Expert Insights in Advanced Psychopharmacology is an ongoing video series featuring members of the Psych Congress Steering Committee and Faculty. The series, which highlights key psychopharmacology topics, is designed to provide mental health clinicians with practical guidance to maximize the effectiveness of treatments.
(Part 7 of 7)
In this video, Psych Congress Steering Committee member Rakesh Jain, MD, MPH, discusses the seventh of 7 habits which clinicians can develop to be highly effective at treating anxiety disorders.
Dr. Jain is Clinical Professor, Department of Psychiatry, Texas Tech University School of Medicine, Austin. He will co-present a session on the 7 habits at Psych Congress 2020, being held virtually Sept. 10-13, 2020, with a preconference on Sept. 9, 2020.
Go to the Expert Insights in Advanced Psychopharmacology page to learn about the other habits.
Read the transcript:
Hello, everyone. Looking forward to a deep conversation about another habit in this seven habits of a highly effective anxiety disorder treating clinician. This is Rakesh Jain, proud member of the Steering Committee at Psych Congress.
This is a final, number 7 habit, which is, embrace psychotherapy. Short statement, but so important because this highly effective clinician values and possesses knowledge regarding the therapeutic benefits of multiple psychotherapy options.
As we have said before, the treatment of anxiety disorders is really permeated by the need for psychotherapy.
First things first, psychotherapy and self‑help recommendations in anxiety disorders, there are just a few general things to remember. Always discuss the benefits and risks. Let's not forget, some of the treatments that are nonpharmacological in certain kinds of patients can be a potential problem, particularly early in the course.
We should also help the patient select the right kind of psychological treatment, the right kind of psychotherapy with the best evidence base supporting its use, and of course what is available in that community. Though I will say this, with the advent of online therapies, this is becoming less and less of an issue.
We do need to recommend that they be connected to a suitably trained clinician. That's important. Too many people call themselves CBT therapists but don't do a lick of it. So it's really important we know, unless we're providing it ourselves, in terms of the quality of the person we're referring them to.
By the way, mild symptoms, fine, psychotherapy by itself, monotherapy, the evidence is quite good, but once it exceeds mild symptoms, then psychotherapy becomes an add‑on treatment to pharmacotherapy.
What is the CBT in terms of anxiety disorders, and why am I such a big fan of CBT therapies? And not just me, all the treatment guidelines support it. Because CBT for anxiety disorders is really a gift that never stops giving.
You get psychoeducation. You get improvement in identifying dysfunctional thought patterns. You get relaxation training. You get behavioral pacing, all of that in the context of manualized cognitive behavior therapy. It not only helps symptoms, but it also helps with symptom relapse or a relapse of the disorder.
Now, if you're at all for a second thinking that CBT is nothing but a psychological intervention, please allow me to dispel that myth.
This wonderful study from over a decade ago showed that individuals who were suffering from even, say, depression, perhaps with comorbid anxiety, when they received CBT therapy, not only did they become less reactive to negative emotional stress as reported by them, but they actually became less reactive even when they were laid in a scanner, in an fMRI.
By the way, cognitive functioning also improved in them, so CBT is far, far, far more than a mere psychotherapy. It's a psychotherapy that clearly has biological implications too. In fact, may I encourage you to look at this.
This is panic disorder. With CBT, and even in a challenge situation such as a sodium lactate or inhalation of carbon dioxide, which regularly brings forth panic attacks in individuals who have panic disorder, can you see, comparing left to the right, the significant decrease, the biological positive response of the individual's brain, mind, and body, to cognitive behavior therapy.
I say this, let's all raise the cause of CBT where it belongs, either as monotherapy or in combination.
The other form of popular therapy that I and you have had conversations about on many occasions is mindfulness‑based therapy, but what is mindfulness? It's paying attention in a particular way, on purpose, in the present moment and nonjudgmentally.
This can be converted into a therapy program, and that therapy program of course is mindfulness‑based cognitive therapy, and mindfulness‑based stress reduction. You might be saying, "How can that happen?"
Here's a paradigm. It could be low mood or high anxiety. It's old patterns that intrude, but mindful awareness creates that gap, creates that safe platform, creates that calm, connected, creative self that leads to the freedom not to go there; rumination, for example, panic attacks, for example, sadness, for example.
You might be saying, "Gosh, this is so simplistic. Is there any biological basis to MBCT, for example?" There it is. This is Barbara Hölzel's work that shows that even in 8 weeks of mindfulness‑based therapy, even the amygdala, which is overactive in anxiety disorders, can actually be calmed down.
The consequences of such biological improvement from the psychological intervention can help the individual, not just for the here and now, but also in the long run. It's time to, again, think of MBCT as a treatment that's both biological as well as psychological.
Now, if you're perhaps saying, "That's in a scanner. Does it actually help individuals who are clinically ill?" These are patients with full‑blown generalized anxiety disorder. These are individuals who receive mindfulness interventions.
Would you just look at from the left to the right? Anxiety improved. Functionality improved. Depression improved. There's global improvement, and very often in relatively short 6 to 8 weeks of a time period.
The other kind of therapy I wanted to draw your attention to is family‑based psychotherapy. If one individual has anxiety in the family, the whole family is suffering. In one way or another, they could become very powerful allies, as I'm showing you here.
It's not just for children. Not just for adolescents. Not just for adults. It's for patients of all ages. Perhaps even a geriatric patient who is dealing with anxiety, involving their family in it is very valuable.
The evidence is in. In fact, please take a look at this blue box in the center of this slide. Look at that. CBT is clearly effective. That's a very high number of people who are doing well.
If you combine CBT with family‑based interventions, family‑focused cognitive behavior therapy interventions, then actually 19 out of 20 no longer meet criteria. That's very impressive.
Let's now turn our attention to looking at clinical pearls. We're going to of course talk about habit number 7, embrace psychotherapy. First of all, multiple forms of psychotherapies are important in the treatment of anxiety disorders, both for the short and the long run. Three in particular come to mind. CBT, mindfulness‑based interventions, and family‑focused therapies.
Of course, we can create the scenario of add‑on with pharmacotherapy or monotherapy. Both are appropriate, depending on the patient.
Finally, it is important to obtain some formal training in these therapies. Should you not have received it in your residency or your fellowship training, it's OK. I certainly did. I received much of my psychotherapy education after graduating from my residency, and I did 2 fellowships. Even then, I was suboptimally trained, so it's perfectly reasonable to say, "Those are my deficits. These are new forms of therapies. I wish to get educated on it."
Let's come back to where we started our journey, habit. Why did I choose the title, Seven Habits of an Effective Clinician? Because habits, as we have said before, those are at the intersection of knowledge, skill, and desire. Those of us who have good habits tend to be very good clinicians in the short and long run for our patients.
I've really enjoyed being with you through this entire series of seven habits of a highly effective anxiety disorder treating clinician. This is Rakesh Jain, on behalf of Psych Congress, thanking you for your time.
Goodbye for now.