Friday, July 03, 2009

Is CBT Worthless?

According to a new meta-analysis in Psychological Medicine (Lynch et al., 2009), Cognitive Behavioral Therapy (CBT) is not helpful for those with schizophrenia and bipolar disorder, and any improvements seen in major depression are rather small:
Conclusions: CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates. It is effective in major depression but the size of the effect is small in treatment studies. On present evidence CBT is not an effective treatment strategy for prevention of relapse in bipolar disorder.
CBT is a form of psychotherapy that attempts to change the patient's unhealthy thoughts and actions. The patient learns to identify distorted thought patterns and beliefs, and to replace them with more productive ways of thinking and acting. Frequently the treatment is very brief, and also "highly structured, problem orientated and prescriptive, and individuals are active collaborators." The short duration of 5-20 weeks in most cases is appealing to insurance companies. Previous studies have endorsed CBT as one of the most effective treatments for major depression and many other disorders (see this review of CBT meta-analyses by Butler et al., 2006). Recommendations for CBT primarily as an adjunct treatment in schizophrenia are fewer, and have been more common in the UK (Rosack, 2002) than in Canada and the US (but see Rector & Beck, 2002). CBT may have beneficial effects during the depressive phase of bipolar disorder, but previous studies have been variable and inconclusive (Miklowitz & Scott, 2009).

Lately we've been treated to a plethora of articles and press releases saying that antidepressants are worthless and no better than placebo. The present meta-analysis by Lynch et al. (2009) came to the same conclusion about CBT in schizophrenia, and ratcheted down its effectiveness in major depression. The press release is quite blunt:
Cognitive Therapy Is Of No Value In Schizophrenia, Analysis Of Studies Suggests

ScienceDaily (June 26, 2009) — Research co-led by an academic at the University of Hertfordshire, concludes that cognitive behavioural therapy (CBT) is of no value in schizophrenia and has limited effect on depression.

. . .

The results of the review suggest that not only is CBT ineffective in treating schizophrenia and in preventing relapse, it is also ineffective in preventing relapses in bipolar disorder.

The review also suggests that CBT has only a weak effect in treating depression, but it has a greater effect in preventing relapses in this disorder.
The meta-analysis included studies examining the effectiveness of CBT against symptoms in schizophrenia and depression, and in reducing relapse in schizophrenia, depression, and bipolar disorder. Rigorous criteria were used when selecting only well-conducted clinical trials of CBT for inclusion:
The studies were required to use a control intervention that the study investigators either explicitly considered not to have specific therapeutic effects or which might reasonably be regarded as lacking these (e.g. supportive therapy, psycho-education, relaxation). We also included studies comparing CBT to pill placebo (which have only been carried out in major depression). Blindness of evaluations was not specified as a requirement for inclusion, but was examined as a moderator variable. In keeping with the general approach of meta-analysing methodologically rigorous trials, we did not include studies with small sample sizes (less than 10 participants in either group) or studies that were identified by the authors as pilot studies.
Lynch et al. provided a list of excluded studies in their Supplementary Materials, and I imagine there will be much debate in the field over the inclusion and exclusion criteria. The authors end on a cautionary note:
The authors of meta-analyses of CBT for depression seem unperturbed by the fact that they are basing their conclusions on studies that have often been carried out against TAU [treatment as usual] or a waiting list control; that have not always been randomized; that sometimes failed to use diagnostic criteria; and that so far have ignored the moderating effect of blindness altogether. These issues are not trivial; the findings of our meta-analysis could be viewed as an object lesson on the importance of taking such sources of bias into account.

Butler AC, Chapman JE, Forman EM, Beck AT. (2006). The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev. 26:17-31.

Lynch, D., Laws, K., & McKenna, P. (2009). Cognitive behavioural therapy for major psychiatric disorder: does it really work? A meta-analytical review of well-controlled trials. Psychological Medicine DOI: 10.1017/S003329170900590X.

Miklowitz DJ, Scott J. (2009). Psychosocial treatments for bipolar disorder: cost-effectiveness, mediating mechanisms, and future directions. Bipolar Disord. 11 Suppl 2:110-22.

Rector NA, Beck AT. (2002). A clinical review of cognitive therapy for schizophrenia. Curr Psychiatry Rep. 4:284-92.

Rosack J (2002). Psychiatrists Assess CBT As Schizophrenia Treatment. Psychiatric News 37:18

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At July 03, 2009 6:58 PM, Anonymous GMBC said...

its cool to read about this stuff

At July 04, 2009 9:16 AM, Blogger Anna said...

I have major depressive disorder - CBT has been effective for me in keeping myself stable, but I require medication to be able to think and function well enough to use the CBT techniques my therapist has taught me. I definitely think it is a useful therapy, but no replacement for medication.

At July 04, 2009 8:22 PM, Blogger The Neurocritic said...

Anna - Most would agree with you that the combination of antidepressants + psychotherapy for major depression is better than either alone. The Treatment for Adolescents With Depression Study, for example, was a randomized control trial with 327 patients:

"Rates of response were 73% for combination therapy, 62% for fluoxetine therapy, and 48% for CBT at week 12; 85% for combination therapy, 69% for fluoxetine therapy, and 65% for CBT at week 18; and 86% for combination therapy, 81% for fluoxetine therapy, and 81% for CBT at week 36."

At July 06, 2009 2:41 AM, Anonymous Anonymous said...

I was first treated for depression in 1991 - and even then, my GP advised me that CBT + AD's were more effective than either treatment alone.
Good to read about the need for more rigorous study - there can be a tendency for complacency when a treatment like CBT (which has been around for a while now) is studied. I hope much more rigorous metholody can be used - of course, CBT research is nowhere near as readily funded as pharmacological studies. At least, that's the situation I find in pain management...

At July 07, 2009 11:00 AM, Blogger Dr. Matthew said...

A number of publications are currently in the works both responding and reanalyzing this article, according to the listserv of the Association of Behavioral and Cognitive Therapists (ABCT). I think it's premature, without adequate chance to examine the source articles more fully and carefully scrutinize the decisions that went into the studies selected. For example, it's clear from the chart of effect sizes that CBTs strongest effects in treating depression were when compared with pill placebos. Given some of the recent publications on the limitations and exaggerated claims of pharmacotherapy, this is an important finding.

Eyeballing the articles selected, however, indicates that the results may be skewed by glossing over differences in severity. For example, while the Teasdale et al. MBCT intervention yielded a relatively weak treatment effect overall, subsequent analyses and ongoing research appear to support a much higher effect size among those with 3+ incidents of major depression - as a result, as an intervention it is only recommended currently as effective for those with recurrent depressive episodes, not 1-2. Similarly, despite dismantling studies indicating that behavioral activation is possibly the primary effective ingredient in CBT for depression, the studies for all disorders appear to be biased away from more behavioral interventions, and toward those that self-label explicitly as just cognitive behavior therapies, or cognitive therapies, from a Beckian approach. For example, despite being deeply grounded in CBT and Behavioral theory and training programs, there's no mention of McCullough's pioneering CBASP approach toward treating chronic depression, etc.

I suspect that the core of some of the printed rebuttals will be along these lines; the definition of what met Lynch et al's criteria as a cognitive behavior therapy is much more rigid, and much more narrow, than even exists within the realm of manualized therapies, and more limited than what most active cognitive behavior therapists would consider CBT. Add in the lumping together of well monitored clinical trials with community clinic studies (like Scott et al, 1992) that simply rely on self-labeling by therapists to determine the style of therapy, and it's tough to see this as the final word.

At July 09, 2009 2:04 AM, Blogger The Neurocritic said...

Thanks for your comments, Dr. Matthew. I'm definitely not an expert in this area. It's interesting that several rebuttals are in preparation already. This seems reminiscent of the "Voodoo Correlation" controversy in fMRI research, in which a critical paper explained how people have been analyzing their data incorrectly, and the criticized parties quickly released rebuttals defending their practices and in turn slamming the original authors.

At July 10, 2009 8:33 AM, Anonymous Mark Davis said...

It's strange that they would consider psycho-education and relaxation to be psychological placebo's. Anxiety is co-morbid with depression 80% of the time, so a relaxation protocol may have some benefits. Psycho-education is core to the CBT model. The client develops a working model of their mind - and in doing so learns how they are distressing themselves. The problem is that good therapists will take a multi-modal approach and bespoke the treatment plan - manualised treatments are excellent for research but will generally lower effectiveness.

At July 10, 2009 1:08 PM, Blogger Professor Keith R Laws said...

Re the point made by Mark, the use of relaxation and psycho-education as control conditions seems to be clearly explained in the paper. It revolves around Lynch et al examining effects that seem *specific* to CBT -
Indeed, Lynch et al state that these are conditions that "the study investigators either explicitly considered not to have specific therapeutic effects or
which might reasonably be regarded as lacking these (e.g. supportive therapy, psycho-education, relaxation).
So, they are using the original authors' own descriptions of 'control'

At July 14, 2009 3:24 PM, Anonymous Anonymous said...

Initial (biased!) reaction: nice to see some sand getting into the gears of the CBT juggernaut.

At July 16, 2009 3:52 PM, Blogger Unknown said...

CBT is and can be helpful to a number of people suffering from a variety of different disorders but it is not effective straight across the board. Of course it tends to be the most common form of therapy out there so I would imagine that plays into its reputation

At July 21, 2009 10:33 PM, Blogger Roman said...

That's an overly sensationalistic post title. The article isn't about CBT being worthless. It's about CBT being worthless for schizophrenia and maybe bipolar disorder, and useful for preventing relapses in depression. That's a bit of a difference.

At July 28, 2009 9:46 AM, Anonymous good ole bobm said...

maybe we need to understand what schizophrenia truly is before we go off and find a hammer to nail it down into the ground. One problem I see with respect to depression or OCD or anything else is that humans are the only animal in nature that learn from extreme masochistic behavior. Personally why is the big deal? let them destroy themselves and clear the way for people who prefer to learn based on the will to perform instead of being tasked into performing. Same thing with drug addiction or alcoholism. Self destructive behavior at its finest. Furthermore, twitter, facebook, blogs and all the other "social media" environments are perfect for supporting this narcissistic attention deficit disorder compulsive behavior. A match made in heaven. On that note I would strongly recommend reading "Of Mind and the Brain." a great tome of the treatise of neuroplasticity. K

At July 28, 2009 1:08 PM, Anonymous Anonymous said...

CBT is the most effective therapy?? Wrong: they promote themselves as the best therapy. Other schools (psychodynamics, experiëntial psychotherapy) have also a lot of studies in which they show they are at least as good, or sometimes even better dan CBT. But, they don't have, like CBT (for example) 10.000 studies to show that, but (for example) 1000 studies to show it. So conclusion of the cognitive psychologists: CBT is superior! And that's the myth of CBT: they have MORE studies, so they're superior... A bias of thinking! I thought CBT therapists were specialists in detecting biases?
CBT is not better than the other schools, but now everybody must have CBT, otherwise you're wrong... Even people who would be better with the other forms of psychotherapy, now are pushed into the hungry arms of a CBT specialist. So it's time that CBT sees here real place: they are not superior! And that CBT recognises the value of the other forms of psychotherapy too. It's also really shocking to see how many psychologists really believe that depression can be solved (forever!) with 15 sessions of CBT... Why? Because they learned that depression is easy to treat... with CBT of course! CBT treats depression in 15 sessions! Yeah, but +/- 50-60% of the people who had one (!) episode of depression and who had been treated with CBT, have a new episode within 2 years! The numbers are even more shocking if one had more episodes of depression. So I don't see that as 'highly treatable'!
It's time again (!!) for the dodo bird effect: they are all equal! Or, like the study of Lambert: the technique (like CBT) is only important for 15%, the relation with the client is important for 30% of the effectivity of the therapy. It's time to stop to connect effectivity ONLY on 'how many costs the therapy'. And CBT is indeed superior in the costs: they 'cure' depression in 15 sessions, can you imagine that??? Other forms of psychotherapy need much more sessions AND they don't claim that they can 'cure' depression in 15 sessions. No, these other forms are really trying to change the personality, not only the symptoms like CBT does (and in which they don't succeed!). And a person has not been changed in 15 sessions! Another thing that CBT needs to consider is emotion or feelings... I wonder when they will be able to see that they have to work on feelings too, not only by cognition (the ratio). They can learn a lot from the experiëntial psychotherapy on how they can deal with emotions. Oww... whoops, I forgot that CBT is superior to the experiential psychotherapy so CBT can't learn a thing of that form of psychotherapy... And now they claim MBCT... That's a joke too: there is nothing cognitive on Mindfulness! But they quickly changed the name into ... based cognitive therapy, so it can be seen as a cognitive therapy too. MBCT is more similar to Focusing (experiëntial, yep, again) and to other elements of other therapies, than to CBT. Nevertheless it's okay for CBT to use the elements of other forms of therapy, I totally agree om that!!! But it would be nice then if CBT admits that the other therapies are at least as good as they are (or even better for some people)!

At August 08, 2009 4:44 AM, Anonymous Ganymede6642 said...

With regard to Anonymous's comments, perhaps CBT is best seen as a set of techniques that should be integrated within the 'Common Factors' approach to psychotherapy and not as a separate approach in its own right.

At August 13, 2009 8:46 AM, Blogger Jeremy Trombley said...

Going back to Dr. Matthew's comment. I've undergone therapy a few times for anxiety disorder. The first time was with a psychologist who used CBT, had me doing the various exercises, etc. It worked great. I moved, lapsed on doing the exercises and had a relapse. My next two therapists claimed to use CBT, but it turned out to be more talk therapy, and it did nothing for me (might have even made me worse). If this study utilized self-labeling by therapists, then I seriously doubt it's validity. I'm not sure that CBT is the best therapy out there or if it's better than drugs, but I know it worked for me, when it was done right.

At August 21, 2009 11:45 AM, Anonymous Anonymous said...

By the same token, how do you know the initial therapist was using"CBT"? On what is that statement based?

At August 24, 2009 8:28 AM, Anonymous Anonymous said...

Hello, interesting subject.

To the anon poster: what is experiëntial psychotherapy? Do you mean guestalt?

At August 29, 2009 5:21 AM, Anonymous Anonymous said...

Experiëntial psychotherapy is not the same of gestalt therapy, but they are of the same family. You can find some information here:
Or here:
Experiental therapy is based on the principles of Carl Rogers (clientcentered therapy: empathy, unconditional acceptance and authenticity) and more recently, Gendlin (focusing).
You have attention for that what is happening now, for the things that are important for you, so how you think and feel about things (not how the therapist feels or thinks). Emotions are really important in experiential therapy. You learn to feel how your body gives you signals about how to live. So you learn how to feel what you're body is 'saying' to you. Saying about what is wrong, but also about what you can do to resolve the problem. Because your body takes it all: you live through your body, by thinking, by feeling, by seeing, hearing, tasting,.... So it's not alone a matter of thinking (like in CBT), but it takes the whole. And because of that, it gives you the best information you can get. That's the basis of focusing.

At October 10, 2009 1:33 AM, Blogger Unknown said...

cbt i believe is not affective in severe depression or schizoprhenia or manic depressive psychosis it may help milder forms of depression or some anxiety disorders personally i think it is over rated and can sometimes make people even worse

At February 08, 2011 5:51 AM, Anonymous Anonymous said...

Why is CBT often refered to as if it was one person? e.g. "And that CBT recognises the value of the other forms of psychotherapy too" Why don't you invite cbt for lunch and ask her/him? Is it not better to se CBT as a method carried out by probably thousands of people with different oppinion and attitudes insted of lumping them all together and ascribing them oppinions that is easy to refute. Just a thought...

At October 24, 2011 10:24 AM, Anonymous Anonymous said...

CBT is less a therapeutic model and more a set of techniques which can help some people manage some of their symptoms, some of the time.

The trouble is that it is sold as a 'cure-all' and has far better marketing than other models of therapy.

It is also attractive to policy makers because it concentrates on re-educating people to get them off incapacity benefits and being econmically viable citizens ASAP.

It's evidence base is flimsy, even by the standards of psychotherapy - but it is an easy sell to accountants. Trouble is, the problems don't get sorted, just glossed over for a bit and the person is soon suffering again - but by then they're removed from the waiting list so what's the problem?

Well - the problem is that this is inhumane, not to mention a false economy as you have to treat them several times over to get no net progress. But by then another government is in power and it is all someone else's vote winner/loser.

Talk to a Psychologits trained in more than one modalioity and see how many of them use CBT. Very few, other than drawing on it to bolster their skill set. Why? Because there are much more potent approaches which get permanent results.

At March 05, 2012 5:57 PM, Anonymous Anonymous said...

CBT is a slick, quick fix which is why insurance companies love it. My own experience of it is that it did me no good; in some ways it left me worse off, because I came away thinking, "He's telling me that my problems are my own fault. There's another example of something in my life that I can't do correctly. If only I could find the perfect way to think, I'd have no problems at all." What rubbish.

I do not wish to be treated like a trained monkey. I don't want to keep mood diaries, or to keep a catalogue of my "errors in thinking." And please don't tell me to be "mindfull." The many traditions of Buddhism are thousands of years old. One must commit oneself to years of training under the direction of a teacher to realize the benefits (even though Buddhism says you should practice with no thought of achievement.) For CBT to take the concept of mindfullness out of context and present it as something that anyone can do if he only tries hard enough does both the client and the tradition a great disservice.

None of the approaches I learned from CBT has helped me gain insight into who I am and why I do the things I do. (Yes, I am familiar with the Buddhist teaching that there is no self.) I feel no better. If anything, I feel worse because now I feel resentment toward the therapist who gave me a thimble of Kool-Aid when I had great thirst, and a slice of Wonder Bread when I was exceedingly hungry.

I want empathy, insight, and most of all guidance. I don't want my therapist to tell me to buy a book and start having the correct kind of thoughts.

I went into therapy with my mind open, trusting that I would find the help I needed. I am quite cynical about the process now.

At March 08, 2012 8:54 PM, Blogger roxyb03 said...

@anon. Thank you for speaking out against the CBT hype.

At May 08, 2012 11:59 PM, Anonymous Steve Harold said...

Any process that enables us to change the thinking that has led to depression can be helpful. The age old question is which process is more effective, CBT or ....

Some research has shown that there is only a small percentage difference in the efficacy of different psychotherapeutic approaches. One of the main factors that reduces or resolves an issue is the patient and therapist relationship.

At August 27, 2012 5:33 PM, Anonymous Anonymous said...

Thanks for bringing this issue to light (though I've discovered it a little late :-).

I have been to half a dozen different therapists in the space of three years, within both the public system and private practices here in Australia. Every single one of them classified themselves as a CBT therapist, and used it exclusively.I stuck with the therapy every time, and tried to put in a really good effort to give it the best chance to do something for me.

The result? Not a single one of those therapists gave me any effective treatment. I have been diagnosed with major depression and, more recently, post-traumatic stress disorder (long-term) and I have been on almost every kind of anti-depressant drug available. None of these did anything much either, by the way (except for the unwanted side effects).

But it is the ultimate let down to have doctors constantly trying to recommend that you do more therapy, and referring you to many different therapists,only to have the same outcome again and again, because they're all just offering you the same shallow, narrow- minded, quick fix treatment.
These therapists did not want to discuss any issues or problems in any kind of detail to work through them, they wanted to skirt around the worst things altogether and focus on treating me by setting goals based on more minor and practical problems. They seemed to want to dismiss emotions altogether, by overriding them with shallow "thought-based" therapy that didn't actually resolve or even reduce any underlying issues at all.

This kind of therapy could be very effective for people suffering from more simple issues (eg. a phobia of needles or public speaking), or for people trying to simply increase their chances of reaching a clear life goal (eg. losing weight). On the other hand, it is definitely overrated for more complex and persistent issues.

As an intelligent, self-aware and deep-thinking individual I felt patronised and insulted in my sessions with these therapists. They told me nothing new, nothing I hadn't thought of, tried and experimented with already myself. They also treated me like an ignorant child and promised things they never delivered on.
I am now studing psychology myself, and have no interest in joining the already swelling ranks of CBT therapists around the world. Surely there is more to offer than a cheap and nasty band aid treatment.

At February 08, 2013 1:39 AM, Anonymous Gerald Bouthner said...

It is more generally accepted that CBT is most effective in helping a person with schizophrenia when used IN COMBINATION with drug therapy.

At February 26, 2013 11:40 AM, Anonymous Anonymous said...

CBT for schizophrenia? That would be funny if it wasn't so unspeakably grotesque.

People in the grip of psychosis need containment, often concrete, and professionals able to receive/hold their immensely powerful projections, process them and feed them back in a manageable form.

You do not contain overwhelming affect and ejected self states or with some inane guff about 'wrong thinking'.

Likewise - the 'mindfulness' shtick won't wash. When your sense of self is in freefall you're not very well placed for 'being in the now', you know? It's the terror of ceasing to 'be' that rather puts a crimp in things.

To work with such patients and not understand or know what to do with powerful unconscious processes is wholly unethical and can be very dangerous for both parties.

Then there's the small matter of personal therapy and personal development during training - often not mandatory in CBT trainings...

CBT? We've been sold a pup. It's symptom management to massage the unemployment figures.

At June 17, 2013 9:11 PM, Anonymous Cindy said...

Exactly. Effective or not, CBT therapy is being rolled out in bulk in schools across the world, group sessions are conducted on mass, even if children show no signs of anxiety or depression. Why does the WHO think pre-treating all children for psychological problems is appropriate? See this program rolled out to 500,000 children already across the world


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