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The Future of Computer-assisted Cognitive Behavioral Therapy

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

- “…new 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.”

- “Of course, most kids have fears with­out hav­ing a full-blown anx­i­ety dis­or­der. And some anx­i­ety is healthy: It makes sense, for exam­ple, to be a lit­tle ner­vous before a big test. Doc­tors and psy­chol­o­gists do cau­tion that the increased focus on child­hood anx­i­ety could lead to an over­diag­no­sis of the prob­lem. What makes anx­i­ety a true ill­ness is when it inter­feres with nor­mal func­tion­ing or caus­es seri­ous emo­tion­al and phys­i­cal dis­tress.”

- “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.”

Full arti­cle: To Be Young and Anx­i­ety-Free.

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:

- “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.”

- “For years, we could only mea­sure the impact of cog­ni­tive ther­a­py based on psy­cho­log­i­cal assess­ments. Today, thanks to fMRI and oth­er neu­roimag­ing tech­niques, we are start­ing to under­stand the impact our actions can have on spe­cif­ic parts of the brain.”

- “For exam­ple, take spi­der pho­bia. In a 2003 paper sci­en­tists observed how, pri­or to the ther­a­py, the fear induced by view­ing film clips depict­ing spi­ders was cor­re­lat­ed with sig­nif­i­cant acti­va­tion of spe­cif­ic brain areas, like the amyg­dala. After the inter­ven­tion was com­plete (one three-hour group ses­sion per week, for four weeks), view­ing the same spi­der films did not pro­voke acti­va­tion of those areas. Those indi­vid­u­als were able to “train their brains” and man­aged to reduce the brain response that typ­i­cal­ly trig­gers auto­mat­ic stress respons­es. And we are talk­ing about adults.”

Full inter­view with Judith Beck: Here

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

- “Cog­ni­tive ther­a­py is one of the few forms of psy­chother­a­py that has been rig­or­ous­ly test­ed in clin­i­cal tri­als. It was first devel­oped to treat depres­sion, but its ben­e­fits extend to obses­sive-com­pul­sive dis­or­der, post-trau­mat­ic stress dis­or­der and per­haps even such “phys­i­cal ail­ments as hyper­ten­sion, chron­ic fatigue syn­drome and chron­ic back pain.”

- “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.”

- “He (founder Aaron Beck) found that peo­ple who are depressed sys­tem­at­i­cal­ly block out the pos­i­tive aspects of their life, see­ing only the neg­a­tive. They inter­pret ambigu­ous events in a neg­a­tive way, which he describes as cog­ni­tive dis­tor­tion. If some­thing gen­uine­ly neg­a­tive does occur, they tend to exag­ger­ate its mag­ni­tude, sig­nif­i­cance and con­se­quences. A minor error becomes a major cat­a­stro­phe.”

- “Although cog­ni­tive ther­a­py usu­al­ly focus­es on prob­lem solv­ing in the present, by doing that task the patients also devel­op life­long skills…The authors spec­u­lat­ed that the last­ing effects of cog­ni­tive ther­a­py reflect the patients new-found abil­i­ty to “do the ther­a­py for them­selves. They remarked that the strate­gies learned “even­tu­al­ly become sec­ond nature, coin­cid­ing with a par­al­lel change from prob­lem­at­ic under­ly­ing beliefs to more adap­tive ones.

- “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.

Full arti­cle: A Road Paved by Rea­son

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 trainingthose 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?”

Think about that next time you see this:

abdominal training

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6 Responses

  1. cinderkeys says:

    but its ben­e­fits extend to … per­haps even such “physical” ail­ments as hyper­ten­sion, chron­ic fatigue syn­drome and chron­ic back pain.

    Myal­gic encephalomyelitis (also known by the unfor­tu­nate name “chron­ic fatigue syn­drome”) is a real phys­i­cal ill­ness. Research done on the effects of cog­ni­tive behav­ioral ther­a­py on ME includ­ed sub­jects who don’t actu­al­ly have it — that is, they expe­ri­enced gar­den-vari­ety fatigue due to depres­sion, but not the crush­ing post-exer­tion­al malaise char­ac­ter­is­tic of true ME. CBT (along with grad­ed exer­cise ther­a­py) made some of the sub­jects worse (most like­ly the ones with true ME), and those sub­jects dropped out of the study. CBT had mild ben­e­fi­cial effects for the sub­jects who stayed.

    Researchers came to the con­clu­sion that CBT helped peo­ple with “chron­ic fatigue syn­drome” after exclud­ing the sub­jects who dropped out from the results

    CBT is per­fect­ly appro­pri­ate for peo­ple with phys­i­cal ill­ness­es as long as it’s under­stood that the goal of ther­a­py is to help them cope with the real­i­ty of liv­ing with said ill­ness­es. Using CBT and grad­ed exer­cise ther­a­py to help “cure” peo­ple with ME, how­ev­er, will do far more harm than good.

  2. Good com­ment. I agree with part of it, dis­agree with anoth­er.

    Yes, it can not be said that CBT can “cure” ME or a num­ber of oth­er clin­i­cal con­di­tions, sim­ply because, to start with, many con­di­tions are not objec­tive­ly diag­nosed. CBT can not be said to cure ADD, for exam­ple, it the same way that Rital­in or oth­er drugs don’t cure ADD, either. And it is also true that, for CBT to work, peo­ple need to stick to the prac­tice so com­pli­ance is an issue-which is why I used the phys­i­cal fit­ness anal­o­gy.

    Now, CBT does more than just “help them cope with the real­i­ty of liv­ing with said ill­ness­es”. Cog­ni­tive ther­a­py can help reduce the symp­toms of said ill­ness­es in a vari­ety of sce­nar­ios, from depres­sion to pho­bias to obses­sive- com­pul­sive behav­ior, and in more sus­tain­able ways (low­er rein­ci­dence rates) than med­ica­tion. The brain is as phys­i­cal as any oth­er organ and sci­en­tists are start­ing to dis­cov­er the rela­tion­ship between brain func­tions and brain struc­ture, open­ing the way for research-based non-inva­sive inter­ven­tions.

    In sum­ma­ry, I’d say that health­care pro­fes­sion­als would do well in adding a cog­ni­tive frame to many of their prac­tices to enhance the lives of their patients. It is not one or the oth­er, but how they can com­ple­ment each oth­er.

  3. cinderkeys says:

    If CBT (minus GET) can reduce stress for ME patients, that has val­ue. I’d like to see stud­ies with much bet­ter method­ol­o­gy being done, though. I’d also like to know if the ben­e­fits of ther­a­py out­weigh the phys­i­cal toll it takes on some ME patients just to make it to the ses­sion. Ther­a­pists, alas, gen­er­al­ly don’t make house calls.

  4. Mike Logan says:

    Hel­lo All,

    Would love to see the pro­grams being used in the com­put­er­ized Tx. of depres­sion. Thanks.

  5. Nerissa Belcher says:

    From the post: “Psy­cho­log­i­cal prob­lems result from the erro­neous mean­ings that peo­ple attach to events.” This is not lit­er­al­ly true. Research shows depressed peo­ple are more accu­rate than opti­mistic ones. Cog­ni­tive ther­a­py attempts to con­vince peo­ple the val­ue of being less accu­rate by fool­ing them into think­ing they are more accu­rate. A more direct approach to men­tal health is to not wor­ry about accu­ra­cy and just enjoy life.

  6. Hel­lo Ner­is­sa, I think you are mix­ing things. First, research doesn’t show that depressed peo­ple are more accu­rate than non-depressed peo­ple (the rel­e­vant com­par­i­son here). Sec­ond, cog­ni­tive ther­a­py doesn’t try to fool any­one. Third, and most impor­tant, there are dozens of pub­lished stud­ies show­ing the val­ue of cog­ni­tive ther­a­py. Can you please share the list of ref­er­ences behind your sug­gest­ed “more direct approach”? (to just enjoy life is a great goal…but pret­ty use­less as the process to get there for peo­ple who need a bit more help)

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