Researchers Question “Gold Standard” Status of Cognitive Behavioral Therapy

Researchers argue for plurality and diversity among psychotherapy approaches and question the perceived superiority of Cognitive Behavioral Therapy (CBT).

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In a new review, Dr. Leichsenring and a team of researchers critically examined the evidence supporting Cognitive Behavioral Therapy (CBT). The authors, who represent a variety of modalities, make it clear that their aim was not to engage in “CBT bashing,” instead, they set out to constructively explore the field’s assumptions and evidence. Their findings suggest that the current evidence supporting CBT’s efficacy is not as robust as claimed.

“Most important, there is no consistent evidence that CBT is more efficacious than other evidence-based approaches,” they write. “These findings do not justify regarding CBT as the gold standard psychotherapy.”

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CBT is one of a number of psychotherapy approaches. Interpersonal, humanistic, systemic, and psychodynamic therapies are commonly practiced alternatives. CBT has received more attention and has been referred to as the “gold standard” of psychotherapy treatment. Some even argue that a single, integrated CBT-based psychotherapy ought to be the only type of psychotherapy. Others disagree, however, arguing instead for plurality and diversity in psychotherapy approaches, particularly if the evidence does not support the superiority of CBT over other methods.

In this review, Leichsenring and colleagues identify four assumptions used to claim CBT’s superior efficacy: (1) more studies are available for CBT than for other psychotherapies; (2) no form of psychotherapy has been shown to be superior to CBT; (3) the theoretical foundations and the (4) mechanisms of change of CBT have been researched most extensively.

They begin by noting that research within psychology and cognitive theory is in the midst of a replication crisis. This puts the status of CBT theory, which comes from cognitive research, into question. Change in therapy, according to many proponents of CBT, involves changing individuals’ thoughts. Yet, research about mechanisms of change in psychotherapy finds that positive treatment outcomes are not uniquely related to CBT features.

While some claim that other approaches “do not even come close” to the quality of studies supporting CBT, the authors find that the evidence “tells a different story.” Leichsenring and team make the following points about the quality of CBT studies:

  1. CBT studies use weak comparators, wherein CBT approaches are often compared with waiting list controls rather than other psychotherapies.
  2. Many CBT studies run a high risk of bias, they argue, when assessed with the Cochrane risk of bias tool. However, they address that this tool may not be optimal for evaluating bias in psychotherapy studies.
  3. The quality of CBT studies was not found to be superior over reviews of other approaches, such as those in psychodynamic psychotherapy.
  4. A review of studies found that when CBT studies featured an appropriate comparator, there was insufficient power.
  5. Allegiance bias of researchers has not been controlled for, and this may affect reported outcomes.

Given these considerations, the authors make their sixth point that there is “high uncertainty” surrounding CBT’s support. “Due to the low number of high-quality studies and the large number of studies with a high risk of bias the authors of a large meta-analysis on depressive and anxiety disorders concluded that the effects of CBT are ‘uncertain and should be considered with caution.’”

Additionally, they note that quantity of studies does not imply quality and that if CBT is to be regarded the “gold standard” of psychotherapy, demonstrations of its efficacy are crucial. They go on to highlight two important considerations: (1) Some studies have failed to find CBT superior to placebo in treating depression, and others have found it to be ineffective for symptoms of psychosis or bipolar. (2) Remission rates and response to CBT are modest.

The authors argue that more convincing evidence is needed to support CBT as the panacea psychotherapy. This compelling point is bolstered by their finding that the available evidence does not support CBT’s superiority over other psychotherapies. Studies that have made this claim feature “small and negligible” effect sizes or did not take into account how clinicians vary in their efficacy.

Additionally, there is considerable evidence to demonstrate that no one approach can claim to be the gold standard when research supports that specific interventions unique to each approach are not the influential factor that drives positive outcomes. Instead, the researchers argue for diversity and plurality in psychotherapy approaches. They write:

“A plurality of research-supported approaches may be advantageous, for example, in patients not responding to one therapy approach. In contrast, a plea for a ‘scientific’ integrated psychotherapy under the hegemony of CBT implies that other approaches are not scientific: this, itself, is a non-scientific position.”

Finally, they call attention to the way that research supporting CBT has stagnated in recent decades. Further, CBT has borrowed techniques from other approaches, and those who practice CBT do not do so exclusively, instead they tend to apply non-CBT approaches featured in humanistic, interpersonal, and psychodynamic therapies.

They conclude that “at present, no form of psychotherapy may claim to be the gold standard.” As a result, they argue for plurality in training, in research, and in practice.

“Different patients may benefit from different approaches, or may benefit through different routes. Therapists are different as well. They should be able to choose which approach fits them best: One size does not fit all. Also learning from each others’ approaches requires that different forms of evidence-based psychotherapy exist and are valued equally. Plurality is the future of psychotherapy, not a CBT-centered “one fits all” monoculture.”

 

 

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Leichsenring, F., Abbass, A., Hilsenroth, J., Luyten, P., Munder, T., Rabung, S., & Steinert, C. (2018). “Gold standards,” plurality and monocultures: the need for diversity in psychotherapy. Frontiers in Psychiatry, 9, 159. (Full Text)

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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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28 COMMENTS

  1. All of this is based on the weird and incorrect idea that “mental illnesses” are uniquely identifiable and should all respond to a particular “treatment.” The truth is, all people are unique and their needs and strengths are unique, and so what is needed to help them is unique to their situation and personality. Milton Erickson opined that therapy needs to be ‘reinvented’ for each new client. I agree 100%, and would go further to say that “therapy” itself assumes that some professional needs to intervene to help someone make their way through whatever they are struggling with, and this assumption is also 100% wrong. Sometimes the best therapy is no therapy at all.

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      • Sounds like the best basis for any kind of helping!

        CBT and any “school” of therapy is mostly just techniques that can be applied. Applying techniques can be done in a connected, caring way or a disconnected, condescending way. Absent the caring part, I don’t think it makes a bit of difference what techniques you use, you will screw someone up in the name of “helping” them. And if you really care, the techniques become secondary, because you’re seeking a real understanding of the person and that is what guides you forward. The search for the “gold standard therapeutic approach” is doomed to failure.

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  2. Humans do struggle, and help is sometimes useful. Over the years our wisdom traditions have provided this, along with families, friends – and nowadays it’s (sometimes) professionals. Science can be part of this. This article is FAR from unbiased: “FL, AA, MH, PL, CS research, teach, and practice psychodynamic therapy (PDT) and have published books or book chapters dealing with PDT” PDT = psychodynamic therapy, Freud and all that followed thereafter. Lead author has many such articles eg “Leichsenring F, Leweke F, Klein S, Steinert C. The empirical status of psychodynamic psychotherapy – an update: Bambi’s alive and kicking. Psychother Psychosomat. (2015)” His everyday JOB is psychoanalytical psychotherapy, “Falk Leichsenring, Dipl.-Psych, Psychoanalyst” and similar for co-authors. There was back and forth in BMJ about this a few years ago. Here’s a very interesting blog on where “CBT” (whatever that phrase means) appears to be going in 2018 – http://drericmorris.com/2018/02/05/post-cbt/

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  3. I’ve never understood how it makes sense to compare the effectiveness of different therapies across many different types of problems. This is like comparing the relative benefits of surgery and medication for medical problems. Which approach to treating medical problems works best? Surely the answer is, at least to some extent, it depends on the type of problem. I have no trouble believing there are psychological issues for which standard CBT is no better than one or more alternative approaches. But I’ll take CBT over psychoanalysis any day for phobias. Context matters.

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    • Techniques can be handy tools for difficult situations, but I don’t think any set of techniques guarantees success in any situation, because people are different. My personal approach to assessment is, “gather information until some picture of what might help emerges. Try that out. If it doesn’t work, gather more information and try something else.” And “work” must be defined by the CLIENT’S perception of what they are seeking, which is where I think most therapists fall down on the job.

      Just as a fer instance, I tend to use “motivational interviewing” techniques a lot when I am trying to help someone out. But I didn’t know it for over a decade! I had no training in “motivational interviewing,” but simply followed what seemed to be working and essentially “invented” a style of motivational interviewing based on the needs of my clients. As such, I am never married to using those techniques – I only use them when they appear to be workable. And when they aren’t, I do something else.

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      • Agree with Steve. Therapy is not a bag of tricks, but a relationship. Once people feel connected with someone else, safe, respected and validated a lot of things seem to fall into place for them anyway. Not saying this is all they need as that will depend on their unique situation. CBT however goes from the standpoint that all people need is symptom relief, that their techniques will work for any client, under any set of circumstances which is medical model thinking in its pure form

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  5. I agree the relationship is critical, that people are different, and that therapy is more than a bag of tricks. I do also believe that for some types of problems, some therapy approaches are better than others. To illustrate, I’m currently seeing numerous clients who for years have been tormented by unwanted, intrusive thoughts of things like killing others, molesting children, etc. They find these thoughts abhorrent and are terrified they might one day act on them. All of these clients have seen numerous therapists in the past, who are described as generally nice, well-meaning, but also unhelpful. These therapists taught my clients mindfulness, breathing and relaxation techniques, and other superficial “skills” for managing their anxiety. In no case did a previous therapist directly address the core concern that the client might act on the thoughts. In our work, I use exposure therapy to address this concern and help clients learn through their own experience that thoughts are just thoughts, and that they will not act on their unacceptable thoughts even if they drop the safety-seeking behaviours they think are preventing them from doing so. Exposure in this case isn’t a skill or technique, it’s an approach that includes a specific way of understanding the problem and a specific way of addressing it. And there is good research to show that this approach is specifically and uniquely effective for this type of problem. So, I generally agree with the sentiments expressed in this comments section, but I will reiterate that context matters. There are circumstances where an empathic, well-meaning, intelligent therapist who genuinely tries to understand the problem and otherwise does most things right can utterly fail to help clients because they are using an approach that doesn’t adequately address the problem.

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  6. To say that a particular approach is specifically and uniquely effective for any kind of problem makes the people with that problem a homogenous group which they are not and it obscures context which you claim matters. I am sure you would agree that people aren’t their presenting problems and that therapy requires a creative mind to assist this person at this particular point in time of their lives under these circumstances. As Steve mentioned elsewhere you have to re-invent therapy for every client. The one size fits all approach seems too simplistic for all our complexities

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  7. Don’t different people (each of whom is unique) sometimes have the same type of problem? And if so, isn’t it possible that this same type of problem can have specific causes/influences, and be addressed using a specific approach, that can benefit most who have the problem despite the fact that each of them is a unique individual? That’s not one size fits all in my book.

    I agree therapy should always be individually tailored to each client. But I’m not reinventing therapy from scratch for each person, with no guiding theoretical assumptions to understand human psychological experience or familiarity with types of strategies that are useful for types of problems. Any therapist who does so has no business being credentialed.

    I have seen far too many cases where therapists believed every client is a unique individual, rejected one size fits all therapies, had no theory or principles for making sense of their client’s experience, had no knowledge or strategies to convey, and tried to “relationship” their client out of a severe and chronic anxiety problem. That approach is what most clients on my caseload have tried time and time again only to find it make little to no dent on their concerns.

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    • I agree with several of your points. I have also read your website and I like your take on things. However, a couple of things to talk about:

      1.) Why don’t people who are licensed as clinical psychologists simply publish all of their interventions in the form of easy to read and understand PDF documents and upload it online? This is horrible for their practice as a business because it takes money out of their pockets, but would be very helpful for a lot of people. This has already been done when it comes to education (mathematics, physics etc.) via mediums like Khan Academy and all the other YouTube (or otherwise) content creators. People have also published free e-books for learning programming for instance.

      2.) In cases where people actually need someone for them to be there, you could take up the real life role in that case.

      3.) The danger of therapy is that it attempts to find the problem within the individual. What if a person is suffering from an abusive individual (even when they are going through it currently)? It is impossible to do anything about it once you have entered the behavioural system and you have ready-made behavioural labels (hell, even the fact that a person is in “therapy”) for the perpetrator to exploit, gaslight you, and use against you in courts, through the police etc.

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    • The same type of problem? People tend to react and adjust to, make sense of and try and manage with what happens to them in seemingly similar ways because they are people. If you see these as their problems, then you and I are worlds apart in terms of how we think about people

      With regards to your last paragraph, I have come across people who described their CBT therapists as cold, technical and appearing to follow a script or recipe. Needless to say they didn’t experience these therapists as helpful, especially when their severe and chronic anxiety had an interpersonal origin (which, and this is where you and I might differ, is most often the case)

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    • Having a pipe wrench, some plumbers’ tape, a snake, and a toolbox doesn’t make one a plumber. Focusing on one particular school of thought as somehow “evidence based” creates detachment from the client and inflexibility in approach. I certainly have lots of tools in my toolbox, and as I said, “techniques can be handy tools for specific situations.” Not being married to a school of thought isn’t the same as having “no theory or principles for making sense of the client’s experience.” It simply means being flexible and building one’s model of reality from direct experience, and being willing to alter and adapt that model when new experiences and data enter the scene. I would maintain that some therapists can and do accomplish this, but many, perhaps most these days, do not. I would also maintain that most untrained folks can do this, too, if they have the right perspective and attitude. It doesn’t require an advanced degree, and it doesn’t require commitment to “evidence based practices,” except to the extent that one needs to observe the evidence of one’s own efforts from the point of view of the client’s goals and intentions. It DOES require sufficient perspective on one’s own emotional needs so that one does not judge or react adversely to the client’s own description of reality. Again, some therapists can do this, but a lot of them can’t, in my experience. And plenty of people with no formal training ARE able to assume this attitude. I would maintain that, with enough practice and attention to their effects on the people they are trying to help, a completely untrained person could become a very effective helper without any kind of formal training at all. (Not that some kinds of training might not be helpful, but again, they are simply adding tools at that point, and are in a position to decide which tools appear to work and which do not.) And it is a CERTAINTY that having training as a therapist in the latest “evidence-based practices” provides no assurance that the therapist would be even marginally capable of connecting with and understanding another human being.

      So I guess I see specific training in specific “schools of thought” as a minimally relevant variable in this case. And I see unflagging commitment to a single school of thought to be deadly to any chance of even marginal competence.

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      • Steve, we are largely in agreement. Regarding “techniques,” they can be simply tools in a toolbox, or can be part of a unified approach that includes philosophy, theory, and strategy, and these two versions are very different. When I use exposure to help a client, I’m not thinking of it as a technique but as an entire therapy. A legitimate complaint about CBT as it is commonly practiced is that it involves a lot of techniques that might not be chosen that thoughtfully, sometimes contradict each other (e.g., simultaneously encouraging a client to face a feared situation while using controlling breathing to suppress anxiety), and are not clearly tied to a defensible theory that suggests the chosen techniques are necessary and effective. Anyway, my experience is that discussions of the value of “technique” vs. the relationship, when engaged in by people who prefer opposite sides, quickly become contentious and never get anywhere, so I think it best I bow out of this thread at this point.

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    • Brett Deacon, I suggest respectfully you try harder to find common ground with Gerard. I don’t want to try to stump you or look superior, but his line of thought makes a lot on sense. Maybe he is a bit stringent with his “interpersonal origin” hypothesis, but still, given that perpective, the form pathology takes is less important than the initial causes. In that perspective, “Depression” becomes a global or generic term for a very large class of disorders of the self with as many root causes. And thus, therapy will be closer to retracing the persons personal and interpersonal story and then helping to sort things out. I don’t know if you agree or not, but I am pretty sure you apply, at least in part what I just wrote. And, if I am right, that points to some common ground between you too. Best regards.

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  10. I’m not against emotional “therapy” like many commenting here are. But do you really need an MSW or PhD in psychology to help people?

    The whole business of “therapy” could easily be replaced with peer coaches. (No MI affiliations!) I found Will Hall’s counseling more effective than any “certified therapy” I ever experienced before. Will almost has his doctorate but chooses to remain uncertified. Not hard to guess why.

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  11. Numerous studies have shown that rumination, worry, etc., substantially contribute to “mental issues.” The following review that looked at various ways in which rumination can be reduced found that mindfulness-based and cognitive behavioural interventions are most useful:

    Querstret, D., & Cropley, M. (2013). Assessing treatments used to reduce rumination and/or worry: A systematic review. Clinical Psychology Review, 33, 996–1009].

    One cannot simply tell someone not to ruminate because the mind automatically does that – the only way one can stop ruminating, worrying, etc., is by training the mind in meditation and mindfulness (and this can be accomplished through cognitive behavioural interventions that include a mindfulness component).

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  12. Happily I stumbled on this….. Its an argument I have had with “heady” co workers, for decades. Korzybski, or Whorf anyone? Ideas simply are not feelings. And to think of them this way, shifts therapeutic work away from feelings to reasoning. Yes you can change reasoning, but you can’t change feelings by changing ideas, because, once again, ideas are not feelings. A large percentage of therapists are academically trained, that means, books, books and more books. It also means, in most states they aren’t required to have much of their own therapy.. How can you be a therapist if you have never had your own therapy and have been exposed to many other forms of treatment, as a patient…?

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