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Reid, J.E., Laws, K.R., Drummond, L., Vismara, M. Grancini, B., Mpavaenda, D., Fineberg, N.A. (2021). Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomized controlled trials. Comprehensive Psychiatry, 106, 152223. https://doi.org/10.1016/j.comppsych.2021.152223.

Cognitive-behavioural therapy (CBT) combined with exposure and response prevention (ERP) is considered by many the treatment of choice for obsessive-compulsive disorder (OCD). However, questions remain about the size of its effects, the reliability of the research, and the relative efficacy of CBT plus ERP compared to other psychological treatments. Reid and colleagues conducted a systematic review and meta-analysis of randomized controlled trials of CBT with ERP in patients of all ages with OCD. They included 36 studies with 2000 patients (537 children/adolescents and 1483 adults) receiving treatment and 1015 in control conditions. When compared against all control conditions, CBT with ERP showed a significant and large effect (g = 0.74: 95% CI = 0.51 to 0.97 k =36). While CBT with ERP was more effective than a “psychological placebo” (e.g., progressive relaxation; g = 1.13: 95% CI 0.71 to 1.55, k = 10) and no treatment control conditions (g = 1.27: 95% CI 0.79 to 1.75), it was no more effective than other active forms of psychological therapy (g = −0.05: 95% CI −0.27 to 0.16, k = 8). When compared to pharmacological treatment with an adequate dosage of selective serotonin reuptake inhibitors, CBT with ERP was marginally better with a small effect (g = 0.32: 95% CI -0.00 to 0.64, p = 0.05). Researcher allegiance or bias had a big impact on the effects of CBT with ERP. Researcher allegiance refers to studies conducted by researchers who prefer, favour, or have a vested interest in the treatment they are testing. In the studies identified as having researcher allegiance, a large favourable effect for CBT with ERP emerged (g = 0.95: 95% CI 0.69 to 1.2). By contrast, in trials where the authors did not identify researcher allegiance (k= 8), CBT with ERP showed no significant effects (g = 0.02: 95% CI−0.29 to 0.33). This difference was statistically significant (Q = 20.33, p < 0.005). There was no evidence of publication bias, but 28 of the 36 studies had a high risk of bias (in which there were deficiencies in the research design, procedures, or data analyses).

Practice Implications

At this point, CBT plus ERP is the most studied treatment for OCD, and it appears to be effective in reducing symptoms post-treatment. However, this meta-analysis raises more questions than it answers about the reliability of the research. Other active treatments (e.g., CBT without ERP) appear just as effective, which suggests that ERP may not be necessary to treat OCD. Researchers who favor or have a vested interest in CBT plus ERP produce much larger effects for their preferred treatment, and the quality of most of the research is low. Such findings lower one’s confidence in the conclusions drawn from the research.

Leichsenring, F. & Steinert, C. (2017). Is CBT the gold standard for psychotherapy? The need for plurality in treatment and research. JAMA, 318(14), 1323–1324. doi:10.1001/jama.2017.13737

Mental disorders are common in the population and are associated with significant impairment and economic costs. For many mental disorders, psychotherapy is considered as a first line treatment, and 75% of patients prefer psychotherapy to medications. For the past few decades CBT has been considered by some as the gold standard of the psychotherapeutic treatments, and this claim is based primarily on interpretations of the research evidence. The phrase “gold standard” implies a few things: that the evidence for the treatment’s efficacy is undisputable, and that the therapy is the most effective treatment available. In this viewpoint article, Leichsenring and Steinert raise concerns about the evidence for these claims about CBT. First, the quality of the evidence is quite low (based on ratings of randomization procedures, blind assessments, sufficient sample sizes). Only 17% of randomized controlled trials of CBT were considered high quality (83% were of low or moderate quality), and researchers have long known that lower quality studies inflate effect sizes. That is, the effects of CBT may be over-estimated, especially in the lower quality studies conducted in the early years of psychotherapy research. Second, there is evidence that researcher allegiance (the researcher’s belief in the superiority of the treatment) also inflates the effects of CBT. In some studies, for example, the therapy compared to CBT was designed to fail which made CBT look relatively more effective. Third, the true efficacy of CBT may be smaller than previously believed. Compared to treatment as usual (clinical management or medication reviews), the true effects of CBT may be small and yet inflated because of researcher allegiance. Publication bias (the tendency for researchers not to publish negative or neutral findings) may further diminish the perceived efficacy of CBT. Finally, there is no clear evidence that CBT is more effective than other psychotherapies for anxiety and depressive disorders. This has been a consistent finding over multiple meta-analyses published over the past 50 years.

Practice Implications

The research evidence does not support the claim that CBT is the “gold standard” (most effective) therapy for mental disorders. CBT is beneficial for some patients, but so are other bona fide therapies. CBT is the most studied therapy, but quantity of research does not translate into quality. Prematurely claiming that one therapy is the gold standard closes many doors for patients, clinicians, researchers, and trainees. Outcomes for patients need to be substantially improved perhaps by providing patients and clinicians with more options. Researchers should broaden their agendas to study what are the common therapeutic elements of psychotherapy. And trainees deserve more than a uniform approach to understanding the people they will treat.

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.