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Why is CBT/GET "evidence-based?"

Discussion in 'Alternative Therapies' started by laura, Apr 28, 2011.

  1. laura

    laura Senior Member

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    WillowJ: (and anyone else who is interested)

    Here is my answer to your questions:

    In my area of the country (SoCal), CBT (Cognitive Behavioral Therapy) and the term evidenced-based practices are linked due towait for itgovernmental financial considerations. Okay, its not quite as nefarious as that. Maybe. But what has happened is this: much of the counseling services that are provided in SoCal are paid for by government contracts to non-profit agencies. Heres how it works:


    When I originally said CBT is organized, I meant it is a neat, clean theory. There are a couple versions of it, but the basic idea is that 1) an activating event leads to 2) a belief, which leads to 3) consequences (emotions, behaviors, other thoughts). Straightforward, follow-the-dots. No worry about the complex nature of psychological functioning and the myriad factors that influence us.


    It is important to remember CBT is, in fact, cognitive behavioral therapy. It is not just a theory of cognitive functioning, but includes behavioral therapy (note that the origin of B.T. is running rats in boxes in a lab. Very mechanistic.). So CBT often includes a lot of behavioral instruction from therapist to client. And they believe in short-term therapy.


    Thus: Combine a straightforward theory and behavioral interventions and you have a researchers dream foundation for creating a study investigating effectiveness of therapy. (To me, the use of CBT in research is a little like CFS researchers ignoring the heterogenic nature of the CFS population. Its just easier.) Add in the possibility of short-term treatment and an easy way to track services provided, and you have a perfect match for over-burdened, under-funded government social services.


    Add in limited research funds, desire for quick results, etc. etc. and it is easy to see the appeal for CBT/BT in a broad spectrum of studies.


    Anyhow, like I said, CBT devotees love to do research. It is one of the most researched psychological theories. Not, by the way, the most effective (according to research!), just often used in studies. So agencies are being told they have to use evidenced-based practices. Makes it sound like therapists are doing better work while forcing them to follow certain protocols which save the government money.


    Regarding medications, e.g. prozac: technically, yes, medications are evidenced-based, as research has been done. But in the counseling world the term evidenced-based is only used regarding practices performed or initiated in the counseling session. Non-medication therapeutic interventions.

    So thats why CBT/GET are evidenced-based because they are coming from a cognitive therapy and behavioral therapy perspective, and someone put them in a research study, so now we can say they are evidence-based.

    [As an aside, less research has been done on psychodynamic form of therapy because it traditionally hasn't focused on research. That is slowly changing. The research that has been done is actually very positive. For example, an article in the most recent issue of Psychology Today points out that the changes produced by psychodynamic therapy often are longer-lasting and deeper than symptom-based treatments.]
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  2. Ian

    Ian Senior Member

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    These people are just sadists, they like watching sick people suffer. Why else would they dream up something as cruel as graded exercise therapy, or as useless as CBT. The NHS in the UK has statistics for the various 'treatments' that are on offer for CFS. GET comes out as the worst, most useless damaging therapies out there. Not that this deters them from recommending this to patients, or victims.
  3. WillowJ

    WillowJ Senior Member

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    laura, thanks for the explanation :)

    so it's kind of like, "assume a cow is a sphere"

    Ian, I think it's less that they are intentionally trying to be cruel, and more that they are simply unwilling to understand that their theory (fear and deconditioning creates, or at least perpetuates, CF and CFS) is incorrect. If they admit that, they must admit to conflicts of interest, zombie science, etc. The cognitive dissonance is simply less to decide the patients are crazed and don't want therapies if they are CBT/GET, even if they help... then to admit that they are wrong.
  4. laura

    laura Senior Member

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    Yes! And also, I think you're right about the cognitive dissonance. They need some kind of incentive that would allow them to admit their folly.
  5. Snow Leopard

    Snow Leopard Senior Member

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    "Evidence based" is based on randomised control clinical studies of significant size and frequency. The "problem" with traditional clinical studies is that they are subject to various biases such as wishful thinking. Any slight improvement observed by the patient is often attributed to the treatment, even if there was no causal role. In pharmaceutical studies, they conduct strict double blind (often mistakenly called placebo-controlled) studies to account for such biases. In cognitive behavioral therapy, no such blinding is possible because the whole point is to cause wishful thinking in the minds of patients. Therefore I argue that if they are to be regarded as 'evidence based', then they need important clinical outcomes other than questionnaire results. Examples include long term improvements in employment, or increases in activity levels as well as a reduction in biological disease markers.
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  6. laura

    laura Senior Member

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    I agree that if those who are believers in CBT for CFS want their research to mean something, then they need to use more objective measures. You highlight well the problem with calling all CBT research "evidence-based" and then making policy decisions based upon that, whether it is in a counseling context or, in a CFS context.

    One of the points I was trying to make (maybe not so clearly), is simply that there is a reason that CBT and BT are the psychological treatments of choice for researchers foolish enough to persist in maintaining CFS has a psychological etiology. They could have chosen to test somatic experiencing, sensorimotor therapy, EMDR, etc. etc. But my experience is that within the professional psychology field, 1) CBT is "in fashion," and 2) the term "evidenced-based" has been disconnected from its original meaning and instead has become code for CBT.
  7. WillowJ

    WillowJ Senior Member

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    any ideas for what kind of incentive might work? (other than Congressional inquiry or other punitive action)
  8. laura

    laura Senior Member

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    Such a great question! I wish I had an answer...

    It's difficult when even here, at PR, among the most well-informed PWC's on the planet,
    I see again and again postings by people who believe they themselves are sick but question whether other PWC's *really* have ME/CFS.

    There are of course all kinds of ideas around motivation, change, etc. I tend to think we shouldn't waste too much time on trying to change the pro-CBT/GET people, just focus on them enough to speak up and challenge them.

    Because I think of our situation more in a "tipping point" fashion a la Malcom Gladwell: One by one as researchers, media, patients, people with influence stand up and advocate for us, they increase the scales in our favor to the point where it becomes accepted and known that ME/CFS is a physical illness that requires funding, research, and treatment. I think of AIDS: sure there are still people who think that people get HIVAIDS because they are gay, have sinned, or whatever, but they are in such a minority that it doesn't substantially hinder research and treatment (at least here in the US. I don't know if the tipping point has been reached in Africa).

    We have great people who have spoken up for us. Laura Hillenbrand, for example, has been amazing for increasing the recognition of ME/CFS as a serious physical illness. But we need to cultivate even more prominent people, those who have the power publicly and/or behind the scenes, to influence large numbers of people. (AIDS had Elizabeth Taylor! And others...)

    What happens sometimes, is after a majority begin to believe a certain way, minority players begin to feel pressure to change their viewpoints. Basic social psychology.
  9. WillowJ

    WillowJ Senior Member

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    good thoughts; thanks :D
  10. Gavman

    Gavman Senior Member

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    Yes its interesting. Seems like thats the standard learning with university psych degrees because it can be measured more than other therapies.
    I believe its a shallow rip off of buddhism or meditation, where you listen to your thoughts and try to change them, which is great especially for chronic fatigue.. but the problem is that -pain- is not emphasised as a big part of the process and its not as deep as meditation, most psych/body repair changes seem to happen in the deep state of meditation or sleep.
  11. alex3619

    alex3619 Senior Member

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    EBM Evidence Based Medicine

    I have been looking at this a lot recently. There is an answer, but its unsatisfactory: its evidence-based because evidence-based medicine is defined that way. The whole idea of evidence-based medicine has taken over because of NHS initiatives in the UK. It has effectively replaced the old discipline of defining what is good or best practice (clinical epidemiology). It has as a central tenet that large random controlled trials are the best form of study, that this is the "Gold" standard. Its being pushed by organizational and governmental interest in the UK.

    Now nobody disputes that basing medical practice on the medical and scientific evidence is a good idea. And they use the evidence, so nobody should dispute them, right?

    Recently this has been challenged with the claim that this is Zombie science: (thanks to Snow Leopard for the link)

    http://charltonteaching.blogspot.com/2009/08/zombie-science-of-evidence-based.html

    There is a whole movement of anti-evidence-based medicine forming. One name used to describe it is science-based medicine, rather than evidence-based. Quite a number of papers have been written on this.

    EBM is essentially medicine by public policy where the evidence base is distorted by selectively including or excluding research. Its a cherry-picking approach. The biopsychosocial school has been linked to this EBM for some time. It suits politicians, public servants and special interest groups. It is not beholden to the patient, and is not run by medical professionals.

    RCTs are the gold standard, and who does the most RCTs? Big Pharma. So they dominate the field, not because what they are doing is wrong, but because nobody else gets listened to very much.

    The Zombies have stormed the barracades (Charlton's words) and are now running the UK medical establishment. We need a mass exorcism of the UK public service, and we need it fast.

    Bye
    Alex

    PS I posted on a Margaret William's post about a Wesseley paper, but it has its own thread now. You might like to read it at:
    http://forums.phoenixrising.me/showthread.php?15443-Defending-the-indefensible
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  12. Sean

    Sean Senior Member

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    Just because a study was run as a randomised controlled trial, doesn't mean it necessarily produced a methodologically reliable outcome, that should be accepted at face value without criticism. Still potential biases, even in an RCT. For example, priming for responses in subjective self-report measures (see PACE).
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  13. Esther12

    Esther12 Senior Member

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    It really pisses me off when CBT which makes claims unsupported by the evidence is described as 'evidence based' because on RCT shows a minor improvement on some subjective measure of fatigue.

    For CBT to be referred to as 'evidence based', it must ensure that the claims made to patients are also evidence based. Promoting positive distortions in order to improve functionality is just quackery, and describing it as 'evidence based' just undermines the importance of developing an evidence based view of the world
  14. biophile

    biophile Places I'd rather be.

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    Also see ...

    (full text in the library? http://forums.phoenixrising.me/attachment.php?attachmentid=6565&d=1325298404)

    Alex, "science based medicine" is an excellent label and goal. Not only is an accurate portrayal of what it should be, but it serves as a counter-jab to EBM when used as a jab at recalcitrant patients who refuse to accept the "evidence base" of CBT/GET. We accept science based medicine thanks!
  15. alex3619

    alex3619 Senior Member

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    Hi Sean, I completely agree with you. They use a cookie-cutter rubber stamp approach. The quality of the studies is not adequately examined. That is what happens when you use checklists and don't do the hard work to understand something. Its an attempt to make things simple, but in the process they have oversimplified to absurdity. The deliberate ignoring of contrary evidence, no matter how robust, is completely overlooked in this approach. Bye, Alex
  16. Dolphin

    Dolphin Senior Member

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    I read the Charlton and Charles et al. papers yesterday.

    The Charlton paper is quite good in terms of showing how EBM might be maintained/grow. However, I found it didn't give many details about where the problems with EBM lie except that at an individual level, "average" results from RCTs might not be the best for any individual patient. It would be good if examples of the problems with this sort of thinking (treat the patients the same basically) were given.

    I had been slightly wary of the term Zombie Science before this as it seemed quite dramatic and perhaps over the top/would seem that way. But am more thinking now that it might be justified.

    Some quotes from the Charlton paper:

    I can see that with all the CBT studies that are churned out by Nijmegen for example. They keep coming up with ways to present the data as a success even though their own studies showed the patients' activity levels didn't increase over the control levels. It also happens to an extent in the UK with all the studies that are churned out there. And all the funding such researchers can get.

    I think this is interesting given how little discussion there can be about biological matters in the ME/CFS field. The Lancet PACE Trial, a substantial paper, doesn't mention biology at all.

    I think a reason/another reason why such a system likes nurses and generally "non doctors" is because they can't prescribe many drugs (and the oens they can are usually only fairly cheap ones) nor can they order tests generally. So cheaper, along with making it easier to estimate what the budgets will be.

    - I think this is particularly interesting. That, say, with the NICE guidelines, or when some other guidelines are being drawn up, some evidence for or against CBT/GET or the alternatives can be seen as acceptable or unacceptable (sufficient/insufficient or good quality/not good quality) as it suits them.
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  17. Dolphin

    Dolphin Senior Member

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    I'm not sure if I have the time to post up all my notes on the Charles et al paper. It isn't a polemic like the Charlton piece.

    It shows how the EBM model has changed over the years. How many aspects of it are unclear.
    In particular, it's unclear how much weighting to give to the different aspects that make up the model.

    At the moment they are:
    - Clinical state, setting and circumstances
    - Patient preferences and actions
    - Research evidence
    - Health care resources
    - Clinical Expertise
    (the paper talks also about how some of these aren't always well-defined or the definition changes).

    I found it interesting that "Patient preferences and actions" (or "Patient preferences") are part of it - they don't seem to play a major role in say the UK, Belgian or Dutch (? - don't know as much about the Netherlands) models of care. And with the PACE Trial and other discussions, patient organisations are often criticised - even though they are often simply giving patient opinions.

    -------
    I've posted the same messages in another thread: http://forums.phoenixrising.me/show...ues-incl-one-calling-it-a-quot-Zombie-Science. I know it's not ideal to have two threads. But wasn't sure how many people would see this interesting discussion down here.
  18. alex3619

    alex3619 Senior Member

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    I was watching a lecture on fanaticism on Australian ABC yesterday. Fanatics, according the lecturer, are convinced they are helping you, helping the world, and this is the most important thing to them. They adopt self-justifying thought structures (my interpretation) and will assure you its for your own good. I wonder if EBM is not a fanatical movement from the UK? They want to help us even if it kills us. Bye, Alex
  19. currer

    currer Senior Member

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    Actually Alex you could be right on that one....yes.... I am impressed with that idea.
  20. Enid

    Enid Senior Member

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    Seems odd to me that CBT/GET - claiming some minor improvement on some subjective measure of fatigue (only) is termed EBM when those claiming it previously denied patients self reporting (subjective) - just in your mind (imagined). Did they think that was somehow "evidence based" too.
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