This week I learned three new things about psychotherapy and depression.
I’m a fan of psychotherapy for everyone. In fact, if we could get the mid-East folks to sit down for some good counselling, I think it would be more effective in bringing peace than anything you can do with a gun.
With that said, there are limitations to therapy and sometimes therapy is not all it’s cracked up to be. So this week, a look at three perspectives on psychotherapy:
- Psychotherapy is no better than placebo in treating depression?
- Which type of psychotherapy is better for depression?
- How does psychotherapy change the brain?
1. Is Psychotherapy Better Than a Placebo in Treating Depression?
When the study came out a couple of years ago alleging that antidepressants were no better at treating mild-to-moderate depression than a placebo, the antipsychiatry world went crazy (if you will). All their dire claims, it seems, had been proven true.
Well, the sky hasn’t fallen yet, but interestingly the same kind of analysis, when applied to psychotherapy, can also allege that psychotherapy is no better than a placebo too.
Placebo for Therapy
Of course, there is no such thing as a placebo in therapy. There is no “inert” counselling session. Scientific literature attempts to compare cognitive behavioural therapy (CBT), interpersonal therapy (IP) and others against wait-listed participants and those who have received therapy not containing the specific therapeutic technique being tested. Basically, they tell a therapist not to therapy. Which is a pretty tough thing to ask a human to do. And naturally, humans aren’t going to do it well.
Does Psychotherapy Work to Treat Depression?
I would say yes, therapy, various types, including cognitive behavioural, interpersonal and supportive therapy, all help treat depression. However, some suggest the jury is still out on how effective therapy really is in treating depression.
2. What Therapy is Best for Depression?
[push]Psychologist Gary Greenberg states CBT is more of an ideology and a “method of indoctrination into the pieties of American optimism.”[/push]
When selecting a therapy for depression one has many choices but the prevailing one in the scientific community right now is cognitive behavioural therapy (CBT). Everybody loves it. It’s the golden child. CBT is a highly intellectual and analytical therapy that is short-term and action-oriented so it’s no wonder that people like it.
In the same article as the one talking about therapy effectiveness in the treatment of depression, they also discuss which therapy is best for depression, and it kind of seems like none of the therapies are best. (This could be because, statistically, some people respond better to one treatment while others respond to other treatments and when you lump them all together, a similar percentage responds to each.)
3. What Does Psychotherapy Do to the Brain?
As I have mentioned several times, depression decreases brain volumes over time – ie, depression shrinks your brain. It does this through decreasing neurogenesis (the creation of new neurons); however, electroconvulsive therapy (ECT) and antidepressants have both been shown to increase neurogenesis and brain volume.
Interestingly, so does psychotherapy.
More on brain changes as a result of psychotherapy here.
I think a lot of psychotherapy is pretty esoteric and all of it is culturally influenced. The best talk therapy I have received is from peers. Art Therapy is a distraction from depression that I participate in weekly it does not get rid of depression but it gets me together with like-minded people. The thing that keeps me stable with out uttering a word is medication. I think it is the gold standard(at least for me).
There is so much talk about CBT and little understanding, it seems faddish to me.
ps. Natasha, I really respect the effort you put into your posts, I don’t always agree with your viewpoint but I am not fool enough to argue with you. You seem like a fantastic person.
Hi Jake,
I agree, a lot of psychotherapy (psychodynamic, or talk therapy especially) is esoteric and depends a lot on the provider and your relationship with them. And again, you are correct, culture plays as a big part in that.
Peers do help a lot of people and art therapy is something that has been getting more attention lately. I haven’t found it useful, I found it tedious and annoying, but then, I’m not a visual artist (believe me). I think it can help many people externalize their pain, which is highly beneficial.
And yes, I’m one of those people for whom medication is the _only_ thing that really helps. I’m sure that therapy has kept me alive at points and I use what I have learned in everyday life, but it just doesn’t do much for my mental illness, per se.
CBT is faddish. However, that doesn’t mean it doesn’t work. It has been clinically proven to work, especially in anxiety disorders. But again, it’s not like it will work for everyone. (And “work,” of course is relative.)
“Natasha, I really respect the effort you put into your posts, I don’t always agree with your viewpoint but I am not fool enough to argue with you. You seem like a fantastic person.”
Well thank-you, that’s sweet. And don’t worry, you can disagree. I’m just one person with one opinion.
– Natasha Tracy
Well if this is the case, biofeedback HEG nIR that increases blood flow through active feedback and interaction between sensors, blood flow and a computer game reward system, must be a good candidate for research into effective therapies for treating depression. Or, at least, counteract the decrease in brain size through cognitive HEG exercise.
Hi Isaac,
Many things increase blood flow but that doesn’t mean they increase neurogenesis (making new brain cells). Neurogenesis requires quite a bit more than I suspect video games offer.
– Natasha Tracy
Can I just say that i really appreciate your work and passion on this subject.
Maybe the professionals in the field could explain it better. Here is some info regarding what i am talking about. I know that for me it worked to treat my IBS and alleviate anxiety and assist with my depression. if it had not worked for me id call it a gimmick.
http://www.edmontonneurotherapy.com/neurofeedback_therapies.html
“In nirHEG neurofeedback, the trainee tries to increase the signal from the HEG sensor, which is equivalent to activating the cortical region of the brain under the sensor. A computer display shows the change in cortical activation over the course of time. nirHEG neurofeedback directly trains the brain itself. The trainee quickly gains greater control over the flow of blood and the density of oxygenation at the chosen scalp site. Trainees are usually instructed to concentrate and perform a task that directly relates to the region of the brain being trained— e.g., reading, doing math problems, thinking about themselves, or playing a computer game, etc. Training in the left hemisphere of the brain is enhanced by cognitive challenges; whereas training in the right hemisphere is enhanced by spatial activities. Training in the back of the head over the occipital lobes (visual cortex) is a form of relaxation and is enhanced by visualization exercises. Because it is a learning procedure, nirHEG neurofeedback is non-invasive and safe.
Whereas EEG neurofeedback appears to effect neurogenesis and neural connectivity; HEG neurofeedback appears to affect angiogenesis and increases the density of the capillary bed that brings oxygen to the area of the cortex being trained. The one form of neurofeedback appears to support the other.”
Also: http://www.isnr.org/PanelsClinicalCorners.cfm (under the heading: Stem Cells and Neurotherapy – Depression, ADD/ADHD, TBI).
Hi Isaac,
Well thank-you.
Yes, neurofeedback is different than just video game playing. Neurofeedback is a special type of therapy (as you know) designed to change the way your body’s nervous system responds to certain stimuli. This therapy requires trained personnel and special equipment and so hasn’t really caught on. I’m not sure what its efficacy rate is and I know some people don’t believe in it. I can’t say one way or the other but I suspect, like EMDR (eye movement desensitization and reprocessing) it may work in some situations specifically, but we don’t know which ones, just yet.
(And I don’t think it works via neuroplasticity. It’s more of a learning model at work.)
– Natasha Tracy
There is research into the use of computer games to treat depression, as well as research on neurogenesis. I would not say that either idea is off track, however, the type of computer game that would treat depression (via neurogenesis or otherwise) is not anything like “Grand Slam Auto Theft” or its ilk. It would have to be specially designed and ultimately refined for different types of depression.
Neurogenesis happens all the time with even the most mundane activities. It need not be promoted and, if it were, we do not have enough knowledge to promote the regrowth of the proper neurons in the proper places at the proper time to solve any particular malady. It is not like exercising your biceps to be able to pick up heavier loads. The brain is way too complex.
Hi Ari,
It’s not that neurons don’t grow on their own – yes, they do. It’s that people with depression lose brain volume, possibly due to a lack of brain-derived neurotrophic factor (BDNF). A lack of BDNF decreases neuroplasticity while antidepressants and electroconvulsive therapy increase BDNF and neuplasticity and they have been shown to reverse the brain volume loss created by depression. And you are correct, that happens in specific parts of the brain.
As for video games, you would have to point me towards that research as I’m unaware of it.
– Natasha Tracy
I have been in therapy for more than five years. It helps me a lot. I think it helps me more when I am stable and thinking clearly than when I am either depressed or manic. My therapist has helped me work through many problems, both small and large, and she has also helped me to become a much more positive thinker. When I have been depressed, our sessions haven’t been as productive because I have a hard time talking when I am depressed, but I have felt supported, and she has helped me to cope with depression until I got through it.
Hi Andrea,
That’s very much how I very therapy. It works best when you’re not acutely ill but can support you during ill times. Somehow, many therapists don’t get this and think therapy should fix the acute illness.
– Natasha Tracy
I’ve studied my own case of MDD and therapy has been critical. I tried meds alone, then meds with an ineffective therapist, then meds alone, and now meds with a wonderful therapist. I work hard with my therapist – We have a partnership. But also, she has changed my self-awareness more than any friend could have done. She has helped me work on a balanced perspective on many issues. Finally, she has given me hope, and what can you say but good things about that?
Hi Carl,
I think your experience is similar to many and I always advise people go to therapy when they take medication (and as you mention, a good therapist is key). I think the type of therapy that works, though, is pretty unique to the individual (again, thus the need for the right therapist) and so pretty much impossible to measure.
CBT though, is a specific therapy and it’s interesting the research around it because it is such a darling of the day.
And no, I can’t saying anything bad about something that makes you feel better and gives you hope. What else is there? :)
– Natasha Tracy
My doctor and I touch upon CBT concepts during each session or most sessions, but as she said, if ALL we did was CBT, I’d get bored, would not progress, get frustrated and lose that little bit of hope. I think I like my doctor because she has a smorgasbord of tools that she uses. She doesn’t glam on to this theory or that…She has years and years and years of experience, so I am sure she’s seen her share of theories come and go…
Carl,
Sounds like you’ve found a good therapist. I’ve had a few. Some can be lifesavers.
– Natasha Tracy
I’ve never seen research where they told therapists not to therapy, but there’s plenty of research where the “therapists” were just psychology students reading from a book, not experienced therapists at all.
It’s understandable that any therapy appears to get worse over time. When CBT was first invented the only people who practised it were really into it, so they got good results. Now that CBT is mainstream many of the people who practise it only have a very vague understanding of what to do, as Ari says above, so these days the results can be disappointing unless you choose your therapist carefully.
For the therapist, it’s true that CBT is intellectual, analytical, short-term and action-oriented. For the patient, these things do not apply. For example, you don’t have to be intellectual to benefit from CBT, but you do have to be intellectual to be a successful therapist. And as a patient the benefits of CBT are long-lasting, but as a therapist you only get to see each patient for a short time.
Hi CBTish,
When I said “not to therapy” that was just my way of expressing a concept. The article I linked to talks about therapists being directed not to provide therapy using the rules of treatment set out in the therapy being tested (in the non-active group). It amounts to something similar and my point is about how hard it is for the therapist not to provide a type of care. As you say, psychology students is one way to go but I don’t think I would put them in the category of a great control group because they don’t know what they’re doing, good or bad.
I agree, many people who practice CBT aren’t properly trained at using it. It is the darling therapy so everyone wants their hands on it. I’ve seen really good treatment providers and not so.
“For the therapist, it’s true that CBT is intellectual, analytical, short-term and action-oriented. For the patient, these things do not apply.”
I really don’t agree. I’ve taken CBT from an expert and know a lot about it and consider it very intellectual. It’s all about identification and analysis of thoughts. We even had written homework where I took it. Pretty analytical. (Not that you have to be an intellectual to benefit; that’s why there is a therapist.)
Oh, and I wouldn’t suggest the benefits of CBT aren’t long-standing, they absolutely can be. They’re a tool set. If you use the tools, they can work.
– Natasha Tracy
Another great post.
Some comments, but my research on this subject is a few years old. I don’t think much has changed.
In the 1970’s there were BIG questions concerning the efficacy of psychotherapy (see Hans Eyesenck), but since then there has been a great many studies that indicate that, in general psychotherapy is effective. Of course, the real questions are when, for what, for who and under what circumstance.
The most important finding is that about 60% of the success of psychotherapy is attributable to factors in the client. (How many therapists does it take to change a light bulb? One. But the light bulb has to want to change.)
CBT is still considered the best modality, but most people who call themselves CBT therapists do not follow the CBT protocols. For serious depression, CBT and meds is better than either alone.
Minor depression (which is over diagnosed in the USA) and people who feel depressed even if they know how to “think straight” have a real hard time finding the right therapist. That messes up the statistics. You have a lot of people who might not even need therapy going for it, and then saying it doesn’t work very well.
Part of the reason is that therapy is designed to relive people from pain and psychological suffering. Once that is accomplished most therapy has nothing to say. But that does not mean that the person is happy. From a “blah” languishing life to a happy flourishing life is a different process. And a different sort of therapy. And in America there are many people who get the diagnosis of depression who don’t deserve it.
Hi Ari,
What I think is that almost any type of therapeutic interaction will make people “feel better” to some extent. I think that’s what some of the comparative studies show. People are crying out for a competent person to listen to them and talk to them about their problem. Yes, there is no doubt that specific modalities seem to work well for some disorders, but in general, I think therapy is helpful for people, in general.
(I find it interesting that for anxiety disorders, CBT can be delivered by computer and still be effective. Speaks highly for the modality.)
And I suspect there’s no reasonable argument against therapy and meds often being better than meds or therapy alone.
But you’re right, therapy can’t make someone “feel happy” necessarily but can help someone find their happiness, I think. At least, for people without a mental illness. People with a mental illness are in a different category, I think. Some of them respond well to therapy, which is great, but I think severe disorders can only incrementally be helped by therapy. At least, that’s my experience.
But it does come down to who will benefit from what. Just like with meds.
– Natasha Tracy
Hi Lynoth,
I forgive you :) This is one place where we get brain meltdowns.
Hm, are psychotherapists lunatics?
Some of us get what we’re looking at. And some not-so-much. Like most people.
I join you in eyerolling in certain interpretations of data, however.
– Natasha Tracy
I’m in the middle of a brain meltdown due to the first cold of the season, so forgive me if this is what you already said, but:
The same therapy doesn’t work for every person the same way. Therefore, if you lump it all together and look at the numbers THAT way, of COURSE “therapy doesn’t work”
Duh.
~eyeroll~ this is the best argument there is for letting the lunatics run the asylum – at least we understand what we’re looking at!