Manufacturing depression (44 page)

The remedy is to compare two kinds of therapy that differ only in their specific interventions. But most forms of psychotherapy weren’t designed to be manualized—not to mention that the people who practice them aren’t leading the charge to measure therapy outcomes. It has been left to cognitive therapists to invent their competition, with the predictable results. One study, for instance, pitted cognitive therapy against “supportive counseling”—a therapy made up by the researchers for their trial—as a treatment for rape victims. The subjects in the supportive counseling group were given
“unconditional support,”
taught “a general problem solving technique,” but “immediately redirected to focus on current daily problems if discussions of the assault occurred.” It’s not surprising that the patients who couldn’t talk about their assault didn’t fare as well as the patients who could (and who were getting cognitive therapy), but that does cast doubt on the conclusion that cognitive therapy should take home the prizes. Proving that a bona fide therapy provided by someone who believes in it, who is inculcated with its values and traditions, works better than an ersatz therapy, implemented by someone who doesn’t think it is going to work, may only show, as one critic put it,
“that something intended
to be effective works better than something intended to be ineffective.”

Allegiances do matter
, both the therapist’s and the client’s. Even in the lab, outcomes are consistently much higher when clinicians believe in what they are doing. I may not be entirely certain of why I want to talk with Eliza about her strawberries, I may indeed be
flying by the seat of my pants, but I do believe that we’re going to land somewhere better than where we were in the first place, and I’m sure I convey that confidence to Eliza. This kind of confidence shows up in the numbers as clearly as Judy Beck’s belief that substituting Positive Triangles for Negative Rectangles will help cure depression. Furthermore, clients who don’t have some loyalty to their therapists, or who don’t believe that whatever is happening between them is going to help them, don’t stick around.

This is why critics object to another statistical procedure common to clinical trials: excluding from the bottom line the subjects who don’t complete the study, people who presumably didn’t feel that confidence or loyalty. Rather than counting them as failures, most studies simply treat dropouts as if they never enrolled in the first place, which, mathematically speaking, makes the treatment look stronger than it would otherwise. And the numbers also exclude those people who were not allowed into the study because their case wasn’t diagnostically pure enough—a move that allows researchers to improve their numbers by cherry-picking the patients most likely to benefit from their treatment.

Researchers can study the effect of these and other methodological problems by using meta-analysis, a statistical technique that allows them to determine the mean of means, or, in layman’s language, what all the studies lumped together say about a particular factor—even one that the original scientists didn’t necessarily intend to examine. So, for instance,
two independent groups
of researchers have used meta-analysis to factor out the advantages that cognitive therapy has when it goes up against treatments intended to fail. They scoured the literature for studies in which all treatment groups were given bona fide therapies. After crunching the numbers, they came to the conclusion that when the competition was fair, there was no difference in the effectiveness of the treatments.

Two other psychologists—Drew Westen and Kate Morrison—meta-analyzed thirteen leading studies of psychotherapies for depression, eleven of which used some form of cognitive therapy.
Overall, about half the subjects improved—results that put the treatment in the same ballpark as antidepressant drugs. But Westen and Morrison discovered that only one-third of the patients who tried to get into the studies were accepted—presumably because they didn’t pass diagnostic muster—which limits the generalizability of the study. And of that select few, so many dropped out before the trial ended that the overall number of subjects who improved was only 36.8 percent. And when they looked at the handful of studies that followed their subjects over the long haul (and this is another way that therapy trials mirror drug trials; the book is closed after eight or ten or twelve weeks, and only rarely does anyone ask if the treatment remained effective), of the 68 percent of completers originally reporting improvement in those trials, only half remained improved after two years.

Westen and Morrison are quick to point out that they aren’t saying that the therapies don’t work. They help a carefully chosen portion of patients for a short time. That’s not trivial, but it is less than the claim that cognitive therapy is the scientifically proven treatment for the disease of depression, and far less than what you would expect of a therapy that has become the standard of care for the AMA or “the most widely practiced approach in America.”

Westen and Morrison acknowledge
that their work is not exempt from allegiance effects. They think that cognitive therapy’s success depends on a redefinition of psychotherapy with which they disagree. Their objection, they warn, may have unconsciously influenced their choice of studies to include or the hypotheses that guided their results. Indeed,
all the critics
of ESTs seem to be similarly inspired by a disagreement about how therapy ought to be practiced and evaluated and a distaste for cognitive therapy’s answer to that question, for the way that therapy, like Heisenberg’s subatomic particles, is changed by the very act of measuring it. The dispute, in other words, is not about the effects of therapy but the nature of therapy—and, by extension, the nature of human suffering and its relief. And like all ideological arguments, this one cannot be settled by numbers alone.

But there is one set of numbers that bears particular weight: findings generated by
a group of loyal cognitive therapists
. The team, led by prominent cognitivists Neil Jacobson and Keith Dobson, set out to investigate Beck’s pivotal claim that his therapy has active ingredients that target the psychological cause of depression. Jacobson and Dobson wanted to determine whether some of those ingredients could be effective in isolation from the others—presumably because this might make an even more efficient therapy. They separated patients into three groups—one that received cognitive therapy according to Beck’s manual, one that was given only the component in the manual directed toward behavioral activation (using activity schedules and other interventions to get patients into contact with sources of positive reinforcement), and one that got the modules that focused on coping skills, and in particular on assessing and restructuring automatic negative thoughts. The experimenters, all of them seasoned cognitive therapists, had an average of fifteen years’ clinical experience, had spent a year training for this study, and were closely supervised by Dobson. And at the end of the twenty-week study, to everyone’s surprise, there was no difference between the groups. Everyone benefited equally, just as the dodo bird hypothesis would predict.

Other studies, like one in which two cognitive therapists discovered that most improvement in cognitive therapy occurs in the first few sessions and before the introduction of cognitive restructuring techniques, strengthen the finding that to the extent that cognitive therapy works for depression, it is not because its specific ingredients act on specific pathologies. Instead,
according to the meta-analysts
, cognitive therapy’s success depends largely on the therapeutic alliance, therapist empathy, the allegiance of the therapist to his technique, and the expectations of the patient—the same nonspecific factors that Aaron Beck intended to eliminate in the first place.
“
How
therapy is conducted
is more important,” as one researcher put it, “than
what
therapy is conducted.” As it does in drug therapies for depression, the placebo effect deserves most of the prizes.

But in real life, the prizes go to cognitive therapy, especially the prizes doled out by insurance companies. A therapist can’t get sued for not practicing cognitive therapy, at least not yet, but there are other, more direct ways, to persuade us. According to the
New York Times
, insurers “often prefer their consumers” to go to cognitive therapists. Only a few health plans—the ones that employ their own counselors—can directly enforce this preference. But they can all require, as most companies do on the treatment reports they make me fill out as a condition of reimbursement, that therapists specify a “definition of successful treatment,” with “desired observable outcomes” and deny coverage if those goals—themselves lifted from cognitive therapy manuals—don’t address dysfunctional thoughts and core beliefs. They can also limit therapy sessions on the grounds that it has been scientifically proven that depression can clear up in fifteen or twenty visits, and that if this didn’t happen then a therapist must not be providing adequate treatment.

I don’t mean to sound unreasonable here. Insurance companies have every right to figure out how to spend their money; that’s just the price we pay for placing our health care in the invisible hand, and every therapy dollar we coax out of it is a small miracle. You can’t blame health care managers for favoring cognitive therapy, not when it’s advertised to take half the time of traditional therapies. Nor can you blame the media for reporting breathlessly on this “scientifically proven” therapy. Or universities for hiring cognitive therapy researchers, who can bring in government money for investigating ESTs, over adherents to other schools. Or the professional journals for running article after article touting the virtues of the therapy without paying much attention to the bell jar problem, or to the statistics indicating that caution is in order. Intentionally modeled on drug therapy, fashioned as a kind of verbal bolus targeted at cognitive symptoms, an antidepressant without side effects or pharmacological Calvinist implications, cognitive therapy just fits in too perfectly with medicine’s magic-bullet aspirations to be resisted, no matter what the numbers really say.

*      *      *

Cognitive therapy resembles antidepressants in one other way that Beck probably didn’t intend—and that he surely doesn’t mind. By succeeding as a treatment whose active ingredient is targeted at a specific pathology, it provides a backdoor validation of the idea that depression is a disease. It also provides a benefit for the disease model that the drugs don’t. Drug manufacturers are vague about exactly what it means for people to “get back to themselves” or just what kind of “life is waiting” for them. It’s enough to reassure people that their medication is only going to restore them to “health”—rather than to remake them—and leave it at that. But cognitive therapy is very clear about who we will be when we are cured: smoothly functioning processors of information, resilient navigators of life’s ebbs and flows who can “take off those tinted lenses and see the world for what it really is,” as Leslie Sokol exhorted us, and get down to business.

After four and a half days in this airless room, I still haven’t accepted the idea that the world really is a place that offers up nothing I can’t handle, if only I can restructure my negative thoughts and shed my self-doubt, that when I repair the glitches in my software, I will finally be able to make it. Indeed, I’m chafing against Beck’s and Sokol’s relentless can-do optimism, weary of their talk of coping skills, their agendas and strategies, their paperwork. Their model of life as a series of challenges to be managed efficiently is as bland and disappointing as this suburban office building. It just doesn’t do justice to the perversity of our nature or to the seemingly limitless tragedy on which it feeds.

Which is why I’m not going along with Judy Beck right now. That’s easy to do in my role as Ann, who was nothing if not perverse. After she tells Ann about her Negative Rectangles and Positive Triangles, Beck asks, “Do you think this is true, that your mind does work this way?”

“I think you’re just trying to get me to set the bar lower.”

“What does that mean exactly?”

“Either I’ve got you fooled, or you’re trying to fool me. You’re trying to argue me out of something I wasn’t argued into in the first place.”

“Well,” Beck says, “let me apologize. Because I wasn’t trying to argue with you at all.”

I am silent. I have no idea how Ann would respond to that. I know what
I
would say: “HUH?” Because arguing is exactly what I think has been going on here, not just in this role play, but for this whole week. After all, they call their examination of a patient’s thinking “Socratic questioning,” and didn’t Socrates seek to argue his students into the correct position by posing questions to which he already knew the answer?

Still, I can see Beck’s point. She’s not arguing. In fact, she’s taking her own medicine, looking for the problem not in Ann’s contrariness (or mine), but in her own cognitive apparatus. She breaks out of character to explain this to the class. “I think what happened in the role play is that I started this process too early with her,” she says. “She doesn’t buy this yet.” But Ann’s resistance is probably futile. Beck addresses her again. “We have to be really careful that I not sell you a bill of goods. I don’t want you to start seeing reality differently if it’s not realistic,” she says. “On the other hand, I don’t want you to sell yourself a bill of goods and see everything as negative if it’s not really that way. Anyway, could we send this piece of paper home with you and you think about it a little bit and we can talk about it more next week?” That’s not arguing. It’s just waiting for Ann to come to her senses.

There’s no need to argue about what is right here in front of our eyes. If Ann just realizes that her way of looking at the world isn’t working, if she just thinks about it a bit, if she just listens to this self-assured and calm woman who doesn’t seem a bit troubled by her own success, she’ll understand that the problem isn’t out there, in an economy that doles out reward and punishment in strange and unequal measure, in a nature that doles out a case of rubella at the worst possible time, in a world where fluke often trounces honest
toil, in which it is possible for a woman to learn, on the very same day, that her mother is dead and her father is not her father, where anyone can meet the fate of Job at any moment; the problem is
in here,
in the faulty cognitions that prevent us from seeing the world as the benevolent place that it really is and moving on to the next item on our agenda.