Some brain scientists are now investigating what happens to the brain during psychotherapy. Studies of depression, obsessive-compulsive disorder, and anxiety disorders have shown that psychotherapy results in brain changes very much like those associated with medication—with some interesting differences. We know that depression is often associated with a decrease in activity in a small area of the brain called the dorsolateral prefrontal cortex. Now we know that ECT, antidepressants, and psychotherapy all stimulate more normal activity in that area.
One study had patients with social phobia read a speech from within the PET scanning machine to a group of strangers; without treatment, there was a significant increase in activity in the amygdala—the brain’s fear center. With either Celexa or psychotherapy, that excessive activity was reduced. Interestingly, the patients’ anxiety levels a year later were predictable by how much change in amygdala activity was achieved at the time of treatment.
These are truly exciting developments. The news that psychotherapy and medication achieve their results by similar, though slightly different, effects within the brain means that science can, by investigating those differences, discover much more about how depression works. We know that life experience changes the brain; now we’re beginning to see how this special experience called therapy has its impact.
There are many ways of conducting psychotherapy, but all depend on an open, trusting relationship. For some patients, the opportunity to disclose to the therapist all the guilt and shame accompanying depression without being judged is enough to start recovery. For others, the therapist will need to provide guidance in such areas as assertiveness, communication skills, setting realistic goals, relaxation, and stress management, which are problems that commonly interfere with recovery from depression.
When I was in graduate school, I had classes taught by Freudians, behaviorists, and family therapists. Freudians wore suits and ties, behaviorists lab coats, and family therapists wore sportswear. The Freudians and behaviorists could barely disguise their contempt for each other—it was interesting to watch them when they had to pretend to be colleagues, for example, at faculty cocktail parties. The family therapists were polite but condescending to each camp, trying to apply their point of view to campus politics, while the Freudians and the behaviorists largely ignored them. From the viewpoint of the advancement of science, it was extremely unfortunate. The different camps didn’t even talk to each other, let alone read each other’s literature. You would find interesting and potentially helpful articles and books on subjects like depression or empathy that didn’t even agree on definitions. There was no way for one point of view to inform another.
You still find that kind of competition and closed-mindedness today, though the players have changed. Fortunately, most of it is confined to academia. Effective therapists out in the world today will use an amalgam of methods that have their roots in different theories, but their combination makes for effective, humane psychotherapy, often short-term in nature. We don’t assume that the patient is in ignorance about the true nature of his problems, but instead that the patient’s expressed pain and needs are the natural focus of treatment. The therapist does not have to be a silent presence behind the couch or a rat-runner in a lab coat, but instead can be a human person with some special expertise whose understanding and advice are freely given. Patients are much better off for the change.
Good psychotherapy can be provided by a psychiatrist (an MD specializing in mental disorders), a psychologist (Ph.D.), a clinical social worker (MSW), a psychiatric nurse, pastoral counselor, or substance abuse counselor. But the fact is that someone with no qualifications at all can hang out a shingle calling himself a “therapist” or “counselor”—these are terms that are not legally defined or regulated. When you call a therapist or see someone for the first time, ask directly about the individual’s professional background and training. Ask if he or she is recognized as reimbursable by health insurance—if not, you should find someone else. (Your therapist might not accept insurance, but that’s a different matter.) Finding someone you trust and can feel comfortable with is most important—you should feel free to shop around. You should ask about the therapist’s background, training, and experience with depression. And if after a few sessions you have any doubts or don’t feel you’re getting anywhere, tell your therapist about it and get a consultation with someone else. Current research reemphasizes the old observation that the emotional connection between patient and therapist may be the most important variable in effective treatment. Because medications can be helpful in serious cases, their use should be strongly considered along with psychotherapy. Nowadays a good therapist should be associated with a psychiatrist or APRN who can prescribe needed medications. If you find a therapist who won’t support the use of medication, go find someone else.
If I were depressed and seeking a therapist I would consider the following factors:
1. My gut reactions—Is this someone whom I can like and trust? Do I feel at ease? Do I have any reservations? Psychotherapy is the one chance we get in modern life to tell the absolute truth about ourselves. Is this person someone I feel can bear that responsibility?
2. References. Talk to friends, your minister, your doctor. A casual professional relationship isn’t a good reference. You want to talk to someone who knows the therapist well—former patients are best.
3. The therapist’s experience with depressed patients, including but not limited to familiarity with cognitive, interpersonal, and mindfulness techniques. I would especially recommend anyone who’s been trained in Mindfulness-Based Cognitive Therapy for depression.
4. The therapist’s openness to medication as part of treatment.
5. The therapist’s willingness to be active and directive when it’s called for, not to assume that listening is curative in itself, or that the patient’s needs for advice or reassurance are infantile and should be ignored.
These last three factors are things you should definitely ask directly of the therapist. We are not gods, though a few of us think so, and we will not be offended by direct questions. If you find a therapist who is offended, go find another therapist. As a matter of fact, it’s best if you can see two or three people for an initial consultation and choose the one you feel can be most helpful. This is a much more important decision than buying a new car, and we should put at least as much energy and time into selecting a therapist as we do which make and model car we want. Feel free to take a few therapists for a test drive.
Patients who request literature on depression from NIMH or other sources will often find cognitive or interpersonal therapy cited as the treatment of choice for depression. Cognitive behavior therapy (CBT), based on the work of Aaron Beck, identifies a person's distorted thinking habits and recasts them in a more accurate light. For instance, "If my husband gets mad at me, that means he doesn't love me, and I can't live without his love" becomes "If he gets mad at me, that's unpleasant but expected; he can be angry and still care about me." Interpersonal therapy (IPT), developed by Gerald Klerman and Myrna Weissman, focuses on communication skills: learning to interpret accurately what others are saying to you (instead of assuming you know), and learning to voice your feelings, desires, and needs effectively. Many experienced therapists will use techniques from cognitive and interpersonal therapies as needed by the individual. These approaches have achieved their level of scientific respect because they have been demonstrated, in experiments with all proper controls, to be effective, at least as effective as medication, over a three-month trial period. But that just means they have met the same low standard as drugs: after three months of treatment, the majority of patients no longer meet all the diagnostic criteria for major depression. However, they can remain miserable and they can relapse in another month.
The reason why CBT and IPT can be proven effective like this is because they are designed to reach a certain level of success in a three-month treatment campaign, and because they have been elaborated to such a concrete level that one therapist's cognitive therapy is much like another therapist's cognitive therapy. This is not the case in most kinds of psychotherapy, where the personality of the therapist is such an important factor. This puts cognitive and interpersonal therapy at a distinct advantage in the research, just because there is so little variability; you are evaluating the effectiveness of a set of techniques, not an art. Experienced therapists sometimes denigrate these approaches as "cookbook" methods because they leave little room for creativity. But with a cookbook, if you set out to make a cake, you get a pretty good cake every time. And all of us in the field owe the developers of these methods a great debt of gratitude, because until they were developed it had been embarrassingly impossible to demonstrate that any psychotherapeutic method had any effect at all. There was a distinct danger of psychotherapy becoming ineligible for reimbursement by health insurance or Medicare, which would have made it only available for the wealthy.
But new research is showing that longer term psychodynamic therapy is more effective than these short-term treatments. In a large review of many studies recently published in the Journal of the American Medical Association, the more treatment sessions, the better the patient did.[i] These were not ten-year psychoanalyses, but the patient simply kept coming until he felt like he didn’t need to anymore. The average treatment period was about a year, and the patient usually saw the therapist twice a week, sometimes more. These were patients with chronic or complex disorders, living in the real world, instead of single-symptom patients carefully screened to maximize the effectiveness of a particular treatment method. Psychodynamic therapy refers to the way of thinking that you find in this book; a belief in unconscious motivations and reactions; in our use of defense mechanisms to deny pain, and their unintended negative consequences; in the importance of childhood experience in shaping the mind and brain; in a basic conflict within all of us between intimacy and independence; in depression as a way of avoiding difficult emotional states. But I wouldn’t argue that long-term treatment for depression has to be psychodynamic in nature to be more effective. Most patients in CBT or IPT continue working with their therapists well past three months, as they should as long as it’s effective.
Now that we know that psychotherapy affects the brain, it shouldn’t be overly surprising to find that the more therapy, the better. As I argue throughout this book, it is practice and repetition that changes the brain, not insight or changes in thinking. There is, of course, no argument that a year of psychotherapy twice a week costs more than medication (though maybe not for long if the drug companies have their way). But you also have to consider that the human cost of chronic depression and complex personality disorders—to the patient and the people around him, and to his lifetime earning power—is much greater than the cost of psychotherapy. One positive development since the first edition of this book is that most insurance companies are not as restrictive about paying for psychotherapy as they used to be, which means you may only have to pay your therapist your usual co-pay. However, you still need to be assertive and savvy about your insurance to get the benefits you’re entitled to.
When I wrote the previous edition, medication still promised great things for depression, and I felt a little like an underdog advocating for psychotherapy. No more. Although the field, and popular stereotypes, continues to be fascinated by meds, thoughtful scientists and clinicians now recognize that, in many ways, psychotherapy is the better alternative. Two independent reviews of all the literature comparing the effectiveness of psychotherapy and medication for treatment of depression were published in 2008. There were about thirty such studies in all, and the reviews concluded that both medication and psychotherapy were about equally effective in treating depression. Both reviews found, and emphasized, that meds were more effective for dysthymia; an ironic result because the meds weren’t designed to help dysthymia; and possibly only the result of the emotional blunting described in the last chapter. Both studies found a significantly lower dropout rate for psychotherapy. Only one review looked at results at follow-up (average length of 15 months), and found a significant advantage for psychotherapy, an advantage that grew the longer the follow-up period. We don’t know if that’s because patients went off meds, or if meds gradually lost their effectiveness, or because psychotherapy gives patients something they can build on, but I suspect all three factors play a role.
People with depression have symptoms (moodiness, lack of energy, self-defeating thinking patterns, anxiety) and they have problems (marital conflict, poor work performance, bad decision-making, procrastination). The hope has been that medication would lift the symptoms and the patient would be able to tackle the problems more effectively alone. When meds work right, this is possible. But far more often, good psychotherapy helps the patient with his problems, and the symptoms begin to diminish. (Of course, it’s really a two-way street.) Or therapy helps with symptom management more than medication can (challenging depressed thinking, using mindfulness to detach from rumination, learning good sleeping habits, communicating more effectively). Once again, it’s the practice of new skills, in both problem-solving and symptom management, that leads to lasting change. The therapist is there, like a coach, to help when the practice isn’t going well, or when there are unexpected obstacles. Depression is highly likely to recur, unless the patient has learned new methods of dealing with life’s obstacles and his own feelings.
[i] Falk Leichsenring and Sven Rabung, “Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-Analysis,” Journal of the American Medical Association 300, 1551–1565 (2008).