Handbook of Cognitive-Behavioral Therapies

I started reading this book yesterday. I’m not super impressed, but it’s not horrible either.

One chapter in the book, chapter 2, deals specifically with ‘The Evidence Base for Cognitive-Behavioral Therapy’, and although this would normally be the sort of thing I’d be very interested in, I actually thought that was a rather weak chapter despite its preferential reliance on RCTs and reviews/meta-analyses – mostly because the authors seem to only care about whether or not there’s an effect, not how large it is; effect sizes are rarely reported. To make matters worse, in one case where they do report effect sizes as well as answering the ‘does this stuff work better than doing nothing?’-question (…and is that actually the question these articles answer? More on this below…), in the case where they’re talking about the treatment effects of cognitive-behavioral therapy (-CBT) on obsessive-compulsive disorder (-OCD), you suddenly realize that a lot of patients will not benefit at all from this stuff. A review article from the chapter notes that “one-third of those who complete a course of therapy, and nearly one-half of those who begin but do not complete treatment, will not make expected gains” – but despite this they conclude towards the end of the chapter when summing up that, “The absolute efficacy of CBT for OCD is positive and well-supported.” It makes you wonder which other conditions they talk about may technically ‘have an effect’ or ‘be well-supported’, yet lead to zero improvement for large groups of patients. A more thorough coverage of the treatment effects of a smaller number of conditions would probably have been advisable. There are other problems in this review – for example the coverage of CBT treatment effects of substance dependence/-abuse relies on material not reporting long-term results, making the results meaningless or worse – the authors note that long-term results are not reported, but the natural conclusion to draw from this problem is not drawn and it really should have been. For more on this topic see this post and Scott Alexander’s post to which I link in that post. Yet another problem is that in some cases the studies comparing the outcomes of CBT and pharmacological treatment options were undertaken so long ago (1980s) that they presumably no longer have much validity today, because they were comparing CBT to previous generations of pharmacotherapy. The problems with this chapter is part of why I don’t post much on this topic below despite being quite interested in this topic: Frankly I don’t really trust the authors’ conclusions, and I find the coverage severely lacking in detail. I should note that although chapter 2 wasn’t great, chapter 3 on ‘Cognitive Science and the Conceptual Foundations of Cognitive-Behavioral Therapy’ was significantly worse, and I actually decided against including anything from that chapter in the coverage below.

Some observations from the first third of the book below:

…

“At their core, CBTs share three fundamental propositions:
1. Cognitive activity affects behavior.
2. Cognitive activity may be monitored and altered.
3. Desired behavior change may be effected through cognitive change.”

“Three major classes of CBTs have been recognized, as each has a slightly different class of change goals […] These classes are coping skills therapies, problem-solving therapies, and cognitive restructuring methods. […] the different classes of therapy orient themselves toward different degrees of cognitive versus behavioral change. […] Therapies included under the heading of “cognitive restructuring” assume that emotional distress is the consequence of maladaptive thoughts. Thus, the goal of these clinical interventions is to examine and challenge maladaptive thought patterns, and to establish more adaptive thought patterns. In contrast, “coping skills therapies” focus on the development of a repertoire of skills designed to assist the client in coping with a variety of stressful situations. The “problem-solving therapies” may be characterized as a combination of cognitive restructuring techniques and coping skills training procedures.”

“Briefly stated, the “mediational position” is that cognitive activity mediates the responses the individual has to his or her environment, and to some extent dictates the degree of adjustment or maladjustment of the individual. As a direct result of the mediational assumption, the CBTs share a belief that therapeutic change can be effected through an alteration of idiosyncratic, dysfunctional modes of thinking. Additionally, due to the behavioral heritage, many of the cognitive-behavioral methods draw upon behavioral principles and techniques in the conduct of therapy, and many of the cognitive-behavioral models rely to some extent upon behavioral assessment of change to document therapeutic progress. […] one commonality among the various CBTs is their time-limited nature. In clear distinction from longer-term psychoanalytic therapy, CBTs attempt to effect change rapidly, and often with specific, preset lengths of therapeutic contact. Many of the treatment manuals written for CBTs recommend treatment in the range of 12–16 sessions […] Related to the time-limited nature of CBT is the fact almost all applications of this general therapeutic approach are to specific problems. […] A third commonality among cognitive-behavioral approaches is the belief that clients are, in a sense, the architects of their own misfortune, and that they therefore have control over their thoughts and actions […] many CBTs are by nature either explicitly or implicitly educative.”

“Other criticisms pertain to research methodology. It has been argued that amalgamating placebo and waiting-list controls into a composite control condition confounds results (Parker, Roy, & Eyers, 2003). Specifically, Parker et al. asserted that participants assigned to a placebo condition are hopeful, because they assume that they are being treated, whereas participants assigned to a waiting-list control condition are discouraged, because they are not undergoing any treatment. They recommended that future research compare active treatments to different control conditions to disentangle potentially differing results. […] In addition to limitations to the research base on the efficacy of CBT, there are limitations to efficacy research in general. Although RCTs are highly utilized and respected in efficacy research, the reelvance [sic] of their results to routine clinical practice has been questioned (Leichsenring et al., 2006). For example, the restrictive exclusion criteria of many RCTs may undermine the representativeness of the participants to the general population of people with the disorder. Also, comorbidities are common among disorders but are controlled for in RCTs through exclusionary criteria, or are simply not addressed. Also, researcher allegiance, or the tendency of the authors of a comparative treatment study to prefer one treatment over another, may introduce bias into the study design that results in findings supportive of the preferred treatment (Butler et al., 2006).”

“Most psychotherapists accept, at least in principle, the value of scientific inquiry, even while they differ widely in what they consider to be acceptable scientific methods. Despite this development, however, there has been a decided lag in the acceptance of scientific findings as the basis for setting new directions or for deciding what is factual among practicing therapists. Indeed for many practitioners, the true test of a given psychotherapy rests in both its theoretical logic and evidence from clinicians’ observations rather than data from sound scientific methods, even when the latter are available […] What practitioners accept as valid hinges on both the methods used to derive results and the strength of their opinions. Practitioners prefer naturalistic research over randomized clinical trials, N = 1 or single-case studies over group designs, and individualized over group measures of outcome […] They also tend to believe research favoring the brand that they practice over research that supports alternative psychotherapy approaches or equivalency among approaches. Since most psychotherapy research fails to comply with these values, psychotherapists often are quick to reject scientific findings that disagree with their own theoretical systems. Thus, while the reasons given for rejecting scientific evidence may be more sophisticated today than in the past, it may be no less likely to occur.”

“CT [cognitive therapy] is a specific form of the more general CBTs […] Cognitive theory has been empirically based since its inception, in that it used findings from formal research to establish its theoretical principles. […] CT may best be defined as the application of cognitive theory to a certain disorder and the use of techniques to modify the dysfunctional beliefs and maladaptive information-processing systems that are characteristic of the disorder […] CT does not depend on the validity of insights into the nature of psychopathology for effectiveness in the therapeutic arena. First and foremost, cognitive theory emphasizes reliable observation and measurement in the assessment of the effects of treatment.”

“the efficacy of CT is differentially influenced by a variety of qualities characteristic of the patient and problem. Qualities such as patient coping styles, reactance levels, and complexity and severity of problems, among others, may influence the way that CT is applied. […] One patient characteristic that has proven to predict patients’ response to CT is “coping style,” the method that an individual adopts when confronted with anxiety-provoking situations, and that typically is viewed as a trait-like pattern. CT has been found to be most effective among patients who exhibit an extroverted, undercontrolled, externalizing coping style […] Internalization and externalization represent opposite poles on the traitlike dimension of coping style. Both coping styles may be used to reduce uncomfortable experience (i.e., provide escape or avoidance). Some patients cope by activating externalizing behaviors that allow either direct escape or avoidance of the feared environment. Alternatively, other patients may prefer behaviors (i.e., self-blame, compartmentalization, sensitization) that control internal experiences such as anxiety. Internalizing patients are typically characterized by low impulsivity and overcontrol of impulses, whereas externalizers generally exhibit highly impulsive or exaggerated behaviors. Additionally, internalizers tend to be more insightful and self-reflective. Internalizers typically inhibit feelings, tolerate emotional distress better than externalizers, and frequently attribute difficulties they encounter to themselves. On the other hand, externalizers tend to deny personal responsibility for either the cause or the solution of their problems, experience negative emotions as intolerable, and seek external stimulation. […] Although the principles of treatment are the same as those for externalizers, the treatment of internalizing individuals is more complex.”

“The major impetus for psychotherapy integration comes from the evidence that no single school of psychotherapy has demonstrated consistent superiority over the others. Rather, psychotherapy research for specific problems, such as drug abuse or depression, has largely led to the conclusion that all approaches produce similar average effects […] Unfortunately, the nonsignificance of treatment main effects often draws more attention than the growing body of research that demonstrates meaningful differences in the types of patients for whom different aspects of treatment are effective […] For example, research indicates that for patients with symptoms of anxiety and depression […] nondirective and paradoxical interventions are more effective than directive treatments in patients with high levels of pretherapy resistance (i.e., “resistance potential”[…]; and (3) therapies that target cognitive and behavior changes through contingency management […] are more effective than insight-oriented therapies in impulsive or externalizing patients, but this effect is reversed in patients with less externalizing coping styles […] The techniques of CT may be used with virtually any patient; however, the greatest benefit is achieved when the strategies or techniques are employed differentially, depending on patient dimensions such as coping style, type of problem, subjective distress, functional and social impairment, and level of resistance.”

“Patient resistance typically bodes poorly for treatment effectiveness, unless it is managed skillfully. It is generally assumed that some patients are more likely than others to resist therapeutic procedures. “Resistance” may be characterized as a dispositional trait and a transitory in-therapy state of oppositional (e.g., angry, irritable, and suspicious) behaviors. It involves both intrapsychic (image of self, safety, and psychological integrity) and interpersonal (loss of interpersonal freedom or power imposed by another) factors […] “Reactance,” an extreme example of resistance, is manifested by oppositional and uncooperative behaviors. […] Resistance is easily identifiable, and differential treatment plans for patients with high and low resistance are easily crafted. The successful implementation of these plans, however, is often quite a different matter. Overcoming patient resistance to the clinician’s efforts is difficult. It requires that the therapist set aside his or her own resistance to recognize that the patient’s oppositional behavior may actually be iatrogenic […] therapists often [react] to patient resistance by becoming angry, critical, and rejecting, which are reactions that tend to reduce the willingness of patients to explore problems.” [This aspect of the treatment dimension was – perhaps not surprisingly – emphasized in Clark as well.]