Professor and Vice Chair for Education and Drexel University College of Medicine. She is the author of four books on psychotherapy, including Combining CBT and Medication: An Evidence-Based Approach (Wiley, 2011). Dr. Sudak has disclosed that she has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
TCPR: How does a brief therapy session differ from the 50-minute hour?
Dr. Sudak: What’s different is the scope of what you can tackle in those 25–30 minutes. There’s a greater need to organize the session and make decisions about what you can take on. For example, trauma is a subject that you’d probably defer to a longer session.
TCPR: How do you manage the patient’s expectations?
Dr. Sudak: I explain in the first session that we will want to use the time together in the best way possible. We’ll focus on one or two things that the patient wants to address and follow up on any assignments from the last session. I recommend having two clocks so that both the patient and the therapist can keep track of time. I also have patients fill out paper-and-pencil measures like the PHQ-9 and GAD-7 before they come in. That saves time and helps alert me to problems that we may need to focus on.
TCPR: How do you end the session?
Dr. Sudak: I’ll let patients know when we have 5 minutes left so we can wrap things up. I ask what they are going to take away from the session and have them write it down. People forget about 50%–70% of what happens at a medical visit, and that is when they are mentally well! Some of my patients tape the session to listen to again in the future.
TCPR: Are there resources you use to help patients keep up the work between sessions?
Dr. Sudak: A lot of people are using apps for that, and a great resource is PsyberGuide (https://onemindpsyberguide.org), which was developed out of Northwestern University and the University of California at Irvine. They rate mental health apps based on the clinical research, the user experience, and how privacy is handled. MoodKit and iPromptU have good cognitive behavioral therapy (CBT) tools, but whatever you recommend, you should try it out yourself first. YouTube is a fabulous resource for exposure therapy because you can access videos that trigger a patient’s phobia, like plane turbulence and blood injuries.
TCPR: Do you use printed materials?
Dr. Sudak: Yes, and you need to have those ready in advance. My office is a symphony of manila folders with labels on them. The Oxford Center for Anxiety Disorders and Trauma and PracticeGround have a wealth of resources for therapists and patients, from training videos to therapy handouts (www.oxcadatresources.com; www.practiceground.org). For books, Oxford’s Treatments That Work series is good, and they have versions for therapists and patients.
TCPR: How do you follow up on assignments?
Dr. Sudak: Homework should always be “no lose,” and I set the stage for that before it’s even assigned. Are patients confident they can do it? Practicing in session is a good way to test that out. Do they understand the purpose of the assignment? Then I’ll get down to specifics with the 4 W’s: Whom are they going to do it with? When? Where? What reminder system are they going to use to remember it? I’ll also ask, “Do you see any obstacles to doing it?” If the assignment is to go for more walks, I’ll ask, “What if it rains? What if you don’t feel like doing it? What has kept you from going for walks up until this point?”
TCPR: What about patients who feel guilty when they don’t do the assignment?
Dr. Sudak: If they are feeling guilty about not doing the assignment, I’ll want to clarify that: “Well, that’s an interesting thought that you’re having. What did you think I might be thinking? Are there other possibilities that I might be thinking?” I’ll also normalize that it’s very hard to engage in new activities, especially during depression.
TCPR: What are your top tips for psychoeducation in a brief session?
Dr. Sudak: I start with, “What do you understand about this problem? From your understanding, what do you need to do to have the best outcome?” You can’t assume patients understand their diagnosis, even if they’ve had it for a long time. They may have gotten psychoeducation during an acute episode when their brain wasn’t working well. Psychoeducation also goes best in small, digestible amounts.
TCPR: What are some tips for brief sessions with schizophrenia?
Dr. Sudak: Sometimes a brief session makes more sense in schizophrenia—and also in bipolar disorder—because a patient may be agitated or cognitively impaired and have a hard time with longer sessions. With schizophrenia we often work with hallucinations: What makes them better or worse? Activities that are distracting or absorbing often offer some relief. We want to get the hallucinations to a point where they are kind of a harmless nuisance, like tinnitus. Patients don’t have to do what the hallucinations tell them to. They can learn rational responses to the content of the hallucinations and verbally speak back to them (and if they are in public, I’ll have them talk into a cell phone).
TCPR: What do you focus on with bipolar disorder?
Dr. Sudak: I’ll want patients to recognize the early warning signs of a new episode. For mania, that might be credit card spending, how much they are texting, how fast they’re driving, and how others say they are talking. Next, we want to make sleep a priority, and I’ll look at what gets in the way of sleep. For the depressed phase, I use “action prescriptions.” We’ll write down important and enjoyable activities that mean something to the patient and use strategies to increase engagement in these activities even when they don’t feel like doing them. Mood charting is also helpful, particularly with rapid cycling cases because there we need to see if the episodes are getting less frequent and less severe during the treatment.
TCPR: Is exposure therapy feasible in a brief session?
Dr. Sudak: That’s difficult because we need time to debrief after exposure. With OCD we generally start with 90-minute sessions because it takes so long for people’s anxiety to go down during those exposures. And you can’t expect them to do the exposure outside of session because it’s often just too terrifying, especially in the beginning of therapy. Brief sessions may be feasible if they’ve already had a successful course of exposure therapy or are very motivated. I’ve seen people with phobias of flying or heights, and once they get the principle down, they run with it.
TCPR: What types of patients are not well suited to brief sessions?
Dr. Sudak: First are patients who have substantial issues with trust. They may need more in the way of relationship building. Some research suggests that patients with personality disorders do better with brief therapy when the focus is on behavioral activation instead of on their way of thinking or relating to others (Coffman SJ et al, J Consult Clin Psychol 2007;75(4):531–541). Also, some patients just prefer or need longer sessions; for example, when they aren’t taking medication and have a disorder that needs a full course of CBT.
TCPR: So you want to make sure that brief sessions aren’t setting the patient up for failure.
Dr. Sudak: Absolutely, and particularly because the instillation of hope is a really important part of what we do. There’s an argument that we shouldn’t combine treatments—like medication and psychotherapy—because if the combination doesn’t work, you’ve used up two hope items. But if you sequence them, using one at a time, you can still give that injection of hope: “We’re doing something new now.” That argument hasn’t been tested, but there is work on sequencing as a means to enhance durability where clinicians will get people better from depression with medication and then add 8 weeks of group CBT to maintain those gains. It did help people stay well much longer, particularly if they had recurrent episodes in the past (Bockting CLH et al, J Affect Disord 2015;185:188–194).
TCPR: Are there other risks with combining therapy with meds?
Dr. Sudak: With anxiety disorders, patients who undergo CBT while on an antidepressant may need more exposure sessions after they come off the antidepressant. These patients are exquisitely tuned to their internal context, and once they are off the medication, their internal environment feels different. It causes them to be concerned, which turns into hypervigilance and, eventually, panic.
TCPR: So they’ve learned the CBT in one context, but it doesn’t translate into the unmedicated state.
Dr. Sudak: Exactly. That was the finding of a large randomized controlled trial in panic disorder that compared CBT + imipramine to CBT + placebo to imipramine alone. The treatments worked equally well in the acute phase, but after the treatments were stopped, the response rate fell in the ones who took imipramine during CBT (41% vs 26%) or imipramine alone (41% vs 20%) compared to CBT + placebo (41%) (Barlow DH et al, JAMA 2000;283(19):2529–2536).
TCPR: Do you warn patients about this?
Dr. Sudak: I’m an informed consent kind of person, so I will tell the patient, “For panic disorder, you could start CBT alone or CBT with an SSRI or just an SSRI. Starting the two together may bring faster results, but the results are more durable if we do the CBT by itself.” Some will say, “I’m just gonna take the meds for the rest of my life.” And that’s certainly a viable option. I don’t see it as a moral issue.
TCPR: What about benzos and CBT?
Dr. Sudak: With antidepressants, the problem comes after discontinuation, but benzos can directly interfere with exposure-based CBT. It’s hard to do exposure if the patient doesn’t get anxious because they are on a benzo. Any sort of avoidance dilutes exposure, and patients can avoid anxiety in all sorts of ways—alcohol, benzos, seeking reassurance, prayers, mantras, or just avoiding the trigger by looking away or distracting.
TCPR: Is the evidence strong enough that you’d avoid exposure therapy if a patient is taking a benzo?
Dr. Sudak: Yes. I’d say, “This is going to be a lot less effective if we do this while you’re taking the benzo,” and look for ways to get them off it first. We can actually use CBT to help people get off benzos. The treatment involves exposure work around the physical sensations, relaxation training, and working with cognitions around the medication.
TCPR: How do you lower the benzo during that therapy?
Dr. Sudak: Very slowly—like 10% of the dosage every month. And all the while I give them choices. “Is this a good month?” “Do you want to extend this two more weeks?” The more we partner with people, the better.
TCPR: On the other hand, there are medications that can enhance psychotherapy, like d-cycloserine. Is that ready for clinical practice?
Dr. Sudak: D-cycloserine is a repurposed antibiotic, and a lot of folks are using it to speed up exposure therapy for anxiety disorders and OCD. It’s given as a 50 mg dose 30 minutes before the exposure exercise. It had a small effect size (0.25) in a meta-analysis of 21 studies. So it’s not the magic everyone’s hoped for, but it can speed up the process (Mataix-Cols D et al, JAMA Psychiatry 2017;74(5):501–510).
TCPR: Final thoughts?
Dr. Sudak: Brief therapy can add a lot to medication treatment. Outcomes are better for patients, and it also enhances quality of life for the provider because you get to use a lot more of your skill set in the service of helping someone.
TCPR: Thank you for your time, Dr. Sudak.
To learn more, listen to our 11/9/20 podcast, “How to Set Behavioral Goals in the Med Visit: An Interview With Michael Posternak” and our 12/14/20 podcast, “CBT in the Med Visit: An Interview with Donna Sudak.” Search for “Carlat” on your podcast store.
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