Is Cognitive Behavioral Therapy the Gold Standard for Psychotherapy?

[Cheshire]

Falk Leichsenring, DSc and Christiane Steinert, PhD

For a treatment to be considered the gold standard requires that substantial supporting evidence exists. Recently, however, additional research findings have emerged that question the prominent status of CBT. In this Viewpoint, we review some of the most important findings

The authors hightlight several problematic points:
- Limited Study Quality
- Weak Empirical Tests
- Uncontrolled Researcher Allegiance
- Central Mechanisms of Change Not Corroborated
- Limited Efficacy
- No Clear Evidence of Superior Efficacy

http://sci-hub.cc/10.1001/jama.2017.13737

 

[Alvin]

This is a joke on humanity. A very sick one, and i don't mean just in the context of ME/CFS. CBT takes a mechanistic view of emotions, and its efficacy rate is dismal (as a result). You don't deal with emotions by ignoring them or recategorizing them. You deal with them by dealing with the issues they are conveying (when the patient is ready to do so, a tricky caveat). An easy lesson to not learn or forget apparently [facepalm]

 

[Adrian]

I think health services like CBT because its cheap and easy to deliver and makes them think they are doing something useful. But that does suggest that it may be less effective than a good therapist.

I suspect it is a real problem running any trials where you are basically reliant on the skills of the therapists. Though as @Alvin suggests maybe training people to just ignore or categorize emotions may not be the best approach as it avoids dealing with the real issues.

 

[Alvin]

I think health services like CBT because its cheap and easy to deliver and makes them think they are doing something useful. But that does suggest that it may be less effective than a good therapist.

I suspect it is a real problem running any trials where you are basically reliant on the skills of the therapists. Though as @Alvin suggests maybe training people to just ignore or categorize emotions may not be the best approach as it avoids dealing with the real issues.

Freud may be the father of modern psychology but he did a lot of damage by having a few good but a lot of bad theories and i think today they want to get as far away from him as possible. That said ignoring reality and treating it with CBT is like putting a band aid on a gushing wound, it won't work. That said they have invented a convenient scapegoat, it doesn't work because its biochemical, when in fact it doesnt work because its based on a stupid premise. Path dependence on a bad theory leads to a bad attempted treatment.

 

[Simone]

CBT has long been controversial within psychology. Researchers like it, because it lends itself to being studied. Professional associations like it, because it provides a medical model of psychology (identify problem, provide treatment at prescribed dose (X sessions of CBT), resolve problem), and they see the medical model as validating of the profession. Governments, of course, love it, because it offers the prospect of inexpensive, fast treatment (they also love the idea that they can cut costs even more by sending people on a short course to learn how to deliver CBT or, even better, cut out the practitioners altogether by delivering CBT online). Clinicians often don't like it, because its reductionism doesn't match the real world of clinical practise.

There has been a schism within psychology for years. Clinicians claiming that the CBT research (which tends to be focussed on a single problem, and use a manualised approach treatment) overestimates the effectiveness of CBT, because most clients don't present with one, neat problem. Researchers, on the other hand, bemoan that clinicians don't follow manualised treatments (which they don't, because a good clinician will follow where their clients lead, rather than a manual).

Those in favour of CBT will claim that research has suggested that CBT is superior to most (if not all) other treatments. Except it hasn't. Many studies have found that there are many well-developed approaches which are about the same in terms of effectiveness (which raises a bunch of other questions).

The human condition, our experiences and emotions, are complex. It never ceases to amaze me that some think that these can be "fixed" with just a few short sessions of CBT.

 

[Alvin]

CBT is basically what an android would come up to treat emotions that it can't comprehend.
Real therapy works when the clinician understands what they are doing (very rare, education today is about CBT) and when there is a good fit between counselor and client.

 

[alex3619]

Gold standard for me = methodologically sound, double blinded, randomized, placebo controlled trial, with objective outcomes.

I have not investigated CBT much, so this is a question not a conclusion - is it methodologically sound?

It is NOT double blinded.

It is NOT placebo controlled.

Typically the findings are not confirmed with objective outcome measures.

Can it be considered scientifically gold standard? No.

Could it be considered gold standard within psychopsychiatric research, much of which might be academic but is not scientific? Maybe. That however raises even more questions about psychopsychiatry.

In this context, PACE would be a Subjective Outcomes Randomized Trial, or SORT. Forgive the pun, but its only sort of science.

 

[Alvin]

Gold standard for me = methodologically sound, double blinded, randomized, placebo controlled trial, with objective outcomes.

Keep in mind you can get positive results but come to the wrong conclusion. If i take a painkiller my arthritis will hurt less but i have not treated the cause, only masked it. One could make the argument its curing it between doses (one who does not understand what a painkiller really does). The same if you bury your feelings by ignoring them or drowning them in psychotropic drugs, your curing nothing yet people who don't know better can argue you are.

 

[alex3619]

Keep in mind you can get positive results but come to the wrong conclusion.

Yes. However with a well designed study and objective measures then many of these issues are minimised. None of that fixes the issue of asking the wrong question. You can have a great study that answers the wrong question, but it will not answer the right question. To ask the right question if the problem is complex requires prior data, sound analysis, and imagination good enough to think outside the box. This is an issue for all science, and not especially for psychopsychiatry.

One of my big issues with psychopsychiatry is that even from the first diagnostic steps there is a lot of uncertainty. Psychiatric classifications, with some possible exceptions around disorders like Alzheimers, are probable category mistakes. That is they are not natural disorders but human imposed classifications.

 

[Alvin]

Yes. However with a well designed study and objective measures then many of these issues are minimised.

I disagree, as my arthritis and painkiller example shows. If i had no idea what a painkiller does i can argue passionately that it treats the core of arthritis, some even reduce inflammation, further "proving" my wrong hypothesis. Same with antidepressants and depression, they work because they are chemical crutches, not because they treat mythical biochemical imbalances.

One of my big issues with psychopsychiatry is that even from the first diagnostic steps there is a lot of uncertainty. Psychiatric classifications, with some possible exceptions around disorders like Alzheimers, are probable category mistakes. That is they are not natural disorders but human imposed classifications.

I agree here, the DSM is a political document, not an amazing classification device. Lets not forget homosexuality and hysteria were mental disorders in the DSM, and suffice it to say our DNA did not radically change the day before they were removed

 

[Inara]

Same with antidepressants and depression, they work because they are chemical crutches, not because they treat mythical biochemical imbalances.

Antidepressants MIGHT work, in ca. 30% of the cases, which is as good as placebo. Please don't mention the side effects and addictive effects.

I agree here, the DSM is a political document,

In the past you had re-education camps, today we have CBT.

 

[Alvin]

Antidepressants MIGHT work, in ca. 30% of the cases, which is as good as placebo. Please don't mention the side effects and addictive effects.

When they work they are making you slightly high. Peter Breggin calls it medication spellbinding, when a drug makes your problems go away its not fixing anything, its covering it up, slightly better then alcohol or marijuana because your not inebriated.

In the past you had re-education camps, today we have CBT.

For a second i thought you said Re-Neducation

 

[Inara]

For a second i thought you said Re-Neducation

Woah! nothing better than a great laugh!

When they work they are making you slightly high. Peter Breggin calls it medication spellbinding, when a drug makes your problems go away its not fixing anything, its covering it up, slightly better then alcohol or marijuana because your not inebriated.

You could take any drug (not meaning "medicine drugs"). I always joke about alcohol working even better than antidepressants with less side effects. Marijuana is even better! I never took antidepressents, so strictly I cannot tell which works better

Clearly, nothing of this will tackle the underlying problems, IF they exist at all (which may be hotly discussed with respect to "psychiatric illnesses"). It's all about functioning like a robot, not about solving real problems.

When I listened to an economics seminar I understood something crucial:
In their mathematical model they had a variable "human". Variables - or even functions - can complicate your model immensely. So they assumed the variable "human" to be a constant which they neglected in the forthcoming.
I guess this is what shall be achieved: to make human behavior a constant, which is easily dealt with.

 

[Sean]

Peter Breggin

I'd be a little careful of citing him. He is a mixed bag.

 

[TiredSam]

When I listened to an economics seminar I understood something crucial:
In their mathematical model they had a variable "human". Variables - or even functions - can complicate your model immensely. So they assumed the variable "human" to be a constant which they neglected in the forthcoming.
I guess this is what shall be achieved: to make human behavior a constant, which is easily dealt with.

You'd like "Thinking Fast and Slow" by Daniel Kahnemann. He talks about the economists' rational human model and then proceeds to completely dismantle the assumption that humans make rational choices.

 

[adreno]

Too many assumptions in the CBT model for it to be truly scientific.

 

[Alvin]

You could take any drug (not meaning "medicine drugs"). I always joke about alcohol working even better than antidepressants with less side effects. Marijuana is even better! I never took antidepressents, so strictly I cannot tell which works better

Edited: I don't believe in antidepressants as a cure and alcohol and marijuana are not cures either

I guess this is what shall be achieved: to make human behavior a constant, which is easily dealt with.

Very true, its hard to analyze something subjective and there is a lot of money involved. Also our "official" understanding of psychology is practically still in its infancy (with a few notable exceptions, there are some experts who have real wisdom, but it needs to get into the textbooks).

I'd be a little careful of citing him. He is a mixed bag.

Edited: I disagree, he takes the position that chemicals for depression are a crutch and depression is caused by hopelessness (of various causes). Pharmaceutical industry money talks

 

[Squeezy]

Coming in here as a layperson, when you are all clearly professionals in the field.

You are enormously damming of CBT, and antidepressants, and I'm SHOCKED.

Have any of you suffered from Major Depression, suicidal feelings, suicide attempts, or anxiety?

I did, from age 14 to 32. 18 terrifying, horrendous years of my life. I did therapy with several psychotherapists, and it was no help. I'm sure you'd say, Ah, bad therapists, but 6 of them, highly recommended?

Short term counselling for specific traumas was very useful - failing a course, miscarriage, relationship breakdown.

But the BEST help in managing my childhood memories of parental emotional abuse was your much-derided CBT.

When a person is assailed by memories, and a cruel internal voice, they need a way to control them. It is not about BURYING memories or AVOIDING them.

When I learnt that I did not have to be at the mercy of my internal voice, but could choose to be consciously KIND to myself, it changed my life.

It is a huge relief to let the awful thoughts come, notice them, and not resist, tense up or drown in them, but to gently notice them and let them float by.

How can you so cavalierly belittle the merit in this?

Talking endlessly about my past has not helped me long term - the memories and feelings of low self esteem do not fade or change. I'd like to see a study on that.

Thank God I'm one of your "30%" who benefit from psychotropic drugs, or I wouldn't be here. Addictive you say? What does that matter when they are prescribed for acutely dangerous conditions like Major Depression is if left untreated?

If you can speak like this, then you have DEFINITELY never been depressed. And you are bloody blessed. Because I'd have ME and my 3 day kill-me-now Migraines 100 times over that again.

 

[Skippa]

Careful everybody. Please stick to debating the merits/problems with CBT, antidepressants etc; Please refrain from making blanket statements regarding other members or turning this into a personal argument. There will always be two sides to this debate, but it's about the treatment; don't shoot the messenger.

Everyone gets their say, everyone gets to agree or disagree.

 

[Inara]

You'd like "Thinking Fast and Slow" by Daniel Kahnemann. He talks about the economists' rational human model and then proceeds to completely dismantle the assumption that humans make rational choices.

Already read it some years ago it's great