Monash study suggests there should be a shift in focus in cognitive behaviour therapy

Cognitive behaviour

It’s almost five decades since Cognitive Behaviour Therapy (CBT) was first recognised as a way to treat depression. CBT is now a commonly-used treatment for depression, anxiety, psychosis and other conditions.

While there have been thousands of published clinical trials documenting the efficacy of CBT, these have been designed to evaluate its overarching results. Often, outcomes have been favorable compared to medication-based treatments, but few research groups have examined the work of the practitioner, or the professional patient-therapist relationship. Even fewer studies have examined how CBT works in a group situation (i.e. for 6-8 people working together) - one of the common ways of receiving CBT. 

Now a new research study, published by clinical researchers at the newly launched Monash Institute for Cognitive and Clinical Neurosciences (MICCN) in the prestigious 'Journal of Consulting and Clinical Psychology', reveals that the relationship between group members (cohesion) is as important as that between the individuals of the group and the therapist (alliance). The alliance was previously believed to be the most important process factor in the success of CBT.

In CBT, the therapist aims to give patients the skills to manage their moods by helping them identify unhelpful thoughts, such as “I’m worthless,” “I’ll always fail” or “people will always let me down”, as well as deeper beliefs, values, rules, and assumptions. Patients learn to evaluate their thinking patterns that serve as barriers to personal fulfillment, healthy relationships and lifestyles. For example, a person could learn to catch and evaluate their immediate interpretations of what is being said during conversations, and ask questions to gather more information, so that they could take a more considered approach when communicating, thereby enhancing their effectiveness and enjoyment from their interactions with others.

MICCN researchers Professor Peter Norton, previously at the University of Houston, and Associate Professor Nikolaos Kazantzis, studied 373 patients with anxiety, who were part of a 10-week CBT program in a group environment for the treatment of anxiety disorders.

“Research into which treatments for mental health disorders has, for the past few decades, been primarily focused on which treatments work and which treatments are most effective. Now we are making a shift towards understanding how CBT works for people, and why some people respond less favourably,” Professor Norton said.

Following screening, diagnostic interview, and psychometric assessments, patients were assessed at regular intervals during the therapy – both for their anxiety symptoms, and evaluations of cohesion and alliance. The researchers involved assessments of these CBT processes at each of the 10 sessions offered within the study – a marked improvement over previous studies involving single assessments, which are unlikely to reflect the time-varying relations among group members.

According to Associate Professor Kazantzis, the study showed that while the “alliance” between the therapist and the patient (i.e. the agreement between the two on the goals of therapy and the ways to attain them) is important to successful CBT. This study was the first to show that the “cohesion” within the group is just as important in achieving clinically significant outcomes for all participants.

“In many ways, this changes the focus to the bond among group members – in support of each other learning through the techniques in CBT – to achieve the best results,” Associate Professor Kazantzis said.

According to Associate Professor Kazantzis, these results indicate that clinicians would be best placed in ensuring that a group is harmonious and committed.

“Such a group is likely to achieve much better results than those where the exclusive focus is on the alliance, or the extent of agreement with the therapist. The therapeutic interaction is more complex, and involves many dynamic elements,” Associate Professor Kazantzis said.

He added that he hopes the findings of the study lead to a change in clinical practice in the use of CBT to an emphasis on how the professional practitioner-patient relationship can enhance outcomes.

The researchers are establishing new research clinics within MICCN to further extend this research. They lead a team of newly appointed research scientists, which will advance the clinical translation research capacity of the new Institute.