CBT Is Not What It’s Cracked Up to Be . . .

Or, Don’t Be Afraid of the EVT Bogeyman

The concept of the EVT (empirically validated therapy) has had enormous recent impact—so far, all negative— on the field of psychotherapy. Only therapies that have been empirically validated—in actuality, this means brief cognitive-behavioral therapy (CBT)—are authorized by many managed-care providers. Graduate psychology schools granting master’s and doctoral degrees are reshaping their curricula to concentrate upon the teaching of the EVTs; licensing examinations make certain that psychologists are properly imbued with the knowledge of EVT superiority; and major federal psy- chotherapy research funding agencies smile with particular favor upon EVT research.

All these developments create dissonance for many expert senior clinicians who are exposed daily to managed-care administrators insisting upon use of EVTs. Senior clinicians see an apparent avalanche of scientific evidence “proving” that their own approach is less effective than that offered by junior (and inexpensive) therapists delivering manualized CBT in astoundingly brief periods of time. In their guts they know this is wrong, they suspect the presence of smoke and mirrors, but have no evidentially based reply, and generally they have pulled in their horns and tried to go about their work hoping for the nightmare to pass.

Recent meta-analytic publications are restoring some bal- ance. (I draw heavily from the excellent review and analysis of Weston and Morrison.) First, I urge clinicians to keep in mind that non validated therapies are not invalidated therapies. Research, if it is to be funded, must have a clean design com- parable to research testing drug efficacy. Design demands include “clean” patients (that is, patients with a single disorder without symptoms of any other diagnostic groups—a type of patient uncommonly seen in clinical practice), a brief therapy intervention, and a replicable, preferably manualized (that is, capable of being reduced to a step-by-step written manual) treatment mode. Such a design heavily favors CBT and excludes most traditional therapies that rely on an intimate (unscripted) therapist-patient relationship forged in genuine- ness and focusing on the here-and-now as it spontaneously evolves.

Many false assumptions are made in EVT research: that long-term problems can yield to brief therapy; that patients have only one definable symptom, which they can accurately report at the onset of therapy; that the elements of efficacious therapy are dissociable from one another; and that a written systematic procedural manual can permit minimally trained individuals to deliver psychotherapy effectively.

Analysis of results of EVT (Weston and Morrison) indicates far less impressive outcomes than has generally been thought. There is little follow-up at the end of one year and almost none at two years. The early positive response of EVTs (which is found in any therapeutic intervention) has led to a distorted picture of efficacy. The gains are not maintained and the per- centage of patients who remain improved is surprisingly low. There is no evidence that therapist adherence to manuals positively correlates to improvement—in fact, there is evidence to the contrary. In general the implications of the EVT research have been extended far beyond the scientific evidence.

Naturalistic research on EVT clinical practice reveals that brief therapy is not so brief: clinicians using brief EVTs see patients for far more hours than is cited in reported research. Research indicates (to no one’s surprise) that acute distress may be alleviated quickly but chronic distress requires far longer therapy, and characterological change the longest ther- apy course of all.

I can’t resist raising one more mischievous point. I have a strong hunch (substantiated only anecdotally) that EVT practitioners requiring personal psychotherapeutic help do not seek brief cognitive-behavior therapy but instead turn to highly trained, experienced, dynamic, manual-less therapists.

From
The Gift of Therapy – an open letter to a new generation of therapists and their patients
Irvin D. Yalom, M.D.