PhD/PsyD RANT: Arguing with therapists with no research background is like screaming at the ocean and begging the waves to subside

[msc545]

Like, here's one of the early studies

Naturalistic Follow-up of a Behavioral Treatment for Chronically Parasuicidal Borderline Patients

Background: A randomized clinical trial was conducted to evaluate whether the superior performance of dialectical behavior therapy (DBT), a psychosocial treatment for borderline personality disorder, compared with treatment-as-usual in the community, is maintained during a 1-year...

jamanetwork.com

Of course, no bias in this: "Superior performance" blah blah blah. A very representative sample: N = 39 is of course huge, right? Gunderson's Diagnostic Interview for Borderline Personality Disorder was used. No mention of reliability or validity data for this thing at all, and a diagnostic interview was apparently conducted, but no mention of inter-rater relaibility assuming they used more than one interviewer.

This is junk.

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[WisNeuro]

Oh, Oh, do this one!

Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder

Context Dialectical behavior therapy (DBT) is a treatment for suicidal behavior and borderline personality disorder with well-documented efficacy.Objective To evaluate the hypothesis that unique aspects of DBT are more efficacious compared with treatment offered by non–behavioral...

jamanetwork.com

 

[msc545]

Like, here's one of the early studies

Naturalistic Follow-up of a Behavioral Treatment for Chronically Parasuicidal Borderline Patients

Background: A randomized clinical trial was conducted to evaluate whether the superior performance of dialectical behavior therapy (DBT), a psychosocial treatment for borderline personality disorder, compared with treatment-as-usual in the community, is maintained during a 1-year...

jamanetwork.com

This study has multiple serious methodological errors that render the results essentially unreliable.

 

[WisNeuro]

This study has multiple serious methodological errors that render the results essentially unreliable.

Such as?

 

[clausewitz2]

This study has multiple serious methodological errors that render the results essentially unreliable.

Perhaps you could point to a psychotherapy RCT that is acceptable to you methodologically?

 

[msc545]

Perhaps you could point to a psychotherapy RCT that is acceptable to you methodologically?

Perhaps you could link one that you think might possibly be acceptable to real researchers?

 

[msc545]

Is it better to have no bandaid? It seems that you consider the alternative to be that BPD is untreatable, and then what? What do you do with these patients who are showing up? If nothing else, we DO know that DBT reduces hospitalizations and overall healthcare utilization/costs. Is that really worse than saying "welp, this is untreatable"?

I also do not think that DBT is promoted as a cure at all, but I suppose it depends on who you talk to.

There is presently no effective or lasting treatment for BPD, and pretending that there is does nobody any good at all.

 

[WisNeuro]

Ah, the answer we all expected. "I actually can't back up any of my criticisms, but you all suck, and I'm right!"

 

[smalltownpsych]

There is presently no effective or lasting treatment for BPD, and pretending that there is does nobody any good at all.

My deep dive into substance abuse research revealed kind of the same thing. Spontaneous recovery rate is pretty close to with tx rate and doesn’t even seem to matter what kind of treatment. One study found that number of vans a program had was correlated with recovery rate which makes sense in a couple of ways. Exposure to triggers while in treatment and introduction to community support.

Ultimately on the front lines I have patients that get better and patients that don’t and we do what we can to try and sort out what helps and what doesn’t. DBT is not a cure but is better than what we had before and I personally integrate the principles of the treatment with Object Relations for Borderline and treat it from a neurodevelopmental perspective and have had some success with some patients. Agree that we need more and better research and Linehan concurs but also thinks she has some pretty good evidence to support some aspects of efficacy already.

 

[cara susanna]

I attended a seminar on BPD (and this was by no means a DBT person, think of one of those old psychodynamic dudes) that said 25% of patients are untreatable, not all of them

 

[msc545]

Ah, the answer we all expected. "I actually can't back up any of my criticisms, but you all suck, and I'm right!"

The research is very flawed so perhaps it should be, "We can't offer any real proof it works, so just take our word for it"

 

[msc545]

I attended a seminar on BPD (and this was by no means a DBT person, think of one of those old psychodynamic dudes) that said 25% of patients are untreatable, not all of them

Probably more like 75%.

 

[clausewitz2]

Probably more like 75%.

Given the extraordinarily high long-term remission rates with BPD that have been fairly well documented, that seems... mathematically unlikely.

EDIT: speaking of mathematics, if we're going to be good Bayesians about this, it seems like we should require stronger evidence than 'I said so' for claims about DBT being uniquely poorly supported given most reasonable priors.

 

[PsychSupreme]

Given the extraordinarily high long-term remission rates with BPD that have been fairly well documented, that seems... mathematically unlikely.

EDIT: speaking of mathematics, if we're going to be good Bayesians about this, it seems like we should require stronger evidence than 'I said so' for claims about DBT being uniquely poorly supported given most reasonable priors.

Unfortunately, it seems like "I said so" is the best we're gonna get.

 

[msc545]

Given the extraordinarily high long-term remission rates with BPD that have been fairly well documented, that seems... mathematically unlikely.

EDIT: speaking of mathematics, if we're going to be good Bayesians about this, it seems like we should require stronger evidence than 'I said so' for claims about DBT being uniquely poorly supported given most reasonable priors.

What "extraordinarily high long-term remission rates " are you speaking of?

 

[AcronymAllergy]

What "extraordinarily high long-term remission rates " are you speaking of?

Can't speak for the OP, but from what I've seen:

Psychiatry Online (78% to 99% attained remission but not recovery over 16 years; although with more rapid and more common symptom recurrence relative to other PDs)

Psychiatry Online (88% attained remission over a 10-year span)

The above two studies, and many others, are from the same group, though.

Per another review (Recovery from Borderline Personality Disorder: A Systematic Review of the Perspectives of Consumers, Clinicians, Family and Carers), "symptomatic remission from BPD is common" (with caveats)

Per this meta, 50% to 70% achieved long-term remission: Long-term clinical and functional course of borderline personality disorder: A meta-analysis of prospective studies | European Psychiatry | Cambridge Core

I don't have a niche in practicing in this area, but anecdotally, have heard those who do say BPD symptomatology often declines with age.

 

[clausewitz2]

@msc545 , have you considered that perhaps your view of BPD and the relevant evidence base is perhaps out of date? I am assuming as a neuropsychologist long term therapy with these folks is not your main area of practice.

 

[cara susanna]

Can't speak for the OP, but from what I've seen:

Psychiatry Online (78% to 99% attained remission but not recovery over 16 years; although with more rapid and more common symptom recurrence relative to other PDs)

Psychiatry Online (88% attained remission over a 10-year span)

The above two studies, and many others, are from the same group, though.

Per another review (Recovery from Borderline Personality Disorder: A Systematic Review of the Perspectives of Consumers, Clinicians, Family and Carers), "symptomatic remission from BPD is common" (with caveats)

Per this meta, 50% to 70% achieved long-term remission: Long-term clinical and functional course of borderline personality disorder: A meta-analysis of prospective studies | European Psychiatry | Cambridge Core

I don't have a niche in practicing in this area, but anecdotally, have heard those who do say BPD symptomatology often declines with age.

I do work with that population and, yes, we find it often declines with age (but not always, lol).

 

[msc545]

@msc545 , have you considered that perhaps your view of BPD and the relevant evidence base is perhaps out of date? I am assuming as a neuropsychologist long term therapy with these folks is not your main area of practice.

Perhaps my view of it repeats older views, but to me, it still seems accurate. I do not treat people with BPD but I often evaluate them.

 

[msc545]

Can't speak for the OP, but from what I've seen:

Psychiatry Online (78% to 99% attained remission but not recovery over 16 years; although with more rapid and more common symptom recurrence relative to other PDs)

Psychiatry Online (88% attained remission over a 10-year span)

The above two studies, and many others, are from the same group, though.

Per another review (Recovery from Borderline Personality Disorder: A Systematic Review of the Perspectives of Consumers, Clinicians, Family and Carers), "symptomatic remission from BPD is common" (with caveats)

Per this meta, 50% to 70% achieved long-term remission: Long-term clinical and functional course of borderline personality disorder: A meta-analysis of prospective studies | European Psychiatry | Cambridge Core

I don't have a niche in practicing in this area, but anecdotally, have heard those who do say BPD symptomatology often declines with age.

I think it probably does decline with age as you suggest.

 

[smalltownpsych]

Perhaps my view of it repeats older views, but to me, it still seems accurate. I do not treat people with BPD but I often evaluate them.

Your population sample might skew your per a bit. Usually some treatment has been tried before an evaluation and for something as severe and persistent as BPD, they have usually had some years of undertreating and poor treatment. Much of the supposed DBT out there is run by people who cant even define what a dialectic is so you will see lots of people who have had DBT and really they have just been told to use their skills to stop cutting. Skills training is just one component of DBT and a focus on preventing the maladaptive behavior is what people do and it tends to make it worse. The dialectic is radical acceptance of negatives while simultaneously desiring change of that negative and most clinicians can’t do that so how can they help patients to develop that perspective? First thing I tell my patients is that we are not going to focus on the cutting. Instead we will focus on the precipitants or causes, ergo, chain analysis of the behavior. What is funny is that the painstaking chain analysis which is designed to help patient begin to learn to communicate distress and develop a more adaptive coping method for that distress is typically used by clinicians or programs as a punishment. Psychologists should know that punishment is of limited usefulness in effecting lasting behavior change.

In short, DBT works it’s just rarely seen outside the research labs.

 

[msc545]

Your population sample might skew your per a bit. Usually some treatment has been tried before an evaluation and for something as severe and persistent as BPD, they have usually had some years of undertreating and poor treatment. Much of the supposed DBT out there is run by people who cant even define what a dialectic is so you will see lots of people who have had DBT and really they have just been told to use their skills to stop cutting. Skills training is just one component of DBT and a focus on preventing the maladaptive behavior is what people do and it tends to make it worse. The dialectic is radical acceptance of negatives while simultaneously desiring change of that negative and most clinicians can’t do that so how can they help patients to develop that perspective? First thing I tell my patients is that we are not going to focus on the cutting. Instead we will focus on the precipitants or causes, ergo, chain analysis of the behavior. What is funny is that the painstaking chain analysis which is designed to help patient begin to learn to communicate distress and develop a more adaptive coping method for that distress is typically used by clinicians or programs as a punishment. Psychologists should know that punishment is of limited usefulness in effecting lasting behavior change.

In short, DBT works it’s just rarely seen outside the research labs.

I am not persuaded that DBT works except temporarily, and probably as a result of exposure. DBT has too many requirements and too many moving parts to really do much in a practical manner.

 

[borne_before]

I had an insight as to why I hate the new trauma narrative. A lot of people are just empowering mass emotional blackmail because no one wants to say “dude harden up a little.”

 

[Dazen]

I had an insight as to why I hate the new trauma narrative. A lot of people are just empowering mass emotional blackmail because no one wants to say “dude harden up a little.”

 

[msc545]

Nobody WANTS to say "dude harden up a little" because it is indicative of a total lack of empathy.

 

[borne_before]

Nobody WANTS to say "dude harden up a little" because it is indicative of a total lack of empathy.

Okay how about “dude, that sucks, harden up a little.”

 

[WisNeuro]

Okay how about “dude, that sucks, harden up a little.”

I believe the psychological term you are looking for is "grit." It is in short supply these days.

 

[msc545]

I believe the psychological term you are looking for is "grit." It is in short supply these days.

No. It is abusive and sounds angry. The woman popularized that term to promote her book.

 

[PsyDr]

No. It is abusive and sounds angry. The woman popularized that term to promote her book.

To clarify: Which type of opinions require empirical evidence? Because when you say an opinion, you're offering zero evidence. When others offer opinions with evidence, that's insufficient to you because of your opinion which has no evidence either.

 

[Dazen]

I also think it’s kinder to empathetically challenge your client if they’re behaving in a way that is unlikely to lead to their success rather than to unconditionally support their narrative.

 

[cara susanna]

Apparently research from the VA is now biased in favor of EBPs because they're motivated to support brief treatment.

(No one who has worked for the VA would ever say that)

 

[borne_before]

Update: the person who made a board complaint against me, made another to a medical provider at my work. There is also documentation from another clinic that they made a board complaint there after being escorted out.

 

[Sanman]

Update: the person who made a board complaint against me, made another to a medical provider at my work. There is also documentation from another clinic that they made a board complaint there after being escorted out.

Isn't it fun engaging with the public?

 

[AcronymAllergy]

Update: the person who made a board complaint against me, made another to a medical provider at my work. There is also documentation from another clinic that they made a board complaint there after being escorted out.

This doesn't sound like pathological behavior at all.

 

[cara susanna]

Gonna hijack this thread...

I've read somewhere that ACES isn't supposed to be used as a clinical tool, but rather was just intended for research. Is this true?

 

[PsychSupreme]

Gonna hijack this thread...

I've read somewhere that ACES isn't supposed to be used as a clinical tool, but rather was just intended for research. Is this true?

I have also been reading this! My understanding is that people caution against using ACEs for individual clinical predictions because ACEs show population-level statistically significant effects on outcomes, but those may or may not be applicable to an individual case (since so many covariables also affect outcomes; e.g., personality, SES, education...). As I understand it, it's not so much that ACEs cannot be used as part of a holistic way of understanding a person and their possible clinical trajectory, but rather that too many folks were using ACEs as a sort of "end all, be all" for determining that a person was likely to have negative outcomes. The ACEs data have also been hijacked by the trauma cult to argue that everything and anything must be the result of childhood adversity.

 

[FutureCycologist]

I have also been reading this! My understanding is that people caution against using ACEs for individual clinical predictions because ACEs show population-level statistically significant effects on outcomes, but those may or may not be applicable to an individual case (since so many covariables also affect outcomes; e.g., personality, SES, education...). As I understand it, it's not so much that ACEs cannot be used as part of a holistic way of understanding a person and their possible clinical trajectory, but rather that too many folks were using ACEs as a sort of "end all, be all" for determining that a person was likely to have negative outcomes. The ACEs data have also been hijacked by the trauma cult to argue that everything and anything must be the result of childhood adversity.

Appreciate this response! This was my feeling as well, so it's good to know it's not off base.

 

[PsychSupreme]

I have also been reading this! My understanding is that people caution against using ACEs for individual clinical predictions because ACEs show population-level statistically significant effects on outcomes, but those may or may not be applicable to an individual case (since so many covariables also affect outcomes; e.g., personality, SES, education...). As I understand it, it's not so much that ACEs cannot be used as part of a holistic way of understanding a person and their possible clinical trajectory, but rather that too many folks were using ACEs as a sort of "end all, be all" for determining that a person was likely to have negative outcomes. The ACEs data have also been hijacked by the trauma cult to argue that everything and anything must be the result of childhood adversity.

I'll add that I've also seen high ACEs scores be unilaterally interpreted as "you probably have trauma" without any further analysis of whether there are criterion A events and trauma symptoms, and without any consideration of resilience and protective factors that may have resulted in those ACEs not resulting in trauma pathology. Anyway, @cara susanna is the in-house traumatogician and is certainly not learning any of this information from me haha.

 

[cara susanna]

Thanks. I've been asked to start administering it to patients as part of a clinic I'm in, so I was hoping to clarify.

 

[smalltownpsych]

Thanks. I've been asked to start administering it to patients as part of a clinic I'm in, so I was hoping to clarify.

As an aside, I hate this approach. I much prefer to just talk to my patients about their life and the adverse experiences. It’s called therapy. When the aces stuff first started being talked about and the less informed would act like it was some revelation my first reaction was “no friggin kidding”. Like we didn’t already know that adverse childhood experiences affected our patients. Makes me glad I’m in private practice and I don’t have to fulfill bureaucratic mandates from people of questionable intellectual acumen.

 

[clausewitz2]

Working in a specialty clinic in a CMHC setting. This is a team with a very small caseload by design so can meet very regularly with therapists. WE discuss the entire caseload weekly. I suggest to the LCSW therapist of a particular patient who suffered a sexual assault in the not-so-distant past has started showing very classical symptoms of PTSD (deeply suspicious of anything that might even suggest that someone is connected to her reported perpetrator, terrible nightmares about the event, pronounced avoidance, irritability that comes out of nowhere, the whole clinical picture). I ask the therapist, who is relatively new to us, if she feels adequately trained and knowledgeable about exposure-based therapies and give examples like PE, CPT, WET. I tell her I know that some therapists do not like working in this framework because it is extremely uncomfortable being responsible for someone feeling very upset and not trying to immediately "fix it". She made a kind of vague affirmative noise, said she was going to start with that soon.

Next team meeting:

Team therapist: "Yeah, we decided to work on some exposure therapy. She said that she didn't want to ride her bike because she was afraid of looking stupid, and I told her, you won't, you won't!"

You don't really understand this idea, you don't, you dont!

...small caseload at least means I can clear enough consistent time to do it myself in the modalities that I am actually trained in.

This is also the lady who told one our least well patients that "you're in active delusion, your thoughts aren't real" and was surprised he stopped answering her phone calls, which....really no words.

 

[chicandtoughness]

Team therapist: "Yeah, we decided to work on some exposure therapy. She said that she didn't want to ride her bike because she was afraid of looking stupid, and I told her, you won't, you won't!"

What. in the.

I’m going to assume she meant “you won’t” as in “you won’t look stupid” and not “I bet you won’t ride your bike haha prove me wrong.”

But also, she needs a PE or CPT manual put on her desk.

 

[cara susanna]

Just saw on Reddit that some people think DBT is "ableist." Okay then.

 

[WisNeuro]

Just saw on Reddit that some people think DBT is "ableist." Okay then.

Therapists sub? They love to hate on DBT there. And it's painfully obvious that they have no real idea what DBT actually is.

 

[cara susanna]

Lol, yup. and now I'm getting a MILLION downvotes

 

[WisNeuro]

Lol, yup. and now I'm getting a MILLION downvotes

That sub does not engender empathy within me for low pay for midlevels.

 

[PsychSupreme]

Just saw on Reddit that some people think DBT is "ableist." Okay then.

Every day, we stray further from God

 

[PsychSupreme]

Lol, yup. and now I'm getting a MILLION downvotes

Wear them with honor! (But also, I just snuck over there and offered you some supplementary upvotes since we happen to be acquainted on Reddit.)

 

[The Cinnabon]

Therapists sub? They love to hate on DBT there. And it's painfully obvious that they have no real idea what DBT actually is.

It's such a concerning trend that the masses have begun scrutinizing legitimate evidence based practices and content experts as elitist, cold, and somehow incompetent while hailing midlevels as the people's hero/provider that knows the "truth."

 

[PsychSupreme]

It's such a concerning trend that the masses have begun scrutinizing legitimate evidence based practices and content experts as elitist, cold, and somehow incompetent while hailing midlevels as the people's hero/provider that knows the "truth."

The r/noctor sub has some toxic undertones, but I follow it because it reminds me that we are not the only field in which this is happening. Expertise is a meaningless term nowadays. Folks can be licensed counselors with no training in neuroscience but will bill themselves as "experts" on trauma and how it affects the body, or "experts" on depression with no background in etiological sciences. We have really loosed the criteria for expertise.