Is it possible to predict who will benefit from cognitive behavioural therapy (CBT)?

The rise of CBT has been welcomed by many as safe, effective alternative to drug treatments for mental illness. However, there are also fears that CBT has grown too dominant, crowding out other less structured, more time consuming forms of psychotherapy.

The fact is, CBT doesn't work for everyone. Precious resources could be better managed, and alternative approaches sensibly considered, if there were a way to predict in advance those patients who are likely to benefit from CBT, and those who are not.

Jesse Renaud and her colleagues administered a ten-item scale – the Suitability for Short-term Cognitive Therapy, first devised in the 90s – to patients who underwent CBT for depression or anxiety at the McGill University Health Centre between 2001 and 2011. The researchers focused their analysis on the 256 patients (88 men) who completed their course of therapy, which lasted an average of 19 sessions.

Renaud's team looked for correlations between patients' answers to the Suitability scale and found that the scale was really tapping two main factors – the patients' capacity for participation in the CBT process, and their attitudes towards CBT.

The first factor includes a patient's insight into thoughts that pop into their heads (so-called "automatic thoughts"); their ability to identify and distinguish their emotions; and their use of safety behaviours to cope with their problems (e.g. avoiding parties to cope with social anxiety). In other words, the researchers explained, this is the patient's "ability to identify thoughts and feelings, and share them in a non-defensive, focused way." The second "attitudes" factor refers to, among other things, the patient's optimism about the outcome of therapy, and their acceptance that they must take responsibility for change.

The higher patients' scored on the first factor (their capacity for participation in CBT), the greater reduction they tended to show in their illness symptoms, based on measures taken before and after the course of CBT. Attitudes towards therapy were not correlated with symptom reductions, but we should bear in mind that this may be because the research focused only on those patients who completed therapy. Also, it may be useful in future to measure how patients' attitudes change during therapy.

There are other reasons for caution. The amount of variance in symptom change explained by both suitability factors combined was statistically significant, but tiny – just .07 per cent. Also, the same therapists who administered the therapy, recorded their patients' improvements, so there was clearly scope for bias. Finally, more research is needed on different forms of mental illness besides depression and anxiety. Nonetheless, this study makes a constructive contribution to a neglected area.

"Given that the patient's capacity provides important information about whether or not a patient will derive benefit from CBT, clinicians who are concerned about limited resources and long wait lists are encouraged to undertake a suitability assessment prior to therapy," the researchers said, "identify patients low in their General Capacity to Participate in the CBT Process, and consider making referrals to alternative treatments (e.g. other psychotherapeutic approaches, pharmacotherapy."

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Renaud J, Russell JJ, & Myhr G (2014). Predicting Who Benefits Most From Cognitive-Behavioral Therapy for Anxiety and Depression. Journal of clinical psychology PMID: 24752934