Is the Dominance of CBT-Lite Coming to an End?
New experiments with enhanced rates for CBT may finally make dissemination work.
Posted Feb 16, 2019
When therapists advertise that they deliver cognitive behavioral therapy (CBT) to clients, what, exactly, do they deliver? In research studies, therapists are monitored very closely to ensure fidelity to the CBT protocols as part of the studies. But in “real-world” community practice, there is no monitoring. So, when therapists advertise they do CBT, it is worth asking how closely they have to follow a protocol for it to count as true CBT.
Having trained and supervised many therapists over the years in both research studies and private practice clinics, and having talked with many patients about their experiences with other therapists, I think the way CBT is delivered falls into two categories: CBT and CBT-lite.
CBT, or what we might call full CBT, faithfully delivers a full course of CBT by following a protocol manual closely. There are different types of manuals, depending on what type of instructions the creators of each type of CBT published. Some manuals are minimally structured in their guidance for therapists, often described broadly as phases of treatments, with the exact sequence of steps allowed to be flexible; the manuals are published frequently as books rather than actual step-by-step manuals. Other manuals are highly structured (including mine), more like cooking recipes, which guide therapists and patients through clearly-defined step-by-step sequences for each weekly session. But all of the protocols, whether phase-driven books or step-by-step manuals, share the concepts of following a sequence of steps, comprehensively covering core topics, repetition of the key activities, relatively high-directive structuring of sessions by clinicians, and a time-limit to the treatment.
In contrast, CBT-lite means using some, but not all, techniques of a protocol. CBT-lite typically means eclectic psychotherapy, usually consisting of non-directive listening to the events of the past week, advice-giving supportive therapy for relatively lower functioning clients, or psychodynamic interpretations for relatively higher functioning clients, with occasional didactics about one or another CBT technique used out of sequence from a protocol. All of the key CBT elements are not covered, therapists are not highly directive, sessions are not routinely structured, and there is no time limit to treatment. In my experience of asking clinicians if they do CBT, they reply yes, but CBT-lite is what they do. For some clients, CBT-lite is all they need or all they can handle, but most are never given choices.
Voluntary Implementation Has Largely Failed
While CBT is the commonly recommended evidence-based treatment (EBT) to treat PTSD, it is rarely available to patients who need it. In a 2009 review of the literature, Shafran and colleagues (2009) documented that less than half of patients with a variety of disorders received EBTs. Lack of access to EBTs, including full CBT, is a problem despite massive dissemination attempts. In addition to large and expensive dissemination and implementation trainings for therapists by the U.S. Veterans Administration and the United Kingdom’s National Health Service, there have been hundreds of such projects sponsored by states, cities, and agencies around the world. Shafran’s review confirmed what folks have long suspected that these dissemination efforts were ineffective, but we’ve lacked systematic data about what happens in these trainings.
With findings from a new study, we now know exactly what happens after a dissemination and implementation training. We conducted the first study that closely tracked how therapists use CBT training in the real world, and the findings provide new details to explain what Shafran and colleagues found. We offered free one-day workshop trainings on CBT for PTSD, plus free six months of phone consultation, to every clinician in the state of Louisiana who treats children and adolescents and who accepts Medicaid (Miron and Scheeringa, 2019). What happened after clinicians attended our CBT training workshops for evidence-based psychotherapies was three things.
(1) Of the 335 who accepted our one-day workshop training, 65% opted not to participate in the phone consultation phase of the training. It may be safe to assume that the majority of participants ignored most of what they learned and rarely, if ever, will attempt to offer the CBT to clients. It is possible that most of them took the training to get free continuing education credits.
(2) Thirty-five percent opted to participate in the phone consultation phase, but two-thirds of them did not complete the full six months of calls. The two-thirds of therapists who dropped out of the phone consultations likely represent, as Shafran and colleagues found, that when an EBT is reportedly delivered, it is delivered suboptimally. Lacking the experience of ever completing a full case with fidelity to a protocol, these therapists likely practice CBT-lite.
(3) Only 13% completed the full training and achieved basic competence in the model. These therapists embraced EBT and are likely to provide it faithfully to clients.
Market Premises and New Initiatives
What happened in our project is likely what happened in the hundreds of previous dissemination projects. I believe that, notwithstanding small changes in practice across the world, these types of voluntary implementation efforts have failed. There need to be new models for implementation.
North Carolina is in the midst of the first-known initiative in the United States to use a reimbursement-based incentive model to try to shift providers toward fuller implementation of evidence-based psychotherapy treatments. In 2013, the state legislature budgeted recurring annual funding to develop a plan to reimburse rostered clinicians with enhanced rates for providing four different EBT’s for traumatic stress, including CBT (Murphy, 2018). The state seems to still be in the training and early start-up phase, and it is not evident yet how the program is working (Amaya-Jackson et al., 2018).
One of the five Medicaid managed care organizations in Louisiana is poised to launch the second state-wide enhanced rate initiative. The trainings have started, but enhanced reimbursement rates are still in the planning stages.
In both the North Carolina and Louisiana market-based initiatives, CBT, but not CBT-lite, will be eligible for the enhanced rates. Money talks, so these programs are probably going to make a lot of clinicians reevaluate their practices. Clinicians who are currently out-of-network for Medicaid may consider becoming in-network. Clinicians who currently know how to do only CBT-lite, may consider switching to full CBT.
The effects of this may be to shift some leverage to consumers and increase transparency in the psychotherapy industry. With a new emphasis on quality of care, and the advances in different ways to access care, clinicians are slowly being forced to look at their practices more from a broader market perspective. A central premise of most businesses is to produce and sell a product to make enough profit to, at the least, stay in business, and, at the most, to outsell their competitors in the market. A central premise of most consumers is to purchase the best quality product they can afford at the lowest price they can find. Priorities for consumers usually include to have a wide range of choices with different levels of quality to pick from. In a free market economy, the push-pull between the business premise and the consumer premise leads to creation of a diversity of products at different levels of quality and price. Individual businesses can opt to produce few or many products with either low- or high-level quality.
Whereas debates about what psychotherapies are best have historically been between clinicians sitting across tables in committees for writing practice guidelines, these new developments open the possibility for consumers to have more choice, and therefore more leverage in the market. But in order for consumers (i.e., patients), to have leverage in the market, they have to have choices of different products to select from, i.e., CBT versus CBT-lite.
Healthcare is not an industry in which high diversity of products and levels of quality are easy to create or define, and consumer-patients have had few choices when it comes to psychotherapy. As market-based initiatives begin to make it more transparent for the consumers what constitutes CBT versus CBT-lite, it may be the start of a business model that consumers can engage with in a more transparent and effective way.
Amaya-Jackson L, Hagele D, Sideris J, Potter D, Briggs EC, Keen L, Murphy RA, Dorsey S, Patchett V, Ake GS, Socolar R (2018). Pilot to policy: statewide dissemination and implementation of evidence-based treatment for traumatized youth. BMC Health Services Research. 18(1):589, 2018 07 28.
Miron D, Scheeringa, MS (2019). A Statewide Training of Community Clinicians to Treat Traumatized Youths Involved with Child Welfare. Psychological Services 16(1), 153-161, doi 10.1037/ser0000317.
Murphy RA (2018). How Medicaid and Managed Care Can Support Evidence-Based Treatment in North Carolina That is Informed by Adverse Childhood Experiences. North Carolina Medical Journal. 79(2):119-123, 2018 Mar-Apr.
Shafran, R., Clark, D. M., Fairburn, C. G., Arntz, A., Barlow, D. H., Ehlers, A., . . . Wilson, G. T. (2009). Mind the gap: Improving the dissemination of CBT. Behaviour Research and Therapy, 47(11), 902-909. doi: 10.1016/j.brat.2009.07.003