In no mood for therapy
Has one of the most popular treatments for depression been oversold?
Trends in psychotherapy have shifted dramatically in the past two decades. Most patients (and medical plans) have taken a pass on the long-term commitment to Freudian analysis, turning instead to shorter approaches. One therapy that has taken over--especially for depression--is a method called cognitive behavioral therapy.
CBT is based on the idea that all moods--and their disorders--originate in thoughts. The therapy aims to adjust attitudes by recognizing and refuting negative thoughts as they occur. For instance, some people react to a mistake or mishap by generalizing to "I'm a failure." A CBT therapist would help the patient get to a more accurate assessment of the event, like "What a bad day." The effectiveness of this hugely popular treatment has been touted in a number of academic studies and general-interest books. Proponents say that it often works faster and can be more effective than traditional psychotherapy--or even antidepressants.
Except they may be wrong. Gordon Parker, head of the School of Psychiatry at the University of New South Wales in Sydney, Australia, and two researchers went over the results of every available effectiveness study that's been done on CBT. Taken together, Parker argues in a recent issue of the American Journal of Psychiatry, the results really don't support the claims. Their conclusion: "CBT has been oversold," says Parker. ". . . As far as we can tell, it doesn't have any superiority over any other psychotherapy."
CBT has snowballed in popularity not because the scientific evidence is compelling, Parker says, but because "it is immensely appealing [and sounds] so terribly logical." Parker, who is somewhat disappointed in his own findings, has recommended the therapy to many of his patients. Now, he speculates that any positive outcomes might have come not from CBT itself but simply from spending time with an empathetic therapist.
The review did contain one caveat: "There may be a subgroup of people who do very well with CBT." Indeed, part of the difficulty with evaluation is that studies tend to be done on heterogeneous groups, instead of subgroups of people with specific symptoms, he says. So it's not clear who is really benefiting.
Taking issue. Not surprisingly, many fans disagree with Parker's conclusions. Andrew Butler, research coordinator for the Beck Institute for Cognitive Therapy and Research in Bala Cynwyd, Pa., is critical of the methodology used in Parker's review. (The institute is named after Aaron Beck, the psychiatrist who came up with CBT in the 1960s.) Butler says that while some research flaws do exist, "numerous studies have shown that clients who overcome their depression using cognitive therapy are twice as likely to remain depression free a year later as clients who got better using antidepressant medication."
Others argue that, while the studies are imperfect, there is enough solid empirical evidence to justify CBT's reputation. Jacqueline Persons, director of the San Francisco Bay Area Center for Cognitive Therapy, says that the bottom line is that CBT does work: "And that is true even though we do not know as much as we would like to about why or how it works."
Psychiatrist David Burns is the most well-known popularizer of CBT. His book Feeling Good: The New Mood Therapy has more than 4 million copies in print. He says: "I'm no less in love with the cognitive model than I was 30 years ago." But even Burns agrees that the studies are "underwhelming" and that "there's a huge need to improve how we do research." Along with faulty methodology, he says, there are several human variables that make valid testing difficult. For example, most studies have no way to control for a patient's motivation. Exercises and other "homework" are a big part of the therapeutic process in CBT. Some patients do the work, and some don't bother, and that could account in part for the mixed outcomes.
Nor do the studies take into account an individual therapist's skills and manner. As a consequence, it's hard to tell if a patient's success or failure is due to the therapeutic technique or the therapist. "We have seen many therapists with big reputations who have poor empathy and get terrible results, and we've seen therapists who seem rather inept get incredible results," says Burns. This despite the fact, he adds, that "all therapists fancy themselves empathetic and warm."
The CBT debate is guaranteed to continue as the studies keep coming. One published last week in the Journal of the American Medical Association showed that young, low-income Latin and African-American women on CBT did almost as well as they did on antidepressants.
This story appears in the July 14, 2003 print edition of U.S. News & World Report.