Introduction
“The ambiguity of the taxon CBT[1] raises interesting and important issues. When talking about the essential nature of CBT, shouldn’t the field be focused on those aspects of CBT that produce change?” (Baardseth & al, 2013, p. 403). This question, raised by authors, has caught our attention, because it points out an argument to go beyond controversy on effectiveness, which polarizes the psychology field.
This research article investigates evidence to support whether cognitive-behavioral therapy (CBT) treatments have a better efficacity to other treatments as Tolin (2010) asserts. To contextualize the researcher’s position, we will say that Tolin supports CBT treatments as others researchers as Shapiro, Glass and Miller.
Regarding this meta-analysis, the authors Timothy Baardseth and colleagues in 2013 reanalyzed the meta-analysis of Tolin (2010) by improving data computation. They then conducted another meta-analysis correcting some biases to explain the relative efficacity of CBT and bona fide non-CBT treatments for adult’s anxiety disorders. Baardseth is an American psychologist, working in Minneapolis Veterans Affairs Hospital. He is an expert of psychotherapeutic processes. With his colleagues, he wants to replicate and extend the meta-analytic findings with this article, watching a rigorous methodology.
After summarizing the document, we will see to what extent it brings new questions to the field.
Summary
This current study aims at reanalyzing the clinical trials from an earlier meta-analysis that compared the efficiency of CBT to non-CBT therapies for depression and anxiety. It concludes on the superiority of the CBT for the two disorders (viz., Tolin, 2010) with a methodologically rigorous and comprehensive meta-analysis to determine the relative efficacy of CBT and bona fide non-CBT treatments for adult anxiety disorders.
First of all, Baardseth et al. (2013), argue that it is very difficult to compare the “efficiency” of the two approaches – the psychodynamic therapy and the CBT – because they don’t have quite the same objective. The CBT aims at alleviation of acute symptoms, which does not exclude their complete disappearance neither their shifting into another types of symptoms. The argument being, that the psychodynamic therapy aims to go beyond the alleviation of acute symptoms and takes in account the global mental state of the patient. This is quite a convincing argument, considering what Shedler (2010, p. 105) says: “Psychological health is not merely the absence of symptoms; it is the positive presence of inner capacities and resources that allow people to live life with a greater sense of freedom and possibility.”
Moreover, Baardseth et al. (2013) deconstruct the main arguments of Tolin’s (2010) conclusion that CBT is more efficient than other therapies (non-CBT treatments), by qualifying the conclusion as “premature” and emphasizing the following four arguments. First, the effect sizes in Tolin’s research, even when statistically significant, are generally small, which means that the results have to be considered with precautions. Second, there is no evidence to support the superiority of CBT for non-disorder specific symptom outcomes. Third, Tolin’s apparent finding that CBT is superior to non-CBT treatments for depression contradicts several prominent meta-analyses (Cuijpers et al., 2012, 2008; Wampold et al., 2002) and professional organizations, such as Division 12 (Clinical Psychology) of the American Psychological Association (APA), which indicates that 12 treatments for depression (including several non-CBT treatments) have strong research support. And last but not least, many well-respected trials comparing CBT to non-CBT treatments were not included in the Tolin’s study (e.g. Power et al., 2002; Watson et al., 2003).
The meta-analysis conducted by Baardseth et al. (2013) on adult anxiety disorders reveals that there is no sufficient evidence that CBT treatments are superior to non-CBT treatments for adult anxiety disorders, which is the contrary of Tolin’s conclusion. These results show how meta-analyses can be particularly sensitive to the way in which studies are selected for meta-analysis, to the way of coding characteristics of the studies and its effects, to which measures effects are based upon.
Critical evaluation
The meta-analysis has strengths but also weaknesses that are going to be discussed below.
First, this article has a real interest in our education because of its scientific rigor, and provides good evidence to support the integrative approach. This article is scientifically rigorous because the authors use a very transparent methodology, and they underline relevant questionings.
The methodology is based on an “intelligent replication”. We know the importance of replicating studies to bring more valid results to the literature. The lack of good replication in psychology research is the cause of the very well-known science crisis in the field (the reader is invited to read more about the replication crisis). By separating the variables into two analysis (first, dealing with the way of computing data, secondly, focusing on the way of selecting studies), the authors reach to circumscribe the Tolin’s biases location. In the second part of the work, methodology allows authors to make reliable conclusions: to define and to respect good inclusion and exclusion criteria for used studies prevents struggling with confirmation biases, for example.
Furthermore, using the Tolin’s article as a basis for further reflection, authors try to go out of a sterile opposition between CBT’s and “other approaches”, and bring the discussion towards a more complex thinking. A pillar element of this meta-analyze would be the redefinition of evaluated constructs. Is “CBT” a homogenic construct? The answer is a definite no, so neither “other approaches” could constitute one. As a consequence, CBT’s cannot be evaluated as a unique element. To bring more complexity – and consequently validity – it is mandatory to define what specific therapy is evaluated: emotionally-focused therapies are very different to EMDR. According to us, focusing on a whole therapy is still too large in scope. Specifying which elements are therapeutic in each therapy would be a more relevant process.
Even though this article opens the reflection field on the topic, the authors could have gone further. They omit to mention the method used to evaluate therapy types, a central element to determine which has a better efficiency. Each theoretical approach is related to different goals, and has different tools to reach those goals. One is focused on symptoms, another on an information flow into a system; one is interested in the existential sense of life, the other in autonomy towards unconscious conflicts.
Take this rather silly example: if you want to have new jeans, is it better to go to Atlantis and buy a pair, or to take sewing lessons? It depends on your goal: do you want to solve the problem quickly, but maybe go back to the shop in a couple of years to buy another pair? Or do you want to know how to make it yourself, at the cost of hours and hours of work? You will easily understand that there is no right or wrong answer. Moreover, if at the end of each story, I measure how many pants the person has, there is no doubt that the first one should have more. In another hand, if I measure the ability to sew clothes, it is obvious that the second one wins. Because therapies do not have the same goals, evaluating them should include their respective goals. The task gets more complex when evaluation is about internal conflict resolution, and appropriated methods have to be used to measure the target (Dodes & Dodes, 2017).
To sum up, this article is valuable as it underlines the importance of better defining what is measured, dealing with valid constructs. However, it should have spoken about the importance of how these constructs are measured.
Conclusion
As we can see in this article, the type of approach or technic is not so much relevant to determine the efficacity of a therapy. As some studies put forward, it depends more on the relationship between therapist and the patient or client, which is why scientists and psychologists speak about the therapeutic alliance as the main predictive factor that influences the patient’s evolution of symptoms or a global change. However, human relationships are very difficult to apprehend in a scientific way, hence the never-ending discussions, arguments or even quarrels about which approach or technic is the better one. Moreover, the relational aspects are not something we learn primarily in Universities as psychology students. These aspects are mainly learned by students in practicing and in experiencing relationships, hence the importance of going through one’s own experience and choosing the approach that best fits them.
Indeed, the approach is more of a tool allowing the clinician to work. It is a tool to meet the patient and to work on their goals, but also to build an identity of clinician. The approach has to be seen as an entrance to the therapeutic space that suits to the therapist, and the patient. Because the therapist is comfortable with the tools they use, they can be free to welcome the patient, and to build a therapeutic alliance.
Tereza Onderkova, Prosper Gauthier, Anahi Dugarte-Butel
Words we have learned
– alleviation : soulagement, réduction (des symptômes)
– bona fide : références sûres, authentiques
– a taxon : groupe, catégorie
– a prominent meta-analysis : une méta-analyse importante
– to sew : coudre
– clothes : vêtements
Bibliography
Cuijpers, P., Driessen, E., Hollon, S. D., van Oppen, P., Barth, J., & Andersson, G. (2012). The efficacy of non-directive supportive therapy for adult depression: A meta-analysis. Clinical Psychology Review, 32, 280–291. http://dx.doi.org/10.1016/j.cpr.2012.01.003.
Dodes, L.M., Dodes, J. (2017). The Case Study Method in Psychodynamic Psychology: Focus on Addiction. Clin Soc Work J 45, 215–226. https://doi.org/10.1007/s10615-016-0610-5
Power, K., McGoldrick, T., Brown, K., Buchanan, R., Sharp, D., Swanson, V., & Karatzias, A. (2002). A controlled comparison of eye movement desensitization and reprocessing versus exposure plus cognitive restructuring versus waiting list in the treatment of posttraumatic stress disorder. Clinical Psychology & Psychotherapy, 9(5), 299–318. http://dx.doi.org/10.1002/cpp.341.
Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. The American Psychologist, 65(2), 98–109. http://dx.doi.org/10.1037/a0018378.
Tolin, D. F. (2010). Is cognitive-behavioral therapy more effective than other therapies?: A meta-analytic review. Clinical Psychology Review, 30(6), 710–720. http://dx.doi.org/ 10.1016/j.cpr.2010.05.003.
Wampold, B. E., Minami, T., Baskin, T. W., & Tierney, S. C. (2002). A meta-(re)analysis of the effects of cognitive therapy versus “other therapies” for depression. Journal of Affective Disorders, 68, 159–165.
Watson, J. C., Gordon, L. B., Stermac, L., Kalogerakos, F., & Steckley, P. (2003). Comparing the effectiveness of process-experiential with cognitive-behavioral psychotherapy in the treatment of depression. Journal of Consulting and Clinical Psychology, 71, 773–781.
Baardseth, T. P., Goldberg, S. B., Pace, B. T., Wislocki, A. P., Frost, N. D., Siddiqui, J. R.,
Lindemann, A. M., Kivlighan, D. M., Laska, K. M., Re, A. C. D., Minami, T., & Wampold,
B. E. (2013). Cognitive-behavioral therapy versus other therapies: Redux. Clinical
Psychology Review, 33(3), 395‑405. https://doi.org/10.1016/j.cpr.2013.01.004
[1] Cognitive and Behavioral Therapies