Psychotherapy Fads: The Case of Trauma-Informed Therapy

[cara susanna]

I hadn't realize there was a real anti-CBT community and so got quite a shock this morning when I started googling. Gem of the first hit I got was "CBT as a modality is based around gaslighting."

No, the source does not really explain the sense in which this is the case.

Yeah, I've seen that claim which just... is painful to me. It not only misunderstands gaslighting, it misunderstands CBT! Especially because I've done CPT (which is traditional CBT) with people who experienced intimate partner violence and actual gaslighting, and they found it so beneficial.

I didn’t know van der Kolk was anti-CBT. I use techniques from CBT and DBT, CPT, psychodynamic, and client-centered. I just pick whichever one the patient doesn’t hate. Sort of only half joking.

Yup, van der Kolk promotes this idea that CBT is a "top down" approach, whereas people with trauma need a "bottom up" approach due to the way they process information. Total BS and disregards the actual rationales of these therapies. The hilarious thing is they looove EMDR, which as we know has basically the same mechanism as PE. They also promote somatic therapies, and we all know what the research says about those.

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[futureapppsy2]

I hadn't realize there was a real anti-CBT community and so got quite a shock this morning when I started googling. Gem of the first hit I got was "CBT as a modality is based around gaslighting."

No, the source does not really explain the sense in which this is the case.

Gaslighting =someone having a different opinion from you in any way.

 

[futureapppsy2]

Yeah, I've seen that claim which just... is painful to me. It not only misunderstands gaslighting, it misunderstands CBT! Especially because I've done CPT (which is traditional CBT) with people who experienced intimate partner violence and actual gaslighting, and they found it so beneficial.



Yup, van der Kolk promotes this idea that CBT is a "top down" approach, whereas people with trauma need a "bottom up" approach due to the way they process information. Total BS and disregards the actual rationales of these therapies. The hilarious thing is they looove EMDR, which as we know has basically the same mechanism as PE. They also promote somatic therapies, and we all know what the research says about those.

But EMDR is so different because the eye movement stuff makes it physiological and therefore “scientific”!

 

[WisNeuro]

Yeah, many of the therapy reddits and the private psychotherapy reddit are pretty wholehog anti-science and anti-cbt. So, just remember folks, anti-scoience/anti-intellectualism ain't just for the Republican party anymore! The tent's big enough for everyone!

 

[cara susanna]

But if my patients feel a negative emotion they'll be RETRAUMATIZED!

There's this TMS video (for my fellow VA peeps) of this exposure therapist doing specific phobia treatment and he's honestly my hero. He does not fragilize the patient at all. He's completely direct and doesn't even bat an eye.

 

[cara susanna]

By the way, I finally watched the video and I liked the point they made. However, I thought the Dodo Bird Effect was essentially debunked?

 

[WisNeuro]

By the way, I finally watched the video and I liked the point they made. However, I thought the Dodo Bird Effect was essentially debunked?

Empirically, it essentially has been, but some people, and midlevels especially, will not give it up.

 

[psychologynbooks]

I was shocked to see a psychologist tell me he diagnosed a patient with PTSD when her “trauma” was finding a text her boyfriend sent to another girl. It’s frustrating when people believe you *need to diagnose to validate. An event could be upsetting/overwhelming and not meet diagnostic criteria for something. I do think broadening the trauma definition in some instances can be helpful, but it has also gone too far in some ways.

I’m also glad to hear others thoughts on EMDR because I know nothing about it other than what was mentioned on Grey’s Anatomy😂

With regard to CBT controversy, I’ve noticed a lot of critique happening on social media apps like tiktok. I find people who do not know what CBT is are often critiquing it. some people assume that if a therapist is lacking in skills/empathy, it’s because of their orientation rather than the clinician/fit. A friend of mine told me she hated CBT, when I asked her why, she actually described a psychoanalytic intervention and didn’t have the right label.

 

[cara susanna]

Yeah, and I have no doubt there are poorly trained clinicians out there who tell patients that they just need to "think positively" and say they're doing CBT.

 

[Fan_of_Meehl]

I hadn't realize there was a real anti-CBT community and so got quite a shock this morning when I started googling. Gem of the first hit I got was "CBT as a modality is based around gaslighting."

No, the source does not really explain the sense in which this is the case.

"CBT as a modality is based around gaslighting."

Wow...just...just...I mean...wow.

It is the absolute opposite of that. It's about helping the client (through Socratic questions) discover the truth within themselves and for themselves. Whoever is asserting that statement isn't just wrong about CBT and what it is 'about,' they are spreading anti-truths.

 

[Fan_of_Meehl]

I hadn't realize there was a real anti-CBT community and so got quite a shock this morning when I started googling. Gem of the first hit I got was "CBT as a modality is based around gaslighting."

No, the source does not really explain the sense in which this is the case.

To someone who is heavily invested in a 'victim' role with all of its attendant cognitive distortions...asking them to explain their positions (even nicely asking) with a sincere spirit of inquiry probably feels like they're being 'attacked' and 'gaslit.' 'Gaslighting' is one of those terms that appears grotesquely over-applied and over-utilized these days to cover any and all situations in which one person may disagree with another person about something (anything).

 

[Fan_of_Meehl]

But if my patients feel a negative emotion they'll be RETRAUMATIZED!

There's this TMS video (for my fellow VA peeps) of this exposure therapist doing specific phobia treatment and he's honestly my hero. He does not fragilize the patient at all. He's completely direct and doesn't even bat an eye.

I think I know the one you're talking about. Really cool and polite guy working with someone with claustrophobia and he had her tolerate increasing exposure to being in an enclosed cardboard box/space. He was pretty creative and did a great job demonstrating how doing excellent 'evidence-based' therapy is really all about truly understanding the fundamental theories (based on the basic science literature) and their flexible and creative application with clients including measurement of outcomes. If that's the one you're referring to, that is. Too many folks treat particular scripted protocols like they're tablets that Moses brought down from a mountain or something.

 

[romanticscience]

I’m starting to formulate that many of these PTSD folks have delusions. Yes, they may be able to check the box next to Criterion A but their mild thought disorganization and rigid beliefs (I CAN’T confront cue, expose WONT work for me, talking about this is abusing—gaslighting me, I NEED to live in my basement with the windows boarded up BECAUSE they’ll get me) are striking. Also, I get there is chronic PTSD but these people are suffering for decades.

Has their chronic avoidance made themselves worse? Akin to panic+avoidance = agoraphobia? Some of this narrative is antithetical to the basis of exposure and habituation learning. I guess PTSD isn’t an anxiety disorder though.

There seems to be a interesting continuum with the disorder and psychosis. I hear the combat vets say they can hallucinate the gunshots. That’s with reality testing intact right? What about that “complex” PTSDer who believes everyone who disagrees with them is persecuting them? Is that covered under the altered cognitions domain?

The diagnosis is so non-specific it gets confusing sometimes!

 

[DynamicDidactic]

I think mental health providers do what they are trained to do.

For example, MDs and advanced nurse practitioners are primarily trained to prescribe. Anecdotally, psychiatrists are much better at prescribing than PCPs or nurse practitioners, which would make sense based on quantity and quality of training.

The problem is the training in the States is not standardized and lacks a culture of adhering to guidelines, which means that most therapists aren't trained to do anything in particular. So, when these folks get out out into practice rather than practicing something that has credible evidence of efficacy or scientifically coherent, they are susceptible to all the biases of human beings (e.g., slick marketing, non-scientific theories, cognitive biases, relying on so-called authorities). Frankly, why would you not love EMDR when bilateral stimulation sounds credible since you do not have adequate training in neurology, are lacking scientific literacy, and do not use valid methods to monitor progress.

Edit: I hope that doesn't sound harsh. I simply mean to say that when the modal system of training does not typically provide enough scientific training and also does not provide adherent training in some sort of scientifically-supported, evidence-based treatment, then the only logical conclusion is this sort of stuff.

 

[WisNeuro]

I think mental health providers do what they are trained to do.

For example, MDs and advanced nurse practitioners are primarily trained to prescribe. Anecdotally, psychiatrists are much better at prescribing than PCPs or nurse practitioners, which would make sense based on quantity and quality of training.

The problem is the training in the States is not standardized and lacks a culture of adhering to guidelines, which means that most therapists aren't trained to do anything in particular. So, when these folks get out out into practice rather than practicing something that has credible evidence of efficacy or scientifically coherent, they are susceptible to all the biases of human beings (e.g., slick marketing, non-scientific theories, cognitive biases, relying on so-called authorities). Frankly, why would you not love EMDR when bilateral stimulation sounds credible since you do not have adequate training in neurology, are lacking scientific literacy, and do not use valid methods to monitor progress.

Edit: I hope that doesn't sound harsh. I simply mean to say that when the modal system of training does not typically provide enough scientific training and also does not provide adherent training in some sort of scientifically-supported, evidence-based treatment, then the only logical conclusion is this sort of stuff.

Why would that sound harsh?

 

[Sanman]

I think mental health providers do what they are trained to do.

For example, MDs and advanced nurse practitioners are primarily trained to prescribe. Anecdotally, psychiatrists are much better at prescribing than PCPs or nurse practitioners, which would make sense based on quantity and quality of training.

The problem is the training in the States is not standardized and lacks a culture of adhering to guidelines, which means that most therapists aren't trained to do anything in particular. So, when these folks get out out into practice rather than practicing something that has credible evidence of efficacy or scientifically coherent, they are susceptible to all the biases of human beings (e.g., slick marketing, non-scientific theories, cognitive biases, relying on so-called authorities). Frankly, why would you not love EMDR when bilateral stimulation sounds credible since you do not have adequate training in neurology, are lacking scientific literacy, and do not use valid methods to monitor progress.

Edit: I hope that doesn't sound harsh. I simply mean to say that when the modal system of training does not typically provide enough scientific training and also does not provide adherent training in some sort of scientifically-supported, evidence-based treatment, then the only logical conclusion is this sort of stuff.

The marketing also makes lives easier for the practitioners. Why learn classic CBT, ACT, CPT/PE, exposure and response prevention, etc when EMDR works for everything?

 

[tr]

Ah, we got a repressed memory crusader here, huh? Is that starting to make a comeback, are we going to start hearing about an epidemic of Satanic Sex Cults?

Apropos of this, I just ran across this paper that reaches the shocking conclusion that *only* the subjectively recalled dimensions of childhood adverse experiences are related to adult psychopathology. Even among individuals who had court-documented abuse in childhood, those who did not recall the abuse (or categorize it as such) had no higher rates of psychopathology than those with no objective or subjective abuse history.

Objective and subjective experiences of child maltreatment and their relationships with psychopathology - Nature Human Behaviour

In a cohort of 1,196 children followed to age 29 years, the authors found that risk of psychopathology was more strongly associated with subjective recall of childhood maltreatment histories than with objective, court-documented evidence of maltreatment.

www.nature.com

Fig. 1: Prevalence of psychopathology in participants with objective and/or subjective measures of child maltreatment.​

From: Objective and subjective experiences of child maltreatment and their relationships with psychopathology

a–d, Prevalence of psychopathology with any type of child maltreatment (physical abuse, sexual abuse or neglect) (a); child physical abuse (b); child sexual abuse (c); and child neglect (d). The first column displays the Venn diagrams for the overlap between groups identified by virtue of objective (O) and/or subjective (S) measures (in green and/or yellow, respectively); the second column refers to any psychopathology (grey shades); the third column refers to any internalizing disorder (depression, dysthymia, generalized anxiety or PTSD; blue shades); the fourth column refers to any externalizing disorder (antisocial personality, alcohol abuse and/or dependence, or drug abuse and/or dependence; red shades). See Supplementary Tables 2 and 5 for details of the analyses. Error bars, 95% CI; asterisks indicate that the corresponding prevalence estimate differs from the prevalence in the ‘none’ group at P < 0.05.

Fig. 2: Prevalence of individual diagnoses in participants with objective and/or subjective measures of child maltreatment.​

From: Objective and subjective experiences of child maltreatment and their relationships with psychopathology

 

[clausewitz2]

Apropos of this, I just ran across this paper that reaches the shocking conclusion that *only* the subjectively recalled dimensions of childhood adverse experiences are related to adult psychopathology. Even among individuals who had court-documented abuse in childhood, those who did not recall the abuse (or categorize it as such) had no higher rates of psychopathology than those with no objective or subjective abuse history.

Objective and subjective experiences of child maltreatment and their relationships with psychopathology - Nature Human Behaviour

In a cohort of 1,196 children followed to age 29 years, the authors found that risk of psychopathology was more strongly associated with subjective recall of childhood maltreatment histories than with objective, court-documented evidence of maltreatment.

www.nature.com

Fig. 1: Prevalence of psychopathology in participants with objective and/or subjective measures of child maltreatment.​

From: Objective and subjective experiences of child maltreatment and their relationships with psychopathology

a–d, Prevalence of psychopathology with any type of child maltreatment (physical abuse, sexual abuse or neglect) (a); child physical abuse (b); child sexual abuse (c); and child neglect (d). The first column displays the Venn diagrams for the overlap between groups identified by virtue of objective (O) and/or subjective (S) measures (in green and/or yellow, respectively); the second column refers to any psychopathology (grey shades); the third column refers to any internalizing disorder (depression, dysthymia, generalized anxiety or PTSD; blue shades); the fourth column refers to any externalizing disorder (antisocial personality, alcohol abuse and/or dependence, or drug abuse and/or dependence; red shades). See Supplementary Tables 2 and 5 for details of the analyses. Error bars, 95% CI; asterisks indicate that the corresponding prevalence estimate differs from the prevalence in the ‘none’ group at P < 0.05.

Fig. 2: Prevalence of individual diagnoses in participants with objective and/or subjective measures of child maltreatment.​

From: Objective and subjective experiences of child maltreatment and their relationships with psychopathology

Is it so surprising that how someone conceptualizes and understands their experience is a huge factor in how it affects them?

Me Too: On Sexual Assault

I want to preface this by emphasizing that I in no way want to trivialize experiences people have had as victims of sexual assault. All feelings are valid, and it’s ok to feel hurt even at something that might seem trivial to others.

aella.substack.com

 

[R. Matey]

The problem is the training in the States is not standardized and lacks a culture of adhering to guidelines, which means that most therapists aren't trained to do anything in particular. So, when these folks get out out into practice rather than practicing something that has credible evidence of efficacy or scientifically coherent, they are susceptible to all the biases of human beings (e.g., slick marketing, non-scientific theories, cognitive biases, relying on so-called authorities). Frankly, why would you not love EMDR when bilateral stimulation sounds credible since you do not have adequate training in neurology, are lacking scientific literacy, and do not use valid methods to monitor progress.

This is 100% the key issue as psychologists and psychiatrists continue to be the minority psychotherapy providers. SWs receive little to any instruction in psychotherapy and many, many mental health counselors are taught to believe they are competent to 'choose' a theoretical orientation instead of being trained in scientifically validated treatment approaches. The idea of the mid-level psychotherapy technician that relies on scientific expertise only works the technicians cooperate with expertise, but the training models don't support that framework.

 

[tr]

Is it so surprising that how someone conceptualizes and understands their experience is a huge factor in how it affects them?

Me Too: On Sexual Assault

I want to preface this by emphasizing that I in no way want to trivialize experiences people have had as victims of sexual assault. All feelings are valid, and it’s ok to feel hurt even at something that might seem trivial to others.

aella.substack.com

No but you're not surprised that the objectively documented maltreatment has zero bearing on mental health outcomes beyond what is subjectively recalled and categorized as traumatic? Your intuition about this is better than mine then.

 

[WisNeuro]

No but you're not surprised that the objectively documented maltreatment has zero bearing on mental health outcomes beyond what is subjectively recalled and categorized as traumatic? Your intuition about this is better than mine then.

Kind of fits with the cognitive reappraisal literature. Also, not very surprising to me given the concussion literature. Tell people that a concussion is terrible, that it will ruin their lives, and they will die early, and guess what happens to that group? Tell them that it will be ok, take it easy for a couple days, lay off contact sports for a few weeks, and get back to normal, and those people do much better. Expectancy and appraisal of the stressors/trauma/injury is huge.

 

[DynamicDidactic]

The marketing also makes lives easier for the practitioners. Why learn classic CBT, ACT, CPT/PE, exposure and response prevention, etc when EMDR works for everything?

That is just one example of the problem with much of psychotherapy training.