Thursday, April 11, 2013

Cognitive Behavioral Therapy (CBT) : Why Don't More Shrinks Do It?

First, I'd ask you to read Harriet Brown's article in the New York Times Well Section in "Looking for Evidence That Therapy Works." 

Ms. Brown talks about how there is little evidence-based data to support most psychotherapies, that psychotherapists tend to be wishy-washy about their approach and are vague with their ability to describe what they do, using the catch-all term "eclectic."  Furthermore, therapists over-estimate their success rates, and while there are proven psychotherapies such as cognitive behavioral psychotherapy (CBT), she notes that surprisingly few therapists use this treatment.  She suggests asking prospective therapists a variety of questions including "What manuals do you use."  

So I think this is a fair question.  If CBT works, why don't shrinks employ the techniques more?  I looked at the 365 comments on the article (anything for a blog post).  Most of them were theoretical discussions about therapy.  Many were from therapists.  There were a fair number of comments citing how screwed up therapists are.  There were 3 comments from patients saying CBT helped them.  There was 1 comment from someone saying a CBT book cured them without the therapist, after other psychotherapy had failed.  There were 3 patients who said CBT was helpful in combination with other therapies --so that awful eclectic approach. A number of people wrote in to say CBT harmed them -- unfortunately I read those comments before I got the idea to keep count, but I want to say there were ?3-4 people saying it injured them.  One person was finally helped by a form of energy therapy.

So let me ask you, especially those who have been in therapy:
 Does CBT work?  If you're a therapist, do you use it? Why or why not?  And since Ms. Brown's article questions so-called eclectic treatments, can I ask you to limit your comments to the manualized version of CBT which includes doing homework and is structured and specifically called CBT. 


Zoe Brain said...

What's the evidence?

Maybe I'm naive, but I'm hoping that there have been some large-scale experiments, double-blind, with adequate control groups and long-term follow-ups, when it comes to quite basic treatment philosophies.

Maybe some indicators to show when CBT is likely to be useful, and signs to look for in cases where it might be contra-indicated.

I know they don't call it "the Art of Healing" for nothing, each patient is different, but where's the scientific basis?

Steven Reidbord MD said...

I found Brown's piece irritating. And not just for non-sequiturs like, "few patients actually get these kinds of evidence-based treatments once they land on the couch." The couch?

CBT is great for relief of anxiety and mood symptoms, and for treating symptom-defined disorders such as major depression. I've referred many patients to CBT therapists for these kinds of complaints. But plenty of people seek therapy for reasons other than symptoms. They self-sabotage, eg, find themselves in the same dysfunctional relationship again and again. Dynamic therapy seems more helpful for such problems. The fact that CBT has more empirical evidence for efficacy says more about what is easier to study, not what is inherently better for all patients.

But the question was why more shrinks don't do CBT, an admittedly helpful modality. First, it's my impression that it's fairly common among non-psychiatrists. Brown cites a survey: 69% of US psychologists "used C.B.T. only part time or in combination with other therapies." She seems to think this proves wanton neglect of this useful treatment. But to me it says 31% use it all the time. And given that it probably isn't the best approach all the time, that seems like a pretty high percentage.

Alas, the real answer is that many of us have read a treatment manual or two, and concluded, perhaps prematurely, that manualized cognitive therapy is concrete, repetitive, and simply less interesting than dynamic work. (There are many health services that are clearly valuable, but that I prefer not to perform; dentistry comes to mind.) I'm sincerely glad formal CBT helps so many people, and also that I don't spend my days doing it myself.

Nathan said...

Part I:
I think the question, "Does CBT work?" is not particularly helpful, particularly when talking about the evidence used to support or not support treatment decisions. Treatments are not evidence-based, but their applications are. I think a more useful question is "For what outcomes is CBT helpful in engendering in particular populations?" So CBT (in its variously manualized forms) has been repeatedly shown to be moderately but reliably helpful for things like depressive symptoms, anxious symptoms, sleep issues, and obsessive/compulsive symptoms. In terms of the evidence base, many consider it a likely first line treatment for depressions,anxieties and sleep, and perhaps a second choice to the more specialized but related exposure/response therapies for OCD. If these are the things that a patient primarily wants help with, given the comparative evidence, CBT focused on these symptoms seems like a pretty good first choice intervention. Like all treatments, evidence doesn't indicate it will be helpful for everyone with these symptoms or folks will like the approach, but given limited information about patients and lack of indicators of what kind of treatments patients will respond to, if folks want symptomatic relief for some particular kinds of distresses, appreciate the clear goal-oriented and task-oriented approach, then evidence supports use of CBT. There should also be an inherent transparancy and honesty with CBT approaches, in that if folks are working at CBT and it is not helping them in the way they want, than with their therapist can focus on more pressing things, or decide that despite their best efforts, CBT in practice with an individual client is not proving to be helpful, and trying a different approach would be warranted. However, both therapist and patient should be commended that they used quality evidence to decide what treatment would be most efficient to try first.

As to Dr. Reidbord, Brown's citation, the 31% could also mean 31% of US psychologists use CBT techniques none of the time. As to the interesting-ness of doing CBT from a practioner's standpoint, I think that is a poor rationale for not doing it with for people where the aims of CBT would be helpful. A surgeon doesn't transplant someone's liver because it is more interesting than removing their appendix when someone's appendix is rupturing. Treatments should be decided on their evidence in producing desired outcomes, patients willingness/values, and clinician judgement given ambiguity of evidence due to the poor state of research in the field or when many applications of a treatment for a patient has research support, not how interesting a treatment is to a therapist (as that is gratifying one's own interest regardless of whether it is in the interest of a patient). I also think you don't give manuals enough credit. Manuals allow for quite a lot of flexibility and responsiveness and connection with patients as part of a manualized treatment approach. If anything, I think they are often less rigid than adhering to a particular theoretical orientation and approach for all patients for all of their issues like many insight-oriented therapists do.

Nathan said...

Part 2:
I do think there is no point of doing strong scientific research in mental health if findings are not widely applied. Instead of bemoaning the fact that mental health outcomes have not been increasing despite increased use of mental health services, perhaps if folks actually used strong evidence from carefully designed and executed studies to inform their practice and not just what they like to do, patients would be doing better. Given that mental health care in the US is primarily pharmacological and when psychotherapies are used either dynamic or uncritically supportive/eclectic, perhaps clinicians should make some changes.

As another aside, applying some systemic evaluation to their own practices, I think clinicians could get a better grasp on the ways and extent they are helpful and harmful, and make data-informed decisions to make personal changes. I believe I have read in a survey of therapists, 90% of therapists consider themselves to be in the top quartile of effective therapists, while all think they are in the top half. Doesn't say much for clinician judgement or understanding of probabilistic thinking that I think would be helpful in choosing and modifying treatment approaches.

I'm not a fan on how much research reifies invalid diagnostic categories as if they are real as part of their process of assessing treatment effect and how potential harm is not often considered in assessing the value of such treatments , but if folks are interested, the clinical psychologist subgroup of the American Psychological Association keeps a list of of treatments for particular issues/disorders that have shown some effect at

Joel Hassman, MD said...

CBT is efficacious therapy for those who fit the profile to apply it, but, it requires work both in the office and at home. Let's be honest, people don't want to work.

Had a patient in private practice last year who came in and was having a bit of relapse of anxiety symptoms and wanted back on an SSRI, when I advised therapy return as well, the patient went into a five minute discussion of how the patient had mastered a combination of meditation and imagery, and it was working with an impact, but was seeing too much vegetative disruptions. Patient went on the meds for 3 months and stopped, and was actually glad I reminded the patient about CBT techniques.

Not too many other examples to note though, shame.

Alison Cummins said...

People get soooo smug and judgemental in psychiatry.

Joel Hassmann, MD,
People don’t want to work at things that feel pointless. CBT can feel pretty g-d pointless.

I don’t know, but do internists spend a lot of time wondering why doctors prescribe antihypertensives or metformin instead of learning to be personal trainers and accompanying their patients to gyms?

Or do internists acknowledge that diet and exercise can do a lot but not everything, and that most patients find it easier to take medication than to lose 80 lbs, and that given that their job is to care for the patient, they are going to end up prescribing a lot of metformin and antihypertensives?

Like, really.

Steven Reidbord MD said...

4324@nathan: I agree that "CBT focused on these symptoms seems like a pretty good first choice intervention". However, you apparently misread what I wrote about "interesting-ness" after I took pains to make it clear as possible. I often refer patients to CBT therapists, just as the liver surgeon refers patients to the appendix surgeon. I'm under no obligation to be an appendix surgeon (or a dentist, or a CBT therapist) myself. The key is to avoid one-size-fits-all, and to recognize the limits of one's own scope of practice. This applies equally to CBT therapists, dynamic therapists, and psychopharm docs.

I couldn't find the source for Brown's "69%" citation, so I can't comment further on what the other 31% are doing. However, in searching for this, I ran across a full-text article that nicely summarizes some of the dilemmas of psychotherapy research:

Anonymous said...

Lisa, who is being smug and judgementsl. People are giving their opinions. We all know how you feel on this topic. That's fine. No need to name call.

Anonymous said...

Oops, I meant Allison, not Lisa. Sorry.

Anonymous said...

CBT is non-intrinsic.Its missing some things you really should be cognitively aware of. So your attending to a cognitive impairment with a cognitive impaired way of thinking.

It puts the shrink on the rap.

Joel Hassman, MD said...

Ms Cummins:

So, CBT is g-d pointless?

So is polypharmacy many times. Your point?

Yeah, patients need to realize that disease or disorder is multifactorial in cause, so therefore in treatment.

Docs don't get paid to reinforce the cognitive and behavioral changes even for hypertension and diabetes, so whip out them pads, docs, and sell your patients out!

I love the circular arguments by dissenters of mental health, meds are bad, therapy is bad, diagnosis is bad, accepting one has a problem is bad.

What do you people who think so terribly of mental health do when people are in your company who have legitimate mental health problems?

I cringe to consider your replies!

Sarebear said...

I felt/saw some holes in CBT, early on, and have been resistant to it for years and years, but in the last two years (the most productive ever, but then my trust has also slowly gotten deeper and deeper; I don't trust anybody, so if you say someone doesn't trust someone fully pretty soon, I say by that measure I'd never settle on any therapist) oy was that add or what? Anyway, in the last two years, I've decided I can set aside the bits I find too disingenuous, and use the rest. Just because something's flawed, doesn't mean it can't be useful. And it has been (over all the years, as I picked up alot, was just resistant to some of it.)

I have a blog post I've been meaning to do, that shows an example of exactly how helpful (although one example is obviously rather limited and can't show perhaps deeper things or whatever, but the issue in question was making me physically nauseaous, and I got rid of the nausea and much of the other distress I was experiencing, about something I had to deal with in physical therapy. Then again I might not get around to posting the post, but I've been meaning to scan and write it for a long time now anyway.

Now, do I think CBT can solve all my problems? No, especially since I feel that there are some disingenous and/or patronizing parts of the techniques, but I'm no longer throwing the baby out with the bathwater, either. I have found much to be helpful, and don't feel I've applied CBT nearly as much as would be beneficial. In fact, I feel I've only used a fraction of its potential for me.

My therapist is eclectic, and I would not accept any disparagement of of him or his approach (although I critically look at therapy and how or if it's working for me from time to time, as I'm the one in best position to assess it, so I'm not just blindly following wherever).

I'm tempted to not comment as I see I'm all over the place, but neither do I have to be in the most organized state of mind to post; I'm doing my best, and I know, here, that many people can understand that.

Sarebear said...

I think I need to clarify, I wouldn't accept any disparagement of my therapist or his approach with me; the eclectic approach in general, I'm not saying I don't accept people having differing regard and opinions about it. I accept that people may have such differences about my therapist's specific approach with me, too, but I won't accept any discussion of such, especially as I've already said I periodicaly critically assess things. Anyway. I don't say this to invite personal comments on my therapist or his approach with me, just saying it because I feel I need to clarify it.

Plain Anon said...

I went through CBT and found some useful bits to it, but it didn't help a lot with self-harm or suicidal ideations. Nor sleep for that matter. I've got wicked insomnia/night terrors.

But of all the kinds of therapies I've been through, I've found psychoanalysis to be the best fit for me and from what I can tell from the internet, it's the most horrible thing ever and I am not being helped at all.

I think one of the things that CBT has going for it is that it's pretty easy to pick up and understand. Most of the hospitals I've been in style their programs around CBT/DBT.

Alison Cummins said...

Joel Hassmann, MD:

I did not say CBT was always pointless. I said that it can feel pointless.

As I’m sure you’ve experienced, it’s very difficult to motivate oneself or others to do something that feels pointless.

My point? It’s not necessary to be so judgemental towards people who don’t share your perspective on what’s best for them.

I didn’t say anything about polypharmacy. However, it’s rare for people to get all judgy about people who don’t like to take lots of pills. I know that it can be frustrating to work with a schizophrenic or bipolar patient with little insight who hates the side effects of the four different medications they’ve been prescribed along with the discouraging label, but it’s rare to hear people ranting on a psych blog in a “yeah, he just wants to do yoga, he thinks he’s too special for the pills the rest of us take” kind of way. People are usually fairly sympathetic towards an individual who would rather use CBT and exercise than take medication, even if it’s obvious that they are not functioning at 100%.

“Docs don't get paid to reinforce the cognitive and behavioral changes even for hypertension and diabetes.”

Some of them do. My sister is salaried and feels lucky to have the flexibility to do exactly that. But she doesn’t spend an hour or two a week with each of her diabetic patients doing exercises with them and her colleagues don’t give her a hard time about that fact.

When she discusses the alternatives of diet and exercise vs antihypertensives with a patient and they choose antihypertensives, she writes a script. When they reject medication and express a desire to go the diet and exercise route, she helps them develop a plan. She doesn’t waste energy thinking of either type of patient as being bad/ resistant/ self-indulgent/ self-important/ lazy/ stupid/ whatever. Their health needs are their own. She’s just there to help.

“What do you people who think so terribly of mental health do when people are in your company who have legitimate mental health problems?”

Do you mean me, my beloved, my brother, my friends, my uncles or my aunt? What’s a “legitimate mental health problem” — alcoholism, bipolar, depression, schizophrenia, substance abuse? I’ve known it all.

What I do:
> Reality checks. If someone is not functioning well, I tell them. I acknowledge when someone is struggling or not at their best. I set limits on the kind of behaviour I will tolerate.
> I tell substance abusers that I am happy to visit with them or go to a movie, but not if they’re high.
> If someone seems to be engaged with a reasonable health care provider, I might generally validate that but leave well enough alone.
> If someone is unhappy with the health care they are getting or doesn’t know how to access it, I might be able to help them sort through their options.
> I try to present alternatives to either/or thinking, to point out that there are a lot of little things a person can do to chip away at depression, for instance — sleep hygeine; vitamin pills if they aren’t able to eat well; getting out into the sunshine; thinking about nice things they do that make them happy; taking antidepressants if that’s acceptable to both them and their doctor.
> I help people focus on what’s useful for them, as opposed to what they think good people should do.
> I celebrate small successes.
> I ask people if they feel up to doing things (having company, eating a meal, visiting someone else, going to the store, walking the dog) so they have the option of saying yes.
> I support people’s decisions to say no.

Life is hard enough, and help is hard enough to find, that it seems a shame to criticise someone for getting the wrong kind of help, if it’s useful.

Randall said...

I almost puked learning CBT. I'm with Bradford Keeney who says to forget theories. Otherwise you are squeezing the patient into your framework, not his. Keeney also thinks therapy should be part of the arts, not the sciences. I could go on no telling how long with the young girl in an abusive relationship. Instead I printed off a picture of Jack Nicholson from "The Shining" with a label "Honey, I'm Home!" Told her to post it on her frig and in case her partner said anything to just tell him she thought it was funny. He never got it but she did. Two weeks later she moved out and to another town. That's real therapy. Research that!

Anonymous said...

Allison, where do I begin? Obviously different things work for different people. If drugs only work for you, terrific! Don't knock others. You seem angry? What happened?

Alison Cummins said...


You could begin by pointing to where I knock others.

(You could follow up by getting my name right.)

PsychPractice said...

In my residency, we were required to participate, as therapists, in a CBT study. It was a 30 session treatment, with each session videotaped. Patients on meds were excluded as subjects, so those admitted to the study mostly had problems with relationships, family members, work-neurotic type stuff, really more amenable to psychodynamic treatment.
My supervisor, well versed in CBT, and one of the stupidest people I've ever met, told me to do CBT kinds of things with the patient that were insulting to my patient's intelligence, like read a paragraph about people on a bus. I didn't do any of the things he told me to do, but that's not what I told him. Clearly, no one actually looked at the video tapes, or they would have seen that I was doing dynamic treatment. The patient improved.
My friend and fellow resident had a patient in the study who was very depressed. She wanted to put the patient on meds, but her supervisor told her not to, so they wouldn't lose a subject. The patient really needed meds, so my friend wrote prescriptions before turning on the video tape. She never told her supervisor. The patient improved.
Most of my fellow residents did something along the same lines. The data looked really good. The patients improved on all outcome measures.
This study was done by a well-respected researcher in the field of CBT, and the study was published with much applause. Boy, look at our results, CBT really works!
Even a careful review of the data will not reveal anything but a successful study, because the data was all fudged.
This is why I don't do CBT. It might be helpful for something like a simple phobia, but, at best, you get short term results. And ala Jonathan Shedler, the "evidence base" for CBT has to do with the fact that people who think they're doing CBT are really doing something else.

Nathan said...


I would be careful looking to Shedler's big article for any well reasoned conclusions on the evidence supporting treatments (dynamic or otherwise). His article was an ideological rallying cry, intended to look tough and build some backbone for covert dynamic therapists, but really did not do/analyze/disseminate any good research.

I really like Mike Anestis's critiques of his work at (search for shedler in their search box to pull up relevant posts.) When actually looking at the individual studies Shedler relies on most (as there are well known problems with the meta-analyses he cites and his methods of comparing meta-analyses), his conclusions don't really stand. Moreso, the studies pulled together in support of his assertion are pretty weak on many fronts.

I don't know what to say in regards to the research ethics and protocols of the studies you worked on. It doesn't bode well for research and trust in this field in general.

Zoe Brain said...

Clearly, no one actually looked at the video tapes, or they would have seen that I was doing dynamic treatment. The patient improved.
My friend and fellow resident had a patient in the study who was very depressed. She wanted to put the patient on meds, but her supervisor told her not to, so they wouldn't lose a subject. The patient really needed meds, so my friend wrote prescriptions before turning on the video tape. She never told her supervisor. The patient improved.
Most of my fellow residents did something along the same lines. The data looked really good. The patients improved on all outcome measures.
This study was done by a well-respected researcher in the field of CBT, and the study was published with much applause. Boy, look at our results, CBT really works!
Even a careful review of the data will not reveal anything but a successful study, because the data was all fudged.

An ethical dilemma: do you act as healer, or scientist?

Obviously you do the best in your professional judgment for the patient.

Then you make sure that that patient is excluded from the experiment.

You didn't do that.

Worse, the experimenter was incompetent, and didn't review the video.

This shows a cultural lack of Integrity that astonishes me. It wasn't just you - you said others did it and saw nothing wrong with that. It's a systemic problem, a lack of ethics.

It means that none of the experiments conducted by the psychiatric "profession" in that time and place are trustworthy, you fake things to match your preconceptions.

Again, I don't blame you for doing the best for your patient. That was ethical. But not to publicise the fact, in medical journals, that you're frauds... and thereby likely harm hundreds if not thousands of patients treated on the basis that you weren't habitual liars.. that's wrong.

I hope your realise the extent of your problem here. I fear you don't, and will dismiss this as a personal attack, rather than someone trying to point out that you've screwed up by the numbers.

Anonymous said...

CBT felt too contrived for me. I tried it, but I just couldn't engage with it. Plus, looking back, I think my therapist at the time was just generally terrible at his job. Maybe having a good therapist would have made a difference re CBT.

Joel Hassman, MD said...

Ms Cummins:

Fine, my apology for taking your initial comment out of context.

But, to use the g-d adjective was making a point not supportive of the process, fair on my part?

Your examples of what you try to do in supporting those with mental health issues are fine. I just use your comment, again perhaps a mistake on my part but do read your overall tone to be negative about mental health care, as an example to other commenters who are very dismissive of mental health care globally.

If that does not apply to you, I won't include you again hereon.

And by the way to all who read here, I hope there is no inference that CBT is the one and only psychotherapy intervention to offer. It is one of many, the point I offer in this thread is just this: try the intervention and do the work outside the office.

If the status quo was working fine, you wouldn't be seeing the provider in the first place, true? So, isn't the reason to come into care is to enact and engage in change?

Taking a pill is "change", but if everything else continues as is, will a pill really treat the ill if it involves a psychosocial stressor of sizeable magnitude?

Change is a leap of faith at times. But, isn't the other side of the jump worth the effort?

Framing is half the battle sometimes! Listening to Vanessa Williams "The Sweetest Days" as I finish this comment, seems appropo for the moment.

JJ said...

I had a negative experience with CBT. I was in a postpartum depression and was really in a bad place. One homework assignment was to read Learned Optimism and then track negative thoughts as they occurred throughout the day via paperclips in my pocket (every time I had a negative thought, put a paper clip into my back pocket.) Anyway, the whole thing devolved into my therapist lecturing me week after week on having a negative explanatory style, because I couldn't catch as many negative thoughts as she wanted and because the CBT disputing-the-belief worksheets felt superficial... I could write it down, but it didn't change at all how I felt or functioned. I left therapy every week feeling even worse than before and in fact one night after therapy I tried to kill myself. I guess my reasoning was, if therapy is so hopeless, what hope do I have? I was so down I didn't have the presence of mine to evaluate whether this was the right therapy situation for me (it wasn't, obviously.) I really benefited from other types of therapy both before and after that experience.

Anonymous said...

I wouldn't see a shrink who could not spell. Exceptions made for ESL docs.
I would not, could not, see a shrink who spewed venom on own blog about Axis 11 types spewing venom on shrink type blogs only to come on other shrink type blogs to spew the same sort of venom. I miss Rob L. He never agreed with anyone, he always had to be right but he smart he is, I give him that.

jesse said...
This comment has been removed by the author.
jesse said...

Very interesting column by T.M. Luhrmann in the New York Times today, titled "when God is Your Therapist". She describes how much of modern evangelical Christian service is very much like CBT. A powerful way to deal with anxiety and distress.

So much in the comments here. Zoe Brain, I'm completely with you. The dilemma faced by so many practioners is that the method or study does not fit what they see the patient needs. They modify the study. You are right that the result is an unethical study that can do harm, making it look like whatever is studied is better than it is.

One problem is the emphasis placed today on "evidence based" medicine. That is fine for antibiotics or some specific surgical intervention, but is rarely fine for psychotherapy or social interventions. They are vastly more complex with myriad variables. Experienced practitioners do not rigidly hold to a precise formula when treating patients but vary what they do guided by that experience.

The implication by practioners/clinics that they use "evidence based" methods is that they are better than non-"evidence based," which may not at all be true.

Just one comment about "anxiety." So many people come for treatment for "anxiety." But if the anxiety is caused by psychological factors the CBT or religious suppression/redirection/extinguishing of symptoms could just leave the underlying issues intact. The anxiety could actually be a warning signal that the patient needs to heed. The anxiety might also come from drinking too much, which the patient does not disclose and the evidence-based practitioner does not suspect strongly enough. There are so many possibilities!

Joel Hassman, MD said...

Hmm, is the DSM 5 going to have an additional 6 Axes, so what is this Axis 11 to be watching out for that creates so much venom? Im sorri if mi speling aint to others' satsfactin.

In all seriousness, if the above anonymous doesn't like my writings, well, don't waste your time at my blog, and feel free to tell the blog authors here I am so out of line interpreting the extreme rigid commentary they allow to be possible Axis 2 features.

For those interested, go back to my third posting back in late November and see why I used the picture to begin my first post about Axis 2 issues.


Anonymous said...


The point of applying evidence based treatments is that because we know individual outcomes in psychotherapy can be quite variable, we want to make choices with treatment informed by systemic inquiry of what has most likely worked to the best effect given limited information about patients. Even if a clinician thinks doing something is in the best interest of a patient, it is responsible to think "why do I think this is the best thing for my patient?" If your answer is based on theory, personal memory, habit, training from many years ago, etc., it may not be the most quality information to inform your current decisio--though, given the very limited systemic evidence base generated in the published literature, and the even more limited systemic evaluations clinicians do in their own practice, they sometimes are as good as any. I think with more and better research, as well as better internal evaluation, people should start to have better quality information to inform their ongoing treatment decisions.

At the end of the day, "evidence-based" should more likely lead to better outcomes than "non-evidence based." If not, then what is "non-evidence based" should be systemically studied with findings more widely disseminated, actually becoming "evidence-based," so more people can reliably get helpful treatment.

jesse said...

@Anon: yes, in principle I agree. The devil is in the details, however. Attempting to isolate symptoms that can be approached in a scientific way is vastly complicated, and over-simplification is a major danger.

The complexity of deciding how to treat many psychiatric problems is similar to the complexity of a country designing a foreign policy that is "evidence based." The stakes are high, so why not use the interventions that are proven to be the best?

One of the problematic consequences of psychiatry moving to a more evidence based model is that medication use may have become a too easily used modality, with the corollary being that skill in doing dynamic psychotherapy is being lost. So the psychological aspect of psychiatry is being ceded to the psychologists and social workers. This has led to the model of med management with others doing the therapy being more prevalent than otherwise might have been the case. As my old mentor Irv Cohen once said in a presentation at an annual APA meeting, "Philosophy Follows Funding."

When I was in training I subscribed to a journal named "Psychiatry" that contained primarily papers on psychotherapy and understanding dynamic issues. The entire field has shifted and while much good has come from it much has also been lost.

So I would try to find psychiatrists who are well trained, open minded, experienced, and thoughtful. Then I would ask them "what would you do?" not "what does the latest evidence based algorithm require?"

Steven Reidbord MD said...

@jesse, I very much agree. Seeking "evidence" for various mental health interventions recalls the old joke about searching for one's keys under the lamp post because the light is better there. Certain types of interventions are easier to study ("the light is better") and have thus amassed lots of evidence. But if our keys happen to be lost in the dark -- if the solution to some psychiatric problems are not in readily studied areas -- then "evidence based medicine" will not even bother to look there, and the keys will stay lost. Sometimes it's better to grope around in the area you know you dropped your keys, than to carefully and precisely search an area where you know you didn't lose them.

Unknown said...

i don't know about other disorders but for bipolar disorder (the disorder that i have) cbt has been very helpful.

EastCoaster said...

First let me say that I am not a therapist.

I do however work with people who have severe and persistent mental illness.

I am currently working on a project with a nurse practitioner where we hope to improve health outcomes (both medical and psychiatric) and to reduce ED and hospital use.

We are collaborating with people who have used a curriculum which incorporates CBT and motivational interviewing techniques.

The clients we are targeting first are among our most troubled, and the curriculum is not working so well. The researchers we are collaborating with have had success in a community mental health center. I'm going into people's homes. In fact, trying to implement their techniques has probably caused harm. (The Ph.d. psychologist is grossly unaware of how much s/he is alienating people at the different sites.

One of my clients with brittle bipolar disorder couldn't tolerate the pre-satisfaction survey without getting angry.

They want us to tape sessions. Many people refused. I'd love to see good research done on people in a public psychiatry setting, because we need to improve what we do, but this particular method ain't working so well for anybody.

Nathan said...

EastCoaster -
There is little evidence supporting CBT as a firstline treatment for symptoms of mania/bipolar disorder, though like most treatments, there are folks who feel helped by their experience in CBT in all sorts of ways. What is a pre-satisfaction survey? How to you assess someone's satisfaction with a treatment before they experience it? Baseline assessments are important, but of the indicators of outcomes you expect a treatment to engender. You also don't expect a treatment to engender anything unless you have some prior evidence/proposed mechanism suggesting it might. CBT is not usually conceptualized as helping with general life outcomes, unless particular psychiatric symptoms are interfering with those outcomes happening or engaging in behaviors that lead to outcomes are part of treating the symptoms (ex. behavioral activation in getting a part-time job or sustained volunteering if someone has been so depressed they really don't do much all day. Getting some work when not working would be a "life" outcome but also start a process of engagement/doing that may have been lacking while that in itself may help alleviate some symptomatically [like sleep issues, withdrawal, etc.]

If you can tell you are doing harm (including participants saying, we feel this is harming us and we are not getting better), then why continue participating in the treatment? It is the responsibility especially of the provider/researcher support a participant do something more helpful or mitigate harm from research if it is noted and experienced. It is also responsible to note this as part of your write-up. Consider the person harmed by the experience, include that as part of your research, and support them in a more helpful way for them.

This whole research process all seems like a lot of poor consent happening as well. If videotaping is part of the process, make sure people know that this is what participating in this research study includes, and if they don't like that, that's fine and they don't have to participate. It seems like the research agenda feels like forced treatment on folks, and I hope it is not. Ethical research does include risk of harm, as long as that harm is as thoroughly explained to participants as possible and mitigating and preventing that harm is built into a study's protocols. That is why we do research, so that we have a better understanding of benefits and harms, so that people aren't exposed to it when engaging in treatment.

EastCoaster said...


(1.) It is technically not a research project, but a demonstration initiative and an addition of services.

(2.) There is an informed consent process for people who want to disclose their demographic data for publication (aggregate info on ED use etc.)

(3.) Our goal is not to treat mania with CBT. Our goal is to help people with SMI who are already medicated and in treatment to better manage their chronic medical conditions, primarily diabetes and hypertension. We hope that we will help people to feel the burden of disease less. The satisfaction questions relate to how people feel that their chronic medical conditions affect their quality of life and how much they feel that professionals and non-professionals are available for support w/ medical and emotional problems. When someone has no family, asking them whether they feel that they are able to get support from friends and family can be upsetting. If people don't consent the aggregate data are submitted to CMS but not published. These are all clients of our department of mental health. A lot of the info is already reported to the state.

EastCoaster said...

They can always refuse any part of this. (Some treatment plans they can't if they want our housing.)

No videotaping. Only audio, an of course we are asking for consent.

Still the experience of the people with research (also with SMI)do not mesh with our experiences now with this population.

Anonymous said...

This post is not related to the topic, but I wished to raise a point concerning psychiatry in general.

I think due to past experiences, I hold no tolerance or patience for the practice, and think it should be outlawed. I don't think mental illness even exists, though I'm not an anti-psychiatry movement adherent.

Psychiatry has essentially ruined me. Many of these "people" have tried to worsen my conditions when in their care, or frankly tell me flagrant falsehoods (such as atheism being a mental illness, or that modern social values are a mental pathology).

I just want to ask - does mental illness actually exist? And on what basis is one actually deemed "mentally ill"? Isn't the concept of mental illness a tool to punish people, since normalcy is a wholly subjective label? A devout theist may not deem an atheist as "normal". An ardent atheist may not see a theist as "normal". Which person in this case is objectively normal?

Anonymous said...

I once read a book called "Cognitive Behavioral Therapy for Bipolar Disorder." It was simplistic to the point of being insulting. And I'm pretty sure its target audience was mental health professionals.

A lot of cognitive behavioral therapy techniques strike me as plain old common sense. It seems a motivated person could do it on her own, rather than go through the process with a therapist.

Simple Citizen said...

I find using a hybrid technique works best: It's a mixture of CBT, ACT, FAP, DBT, Psychoanalytic, and Supportive.

- Honestly - If you learn them all well you can tailor the therapy to the patient and use what is needed from each school of thought.

Joel Hassman, MD said...

On a completely unrelated note, I think ClinkShrink needs to go to and read the piece about "Psychiatric Liability: French psychiatrist sentenced after murder by her patient". It seems that precedence is being set, while across the Atlantic, it will float over here rather quickly with these new gun laws forcing psychiatry to report people with guns.

Serious stuff going on just eroding what little boundaries psychiatry has left. I'm sure some commenters here will be cheering for all of us to be imprisoned, simply for trying to help people. Cheers!

Anonymous said...

I have PTSD, and found CBT to be incredibly helpful in getting me into remission. I did eventually require some medications for a period of time, but the CBT helped me get my life back on track and correct a lot of the self-defeating behaviors I developed as a result of my illness. I'm so thankful that I had an excellent therapist to guide me through the process... I am pretty sure that I would not be the functioning, successful person that I am today without it.

Anonymous said...

I'm 37 yrs old and started CBT back in November for Depression and Borderline P.D. and to be honest, I still feel like shit. I don't feel like I've accomplished anything at all. The CBT worksheets are insufferable! They're not actually helping me change my disfunctional way of thinking about myself or the world.

Recently my therapist recommended I start Wellbutrin and in the same breath said my CBT sessions must end by Febuary. I was shocked but did'nt complain. I just thought I would feel better by now but given that I don't and just received a "deadline" so to speak to get my shit together, I feel rushed and confused.

DBT isn't available in my country and Psychoanalysis just seemed like aimless talking with no benefit for me, so CBT really was my last option. It's frustrating when you know you need help but can't find proper help!!!

Anonymous said...

I just noticed this is an extremely old thread!!! Ooops.