Psychotherapy: an effective treatment for mental illness
By Ayda Ghahremani
Acknowledgments: I wish to thank Dr. Paula Ravitz, Associate Professor of Psychiatry at University of Toronto, for her help in reviewing this article.
Mental illness is a serious public health issue with considerable impacts on individual patients with respect to symptoms, quality of life, and disability. Mental illness also affects society as a whole and the World Health Organization has recognized its importance as an under-addressed global health problem.1 Over the past 50 years, numerous attempts have been made to develop more effective treatments for psychiatric disorders. These treatment developments include both medications and psychotherapies. Psychotherapy treatments for major mental disorders have been established as highly effective through rigorously conducted randomized control trials leading to their inclusion in consensus treatment guidelines.
Psychotherapy is a talking-based treatment provided by a trained healthcare professional that may be a psychiatrist, psychologist, or other mental health professionals such as licensed clinical social workers. During face-to-face sessions, patients can gain an understanding of their thoughts, feelings and behaviours and find ways to manage their symptoms and stressors. Although there are numerous differing types of psychotherapy, such as cognitive behaviour therapy (CBT)2 and interpersonal psychotherapy (IPT),3 these differing treatment models share important common factors such as the therapeutic alliance, which refers to the patient-therapist relationship. A therapist empathically connects with the patient and develops a shared understanding of the patient’s problem. For the therapist, to provide an effective treatment, it is necessary to make sure that the patient feels psychologically safe and that a solid therapeutic alliance has been established. The goals of psychotherapy are just the same as the goals of all medical treatments to help the patient feel and function better. We are at a very exciting time in the history of the treatment for mental health problems, since we have increased treatment options with the accumulated evidence on the efficacy of different psychotherapy techniques.
Two Psychotherapy Treatment Models
One commonly used psychotherapy technique is CBT. The theory of CBT is based on thoughts, feelings and behaviours and their bidirectional relationships. The main concept of CBT is that the way we think affects our feelings and behaviours and, reversibly, the way we behave affects our feelings and thoughts. For example, consider we see a familiar person walking by without saying hello. We might have automatic thoughts and core beliefs about our sense of self-worth or the judgments of others, and feel downcast. In fact, our interpretation of such situations causes problems, not originating from the situations themselves. This illustrates the core concept of CBT and the role of the psychotherapist is to detect and help change patients to modify their automatic thoughts. Changes in thoughts and the way one appraises an experience can lead to significant changes in feelings and associated improvements in symptoms.
CBT is offered to patients with mental health disorders including depression and anxiety disorders. CBT consists of face-to-face sessions of approximately an hour between a patient and a therapist. Research studies have shown that CBT can be very effective in the treatment of depressive symptoms and considered as a first line treatment, an adjunctive treatment with medication, or an alternative to anti-depressant drugs in treatment-resistant cases.4 Furthermore, unlike medications, CBT can have long-lasting effects, decreasing the risk of relapse, even long after the active treatment sessions have concluded.4 CBT is also effective in psychosis. For example, in schizophrenia, CBT for psychosis leads to significant reductions in delusional distress and abnormal social behaviours, according to a randomized control trial.5
Other than CBT, IPT has also been established as an effective depression treatment validated by meta-analyses and randomized control trials. This therapy also involves face-to-face sessions between a patient and a professional therapist. The core idea behind IPT is the importance of relationships and managing interpersonal stressors associated with the onset or perpetuation of symptoms. IPT classifies stressors into broad categories of losses, changes and conflicts that can occur in the contexts of bereavement, significant social role transitions or marital disagreements. One prominent difference between IPT and CBT is that whereas CBT addresses internal cognitions, IPT addresses interpersonal relationships and external psychosocial aspects of mental health and well-being. Research studies have shown the efficacy of IPT was superior to placebo, wait-list controls, and other active treatments in randomized control trials for depressive spectrum disorders.6
Neuroscience Links Psychotherapy to the Brain
Research in psychotherapy is not limited to clinical research outcome studies testing the efficacy or effectiveness of treatment models. Understanding their mode of action has been facilitated through research on the mechanisms of these treatments and relies on new discoveries of neuroscience. Neuroscience has advanced over the last two decades by bridging complex functions of the human brain such as cognition, motivation, and relational behaviours to the physical brain systems. This has been facilitated by the development of neuroimaging techniques in measuring brain activities in real-time, such as functional MRIs or PET scans. During scans, person’s brain activity is observed, while performing specific tasks that engage their cognition, emotions, and motivations. For example, using this technique, brain scans of patients with anxiety disorders were obtained before and after CBT. In the treatment responders group, specific changes were revealed in the brain systems, specialized for regulation of negative emotion and fear extinction.7 Moreover, CBT is hypothesized to improve major depressive symptoms in depression by changing the activity of brain systems involved in emotions and cognition.8 However, we are still far from distinguishing different psychotherapy techniques and their exact mechanisms of actions in the brain. More research discoveries are needed to elucidate the neuroscience of psychotherapy that can help in the design of more strategic treatments in future.
Given the importance of mental health among students and the efficacy of psychotherapy, University of Toronto offers individual psychotherapy services through Counseling and Psychological Services.
- World Health Organization. Mental health: a call for action by world health ministers. Geneva: World Health Organization, 2001 [Internet]. who.int. 2001. Available from: http://www.who.int/entity/mental_health/media/en/249.pdf
- Beck AT. Cognitive therapy and the emotional disorders [Internet]. Cognitive therapy and the emotional disorders. 1976. Available from: http://search.epnet.com/login.aspx?direct=true&db=psyh&an=1976-28303-000
- Klerman GL, Weissman MM, Rounsaville BJ, et al. Interpersonal psychotherapy of depression [Internet]. Journal of Psychotherapy Practice and Research. 1984. Available from: http://apt.rcpsych.org/cgi/doi/10.1192/apt.bp.109.007641
- Driessen E, Hollon SD. Cognitive behavioral therapy for mood disorders: Efficacy, moderators and mediators. Psychiatric Clinics of North America. 2010. p. 537–55.
- Garety PA, Fowler DG, Freeman D, et al. Cognitive-behavioural therapy and family intervention for relapse prevention and symptom reduction in psychosis: Randomised controlled trial. Br J Psychiatry. 2008;192:412–23.
- Feijo De Mello M, De Jesus Mari J, Bacaltchuk J, et al. A systematic review of research findings on the efficacy of interpersonal therapy for depressive disorders. European Archives of Psychiatry and Clinical Neuroscience. 2005. p. 75–82.
- Porto PR, Oliveira L, Mari J, et al. Behavioral Therapy Change the Brain ? A Systematic Review of Neuroimaging in Anxiety Disorders. 2009;114–25.
- Goldapple K, Segal Z, Garson C, et al. Modulation of cortical-limbic pathways in major depression: treatment-specific effects of cognitive behavior therapy. Arch Gen Psychiatry. 2004;61:34–41.