A recent study (Johnsen, Tom J.; Friborg, Oddgei 2015) titled The Effects of Cognitive Behavioral Therapy as an Anti-Depressive Treatment is Falling: A Meta-Analysis indicating that over the years studies on CBT for depression are showing progressively poorer results should come as no surprise to anyone who actively works with real people. The findings should be a red flag to the mental health industry, as one would logically think that as a therapy becomes more developed with more expertly trained therapists that the efficacy should improve and not decline. There is a saying among psychiatrists in regard to new medications on the market that one should start using them quickly before they stop working. This clearly speaks to both the enhanced placebo effects of new treatments as well as possibly the sense that repeated studies will with time show the limitations of these treatments. This saying now seems to apply to CBT as well.
Cognitive Behaviour Therapy has been highly promoted by the pharmaceutical and mental health industry as it fits well with the needs of these industries despite evidence that has always been present that it is less effective than more humanistic or emotionally based therapies. Now there is clear evidence that is nothing more than an enhanced placebo. So why is CBT a fraud? Very simply, CBT was developed to take advantage of many natural limitations and biases in psychotherapy research. Psychotherapy research has tended to be difficult to do, as in order to quantitative research on any treatment one has to standardize the treatment and simplify outcome measures. The therapy needs to be structured so that all the therapists are doing exactly the same thing, and ensure that the primary aspect of therapy that one is testing is being consistently used. For all emotionally based therapies this essentially means that one has to dumb down the therapy. For example, if one is testing a psychoanalytically based short-term therapy, all the therapists have to make regular transference interpretations, regardless of whether this makes therapeutic sense. Interpersonal Psychotherapy (IPT) which is an empirically validated psychotherapy, is one of the best known dumbed down psychodynamic therapies. Pretty much all psychotherapies that have been studied, unless one looks at naturalistic studies, are on standardized or manualized approaches, except for CBT, which is highly structured to begin with. Advanced form of schema therapy, which is in the hands of an empathetic therapist is very similar to traditional therapy may be an exception. So in most studies,s one is comparing a therapy that is actually practiced as is (CBT) to dumbed down forms of more complex therapies. Yet research has consistently shown no difference between these therapies. CBT has never been shown to be superior to other researched therapies. It has just been shown to be better than placebos.
What are the biases and limitations in psychotherapy research? As explained above, one can not just let expert therapists do what they normally do in standard quantitative research, though more qualitative “super shrink” research is attempting to analyze the practices of really good therapists. There is also significant selection bias and limitations in the populations studied. Most research eliminates potential subjects with co-morbid conditions. As any seasoned practitioner knows, very few patients ft cleanly into one diagnostic category, yet studies are almost always restricted to these type of cases. As more complex problems tend to show worse results, especially with mono-modal treatment, it is difficult to apply the results of any research to actual clinical populations. A major limitation and bias of psychotherapy research are the tools that are used to measure outcome. The most used tools are primary symptom based, and do not necessarily measure well-being or functioning. If one uses these tools, and focuses treatment primarily on symptom reduction, then one would predict that one would get some type of positive result. This certainly is true both of CBT and medication research, though psychotherapies that do not focus on symptom reduction, also show equally positive results. A major bias that should be in favour of CBT is the reality that CBT basically trains people to report less symptoms, while emotionally based therapies encourage people to express their feelings. It has been long recognized, and shown in research, that people will want to please their therapists and comply with expectations. If a therapist gives consistent positive feedback when patient reports less negative feelings, than a patient will with time report less negative feelings. If a therapist gives positive feedback whenever a patients expresses painful feelings than the patient will continue to express painful feelings. If one then gives these patients a tool that measures these feelings, the patient who was encouraged to report less feelings should show “better” response on this tool regardless of whether or not the person is doing better in life. This is the exact situation that occurs when comparing CBT to more emotionally based therapies, yet CBT, on these tools, does not show better results. This clearly indicates that CBT is an inferior therapy.
Psychotherapy research also closely controls the placebo condition to which therapies are compared. Clearly in psychotherapy research there are no real double blind studies. The therapists always know if they are doing a placebo or sham therapy. Thus the therapists who may be part of the control group are not going to have much belief or enthusiasm for their treatment. They are also forced to do really bad therapy, as they are restricted from using any of the modalities that are a part of the studied therapy, and are only allowed to make simplistic comments. Thus, if CBT is being compared to a “supportive” psychotherapy, the therapist doing the control therapy is only allowed to make “supportive” comments and not help the individual with real life problems or try to put together issues the control subject brings up. Basically, control psychotherapies are carried out by therapists who aren’t allowed to use most of their skills and are designed to frustrate both the therapist and the patient.
Research conditions also work against any psychotherapy that relies on the relationship between the therapist and the patient. In research models people do not choose their own therapist, but are randomly assigned to therapists, with the understanding from the beginning that seeing this therapist is a part of a research study, that the study is for a defined limited time, and that the person will have no access to the therapist following the study. Thus any aspect of real caring or connection is severely limited before the therapy even starts. The only aspect of any therapy that has ever shown a consistent correlation with outcome is “therapeutic alliance” despite the reality that the basic structure of psychotherapy research interferes with the therapist-patient relationship. The positive results in research of any therapy that relies strongly on the therapeutic relationship will be downgraded while the results therapies that rely more on teaching tools should not be as effected.
The reality of psychotherapy is that most expert psychotherapists, regardless of their orientation, spend a significant amount of time in therapy helping people work out real life problems and relationships. They do not only make interpretations, only make supportive statements, or only give techniques for controlling symptoms or negative thoughts. Working with distortions in cognitions has always been a part of most expert therapies. CBT theorists did not reinvent the wheel. They just put a manualized superficial structure together that allows research to be done easier and that should show better results in research by using to full advantage the limitations of quantitative research. While being able to promote this therapy by doing massive amounts of research for just about all mental health conditions, if one adjusts the apparent results of this body of research to take into account the distortions caused by the biases, the research shows no advantage over placebo for this so-called therapy. Of course, the systems that prefer that people just shut up about their symptoms and go away love this therapy. The pharmaceutical industry that wants to convince people that feelings are bad so that it’s okay to just numb people also naturally loves this therapy. The only patients that I’ve met who have claimed to have had significant benefit form CBT are all individuals that have bought into the mental illness model and have come to believe that they are inherently damaged so that all they can hope for is to control some symptoms. None of these people have shown emotional progress in life.
It is time that the mental health industry looks critically at psychotherapy research to be able to promote a balance view as to what actually helps real people. The need for naturalistic and proper qualitative studies is evident. Superficial quantitative studies cannot indicate what works best for any individual. The insistence in using research models with actual people has to stop. It should be understood that these models, and especially CBT, just indicate that therapy works, but does not indicate what works best, and certainly don’t indicate that research models are preferable to expert modes of treatment. True experts treat the person, not the symptoms, and do not buy into simplistic models. Good therapists care about their patients’ lives, and will always put patients’ well-being above any allegiance to theory.