Solving the Problem of Small Effect Sizes in CBT – 4 Reasons to Rethink Extinction Strategies

(Free Training Program – eliminating maladaptive feelings, thoughts, and behaviours HERE.)

To this day CBT is regarded by many as the “gold standard” of therapy for a very wide range of problems and disorders from anxiety and depression, through to unresolved chronic pain.

The theoretical basis of CBT is really the theory of inhibition in classical conditioning, and it is true that inhibition has been shown to (over time) weaken some conditioned responses. In more recent times as the field of neuropsychology has developed, we’ve been able to observe that conscious thought can have a dampening “feedback” effect on impulses arising from the amygdala region of the brain.

However there are critical flaws in any inhibition strategy, not just CBT but also mindfulness, and in fact ANY cognitive attempt to achieve an inhibition effect.

Here are four reasons we should rethink the use of CBT as a therapy standard:

  1. What works in animal studies does not necessarily translate to the human condition

Using inhibition to weaken or extinguish (for example) a simple reward response, or a simple avoidance response, is nothing like working with a human being whose maladaptive feelings, thoughts and behaviours may be comprised of a vast myriad of conditioned responses, most of which are environmental and outside their control anyway.

  1. Inhibition strategies have demonstrated only a weak or nil effect in humans

There is a great mass of evidence, in the form of quality papers and meta-analyses, which purport to actually show the benefit of CBT (and mindfulness). However when one reviews the actual data in these studies, we find without exception that the glowing conclusions are not supported by the data.

Time after time we see “weak effect” or “nil difference compared to placebo”. Even those studies which report a moderate effect do so when comparison is with a waiting list rather than a appropriate control (we all know that waiting list controls are not valid comparators because “anything” always performs better statistically than “nothing”, even when that “anything” is patently worthless.)

Here are some examples:

Morley, S, Williams, A, Eccleston, C. Examining the evidence about psychological treatments for chronic pain: Time for a paradigm shift? Pain, 2013, Vol. 154, No. 10, pp. 1929-1931.

Just like many studies of CBT, this study purported to show the effectiveness of CBT in enhancing positive affect and thereby achieving higher pain resilience. In marked contrast to that claim, it actually includes the statement “Half of the comparisons showed no effect of CBT and half showed weak effect sizes of unknown clinical significance on pain, mood, disability and catastrophic thinking outcomes.”

Lim, J, et al. CBT for chronic pain. Medicine (Baltimore). 2018 Jun; 97(23): e10867.

We already know that studies which use a waiting list instead of a placebo generally result in statistically significant results which are merely an outcome of comparing “something” to “nothing”.

Like most studies investigating CBT for chronic pain, this one is flawed by not having an appropriate control group such that outcomes could be compared with a group utilising some other treatment (eg physical therapy). Nevertheless the results were completely unimpressive.

Hofmann, S, et al.  The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognit Ther Res. 2012 Oct 1; 36(5): 427–440.

This large review of meta-analyses is typical unfortunately. It first makes a claim that CBT has strong evidence, but then provides data and conclusions which demonstrate that CBT has a weak effect compared with waiting list or no treatment, and is not at all effective in many cases.

Faucett, K, et al. A Systematic Review of Comparative Efficacy of Treatments and Controls for Depression. PLoS ONE 7(7): e41778.

This major meta-analysis reviews several different types of treatment and reports that in blind studies all interventions, including CBT, are better than doing nothing but none are more effective than placebo.

  1. CBT takes considerable time, effort, and self-discipline to learn and apply consistently

For something so weak in its effect (that’s if there is any effect at all) it seems incredibly unkind to expect clients to apply so much time and effort. Indeed, even these weak effects mostly disappear shortly after the client leaves the therapist’s office.

In addition I question the burden placed on the client when a common “teaching” of the client is an implicit (or explicit) blame for their suffering on the client’s attitude or self-talk.

In the case of chronic pain (more on this shortly) this blame, together with the burden on the client to work so hard for so little, seems particularly cruel, since the pain itself is not amenable to CBT.

The same goes for all disorders where the client is already in a great deal of distress or turmoil.

  1. We do not need to tolerate inefficient CBT or mindfulness when we have an alternative, highly-efficacious new extinction technique

We do not need to apply slow, burdensome, inefficient inhibition strategies when we have a fast, easy, highly-reliable and efficient strategy to achieve permanent extinction of problematic feelings, thoughts and behaviours.

This new extinction technique is known as “disruption of reconsolidation”. It was first noted by Pavlov over 100 years ago, but neither he nor anyone else recognised its massive significance. At the time, Pavlov wrote it up in his notes as a “failure of the response” without realising he had just caused instantaneous extinction.

In very recent times we’ve seen extremely exciting research on disruption of reconsolidation by neuroscientists such as the highly-respected team of Soeter and Kindt.

Soeter, M, Kindt, M. Disrupting reconsolidation: Pharmacological and behavioural manipulations. Learn. Mem. 2011. 18: 357-366

This clinical trial demonstrated that it was possible to implement an extinction procedure within the window of reconsolidation in order to successfully eliminate a conditioned response.

This is a very exciting advance in current knowledge about extinction and provides a solution which is more practicable and also much faster and more gentle than other methods (inhibition, flooding) used to date.

We had been working on this method of extinction since 1992, so to see researchers delving deep into the neuroscience behind our theory was beyond exciting to us.

Our own multitudinous case studies, together with our formal pilot studies, show very rapid and permanent resolution of a variety of issues, including depression and chronic pain.

Indeed it is difficult to think of any issue where disruption of reconsolidation could not play a vital and transformative role.

Perhaps the biggest CBT failure – non-malignant chronic pain

It is completely uncontroversial to state that non-malignant chronic pain is not amenable to CBT.

While claims are made for a weak improvement of emotional suffering from pain, no-one is claiming that CBT can reduce or eliminate chronic pain. It is an abject failure in this regard and therapists merely talk about supporting the client to “manage”, or “live with” their pain.

Inhibition strategies may help the client to remain more social, and engage in less avoidant behaviour (to a minimal degree), but they don’t help the pain itself, and the client continues to suffer from the very problem that drove them to therapy in the first place.

In dramatic contrast, disruption of reconsolidation has been shown to quite quickly actually eliminate (or extremely reduce) pain signalling in the vast majority of these cases so that they get back to work, and back to their roles in their families and communities. They’re returning to their roles pain free and usually medication free as well.

The overwhelmingly biggest health burden in the area of workers compensation, costing billions of dollars every year, is low back pain, which can be almost completely eliminated by using disruption of reconsolidation instead of CBT.

Is there a risk that very effective therapy could lead to too-rapid discharge from a therapeutic program?

There is a risk that some therapists may mistakenly confuse “technique/strategy” with a therapeutic journey. It should however be obvious that this degree of transformative change, for a multitude of reasons requires support over time.

And therapy is rarely merely about eliminating maladaptive feelings, thoughts or behaviours. Education, information, role play and solution exploration of course remain as crucial as ever.

The big advantages of disruption of reconsolidation

Perhaps one of the most surprising aspects of disruption of reconsolidation is what happens when the client very suddenly becomes free of problematic feelings, thoughts and behaviours.

In the absence of these unwanted reflex responses, new highly-adaptive cognitions arise of their own volition, without prompting. The client moves quickly and naturally into a solution orientation and a much more effective, deeper and rewarding therapeutic alliance is achieved.

What this means is that barrier to progress are removed, and the bulk of therapy time can be dedicated to bedding in beneficial changes in a way that is safe and enjoyable, providing deep transformation for the client and for all of his/her relationships, both personal and professional.

How do we achieve disruption of reconsolidation?

We use multi-sensory stimulation in a variety of ways as a very convenient and safe disruptor of the reconsolidation phase of conditioned responses. We have named the stable of techniques which provide disruption of reconsolidation “MDR” (Multi-sensory Disruption of Reconsolidation).

A free training program is available HERE.

Disclaimer

Our mission is to drive crucial change away from minimally-effective inhibition strategies such as CBT and assist colleagues to integrate far more efficacious strategies for extinction of learned feelings, thoughts and behaviours in order to support deeper, more transformative experiences for clients, and more satisfying and rewarding practice development.

On completion of the free training, some therapists may like to consider enrolling in the full program, which you can read about HERE if you wish.