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Does Therapy Really Work? Let’s Unpack That. (Published 2023)
Research shows that counseling delivers great benefits to many people. But it’s hard to say exactly what that means for you.
Of course not.![]()
Does Therapy Really Work? Let’s Unpack That. (Published 2023)
Research shows that counseling delivers great benefits to many people. But it’s hard to say exactly what that means for you.www.nytimes.com
I think many of the principles are sound and evidence-based. As a full-time practitioner, I'd say that the task of actually getting patients to implement those principles of behavior change is a task that is often enormously difficult and which administrators or the public greatly underestimate in terms of complexity.I just skimmed (study section & promotion paperwork due next week), but am I right that the TLDR version just seems to be "It works some, but a lot of people still don't get better"? If so, that seems so obvious as to not be worth saying. Its true of many areas of healthcare. I work in a cancer hospital - believe me a lot of cancer patients still die even though we have effective treatments for many.
I do agree we rest on our laurels a bit too much. Mental health treatment is largely stagnating (both therapy and psychopharm). There are a small handful of conditions we can treat extremely effectively with psychotherapy in the modest subset of people who will fully engage and tolerate the treatment. Pharmacological approaches are moderately effective for managing SPMI, but generally not to a degree where folks can function normally. We aren't exactly doing fabulous and I'm baffled when we pretend otherwise. We can both encourage uptake of available treatments AND acknowledge we desperately need better treatments. Oncology is actually a good model in my eyes - I doubt you can find a single oncologist who thinks we're downright fabulous at treating cancer as a whole. Certain cases/types for certain people when diagnosed correctly early on....sure. As a field, we seem to be driven by insecurity and afraid admitting the limitations of therapy will get us kicked out of healthcare or something. Personally, I think it makes us look less like professionals. Suffering is just less visible than death, so we have an easier time getting away with it.
Pharmaceutical companies ever advertise in the NY Times?I would imagine that oncology has a much lower no show rate than we do, lol
I also thought it was funny that the article praised meds so much when, really, the research for that isn't so great.
Pharmaceutical companies ever advertise in the NY Times?
I'm sure that wouldn't impact any editorial decisions.
At all.
Ever.
/"conspiracy theory".
/ooga booga
Humans never conspire. They have no selfish motives or fallibility.
I've always considered the lack of dependence on extensive, expensive, or complex technology a superpower. All I need is a pen and few sheets of paper--if that--to implement my professional course of treatment. Or dispense with that entirely and just use my words/speech.Still, oncologists can offer fancy big radiation machines and chemo suites whereas we, well, have a pen and notepad. Never mind the research, to a layperson's eye, the oncologists definitely seem to know what they are doing more than we do. Placebo effect is a powerful thing.
I actually believe evidence-based therapy can work very well for most people, if the client is ready and motivated to do the work. The tricky part is to help them get there.
the TLDR version just seems to be "It works some, but a lot of people still don't get better"? If so, that seems so obvious as to not be worth saying.
That was my take-away, and largely agree that the statement is so bland that it's almost meaningless. There are loads of variables that affect treatment outcomes; if just pure sx reduction is what we should be measuring anyways. All-in-all, it read like a reader's digest version of the great psychotherapy debate, which is hardly interesting to me at least, as a professional psychologist.
Lol, I use the same analogy. I also extend it to practice and maintenance of techniques learned.Haven't had the chance to read the article but one thought I had is that while there has been some awesome reductions in stigma about seeking therapy/MH services in general, a next step would be qualifying what therapy is, what it isn't, and how people actually benefit from it.
I tell my new VA patients to think of psychotherapy like physical therapy (which many have done) in that even if you show up to every appointment but never apply any of these new things we discuss on your own time, you won't get better.
Or if you do, it was largely by chance or because of good things that you're already 100% capable of doing so our meetings would be mostly pointless/redundant without that level of participation.
Haven't had the chance to read the article but one thought I had is that while there has been some awesome reductions in stigma about seeking therapy/MH services in general, a next step would be qualifying what therapy is, what it isn't, and how people actually benefit from it.
I tell my new VA patients to think of psychotherapy like physical therapy (which many have done) in that even if you show up to every appointment but never apply any of these new things we discuss on your own time, you won't get better.
Or if you do, it was largely by chance or because of good things that you're already 100% capable of doing so our meetings would be mostly pointless/redundant without that level of participation.
Lol, when some people in the comments pointed that out they got some negative reactions like "so you're saying I'm not getting better because I'm not trying hard enough?" Shows the battle we're up against, imo.
Well said. I've done and currently do work in health care settings with older adults. So I work around a lot of medical doctors, PT, OT, nurses, oncology, etc. I sometimes go in a room and introduce myself, I have to chuckle when occasionally a patient goes "oh so you're not a real doctor then..." There's a lot of misconceptions about mental health therapists and psychologists, you sometimes get the "well can't you just give me a pill to fix this?"Haven't had the chance to read the article but one thought I had is that while there has been some awesome reductions in stigma about seeking therapy/MH services in general, a next step would be qualifying what therapy is, what it isn't, and how people actually benefit from it.
I tell my new VA patients to think of psychotherapy like physical therapy (which many have done) in that even if you show up to every appointment but never apply any of these new things we discuss on your own time, you won't get better.
Or if you do, it was largely by chance or because of good things that you're already 100% capable of doing so our meetings would be mostly pointless/redundant without that level of participation.
C.B.T. does contain a theory of change—and it’s not entirely convincing. If people could change just because rational thinking told them to, we wouldn’t live in such a crazy world. Yet the rationality of C.B.T. is aspirational. We can wish that we were the kinds of people who could solve our biggest problems simply by seeing them more clearly. Sometimes, by acting as though we are those people, we can become them.
Another New Yorker piece on CBT, which I thought was fairly balanced (though the mindfulness person with the fancy title they interviewed is clearly strawmaning):
Can Cognitive Behavioral Therapy Change Our Minds?
One quote I thought was interesting:
This is probably speaking more to the cognitive elements since the author spends a lot of time on Burns and J. Beck (even interviews her), less so on the behavioral side, which I think would support the idea that we can be rational about our irrationality by knowing what we need moment to moment. Be it by temperament, psychopathology, or personality, it can sometimes be hard to be rational in every moment of every day and I don't think CBT mandates that we are. That said, I do agree that it goals of CBT are inherently aspirational given that it requires people to refute and invalidate what otherwise might be 'natural' or 'automatic.'
Another New Yorker piece on CBT, which I thought was fairly balanced (though the mindfulness person with the fancy title they interviewed is clearly strawmaning):
Can Cognitive Behavioral Therapy Change Our Minds?
One quote I thought was interesting:
This is probably speaking more to the cognitive elements since the author spends a lot of time on Burns and J. Beck (even interviews her), less so on the behavioral side, which I think would support the idea that we can be rational about our irrationality by knowing what we need moment to moment. Be it by temperament, psychopathology, or personality, it can sometimes be hard to be rational in every moment of every day and I don't think CBT mandates that we are. That said, I do agree that it goals of CBT are inherently aspirational given that it requires people to refute and invalidate what otherwise might be 'natural' or 'automatic.'
I don't believe that the tenets of CBT invalidate automatic thoughts at all. CBT expressly acknowledges that automatic thoughts and intermediate beliefs are normal things that everyone has. It's just that many of those beliefs are not anchored in reality and most of the time those thoughts just come and go, and we do not dwell or ruminate on them. That's not how I would define invalidation. If CBT merely said" those thoughts are wrong and you should not be having them," that;d be invalidating. But, anyone doing CBT that way was either improperly trained or just plain incompetent.
Not really sure where the disagreement is. Automatic thoughts are normal and common, Yes, but by definition some are more harmful than others. These are 'invalidated' in the sense they are pointing out alternative explanations that are more grounded in reality. You may not like the word, but that is what's happening.
I suspect it's more of a semantic issue. Invalidating when used in a therapuetic context vs. technical definitions in other contexts. Generally, in therapy, we look at it in the sense of invalidating someone's emotions or subjective experience.
Legitimately asking: If cognitive therapy isn't invalidating harmful, negative thoughts to replace them with thoughts that are more grounded in reality, then what is it doing?
In a technical sense, that is what it's doing. And, I believe that those well trained in CBT would agree. But, I think that the verbiage needs to be different with lay people and patients, as they will easily misconstrue it. Just look at therapy forums for patients, or even midlevel provider forums who would equate that with their false belief that CBT is gaslighting.
Legitimately asking: If cognitive therapy isn't invalidating harmful, negative thoughts to replace them with thoughts that are more grounded in reality, then what is it doing?
It's behind a paywall. Want to summarize?Very directly bearing on this question:
It's behind a paywall. Want to summarize?
Very directly bearing on this question:
This strikes me as an absurdly primitive 'attack/critique' on cognitive therapy.Another New Yorker piece on CBT, which I thought was fairly balanced (though the mindfulness person with the fancy title they interviewed is clearly strawmaning):
Can Cognitive Behavioral Therapy Change Our Minds?
One quote I thought was interesting:
This is probably speaking more to the cognitive elements since the author spends a lot of time on Burns and J. Beck (even interviews her), less so on the behavioral side, which I think would support the idea that we can be rational about our irrationality by knowing what we need moment to moment. Be it by temperament, psychopathology, or personality, it can sometimes be hard to be rational in every moment of every day and I don't think CBT mandates that we are. That said, I do agree that it goals of CBT are inherently aspirational given that it requires people to refute and invalidate what otherwise might be 'natural' or 'automatic.'
Moreover, the dichotomy of classifying thoughts as either 'irrational' or 'rational' is quite crude an unsophisticated. Just as our thoughts exist at varying levels of awareness, there are varying degrees of match between thoughts and reality. Cognitive theory doesn't sort the people of the world into two bins ('you rational people go over here, you irrational (mental health patients) people go over there'). A good cognitive therapist uses Socratic dialogue, guided discovery, collaborative empiricism, humility, humor, laughter, relationship building, and even targeted self-disclosure to invite patients to identify the thoughts/beliefs that influence their emotional and behavioral responses and--where those emotional and behavioral responses are causing them severe trouble--to question them and see what happens. I've seen it 'work' for 30+ years. Not perfectly, not every time, but I've witnessed people get better. The term/concept 'empirical' literally means 'based on, concerned with, or verifiable by observation or experience rather than theory or pure logic.'
Therapy is great...when it tells me that everything I'm doing is fine. Otherwise, it's invalidating of my lived experience and probably traumatic.I love it when the articles are about how therapy is useless and then the articles on how meds are useless and overprescribed. I think they don't believe in mental illness or treating it
So much this. I feel like the silly attacks on CBT as rigid, proscriptive, invalidating, etc are just a bunch of straw-manning by people who have no idea how to do it.However, as we engage in good faith Socratic dialogue, make efforts to listen to one another and be persuaded by evidence, and try to stumble toward better and better (more functional) approximations of 'the truth' through our interactions both they and I are transformed. It isn't some one-sided affair where my job is to tell them how or what to think. Cognitive theory doesn't sort the people of the world into two bins ('you rational people go over here, you irrational (mental health patients) people go over there'). A good cognitive therapist uses Socratic dialogue, guided discovery, collaborative empiricism, humility, humor, laughter, relationship building, and even targeted self-disclosure to invite patients to identify the thoughts/beliefs that influence their emotional and behavioral responses and--where those emotional and behavioral responses are causing them severe trouble--to question them and see what happens.
Also, for most of my patients who are on the more severe side of things with multiple comorbidities, they will continue to be vulnerable to exacerbation of symptoms or relapse and/or need ongoing support or treatment to mitigate that. In other words, they won’t get “all better” and the pressure for them to be normal or get better keeps them in a cycle of not getting better and actually getting worse. Some of this is because my patients don’t return to their normal pre or I’d level of functioning after symptoms are reduced because they have been struggling their whole life and so reducing their symptoms just gets them back to that baseline. I do like working with the occasional mild to moderate case who is high functioning. They sure do get better quickly and then resume their successful pursuits. It’s just that they seem to be the exception of who presents for treatment rather than the rule. Maybe in New York it’s still fashionable to have a therapist or even analyst so it’s a different dynamic.I do think that there is this attitude in therapy that is not found in other healthcare areas, which is that treatment cannot and should not fail. I think Ollie was saying, and not sure if it was this thread or somewhere else, but it'd be nice if we could promote therapies the same way we do other treatments for other problems, which is like: this has a good chance of success, but it may not work for everyone.
Really? I feel like I see articles about endometriosis in the popular media with some regularity. (Rightfully so, since a lot of people who have it are pretty irritated at the relative dearth of treatment options.)Yeah, and if you give a few treatments your best shot and they don't work, it doesn't mean that you need to be in therapy forever. Maybe therapy is just learning to manage these symptoms more effectively rather than improve them.
I have endometriosis and treatments for that really suck in terms of effectiveness, but you don't see numerous articles about that in the NYT.
Really? I feel like I see articles about endometriosis in the popular media with some regularity. (Rightfully so, since a lot of people who have it are pretty irritated at the relative dearth of treatment options.)
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A Debilitating Illness, Often Ignored (Published 2022)
Nearly one in 10 women experiences the chronic pain of endometriosis, but for many the symptoms are dismissed. Why is this still happening?www.nytimes.com
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They Call It a ‘Women’s Disease.’ She Wants to Redefine It. (Published 2021)
As a bioengineer, Linda Griffith once grew a human ear on the back of a mouse. Now she is reframing endometriosis as a key to unlocking some of biology’s greatest secrets.www.nytimes.com
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Tanning Beds and Sunbathing May Raise Endometriosis Risk (Published 2020)
Living in areas that are sunnier, however, lowered the risk.www.nytimes.com
I think this also ties into the belief that suicide is 100% preventable, and if a patient dies by suicide, the mental health professional must be negligent. The said truth is that, for some people, mental illness is truly a terminal illness--I think the Dooce blogger who died by suicide recently (after decades of trying every treatment under the sun) is a good example of this sad reality.. Personally, I think it makes us look less like professionals. Suffering is just less visible than death, so we have an easier time getting away with it.
Interesting that Cuijpers found the research to be underpowered. This 2022 umbrella review of meta-analyses found an overestimation of both psycho- and pharmacotherapy effect sizes, after accounting for risk of bias, weak "intent to fail" comparators, and overall study quality,.I don't have the citation on hand, but Cuijpers published a well known study in the last decade emphasizing how underpowered the current state of treatment outcomes research -- I cite that paper a lot when justifying why fluency with evidence-based principles of behavior change (versus just microskills, common factors, etc.) is a must for all psychologists. Didn't have a chance to pull up either the NYT or NY articles, so maybe this is the Cuijpers article they cite.
How would you change the conceptualization?Interesting that Cuijpers found the research to be underpowered. This 2022 umbrella review of meta-analyses found an overestimation of both psycho- and pharmacotherapy effect sizes, after accounting for risk of bias, weak "intent to fail" comparators, and overall study quality,.
The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: an umbrella review and meta-analytic evaluation of recent meta-analyses https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20941
They found small effect sizes for both therapy and pharmaco. This matches my own experience of therapists and psychiatrists generally overestimating their clinical outcomes. I agree with the authors' conclusion that the status quo, ebt's and all, is failing too many people with mental illness. The way we currently conceptualize and treat mental disorders is ripe for change, imho.