How effective is Cognitive Therapy and Cognitive Behavioural Psychotherapy?
A brief review of five pieces of evidence, by Dr Jim Byrne, November 2018
A 2013 study using therapy trainees in Sweden suggested that CBT was an effective form of treatment… https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3888554/
However, we know from the Common Factors approach, that all systems of counselling and therapy that are tested against each other prove to be about equally effective! So, ‘being effective’ does not mean ‘being better than other therapies’. (Source: Wampold, 2001, etc.).
Indeed, the government of Sweden, having invested heavily in training people to deliver CBT, and investing heavily in making CBT available to all of their citizens, to prevent people retiring from the labour force with anxiety and depression, have found that, after investing three billion crowns (or £255 million British Pounds) in this CBT project, that it made no positive contribution whatsoever to reducing their national problem of anxiety and depression. (See the article that follows):
Revolution in Swedish Mental Health Practice: The Cognitive Behavioural Therapy Monopoly Gives Way
Sunday, May 13th, 2012
Arlanda Airport, Sweden
Over the last decade, Sweden, like most Western countries, embraced the call for “evidence-based practice.” Socialstyrelsen, the country’s National Board of Health and Welfare, developed and disseminated a set of guidelines (“riktlinger”) for mental health practice. Topping the list of methods was, not surprisingly, cognitive-behavioural therapy.
The Swedish State took the list seriously, restricting payment for training of clinicians and treatment of clients to cognitive behavioural methods. In the last three years, a billion Swedish crowns were spent on training clinicians in CBT. Another billion was spent on providing CBT to people with diagnoses of depression and anxiety. No funding was provided for training or treatment in other methods.
The State’s motives were pure: use the best methods to decrease the number of people who become disabled as result of depression and anxiety. Like other countries, the percentage of people in Sweden who exit the work force and draw disability pensions has increased dramatically. As a result, costs skyrocketed. Even more troubling, far too many became permanently disabled.
The solution? Identify methods which have scientific support, or what some called, “evidence-based practice.” The result? Despite substantial evidence that all methods work equally well, CBT became the treatment of choice throughout the country. In point of fact, CBT became the only choice.
As noted above, Sweden is not alone in embracing practice guidelines. The U.K. and U.S. have charted similar paths, as have many professional organizations. Indeed, the American Psychological Association (APA) has now resurrected its plan to develop and disseminate a series of guidelines advocating specific treatments for specific disorders. Earlier efforts by Division 12 (“Clinical Psychology”) met with resistance from the general membership as well as scientists who pointed to the lack of evidence for differential effectiveness among treatment approaches.
Perhaps APA and other countries can learn from Sweden’s experience. The latest issue of Socionomen, the official journal for Swedish social workers, reported the results of the government’s two billion Swedish crown investment in CBT. The widespread adoption of the method has had no effect whatsoever on the outcome of people disabled by depression and anxiety. Moreover, a significant number of people who were not disabled at the time they were treated with CBT became disabled, costing the government an additional one billion Swedish crowns. Finally, nearly a quarter of those who started treatment, dropped out, costing an additional 340 million!
In sum, billions (of crowns were spent) training therapists in and treating clients with CBT to little or no effect.
Since the publication of Escape from Babel in 1995, my colleagues and I at the International Center for Clinical Excellence have gathered, summarized, published, and taught about research documenting little or no difference in outcome between treatment approaches. All approaches worked about equally well, we argued, suggesting that efforts to identify specific approaches for specific psychiatric diagnoses were a waste of precious time and resources. We made the same argument, citing volumes of research in two editions of The Heart and Soul of Change.
Yesterday, I presented at Psykoterapi Mässan, the country’s largest free-standing mental health conference. As I have on previous visits, I talked about “what works” in behavioural health, highlighting data documenting that the focus of care should shift away from treatment model and technique, focusing instead on tailoring services to the individual client via ongoing measurement and feedback. My colleague and co-author, Bruce Wampold had been in the country a month or so before singing the same tune.
One thing about Sweden: the country takes data seriously. As I sat down this morning to eat breakfast at the home of my long-time Swedish friend, Gunnar Lindfeldt, the newscaster announced on the radio that Socialstyrelsen had officially decided to end the CBT monopoly (listen here). The experiment had failed. To be helped, people must have a choice.
“What have we learned?” Rolf Holmqvist asks in Socionomen, “Treatment works…at the same time, we have the possibility of exploring…new perspectives. First, getting feedback during treatment…taking direction from the patient at every session while also tracking progress and the development of the therapeutic relationship!”
“Precis,” (‘Exactly’) my friend Gunnar said.
And, as readers of my blog know, using the best evidence, informed by clients’ preferences and ongoing monitoring of progress and alliance is evidence-based practice. How … the concept ever got translated into creating lists of preferred treatment is anyone’s guess and, now, unimportant. Time to move forward. The challenge ahead is helping practitioners learn to integrate client feedback into care—and here, Sweden is leading the way.
… End of blog text.
Moving forward to 2018, we now find a report of a study, conducted in the University of Connecticut, School of Medicine, which is headlined: Antidepressants and cognitive therapy aren’t working. This is it:
Antidepressants and cognitive therapy aren’t working
This is a news item, which describes a follow-up study published in the Journal of American Academy of Child and Adolescent Psychiatry, 2018, Vol.57, pages 471-480. The item begins like this:
‘Proven treatments for chronic depression and anxiety in teens – such as SSRI antidepressants and cognitive behavioural therapy (CBT) – don’t actually work, a follow up study has established.
(And if they don’t work in teens, we have no good reason to believe they work for anyone else! JWB).
‘Although the therapies appeared to be effective at the time (when they were ‘administered’), most of the teenagers who were treated relapsed within a few years. Just 22 percent were still free from their anxiety or depression six years later, researchers discovered.
(That is no better than a placebo – or sugar pill – and probably a lot worse! JWB).
‘They checked on the progress of 319 teenagers who had been treated for three months with the SSRI antidepressant Sertraline ([also known as] Zoloft and Lustral), CBT, or both. These are established treatments for anxiety and depression – “the best treatments we have”, according to lead author Dr Golda Ginsburg of the University of Connecticut’s School of Medicine.
‘And yet, at least four years later, when the teenagers were an average of 17 years old, 30 percent of the group were still chronically ill, and 48 percent had initially improved after treatment and then relapsed, leaving just 22 percent of the group that were free of anxiety or depression.
(So the CBT/drugs treatments were unsuccessful in 78% of cases! JWB).
‘The teenagers given the drug didn’t fare any better – or worse – than those who had the therapy, the researchers found.
(So the drugs and the CBT are equally ineffective! JWB).
‘Assessing the difference between those who remained free of anxiety or depression and those who relapsed, the researchers said other factors that played a part included strong family support and the number of “negative life events” they had experienced.
(So, this shows that the environment is much more powerful than any short-term attempt to change beliefs or thoughts! And these kinds of environmental factors are also more potent than the psychiatric drug in this test! JWB)
‘But with those problems (of depression and anxiety – JWB) affecting around 10 percent of young people, it’s very concerning that medicine doesn’t have any effective response, the researchers said.’
(This means that neither CBT nor psychiatric drugs are doing the jobs they claim to do. Which is why we’ve developed Lifestyle Counselling, which looks at all the factors that affect the client’s body-brain-mind, and coach them to change their lifestyle to support their physical and mental functioning! JWB)
Source: Drug News, on page 17 of the October 2018 edition of What Doctors Don’t Tell You. Commenting upon the Journal of American Academy of Child and Adolescent Psychiatry, 2018, Vol.57, pages 471-480.
And here’s an extract from a blog by Psychotherapy Networker:
“…recent findings about the effectiveness of CBT have made waves among psychotherapy outcome researchers. A 2013 meta-analysis published in Clinical Psychology Review comparing CBT to other therapies reported that it had failed to ‘provide corroborative evidence for the conjecture that CBT is superior to bona fide non-CBT treatments.’ In November 2014, an 8-week clinical study conducted by Sweden’s Lund University concluded that CBT was no more effective than mindfulness-based therapy for those suffering from depression and anxiety.”
Postscript 2: REBT is so flawed that it is unfit for therapeutic purposes
And finally, I (Jim Byrne) was a keen fan of the original system of CBT – which is called Rational Emotive Behaviour Therapy (REBT) – but I have found so many flaws in the system, contained in the writings of Dr Albert Ellis, that I have abandoned CBT/REBT, and developed my own system of Emotive-Cognitive Embodied-Narrative Therapy (E-CENT), which takes account of the strengths of many systems of self-care based on our (human) existence as body-brain-mind-environment complexities.
See my book, REBT: Unfit for Therapeutic Purposes.***
See also my E-CENT Books Page.***
 Wampold, B.E. (2001) The Great Psychotherapy Debate: Model, methods, and findings. Mahwah, NJ: Lawrence Erlbaum. And:
Messer, S. and Wampold, B. (2002) Let’s face facts: Common factors are more potent than specific therapy ingredients. Clinical Psychology: Science and Practice. 9: 21-25. And:
Duncan, B.L. and Scott D. Miller (2009) The Heart and Soul of Change: Delivering What Works in Therapy. Washington, DC: American Psychological Association.
Postscript 3: An extract from an article in Aeon Magazine (online):
Do antidepressants work?
Depression is a very complex disorder and we simply have no good evidence that antidepressants help sufferers to improve
“Your grief and guilt overwhelm you. You are so tired you cannot think straight. Your simple joys are lost in an invisible agony. You have pain in your head and back and stomach, real pain. The swamp of your soul suffocates you with despair. All this is your fault, you are worthless, and you might as well die. This is how depression can feel, though people’s experiences of it, including the severity of symptoms, can vary widely. This terrible disease affects about one person in 10 at some point in life and, to treat it, many millions of people have taken antidepressants. Unfortunately, we now have good reasons to think that antidepressants are not effective.
“To know if antidepressants work we must, of course, pay close attention to the best evidence about these drugs. There have been many empirical trials of antidepressants, and in the past 10 years or so there have been some good meta-analyses of these trials (a meta-analysis pools data from multiple trials into a single analysis). However, there is a problem: experts disagree about the merits and problems of these empirical studies, and about what we should conclude based on them. Philosophy can help. Philosophy of science is the discipline that studies the concepts and methods of science, and offers a lens through which we can understand what scientific evidence shows us about the world. After witnessing the darkness of depression and the struggle by some of my dearest friends and family to treat this disease with drugs, I began to use my training as a philosopher to understand the evidence about antidepressants. Diving into the details of how antidepressant data are generated, analysed and reported tells us that these drugs are barely effective, if at all. …”
…End of extract. For more, please click the following link: The flawed evidence about antidepressants.***