Potentially harmful therapies

[Pragma]

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I am sure that some of you are more familiar with this author's work than I am, as I had not read this article before today. I posted it in the gay conversion therapy thread, but thought it might be worth it's own discussion.

http://commonsenseatheism.com/wp-co...-Psychological-Treatments-That-Cause-Harm.pdf

Although not entirely recent (2007), the paper classifies therapies into tiers of potential harm based on available evidence.

Does anyone have thoughts on how to address these therapies? On how we operationalize "harm" if we are going to make decisions (within our profession or via the legal system) about offering the therapies? Just curious what folks think.

 

[crim84]

This is an interesting topic!

 

[Pragma]

Thanks and I hope this is something that people will discuss. I saw a series of 2010 articles in The American Psychologist as well addressing this issue. I also noticed an article about how important this should be to address in training programs. In my own training, we discussed iatrogenic effects in principle with a couple of examples, but specific types of therapy that have negative effects and the magnitude of those effects was not fleshed out at all. I think there is a tendency to focus on EBTs and as the author argues, we really should be looking at things this way first. An article like this is at least a good starting point.

Unless we can come up with a good way to define harm in the context of evaluating iatrogenic effects, this issue will continue to be fuzzy. I felt that the author glossed over that a bit in this lit review.

Edit: Part of why I like this author is that he cites practioner surveys showing that a large number of therapists out there are not using evidence-based treatments, either. I have to admit that I have a bias against therapy in some ways, because of my exposure to people who just fly by the seat of their pants when doing interventions (or just talking about the weather/politics, if that is considered an intervention). When I make referrals, I like to refer to people who get down to business and don't view their clients as a weekly contribution to their paycheck that can be seen indefinitely. I really hope that our field can do a better job of regulating things, because as it is now I am skeptical of therapists I don't know. I vetted my own therapist in grad school pretty thoroughly.

 

[Psychadelic2012]

That article is a keeper!! I haven't seen it before, so thanks. As I've aged and matured as a scholar/practitioner, I've become much more critical so I appreciate where this article is going. I agree that it is a good start, but that it could go further. I do agree with the author's quick point about how we, in mental health, are not very good at first testing the safety of a treatment before testing its efficacy, as it is done in medical trials. Part of that might be due to the fact that we have to wait for time to pass (e.g., the D.A.R.E. disaster), but then again they have to do that in medicine, too. I also tend to think that practitioners are just lazy and unwilling to critically examine the research. I have heard, "This is based on research!!" way too many times in my day, when in fact that thing is either on Lilienfeld's list of PHT's or has multiple studies/meta-analyses citing its controversy--hate that!

I'm inspired by the article, however, and it makes me want to do more reading and examining of this topic.

 

[KillerDiller]

I have only skimmed the article so far, but I was surprised to see grief counseling for bereavement on the list of potentially harmful treatments. I hadn't heard about the meta-analysis the paper cites. I'm glad I saw this, as it will make me re-think how I work with clients experiencing normal bereavement.

 

[cara susanna]

That's interesting because I saw a grief counselor for normal bereavement. My brother did as well. Neither of us had a great experience with it.

 

[LivingOffLoans]

I either heard about this article last year in class, or the lecturer was taking a stab in the dark at the topic that Lilienfeld is discussing. This is a lot more specific though. I read most parts, and skimmed others for now...but this is going in my articles folder for sure.

One thing I really found interesting was the section toward the end that suggests we look further at what traits in a therapist may predispose treatment to be harmful. I do not believe there is sufficient attention in training or continuing education about cultivating the personhood of the therapist. This is why, for example, some of the sessions I have sat in on of colleagues who are orthodox behaviorists (particularly with 'borderlines'), and can't be bothered to be empathically involved in their clients' lives, come off as absolutely sordid to me - because they use behaviorism to avoid any relational responsibility ("I'm a good therapist, the client just sucks because they won't do what I'm saying"). I get absolutely fumed about this kind of relational injustice.

For the record, I'm not anti-behaviorism, but I do not look favorably at clinicians who rely so heavily on a theory (and that goes for any theory or combination of theories) that they then wipe their hands clean of the proper and powerful responsibility they carry as people who are also clinicians (not clinicians who are also people), when if they had a more developed disposition toward their clients, the process and outcome may appear quite different than it did.

 

[Psychadelic2012]

That's interesting because I saw a grief counselor for normal bereavement. My brother did as well. Neither of us had a great experience with it.

I also agree that it is particularly interesting. I had a good experience with grief counseling and due to that good experience I've wanted to get clinical experience in that area--however, I've noticed that it's an area that seems to want master's clinicians. Even in my doctoral program, the local hospice wants social work students, not doc psych students. I didn't understand it until now.

 

[AcronymAllergy]

This is big into Lilienfeld's area (he's also a fairly vocal critic of the Rorschach), so I look forward to reading the article. I wish I'd had a chance to meet with him when I interviewed at Emory.

 

[PsychBrownBag]

I've made undergrads in my classes read this one for years (as well as Dawes, Faust, & Meehl) and it's on my syllabus for a grad class I'm teaching in the spring. It really sets the tone well for why it is so important to look at the evidence-base for a treatment.

Lilienfeld is a master of describing the evidence-base for various issues. His "Great Readings in Clinical Science" book is also on my syllabus for the grad course this spring.

 

[Ollie123]

Solid article. Surprised I hadn't seen it before given I've read a LOT of Lilienfeld's work (both for class and on my own), but somehow missed this one. I'm familiar with most of the issues/therapies raised, but was unaware of a concise review.

There is an implicit assumption many seem to have that even if they aren't using EBP they are at least not causing harm because....how could sitting around talking to a therapist be bad for someone? Work like this is a much-needed challenge to this notion, though of course as always it doesn't mean practitioners will listen to it, or that APA will do anything out of fear the rebirthing contingency (or whoever else) will cancel their memberships.

Some of these are clearly completely off-the-wall and I still find it hard to believe people actually use, but I think others challenge a related belief...that "good intentions" is enough to make it okay. CISD and grief counseling (which interestingly enough...might cause problems by the same mechanism) are both outstanding examples of this. Related to the issues I raised in another thread, this also came up at my last practica - I got very uncomfortable when the staff would push folks to do things that seemed logical but had absolutely no supporting evidence.

 

[Doctor Eliza]

Grief is a particular area of interest for me. I have worked fairly extensively at a community agency and in PP with parents who have had children die. I also have worked quite a bit with children who have experienced loss. I would like to get my hands on the study cited here because I think there are a lot of complexities to "grief therapy."

One of the first things i think of is that therapy for grief often entails a significant psychoeducation component and a significant supportive component. It is often much less therapy-y (to use a technical term) than other issues. I'm not usually poking around and stirring up issues. For this reason, I thnk there is a real place for peer and paraprofessional support in dealing with this issue. i think support for the bereaved is necessary, but that support does not necessarily need to come from a psychologist.

I also think that distinguishing "normal" bereavement from a pathological reaction can be difficult. DSM provides some guidance on this, but in reality it seems fuzzier than other diagnostic issues. For example, in my experience working with parents who have had a child die, they typically experience very intense grief for the first 2 yrs. So does this constitute complicated grief? It is a very long time, but it is in proportion to the loss.

I also would be interested how the efficacy of tx relates to age of participant. It can be very tricky working with kids and grief because at certain developmental stages it is hard for them to understand what death is (at least at first) but they can profoundly miss the person who died. Young children also often need help expressing their feelings. Some brief tx could be helpful here. On the other hand, there are many parents seeking tx for their child after a loss that means a lot more to the parent than the child. For example, at our agency we had several families bring in preschool aged kids to grieve the loss of an unborn child. Of course the situation was painful for the parents, but the situation was so abstract for the preschooler. This was a case in which I became concerned that participation in bereavement groups could be more problematic than the loss.

I also think that there is a good deal of self-selection with regard to patients who seek out psychologists for therapy related to bereavement. In my experience, adults who come in asking for grief therapy usually have some complexity to their experience or reason to believe that their grief process will be difficult (e.g. Death of an abusive parent). I have had a few people come in shortly after a loss because a family member urged them to come in. I talk with them about their grief-related concerns, provide psycho education, discuss red flags that intervention is needed (e.g. Suicidality, inability to function) and tell them that they don't need to come in if they don't want to. I give them my card and send them on their way, welcoming them to call me if needed.

If anyone has a link to the bereavement article, that would be cool. I miss my university library access! 🙁

Dr. E

 

[Doctor Eliza]

One more thing...

I do think grief is an area in which a lot of people repeat myths that have not been empirically validated. I am always concerned when I hear professionals talking about fixed, sequential "stages of grief." This idea has not been borne out in the data, yet many professionals (who should know better) present it as fact.

Dr. E

 

[Pragma]

Grief counseling surprised me too. But I liken it to the immediate counseling for PTSD - it is almost like the power of suggestion and over-zealous therapy can create problems that wouldn't otherwise happen.

I don't think there is necessarily a problem with grief counseling in theory, it is just that if a practitioner projects things beyond normal bereavement, I'd imagine the client could get confused.

 

[Member1928]

I'm really surprised more people have not read this. I was an undergrad when this came out, and a graduate student in my lab handed me a copy saying, "look a new Lilienfeld paper is out." I was in a department with a clinical science orientation, but this paper was subsequently assigned as required reading in more than one course in my graduate program, which was much more practitioner focused.

 

[Pragma]

I'm really surprised more people have not read this. I was an undergrad when this came out, and a graduate student in my lab handed me a copy saying, "look a new Lilienfeld paper is out." I was in a department with a clinical science orientation, but this paper was subsequently assigned as required reading in more than one course in my graduate program, which was much more practitioner focused.

I'd like to think that things like this would be required reading, and I am sure that they are in some programs. I am guessing that faculty in my program would have included this in their classes (this came out after I was done with a good portion of my therapy coursework). Not sure if they have put it in since.

The authors point about addressing harm before considering something an EST I think is a good one.

 

[AcronymAllergy]

I'd like to think that things like this would be required reading, and I am sure that they are in some programs. I am guessing that faculty in my program would have included this in their classes (this came out after I was done with a good portion of my therapy coursework). Not sure if they have put it in since.

The authors point about addressing harm before considering something an EST I think is a good one.

Ditto. While I did learn many/most of the points mentioned in the article in my therapy/intervention classes, having it all "packaged" together into a single article is very convenient.

 

[nitemagi]

Good topic.

The Institute of Psychiatry had a debate on this some time ago, focused on "Is Counseling Harmful." In that context they seemed to refer to supportive psychotherapy, and the argument primarily being that it fosters dependence without development of insight, independent coping skills, and encourages externalization of blame. This may also be why it's considered harmful in sociopaths.

 

[Iwillheal]

Good topic.

The Institute of Psychiatry had a debate on this some time ago, focused on "Is Counseling Harmful." In that context they seemed to refer to supportive psychotherapy, and the argument primarily being that it fosters dependence without development of insight, independent coping skills, and encourages externalization of blame. This may also be why it's considered harmful in sociopaths.

By "sociopath" do you mean psychopath or people with ASPD? I always get these confused and the distinction is not always clear. Regardless, in people with these types of personality there is no therapy I know of that actually does work though some minor improvements are not unheard of. As far as supportive therapy, I sure hope they are not going to deem it harmful just because of the sociopath outcome. This is anecdotal but I personally know of a few cases of patients with schizophrenia for whom supportive therapy has been quite helpful.

 

[Pragma]

Good topic.

The Institute of Psychiatry had a debate on this some time ago, focused on "Is Counseling Harmful." In that context they seemed to refer to supportive psychotherapy, and the argument primarily being that it fosters dependence without development of insight, independent coping skills, and encourages externalization of blame. This may also be why it's considered harmful in sociopaths.

When I hear (and used to read this term or "empathic listening" in progress notes), I immediately think "venting without clear purpose" and I could see it being harmful in the ways you listed (sociopaths aside).

But I am glad that research on specific interventions is being put together in this manner.

 

[Iwillheal]

That's great, except that there are other therapies (namely Cognitive Therapy) that have demonstrated empirical gains for psychosis and negative symptoms. I don't see any reason to do generic "supportive therapy" when we have therapies for most of the disorder spectrum which are effective.

I understand what you're saying but let me come at this from a different angle. Why can't we match the therapy to the person's needs and functioning? Not everybody benefits from cognitive therapy to the same extent. If we can incorporate supportive therapy into it, then great. So depending on the patient's needs and functioning, we may need to have sessions where, from one perspective, not much happens, but from another perspective, the patient spends an hour with a caring and compassionate person who is there for him/her, is willing to listen attentively, respectfully, and is encouraging and supporting. Of course, all sorts of therapies are changing and evolving and merging with other ones these days and I certainly see no trouble with taking the best of each world and doing the kind of therapy that is more efficient use of therapist and client's time and effort.

 

[Iwillheal]

This thread also brings to mind a parallel idea that I think also warrants discussion. Is it potentially harmful (or potentially unethical) to not offer clients the intervention with the most empirical support (and thus chance of success) before offering interventions with lesser or no support?

This can get philosophical. But I think a lot of times it's about the practical concerns. Like the time and money to do a particular kind of therapy, availability of therapist, public view of certain kind of therapy, etc. And sometimes I eat at McDonald's not because I think it's healthy or high quality but because that's all I can afford or it's on the way home or whatever.

 

[Iwillheal]

So saying that such a patient wouldn't benefit because that's what you *think* (and not what research has demonstrated) doesn't make much sense to me.

Okay, just to be clear (I feel like Obama), if you read my post carefully, I did not say cognitive therapy doesn't work. I was arguing against the potential possibility of supportive therapy being deemed illegal merely because of certain harmful outcome in sociopaths. Schizophrenia is not my area of research and that's why I cited anecdotal example and also because one of my professors works with that population and did tell me that supportive psychotherapy was quite helpful with certain low functioning clients. But at this point I suppose what I need to look into are two things: One, quality research that shows that CT is always better than supportive therapy with every population. Two, research that shows supportive therapy is harmful or useless for the people with schizophrenia. But I do agree with you that CT is helpful for people with schizophrenia. And also interesting point you made about CT with that population being different than standard CT. I did not even think of that. Good debate though.

 

[Iwillheal]

If you're interested in the differences in the model and specific intervention, there are a couple good books out on CT for schzophrenia. Look for the ones by Turkington and Beck.

I agree with your post...also thanks for the recommendations, psycscientist. I will look them up.

 

[nitemagi]

By "sociopath" do you mean psychopath or people with ASPD? I always get these confused and the distinction is not always clear. Regardless, in people with these types of personality there is no therapy I know of that actually does work though some minor improvements are not unheard of. As far as supportive therapy, I sure hope they are not going to deem it harmful just because of the sociopath outcome. This is anecdotal but I personally know of a few cases of patients with schizophrenia for whom supportive therapy has been quite helpful.

I use sociopath a little more colloquially, recognizing ASPD criteria has the better sensitivity but not terribly specific for much of what we're talking about, and psychopathy exists as a trait and thus on a spectrum.

A little study (cochrane 😀) on therapy for ASPD.
http://www.ncbi.nlm.nih.gov/pubmed/20556783
Mainly concludes not much is proven to help, but far from showing anything should be contra-indicated.

If we want to talk about this subpopulation we should find the data on the "DSPD" experiment in the UK.

 

[Pragma]

I don't necessarily agree with the premise that supportive therapy should be "illegal". I also don't think that it's "useless" - certainly nonspecific factors can be helpful to folks. What I'm saying is that we have things that are likely to be much MORE useful to people. Also, sometimes patients don't benefit from ESTs and that may be the last resort to offer someone. I think that's fine. There are also plenty of people that go to therapy for "problems of normal life" that don't really have much functional impairment or psychopathology. Supportive therapy is probably fine for those cases, as well. What I don't think is fine is offering supportive therapy before offering something else that actually has more science behind it and has a better shot of working.

If you're interested in the differences in the model and specific intervention, there are a couple good books out on CT for schzophrenia. Look for the ones by Turkington and Beck.

Sadly, I think these nonspecific factors end up being the bread and butter of therapy for many providers (maybe more master's level?). Particularly when they are in PP and it is to their benefit to keep their clients. Better to be likable and have someone perceive utility from the warm fuzzies of long-term therapy (with some nonspecific goals) rather than try to resolve a specific issue within 10-15 sessions.

Yeah, I know, I am jaded. But the confidential nature of therapy doesn't lend itself well to quality control. I recall hearing some PP folks talking about insurance and being overjoyed that they had unlimited sessions. Seems to me that having unlimited sessions is only a good thing if you plan on using a lot of sessions...

Keep in mind, I think that is different than someone who charges a high fee-for-service rate to provide a time-limited, evidence-based service that gains their reputation based on getting results as opposed to "nonspecific factors" like likability and catering to the whims of the clientele.

 

[thewesternsky]

Oh, no doubt. It's even worse in community mental health. I would actually prefer clinicians who do good supportive therapy to some of what I've seen people doing in CMH centers.

I find this really interesting... Can you elaborate, even in generalities?

 

[rilo]

Sure. What I've found in my observations of CMH clinicians in multiple places is that some therapists either don't have or have other factors (e.g., job dissatisfaction, burnout) that inhibit the use of good nonspecific therapy skills like empathy and warmth. So sometimes "supportive therapy" is not all that supportive. This is definitely not meant to be a slam to people working in these settings, as I know how difficult working in the trenches is. But treatment in these settings is just highly variable.

ITA. I've had SMI-focused practicum placements in a few different settings (CMH, VA, AMC), and the level of care that I've observed in CMH is just not the same. Virtually none of the day program staff I've worked with at the CMH have ever used a manualized intervention. All of them are Bachelor's level making less than $35k a year, and when approached about learning evidence-based interventions or attending supervision with us, they've said in so many words that there's no incentive for them to learn anything "new." Though the groups they lead seem, on the surface, to be relevant (e.g., Stress Management), there's little substance when you dig a little deeper... well, when you look at all, really. Even basic things like goal-setting, self-monitoring... nope. One of the clients I see there for individual Social Skills Training said that they did "aromatherapy" in their last group.

This is all anecdotal, of course. YMMV.

 

[AcronymAllergy]

ITA. I've had SMI-focused practicum placements in a few different settings (CMH, VA, AMC), and the level of care that I've observed in CMH is just not the same. Virtually none of the day program staff I've worked with at the CMH have ever used a manualized intervention. All of them are Bachelor's level making less than $35k a year, and when approached about learning evidence-based interventions or attending supervision with us, they've said in so many words that there's no incentive for them to learn anything "new." Though the groups they lead seem, on the surface, to be relevant (e.g., Stress Management), there's little substance when you dig a little deeper... well, when you look at all, really. Even basic things like goal-setting, self-monitoring... nope. One of the clients I see there for individual Social Skills Training said that they did "aromatherapy" in their last group.

This is all anecdotal, of course. YMMV.

My CMH experiences weren't quite that bad, although the level of evidenced-based care delivered varied significantly across providers. I don't actually know anything about what sorts of training the workers received regarding EBTs, although I can say that all were master's-level folks, and I did see a manual or two when borrowing offices. The main sticking point was the frequency of appointments--based on the sheer number of clients these workers had on their caseloads, in general, the most often they could realistic see any individual was probably once per month.

This is actually one of they reasons they loved having us psych grad students--we could see people weekly, offer various groups, and provide various treatments that just weren't logistically possible otherwise.

 

[rilo]

My CMH experiences weren't quite that bad, although the level of evidenced-based care delivered varied significantly across providers. I don't actually know anything about what sorts of training the workers received regarding EBTs, although I can say that all were master's-level folks, and I did see a manual or two when borrowing offices. The main sticking point was the frequency of appointments--based on the sheer number of clients these workers had on their caseloads, in general, the most often they could realistic see any individual was probably once per month.

This is actually one of they reasons they loved having us psych grad students--we could see people weekly, offer various groups, and provide various treatments that just weren't logistically possible otherwise.

The director of the day program seems to really appreciate having psych grad students, and she's always on board with our plans to incorporate evidence-based interventions into their rotation of groups. She's a psychiatrist for whatever that's worth. But the issue is that there's a fairly large gap between her (and the other "upper management" people) and the day program staff. The latter, who are the ones actually leading or co-leading the groups, seem much less enthusiastic about EST's, the recovery model, etc.

There's just a large sense of complacency at the CMH place I work at that I don't sense in any of my other placements. Not to mention the lack of accountability- there's no supervision, very little discussion of how to improve groups, etc.

ETA: I wonder if this is partially attributable to the fact that this program is SMI-focused? Perhaps the supply of competent mid-level providers for this population is not there? It's a fairly large, urban location with predominantly African-American, lower SES clients.

 

[Iwillheal]

Sadly, I think these nonspecific factors end up being the bread and butter of therapy for many providers (maybe more master's level?). Particularly when they are in PP and it is to their benefit to keep their clients. Better to be likable and have someone perceive utility from the warm fuzzies of long-term therapy (with some nonspecific goals) rather than try to resolve a specific issue within 10-15 sessions.

Drawing a blank, PP? Psychoanalytic psychotherapy?

Regardless, something bothers me about the distinction you draw here as if one is EITHER caring, compassionate, likeable, whatever, and provides encouragement and hope OR is able to "resolve a specific issue within 10-15 sessions." You later also use "likability and catering to the whims of the clientele" in the same vein and it makes me think maybe we are not talking about the same "nonspecific factors." But just in case you are, then, yes, by nature these factors are nonspecific so I suppose some do keep clients in therapy and fatten the wallets of some unethical therapists who want to charm their clients and keep them hooked, but that is not reason enough for me to ignore the fact that nonspecific factors DO play a major role in successful therapy that leads to change in client and improvement in mental health. Books like "The Heart and Soul of Change" and "The Great Psychotherapy Debate" do address these issues.

 

[rilo]

^ I believe PP = private practice.

 

[Pragma]

Drawing a blank, PP? Psychoanalytic psychotherapy?

Regardless, something bothers me about the distinction you draw here as if one is EITHER caring, compassionate, likeable, whatever, and provides encouragement and hope OR is able to "resolve a specific issue within 10-15 sessions." You later also use "likability and catering to the whims of the clientele" in the same vein and it makes me think maybe we are not talking about the same "nonspecific factors." But just in case you are, then, yes, by nature these factors are nonspecific so I suppose some do keep clients in therapy and fatten the wallets of some unethical therapists who want to charm their clients and keep them hooked, but that is not reason enough for me to ignore the fact that nonspecific factors DO play a major role in successful therapy that leads to change in client and improvement in mental health. Books like "The Heart and Soul of Change" and "The Great Psychotherapy Debate" do address these issues.

I am not saying that nonspecific factors aren't important and I am not drawing any dichotomies. I am simply making an observation: that some therapists (knowingly or unknowingly) aren't really doing much of an intervention.

I am not sure if it is poor training or apathy over time, but I get the sense that some folks are just there to fill time. Exhibit A: The sessions I overheard next to my office on postdoc that involved the therapist and their client talking politics and complaining about their kids. This continued for two years. As far as I know, they still are in weekly sessions.

 

[Pragma]

PP = private practice, I believe.

I don't think anyone is arguing that you are either empathetic or a CBT robot. Of course, evidence based therapies should involve good alliance. However, I think what Pragma was arguing is that people become empathetic head nodders that do nothing to move people toward better functioning or achieving goals and keep people in therapy for years unnecessarily. Nonspecific facors are the placebo of the psychotherapy world. They should be present regardless of what treatment you are doing - but the active evidence-based treatments are where the action is, especially when it comes to long-term functioning and relapse.

You said it better than I was going to - and I also have to go 😀

 

[Iwillheal]

Okay, agree with both posts. That's totally not what I had in mind. Talking about their kids and politics...that's so not the right way to use that time. This is a not a social gathering of friends.

 

[paramour]

Add me to the masses saving the article for future reference. 👍 I was interested in a few that were added to the list (e.g., CISD), so definitely need to look into this more. Thanks for the additional material.

Okay, agree with both posts. That's totally not what I had in mind. Talking about their kids and politics...that's so not the right way to use that time. This is a not a social gathering of friends.

Yet I've had numerous clients whose past experiences were just that and that's what they expected and WANTED for their current therapy... and then wondered why their lots in life were not improving.

"I just want, no need, someone to talk to . . . "

And said therapist allows them to do just that for the clinical hour. Session note reads that they provided an "empathetic, supportive intervention" during the client's time of need. They were "client-centered." Um, except there was no intervention. Two people talking, and in most situations it's the client rambling about whatever their li'l ole' heart desires regarding their week to "update" their clinician. <bigbreath> "Okay, I feel better now, I'll see you next week, same day, same time, same bat channel."

Buuut, no improvement in whatever their presenting complaints were on day 1. This purported "supportive" therapy without the remote presence of any empirically guided intervention is not uncommon.

 

[erg923]

Perhaps we could discuss/contrasts the current ideology expressed in this thread with that which was put forth by Rogers (1957). Which is the first reading I assigned to my students this year...🙂 I'd be interested to hear this considering some of the narrow views of therapy I have read thus far. I am particularly interested in the view that empathy, warmth, and genuine human interaction is not an "intervention."

 

[Pragma]

Perhaps we could discuss/contrasts the current ideology expressed in this thread with that which was put forth by Rogers (1957). Which is the first reading I assigned to my students this year...🙂 I'd be interested to hear this considering some of the narrow views of therapy I have read thus far. I am particularly interested in the view that empathy, warmth, and genuine human interaction is not an "intervention."

Can you provide the reading?

Obviously the nonspecific factors we are discussing are important for therapy. Things like empathy, warmth, and genuineness are the key to a strong therapeutic alliance. I guess my issue is that in many of my own therapy cases during training, there was some prior exposure to therapy. Many of these folks seemed shocked at the idea that we'd have a focused intervention with specific goals.

In my neuropsychology training, many patients had very negative views of their previous therapy experiences because "we never really got much done." I had to do a lot of convincing to give therapy another try if it seemed it could be useful for them, and do some vetting to assure them that they would go to a practioner focused on working on specific issues, and not just "checking in" and staying positive. They often viewed their past experiences as a waste of time. That's sad that such complaints would come up more often than not, and suggests a problem with the therapists to me.

Do I think all therapists operate that way? No. But I don't think my concern represents a narrow view, and as others have concurred, I think we are talking about a legitimate problem.

 

[IT514]

One key for me is lasting symptom reduction. Most people feel better after talking to someone who is warm, genuine, and empathic. This is fine. However, if you have major depression, feeling a little better for just a short time doesnt work out too well. The side-by-side comparison research I am familiar with suggests that other interventions, be it CBT or emotion-focused therapy, are necessary to make persisting change.

 

[erg923]

Can you provide the reading?.

http://shoreline.edu/dchris/psych236/Documents/Rogers.pdf

 

[Pragma]

http://shoreline.edu/dchris/psych236/Documents/Rogers.pdf

I am one of the people that views this theoretical orientation as not sufficient for most of the things that people come in for therapy for these days. But I am also a product of my experience. Perhaps for some people, developing a good rapport using humanistic principles (and no other intervention) is useful in the long-term. But I am of the mind that humaistic principles are fairly basic to most therapeutic interventions these days, and that additional parameters are necessary to manage specific presenting problems. It's generally good to follow the evidence base, and, as the topic of this thread is intended to point out - avoid doing harm.

 

[Iwillheal]

Erg, the link there, that's not to your course is it?

 

[erg923]

no

 

[Psychadelic2012]

I am one of the people that views this theoretical orientation as not sufficient for most of the things that people come in for therapy for these days. But I am also a product of my experience. Perhaps for some people, developing a good rapport using humanistic principles (and no other intervention) is useful in the long-term. But I am of the mind that humaistic principles are fairly basic to most therapeutic interventions these days, and that additional parameters are necessary to manage specific presenting problems. It's generally good to follow the evidence base, and, as the topic of this thread is intended to point out - avoid doing harm.

And yet, there is so much evidence that it doesn't matter what theoretical orientation the therapist has or uses! I feel the way you do when someone starts going psychodynamic/analytic on me--perhaps, for some, talking about unconscious, "deep," or past underlying conflicts gives meaning to experiences. To me, it makes me want to punch the therapist because I feel pathologized and icky. I think a good, pure person-centered approach is golden. I do like a good dose of CBT thrown in for specific issues, but I subscribe to the belief that people will change on their own if they feel enough support and validation for what they're going through, because the world doesn't have that and we spend so much time and energy just being defensive. Anyway, everyone has different perspectives, but we don't tend to want to admit that, so we spend a lot of time fighting each other about it rather than moving forward (hmmmm...sounds familiar). 😀

 

[Pragma]

And yet, there is so much evidence that it doesn't matter what theoretical orientation the therapist has or uses! I feel the way you do when someone starts going psychodynamic/analytic on me--perhaps, for some, talking about unconscious, "deep," or past underlying conflicts gives meaning to experiences. To me, it makes me want to punch the therapist because I feel pathologized and icky. I think a good, pure person-centered approach is golden. I do like a good dose of CBT thrown in for specific issues, but I subscribe to the belief that people will change on their own if they feel enough support and validation for what they're going through, because the world doesn't have that and we spend so much time and energy just being defensive. Anyway, everyone has different perspectives, but we don't tend to want to admit that, so we spend a lot of time fighting each other about it rather than moving forward (hmmmm...sounds familiar). 😀

I think that there is a good reason that counseling has almost universally adopted humanistic principles. If most of your clienetele present with a milder set of symptoms, these general principles are no doubt a good place to begin.

If someone comes in for therapy for a serious case of a specific phobia, I think it would be idiotic to assume that just by being empathetic/humanistic we are going to help them with their phobia.

It all depends on the purpose of treatment, IMO. If someone is looking to be in therapy long term for an unspecific set of concerns that are not serious enough to keep them from working or a basic level of functioning, that is different than many of the issues that I see people go to therapy for. I also find the number of complaints about therapy from past patients to be particularly distressing.

So no doubt basic humanistic principles are very important for the therapeutic alliance. But things like "how long am I going to be in therapy for" and specific goals often escape treatment when they should not.

Edit: As far as the topic of thread is concern, I DO worry about people taking a nonspecific approach to therapy with particular tytpes of clients causing harm. I worry about some MA level private practice person taking on a therapy case for PTSD, believing that their empathy and client-centered approach will support that person with PTSD into change. Therapy such as this might have iatrogenic effects, no doubt.

 

[wigflip]

Here's the issue to which I keep returning:

Across various threads and over time, the following discourses seem to prevail on the doc forum here. I'm not saying that any one person has pulled these together at any one time (that's what I'm doing):

1. ESTs are essential. Implementing them effectively requires a certain level of formal education and training, a familiarity with the literature, and an ability to correctly interpret the literature, which includes advanced statistical and methodological training (and, many would argue, conducting one's own research in the form of an original empirical study, rather than a "critical review of the literature" or a study of "human-raven relations" etc.).

2. The above training seems most likely to be acquired in uni-based doctoral programs.

3. If one "only" wants to be a clinician, masters level training is sufficient. If you're not interested in going the academic route and publishing, or in conducting assessments, the extra years in school (and accumulated debt/lifetime earning potential) simply aren't worth the additional sacrifice.

4. But masters level clinicians typically lack the training to do #1, at least to the same extent that doctoral students can. For one, the focus on research isn't the same. In fact, the complaints on these boards indicate that numerous doctoral students have a shallow grasp of the empirical literature, misinterpreting results, cherry-picking studies but ignoring the wider field of lit (here I'm citing various folks who've complained about other students with whom they've worked at practicum, internship, etc.)

#4 is of course particularly problematic in light of #3.

Any thoughts?*

*I say this as someone who initially followed the advice in #3, but left my reputable masters program (for many reasons, but largely because I thought it failed the #1 test).

 

[Psychadelic2012]

Citations? My read of the literature is that theory, conceptualization, and technique DO matter (especially for particular classes of disorders like anxiety disorders).

Oh, come on. I didn't give a citation or a handful of citations for the same reason you didn't, and it's exactly what wigflip picked up on--we can cherry pick a few studies that support our claims, but that doesn't tell us anything. We all know that we can do that and that anyone who opposes it will find just as many studies that refute it. Pointless. If you don't even want to try to understand what someone (I) am saying, then just say you disagree based on principle/opinion and don't use the literature as a weapon.

I'm a little offended that person-centered approaches are being equated with "non-specific therapy" or "non-directive" which is then equated with "lazy" or "uneffective." The high road is not about how severe our patient's pathology is, where it is somehow easier to treat a less-ill person. I can't even pursue these types of argument with anyone--if you're not even willing to admit that literature (individual studies as well as broad meta-analyses) frequently supports the relationship over the technique in many cases, I throw my hands up in frustration. Regression to the mean, anyone? Or, is this just a philosophical debate, ala Freud? Have we changed at all, as a profession? Are we scientists who question and become surprised at our findings, even though they are not what we hypothesize, or are we stuck in our belief systems?

 

[Psychadelic2012]

If someone comes in for therapy for a serious case of a specific phobia, I think it would be idiotic to assume that just by being empathetic/humanistic we are going to help them with their phobia.

I actually think this is a good place to begin. We need to be talking about specific diagnoses or presentations when discussing whether specific treatments work or not, or are harmful or not. EST does not mean one thing works or doesn't work in every single case--not even person-centered therapy. The problem is when we lump them all together and then we have a case where the relationship becomes the most important thing, statistically speaking. But, I agree, how does that help with a case of specific phobia, for example?

 

[Pragma]

I actually think this is a good place to begin. We need to be talking about specific diagnoses or presentations when discussing whether specific treatments work or not, or are harmful or not. EST does not mean one thing works or doesn't work in every single case--not even person-centered therapy. The problem is when we lump them all together and then we have a case where the relationship becomes the most important thing, statistically speaking. But, I agree, how does that help with a case of specific phobia, for example?

Oh I know that one thing doesn't work for every case and such. I just think therapists use that as an excuse to do whatever they want sometimes.

 

[Iwillheal]

I don't understand all the hostility towards therapy emphasizing common factors. Is it that we call them "common factors"? Because as you know, they're not common at all! And it take heck of a lot of practice to get just decent at following those principles. Maybe we should call common factors something else, something that has a real punch to it, maybe an abbreviation can also help: RCPT (Rational Compassionate Positive Therapy). Sweet, that sounds REBTish enough. Or something that sounds like an SSRI...common factors...Factorox! Yes, Factorox! Maybe with the support of Big Pharma, people will actually start spending millions on it and studying it and publish high quality papers on it.