NYT Article - "Does Therapy Really Work?"

[cara susanna]

Does Therapy Really Work? Let’s Unpack That.

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

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[iliketohelppeople]

Unpaywalled version here.

 

[Fan_of_Meehl]

Does Therapy Really Work? Let’s Unpack That.

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

Of course not.

Exposing yourself repeatedly and systematically to situations that you irrationally fear under controlled conditions and invalidating your irrational fears resulting in a new learning history that allows you to repeatedly experience the situation of riding on an elevator without plummeting to your death does NOTHING for your specific phobia of elevators.

Physical exercise and behavioral activation don't help depression either.

And, oh yeah, your grandmother was wrong about eating your vegetables being good for your health, too.

 

[Ollie123]

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.

 

[Fan_of_Meehl]

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.

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.

For many (not all...maybe not even most) problems in mental health...'does therapy work?.' Only if the patient does and only if the problem is competently assessed/ formulated. Not blaming patients, either. Change is hard. But 'does therapy work?' requires at least a book-length answer and isn't yes/no.

 

[cara susanna]

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.

 

[Fan_of_Meehl]

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.

 

[eeor1006]

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.

 

[Sanman]

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.

The problem here is likely more one of layperson perception than just advertising. You know how many folks I see with moderate to severe dementia on donepezil and namenda with a neurologist seeing them every 6 mths? And for what?

Bottom line, there is a lot of crap medical tx when the system is fee for service and for profit. Some of it works and some less so, caveat emptor!

 

[Fan_of_Meehl]

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.

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.

Of course, I am currently burdened with the VA's cyborg system of redundant electronic documentation systems that seems to equate excellent care with how complicated, redundant, and inconvenient the required electronic procedures are.

 

[R. Matey]

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.

 

[cara susanna]

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.

As one of the comments pointed out, it also mischaracterizes CBT

 

[summerbabe]

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.

 

[Sanman]

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, I use the same analogy. I also extend it to practice and maintenance of techniques learned.

 

[cara susanna]

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.

 

[smalltownpsych]

Many of the people I work with are the patients who psychotherapy as usual doesn’t help. These types of articles and the perspective that my patients can be fixed is part of why both medications and psychotherapy doesn’t work. Having a dialectical perspective, which is beyond what our current society is capable of, is what is necessary and part of why Linehan’s perspective is so revolutionary. My patients first have to accept that they won’t get better, fixed, cured, and once they accept that then they can start to improve. Dialectics 101

 

[R. Matey]

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.

What if the answer is "yes, also your provider might be s*** at their job"?

 

[sloh]

“Pim Cuijpers, a professor of clinical psychology at Vrije University in Amsterdam, co-wrote a 2021 meta-analysis confirming that therapy was effective in treating depressioncompared with controls, but he also found that more than half of the patients receiving therapy had little or no benefit and that only a third entered “remission” (meaning their symptoms lessened enough that they no longer met the study’s criteria for depression). Given that the patients were assessed just one to three months after treatment started, Cuijpers said he considered those results “a good success rate,” but he also noted that “more effective treatments are clearly needed” because so many patients did not meaningfully benefit.

The most significant difference in patient outcomes, Wampold says, almost always lies in the skills of the therapist, rather than the techniques they rely on. Hundreds of studies have shown that the strength of the patient-therapist bond — a patient’s sense of safety and alignment with the therapist on how to reach defined goals — is a powerful predictor of how likely that patient is to experience results from therapy. But what distinguishes the therapists most likely to forge those bonds is not intuitive. Wampold says that some of the attributes that would seem most salient — a therapist’s agreeability, years of training, years of experience — do not correlate at all with effectiveness of care.

but he also referred to a study from the 1970s suggesting that laypeople who naturally have those skills performed nearly as well in therapeutic simulations as trained therapists with Ph.D.s.”

 

[sloh]

“Other researchers try to provide a control group by offering a neutral nontherapy therapy, but even those are thought to have some placebo effect, which could make the effect of therapy look smaller than it really is. (One researcher, in trying to devise a neutral form of therapy to serve as a control, even managed to stumble on a practice that improved patients’ well-being about as well as established therapies.)”

lol isn’t one of the goals of studies to control for placebo?

 

[sloh]

Good responses in the comments:

"There’s an old joke in medicine: It only takes one psychiatrist to change a lightbulb, but the lightbulb has to want to change."

"I'm a clinical psychologist and have been working as a therapist for around 20 years. The reality is that the biggest obstacle to effective therapy is attrition. Studies indicate that between 20-57% of patients drop out of therapy, and in community mental health clinics the attrition rate is even higher. My experience has overwhelmingly been that therapy works if you work it: if you treat it as a major life commitment that you prioritize, if you attend your appointments consistently, if you actually use the sessions to talk through issues that are important to you even if doing so can be uncomfortable, and if you follow up on your goals between sessions, therapy is usually helpful. If that level of commitment isn't available to you, then therapy may not be the best form of support for you."

"I do wish that people would stop saying this kind of thing; 'cognitive-behavioral therapy, which helps people learn to replace negative thought patterns with more positive ones'. It's not only misleading, it is counter-productive. Cognitive-behavioural therapy helps people learn to replace negative thought patterns with more flexible, neutral and realistic ones. So not changing 'I will bomb this presentation at the meeting, I am an idiot and I always mess up!' to 'I will do great on this presentation! I am successful and people appreciate me!' But rather, changing to 'I am nervous about this presentation. But I am well prepared and I usually do fine in the end. This one will probably also go alright.' and 'I sometimes feel like a failure, but the reality is that I do quite at most of the things that are important to me, and even when something goes poorly, it's not the end of the world, I can bounce back.' The difference may not seem important, but it is HUGE. Going from one type of extreme, unrealistic and inflexible thinking to another truly doesn't work to help us feel better and function better. Also, Cognitive BEHAVIOURAL Therapy also helps people change their behaviours - often essential to feeling better and doing better. Otherwise it's just Cognitive Therapy."

 

[quickpsych]

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.

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?"

Also to your point, I sometimes either get asked by a facility to see a patient who is "acting out" and/or the patient is upset that "nothing is being done." Then you go talk with them and they either go "well why should I change they're the ones who are the problem!" or when asked if they've asked or inquired about their concern/need they go "well why would I do anything, they should just know what I want." Then it gets a bit sad to see when you see family dynamics and a patient feels abandoned by their family in the facility , but you happen to observe an interaction between them and family members on a rare visit or phone call and even if you've worked in therapy on these interpersonal "stressors" it's plain as day the patient has taken nothing from that work and applied it to being part of the solution to these stressors.

 

[R. Matey]

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:

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.

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.'

 

[WisNeuro]

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.

 

[Sanman]

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.'

The author thinks people are inherently irrational. The author also thought it was a good idea to pursue a career as an English prof in the late 2000s. Maybe he is not the most rational of people. That said, saying CBT does not work because some people are not the most rational is akin to saying exercise is not beneficial because some people will never be elite athletes.

 

[R. Matey]

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 being challenged by a therapist pointing out alternative explanations that are more grounded in reality. You may not like the word, but that is what's happening.

(edited for clarity)

 

[WisNeuro]

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.

 

[R. Matey]

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?

 

[WisNeuro]

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.

 

[R. Matey]

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.

Great, glad we agree. I understand the point about misunderstanding CBT. Most people forget that CBT is collaborative and should be delivered in the context of a compassionate relationship (as J. Beck also points out in the article).

 

[clausewitz2]

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?

Very directly bearing on this question:

Project MUSE - It's Been Utility All Along: An Alternate Understanding of Cognitive Behavioral Therapy and The Depressive Realism Hypothesis

muse.jhu.edu

 

[MiniLop]

Very directly bearing on this question:

Project MUSE - It's Been Utility All Along: An Alternate Understanding of Cognitive Behavioral Therapy and The Depressive Realism Hypothesis

muse.jhu.edu

It's behind a paywall. Want to summarize?

 

[R. Matey]

It's behind a paywall. Want to summarize?

It's on researchgate: https://www.researchgate.net/public...Therapy_and_The_Depressive_Realism_Hypothesis

Will read and reply.

 

[R. Matey]

Very directly bearing on this question:

Project MUSE - It's Been Utility All Along: An Alternate Understanding of Cognitive Behavioral Therapy and The Depressive Realism Hypothesis

muse.jhu.edu

Gave it a quick read. Returning with thoughts: largely agree that 'altering negative thoughts to better reflect reality' can be a bit epistemologically sticky and I know that I've emphasized utility in my own clinical applications of CBT though I wouldn't say I put it that way explicitly ("don't worry about if it's true, it just needs to be useful!"). But I do think we all have to acknowledge that our perceptions of reality of probabilistic at best and doubling down on one interpretation over another, equally productive interpretation, is not necessarily all that useful in therapy (speaking as a clinician). I think that's why non-judgmental integration and Socratic Questioning are both pretty important here, as J. Beck points out in her later edition of the CBT manual.

 

[Fan_of_Meehl]

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.'

This strikes me as an absurdly primitive 'attack/critique' on cognitive therapy.

Obviously, thoughts/beliefs and streams of thoughts exist at varying levels of awareness. The majority of 'automatic thoughts' probably occur for most people just below/outside their level of awareness. Schemas generally operate implicitly (rather than explicitly)...at least until you're able to identify them and call them out.

Cognitive therapists help people learn how to slow things down and pay attention to their thoughts, intermediate beliefs (rules, attitudes, assumptions, if-then statements/predictions) and schemas so that they can identify --> label --> modify. By practicing, over and over again, cognitive restructuring exercises, the patient is training their mind to think differently (new habitual way of thinking) that--once learned (or overlearned)--becomes their new automatic way of thinking or processing events. It's like acquiring any other relatively complex skill. If you play an instrument, when you first started learning how to play, it took a great deal of concentration and mental effort to, say, place your fingers on the fret of the guitar to make a 'C' chord. After several months of practice, you don't even pay attention to it. It is 'automatic.' Same with altering your patterns of thinking/interpretation.

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 would posit that we all experience the world through various lenses of cognitive distortions (that's the constructivist assumption), lenses that can be relatively clear or cloudy but no one (not even ole Aaron T. himself) is some paragon of rationality who sees the world completely 'objectively' and without some degree of irrationality/distortion. And, as an experienced cognitive therapist, I find myself and my clients agreeing to disagree all the time. 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. 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.'

Cognitive therapists don't just tell clients, 'You need to think rationally instead of irrationally,' and then expect clients to go, 'hmm...thanks, doc...I never thought of that...I feel much better now and probably won't need to reschedule. You cured my depression.'

 

[R. Matey]

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.'

Great thoughts all around. Agree that it's not so simple as rational vs. irrational, but rather the goals are to replace thoughts that are probabilistically true (logical positivism has its flaws after all) and helpful. The process is more collaborative than most critics think it is.

 

[PikminOC]

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

 

[AcronymAllergy]

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

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.

In all seriousness, to some extent the various MH disciplines have done this to ourselves via years/decades of therapists providing "supportive therapy" (i.e., weekly social hour and/or vent sessions); perpetually saying how therapy is art not science and can't be quantified, measured, or structured (which is, of course, different than saying it should be individualized to the patient); and confusing unconditional positive regard with agreeing with everything the patient says because we're uncomfortable with therapeutic confrontation.

 

[tr]

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.

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.

 

[bcliff]

I'll echo the benefit of connecting evidence-based psychotherapy with physical therapy - I've found it particularly helpful in establishing buy-in to the use of non-pharmacological / non-surgical techniques when treating patients for whom having a medical diagnosis is important (e.g., chronic pain, long COVID, history of concussion, etc.). The shared / similar focus of psychotherapy and physical therapy on successive approximations of some target behavior, behavioral activation, pacing / graded exposure, etc. is also helpful in orienting patients to what psychotherapy with me will look / feel like. It's also useful in disentangling discomfort from danger (or hurt doesn't equal harm); e.g., discomfort in psychotherapy as an analogue to soreness in physical therapy / exercise. Also like PT, psychotherapy with me is time-limited and focused on building skills that can continue to be practiced after treatment ends, etc.

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.

 

[cara susanna]

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.

 

[smalltownpsych]

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.

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.

 

[cara susanna]

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.

 

[tr]

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.)

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

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

Tanning Beds and Sunbathing May Raise Endometriosis Risk (Published 2020)

Living in areas that are sunnier, however, lowered the risk.

www.nytimes.com

 

[cara susanna]

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.)

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

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

Tanning Beds and Sunbathing May Raise Endometriosis Risk (Published 2020)

Living in areas that are sunnier, however, lowered the risk.

www.nytimes.com

I'm referring more to treatment, most of the coverage I see is like the above where it's about how it's misdiagnosed or develops in research about its etiology.

 

[futureapppsy2]

. 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.

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.

 

[smalltownpsych]

Maybe individual psychotherapy isn’t quite able to overcome the negative effects of toxicity in our culture? Me and a patient were talking about the research neuronal development in the rats in the crowded environment and the rats on the understimulated environment just the other day. I know that I didn’t like working with younger kids because of the inability to affect the environment sufficiently to make any real progress with many or even most of the cases. At least with adolescents and adults there is the ability to begin shaping your environment so A little more of a fighting chance.

 

[PsyDr]

FOR WHAT?

Sorry, this question is ridiculous. It’s like asking “do antibiotics work?”.

Does supportive therapy work for osteoporosis? No.

Does CBT-I work for insomnia? Absolutely.

Does undefined “therapy” work for some ill defined environmental thing? Who knows?


It’s a ridiculous question that implies practitioners are using unsubstantiated treatment for undefined diagnoses.

Does chemotherapy work? For what? It sure as hell doesn’t work for somethings, for other things it kinda works, for other things it absolutely works. It’s ridiculous to ask that question in a broad way.

 

[WisNeuro]

Knowing how to report on mental health issues is probably one of NYT's, and most media outlets, biggest weaknesses. Though, it does kind of fit into the current zeitgeist of anti-intellectualism and derision of true experts in the US today.

 

[LurkerNow]

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.

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.

 

[PikminOC]

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.

How would you change the conceptualization?