The Future of Cognitive Behavioral Interventions within Behavioral Medicine
Hart, Stacey L., Hart, Trevor A., Journal of Cognitive Psychotherapy
There is a growing body of evidence supporting the use of cognitive behavioral treatment within behavioral medicine. There are several limitations to the current body of literature, including external validity of findings from randomized controlled trials, dissemination of findings, and the use of CBT when patients are unmotivated to make behavior change. The current paper proposes several future directions to address these limitations. Solutions to be explored in future research include practical behavioral trials, stepped care approaches, remote technology approaches such as telephone and Internet-based treatments, and the integration of motivational interviewing into cognitive behavioral treatment.
Keywords: behavioral medicine; cognitive behavior therapy; health interventions; health psychology; psychotherapy
An abundance of data exist for the efficacy of cognitive-behavioral therapy (CBT) approaches for psychological disorders, such as anxiety and depression (Butler, Chapman, Forman, & Beck, 2006; Hoffman & Smits, 2008). Moreover, several studies support the efficacy of CBT for treating psychological disorders and reducing psychological distress in behavioral medicine populations, such as patients with cancer (e.g., Osborn, Demoncada, & Feuerstein, 2006), HIV/AIDS (e.g., Safren et al., 2009), type 2 diabetes (e.g., Lustman, Griffith, Freedland, Kissel, & Clouse, 1998), multiple sclerosis (e.g., Mohr et al., 2005), primary insomnia (e.g., Edinger, Wohlgemuth, Radtke, Marsh, & Quillian, 2001), and chronic pain (e.g., McCracken & Turk, 2002). The studies presented in this special issue of the Journal of Cognitive Psychotherapy add to our knowledge by demonstrating the efficacy and utility of CBT approaches for patients with cancer (Greer, Park, Prigerson, & Safren, 2009; Hopko & Johanson, 2009), cardiovascular disease (Irvine et al., 2009), diabetes (Gonzalez et al., 2009), and HIV (Brown, Vanable, Carey, & Elin, in press) in the rapidly changing world of chronic disease management.
Although the current studies do provide support to the notion that "CBT works" to reduce depression and distress in those with medical illnesses, it is important to note that there are a number of studies that run counter. For example, a systematic review showed scant support for the efficacy of CBT to reduce anxiety and depression in those with chronic obstructive pulmonary disease (Coventry & Gellatly, 2008). In poststroke patients, CBT did not significantly improve mood compared to an attention placebo condition or a usual care condition (Lincoln & Flannaghan, 2003). And, in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial, which compared CBT to usual care for depressed patients postmyocardial infarction, CBT produced significant decreases in depression at the 6-month follow-up, but those improvements were not maintained at the 2.5-year follow-up (Writing Committee for the ENRICHD Investigators, 2003).
Why does CBT not always "work" as well as we expect it to? How can we, as CBT researchers and practitioners, continue to advance the field in behavioral medicine? There are a number of limitations to the current literature on CBT in behavioral medicine. First, one shortcoming of the CBT research conducted to date (both in the psychopathology and behavioral medicine literatures) is the emphasis on internal validity to the detriment of external validity (see Glasgow, 2008, for a discussion). Although both types of validity are critical, we lack data as to how the findings of our randomized controlled trial (RCT) apply to other settings and populations. As clinicians, we lack information as to what extent a particular treatment will actually produce results in our clinical setting or with the particular population of patients whom we treat.
Another limitation of CBT research with behavioral medicine populations is in the shortage of data that provide support for the use of CBT to promote health behavior change. …