Mind the gap: cognitive behaviour therapy in the real world

Clinicians favour ‘evidence-based practice’. Researchers aim for ‘translational research’. So why is clinical provision of CBT – which boasts the strongest evidence-base of all psychological therapies – lagging behind?

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As somebody who works in both academic and clinical settings, I am often struck by the disconnect that occurs between research findings and clinical practice. My observation is not a novel one, and in recent years major efforts have been made to promote the clinical application of empirical findings. Indeed, phrases such as “translational research”, “bench to bedside” and “patient benefit” seem to be important buzz words when it comes to grant writing and securing research funding.

In a similar vein, terms such as “evidence-based practice” win favour with NHS commissioners. So it seems that the people holding the purse strings on both the clinical and academic side are keen to bridge the gap between research and clinical care. These efforts are no doubt proving fruitful but it seems that there is still a long way to go. Here I will consider cognitive behaviour therapy (CBT) as an example.

CBT in limited supply

CBT has the strongest evidence-base of all psychological interventions and has been shown to be an efficacious treatment for a wide range of mental health disorders. However, a large number of studies have shown that only the minority of individuals with diagnosed mental health problems receive CBT in routine clinical practice^1-7.  For example, a national survey of over 500 child and adolescent mental health practitioners in the United Kingdom (UK) found that only 20% of clinicians reported CBT as their main therapeutic approach, and 40% reported rarely using CBT⁷.

One might expect the situation to be improving over time, particularly with the publication of national clinical guidelines recommending CBT, but this is not necessarily the case. For example, the National Institute for Health and Clinical Excellence (NICE) guidelines for obsessive-compulsive disorder (OCD) were published in 2005 and recommend CBT as the first-line psychological treatment⁸. However, an audit of the treatment histories of young people referred to a specialist OCD Clinic in the UK indicated that only the minority of patients had received previous CBT and rates did not improve following publication of the NICE guidelines⁵. Somewhat surprisingly, there was a significant increase over time in the rates non-CBT psychotherapies that were received (such as family therapy and psychodynamic psychotherapy), despite the fact that these interventions are not evidence-based treatments for OCD. So it seems that there is manpower available in child and adolescent health services (CAMHS) but that there is a specific shortage of CBT therapists.

The quality of CBT varies

Even when individuals with mental health problems manage to successfully navigate their way through services and are offered CBT, it may be delivered in a suboptimal form^9-16. For example, research has shown that exposure techniques are a key active ingredient in CBT for anxiety disorders, yet exposure is strikingly under-utilised by clinicians in routine practice^11-16. In a survey of 331 child anxiety therapists in North America, approximately 80% reported using CBT but only 5% said they used exposure techniques¹⁴. In another survey of over 2,200 North American therapists, exposure techniques were found to be used at comparable rates to non-evidence based practices such as art therapy and dream analysis¹⁵. To be clear, failure to include certain core elements of CBT is not a minor issue. At best, treatment that deviates from evidence-based protocols may be less effective (or ineffective), but at worst it could be harmful.

So why do therapists fail to offer evidence-based treatments? In some cases, it may reflect a lack of adequate training¹⁷ and/or constraints imposed by services (e.g. limits on the number of sessions that can be offered). However, in other cases therapists may veer away from evidence-based practice of their own accord, a phenomenon that has been referred to as “therapist drift”¹⁸. It has been suggested that therapist drift might reflect unhelpful (and inaccurate) beliefs that clinicians commonly hold about the relevance of research findings in the real world. For example, they may feel that CBT protocols only work for “straightforward” patients, not those with complex issues such as comorbidity and additional risk.

Interestingly, CBT therapists appear to most commonly drift away from behavioural aspects of treatment in favour of talking techniques¹⁸, despite behavioural interventions often being the most effective component of treatment. It has been proposed that therapists might avoid behavioural techniques because they are often aversive for the patient in the short-term, and therefore uncomfortable for the therapist¹⁸. In other words, therapists might prefer to use strategies that reduce or avoid immediate patient distress as opposed to opting for behavioural strategies that often involve short-term pain for long-term gain.

What next?

So how can we ensure that everyone suffering from mental health problems has access to good quality, evidence-based CBT?

One priority is to train a larger workforce of CBT therapists, and this is precisely what initiatives such as Increasing Access to Psychological Therapies (IAPT) are aiming to do. But this then raises the question of what the most effective approach is for training CBT therapists on a large-scale and preventing therapist drift. Few studies have attempted to answer this question and it is an area that warrants further research. However, even if successful training of a larger CBT workforce is achieved, it is unrealistic to expect that there will ever be enough therapists to treat everyone in need. A second priority therefore is to develop innovative, evidence-based methods for disseminating CBT that make use of the limited resources available. For example, internet CBT has shown great promise^19,20 and can be integrated into stepped-care models of treatment, being used as a “low intensity” option for milder cases. There are some examples of internet CBT being successfully integrated into clinical services to treat specific problems, but on the whole such treatments remain unavailable, especially for children and adolescents.

References

1. Crow, S., Mussell, M. P., Peterson, C., Knopke, A., & Mitchell, J. (1999). Prior treatment received by patients with bulimia nervosa. International Journal of Eating Disorders, 25, 39–44.

2. Ehlers, A., Gene-Cos, N., & Perrin, S. (2009). Low recognition of posttraumatic stress disorder in primary care. London Journal of Primary Care, 1, 36–42.

3. Goisman, R. M., Warshaw, M. G., & Keller, M. B. (1999). Psychosocial treatment prescriptions for generalized anxiety disorder, panic disorder and social phobia, 1991–1996. American Journal of Psychiatry, 156, 1819–1821.

4. Kohn, R., Saxenall, S., Levavill, I., & Saracenoll, B. (2004). The treatment gap in mental health care. Bulletin World Health Organisation, 82, 858-866.

5. Nair, A., Wong, Y. L., Barrow, F., Heyman, I., Clark, B., & Krebs, G. (2015). Has the first-line management of paediatric OCD improved following the introduction of NICE guidelines?. Archives of Disease in Childhood, 100, 416-417.

6. Wang, P. S., Lane, M., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2005). Twelve month use of mental health services in the USA. Results from the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 629–640.

7. Stallard, P., Udwin, O., Goddard, M., & Hibbert, S. (2007). The availability of cognitive behaviour therapy within specialist child and adolescent mental health services (CAMHS): A national survey. Behavioural and Cognitive Psychotherapy, 35, 501-505.

8. (2005). Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. NICE, London.

9. Kessler, R. C., Merikangas, K. R., & Wang, P. S. (2007). Prevalence, comorbidity and service utilization of mood disorders in the United States at the beginning of the twenty-first century. Annual Review of Clinical Psychology, 3, 137–158.

10. Waller, G., Stringer, H., & Meyer, C. (2012). What cognitive behavioral techniques do therapists report using when delivering cognitive behavioral therapy for the eating disorders?. Journal of Consulting and Clinical Psychology, 80(1), 171.

11. Stobie, B., Taylor, T., Quigley, A., Ewing, S., & Salkovskis, P. M. (2007). ‘Contents my vary’: a pilot study of treatment histories of OCD patients. Behavioural and Cognitive Psychotherapy, 35, 273–282.

12. Krebs, G., Isomura, K., Lang, K., Jassi, A., Heyman, I., Diamond, H., … & Mataix‐Cols, D. (2015). How resistant is ‘treatment‐resistant’obsessive‐compulsive disorder in youth?. British Journal of Clinical Psychology, 54, 63-75.

13. Hipol, L. J., & Deacon, B. J. (2013). Dissemination of evidence-based practices for anxiety disorders in Wyoming: a survey of practicing psychotherapists. Behavior Modification, 37, 170-188.

14. Whiteside, S. P., Deacon, B. J., Benito, K., & Stewart, E. (2016). Factors associated with practitioners’ use of exposure therapy for childhood anxiety disorders. Journal of Anxiety Disorders, 40, 29-36.

15. Cook, J. M., Biyanova, T., Elhai, J., Schnurr, P. P., & Coyne, J. C. (2010). What do psychotherapists really do in practice? An Internet study of over 2,000 practitioners. Psychotherapy: Theory, Research, Practice, Training, 47, 260.

16. Valderhaug, R., Gunnar Götestam, K., & Larsson, B. (2004). Clinicians’ views on management of obsessive–compulsive disorders in children and adolescents. Nordic Journal of Psychiatry, 58(2), 125-132.

17. Reid, A. M., Bolshakova, M. I., Guzick, A. G., Fernandez, A. G., Striley, C. W., Geffken, G. R., & McNamara, J. P. (in press). Common Barriers to the Dissemination of Exposure Therapy for Youth with Anxiety Disorders. Community Mental Health Journal.

18. Waller, G. (2009). Evidence-based treatment and therapist drift. Behaviour Research and Therapy, 47, 119-127.

19. Ebert, D. D., Zarski, A. C., Christensen, H., Stikkelbroek, Y., Cuijpers, P., Berking, M., & Riper, H. (2015). Internet and computer-based cognitive behavioral therapy for anxiety and depression in youth: a meta-analysis of randomized controlled outcome trials.PloS one, 10(3), e0119895.
20. Spek, V., Cuijpers, P. I. M., Nyklícek, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis.Psychological medicine, 37(03), 319-328.