Have we overestimated the effectiveness of psychotherapy?

https://digest.bps.org.uk/2017/03/20/have-we-overestimated-the-effectiveness-of-psychotherapy/

by laurex • 8 years ago

144 145 8 years ago

digest.bps.org.uk

Simulacra• 8 years ago

It depends. What do you think?

jowsie• 8 years ago

Severely underrated comment.

com2kid2• 8 years ago

Problems with therapy:

A. No standards of treatment. It is therapists choice, and therapists are free to pick and choose whatever they want. Because results are so hard to measure, therapists who are really bad at their job can continue to operate, dragging overall results for the field down.

B. Licensing requirements are all over the place. From psychologists with PhDs from well established institutions, to people who got an online professional degree. The type of training someone receives heavily impacts their approach to therapy, and the quality of their education determines how high quality their treatment program can be.

For fun sometime, pay the arm and a leg it costs to get a full battery of psychology tests done from a psychologist. You'll get a personality test and an actual IQ score. It takes a long time (multiple sessions each lasting a couple hours), but you will get to see the real scientific part of psychology.

I actually got a practical result out of it. My doctor was able to tell me that the reason I kept dropping cups was due to a co-morbid congenital condition. Apparently a certain % of people who have an underdeveloped optic nerve also have weak grip strength.

The grip strength trainer I bought has more than paid for itself in saved cups and glasses.

lstodd2• 8 years ago

Good for you and I'm glad that you've got your condition under control.

But no amount of standards and licensing can help one who's slowly killing himself due to their conditons.

If anything, increased red tape will only raise prices and do nothing to the quality of help.

Source: own experience. $/hour never correlates to help/hour, and any regulation just drives $ up, no positive effect on help/$.

nickthemagicman2• 8 years ago

You're saying you don't agree with standards and licensing in medical professions?

0xcde4c3db2• 8 years ago

A1. Independently of their efficacy, each school's explanations of how their therapy approach works range from plausible-but-unproven (some aspects of some CBT approaches) to blatant pseudoscience (EMDR, psychoanalysis). Many constructs used to describe personality and behavior are little more than ad hoc descriptions with no grounding in a more general theory.

laretluval• 8 years ago

This is also true for many other branches of medicine.

sonnyblarney2• 8 years ago

One could cut much deeper: No accepted view of what the mind and consciousness really are, no model for the mind, no accepted view of 'what normal is', and no real way to truly identify and diagnose most supposed disorders.

For things like schizophrenia maybe we can help.

But for things like 'depression' we're still walking around in the dark, notwithstanding good progress on some specific things.

SubiculumCode• 8 years ago

I don't see the fundamental difference between schozophrenia and depression in terms of why one is more or less valid as a target for treatment.

nickbarnwell2• 8 years ago

A) With regard to "no standards of treatment", that is not the case, at least in the US. Licensing and professional bodies for both Masters-level clinicians (LPCs, LMHCs, MFTs, MSWs and others) and Doctorates (PhDs, PsyDs) effectively mandate therapists rely on evidence based practices, and insurance companies are quick to push highly manualised behavioural therapies.

Private practice is one thing, but treatment outcomes are tracked in CMH settings as well as IP psychiatric settings.

B) Licensure is not all over the place. At a bare minimum, an independent clinician in the US will have several thousand hours of client contact (e.g. group facilitation), a thousand to fifteen hundred hours of 1:1 counselling with clients, a hundred hours of supervision, and have taken two years of graduate level coursework on psychology and psychotherapy, with the curriculum on its way to being standardised nationwide by CACREP.

Studies have demonstrated that treatment outcomes are not strongly correlated with clinicians' educational background, and that the perceived therapeutic alliance is the strongest predictor of success.

There are problems with psychotherapy research, but they're mostly those shared with the rest of the sciences.

gusts• 8 years ago

pfft I like to ask every doc I go to, what outcomes they have produced in cases like mine and how many such cases they see a year. The CBT ppl just blink at me like the question is not on their manual. And one even said no great outcomes but here are the things you should do. Why would I spend my time doing them if they haven't produced results?

I mean these are nice people with good intentions but so is a priest in a church or a temple. The whole thing feels half baked. Ya ya I know reprogramming the mind is complex and this is a work in progress. But my experience from work and coaching team sports is people follow authority figures when in doubt/outcomes are unknown. And most shrinks and counsellors in my case atleast are unable to establish authority.

lambdasquirrel• 8 years ago

There’s a rub to all this in that all the good therapists are licensed, but not all licensed therapists are good. Anecdotally, therapy is at least as much art as it is science. There will always be those things that science cannot answer, that “logic” cannot provide a sufficient answer for. But yoga, meditation, art, dance, all these other things are also difficult to measure and quantify, and, we apply scientific rigor with various levels of failure to them.

How do you know someone has really meditated? You don’t. How do you know someone has had a good dance? You kinda don’t know that either.

There is a basis for understanding this from an engineering perspective, and it’s right there in what you just said — that outcomes are not correlated with educational background of the clinician. Sound like programming at all? Programming is also as much art as it is a science.

So therapy is no sure thing. That much, to me, is fine. And that’s the other rub. If you want to get something out of therapy, you’ll only get out as much as you get in. There can be no shortcuts blaming things you don’t like, nor idealizing the things you want to like. We can talk standards and rigor all day. But there’s no getting around having an internal compass of honesty, and a desire to apply that honesty to one’s life. That’s what a therapist (or therapy group) should be for you — an objective voice that questions your view of things while letting you be heard, as well as creating a safe environment for you to unwind the dark corners of the mind that are normally difficult to reflect upon on one’s own. Even there it is up to you to reflect on what happened afterwards. Your therapist cannot follow you all the way.

jkaplowitz2• 8 years ago

You listed a lot of specific licensed professions, titles, and degrees.

Across much of the US and Canada, words like "therapist" and "psychotherapist" are unregulated titles and practices, if not claimed to count as one of the licensed professions

I know for sure that this is true at least in New York where my mother is a (licensed PhD-holding) psychologist, and in Quebec where I live now, but I think this is typical.

"Psychologist" and "psychiatrist" are of course regulated, as is "social worker," but the generic unregulated therapy terms lead to lots of underqualified people doing bad diagnosis and treatment.

com2kid2• 8 years ago

A) With regard to "no standards of treatment", that is not the case, at least in the US. Licensing and professional bodies for both Masters-level clinicians (LPCs, LMHCs, MFTs, MSWs and others) and Doctorates (PhDs, PsyDs) effectively mandate therapists rely on evidence based practices, and insurance companies are quick to push highly manualised behavioural therapies.

A giant % of therapists around my area advertise that their treatment methodology is "eclectic".

Trying to find someone who follows even CBT is almost impossible.

I have seen at least a few people advertising themselves as following Freudian principles. So there is that.

Licensure is not all over the place.

The quality of programs that provides those licenses are. And thousands of hours of training under someone who is not very good, does not lead to a good practitioner.

I'm not saying all therapists are bad, but I'd say that picking a therapist at random will have about as good of luck as picking a mechanic at random: Greater odds of your wallet being emptied than your problem being fixed. Finding an honest and talented practitioner is hard.

Studies have demonstrated that treatment outcomes are not strongly correlated with clinicians' educational background

Isn't that a huge problem?

Imagine if that was the case for any other medical profession! "The surgical techniques we teach in school, and charge a lot of money and put students deep into debt for, aren't shown to be any better than someone coming off the street with a hacksaw and a really good smile."

Now that said, I've met people entering LMHC programs who obviously didn't need the credentials, their natural understanding of people was blatantly better than what 80% of their courses would cover. But those people are the obvious exception.

JamesBarney• 8 years ago

In addition you have that the research is not nearly as careful as pharmaceuticals and even they run into tons of issues.

barry-cotter2• 8 years ago

There’s a reason there’s little agreement on standards for treatment or licensure. The only thing we have solid evidence helps in therapy/counselling/psychotherapy is a strong client therapist relationship, the therapeutic alliance. Up until recently the literature suggested cognitive behavioural therapy worked better than other schools but the case for that isn’t looking great lately either.

Therapy is hard and it only works if the client works at it. They can even work at it on their own, but they must work at it. Bibliotherapy, using a CBT workbook, works as well as a therapist if you actually do it but a therapist is an expensive means of ensuring you follow a programme.

Is Professional Training Worth the Bother? A Review of the Impact of Psychotherapy Training on Client Outcome
Abstract This article reviews the research literature on the effectiveness of paraprofessional counsellors and the impact of psychotherapy training on client outcome. Methodological and conceptual difficulties that have hampered previous research in this area are noted, and several well‐designed individual studies are highlighted. The existing evidence supports the efficacy of paraprofessional counsellors, although professional training may lead to better outcome in specific areas, such as greater client retention, briefer therapy, and better overall wellbeing for clients. However, methodological limitations of the research prohibit definitive conclusions. Guidelines for future research are offered.

arthurofbabylon• 8 years ago

I’d argue that A. and B. aren’t necessarily problems. After all, if it’s hard to quantify and empirically measure, wouldn’t the hypothetical standards be arbitrary?

I’ll speak from personal experience: the most effective psychotherapy treatment I’ve received is very “unconventional,” with emphases on philosophy, meditation, and physical activity in nature. Those experiences have hugely impacted me in positive ways.

When an entity doesn’t know how to standardize or effectively certify, but does so anyway, we get quack systems as a result.

mercer• 8 years ago

How'd you go about finding such a form of treatments?

orblivion• 8 years ago

Here's what comes to my mind. There's this notion that if it isn't scientific it isn't serious. But if you want to take a scientific approach to everything, you won't be able to navigate life. If someone gives you personal advice on how to find a trustworthy contractor for your roof, do you demand a scientific study?

I'm not a scientist, so correct me if I'm wrong, but it seems that science is by far the best method of finding truth within pretty small parameters. A law of physics. The effects of one particular chemical on a certain kind of animal. Etc. For complicated things the best thing you can do is make a really simple model of it and draw a conclusion from that. The other details are anecdotes. Again, people say to avoid trusting anecdotes, but it's what we live by all the time day to day.

So when it comes to psychotherapy, it's an art form. Especially given the multiple incompatible schools of thought. It's not that much of a science. If a lot of people swear by it, well, maybe it's a placebo (though what would that even mean for psychotherapy?). Or maybe there's something to it for a decent number of people.

mmt3• 8 years ago

When it comes to health, yes, I prefer science. To me, that falls well within the same category as laws of physics, where the best method of finding truth is science.

Even picking a roofing contractor (or anything else that merely has to do with money or material possessions), I may not demand all the trappings of the scientific method, but, if possible, I want at least some of them, like data, and borrowing methodologies and reasoning. Relying on the advice/authority of a single other person is unappealing, unless I believe that other person actually did the research I would have done.

Sometimes, though, it's not possible. If a tree fell through the roof, it may not matter who the "best" one is, only the good-enough one available now.

pas9ur0i3jjdj• 8 years ago

I'm a tenured professor of clinical psychology who doesn't focus on therapy in research, but who does focus on meta-analysis.

A. This either true or not true depending on how you look at it. There are standards of treatment, but the differential evidence in favor of any given treatment is usually poor except in some cases so it is difficult to justify any particular approach. There is no reason to mandate a specific treatment from a licensed professional if there's no strong evidence in favor of it over any other.

B. Licensing requirements are all over the place, but in some ways they are overly stringent. The licensing requirements per se aren't the problem, they're the admitting standards of certain programs, and the abuses of for-profit degree programs, which can actually be quite predatory. By the time a psychologist is licensed, the level of clinical training experience required by most states is probably equivalent to a psychiatrist. Many psychologists with bio backgrounds from reputable PhD programs (note many of these students do neuroscience or genetics research of some sort) have the odd experience at a particular point in their careers of being unlicensed but being more familiar with psychiatric issues (including drugs) than first or second-year psychiatry residents.

The meta-analysis in this piece is interesting, but not novel. Similar things have been shown in other meta-analyses in the past.

If you asked me to summarize the literature on therapy from a meta-analytic perspective, this is what I would say:

There is strong evidence that therapy is effective, from all sorts of randomized controlled designs with all sorts of controls (behavioral, pharmeceutical controls of all sorts).

There is little evidence of differential efficacy between therapies overall. This means that, e.g., there is no real evidence that CBT is more efficacious than psychodynamic therapy, despite what you might think or have been told. There is some evidence that for very specific targeted outcomes (e.g., reduction of a particular type of behavior), some therapies are better, but not for general outcomes.

There is evidence of publication bias. If you adjust for this, the positive effect of therapy does not go away, but it does reinforce the lack of differential efficacy. CBT and behavioral studies as a literature show the largest publication bias in previous second-order meta-analyses. (I want to point out that drug therapies also have problems with publication bias, as do all sorts of other scientific studies. This is a problem with science at the moment.)

The effect of individual therapist dwarfs that of therapy type. That is, there is strong evidence that there are very good therapists, but we don't really understand what they are doing.

There is some evidence that therapist-client match and cohesiveness, is important. So if you don't feel like things are working with your therapist, try a different approach. Incidentally, this is also true of drugs; trials show that people might fail with one drug but succeed with another.

I want to point out that treating (or hell, assessing and measuring) mental illness is a difficult problem, regardless of how you approach it. The ambiguities in the field are not because people are just stupid. There are very intelligent people who have been working on these things from many angles, and things are complicated and multilayered, from genes to social systems. Many good ideas just don't work, or don't work the way you'd think.

mmt3• 8 years ago

also have problems with publication bias, as do all sorts of other scientific studies. This is a problem with science at the moment

There is also the "reproducibility crisis" which can be very closely related to publication bias, since a reproduced result may be even less remarkable than a negative result.

The ambiguities in the field are not because people are just stupid. There are very intelligent people who have been working on these things

At the risk of sounding flippant, I am reminded of the {Forrest Gump} quote "Stupid is as stupid does" (which is, of course, an update of earlier aphorisms with similar meaning).

To whit, in light of all the well-understood, self-admitted, fundamental problems with science at the moment, that are at least partially due to the behavior of the participants, at what point is the innate intelligence of those participants no longer a defense against an accusation of "just stupid"?

themodelplumber2• 8 years ago

Evangelou and his team conclude that the field of psychotherapy research needs to work harder to ensure that negative results are published as well as good news results, especially given the findings of another recent paper suggesting that the field has a problem with undeclared researcher allegiance to particular therapeutic approaches.

And from that other recent paper:

Reviews with a conclusion in favour of psychological therapies (vs pharmacological interventions) were at high risk for a spin in conclusions

For a field so rich in therapeutic models, I find it somewhat surprising that people are not more educated, walking in to visit with a therapist, as to what kind of model or therapy is being used, and what alternatives might be available.

I'm not a psychologist myself but rather a coach, and I love taking little breaks with my clients to move to a meta-perspective and walk them through the variety of models we can use together. Eventually they learn that each model has key leverage points as well as key weaknesses, and tying oneself to a single model as if it has no significant blind spots can quickly put one's desired outcomes at risk.

Maybe some psychologists here can weigh in; perhaps this is already a thing in the therapy world.

projektir3• 8 years ago

For a field so rich in therapeutic models, I find it somewhat surprising that people are not more educated, walking in to visit with a therapist, as to what kind of model or therapy is being used, and what alternatives might be available.

This seems like a bizarre expectation to me. People walking in about a stomach problem generally don't know much about that subject, either. I'm not sure what the ratio is, but unless you only see people from a very narrow background, I don't really see why the average person would be educated in psychological techniques any more than they're educated in types of rock.

softwaredoug• 8 years ago

From the article:

For the reader undertaking psychotherapy or who knows someone who is, it is worth keeping some perspective: this is just one critique and the weight of evidence still suggests that psychotherapy is, more often than not, beneficial.

beagle3• 8 years ago

Does anyone have dependable reference for that?

s-shellfish• 8 years ago

I've shared similar sentiments in various threads, but yes, for some people psychotherapy has an adverse effect.

I honestly believe this happens because the person getting therapy does not respond well to hyperfocus on themselves. There's a point at which oneself must be able to say 'yes, I'm okay, I don't need help anymore' and modern psychotherapy doesn't really have anything beyond 'algorithms' to really establish that.

Once labeled ill, it feels like it can be with you forever. I'm sure some mental health care professionals believe that's an essential crutch mentally ill people need, but from personal experience it can be just as handicapping as it is intended to be helpful.

Sometimes people just want to know they'll be psychologically fine independently, and that's not something psychotherapy can prove to a person while guiding them.

It's not an easy problem, but it exists. Also, pointing out problems doesn't mean oneself created them. It's something humanity needs to work on collectively.

meesterdude• 8 years ago

For the reader undertaking psychotherapy or who knows someone who is, it is worth keeping some perspective: this is just one critique and the weight of evidence still suggests that psychotherapy is, more often than not, beneficial.

It's good to bring a more critical eye to the field - but be mindful that it's still overall beneficial. My own experience has lead me to find it helpful, but not able to really address the core of issues. And maybe that's too much to ask for - but it's certainly not something they object to trying to address.

leot• 8 years ago

Certain treatments have outcomes with high variance even when practiced perfectly.

Combined with no clear way to evaluate whether the treatment is being applied well, this makes it difficult for practitioners and patients to evaluate treatment quality. Which discourages expertise development in the first place (why bother working really hard when the results are hard to pin down anyway?).

Ensorceled• 8 years ago

I’ve had terrible martial arts instructors, inept teachers, ineffective professors, one brutal physiotherapist.

I presume that there are a fair share of bad psychotherapists as well.

That some people do not see improvement should not be surprising.

sonnyblarney2• 8 years ago

I don't think anyone would suggest that there should be perfectly consistent outcomes, rather, on the whole that outcomes should be positive. We know there will be poor performers.

The study is suggesting that 'on the whole', there are negative outcomes, implying that 'most psychotherapists' are just bad at what they do, or more likely, there's a more fundamental issue with the nature of psychotherapy itself.

projektir3• 8 years ago

All these things have something in common.

Martial arts is definitely an area where I don't give it much stock because a lot of it seems rather iffy. If that's where therapy is, it'd be good to know.

ShabbosGoy4• 8 years ago

The only psychotherapy we need is from plant medicines. DMT and psilocybin are natural plant teachers that can help us through the traumas we go through in our life.

ClassyJacket• 8 years ago

I'd add MDMA in there as well. It's had good results in testing for PTSD (look up MAPS) and it changed my life for sure. Not a plant, but I hold onto no idealism about that.

ShabbosGoy4• 8 years ago

I agree with you. LSD trips gave my life new meaning.

wavefunction2• 8 years ago

It was commonly synthesized from sassafras oil (safrole) so you can add it to the list I think:

https://erowid.org/archive/rhodium/chemistry/safrolefaq.html

gsaga• 8 years ago

Add cocain and weed to that list as well

ShabbosGoy4• 8 years ago

Wow very intelligent. Your comment really made me think.

wavefunction2• 8 years ago

You need some people in your life you click with.

tombh2• 8 years ago

I'm not psychotherapy's biggest fan, but I did do 2 years training in it, and I must say the world is a better place for psychotherapy's existence. Because before psychotherapy we were cutting bits of people's brains out and electrocuting them. For all Freud's frankly odd theories he was the first big name to stand up and suggest that well intentioned dialogue was enough to help traumatised people.

It's not rocket science, we don't need any big theories or research to know that talking helps. And of course by that same token some combinations of client and therapist are going to be constructive and some damaging. I believe psychotherapy is first and foremost an institution of accountability not academic theory.

cat199• 8 years ago

we were cutting bits of people's brains out and electrocuting them

in some cases. in other cases not.

see also: monasticism, healthy spiritual/religious practices.

tombh2• 8 years ago

indeed. in fact i got into psychotherapy via meditation, which is actually my preferred therapeutic practice.

Noos• 8 years ago

...monasticism was never healthy. I really defy someone to read the Rule of Saint Benedict and not think of a modern prison at least once. Monasticism is even considered spiritually dangerous at times, and is linked to its own specific sin, Acedia:

https://en.wikipedia.org/wiki/Acedia

I recommend Kathleen Harris's The Noonday Demon for a good account of that. If anything, monastic life would destroy you if you suffered from depression, not heal you.

maxerickson• 8 years ago

Electroconvulsive therapy is still practiced. It is done under anesthesia and better calibrated than the horror show people tend to imagine.

https://www.mayoclinic.org/tests-procedures/electroconvulsiv...

jdietrich3• 8 years ago

Because before psychotherapy we were cutting bits of people's brains out and electrocuting them.

The great tragedy is that cutting bits of people's brains out and electrocuting them worked. It still does. Electroconvulsive therapy is still available and highly effective. Here in the UK, we still have two specialist psychosurgery units that perform a handful of procedures every year to treat the most severe cases of depression and obsessive-compulsive disorder.

Psychosurgery used to be crude, dangerous and often ineffective, but that's because surgery used to be crude, dangerous and often ineffective. We pretty much abandoned psychosurgery before the invention of CT and MRI, before the invention of endoscopic surgery, stereotaxy and the gamma knife. There is tremendous potential for psychosurgery that remains largely unexplored.

For all the cheerleading about how humane and enlightened we are, for all the drugs and talking therapies we have, it remains the case that many people with severe mental illnesses never find an effective treatment. We were right to stop locking people up in asylums and stop hammering icepicks through their eye sockets, but we've become incredibly blasé about the millions of people living lives of misery who we are unable or unwilling to help. Take a walk around downtown San Francisco and you'll see the legacy of deinstitutionalisation - thousands of people who are incapable of caring for themselves, just dumped on the street.

What if future generations decide that our ideology is just as barbaric as the one it replaced?

eeZah7Ux3• 8 years ago

Strawman. Neurosurgery is being practiced today but the context is entirely different.

methodover• 8 years ago

I’ve wondered for a long time about crowdsourced “therapy” — a kind of it, anyway.

I don’t want to just hear myself talk for an hour, which is usually what therapy amounts to for me anyway. I want other perspectives. I want to hear other people whove been through what I’ve been through talking deeply and honestly about their lives. And I want enough perspectives that I can figure out for myself what modes of thinking, strategies, etc, I might make the most use of.

The problem is most people are incredibly closed. Myself included. We don’t talk about our internal mental life as it relates to the outside world. Well, we do - but not with much transparency. And we don’t talk about our personal histories, our childhoods, our teenage years, etc. We don’t talk about the intimate details of our lives.

(And we really shouldn’t; to be clear. Not in a way that can be traced back to us. Much of personal histories are deeply embarrassing.)

And yet, we’re supposed to figure out on our own what’s normal and what isn’t.

I feel like I’ve spent literally years learning things that other people figured out a long time ago.

I’ve been thinking for a while about making a website that’s 100% anonymous (but moderated), but encourages people to write honestly about their own lives.

No advice. It wouldn’t be about advice. It’d be only a repository of individual experiences.

I feel like such a site, if done well, could be a real boon to people who are struggling to figure out life, as I was.

taneq• 8 years ago

Online forums are great for this. At various points in my life I've spent times on forums which provided exactly what you're talking about - a chance to talk openly and anonymously with other people who've faced the same challenges.

smt883• 8 years ago

There is a group model similar to what you describe called DBT, and it's a standard treatment for borderline personality disorder. It's been around for decades. It seems to be useful for many conditions.

serpix• 8 years ago

There can be no real connection without showing your own wounds.

Your wounds also heal when you look into the eyes of another human telling you their fear and trauma with tears in their eyes. You connect with the experience of very humbling and deep empathy as the pain and feelings you share are the same. They are universal. You are not separate and you become to understand that you were never broken or incomplete or different.

This is the power of sharing yourself with others. We are not here alone and were never supposed to figure thins out alone.

aizatto• 8 years ago

I built a platform for myself to think about life's deepest questions, and I've been going around asking people their questions.

On my business cards are different set of questions, and here are some of the answers

https://www.deepthoughtapp.com/packages/189/business-cards-i...

So far I have 50,000+ questions, 3,600+ answers (mostly mine)

The platform isn't about advice, it's about people answering the deep questions to themselves.

jm__8717• 8 years ago

How would this help you, though? I would think for therapy to work, you have to go through the process of challenging your own unhelpful thoughts and beliefs and then act in a way to reinforce new thoughts and beliefs which are more useful. The therapist is someone who knows which questions to ask to help you with the first part (as well as provide emotional support), but the second part has to be done 100% by yourself. This is a very difficult thing to do. Just reading about other people's life challenges may help motivate you a little bit, but otherwise the hardest part is making the change yourself.

dnenandz• 8 years ago

I have undergone CBT with 5 therapists and so I am quite experienced with it. Every time I have been left completely and utterly disappointed.

One of the unfortunate problems I faced with psychotherapy was the convenient shift of outcome being dependent on the quality of care given by the therapist to the mental fortitude of the patient following through on their exercises. In every case it was my fault that I wasn't progressing, and I found this to be extremely frustrating.

It would go something like "Did your CBT methods help you not have a panic attack?", "No they didn't work and I threw up and collapsed in a Starbucks bathroom". "Oh well just practice more and identify those bad thoughts better and earlier and do some more breathing exercises and it will work out fine!"

My very last encounter with psychotherapy is when I went to a doctor and explained that CBT doesn't work for me and that I was looking for someone else who practiced other methods, and yet again they claimed that I needed more practice and that I probably had not mastered CBT. Although we don't practice lobotomies anymore, if you have severe issues mental health treatment is still in the stone age.

SteveCoast• 8 years ago

Try EMDR?

I met an EMDR person once who I think roughly accurately describes CBT as how to deal with issues, and EMDR solves them so you don't have to deal with them in the first place.

Worth a try.

ParanoidShroom• 8 years ago

I tried this, ended up with no results and down a few hundred euros. It might work, depending on the person and the person teaching/applying it. Not for me though.

shakna• 8 years ago

It's sad the CBT is pushed to the forefront by regulation and funding, but there are certain conditions where we know it may not help, and beyond that may be harmful.

I know for GAD, SPD and similar illnesses where anxiety is a core component, that a combination of methods, where at least one is DBT, is one of the recommendations. However, there are fewer practitioners for it.

raverbashing2• 8 years ago

CBT in a nutshell: "our theory works on paper, it's your problem if it doesn't work for you"

tim3332• 8 years ago

It more it works experimentally in many cases eg:

CBT showed higher response rates than the comparison conditions in 7 of these reviews and only one review reported that CBT had lower response rates than comparison treatments. In general, the evidence-base of CBT is very strong. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/

And I guess a lot of doctors are not that up on the other therapies.

Aaargh203189• 8 years ago

I've undergone CBT too and it always felt like quackery to me. The point of CBT seems to be to get people to accept their shitty circumstances instead of actually fixing things. Psychology is the new religion. Instead of saying "accept your shitty life, you'll be rewarded after death" they are saying "you think you have a shitty life, but you just need to look at it differently".

CBT felt like an exercise in self-deception to me. The 'bad thoughts' are a result of the shitty circumstances in life, so shouldn't we be working on those instead of trying to convince myself that shit doesn't stink ?

I strongly believe that 99% of people who visit a psychiatrist could be cured by just handing them 20 million dollars. That would return a persons freedom and remove a huge amount of stress-factors.

ryanwaggoner• 8 years ago

Given how miserable lottery winners are, or how many wealthy people are in therapy, it doesn’t seem like cash solves people’s mental health problems. If anything, it can exacerbate them.

jdietrich3• 8 years ago

See also Buddhism.

raverbashing2• 8 years ago

Proponents of more "evidence based" psychotherapies usually oversell their "scientific" rigour (even if there are several question on their reproducibility) while usually leaving the patient's own characteristics in the background plane (or just ignoring it).

Realizing what you are feeling/thinking and being able to say that is halfway to the solution.

And yes, it is very dependant on practitioner and on the patient's own willingness. (In the same way exercise is good but if you run 100m per day or lift light weights at the gym it won't do much)

wskinner• 8 years ago

This article could be summarized in two sentences, both of which should be unsurprising to most HN readers:

1. Publication bias means that the reported results for efficacy of psychotherapy are likely to be stronger than the actual efficacy. 2. Observational studies showed a negative relationship between mental health outcomes and psychotherapy.

The clickbait title aside, 1 is not really news as this bias affects every field, especially social science, and has been widely reported. 2 is basically a no-op. You cannot under a causal relationship based only on observational studies. Full stop. The idea that people who developed poor mental health sought professional help is if anything more plausible than the clickbaity alternative.

Pica_soO• 8 years ago

Its glorified navel gazing. You can see everything in a navel, especially a lot of you and how that severed connection from your mother started all this trouble.

In the end, its some sort of synthetic friendship, which in a ultra-individualistic society has become rare. But its not resulting in good advice like true friendship. Its resulting in pushing egomaniac tendencies onwards.

Imagine a psychotheraphist not giving libertarian advice. "You should integrate more into your family, visit your brother more often, sacrifice a part of your life to the commons, so that the commons is more willing to sacrifice parts of its life to you.."

"I had a very bad vibe with that psychotherapist, i came to be unrepressed and he pushed for even more repression. In fact i think, i need therapy to overcome this therapy..."

crawfordcomeaux• 8 years ago

A big issue I see is this idea of judging outcomes as positive/negative, instead of accepting people's processes.

After starting therapy, I cut off communication from my parents at least twice. Is this a positive example of someone who's codependently avoiding their parents or someone learning to detach from their parents?

Trick question: it's both.

Another issue with measuring effectiveness is we aren't gathering information about the therapists' beliefs/mindsets. I dropped a therapist because she started adopting my own parents' financial insecurities, shouted "you're going to run out of money" at me a couple times during a session. Anxiety over money was a key issue for me, so I asked her multiple times not to repeat messages to me that might reinforce my thinking. She ended the session with a comment about running out of money, so I dropped her.

I've since gotten over my money anxieties to the point that I've essentially taken a vow of service & poverty as I try to minimize my participation in capitalism. While I'm happy and love my new life free from worrying about money or how to meet my needs, I don't know if this would be considered a desirable therapeutic outcome when considering the rest of society. Of course, society's wellbeing is also really subjective and we are slow to evaluate our culture for long-term effects.

I also started practicing Nonviolent Communication 2.5 years ago. For a while, I was kind of robotic in my communication style after, since I was structuring most sentences as "When (I|you) <observation without evaluation>, (I|you) feel <emotions without evaluation>, because (I|you) need <specific human need without specifying strategy for meeting the need>." Is this temporary rigidity considered negative? What about any person who sticks with the language they use throughout their life?

We program ourselves & each other with our words and I view therapy sessions as guided debugging sessions where I work to figure out ways I've programmed myself or been programmed that are unsustainable. This perspective is therapeutically useful to me & the success of my therapy sessions has deepened, as a result. These days, therapy is more of a safe guard to keep me in check as I play with my mind and perceptions, though I'm still working on my anxiety with writing. I don't know how any of that can be accounted for in these studies and while I may be an outlier, I know that learning to pay attention to outliers is how innovations can come about.

dboreham2• 8 years ago

The big problem with therapy is that it is too expensive to be available to most people. We need to find some viable alternative that doesn't depend on paying a very costly human to listen for an hour a week.

avereveard• 8 years ago

there are also a lot of quacks around. doesn't help that psychotheraphy really lacks a solid background in medicine tbh. we're only scratching the surface of the deep mind structures and issues stemming from there and how they all relate to trauma or even what trauma actually is and yet pretend like we can cure ailments talking people out of it.

bachbach2• 8 years ago

My suspicion is that many people going to therapy are lacking in one or more items from the basic hierarchy of needs.

I went to therapy once. In hindsight I'd have been better off with a girlfriend and friend companionship.

I'd ask myself.

1. Am I getting good quality sleep? 2. Am I getting good quality food? 3. Am I interacting with people socially? 4. Am I sexually active? 5. Am I physically active to the point of breaking sweat?

The mental and physical are intertwined and it is easy to forget to take care of yourself. Your machine requires maintenance.

I don't only mean sometimes take it easy - that too - but also people can grow very neurotic by ignoring their social and sexual needs, and like a machine - we are meant to perform functions - without which we can suffer aka a certain amount of physical or mental stress is good for us and we can err by doing too little or too much.

themodelplumber2• 8 years ago

For a lot of people, deeply subjective-analytical thinking of this sort is very brittle, and they lack the experience that would teach them what to do even if they knew they were lacking some important thing on the hierarchy.

It also happens that some very depressed and anxious people will e.g. read only the "criticisms" portion of the Wikipedia page for the hierarchy concept, and determine in the end that what they need is an experienced professional rather than a possibly-unscientific concept. This is really sad to observe, because their inability to be open to certain kinds of information can make them more dependent, not less.

bachbach2• 8 years ago

It is easy to dismiss 'get laid' as boorish and interpret 'did you get enough sleep?' or get out more' as semi-accusatory, because we're prone to thinking crude feedback is less apt for us, we must be more complex than this.

Look at the rise of ASMR videos. Millions of people desire an experience,a simulation, of being touched in a non-sexual way. This isn't a critique of ASMR - it's fine - but there's this simple need at the heart of it - little different to those gorillas grooming each other.

There's a running gag in AMSR circles where the ASMR viewer is interrupted by somebody and reacts by <laptop lid slam> pretending they were watching porn.

Hackerspaces and makerspaces are a great thing. I heard a quote recently "Women communicate, men shoulder to shoulder".

davidy123• 8 years ago

When I worked in the health system, specifically around pain relief, there was a comparison of different approaches. Among them was "distraction therapy." That phrase has stuck with me, and I think it applies to many therapies people are mentioning here. It's basically a variation of "hit your head so you don't notice your sore elbow." But with the right application I think it can be entirely positive. If the attention required of therapy X shifts you away from problem Y, even if it's not really "helpful" on its own, then it's an excellent therapy. This is why some people realize they'd rather get a gym membership than therapy sessions. That said, I think psychotherapy, as an intentional focus on underlying or neurochemical issues, can go much deeper than this approach and should be considered by many people (though positive results could themselves be considered a 'distraction' if they don't address an inherent problems).

jm__8717• 8 years ago

My viewpoint on mental health: how you feel at any given moment and how long that feeling will persist will depend on the structure of your brain and the environment in which your brain is in. There are a huge number of variables at play. This environment includes things like: baseline levels of chemical signalling of various kinds going on in your brain (this is plainly apparent when you do any sort of perception or mood altering substance which significantly changes the chemical signalling in your brain); physical health of the body attached to the brain; inputs from your senses and any feelings that may be arising as a result of these inputs; beliefs and assumptions about the world in which you're in; and finally structural considerations of your brain (e.g. is some part of your brain damaged or non-existent). For some people, the majority of problems lie in the "beliefs and assumptions about the world" variable and for these people, therapy is the answer. I imagine for the large majority of people, therapy may give some minor benefits but if you don't attend to your own physical and emotional needs on a regular basis, you are going to feel like garbage. This means eating a healthy diet (with enough calories), getting some exercise, spending time with family and friends, taking some time for yourself to relax and unwind. For those with persistent chemical signalling or structural problems in their brains, they may have to do way more to feel right, including getting on the right drugs and therapy for emotional support. It may suck, but we can only play the hand we're dealt.

A few more thoughts on this topic: the world we live in now is so different from the one humans evolved in. We eat different food and eat way more frequently than our ancestors did. We exercise way less and spend very long periods of time in low to medium stress situations instead of short periods of time in high stress situations, which is what our stress response system evolved for. Many of us live semi-isolated lives thinking about how we can help ourselves as individuals instead of living in small to medium sized groups thinking about how we can help ourselves within the context of the group (you would likely have to be doing prosocial things with higher regularity). While there are many advantages of living in the world we now live in as compared to how our paleolithic ancestors lived, there are some incompatibilities with how we have evolved and I think we should be doing more as a society to address these issues.

perseusprime11• 8 years ago

The untold truth is that therapy is not for all people. Similarly, meditation is not for all people either. For some people, neither therapy nor meditation really work. For those people, medication to elevate mood is the only real option. I have seen too many therapists exploit this and raise hopes of their patients and try CBT for a long time without results. Just like any disease, you need to manage this and there is nothing wrong in taking medication to fix yourself.

totierne2• 8 years ago

I participated in 3 CBT sessions 10 years ago I asked what will I get out of 6 sessions (the most my employer would pay for). The therapist said I would know my problems but not solved any of them. I did not attend any further sessions. I am a male programmer with bipolar. I did try a excel based survey labelled CBT which quantified where I was on general personality traits which was OK and free. I did read some popular therapy books. I could probably do with more work focussed excutive coach lite training if I could avoid the bad ones. I called works employee helpline recently, after a manic episode, I will see how that goes, it is more of a seen to be doing something rather than letting mania (occasionally) take its natural course.

Have we overestimated the effectiveness of psychotherapy?

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