CBT forty years on

Albert Ellis (1913-2007)

Last year, the World Health Organization ranked depressive disorders as the third highest cause of disease burden in the world. You don’t have to look very far to verify this claim.

Psychotherapy has been rightly identified as a fundamental approach to its treatment and Cognitive Behavioural Therapy (CBT) has enjoyed pride of place in the official psychotherapeutic armamentarium.

CBT was introduced more than forty years ago. Its founding fathers were Albert Ellis (pictured above) and Aaron Beck, who essentially put forward the hypothesis that emotional distress and dysfunctional behaviour were a product of maladaptive thoughts, with ‘thoughts’ being the critical word. In their world, all one needed to do to return to emotional wellness was to realise this and change ones’ thoughts. Such change, they maintained, could be accomplished in a small number of sessions.

Studies since its inception have generally shown CBT to be a helpful intervention – so much so, that it has been adopted as the treatment of choice by Big Government – for example, patients in the UK have been able to receive CBT free of charge on the NHS; likewise patients within the public health system in Australia. The consensus has been that CBT is the way to go and there has been plenty of money thrown in its direction.

What hasn’t been looked at, until now, is how the efficacy of CBT has evolved over time, a fact which two Norwegian researchers (Johnsen and Friborg) sought to rectify.

Their paper, entitled The effects of Cognitive Behavioural Therapy as an anti-depressive treatment is falling: a meta-analysis’ leaves little to the imagination.

They examined outcome data from seventy clinical trials from the mid-1970s up until 2014, encompassing data from almost 2,500 patients diagnosed with depression. Almost 70% of subjects were women and the average age was 41 (in itself an interesting finding).

As part of the protocol, the authors focused only on studies which used the Hamilton Depression Rating Scale and Beck’s own Depression Inventory, two popular ratings scales that involve either therapist or patient objectively scoring the efficacy of the CBT intervention.

The results showed that CBT has diminished in efficacy since the 1970s, a finding that holds true across different exclusion criteria.

So what’s going on here? Is the psychotherapy model funded by governments around the world proving itself to be progressively less effective? The authors speculate:

“In the initial phase of the cognitive era, CBT was frequently portrayed as the gold standard for the treatment of many disorders. In recent times, however, an increasing number of studies… have not found this method to be superior to other techniques. Coupled with the increasing availability of such information to the public, including the internet, it is not inconceivable that patients’ hope and faith in the efficacy of CBT has decreased…”

In other words, CBT appears not to have lived up to the hype and people are finding out.

Many therapists would argue that this finding is a formality, knowing that in practice, there is rarely one technique or remedy which ‘does the trick’. One obvious short-coming of CBT is that it fails to recognise the psychodynamic – that is, the role of unconscious material in creating emotional distress and dysfunctional behaviour.

Mining the depths of a soul is rarely a rapid undertaking and so the notion that a sharp burst of six sessions could reliably unscramble thinking was always going to fall short of the mark. The emotions are, arguably, driving the thinking, so dealing with them must be top priority.

That’s not to say there is no place for CBT in psychotherapy – far from it. As part of an integrated programme of change, it can be an invaluable tool. But it’s not the only one, nor necessarily the optimal way.

Written by Jacqui Hogan