This is an important enterprise story examining the debate among mental health professionals over cognitive behavioral therapy versus traditional psychoanalysis. This is not a story that was done simply in reaction to a news release or a journal article or a talk at a scientific meeting. Rather, it is an exploration of a trend in patient care, and it’s the kind of evidence-based exploration we need more often.
Should we base treatments/interventions on science, on science tailored to the individual, or on experential approaches? (The middle option is best.)
Are clinicians paying attention to the latest science or walking to their own drumbeat – not listening to or incorporating the scientific data?
The story does not discuss the cost of CBT compared to other therapies. The story notes it is seen as a cost-effective treatment when compared to older modes of treatment that can stretch over many years (e.g. psychoanalysis) which may not have a target date or specific goals for making behavioral changes. However, cost effectiveness is a relative term; a consumer needs to know real costs – cost/session and how many sessions on average, if possible, whether insurance covers the treatment, etc. Looked at this way there may be a big difference in cost between CBT and long-term psychotherapy.
The story notes the potential benefits of CBT as improving mental health outcomes for patients with mainly mood disorders. The story does not provide any data regarding this comparison. We are told that patients using CBT sometimes do better than medicated peers, but this may be complicated by patients in a "real-life" clinical setting who do a combination therapy (meds and CBT).
A clinician makes the case that many peoples’ suffering could be avoided if a therapist "provided the right kind of treatment." This is not the case. Certain evidence-based therapies like CBT may help people identify thought processes that perpetuate depression, anxiety and other mood disorders, but peoples’ mental struggles and struggles of life cannot be avoided by psychological treatment.
The story notes that in clinical practice the drop-out rate for strict CBT therapy is high, but does not really explain why this is the case. The story notes that evidence from research studies that CBT is valuable treatment for all may be biased toward people who are motived to stick with this therapeautic apprach. The story does not mention that CBT requires a great deal of homework and motivation on the part of a patient. Some patients may prefer a more passive approach to therapy or a more relational approach with their therapist. Other patients may not be capable of the homework required in many CBT protocols. We are not told what the next step is for patients who do not do well with CBT.
This is a difficult area: The harms of meds are often pretty clear – but what harms can one expect from a therapy? This requires some unconventional thinking – what are the effects on employability if you’re taking off work regularly for treatment? Or what are the effects on interpersonal relationships?
The story interviews clinicians who provide different perspectives and cite their rationale (and in some cases, their own research) for preferred evidence-based therapies.
The story cites clinicians who state that case studies establish other forms of psychotherapy, but then the story misses the opportunity to ask critical questions about this statement. Are case studies, case-series a convincing form of evidence? Rarely – we wouldn’t want public policy shaped by this type of evidence and if better evidence is available.
The story does not engage in disease-mongering.
However, the story notes that "in the last 20 years the treatment rate for mental disorders has nearly doubled". The story doesn’t note that diagnostic criteria for many mood disorders had broadened, so many people with milder symptoms are included in epidemiological surveys; people with milder symptoms may now be encouraged to seek professional treatment, whereas in the past they may have relied on social/family support.
The story cites many clinicians and researchers who provide their perspective on the most appropriate evidence-based psychological therapies. The interview material helps to create a balanced overview and places CBT in the context of other available and tested therapies. CBT is useful, but it may not be a panecea for all patients with mental illness.
The story does discuss different treatment approaches used by psychotherapists. Some of these approaches are supported with a larger body of scientitic evidence than others. Other empirically based psychotherapies were missed – problem solving therapy, interpersonal psychotherapy and even short-term psychodynamic. CBT is not the only evidence based psychotherapy.
The story focused on psychotherapy but it would have been useful to give more direct comparisons to alternatives.The story does not mention that many patients may use medications in combination with therapy, which can further muddy the research outcomes evidence for any therapy.
CBT is not a novel treatment. The novel aspect of the story is the question of whether clinicians are using evidence based treatment.
The focus of the story is the suggestion that too many therapists are using clinical experience rather than evidence-based, tested therapies to inform their clinical practice. The story notes that there are many variables in treating emotional problems (and people!) and one therapeutic approach does not fit all. The story notes new outcome questionnaires as a way to drive a more collaborative therapy process and provide data on cost-effectiveneness for certain therapies as effective for certain conditions and personalities.
The story does not appear to be taken from a press release. There is a great deal of independent reporting.
Systematic, Criteria-Driven
The tale of two “negative” studies. Or, how spin is applied to make research findings look more impressive. A must read. https://johnmandrola.substack.com/p/the-tale-of-two-negative-studies
The @nytimes chose to interview one of the editors of the @AnnalsofIM (publisher of this paper) who "gushed with extraordinary glee: It’s huge! There are very few things that reduce your mortality by 30%."
Turns out coffee is not one of those few things despite all that glee. https://twitter.com/garyschwitzer/status/1533202075928215558
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