Tuesday, February 7, 2012

How long does it take for psychotherapy to work?

There are various research articles done in the past which describe rates of change in psychotherapy patients, some studies for example describing a plateau after about 25 sessions or so.  I find these studies very weak, because of the multitude of confounding factors:  severity and chronicity are obvious variables, also the type of follow-up assessments done.

In the CBT literature, a typical trial of therapy is perhaps 16-20 sessions.

In light of our evolving knowledge of neuroplasticity, and our breadth of understanding about education & learning, it seems to me that the most important variable of all is the amount of focused, deliberate practice time spent in a therapeutic activity.  Oddly, most psychotherapy studies--even CBT studies--do not look at how many hours of practice patients have done in-between therapy appointments.  This would be like looking at the progress of music students based on how many lessons they get, without taking into account how much they practice during the week. 

I have often compared psychological symptom change to the changes which occur, for example, with language learning or with learning a musical instrument.

So, I believe that a reasonable estimate of the amount of time required in psychotherapy depends on what one is trying to accomplish:

-Some types of therapeutic problems might be resolved with a few hours of work, or with a single feedback session with a therapist.  This would be akin to a musician with some kind of technical problem who needs just some clear instruction about a few techniques or exercises to practice.  Or it might be akin to a person who is already fluent in a foreign language, but needs a few tips from a local speaker about idioms, or perhaps some help with editing or grammar in a written text.

-Many more therapeutic problems could improve with perhaps 100 hours of work.  This would be like learning to swim or skate competently if you have never done these activities before.  Regular lessons ("therapy") would most likely speed up your rate of progress substantially.   But most of those 100 hours would be practice on your own, unless you're okay with the progress taking place over a year or more.   With the language analogy, think of how fluent you might become in a foreign language with 100 hours of focused, deliberate practice.  For most of us, this would lead to an ability to have a very simple conversational exchange, perhaps to get around in the most basic way in another country.  

-A much larger change is possible with 1000 hours of work:  with music, one could become quite fluent but probably not an expert.  With a foreign language, comfortable fluency would probably be possible, though probably still with an accent and a preference for the old language.
-With 5000-10000 hours of work (this is several hours per day over a decade or more) one could become an expert at a skill or a language in most cases.  

In psychotherapy, another confound though is whether the times in-between "practice sessions" lead to a regression of learning.  An educational analogy would be of practicing math exercises an hour per day with a good teacher, but then practicing another 8 hours a day with another teacher whose methods contradict the first.  Often times, learning will still take place with this paradigm, but it might be much less efficient.    Persistent mental habits, in the context of mental illnesses, can be akin to the "second teacher" in this metaphor, and unfortunately they do tend to plague people for many hours per day.

This reminds me of the evolving evidence about stroke rehabilitation & neuroplasticity:  substantial brain change can happen in as short a time as 16 days--but it requires very strict inhibition or constraint of the pathways which obstruct rehabilitation. (note: 16 days of continuous "immersion" = 16*24 = 384 hours!)  In stroke rehabilitation, the neuroplasticity effect is much more pronounced if the unaffected limb is restrained, compelling the brain to optimize improvement in function of the afflicted limb.  Here is a recent reference showing rapid brain changes following limb immobilization: http://www.ncbi.nlm.nih.gov/pubmed/22249495

In conclusion, I believe that it is important to have a clear idea about how much time and deliberate, focused effort are needed to change psychological symptoms or problems through therapeutic activities.  A little bit of meaningful change could happen with just a few hours of work.  In most cases, 100 hours is needed simply to get started with a new skill.  1000 hours is needed to become fluent.  And 5000-10000 hours is needed to master something.  These times would be much longer still if the periods between practice sessions are regressive.  In the case of addictions, eating disorders, self-harm,  or OCD, for example, relapses or even fantasies about relapse will substantially prolong the time it takes for any therapeutic effort to help.  Of course, it is the nature of these problems to have relapses, or fantasies about relapse--so one should let go of the temptation to feel guilty if there are relapses.   But if one is struggling with an addictive problem of this sort, it may help to remind oneself that the brain can change very substantially if one can hold onto to quite a strict behavioural pattern for the hundreds or thousands of hours which are needed.

As a visual reminder of this process, start with an empty transparent bottle, which can hold 250-500 mLof liquid (1-2 cups), and which can be tightly sealed with a small cap.  Add one drop of water every time you invest one hour of focused, deliberate therapeutic work.   The amount of time you need to spend in therapy depends on your goal.  If the goal is total mastery--then you must fill the entire bottle.  If simple competence in a new skill is an adequate goal, then you must fill just the cap of the bottle.  If there are activities in your day which contradict the therapeutic work, it would be like a little bit of water leaking out of your bottle.  So you must also attend to repairing any "leaks."  But every hour of your effort counts towards your growth.


ANON said...

part 1

Dear GK,

I must be honest and admit that after reading this post yesterday I have been feeling significantly more depressed.

There are a number of things at work here which I will try to explain.

1)(This may be more of a semantic problem)
FUN. You left out FUN. Change can be fun. Psychotherapy can be fun. It definitely isn't always fun. But some of it can be. The idea that psychotherapy is just more work makes me really upset. This could perhaps reflect my connotation with work as extremely uncomfortable. However, I don't think I am the only one who feels this way.

2) Multitasking. I think it is important to note that much of the psychotherapy change can be integrated into your normal daily work. Actually I am pretty sure you would agree that this would be the best way to practice. If someone were to practice CBT in a workbook with pre-set problems about another random individual, it would not be as effective as doing a CBT exercise waiting for a bus with problems occurring in your own life.

(In this sense perhaps, your metaphor may not quite fit.
Usually when you practice an instrument, you practice with the instrument, during a structured practice time and you are not disturbed by other things. However, I understand that visualization practicing can be effective too. )

3) Numbers are nice sometimes, but honestly, if someone were to tell me that I needed to spend 10,000 hours before I were to be completely fluent… well let's just say that can be really intimidating. (For myself, I have been volunteering once a week for a year and haven't even reached the 100 hour mark. Does that mean I haven’t even learned my volunteer position..?)

In your post I get the feeling that the number of hours of practice results in a linear increase in the amount of "psychotherapy workage." I don't know if this is the case. I would perhaps like to think it is either a chemistry pH titration curve or even a Michaelis-Menten plot.

Another way to look at this is to believe that there is a compounding effect. For example each hour of therapy makes the next hour a little easier, faster, more fun,...etc.. There for the rate of change shouldn't be constant.

Perhaps I want a more concrete operationalization of the term "work."---hmmm

But what I am really wanting to emphasize is that very significant and meaningful changes can be made in small amounts of time. I also think that the research supports this as well. And if the research isn’t clear, then I would definitely say that very significant changes can be made in the eye of the person afflicted with psychological problems (with just a little bit of practice)

4) MUCH of psychotherapy isn't deliberate work. It is work that sometimes you don't even know is occurring. Many people just get better through the use of a therapeutic alliance and many do just get better from medications (although not all for sure!)

GK said...

The "work" I allude to here could exactly be "play" or "deliberate positivity" or "fun" etc.

I believe most of us underestimate the length of time or total committment required to make significant brain changes, and therefore we tend to abandon efforts prematurely or in frustration.

The other huge problem I am alluding to here is of "unlearning" happening frequently between therapeutic moments severely reducing the rate of therapeutic change, in the same way that ordinary stroke rehabilitation is much less effective than immersive rehabilitation, in terms of neuroplasticity and recovered function. So, for example, a relapse into substance use, or a bout of willful negative rumination, will greatly slow the progress of therapy (possibly with no progress at all). While such phenomena should be empathized with and recognized as normal features of the underlying problem, i think it is dishonest to be promising much progress while these phenomena are still occurring. This phase of therapy might be framed as a preparatory phase of a journey, as opposed to the journey itself.

Every moment of life can be very special & transformative, and I do not mean this discussion to distract us from focusing & savoring such immediate goodness -- ironically such savoring is much of what I think good therapy can be -- part of my point here is that we need more time with this, and much less negativity in-between those moments.