Sahanika Ratnayake discusses the intersection between cognitive-behavioural therapy and evidence-based health research.
In 1958 the firebrand British psychologist, Hans Eysenck, dared to question the efficacy of talking therapy in front of an audience of psychoanalysts. In his memoirs he recounts their reaction: “When I finished there was not even a pretence at polite hand clapping; the audience seemed to erupt, jumping up and down, yelling, screaming imprecations, and waving their fists in the air” (Eysenck 1990, 145).
In recent years Eysenck has come under fire for his dubious work on race and intelligence, not to mention his insistence that lung cancer had little to do with smoking (Eysenck 1965). He was certainly wrong about those things, but the challenge he laid down that day in 1958 has made him a thorn in the side of therapy research ever since. Eysenck believed that at the time there was no robust evidence to show that therapy (largely psychoanalysis) worked, instead positing that most psychological problems get better with time, the same way as a cold – what he termed ‘spontaneous remission’ (Eysenck 1994). A 1952 review of the available research on therapy seemed to support his hypothesis, showing that therapy did not fare better than no treatment or standard care in clinical settings (Eysenck 1952). The review relied on patchy, nascent research, making it difficult to draw definite conclusions, but Eysenck nonetheless challenged proponents of psychotherapy to prove that it had a measurable effect, calling for evidence from clinical trials, which were becoming the norm across medicine.
Some twenty-five years after Eysenck’s notorious presentation, Aaron Beck, often described as the grandfather of Cognitive Behavioural Therapy (CBT), seemed to meet this challenge: proving the efficacy of therapy via clinical trials. Beck and his colleagues ran a trial where patients with depression who underwent therapy were compared with patients who were given a popular antidepressant (Rush et al. 1977). The trial not only showed the efficacy of Beck’s therapy but showed CBT actually outperforming the antidepressant, according to clinical measures typically used in drug trials for depression (Hamilton Depression Scale) and a measure Beck himself had developed (Beck Depression Inventory). That antidepressants and therapy perform on par with each other, within the parameters of a clinical trial, is common knowledge amongst researchers now, but at the time this was a staggering result. Since the 1977 trial, CBT has become a staple of mental healthcare: offered via public health systems and covered by medical insurance, constituting the main therapeutic offering of the NHS.
Strangely when CBT proponents describe its meteoric rise and the way in which it seemed to supplant psychoanalysis, they do not mention this influential clinical trial of the efficacy of CBT. Instead, the story often goes something like this (Dryden 2012, 25):
Beck was a somewhat sceptical recruit into both psychiatry and psychoanalysis. His open and enquiring mind has served the generation of Cognitive Behaviour therapists who followed his work well. He was particularly interested in trying to establish the validity of psychoanalytic concepts by empirical research and set out to test the hypothesis that depression was caused by anger turned inward on the self. His research found that this theme was not reflected in the content of dreams reported by depressed patients. At the same time he discovered the existence of a constant stream of nonconscious negative thoughts in depressed clients. Eventually he concluded that the content of dreams of depressed patients was better explained by the nature of this negative thought stream than by any unconscious ‘need to suffer’ — a completely extraneous concept, he suggested.
The preceding story of CBT’s origins emphasises how it supplanted psychoanalysis by proving its theory of depression false rather than demonstrating that it was better at treating depression.
In a series of papers at Philosophy, Psychiatry and Psychology (Ratnayake 2025a; 2025b; 2025c), I chart the decline of psychoanalysis alongside the ascendance of CBT and try to make sense of this peculiarity — why is it that the question of whether CBT or psychoanalysis is more accurate in accounting for depression (and other mental disorders) seems to have come apart from the question of whether they can treat such disorders?
In the 25 years between Eysenck’s review of therapy research and the CBT trial, talking therapy fell under the auspices of Evidence Based Medicine (EBM). EBM calls for an evaluation of medical interventions based on a strict hierarchy of supporting evidence, with clinical trials and aggregations of them at the pinnacle of this hierarchy. In the papers, I adopt the methodology of History and Philosophy of Science (HPS) to wed the history of contemporary medicine with that of contemporary psychotherapy.
Contrary to the origin story of CBT, I show instead that it is not so much that Aaron Beck proved the psychoanalytic account of mental disorder false, but rather once psychopharmaceuticals had ushered in clinical trials, Beck and other early researchers were quicker to meet this new evidential standard. I argue that it was the question of whether psychoanalysis was better at treating depression (according to the new evidential standard of trials), rather than the refutation of its account of depression as claimed by CBT proponents, that accelerated the decline of psychoanalysis. Eventually clinical trials became the ‘gold standard’ of evidence in a number of influential institutions responsible for research funding and determining public healthcare provisioning, such as the National Institute for Healthcare Excellence in the UK and the National Institute for Mental Health in the US, thereby guaranteeing the institutional entrenchment of CBT.
Though many historians have noted the influence of clinical trials on the development and success of cognitive-behaviour therapy (Rosner 2018; Marks 2012; Buchanan 2010), a philosophical lens highlights a set of interlocking conceptual shifts in: understandings of evidence, scientificity, as well as mental disorder and its treatment, that accompanied the move towards clinical trials. It is not so much that CBT was more ‘scientific’ than psychoanalysis but rather than the standard of evidence and with it related concepts like mental disorder differ between the two therapeutic modalities. In psychoanalytic case studies, the standard of evidence replaced by trials, detailed histories of clients and the specific aetiologies of particular neuroses and attempts to address them abound. In contrast, clinical trials notoriously adopt a ‘black box’ methodology consider only whether the symptoms of mental disorder have been alleviated. As a consequence, they are agnostic to specific understandings of mental disorder and recovery, which eventually comes to be understood purely in terms of symptom alleviation — a great distance from the initial scuffle between rival theories of depression found in CBT’s origin story. In contemporary therapy research the dominance of clinical trials has all but dissolved such theoretical debates, instead focusing almost solely on which therapeutic interventions can best alleviate the symptoms of mental disorder.
The shift to a notion of evidence developed for a very different intervention, pharmaceuticals, has reshaped therapy. Instead of being a long-term, open-ended flexible practice, uniquely determined by the specific issues of the client, their personal history and the relationship with the therapist, the ‘evidence-based’ (read clinical trial-based) of contemporary therapies tend to be brief, targeted towards particular mental disorders and focused on the modification of behaviour and emotion management. Interestingly, even CBT which so profited from this shift has also been transformed. For example, during the 1977 trial a course of therapy was twelve sessions, now it can be as short as five. And where Beck’s CBT probed more fundamental aspects of the client’s psyche, contemporary versions largely probe surface level patterns of distorted thoughts.
Historical narratives of professions and disciplines trade in transformative moments. For example, deinstitutionalisation and the shift to community care is one of watershed moments in histories of psychiatry (and with it, the history of talking therapy). In putting the histories of talking therapy and medicine together, I wondered whether there was another watershed moment, one that is so contemporaneous that it is sometimes difficult to see: the transformation of therapy as it collides with Evidence Based Medicine — a collision that not only launched CBT and allowed it to become a fixture in the landscape of contemporary mental healthcare but one which continues to influence the development and understanding of therapy.
About the author
Sahanika Ratnayake is a philosopher of psychiatry and medicine specialising in contemporary talking therapies. She is currently a research associate at the University of Manchester.
References
Dryden, Windy. 2012. Cognitive Behaviour Therapies. Los Angeles: SAGE Publications Ltd
Eysenck, Hans. J. 1952. “The Effects of Psychotherapy: An Evaluation”. Journal of Consulting Psychology 16 (5): 319–24.
Eysenck, Hans. J. 1965. Smoking, Health & Personality. Smoking, Health & Personality. Piscataway, NJ: Transaction Publishers.
Eysenck, Hans. J. 1990. Rebel with a Cause. London: WH Allen.
Eysenck, Hans. J. 1994. “The Outcome Problem in Psychotherapy: What Have We Learned?” Behaviour Research and Therapy 32 (5): 477–95.
Layard, Richard and Clark, David. 2015. Thrive: The Power of Psychological Therapy. London: Penguin
Marks, Sarah. 2012. “Cognitive Behaviour Therapies in Britain: The Historical Context and Present Situation.” In Cognitive Behaviour Therapies, Los Angeles: SAGE Publications Ltd
Ratnayake, Sahanika. 2025a. ‘The Decline of Psychoanalysis and the Rise of Cognitive-Behavioral Therapy: Part I: Dismantling the Legend of CBT’. Philosophy, Psychiatry, & Psychology 32 (1): 81–92.
Ratnayake, Sahanika. 2025b. ‘The Decline of Psychoanalysis and the Rise of Cognitive-Behavioral Therapy: Part II: The Challenge of Psychopharmaceuticals’. Philosophy, Psychiatry, & Psychology 32 (1): 93–104.
Ratnayake, Sahanika. 2025c. ‘Playing Someone Else’s Game: Therapy and Evidence-Based Medicine’. Philosophy, Psychiatry, & Psychology 32 (1): 111–14.
Buchanan. Roderick D. 2010. Playing with Fire: The Controversial Career of Hans J. Eysenck Oxford: Oxford University Press.
Rosner, Rachael. 2018. “Manualizing Psychotherapy: Aaron T. Beck and the Origins of Cognitive Therapy of Depression”. European Journal of Psychotherapy, Counselling, and Health, 25–47.
Rush, Augustus J., Aaron T. Beck, Maria Kovacs, and Steven Hollon. 1977. ‘Comparative Efficacy of Cognitive Therapy and Pharmacotherapy in the Treatment of Depressed Outpatients’. Cognitive Therapy and Research 1 (1): 17–37.
