In a recent Viewpoint article in the Journal of the American Medical Association (JAMA), Falk Leichsenring and Christiane Seinert of the University of Giessen review findings which reveal limitations in CBT research. The authors question CBT’s status as the “gold standard” for psychotherapy, advocating instead for the inclusion of diverse approaches in psychotherapy treatment and research.
“A first-line treatment usually is clearly more effective than other treatments. However, there is no clear evidence that CBT is more effective than other psychotherapies, either for depressive disorders or for anxiety disorders.”
As previous Mad In America reports have documented, numerous research studies have found psychotherapy to be an effective treatment for depression, anxiety, and other conditions. These findings are particularly significant given that 75% of patients prefer psychotherapy to medication.
Cognitive-behavioral therapy (CBT), a form of psychotherapy which targets “maladaptive” thought and behavioral patterns, is currently viewed as the psychotherapy of choice for many conditions because it is considered to be “evidence-based.” However, as the authors of this article discuss, there exist numerous alternative forms of psychotherapy (some examples include psychodynamic, interpersonal, and humanistic approaches), which often receive less official recognition than CBT, perhaps due in part to CBT’s dominant status.
In their piece, Leichsenring and Seinert examine findings from recent CBT meta-analyses and other psychotherapy studies. They stress several limitations in the CBT research which bring its evidence-based standing into question.
One such limitation is the questionable quality of CBT studies. The authors discuss a 2016 meta-analysis in World Psychiatry which used the Cochrane Risk of Bias tool to assess the quality of CBT randomized clinical trials (RCTs) from the perspective of sources of bias which may have contaminated research quality. Using this tool, the authors of the meta-analysis found that only 17% of CBT RCTs for anxiety and depressive disorders were high-quality studies.
Additional weaknesses include inadequate empirical tests and “researcher allegiance” issues. As Leichsenring and Seinert note, certain control group conditions (e.g., receiving another recognized treatment, treatment as usual, or placebo) are much stronger points of comparison than others (e.g., waiting lists).
Studies which find treatments to be more effective than waiting list controls are not strong evidence of treatment efficacy. However, the 2016 World Psychiatry meta-analysis found that CBT was compared with waiting list conditions in 80% of anxiety disorder studies, and in 44% of major depression studies.
Researcher allegiance, or a researcher’s belief in a particular treatment’s effectiveness, can also sway research results. The authors discuss Bruce E. Wampold and Zac E. Imel’s findings that “uncontrolled researcher allegiance” was a factor in a number of CBT studies.
Wampold and Imel suggest that this can cause studies to be designed in such a way that control group treatments consist of ineffective therapies which serve to boost CBT results. For example, therapists working with traumatized patients in one study’s comparison group were prohibited from “directly address[ing]” their patients’ trauma.
In light of these limitations in the CBT research literature, the authors conclude:
“Prematurely declaring one treatment as the gold standard not only has important clinical implications, but also may seriously limit the progress of research because research on other methods of psychotherapy may not be given an equal chance for funding. No form of psychotherapy can presently claim to be the gold standard, suggesting the need for plurality in treatment and research.”
As the authors contend, different research-supported psychotherapies have unique contributions to offer. Moving towards “plurality in treatment and research” will enable researchers and practitioners to understand better which approaches work best, with whom, under which circumstances, while also empowering clients to make more informed decisions about their care.
Leichsenring, F., & Steinert, C. Is cognitive behavioral therapy the gold standard for psychotherapy?: The need for plurality in treatment and research. JAMA. Published online September 21, 2017. doi:10.1001/jama.2017.13737 (Link)
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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