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?


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.

Mind the gap

Work to be done translating research to practice for CBT

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 practice1-7.  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.

Supply demand

Pressure on psychiatric services is always high, but there seems to be a particular shortage of CBT-trained 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 form9-16. 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 practice11-16. 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 promise19,20 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.


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Yueqi Liang

Author Yueqi Liang

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