Tom Sensky & Jan Scott's Response to Criticisms of CBT from the British Medical Journal

EDITOR:

The article by Jeremy Holmes and the accompanying commentaries (1-5) are essentially about evidence for the efficacy and effectiveness of the psychotherapies, and how this evidence base should be applied in everyday clinical practice. It is ironic that in their arguments against cognitive behaviour therapy (CBT), these papers include numerous instances of idiosyncratic use of research evidence. The examples below illustrate this point.

Arguing that the evidence favouring the benefits of CBT is relatively weak, Bolsover (5) selects three studies for comment which happen to fit his argument. He has conveniently ignored the scores of published studies which have demonstrated the clinical benefits of CBT. The Cochrane database (6) is widely acknowledged (and sometimes criticized) for the close attention in its reviews to research studies of high methodological quality. The Database of Systematic Reviews contains two full reviews focusing on CBT, and the Database of Abstracts of Reviews of Effectiveness (DARE) includes five systematic reviews of CBT used to treat a variety of clinical conditions. Papers selected for abstraction in Evidence Based Mental Health or Evidence Based Medicine similarly go through a process of rigorous methodological review. Papers on CBT appear regularly in these journals. We would challenge Bolsover to apply his arguments to these papers.

Holmes (1) argues that CBT works well in university based clinical trials with subjects recruited from advertisements, but the evidence about how effective it can be in the real world of clinical practice is less secure. To support this, he cites a single paper from a study also cited by Bolsover. This caricature may have applied to a limited extent to the early trials of CBT in depression conducted thirty years ago, but is certainly irrelevant now. To give just two examples of many possible, the MRC funded trial of CBT for chronic depression (7,8) specifically recruited individuals who had depressive disorders that had failed to respond to adequate trials of standard pharmacological and psychological treatments (including previous psychotherapies) in both primary and secondary care. Second, the Cochrane review of CBT for schizophrenia includes examples of “real world” interventions, although the reviewers argue that further similar studies are required to be confident that these interventions are generalisable (9).

Holmes also argues that leading cognitive therapists are starting to question aspects of their discipline and recognize some of its limitations. CBT was first developed as a treatment for depression, and its exponents have been very cautious about widening its applications. The two apparent critics of CBT cited by Holmes are quoted out of context; in both cases, the criticisms refer to the need to adapt and develop the basic CBT model developed for the treatment of depression and anxiety to enhance its effectiveness in other applications. Far from being a weakness of CBT, the critical review of its methods by its practitioners is an important reason why it has been evaluated in an increasingly wide range of conditions.

Hinshelwood (4 ) argues, without evidence, that while psychoanalytic psychotherapy is compliance-neutral, CBT relies heavily on the compliance of the patient. On the contrary, CBT has been shown to be effective in improving overall adherence among people with acute schizophrenia (10,11). Hinshelwood also argues that CBT ignores the relationship between therapist and patient. The first treatment manual in CBT included a checklist for rating the process of therapy, which has a subscale evaluating generic therapeutic skills and interactions (12). True, there is no direct equivalent in CBT for “transference”, but the relationship between patient and therapist can certainly form a major focus of the therapeutic work in CBT, particularly in treating people with personality disorders.

We agree with Holmes that it is unhelpful to expect to evaluate psychotherapeutic interventions (including CBT) using only the same research methods applied to drug trials. However, if clinicians and researchers aspire to an evidence-based health service, they have to accept two challenges. First, there is the challenge of evaluating what they think they do. We look forward to the evidence base of the psychodynamic psychotherapies developing, to allow more valid comparisons between the psychotherapies. Until then, there is no way escaping the fact that robust evidence exists for the use of CBT in a growing variety of clinical conditions and settings, and much of this research evidence is applicable to the NHS. The second challenge is for clinicians and commentators to understand and respect the critical appraisal of the evidence base. Regrettably, some of the contributors to this series of articles have failed in this.

References

(1) Holmes J. All you need is cognitive therapy? BMJ 2002; 324: 288-290.2 Neighbour R. Commentary: benevolent skepticism is just what the doctor ordered. BMJ 2002; 324: 290-291.

(3) Tarrier N. Yes, cognitive therapy may well be all you need. BMJ 2002; 324: 291-292.

(4) Hinshelwood RD. Commentary: symptoms or relationships. BMJ 2002; 324: 292-293.

(5) Bolsover N. Commentary: the ěevidenceî is weaker than claimed. BMJ 2002; 324: 294.

(6) The Cochrane Library, Issue 1, 2002. Oxford: Update Software.

(7) Paykel E, Scott J, Teasdale J, Johnson A, Garland A, Moore R, Jenaway A,

(8) Cornwall P, Hayhurst H, Abbott R, Pope M. Prevention of relapse in residual depression by cognitive therapy: A Controlled Trial. Archives of General Psychiatry, 1999, 56, 829-835

(9) Scott J, Teasdale J, Paykel E.S, Johnson A, Abbot R, Hayhurst H, Moore R, Garland A. The effects of cognitive therapy on psychological symptoms and social functioning in residual depression. British Journal of Psychiatry, 2000, 177, 440-446.

(10) Cormac I, Jones C, Campbell C. Cognitive behaviour therapy for schizophrenia (Cochrane Review). The Cochrane Library, Issue 1, 2002. Oxford: Update Software.

(11) Kemp R, Hayward P, Applewhaite G, Everitt B, and David A (1996). Compliance therapy in psychotic patients: randomised controlled trial. BMJ 312, 345-349.

(12) Kemp R, Hayward P, Applewhaite G, Everitt B, and David A (1998). A randomised controlled trial of compliance therapy: 18 month follow-up. Br J Psychiatry 172, 413-419.

(13) Beck AT, Rush AJ, Shaw BF and Emery G. Cognitive Therapy of Depression. New York: Guilford Press, 1979.

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