Psychotherapy May be the Best Treatment
Psychotherapy, or "talk therapy," is a way to treat people with a mental disorder by helping them understand their illness. It teaches people strategies and gives them tools to deal with stress and unhealthy thoughts and behaviors. Psychotherapy helps patients manage their symptoms better and function at their best in everyday life.
Sometimes psychotherapy alone may be the best treatment for a person, depending on the illness and its severity. Other times, psychotherapy is combined with medications. Therapists work with an individual or families to devise an appropriate treatment plan.
What are the different types of psychotherapy?
Many kinds of psychotherapy exist. There is no "one-size-fits-all" approach. In addition, some therapies have been scientifically tested more than others. Some people may have a treatment plan that includes only one type of psychotherapy. Others receive treatment that includes elements of several different types. The kind of psychotherapy a person receives depends on his or her needs.
This section explains several of the most commonly used psychotherapies. However, it does not cover every detail about psychotherapy. Patients should talk to their doctor or a psychotherapist about planning treatment that meets their needs.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is a blend of two therapies: cognitive therapy (CT) and behavioral therapy. CT was developed by psychotherapist Aaron Beck, M.D., in the 1960's. CT focuses on a person's thoughts and beliefs, and how they influence a person's mood and actions, and aims to change a person's thinking to be more adaptive and healthy. Behavioral therapy focuses on a person's actions and aims to change unhealthy behavior patterns.
CBT helps a person focus on his or her current problems and how to solve them. Both patient and therapist need to be actively involved in this process. The therapist helps the patient learn how to identify distorted or unhelpful thinking patterns, recognize and change inaccurate beliefs, relate to others in more positive ways, and change behaviors accordingly.
CBT can be applied and adapted to treat many specific mental disorders.
CBT for depression
Many studies have shown that CBT is a particularly effective treatment for depression, especially minor or moderate depression. Some people with depression may be successfully treated with CBT only. Others may need both CBT and medication. CBT helps people with depression restructure negative thought patterns. Doing so helps people interpret their environment and interactions with others in a positive and realistic way. It may also help a person recognize things that may be contributing to the depression and help him or her change behaviors that may be making the depression worse.
CBT for anxiety disorders
CBT for anxiety disorders aims to help a person develop a more adaptive response to a fear. A CBT therapist may use "exposure" therapy to treat certain anxiety disorders, such as a specific phobia, post traumatic stress disorder, or obsessive compulsive disorder. Exposure therapy has been found to be effective in treating anxiety-related disorders.1 It works by helping a person confront a specific fear or memory while in a safe and supportive environment. The main goals of exposure therapy are to help the patient learn that anxiety can lessen over time and give him or her the tools to cope with fear or traumatic memories.
A recent study sponsored by the Centers for Disease Control and Prevention concluded that CBT is effective in treating trauma-related disorders in children and teens.
CBT for bipolar disorder
People with bipolar disorder usually need to take medication, such as a mood stabilizer. But CBT is often used as an added treatment. The medication can help stabilize a person's mood so that he or she is receptive to psychotherapy and can get the most out of it. CBT can help a person cope with bipolar symptoms and learn to recognize when a mood shift is about to occur. CBT also helps a person with bipolar disorder stick with a treatment plan to reduce the chances of relapse (e.g., when symptoms return).2
CBT for eating disorders
Eating disorders can be very difficult to treat. However, some small studies have found that CBT can help reduce the risk of relapse in adults with anorexia who have restored their weight.3 CBT may also reduce some symptoms of bulimia, and it may also help some people reduce binge-eating behavior.4
CBT for schizophrenia
Treating schizophrenia with CBT is challenging. The disorder usually requires medication first. But research has shown that CBT, as an add-on to medication, can help a patient cope with schizophrenia.5 CBT helps patients learn more adaptive and realistic interpretations of events. Patients are also taught various coping techniques for dealing with "voices" or other hallucinations. They learn how to identify what triggers episodes of the illness, which can prevent or reduce the chances of relapse.
CBT for schizophrenia also stresses skill-oriented therapies. Patients learn skills to cope with life's challenges. The therapist teaches social, daily functioning, and problem-solving skills. This can help patients with schizophrenia minimize the types of stress that can lead to outbursts and hospitalizations.
Dialectical Behavior Therapy
Dialectical behavior therapy (DBT), a form of CBT, was developed by Marsha Linehan, Ph.D. At first, it was developed to treat people with suicidal thoughts and actions. It is now also used to treat people with borderline personality disorder (BPD). BPD is an illness in which suicidal thinking and actions are more common.
The term "dialectical" refers to a philosophic exercise in which two opposing views are discussed until a logical blending or balance of the two extremes—the middle way—is found. In keeping with that philosophy, the therapist assures the patient that the patient's behavior and feelings are valid and understandable. At the same time, the therapist coaches the patient to understand that it is his or her personal responsibility to change unhealthy or disruptive behavior.
DBT emphasizes the value of a strong and equal relationship between patient and therapist. The therapist consistently reminds the patient when his or her behavior is unhealthy or disruptive—when boundaries are overstepped—and then teaches the skills needed to better deal with future similar situations. DBT involves both individual and group therapy. Individual sessions are used to teach new skills, while group sessions provide the opportunity to practice these skills.
Research suggests that DBT is an effective treatment for people with BPD. A recent NIMH-funded study found that DBT reduced suicide attempts by half compared to other types of treatment for patients with BPD.6
Interpersonal therapy (IPT) is most often used on a one-on-one basis to treat depression or dysthymia (a more persistent but less severe form of depression). The current manual-based form of IPT used today was developed in the 1980's by Gerald Klerman, M.D., and Myrna Weissman, M.D.
IPT is based on the idea that improving communication patterns and the ways people relate to others will effectively treat depression. IPT helps identify how a person interacts with other people. When a behavior is causing problems, IPT guides the person to change the behavior. IPT explores major issues that may add to a person's depression, such as grief, or times of upheaval or transition. Sometimes IPT is used along with antidepressant medications.
IPT varies depending on the needs of the patient and the relationship between the therapist and patient. Basically, a therapist using IPT helps the patient identify troubling emotions and their triggers. The therapist helps the patient learn to express appropriate emotions in a healthy way. The patient may also examine relationships in his or her past that may have been affected by distorted mood and behavior. Doing so can help the patient learn to be more objective about current relationships.
Studies vary as to the effectiveness of IPT. It may depend on the patient, the disorder, the severity of the disorder, and other variables. In general, however, IPT is found to be effective in treating depression.7
A variation of IPT called interpersonal and social rhythm therapy (IPSRT) was developed to treat bipolar disorder. IPSRT combines the basic principles of IPT with behavioral psychoeducation designed to help patients adopt regular daily routines and sleep/wake cycles, stick with medication treatment, and improve relationships. Research has found that when IPSRT is combined with medication, it is an effective treatment for bipolar disorder. IPSRT is as effective as other types of psychotherapy combined with medication in helping to prevent a relapse of bipolar symptoms.8
Family-focused therapy (FFT) was developed by David Miklowitz, Ph.D., and Michael Goldstein, Ph.D., for treating bipolar disorder. It was designed with the assumption that a patient's relationship with his or her family is vital to the success of managing the illness. FFT includes family members in therapy sessions to improve family relationships, which may support better treatment results.
Therapists trained in FFT work to identify difficulties and conflicts among family members that may be worsening the patient's illness. Therapy is meant to help members find more effective ways to resolve those difficulties. The therapist educates family members about their loved one's disorder, its symptoms and course, and how to help their relative manage it more effectively. When families learn about the disorder, they may be able to spot early signs of a relapse and create an action plan that involves all family members. During therapy, the therapist will help family members recognize when they express unhelpful criticism or hostility toward their relative with bipolar disorder. The therapist will teach family members how to communicate negative emotions in a better way. Several studies have found FFT to be effective in helping a patient become stabilized and preventing relapses. 9,10,11
FFT also focuses on the stress family members feel when they care for a relative with bipolar disorder. The therapy aims to prevent family members from "burning out" or disengaging from the effort. The therapist helps the family accept how bipolar disorder can limit their relative. At the same time, the therapist holds the patient responsible for his or her own well being and actions to a level that is appropriate for the person's age.
Generally, the family and patient attend sessions together. The needs of each patient and family are different, and those needs determine the exact course of treatment. However, the main components of a structured FFT usually include:
- Family education on bipolar disorder
- Building communication skills to better deal with stress, and
- Solving problems together as a family.
It is important to acknowledge and address the needs of family members. Research has shown that primary caregivers of people with bipolar disorder are at increased risk for illness themselves. For example, a 2007 study based on results from the NIMH-funded Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) trial found that primary caregivers of participants were at high risk for developing sleep problems and chronic conditions, such as high blood pressure. However, the caregivers were less likely to see a doctor for their own health issues.12 In addition, a 2005 study found that 33 percent of caregivers of bipolar patients had clinically significant levels of depression.13
Are psychotherapies different for children and adolescents?
Psychotherapies can be adapted to the needs of children and adolescents, depending on the mental disorder. For example, the NIMH-funded Treatment of Adolescents with Depression Study (TADS) found that CBT, when combined with antidepressant medication, was the most effective treatment over the short term for teens with major depression.14 CBT by itself was also an effective treatment, especially over the long term. Studies have found that individual and group-based CBT are effective treatments for child and adolescent anxiety disorders.15 Other studies have found that IPT is an effective treatment for child and adolescent depression.16,17
Psychosocial treatments that involve a child's parents and family also have been shown to be effective, especially for disruptive disorders such as conduct disorder or oppositional defiant disorder. Some effective treatments are designed to reduce the child's problem behaviors and improve parent-child interactions. Focusing on behavioral parent management training, parents are taught the skills they need to encourage and reward positive behaviors in their children.18 Similar training helps parents manage their child's attention deficit/hyperactivity disorder (ADHD). This approach, which has been shown to be effective, can be combined with approaches directed at children to help them learn problem-solving, anger management and social interaction skills. 19
Family-based therapy may also be used to treat adolescents with eating disorders. One type is called the Maudsley approach, named after the Maudsley Hospital in London, where the approach was developed. This type of outpatient family therapy is used to treat anorexia nervosa in adolescents. It considers the active participation of parents to be essential in the recovery of their teen. The Maudsley approach proceeds through three phases:
- Weight restoration. Parents become fully responsible for ensuring that their teen eats. A therapist helps parents better understand their teen's disease. Parents learn how to avoid criticizing their teen, but they also learn to make sure that their teen eats.
- Returning control over eating to the teen. Once the teen accepts the control parents have over his or her eating habits, parents may begin giving up that control. Parents are encouraged to help their teen take more control over eating again.
- Establishing healthy adolescent identity. When the teen has reached and maintained a healthy weight, the therapist helps him or her begin developing a healthy sense of identity and autonomy.
Several studies have found the Maudsley approach to be successful in treating teens with anorexia.20,21 Currently a large-scale, NIMH-funded study on the approach is under way.
What other types of therapies are used?
In addition to the therapies listed above, many more approaches exist. Some types have been scientifically tested more than others. Also, some of these therapies are constantly evolving. They are often combined with more established psychotherapies. A few examples of other therapies are described here.
Psychodynamic therapy. Historically, psychodynamic therapy was tied to the principles of psychoanalytic theory, which asserts that a person's behavior is affected by his or her unconscious mind and past experiences. Now therapists who use psychodynamic therapy rarely include psychoanalytic methods. Rather, psychodynamic therapy helps people gain greater self-awareness and understanding about their own actions. It helps patients identify and explore how their nonconscious emotions and motivations can influence their behavior. Sometimes ideas from psychodynamic therapy are interwoven with other types of therapy, like CBT or IPT, to treat various types of mental disorders. Research on psychodynamic therapy is mixed. However, a review of 23 clinical trials involving psychodynamic therapy found it to be as effective as other established psychotherapies.22
Light therapy. Light therapy is used to treat seasonal affective disorder (SAD), a form of depression that usually occurs during the autumn and winter months, when the amount of natural sunlight decreases. Scientists think SAD occurs in some people when their bodies' daily rhythms are upset by short days and long nights. Research has found that the hormone melatonin is affected by this seasonal change. Melatonin normally works to regulate the body's rhythms and responses to light and dark. During light therapy, a person sits in front of a "light box" for periods of time, usually in the morning. The box emits a full spectrum light, and sitting in front of it appears to help reset the body's daily rhythms. Also, some research indicates that a low dose of melatonin, taken at specific times of the day, can also help treat SAD.23
Other types of therapies sometimes used in conjunction with the more established therapies include:
- Expressive or creative arts therapy. Expressive or creative arts therapy is based on the idea that people can help heal themselves through art, music, dance, writing, or other expressive acts. One study has found that expressive writing can reduce depression symptoms among women who were victims of domestic violence.24 It also helps college students at risk for depression.25
- Animal-assisted therapy. Working with animals, such as horses, dogs, or cats, may help some people cope with trauma, develop empathy, and encourage better communication. Companion animals are sometimes introduced in hospitals, psychiatric wards, nursing homes, and other places where they may bring comfort and have a mild therapeutic effect. Animal-assisted therapy has also been used as an added therapy for children with mental disorders. Research on the approach is limited, but a recent study found it to be moderately effective in easing behavioral problems and promoting emotional well-being.26
- Play therapy. This therapy is used with children. It involves the use of toys and games to help a child identify and talk about his or her feelings, as well as establish communication with a therapist. A therapist can sometimes better understand a child's problems by watching how he or she plays. Research in play therapy is minimal.
What research is underway to improve psychotherapies?
Researchers are continually studying ways to better treat mental disorders with psychotherapy, and many NIMH-funded studies are underway.
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