient’s ratings of therapist empathy corresponded to levels of physiologic concordance during the therapy sessions. Overall, the findings suggest that shared positive emotions and shared physiologic arousal contribute to an empathic connection during psychotherapy.

"We were pleased to find evidence for a biological basis to that feeling of connection,” Marci says. “Taken together with current neurobiological models of empathy, our findings suggest that therapists perceived as being more empathic have more positive emotional experiences in common with patients during the therapy session.” He adds another finding not reported in the published report – that there was much less physiologic concordance when therapists were talking than listening. “That suggests it is hard for clinicians to be empathic when they are talking.”

One of the things that comes to mind is that you could utilise this as a biofeedback mechanism to help clinicians improve their empathy. The other interesting note was that when we talk we become less empathetic. I wonder is this is even when we are making an empathic statement? The other question to wonder about is, will we see the same physiological correlates to empathy when clinicians are delivering other sorts of therapy?

Therapeutic Oxymoron Laid to Rest

Posting has been a little light lately as I discover, like 60 million bloggers before me, the inverse relationship between blogging and work.

In the mail this week is Paul Gilbert and Robert Leahy’s new book titled: The Therapeutic Relationship in the Cognitive Behavioral Therapies.

I’ve been holding the book up to everybody who comes to my office over the week with a range of responses from “unbelievable” to “about time". I have to say I was delighted to see this title which I see as a sign of the rounding out and maturing of cognitive approaches to therapy.

I know my headline will invoke some criticisms from the Cognitive Therapists. However looking through all the books on cognitive therapy in our clinic (and we have a lot) I could not find one that had a chapter on the therapeutic relationship except for the more in-depth DBT and Schema Therapy books.

…….there may be a grain of truth in the observation that many of us who utilize CBT could do a better job of understanding and working with the therapeutic relationship.

A full review in a week or two when I have had time to read it through.