I think I deeply regret entering a Counseling Psychology Program

[Justanothergrad]

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A particularly salient quote I recall from Doing CBT was Tolin stating they would immediately invest in a leech farm if massive swaths of evidence suddenly suggested that bloodletting was the bees knees of mental health treatmentts. Ultimately that's what attracts me as a much newer trainee, while there are strong limitations in exact mechanisms of action ... CBT ultimately seems to be the most practical choice and the theory that is most rooted in empiricism as a central tenant. My anecdotal experiences with your average CBT practitioners I've ran accross has generally been that they would happily discontinue usage of CBT in their practice if something new came along with more promising, well-understood, and robustness in evidence. I can't say the same about practioners I've interacted with who strongly align with other theoretical orientations where it seems to be described as more of an emotional "click" so to speak.

The concepts are the same as other theories. And there is no relative efficacy support to suggest its better. How do you mean more empirically based?

 

[Justanothergrad]

I get where you're coming from, but I don't think that belies CBT's position as a first/front-line treatment. Sure, there are mechanistic limits to the research, but that is true for literally every idea in psychotherapy as well as many in psychiatric medications. Should we not issue clinical guidance until we have absolute mechanistic certainty? We have enough evidence from clinical experience, case studies, and RCTs to know that it works or can be modified for many physical and mental health problems to a degree that allows us to have probabilistic confidence in the treatment. Does it work for absolutely everyone? No, I don't even think David Tolin would claim that. My experience as a clinician is that CBT fails usually due to problems with patient feasibility (they don't want to do it due to misinformation, low motivation, etc), but I remain open to the idea that something sometime may surpass CBT as a front/first-line treatment with greater efficacy. I think the emphasis on EMAs using DSEM has been a really promising development in the psychopathology field as of late. One that I'm watching with interest.

ETA: Regarding legal stuff, I imagine that issuing guidelines actually protects clinicians given that it sets up a community standard from which they can practice.

Na, it doesnt protect clinicians. That has not been the issue of concern. I was in a meeting this week on tolin criteria and est use. The issues im raising are openly acknowledged in those.

 

[Sanman]

Salient to this conversation is my favorite new Pesi ad for a 15 credit course in Neuropsychotherapy.

"The “Secret Brain Techniques” Top Therapists Are Using to Successfully Treat Their Clients in Record Time!"

How does that fit into common factors? Efficacy of treatment? Effectiveness?

Real world treatments here.

 

[cara susanna]

15 CEUs? Might be worth the gobbledeegook, honestly

 

[Justanothergrad]

Salient to this conversation is my favorite new Pesi ad for a 15 credit course in Neuropsychotherapy.

"The “Secret Brain Techniques” Top Therapists Are Using to Successfully Treat Their Clients in Record Time!"

How does that fit into common factors? Efficacy of treatment? Effectiveness?

Real world treatments here.

send that evidence based link! Its time to learn science. The irony is that treatments like this are submitted as ests. I cant legally say more unfortunately.

 

[R. Matey]

Na, it doesnt protect clinicians. That has not been the issue of concern. I was in a meeting this week on tolin criteria and est use. The issues im raising are openly acknowledged in those.

I’m sure you’ll forgive me for being unmoved by these appeals to authority and secret knowledge. Many dumb things have been said and done in smoked filled back rooms, especially when psychologists are involved.

 

[Sanman]

send that evidence based link! Its time to learn science. The irony is that treatments like this are submitted as ests. I cant legally say more unfortunately.

Eye-Movement Intervention Enhances Extinction via Amygdala Deactivation

Here is a fun one involving neuropsychotherapy and EMDR. Though I think they do a more convincing job of suggesting folks just play Tetris while on propranolol.

 

[DoubtfulDoc]

So since we’re talking about Tolin, you see his new article? Just dropped…APA PsycNet. PDF is free.

 

[Justanothergrad]

So since we’re talking about Tolin, you see his new article? Just dropped…APA PsycNet. PDF is free.

Yeh i commented on it as a draft (went back and forth with david and others) for the d12 committeee in my role there. I expressed my concerns there to them and others, nothing new tho- just a push towards our field needing better standards and more meaningdul definitions. I continue to advocate for us to reconsider standards and move beyond 1980s research models. Its reasonable and doable. I dont find this article convincing of a good standard, personally for several reasons in there or not.

 

[Justanothergrad]

I’m sure you’ll forgive me for being unmoved by these appeals to authority and secret knowledge. Many dumb things have been said and done in smoked filled back rooms, especially when psychologists are involved.

Believe it or not. This vagueness is a liability issue and something im staying tight tipped about because of apa legal.

 

[R. Matey]

Believe it or not. This vagueness is a liability issue and something im staying tight tipped about because of apa legal.

I don't doubt it. I was only taking issue with your argument about the science of CBT being insufficient to guide clinical practice. If this claim is related to the legal issues you are raising, it seems unproductive to continue the debate in this format since all parties aren't privy to the same information.

 

[Justanothergrad]

I don't doubt it. I was only taking issue with your argument about the science of CBT being insufficient to guide clinical practice. If this claim is related to the legal issues you are raising, it seems unproductive to continue the debate in this format since all parties aren't privy to the same information.

Ah I see what you mean. Na, I thought you were referring to something else. And agreed on that point.

I dont know what the phrase "guide Clinical practice" means, but i see no evidence that CBT should be THE primary treatment. It seems fine, though, for sure. Its not cooky or stupid. Like dolphin therapy. It works well. Like dolphin therapy. It is psycholohically based (unlike dolphin therapy). So far the Tolin criteria and I are on the same page about evidence based treatments and defining how we define them. Again, its fine. Nothing special. Its fine tho. I like it sometimes. Not others.

In CBT, the processes it actives (or claims to active as we lack causal evidence and clear operational definitions for the processes) seem to produce the exact same effects as other processes (eg. I have yet to see sufficient relative efficacy validity studies to indicate why i would pick CBT or any other active-psychological process based therapy- rather theyre all basically equal). removing these specific ingridients doesnt seem to do much difference either (eg dismantling study literature), and its unclear if our definitions of success are really sufficient (eg i would argue that a target to treat of 8 is not a gold standard anything- even if its a step in the right direction in some ways or cases). An added set of issues is our limited ability to define or explain (1) normal and healthy mental health (2) standard recovery of conditions or (3) treatment engagement, for instance. This isnt an exhaustive list of basic questions we dont sufficiently understand, but that we need to for me to conclude CBT works better than other things. Again, which is probably why the effect sizes arent really any different. For instance, if I teach you to embrace your inner scholar archetype to help use your ego drive to active the mature defense mechanism of intellectualization, can you really prove to me that I did that or if I just created a cognitive schema in which I helped alter coping strategies by learning to more aptly use the intellectual side of the wise mind? Again, this example isnt alone to be analyzed. Rather it is just one such example of of how language and conceptual understanding is insufficient to parse apart theory. Marvin Goldfried has done some remarkable work in and related to this area and his models of psychotherapy integration.

 

[R. Matey]

I dont know what the phrase "guide Clinical practice" means, but i see no evidence that CBT should be THE primary treatment. It seems fine, though, for sure. Its not cooky or stupid. Like dolphin therapy. It works well. Like dolphin therapy. It is psycholohically based (unlike dolphin therapy). So far the Tolin criteria and I are on the same page about evidence based treatments and defining how we define them. Again, its fine. Nothing special. Its fine tho. I like it sometimes. Not others.

I'm going to guess you know what the words "guide" and "clinical practice" mean and you are also familiar with how verbs modify nouns. But for the record, guide means inform clinical practice. You don't reinvent the wheel with every patient. It turns out we have studies where approximately the same set of interventions work for a large group of people but individual differences necessitate that clinicians remain in control what will work best for their patients. I actually don't think we disagree on this point. By no means have I claimed that CBT works for all patients for all time. But I would claim that, on average, CBT will work better than dophin therapy (mainly due to the access issue, 🙂)

In CBT, the processes it actives (or claims to active as we lack causal evidence and clear operational definitions for the processes) seem to produce the exact same effects as other processes (eg. I have yet to see sufficient relative efficacy validity studies to indicate why i would pick CBT or any other active-psychological process based therapy- rather theyre all basically equal). removing these specific ingridients doesnt seem to do much difference either (eg dismantling study literature), and its unclear if our definitions of success are really sufficient (eg i would argue that a target to treat of 8 is not a gold standard anything- even if its a step in the right direction in some ways or cases).

Disagree here. First, not all CBT interventions are created equally. Second, dismantling studies have shown that some work better than others. Here is one dismantling study example for CBT for Panic Disorder, which supports interoceptive exposure and face to face settings are associated with the largest treatment gains. You can critique the study designs all you want, but the effect sizes are still quite large. Larger than supportive therapy. Larger than cognitive restructuring. Larger than PMR. This also matches my clinical experience treating panic disorder using CBT (some I regular did in primary care). Does this that these interventions will succeed with absolute certainty? Again no. Any good psychologist knows that statistics are probable and do not necessaily reflect reality for everyone. That's as true for common factors metas as it is true for RCTs for CBT protocols, as Culjipers has pointed out.

An added set of issues is our limited ability to define or explain (1) normal and healthy mental health (2) standard recovery of conditions or (3) treatment engagement, for instance. This isnt an exhaustive list of basic questions we dont sufficiently understand, but that we need to for me to conclude CBT works better than other things. Again, which is probably why the effect sizes arent really any different. For instance, if I teach you to embrace your inner scholar archetype to help use your ego drive to active the mature defense mechanism of intellectualization, can you really prove to me that I did that or if I just created a cognitive schema in which I helped alter coping strategies by learning to more aptly use the intellectual side of the wise mind? Again, this example isnt alone to be analyzed. Rather it is just one such example of of how language and conceptual understanding is insufficient to parse apart theory. Marvin Goldfried has done some remarkable work in and related to this area and his models of psychotherapy integration.

You raise some interesting philisophical issues with which I don't entirely disagree. For instance, the Big-5 model has been criticized on similar grounds (i.e., the use of psychometrics to establish a model of personality is wholly reliant on language). I'm more of a Popper person than a Wittgenstein person so I would argue that CBT does have language that at least reflects a model of health. When treating depression, for instance, adaptive, flexible core beliefs that do not conform to Beck's negative cognitive traid are more likely to be associated with psychological health (there is a good deal of mechanistic literature on psychological flexibility, IIRC). This is why Socratic questioning becomes important because it reduces the amount of certainty in thoughts that are associated with the negative affective state. I personally think of it as graded exposure to alternate points of view regarding one's own mental health (why the intervention needs to be skillfully done and also why it fails so often in the hands of the unskilled), but I admit that I can't prove that with mechanistic certainty. Is that different that "taming a harsh superego" or "living in your wise mind?" Hard to say, but recognize that we're only talking here about cognitive restructuring rather than the behavioral components of some protocols, which are more effective than restructuring alone (e.g., ERP).

I would be interested in reading more about Goldfried's work. If you have a good starter article, I'll take a look.

 

[Justanothergrad]

I'm going to guess you know what the words "guide" and "clinical practice" mean and you are also familiar with how verbs modify nouns. But for the record, guide means inform clinical practice. You don't reinvent the wheel with every patient. It turns out we have studies where approximately the same set of interventions work for a large group of people but individual differences necessitate that clinicians remain in control what will work best for their patients. I actually don't think we disagree on this point. By no means have I claimed that CBT works for all patients for all time. But I would claim that, on average, CBT will work better than dophin therapy (mainly due to the access issue, 🙂)

Being better than dolphin therapy makes a poor comparison. Systematically, CBT must be better than other active, psychological therapies. Otherwise, why would I pick that thing over the other? I don't see a rationale to pick CBT because it's better than getting stung by bees, for instance. Nor a reason that CBT should be picked over not going to therapy, or doing therapy but without any active components. Thats a good proof of concept, but it doesn't shore up why CBT should be relied on, or answer any questions about 'what is it' and 'when is it enough'. Thus, the wording I indicated I was unclear about remains unclear.

While the good humor sounds logical and clear, it is not. The issue is one of replicability and clinical efficacy, and becomes a question of not just EST v EBP but also one of efficacy versus effectiveness. When you tell me to use CBT to "guide clinical practice", I do not know what that means. Do you mean (1) the inclusion of homework as a basis of exposure based learning? (2) a particular and correct balance of cognitive OR behavioral component, which operate on different supposed pathways, (3) specific content which I must include (e.g., could it be exposure discussion, exposure hierarchies, or exposure principles- are all three 'equally CBT')? How much does it matter if I choose CBT version 1 or CBT version 2 to reduce symptoms largely enough related nomologically, even if they aren't the same (e.g., anxiety/depression/ptd symptom decline patterns in treatment for any of the three). It sounds good, but its not clear because its not specific. The reason it's not specific is that CBT means so many different things, and all of them are correct. In using phrases like 'the clinician stayins in control' you are implying a more EBP approach, but one which relies more widely on adoption. In return, such EBP practices focus on effectiveness research, which assumes that there is variability and that manuals won't be followed (versus efficacy, which is in lab-based ideal conditions; like an RCT). The balance and nature of worksheets, the specific phrases (e.g., which distortion lists are used), etc don't seem to matter as much, and good thing since clinicians have no set order to the ones they select based on folks I use. They were given to them from local or regional or specialty-based treatment source (e.g., division, organization, etc), they made it, it was online for free, their friend made it, or they work in a setting where they are given a list (VA, DOD, etc). All of these factors make it unclear to me what you mean, in concrete and practical terms, that people should use CBT to guide their practice.

Also, I agree a lack of opportunity for dolphins is likely the largest issue at play in this thread.

Disagree here. First, not all CBT interventions are created equally. Second, dismantling studies have shown that some work better than others. Here is one dismantling study example for CBT for Panic Disorder, which supports interoceptive exposure and face to face settings are associated with the largest treatment gains. You can critique the study designs all you want, but the effect sizes are still quite large. Larger than supportive therapy. Larger than cognitive restructuring. Larger than PMR. This also matches my clinical experience treating panic disorder using CBT (some I regular did in primary care). Does this that these interventions will succeed with absolute certainty? Again no. Any good psychologist knows that statistics are probable and do not necessaily reflect reality for everyone. That's as true for common factors metas as it is true for RCTs for CBT protocols, as Culjipers has pointed out.

Versions of treatments for the same thing (e.g., WET, CPT, PE for PTSD etc etc) are generally the same in their outcomes and "non-inferior" to one another, with specific ingredients really only mattering with respect to avoidance/exposure based interventions, as described in a variety of meta analyses (Bruce Wampolds work, Pim's work, etc). If you pick a random treatment based on a random psychological disorder in a random population, the treatment will probably be about .68 to 1.3 effect size, with differences reflecting methods/measures/sample sizes/etc more than anything else. This finding and its unwavering stability is as old as meta-analysis, almost 50 years. We can agree that other general effects are also common. For instance, in vivo exposure is better than imagined, etc. But thats not untrue of other theories. The point I made about my defense mechanism of intellectualization here stands. As a dynamic therapist, I will absolutely tell my clients to directly confront and talk through their feelings with someone. We will do role plays. We will talk about how to express our needs, drives, and fears, and how to remain in control of our egos while facing our cultural father figure seen in the role of our employer.... Is that exposure? Is it in vivo? Is this CBT....? Why not? Is it because I said dynamic? or drive? Or is what I am actually doing (encouraging engagement/exposure via in vivo and imaginal activaties, likely with psychoeducation about emotional states and identification of distorted thinking [cognitive fragmentation, for instance]) going to work anyway? What if I told you I'm not dynamic but actually CBT, but I like those words and terms because they resonate with clients? What if a dynamic therapist reads what I wrote, and says thats who they do it? Is it still CBT? Is ACT CBT since it assumes different things about symptom control? If thats CBT, what is not?

As to the phobia specific point, some portions of explained variances change by treatment and condition and setting - that's not surprising - effect sizes vary by setting, population, etc as well. That said, the relative portions remain highly weighted towards share method variance across conditions. I haven't read the phobia specific work you're citing, but it's the same reason, to my eye, that behavioral interventions for anxiety/phobia were those most heavily weighted towards larger effects in older meta-anlaysees (e.g., Smith & Glass; etc). Largely, that behavioral intervention (exposure) were those most likely to show incremental gains relatively. That said, a majority of the literature does not support this case. It also means that its hard to define what CBT is (to my point above). Is it CBT if I only do BT? What about only CT? What about ACT? What, again, about my intellectualization example? or my boss issue?

Marv has a ton of great work. He was kind enough to speak to the students in my program a few years ago about change processes and his career work. I can't say enough kind things about him. His 2019 paper is probably my favorite, but he's been doing this work for decades. he's a big part of what made SUNY such a powerhouse for treatment outcome research for so many years
Goldfried, M. R. (2019). Obtaining consensus in psychotherapy: What holds us back?. American Psychologist, 74(4), 484.

Busy for the last point. I'll finish later.



I will add, as it is relevant to this thread, I expect all first year counseling psychology doctoral students I train to be able to have this exact same debate, at this same level as they learn about theories. It's a heavy reading load; and it helps form an extremely strong theory understanding.

 

[R. Matey]

The issue is one of replicability and clinical efficacy, and becomes a question of not just EST v EBP but also one of efficacy versus effectiveness. When you tell me to use CBT to "guide clinical practice", I do not know what that means. Do you mean (1) the inclusion of homework as a basis of exposure based learning? (2) a particular and correct balance of cognitive OR behavioral component, which operate on different supposed pathways, (3) specific content which I must include (e.g., could it be exposure discussion, exposure hierarchies, or exposure principles- are all three 'equally CBT')? How much does it matter if I choose CBT version 1 or CBT version 2 to reduce symptoms largely enough related nomologically, even if they aren't the same (e.g., anxiety/depression/ptd symptom decline patterns in treatment for any of the three). It sounds good, but its not clear because its not specific. The reason it's not specific is that CBT means so many different things, and all of them are correct. In using phrases like 'the clinician stayins in control' you are implying a more EBP approach, but one which relies more widely on adoption. In return, such EBP practices focus on effectiveness research, which assumes that there is variability and that manuals won't be followed (versus efficacy, which is in lab-based ideal conditions; like an RCT). The balance and nature of worksheets, the specific phrases (e.g., which distortion lists are used), etc don't seem to matter as much, and good thing since clinicians have no set order to the ones they select based on folks I use. They were given to them from local or regional or specialty-based treatment source (e.g., division, organization, etc), they made it, it was online for free, their friend made it, or they work in a setting where they are given a list (VA, DOD, etc). All of these factors make it unclear to me what you mean, in concrete and practical terms, that people should use CBT to guide their practice.

I'm not going to go down the rabbit hole dithering over definitions of "clarity", and "specificity. " I think those goalposts might be located somewhere in the capital city of Planet Tralmafadore. For our purposes here, variability in how interventions are administered based on individual differences does not discount that, on average, patients benefit from structured cognitive behavioral interventions. Cognitive-behavioral means interventions based on cognitive behavioral principles (exposure, cognitive restructuring, and behavior activation) derived from scientific principles of reinforcement learning, information processing, and social cognition. We don't have entire mechanistic certainty in CBT, but these mechanisms are far more studied than many other ideas in psychotherapy. Interventions based on these principles sometimes manualized, sometimes not, depending on what patients tolerate/need. Arguments about variability in EST vs. EBP and Efficacy vs. Effectiveness strike me as academic handwaving only because CBT has shown to be more effective or at least not inferior to other treatments when studied or administered under these conditions. Largely unique (but not completely) to CBT is also its effectiveness for treating or ameliorating number of health conditions (e.g., chronic pain, insomnia, hypertension, headaches, tinnitus), something common factors people often seem to forget.

As a clinician, my social responsibility to patients is to bring them the best that psychological science has to offer, individualized to their personal needs. Because the current weight of evidence support cognitive behavioral therapy done with respect to patient autonomy and individual differences, that is what I will do. But I did pursue training in other forms of psychotherapy because I also recognize that this paradigm will not work for every person.

If you pick a random treatment based on a random psychological disorder in a random population, the treatment will probably be about .68 to 1.3 effect size, with differences reflecting methods/measures/sample sizes/etc more than anything else. This finding and its unwavering stability is as old as meta-analysis, almost 50 years.

This is true, but are methods for meta-analytic studies are also improving. Concerns about measurement error can now be explicitly modeled in more advanced frameworks (under Bayesian assumptions for instance). In the meantime, GRADE and other such tools are available for studies to be rated on their quality. Network meta-analyses allow for more comparators than fixed-effect or random-effect models. Advanced modeling still continues to support CBT, but as Cuijpers pointed out in his 2024 article in AP, there needs to be more intervention work in other theories.

thats not untrue of other theories. The point I made about my defense mechanism of intellectualization here stands. As a dynamic therapist, I will absolutely tell my clients to directly confront and talk through their feelings with someone. We will do role plays. We will talk about how to express our needs, drives, and fears, and how to remain in control of our egos while facing our cultural father figure seen in the role of our employer.... Is that exposure? Is it in vivo? Is this CBT....? Why not? Is it because I said dynamic? or drive? Or is what I am actually doing (encouraging engagement/exposure via in vivo and imaginal activaties, likely with psychoeducation about emotional states and identification of distorted thinking [cognitive fragmentation, for instance]) going to work anyway? What if I told you I'm not dynamic but actually CBT, but I like those words and terms because they resonate with clients? What if a dynamic therapist reads what I wrote, and says thats who they do it? Is it still CBT? Is ACT CBT since it assumes different things about symptom control? If thats CBT, what is not?

Yeah so as I said, I'm really not much for language games and jingle/jangle fallacies are a problem for many psychological theories, not just in psychotherapy. As a postpositivist, my tendency is formulate and share a case formulation with a patient that is based on scientific principles that CBT rests on. I share this formulation with the patient and then we begin testing hypotheses based on the shared formulation. The patient is active in this process. The case formulations are based on theoretical models formulated by cognitive behavioral theorists, carefully adapted by me to fit the patient's personal experience. When I do interpersonal psychotherapy with a person, I use the interpersonal case conceptualization, which includes challenging beliefs about relationships. Does that mean, for instance, that interpersonal therapy shares common characteristics with CBT? It probably does. But the point is that the theoretical mechanisms (i.e., a drive towards social connectedness vs. a negative cognitive triad) differ enough in their overall goals to warrant separate approaches. This difference is likely a point of emphasis. Those are admittedly blurry boundaries so there's nothing inherently wrong for searching for common ground among psychotherapeutic approaches, but it does seem to me that many effective approaches to therapy contain elements of CBT (as defined above), even if they are claiming otherwise.

As to the phobia specific point, some portions of explained variances change by treatment and condition and setting - that's not surprising - effect sizes vary by setting, population, etc as well. That said, the relative portions remain highly weighted towards share method variance across conditions. I haven't read the phobia specific work you're citing, but it's the same reason, to my eye, that behavioral interventions for anxiety/phobia were those most heavily weighted towards larger effects in older meta-anlaysees (e.g., Smith & Glass; etc). Largely, that behavioral intervention (exposure) were those most likely to show incremental gains relatively. That said, a majority of the literature does not support this case. It also means that its hard to define what CBT is (to my point above). Is it CBT if I only do BT? What about only CT? What about ACT? What, again, about my intellectualization example? or my boss issue?

The meta I linked was for panic disorder, not specific phobia. The majority of the literature in panic disorder does support exposure. I'm happy to provide other sources.

Marv has a ton of great work. He was kind enough to speak to the students in my program a few years ago about change processes and his career work. I can't say enough kind things about him. His 2019 paper is probably my favorite, but he's been doing this work for decades. he's a big part of what made SUNY such a powerhouse for treatment outcome research for so many years
Goldfried, M. R. (2019). Obtaining consensus in psychotherapy: What holds us back?. American Psychologist, 74(4), 484.

Thanks, I will take a look at it in earnest. I strive against dogmatism and am happy to be challenged in my thinking. I appreciate this discussion because you're steelmanning the common factors approach, which doesn't get a lot of traction on SDN typically. As I've said, the smarter common factors arguments tend to be about variance and research design. We get a lot of the dumb ones on here so seeing the more difficult-to-challenge arguments is refreshing.

 

[Justanothergrad]

I think this is a bit of where the argument becomes a dead end then, unfortunately. A key and critical factor of my argument is the jangle fallacy, in fact, exists and is one of the largest flaws and limitations in productive psychotherapy research. The terms used across theories can easily be mapped across constructs, allowing transformative interpretation of process without falsifiable theory - just promise of it. Take for instance if we design a study as I mentioned before two treatments (Psychodynamic ego drive versus CBT). Outside of terms easily replicable in a mad-lips style journey, the treatment themselves are likely to not truly differetiate on specific factors. And if the quality of the specific factor ingredients themselves are also not up for evaluation, I remain unsure what the argument for CBT is, except that you prefer it as 1) it largely remains equal to other therapies, with favor of BT towards fear-based processes and arousal systems (phobia and panic) and more disorganized processes. That said, arguing CBT is the best also begs the question of 'at what' and 'for what purpose is therapy', again, the nuance question but one equally as important as defining what is "cbt" and what is required for it to be CBT. At an easy level, is ACT part of CBT here for your argument, despite different assumptions of control of emotion- for instance. There are various CBT wave differences in assumption that are key to answering before defining CBT, and then 'levels' of CBT are critical. I understand not wanting to get into that murkiness. I don't really want to try and solve a good way to think of it for myself either online lol, but I do think those issues are critical to understanding objections to CBT as a dominant force. A useful one? Sure. Better? Haven't seen the evidence.

You keep pointing to the 'scientific basis' of CBT, but I'm unsure what that basis is and how it is different from any other therapy based on psychological processes, regardless of if they conform to theories with given assumptions. The reality of data in the real world suggests that clinicians are not monolithic in their incorporation of theory, and the research base is largely equitable with caveat strengths of each in different cases. Selecting CBT as 'the answer' does harm by restricting innovation to what seems largely regurgitated theories, likely due to that they are.

Enjoy Marv! I'd be curious your thoughts after you finish. I believe his language will pick up on the points above about jangle fallacies and where the real issue with them lies. The methods are a major issue for sure. I'd argue that language is probably a larger one, thus my sematic focus. I'll be curious to see if Marv changes your mind ;p

And cheers for the compliment - I was trained by the folks who wrote the D17 guidelines and did some treatment research with one that helped shape my thinking. I'm enjoying the back and forth; its always fun to chat ideas and consider the arguments. That we are arguing is an argument of sorts itself too, or perhaps its my whiskey. I'll have to take a peep at the studies you mentioned. I've got my hypothesis so I'll be curious if it unfolds as I expect.

 

[smalltownpsych]

Great discussion and I appreciate the reference to the jangle fallacy. I have long been aware of this problem in our field but had not heard the term before. In my doctoral program we spent a lot of time trying to parse out difference between CBT and psychodynamic theories with people falling in different camps. In my mind it was often just shades of meaning and perception. Internalized object relations as opposed to schemas or even just interpersonal patterns. I tend to be more psychodynamic in my core conceptualizations and general stance, but recent supervision of a more psychoanalytic postdoc has made me realize how much I rely on behavioral principles and understanding of neurobiological processes. Also, just helping people improve their communication and regulating/expressing emotions might be a bigger effect than a lot of other stuff we do. How we do that might vary a bit based on orientation or style, but if we aren’t helping with these things, then patients probably won’t get much better. One more thing, chasing insights or aha moments is rarely useful regardless of orientation. It happens on tv a lot and occasionally in treatment and is occasionally useful, but the less trained and often the public think that is the goal and this belief gets in the way.

 

[Shiori]

I appreciate reading the back in forth in these threads after getting a consult for someone who has diagnosed with MDD, GAD, PTSD, Autism, and ADHD after one or two meetings with psychiatry. Or getting tagged in a note with the recommendation to do EFT tapping. It gives me hope.

 

[Justanothergrad]

EFT tapping

Fml.

 

[Shiori]

Fml.

Yeah, I had to look it up. I did not follow the recommendation.

 

[The Cinnabon]

I appreciate reading the back in forth in these threads after getting a consult for someone who has diagnosed with MDD, GAD, PTSD, Autism, and ADHD after one or two meetings with psychiatry. Or getting tagged in a note with the recommendation to do EFT tapping. It gives me hope.

I've honestly gotten more readings and insight into clinical practice from SDN then I would care to think about

Not that I'm not getting good supervision or am doing my own due diligence ... but it's still more than I'd care to admit.

 

[R. Matey]

Yeah, I had to look it up. I did not follow the recommendation.

Every psychiatrist I worked with on fellowship recommended EMDR for trauma treatment. 0% of them had heard of prolonged exposure.

 

[DoubtfulDoc]

Every psychiatrist I worked with on fellowship recommended EMDR for trauma treatment. 0% of them had heard of prolonged exposure.

Yikes

 

[cara susanna]

I give a PTSD seminar series to our psychiatry residents and am VERY explicit about the research on EMDR, so I'm trying to be the change I want to see in the world.

 

[Shiori]

I give a PTSD seminar series to our psychiatry residents and am VERY explicit about the research on EMDR, so I'm trying to be the change I want to see in the world.

Can you tell them to stop using "cluster b traits" in their coding?

 

[cara susanna]

Can you tell them to stop using "cluster b traits" in their coding?

Oh man, that's a pet peeve of mine too.

 

[Sanman]

Can you tell them to stop using "cluster b traits" in their coding?

I actually appreciate that. Code for "pain in the ass".

 

[Shiori]

I actually appreciate that. Code for "pain in the ass".

I don't mind it as much from seasoned clinicians. I very rarely find it helpful from residents. I would rather they focus on not sending me clients with untreated mania or psychosis.

 

[Sanman]

I don't mind it as much from seasoned clinicians. I very rarely find it helpful from residents. I would rather they focus on not sending me clients with untreated mania or psychosis.

I understand that. I mostly find it useful from long term providers during a deep dive into the chart. Ah, this guy was difficult to deal with 20 years ago, this is a personailty issue not mood or age.

 

[cara susanna]

I don't mind it as much from seasoned clinicians. I very rarely find it helpful from residents. I would rather they focus on not sending me clients with untreated mania or psychosis.

I understand that. I mostly find it useful from long term providers during a deep dive into the chart. Ah, this guy was difficult to deal with 20 years ago, this is a personailty issue not mood or age.

Here's my hot take: if you're gonna document that a pt has personality traits to a degree that is clinically significant, you should at least specify which one. "Cluster B" is a copout.

Or, if you really must, then use "Other specified."

 

[Sanman]

Here's my hot take: if you're gonna document that a pt has personality traits to a degree that is clinically significant, you should at least specify which one. "Cluster B" is a copout.

Or, if you really must, then use "Other specified."

The problem with being more explicit in this disability system that is also a hospital system is that you then have patients harassing you to change your session notes.

 

[bcliff]

Is that exposure? Is it in vivo? Is this CBT....? Why not? Is it because I said dynamic? or drive? Or is what I am actually doing (encouraging engagement/exposure via in vivo and imaginal activaties, likely with psychoeducation about emotional states and identification of distorted thinking [cognitive fragmentation, for instance]) going to work anyway? What if I told you I'm not dynamic but actually CBT, but I like those words and terms because they resonate with clients? What if a dynamic therapist reads what I wrote, and says thats who they do it? Is it still CBT? Is ACT CBT since it assumes different things about symptom control? If thats CBT, what is not?

This back-and-forth has been a great read.

Not to belabor the point, but as a behaviorist and pragmatist, my focus is on the function of an intervention rather than its label or appearance. I was not familiar with these jingle-jangle fallacies before this thread (what great names) and wonder if part of that is because of how behaviorist my training has been slanted (i.e., behaviorists don't really like to label psychological processes).

I don't want to get overly specific, but I generally provide very little psychotherapy right now. However, I have a strong background in evidence-based psychotherapy and incorporate ACT into what clinical work I am doing these days.

I specifically like ACT because of its strong connection with basic behavioral science and transdiagnostic principles of behavior change. I often tongue-in-cheek refer to ACT as "graded-exposure-and-values-based-behavioral-activation therapy" when training externs, interns, and fellows, emphasizing what active ingredients I find most salient. Jacobson's CBT for depression dismantling study from the early 1990s is often mentioned in this context, too. I'm not specifically familiar with the CBT for panic literature @R. Matey referenced, but I do know that Hayes completed his postdoctoral training with Barlow, and the acceptance (i.e., graded exposure) pieces of ACT have always struck me as quite similar to the interoceptive exposure components of CBT for panic (just with cognitive-emotional rather than sensory-physical interoceptive cues). The mindfulness-based foundation of ACT, to me, is strategic attention with emphasis on viewing one's own behavior in context; self-monitoring is therefore my primary intervention on this side of the ACT hexaflex.

I agree with @R. Matey's points throughout this thread on the importance of a theory of behavior change, which I doubt you disagree with, JAG--I'm a major proponent of Lewin's point that "there's nothing more practical than a good theory," which seems worth mentioning here.

 

[Justanothergrad]

As you all may have seen, the country is on fire including my univ. Apologies for not getting back to this. Love the posts though! And yes, love the chat.

 

[R. Matey]

The door swings both ways for jingle-jangle fallacies. In the psychotherapy example, jingle fallacies would claim that two things are the same even when they are not. For instance, the process of psychodynamic intervention usually assumes a model of developmental arrest in the way that behavioral therapy does not. So overcoming your fear of panic attacks via an in-vivo or interoceptive exposure hierarchy would be materially different than, say, exploring the dynamic meaning of fear. It would be a jingle fallacy to claim that these two activities are the same because they both produce therapeutic benefit because you could not rule out that they do so via alternate means and one method maybe more effective than another for certain people (i.e., Hayes and Hofman's more recent writings on 'process-based psychotherapy'). Personally, I struggle to see the difference between most dynamic intervention and what I would call inefficient cognitive restructuring, but I admit that as a personal bias.

the acceptance (i.e., graded exposure) pieces of ACT have always struck me as quite similar to the interoceptive exposure components of CBT for panic (just with cognitive-emotional rather than sensory-physical interoceptive cues).

Maybe a topic for another thread, but I've struggled with concept of cognitive defusion as distinct from cognitive restructuring because it seems to me that categorizing automatic negative thoughts is an admission to their uncertainty, which I perceive to be the function of cognitive defusion. In other words, how in the world is labeling a thought as "emotional reasoning" really any different than defusing a thought "detaching from a thought" or "seeing a thought rather than experiencing a thought"?

 

[bcliff]

I've struggled with concept of cognitive defusion as distinct from cognitive restructuring because it seems to me that categorizing automatic negative thoughts is an admission to their uncertainty

I agree with this point and actually lean into it. What a better way to learn that thoughts "are just thoughts" (defusion) than learning that your thoughts are malleable and aren't objective indicators of truth or reality (restructuring)? I frequently had this conversation with an internship supervisor training me in CBT for chronic pain, who would good heartedly pick on me for being too ACT-focused.

When teaching, I describe traditional cognitive restructuring as changing the content of one's thoughts and defusion as changing the relationship one has with them. It therefore makes sense that changing one may lead to changes in the other. This emphasizes my focus on the impact or function of an intervention, rather than its label or descriptive qualities.

I find defusion a much more flexible framework than traditional restructuring, though--for example, when a patient with a spinal cord injury tells me that they're never going to walk again, it would obviously be inappropriate for me to label that thought as "distorted" and in need of being changed or modified.

Defusion offers a much more flexible means by which the impact of that thought can be explored and addressed. What does it mean that you're never going to walk again? Where do we go from here? How do we live a meaningful life with the knowledge that that thought may be entirely accurate? We come into incredibly close contact with the thought (acceptance, graded exposure), as a means of changing the relationship the individual has with it, which is a very different approach than traditional restructuring.

Beyond physical disability, as a neuropsychologist, I find the hexaflex (defusion, in particular) incredibly useful when delivering patient feedback. It lets me provide more rehabilitation-oriented, therapeutic neuropsychological evaluation services focused on maximizing engagement in meaningful and enjoyable activities in the context of major uncertainty and potential distress (e.g., related to a newly diagnosed neurodegenerative disorder). There's an emerging literature on this front.

 

[cara susanna]

When teaching, I describe traditional cognitive restructuring as changing the content of one's thoughts and defusion as changing the relationship one has with them. It therefore makes sense that changing one may lead to changes in the other. This emphasizes my focus on the impact or function of an intervention, rather than its label or descriptive qualities.

Yes, I've heard that described numerous times as one of the major differences between traditional and third wave CBT.

 

[R. Matey]

I find defusion a much more flexible framework than traditional restructuring, though--for example, when a patient with a spinal cord injury tells me that they're never going to walk again, it would obviously be inappropriate for me to label that thought as "distorted" and in need of being changed or modified.

Thanks for the dialogue. I'm likely way too much into late 20th century rationalist cognitive therapy for my own good, but is this example strikes me as one of rhetoric vs. a meaningful difference in the psychological process. I probably wouldn't use the moment when a patient is dysregulated and expressing utter hopelessness as an opportunity to label an automatic negative thought even if it occurred to me that the thought was distorted (assuming a good prognosis about the health condition in this example). But by suggesting that this thought (an expression of hopelessness based on a forecasted future outcome) is a target for intervention, does it really deeply matter if we say, for instance, "put that thought on a spaceship and send it to the sun" or "what else could be true about your future?" Both seem to cast uncertainty to me and likely reflect a stylistic difference more than anything else. As you may have guessed, I have a habit of asking really annoying questions, which makes a pretty decent cognitive therapist 🙂

 

[bcliff]

Thanks for the dialogue. I'm likely way too much into late 20th century rationalist cognitive therapy for my own good, but is this example strikes me as one of rhetoric vs. a meaningful difference in the psychological process. I probably wouldn't use the moment when a patient is dysregulated and expressing utter hopelessness as an opportunity to label an automatic negative thought even if it occurred to me that the thought was distorted (assuming a good prognosis about the health condition in this example). But by suggesting that this thought (an expression of hopelessness based on a forecasted future outcome) is a target for intervention, does it really deeply matter if we say, for instance, "put that thought on a spaceship and send it to the sun" or "what else could be true about your future?" Both seem to cast uncertainty to me and likely reflect a stylistic difference more than anything else. As you may have guessed, I have a habit of asking really annoying questions, which makes a pretty decent cognitive therapist 🙂

As a pragmatist, if it works, then who am I to judge? 🙂