Money for Clinical Research in CBT
Dr. Richard Friedman, a well-known psychiatrist in New York, recently published an Op-Ed article in the New York Times, which made a strong case for increasing federal funding for research on psychotherapeutic interventions. Dr. Friedman's article is a laudable effort to draw the public's attention to both the value of therapy as a treatment for psychiatric disorders, and to the growing overemphasis on psychopharmacological and neuroscience research over psychotherapeutic/non-biological treatments for psychiatric disorders. As staunch proponents of cognitive and behavioral interventions, I'm sure many members of the Association for Behavioral and Cognitive Therapies (ABCT)- especially our colleagues who strive annually for ever-scarcer research dollars- will welcome the sentiment of more equitable funding for psychotherapy research.
Fortunately, ABCT has been at the forefront of the issue that Dr. Friedman discusses in his article. The National Institute of Mental Health (NIMH) released its strategic plan last November, which indicated a strong (almost exclusive) emphasis on funding for (neuro)biologically based research. Thanks to a rapidly formed collaborative effort shortly thereafter between ABCT, the Association for Psychological Science (APS), and the Society for a Science of Clinical Psychology (SSCP), the voice of the large constituency in our field that recognizes the value and strong scientific evidence for non-biological behavioral interventions was heard by the highest level of NIMH. I am hopeful that the voice given to the importance of psychotherapy research can translate to a place at the table for future strategic planning at the federal level.
Psychotherapy is a broadly defined term reflecting an even broader "tent" of treatments. Many of these treatments are very effective; some have yielded a wealth of scientific data to support their recommendation as first line interventions. While the overall efficacy of most psychotropic medications appears to decline as post-FDA approval studies are conducted (matched, perhaps, by the decline in their popularity as pharmaceutical company patents expire), this is rarely the case with psychotherapy, especially CBT. The best data available indicate that the effects are robust; basically, when it's good, it's good.
CBT can be thought of as a growing family of related interventions. However, unlike "psychotherapy" in general, for an intervention to be considered "CBT", that intervention must be connected to a cogent empirically-supported cognitive-behavioral theory, and must have scientific evidence supporting its efficacy before being included. Not just anyone can become a member of the CBT family, so to speak. A variety of myths continue to pervade the public's --and even some clinicians'-- understanding of CBT interventions (e.g., the misconception that CBT is rigidly procedure/protocol-focused and precludes seeing the person as an individual; or that exposure is unnecessarily distressing, intolerable, leads to high drop out rates, or is even somehow iatrogenic). However, those of us who are trained to conduct these scientifically-supported CBT treatments see these myths for what they are -- i.e. counterfactual assumptions based more on emotion and lore than fact. Indeed, CBT has science on its side. That's because we don't just "trust the process" in CBT, we examine it empirically. Research is clear that CBT is not only effective, but is also individualized, adaptable, and well-tolerated (see: Dobson & Dobson, 2009 and Feeny, Hembree & Zoellner, 2003). Perhaps we need to discuss the "tolerability" data for CBT as often as we discuss CBT's efficacy data!
As Dr. Friedman astutely notes, the "Decade of the Brain" (the 1990s) ended nearly 2 decades ago, and we appear no closer to achieving the dreamed of neurobiological solutions to the alleviation of human suffering than we were before that initiative. This is certainly not due to a lack of time or effort, as neuroscience was already flourishing before the 1990s. The 1980s was characterized by a substantial growth in neuroscience research publications, with an approximately 70% increase in the number of articles in neuroscience journals. This, in turn, was preceded in the 1970s by an overall growing interest in the field of neuroscience; consider that membership in the Society for Neuroscience increased nearly 7 times between 1970 and 1980, and witnessed a nearly 17-fold increase in membership from 1970-1990 (U.S. Congress, 1992). There is an important lesson to be learned: a major, strategic initiative in any area of research requires a long-term trajectory. The Decade of the Brain was decades in the making. If we are to see a Decade of Cognitive and Behavioral Therapies, we need to start today.
There is a very basic reason that funding for CBT research should be given equal footing, and perhaps even be made a priority: while we know CBT interventions are effective, they can still be better if we understand how change happens. As we begin to better understand the mechanisms of change in CBT, we have an opportunity to refine our interventions to be more effective and more efficient. With more research on mechanisms of change in CBT, we can make even more of an impact on the lives of people who seek treatment for psychiatric disorders.
Psychiatric disorders (or, from a behaviorist's perspective, behaviors that cause suffering) have not become less common in recent years, and some appear to be increasing in prevalence. We need "all hands on deck" to tackle such serious public health problems. Neuroscience and neurobiological research have a role to play, but they do not tell the whole story about psychopathology or its treatment. As we move into the future, it will be essential to include those "hands on deck" that have the strongest base of scientific evidence. This must certainly include behavioral and cognitive therapies.
Dobson, D. J. G., & Dobson, K. S. (2009). Evidence-based practice of cognitive-behavioral therapy. (pp 244-264) New York, NY: Guilford Press.
Feeny, N. C., Hembree, E. A., & Zoellner, L. A. (2004). Myths regarding exposure therapy for PTSD. Cognitive and Behavioral Practice, 10(1), 85-90.
Congress, U. S. (1992). The biology of mental disorders. In OTA-BA-538. US Government Printing Office St. Louis.