There is no doubt that having ways to cope with depression and anxiety is important for recovery, but does having good (or bad) ways of coping (i.e. coping mechanisms) at the beginning of therapy help patients improve? Based on my current research project, I don’t think so.
Coping mechanisms are essentially how we change the way we behave or think in order to minimise the psychological effects of this stress (Lazarus & Folkman, 1984). Some mechanisms are good – that lift us out of distress, and some are bad – that we get more distressed as we engage in them. Generally speaking, when we try to approach the stressor, solve problems or deal with the emotions caused by the stressor, it’s good. But when we avoid the stressor, it’s bad. Here are a list of coping mechanisms which researchers have a consensus on whether they’re good or not:
One way that psychological therapy helps with depression and anxiety is by helping patients develop adaptive coping mechanisms and discourage maladaptive ones. For example, the low-intensity variant of CBT, or “guided self-help”, consists of therapists going through a self-help booklet (see this as an example) with the patient with a wide array of skills which help a patient cope with a problem. Studies suggested that if patients use less maladaptive coping mechanisms (e.g. avoidance) and use more adaptive coping mechanisms (e.g. problem-solving) during a course of therapy, their depressive symptoms are reduced.
If patients can learn coping mechanisms through guided self-help, their coping mechanisms before therapy might be just as relevant. Take a patient who has lots of maladaptive coping mechanisms (or has fewer adaptive coping mechanisms) before therapy as an example. During therapy, they might learn that their coping mechanisms don’t work and they have to take up new ones to cope, thus they have better recovery compared to those who already have adaptive coping mechanisms. These two studies (this and that) found that the use of problem-solving before treatment is negatively related to recovery from depression. However, a more recent study did not find this relationship. These studies are limited in that they use relatively small sample sizes (the most being 126). They are also subject to selection biases. Patients have to opt in to do the research. And studies suggest that people who opt in clinical research are different from those who don’t, which may bias the results of the study.
Therefore, I investigated this question using electronic health data from NHS Talking Therapies. This dataset includes all patients who went through guided self-help from 2021 to 2022 – maximising the sample size and reducing the possible selection bias. This dataset also had the symptom severity measures commonly used in psychotherapy practice, namely the Patient Health Questionnaire-9 (PHQ-9) scores for depression and Generalised Anxiety Disorder-7 (GAD-7) scores for anxiety before and after treatment. I also made use of the pre-treatment coping mechanisms that patients reported during the assessment (and at the first treatment session), categorised them into adaptive and maladaptive ones, and tallied them up. Moreover, the dataset contains data which can reliably affect improvement (i.e. patient variables) such as age, gender, ethnicity, treatment medium (telephone, video call or face-to-face), and even whether the patient needs an interpreter for treatment and how many sessions they missed. This makes the dataset perfect to answer this research question.
Running statistics on the dataset, I first established the association between depression and anxiety symptom improvement and age, gender, ethnicity and the like, separately, and then added the number of adaptive and maladaptive coping mechanisms separately into the equation to see if they make that association stronger. I used both raw score improvements and clinically relevant recovery and improvement metrics for symptom improvement.
I didn’t find any improvements in associations for all improvement metrics.
There are at least two ways of seeing that result: either pre-treatment coping mechanisms are not important in determining treatment improvement at all, or there are ways for people with predominantly adaptive or maladaptive coping mechanisms to improve during therapy. I believed in the second explanation for the following reasons:
- We were not able to investigate whether patients picked up new coping mechanisms during therapy, but research suggests that they are what directly affect their recovery. The dataset doesn’t have that information, and collecting that information risks some patients not consenting, creating selection biases that I mentioned before.
- The therapist’s role in therapy can be manifold: they can encourage patients to engage in adaptive coping mechanisms as well as suggest adaptive alternatives to their maladaptive coping mechanisms.
This research teaches us that coping mechanisms before therapy have a minimal effect on whether or how much their depressive and anxiety symptoms improve. This is good news because CBT is good for patients with all sorts of coping mechanisms. However, whether they improve would likely depend on what happens within the therapy, such as whether they picked up adaptive coping mechanisms and whether the therapist can build rapport with the patient. If some patients have doubts about whether CBT is useful for them because they are already coping well, why not give it a go anyway?
If you are thinking about getting guided self-help or CBT, this is good news for you too – CBT is suitable for you regardless of how well you cope right now. In addition, you can pick up new coping mechanisms during therapy, which helps you cope better with whatever you are facing.
A lot of research attention is currently put into what types of people would benefit from certain types of psychotherapy. I understand the importance, but my research suggests that this should not be the priority. We should research more into how improvement happens in psychotherapy, especially in CBT. The field is still in its infancy, but once we understand that more, we can hopefully see more people reaping benefits from our existing evidence-based therapies.
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