Cognitive Behaviour Therapy Wins Again

Personality disorder is still pretty much untreatable, and major psychoses occasionally require drugs, but for almost all other mental illness, cognitive behaviour therapy (CBT) is the best treatment. This week we learned that it works even for rape victims in war-torn Congo (click here).

The cluster trial, with villages the unit of randomisation, run by researchers from John Hopkins Hospital in Baltimore, was registered here in June 2011. Although villages were randomised before women were recruited, a potential source of bias, recruitment and consent was done by research assistants  unaware of the village allocation.  The interventions, individual support (8 control villages; 248 women) or cognitive processing therapy (7 experimental villages; 157 women) were administered between April and July 2011. For those who fret about such things cognitive processing therapy is a variant on the behavioural version.

There were methodological weaknesses – the timing of the primary outcome did not appear to be pre-specified, and no reason was given as to why the planned sample size of 1000 was less than half achieved, but remember the setting, and the beneficial effects were large, and seen on all outcome measures and at both time points. Data dredging seems unlikely, and CBT works pretty much everywhere else, so the result is convincing.  But what is cognitive processing therapy?

It’s basically helping clients get bad thoughts out of their heads by encouraging them to think rationally. Therapists might encourage rape victims to question the ideas that it was their own fault, or that everyone despises them.  It’s hardly rocket science, although there are “tricks of the trade”, and clients need to be encouraged to persist with treatment, and to work on it without the therapist.  These researchers based their treatment on a well-known manual used by the US Veterans Administration for treating Post Traumatic Stress Disorder in the armed services,  Cognitive Processing Therapy Manual 8.08, which they adapted for use by people who could not read or write.

It works. This is an important trial.

Jim Thornton