Editing Cognitive behavioral therapy (section)

==Criticisms<!--[[Criticism of cognitive behavioral therapy]] redirects here. This section is also linked from other articles: do not rename without including an anchor to the previous name ([[MOS:HEAD]])-->==
{{See also|Behavior modification#Criticism|Psychotherapy#General critiques}}

===Relative effectiveness===
The research conducted for CBT has been a topic of sustained controversy. While some researchers write that CBT is more effective than other treatments,<ref name="Tolin_2010" /> many other researchers<ref name="Barth_2013" /><ref>{{cite journal | vauthors = Wampold BE, Flückiger C, Del Re AC, Yulish NE, Frost ND, Pace BT, Goldberg SB, Miller SD, Baardseth TP, Laska KM, Hilsenroth MJ | display-authors = 6 | title = In pursuit of truth: A critical examination of meta-analyses of cognitive behavior therapy | journal = Psychotherapy Research | volume = 27 | issue = 1 | pages = 14–32 | date = January 2017 | pmid = 27884095 | doi = 10.1080/10503307.2016.1249433 | s2cid = 37490848 }}</ref><ref name="Baardseth_2013" /><ref name="Cuijpers_2008" /><ref name="Glenn">{{cite journal | vauthors = Glenn CR, Franklin JC, Nock MK | title = Evidence-based psychosocial treatments for self-injurious thoughts and behaviors in youth | journal = Journal of Clinical Child and Adolescent Psychology | volume = 44 | issue = 1 | pages = 1–29 | year = 2014 | pmid = 25256034 | pmc = 4557625 | doi = 10.1080/15374416.2014.945211 }}</ref> and practitioners<ref name="Slife">{{cite book | vauthors = Slife BD, William RN | date = 1995 | title = What's behind the research? Discovering hidden assumptions in the behavioral sciences | location = Thousand Oaks, CA | publisher = Sage }}</ref><ref name="Fancher">{{cite book | vauthors = Fancher RT | date = 1995 | title = Cultures of healing: Correcting the image of American mental health care | location = New York | publisher = W. H. Freeman and Company }}</ref> have questioned the validity of such claims. For example, one study<ref name="Tolin_2010" /> determined CBT to be superior to other treatments in treating anxiety and depression. However, researchers<ref name="Baardseth_2013" /> responding directly to that study conducted a re-analysis and found no evidence of CBT being superior to other bona fide treatments and conducted an analysis of thirteen other CBT clinical trials and determined that they failed to provide evidence of CBT superiority. In cases where CBT has been reported to be statistically better than other psychological interventions in terms of primary outcome measures, effect sizes were small and suggested that those differences were clinically meaningless and insignificant. Moreover, on secondary outcomes (i.e., measures of general functioning) no significant differences have been typically found between CBT and other treatments.<ref name="Baardseth_2013" /><ref>{{cite journal | vauthors = Marcus DK, O'Connell D, Norris AL, Sawaqdeh A | title = Is the Dodo bird endangered in the 21st century? A meta-analysis of treatment comparison studies | journal = Clinical Psychology Review | volume = 34 | issue = 7 | pages = 519–530 | date = November 2014 | pmid = 25238455 | doi = 10.1016/j.cpr.2014.08.001 }}</ref>

A major criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e., either the subjects or the therapists in psychotherapy studies are not blind to the type of treatment). They may be single-blinded, i.e. the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in.<ref name="psychiatrictimes.com" />

The importance of double-blinding was shown in a meta-analysis that examined the effectiveness of CBT when placebo control and blindness were factored in.<ref>{{cite journal | vauthors = Lynch D, Laws KR, McKenna PJ | title = Cognitive behavioural therapy for major psychiatric disorder: does it really work? A meta-analytical review of well-controlled trials | journal = Psychological Medicine | volume = 40 | issue = 1 | pages = 9–24 | date = January 2010 | pmid = 19476688 | doi = 10.1017/S003329170900590X | doi-access = free | hdl = 2299/5741 | hdl-access = free }}</ref> Pooled data from published trials of CBT in [[schizophrenia]], [[major depressive disorder]] (MDD), and [[bipolar disorder]] that used controls for non-specific effects of intervention were analyzed. This study concluded that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates; treatment effects are small in treatment studies of MDD, and it is not an effective treatment strategy for prevention of relapse in bipolar disorder. For MDD, the authors note that the pooled effect size was very low.<ref>{{cite journal | vauthors = Lincoln TM | title = Letter to the editor: a comment on Lynch et al. (2009) | journal = Psychological Medicine | volume = 40 | issue = 5 | pages = 877–880 | date = May 2010 | pmid = 19917145 | doi = 10.1017/S0033291709991838 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Kingdon D | title = Over-simplification and exclusion of non-conforming studies can demonstrate absence of effect: a lynching party? | journal = Psychological Medicine | volume = 40 | issue = 1 | pages = 25–27 | date = January 2010 | pmid = 19570315 | doi = 10.1017/S0033291709990201 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Wood AM, Joseph S | title = Letter to the Editor: An agenda for the next decade of psychotherapy research and practice | journal = Psychological Medicine | volume = 40 | issue = 6 | pages = 1055–1056 | date = June 2010 | pmid = 20158935 | doi = 10.1017/S0033291710000243 | doi-access = free }}</ref>

===Declining effectiveness===
Additionally, a 2015 meta-analysis revealed that the positive effects of CBT on depression have been declining since 1977.<!-- <ref name = Johnsen2015/> --> The overall results showed two different declines in [[effect size]]s: 1) an overall decline between 1977 and 2014, and 2) a steeper decline between 1995 and 2014. Additional sub-analysis revealed that CBT studies where therapists in the test group were instructed to adhere to the Beck CBT manual had a steeper decline in effect sizes since 1977 than studies where therapists in the test group were instructed to use CBT without a manual. The authors reported that they were unsure why the effects were declining but did list inadequate therapist training, failure to adhere to a manual, lack of therapist experience, and patients' hope and faith in its efficacy waning as potential reasons.<!-- <ref name = Johnsen2015/> --> The authors did mention that the current study was limited to depressive disorders only.<ref name="Johnsen2015">{{cite journal | vauthors = Johnsen TJ, Friborg O | title = The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis | journal = Psychological Bulletin | volume = 141 | issue = 4 | pages = 747–768 | date = July 2015 | pmid = 25961373 | doi = 10.1037/bul0000015 | s2cid = 27777178 }}</ref>

===High drop-out rates===
Furthermore, other researchers write that CBT studies have high drop-out rates compared to other treatments.  One meta-analysis found that CBT drop-out rates were 17% higher than those of other therapies.<ref name="Cuijpers_2008" /> This high drop-out rate is also evident in the treatment of several disorders, particularly the [[eating disorder]] [[anorexia nervosa]], which is commonly treated with CBT. Those treated with CBT have a high chance of dropping out of therapy before completion and reverting to their anorexia behaviors.<ref>{{cite book | vauthors = Nolen-Hoeksema S | date = 2014 | title = Abnormal Psychology | edition = 6th | publisher = McGraw-Hill Education | page = 357 | isbn = 978-1-259-06072-4 }}</ref>

Other researchers analyzing treatments for youths who self-injure found similar drop-out rates in CBT and [[Dialectical behavioral therapy|DBT]] groups. In this study, the researchers analyzed several clinical trials that measured the efficacy of CBT administered to youths who self-injure. The researchers concluded that none of them were found to be efficacious.<ref name="Glenn" />

===Philosophical concerns with CBT methods===
The methods employed in CBT research have not been the only criticisms; some individuals have called its theory and therapy into question.<ref>{{cite book | vauthors = Fancher RT | date = 1995 | title = Cultures of healing: Correcting the image of American mental health care | page = 231 | location = New York | publisher = W. H. Freeman and Company }}</ref>

Slife and Williams write that one of the hidden assumptions in CBT is that of [[determinism]], or the absence of [[free will]]. They argue that CBT holds that external stimuli from the environment enter the mind, causing different thoughts that cause emotional states: nowhere in CBT theory is agency, or free will, accounted for.<ref name="Slife" />

Another criticism of CBT theory, especially as applied to major depressive disorder (MDD), is that it confounds the symptoms of the disorder with its causes.<ref name="psychiatrictimes.com">{{cite web |date=30 July 2013 |title=Cognitive Behavioral Therapy: Escape From the Binds of Tight Methodology |url=https://www.psychiatrictimes.com/view/cognitive-behavioral-therapy-escape-binds-tight-methodology |publisher=Psychiatric Times |vauthors=Berger D}}</ref>

===Side effects===
CBT is generally regarded as having very few if any side effects.<ref>{{Cite web|url=https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610|title=Cognitive behavioral therapy – Mayo Clinic|website=www.mayoclinic.org}}</ref><ref>{{Cite web|title=Ten Things You Need To Know To Overcome OCD|url=https://beyondocd.org/expert-perspectives/articles/ten-things-you-need-to-know-to-overcome-ocd|access-date=2 August 2020|website=Beyond OCD|language=en-US}}</ref> Calls have been made by some for more appraisal of possible side effects of CBT.<ref>{{cite web|url=http://www.nationalelfservice.net/treatment/psychotherapy/psychotherapy-trials-should-report-the-side-effects-of-treatment/|title=Psychotherapy trials should report on the side effects of treatment|date=30 April 2014}}</ref> Many randomized trials of psychological interventions like CBT do not monitor potential harms to the patient.<ref>{{cite journal | vauthors = Jonsson U, Alaie I, Parling T, Arnberg FK | title = Reporting of harms in randomized controlled trials of psychological interventions for mental and behavioral disorders: a review of current practice | journal = Contemporary Clinical Trials | volume = 38 | issue = 1 | pages = 1–8 | date = May 2014 | pmid = 24607768 | doi = 10.1016/j.cct.2014.02.005 | url = http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-219714 }}</ref> In contrast, randomized trials of pharmacological interventions are much more likely to take adverse effects into consideration.<ref>{{cite journal | vauthors = Vaughan B, Goldstein MH, Alikakos M, Cohen LJ, Serby MJ | title = Frequency of reporting of adverse events in randomized controlled trials of psychotherapy vs. psychopharmacotherapy | journal = Comprehensive Psychiatry | volume = 55 | issue = 4 | pages = 849–855 | date = May 2014 | pmid = 24630200 | pmc = 4346151 | doi = 10.1016/j.comppsych.2014.01.001 }}</ref>

A 2017 meta-analysis revealed that adverse events are not common in children receiving CBT and, furthermore, that CBT is associated with fewer dropouts than either placebo or medications.<ref>{{cite journal | vauthors = Wang Z, Whiteside SP, Sim L, Farah W, Morrow AS, Alsawas M, Barrionuevo P, Tello M, Asi N, Beuschel B, Daraz L, Almasri J, Zaiem F, Larrea-Mantilla L, Ponce OJ, LeBlanc A, Prokop LJ, Murad MH | display-authors = 6 | title = Comparative Effectiveness and Safety of Cognitive Behavioral Therapy and Pharmacotherapy for Childhood Anxiety Disorders: A Systematic Review and Meta-analysis | journal = JAMA Pediatrics | volume = 171 | issue = 11 | pages = 1049–1056 | date = November 2017 | pmid = 28859190 | pmc = 5710373 | doi = 10.1001/jamapediatrics.2017.3036 }}</ref> Nevertheless, CBT therapists do sometimes report 'unwanted events' and side effects in their outpatients with "negative wellbeing/distress" being the most frequent.<ref>{{Cite journal|date=1 June 2018|title=Unwanted Events and Side Effects in Cognitive Behavior Therapy|journal=Cognitive Therapy |volume=42 |issue=3 |pages=219–229 |doi=10.1007/s10608-018-9904-y |s2cid=44034271 |issn=1573-2819| vauthors = Schermuly-Haupt ML, Linden M, Rush AJ }}</ref>

===Socio-political concerns===
The writer and group analyst Farhad Dalal questions the socio-political assumptions behind the introduction of CBT. According to one reviewer, Dalal connects the rise of CBT with "the parallel rise of [[neoliberalism]], with its focus on marketization, efficiency, quantification and [[managerialism]]", and he questions the scientific basis of CBT, suggesting that "the 'science' of psychological treatment is often less a scientific than a political contest".<ref>{{cite web|url=https://melbournelacanian.wordpress.com/2018/12/18/review-of-cbt-the-cognitive-behavioural-tsunami-by-farhad-dalal/|title=Review of CBT: The Cognitive Behavioural Tsunami | work = Archives of a Divided Subject |date=18 December 2018}}</ref> In his book, Dalal also questions the ethical basis of CBT.<ref>{{Cite web|url=https://www.routledge.com/CBT-The-Cognitive-Behavioural-Tsunami-Managerialism-Politics-and-the/Dalal/p/book/9781782206644|title=CBT: The Cognitive Behavioural Tsunami: Managerialism, Politics and the Corruptions of Science|website=Routledge & CRC Press|date=19 September 2018 }}</ref>