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BY RoBERT TANGRETH

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80 po*tFes APRIL9,2oo7

ERRIN GERSON SURVTVED A TRAUMATIC AND TURBU.

Ient childhood growing up in the Deep South in the 1980s. Hermother died of breast cancer when Kerrin was 15; her relation-ship with her father disintegrated when he remarried soon after.She left home and spent her last two years of high school livingout of her car or crashing with friends. "One moment I had a lov-ing mother, and the next moment I had nothing. Absolutelynothingi'she says.

She married at 26, divorced two years later, in 1996, and fellinto even deeper depression. Antidepressants did little to ease hersymptoms; Paxil made her anxiety worse. She had suicidalthoughts. "I was convinced I was worthless, unlovable and afraud]'says Gerson, now 39.

Today Gerson is offmedication, out oftherapy and happier thanshe has ever been. She owes her rebound to a startling revolutionin psychological counseling that has taken four decades to unfold-and which now is spreading to the farthest reaches of Americanmedicine. She fixed herself with cognitive behavioral therapy.

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APRIL9.2OO7 FORBES

Gerson turned to CBT in 1997 after spotting an ad for a patient think has a powerfi.rl influence on symptomsl' says Harvard psy-trial in a Nashville newspaper. She was surprised when her thera- chiatrist Arthur Barsky, who has tested CBT. "You first get thepist, Vanderbilt Universitypsychologist Steven Hollon, didntbother anxiety-producing ideas, and then you get the emotionsl' Bostonto dwell on her troubled childhood. Instead he focused on fixing University psychologist Michael Otto adds: "Now there is anthe present. He made her write a log of daily activities and gave alternative to being on the couchl'her homework assignments, such as a night out with friends. He Moreover, CBT intentionally is finite in duration. It aimszeroed in on her negative thoughts about herself and slowly con- to push patients out of the shrink's office after only l0 to 25 vis-vinced her that they were distortions. its, in sharp contrast to traditional psychotherapy that can run

on for many years. (Some CBT

"Ther* has always hecn soffi* ryl*sJicn H[T:ilff[ilT:[:|"*;ab**t how effectve is psychotherapy :Iii?:1iTT:J,l:il;ifJ:::i;CBT ncw has clear evrdence behrnd it." of psychotherapy. "Woody Allen

therapy is foreveri' says Hollon,Kerrin Gerson's shrink. "This is

"It turned out to be the greatest giftj'says Gerson, a first-gradeteacher who has just opened a yoga studio with a friend. cBT, shesays, "saved my life and gave me an entirely new worldviewl'

And that is the essence of CBT: Depression, anxiety and otherills arent the cause of a cascade of debilitating thoughts and self-Ioathing-they are, instead, a result of the same. Eliminate badthoughts and you can short-circuit bad feelings. cnt drops theendless search for past hurts, teaches patients how to preventnegative thoughts from creeping into their minds and coachesthem on how to cope. "We are starting to believe that what you

Family therapy:U. Penn's AaronBeck pioneeredCBT; daughterJudith Beck isspreading thedoctrine.

about taking action."In dozens of smali patient trials staged over three decades,

cognitive behavioral therapy has been shown to be surprisinglyeffective in quelling an ever expanding array of mental maladies:depression, anxiety, panic attacks, obsessive-compulsive disorder,post-traumatic stress syndrome, bulimia, hypochondria-eveninsomnia (see box, p. 84). Now almost 150 clinical trials are underway to learn whether CBT also can help patients with Tourette'ssyndrome, gambling addiction, obesity, irritable bowel slndromeand more; one trial studies the therapy in children who have

been sexually abused.The rise of cognitive therapy

rankles psychotherapists and psy-chiatrists who ply the retrospectiveanalysis and soulful conversation,whose origins date back to Sig-mund Freud and the 1890s. CBT is"a simplistic method of treatmentl'

it is "being oversoldl'and it appealsto health plans simply because it ends

so quickly, says Charles Brenner, a psycho-analyst in New York and past president

of the American Psychoanalyt ic

Association

He practiced analysis tor60 years before retiring in2001, seeing most patientsfour to five times a weekfor two to five years (and

sometimes far longer).People need this time to

understand why they areneurotic so they can 'torrect

those influences in the pastthat are causing trouble rnthe presentJ' Brenner says.CBT "is just telling a patientto stand up and fly rightl'hesnipes. 'And that is just not

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enough in very many casesi'Yet CBT, in numerous trials, has been shown to be as effec-

tive in treating depression and anxiety as some of the priceypills that have defined (and soothed) a generation, potentiallyundercutting a $13.5-billion-a-year business in such brand-name remedies as Prozac, Zoloft, Effexor and Lexapro. CBTsidesteps side effects like reduced sex drive and ejaculationproblems.

"It is at least as effective as drugs for virtually any nonpsy-chotic disorder," says Vanderbiltt Hollon. "We thoroughlyembrace the concepti'says Rhonda Robinson Beale, chief med-ical officer at the behavioral health unit of UnitedHealthcare.Psychiatrist Hyong Un, a national medical director at Aetna,says he sees "a pendulum shift" away from simply puttingpatients on antidepressants, a quick fix that gained widespreadpractice in the 1990s. "There has always been some questionabout how effective is psychotherapy and should we pay for it.CBT now has clear evidence behind itl'he savs.

ls"c"or"rRApy IS THE 'LTTMATE

corrAGE TNDUSTR'. rNthe U.S. the business encompasses 60,000 psychologists, 40,000psychiatrists and many more social workers, licensed coun-selors, and marriage and family therapists. Among psycholo-gists, CBT now has almost twice as many adherents as old-guardpsychoanalysis, according to a survey by University of Scrantonpsychologist |ohn Norcross. "This is just a sea changel'he says."Historically, Freud ruledl'

In2004,10 million Americans saw therapists, for a total of 84million sessions, at a cost of close to $9 billion, up 40o/o in sevenyears, the U.S. Agency for Healthcare Research & Quality says.Cognitive therapy likely reaped a large share of that growth. AtIntegrated Behavioral Health, which manages mental health ben-efits for companies employing 1.5 million Americans, over half ofthe cases now involve CBT, up from l07o or 20o/o a decade ago,says Samuel Mayhugh, founder of the Costa Mesa, Calif. firm.Old-style psychotherapy, with its protracted bonding of caregiverand patient, is akin to 'rent-a-friendi' Mayhugh says. "Employerscannot afford to be renting friends for their employees."

At managed care provider Kaiser Permanente's clinic in Hay-ward, Calif. upward of 70o/o of mental health patients now usesome form of cgt. Psychologist Michael Wetter, who headsadult psychiatry at the site, employs 35 therapists to keep upwith the demand and just a dozen psychiatrists who prescribedrugs. Says he: "People are starting to ask for CBT by name."

Even in New York City, modern-day mecca of psychoanaly-sis, CBT "is spreading everywherel' says New York psychologistRobert Leahy, author of The Worry Cure. His CBT practice inmidtown Manhattan had little competition when he set up shop24years ago; now 150 or more rivals claim varying degrees ofexpertise in the method.

One Leahy patient, a bond trader, had been mildly depressedfor years, ignoring the problem until he heard about CBT lastyear. The trader,48, had grown up poor, working since age 11

Tlials AndTfibulations{lBT transfarms how dcctcrs treat all s*rts afm*ntcl haeith disorders. thanks to impressnre*gid*nc# ic thre* d*cades of clinical trials.

f6 {3*3*3AW # f DEPRESSION

Landmark 41-patient trialby CBT creator Aaron Eerkfinds the therapy :rtrcrks aswell as antidepressants.

s ftb{}flre{F4}qi cBT

The term rognitive behav-ioral therapy first appearsin medicaliourn"ll:

*.S#*orpREssroNIn {ollow-up study, Beckfinds adding drugsprcduces nc clearextra benefit.

q d*hfgdh&#lfd PANrcSeck's team shovusthat CBT works in panicdisorder.

4 ghfl .dER##q& PANICBritish researchers showCBT is as effective asdrugs for panic attacks.

3#ffi4 ANxrErYScsttish study shows CBTbetter than old-fashionedpsychoanalysis forgeneralized anxiety.

3ffi#{pDEPREssroNAnalysis of governmentstudy casts daubt sneificary of CBT in severedenlelslon,

g##ffi rNsoMNrAIAMA study finds CBTworks for chronicinsomnia.

?S04 HYPocHoNDRTASix sessions of CBT easehyporhondria, Harvard researchersshsw.

DEPRESSED KIDSGsvernment study finds Prozac andCBT combined is best fsr depressedadolescents; Prszac is the masteffective stand-alone treatment.

OBSESSIVE-COMPULSIVEDISORDER CBT and drugs helpkids with obsessive compulsivediscrder, /AllfA study shows.

INSOMNIAHarvard study ccncludes CBTbeats Ambien over the lons term.

ffi##ffi DEPREssToNRELAPSE Study finds that CBTholds its own versus Paxil insevere depression*and is betterat preventing relapse.

LOW BACK PAINExercise along with CST isalmost as good as majorssrgery for chronic low back pain.349-patient study concludes ing titish l*edical Journal.

SUICIDEJAMA study finds C8T preventssuicide attempts in patients whohave lried to kil l themselveshefors.

ffi### rNsoMNrACBT beats Lunesta-style drug forinssmnia in JAMA study.

Xff,W.F rRrALsA tstal 148 trials study CBT ineverything from fibromyalgiato schizophrenia to irritablebowel syndrome.

APRIL9.2oo7 FoRBEs 83

xhausted. insom-niac Americansfi l led 47.8 mill ionprescriptions for

sleeping pills last year,spending $3.6 bil l ion, or30olo more than the yearbefore, says rMs Health.For some of them thisalso entailed strange anddisturbing side effects:sleepwalking, late-nightfood binges. even driving inthe wee hours while asleep.

The Food & Drug Ad-ministration last monthordered that warnings of

such bizarre possibil i t iesshould be handed out topatients picking up lunesta,Ambien and 11 other sleep-ing pills. The pon left outwhat may well be betteradvice: Skip the pil ls-andtry cognitive behavioraltherapy.

For those with chronicinsomnia, just four to sixsessions of cBT can workbetter than pilll withfewer side effects, multiplesmall studies suggest. "Thescientific literature is nowvoluminous. There is no

question that CBT is moreeffective," says Universityof Massachusetts sleeppsychologist Gregg Jacobs. .Borge Sivertsen. a psycholo-gist at the University ofBergen in Norway, adds:"lf you suffer from insomniafor more than a month ortwo, [pills] are definitely notthe way to go."

Insomnia poses a viciouscycle for some patients; Theycan't sleep ... because theyworry too much about thefact that they can't sleep. SocBT practitioners work toease patients' exaggeratedfears of the consequences oftheir sleeplessness. They alsouse behavioral techniquesand relaxation exercises toincrease the associationbetween bedtime and sleep.

"Usually a negative lifeevent causes the insomnia,but catastrophizing, negativethinking and worrying makethe insomnia become chron-ig" says Sivertsen. The act offretting "stimulates the cen-tral nervous system just asmuch as going for a run."

Sivertsen led the lateststudy to pit drugs againstcar, published last June inthe prestigious Journal ofthe American MedicalAssociation. lt compared aLunesta-style drug (zopi-clone) with six sessions ofcBT in 46 men and womenwho had struggled with

insomnia for at least threemonths. Patients on cBTslashed the time they spenttossing and turning in bedby a full hour; they also gotmore deep sleep, makingthem feel refreshed thenext day.

Surprisingly, patients onmeds showed little objectiveimprovement, the studyfound. This stunning routfor therapy follows a 2004study led by Jacobs, whichcompared cBT with Ambienin 53 patients. Ambien'seffect faded when patientsstopped taking it; patientson therapy were still sleep-ing better a year late4according to the resultsfound in the Archives oflnternal Medicine.

Ambien maker Sanofi-Aventis shies away fromcrit iquing the studies butsays, "No single treatmentis effective and acceptablefor all insomnia patients."Sepracor, which makesLunesta, says its drug is"different from zopiclone"and has been proved towork for up to six monthsin two studies.

Jacobs now has taken thecBT insomnia cure online,devising a Web-based inter-active treatment for insom-nia. ln an init ial test on 200insomniacs, it reduced sleep-ing pil l consumption by 40%in five weeks. -R.L.

and putting himself through college. Though he had millions inthe bank, he constantlyworried he would go broke. So Dr. Leahyhad him review his finances at therapy sessions to convince him-self he was in good shape; therapist exhorted patient to stop com-paring himself to $100 million hedge-fund managers. "It's had adramatic impactl' the trader says. "Dr. Leahy got me to under-stand that it wasnt just about the money; it was about lifestyleand family. I am as happy as I have ever beenl'

Thomas Duffy, 59, says CBT helped him conquer his fear ofbridges and tunnels. A medical salesman in New fersey, he mustdrive to hospitals in four states, but in the late 1990s a car trip over

84 FoRBES APRIL9.2oo7

a big bridge would spark a panic attack that felt like a crushingheart attack He would leave home at dawn to allow time to drivearound major spans such as the Verrazano-Narrows. He triedXanax, an antiarxiety pill, but it made him sleepy. Then Duffyheard a radio commercial about CBT while driving, and he signedup in 2000. In 12 weeks a therapist taught him breathing relaxationexercises, helped him confront his fears and slowly weaned him offdrugs. Now he drives wherever he wants. "I would say I am curedl

The Austrian neurologist Sigmund Freud viewed such mat-ters as far more complicated. He theorized that psychologicalproblems were rooted in a hidden world of past traumas, subcon-

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scious emotions and repressed sexual desires and that digging upthese hidden forces could prompt a catharsis in patients. It wasdubbed "the talking curei'

OME OF FREUD'S IDEAS, ESPECIALLY THOSE ABOUT SEX,later would come into question, but patients have gone on thecouch ever since. By the late 1950s psychoanalysis had become apillar ofpsychiatry, though it never had been rigorously tested intrials. Some therapists, however, grew skeptical of the long-winded Freudian methods. By the 1960s two men had broken offto pursue, separately, new techniques that formed what becameknown as cognitive behavioral therapy: New York therapistAlbert Ellis and the University of Pennsylvania's Aaron Beck.

Ellis today is 93, sickly and nearly deaf, but he still bristles withattitude. "Freud wasn't working, it was incompetent, so I lookedaround for something betterl'he says. He found inspiration in thewords of the ancient philosopher Epictetus: "Men are disturbed notby things but by the principles and notions which they form con-cerning thingsi' In 1955 he introduced a method called rationalemotive behavior therapy that focused on eliminating irrational,self-defeating thoughts and replacing them with healthy ones.

"lf you were abused, you accept it, too damn bad," he says."You want to get rid of the idea, 'It harms me for lifel" Over theensuing decades Ellis formed his own teaching institute and

another 50 or so who went into private practice; they establishedtheir own training programs. tn 1994 he founded the nonprofit BeckInstitute for Cognitive Therapy & Research to help teach the methodmore widely. It is run by his 52-year-old daughter, fudith Beck

Meanwhile, other psychologists rebelling against Freud pur-sued behavioral techniques, including relaxation breathing exer-cises and "exposurd' therapy for panic attacks. The two methodsbegan merging in the 1970s to form cognitive behavioral therapy.The first mention of it in medical journals shows up in 1980.

Psychoanalysts dismissed it. "It was a knockdown, drag-outfight. The nonbehavior therapists would always make ad hominenattacksl' says University of Washington's Marsha Linehan, whodeveloped a CBT spinoff for suicidal cases, called dialecticalbehavior therapy. "They said it was superficial, like treatingmeningitis with mood musicl' Beck recalls.

His bent for scientific proof led him to accumulate three decadesof small triais proving his therapyworked-and that it couldhold its own even against

the antidepressants thatbegan to take hold by thelate 1980s. A turning pointcame in 1977 when Beckcompared cognitive ther-apy with standard antide-pressants in a 4l-patient din-

Freud thsonzed that psychologcalproblems were rooted ur a hidden worldof past traumos, subconscious emo*onsand repressed se>nial desues.clinic, traveled the world and trained thousands ofstudents.

Beck, now age 85, is methodical, bookish and a fan of bow ties;he threw out his analyst's couch in 1959 to focus on an approachhe had devised that he called cognitive therapy. He had started outintent on giving scientific heft to the prevailing Freudian theorythat depression was caused by unconscious rage. It didnt go well;each experiment he tried seemed to disprove Freud's claims.

Early on Beck noticed that his depressed patients always putthe worst possible spin on everyday events, thinking things thathad no real basis in realiry:"Nobody loves me" or "lt's hopelessl'He theorized that distorted thoughts were the real cause of theirbad bout of the blues. Replace the bad thoughts with better, morerealistic ones and happier emotions would follow.

i t. started coaching patients face-to-face on how to critically? evaluate their own fretting, teaching them to interpret everyday sef! bacla more realistica$r The patients got better in just l0 to 12 weekly3 sessions. In 1975 he founded the Center for Cognitive Therapy at! U. Penn, treated thousands of patients, trained 30 disciples who1 formed their own research programs to study CBT and indoctrinated

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ical trial, the fust rigorous test of its kind Thetherapy worked slightly better than the drugs.

Over the next decade Beck and a cadreofstudents developed cnt for anxiety disor-der, panic attacks and more. In 1985 a Beckstudy found adding drugs to cBT producedno clearbenefiq in 1992 he showed cBTworlain panic disorder. Two years later a Scottishstudy sang CBT's praises for general anxiety.

All the while, however, the Prozac Rev-olution swept across America. The antide-pressant, approved in 1987, was soon in themedicine cabinets of millions of Ameri-cans, pushing therapy out of the limelight.In 1995 an analysis of a government studyfurther dampened enthusiasm by conclud-ing that drugs were more effective thanCBT for severe depression. By 1997 drugshad overtaken talk therapy in treatingdepression: 75o/o ofpatients used drugs (upfrom 37o/o in 1987) versus an overlapping60% who got some form of therapy (downfromTlo/o in.l987), a study in the /ournal ofthe American Medical Association found.

Counseling i::"ffiiffilfi|1$,lm,f""l#nroBy the Nuftrbers [HTsH:$*:fl1*]* t##*iffi"ffi xae933fs:ra Americansreceive psychotherapy annually. 1

i*ffi .* aea{&$*.r:xxx r*"rcounseling sessions annually-1

spending cn psychotherapy.l

fjT.ffi"ffi fus3'$$mxa Annua!sales of antidepr*ssants.2

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' '* (1 Ongoing studies testingcognitive behavioral theraFy,

12004 figure. 'l2005 U.S. sales. Sources: Agencyfor Healthcare Research & Quality; IMS Health;clinicaltrials.oov.

which had been seen as treatable onlywith drugs.

hoc^c sn-rEs FrAVE BEGLTN ro RE\T,A'CBT can render long-term phpiological changesin the brain, just as antidepressants can. In onestudy in 2004 researchers at the University ofToronto used positron emission tomographyscanning to track the brain activity of 14depressed patients who had successfirlly beentreated with CBT, comparing them with 13patients who got better by taking only PaxiL cerdampened down activity in higher areas of thebrains cortex, indicating patients were learningto quell rampant negative thoughs. Bycontrast,Paxil ramped up actMty in the cortex, whiledampening actMty in the limbic parts of thebrain responsible for emotions.

cBT has its downsides: time commit-

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"The 1990s were all Prozac all the time. It was easy for anyonetraining psychiatrists to say these great little pills are the only thingyou needl'says U. Penn psychologist Robert DeRubeis.

But CBT trials continuedto tum in impressive results. Inl999IAMApublished a study saying CBT works for insomnia. In2004 CBT wasshown to alleviate hypochondria in six sessions; to help depresed ado-lescents and kids with obsessive compulsive disorder; to quell insom-niabetterthanthe drugAmbien overthe longterm. In 2005 CBT stanedin studies of severe depression and in preventing suicide attempts.

A 240-patient trial led by Penn's DeRubeis and

Vanderbilt's Hollon found that 16 weela of

CBT was as effective as the drug Paxil for

--*y---- -=. moderate to severe depression. CBT

ment, expense and the elusive search for a good practitioner.Few have received rigorous training in the method. Psychiatriststend to have expertise in drugs, not CBT; hospitals didnt requirepsychiatry residents to learn CBT until 2001. "There is a seriousquality issue no one is talking abouti' University of New Mexico's

Jan Fawcett frets.Moreover, some say CBT's advantages over other types of

therapy are overblown. "There is a kind ofarrogance that otherqpes of therapy are less effectivel' complains University of Wis-consin-Madison psychologist Bruce Wampold. "But it is the ther-apist that makes the difference, not a particular type of therapyi'Emory University psychologist Drew Westen says he has treated"refugees" of failed cognitive therapy and that most of them have

benefited from his longer-term approach. He laments "a tremen-dous bias" toward quick-fix treatments like CBT.

But Zoloft and its chemical siblings are a quick fix, too. Ulti-mately the choice between cognitive behavioral therapy anddrugs comes down to: Do you want to take extra time to talk tosomeone or pop a pill and put up with its side effects?Antidepressants historically have far more data backing theirbenefits, but now CBT has caught up, and ultimately this newwave of therapy offers the possibility of lasting benefits that med-ications cannot: It may change how you think about yourself. F

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"CBT is at least as effective as drugsfor vrlua]ly any n*npsychctlc disorder."

kept working even after patientsstopped treatment: Only 3l% of cnr

patients had a relapse in the year afterthey completed treatment, versus 767o of those who stopped takingPaxil. Still, say psychiatrists, severe cases are likely to call for drugs.

Many of these trials involved only a few dozen patients or a fewhundred" far smaller than drug trials that involve thousands of sub-jects. Beck pleads poverty and says the profusion of positive resultsproves the power of CBT. "The drug companies spend several bil-lion dollars a year on their consumer ads and promotions to profes-sionals. This has created an aura of success" for drugs, Beck says. "It

is difficult to compete with such a juggernaut, but gradually it is

86 FoRBES APRIL9.2oo7