Dr. Wright, first of all, I can’t resist plugging your new book on cognitive therapy, which I found really outstanding because it comes packaged with a DVD demonstrating how to actually do CBT with patients. Thank you. Your readers might also be interested in an upcoming book that we’re working on focusing on how to use CBT techniques in a psychopharmacology practice.

Give us a preview. How do you combine CBT and psychopharm? I think it is practical to do CBT in the context of 20-minute brief psychotherapy along with medication management – what we code as a “90805”. But it depends on the patient. Sometimes I’ll do what I call “front-loading” where I will do some intensive CBT for 5 or 10 sessions in the beginning, and then transition them to 20-minute sessions when they are in the maintenance phase. Or, if I don’t have room in my schedule, I might refer such patients to a specialized CBT therapist for this initial work, and then take over the maintenance therapy later.

I’ve heard you talk about several “high yield” CBT techniques that we can use in our practices. Can you describe some of them? One of the best techniques is exposure therapy for anxiety disorders. Let’s say you have a patient with panic disorder with agoraphobia who avoids stores in which there are large numbers of people. I would set up an exposure-based protocol in which we would write down a hierarchy of various triggers that would stimulate anxiety, and have the patient rate them on 0-100 point scale.

Can you go into a bit more detail on this technique? Sure. Let’s say the patient rated herself as 100 if she went to Macy’s on a busy day. She has been completely avoiding that. She rated going to the local convenience store as a 50 and going to a small women’s clothing store in her neighborhood as a 20. We would collaboratively work on a stepped plan to expose her to these anxiety triggers until she becomes habituated to the anxiety. We might also use some adjunctive techniques like breathing training to break panic attack.

How do you recommend that we do breathing training with patients? The technique that I like is to focus on breathing in a normal pattern of roughly 15-16 breaths per minute. I actually role-play normal and anxious breathing in a session. I show them what it is like to go into a panic attack and how people begin to become anxious. They breathe irregularly and deeply, they sigh, and they may begin to writhe around. I then show the patient what it is like when someone is at rest and calm and not anxious. At that time you can hardly even see the person breathing at all. I ask them to practice this breathing training three or four times a day and then come back and tell me how it is going. I also suggest that they use a watch with a second hand to slow their breathing down to one cycle every four seconds, which is roughly normal breathing.

What other techniques do you use to help patients manage anxiety? I often combine breathing training with imagery techniques. I ask the patient what images might be calming for them, because everyone has a different kind of image. I had one man, for example, who said he enjoyed watching Tiger Woods play on golf matches on TV. So we worked on having him visualize Tiger’s very smooth golf swing, which took his mind away from some of his anxiety-provoking triggers.

Are there any other high-yield techniques that you like to use in CBT? Yes, behavioral activation is one of the key ones. By this I mean anything that gets people who are inactive involved in more activities. The classic would be depressed patients who have low energy and anhedonia who have stopped doing the things they used to do, which tends to just escalate their depression. So in behavioral activation we work with patients in developing things for them to do.

How do you do this in a session? It’s collaborative – I don’t say, “You’d better get your sneakers on and start running or you are not going to beat this depression.” Instead, I might say something like: “Well, Mr. Green, I think we have had a good talk today and we plan to work on this depression, but I am wondering if there is something that you might be able to do this week that would be a change in your behavior, a change in your habits, that if you did it you would start to feel better. It doesn’t have to be anything that complex or demanding, but just a step that you could take that would get you moving in the right direction. Why don’t we just brainstorm for a minute to see if there is anything that would fall into that category.” The patient might say something like, “Well, I stopped exercising completely. I think I could start my walking program again.” But I wouldn’t just leave it at that. I would follow up with, “That sounds like a really good idea. Why don’t we talk about that for a moment, just to plan it out so it has a high chance of working out for you. Let’s see if there is anything that would get in the way of your starting this walking program up again.”

So you’re really doing two things here: working out a behavioral plan and anticipating what might prevent it from working. That’s right. Actually, exploring barriers to implementing a behavioral technique is in itself a valuable, high yield technique. In this case, the patient might say, “I don’t have any exercise equipment” or “I would have to join the gym.” We would try to work out a plan around that. Typically, once we’ve developed out a behavioral activation plan, we pay close attention to the effects on symptoms. Depressed patients will often report back that these activities begin to cause at least little positive blips in their mood – and these are simple things, like watching their son’s soccer game or helping their daughter with homework or going to a movie. This teaches patients that how they spend their time can affect their mood and sense of competence.

I understand that some CBT techniques are helpful in schizophrenia. Can you elaborate on that? One technique is to determine the meaning that patients attach to their symptoms. In CBT we use the term “attribution” to describe this phenomenon. For example, a patient with auditory hallucinations might believe a voice is coming from the devil and that it has control over them. You want to move them toward an attribution that goes something like this: “I have a chemical imbalance and this is just a symptom of my illness. If I practice some coping skills I am going to be able to reduce the intensity of this.”

What techniques are helpful for reducing hallucinations? I’ll work with my patients in coming up with some good coping skills. I’ll ask, “What makes your voices worse? And is there anything that ever makes your voices quieter, better or less troublesome to you?” It is interesting that sometimes music helps people; other times it makes it worse. I have a patient who uses imagery for voices, which I think is quite interesting and creative. She imagines the voice going into a closet in her home and she sees herself locking the door to the closet, then she imagines putting a blanket over the top of the voice. And with each step they get softer and softer.

Do you use CBT specifically to improve adherence to medications? Yes, and this is another very high-yield technique. I’ll start by exploring patient’s attitudes toward medications, and they’ll say things like, “I should be able to do this on my own,” “People that take medications are weak people,” “I don’t want to be labeled as a patient with depression so maybe I shouldn’t take this medication,” “I am the one who always gets side effects.” Once these attitudes are on the table I will try to educate my patient or gently ask questions that help to modify their thinking in a more adaptive direction. I had a psychotic patient who said “You are using an experimental drug on me.” It wasn’t an experimental drug, but they were doing a research study on the unit and he thought that an experimental drug was being given to him against his will. So we did an examining-the-evidence exercise. “Let’s take a look at this. Is there any evidence we can think of that you are getting an experimental drug? Let’s see if there is any evidence on the other side.” So we wrote the exercise out over the course of a 10-minute session on an inpatient unit, and it led him to agree to take clozapine.

Any other high yield techniques that you’d like to mention? A very simple yet powerful technique is the coping card. Once you’ve figured out a couple of things that your patient can do to help them cope with a situation you just write that down on a 3 x 5 card and they take it with them. It is a way of reinforcing their learning and encouraging them to practice it.