Small changes in thinking and behavior can be as effective
By Benedict Carey
Times Staff Writer
April 19, 2004
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 because it's not a prescription drug, there are no side effects.
As health officials around the world debate the risks of antidepressant drugs such as Prozac and
Paxil, doctors are reevaluating standard treatments for conditions from depression to obsessive
compulsive disorder to panic attacks. Some say antidepressants have been oversold; most say
that they're being needlessly vilified.
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% and 60% 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. The popularity of TV's Dr. Phil notwithstanding, they say, the very idea of
private psychotherapy still carries a whiff of indulgence, mental fragility and neurotic self-
"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."
* Treatment's origins
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
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 past 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. Arguments at
home and strained relationships are actual side effects of talk therapy, psychiatrists said.
Depending on the condition being treated, anywhere from 30% to more than half of patients find
cognitive therapy too disruptive, demanding or ineffectual to benefit from it.
For many people with stubborn mental problems, recent research suggests that it's worth a try:
• In a study of 187 hypochondriacs, Harvard researchers reported last month 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, relatively free of the dread that, say, a bad
headache was because of a brain tumor. Hypochondriacs often suffer under mistaken
assumptions like "I have to be 100% certain that I am not ill," or "A bodily symptom is always a
sign of serious disease." The men and women still had psychosomatic symptoms after
undergoing the therapy, but they were less likely than before to call the doctor or to panic, the
• 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 over the first month and allowed people to walk, socialize and sleep more comfortably,
the doctors said.
Combination of regimens
In cases of severe depression, anxiety and other mental illness, psychiatrists generally try
cognitive techniques in combination with drugs. Terry Wise, 39, a lawyer in Boston, attempted
suicide in 2000, after losing her husband to Lou Gehrig's disease. Wise was drinking heavily and
using painkillers, and she overdosed. At the hospital she was put on an antidepressant and felt
better almost immediately, she said.
But it was in talk therapy, using cognitive behavior techniques, that Wise began to regain some
control of her life. "I felt I had a loser gene, a malcontent gene, that I was an impostor, unlikable,
unworthy of good friends," said Wise, in an interview. She describes her recovery in the book
"Waking Up" (Pathfinder, 2004).
Her therapist challenged Wise to name one person she cared about who ignored or avoided her.
She couldn't. Next, Wise was made to focus on the friends she did have. "The therapist said,
'You tell me they're such stellar people, and yet you must not think so highly of them — you're
calling them fools, because they don't see through you.' It forced me to reevaluate all those
assumptions," Wise said.
Though research has shown how antidepressants affect the brain — drugs like Prozac act on a
chemical messenger called serotonin, which affects mood — it's still unclear what, if any, lasting
neurological changes result from cognitive therapy.
Using brain imaging techniques, neuroscientists have shown that cognitive talk therapy produces
changes in the areas of the brain that are also affected by drug therapies. Conscious mental effort,
in short, induces a distinct biological effect on the brain that's visible on brain scans.
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 $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 the therapy is often fully
covered by health insurance.
"The cognitive therapy takes time and effort, and for many people the time costs are high. They'd
rather have medicine," said Dr. Ken Wells, a research psychiatrist at UCLA and Rand Corp.,
which studies trends in psychiatric care.
* A matter of choice
But not everyone wants a prescription. This month Wells and colleagues from Rand and UCLA
reported findings from a five-year study of almost 1,000 men and women with depression who
tried different forms of treatment.
Some groups of depressed patients — black and Latino populations, in particular — prefer talk
therapy to antidepressants, the doctors found. When given the choice of enrolling in a cognitive
behavior course and provided with financial incentives, such as low insurance co-payments,
these patients were significantly more likely to shake their chronic low moods than they would
have been in standard care.
And when patients show lasting benefits from short-term talk therapy, the economics begin to
change. In one 1997 analysis, doctors at a Veterans Administration hospital in Reno calculated
that the cost of Prozac prescriptions and visits to a doctor outpaced the fees for a typical course
of cognitive behavior therapy by 33% over a two-year period. (To be sure, the VA analysis was
done before the expiration of Prozac's patent, a change that significantly reduced the drug's cost.)
"It's really a matter of people being informed about the therapy," said Judith Beck, director of the
Beck Institute, a nonprofit cognitive treatment clinic near Philadelphia. "When people are
informed, they're usually interested, whether they've tried drugs, or want to avoid them."
One of Beck's recent patients, a 42-year-old mother of two, quit her job after suffering a sudden
episode of depression. Believing that her family faced imminent financial disaster, the woman
became paralyzed by her depression, barely able to get out of bed, care for her children or
maintain her household, Beck said.
Beck had the mother try a few simple experiments. She asked her husband about the family
finances. They were stretched but in no danger of losing the house. On one day, she called a
friend to meet for lunch. On another, she went for a walk. As a matter of routine — again, an
experiment — she started doing the breakfast dishes, instead of fretting about not having done
"It took 20 minutes, that's it, but it kept her from going right to bed," Beck said. "Small things;
you're breaking the day down into small parts and handling them one at a time."
By small steps, the woman made her way back to work. She has not needed medication.
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