FROM RESEARCH TO PRACTICE
BY JAY LEBOW
The Verdict Is Clear
ESTs have an incontestable track record with anxiety
Every self-respecting therapist knows that the value of empirically supported therapies is a hotly debated subject these days. Critics repeatedly point out that, outside of therapy outcome studies, clients rarely present themselves with the sort of uncomplicated, pure, DSM-delineated diagnosis around which empirically validated treatments are structured and show such high success rates. To many therapists, manualized treatments feel rigid, agenda driven, and unequal to the messy reality they see in their offices every day. Even therapists who work on manual-driven projects have been known to report, off the record, that after the first few sessions, their work becomes increasingly variable and idiosyncratic—just like the real people they're treating.
Nonetheless, it can't be denied that, with certain problems, some empirically supported treatments (ESTs) have been proven highly effective. Probably the best example is anxiety treatment. The ESTs developed to treat anxiety have consistently demonstrated better results than medications, without the side effects and treatment dropout that often accompany meds. They've proven to be highly effective for the following problems:
Panic Disorder. Panic disorder strikes between three and six million Americans, and is twice as common in women as men. People diagnosed with it have recurrent attacks that include a variety of unpleasant symptoms—palpitations, pounding heart, or accelerated heart rate, sweating, trembling or shaking, sensations of shortness of breath or smothering, choking feelings, chest pain or discomfort, lightheaded or fainting sensations, and fears of losing control. They also typically have pervasive fears of future attacks. Often, the fear of the fear is worse than the attacks themselves, so that people with panic disorder are endlessly worried about and preoccupied with the possibility of having an attack.
Although traditional talk therapies don't appear to have much impact on panic, there are several variants of cognitive-behavioral therapy that have been demonstrated to ameliorate this disorder. Most of these treatments share several interventions, including increasing clients' exposure to situations that lead to panic, helping them more effectively manage thoughts and feelings associated with panic, and teaching them how to engage in problem-solving self-talk.
Perhaps the most widely disseminated of the treatments for panic disorder is Panic Control Treatment (PCT), developed by David Barlow of Boston University and Michele Craske of UCLA. In PCT, clients are encouraged to experience the sensations of panic, so that they can master them. For example, Shannon, whose disabling panic in the workplace has left her reluctant to seek work, is encouraged in session to imagine being in an anxiety-laden work situation and to breathe in the same way that she does when she has a panic attack. By visiting her worst-case scenario, she's invited to master her fear.
PCT includes cognitive examination of the distortions typical in panic, as well as the automatic thoughts that go along with it—like overestimating the level of real threat during a panic attack. Thus, Shannon's dominant thought that her panic will lead to humiliation and rejection by others is elicited and examined in the light of her experience. This balanced examination of the evidence points to the fact that her panic is much more of a problem for her than for others. She's then encouraged to remind herself of this clear conclusion, and to engage in a rational examination of similar beliefs as they come into consciousness and influence her behavior. This therapy works with breathing to help people acquire the feeling that they can cope with the signs of impending panic and, eventually, acquire the ability to calm themselves down.
PCT has been frequently studied with impressive results. For example, in a large, rigorous, multisite study of this treatment conducted by David Barlow, Jack Gorman, and colleagues, clients were randomly assigned to groups receiving PCT, placebo, PCT plus medication, or PCT plus placebo treatments. The treatment period was three months. Although all the treatments produced more change than the placebo alone, several findings suggested the superiority of PCT. Adding medications to PCT didn't yield better outcomes than using PCT alone. And six months after treatment, there was greater relapse for those receiving medication alone or PCT plus medication than for those receiving PCT alone
Cognitive-behavioral therapy (CBT) for anxiety, following the protocol developed by Aaron Beck and colleagues and based on correcting cognitive distortions in self-talk, has amassed a similarly impressive record of outcomes when compared to medication in studies of treatments for panic. In fact, the evidence for the effectiveness of PCT and other cognitive-behavioral therapies for panic disorder vastly outweighs evidence for other approaches. As an example, a recent study by Michael Addis of Clark University and his colleagues found that 43 percent of those getting cognitive therapy in a managed care setting achieved clinically significant improvement, compared to only 19 percent of those getting other treatments in the same setting.
Just as CBT treatments are coming to be regarded as the treatments of choice for panic disorder, related treatments are emerging as especially potent in treating other anxiety disorders. Because conditioning plays such an important role in causing these difficulties, CBT seems to work by teaching clients new skills that override the earlier conditioned patterns.
Obssessive-Compulsive Disorder (OCD). This disorder includes recurrent obsessions and compulsions that interfere considerably with daily functioning. Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and cause marked distress. Compulsions are repetitive behaviors designed to reduce anxiety that become problems in themselves. Examples include people who feel compelled to check and recheck their clothing, or the stove to make sure it's turned off, before leaving the house, making them chronically late. CBT treatments for these disorders, including those developed by Edna Foa of the University of Pennsylvania, typically feature exposure to the source of anxiety, coupled with disruption of the obsessive or compulsive behavior and the introduction of some other alternative behavior.
For example, Maurice, who engages in endless rituals of washing and straightening his clothes, is prevented from doing these behaviors. Instead, when thinking about going to school, a subject about which he has a good deal of anxiety, he's taught to fold his hands. Self-talk is also a frequent part of these treatments. So Maurice is helped to examine his belief about what'll happen if he doesn't engage in his compulsive washing. He and his therapist conduct a balanced examination of the chances that germs will harm him if he doesn't do his ritual washing is correct. As with panic disorder, he's taught a process of rationally examining his beliefs to be used when he encounters variants of these beliefs.
Here again, the CBT treatments are impressively effective. For example, a multisite study conducted by Foa found that both the exposure program and medication significantly reduced the symptoms of OCD, but that the exposure treatment was more effective than medication alone. The addition of the medication to the exposure treatment didn't seem to improve outcomes.
Simple phobia. Exposure-based treatments clearly are the treatment of choice for simple phobias. In these treatments, clients are gradually exposed to the feared situation, and given an opportunity to master their fear step by step. Generally, lots of exposure in short duration produces the best results.
New technologies that seem to improve upon the impressive results from these treatments are evolving. One technology is the virtual-reality simulator, which provides vivid exposure to feared situations without having to go out of the therapist's office. For example, Mike, who's afraid of crossing bridges, experiences in virtual reality the sights and sounds of this feared activity. Recent research demonstrates that virtual-reality procedures are especially effective as exposure-based treatments.
Other research has begun to look at the use of cognition-enhancing medications in these treatments. Cognitive enhancers aren't like traditional psychopharmacological medications. These medications, such as D-Cycloserine, increase the ability to learn without affecting feelings directly. Experiments in animals and humans have shown that these drugs lead to better, classically conditioned learning (like that experienced by Pavlov's dogs), which are at the root of behavioral treatments for phobia. A recent study by Kerry Ressler of Emery University utilizing D-Cycloserine showed that using this drug in treatment was more effective in conditioning people to be less afraid of heights than was traditional behavior therapy conducted without the drug.
It's essential here to grasp the role of these medications. These are medications that help clients learn, not medications that reduce anxiety directly. It continues to be a well-established finding that simple phobias typically don't respond well to medications that reduce anxiety, because clients develop less confidence in their ability to master a situation when that mastery is achieved while taking meds. With anxiety-reducing medications, clients usually attribute the lessening of symptoms to the medication and, therefore, fail to learn new coping behaviors. In contrast, these new cognition-enhancing medications seem to improve clients' ability to recondition themselves.
Generalized Anxiety Disorder (GAD). Individuals with GAD worry pervasively much of the time. The tendency to worry is the meat and potatoes of many psychotherapy practices, encountered far more often by more therapists than the relatively rare OCD and Panic Disorder. What probably isn't well-known by many therapists, however, is that CBT treatments have been shown to be highly effective with GAD. In one study, conducted by Thomas Borkovec at Pennsylvania State University, 60 percent of the clients engaging in a treatment were able to attain a level of functioning of anxiety and worry comparable to that of the general population. The treatment used in the study included an array of CBT techniques aimed at the rigid behavior and thoughts typical of those with GAD, including active self-monitoring to understand the anxiety triggers, specific training and practice in such relaxation techniques as progressive muscle relaxation and diaphragmatic breathing, "self-control desensitization" in which clients imagine their worries while practicing relaxation, and having designated worry periods to establish a sense of control over this experience.
A recent metanalytic review by Kristin Mitte of the University of Jena in Germany found that across 65 studies, CBT for GAD worked as well as medication, but without either the side effects or treatment dropout. The dropout rate for medications, Mitte pointed out, was 25 percent, compared to 9 percent for CBT. She found that studies that directly compared the two treatments should CBT to be superior.
So what are the implications from this research for us as clinicians? For anxiety disorders, it appears clear that the variants of CBT described above are the treatments of choice at this time. Nevertheless, these methods don't work for everyone, nor do they produce change in every aspect of a person's life—they aren't all-purpose therapy. But when clients specifically want relief from the symptoms of anxiety, these are the treatments they should get.
This means that, as responsible therapists, we need to know how to practice these techniques or be prepared to refer these clients to therapists who do. However, this doesn't mean that clients with anxiety problems should see only CBT therapists. At the Family Institute at Northwestern, where I practice, clients who are receiving more traditional therapies focused on broader life issues are often referred to an Anxiety Clinic for CBT, when they need help with their anxiety symptoms. In short, CBT isn't necessarily the only therapy people suffering from anxiety disorders need, but it's hard to argue that their anxiety treatment can appropriately exclude evidence-based CBT interventions.
Barlow, David H. Anxiety and Its Disorders. New York: Guilford Press, 2002.
Mitte, Kristin. "Meta-Analysis of Cognitive-Behavioral Treatments for Generalized Anxiety Disorder: A Comparison With Pharmacotherapy. Psychological Bulletin 131, no. 5 (September 2005): 785-95.
Nathan, Peter, and Jack Forman. A Guide to Treatments that Work. New York: Oxford University Press, 2005.
Jay Lebow, Ph.D., is a contributing editor to the Psychotherapy Networker, senior therapist and research consultant at the Family Institute at Northwestern, and Clinical Professor at Northwestern University. Contact: firstname.lastname@example.org.Letters to Editor about this department may be e-mailed to email@example.com.