Sunday, September 24, 2017

Cognitve Behavioral Therapy "Evidence-Base" Grossly Exaggerated

In my post on my Psychology Today blog on November 21, 2011, I discussed how the purveyors of today’s most predominant psychotherapy methodology, cognitive behavioral therapy, grossly exaggerate the strength of their research evidence base in the psychotherapy outcome literature.

My opinion was recently confirmed in a review of meta-analyses of the CBT literature in the Journal of the American Medical Association, published online September 21, 2017 (“Cognitive Behavioral Therapy the Gold Standard for Psychotherapy:  The Need for Plurality in Treatment and Research” by Falk Leichsenring and Christiane Steinert).

They reported that a recent meta-analysis using criteria of the Cochrane risk of bias tool reported that only 17% (24 of 144) of randomized clinical trials of CBT for anxiety and depressive disorders were of high quality. The “allegiance factor”—study authors were CBT therapists themselves and often designed the studies to make their treatment look better than it was, and opposing treatments look worse that they were—was rarely controlled for.

Compared with "treatment as usual" —letting subjects get whatever other treatments outside of the study treatment that they chose to have, allowing good therapists and bad therapists, and good therapies and bad therapies, to essentially cancel each other out—the sizes of treatment effects were only small to moderate and might eventually even be found to be due to the allegiance effects.

In panic disorder, CBT was not more effective than treatment as usual but only to being on a waiting list.

Even with these amazing biases, for depressive disorders, response rates of about 50% were reported. This was true for anxiety disorders as well. “Response” just meant there was some significant improvement in symptoms, not that the symptoms of the disorders actually went away. Rates for actual remission from the disorders were even smaller. Conclusion: a considerable proportion of patients do not sufficiently benefit from CBT.

Last but certainly not least, there was no clear evidence that CBT was more effective than other psychotherapies, either for depressive disorders, anxiety disorders, personality disorders or specific eating disorders.

Personally, my biggest beef with CBT and other psychotherapy outcome studies has less to do with symptom relief than with actually changing maladaptive interpersonal behavior. The latter is almost never even looked at, let alone measured in these studies.

CBT’ers seem to think anxiety, depression, and self-destructive behavior are all due to screwed up thinking by individuals rather than being normal reactions to stress-inducing environments. In experimental psychology circles, this is known as the fundamental attribution error. Telling people with these particular symptoms that their problems are basically “all in their heads” in this manner is very invalidating for them.  Ironically, an ‘invalidating environment” is one of the two primary factors these very same therapists cite as the main causes for borderline personality disorder.


  1. With both CBT and psychopharmacology, it's almost as if patients and their therapists are afraid to engage with the implications of emotions. You're depressed or anxious because you were raised by psychopaths or are married to a psychopath, and instead of radically re-ordering who you think you are and your circumstances, just take a pill or kill a thought and you can merrily go on your way.

  2. I would love to see a study which shows how much money insurance companies save by paying for time-limited treatments, and how that correlates with what kinds of studies they fund.

  3. "has less to do with symptom relief than with actually changing maladaptive interpersonal behavior."

    This describes my frustration with CBT. My stepson has been in CBT-type therapies for nearly 10 years now for behavioral problems and developmental delay. He does have a history of childhood trauma and neglect, however he began therapy because he was such an aggressively disruptive presence at school and at home.

    Over the last three years since he has come to live with me, I became convinced that it's not just bipolar disorder that he deals with, but also BPD (the Quiet type). He's a child of an alcoholic, so he's good at guessing what normal is and giving answers that people expect to hear. He flies under the radar of evaluators and therapists, even after he has mood shifts in front of the therapist which take him from happy go lucky to suicidal in a blink.

    He's obsessive and needy toward online friends, and uses them to his own ends, for on-demand sexting, for "likes" on his posts, and for surreptitiously posting his content because I blocked him from access. I blocked because I thought this unhealthy, like he needed to learn real-life interpersonal behavior and stop operating an avatar and not get addicted to sexting.

    No therapists ever address his manipulative behavior, even when he uses it to manipulate them. (He's good at distracting MHP's who ask hard questions - he'll start drawing something and make them focus on the drawing, or he'll make a funny comment and derail, or he'll say 'he's thinking about it' and then just stall until they forget they asked him a question.) When he was little, he had one therapist trained that he wouldn't talk till he had ice cream and videogames.

    CBT therapists haven't addressed stinkin' thinkin' - and allow his unreasonable interpretations of events to continue. I was told to apologize to him for raising my voice to be heard to call him out of a stupor (the car window was open and I was hoarse from a summer cold.) He had interpreted this as threatening behavior which it clearly was not, and which needed to be challenged not accepted.

    I am told to validate his feelings when he flips out over critique (which I deliver very calmly, like I would with an employee.) He rages if he's told to by a classmate that he's being disruptive, or if he's made to return to a chore because it was not completed or done poorly. Why should I validate that? There's no validity in feeling threatened by critique, and learning to take critique calmly is a life skill that must be learnt.

    He is also a master at avoidance of any kind of responsibility. Sleeping, forgetting, twisting words, triangulating, are all his favorite tactics, and no therapists call him on this. They give him 'homework' to do, and when he 'forgets' they all just try something new. Instead of accountability, they just want to "build a relationship" - which DS interprets as an invitation to manipulate. As soon as the therapist starts to call him on it, he protests that he hates the therapist and he wants to try something new...

    Right now he's in the psych ward for threatening suicide after I told him he'd have to move back in with his mom if he wants to quit high school and/or mental health treatment. So, he wants me to know that he's going to kill himself just as soon as I move him out, and it will be my fault.

  4. I agree that it is invalidating, and, mostly stuff that an intelligent, adult neurotic has already figured out and tried on their own. It has everything to do with insurance companies and "quick cures."