Ever since I learned about Cognitive Behavior Therapy years ago, I haven’t been able to believe it’s the solution to anything but immediate, superficial problems.
The grounding belief of Cognitive Behavior Therapy is that it’s our thinking that drives our feelings and that by changing what we think we can change what we feel. Oh, so clever, aren’t we?
But thinking and feeling are interdependent: how we feel affects how we think, which then affects how we feel, which then affects how we think, and so on and on. I find this disregard for the state of organic human feelings a fatal flaw; we are not such simplistic “computing machines”.
By taking an exclusively rational approach to human beings and behaviors, CBT glosses over the critical distinction between what we feel versus how we feel.
There’s a difference between feeling sad and being depressed, between feeling fearful and being anxious, but CBT simply ignores the deeper influence of mood disorders and personality problems.
With my belief running so counter to current thinking====
a mental health crisis looms – especially in the United States. More than 45 million adults – one in five – experience mental illness, and one in 25 are diagnosed with a serious mental illness.
The mental health of American children has never been worse, and suicides and drug overdoses are increasing, contributing to the longest sustained decline in life expectancy in more than a century, even as the opposite is true throughout much of the rest of the world.
Juxtaposed with this mental health crisis, news media and headlines tout the benefits of cognitive behavioural therapy (CBT), explicitly recommended as ‘evidence-based’ and said to work rapidly,
Varieties of CBT apply to a host of different diagnoses: dialectical behaviour therapy (DBT) for personality disorder; cognitive processing therapy (CPT) for post-traumatic stress disorder (PTSD); interpersonal therapy (IPT) for mood disorder.
antidepressant use alone went up 64 per cent from 1999 to 2014. The increase is so steep that an estimated 13 per cent of the US population now take the drugs.
What is wrong with this picture? Why do modern ‘evidence-based’ treatments fail to produce better outcomes?
Indeed, why do things seem to be getting worse, with many forms of suffering, even suicide, on the rise?
Is it possible that one type of therapy – CBT and its family of treatments – can work for nearly every person and every problem so successfully?
This, plus personal experience, is what makes me think CBT isn’t nearly as effective as we are being told. While it would be very effective for certain kinds of problems, ones that arise from “spinning” in destructive thinking patterns, it’s useless for anything regarding deep feelings and values.
The goal of CBT is only to “fix” what you’re thinking “wrong” about. If you’re struggling with real problems in life, your thinking isn’t “maladjusted”; you’re just being realistic.
CBT never acknowledges that your life situation might be the problem, and not just what you think about it.
CBT fits right into the “catastrophizing”, blame-the-patient theory of chronic pain. They posit that thinking “too much” about it is a sign of disordered thinking and leads to the intensification of our pain.
If you’re distraught over how you’re going to survive this life with so much pain, how to continue earning a living, to continue taking care of your self and others, CBT assumes your thinking about these difficulties is the driver of your pain and ignores the pressing realities of your life out in the real world.
Even worse, if you don’t find CBT helpful you will be blamed for “failing therapy”–not the therapist, not the healthcare system that sent you to this therapist, not the standardized pain treatment directives that deny us effective medication–only you will be blamed.
The avalanche of research belies weakness within.
For example, brief CBT treatments have been found to be ‘ineffective for most depressed patients most of the time’
Whatever benefits there are, they are short-lived and don’t endure; the majority of patients who receive CBT seek treatment again, within six to 12 months, for the same condition
Recent studies have also shown that CBT is 50 per cent less effective than initially believed because ‘the effects of CBT have declined linearly and steadily since its introduction, as measured by patients’ self-reports, clinicians’ ratings and rates of remission’.
I think this might be due to the increased complexity and pressure of our modern societies.
Publication bias (where studies with positive results tend to get published, and those with negative results get shelved) has also contributed to overstating the benefits of CBT by an estimated 75 per cent.
Claims of a ‘gold standard’ teeter on a cracked foundation, bearing marks of influence by profit-seeking industries and their PR tools – from pharmaceutical companies selling drugs, to insurers looking for the lowest-cost solutions they can find.
According to the prevailing biomedical, evidence-based narrative, therapies of depth, insight and relationship are ineffective, antiquated, never-ending, and excessively expensive – lacking scientific basis to boot. Yet these more individualised, open-ended, in-depth treatments are evidence-based, too.
For instance, when in 2010 the independent Cochrane Database of Systematic Reviews performed a meta-analysis of 23 randomised controlled trials (RCTs) covering more than 1,400 patients,psychodynamic psychotherapy fared well in the short-term.
When measured nine months later, after treatment ended, improvement was more notable still. This is significant because most of the research studies on ‘evidence-based treatments’ assess short-term protocols that typically last 8-10 weeks, and the outcome or efficacy of the treatment is measured only once, on the last day of the study.
Harvard study included treatments lasting an average of 150 sessions, across a range of diagnoses.
Psychoanalytic treatment helped significantly with both mild and moderate symptoms and severe personality issues. Measured again at three years and five years after treatment ended, effect sizes increased even more.
One of the strongest studies to date is a meta-analysis that pitted psychodynamic treatment head-to-head against the prevailing favourites, namely CBT and medication
In 2017, Christiane Steinert of the University of Giessen in Germany and colleagues conducted a meta-analysis of 23 RCTs.
It should be noted that researcher allegiance, which can easily lead to confirmation bias, is a significant problem within the field, and one of the concerning problems with the evidence base holding up the CBT orthodoxy.
Steinert’s high-quality study unambiguously found that psychodynamic therapy is as efficacious as CBT and/or medication.
Steinert added that a CBT-aligned researcher had told her that he didn’t care what the results of her research actually were, he would never believe them!
- is evidence-based,
- works just as well as other forms of evidence-based treatment, and
- also offers special additional benefits.
It’s more effective than other treatments when it comes to personality and relationship issues, and it’s the only one shown to offer enduring results.
One of the first hurdles facing depth therapy is the myth that mental illness is always a chemical imbalance.
For me, the powerful rescue provided by antidepressants seems to prove that my anxiety and depression truly are biochemical.
When the cachet of ‘evidence-based treatment’ is oversold to the public, people don’t realise that, despite decades of research, no single form of treatment has been found to be conclusively superior; in fact, it’s the common factors that provide significant therapeutic benefit.
Clients don’t realise that treatment can be useful not only in reducing symptoms, but also in
- helping people mature,
- deepen their relationships, and
- create better lives.
The original concept of evidence-based practice, derived from the field of medicine, includes three overlapping spheres to guide treatment –
- relevant scientific research,
- therapists’ clinical judgment, and
- patients’ values and preferences.
The field of psychology, ever trying to emulate medical doctors, adopted the evidence-based practice model. Unfortunately, the model was then promptly stripped of two-thirds of its key components while the remaining third was severely restricted:
- the spheres of therapists’ clinical judgment and patients’ values/preferences have been subordinated, and
- the third component, relevant scientific research, has been reduced to mean only data from RCTs.
Instead of gathering up lists of evidence-based treatments and marketing these lists to the public, therapists and insurance companies, what we should be communicating is that many problems are complex – often generations in the making – and that treatment that’s useful in the long term can take time.
For example, in a comprehensive study of 10,000 people, 75 per cent needed 40 sessions to show significant clinical improvement. Other studies have suggested that the average client needs at least 50-75 sessions.
We don’t need a crystal ball to predict the damage we’re doing by restricting care.
Such brief, time-limited treatments, by definition, cost the least in the short term; it goes without saying that they are the kinds of treatment that insurance companies like best. But why is the insurance industry helping to write science-based guidelines at all?
Already, other countries have been unwinding the CBT orthodoxy on the ground. Sweden’s gigantic push of evidence-based methods, including pills and CBT, cost $6.7 billion and ‘in no way had the intended effect’
Scotland evaluated outcomes and cost-effectiveness of CBT from 10 previously positive studies and concluded that the positive effects eroded over longer time periods
England trained 10,000 therapists, and its mental health budget more than doubled – from £80 million to £170 million. Yet the treatments, which sometimes lasted only one or two sessions, had a 63 per cent dropout rate.
We must put aside our denial that complex problems in living take time to heal. We know in our hearts and minds that this is true – quick fixes fade fast, you can’t hack your way to a better life, and there are no shortcuts to lasting change.
We do have treatments with the power to improve relationships, increase both personal and professional satisfaction, develop increased resiliency and agency, and leave people less at the mercy of their repetitive historical patterns that deprive them of getting what they want.
It should be as easy for the public to learn about these treatments as it is to read headlines about ‘evidence-based’ CBT and meds.
We are so much more than sources of evidence or collections of symptoms to be managed.
We deserve treatments and models that put our humanity – that of patient and therapist alike – front and centre, and that allow relief from psychic suffering on our most human of terms.
Author: Linda Michaels is a psychologist. She serves as co-chair of the Psychotherapy Action Network (PsiAN) and is a fellow of the Lauder Institute Global MBA programme. She lives in Chicago, Illinois