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Newman, M.G., Agras, W.S., Haaga, D.A.F., & Jarrett, R.B. (2021). Cognitive, behavioral, and cognitive-behavioral therapy. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 14.

Cognitive-behavioral therapy (CBT) is the most researched psychotherapy for many disorders including depressive disorders. Depression is a global health problem that affects physical and emotional health and is associated with many adverse effects (substance dependence, poverty, illness). And so, finding good treatment options for patients with depression is an important goal. Many treatment guidelines view CBT as one of the first-line treatments for depression based on the research that demonstrates its efficacy. In this chapter of the Handbook, Newman and colleagues review the research on the efficacy of CBT. Immediately post-treatment, the effect sizes for CBT were medium to large when compared to treatment as usual (g = .59, 95% CI [0.42, 0.76]), placebo control groups (g = 0.51, 95% CI [0.32, 0.69]) and wait list/no treatment control groups (g = 0.83, 95% CI [0.72, 0.94]). The effects of CBT for depression tend not to differ from other bona-fide psychotherapies including interpersonal psychotherapy (IPT) (g = –0.09, 95% CI [–0.39, 0.20]), psychodynamic therapies (g = 0.25, 95% CI [–0.07, 0.58]), and supportive psychotherapy (g = 0.15, 95% CI [–0.06, 0.25]). The effects of CBT are also similar to those achieved with anti-depressant medications (g = 0.03, 95% CI [-0.13, 0.18]). Approximately 41% of patients with major depression who receive CBT have significantly fewer depressive symptoms immediately post-treatment than the average patient treated in a placebo or waiting list/no treatment control group. There have been some criticisms of the effect size estimates for CBT in some of these studies. For example, research indicates that newer and higher quality studies have resulted in smaller effects. And so there remains concerns that the overall effects of CBT for depression may be over-estimated.

Practice Implications

Treatment guidelines indicate that CBT is one of the first-line treatment for depressive disorders along with anti-depressant medications and other psychological therapies. CBT appears to improve both short-term and longer-term outcomes for some adults. There is also some evidence that if CBT is combined with pharmacotherapy, then patients might experience even greater improvement. CBT may result in patients learning something about themselves and their depression, which might reduce relapse and recurrence of the depression, although evidence for the latter is still uncertain.

Wampold, B.E., Flückiger, C., Del Re, A.C., Yulish, N.E., Frost, N.D., …Hilsenroth, M. (2017) In pursuit of truth: A critical examination of meta-analyses of cognitive behavior therapy, Psychotherapy Research, 27, 14-32.

The vast majority of meta-analyses of studies that compare different brands of psychotherapy for any particular disorder indicate that differences between treatments are quite small and clinically trivial. Meta-analyses are an important way of aggregating effect sizes across studies and of providing reliable estimates of the state of a research field. But meta-analyses are not perfect - they rely on judgements made by the researchers that may bias findings. Despite a large body of evidence to the contrary, three meta-analyses in particular have purported to demonstrate that cognitive-behavioral therapy (CBT) is superior to other therapies for some specific disorders. In this paper, Wampold and colleagues critically review these three meta analyses to see if in fact CBT is superior to other psychotherapies. A meta-analysis by Tolin that reported that CBT was more efficacious than other therapies for anxiety and depression was surprising given that it contradicted 5 previous meta-analyses. It turns out that Tolin misclassified some treatments as CBT (including eye movement desensitization and reprocessing [EMDR] and present-centred therapy [PCT]). Further, Tolin made a critical computational error with one of the studies that when corrected wiped out any superiority for CBT. A second meta-analysis by Marcus and colleagues reported small differences in favor of CBT for primary (i.e., target symptoms) outcomes at post-treatment but not at follow up. Wampold and colleagues reported that the small difference at post-treatment was unduly affected by one study in the meta-analysis that showed unusually large effect in favor of CBT (i.e., the study was likely unreliable because its results were so much out of line with all other studies). Further, the purported superiority of CBT disappeared in the longer term. Finally, a meta-analysis by Mayo-Wilson and colleagues published in the prestigious journal Lancet Psychiatry used a network meta-analysis to compare treatments, and reported that CBT was more effective than other psychotherapies. Network meta-analysis relies heavily on indirect comparisons rather than including only studies that directly compared two therapy modalities. For example, if there are only a few studies that compare treatment A to treatment B (AB), one could look at studies of treatment A versus treatment C (AC), and studies of treatment B versus treatment C (BC), and then use the transitive property (remember high school math?) to estimate the effect of AB indirectly from the studies of AC and BC. It turns out that this practice in the context of meta-analysis is unreliable and can grossly over-estimate differences between treatments.

Practice Implication

The vast majority of meta-analyses show that bona-fide psychotherapies are effective, and one therapeutic orientation does not seem to be superior to another. The three meta-analyses that run counter to this conclusion are deeply flawed. To claim that one treatment is more effective than another will limit patients’ access to other treatments. This is concerning, since most time-limited treatments result in about half of patients recovering from their mental health problems. And so many patients and their therapists need more therapeutic options to draw upon. Falsely claiming that one treatment is more effective than others may lead insurance companies and government policy makers to make erroneous decisions to fund only one type of therapy.

Jennissen, S., Huber, J., Ehrenthal, J.C., Schauenburg, H., & Dinger, U. (2018). Association between insight and outcome of psychotherapy: Systematic review and meta-analysis. The American Journal of Psychiatry. Published Online: https://doi.org/10.1176/appi.ajp.2018.17080847

For many authors, one of the purported mechanisms of change in psychotherapy is insight. In fact, the utility of insight for clients with mental health problems was first proposed over 120 years ago by Freud and Breuer. Briefly, insight refers to higher levels of self-understanding that might result in fewer negative automatic reactions to stress and other challenges, more positive emotions, and greater flexibility in cognitive and interpersonal functioning. Although insight is a key factor in some psychodynamic models, it also plays a role in other forms of psychotherapy. Experiential psychotherapy emphasises gaining a new perspective through experiencing, and for CBT insight relates to becoming more aware of automatic thoughts. Jennissen and colleagues defined insight as patients understanding: the relationship between past and present experiences, their typical relationship patterns, and the associations between interpersonal challenges, emotional experiences, and psychological symptoms. In this study, Jennissen and colleagues conducted a systematic review and meta analysis of the insight-outcome relationship, that is the relationship between client self-understanding and symptom reduction. They reviewed studies of adults seeking psychological treatment including individual or group therapy. The predictor variable was an empirical measure of insight assessed during treatment but prior to when final outcomes were evaluated. The outcome was some reliable and empirical measure related to symptom improvement, pre- to post- treatment. The review turned up 22 studies that included over 1100 patients mostly with anxiety or depressive disorders who attended a median of 20 sessions of therapy. The overall effect size of the association between insight and outcome was r = 0.31 (95% CI=0.22–0.40, p < 0.05), which represents a medium effect. Moderator analyses found no effect of type of therapy or diagnosis on this mean effect size, though the power of these analyses was low.

Practice Implications

The magnitude of the association between insight and outcome is similar to the effects of other therapeutic factors such as the therapeutic alliance. When gaining insight, patients may achieve a greater self-understanding, which allows them to reduce distorted perceptions of themselves, and better integrate unpleasant experiences into their conscious life. Symptoms may be improved by self-understanding because of the greater sense of control and master that it provides, and by the new solutions and adaptive ways of living that become available to clients.

Author email: Simone.Jennissen@med.uni-heidelberg.de

Cristea, I.A., Gentili, C., Cotet, C.D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.4287.

Borderline personality disorder (BPD) is a debilitating disorder characterized by: severe instability of emotions, relationships, and behaviors. More than 75% of those with BPD have engaged in deliberate self-harm, and suicide rates are between 8% and 10%. BPD is the most common of the personality disorders with a high level of functional impairment. Several psychotherapies have been developed to treat BPD. Most notably, dialectical behavior therapy (DBT), cognitive behavioral therapy (CBT), and psychodynamic treatments like mentalization-based and transference-focused psychotherapy. This meta-analysis by Cristea and colleagues examined the efficacy of psychotherapy for BPD. Studies included in the meta-analysis (33 trials of 2256 clients) were randomized controlled trials in which a psychotherapy was compared to a control condition for adults with BPD. For all borderline-relevant outcomes (combined borderline symptoms, self-harm, parasuicidal and suicidal behaviors) yielded a significant but small effect of the psychotherapies over control conditions at post treatment (g = 0.35; 95%CI: 0.20, 0.50). At follow up, there was again a significant effect of the psychotherapies over control conditions with a moderate effect (g = 0.45; 95% CI: 0.15, 0.75). When the different treatment types were looked at separately, DBT (g = 0.34; 95% CI: 0.15, 0.53) and psychodynamic approaches (g = 0.41; 95% CI: 0.12, 0.69) were more effective than control interventions, while CBT (g = 0.24; 95% CI: −0.01, 0.49) was not. The authors also reported a significant amount of publication bias, suggesting that published results may be positively biased in favor of the psychotherapies.

Practice Implications

The results indicate a small effect of psychotherapies at post-treatment and a moderate effect at follow-up for the treatment of BPD. DBT and psychodynamic treatment were significantly more effective than control conditions, whereas CBT was not. However, all effects were likely inflated by publication bias, indicating a tendency to publish only positive findings. Nevertheless, various independent psychotherapies demonstrated efficacy for symptoms of self harm, suicide, and general psychopathology in BPD.

The Great Psychotherapy Debate: Starting in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Change in dysfunctional attitudes or cognitions is one of the specific mechanisms by which cognitive therapy (CT) is thought to be effective in the treatment of depression. In this part of their book, Wampold and Imel discuss the evidence that addresses the specific change mechanisms for CT. The reason they focus on CT is that CT is by far the most researched psychotherapy approach, and there is a substantial number of CT studies that have addressed this issue of change mechanisms. In an early meta analysis, Oei and Free (1995) found a significant relationship between change in cognitions and CT. However, in the same meta analysis, the authors found that CT and non-cognitive therapies did not differ in terms of their effects on cognitions. That is, most treatments, whether CT or not, appeared to change cognitions. In another study, three different interventions (behavioral activation, CT, and CT plus behavioral activation) all resulted in change in cognitions and improved depression. In other words, cognitive interventions do not seem to be needed to alter cognitions and reduce depression. Wampold and Imel argue that nonspecific processes in CT (and other psychotherapies for that matter) are largely responsible for the effectiveness of psychotherapy. For example, there is evidence to suggest that a number of patients show substantial symptom improvement early in treatment before specific cognitive techniques are introduced. Some have argued that this early favourable response is largely due to the effects of client expectations, reassurance, and remoralization rather than the specific procedures of the therapy. Moreover, patients who experience this remoralization early-on may be better at successfully applying techniques taught in CT. A large review of this literature concluded that there was insufficient evidence to support the notion that challenging thoughts was responsible for the positive effects of CT.

Practice Implications

This line of research appears to indicate that the specific practice of challenging thoughts or dysfunctional attitudes is not primarily responsible for patient change in CT. It may be that for any psychological treatment that has a cogent rationale for the disorder and is administered by an acknowledged expert, client progress may be determined largely by contextual factors. These factors may include a therapeutic alliance, client expectations of benefit, and client remoralization, which may in turn allow clients to benefit from the specific interventions of psychological treatments.

Hollon, S.D. & Beck, A.T. (2013). Cognitive and cognitive-behavioral therapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 393-442). New York: Wiley.

Cognitive (CT) and cognitive behavioural therapies (CBT) are among the most empirically supported and widely practiced psychological interventions. CT emphasizes the role of meaning in their models of depression and CT interventions emphasise testing the accuracy of beliefs. More behavioural approaches like CBT see change in terms of classical or operant conditioning of behaviours, in which cognitive strategies are incorporated to facilitate behavioural change. In this section of their chapter, Hollon and Beck review research on CT for depression. Depression is the single most prevalent mental disorder and is a leading cause of disability in the world (see this month’s blog entry on the global burden of depression). Most patients have multiple episodes of depression (i.e., recurrent) and about 25% have episodes that last for 2 years or more (i.e., chronic). CT posits that depressed individuals have negative automatic thoughts that are organized into depressogenic automatic beliefs (or underlying assumptions) that put them at risk for relapse. Automatic beliefs can be organized in latent (or unconscious) schemas often laid down in childhood and activated by later stress that influence the way information is organized. In CT patients are taught to evaluate their beliefs (also called empirical disconfirmation), conduct “experiments” to test their accuracy and to modify core beliefs and reduce maladaptive interpersonal behaviours. Most reviews show that CT for depression is superior to no treatment (with large effects) and at least as effective as alternative psychological or pharmacological interventions. Most patients show a good response to CT with about one third showing complete remission. Although some practice guidelines have concluded that medications are preferred to CBT (or any psychotherapy) for severe depression, more recent meta analyses show that CT is as efficacious as medications and is likely better in the long term. CT also has an enduring effect that protects clients against symptoms returning. Medications, on the other hand suppress depressive symptoms only as long as the patient continues to take the treatment, but medications do not reduce underlying risk. As a result, relapse rates for medication treatment of depression are much higher than for CT. These findings suggest that patients who receive CT learn something that reduces risk for recurrence, which is the single biggest advantage that CT has over medications. Further, CT is free from problematic side effects that may occur with medications.

Practice Implications

CT and CBT are the most tested psychological treatments for depression and the evidence indicates that many patients benefit. CT and CBT are as effective as medications for reducing acute distress related to depression, and even for those with more severe depression when implemented by experienced therapists. CT has an enduring effect not found in medications, may also help prevent future episodes of depression, and may prevent relapse after medications are discontinued.