Why Not Talk Therapy

You did not fail out of therapy, therapy failed you.

The most common therapy modality in the US is Cognitive Behavioral Therapy (CBT) or what is commonly referred to as talk therapy. The focus of CBT is on identifying and revising distorted thoughts and belief systems that create stress or other disturbances in people’s lives and relationships. This modality involves reality testing and establishing new behavioral habits that help people cope better with their situation.

However, even while CBT is considered an evidence based practice, the effectiveness is quite limited. In a large scale study conducted by the National Institute of Mental Health looking at CBT for depression (Treatment of Depression Collaborative Research Program), CBT was only 1.2 points better than no therapy on a 54 point Hamilton depression scale. In this and other trials, CBT had an effectiveness rate ranging between 17% and 24% under the most ideal, rarified laboratory conditions. In real world circumstances, we see CBT's effectiveness decrease to the 5% mark. These results for the effectiveness of CBT have remained consistent from that early trial to much more recent studies which is to say the state of the art in evidence based psychotherapy yields a 75% to 95% failure rate for the treatment of depression.

If we turn our attention to CBT and post traumatic stress disorder (PTSD), the randomized control trial data used by the American Psychological Association to recommend CBT as a trauma treatment is even more problematic. Excerpting from Jonathan Shedler’s excellent summary article on the topic:

...[these are the] findings of the largest and arguably best RCT [randomized controlled trial] behind the guidelines. The RCT was funded by the U.S. Department of Veterans Affairs and the Department of Defense and published in the Journal of the American Medical Association. It studied 255 female veterans. The most frequent trauma was sexual trauma, followed by physical assault.

Patients received one of the “highly recommended” forms of CBT (prolonged exposure therapy) or a control treatment. Here is what the study found:

Nearly 40 percent of those who started CBT dropped out of treatment. They voted with their feet about its usefulness.

Sixty percent of the patients still had PTSD when the study ended.

One hundred percent of the patients were clinically depressed when the study ended.

At six-month follow-up, patients who received CBT were no better than those in the control group.

Nineteen serious “adverse events” (suicide attempts,psychiatric hospitalizations) occurred over the course of the study.

The authors soberly noted that the patients “may need more treatment than the relatively small number of sessions typically provided in a clinical trial.”

I did not choose this study as an example because it is a poor study. I chose it because it is arguably the best.

Even though 40% of patients did not have PTSD when the study ended, this number drops to the same level as that of the control group at the 6 month follow up. This is what we mean when we say you didn't fail therapy, therapy failed you. Our best, state of the art, evidence based treatments have had very high failure rates when it comes to depression and PTSD.

The other reason we don't use CBT at Innate Path is that we know from neuroscience research that while there are parts of the mind that we can see and verbalize (what is known as explicit, declarative memory), there are much larger parts of the mind that are hidden from view and cannot be put into language (implicit and non-declarative memory)…or what is more commonly known as the subconscious mind. CBT and talk therapies work with the part of mind that is visible and can be reasoned with. In this way, these therapies are considered top-down approaches. They use the more recently developed, verbal, rational, conscious parts of the brain to manage the reactions that come from the more primitive, hidden, non-rational, subconscious parts of the brain. Top-down talk therapy and CBT are effective to some degree but largely as workarounds or coping tools to make symptoms more manageable. These treatments provide management tools, but they do not provide a cure.

Symptom management is a necessary and good skill to develop. However, we have the ability to work at a much deeper level with the combination of psychedelic medicines and bottom-up, experience focused therapies. Symptoms like depression, anxiety, panic, compulsions, and addiction are considered bottom-up reactions. They emanate from the hidden, more primitive, non-conscious parts of the mind. There is solid evidence suggesting that these symptoms come from life experiences that have taken place in childhood, in your family of origin, and are most often cloaked in dissociation.

The good news is that psychedelic medicines, such as ketamine, MDMA, cannabis, and psilocybin (mushrooms), are excellent at engaging the subconscious. These medications do not produce random, meaningless displays of color, images or sound. Quite the opposite: they express meaningful manifestations of your mind. The non-rational sensations, emotions, thoughts, and images that are seen in these altered states of consciousness are your body and mind’s way of expressing deep, subconscious truths that have shaped you. Furthermore, they allow for bottom-up processing to take place, which has little to do with insight and understanding and much more to do with the shifts that take place at the level of the subconscious.

We highly recommend viewing this video on how your mental health symptoms are part of your autonomic nervous system’s response.