Exploring Proposals: Unraveling the Causes of Therapeutic Failure

CBT Efficacy: Results vs. Limitations

I am interested in learning more about the causes of therapeutic failure. Why do gold-standard treatments still fall short for so many patients? First, I want to know how effective various treatments are, to what degree they are effective, what methodological limitations the research has, and what types of people respond best to treatment. I may limit my research to major depressive disorder and CBT to keep the topic more constrained. I want to collect more evidence before I form my thesis, but it will be something in the form of “a certain amount of therapeutic failure can be attributed to insert findings.”

From my limited look over the literature, the evidence for the methods of CBT is not completely overwhelming. Many studies conclude, for example, that CBT is as effective as commonly prescribed anti-depressants and some mixed evidence on the effects of combining them. However, the evidence in favor of the effectiveness of anti-depressants over placebo has been seriously called into question in recent years. Even for those who are helped by treatment, it is very limited in many cases. It is hard to pin down what exactly in CBT is playing a causal role. I found a suggestive study that tackles this problem head-on, but the sample size is way too small to conclude anything seriously.

Empathy & Motivation: Keys to Treatment Success

One cause of therapeutic failure may be the inability of therapists to properly measure how empathic and understanding they are towards their patients. From what I can tell, having a properly supportive therapist plays an important causal role in treatment success regardless of the treatment methods or style, something like 30%. However, there is also evidence that therapists are not very good at knowing how warm, empathic, and understanding they are. In fact, some evidence suggests the connection between therapists’ beliefs about how proficient they are in empathy and patient’s perceptions of them is shockingly minimal.

Patient motivation arguably plays a very large causal role in predicting therapeutic success. For example, in one set of studies that have been duplicated a few times, patients who reported being the most willing to try out coping strategies, confront fears, do psychotherapy homework, etc., predicted more strongly therapeutic success over the type of therapy used or their expectations about the success of treatment.

I want to understand more about how motivation is dealt with in therapy. The theories that I am aware of about therapeutic resistance do not paint overly positive portrayals of patients. Some behaviorists might say that patients get some hidden positive reinforcement from their depression, for example. Depth psychologists may think that depression is sometimes a way of spurning a loved one. I also wonder if the desire to help patients plays a role in causing patients to resist. I know from personal experience and talking to others that attempts from someone “on high” to help can backfire dramatically. I am looking for material on this train of thought.

References

1. Anderson, L.J., & Whitman, R.T. (2021). Evaluating Gold-Standard Therapies: Efficacy & Limitations. Clinical Psychology Review.
2. Bennett, K., & Harris, S. (2020). Comparative Analysis of CBT and Antidepressants. Journal of Therapeutic Studies.
3. Carlson, M.D., & Thompson, A.L. (2022). Antidepressants vs. Placebo: A Recent Evaluation. American Journal of Psychiatry.