Monday, August 24, 2009

Online Cognitive Behavioral Therapy effective when delivered in real time by a therapist

Online therapy or “eTherapy” has been provided by some therapists in a number of different ways, ranging from email, to computerized therapeutic programs (one to be posted here soon), to real time video, for over 10 years. A brief history from 1972-2002 can be found at

A number of questions remain fully unanswered. Probably the most critical question is how to ensure confidentiality. Additionally, there are questions of how effective these interventions are.

A study in England looked at 297 adults who were diagnosed with depression. Half of these people (149) received online cognitive-behavioral therapy and “usual care” (presumed to mean anti-depressant medication) and half (148) received “usual care” from their general practitioner while on an 8-month waiting list for online CBT. At fourth months, 113 in the CBT group and 97 in “usual treatment” completed a four month follow-up, where 38% of the CBT group were considered recovered from depression compared to 24% of the second group. There was a small increase at eight months to 42% for the CBT group and 26% of the second group.

The authors conclude: “The number of patients for whom online CBT is feasible and attractive will grow. It could be useful in areas where access to psychological treatment is scare, and for patients whose first language is not English. It could make access to psychotherapies more equitable by providing a service to patients in areas or even countries where psychological treatment is not readily available. Real-time online CBT offers the flexibility and responsiveness of face-to-face CBT and is appropriate for people with severe symptoms. It affords an opportunity for reflexion and review as part of the therapeutic process, which could enhance its effectiveness.”

There are some limitations to this study. There was no no-treatment control group. The summary did not report how much improvement there was or was not in the majority of people who were not considered “recovered.” It is also unclear whether online CBT would be as effective as in-person treatment. Many questions for further studies.

For a summary of the study

Best wishes,


Thursday, August 20, 2009

Leaving the Land of Misery

While this is aimed at teens, it is relevant for ALL of us.

Do you tend to assume the worst in how you will be treated? Do you often have thoughts like “People are ALWAYS mean to me,” “NOBODY likes me,” “EVERYBODY is mean to me,” “Why bother? NOTHING EVER goes my way,” etc? None of these thoughts are true and any of these thoughts are guaranteed to make you MISERABLE!

Do you look for being wronged? Do you tend to assume the worst? Or do you look for the best in others? (Some do a good job of hiding the good from you.)

It probably surprises you that you CAN CHOOSE how to feel. Many say things like “But that is how I FEEL” and “That's the way I've ALWAYS been.” Take a moment and decide, “How do I WANT to feel?” If you want to feel miserable, you are already an expert. If you don't want to feel miserable, then you can work on changing your thinking and behavior.

WHY would anyone CHOOSE to be miserable? There are a number of possible reasons:

1) It is habit. An automatic response, requiring nothing to be done;
2) Feeling miserable can prevent you from trying something new;
3) It keeps you from facing that you are anxious about something;
4) It is human to hold on to our hurts when we are wronged;
5) It can be addictive.

Misery usually results from us holding on tightly to how we have been wronged. It can feel like there are no other alternatives but to feel upset. Actually, we can hold our resentments; we can feed our resentments; or we can work on letting them go. Letting go often takes time, along with effort. It usually helps to repeat statements like, “Today, I'll do my best to let go,” or “Today, I'll do my best to take back my power from those who are mean to me.” Some find it helpful to write down the offense and/or offender and then tear that paper up, burn it, or even flush down the toilet. Letting go is a gift you give yourself.

Make lists of:

1) Your friends;
2) Your favorite memories;
3) Your favorite possessions;
4) Things you enjoy doing;
5) Anything else that makes you happy.

When you feel badly, look at your lists BEFORE you are miserable. Do some of the things you enjoy instead of dwelling on the negatives. Listen to some music that makes you happy. Don't listen to down or angry music that makes you feel worse.

Misery loves company. Are your friends negative? If so, the two of you will reinforce how lousy the world is. This will keep you stuck in your misery. If some of your friends are more positive, ask them how they would look at a situation that is difficult or upsetting to you.

Does any of this mean that everyone will treat you well? Of course not! Rather, you can choose how you want to respond to being mistreated.

Best wishes,


Sunday, August 9, 2009

Tale of the Two Wolves Revisited

There is a long told Native-American tale that I will paraphrase a little.

There was a wise grandfather who was speaking with his grandchildren about life. He told them that he had two wolves battling inside of him. He went on to explain that Everybody has these two wolves.

He said that the first wolf stands for love, peace, charity, kindness, forgiveness, and letting go of past wrongs that were committed against us.

He said that the second wolf stands for anger, depression, excessive worry, resentment, panic, obsessive thoughts, hopelessness, and suicidal thoughts.

After a brief silence, one of the grandchildren asked, “Which wolf will win?”

The grandfather replied, “The one we feed.”

I have known this story for many years, but hadn't thought of it for some time. I suppose the reason it came to mind was my reflecting on how I had been feeding the second wolf. Most of us will sometimes feed the second wolf. When we do, the results are reliably misery of different flavors.

Have YOU been feeding the second wolf lately?

Best wishes,


Thursday, August 6, 2009

Medical Cost-Savings from Counseling

Medical insurance is increasingly being priced out of what many feel they can afford. It can be argued that ever increasing health insurance costs have largely decimated the US car manufacturers.

What if there was a way to save 20% of medical costs? What if I told you that is such a way? It has been reported that when numerous rigorous studies were examined on medical cost savings after psychotherapy, that the average savings was about 20%! Some studies have shown higher.

Many will be surprised to learn that psychologist Nicholas Cummings, PhD first wrote about this in 1962! One of the first studies to look at these issues was conducted in the 1960s at Kaiser. Records were followed over a 5 year span for 152 patients who had received psychotherapy. Of those, 80 were seen for only one session. A control group (No therapy) was matched for age. Over the five years, the medical utilization of the control group increased. Utilization decreased for those who had received therapy. Hospitalization rates fell from 5 days/year prior to the study to .7 days/year.

Studies range from studying groups with no common diagnoses to groups of distinct diagnoses. While some studies looked at single issues, such as depression, panic attacks, etc, many of the studies looked at people with all kinds of medical problems, such as hypertension, other cardiac difficulties, chronic pain, cancer, etc. In addition to looking at those who received individual therapy, other studies looked at marital therapy as an adjunct to alcohol treatment, brief intensive in-home family therapy for children and adolescents with severe behavioral issues, and group therapy.

Another review of studies showed that 85% of 58 studies showed a decrease in medical utilization after psychotherapy.

There is momentum where health care reform will soon be attempted. It is past time for the public to learn that psychological interventions often decrease and sometimes eliminate the need for medical interventions. There needs to be a greater education of this information.

If you are interested in learning more about these issues, an excellent read is The Impact of Medical Cost Offset on Practice and Research: Making It Work for You (2002) edited by Nicholas Cummings, et. al.

Best wishes,
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