Living With The Devil We Know

Living With The Devil We Know

We May be Anxious, but not to Change

January/February 2013

For the last 40 years or so, our profession has assumed that by copying the medical model, using science-based, pathology-focused, diagnosis-specific treatments, we’d have medical-style success (forget, for the moment, that medicine itself isn’t nearly as predictable and successful as advertised, nor even as scientific). By now, you’d think we’d have just about licked most ordinary mental disorders. Anxiety and depression—which get the lion’s share of therapists’ attention—should have gone the way of smallpox and polio, shouldn’t they? Well, not so much. If anything, given the sheer numbers of depressed, anxious, angry, violent, drug- and alcohol-addled people we see in our offices and around us, it would seem that rates of emotional and mental disorders in our society are just as high as ever, or possibly even on the rise.

Of course, psychotherapy “works”; we have plenty of evidence for that. It’s just that, even with all the fancy high-tech, evidence-supported, protocol-driven therapies, we aren’t doing nearly as well as we sometimes imagine, even with our own patients.

The findings from the British CoBalT trial that were recently published in the The Lancet underscore this fact. The investigators randomly assigned 469 chronically depressed, treatment-resistant patients either to the usual care (primarily antidepressant medications) or to the usual care plus cognitive-behavioral therapy (CBT). At the six-month evaluation, only 22 percent of the treatment-as-usual group had improved significantly, as compared with 46 percent of the patients in the meds-plus-CBT group.

These results indicate that neither treatment was terribly effective, since improvement was defined as a 50-percent reduction in patients’ scores on the Beck Depression Inventory (BDI). That’s not too impressive, since most patients with such a reduction in BDI scores will still be quite symptomatic: they definitely won’t be feeling much joy or self-esteem. The results also indicate that the antidepressants the patients in the treatment-as-usual group received appeared to have few, if any, beneficial effects above and beyond the positive effects caused by the passage of time. A 22-percent “improvement” rate is pathetic, to be blunt. Finally, although the psychotherapy helped, the effects left a lot to be desired, too, since more than half the patients didn’t even achieve a 50-percent reduction in depression severity.

Unfortunately, the findings from this study aren’t unusual. I’m not aware of any controlled-outcome studies in which any form of psychotherapy (or antidepressant drug therapy) has shown really dramatic or impressive results. In fact, in most cases, the outcomes for the treatment groups are barely greater than the outcomes for patients receiving placebos. I think all of us can agree that, despite the significant progress that’s been made in therapeutic treatment, there’s still enormous room for improvement in even those forms of psychotherapy that are heralded as state-of-the-art.

The Learning Curve

I began my career as a biological psychiatrist at the University of Pennsylvania during the early ’70s, the opening years of psychopharmacology’s appropriation of psychiatry. At the drug company presentations at the conferences I attended, I heard that 85 percent of depressed patients could be treated effectively with meds, but soon discovered otherwise. While some of my patients improved a bit, many others continued to suffer, no matter how many drugs I prescribed or how long I listened and supported them with traditional talk therapy. I could clearly see that my success rates were fairly similar to those in the treatment-as-usual arm of the CoBalT trial.

I began looking for a new and different treatment method to supplement the drugs, and my department chairman suggested I try the relatively new CBT approach, but I was highly skeptical. The idea of trying to change the negative thinking patterns of depressed and anxious people sounded too superficial, too “power of positive thinking,” and not nearly “deep” or “biological” enough to have any meaningful effects. To my amazement, however, CBT seemed to work a lot better than medications and talk therapy, and clients liked it. Sometimes, the results were fast and spectacular, even with discouraged clients who’d tried years of talk therapy and meds without much success.

However, despite many successes, my results were still far from perfect, especially in the treatment of anxiety. Many patients would begin to improve, achieving a 50- to 60-precent reduction in symptoms. Then they’d get stuck and continue to struggle with crippling shyness, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), or some other type of anxiety, no matter how many techniques I tried.

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Thursday, January 24, 2013 8:01:53 PM | posted by Michele Rivette
I have to say as a psychoanalyst, that Dr. Burns "hidden emotion technique", with all due respect, sounds very familiar. Sadly, with the move to manualized treatments in recent decades, therapists are not trained in exploring the unconscious or pre-conscious fears, motivations, conflicts (i.e. sources for resistance to change), so this may seem like a new idea. Understanding the deeper meanings of why patients remain stuck in painful feelings or behaviors despite conscious discomfort or desire to change is the focus of psychodynamics. I am so grateful to have this deeper training because it makes my work so much more rich and patients feel validated and curious about their own psyches.

Monday, January 28, 2013 9:26:06 PM | posted by jeffrey von glahn
Completely agree with Michele re: the "hidden emotion technique" and the influence of manualized therapy. Burns' examples confirms my own view of therapy. 1) The cause and the resolution of the client's problems resides in the client, not in any theory. So keep inviting the client to say more, and which prevents the therapist from getting ahead of the client. 2) The most effective resolution for the most typical problems is the client re-visiting the hurtful event that caused it, BUT ONLY IF that experiencing emerges as a manifestation of the support the client receives for his experiencing. See my short article in May/June 2012.

Wednesday, January 30, 2013 2:15:24 AM | posted by Sophie Benoit
I have found this article very meaningful and thorough. Many interesting reflection points personally and professionally. I have been telling my patients for sometime that whatever is here and bothering them is there for a reason and that once, this part of themselves has been given a space to 'say what it needs to say' it will go by itself. I have found the way Dr. Burns talks about resistance and what they say about a person, will give me a new direction for looking at my work and difficult cases. Thank you

Friday, February 15, 2013 7:04:04 AM | posted by Ben Jones
This sounds a bit like Depth Oriented Brief Therapy, DOBT. Please see the 1996 book of the same name by Bruce Ecker and Laurel Hulley. They develop this idea into a compelling and effective practice, using what they call Radical Inquiry.

Wednesday, March 6, 2013 1:54:27 PM | posted by roberto flachier
Though I agree with Dr. Burns, I found nothing new in it. It is a well written summary of what many authors have been saying, including himself. His thoughts on resistance reminds me of Rolnick's;there are similarities with Steven Hayes et al (the concept of emotional avoidance and fusion), etc. The idea that individuals with anxiety resist change because of their sense of safety is a very well known fact, and just about everyone with anxiety expresses it. The concept of validating the pt's reality/painful experience is the basis of any good therapy (DBT, dynamic, person centered, and, yes CBT and Beh. Therapy), it is essential. very good article.

Thursday, April 4, 2013 5:48:18 PM | posted by max strom
Milton Erickson's Utlization approach springs to mind reading this article..

thank you for the article

Friday, October 10, 2014 12:19:52 PM | posted by phil griffin
I can't begin to express my appreciation for this insightful article. I am reminded of a comment by a colleague of mine: If you need to be a counselor, you shouldn't be one. The need to help can sabotage ourselves and our clients.