Doug Berger, MD, PhD

Dedicated to the Amazing Houdini
American stunt performer (March 24, 1874 – October 31, 1926)

The start of Chapter 3 of the famous book 

 on cognitive behavioral therapy (CBT) hit me, “Depression is not an emotional disorder at all! Every bad feeling you have is the result of your negative thinking

In this paper, I intend to give this conclusion some good natured trouble.

CBT has become rooted as a proven dogma in the treatment of depression in spite of large problems remaining in the methods of CBT clinical trials and the logic of how CBT works. In this paper, I would like to discuss 4 major problems. (“Depression” in this article is defined as DSM-IV major depressive disorder [MDD]

1. The premise of CBT that negative cognitions are the cause of MDD is the only instance in all of medicine and psychiatry where a symptom of an illness is also construed to be the cause. 

The diagnosis of MDD includes negative cognitions as a symptom (ie, feeling worthless or excessive or inappropriate guilt

), and it is known both in clinical practice and in research, that negative cognitions may resolve either with antidepressant medications or with cycling out of the depression.

Negative cognitions as a symptom can also make depression worse, however, asthmatic coughing as a symptom of asthma may also make asthma worse. If we make a therapy that helps to decrease coughing in asthma, we might conclude the therapy was efficacious in asthma. Is that really true? It depends on whether you state that therapy helped asthmatics to feel and function better (true) versus if you state that the therapy is the fundamental treatment of asthma (false).

2. The statement that CBT clinical trials are “randomized and controlled” obfuscates that the studies are not double-blind (ie , neither subjects nor therapists in psychotherapy studies are blind to the type of treatment). 

No CBT study (no psychotherapy study) can be a double-blind study. They may be single-blinded, the rater may not know the treatment the patient received, but neither the patients, nor the therapists, can be blinded to the type of therapy given (two out of three of the persons involved in the trial, ie, all of the persons involved in the treatment, are unblinded). Moreover, the patient must be an active participant in correcting negative distorted thoughts, so they are quite aware of the treatment group they are in.

While a drug study can use a double-blinded placebo control, psychotherapy arms that are called controls are not a blind-placebo, the therapist is also likely a believer in the therapy approach and may transmit this hope to the patient in some way, and large uncontrolled bias is the result in these studies.  

In addition, MDD studies are known to have large random error because subjects with a variety of mildly low mood are included, investigator and patient preference, non-perfect rating instruments, etc. Bias can then lead to a result very far from the true value, 

 A study on bias in treatment outcome studies concluded that the results of unblinded randomized clinical trials (RCTs) tended to be biased toward beneficial effects if the RCTs' outcomes were subjective (as they are in psychotherapy studies) as opposed to objective.

A recent meta-analysis examined the effectiveness of CBT when placebo control and blindedness were factored in.

 Pooled data from published trials of CBT in schizophrenia, MDD, and bipolar disorder that used controls for non-specific effects of intervention were analyzed. This study concluded that (1) CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates; (2) CBT is not an effective treatment strategy for prevention of relapse in bipolar disorder; (3) CBT treatment effects are small in treatment studies of MDD. For MDD, the authors note that the pooled effect size was very low at 0.28 (Hamilton Depression Scale) and 0.27 (Beck Depression Inventory). Remember, these studies are still not double blind making the findings of even small efficacy questionable.

When medication arms are compared to a psychotherapy arm, they also include a blind placebo drug arm, but no blind psychotherapy arm. This inherently makes the study prejudiced against the medication arms, making these studies fatally flawed.

Another recent meta-analysis found no differences between directive or non-directive therapies when controlled for researcher allegiance, and that most of the effects of therapy were realized by non-specific factors.

3. Symptoms in MDD include primary symptoms such as low mood, and negative cognitions as secondary reactions to these symptoms such as hopelessness and despair that may be easily assuaged by a psychotherapy. The person is then deemed a responder because “responder” is defined as a 50% improvement on a rating scale.

That negative cognitions may resolve either with antidepressant medications or with cycling out of the depression supports the notion that the negative cognitions were secondary to the depressed mood.

The concept of primary and secondary symptoms, are also not new to psychiatry. Some authors have described psychological symptoms as a consequence of physical symptoms,

 and negative symptoms in schizophrenia may be classified as primary and etiologically related to the core pathology of schizophrenia, or secondary negative symptoms, some of which are derivative of other symptoms of schizophrenia ( ie, reclusive behavior resulting from paranoia).

In this way, negative conclusions such as, “I don’t deserve anything,” “I am a nobody,” “no one likes me,” etc, can be seen as a psychological reaction to depressed mood. Many therapists have seen that giving persons hope and support can alleviate symptoms and decrease depression scores, but the person still suffers from the disorder. Even if the psychological symptoms of negative self content are construed to not be secondary, it is easy to consider how they may be more pliable to un-blinded psychotherapeutic intervention.

In addition, because “response” in a clinical trial of MDD is defined as a 50% improvement on a rating scale, “response” can be as a result of assuaging of psychological pain thus making the patient a “responder” in a clinical trial without actually changing the underlying biologic illness of MDD.

While CBT trials have been shown to maintain gains in depression over long study periods, we are still left with the problem of the impossibility of double blinding of a psychotherapy trial putting the validity of these long-term studies into question.

4. Patients’ response to psychotherapy can strongly differ depending on whether they have non-melancholic, melancholic, or psychotic MDD (

), and this can critically affect the results of a clinical trial.

Pre-treatment severity of MDD symptoms portends better outcome with antidepressants

 suggesting that the worse MDD is the more biologically based the etiology. In addition, patients with non-melancholic MDD are not deemed to clearly have an illness with biologic underpinnings compared to those with more severe melancholic and psychotic features.

If a patient does not have an actual biologic depression, then they more easily improve because their non-melancholic depressed mood was based on personality issues and/or psychosocial problems.

 The psychotherapy intervention being studied will then be NON-inferior to any other intervention, and if the patients and therapists are studying CBT, the element of hope and expectation on the part of the patients to get better in these non-blinded trials will bias the results in favor of the CBT arm of the study. In addition, non-melancholic MDD is thought to be the most 

 thus the most likely type of MDD subject to enter a CBT trial, and the informed consent procedure biases the subjects who enter to those that are favorably inclined to the psychotherapy.

Until a reliable biologic marker for MDD is discovered, only persons with at least a melancholic MDD should be considered to have MDD for the purpose of being included in such trials, assuming they can be double-blind. Unfortunately, these studies can never be double-blinded.

The combination of points raised this article leads to the conclusions that:

1. CBT may help depressed persons function and feel better, but that is not an intervention proven to treat the core pathology of MDD

2. CBT is not a psychotherapeutic modality proven to be better than any other type of psychotherapeutic intervention for MDD

3. CBT should not be given as mono-therapy for persons with melancholic or psychotic MDD

4. Our field must not allow studies that are not double-blinded to be called “controlled,” or “evidence-based,” they need to be in a different category, ie, “uncontrolled clinical data”

I can see what they mean now on the back side of the 

 book that states, “The amazing, scientifically proven techniques described by eminent psychiatrist David D. Burns, MD, will show you what you can do immediately lift your spirits and develop a positive outlook on life.”

 Reminds me of a Houdini show promotion poster circa 1920.

Dr Berger is in private practice in Japan and consults on clinical trials with pharmaceutical companies. He reports this article received no support or grants, and that he has no conflicts of interest concerning the subject matter of this article. His website is at 

 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.

 Washington DC, American Psychiatric
Association; 2000.

3. Fava M, Davidson K, Alpert JE, et al. Hostility changes following antidepressant treatment: relationship to stress and negative thinking. 

Clinical Trials: A Methodologic Perspective

, 2nd ed. New York: Wiley-Interscience; 2005.

5. Wood L, Egger M, Gluud LL, et al. Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study. 

6. Lynch D, Laws, KR, McKenna PJ. Cognitive behavioral therapy for major psychiatric disorder: does it really work? A meta-analytical review of well-controlled trials. 

7. Vitiello B, Rohde P, Silva S, Wells K, Casat C, Waslick B, et al. Functioning and quality of life in the Treatment of Adolescents for Depression Study (TADS). 

8. Cuiipers P, Driessen E, Hollon SD, et al. The Efficacy of non-directive supportive therapy for adult depression: a meta-analysis. 

9. Kroenke K. The interface between physical and psychological symptoms. Primary care companion.

10. Kirkpatrick B, Fischer B. Subdomains within the negative symptoms of schizophrenia: commentary. Schizophr Bull. 2006;32:246-249.

11. Trivedi MH, Corey-Lisle PK, Guo Z, et al. Remission, response without remission, and nonresponse in major depressive disorder: impact on functioning. 

12. Khan A, Leventhal R, Khan SR, Brown WA. Severity of depression and response to antidepressants and placebo: an analysis of the Food and Drug Administration database. 

The American Psychiatric Press Textbook of Psychiatry

. Washington, DC: American Psychiatric Publishing, Inc; 2003.

14. McGrath, P; Ashan K, Madhukar T, et al. Response to a selective serotonin reuptake inhibitor (Citalopram) in major depressive disorder with melancholic features: A STAR*D report. 

15. GonzÃ¡lez-Tejera G, Canino G, Ramirez R, et al. Examining minor and major depression in adolescents. 

16. Black Dog Institute. Non-Melancholic Depression; 2005. 

http://www.blackdoginstitute.org.au/healthprofessionals/depression/non-melancholicdepression.cfm

17. Sathyanarayana R, Andrade C. Screening for disease, psychologic testing, and psychotherapy: Looking behind the mirror. 

Articles

CBT has become rooted as proven dogma in the treatment of depression despite large problems remaining in methodology of CBT clinical trials and the logic behind how CBT works. This article will describe the major methodologic problems in the clinical trials of CBT.

Cognitive Behavioral Therapy: Escape From the Binds of Tight Methodology

Psychiatrists Should Not Fall Back on DSM

The Lure of the Context-Dependent Psychiatric Diagnosis

 November 2008, page 44) raised the issue that 

 does not take into account the context in which symptoms arise for the diagnosis of MDD. The authors opine that the diagnosis should require that symptoms be “excessive” or “unreasonable” relative to the context in which they arise, and that “the efficacy of these medications for the treatment of normal sadness is often overstated.”

This is really a discussion of whether first–episode reactive depression should be considered a type of MDD, even if the symptoms are considered “excessive” given the context. (Certainly, persons with recurrent endogenous depression do not need much stress to have a relapse). Some persons react to high stress levels and develop a disorder and some do not (it is now known that holding the short form of the serotonin transporter gene is a risk factor for MDD).

While the authors note that a few symptoms of sadness related to “overwhelming” distress may be “too often treated as a mental disorder,” they do not operationally define “a few symptoms of sadness.” If the stress is “overwhelming,” then it makes sense that many persons will succumb to MDD as a result. I think that most psychiatrists would only give an antidepressant to someone with a first episode of reactive depression in which there are concerning cognitive and/or vegetative symptoms that persist despite psychotherapy; in this setting, they may also consider a short course of a soporific or minor tranquilizer.

My vote is that each patient needs to be looked at individually and treated based on the clinical judgment of the physician, who should take past and family history into account. Including criteria for excessive reaction to stress in 

 goes against the recent genetic and neuroscience findings that support the clinical experience of MDD seen in a variety of stress contexts and may lead to a delay in medical intervention when needed.

“An Epidemic of Depression” by Wakefield and Horwitz (Psychiatric Times, November 2008, page 44) raised the issue that DSM does not take into account the context in which symptoms arise for the diagnosis of MDD. The authors opine that the diagnosis should require that symptoms be “excessive” or “unreasonable” relative to the context in which they arise, and that “the efficacy of these medications for the treatment of normal sadness is often overstated.”

An Epidemic of Depression

Cognitive Therapy: What Is Its Role in Depression Treatment

" by Dr Edward S. Friedman mainly focused on the STAR*D trial as providing a guide to the role of cognitive therapy (CT) in the treatment of depression (he was the national CT director for STAR*D). While the article also briefly mentions some equivocal results for CT in depression treatment, I don't think any up-to-date article on the topic of the role of CT in depression treatment can be complete without mentioning another recent study by Parker and Fletcher.

 Their study was a systematic literature search that suggests that because of the general effects of the therapeutic relationship, the specificity of CT (and interpersonal psy- chotherapy [IPT]) for depression treatment has yet to be demonstrated. The review should also be lauded because it has almost become "politically incorrect" to suggest that CT may not have specific effects on major depression.

Another study that should be given more attention in relation to the cognitive distortions that are the focus of CT is by Fava and associates,

 who showed that antidepressant medication can reverse the cognitive distortions of patients with major depression. My clinical experience as well as that of others supports Fava's findings that distortions are more likely the result of biological factors in major depression, while distortions that result from one's personality style may be more of a cause of disturbed mood in milder depression and transient dysphoric mood states. I have seen many patients with major depression conclude that the problem results from a situation in their lives rather than a disorder in mood-regulating neurotransmitters because their life situations are easier to see and because the prospect of having a brain-chemical disorder is a personal weakness that is not easy for one to accept. This can itself become a "cognitive distortion" that impairs their ability to seek important medical help.

To me, it still makes clinical sense to use CT to give patients an idea of how their cognitive distortions may be contributing to their emotional trouble; however, as psychiatrists we need to clarify within our profession and with our patients what therapies actually treat an illness and what therapies help one learn to function better. As Parker and Fletcher have found, the process of learning to function better itself may alleviate symptoms of depression.

1. Parker G, Fletcher K. Treating depression with the evidence-based psychotherapies: a critique of the evidence. Acta Psychiatr Scand. 2007;115: 352-359.

2. Fava M, Davidson K, Alpert JE, et al. Hostility changes following antidepressant treatment: relationship to stress and negative thinking. J Psychiatr Res. 1996;30:459-467.

As psychiatrists we need to clarify within our profession and with our patients what therapies actually treat an illness and what therapies help one learn to function better.

Cognitive Therapy Research in Depression Treatment: Not Just STAR*D

Psychotherapy has an interesting paradoxical twist to it in the therapist's attempt to provide help. When one goes to a surgeon, for example, to remove a lump, the patient recognizes they have a lump and agrees to have the surgeon remove it. With a psychological problem, however, patients may recognize that they have some problem, but they often do not see it as a result of their own life strategies (defenses or personality styles), and in trying to protect themselves with these defenses, patients may actually sabotage their own therapy.

Even if they do have some insight into their maladaptive use of defenses, patients often show resistance to changing their life strategies. They would prefer that things go smoother in the world using the same life strategies they have been using up to now. In fact, patients may seek validation on their style from the therapist or even advice on how to make their maladaptive defenses work better. Can you imagine a patient with a lump telling the surgeon to remove the lump but at the same time trying to convince the surgeon why it is better to live with the lump?

This is where the unconscious nature of defenses, and the resistance to changing one's defenses, comes into play. Resistance is often unconscious in patients as they may provide many rationalizations on why their maladaptive life strategies are valid. This resistance may occur even in the face of significant psychosocial troubles arising from these defenses as seen from the outside. The work of the therapy needs to overcome these barriers.

These maladaptive life strategies have been used by the patient both in past and present relationships, so it is no surprise that these personality styles will also manifest in the relationship with their therapist. It is the therapist's challenge to find the common thread that runs through the patient's interpersonal style and then guide the patient to use new and more adaptive life strategies. The therapist attempts to remain neutral in attitude and does not disclose personal material to the patient. In this way therapists try to keep their countertransference issues out of the session. Thus, the therapist and patient can begin to create a picture of the patient's personality style without undue influence of the therapist's style. If the patient's insight is poor and/or their defenses are of a certain quality that leads to dissatisfaction in the therapy, the defenses themselves can sabotage the help the patient needs to fix their defenses.

 These patients use the defense of rejecting others to protect themselves from the pain of being rejected first. They may have had some childhood experiences of feeling abandoned. They set up relationships to relive patterns of rejecting others. They find faults with others, often not getting into or terminating intimate relationships early on and complain that they cannot find the right partner. They tend to engage in relationships that clearly have problems from the start, thus planting the seeds for their next termination. They may report conflict and terminations with prior therapists. They often make detailed rationalizations about why their relationships do not go well.

These patients may fault-find with the therapist and complain that the therapist is not caring enough, especially if the therapist does not side with their misery and instead attempts to have them see how their tendency to reject others is actually undermining their own needs. They may request phone calls or e-mails between sessions in order to satisfy their underlying dependency needs; however, this will also lead to complaints that the therapist does not care enough when the therapist begins to put limits on these contacts.

Eventually these patients' rejecting nature will cause them to "fire" the therapist and terminate therapy. Complaints about the therapist may also grate on the therapist's own countertransference self-esteem issues, and the therapist may subtly or overtly reject the patient. The therapist may be able to manage these patients by getting them to see their rejecting nature in a neutral fashion, not too early in the therapy, but also not when it is too late.

 These patients use the defense of exhibiting greatness to protect themselves from the pain of feeling diminished. They may have had some childhood experiences of ungratified or invalidated strivings from their family or peers. They always need to show strength in everything they do, connect themselves with important people, devalue others and try very hard to be important themselves, e.g., to become the class president or the company president.

These patients can become very aggravated when they are not the center of attention or at the top of their social group, and challenges to their greatness or rejection from partners who are tired of their grandiosity are often the reason they have come for help. They often have a detailed rationalization on why they only need more greatness in order to gain mental stability.

These patients will look for validation of their greatness and seek advice from the therapist on ways to gain more greatness rather than ways to change their life strategies. They may subtly or openly devalue the therapist. If the therapist's countertransference causes them to retaliate the devaluations or if these patients think the therapist is not validating them or when the therapist attempts to guide them to use other life strategies or explores their underlying low self-esteem, these patients may begin to feel diminished and are at risk of terminating the therapy before they have really started to improve the underlying problem.

Sometimes these patients will invest their defense of greatness in becoming a great patient. They will read all about their problem and gain a considerable amount of knowledge of psychology to gain validation from and protect themselves from feeling diminished compared with the therapist. They profess that they have completely eliminated their problem of low self-esteem. It may be possible to enlist these patients' sense of greatness to the therapy's advantage if the therapist can convince them that great people are those that are able to really look at themselves and accept they use greatness as a defense against low self-esteem.

 These patients use the defense of controlling others to protect themselves from the aggravation of being controlled. They may have had childhood experiences with controlling or authoritarian parents. They tend to try to control others, especially in intimate relations or in the workplace, and have conflict with people in these areas. This is often the main reason they come for therapy.

Patients may get in power struggles about scheduling, cancellation policy or other issues, and begin to argue about the therapist's opinions and complain that the therapist will never see things their way. They need to feel they are right about everything; tend to be argumentative; want the therapist to validate their rationale in arguments they have had with others; will not easily agree to see the types of defenses they use; and eventually terminate the therapy before the therapist can begin to address the process of how to get better. The therapist's countertransference may provoke counter-arguments with these patients.

The therapist may be able to enlist these patients' need to be correct by praising them about how they seem to usually be on the mark and that the challenge now is to see if they can be on the mark about the analysis of their own deficits.

 These patients use the composite defense of obedience and passive defiance to protect themselves from the aggravation of being controlled or belittled. They may have had belittling or authoritarian parents. They seem to be very compliant and cooperative on the surface, but on deeper interaction they are withholding and uncooperative and seem to have a wall around themselves against real intimacy. They tend to not show up for important events, are late for work, do not complete chores they agree to do at work or with significant others, and have conflict with people in these areas; this usually being the reason they have come for therapy.

Patients may often be late for sessions, not show for the sessions and often be in arrears with fees. They set up relationships so that they can relive a pattern of being oppositional to a scolding person in authority (e.g., spouse, boss, therapist). They will often use intellectualization and rationalization to describe their behavior, and while they ostensibly agree with everything the therapist has said, there is no effective change in their life strategy. If the therapist does not terminate the therapy because of either reasonable or oversensitive (countertransference) reactions to these patients because of their invisibility (e.g., poor attendance, late fees), these patients may eventually terminate the therapy using an excuse such as "work or family duties" that are only more displays of passive defiant behavior.

Standard approaches to gain insight may be of help. In some patients, however, the passive defiance may be so ingrained that a paradoxical approach, where the therapist tells the patient that the problem is unfixable and that the therapy should focus on how to live with the defiance, will engage this patient in a defiant stand to fix the problem.

 These patients use the defense of clingy "object hunger" (intense persistence to avoid separation from significant others) in order to protect themselves from the fear of being alone. They may have had some childhood experiences of feeling abandoned or, in reverse, of never practicing being on their own. Some children are also born with intense dependency needs that can develop into a maladaptive style when mixed with a particular upbringing.

These people often get into and/or stay in relationships that are clearly unhealthy from the start, causing conflict that brings them to therapy; or they may present to therapy when their partner proposes a breakup. They may get involved with partners who are inappropriate for them (e.g., violent, alcoholic, promiscuous). It is not necessarily that these patients are "looking for" difficult people, but because most people would avoid entering or continuing in these unhealthy relationships, these potential partners naturally do not realize relationships until they come across a dependent person willing to cross these hurdles and stick with them. The patients also tend to have trouble realizing relationships because the intensity of their neediness pushes people away. They may have a repertoire of rationalizations for their behavior.

These patients will implore the therapist to help them find ways of improving a destructive relationship or try to get the therapist to convince their partner not to break up with them rather than change their maladaptive defensive strategy. They may request phone calls or e-mails from the therapist between sessions to hold on to a connection with the therapist to tide themselves over their pain. They may push for the therapist to give them the answer on how to prevent a breakup.

These patients are mainly interested in having their defense of object hunger work better for them and will terminate the therapy when they sense that the therapist cannot or will not collude with their determination to promote their defense of clingy dependency. The therapist may react by trying to save these patients too much and thus break boundaries by trying to give too much concrete help, or the therapist may devalue these patients because their clingy behavior becomes annoying to the therapist.

Again, the problem itself has sabotaged the treatment of the problem. In addition to giving insight into the nature of their defenses, a potential method of treatment for these patients is to encourage them to tolerate activities they can do without a partner. However, patients still need to use the therapeutic relationship as a transitional object that can help them move out of bad relationships and/or to help them avoid getting into future bad relationships.

While some patients exhibit only one of the major traits exampled above, some patients may have a mix of the different styles. I have purposely avoided the use of diagnoses here in order to keep the focus on the interpersonal mechanisms involved rather than a label. Everybody has some amount of one style or another, no matter how subtle. The examples above are also not an exhaustive list of potential life strategies. In addition, this paper is mainly a description using personality styles and does not discuss situations complicated by depression or other psychiatric illnesses.

One can see how the problem itself can sometimes sabotage its own treatment. It takes a considerable amount of courage to admit that one's personality style needs changing, so it is natural that one will have resistance to this endeavor. This is the challenge that faces the psychotherapist and the patient in the sessions. Many patients do, of course, get better without sabotaging their therapy.

If the therapist can gain the trust of the patient and effectively explain the way therapy can work and the pitfalls involved, then progress can be made. It is often not easy for the therapist to articulate this process; and if the patient is relatively mature and uses rationalization and other intellectual defenses (as in the examples above) that "hide" the more underlying defense, these patterns can be subtle and not evident to the therapist until it is too late.

Dr. Berger is in private practice and consults with pharmaceutical companies in Tokyo.

MacKinnon RA, Michels R (1971), The Psychiatric Interview in Clinical Practice. New York: W.B. Saunders Company.

Perry S, Cooper AM, Michels R (1987), The psychodynamic formulation: its purpose, structure, and clinical application. Am J Psychiatry 144(5):543-550.

Patients often try to protect themselves from the world by putting up defenses. This article presents five types of defenses and shares ways a therapist may go about getting past them to help the patient.

Author | Doug Berger, MD, PhD

Articles

Cognitive Behavioral Therapy: Escape From the Binds of Tight Methodology

An Epidemic of Depression

Cognitive Therapy Research in Depression Treatment: Not Just STAR*D

Defenses Can Sabotage the Therapy