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Unread March 11th, 2005, 11:15 PM
James Pretzer James Pretzer is offline
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Join Date: Jun 2004
Posts: 283
Default Re: What uncertainties do we face in CT/CBT?

No, you haven't reached the end of my responses. It's just a matter of my finding time to respond and this isn't always easy.

You wrote "I'm still left wondering about the 'relative' simplicity of CT work when one considers trying to have a lasting impact on mental life that entails this constant stream of affects, mood, cognitions, inner life (the discussions and fantasies people have with themselves), interpersonal/familial transactions, perceptual transactions with the world at large, the long and short term memories that interact with all of this---much of it driven by automaticity). It is hard for me to shake the idea that attempting to intervene and create change-- and more importantly-- maintain those changes--- to be daunting."

I don't think I've ever argued that attempting to intervene and create long-term change is simple. Effective psychotherapy is not at all simple, no matter what one's theoretical orientation. Cognitive Therapy has the advantage of using a relatively simple vocabulary and having a theoretical framework which makes if fairly simple to conceptualize many problems and develop a promising treatment plan. However, this does not mean that it is simple to implement that plan effectively.

For example, I was lecturing on the treatment of obsessive-compulsive disorder today. From a CT perspective it is fairly simple to describe what we need to do in treatment:
  1. conduct a good evaluation (and confirm that we are indeed treating OCD, not some other problem that superficially resembles OCD)
  2. establish a collaborative relationship
  3. develop a thorough understanding of the client's obsessive thoughts, compulsions and rituals, and their fears regarding what will happen if they don't engage in their compulsions and rituals.
  4. share our conceptualization of their OCD and the rationale for exposure-based treatment (i.e. facing anxiety-provoking stimuli, refraining from their usual avoidance behavior and anxiety-reduction strategies, and tolerating the anxiety until it peaks and subsides)
  5. address their fears, beliefs, and assumptions cognitively in order to get to the point that they are willing to follow through on exposure-based treatment
  6. implement exposure and response-prevention persistently until their OCD subsides
  7. develop and implement a relapse prevention plan
Unfortunately, just because it is simple to say what we need to do this doesn't mean that it is simple to do this effectively. I've been treating OCD for more than 20 years and still find it to be challenging.

Your question about long-term follow-up is a good one and highlights one area of uncertainty we have to contend with. Most outcome studies use a 12-month follow-up and there are a limited number of studies with longer follow-up periods. What data we have is encouraging and there are a few studies that show that improvement is often maintained for years. However, given the proclivity of humans to slip back into old habits, it would be useful to have more long-term follow-ups.

Because it is expensive, difficult, and time-consuming to do this kind of research, it may be a while until we know how well the results of CBT persist years after treatment. I find both the available data and my clinical experience encouraging but much more research is needed.
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