The Quick Therapy That Actually Works
Just a few hours of therapy-like interventions can reduce some people’s anxiety.
The strange little PowerPoint asks me to imagine being the new kid at school. I feel nervous and excluded, its instructions tell me. Kids pick on me. Sometimes I think I’ll never make friends. Then the voice of a young, male narrator cuts in. “By acting differently, you can actually build new connections between neurons in your brain,” the voice reassures me. “People aren’t stuck being shy, sad, or left out.”
The activity, called Project Personality, is a brief digital activity meant to build a feeling of control over anxiety in 12-to-15-year-olds. Consisting of a series of stories, writing exercises, and brief explainers about neuroscience, it was created by Jessica Schleider, an assistant professor at Stony Brook University, where she directs the Lab for Scalable Mental Health. She sent it to me so I could see how teens might use it to essentially perform psychotherapy on themselves, without the aid of a therapist.
In the middle of my new-kid scenario, the program tells me the story of Phineas Gage, the 19th-century railroad worker whose behavior changed radically after a metal spike was driven through his skull. With white backgrounds and rudimentary drawings, the program uses Gage’s experience to suggest that personality resides at least partly in the brain. If a metal spike can change your disposition, Project Personality reasons, so can something less violent—such as a shift in your mind-set. There are, perhaps, better ways to illustrate this than an extreme and hotly disputed historical event, but Project Personality finds a way to make it uplifting: “By learning new ways of thinking, each of us can grow into the type of person we want to be.”
Toward the end, the activity asks me to reassure a friend who was snubbed by another friend in high school. What would I tell the friend about how people can change? It encourages me to apply what I just learned about personality and the brain. The total program takes me less than an hour to complete.
Schleider admits that the production values are a little rudimentary; she’s currently working on a slicker version. Still, last year, she and her colleague John Weisz found that a single session with a very similar program helped reduce depression and anxiety among 96 young people ages 12 to 15. Beyond digital programs such as Project Personality, Schleider’s lab is about to test how well a single session of in-person psychotherapy can help teens and adults. The session will focus on “taking one step toward solving a problem that’s very troublesome,” she told me. “People will leave with a concrete plan for how to cope.”
If Schleider’s work is successful, it may help upend the traditional, pricey model of American psychotherapy. She wants to see whether people can get the same benefit from just an hour of digital or in-person therapy as they can from paying $200 an hour every week for months.
Granted, there are known risks to using well-meaning quick fixes as therapy. In one of her studies, Schleider points out that Scared Straight programs, in which teens visit with prisoners, are a type of single-session intervention, but they actually have been found to increase youth delinquency. There are also plenty of apps these days that allow people to access therapy-like programs without either an expensive psychologist or a primitive PowerPoint.
But Schleider argues that many wellness apps out there haven’t been proved to work. Her lab’s goal is to study the effectiveness of various programs, digital and in-person, to be sure that they’re doing what they’re supposed to. Effective solutions are crucial because Americans—stressed out, lonely, and ghosted by Tinder dates—are in desperate need of someone to talk to. The data suggest that most of the Americans who have a mental illness aren’t receiving treatment. About 30 percent of psychotherapists don’t take insurance. The wait list for the roster of therapists at Stony Brook’s community clinic, who take insurance and charge relatively lower fees, is three to six months. As Schleider put it to me, her quick interventions offer “something, when the alternative is nothing.”
Single-session interventions, like the kind Schleider studies, are typically five to 90 minutes long and, eventually, could be deployed in schools or pediatricians’ offices, rather than in traditional therapists’ offices. Schleider’s lab is especially interested in targeting adolescents, since about half of all mental illnesses set in by age 14. Unlike traditional therapy, Schleider’s program and others aim to get participants to become “helpers” for their peers after they’ve learned information about personality change for themselves. The point is to increase intrinsic motivation: Kids might be more likely to want to sort out other kids’ problems than to sit in their room and do therapy homework.
Perhaps to the chagrin of those of us who have sunk entire paychecks into traditional psychotherapy, there is some evidence that extremely brief therapy is indeed effective. Schleider published a meta-analysis of single-session interventions focused on children and teens (not including her own work, which was tested later) that found that a teen who received a single-session intervention had a 58 percent greater chance of having his or her symptoms improve than one who did not. The single sessions worked especially well for decreasing anxiety and behavioral problems. In fact, Schleider says, on these measures, one session of therapy turned out to be about as effective as 16 sessions. “I don’t know if that’s great or scary,” she says.
Other researchers have also discovered some surprising benefits to quick interventions. One study found that just four days of exposure therapy—in which patients confront whatever they are preoccupied with—helped two-thirds of teens with obsessive-compulsive disorder go into remission. A separate 90-minute intervention increased college students’ sense of “hope, life purpose, and vocational calling.” And a somewhat longer-term program of four to eight weeks was enough to change a person’s personality. That’s longer than 90 minutes, but it’s shorter than many traditional psychotherapy regimens, which can be open-ended and go on for years.
“Definitely, there are times when one session can be powerful,” says Michael Brustein, a clinical psychologist in Manhattan. One fast-acting technique he mentions is motivational interviewing, in which the therapist prods the patient to examine whether his actions are helping him achieve his goals. For example, a father who missed his son’s basketball game because of a drinking problem might be asked whether he’s living up to his sense of what it means to be a “good father.” Certain phobias can also be dealt with in a few short consultations: Brustein told me he once helped a yoga instructor manage an elevator phobia by applying mindfulness techniques from his yoga practice.
Shorter-term therapy is also more likely to work if your definition of “work” isn’t “become permanently and totally happy.” “For too long, our target has been total amelioration of symptoms,’” Jodi Polaha, a psychologist and East Tennessee State University professor, told me via email. (Polaha researches therapeutic interventions that are as short as 20 minutes and delivered in a doctor’s office; I profiled her clinic in 2017.) Rather than complex mental illnesses, simpler problems—such as smoking cessation, weight loss, and even medication adherence—might yield to the precision strike of a short intervention, Polaha said.
The big challenge to scaling up this kind of microtherapy, according to Polaha, is convincing both patients and doctors that there’s no special transformation that happens at 50 minutes. “When I start sessions with my patients, I always tell them we will talk for 30 minutes and then decide if follow-up is needed,” she said, “because change can happen at any time.”
Lynn Bufka, a psychologist with the American Psychological Association, says that these types of brief interventions could be just a first step toward the treatment of various mental-health woes. They might be enough for some people, while others go on to get more intensive therapy. But Brustein and Bufka both say that for more severe issues, such as bipolar disorder and major depression, a quick dose of therapy is unlikely to be enough. “These kinds of interventions are probably more likely to be beneficial before full-blown symptoms or disorders have developed,” Bufka told me.
If Schleider succeeds, and the air begins to leak out of the 50-minute, weekly therapy model, we may begin to wonder: What is the point of therapy? For decades, Americans have been told that the key to inner tranquility is to talk to someone. Have you tried cognitive-behavioral therapy? is the cop-out solution of stumped advice columnists everywhere. But how can talking to a stranger (or looking at a slide deck) for less than the length of a superhero movie be enough to fix your brain? What are we after when we go to therapy, anyway?
The fact that the short-term interventions span about the length of a movie is actually relevant, based on a metaphor Brustein used to describe the benefit of therapy. When you go to a movie, he noted, you can see the characters and understand their motivations. You can tell when they’re about to make a mistake: You wish you could scream at them to not go down to the basement, or back to that guy. But when it comes to our own lives, we have a harder time seeing those patterns. We’re too close to our own problems, so the basement seems like the perfect place to run to. One major goal of therapy, Brustein said, “is to observe ourselves from the outside.”
Therapists, like the anonymous narrator of Project Personality, aim to send a message: Your story isn’t over till it’s over. Your character’s plot is still unfolding; there’s still time to escape. Sometimes, it can take hours and hours on a therapist’s couch to understand that. Maybe, just maybe, it could start to take less.