Cognitive Behavioral Therapy Is Losing Its Effectiveness In Clinical Trials

Rob Wipond
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The relative effectiveness of Cognitive Behavioral Therapy (CBT) in alleviating depression has been declining steadily for the past 40 years, according to a study in Psychological Bulletin.

Authors Tom Johnsen and Oddgeir Friborg examined data from 70 studies between 1977 and 2014 involving 2,426 people diagnosed with depression. The effect sizes were quantified based on the Beck Depression Inventory (BDI) and the Hamilton Rating Scale for Depression (HRSD), and rates of remission were also factored in.

“The main finding was that the treatment effect of CBT showed a declining trend across time and across both measures of depression (the BDI and the HRSD),” wrote the authors. “Contemporary clinical treatment trials therefore, seem to be less effective than the therapies conducted decades ago.”

The authors examined the results from many angles and considered many different possibilities for what may be affecting these outcomes. In the main, they suggested that the “placebo effect” of CBT as a potential cure for depression may be waning. “(I)t is not inconceivable that patients’ hope and faith in the efficacy of CBT has decreased somewhat, in recent decades.” They added, “Moreover, whether widespread knowledge of the present meta-analysis results might worsen the situation, remains an open question.”

Johnsen, Tom J., and Oddgeir Friborg. “The Effects of Cognitive Behavioral Therapy as an Anti-Depressive Treatment Is Falling: A Meta-Analysis.” Psychological Bulletin, May 11, 2015. doi:10.1037/bul0000015. (Abstract) (Full text)

Is CBT for depression losing its efficacy? (BPS Research Digest, June 8, 2015)

34 COMMENTS

    • John, I think your point about this is spot on. CBT has become the therapy of choice because new clinicians receive relatively little with regard to treatment modalities in their academic training. Most clinical professions here in the US require a practicum or other unpaid internship as part of academic training. As the focus of clinical work has increasingly become the production of billable hours, however, the “students” are often treated as unpaid billable hours rather than true students. This trend is supported by the fact that the student’s mentor or supervisor is most often not paid to provide mentorship, and is not excused from the production of any of their own billable hours in order to provide mentorship. CBT is a relatively rote treatment modality that can be taught to new clinicians or student clinicians essentially by instructing them to follow a set of handouts and homework assignments. Before I got out of practice, I lost count of the number of novice practitioners proudly proclaiming “I am a CBT clinician” without any knowledge of the history of behaviorism as a whole.

      Long time clinicians also known, anecdotally, for a long time that CBT loses its efficacy over time. Thus, it fills both the role of the “brief” therapy that has become so popular with managed care and the need for repeat customers to continue producing those all important billable hours.

      The popularity of CBT is also tied to the complicity of academia in the financial corruption of the mental health system. I describe more about academic complicity recently in my own forum.

      • That’s good to know about your work on this issue, Sharon. Did you catch the recent link to the paper discussing the five European psychiatrists publishing a pilot research article for inventing “towards” a new definition of “mental health”? They as well as intend to make cognitive therapy of whatever kind prescriptive of what it means to be human–ideological sweet-smelling crap from front to back, by your oppressors. Since the data and theoretics for cognitive psychology won’t sustain the effort to build an ontology that supports it, then once again, the clinical applications and treatment modalities in sum total will just leave out the whole person, and this will eventually become clearer over time. The relationship in therapy counts a priori somehow, and Beck et al. must get tired of that fact showing up their work, and as much as they go along with meds and whatever else. As usual, we need the science but our interpretations have to be much wiser than the official rubrick allows. Something about respect and mutual consideration modifies the clinical encounter and allows personality changes to happen, which as I understand it only can come about if the whole personality is present for the “helped” person who must also count as one who observes the changes. Probably we change our personality in its elemental structure when we rather wouldn’t when getting physically or psychologicaly beaten down, but what is worse we have no reliable help then in seeing the evidence of how we went about our work at it, nor any trustworthy assistance to alert us to what we chose to act on in order to give it a go. So trying to avoid something that seemed even more painful to put up with from the abuse or disregard, or from the potential range of the other problems we believed it might cause if not “compensated” for, suggests very much that is substantial along the lines of common sense for bolstering the plausability of your trauma model. If we accounted for such things as the motor skills and reaction times for committing actions in emergency response to threats, the model for PTSD, generally, could work for every pathological state of self-sustaining disorder in cognition. But the relationship would outdo the focus on some theory, then, too.

    • As a clinical social worker who uses CBT almost exclusively, I agree that there are more untrained therapist saying they practice CBT when they have no or very little training in the intervention. Often what they do not know is that the therapy requires a specific session
      structure and specific cognitive or behavioral interventions. They believe that if they are asking their patient about thoughts and recommending alternative behaviors (advice) they are now magically CBT therapists.
      I wonder how many of the therapist providing therapy in this study actually went to the Beck Institute or another respected training site?

  2. The answer to the (possible) falling success of CBT is that today people have more reason to BE depressed by there (living) environment.

    If your environment is crap, you will feel like crap. Put a monkey in a cage 24/7 and yes it will affect their behaviour.

    Cities , where most people live, are getting bigger and bigger with noise and visual pollution/ less green space.

    http://www.cbc.ca/news/health/urban-parks-offer-breath-of-fresh-air-for-improved-health-1.1233626

    “Three of every five people worldwide will live in a city by 2030”
    “…found that 20 people with an average age of 26 who were diagnosed with clinical depression scored better on a series of tests of attention and short-term memory when they walked in a quiet nature setting compared with a noisy urban setting.”

    • Marie – Thank you. I spend so much time concentrating on the fact that you can’t believe everything you read and that all scientific proof is probablistic, that it is extra good to hear about the need for skepticism wherever pertinent. Too bad the author didn’t craft that more explicitly into his take on the study results.

    • Ron, I agree with you 100%. I think we’re seeing more intractable cases of depression mostly because we’re seeing more antidepressant-exposed clients.

      Additionally, I am guessing that the further we get away from the fundamental relationship-based approach to therapy, the worse the results will become. CBT becomes something you do TO someone instead of helping them decide if it’s a tool they want to use.

      One size doesn’t fit all!

      —- Steve

  5. It’s strange when these studies try to “quantify” psychotherapy – a complex interpersonal interaction where one human tries to help another – as an object that can be measured like Prozac and Zoloft.

    Each therapist and client interact in a unique, idiosyncratic way that shifts from week to week and even minute to minute in sessions. CBT is not one consistent form of therapy: The way a given therapist understands and applies cognitive-behavioral principles will vary depending on the therapist’s personality and on the changing needs of the client in each case.

    Then depression is not one consistent thing, either – it’s reliability ratings are notoriously low, often little better than chance (close to 0.2 in recent DSM field trials). As people so often note here, there are no biomarkers that can identify depression.

    Despite the nebulous unreliable nature of CBT and depression, maybe something really is happening in these studies. Perhaps increasing urbanization, rising stress levels, and the decline of the middle class are making psychotherapy less effective, pound for pound. But I doubt we’ll ever know.

  6. This study should come as no surprise. Research has always indicated that CBT is no better than other studied therapies, and if one takes into account inherent biases in research, it is clear that CBT has always been worse than other therapies. The most obvious artefact of research regarding CBT is that if one trains someone to report less symptoms, then less symptoms will be reported regardless of whether a person had actually improved. CBT, as it is practiced in research models does the opposite of what research on what actually works in therapy shows. Research on therapists variables and patient therapist relationships clearly indicate that a therapist being able to have an in-depth understanding of the person and being able to relate this to the individual in a comprehensive, empathetic manner is crucial for therapy to work. CBT tends to claim that a deep understanding of someone is irrelevant, while technique counts a lot. Research has indicated that technique is the least important variable in outcome. Training in other forms of therapy, like psycho-dynamic takes 2-3 years. One can get a certificate in CBT in 12-16 weeks. We need to move away from superficial therapies performed by poorly trained therapists with a poor grasp of humanistic approaches, and focus on helping real people with real issues.

      • Thanks Steve,

        One aspect that should be obvious and common sense about research is that research done from various aspects should make sense together and should correspond to clinical experience and patients’ experience. When research results depart from common sense, don’t fit together and don’t bear any resemblance to actual experience there is clearly something wrong with the research. All symptom and diagnosis based quantitative psychiatric research suffers from this problem. We need to interpret all research in the light of actual clinical experience and stop forcing clinical practice into superficial research models. Hence the title of my blog “Real Life Psychiatry”

      • I had CBT tried on me and all it felt like was a person with “professional” training is trying to convince me that if I only use some cheap mental “techniques”, which I have either discovered in kindergarten without the help of this highly educated person or they simply never worked for me, my problems will go away. Sure…

        The main problem with CBT and a lot of other psychotherapies is that they ignore the reality of one’s problems (sorry but talking to you won’t revive my grandmother or sexually un-abuse me or fill my bank account with much needed money) and offer simplistic advice on how to control one’s emotions which are insulting to anyone with intelligence only slightly above a very dumb cat.

  7. Norman, thank you for bringing up the “inherent research biases” that were probably present in original CBT research. CBT has been the beneficiary of good press for years (and continues to be), nothing more. As you pointed out, meta-analysis has shown that all therapeutic modalities are about equally effective – it is the person of the therapist that makes the difference int therapy outcome.

  8. Norman wrote: “Research has always indicated that CBT is no better than other studied therapies, and if one takes into account inherent biases in research, it is clear that CBT has always been worse than other therapies.”

    This is utter nonsense. You are entitled to believe that CBT targets the wrong variables, that it is superficial, etc., but you are not entitled to your own facts about the scientific literature on CBT’s effectiveness. There is a mountain of scientific evidence showing that various forms of CBT are effective for many different problems. Not all evidence-based therapies are CBTs, but most are. Such approaches are summarized here: https://www.div12.org/psychological-treatments/. The science in this area is not perfect, and reasonable criticisms can be offered about it. But the idea that various forms of CBT are no better than other therapies, and particularly the idea that “CBT has always been worse than other therapies,” is baloney.

    • Thank you, Brett. Good hunches about something afoot can often not come to you with clear perceptions of the environment that occasions them, as we all know. My issues with CBT just are the quieting down of the issues of the proliferation of insupportable disagnoses, such as we have increasingly seen–or that tendency ongoing in how its groups get their work and word out along with the colonization of independent survivor efforts at direct patient or peer survivor advocacy. The talk of its scienc-iness also goes on a little long and gets somewhat hackneyed for failing to say what it as a program is all about: compatibility with the current paradigm to no end of the ease with which it can command psychiatry’s attention with its results. I mean that in my DPAFU handbook, the details for some ordinary example of what that could all mean for a consumer (that is, to have “waited” on their neat label) are hinted at to the end of leading you to feel assured that you are in the right program now. Since the book can’t talk or stop you from talking and inject you, we’re all fine again. On the other hand, the several bywords aimed at clinicians themselves for getting this “unpopular label” to command some attention, are all left in the language of saying all that can be said about the poor undiagnosed and undrugged and stigmatized among the masses. Clearly, practitioners know that breathing a word of anything appearing shakily unreal about everyday experiences, in the majority of clinical settings in behavioral healthcare for decades has led from to bad to awful results for years for numerous individuals. CBT advocates sure know and noticeably want it thought most appropriate if kept inexplicit. What’s up with that?

    • Brett,

      You are failing to understand the issues, the facts and limitations of research. Quantitative psychotherapy research has clearly shown that many forms of therapy appear to work equally well, with CBT having no advantage over many other forms of therapy. CBT is much easier to do research on because it is fundamentally a manualized therapy to begin with, while other forms of therapy need to be standardized (or dumbed down) in order to fit research protocols. The fact that there is so much research on CBT does not make it batter or even a valid form of therapy. There is plenty of research evidence that indicates that the type of variables that correlate with good outcomes are very different to the type of approach that CBT promotes. I stand fully behind my opinion which is well backed by research.

  9. Please do not believe that CBT Therapists train for 12-16 weeks as referred to above as it is simply untrue. I have trained for five years with BSc & MSc in Cognitive Behavioural Psychotherapy and for anyone to get a job as a CBT Therapist in the UK you need to be at least post grad qualified.

    • Hi Josephine,

      I’m glad to hear that those are the requirements in the U.K. While in Quebec one does need to log many hours of supervision to be certified as a psychotherapist, I know many people in Canada and the US who have received a certificate in CBT after a 3-4 month training. The main issue is that to be a good therapist, one should have a solid knowledge of developmental psychology, and many hours of practice and supervision. There are many people who have received certification in CBT in North America with little in depth knowledge of crucial developmental issues.

  10. Actually, in the UK anybody can call themselves a CBT counsellor or psychotherapist without any training, insurance or regulation. Counselling and psychotherapy are completely unregulated. We have a voluntary system, which the majority of service users do not realise exists. Many assume we’re regulated like the medical profession.
    Granted, the NHS have minimum standards of training for their practitioners but the private market is huge.

    As a professional in private practice (who elects to be accountable via BACP registration and accreditation) I sometimes wonder if I’m part of a profession at all.

    As for CBT, it certainly has its uses but I see many people for whom it simply has not worked and for whom a relational framework is more suitable. I appreciate the desire to measure personal process but we clearly haven’t got a measuring system sophisticated enough right now.

  11. It is possible that certain of the techniques of CBT may have their uses, but the evidence that they do is lacking. Research on what actually works in therapy supports relational frameworks and show that techniques themselves have minimal impact. The research on which CBT’s tremendous rise in popularity is based is all quantitative symptom and diagnosis based research. This mode of research, on whatever therapy or drug is being tested, has always shown only very moderate results, and far poorer results than one would expect in clinical practice. A 20-30% difference from placebo in people showing greater than a 50% reduction in symptoms is not impressive. If one then takes into account the fact that these therapy studies are never double-blind that their are biases that favour CBT, and that therapeutic allegiance tends to account for a significant part of successful outcomes in research models, then one has to really question all research done by these models, especially if the results aren’t in line with research on outcome variables. Relational frameworks have always, will always , and have been shown in more sophisticated and qualitative models., to be the gold standard in psychotherapy. The value of any technique remains to be proven.

  12. CBT is mostly based after darwin work; social darwinism: the stronger, faster, luckier, fitter, individuals dominate the weaker, less educated, poorer, unluckier individuals in society -and in all animal species-.

    PEople tend to realize life is brutal and cruel; only the strong survive. And that s just the way it is. Being able to dominate, makes one feel good and confident, being unable to do so frustrate and makes one miserable. Hope is envisioning yourself or your offsrping dominating in the future.

    We are animals , just like other animal species. That s the main conclusion all people who really think hard come to. And it quite a depressing conclusion, even if it s the only true one. It means we re just animals fighting for resources and partners of reproduction on a rock flying aimlessly in space, until there are no more resources or until a man made or natural cataclysm destroys us all for good. In the meanwhile we re destroying everything on the planet to satisfy our egos. But that s wht animals do; they re not designed to see long term; only short term, our own survival.

    Every adult will tell you, especially in bday and age of information where anyone can get a global understanding of life everywh ere on earth: we are indeed just animals killing other animals or enslaving them for our own interests. And we throw each others in the trashbin if needed.

    You can sugarcoat it all you want, we re just clothed, shaved monkeys fighting for jobs and partners of repdocution in “peace times”, and for resources and teritory in “war times”.
    We will do so indefinitely until we or something puts an end to it. Life is a constant struggle for survival and has no other purpose.

  13. I d add that in a scientific, cold world where religion is completely disapearing, the sheer cruelty of life depress more and more people sooner than ever, at young ages, especialy in dysfunctional families where kids learn very early that we are cold hearted individuals.

    This is the way of the world, as we understand we re just animals, we lose interest in playing the “game ” of life and are more interested in having as much fun as possible before dying without caring about the next genereations, also people want less and less to have kids as they become intelligent and richer, stronger. As a result the third world immigrants who are still believers are replacing us at a rapid rate but will eventually become cynical atheists too once they have replaced us in our own societies.

  15. The Johnsen and Friborg meta-analysis is deeply flawed:

    1. The most important limitation is the combination of uncontrolled and controlled trials, or rather of non-randomised and randomised studies in the meta-analysis.

    2. They only included 15 RCTs in their study, but there are many more published trials in this field. Why were the others excluded?

    3. It’s well documented that the quality of trials has improved over time. It is therefore plausible that the apparent decrease in the efficiency of CBT for depression over time might simply be a by-product of increasing quality of trials. Johnsen and Friborg did look at study quality and found no moderating effect. But given their hotchpotch of uncontrolled and controlled trials and their limited sample of CBT studies, this analysis is not very informative.

    4. There is no analysis of heterogeneity in the study. The authors say they did this, but it’s not present in the published paper. Given their combination of studies, heterogeneity was probably very high. So high, in fact, as to indicate there is not much point in combining these studies at all.

    We have blogged about this meta-analysis today on the Mental Elf. You can read more here: http://www.nationalelfservice.net/treatment/cbt/crisis-of-faith-instead-of-cbt-we-should-be-worrying-about-meta-analyses/

    Cheers,
    André Tomlin
    The Mental Elf