The structured nature of cognitive behavioural therapy (CBT) and its clearly defined principles (based on the links between thoughts, feelings and behaviours) make itrelatively easy to train practitioners, ensure standardised delivery and measure outcomes.
Being easy to learn, easy to standardize, and easy to measure nails the trifecta of cheap and widely scaleable medical treatment, making this quick and profitable therapy an instant hit among medical “providers” and insurance companies.
Consequently, CBT has revolutionised mental-health care, allowing psychologists to alchemise therapy from an art into a science.
What it has revolutionized is the impersonal standardization of medical mental healthcare.
I believe psychotherapy will always be an interpersonal skill/art and not a hard science because humans’ psyches are not digital and not based on pure rationality. The more psychotherapy is quantified so that it can be measured, the less value there will be in the measurements.
For many mental-health conditions, there is now considerable evidence that CBT is as, or more, effective than drug treatments. Yet, just like any form of psychotherapy, CBT is not without the risk of unwanted adverse effects.
Of course, if a therapy is powerful enough to significantly help a patient, it must by its very nature also be powerful enough to cause significant harm.
A recent paper in Cognitive Therapy and Research outlines the nature and prevalence of these unwanted effects, based on structured interviews with 100 CBT-trained psychotherapists.
I’ll post this paper in detail later.
The researchers asked each CBT therapist (78 per cent of whom were female, average age 32, with an average of five years’ experience) to recall their most recent client who had taken part in at least 10 sessions of CBT.
The chosen clients mostly had diagnoses of depression, anxiety or personality disorder, in the mild to moderate range.
But not the life-changing diagnosis of chronic pain.
The interviewer – an experienced clinical psychologist trained in CBT – followed the checklist of unwanted events and adverse treatment outcomes, asking each therapist whether the client had experienced any of 17 possible unwanted effects from therapy, such as deterioration, new symptoms, distress, strains in family relations or stigma.
The therapists reported an average of 3.7 unwanted events per client.
To me, this seems utterly meaningless without a glimpse into the number of desirable events for each client.
In most forms of therapy, the therapist’s skill lies in helping their client confront or cope with unhappy or unhealthy approaches to life. By its nature, this requires nudging clients past their comfort zones and arousing “undesirable events”, but for the purpose of helping the client learn to manage them and allow more “desirable events” into their lives.
Based on the therapists’ descriptions, the interviewer then rated the likelihood of each unwanted event being directly attributable to the therapeutic process – making it a true side effect (only those rated as ‘definitely related to treatment’ were categorised as such).
Following this process, the researchers estimated that 43 per cent of clients had experienced at least one unwanted side effect from CBT, equating to an average of 0.57 per client (one client had four, the maximum allowed by the research methodology): most often distress, deterioration and strains in family relations.
More than 40 per cent of side effects were rated as severe or very severe, and more than a quarter lasted weeks or months, though the majority were mild or moderate and transient.
‘Psychotherapy is not harmless,’
the researchers said.
Examples of severe side effects included:
- negative feedback from family members,
- withdrawal from relatives,
- feelings of shame and guilt, or
- intensive crying and
- emotional disturbance during sessions’.
Such effects are not so surprising when you consider that CBT can involve
- exposure therapy (ie, gradual exposure to situations that provoke anxiety);
- discussing and focusing on one’s problems;
- reflecting on the sources of one’s stress, such as difficult relationships;
- frustration at lack of progress; and
- feelings of growing dependency on a therapist’s support.
The longer that a client had been in therapy, the more likely she was to have experienced one or more side effects. Also, and against expectations, clients with milder symptoms were more likely to experience side effects, perhaps because more serious symptoms mask such effects.
Often it was only when prompted to think through the different examples of potential side effects that therapists became aware of their prevalence.
This chimes with earlier research that’s documented the biases which can lead therapists to believe that therapy has been successful when it hasn’t.
I think this is especially true of CBT for catastrophizing. A therapist will assume they’ve proven to the patient that their fears are not reasonable, but a patient dealing with chronic pain all day every day may realize over time that their fears really *are* happening (like losing a job or a relationship or access to effective pain relievers).
‘We argue that they are side effects although they may be unavoidable, justified, or even needed and intended,’ they said. ‘If there were an equally effective treatment that did not promote anxiety in the patient, the present form of exposure treatment would become unethical as it is a burden to the patient.’
Amidst all this focus and praise for CBT, we have to remember how quickly different modes of therapy fall into and out of favor.
The researchers concluded that: ‘An awareness and recognition of unwanted events and side effects in all therapies will benefit patients, improve therapy or reduce attrition, analogous to the benefit of measurement-based monitoring of treatment progress.’
Christian Jarrett is a cognitive neuroscientist turned science writer, whose work has appeared in New Scientist, The Guardian and Psychology Today, among others. He is editor of the Research Digest blog published by the British Psychological Society, and presents their PsychCrunch podcast. His latest book is Personology: Using the Science of Personality Change to Your Advantage (forthcoming). He lives in Brighton, UK.