Sunday, May 13th, 2012
Arlanda Airport, Sweden
Over the last decade, Sweden, like most Western countries, embraced the call for “evidence-based practice.” Socialstyrelsen, the country’s National Board of Health and Welfare, developed and disseminated a set of guidelines (“riktlinger”) for mental health practice. Topping the list of methods was, not surprisingly, cognitive-behavioral therapy.
The Swedish State took the list seriously, restricting payment for training of clinicians and treatment of clients to cognitive behavioral methods. In the last three years, a billion Swedish crowns were spent on training clinicians in CBT. Another billion was spent on providing CBT to people with diagnoses of depression and anxiety. No funding was provided for training or treatment in other methods.
The State’s motives were pure: use the best methods to decrease the number of people who become disabled as result of depression and anxiety. Like other countries, the percentage of people in Sweden who exit the work force and draw disability pensions has increased dramatically. As a result, costs skyrocketed. Even more troubling, far too many became permanently disabled.
The solution? Identify methods which have scientific support, or what some called, “evidence-based practice.” The result? Despite substantial evidence that all methods work equally well, CBT became the treatment of choice throughout the country. In point of fact, CBT became the only choice.
As noted above, Sweden is not alone in embracing practice guidelines. The U.K. and U.S. have charted similar paths, as have many professional organizations. Indeed, the American Psychological Association has now resurrected its plan to develop and disseminate a series of guidelines advocating specific treatments for specific disorders. Earlier efforts by Division 12 (“Clinical Psychology”) met with resistance from the general membership as well as scientists who pointed to the lack of evidence for differential effectiveness among treatment approaches.
Perhaps APA and other countries can learn from Sweden’s experience. The latest issue of Socionomen, the official journal for Swedish social workers, reported the results of the government’s two billion Swedish crown investment in CBT. The widespread adoption of the method has had no effect whatsoever on the outcome of people disabled by depression and anxiety. Moreover, a significant number of people who were not disabled at the time they were treated with CBT became disabled, costing the government an additional one billion Swedish crowns. Finally, nearly a quarter of those who started treatment, dropped out, costing an additional 340 million!
In sum, billions training therapists in and treating clients with CBT to little or no effect.
Since the publication of Escape from Babel in 1995, my colleagues and I at the International Center for Clinical Excellence have gathered, summarized, published, and taught about research documenting little or no difference in outcome between treatment approaches. All approaches worked about equally well, we argued, suggesting that efforts to identify specific approaches for specific psychiatric diagnoses were a waste of precious time and resources. We made the same argument, citing volumes of research in two editions of The Heart and Soul of Change.
Yesterday, I presented at Psykoterapi Mässan, the country’s largest free-standing mental health conference. As I have on previous visits, I talked about “what works” in behavioral health, highlighting data documenting that the focus of care should shift away from treatment model and technique, focusing instead on tailoring services to the individual client via ongoing measurement and feedback. My colleague and co-author, Bruce Wampold had been in the country a month or so before singing the same tune.
One thing about Sweden: the country takes data seriously. As I sat down this morning to eat breakfast at the home of my long-time Swedish friend, Gunnar Lindfeldt, the newscaster announced on the radio that Socialstyrelsen had officially decided to end the CBT monopoly (listen here). The experiment had failed. To be helped, people must have a choice.
“What have we learned?” Rolf Holmqvist asks in Socionomen, “Treatment works…at the same time, we have the possibility of exploring…new perspectives. First, getting feedback during treatment…taking direction from the patient at every session while also tracking progress and the development of the therapeutic relationship!”
“Precis,” (exactly) my friend Gunnar said.
And, as readers of my blog know, using the best evidence, informed by clients’ preferences and ongoing monitoring of progress and alliance is evidence-based practice. However the concept ever got translated into creating lists of preferred treatment is anyone’s guess and, now, unimportant. Time to move forward. The challenge ahead is helping practitioners learn to integrate client feedback into care—and here, Sweden is leading the way.
“Skål Sverige!”
Very very good that you write about this long-anticipated change in directions on your blog Scott!! And skål to you too!! You’re doing a fantastic work everytime you come over here to hold lectures and seminars! Been too a few myself and I hope I can come and participate next spring when you’re in Gothenburg again!
Well, how about over 1000 studies that SUPPORT that CBT works?
And what’s the evidence that because it didn’t work in Sweden, the causes lie entirely with the therapy?
Dr. Shishir Palsapure MD MSc (Psy)
Certified Rational emotive and Cognitive behavior therapy supervisor
India.
I think the issue here is not that CBT does not work. The point is that it is not the panacea for everyone.
I come from India and have been trained in psychological medicine in Europe. It is difficult for me to appreciate the fanatical fetishism of CBT in the west when I know that many other methodologies also work. In the psychotherapy circles,no one wants to discuss hypnosis. For those who have any idea of hypnosis, they know that it is a powerful medium to do therapy work. But every method or approach has its limitations. Likewise CBT and hypnosis also have their limitations. Strangely, a society that prides itself to be open to new ideas is closed to innovation and does not embrace change readily. We are after all human beings who live by ‘intuition’ and ‘feelings’ and less by reason, logic or thinking.
Thank you for this. For far too long, despite criticism, the UK’s so-called National Institute for Clinical excellence (NICE)!!! has advocated CBT to be THE preferred approach, with billions of Pounds pumped into training practitioners in CBT and patients/clients taking CBT. It amazes me how NICE misses the very obvious point altogether that it is the PROCESS (ie relationship between therapist and client) rather than the TECHNIQUE (ie CBT) that really counts for success or lack of it!! You can have the most wonderful machine in the world for doing a job, but it is only as good as the person who uses it. Thank you, Sweden for advocating for the right of patients/clients to CHOOSE! I particularly admire your stance that “All approaches worked about equally well”
Let’s hope the NICE people will now listen!!! And revise their rigid attitudes!!
We are in the first step to establish a basic psychological mental health service by providing a comprehensive CBT training for the Libyam Trainees who will start to offer basic service within the ground. I’ll appreciated if you post or send me plans or resources to start in a balanced way to ensure that we are in the right track. thanks for all in advanced.
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I can’t find anything about this failure published anywhere, seems to me like that would be a huge story. Its not on PubMed, PsychInfo, Google, no where.
Its one thing to not like mandated care, I get that, but to bash an effective intervention because it tends to be mandated by socialized medicine, that’s a different — and dangerous — matter.
Fight the mandates, not the treatments!
I disagree about relationship between client/therapist statement. I have never met Albert Ellis. We have no relationship. His work changed my life.
You say CBT only works if the client works at it. Why is that a problem, has anything of value in life been accomplished without hard work? Why should mental health be any different from getting an education, developing a relationship or buying a home, for example.
Some folks do well in a dependant relationship with the therapist, some do better in a group, and some, prefer to read a book and study. So, we are different…this is news?
I think your premise that ill people diagnosing their treatment before it is completed is a little odd in terms of evidence based anything.
Cheers.
There isn’t an English translation of the Socionomen article, is there?
Counseling is all about the client; who they are, where they are and where are they going/see themselves. Counseling is a smorgasbord of methods which is tailored around the clients needs. We just need to ask, listen and be curious.
Kudos to Sweden and to you Scott!
Be careful. No one said CBT doesn’t work. The issue is whether one approach deserves to be priveleged over all others. Here the data is clear: All Have Won and All Deserve Prizes.
Forcing clinicians to adopt one way of working, when all of the research indicates equivalence is a serious error in social policy. At the same time, it is exacylt what I predicted would happen years ago when evidence based PRACTICE was misinterpreted as specific methods for specific disorders.
Sorry, no English translation that I know of…
Yes, there are many studies. 1000’s? Absolutely not. Read, "The Great Psychotherapy Debate" and you’ll get an idea of the current evidence base. At the same time, when models are directly compared, there is no difference in outcome. The conclusion one should draw? No method deserves privilege. Instead, as the definition of evidence based practice makes clear, therapist and client must decide together what works based on the client’s culture and preferences. If those advocating specific models for specific treatments would simply acknolwedge the REAL definition of EBP, I’d be happy!
The big attraction of IAPT style CBT for the NHS is that it is protocol driven and manualised and therefore very easy to measure.Outcome measures abound and the computer systems that support it churn out masses of key performance data which is used to decide if the contract terms are being met and money can be handed over in ‘payment by results’. All in all an accountants dream. As a tiny cog (a lowly High Intensity CBT practitioner of nearly 4 years standing)in this ridiculous machine I can honestly say it’s far from the vision Lord Layard intended. Old school CB psychotherapists think we are badly trained and lacking in fundamental skills. Patients in my experience don’t really mind what sort of therapy they have as long as they get something. I’m really an Integrative Counsellor who is trained in EMDR(now there’s an fantastic therapy)- the NHS don’t want to know, how on earth would they measure it? CBT will inevitably fall out of fashion in time, we just need to convince NICE of the error of their ways. Good work Scott for bringing this to our attention.
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As a practising homeopath can I put in a little plea for how well homeopathy soemtimes works with people presenting with “mental health issues”. And can I also observe that such homeopathy depends partly, as with anything else, on the rapport between the client and homeopath aswell as the skill and understanding of the practitioner. I know this is not main stream – but it can be so valuable for some people, sometimes.
Interesting to read this article, especially to see that some kind of change supposedly happened in 2012. Here we are in 2015 and I’m an American in Sweden facing the same “CBT only” problem. I’ve been a consumer of mental health care for many years now in the U.S., where I did individual talk therapy and DBT, as well as counseling from both my doctor who monitored my medication and from separate therapists. Getting ready to give birth to my first child, I pushed VERY hard to get any mental health services here in Sweden at all as a preparatory measure as I enter a new and challenging phase of my life. I’ve found here that the strategy here in Sweden is “wait til it’s bad, then call us.” I’ve been through mental health crises enough to know this is a bad method. People in crisis don’t always make the best decisions. It’s better to be connected to service providers and have a plan in place and be ready to act at the first sign of trouble. Anyway, to get to the CBT point, that’s ALL I hear about. I’m sure it’s very effective in some situations for some people, but is it appropriate for MY potential postpartum depression when I may be totally overwhelmed with new baby? Maybe I can’t do the assignments, but really need support from someone besides my husband. Then what? I’ve been told that there are “options”, but then the statement is ALWAYS followed by a long winded description of CBT. We shall see what happens, but right now I honestly feel like I’m in some episode of the Twilight Zone, and not in a land of highly educated and up-to-date mental health care providers.
Oops! I mean it’s 2016, not 2015! Time flies.
The only reason CBT ever works at all is that something human happens between a caring practitioner and their client. This has masked the fact that CBT itself is completely useless and based on old fashioned, outmoded and seriously flawed theories and practices from animal research all the way back to Yerks Dobson, Pavlov and Skinner. To spend any money whatsoever or any time whatsover on the study of CBT is an absolute waste of money at any level. Look at the theoretical foundation, the so-called experimental evidence and discard this outdated, inhumane, old fashioned NONSENSE asap.