For Better Talk Therapy, Try Napping

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David H. Barlow of Boston University and colleagues have developed a therapy called the Unified Protocol that tweaks elements of cognitive behavioral therapy to more efficiently treat a range of anxiety disorders and depression. Photo: Boston University

New tweaks are improving the age-old practice of talk therapy.

Doing therapy in the morning, taking a nap afterward or adding a medication that enhances learning are just a few of the methods scientists are investigating to make cognitive behavioral therapy work better.

CBT, which involves changing dysfunctional patterns of thoughts and behaviors, is one of the most well-researched and effective treatments for a range of mental health issues, including anxiety disorders, depression and eating disorders.

But about a quarter to half of people with depression and anxiety don’t get significant relief after a course of CBT, which usually consists of about 12 to 15 weekly sessions. Some patients find the treatment time-consuming and difficult. Anywhere from 15% to 30% of people who begin it don’t finish, says David H. Barlow, founder of the Center for Anxiety and Related Disorders at Boston University. “There’s still plenty of room for improvement,” he says.

A study published in September in the journal Psychoneuroendocrinology that involved 24 patients with anxiety disorders found that therapy appointments earlier in the day were more effective than those later in the day.

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Illustration: JON KRAUSE for The Wall Street Journal

In the study, subjects—who all had panic disorder with agoraphobia (fear of situations where escape may be difficult)—were treated with exposure therapy, a common component of CBT: They repeatedly confronted situations they feared, such as being in elevators or crowds. Subjects with sessions early in the day reported less severe anxiety symptoms at their next session than those who had sessions later in the day.

The researchers found that higher levels of the stress hormone cortisol that naturally occur in the morning were responsible for at least part of the benefit of the earlier sessions. “Acute boosts of cortisol can actually facilitate learning,” says Alicia E. Meuret, associate professor of psychology at Southern Methodist University and lead author of the study.

Taking a nap after therapy can be beneficial, too. A study published in Psychological Medicine in 2014 had 40 people with spider phobias do a session of exposure therapy using virtual reality: They moved through simulated rooms containing several spiders. After the session, some subjects were given 90 minutes to nap. (Actual sleep was recorded via EEG.) Others watched a video. Then they were asked to approach a live tarantula in a cage. At this point, there were no significant differences in anxiety symptoms between the groups.

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A study by Alicia E. Meuret of Southern Methodist University found that patients who did exposure therapy, like facing their fears of crowds and heights shown here, in the morning benefited more than those who did it later in the day. Photo: Southern Methodist University, Hillsman S. Jackson

But at a follow-up appointment a week later, the subjects were asked to approach the tarantula again. This time, the people who had napped after exposure therapy had a greater reduction in anxiety and catastrophic thoughts about spiders as they approached, compared with those who didn’t sleep after the treatment. Scientists believe that sleep can strengthen the memories of new learning that occurs during therapy.

Psychologists are also adding other components to improve CBT. In a study published in the Journal of Consulting and Clinical Psychology in September, researchers added motivational interviewing, an approach where therapists focus strongly on expressing empathy and validating patients’ feelings, to CBT in treating patients with severe generalized anxiety disorder.

Those who got the combined therapy saw a greater reduction in worry and distress over a one-year period after the treatment ended, compared with those who got traditional CBT. And during the treatment, far fewer patients who had the combined therapy—about half as many—dropped out compared with those who had CBT only.

Researchers are also experimenting with combining CBT and attention bias modification, a treatment that uses a simple computer task to train patients to focus their attention on more benign stimuli in their environments and away from threatening things.

This is thought to combat a tendency in many people with anxiety disorders to pay more attention to threats. They scan their environments looking for things that could potentially be scary and have a harder time disengaging from things that seem threatening. Such behaviors are often unconscious and are thought to fuel anxiety symptoms, says Daniel S. Pine, chief of the section on development and affective neuroscience in the Intramural Research Program at the National Institute of Mental Health.

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A study by Michelle G. Craske and colleagues at UCLA found that putting people in a good mood before exposure therapy makes the treatment more effective. Photo: Reed Hutchinson/UCLA Dept of Psychology

Psychologists are also finding that putting people in a good mood before exposure therapy by having them vividly imagine happy scenes might actually make the treatment work better. “There’s some evidence that positive affect enhances the encoding of information at a deeper level, which may improve learning during exposure,” says Michelle G. Craske, director of the Anxiety and Depression Research Center at the University of California, Los Angeles.

Dr. Craske and colleagues are also finding success in modifying exposure therapy, like varying where and how patients do the therapy and making the sessions more intense (like having a person with a dog phobia encounter two dogs at one time). Dr. Craske is also launching a study to see if exercising after exposure therapy will boost its effectiveness, since exercise increases the level of a protein that is critical for the consolidation of memories.

Scientists are finding that certain medications that enhance learning may make therapy work more quickly. Some studies have shown that taking D-cycloserine, a drug commonly used to treat tuberculosis, before treatment sessions can enhance and speed up improvement from exposure therapy. But the research is mixed—some studies haven’t shown the effect. Researchers are also looking at yohimbine, which is derived from the bark of a tree typically found in parts of Africa, and hydrocortisone, better known as an anti-itch cream, but used in pill form.

Write to Andrea Petersen at [email protected]