The Value of Evidence-Based Treatment That Fails

• In CBT I Trust
• Another Form of Healing
• A True Presence
• Lessons Learned
• A Broader Lens

In CBT I Trust

I became a psychotherapist because I wanted to help people feel better. I’m sure all therapists share that motivation. In my master’s program, I learned about cognitive behavioral therapy (CBT), and that no other type of therapy had as much research evidence to support it. I was drawn to its promise of rapid relief from suffering.

I sought out a doctoral program where I could receive specialized training in CBT for depression and anxiety. During my training, I saw firsthand how a few weeks of treatment could lead to big improvements in symptoms—not for everyone, but for many.

As an assistant professor I joined a leading center for the treatment of PTSD and OCD, and I witnessed the power of CBT to reopen lives that had been completely subverted by these conditions. When I found that cognitive and behavioral techniques weren’t always effective, I sought training in mindfulness and acceptance-based approaches. I wanted to be equipped to help everyone who came to me. Just as when I began this journey, I wanted to be a healer.

Later, I added CBT for insomnia so I could treat the frequent sleeping problems I encountered in my work. I began writing about the power of CBT to relieve suffering, first on my blog, then through a co-authored account of recovery from OCD, and then in two self-directed books on CBT techniques. I developed a blog and a podcast under a label that captures cognitive, behavioral and mindfulness-based approaches: “Think Act Be.” I was fully immersed in the evidence-based model, and I continued to be inspired by the successes I witnessed.

And yet I often remembered best the people I couldn’t help—the ones who came to me for a few sessions, or for many months, and never experienced lasting progress. They seemed to feel just as depressed, just as anxious, just as gripped by constant worries or obsessions as they did on the day I first met them. Some felt worse. My inability to help them weighed on me as I felt I’d let them down. Sometimes, when they left my office in obvious emotional pain, I cried at my desk.

Another Form of Healing

My work with Evan comes to mind (details changed to protect his identity). Evan was in his fifties and had been dealing with anxiety, depression, and obsessional thinking for his entire adult life. I introduced the standard CBT and mindfulness-based strategies, which Evan struggled to use. He experienced some relief from the meditations I led him in, but otherwise continued to have debilitatingly severe anxiety and depression. I could have blamed his lack of progress on his infrequent practice between sessions, but I didn’t believe that was the whole story, or even most of it. Whatever the reason, I couldn’t help him find relief.

And yet Evan often expressed his gratitude for everything I did for him. Like what?, I often wondered to myself. On one occasion when he thanked me “for everything,” I told him I wished I could do more to take away his pain. He expressed how much relief he found in our meetings, and particularly in the meditations I led him in and which he diligently recorded for listening between our sessions. “And you listen to me,” he said, “and you don’t give up on me. And I can tell sometimes when we’re talking that you’re feeling what I feel. And that’s huge.”

Many other names and faces stand out from over the years, people whose symptoms I seemed unable to touch. No one ever yelled at me or demanded that I do more to help them. Some expressed frustration at their continued suffering, occasionally directed at me, but most were entirely gracious, even grateful despite our lack of progress. Some even referred their friends or family members to me. It took me several years to realize that some of the deepest work I’ve done as a therapist has been with individuals whose symptoms didn’t improve.

This realization didn’t come until a few years ago as I sat with my friend Jim at his kitchen table. Jim had been battling an aggressive form of cancer for two years and had just learned it had returned. I didn’t realize as we sat there that it was the last time I would see him; Jim died two months later.

What surprised me in our final conversation was the gratitude Jim expressed for his treatment team. I expected he would be disappointed in them; after all, he was receiving the most state-of-the-art cancer treatment in the world, and yet it hadn’t kept his cancer away. I could imagine being bitter if I were in his shoes, and not at all happy to have to return for treatment.

Quite the contrary, Jim described how grateful he was for the care he’d received over the past two years. He noted that his medical team had extended his life, giving him time to put his things in order. He had been given more time with his family than he would have had without treatment. He was dying, and yet he was thankful to those who had done all they could to help him.

And more than the cutting edge care they provided, Jim seemed to appreciate that they cared. Jim wasn’t treated as a cancer case, or a research trial number. He was a complete human being, with a family, with hopes and fears, and likely a foreshortened future. The professionals with whom he worked provided compassionate care right until the end.

When I went through my own debilitating illness—much less severe than Jim’s, I learned what it meant to receive compassionate care. By my count, I saw 13 specialists over a 4-year period, and none of them was able to completely resolve my health problems. And yet most of them provided another form of healing—not of the body and mind, but perhaps of the spirit. I would leave their offices feeling a little less alone, a bit less afraid.

A True Presence

When I was in my late thirties, I was diagnosed with open-angle glaucoma. My optometrist who detected it reassured me that I wasn’t “guaranteed to lose my vision,” but the prospect of going blind hadn’t occurred to me until his reassurance. I didn’t ever want to not be able to see my kids.

The ophthalmologist I was referred to treated me with two rounds of laser surgery in each eye. The first involved boring a hole in the iris, making a tiny second pupil to decrease the dangerously high pressure inside the eye that could destroy the optic nerve. The second was meant to dissolve the blockage in the eye’s drainage ducts, allowing the pressure to return to normal. Unless it wouldn’t!

I learned through my own research that these procedures are effective in about seventy-five percent of patients. Thankfully, mine were successful and my pressures have been in a healthy range for the past few years. But I was struck by the failure rate of this treatment, given how directly it seems to target the root of the problem. Examples like this one abound across medical specialties; whatever the medication or procedure, the success rate of evidence-based interventions is significantly less than one hundred percent.

In light of the limitations of modern medicine, we shouldn’t be surprised at our limits as therapists. And yet many of us are quick to assign blame when a client isn’t showing obvious improvement. Often, we’ll blame the client, assuming there must be personality pathology or that they “don’t want to get better.” We may assume the symptoms bring secondary gain. We might prefer to believe that the treatment is effective, but the client just isn’t ready for change. These factors may be present, but they also have the convenient effect of letting us off the hook. It’s not us, it’s them.

The danger that I found in my own reaction to ineffective treatment was running ahead of the client, as it were, and trying to pull them along. This tendency showed up in things like assigning homework that I knew they weren’t going to complete, so at least I could feel like I was “doing something.” My conscience could be clear. Except it wasn’t, because I knew on a deep level that I wasn’t meeting the person where they were. They needed me to walk alongside them, to sit down with them when they sat to rest. They needed my true presence.

Our presence is what matters most. Otherwise, we would dispense therapy techniques from vending machines, or in fortune cookies. Even self-guided CBT books are written with a personal and encouraging tone. It’s crucial to feel that the guidance is coming not only from someone who is supposedly an authority, but from someone who wants the best for us, who’s in it with us. The relationship with an author matters.

Lessons Learned

I suspect I’m not alone in finding that my eagerness to help is actually unhelpful at times. For example, when Rick told me he felt like his life “hadn’t even been a prelude to anything,” I immediately jumped into cognitive therapist mode. My knee-jerk assumption was that this belief was exaggerated; after all, Rick had done many things in his life--graduated at the top of his high school and college classes, worked abroad, completed law school.

“Is that true?” I asked with skepticism. Immediately I knew I’d missed the mark. Rick wasn’t asking me to change his mind, especially not before he felt I’d really heard him. The truth was that his life hadn’t turned out the way he’d imagined. He’d come close to getting married twice, but never tied the knot, and he never had children. And despite his intelligence and education, his major struggles with anxiety and depression had left him unable to work since a year after he got his law degree. His life consisted mostly of tending to his garden, reading the news, and occasionally seeing a friend.

While I may have been on the lookout for distorted cognitions, on an unconscious emotional level I was motivated to look away from the deep pain expressed in Rick’s statement. It would have been much easier if I could have fixed his thinking and taken away his unhappiness. “See! It’s not that bad,” I wanted to say. But maybe it was. And the life Rick had lived wasn’t a problem I could solve.

As a therapist, I have come to appreciate the importance of remaining with and tolerating my discomfort and feelings of inadequacy, if I am going to serve as a full human being to those I treat. I must make peace with what I can’t change. Otherwise, I run the risk of compelling my clients to fight on two fronts, as they must contend not only with their suffering but with my expectations that there must be a solution.

All of this probably seems patently obvious to many therapists, perhaps especially those from a more psychodynamic background. Maybe my tendencies are specific to CBT, or to me. I do suspect CBT fosters some of the expectation about taking away symptoms, but I imagine some form of that expectation lives in all of us in the healing professions.

Sometimes life-changing work gets done while the symptoms are unchanged. For some that might mean connecting with the strength they have to meet their challenges. Others may discover the life that’s possible even through ongoing struggles. Still others will have their experience validated after a lifetime of being told what they felt wasn’t real or will simply feel less alone.

A Broader Lens

Hopefully it goes without saying that I still want to help people reduce their symptoms, and I want to offer each person all the tools that might be useful. Accepting the limits of my abilities and the value of our presence doesn’t mean I must stop trying to reduce suffering in any way I can. It’s also not a way to settle for less than optimal outcomes for my clients. And it certainly doesn’t mean that I have secret insights into what my clients really came to treatment for and that MY job is somehow to get them there.

I still want everyone I treat to experience less anxiety, better sleep, fewer OCD compulsions, or whatever else they came to me for. I provide referrals when I don’t feel that I have the expertise a person needs. At the same time, I’m trying to use a broader lens through which I see a person’s experience. As physician Rachel Naomi Remen suggests, there is a difference between fixing and healing. This stance isn’t a cop out, as I used to believe—a way to make myself feel better about my lack of skill. Rather, it’s a recognition of the reality that there is pain I cannot take away, and that “treatment success” is a bigger concept than can be easily captured in data from a randomized clinical trial, or from a well-validated self-report measure.

Therapy is as complex as any human relationship, with effects that potentially penetrate much more deeply than the apparent symptoms. The best we can do for anyone is to provide compassionate care until the end, whether that means a triumphant recovery, ruinous tragedy or the wide expanse in between.

I’ve also come to recognize that the end of our time together is not the end of the person’s road to healing. For some the time we spend together will be transformational, while for others there will be no obvious effect. For many others, the work we do together will plant seeds that grow only later, well after therapy has ended. It’s easy for me now to recognize the hubris in believing that the evidence-based therapy I offered was the person’s last hope. Now I know that I’m only ever part of a longer journey.  

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