Best Practice: Harmful to Consumers?

There has been some interesting responses to the statement that I have made on the "Cognitive Behavioral Therapy: Best Practice?" blog that goes as follows: "Cognitive-Behavioral Therapy and its proponents claims of being a superior method indicates a very dubious plan that may be harmful to many consumers." The main question that I have been confronted with is: How can Cognitive-Behavioral Therapy (CBT) be harmful to anyone?

I believe that the damage has more to do with the "Best Practice" idea than CBT. The idea of consumers being forced into having no options for treatment is flawed and possibly fatal. This forced method monopoly will have the effect of being harmful to some consumers while useful to others. Not everyone can be helped with CBT even though it can be a useful approach. It is harmful when managed care companies dictate a cost effective CBT treatment to consumers when it does not work for some of them. Limiting consumer choices to treatment is not a good idea as far as I am concerned.

By trying to demonstrate CBT's superiority, researchers take positions such as this one:

For global functioning as measured by the Global Assessment Scale(GAS), clients in the CBT group showed a significant improvement in mental functioning compared to standard therapy. (1)

Now, I have no idea what they mean by Standard Therapy. I have never heard of a model or therapy called Standard. Somehow this is rarely questioned.

Here is a sample of some interesting questions along with my attempts at answering them that were brought up from a listserve:

Question: What evidence do you have that insurance companies only cover CBT?

My Answer: A huge majority of managed care insurance companies require a diagnosis and a treatment plan. CBT claims to treat diagnoses. The treatment plans are designed with objectives that should be measureable in a way that satisfies CBT style interventions. There has been absolutely no evidence that diagnosing and developing treatment plans reflect better outcomes in therapy. Here is a quote from a September 2, 2002 Washington Post article (2):

What will be the ultimate effect of managed care's push for quantifiable, short-term results and the mental health profession's struggle to meet patients' needs? Psychotherapies that may be as effective as CT but take longer and have little if any data to show they work will be screened out, says Lloyd Sederer, who worked on managed care issues at APA before becoming New York City's commissioner for mental hygiene.

The article continues to state:

Therapists feel they are being railroaded into a single school of therapeutic thinking -- the one supported by managed care companies, which care less about patients than about holding costs down.

If you happen to read the whole article, you will find that CBT is only compared to psychoanalysis. Where are the other treatments and why do they get excluded? Perhaps, politics?

It appears to me that CBT has developed itself in relation to the DSM diagnoses and then measures its relative strength, given its reality, to a Standard Therapy (whatever that seems to be). Could their position of superiority (Best Practice) be more vague and erroneous?

Question: Why do you believe CBT is so connected to the medical model? I think CBT can be practiced without any reference to biology.

My Answer: CBT treats DSM diagnostic labels that are believed to have biological origins. You can look up NAMI, a political organization that lobbies for the medical model, in order to see what treatment it recommends for people. (3)

Question: Are you familiar with any of the literature or research as to why CBT should be best practice?

My Answer: Yes, I am. I am glad you asked. Here is a couple of paragraphs from a paper by Scott Miller, Mark Hubble, & Barry Duncan called "No MoreBells or Whistles" (4):

The only problem is that there is not a single shred of evidence to support such claims. In fact, there is not any evidence that brief therapy is actually briefer than existing therapeutic approaches. Rather, the research clearly indicates that most therapy is of relatively short duration and always has been regardless of the treatment model employed. The average client of any therapy, for example only attends five or six sessions! Similarly, there is no evidence that brief therapy results in more single session cures. Once again, the research indicates that a single session is the modal number of sessions for all clients in therapy regardless of the treatment model employed. Finally, there is absolutely no evidence that brief therapy results in more effortless, reliable or even enduring change than "longer term" treatment. Indeed, available data suggest that brief therapy achieves roughly the same results as the traditional approaches they are supposed to replace. In short, whatever differences the experts may believe exist between brief and traditional therapy, there simply isn't a difference in terms of outcome.

Why then do the developers of treat­ment models spend so much time and effort highlighting the differences between their respective approaches when no empirical support exists for such differences? One possibility is that advocates for the various models are trying to influence and impress their primary consumers; not clients, but other therapists. After all, therapists are the ones most likely to be interested in one theory or another, to use the various models to conceptualize and organize their clinical work and to buy professional books and attend training workshops. From a marketing point of view, prop­onents of brief therapy should be con­sidered especially skilled salespeople since they have successfully convinced large numbers of clinicians to buy a model that produces essentially the same results as other models presently in use. How could such a large segment of practicing clinicians be sold such a bill of goods?

In closing, I do believe that CBT can be a useful approach to therapy but should not take a superior stance to therapy. It is the "Best Practice" idea that needs to be further scrutinized because there is nothing more dangerous than an idea when it is the only one you have.

Footnotes:

1) http://www.joannabriggs.edu.au/best_practice

2) http://www.washingtonpost.com

3) http://www.nami.org/

4) http://www.talkingcure.com/reference2.htm