What if you could just forget about all that complex cognitive challenging, understanding of logical fallacies and the mental demand this asks of the clinician working in the room? A new paper out in the latest Clinical Psychology Review suggests that maybe you can. Richard Longmore and Michael Worrell have a provocative paper (can't make a link) entitled: Do we need to challenge thoughts in cognitive therapy?
..... is the direct, explicit modification of maladaptive cognitions a necessary or sufficient intervention in CBT? Hayes (2004) identified three empirical anomalies in the CBT outcome literature. First, component analyzes do not show that cognitive interventions provide added value to the therapy. Second, CBT treatment is often associated with a rapid, early improvement in symptoms that most likely occurs before the implementation of any distinctive cognitive techniques. Third, measured changes in cognitive mediators (the thoughts and beliefs held by the cognitive model to underpin disorder) do not seem to precede changes in symptoms.
Longmore and Worrell take us through a range of depressive and anxiety disorders including OCD and provide research showing that behavioural components are as effective if not more effective than the CT component. In other words leaving out cognitive challenging doesn’t make a lot of difference to outcome. I would have to say the paper appears pretty convincing and it will be interesting to see what scholarly refutation to this is raised. Studies on behavioural activation by Jacobson et al in the mid nineties raise some interesting questions.
Jacobson et al. (1996) study has potentially serious implications for both the theory and practice of CBT for depression. In practical terms, behavioral activation is simpler and more cost effective, both in the training of therapists and delivery to patients. Further, they suggest that efficacy of behavioral interventions in the trial must lead to doubt regarding the significance of cognitive factors in the etiology and maintenance of depression.
This study is currently being replicated and preliminary results suggest:
Here, it is stated that Behavioural Activation proved as effective as antidepressant medication, and that both produced superior outcomes to cognitive therapy, which was no more effective than the pill placebo condition. Given that the Washington University study purports to be the largest outpatient therapy trial for depression yet undertaken, these would appear to be perplexing results for the proponents of cognitive therapy as a treatment for depression. However, putting aside the comparison with BA, the Washington results would seem to contradict many previous studies which have shown CT to be equally effective as pharmacotherapy as a treatment for moderate depression and severe depression. Therefore, it will be necessary to wait for the publication of the study's data before its full implications can be assessed.
On a practical level the behavioural stuff is so much easier to learn and to implement that the CT stuff. My observation as a supervisor is that it takes quite some time for beginning psychologists to become really competent at the cognitive challenging aspects of CBT.
The review also looks at the rapid early response debate. Reviews of CBT for depression suggest that a majority of the patients showed significant improvement in the first four weeks.
…… initial improvement was unlikely to be explained by cognitive modification techniques, and concluded instead that non specific factors mediated the majority of the improvement seen in CBT.
So maybe after all the non-specific factors that at the end of the day make for change. The therapeutic alliance seems to be making a comeback in the cognitive therapies from a number of angles.
The final aspect of the review looks at whether cognitive variables actually mediate therapeutic change. They again suggest there is limited support.
Meanwhile, a variety of studies has shown that cognitive change is an outcome of other treatments, to the same extent as in CBT. Jacobson et al (1996) suggest that difficulty identifying cognitive mediators of therapeutic change may reflect the poor quality of measures of beliefs and attitudes. Nevertheless, an important element of the rationale for cognitive interventions that changes in cognition mediate therapeutic change in CBT currently lacks empirical support.
I think what I find most interesting is that both pharmacotherapy and exposure alone treatments appear to produce cognitive changes the same as CBT.
Given how standard CBT has come to dominate the therapy delivered by psychologists and other therapists worldwide this paper is both worrying and challenging. CBT holds itself out to be empirically validated therapy and it will be interesting to see how it goes about explaining all of this. Probably it will also give a certain amount of schadenfreude for those who see CBT as Orwellian thought police.
BTW: No saying I told you so from the third wavers.