In May 2012, I blogged about results from a Swedish study examining the impact of psychotherapy’s “favorite son”–cognitive behavioral therapy–on the outcome of people disabled by depression and anxiety. Like many other Western countries, the percentage of people in Sweden disabled by mental health problems was growing dramatically. Costs were skyrocketing. Even with treatment, far too many left the workforce permanently.
Sweden embraced “evidence-based practice”–most popularly construed as the application of specific treatments to specific disorders–as a potential solution. Socialstyrelsen, the country’s National Board of Health and Welfare, developed and disseminated a set of guidelines (“riktlinger”) specific to mental health practice. Topping the list? CBT.
A billion crowns were spent training clinicians in the method; another billion using it to treat people with diagnoses of depression and anxiety. As I reported at the time, the State’s “return on investment” was zilch. Said another way, the widespread adoption of method had no effect whatsoever on outcome (see Socionomen, Holmquist Interview). Not only that but many who were not disabled at the time they were treated with CBT became disabled along the way, bringing the total price tag, when combined with the 25% who dropped out of treatment, to a staggering 3.5 billon!
And now, a new study–this time from Norway, Sweden’s neighbor to the west.
Norwegian researchers looked at how the effectiveness of CBT has fared over time. Examining data from 70 randomized clinical trials, study authors Johnsen and Friborg found the approach to be roughly half as effective as it was four decades ago. Mind you, not 10 or 20 percent. Not 30 or 40. Fifty percent less effective! Cause for concern, to be sure.
Naturally, the results published by the Norwegian researchers generated a great deal of activity in social media. Critics were gleeful (see the comments at the end of the article). Proponents, of course, questioned the results.
If the findings are confirmed in subsequent studies, CBT will be in remarkably good company. Across a variety of disciplines–pharmacology, medicine, zoology, ecology, physics–promising findings often “lose their luster,” with many fading away completely over time (Lehrer, 2010; Yong, 2012). Alas, even in science, the truth occasionally wears off. In psychiatry and psychology, this phenomenon, known as the “decline effect,” is particularly vexing.
That said, while the study and commentary have managed to generate a modest amount of heat, they’ve shed precious little light on the question of how to improve the outcome of psychotherapy. After all, that’s what led Sweden to invest so heavily in CBT in the first place–doing so, it was believed, would improve the effectiveness of care. So today, I called Rolf Holmqvist.
Rolf is a professor in the Department of Behavioral Science and Learning at Linköping University. He’s also the author of the Swedish study I blogged about over three years ago. I wanted to catch up, find out what, if anything, had happened since he published his results.
“Some changes were made in the guidelines some time ago. In the case of depression, for example, the guidelines have become a little more open, a little broader. CBT is always on top, along with IPT, but psychodynamic therapy is now included…although it’s further down on the list.”
Sounded like progress, until Rolf continued, “They are broadening a bit. Still the fact is that if you look at the research, for example, with mild and moderate depression, almost any method works if it’s done systematically.”
Said another way, despite the lack of evidence for the differential effectiveness of psychotherapeutic approaches–in this case, CBT for depression–the mindset guiding the creation of lists of “specific treatments for specific disorders” remains.
Rolf’s sentiments are echoed by uber-researchers, Wampold and Imel (2015), who very recently pointed out, “Given the evidence that treatments are about equally effective, that treatments delivered in clinical settings are effective (and as effective as that provided in clinical trials), that the manner in which treatments are provided much more important than which treatment is provided, mandating particular treatments seems illogical. In addition, given the expense involved in “rolling out” evidence-based treatments in private practices, agencies, and in systems of care, it seems unwise to mandate any particular treatment.”
Right now, in Sweden, an authority within the Federal government (Riksrevisorn) is conducting an investigation evaluating the appropriateness of funds spent on training and delivery of CBT. In an article published yesterday in one of the countries largest newspapers , Rolf Holmqvist argues, “Billions spent–without any proven results.”
Returning to the original question: what can be done to improve the outcome of psychotherapy?
“We need transparent evaluation systems,” Rolf quickly answered, “that provide feedback at each session about the progress of treatment. This way, therapists can begin to look at individual treatment episodes, and be able to see when, where, and with whom they are and are not successful.”
“Is that on the agenda?” I asked, hopefully.
“Well,” he laughed, “here, we need to have realistic expectations. The idea of recommending that you should employ a clinician because they are effective and a good person, rather than because they can do a certain method, is hard for regulatory agencies like Socialstyrelsen. They think of clinicians as learning a method, and then applying that method, and that its the method that makes the process work…”
“Right,” I thought, “mindset.”
“…and that will take time,” Rolf said, “but I am hopeful.”
But, you don’t have to wait. You can begin tracking the quality and outcome of your work right now. It’s easy and free. Click here to access two simple scales–the ORS and SRS. the first measures progress; the second, the quality of the working relationship.
Next, read our latest article on how the field’s most effective practitioners use the measures to, as Rolf advised, “identify when, where, and with whom” they are and are not successful, and what steps they take to improve their effectiveness.
Finally, join colleagues from around the world for our Fall Webinar on “Feedback-Informed Treatment.”
Until next time,
Scott D. Miller, Ph.D.
International Center for Clinical Excellence