Kashish Janiani
Typically, when we hear the word ‘therapy,’ we imagine the patient sitting on a couch in front
of the therapist for about an hour every week, for months or even years. Cognitive Behavioural Therapy (CBT) is a present-oriented form of psychotherapy based on the cognitive model and on an average requires 10-20 weekly sessions. Even Psychodynamic therapy, which focuses on uncovering the unconscious consists of weekly sessions typically running up to 37 weeks. What we do not imagine, however, is a quick fix. So, does the efficacy of therapy depend on its duration? Does it have to stretch out over months and years?
Although most forms of psychotherapy are rooted in the practice of weekly sessions over an extended time period, clinicians have started exploring the possibility of brief, but intensive therapies. These therapies - some lasting for hours, some for a few days, have specifically been targeting anxiety disorders such as Obsessive Compulsive Disorder (OCD) and phobias. These forms of therapy place patients in a bubble. This bubble allows them to effectively tackle their anxieties without having to worry about additional experiences between sessions.
The idea of intensive therapies originated with the Swedish psychologist Lars-Göran Öst who conducted a clinical trial of 20 patients with specific phobias. The mean treatment time was 2.1 hours and after a four year follow-up, 90% of the patients had either improved significantly or completely recovered (Öst 1989, p.1). Ost argues that most patients with a phobia rarely apply for therapeutic treatment and simply adjust their lives in accordance to the phobia. With these, he hoped to increase the number of people seeking treatment. This trial, however, was only the beginning.
Öst also contributed to the four-day Bergen treatment developed by Gerd Kavle and Bjarne Hansen in Norway. The concentrated form of exposure and response prevention therapy aims to treat OCD and works in three stages. First, patients are given information on OCD and prepared for the upcoming exposure tasks. Next - the exposure phase is when they face their fears head on. It often involves the therapist accompanying the patient around their communities to face as many anxiety-inducing situations as possible. Finally, the third consists of planning how to maintain these behavioural changes post-treatment. Another key feature of the Bergen treatment is the LET-technique (LEan into The Anxiety) which encourages the patient to focus on these anxiety-ridden moments. In fact, in a study with 77 participants, 72% participants had recovered on a long-term basis (four-year follow up). More importantly, when compared to other published studies on effectiveness of less intensive treatments (weekly sessions), they found the Bergen treatment led to significantly higher rates of recovery and remission (Hansen, 2018, p.89).
Another upcoming intensive treatment is Thomas Ollendick’s High Intensity CBT. It delivers treatment in fewer sessions than the standard CBT and has been developed specifically for childhood anxiety disorders (Ollendick, 2014, p. 169). The principles of HI-CBT are similar to those of the Bergen treatment - psychoeducation, gradual exposure, and finally a plan of action or homework to reinforce the lessons. In fact a meta-analysis looked at 23 controlled studies testing the effectiveness of brief, intensive or concentrated therapies for childhood anxiety disorders. With the intensive therapy, 64% patients had recovered after a follow-up compared to the 63% treated with the standard CBT, making it comparable to the efficacy of standard CBT interventions (Ost and Ollendick 2017, p. 134).
We’ve established the potential of these intensive therapies, but what change can they bring? The most obvious advantage is - they accelerate relief. Mental illnesses often tend to disturb daily functioning. For instance, a person with a phobia of heights will adjust their lives so as to avoid heights in order to not seek treatment at all. However, briefer treatments will incentivize people to seek treatment. One could be treated over a week-long break or in some cases even over a weekend. Intensive treatments would increase the reach and accessibility of treatment for anxiety disorders. These therapies could even make their way to more rural, isolated areas.
A point of concern, however, is how applicable these methods are to cultures around the world. Most of these treatments were developed in Scandinavian countries and have gradually been developing successfully in the USA. However, since this form of therapy is still in its nascent stages, there is a need to conduct randomised controlled trials in different contexts.
Currently, it seems as though there is a fountain of potential here. Intensive therapy could be a transformative experience. Yes, this would mean a big shift for therapists, the healthcare system and even health insurers, but its a change we should definitely strive for.
References
Hansen, Bjarne, et al. "The Bergen 4-day treatment for OCD: four years follow-up of concentrated ERP in a clinical mental health setting." Cognitive behaviour therapy 48.2 (2019): 89-105. https://doi.org/10.1080/16506073.2018.1478447
Ollendick, T. H. (2014). Brief, high intensity interventions with children and adolescents with anxiety disorders: Introductory comments. Psychopathology Review, 1(1), 169-174. https://doi.org/10.5127/pr.034813
Öst, L. G. (1989). One-session treatment for specific phobias. Behaviour research and Therapy, 27(1), 1-7. https://doi.org/10.1016/0005-7967(89)90113-7.
Öst, L. G., & Ollendick, T. H. (2017). Brief, intensive and concentrated cognitive behavioral treatments for anxiety disorders in children: A systematic review and meta-analysis. Behaviour research and therapy, 97, 134-145. https://doi.org/10.1016/j.brat.2017.07.008.
Wallis, C. (2019, April 1). A Three-Hour Fix for Phobia, a Four-Day Therapy for OCD. Scientific American. doi: 10.1038/scientificamerican0419-20.
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