Commentary: Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy

We read with great interest the commentary by David, Cristea, and Hofmann (2018) in which the authors give a series of reasons to justify that cognitive behavioral therapy (CBT) constitutes the current gold standard of psychotherapy. Their main argument revolves around the fact that CBT gathers the most solid body of evidence in terms of efficiency (both efficacy and effectiveness). The authors support this idea, principally, by means of providing a demonstration about methodological aspects and finally presenting some conceptual arguments. Although we broadly agree with the three described reasons outlined by the authors, we consider important to incorporate some additional ideas to this discussion.Our principal interest is to extend the discussion regarding the integrative efforts that are being carried out in our field. We are firmly convinced that CBT conforms the ideal pivot we can count with in order to foster the integration between the different psychotherapeutic theoretical approaches (Fernández-Álvarez & Fernández-Álvarez, 2017). Psychotherapy is still diving into pre-paradigmatic waters, and the integration of theories is a rather logical goal that any scientific discipline that aspires to reach a paradigmatic stage should set (Goldfried, 2018). As some of the authors explained elsewhere (David, Lynn, & Montgomery, 2018; David & Montgomery, 2011), the mere accumulation of empirical evidence is not enough to demonstrate the theoretical consistency of an approach. In other words, the empirical evidence of the benefits of CBT does not ensure its theoretical foundations (Dozois & Quilty, 2014). By theoretical consistency we not only understand “evidence based on (1) experimental studies (and sometimes additional/adjunctive correlational studies) and/or (2) component analyses, patient–treatment interactions, and/or mediation/moderation analyses in complex clinical trials (CCTs)” (David, Lynn, et al., 2018), but also epistemological consistency as a result of incorporating an accurate conceptual debate. In that sense, some of the most important epistemological objections to CBT focus on the representational nature of thoughts and beliefs. Representational theories of cognition take beliefs and thoughts to be causally efficacious mental representations of facts, states of affairs, or propositions. Critics of representationalism have argued that CBT confuses individuals’ thought reports (which are represented as having imagistic or linguistic content), with their thoughts (which need not have any distinct representational content at all) (Leder, 2016).It is important to emphasize that the theoretical structure of CBT is permeable, precisely, to employ a model of theory of mind capable of taking into account not only the information processing paradigm in formal and logical terms but also the diverse modalities of this paradigm. Nowadays, we count with a myriad of models developed within the cognitive sciences to more accurately explain the different modalities in which the reality is processed. Among those models, embodied cognition, situated cognition, extended cognition or dynamic cognition should be mentioned (Osbeck, 2009). Each of these modalities can be articulated with the different theoretical approaches that constitute the other principal axes of contemporary psychotherapy: the psychodynamic approach, the humanistic approach and the systemic approach. Following the characterization of scientific progressed offered by Kuhn (1962) and used by David, Lynn, et al. (2018), we believe that in order to reach a state of normal science, the integration of the four main theoretical models should be attempted.Why CBT as the organizing axe?CBT is conceptually organized around a strongly connectionist model of explanation that permits to articulate the different approaches in a common axe, in which the diverse mental operations can be integrated into a hierarchical schema. In turn, this schema can account for the multiple levels of organization that characterizes the architecture of mental phenomena. Said model enables the integration of the two ways in which the processes within psychotherapy are deployed and organized in order to find adequate therapeutic designs and more efficient interventions. These two dimensions are the behavior and the experience, phenomena that are developed simultaneously at different levels. Both should be taken into account, given that patients’ demands and needs always require to address both facets.In turn, what permits to reach an adequate articulation between behaviors and ways of organizing the experience (functional or dysfunctional) is to count with a psychopathological model that place personality in a central role to enable a solid diagnosis and prognosis of the clinical situation. An illustrative example of how this integration can be achieved, is the cybernetic framework of personality proposed by De Young, which takes principally into account the study of goal-directed, self-regulating systems (DeYoung, 2015).Apart from our own model that seeks to provide this kind of integrated psychopathological understanding and therapeutic intervention (Fernández-Álvarez, 1992; Fernández-Álvarez & Fernández-Álvarez, 2017), there are many other expressions that at some extent reflect this philosophical and practical standpoint. We can mention the efforts that are being made by Sander Koole and colleagues. Their cognitive perspective is integrated with principles of embodied and situated cognition which permits to grasp the emotion regulation phenomenon from a wider perspective (Koole & Veenstra, 2015). Another illustrative example of this integrative spirit is constituted by the Methods of Levels (Carey, Mansell, & Tai, 2015), based on the Perceptual Control Theory and whose main focus is placed on working at the two aforementioned levels: (control of) behaviors and experience.We acknowledge the difficulty in establishing a model capable of addressing simultaneously nomothetic and ideographic aspects that define the mental functioning and clinical situation (context / practice). And thus, it is greatly intricate to translate this complexity into specific empirical research lines. However, our proposal is that CBT should be the central path for integration not only for the empirical evidence but for the epistemological solidity that permits to articulate in the best possible way the different levels that conform the ontological status of the mind. CBT is not free of pitfalls. First, as the authors described at the end of their comment, CBT, in line with psychotherapy in general, presents little stability of results, relapses, and symptom recurrence, early dropout and poor response to the treatment, especially when there is an association with a complex dysfunction (personality disorders stand out). And all these limitations are not even accurately identified due to the greatly underestimation of negative effects in clinical psychology and psychotherapy research. As an illustrative example, a recent meta-analysis has yielded that in the field of depression only 6% of the studies had informed deterioration rates (P. Cuijpers, Reijnders, Karyotaki, de Wit, & Ebert, 2018) or Jonsson, Alaie, Parling, and Arnberg (2014) who showed that in all trials published in 2011 in mental and behavioral disorders, only 3% explicitly described the procedures used to collect data regarding harmful effects.Another important issue that is source of a great debate within the scientific and professional community is the validity of randomized control trials (RCTs) as a methodological path to establish the utility of a clinical intervention. Despite the undoubted advantages of counting with evidence from RCTs, some experts in psychotherapy claim that there has been an overestimation of their capacity to inform routine clinical practice (Beutler & Forrester, 2014). This has derived in an unarguable imbalance between results from research based contexts and naturalistic context (Hunsley, Elliott, & Therrien, 2014). This imbalance has been often conceptualized as a problem of dissemination (McHugh & Barlow, 2010). Although it may be partially true, we suggest that RCTs by themselves are not enough to build solid grounds of communication between science and practice (Castonguay, in press). In that vein, traditional outcome centered research mainly focused on RCTs cannot always grasp the complexity of the clinical practice, where patients, therapists and institutions have realities that greatly differ from research contexts. In particular, this problem is aggravated as long as the greatest amount of research comes from the wealthiest countries in the world. As an illustrative example, Henrich, Heine, and Norenzayan (2010) described how a substantial percentage of the behavioral science publications were conducted with people coming from western, educated, industrialized, rich and democratic societies. Hence, it is both encouraging and inspiring to see the proliferation of messages focused in the necessity to deepen our knowledge regarding the process (Hofmann & Hayes, in press) and the need of replacing RCTs procedures in order to accomplish the long-awaited personalization of psychological treatments (Pim Cuijpers, Ebert, Acarturk, Andersson, & Cristea, 2016).In summary, we celebrate the integrative spirit that is starting to arise within the CBT community. Nonetheless, we do consider essential to conceptualize psychotherapy still as a pre-paradigmatic discipline that could be greatly benefited from a deep discussion to solidly integrate the main therapeutic approaches. In that sense, we strongly advocate for adding the epistemological discussion to the empirical one in order to support CBT as the pivot in this path towards integration.