Why Not Talk Therapy

You did not fail out of therapy, therapy failed you.

The most common therapy modality in the US is Cognitive Behavioral Therapy (CBT). The focus of CBT is to identify and revise distorted thoughts and belief systems that create stress or other disturbances in people’s lives and relationships. This modality involves reality testing, cognitive restructuring and establishing new behavioral habits that help clients cope better with their situation.

However, even while CBT is considered an evidence based practice, the effectiveness is quite limited. In a large scale study conducted by the National Institute of Mental Health looking at CBT for depression (Treatment of Depression Collaborative Research Program), CBT was only 1.2 points better than no therapy on a 54 point Hamilton depression scale. In this and other trials, CBT had an effectiveness rate ranging between 17% and 24% under the most ideal, rarified laboratory conditions that ruled out participants with other comorbidity. In real world circumstances, we see CBT's effectiveness decrease to the 5% mark. These results for the effectiveness of CBT have remained consistent from that early trial to much more recent studies which is to say the state of the art in evidence based psychotherapy yields a 75% to 95% failure rate for the treatment of depression.

If we turn our attention to CBT and post traumatic stress disorder (PTSD), the randomized control trial data used by the American Psychological Association to recommend CBT as a trauma treatment is even more problematic. Excerpting from Jonathan Shedler’s excellent summary article on the topic, the author notes:

...[these are the] findings of the largest and arguably best RCT behind the [APA] guidelines. The RCT was funded by the U.S. Department of Veterans Affairs and the Department of Defense and published in the Journal of the American Medical Association. It studied 255 female veterans. The most frequent trauma was sexual trauma, followed by physical assault.

Patients received one of the “highly recommended” forms of CBT (prolonged exposure therapy) or a control treatment. Here is what the study found:

Nearly 40 percent of those who started CBT dropped out of treatment. They voted with their feet about its usefulness.

Sixty percent of the patients still had PTSD when the study ended.

One hundred percent of the patients were clinically depressed when the study ended.

At six-month follow-up, patients who received CBT were no better than those in the control group.

Nineteen serious “adverse events” (suicide attempts,psychiatric hospitalizations) occurred over the course of the study.

The authors soberly noted that the patients “may need more treatment than the relatively small number of sessions typically provided in a clinical trial.”

I did not choose this study as an example because it is a poor study. I chose it because it is arguably the best.

Even though 40% of patients did not have PTSD when the study ended, this number drops to the same level as that of the control group at the 6 month follow up. Our best, state of the art, evidence based treatments have had very high failure rates when it comes to depression and PTSD. Again, many clients did not fail in therapy, therapy failed the client.