The Fallacy in "Evidence-Based" Treatment

"Evidence-based" sounds so right. Why is it so wrong?

Posted Jul 05, 2019

Today's topic is relevant to addiction, but goes beyond it to treatment of any psychological problem. To begin, readers of this blog know that addiction is neither more nor less than a psychological symptom, and that it can be understood and treated by discovering the emotional factors that lead people to repeat their addictive behaviors. 

Sadly, however, much of psychological treatment in this country doesn't work that way. Most psychotherapy for emotional symptoms, including addiction, uses cognitive-behavioral therapy (CBT), which is a short-term behaviorally-focused method to change behavior by following scripted steps in a manual. 

This approach is in contrast to psychoanalytic, or psychodynamic, therapy, which focuses on resolving the emotional causes for behavior. A lot of the country believes that CBT is the gold standard for psychotherapy because it is widely touted as "evidence- based," supposedly in contrast to psychodynamic therapy.

However, that popular belief is wrong. It is wrong whether one looks at treatment of addiction, or treatment of depression, or treatment of anxiety.

Here is the actual science. Numerous studies have shown that CBT and psychoanalytic/psychodynamic treatments are equally successful over the first few months of therapy (for example, see Baardseth et al 2013; Clinical Psychology Review, v. 33(3)). It is these short-term outcomes that are the basis for claims of the "evidence-based" value of CBT. 

The problem, though, is that the CBT results often don't last. Following completion of treatment with CBT for depression, for instance, patients begin to relapse almost immediately (see, among others: Am J Psychiatry 2013;170(9):1041–50; Journal of Psychological Therapies in Primary Care 2015;4:47–59; Johnsen, T & Friborg, O. 2015; Psychological Bulletin). The average time to relapse is 3-4 months and overall relapse rates are as high as 71 percent by one year (Am J Psychiatry 2006; 163(11):1905-17). 

At least two countries have tried turning over their entire psychiatric national health services to CBT, producing by far the largest studies of CBT relapse. Scotland did this after finding positive short-term results from 10 studies with CBT therapy. When their National Health Service followed up these patients 1 to 8 years later, they discovered the initial results had eroded, that even more intensive CBT treatment didn't help, and, important to their health system, they hadn't even saved any money by relying on this short-term approach. 

Sweden had almost identical results when they switched to CBT to treat people with mental or physical disorders (80 percent were psychiatric patients), between 2008-2012. They hoped to reduce sick days due to physical or emotional illness. Each year 40,000-50,000 people were treated. When they were followed up, people who received CBT were found to have slower recovery and more sick days than those not receiving CBT. The researchers could find no link between the short-term benefits and longer-term outcomes.

In contrast, multiple studies published (among other journals) in the Harvard Review of Psychiatry, the Journal of the American Medical Association, and the Cochrane Review all showed the opposite result for psychodynamic therapy (for example: Journal of the American Medical Association 2008; 300: 1551-1565). When people were followed up from 9 months to 5 years after the end of psychodynamic treatment, instead of declining and relapsing, measures of improvement actually got better.  "Effect sizes" (the measure of effectiveness of treatment) went up, meaning that the highly significant initial gains from the therapy were not just maintained but were greater over time. This makes sense, since the treatment is directed not only at the presenting behavior but its underlying causes. By resolving the causes, people became more resistant to relapsing in the future and more resilient to deal with future challenges in their lives.

This applies equally to treatment of addiction. Major addiction relapses are of course very common after just a few months of treatment in CBT, 12-step programs, and inpatient rehabs. The well-known poor results from most addiction treatments are just like the results from using these treatment methods with other psychological symptoms.

Adding to the pain, after a few rounds of such unsuccessful treatment, people suffering with addictions tend to feel worse and worse about themselves. It's all too easy to believe that they have personally failed when people insist that the treatment they've received is the gold standard.

Certainly, brief relapses ("slips") are perfectly normal in any addiction treatment. But when therapy is focused beyond the behavior, slips are typically minor, bumps on the way toward something far more lasting. In fact, as I've often emphasized, in a psychodynamic therapy, slips, or even the thought of slipping, are prime moments to explore the emotional forces that have led to the compulsive urge.

If you or a loved one is suffering with addiction and have gone through the cycle of relapse, you owe it to yourself to seek a different treatment. You can find therapists who describe their practice as "psychoanalytic" or "psychodynamic," either locally or through the listings here at Psychology Today. Even with these professionals, you should definitely ask if they will treat you in the same way as any other person (rather than sending you off to AA or to a counselor with no psychological training). You can probably even find someone familiar with the new treatment approach I've described in my academic papers or my general-audience books. Finally, you can also learn much more about these ideas for yourself in the numerous case stories in both of my first two books, The Heart of Addiction and Breaking Addiction.