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Cognitive Behavioral Therapy

Cognitive-Behavioral Therapy: Proven Effectiveness

CBT is the treatment of choice.

In a recent blog post, Dr. David M. Allen, a psychoanalytic psychiatrist, attacks cognitive-behavioral therapy (CBT), claiming that it is a simplistic approach that only addresses simple problems. He discounts the "evidence-based" model underpinning CBT and claims that there is a conspiracy in the National Institute of Mental Health (which he calls "the cognitive behavioral mafia") that appears reluctant to fund psychoanalytic research. In addition, he claims that CBT is simply another way of viewing people as "stupid" because they hold irrational beliefs that contribute to their suffering. He also claims that CBT says almost nothing about the origin of these beliefs except to say that people are just "born that way." Dr. Allen then goes on to provide some anecdotes which are intended to demonstrate his skill as a therapist, finishing his diatribe with the following: "Therapists who challenge these ideas without understanding how central they are to a person's psychology do so at their own risk. Patients will fight them tooth and nail, and they will get absolutely nowhere. Cognitive therapists, put that in your pipe and smoke it."

As a former pipe smoker and current cognitive behavioral therapist, I gave up smoking a pipe long ago-actually, several years after I abandoned psychoanalytic approaches. I read the evidence on effectiveness and I thought, "I owe it to my patients to provide them with the best treatments available." Those treatments were CBT.

Let me address Allen's criticisms, which I think are based on a lack of understanding of CBT, a lack of ability to recognize the importance of scientific evidence, and a practiced misrepresentation of the reality that exists.

1. Yes, CBT is empirically based

Allen minimizes the importance of the empirical support for CBT, claiming that it appears to deal with simple problems (see below). But what would it mean to you as a patient—or a family member of a patient—who had life-threatening cancer if your doctor said, "I don't really care about all this empirical research. I base my practice on my experience?" I doubt that one could stay in practice very long with that approach. Our patients deserve the very best treatments-treatments that have empirical support. Fortunately, one of those treatments is available—it's called CBT. Research on the effectiveness of treatment can be summarized in "meta-analyses" where numerous studies can be surveyed, combined, and effect sizes extrapolated. I cite three such analyses for those interested (below). In each analysis, CBT has been found to be effective for a wide range of disorders. These are not simply studies by true-believers—they are well-controlled, the data are analyzed sufficiently, and the results (repeatedly) speak for themselves. CBT works.

If psychiatry or psychotherapy is to be taken seriously it must rely on empirical research. We cannot simply use anecdotes, testimonials, narratives, or tirades to guide our choice of treatments.

The interested reader can consult these articles for further review:

Butler, A.C., Chapman, J.E., Forman, E.M., & Beck, A.T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17-31.

Chambless, D.L., & Ollendick, T. H. (2001). Empirically Supported Psychological Interventions: Controversies and Evidence. Annu. Rev. Psychol, 52, 685-716.

Tolin, D.F., Is cognitive-behavioral therapy more effective
than other therapies? meta-analytic review, Clinical Psychology Review (2010),

2. Yes, CBT deals with serious problems

It is not uncommon for psychoanalytic or other therapists to criticize the empirical support for CBT. Allen claims that CBT "is a simplistic approach that only addresses simple problems." What are these "simple problems" that we address? Well, they include major depressive disorder, Post-traumatic Stress Disorder (PTSD), social anxiety disorder, panic disorder, generalized anxiety, specific phobia, OCD, dysthymia, substance abuse, ADHD, eating disorders, marital distress, and other significant problems. Indeed, labeling "depression" as a simple problem is not only insensitive to the millions of people who suffer, but also is in total disregard of the devastating effects that result from depression. Let me quote from my Huffington Post article:

"Depression is the leading cause of medical disability for people aged 14 to 44 (Stewart, Ricci, Chee, Hahn, & Morganstein, 2003). Depressed people lose 5.6 hours of productive work every week when they are depressed (Stewart, 2003). Eighty percent of depressed people are impaired in their daily functioning (Pratt & Brody, 2008). Fifty percent of the loss of work productivity is due to absenteeism and short-term disability (R. C. Kessler, et al., 1999). In any 30 day period, depressed workers have 1.5 to 3.2 more short-term disability days (Druss, Schlesinger, & Allen, 2001).

People with symptoms of depression are 2.17 times more likely to take sick days (Adler, et al., 2006; Greener & Guest, 2007). And when they are at work their productivity is impaired—less ability to concentrate, lower efficiency, and less ability to organize work. In fact, absenteeism and work performance are directly related to how severe the depression is—the more severe the depression, the worse the outcome. In one study the costs of absenteeism were directly related to actually taking antidepressant medication (Birnbaum, et al., 2010; Dewa, Hoch, Lin, Paterson, & Goering, 2003). Those who took the prescribed medication had a 20 percent lower cost of absenteeism. Depressed people are seven times more likely to be unemployed (Lerner, et al., 2004)."

Moreover, CBT has been found to provide significant advantages in the treatment of bipolar disorder and schizophrenia, with higher functioning for patients receiving adjunctive CBT (along with medication), higher medication compliance, and fewer days in hospital. Dialectical Behavior Therapy (DBT), which was developed by Marsha Linehan, has received more empirical support than any other treatment for helping individuals with Borderline Personality Disorder—again, resulting in fewer days in hospital, lower rates of suicide, and lower rates of para-suicidal or self-injurious behavior.

My colleagues and I find it quite alarming that a psychiatrist would characterize these as simple problems. Indeed, these are sometimes life-threatening problems with pervasive effects on individuals and their families. The fact that we have empirically supported treatments is a considerable advance in psychotherapy and one that should be lauded and advanced further.

3. Yes, CBT examines the origins of problems

Dr. Allen apparently is unfamiliar with anything that has been written from the cognitive therapy perspective over the last 35 years on case conceptualization, the origin of early maladaptive schemas, socialization effects on attribution style, the effects of trauma, the implementation of programs to reduce vulnerability to depression, or the use of induced imagery to recall and re-construct early childhood experiences. It is remarkable to me that a commentator on the leading approach in psychotherapy (CBT) could be so ill-informed. Yet, he is. Indeed, in Beck's earlier books in the 1970s—Cognitive Therapy and the Emotional Disorders and Cognitive Therapy of Depression—Beck describes the formation of early schemas (during childhood) that then direct selective attention and maladaptive coping. Moreover, in both the first edition and second edition of Cognitive Therapy of Personality Disorders Beck and colleagues describe the formation, persistence, and maladaptive coping of early schemas. In addition, other scholars-such as Guidano and Liotti (Cognitive Processes and Emotional Disorders: A Structural Approach to Psychotherapy, 1983) integrate Piaget and Bowlby in their model. Jeffrey Young's Schema Focused Therapy (a branch of CBT) places considerable emphasis on early maladaptive schemas. Marsha Linehan's DBT model emphasizes the importance of early invalidating environments. In addition, sophisticated cognitive therapists utilize case conceptualization, developing a model of the origins of early schemas, linking them to underlying core beliefs and maladaptive assumptions and developing strategies to modify the patient's coping and belief system. Books by Judith Beck, Jackie Persons, Willem Kuyken, Christine Padesky, Robert Dudley, and Larry Needleman all attest to the importance of more complex case formulations, which draw on our understanding of the origins of schemas. Work by Emily Holmes and her colleagues at Oxford on the use of imagery induction and restructuring also draw on reworking early memories. In regard to resistance, which Allen mentions, I have written an entire book on this topic, Overcoming Resistance in Cognitive Therapy, and my colleagues, such as Dean McKay, Jon Abramowitz, and Steve Taylor have recently published a book entitled, Cognitive-Behavioral Therapy for Refractory Cases: Turning Failure Into Success. I could go on, but I believe the objective reader understands that cognitive therapy is not a simplistic approach.

4. CBT is often viewed as the psychotherapy treatment of choice

Dr. Allen characterizes the National Institute of Mental Health as a kind of "mafia," since it appears to favor research on CBT. Well, another way of looking at this is that the NIMH has a mandate to advance the development of effective treatments. Rather than characterize scientific research as some kind of gangster rap, we might consider the fact that noted social scientists and medical scientists have now come to realize that the research is overwhelmingly in favor of CBT. Indeed, the National Health Service in the United Kingdom has an office called, National Institute for Clinical Excellence (NICE). On their website, consumers and professionals can look up a disorder and find the ratings provided for different treatments. If you go to their website and look up depression you can download a document that clearly recommends CBT. Unless we want to consider a world-wide conspiracy of a CBT mafia, we might want to consider the fact that leading serious scientists have concluded that the evidence favors CBT. Indeed, the United Kingdom has advanced the largest dissemination of psychological treatments ever implemented—primarily CBT—in the program called, Improving Access to Psychological Treatments. This program was begun under Prime Minister Tony Blair who, in my view, bears little resemblance to a Mafia Don.

Let me finish with a few words of gratitude on this Thanksgiving Eve. My gratitude, my respect and admiration, goes out to Dr. Aaron Beck, the founder of cognitive therapy. Beck is 90 and still active-still publishing, still doing research, still training people, still an inspiration. Those of us who know him as "Tim" are in considerable debt to his courage in facing down the forces of the psychoanalytic movement in the 1960s and in his brilliance in advancing CBT. I first met Tim 30 years ago—December 1981. This is a celebration for me, in my view, of that meeting. But it is not only my own personal gratitude that Tim deserves. It is the gratitude of the thousands of people worldwide who have used his powerful ideas to change the world one person at a time. And it is the gratitude of the hundreds of thousands of people whose lives have been made better and made more meaningful by this gentle, brilliant, and courageous man. So, let me end by saying, "Happy Thanksgiving, Tim, from all of us to you and your family."

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