Saturday, November 2, 2013

Is the Future of Cognitive Therapy Similar to Training One's Abdominal Muscles?

The Wall Street Journal had a very interesting article yesterday, titled To Be Young and Anxiety-Free, focused on the value of cognitive behavioral therapy to help children with high levels of anxiety learn how too cope better and prevent the snowball scenario, when that anxiety grows and spirals out of control resulting in depression and similar

- " research showing that treating kids for anxiety when they are young may help prevent the development of more serious mental illnesses, including depression and more debilitating anxiety disorders."

- "But the use of antidepressants in children has come under fire because of recent evidence showing an increase in suicidal thoughts in kids taking the drugs. Partly as a result, many doctors and psychologists employ as a first line of treatment cognitive behavioral therapy, or CBT, which is often just as effective as medication."

What is Cognitive Therapy (the most common type of cognitive behavioral therapy) and what are its cognitive and structural brain benefits? Judith Beck guides us here, explaining that "Cognitive therapy, as developed by my father Aaron Beck, is a comprehensive system of psychotherapy, based on the idea that the way people perceive their experience influences their emotional, behavioral, and physiological responses. Part of what we do is to help people solve the problems they are facing today. We also teach them cognitive and behavioral skills to modify their dysfunctional thinking and actions."

Cerebrum, a publication by the Dana Foundation, just released an excellent article titled A Road Paved by Reason, with background on cognitive therapy: how the technique was developed and refined, its short and long-term benefits, and future trends. A few quotes:

- "Psychological problems result from the erroneous meanings that people attach to events, not from the events themselves."

- "In cognitive therapy, patients learn through a variety of strategies to test their faulty beliefs. They then learn to appraise themselves and their futures in a way that is realistic, unbiased and constructive."

- "Various managed-care companies and mental health centers now expect their therapists to be trained in cognitive therapy. The British government has recently set up a large program for training over 6,000 mental health workers to do cognitive therapy. There are now dozens, if not hundreds, of researchers focusing on the theoretical underpinnings of cognitive therapy, or on its applications."

In short, here we have a number of major societal problems (anxiety, depression...) that affect people of all ages, and an intervention that teaches people cognitive skills to be able to manage those related challenges better. Talk about "teaching how to fish" vs. simply handing out fish (which we could argue is what antidepressant medications do).

Why don't more people benefit today from that approach? A major problem, in my view, is the lack of a scalable distribution model. Meaning, using the traditional face-to-face approach, one needs to create, train, certify, ensure quality of, a very large network of practitioners. Which is what, as mentioned above, the British government is doing: training 6,000 mental health workers.

This is certainly a worthy initiative. Now, is it the most scalable one to deliver results while being cost and resource efficient? Perhaps not.

We can view cognitive therapy as a method for well-structured cognitive exercise, where a key factor of success is practice. Same as training your abdominal muscles: if you just join the local club, which has a set of superb machines for abdominal training, but don't use abdominal training those machines in a disciplined manner, your abdominal muscles are unlikely to become very impressive.

We can then view the therapist as the personal trainer who motivates you to stay on track, to propose the right exercise routine based on your personal goals. If the trainer is with you the whole time, encouraging you to do and monitoring your abdominal exercises, you are most likely to complete them. But it is a very expensive approach.

Perhaps a hybrid approach makes more sense: the personal trainer helps you define goals, supervise progress and make modifications to the training regime, AND you do your own abdominal exercises with the machine that has been designed precisely with that goal in mind. There were no such mainstream machines only 50 years ago, before physical fitness became a popular concept and practice. Now there is one in every health club and TV infomercial.

Let's go back to cognitive therapy. Of course there is a need for more and better trainer professionals who can help patients. But of course technology will help complement existing approaches, reaching corners we can not even predict now, and helping more people of all ages better cope with change, life, anxiety, a range of cognitive and emotional challenges. Without any stigma. Just as naturally as one trains abdominal muscles.

There is already research showing the value of computerised cognitive therapy. A recent systematic review published in the British Journal of Psychiatry concluded that "There is some evidence to support the effectiveness of CCBT for the treatment of depression. However, all studies were associated with considerable drop-out rates and little evidence was presented regarding participants' preferences and the acceptability of the therapy. More research is needed to determine the place of CCBT in the potential range of treatment options offered to individuals with depression."

Yes, more research is always needed. However, we also need to refine the questions. Not so much "Will computerized cognitive therapy leave thousands of therapists out of work?" but "How can computerized cognitive therapy be used to increase the reach and effectiveness of therapists" and "Can computerized cognitive therapy help reach populations that receive no intervention whatsoever today?"

Please think about that next time you see someone training his or her abdominal muscles.

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