cognitiverationalemotivebehaviorism -- and why it's so great.

What are CBT Psychotherapies?

This article highlights one of the greatest concerns I’ve had as we move through our review of the empirical foundations underlying clinical psychology at present: its disconnect with the views of so many practitioners in the field. While many of the academic articles we’ve read have tried to cautiously circumscribe their positions in terms of support for specific interventions, clearly the British Association for Behavioural and Cognitive Psychotherapies has no such imperative. Bald-faced claims such as CBT being “based on concepts and principles derived from psychological models of human emotion and behaviour,” and involving therapists who only work “once a therapeutic alliance has been formed,” ‘treatment interventions are predicated on a robust evidence base derived from studies utilising randomised controlled and single-case methodologies that have demonstrated the efficacy and effectiveness of cognitive and behavioural psychotherapies” are proudly put forth with little or no citation. Such claims, of course, and ones much worse, are the norm amongst organizations like this one, much to the detriment of a field desperately clamoring to come out from the pall of practices like phrenology and tarot cards.

Though organizational self-promotion is a fact of life in a free market society, it occurs to me that even bare-bones regulations could reasonably be put in place for psychotherapy organizations mandating a more balanced perspective. In particular, the BABCP site espouses the various strengths of CBT (populations it’s been proved effective for, skills CBT therapists apparent must possess), but nowhere does it make mention of its limitations. I know of few who would advocate that symptoms of MR could be effectively addressed by CBT, and, as mentioned in class, CBT could certainly be shown to be nominally effective at best as a unitary treatment for severe schizophrenia, though such disclaimers (necessary in medicine as regulated by the FDA) are nowhere to be found in this field. Perhaps this would be a good role for a new APA task force.

Butler, et. al, 2006, Empirical status of CBT: review of meta-analyses

Where the BABCP article/site was unapologetically overzealous, the Butler et. al article is surprisingly evenhanded. Though clearly written by proponents of the CBT model (Beck himself is a co-author), this meta-meta analysis (a it is proudly defined in Kazrin, 1978) does an impressive job of delineating the limitations of its findings by being very careful to not compare apples-to-oranges in review of meta-analytic design, and to address such effects as researcher allegiance on outcomes. More importantly, the authors expressly address the critical issue of the persistence of treatment effects after treatment cessation. Some of these efforts seem to come up a bit short -- for instance, I’m not sure I buy the “possible explanation for the difference in findings… that researcher allegiance influences study outcomes when a new treatment is first tested, but its influence fades over time” (p. 20) – but, on the whole the findings are impressive. Most impressive, I thought, was the comparisons with psychopharmacological conditions, in which CBT (or its variant) outperformed pharmacological treatment and combination treatment for panic disorder, and outperformed medication for Bulimia. This seems to be powerful supporting evidence for treatment specificity for these disorders.

The one caveat I might offer is one the authors attempt to address. Specifically, I’m speaking of the differential effects offered by the unfortunately wide array of heterogeneous treatments being offered under the title of “CBT.” Though Butler, et. al attempt valiantly to address this (they clarify differences in modality, such as CT, CBT, Cognitive-behavioral Marital Therapy, Trauma-focused CBT, etc), for there to be truly sufficient internal validity (not my favorite axe to grind, but so be it) to ensure real equivalence, it might behoove the authors to ensure that similar methodologies (in additional to similar modality) are being appropriately compared.

Engels, et. al, 1993, Efficacy of RET: a Quant. Analysis

… and just when I thought that such an approach to treatment research might be hard to find, along comes an article from 1993 that is up to the task. In painstaking detail, Engels, Garnefski, and Diekstra provide a useful meta-analysis of RET that (in my mind) more than adequately breaks down the treatments being aggregated using a useful coding system which accounts for methodological treatment variance (i.e. types of interventions “said to be used”), allegiance effects, and other relevant variables. That such a system was devised more than 15 years ago (with little follow-up as far as I can see) is a little disheartening, but I digress. Addressing all these relevant variables, Engels et. al tentatively conclude that RET does, in fact, seem to demonstrate effects above and beyond wait-list control and placebo. Interestingly, though, it seems that a major theme of the findings in this article is that these effects are “mainly due to the therapeutic effects of rational thinking” (p. 1086). That is, rational thinking seems to have a differential effect above and beyond behavioral components – a very different finding than many studies on CBT-related interventions. I would be curious to find out more about follow-ups in RET meta-analyses since 1993 to see if such findings (as well as findings for non-YAVIS populations, as Engels et. al ask for) bear out.

Ellis, 1999, Why RET to REBT?

Our readings this week conclude with a funny little article from Ellis that, at first, seems to cast his RE(B)T as an aspiring also-ran in the emergent world of empirically-supported behavior therapies. This initially struck me as rather odd, and I wasn’t entirely dissuaded of this conception as the article progressed. However, I was certainly struck by the astonishing amount of versatility Ellis packs into (his conception of) RE(B)T. In particular, I found his framing of the empowerment of human agency (and its consequent relating of human choice to human behavior) rather compelling as a therapeutic foundation – though, admittedly, it certainly seems well-tailored to the YAVIS set. By and large, though, I had trouble distinguishing the characteristics Ellis describes as endemic to good RE(B)T specifically, from those qualities one might use to describe good therapy in general.