What is the secret of the enduring success of Cognitive Behavioural Therapies?

Do not seek for what is good outside of yourself, but seek it within you, or else you would never find it [1]; These words by a 2nd century AD Greek philosopher Epictetus can be looked upon as epitomizing cognitive behavioral therapy (CBT), a popular method of therapy that has been widely applied to a variety of problems [2]. The success of this therapy was predicted aptly in a 2002 Washington Post article: “For better or worse, cognitive therapy is fast becoming what people mean when they say they are ‘getting therapy’”[3]. Since then, Surveys of therapists evince that CBT is quickly becoming the main orientation of practicing psychologists [4]. To the extent, that some have ventured to call it the gold standard of the psychotherapy field [5]. To understand the success of CBT we must look at its origin, its nature, and its effects.

CBT was pioneered by Aaron T. Beck (1921-2021) when in one of his psychoanalytical sessions he noticed that thoughts were not as unconscious as Freud (1856-1939) had theorised and certain ways of thinking could be responsible for emotional distress [6]. In contrast to the prevalent psychoanalytical methods which were focused on unearthing unconscious materials, with a strong focus on the past, CBT emphasises the present-it focuses on the “here and now” problems [7] CBT in the present day refers to class of therapies that have the prime premise that psychological distress and mental disorder are maintained by cognitive factors [2].

CBT has proven to be a popular treatment among therapists [4]. This success can be attributed to various reasons: Firstly, it is the most researched form of psychotherapy. Moreover, CBT was the first form of therapy that was tested with the strictest criteria of evidence based-framework used in the field of health. Therefore, it became the first evidence-based psychotherapy in most clinical guidelines and this led to its adoption instead of less thoroughly researched, newer, and later-tested psychotherapies [5].

Another fundamental reason for the success of CBT is its effectiveness. In a combined study Fordham et al., [8] found that CBT improves the quality of life by a modest amount and these improvements were maintained for more than 12 months after CBT was administered. CBT has also proven reliable for Anxiety Disorders [9], which are the most common class of mental disorders [10], for instance, CBT for social anxiety disorders showed a medium to large effect size post-treatment. Furthermore, it showed superior performance over psychopharmacology in the long term. Even in the case of Panic disorders, without agoraphobia, CBT was superior when compared to medications [11][2].

A further reason for the preference for CBT is grounded in an economic rationale. Considering an estimated 1.7 billion pounds was spent in England in 2007 treating people suffering from depression [12], a cost which has risen yearly, although is eclipsed by costs of lost productivity which have been estimated to be 4 times greater. This need to find a cost-effective treatment has led to the further success of CBT. CBT as an adjunct to usual care (e.g., Pharmacotherapy ) has been proven to be a cost-effective treatment for people with treatment-resistant depression [13] As an individual intervention for anxiety and depression, CBT has proven cheaper than medication. Various studies have found that CBT costs less and increases societal benefits [14].

While there is no denying that CBT is one of the best treatments we have currently, it has its shortcomings. Some relate to its lack of efficacy when compared to medicines (eg., 15) and psychosocial treatments for some psychological disorders. While others point out an overestimation of its effect because of bias [16]. Others still, point out experimental flaws that weaken the research studying CBT (use of waitlist treatments) [17][18].

In light of all the flaws, is the success of CBT justified and are researchers reasonable in calling it the gold standard? while the evidence in favour of CBT is less strong than has been claimed, it is important to recognise that CBT is the best empirically studied psychotherapy; in the case of other psychotherapies, fewer high-quality studies exist [18].

Yet, It cannot be called Gold standard if gold standard is defined as the best we can have in the field; However, if gold standard is defined as the best we have at the moment then it can be argued that indeed CBT is the gold standard [5]. In other words, CBT may not be perfect but it is the best we have right now.

References

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Epictetus. Discourses, Fragments, Handbook. London, England: Oxford University Press; 2014.

2.

Hofmann SG, Asnaani A, Vonk IJJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognit Ther Res [Internet]. 2012;36(5):427–40. Available from: http://dx.doi.org/10.1007/s10608-012-9476-1

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Simon CC. A change of mind. The Washington Post. 2002 Sep 3.

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Norcross JC, Karpiak CP, Santoro SO. Clinical psychologists across the years: the division of clinical psychology from 1960 to 2003. J Clin Psychol [Internet]. 2005;61(12):1467–83. Available from: http://dx.doi.org/10.1002/jclp.20135

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David D, Cristea I, Hofmann SG. Why cognitive behavioral therapy is the current gold standard of psychotherapy. Front Psychiatry [Internet]. 2018;9:4. Available from: http://dx.doi.org/10.3389/fpsyt.2018.00004

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Oatley K. Emotions: A Brief History. Oatley K, editor. Vol. 190. London, England: Blackwell Publishing; 2004.

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Fenn K, Byrne M. The key principles of cognitive behavioural therapy. InnovAiT [Internet]. 2013;6(9):579–85. Available from: http://dx.doi.org/10.1177/1755738012471029

8.

Fordham B, Sugavanam T, Edwards K, Stallard P, Howard R, das Nair R, et al. The evidence for cognitive behavioural therapy in any condition, population or context: a meta-review of systematic reviews and panoramic meta-analysis. Psychol Med [Internet]. 2021;51(1):21–9. Available from: http://dx.doi.org/10.1017/s0033291720005292

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Hofmann SG, Smits JAJ. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry [Internet]. 2008;69(4):621–32. Available from: http://dx.doi.org/10.4088/jcp.v69n0415

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Bandelow B, Michaelis S. Epidemiology of anxiety disorders in the 21st century. Dialogues Clin Neurosci [Internet]. 2015;17(3):327–35. Available from: http://dx.doi.org/10.31887/dcns.2015.17.3/bbandelow

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Mitte K. Meta-analysis of cognitive-behavioral treatments for generalized anxiety disorder: a comparison with pharmacotherapy. Psychol Bull [Internet]. 2005;131(5):785–95. Available from: http://dx.doi.org/10.1037/0033-2909.131.5.785

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Overview | Depression in adults with a chronic physical health problem: recognition and management | Guidance | NICE. [cited 2023 Mar 27]; Available from: https://www.nice.org.uk/guidance/cg91

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Hollinghurst S, Carroll FE, Abel A, Campbell J, Garland A, Jerrom B, et al. Cost-effectiveness of cognitive–behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: economic evaluation of the CoBalT Trial. Br J Psychiatry [Internet]. 2014;204(1):69–76. Available from: http://dx.doi.org/10.1192/bjp.bp.112.125286

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Myhr G, Payne K. Cost-effectiveness of cognitive-behavioural therapy for mental disorders: implications for public health care funding policy in Canada. Can J Psychiatry [Internet]. 2006;51(10):662–70. Available from: http://dx.doi.org/10.1177/070674370605101006

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Van der Oord S, Prins PJM, Oosterlaan J, Emmelkamp PMG. Efficacy of methylphenidate, psychosocial treatments and their combination in school-aged children with ADHD: a meta-analysis. Clin Psychol Rev [Internet]. 2008;28(5):783–800. Available from: http://dx.doi.org/10.1016/j.cpr.2007.10.007

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Cuijpers P, van Straten A, Andersson G, van Oppen P. Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. J Consult Clin Psychol [Internet]. 2008;76(6):909–22. Available from: http://dx.doi.org/10.1037/a0013075

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Cuijpers P, Cristea IA, Karyotaki E, Reijnders M, Huibers MJH. How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry [Internet]. 2016;15(3):245–58. Available from: http://dx.doi.org/10.1002/wps.20346

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Leichsenring F, Steinert C. Is cognitive behavioral therapy the gold standard for psychotherapy?: The need for plurality in treatment and research. JAMA [Internet]. 2017 [cited 2023 Mar 27];318(14):1323–4. Available from: https://jamanetwork.com/journals/jama/article-abstract/2654783