After Freud, CBT offers hope

Formulated over six decades ago, cognitive behavioral therapy is healing disturbed minds with the Internet. A European congress in Jerusalem discussed it and other developments.

Dr. Sofi Marom (left) and Prof. Eva Gilboa-Schechtman (photo credit: JUDY SIEGEL-ITZKOVICH)
Dr. Sofi Marom (left) and Prof. Eva Gilboa-Schechtman
A century after Sigmund Freud put mentally disturbed patients on his couch and probed their childhoods for months and years, therapists are increasingly relieving and even curing depression, anxiety, social phobias, eating disorders, insomnia and obsessive-compulsive disorder in a matter of weeks using a technique pioneered in the 1960s.
While classical psychoanalysts continue to use psychodynamic, insight-oriented therapy and probe their patients’ psyche in the long-term effort to face their past and make them well, cognitive behavioral therapists (CBT) are forging ahead, even offering much of their help over the Internet rather than just face to face. The technique is used not only in adults but also in adolescents and children.
Two of the pioneers of CBT were Jews - Pittsburgh-born psychologist Albert Ellis and University of Pennsylvania psychiatrist Dr. Aaron Beck. The long-lived Ellis (1913 to 2007) developed six decades ago what he called Rational Emotive Behavior Therapy.
Ellis is regarded as one of the founders of the cognitive paradigm shift in psychotherapy and the founder of cognitive-behavioral therapies.
His psychologist wife, Dr. Debbie Joffe Ellis (who was much younger than him) was born and raised in Melbourne and became a mental health and adjunct professor at New York’s Columbia University. She worked with her husband until his death and is connected with a number of psychological associations in the US and Australia that are involved in CBT.
Beck independently carried out a number of clinical trials to test psychoanalytic concepts of depression. While he was certain that his studies would provide backing for Freudian ideas, he was amazed to find that they didn’t. Looking for other ways to deal with depression, Beck believed people suffering from clinical depression had “automatic streams of negative thoughts” about themselves, the world and/or the future; by helping them identify and evaluate these automatic thoughts, Beck said, they felt better and were able to function much better; surprisingly, these changes were not evanescent but lasting.
One of the forerunners of CBT – before cognitive theory was combined with behaviorism – was the noted Russian physiologist Ivan Petrovich Pavlov, who was famous for his work on animal learning, digestion and salivation in dogs and his theories of classical conditioning. In his experiments, he found that if a buzzer was sounded when food was brought to them, eventually dogs learned to connect the noise to the food and would salivate reflexively even without the arrival of the food. Classical conditioning eventually served as a basis for some CBT treatment.
Another early forerunner was US psychologist B. F. Skinner, famous for his utopian novel Walden Two, who described his theories as “radical behaviorism” and believed that reinforcement shapes and controls behavior. Positive reinforcement, he said, was bolstering behavior with an event such as praise, while negative reinforcement is the strengthening of behavior via some unpleasant stimuli, such as punishment. These ideas too have been incorporated into CBT.
SINCE THE CBT approach was launched, more than 500 studies have been carried out showing that it is effective in treating not only depression but also a wide variety of mental disorders. The younger generation of psychiatrists, psychologists and even some social workers have been taught CBT as a basic technique, to be used alone or combined with psychodynamic therapies. Public health systems starved for funds have embraced the technique – which has been modified and expanded by subsequent generations of CBT experts – as a way to heal large numbers of patients in a short time and at minimal cost.
The first world CBT conference was held in Israel in 1980; the first Israeli congress of the European Association for Behavioral and Cognitive Therapies – the 45th annual event – has just been concluded at Jerusalem’s International Convention Center. Some 1,200 experts from 50 countries participated in the four-day event. One of them was the daughter of Beck himself; she led a workshop at the event, while Ellis’s wife also attended and participated.
The Jerusalem congress was five years in the making, said Dr. Sofi Marom, its chairman, who is head of the program for CBT in Anxiety Disorders at the Geha Mental Health Center.
About half of the participants were Israeli psychologists, psychiatrists, social workers and family physicians and the rest counterparts from abroad.
The chairman of the scientific committee was Prof. Jonathan Huppert, the chairman of the psychology department at the Hebrew University of Jerusalem. Israel has its own CBT association, ITA , which gives accreditation to those who have received training in the field.
“All of the lectures at the congress showed how much the understanding of mental disorders and the improved use of CBT are based on developments of the science,” said Huppert in an interview with The Jerusalem Post as the congress began.
It is estimated that at lest half of people treated using CBT techniques for depression recover during the weeks of treatment and that many others feel significantly better. “CBT is meant to help deal with mental health problems in as focused a way as possible,” said Huppert. “CBT does not replace psychoanalysis,” he added, “but it offers something else beyond the long-term therapy. There is a distinction between psychological treatments that are part of the public health system and psychotherapies that help people to explore their lives.”
The haredim (ultra-Orthodox) in Israel are often much more likely to seek out CBT - especially online - than face-to-face care because it gives them privacy. No one else knows they are getting treatment, he said, adding that as many as a third of them have access to personal computers. “We have a new program at the Hebrew University and Bar-Ilan University to train new haredi psychologists who will learn CBT techniques,” he said.
Marom noted that the new mental health reform carried out by the Health Ministry in which it handed over responsibility for mental health treatment to the four public health funds “is very suited for CBT,” as it is short-term, successful, accessible and relatively inexpensive.
But while delivering CBT online after an initial face-to-face meeting is widespread in the US and Europe, Israel is for some reason much behind in such delivery, noted Huppert. CBT in general is much less known to Israelis than it is abroad. “I suppose the professional organizations are partly to blame. We should be giving much more information to the public,” he said.
Prof. Eva Gilboa-Schechtman of the psychology department of Bar-Ilan University, who was a member of the congress’s steering committee, said that between 17 percent to 20% of Israelis currently suffer from anxiety or depression and more than twice that will during their lifetimes. Despite Israel’s wars, terrorist attacks and presence of elderly Holocaust survivors, the rate is lower here than in the US, she added.
“There are theories that [this is due to] more social cohesiveness and closer families in tiny Israel than in the US. But admittedly, stress levels, especially in the south as during the last war, are higher here than in the US.”
Fewer than 40% of sufferers go for help, mostly because of the stigma, said Gilboa-Schechtman.
Thus reducing the stigma of emotional problems “was a goal of the reform, but it’s hard to know so early in its implementation if it’s working. One has to measure outcomes and compare those that are being provided by the health funds and mental health centers that have been under auspices of ministry until now,” the Bar-Ilan psychologist said.
PROF. DAVID Clark, chairman of experimental psychology at Oxford University in England, attended the conference; his third visit here.
“I was first here in 1987 and then attended a workshop on social phobia two years later. Israelis in the field are a wonderful group of people,” he said.
Clark, one of the world’s leading experts on CBT, was with British labor economist Richard Layard the main driver behind the UK’s Improving Access to Psychological Therapies program.
Together with Layard, Clark wrote a popular 373-page book, Thrive: The Power of Psychological Therapy, in 2014 to explain mental illness and what can be done to relieve it. CBT, he wrote, refers to a variety of interventions, depending on which emotional problem is involved. Among the techniques are imagery, distraction, motivational self-talk, relaxation, biofeedback, development of adaptive coping strategies (e.g. minimizing negative or self-defeating thoughts) and changing maladaptive beliefs about pain. People with phobias or obsessive compulsion disorder are exposed to the cause of their problem gradually, and so are gradually liberated from it.
With Internet CBT, after a session or two of face-to-face encounters, there may be four to 16 more sessions over the Internet, with a one- to three-week gap between sessions.
The patient is very much involved in the treatment, often given “homework” such as going to a small party if he suffers from a social disorder.
The half-dozen phases of CBT are assessment, reconceptualization, the acquisition of skills, the consolidation of skills and training to apply them, generalization and maintenance of positive behaviors and post-treatment follow-up.
“You have post-trauma, anxiety and depression here in Israel, but we have plenty of our own in England too – rapes, other violent crimes, the London bombings and more. We have found CBT is very helpful. There have been no really new psychoactive drugs in decades, although there have been variations that cause slightly different side effects,” Clark pointed out. “If there were new drugs, they would make money for pharmaceutical companies, but it hasn’t happened. I can’t explain why. So in their absence, psychological treatments based on very sound research have been developing and proven effective by evidence-based medicine,” he stressed.
In the early days of CBT, “there were lots of fights with psychotherapists on who gave better treatment. But it has been much reduced because of evidence-based studies. I have been involved in a government program to improve access of the population to CBT. For patients suffering from depression, we support short-term psychodynamic therapy as well as CBT. For anxiety, we support only CBT, because research has shown it is the leading treatment and very effective. Some patients get both CBT and medications for their problem.”
Clark added that half-a-million Brits are treated in the CBT program each year.
Treatment usually goes on for two or three months, and all is covered by the National Health Service.
“This has been a revolution for us, and it has changed a lot of attitudes - including those of the older psychodynamic therapies; now they measure their successes and failures as well.”
The biggest mental problem that CBT therapists in the US have to treat is suicidal tendencies, said Prof. David Barlow, a senior psychologist at the Center for Anxiety and Related Disorders at Boston University who has been doing CBT for 40 years.
“We also have to cope with substance abuse and military veterans returning from distant wars. We had a big scandal that Veterans Administration Hospitals were unable to accommodate all those who needed help, and ex-soldiers had to wait to get CBT for as much as a year.”
So Barlow and his colleagues developed a sophisticated program called “VETchange,” and the government invested a lot of money in it. It is an interactive, Internet-based program for returning veterans.
“We can deploy immediate help, and veterans never have to leave their home to get about a dozen session.”
There is a huge need for this in the US and many other countries. “At this stage,” concluded Barlow, “we are just scratching the surface. We need to make primary physicians more aware of it so they can refer their patients. I don’t believe that one-on-one psychotherapy will disappear. It will be for the most severely disturbed and for the well off,” said Barlow.