There is often zealous disagreement about which psychotherapy is the more effective. The viewpoint that one therapy is just as effective as another has been coined the 'Dodo Bird verdict' [2, p. 18], based on a line from Alice of Wonderland: "All have won and all must have prizes". Psych & Soma's acquisition and synthesis of trends and current topics in the field of psychotherapy rendered twelve articles and one report on the use and outcomes of cognitive-behavioural therapy (CBT), published during the last three years. This review presents a synopsis of the findings.
By early 2005 there were more than 325 published articles [2] on cognitive-behavioural interventions. The ongoing adaptation of CBT for an expanding range of disorders and problems are mostly the reason for the proliferation of literature. In the eight years between 1986 and 1993, more than 120 controlled clinical trials were undertaken on the impact of CBT on the patient. A review of 16 meta-analyses [2] suggests that CBT is highly effective for adult and adolescent unipolar depression, generalised anxiety disorder (GAD), panic disorder with/without agoraphobia or social phobia, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), schizophrenia, anger management, bulimia nervosa, internalising childhood disorder, sexual offences and chronic pain. The review furthermore suggests strongly that the effects of CBT is maintained, across many disorders, for considerable periods after treatment has ended.
Anxiety and depression
In contrast to the previous review, a recent [10] meta-analysis comparison of CBT vs. other bona fide non-CBT psychotherapies for anxious and depressed children did not show a notable greater impact for CBT than for the other therapies. This is consistent with the Dodo Bird conjecture. An earlier meta-analysis [9] of 71 studies, comparing the effects of behavioural parent-training (BPT) vs. CBT, found that BPT interventions may be more effective for youths in the 6-12 years old range, because these children are dependant on their parents. The analysis recommends careful consideration of the effect of the treatment setting of BPT and CBT.
Juvenile delinquency
A meta-analysis [6] was done of 58 experimental and quasi-experimental studies into the effect of CBT for reducing recidivism among adult and juvenile offenders. The analysis affirmed the positive effect of CBT, but no significant differences in the effect of the various versions of CBT were found. Close monitoring of the quality and adequate training of CBT providers are shown to be essential. The effect of CBT on offenders with a high risk of recidivism is very encouraging, as the therapy targets criminogenic factors, including criminal thinking patterns.
General anxiety disorder
Meta-analyses to assess the ability of CBT to reduce anxiety symptoms in patients with (GAD) mostly used general measures of anxiety to assess symptom severity and improvement. However, these studies do not provide sufficient data to measure the ability of CBT to reduce the cardinal symptom of GAD, pathological worry[3]. A meta-analysis of the impact of CBT on pathological worry in patients with GAD found the largest gains for younger adults, but also notable gains for geriatric patients [3]. These gains were maintained over the 6- and 12-months follow-up periods. The analyses also revealed that certain specific treatment CBT packages may be more effective than others, but more research is needed into this issue.
A second meta-analysis [5] of 25 studies shows that CBT can alleviate the anxiety symptoms in patients with GAD. CBT was more effective than usual treatment or a waiting list control in achieving a clinical response after treatment, at 46% versus 14% of patients, respectively. CBT was also very effective in reducing the secondary symptoms of worry and depression. However, none of these studies looked at the long-term effectiveness of CBT, and there were too few data to determine whether CBT was more effective than other psychological therapies. Patients responded slightly better to CBT than to psycho-dynamic therapy, but there was only one trial comparing these two psychotherapies.
Schizophrenia spectrum disorders
The first-line treatment of schizophrenia spectrum disorders is usually antipsychotic drugs, which are thought to have the greatest effect on the positive symptoms of schizophrenia such as delusions, auditory hallucinations and thought disorder. However, medication does not always completely resolve these symptoms. A meta-analysis of 14 studies [13], including 1484 patients and published between 1990 and 2004, showed that, compared with other therapies such as waiting-list, treatment as usual and supportive counseling, CBT is a promising adjunctive treatment for the positive symptoms in schizophrenia. Moreover, the therapeutic effects are present at follow-up, suggesting that the CBT has long-term effects. The authors point out, however, that the global mean weighted effect is very modest. The results also show that CBT is more effective for patients in an acute psychotic episode than for stabilized chronic patients suffering from persistent psychotic symptoms.
Body-image disturbance
Body image (BI) has attitude, behaviour and perceptual components [8]. BI-attitude has two dimensions, namely the degrees of satisfaction and of importance given to appearance. BI-disturbance is revealed in difficulties experienced with one or more of these areas. A meta-analysis of the effectiveness of CBT on BI found that CBT that addresses all three components of BI are more effective than when only behaviour and attitude are addressed.
Cancer patients
A meta-analysis [11] of 20 studies indicated that CBT can help breast cancer patients control their distress and pain. The findings are congruent with the positive effects of CBT on cancer patients in general. Data suggest further that hypnosis, a common CBT intervention used with cancer patients, may be especially effective (with some or all of the CBT techniques of distraction, relaxation, imagery and visualisation).
Trauma and PTDS
A 3-year follow-up study [1] found that trauma survivors with acute stress disorder benefited more from CBT or CBT with hypnosis in the initial month after their trauma than those treated with supportive counselling. They experienced fewer PTDS symptoms, in particular re-experiencing and hyperarousal symptoms. In contrast, there is evidence that 70% of patients diagnosed with acute stress disorder still experienced PTSD two years after the trauma. These findings point to long-term benefits of CBT for trauma survivors. In this study, CBT with hypnosis did facilitate recovery, but the impact was not evident at the 6-month or 3-year follow-up assessments. This finding may indicate that hypnosis does not enhance the treatment gains of CBT, or that the researchers' use of hypnosis was not optimal. They note that previous studies have indicated that the addition of hypnosis to CBT techniques do lead to greater symptom reduction across a range of disorders.
CBT in routine clinical practice
The outcome data [12] from the routine clinical practice of a National Health Service (NHS) psychology service suggest that CBT is an effective treatment in a routine clinical practice context, as opposed to CBT in research trials. However, CBT may not be as effective in ordinary clinical settings as in research trials. This study represents probably the largest sample of routinely treated CBT patients.
The 'third wave' CBT therapies: emphasis on behavioural aspects
Acceptance and Commitment Therapy (ACT) is a branch of cognitive-behavioural therapy that uses acceptance and mindfulness strategies, together with commitment and behaviour change strategies, to increase psychological flexibility (Wikipedia, Acceptance and Commitment Therapy). This is just one of a new generation of CBT-based therapies, the so-called 'third wave' of CBT, that focus on the behavioural aspects of CBT as opposed to the cognitive aspects, placing an increasing emphasis on behavioural change, constructivism and attentional control. Advocates of these new behavioural therapies argue that the challenging of thoughts is superfluous in CBT [7], in part because CBT treatments often show a rapid symptomatic improvement before the effects of cognitive modification should have been evident - the so-called "rapid early response".
However, an empirical examination [7] undertaken of the status of cognitive interventions in CBT found that there is no difference in the effectiveness of the behavioural and the cognitive elements of CBT, if they are used separately. Cognitive interventions did not provide "added value" to behavioural intervention. In addition, studies that dismantle the components of CBT might be flawed, as they neutralise what makes the therapy effective: the interaction of cognitive and behavioural techniques. Research on "rapid early response" was also reviewed, and it was found that evidence for such an effect was lacking.
A lack of empirical evidence
Numerous studies have shown that CBT is effective for a range of psychological disorders. However, one researcher emphasises that, for CBT to develop, it must keep sight of its empirical roots [7]. There is a worrying lack of empirical support for some of the fundamental tenets of CBT, such as that cognitive interventions, which form the core of CBT, are differentially effective in reducing distress. There is also a lack of evidence that cognitive variables mediate therapeutic change [7]. These gaps in knowledge make the development more effective therapeutic interventions difficult.
[1] Bryant, R.A., Moulds, M.L., Nixon, R.D.V., Mastrodomenico, J., Felmingham, K. & Hopwood, S. 2006. Hypnotherapy and cognitive behaviour therapy of acute stress disorder: a 3-year follow-up. Behaviour Research Therapy, 44: 131-1335.
[2] Butler, A.C., Chapman, J.E., Forman, E.M. & Beck, A.T. 2005. The empirical status of cognitive-behavioural therapy: a review of meta-analyses. Clinical Psychology Review, 26: 17-31.
[3] Covin, R., Quimet, A.J., Seeds, P.M. & Dozois, D.J.A. 2007. A meta-analysis of CBT for pathological worry among clients with GAD. Journal of Anxiety Disorders, article in press.
[4] Durham, R.C., Chambers, J.A., Power, K.G., Sharp, D.M., Macdonald, R.R., Major, K.A., Dow, M.G.T. & Gumley, A.I. 2005. Long-term outcome of cognitive behaviour therapy clinical trials in central Scotland. Health Technology Assessment, 9(42), November.
[5] Hunot, V., Churchill, R., Silva de Lima, M. & Teixeira, V. 2007. Psychological therapies for generalised anxiety disorder. Cochrane database of systematic reviews, 1.
[6] Landenberger, N.A. & Lipsey, M.W. 2005. The positive effects of cognitive-behavioral programs for offenders: a meta-analysis of factors associated with effective treatment. Journal of Experimental Criminology, 1: 451-476.
[7] Longmore, R.J. & Worell, M. 2007. Do we need to challenge thoughts in cognitive behaviour therapy. Clinical Psychology Review, 27: 173-187.
[8] Jarry, J.L. & Ip, K. 2005. The effectiveness of stand-alone cognitive-behavioural therapy for body image: a meta-analysis. Body Image, 2: 317-331.
[9] McCart, M.R., Priester, P.E., Davies, W.H. & Azen, R. 2006. Differential effectiveness of behavioural parent-training and cognitive-behavioural therapy for antisocial youth: a meta-analysis. Journal of Abnormal Child Psychology, 34 (4): 527-543.
[10] Spielmans,G.I., Pasek, L.F. & McFall, J.P. 2007. What are the active ingredients in cognitive and behavioural psychotherapy for anxious and depressed children? a meta-analytical review. Clinical Psychology Review, article in press.
[11] Tatrow, K. & Montgomery, G.H. 2006. Cognitive behavioural therapy techniques for distress and pain in breast cancer patients: a meta-analysis. Journal of Behavioural Medicine, 29(1): 17-27.
[12] Westbrook, D. & Kirk, J. 2005. The clinical effectiveness of cognitive behaviour therapy: outcome for a large sample of adults treated in routine practice. Behaviour Research and Therapy, 43: 1243-1261.
[13] Zimmerman, G., Favrod, J., Trieu, V.H. & Pomini, V. 2005. The effect of cognitive behavioural treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis. Schizophrenia Research, 77: 1-9.
