The NIMH published a press release in January 2024 that may have slipped through people’s consciousness.
Depending on when you read this blog entry, you may run into the study from the National Institutes of Health (NIH), or subsequent reporting, but I was struck by the title of the article.
“Cognitive Behavioral Therapy Alters Brain Activity in Children with Anxiety”.
The long and short of the study was that children who had been diagnosed with anxiety who were unmedicated, and were treated with CBT, were found to experience improvements in clinical symptoms and brain function. Those of us who have utilized CBT as a modality in the treatment of anxiety and depression have used it because we’ve found it effective, but we may have not understood quite why or how it works. As you read the study, that's actually more true than we may have thought, as the study was focusing on some new territory as it sought to understand the impacts CBT might have on the frontoparietal lobe of the brain. For those of us that may not quite remember what the frontoparietal lobe does, Scott Marek, PhD, in his article published in the Dialogues in Clinical Neuroscience wrote:
"The frontoparietal network is a functional hub both globally, and specifically in terms of distributed connectivity. Moreover, fluid intelligence is positively correlated with the degree to which the frontoparietal network's coupling is distributed to other brain networks; in particular, greater connectivity between the frontoparietal and default mode networks during resting state was correlated with higher intelligence scores. Furthermore, there is a significant positive correlation between functional integration of the frontoparietal network and overall cognitive ability, indicating that the strength of functional integration of the frontoparietal network and the rest of the brain is crucial for supporting superior cognitive functioning. Given previous evidence for its role in task adaptation and implementation, the frontoparietal network was hypothesized to play a role in instantiating and flexibly modulating cognitive control."
There's a lot more to it than that, but you get the point. The frontoparietal region does a lot in our brain. And while the effectiveness of CBT in working with children with anxiety is well known, what was occurring in the brain was not.
I’m not saying this to regurgitate the press release or the findings of the study. I’d encourage you to read the details of the study -- its groundbreaking stuff.
But in reading this press release, which led me to read the study, it got me to thinking about how much we might take for granted in our work as therapists. We have a therapeutic technique that works, and that might be enough. It's not necessarily important for understand why it works.
I think that, as clinicians, it is important that we are reminded, from time to time, that evidence-based practice is supported by science, and that science is ongoing. I think it gets easy for us to lose track of the work we’re actually doing.
I spend a lot of time talking and writing about Medical Necessity. It is the key element in understanding how insurance works and what they cover and why. Insurance companies, as well as the Centers for Medicare and Medicaid Services, cares deeply that we are treating something, and we are using techniques that show evidence of being effective.
As we think about the treatments that we employ to help our clients, the focus of our work should be related to alleviating symptoms and improving functioning. It is helpful when we are really aware of what is actually happening to the client.
When we deploy the use of EMDR for an individual with PTSD, while we know that its been shown to be highly effective with this disorder, it is also true that there are some risks of the treatment, including increased intrusive memories, vivid dreams, and an increase in anxiety and distress. This does not mean that we shouldn’t use it at as a modality for treating people with PTSD, but that we should be aware that there are side effects.
When we utilize MCBT as a modality, its important for us to remember that there are limits to its effectiveness, and some qualitative studies have shown at least some risk related to an elevated potential of experience of flashbacks from individuals with a history of trauma, and a potential for increased suicidality for individuals struggling with significant depressive symptoms. Again, this does not mean we should not use Mindfulness in our practice. It is core to a lot of great work with clients and has been shown to be very effective. It is simply that we need to understand its limitations and that, as with all forms of therapy, there are some inherent risks.
Our work is serious, important, and it calls for us to really understand what we are doing, and at least some level know what’s actually occurring when we do it, as well as the risks of what to be aware of when we employ any particular modality. Our work to continue to educate ourselves through continuing education and certifications is key to our continued professional development.
I appreciate those trainers in the skills-based continuing education programs explaining what the risks are of what we are learning, and when they walk through when a particular modality is contraindicated for a particular diagnosis. That way, we know the limits of the work we can do for particular clients so that we minimize the therapeutic process to as close to zero as we can get.