PhD/PsyD Do psychologists have a distorted or exaggerated view of psychotherapy

[erg923]

I often wonder if we, as profession, overplay therapy a bit--in term of its effectiveness, in what it can help with, and who can benefit from it? Working at the VA, the predominant zeitgeist seems to be that if there is any mental health concern, then therapy should be offered...and in some cases required by some of the prescribing providers. This seems quite silly, as I actually don’t think that psychotherapy is universally beneficial. And for some problems/circumstances it seems like its actually quite a waste of time for both parties. People often wonder why VA MH is so overburdened, and I might suggest it’s because we have it open to all, for any problem, and the is no time limit on the services (people are in it way too long).

Thoughts??

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[Therapist4Chnge]

While I think the vast majority of people could benefit from some sort of supportive therapy or more direct/goal driven therapy…that doesn't mean everyone should go that direction. I tend to have a high % of referrals from my neuropsych evals, though my patient population tends to be in moderate to significant need, though it's nice when someone comes in with an established relationship with a quality provider.

When I make referrals for therapy I provide specific areas of foci, identify a treatment modality (EBTs only), and try and identify one or more providers who may fit those needs. Having access to list servs has been invaluable for tracking down clinicians.

It drives me nuts when I see, "Referral: Out-Pt Psychotherapy for adjustment." I try and be as specific as possible because I don't want to put up any additional roadblocks for the patient AND it helps fend off most of the hacks looking for new ppl. If I feel that the pt. may look to the energy crystal moonbeam therapists…I'll take some time to explain to the pt (and spouse/caregiver/etc) about the best supported treatments and warn against "holistic" or "alternative" clinicians who are not licensed and/or practice junk science. I sometimes provide citations and/or articles to the referring physician if they have questions about a specific EBT. So far so good.

 

[Ollie123]

The "therapy for everyone and everything, 7x/week for all eternity" attitude is not terribly uncommon in our field. In my experiences, it is generally from folks with traditional humanistic or analytic approaches who do little besides provide social support or a means to vent anyways - so I can see how that attitude might come about. I would certainly agree that everyone would benefit from social support or someone to talk about things with in some form. I don't think it is necessary or even beneficial that said person be a therapist in the vast majority of cases.

 

[PsyDr]

I think there are really three therapy "streams".

1) In a very traditional sense: Pt has a specific disorder. The clinician applies an EBT. Remission is achieved in a time limited fashion. Move on.

2) There are instances in life when you encounter something that you are just incapable of dealing with (e.g., you walk in on your kid involved in some super weird masturbatory habit). While this might not be a formal psychiatric disorder, just having someone that is trained to deal with the weird can be helpful.

3) In the DSM-II, there was indications of a personality structure that would just traditionally need some form of psychotherapy. I've seen some such people.

I don't know if any are more valid than the next.

Then again, I don't do any psychotherapy.

 

[futureapppsy2]

I think this can really depend on the setting....

In UCCs, I've definitely seen a "therapy for everyone! Therapy, yay!" type attitude, which I think comes out of a desire to destigmatize therapy among students, especially now that universities are moving towards behavioral intervention team/threat assessment team models (which are riddled with confidentiality issues and like to equate homicidality, suicidality, and NSSI much much more than I think is wise).

Otoh, I'm currently doing a prac at an assessment clinic that focuses on autism spectrum, educational, and SPMI assessments, and often therapy isn't recommended to clients even if there are significant life stressors, because the focus is on persistent pathology and characterological disorders.

Tbh, I think most people with an active, clinically diagnosed psychological disorder could benefit from therapy. For v code/adjustment type issues, it's a bit murky.

 

[Rivi]

I agree with the idea that therapy services should be offered (not required) to everyone seeking mental health services, as long as they have a clear understanding of what it is and how it might be helpful. I only think that people should be "encouraged" to start therapy in more limited circumstances. This can backfire, as mentioned above, but I think we can design a system to better accommodate these with group seminars, support groups for individuals feeling lonely, etc.

I think we have to be careful as therapy is more often underutilized, especially for some populations (Schizophrenia, Bipolar Disorder), and an ounce of prevention is worth a pound of cure. If someone has a history of Major Depressive Episodes, I would rather them come in sooner rather than later.

 

[Ollie123]

In UCCs, I've definitely seen a "therapy for everyone! Therapy, yay!" type attitude, which I think comes out of a desire to destigmatize therapy among students.

Interesting. I attributed this to orientation, but orientation and setting were heavily confounded for me. I did see it more strongly within the UCC setting, but the couple analytic folks here do seem to have a similar attitude (albeit something they believe less strongly). If the goal really is destigmatization, I think that is possibly the most ridiculous and inefficient way I have ever heard of to go about achieving that.

Tbh, I think most people with an active, clinically diagnosed psychological disorder could benefit from therapy. For v code/adjustment type issues, it's a bit murky.

I fully agree and I think most people would with this. The folks I'm referring to seem to believe that it would be ideal for everyone to be in therapy all the time...regardless of the presence of even any adjustment issues. This is where I think it crosses into the realm of ridiculousness. It shows complete detachment from reality - there is simply no way for something like that to be cost-effective or practically possible and it would make it more difficult to help those who 1) Actually need help and 2) Research shows we CAN help.

 

[Spydra]

I fully agree and I think most people would with this. The folks I'm referring to seem to believe that it would be ideal for everyone to be in therapy all the time...regardless of the presence of even any adjustment issues. This is where I think it crosses into the realm of ridiculousness. It shows complete detachment from reality - there is simply no way for something like that to be cost-effective or practically possible and it would make it more difficult to help those who 1) Actually need help and 2) Research shows we CAN help.

I've met a lot of people over the years who likely have therapists like this because they've later told me how they've been in therapy pretty much their whole lives with said therapist. Now of course I'm not reviewing their whole mental health history, but there still seems to be something wrong with this picture. I could understand going once or twice a year for a tune up, kind of like you might with a chiropractor, but I do not see the point of once or twice a week indefinitely when one does not have a severe mental illness and has made significant strides to work through whatever major issue brought them to therapy in the first place. I can't even imagine how the therapist wouldn't burn out in cases like that or start to wonder if their patients are actually improving.

 

[Ollie123]

My impression is more that it is a way to avoid burnout (particularly for cases that may never have even had a major issue that brought them in!). Filling your caseload with a bunch of folks who just want someone to listen to them vent about the minor stressors of everyday life sounds like a pretty easy way to coast as a therapist...something I think that (sadly) many do not seem opposed to doing.

 

[Sanman]

My impression is more that it is a way to avoid burnout (particularly for cases that may never have even had a major issue that brought them in!). Filling your caseload with a bunch of folks who just want someone to listen to them vent about the minor stressors of everyday life sounds like a pretty easy way to coast as a therapist...something I think that (sadly) many do not seem opposed to doing.

More than a way to avoid burnout. I think it is essential to the output therapy market. People with minor issues and money to burn help fill empty slots. Of the output therapists I know and the people I have seen, this seems to be the truth.

 

[WisNeuro]

The VA is so different from other systems though. No other system bends over backwards as much for the consumer. Sometimes out of genuine patient empathy. Sometimes out of fear of congressional letters and bad press. Having worked in a few systems, the VA hands out so much more in the way of unnecessary procedures and appointments due to patient pressure than other systems I have been in.

That being said, I think part of it is also laziness on the front end. Primary providers don't have the time, or desire, to do an accurate diagnostic interview, so they tend to do the shotgun approach. Blood tests and therapy for everyone!!!

 

[spemat31]

The ones I know are. Which is part of why I don't see one but I see a psych nurse practitioner.

 

[MikePsychNpPsyD]

I dont get whats so hard to understand about this issue. Some things DO require therapy, others REQUIRE meds (usually meds + at least a little therapy). The things/ issues that have origins in the biology and biological pathology of a person (IE- a person has aids and is developing dementia and other issues as a result), you obviously treat that primarily with drugs, as therapy will not be addressing the actual origin of the issue, but you of course can supplement the drugs with therapy.

My approach is that you should be supplementing either or, with the other. If the origin of the problem is biological, the primary treatment should be meds, and you supplement that with therapy. If the origin of the problem lies in something environmental and via some harmful, traumatic experiences the person had/ is having, the therapy should be the primary treatment, and that can be (doesn't HAVE to be) supplemented with meds (often time LIGHT meds). With that being said, when this ISNT done, it doesnt help that patient and often times causes even more problems and destruction. IE- the person was robbed and beaten, and now has anxiety, panic disorder, OCD, and/ or PTSD....and you treat that primarily (if not solely) with meds? That's not addressing the actual origins, causes, triggers, of the problem/ issue, and there for the issue not only continues on unaddressed, but continues on and gets worse...and worse..and worse, while also often times triggers additional, separate issues.

So yea, im not understanding why this is still not understood.

 

[smalltownpsych]

I don't know if the stereotype of the psychotherapist seeing the worried well really holds that much water in the real world. It has not been my experience in outpatient therapy at all. Yes, I have seen that dynamic and that type of clientele, but most people.come to me for help with serious problems. A significant portion of my case load has been hospitalized for suicidality at some point. Others are struggling with OCD, substance abuse issues, panic attacks, PTSD, BPD, Bipolar, reactive attachment, childhood loss of parent, adult with death of a child, and even an occasional patient with schizophrenia. Some days I am grateful for a few patients with milder symptoms, but they don't last long in treatment cause they don't really need it much. I did have a good session today with a patient who I hospitalized almost a year ago and we are now beginning the termination phase and I will be seeing only biweekly for the next couple months and then we'll be ending most likely. If I could just find more uncomplicated patients, I could cure them faster.

 

[MikePsychNpPsyD]

I don't know of the stereotype if the psychotherapist seeing the worried well really holds that much water in the real world. It has not been my experience in outpatient therapy at all. Yes, I have seen that dynamic and that type of clientele, but most people.come to me for help with serious problems. A significant portion of my case load has been hospitalized for suicidality at some point. Others are struggling with OCD, substance abuse issues, panic attacks, PTSD, BPD, Bipolar, reactive attachment, childhood loss of parent, adult with death of a child, and even an occasional patient with schizophrenia. Some days I am grateful for a few patients with milder symptoms, but they don't last long in treatment cause they don't really need it much. I did have a good session today with a patient who I hospitalized almost a year ago and we are now beginning the termination phase and I will be seeing only biweekly for the next couple months and then we'll be ending most likely. If I could just find more uncomplicated patients, I could cure them faster.

interesting post my friend. I have a question, the individuals who you hospitalize do most, some, or a small minority of them, have anger and/ or resentment towards you because of that?

Lets also include the individual that you had a a nice session with today. What were/ are, his/ her feelings regarding you hospitalizing them? And what are their particular issues? And has there been any improvement in their issues?

 

[erg923]

My approach is that you should be supplementing either or, with the other. If the origin of the problem is biological, the primary treatment should be meds, and you supplement that with therapy.

That's fantastic and all, but frankly, therapy is useless if you don't have "buy-in" and substantial effort from the patient. A short course of supportive therapy or ME/MI can almost always be done, but no one "needs" therapy if they don't want it, right? No therapist should be working harder than their patient in therapy.

 

[smalltownpsych]

interesting post my friend. I have a question, the individuals who you hospitalize do most, some, or a small minority of them, have anger and/ or resentment towards you because of that?

Lets also include the individual that you had a a nice session with today. What were/ are, his/ her feelings regarding you hospitalizing them? And what are their particular issues? And has there been any improvement in their issues?

It was not involuntary. When hospitalizing patients, we discuss it and most will agree that they need a safe place to stay when they are in that state of mind. Involuntary hospitalization is something to avoid whenever possible IMO. Of course the patient I was referring to has improved. That is why we discussed tapering the treatment and that was why it was a good session as we reviewed the progress they had made.

When involuntarily commitment is necessary, it will often fracture rapport, but I have never had to do that with an outpatient client.

 

[smalltownpsych]

That's fantastic and all, but frankly, therapy is useless if you don't have "buy-in" and substantial effort from the patient. A short course of supportive therapy or ME/MI can almost always be done, but no one "needs" therapy if they don't want it, right? No therapist should be working harder than their patient in therapy.

Exactly. I sort of was sidetracked into another issue but I wanted to state that I am also tired and frustrated with the referrals for treatment for unmotivated people. Bad behavior is not a mental illness and this notion has permeated society and it just becomes an excuse or a game for the abusers and perpetrators. They burn us out and use up our resources. "I can't help it that I attacked her because of my bipolar". Patient with history of substance use, no pressured speech, euthymic mood and congruent affect, no hospitalization for mania, complains of difficulty falling asleep not decreased need. Send them to a court mandated structured educational type of program sure, but don't send them to us or the psychiatrists. Unless it is just to rule out that they really do have a serious mental illness that they might need treatment for as an adjunct to their highly structured program, but most of them don't.

 

[WisNeuro]

Long story short. We overestimate the effects of both therapy and psychotropic medications, when we examine large group studies.

 

[Ollie123]

That's fantastic and all, but frankly, therapy is useless if you don't have "buy-in" and substantial effort from the patient. A short course of supportive therapy or ME/MI can almost always be done, but no one "needs" therapy if they don't want it, right? No therapist should be working harder than their patient in therapy.

I think this is the point that eludes even most professionals outside the field. Most folks have some level of ambivalence and we're trained to work with that and capitalize on/build the motivation that is present (using MI and similar techniques). I lack a magic therapy wand that bends people to my will (or perhaps more to the point - someone else's will). I say this even as someone who has worked almost exclusively with the populations that are generally less motivated (addiction, health behaviors).

This was never more salient than embedded in the legal system last year. Most court-mandated therapy is about politics and appearances - not about helping anyone. There are exceptions, but I think the general rule holds.

 

[BuckeyeLove]

Yes.

This was never more salient than embedded in the legal system last year. Most court-mandated therapy is about politics and appearances - not about helping anyone. There are exceptions, but I think the general rule holds.

and, This ^^^^ so much this ^^^

 

[smalltownpsych]

I often wonder if we, as profession, overplay therapy a bit--in term of its effectiveness, in what it can help with, and who can benefit from it? Working at the VA, the predominant zeitgeist seems to be that if there is any mental health concern, then therapy should be offered...and in some cases required by some of the prescribing providers. This seems quite silly, as I actually don’t think that psychotherapy is universally beneficial. And for some problems/circumstances it seems like its actually quite a waste of time for both parties. People often wonder why VA MH is so overburdened, and I might suggest it’s because we have it open to all, for any problem, and the is no time limit on the services (people are in it way too long).

Thoughts??

Another thought about the way too long part. I do a lot of longer term psychodynamically oriented treatments, but the patient and I always have goals for the treatment. They are either progressing or not and the end goal is for them to progress to where they don't need psychotherapy. I don't need it, why would they? (I do attend a community-based support group, i.e. free except for donations for snacks ) The biggest obstacle, and you know all about this, is when there is a reinforcement for not progressing. As long as they are not on disability, the reinforcements from making progress on goals will keep most of them going in the right direction.

On the other hand, I do have a few patients who use psychotherapy as a support and should always have access to it because of severe mental illness or cognitive impairments combined with a lack of family support. The goal for them is to stabilize and then check in with me every few weeks to help keep them on track.

 

[psych844]

We do also need to study the role of gender in terms of therapy effectiveness. I've read some research that states that women find talk therapy lot more useful, as they find the process of disclosure a lot more meaningful and useful. They often feel the therapist is understanding and caring, and this results in a favorable view of therapy. A lot of males feel therapy is weird or just a waste of time. They don't feel it is at all useful to disclose their issues to strangers, as they can't see how someone saying something to them could help them..so why do it?. I'd wager this is connected to boys in general being more practical/liking concrete things. (heck you see this even in terms of what majors males select in college (engineering, math, science, while a lot more women in the arts)

I'd love to be able to blame poor motivation of patient, but I feel that a good part of the problem is the poor providers themselves. Even from my own experience (having received therapy), and others around me, what therapy ends up being is the Psychiatrist/Psychologist listening to you and offering a few tidbits here or there (often very obvious stuff that certainly wouldn't take you more than a week course to master, or something that a random friend with no experience has also said to you). You just expect a lot more from someone that went to school for 10yrs. Not having gone through graduate school, i'm not sure if providers are not taught how to come up with very specific plans and concrete plans for patients..or do the providers finish school and then become lazy? or is it not practical because you have to balance money/coming up with plans for people?

 

[smalltownpsych]

We do also need to study the role of gender in terms of therapy effectiveness. I've read some research that states that women find talk therapy lot more useful, as they find the process of disclosure a lot more meaningful and useful. They often feel the therapist is understanding and caring, and this results in a favorable view of therapy. A lot of males feel therapy is weird or just a waste of time. They don't feel it is at all useful to disclose their issues to strangers, as they can't see how someone saying something to them could help them..so why do it?. I'd wager this is connected to boys in general being more practical/liking concrete things. (heck you see this even in terms of what majors males select in college (engineering, math, science, while a lot more women in the arts)

I'd love to be able to blame poor motivation of patient, but I feel that a good part of the problem is the poor providers themselves. Even from my own experience (having received therapy), and others around me, what therapy ends up being is the Psychiatrist/Psychologist listening to you and offering a few tidbits here or there (often very obvious stuff that certainly wouldn't take you more than a week course to master, or something that a random friend with no experience has also said to you). You just expect a lot more from someone that went to school for 10yrs. Not having gone through graduate school, i'm not sure if providers are not taught how to come up with very specific plans and concrete plans for patients..or do the providers finish school and then become lazy? or is it not practical because you have to balance money/coming up with plans for people?

If you are seeking advice, then psychotherapy is not going to be that useful. Yes, men tend to get stuck in this conceptualization of emotional distress being something to fix and want me to tell them how to fix it much more than women and it makes it more challenging to work with them. With more concrete diagnoses like PTSD it can be a little easier to explain this to male patients, but a bit harder with more generalized anxiety and depression that is more interpersonal in nature. In more rural areas, especially the cowboy-up areas, the male resistance is even more pronounced. Might be one reason that the suicide rate is double the national average in some of these same states.

Another factor to consider is that women are 2x as likely to be depressed whereas men are 2x as likely to abuse substances. Guess which does better in individual psychotherapy?

 

[psych844]

If you are seeking advice, then psychotherapy is not going to be that useful. Yes, men tend to get stuck in this conceptualization of emotional distress being something to fix and want me to tell them how to fix it much more than women and it makes it more challenging to work with them. With more concrete diagnoses like PTSD it can be a little easier to explain this to male patients, but a bit harder with more generalized anxiety and depression that is more interpersonal in nature. In more rural areas, especially the cowboy-up areas, the male resistance is even more pronounced. Might be one reason that the suicide rate is double the national average in some of these same states.

Another factor to consider is that women are 2x as likely to be depressed whereas men are 2x as likely to abuse substances. Guess which does better in individual psychotherapy?

I would wager CBT would work way better with most males than psycho-dynamic therapy or humanistic. You could put together a very practical plan with CBT.

 

[smalltownpsych]

I would wager CBT would work way better with most males than psycho-dynamic therapy or humanistic. You could put together a very practical plan with CBT.

To an extent this is true and I utilize this strategy, but sometimes it can be a collusion with the defensive pattern that is causing them problems in the first place. That is one point of contention that I have with some in the CBT camp is that I do believe that emotional expression and insight are more important than they tend to. Catharsis or insight alone are not sufficient, true; but psychological change without catharsis or insight isn't always sufficient either. Figuring out this stuff and trying to help our patients despite the difficulties is where the 10 years of school comes in to play.

One more thing, providing advice is not psychotherapy. Too many people and providers think that it is, unfortunately.

 

[PsyDr]

Or you could just use behavioral therapy.

 

[WisNeuro]

Or you could just use behavioral therapy.

Don't pigeonhole me!!

 

[Ollie123]

. Not having gone through graduate school, i'm not sure if providers are not taught how to come up with very specific plans and concrete plans for patients..or do the providers finish school and then become lazy? or is it not practical because you have to balance money/coming up with plans for people?

Depends what you mean by "specific and concrete plan." I imagine (hope?) most therapists have an overarching framework in mind. Some may be working at least loosely off a manualized intervention. Even for those of us very EBP-oriented, its not like planning a lecture for a course. Therapy is simply not a concrete process and part of doing it properly means coming to accept that. Caseload can certainly impact that - I have way less time to devote to conceptualization than I did in graduate school. Back to back patients can be limiting, but that's the reality of our healthcare system.

Even as a strong believer in therapy, I do think there is a tendency to oversell it - and that is particularly true for certain components. I have felt ridiculous walking someone through deep breathing or PMR. I've reviewed manuals that encourage you to talk every skill up like it has magical power to make your problems go away. Part of this ties in to the other fundamental misunderstanding of what we do. I can't make bad things not happen or teach you to be happy all the time. I can teach you to better cope with bad things that do happen and improve your functioning across a variety of settings. I can explore your role in making bad things happen to you more often than they should. Grandpa is still going to die and you are still going to miss him when it happens. Sorry.

These are among the many reasons I'm hoping for a career with 80% or more research time

 

[erg923]

Our job is not to make people happy, but to turn hysterical misery into common unhappiness.

 

[Ollie123]

That is one point of contention that I have with some in the CBT camp is that I do believe that emotional expression and insight are more important than they tend to.

Done much ACT? Far from an expert, but in my limited experiences with it, it seems to provide a great blend of the two approaches and aligns very well with what you describe.

 

[psych844]

To an extent this is true and I utilize this strategy, but sometimes it can be a collusion with the defensive pattern that is causing them problems in the first place. That is one point of contention that I have with some in the CBT camp is that I do believe that emotional expression and insight are more important than they tend to. Catharsis or insight alone are not sufficient, true; but psychological change without catharsis or insight isn't always sufficient either. Figuring out this stuff and trying to help our patients despite the difficulties is where the 10 years of school comes in to play.

One more thing, providing advice is not psychotherapy. Too many people and providers think that it is, unfortunately.

Interesting. Well you are the pro lol, so you know more, but I do come at this as a person that has faced social anxiety myself/panic disorder (and a very complicated/tough life), and someone that is very interested in psychology and wants to start grad school in the next 1.5yrs or so. As mentioned, I also have friends and even family members that have dealt with mental health professionals.

First, you are absolutely right..too many providers think advice = psychotherapy.

Second, I understand the defensive pattern as a male who has gone through treatment. I came into therapy at my worst point,(as many people do) so when this provider starts suggesting to me that I should try to desensitize myself by going out into public and facing my fears (and i came into therapy without sleeping much for 3 days, and have anxiety)..this seemed like the dumbest/most useless thing I've ever heard. This is the help? You telling me what my mom also suggested? A friend of mine who had similar issues found it very difficult to pay attention to what was being said during sessions because of mental fatigue (the anxiety) + lack of sleep.

I feel that for my particular problem with the provider (finding her advice was obvious but sort of ridiculous for me in that state as well) it would have been very useful if she had straight out told me "because you are at your worst, you're going to think what I'm saying is sort of silly, etc" or if she said "these cognitive methods i'm giving you might seem very simple, and they sort of are, but they will work..just please give it a try" or "these cognitive methods will only really start working once you start getting some confidence and changing your behavior..not before"..that be very useful.

As a result of the poor communication, i only really started to appreciate those sessions maybe a year down the line. Once I started to trust what she was saying..got on one medication, started changing behavior, then my cognitive methods started being really useful too, and everything was clicking. If she had been a good communicator, and really explained things well, i'd feel it be a totally different experience.

 

[psych844]

Our job is not to make people happy, but to turn hysterical misery into common unhappiness.

In many ways, yes. And maybe the way to get that across to patients is to see therapy a lot like exercise. To stay in really good physical condition exercise has to be a life-long thing, and yes it's difficult, but we have proof that it works. I feel talk therapy is that way. All those methods to stay mentally strong have to be practiced to keep that state. It isn't quick, it isn't easy, but it does work. And the job of the provider has to be to communicate this properly, to not give false hope, and to very clearly explain what it is/what it isn't.

 

[psych844]

I also think that providers should get their patients interested in educating themselves, as educating yourself can be quite therapeutic in itself. (as the patient will have hope when they read up on interesting theory) But don't just say '"read this resource". Instead, bring up hierarchy of needs, or reciprocity principle, or how Freud viewed love (or whatever, if it's relevant) and explain it in detail. Not only will the patient have more of an understanding of the providers knowledge base (which will lead to a bit more respect), but it will give them hope/get them excited, that there are so many potential solutions or ways to see their problem.

 

[Therapist4Chnge]

There is a great deal of variance between and within different therapy modalities. I think therapy is only as good as the appropriateness of the intervention, the willingness of the patient, and the ability of the clinician to facilitate the work. In regard to the appropriateness of the intervention, this involves both the clinician/pt fit and fit of referring problem and expected intervention(s). A positive outcome is dead in the water if the patient does not want to engage in the work. Lastly, the clinician's training and abilities matter.

 

[Nahsil]

The "therapy for everyone and everything, 7x/week for all eternity" attitude is not terribly uncommon in our field. In my experiences, it is generally from folks with traditional humanistic or analytic approaches who do little besides provide social support or a means to vent anyways - so I can see how that attitude might come about. I would certainly agree that everyone would benefit from social support or someone to talk about things with in some form. I don't think it is necessary or even beneficial that said person be a therapist in the vast majority of cases.

eh, in my experience these people understand that what they're aiming for is personal transformation, and that that's most certainly not for everyone.

"social support" and "venting" is also really reductionistic, at least based on what they think they're doing.

 

[Chalupacabra]

Saw this article and was reminded of this discussion - http://www.theguardian.com/science/...evenge-of-freud-cognitive-behavioural-therapy

Would be curious to hear people's thoughts.

 

[WisNeuro]

Saw this article and was reminded of this discussion - http://www.theguardian.com/science/...evenge-of-freud-cognitive-behavioural-therapy

Would be curious to hear people's thoughts.

I wish people arguing for the equivalency of therapy didn't hang ALL of their hopes on depression when they examine studies. I'm more of the mind that certain modalities are probably superior for certain diagnoses/classes of diagnoses. Depression seems to be mixed depending on certain characteristics of the depression (i.e., chronic severe seems to respond better to IPT, etc.) While things like panic disorder respond very well, and very quickly, to things more CBT based (e.g., PCT). Arguing for equivalency across all psychopathology based on one line of research would be like saying statins would be great for treating kidney disease since they kind of do an ok job at cholesterol management.

 

[hamstergang]

I dont get whats so hard to understand about this issue. Some things DO require therapy, others REQUIRE meds (usually meds + at least a little therapy). The things/ issues that have origins in the biology and biological pathology of a person (IE- a person has aids and is developing dementia and other issues as a result), you obviously treat that primarily with drugs, as therapy will not be addressing the actual origin of the issue, but you of course can supplement the drugs with therapy.

My approach is that you should be supplementing either or, with the other. If the origin of the problem is biological, the primary treatment should be meds, and you supplement that with therapy. If the origin of the problem lies in something environmental and via some harmful, traumatic experiences the person had/ is having, the therapy should be the primary treatment, and that can be (doesn't HAVE to be) supplemented with meds (often time LIGHT meds). With that being said, when this ISNT done, it doesnt help that patient and often times causes even more problems and destruction. IE- the person was robbed and beaten, and now has anxiety, panic disorder, OCD, and/ or PTSD....and you treat that primarily (if not solely) with meds? That's not addressing the actual origins, causes, triggers, of the problem/ issue, and there for the issue not only continues on unaddressed, but continues on and gets worse...and worse..and worse, while also often times triggers additional, separate issues.

So yea, im not understanding why this is still not understood.

I think it's not understood because I'm not sure that it's true. It is, at the least, not evidenced based as far as I know.

Some studies have shown that psychotherapy can make physical changes to the brain. So the whole premise that therapy can't affect a biological process seems flimsy. Even ignoring this, I don't know why it wouldn't be plausible that therapy could teach people ways to compensate for physical brain issues.

On the other side of this, some biological reductionists would say that trauma induces changes in neuronal pathways and neurotransmitters. That would make medications reasonable even when you can identify a trauma or psychological cause.

In the end, we don't ever know if we address the actual causes of psychic disturbances. We have models that implicate causes, and working under these models we can make people better, but that doesn't actually mean these models are true.

 

[Peacemaker36]

Saw this article and was reminded of this discussion - http://www.theguardian.com/science/...evenge-of-freud-cognitive-behavioural-therapy

Would be curious to hear people's thoughts.

I think it's a thought provoking article. I agree with the point that "empirically supported therapies" is a synonym for CBT. Our research, for the most part, has excluded psychodynamic approaches for many years; the national research machine does not slow down for analytic treatments. I work with trainees and I'm often surprised by how thoroughly indoctrinated some of them are to believe that psychodynamic therapy is a farce. Even the ones who respect it, know very little about it. This is often true with students from the most competitive programs.

 

[MCParent]

I work with trainees and I'm often surprised by how thoroughly indoctrinated some of them are to believe that psychodynamic therapy is a farce.

I agree. Even if you think psychodynamic approaches are complete garbage, patients don't. I'd wager 95% of people come into therapy with a psychodynamic mindset--no one comes in and says "Geez, doc, here are the ways I'm cognitively distorting what happens to me"; they come in and say "here are the ways my mom and dad messed me up." I've always found it useful to give them a little of what they expect/want before doing psychoed toward more CBT-type approaches.

 

[psych844]

I agree. Even if you think psychodynamic approaches are complete garbage, patients don't. I'd wager 95% of people come into therapy with a psychodynamic mindset--no one comes in and says "Geez, doc, here are the ways I'm cognitively distorting what happens to me"; they come in and say "here are the ways my mom and dad messed me up." I've always found it useful to give them a little of what they expect/want before doing psychoed toward more CBT-type approaches.

Well, I'd assume to get a proper history you would have to obviously talk about their past.

 

[smalltownpsych]

Saw this article and was reminded of this discussion - http://www.theguardian.com/science/...evenge-of-freud-cognitive-behavioural-therapy

Would be curious to hear people's thoughts.

Surprisingly well-written article. Although it did tend to frame it in the classic analytic vs CBT whereas current psychodynamic theory and practice are a bit different from that and as Wis stated only talks about depression. I personally have never been in the Freud was all wrong or the CBT is too superficial camp. Of course, I see the pluses and minuses of both sides of the political spectrum, too so that makes me a bit unusual in that respect.

 

[Ollie123]

Mixed feelings on the article. Some points are excellent, some are distorted and some are simply incorrect.

This is a big interest of mine, but have a grant due soon so didn't have as much time to go through as I'd like. Nonetheless, some point-by-point thoughts:
1) Freudian psychoanalysis does not equal short-term psychodynamic treatments. They screw this up left and right in the article.
2) True CBT is more insight-oriented than I think many realize. Automatic thoughts are superficial. Schemas and core beliefs are where much of the long-standing work happens. The two treatments have more in common than many realize - largely at that level.
3) They mention a meta-regression showing the efficacy of CBT shows a downward trend over time. The author seems to think this is evidence that CBT doesn't work as well as it used to. They fail to mention this is true of a huge number of findings that have an adequate literature base to draw on sufficient power to show the effect. Some may be a publication bias effect. It has always seemed a huge leap to me to think it disproves the original effect. Its meta-analysis people - we're collapsing studies together and losing information about individual ones. It certainly has merits, but you can't ignore the methodology. I think an easier explanation is that it is a function of study design. Initially, we set up studies to show something works at all (high effect size). Eventually, we push the bounds of what it can do more and more (different populations it wasn't designed for, more active control groups, messier settings and designs). Covariates are rarely used in such analyses (they are a PITA to implement in meta-analysis). Of course...we can't see the effect for psychoanalysis because there aren't enough well-designed studies to even attempt something like that.
4) Author logic: CBT effect size is overrated. In some cases it is only slightly better than psychodynamic treatments. Therefore Psychoanalysis is more effective in the long-run (unless I'm mistaken, that actually seems to be the argument at one point).
5) Depression is not the only mental illness that exists. What about OCD? What about panic disorder?
6) Not a fan of ad hominem, but if we are going to paint Shedler as a savior doing cutting edge science showing the efficacy of analysis...let's look a little deeper at that. He's never held an NIH grant per Reporter. In the last 3 years, it looks like he's published a bunch of personality structure work (some of which is pretty good), but otherwise his contributions seem to be mostly narrative critiques of the CBT literature. It ain't perfect. Its miles ahead of what the dynamic literature has at the moment. He has a habit of doing this, but showing that someone else's point is weaker is not the same thing as proving that your point is stronger. This is really what the EBP crowd has been saying all along. If it works, prove it. We're trying to prove our points. Not every execution is perfect, but we're trying. Why aren't you?
7) Anyone can pick out a poorly designed study (the reference to grad students with 2 days training in the therapy). If I find a poem a patient wrote about how much analysis helped them - does that tell us anything about how strong the evidence is for analysis?
8) Does anyone know a researcher developing treatments who only has 10 hours of therapy experience? Public health folks do some evaluations of it. Obviously some folks get to a point they no longer actively practice. My experience is that the vast majority on that side are actively practicing or at least have extensive practice experience.
9) Symptom relief shouldn't be the only outcome of interest. Agreed, I'm down. Do we have strong evidence that analysis improves other outcomes (functioning across a variety of settings, interpersonal relationships, etc.)? Nope. Actually, there is more for CBT.

Phew...5 minutes reading and 15 minutes typing. I'm a little harsh above, but don't take this to mean analysis doesn't work. I don't even take the stance that it shouldn't be used. I do think it makes way more sense to try a treatment that has been known to work first, before trying something that is 1) Less cost effective and 2) There is less evidence to suggest will be efficacious. "This is my therapeutic orientation" is never a good reason to do anything...whether that is CBT, psychoanalysis or anything else. Think more and think better.

 

[WisNeuro]

Dayummm, Ollie. *slow clap*

 

[CheetahGirl]

You've really seemed to mature as a clinician and scholar, Ollie. I'd give you that grant.

 

[Ollie123]

I'd give you that grant.

Thank you. Let's hope NIH agrees

 

[deleted343839]

+1 to everything Ollie said.

I've run out of patience for debates about the merits of CBT versus dynamic treatments. Even the premise is stupid - as though there is one CBT and one psychodynamic therapy.

There are several things that distinguish good practitioners of any orientation. They educate their patients about the therapy process and get the patient on board to do the work. They develop a coherent working formulation that informs their clinical hypotheses and how they intervene. They choose meaningful outcomes and re-assess the patient in some sort of valid and replicable way at intervals that make sense in the scope of the therapy. They strive to make good use of therapy time and to minimize things that are counterproductive (eg, letting the patient vent unchecked) or potentially harmful (eg, "recovering" memories). And they understand that therapy, even when executed well, doesn't help everyone, and they have a means of deciding if this is true for their patients and a plan for what to do in that case. Thinking about why you're doing what you're doing, maintaining reasonable doubt, and considering alternative hypotheses transcends orientation.

 

[PsyDr]

Eh, using that 1950s book that explained why psychoanalysis works from a behavioral standpoint, you can see the utility of some of psychoanalysis' techniques. FAP uses it. Skinner's verbal behavior book also provides a good framework for it. IMO, psychotherapists are simply using different reinforcement schedules and different words.

The most skilled behavioral therapist I ever met knowingly used different reinforcement schedules within conversations to guide people to what he wanted. Old as hell, and it was impressive. Especially watching him flirt.

 

[temppsych123]

I often wonder if we, as profession, overplay therapy a bit--in term of its effectiveness, in what it can help with, and who can benefit from it? Working at the VA, the predominant zeitgeist seems to be that if there is any mental health concern, then therapy should be offered...and in some cases required by some of the prescribing providers. This seems quite silly, as I actually don’t think that psychotherapy is universally beneficial. And for some problems/circumstances it seems like its actually quite a waste of time for both parties. People often wonder why VA MH is so overburdened, and I might suggest it’s because we have it open to all, for any problem, and the is no time limit on the services (people are in it way too long).

Thoughts??

In answer to the original question, yes. I think we are like lots of other professions - we see things through our lens and think what we do is awesome, not realizing that a) we can't help everyone and b) sometimes other professions' skills are more useful (e.g. medications for certain disorders, social work for certain types of problems, etc.). Do I think most people would, at some point in their lives, benefit from talking to someone who is empathetic and non-judgmental? Yes. Do I think all of those people need to work with a licensed psychologist to get that help? No. And we know from treatment outcome research that even our best/most effective treatments don't work for everyone. So I think from both ends of the spectrum (people with limited impairment who just "could use someone to talk to" and people with treatment-resistant pathology) we can definitely overstate our importance and/or usefulness.

SOURCE: six years of a clinical psych PhD program and my own experiences in many types of therapy (CBT, EFT, supportive) for treatment-resistant depression.