We Need the Next Aaron Beck: Psychotherapy is long past due for a breakthrough

Aaron Beck, father of cognitive-behavioral therapy, just died at the admirable age of 100.  My Psychology Today article today discusses how cognitive-behavioral therapy deservedly has largely replaced Freudian psychoanalysis but that we're long past due for another breakthrough in therapy.

4 Approaches to Change: advice-offering, rational-emotive behavior therapy, motivational messages.

He can’t stop pigging out. She can’t stop worrying. He can’t stop his substance abuse.

Even good psychotherapists (and advertisers) have a hard time getting people to change. It’s been said that it takes six to nine exposures to an ad to get someone to change their brand of toilet paper!

So, there are no magic pills yet. Best we can do, in our own lives and in trying to shepherd others to change, is to have a toolkit of interventions to draw from.  My PsychologyToday.com article today describes four widely used ones.

On an Albert Ellis Quote

The famed cognitive-behavioral therapist, Albert Ellis, said, "The best years of your life are the ones in which you decide your problems are your own. You do not blame them on your mother, the ecology, or the president. You realize that you control your own destiny. "

In my PsychologyToday.com article today, I argue he's being simplistic.

Cognitive-Behavioral Therapy Should No Longer Be THE Therapy

Fueled by patients and insurers wanting faster results, cognitive-behavioral therapy has become the therapy of the last few decades.

My PsychologyToday.com article today argues that it's time to move CBT from the therapy to its proper role as a tool in the toolkit. The article mentions alternatives.

Beyond SSRIs and Cognitive-Behavioral Therapy: What are other approaches to mild to moderate depression?

Recently on PsychologyToday.com I interviewed Dr. Thomas Insel, Director of the National Institute of Mental Health (NIMH).on how to treat depression.

That interview as been gnawing at me ever since. You see, the advice he gave is pretty much what has been recommended for a decade or more, that most people with mild to moderate depression are best treated with an SSRI (like Prozac and Zoloft) and/or cognitive-behavioral therapy (CBT.)

In my admittedly anecdotal experience, having been career and personal coach to many people with depression, their most common experience is that the drug yields some benefit, typically taking the edge off their depression but often, the effect wears off. And the side-effects are often problematic, for example, sexual dysfunction, flattened affect, nausea, and drowsiness. People often go off the medication feeling unsure that the benefits outweigh the side effects

And my clients’ typical experience with cognitive-behavioral therapy is that it helps but, pardon the pun, it’s no magic pill.

Without turning to the treatments usually reserved for severe depression such as electro-convulsive therapy (ECT) or vagus nerve stimulation, what else seems worthy of trial? I address that question in my PsychologyToday.com article today. HERE is the link

The Present and Future of Treatment for Depression

Almost seven percent of the U.S. population, 16 million people, had at least one major depressive episode in the last year. Many more family members, friends, and coworkers are affected.

What’s best practice for treating depression? And what’s on the horizon?

For answers, I turned to Dr. Thomas Insel, Director of the National Institute of Mental Health (NIMH), the mental-health component of the National Institutes of Health. He is a member of the Institute of Medicine of the National Academy of Sciences and recipient of the Outstanding Service Award from the U.S. Public Health Service. I interviewed him today for my PsychologyToday.com article. HERE is the link.

Psychotherapy Reinvented

Psychotherapy is expensive, time-consuming, and too often doesn't work well enough. It needs to be reinvented or at least made more time- and cost-effective.

Traditionally, the first therapy session or two is spent on intake, asking lots of questions to gather information about the client. I'd replace that with a probing questionnaire to be sent to the therapist in advance of the first session. Not only would that save the client time and money, it would give both client and therapist a chance to reflect on the questions rather than have to try to be maximally insightful on the spot.

I believe it's worth creating a video version of the questionnaire. Of course, each therapist could create his or her own, but I'm wondering if the following is worth a try: A preeminent psychotherapist who is eclectically oriented (using cognitive-behavioral as well as traditional techniques) would create a probing new-client questionnaire and then, instead of giving it to the client in text form, ask the questions in a YouTube video, charging a small fee for each use. I believe that many clients would prefer seeing that world-class therapist ask the questions and might give them greater thought. There's certainly little downside to that approach.

More therapists should offer sessions by phone or SkypeVideo. I've found that, if the client is open to it, those are nearly as effective as in-person sessions. Not only does phone/Skype therapy avoid the client having to shlep to and from the therapist's office, it gives clients more therapists from whom to choose. That's especially important for clients in regions with few top therapists, for example, rural areas.

Of course, every situation is different, and severe cases may need more long-term therapy, but I believe that, in most cases, psychotherapy need consist only of one two-hour solution-generation session followed by one one-hour session to assess how helpful the solution(s) have been and, if needed, to tweak solution(s) or generate new ones.

How could it all be done in two sessions? Not only is there the efficiency that comes from a probing new-client questionnaire completed and reviewed by the therapist in advance, the therapist and client knowing there's only one session to develop solutions motivates them to make the most of the session time. (Remember Parkinson's Law: Work expands to fill the time allotted?) Too often, much time in therapy sessions is wasted on unimportant tangents. Another benefit of developing the solution(s) in one session is that both therapist and client have all the input currently in-mind rather than having to recall it from notes and memory of the previous session(s.)

Generally, therapists should try to elicit solutions from the client--they're more likely to be helpful and certainly to be acted upon. But, unlike in traditional models of therapy, sometimes the client really does need and is open to the therapist's input. So if a therapist would like to suggest a possible solution, s/he should do so. The key, however, is to offer it in a client-empowering way, for example, "Would you mind if I suggest something?" With assent, then say something like, "I'm not sure I'm right but I'm wondering if it might help if you did (

Other time-effective techniques used in psychotherapy and coaching should be part of the therapist's repertoire. One example: Ask the client, "If I waved a magic wand and your problem were solved, how would your behavior be different?" After they explain, ask, "Could you change any of that now?"

Unlike in many traditional therapy sessions, the first session should end with a specific behavior(s) the client is enthusiastic about trying. Examples:

The moment an irrational fear enters consciousness, say "Stop" and ask yourself, "What's the next positive step I can take?"

Write down everything you eat.

Write a letter of reconciliation to your mother. Set it aside for a day. If it still feels good, send it.

Every time you drink something, say aloud, with expression, "I deserve to be good to myself." That will build the brain memory neurons associated with that constructive thought.

In the follow-up session, the client would report the extent to which the solution(s) have been helpful. If changes are needed, the therapist should, as recommended above, usually first try to get solutions to come from the client. If the client didn't do the homework, the therapist should try to ascertain if that was because of a fear, ran into a conundrum, the assignment ended up feeling inappropriate, etc, and try to help ensure that, subsequently, the client be more likely to complete that assignment or a more appropriate one.

At the end of the second session, unless it's clear that more sessions are needed, it's often best to end with something like, "I think you've come up with all the tools you need. So do you agree we don't need to see each other for a while?" If the client agrees, the therapist should say something like, "But I care about you and so I'd welcome your emailing me about your progress, and if you do feel you need another session, just let me know." That makes the client feel supported, assures the client that s/he can have more sessions, and increases the chances that therapists get feedback that can improve their effectiveness.

The World's Shortest Acting Course

A friend of mine, psychotherapist, Dr. Michael Edelstein, wanted to make a video of his unique three minute therapy.

He knows that I'm an amateur actor so he asked if I'd play the role of a depressed person who came to him for therapy.

Before I turned the camera on, I just reminded myself, "You're not acting; you're being that person." I banished all thoughts about what to look or sound like. I reminded myself, "It's of no consequence that the camera is on. I'm just being a depressed person." Here's the video: