Cognitive Behavioral Therapy "Evidence-Base" Is Exaggerated

Indeed, I think this is getting at a much larger and more fundamental problem in clinical practice. The status quo and our assumptions and biases might obstruct our ability to approach thinking and behavioral issues logically. But if we look around, there is no shortage of evidence that the foundations are weak.

For example, some of the practitioners here provide CBT as part of court orders in criminal cases. Sometimes it is for an NGRI or related case or due to a judge's demand for "treatment" in a bizarre case. More often, it's mandated by law for people convicted of sex offenses. It's actually quite lucrative. The presumption - and since this is a legal assertion it cannot be challenged - is that the conviction of a qualifying sex offense, no matter how mundane or the context or the nature of the person, the defendant is a 'predator' with distorted thinking and must be 'contained'. The problem with that, which quickly becomes apparent when actually getting to know these guys, is that it's more often than not unnecessary and irrelevant. There is some data that shows that "sex offender treatment" reduces recidivism, but there is more data that shows no discernable effect, and there is no data that shows any positive difference being made by "sex offender treatment", which is partially defined by law, as opposed to anything else.

Interestingly, this legal trend got its start with a Psychology Today article describing bunk claims about danger, motivation, and effectiveness of one doctor's new "program" that he was pitching not to a medical audience, but to legislators.

I think CBT has an allure to it. It allows us to point at a behavior and assert that there must be medically validated wrongthink motivating it, especially when it's something unpleasant. Doing so often obscures real underlying issues, and can compound upon them. We've had more than a few individuals express that they feel manipulated (ironic, since it is often assumed and asserted that they are inherently manipulative) and mistreated, frustrated and unsure of how to respond to treatment. In any other context, there would be no question about labelling the treatment itself as abusive.

if the patient is more of the cluster C vs. cluster B personality type, or more of a STEM/business than humanities type, more modern than postmodern, then it is more effective. The very act of challenging an untested subjective perception in narcissistic and postmodern type is too much of an invalidation to overcome. When the empirical has little value in one's life, CBT has little value. This is kind of what Kohut talked about.

Thank you for your great article.

Please have a look at these studies as well:

1) The ‘cognitive behavioural model’ of chronic fatigue syndrome: Critique of a flawed model

2) Rethinking the treatment of chronic fatigue syndrome—a reanalysis and evaluation of findings from a recent major trial of graded exercise and CBT.

3) Cognitive behavioural therapy for myalgic encephalomyelitis/chronic fatigue syndrome is not effective. Re-analysis of a Cochrane review.

4) Assessment of the scientific rigour of randomized controlled trials on the effectiveness of cognitive behavioural therapy and graded exercise therapy for patients with myalgic encephalomyelitis/chronic fatigue syndrome: A systematic review.

Although I agree regarding the need for more thorough and balanced research, I am struck by your characterization of CBT as focused on irrational thinking to the point of invalidation. CBT is similar to all treatments, in that it’s effectiveness and utility depend largely on the therapeutic relationship and skill of the clinician. Skilled CBT therapists utilize a wide array of cognitive, behavioral, and experiential techniques to walk patients through the process of disrupting and changing maladaptive coping, relationship, and emotional patterns. Furthermore, DBT is a complex form of CBT that focuses specifically on interpersonal problems and validation, among other areas.

Fantastic article, thanks for summarising. I've never been a fan of CBT and have experienced BPD my whole life. You hit the nail on the head with everything!