Is CBT the ‘Gold Standard’? Examining the Evidence

As a therapist working with diverse people who have diverse minds and diverse emotional struggles, I call upon a diverse range of ideas and skills for helping. I try (emphasis on try) not to idealize or devalue any one style of therapy, and to learn as much as I can from books, teachers, and colleagues. I know only about 50% of people in therapy get better (e.g., Lambert, 2013), so at this point, no style of therapy offers a “cure-all.” We’re all doing our best to help as many people as we can, but we’re also failing a lot.

Because of my familiarity with the mixed outcome data about psychotherapy, I get a bit concerned when I hear someone refer to any one school of therapy as a “gold standard,” or when one school of therapy becomes the “go-to” referral. The “gold standard” designation does not square with my awareness that the field of psychotherapy is quite young (around 120 years old if you start with Sigmund Freud) and still has a lot to learn. Nonetheless, proponents of cognitive behavioral therapy (CBT) make this claim (e.g., Cristea & Hoffman, 2018). Naturally, claims like this can influence people’s decisions when making referrals to therapy or when choosing a therapist.

And who can blame us for believing a “gold standard” exists? It’s comforting to believe the treatment your doctor refers you to is the best treatment for your suffering, or that your therapist practices the best therapy out there. The idea alone can be relieving. But how do we decide what is or is not a “gold standard” treatment? Do we have adequate information for any therapy to make such a claim? What does the therapy research literature say about this?

Is CBT a “Gold Standard” Therapy?

In the 50 years since its founding, cognitive behavioral therapy (CBT; e.g., Beck, 2011) has developed a reputation as a “gold standard” treatment. It appears to be a first-line intervention for people with any kind of emotional difficulty and some physical difficulties. In my experience, most people who seek treatment for emotional struggles are initially referred to CBT. Medical colleagues have mentioned that CBT is the only therapy they are introduced to in school or encouraged to refer to, and I know of psychology programs that focus on CBT to the exclusion of other approaches to the mind, such as psychoanalytic and systems approaches. My observations indicate there is a general movement away from diversity in psychotherapy approaches to a “monoculture” of CBT and models derived from it.

There is no doubt some people benefit from CBT, but is it a true “gold standard”? Does research about CBT support its heavy use compared to other models? Has CBT demonstrated itself to be better than other therapies?

I do not claim to have decisive answers, but what I do have are two recently published journal articles that review the evidence regarding the effectiveness of CBT versus other therapies. I have picked out some findings from those articles that seem important to me, and I will share them below. Those who are interested in exploring the original sources in more detail can do so here and here. Both articles are concise and highly readable, even for people without advanced training in research and therapy.

Is CBT Effective?

In response to claims by CBT-oriented researchers that CBT is a “gold standard” treatment, Leichsenring, et al. (2018) and Shedler (2018) reviewed evidence. You can explore their article for details, but here I will restate their conclusions:

This is important information for anyone considering therapy, or who has been referred to CBT to the exclusion of other therapies. It may be especially important for people who have tried CBT, not benefited, and, sadly, blamed themselves or concluded therapy won’t work for them.

• Effectiveness vs. placebo. Some of the research cited by Leichsenring, et al. (2018, p. 3) suggests that while CBT may outperform the placebo effect slightly in a research setting, it does not outperform placebo enough to be considered more effective than placebo in a real-life clinical setting. Theoretically, that suggests that taking a sugar pill is equally effective to CBT.
• Effectiveness vs. control groups. The cited studies also show that CBT has only “limited superiority” to the control conditions it is compared to for research purposes (p. 3). Control conditions are comparison groups in which no treatment is given; for instance, one group in a study tries CBT, while the other group receives no intervention, such as remaining on a waiting list. In this sense, some evidence suggests CBT is only slightly superior to being on a waiting list and receiving no treatment.
• Remission rates. According to Leichsenring, et al. (2018, p. 3), only about 25% of people who tried CBT in the studies reviewed experienced remission, meaning only a quarter of people in the studies no longer had the condition they sought help for by the end of the study. Shedler’s (2018, p. 321) review supports this finding.
• Effectiveness vs. other therapies. The studies reviewed by Leichsenring, et al. (2018, p. 4) found no research evidence that CBT was superior to any other therapy.
• Effects of treatment can be short-lived. Shedler (2018, p. 322) notes a finding that 50% of people treated with CBT seek treatment for the same difficulties again within six to 12 months.
• No increases in effectiveness across decades. According to the Leichsenring, et al. (2018, p. 4) review, CBT research has not demonstrated an improvement in outcomes of CBT across five decades of research.

Based on this information alone, you may find yourself questioning why anyone would claim CBT is a “gold standard”—it has not demonstrated superiority, and the research seems, more than anything, to have demonstrated the limits of its effectiveness. This is important information for anyone considering therapy, or who has been referred to CBT to the exclusion of other therapies. It may be especially important for people who have tried CBT, not benefited, and, sadly, blamed themselves or concluded therapy won’t work for them.

Conclusion

No approach to therapy is a cure-all, and in fact there is much evidence for equivalence between therapies. If this is the case, though—that all therapies are limited and all produce roughly equivalent results—why are so many people referred to CBT? Why is there, as the review article claims and as I have observed, a “monoculture” of CBT?

A discussion of the scientific, economic, political, and ultimately human forces that have led to and perpetuated the myth of CBT as a “gold standard” is beyond the scope of this article, and readers interested in exploring that topic can check out the Leichsenring, et al. (2018) and Shedler (2018) articles in the references section below; both are quite articulate concerning these questions.

Whether we understand the reasons for the perpetuation of this belief or not, what is important is that consumers of mental health care are educated and aware of the well-documented limitations of CBT that seem to have been obscured by its self-presentation and public image as a “gold standard.”

Without a clear understanding of the virtues and limits of CBT, we may not consider other options that may be at least equally helpful. Even worse, we may blame ourselves and think we’re treatment-resistant when CBT doesn’t help. We may think we failed at the therapy when in fact the therapy failed us, as it does many people. If CBT fails us, we may think, “Therapy won’t work for me,” when in fact only one therapy out of many possible therapies didn’t work. Without more information about other evidence-based treatments, we may feel unnecessarily hopeless. That is why I felt these papers were important enough to share.

It may take some time before the medical and psychotherapy communities begin to recognize and respond to the research evidence that CBT is, like all therapies, helpful but limited. For now, however, we can help people make informed choices about their care. I hope you find this useful and look forward to your comments below.

References:

1. Beck, J. (2011). Cognitive behavior therapy, second edition. New York: Guilford Press.
2. David, D., Cristea, I., & Hofmann, S.G. (2018) Why cognitive behavioral therapy is the current gold standard of psychotherapy. Frontiers in Psychiatry, 9. doi: 10.3389/fpsyt.2018.00004
3. Lambert, M. J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (169-208). Hoboken, NJ: Wiley.
4. Leichsenring, F., Abbass, A., Hilsenroth, M. J., Luyten, P., Munder, T., Rabung, S., & Steinert, C. (2018). “Gold standards,” plurality and monocultures: The need for diversity in psychotherapy. Frontiers in Psychiatry, 9, 1-7.
5. Shedler, J. (2018). Where is the evidence for “evidence-based” therapy? Psychiatric Clinics of North America, 41, 319-329.

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