In pursuit of truth: A critical examination of meta-analyses of cognitive behavior therapy.

OBJECTIVE: Three recent meta-analyses have made the claim, albeit with some caveats, that cognitive-behavioral treatments (CBT) are superior to other psychotherapies, in general or for specific disorders (e.g., social phobia). METHOD: The purpose of the present article was to examine four issues in meta-analysis that mitigate claims of CBT superiority: (a) effect size, power, and statistical significance, (b) focusing on disorder-specific symptom measures and ignoring other important indicators of psychological functioning, (c) problems inherent in classifying treatments provided in primary studies into classes of treatments, and (d) the inclusion of problematic trials, which biases the results, and the exclusion of trials that fail to find differences among treatments. RESULTS: When these issues are examined, the effects demonstrating the superiority of CBT are small, nonsignificant for the most part, limited to targeted symptoms, or are due to flawed primary studies. CONCLUSION: Meta-analytic evidence for the superiority of CBT in the three meta-analysis are nonexistent or weak.

Ten things to remember about common factor theory.

Recently, we (Laska, Gurman, & Wampold, 2014, pp. 467-481) discussed the implications of taking a common factor approach for practice and policy. In this response to the commentary on our article, we reiterate 10 things that need to be remembered about common factor theory.

The evidence for present-centered therapy as a treatment for posttraumatic stress disorder.

To examine the evidence for present-centered therapy (PCT) as a treatment for posttraumatic stress disorder (PTSD), 5 randomized clinical trials that compared PCT to an existing evidence-based treatment for PTSD were reviewed. A meta-analysis was used to estimate between-treatment differences on targeted measures, secondary measures, and dropout. PCT was found to be as efficacious as the comparison evidence-based treatment in 3 of the 5 trials, and in the 2 cases where a no-treatment condition was included, PCT was superior, with large effect sizes for targeted variables (d = 0.88, 0.74, and 1.27). When results were aggregated using meta-analysis, effects for PCT versus an evidence-based treatment for both targeted and secondary measures were small and nonsignificant (d = 0.13 and d = 0.09, respectively). As well, the dropout rate for PCT was significantly less than for the comparison evidence-based treatments (14.3% and 31.3%, respectively). It appears that PCT is an efficacious and acceptable treatment for PTSD.

Expanding the lens of evidence-based practice in psychotherapy: a common factors perspective.

In this article, we examine the science and policy implications of the common factors perspective (CF; Frank & Frank, 1993; Wampold, 2007). As the empirically supported treatment (EST) approach, grounded in randomized controlled trials (RCTs), is the received view (see Baker, McFall, & Shoham, 2008; McHugh & Barlow, 2012), we make the case for the CF perspective as an additional evidence-based approach for understanding how therapy works, but also as a basis for improving the quality of mental health services. Finally, we argue that it is time to integrate the 2 perspectives, and we challenge the field to do so.

Cognitive-behavioral therapy versus other therapies: redux.

Despite the evidence suggesting that all treatments intended to be therapeutic are equally efficacious, the conjecture that one form of treatment, namely cognitive-behavioral therapy (CBT), is superior to all other treatment persists. The purpose of the current study was to (a) reanalyze the clinical trials from an earlier meta-analysis that compared CBT to 'other therapies' for depression and anxiety (viz., Tolin, 2010) and (b) conduct a methodologically rigorous and comprehensive meta-analysis to determine the relative efficacy of CBT and bona fide non-CBT treatments for adult anxiety disorders. Although the reanalysis was consistent with the earlier meta-analysis' findings of small to medium effect sizes for disorder-specific symptom measures, the reanalysis revealed no evidence for the superiority of CBT for depression and anxiety for outcomes that were not disorder-specific. Following the reanalysis, a comprehensive anxiety meta-analysis that utilized a survey of 91 CBT experts from the Association of Behavioral and Cognitive Therapists (ABCT) to consensually identify CBT treatments was conducted. Thirteen clinical trials met the inclusion criteria. There were no differences between CBT treatments and bona fide non-CBT treatments across disorder-specific and non-disorder specific symptom measures. These analyses, in combination with previous meta-analytic findings, fail to provide corroborative evidence for the conjecture that CBT is superior to bona fide non-CBT treatments.

Uniformity of evidence-based treatments in practice? Therapist effects in the delivery of cognitive processing therapy for PTSD.

OBJECTIVE: Various factors contribute to the effective implementation of evidence-based treatments (EBTs). In this study, cognitive processing therapy (CPT) was administered in a Veterans Affairs (VA) posttraumatic stress disorder (PTSD) specialty clinic in which training and supervision were provided following VA implementation guidelines. The aim was to (a) estimate the proportion of variability in outcome attributable to therapists and (b) identify characteristics of those therapists who produced better outcomes. METHOD: We used an archival database of veterans (n = 192) who completed 12 sessions of CPT by therapists (n = 25) who were trained by 2 nationally recognized trainers, 1 of whom also provided weekly group supervision. Multilevel modeling was used to estimate therapist effects, with therapists treated as a random factor. The supervisor was asked to retrospectively rate each therapist in terms of perceived effectiveness based on supervision interactions. Using single case study design, the supervisor was interviewed to determine what criteria she used to rate the therapists and emerging themes were coded. RESULTS: When initial level of severity on the PTSD Checklist (PCL; McDonald & Calhoun, 2010; Weathers, Litz, Herman, Huska, & Keane, 1993) was taken into account, approximately 12% of the variability in the PCL at the end of treatment was due to therapists. The trainer, blind to the results, identified the following characteristics and actions of effective therapists: effectively addressing patient avoidance, language used in supervision, flexible interpersonal style, and ability to develop a strong therapeutic alliance. CONCLUSIONS: This study adds to the growing body of literature documenting the importance of the individual therapist as an important factor in the change process.

Evidence-based treatments for depression and anxiety versus treatment-as-usual: a meta-analysis of direct comparisons.

OBJECTIVE: The aim of this study was to examine the relative efficacy of evidence-based treatments (EBTs) versus treatment-as-usual (TAU) in routine care for anxiety and depression in adults. METHOD: A computerized search of studies that directly compared an EBT with a TAU was conducted. Meta-analytic methods were used to estimate effectiveness of EBTs relative to TAU and to model how various confounding variables impacted the results of this comparative research. RESULTS: A total of 14 studies were included in the final meta-analysis. There was significant heterogeneity in the TAU conditions, which ranged from unknown and/or minimal mental health treatment to psychotherapeutic interventions provided by trained professionals. Although the effect for EBT vs. TAU was significantly greater than zero, the effect for EBT vs. TAUs that were psychotherapeutic interventions was not statistically different from zero. CONCLUSIONS: Heterogeneity of TAU conditions in this meta-analysis highlight the importance of clarifying the research questions being asked when investigating and drawing conclusions from EBT-TAU comparisons. Researchers need to clarify if they are comparing an EBT to psychotherapeutic services in routine care or to minimal mental health services. Extant research on EBT versus TAU reveals that there is insufficient evidence to recommend the transportation of EBTs for anxiety and depression to routine care, particularly when the routine care involves psychotherapeutic services.

Determining what works in the treatment of PTSD.

Many researchers accept that trauma-focused treatments are superior to non-trauma focused treatments for Post-Traumatic Stress Disorder (PTSD). However, Benish, Imel, and Wampold (2008) recently published a meta-analysis of clinical trials directly comparing 'bona fide' PTSD treatments that failed to reject the null hypothesis that PTSD treatments are similarly effective. They concluded that the results of previous meta-analysis may have been influenced by several confounds, including the use of control treatments, to make conclusions about the relative efficacy of specific PTSD treatments. Ehlers et al. (2010) claim that the selection procedures of the Benish et al. meta-analysis were biased and cite results from individual studies and previous meta-analyses that suggest trauma-focused psychological treatments are superior to non-trauma focused treatments. We first offer a review and justification of the coding criteria and procedure used in Benish et al. In addition, we discuss the appropriateness of utilizing treatments designed to control for non-specifics or common factors such as 'supportive therapy' for determining the relative efficacy of specific PTSD treatments. Finally, we note several additional confounds, such as therapist effects, allegiance, and alteration of legitimate protocols, in PTSD research and describe conceptual problems involved in the classification scheme used to determine the "trauma focus" of interventions, which lead to inappropriate conclusions about what works in the treatment of PTSD.