Prof. Joseph Levine

Senior Psychiatrist

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29

2009

Introduction – The Scientific Search for Basic Elements of Psychotherapy

By Prof. Levine

As early as 1952, in one of the earliest studies of psychotherapy treatment, the psychologist Hans Eysenck reported that two-thirds of patients either improved significantly in response to psychotherapy or recovered spontaneously while waiting for treatment with psychotherapy within a period of two years.

Some half a century later, the psychologist James W. Pennebaker, showed that a group of subjects who devoted 20 minutes daily recording in a diary their deepest feelings about the loss of a job fared better in a variety of outcome measures than either those who noted how they spent their time each day or those where no record was required. Various other studies involving different groups of patients where a similar task was used showed the same results (see Smyth & Pennebaker, 2008).

Wampold et al (Wampold ,2005) in a re-analysis of psychotherapeutic trials claimed that the use of psychological placebos may demonstrate a level of effectiveness which may occasionally attain that of accepted psychotherapies. Wampold et al (Wampold ,2007) also stated that no single treatment modality is superior in efficacy, and proposed that different psychotherapies have common factors [elements] which seem to account for much of the variance in outcome measures rather than specific techniques or modalities.

We suggest that two basic elements of psychotherapy, namely re-organization (of mental representation, metal operations or its output as behavior etc.) and association (via the repeated activation of two mental operations at the same time), are common not only to traditional psychotherapies but also to those waiting for psychotherapy, to certain forms of diary writing, and to the follow-up of patients receiving placebo psychotherapy.

Recently two intellectual giants have paved future avenues for psychotherapy research, approaching this subject from different angles.

The first is Isaac Marks, one of the founding fathers of behavioral therapy for anxiety disorders. Marks recently reviewed the research literature describing brief psychotherapies for anxiety and depressive disorders (Marks, 2002). This author stated that: " Brief behavioral, interpersonal, cognitive, problem-solving and other psychotherapies have a mature ability to improve anxiety and depressive disorders reliably and enduringly, often only with instruction from a manual or a computer. However we know little about which treatment components produce improvement, how they do so and why they do not help all sufferers"……" Therapy is coming of age regarding efficacy for anxiety and depression, but is only a toddler regarding the scientific principles to explain its effects". Marks himself suggested the existence of three components: relevant exposure (to environmental stimuli), introceptive exposure (to bodily stimuli) and cognitive restructuring.

Marks called for further research of these components of treatment. While agreeing with Marks, we suggest that these components are based on more basic elements.

The second giant is Eric Kandel, a memory researcher and Nobel laurent, who recently stated: "What our study group is discussing is whether or not the time is ripe to use brain imaging to evaluate the outcome of psychotherapy. There are now two forms of psychotherapy that have been medically proven to be effective. One is cognitive behavioral therapy…… the other is interpersonal therapy….Those are two scientifically validated forms of short-term therapy….we want to see whether there is a science here…" (Dobss, 2007)

However, exploring the brain changes associated with the therapeutic effects of proven psychotherapies as a whole will not advance the knowledge as to the specific brain changes induced by basic treatment elements.

In analogy with the search for endophenotypes for complex genetic disorders, we suggest that once the basic elements have been determined, the time will be ripe to look for the biology of these elements.

Thus it seems more logical first to determine and validate via research the basic elements of psychotherapy, and only thereafter to explore the therapeutic effects of these elements on the brain using a variety of imaging techniques.

What basic elements should be researched?

We propose that such basic elements should fulfill 3 criteria:

  1. They appear to be present in most practiced therapies and certainly in those with proven therapeutic outcomes
  2. They should be simple and not be based on purely theoretical grounds, enabling them to serve as building blocks for more sophisticated therapeutic maneuvers
  3. They should be in accordance basic principles of brain functioning.

In this regard the 2 basic elements we propose here, namely association and re-organization depend on the following principles of brain functioning respectively:

A] Hebbian learning: "Neurons that fire together wire together." commonly referred to as Hebb's Law (Hebb, 1961).
B] Neuroplasticity (variously referred to as brain plasticity or cortical plasticity or cortical re-mapping) which refers to the changes that occur in the organization of the brain as a result of experience (see Buonomano & Merzenich, 1998).

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