Improving CBT: Problems and Prospects

G. Terence Wilson, Ph.D.

Evidence-Based Practice

Obstacles to Evidence-Based Treatment

Two classes of obstacles:• misconceptions about “evidence” and the

applicability of research findings to clinical practice

• gaps in our current knowledge about treatments, mechanisms of change, and reliable means of training competent practitioners

(Shafran et al., BRAT 2009)

Problems with Clinical Judgement

• “Although this desire to tailor treatments to individual needs has face validity, it may be misguided. Reliance on clinical judgment is at odds with a body of research on clinical versus actuarial prediction indicating that, on the whole, actuarial methods are superior” – (von Ranson & Robinson, 2006)

Problems with Clinical Judgement

• “In predicting behavior, highly trained clinical experts who assess all available information, and integrate it based on their own understanding of the details of the individual case, do no better and usually worse than actuarial prediction” (Dawes, Faust, & Meehl, 1989)

Problems with Clinical Judgement

• Therapists may choose components of evidence-based treatment protocols based on “clinical experience,” subjective preference or ease of administration, hence omitting or diluting what may be the most effective therapeutic elements (von Ranson & Robinson, 2006; Waller, 2009)

• Given free reign, even behavior therapists do not always use exposure in treating anxiety/phobic disorders (Becker et al., 2004; Schulte et al., 1995)

Limitations of Clinical Judgement

• It is precisely these limitations in decision making and case formulation, so well documented, that necessitate treatment guidelines(Dawes, 1994; Wilson, 1996)

What Type of Clinical Judgement?

• Addressing patient non-response to treatment, and possibly revising the treatment formulation, requires clinical judgment

• Not subjective clinical judgment based primarily on the therapist’s experience, but evidence-based judgment within the overall framework of CBT and in accordance with guidelines that are part of the treatment protocol – e.g., “taking stock” early (and possibly revamping the

treatment plan) is a required feature of CBT-E for eating disorders (Fairburn, 2008)

Competent manual-based therapy

• “….. Two core skills are required: first, ensuring that patients remain engaged in the treatment and maintaining their motivation to change; and second, implementing and individualising the treatment’s strategies and procedures. Neither is straightforward “– (Fairburn, 2010)

Best Available Evidence?

• A scientifically-based approach to treatment must differentiate between types of evidence, and assign primary value to empirical research (i.e., RCTs)

• APA scheme does not assign priority value to empirical research in clinical decision making

NICE Guidelines• “. … where sufficient evidence exists

to allow general recommendation, the best practice must be to implement the treatment that enjoys the most empirical support rather than invoke subjective judgment” (Wilson & Shafran, 2005 - Lancet)

Which Evidence-based Treatment?

Selection criteria should include (among others):

• Enduring effects• Robust effects

– broadly applicable, generalized effects• Brevity –rapid response• Cost-effectiveness

Therapies or Therapists?• It has been claimed that the

evidence does not demonstrate the superiority of specific interventions, and that therapist effects may be more important than the therapy

CBT treatment administered by competent therapists

• Typically few therapist effects in well-conducted RCTs showing superiority of one treatment over another– Unsurprisingly, studies of weaker treatments

without manuals have shown therapist effects (Crits-Christoph & Mintz, 1991)

• Therapeutic relationship does not mediate outcome

Empirically-supported treatments administered by competent therapists

• Therapists obtain better results as they become more competent in cognitive therapy (DeRubeis et al., 2005)

• Less experienced therapists using evidence-based treatment more effective than “expert” therapists using their preferred (non-CBT/DBT) approach (Linehan et al., 2006)

Towards Developing More Effective Therapy

Treatment Research PrioritiesIn evidence-based treatments, identify:1. Non-specific predictors of outcome (who is

“treatment-resistant”?)2. Moderators of treatment effects (what works for

whom under what conditions?)3. Necessary and sufficient procedural components

of effectiveness4. Mechanisms of change5. Treatment integrity6. Dissemination and implementation

The Treatment Outcome Research Question

• “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances”

Gordon Paul (1967)

Moderators

Importance of Moderators• Practitioners understandably want

to know if a specific treatment is the most effective for an individual patient in particular? – “personalized medicine” (Insel, 2009)

Importance of Moderators

Yet this is an unanswerable question:• “… the best science can do is provide

evidence for how well a given treatment works for a study population that shares with a given patient the same characteristics pertinent to the success of the treatment” – (Kraemer, Kupfer, & Frank, 2006, JAMA)

BA versus CTDesign• BA vs. CT vs. Meds in placebo-controlled

RCTResults• BA at least as effective as meds; both

significantly outperformed CT with severely depressed patients

Dimidjian et al. (JCCP, 2006)

Implications for Clinical Practice

• “more difficult patients may benefit from sustained focus on more limited goals. Using fewer intervention strategies and targeting fewer areas of change could accomplish this” – Coffman et al. (2007)

Identifying necessary and sufficient procedural components of treatments

• e.g., treatment of depression– Jacobson et al. (1996) dismantling

study– early response findings (Ilardi &

Craighead, 1994)

Beck’s CT: A Component Analysis

Implications:• major challenge to the cognitive theory of CT• development of BA into a therapy in its own

right – a functional analytic treatment grounded in contextualism (Martell, Addis, & Jacobson, 2001)

• BA is “clearly easier to teach and easier to learn than cognitive therapy…”(Hollon, 2001)

Early Response to CBT• Manual-based CBT produces much of its

success within the first 4 – 8 sessions of treatment (Ilardi & Craighead, 1994; Wilson, 1999)

• This robust finding has important theoretical, methodological, and practical implications

Innovation• Evidence: manual-based

treatments have encouraged testing of therapies, spurred theoretical debate, and facilitated practical innovations

Identifying mechanisms of change

• Active therapeutic components can be intensified and refined; inactive or redundant ingredients eliminated

• Results in more effective and efficient treatment

• May allow more efficient (and effective?) treatment of comorbid disorders

(Craske et al., 2007; Kazdin & Weisz , 1998; Kraemer et al., 2002)

Mechanism-based Treatment?

• Single targeted treatment yields more positive influences on co-occurring disorders than multiple targeted treatments

• Effects on co-occurring disorders may be mediated by success in lessening fears of bodily sensations– Craske et al. (2007)

Improving CBT?• Combine with other treatments

– need to identify mechanisms of change in order to usefully “integrate” different treatments

– failed (to date) but endlessly popular goal of “integrating” different psychological therapies

– inconsistent effects of combining CBT with antidepressant meds

– D-cycloserine and exposure treatment

Treatment Integrity• Treatment integrity has 2 components:

a) adherence to the protocol; and b) therapist competence

• systematic evaluations of this critically important aspect of treatment studies have been “extremely rare” (Perepletchikova et al., 2007)

– Complicates if not makes impossible interpretation of research studies

– Hinders dissemination of effective treatments

Generalizability of Research Findings

• Clinical trials can be representative of the usual clinical population

• Mounting evidence that the results of RCTs can, and do, generalize to routine clinical practice in different settings

• Research on generalizability remains a priority

Dissemination and Implementation

Dissemination

• Clear evidence that patients are not receiving empirically-supported treatments in routine clinical care

• Even when patients do receive these treatments there is evidence that they are often not well-delivered

Barriers to Dissemination and Implementation

• Clinicians are increasingly eager to learn – we have failed them to date

• Need to identify and assess competency levels required for therapists to implement empirically-supported treatments effectively

• Need to improve training methods and supervision

Does CBT Pose Particular Problems for Dissemination?

Yes• Technical expertise required

– Complex treatment strategies/packages• Need to combine technical expertise with

relationship skills– blending focus (structure of manual) with

flexibility

Can Less be More?• Less complex treatments may be more

easily disseminated • Reduced training requirements for less

complex treatment– BA for depression (Dimidjian et al., 2006)– PE for PTSD (Foa et al., 2005)– CBTgsh for Binge Eating Disorder (Wilson et

al., 2010)

Barriers to Dissemination

Problem: “Too many multi-component manuals designed to

treat ever-expanding array of topographically defined syndromes”

• “such a ‘brute force’ empirical approach makes it increasingly difficult to teach what is known or to focus on what is essential”

Hayes et al. (BRAT, 2006)

Transdiagnostic CBT• Transdiagnostic treatments may maximize

the benefits of both fidelity and adaptation• by treating similar disorders using

interventions that may target underlying processes they offer greater flexibility in the pacing and content of treatment while still providing structure (Craske et al., 2009; Fairburn, 2008; McHugh et al., 2009)

Partnering with Practitioners

• “Clinicians do not want to be disseminated on…. ” (Westen et al., 2005)

• Can we adopt a “collaborative, cyclical and iterative process” between researchers and practitioners? (Becker et al., BRAT 2009)

Partnering with Practitioners

• Can we allow/encourage local adaptation of research-based treatments – and thereby improve adoption – without losing effectiveness?

• “where are the bounds of flexibility before effectiveness is compromised?” (Proctor et al., 2009)