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

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As much as I hear psychodynamic/psychoanalytic folks whine about pro-CBT bias in the field, it’s certainly ironic that I hear much more CBT bashing by them than I ever hear psychodynamic bashing from CBT folks.
 
PsychSupreme said:
As much as I hear psychodynamic/psychoanalytic folks whine about pro-CBT bias in the field, it’s certainly ironic that I hear much more CBT bashing by them than I ever hear psychodynamic bashing from CBT folks.
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And, usually within the first three sentences of CBT bashing, it is abundantly clear that the person knows almost nothing about CBT.
 
Anyone else involved in training programs and seeing applicants who talk a lot about IFS? I'm really surprised to see it in doctoral psych programs!
 
IFS makes me think of the Inner Child stuff from the 90s. It is obviously true that we learn and develop and practice patterns of relating based on prior experiences but they take it to a woo woo place. I had one friend who liked to joke that he ever found his little child he would beat the crap out of that little bastard. Basically referring to immature and irresponsible patterns of behavior and thinking that he held onto from childhood. The problem I see with this type of “therapy” is that it reinforces maladaptive patterns. My foundations have always been psychodynamic and I just don’t see the need for a conflict between CBT and Attachment theory or Object Relations. My main objection to CBT is I don’t like homework, but that’s a personal issue, not a criticism of the techniques, that’s for sure.
 
smalltownpsych said:
IFS makes me think of the Inner Child stuff from the 90s. It is obviously true that we learn and develop and practice patterns of relating based on prior experiences but they take it to a woo woo place. I had one friend who liked to joke that he ever found his little child he would beat the crap out of that little bastard. Basically referring to immature and irresponsible patterns of behavior and thinking that he held onto from childhood. The problem I see with this type of “therapy” is that it reinforces maladaptive patterns. My foundations have always been psychodynamic and I just don’t see the need for a conflict between CBT and Attachment theory or Object Relations. My main objection to CBT is I don’t like homework, but that’s a personal issue, not a criticism of the techniques, that’s for sure.
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My thing is...not only is IFS just plainly unfalsifiable (I mean, how are we supposed to study these "parts?"), but even if one isn't bothered by the non-empirical nature of it (I am bothered, for the record, but even if one is not), why would someone want to reinforce feelings of multiplicity? Wouldn't the goal of trauma therapy be to promote feelings of integrated identity and sense of self, rather than further reinforce feelings of instability? I would imagine there could be really unfortunate results if this were used on people with BPD or BPD-like traits. Also, interestingly enough, IFS was the modus operandi of the Castlewood Institute, which most here will know was notorious for accepting patients with severe eating disorders as inpatients, only for many of those same patients to end up diagnosed with DID and full of confabulated memories of early childhood abuse. The institute was sued into oblivion and now either doesn't exist or has been rebranded enough to shed its reputation.
 
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smalltownpsych said:
IFS makes me think of the Inner Child stuff from the 90s. It is obviously true that we learn and develop and practice patterns of relating based on prior experiences but they take it to a woo woo place. I had one friend who liked to joke that he ever found his little child he would beat the crap out of that little bastard. Basically referring to immature and irresponsible patterns of behavior and thinking that he held onto from childhood. The problem I see with this type of “therapy” is that it reinforces maladaptive patterns. My foundations have always been psychodynamic and I just don’t see the need for a conflict between CBT and Attachment theory or Object Relations. My main objection to CBT is I don’t like homework, but that’s a personal issue, not a criticism of the techniques, that’s for sure.
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Should we blame that on your inner child?
 
PsychSupreme said:
My thing is...not only is IFS just plainly unfalsifiable (I mean, how are we supposed to study these "parts?"), but even if one isn't bothered by the non-empirical nature of it (I am bothered, for the record, but even if one is not) why would someone want to reinforce feelings of multiplicity? Wouldn't the goal of trauma therapy not be to promote feelings of integrated identity and sense of self, rather than further reinforce feelings of instability? I would imagine there could be really unfortunate results if this were used on people with BPD or BPD-like traits. Also, interestingly enough, IFS was the modus operandi of the Castlewood Institute, which most here will know was notorious for accepting patients with severe eating disorders as inpatients, only for many of those same patients to end up diagnosed with DID and full of confabulated memories of early childhood abuse. The institute was sued into oblivion and now either doesn't exist or has been rebranded enough to shed its reputation.
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Yup. Bad therapy 101. Fragile patients with an unstable sense of self are very vulnerable to this crap.
As far as research goes, you can’t really study the parts, but you can study the efficacy of using that conceptualization in treatment. It actually wouldn’t be hard to test. The hard part is finding an actual researcher who wants to compare a treatment like CBT to a treatment that is likely to make some patients worse. We tend to wait until lots and lots of people have been harmed before we come to the conclusion that something like this can be harmful.
 
smalltownpsych said:
Yup. Bad therapy 101. Fragile patients with an unstable sense of self are very vulnerable to this crap.
As far as research goes, you can’t really study the parts, but you can study the efficacy of using that conceptualization in treatment. It actually wouldn’t be hard to test. The hard part is finding an actual researcher who wants to compare a treatment like CBT to a treatment that is likely to make some patients worse. We tend to wait until lots and lots of people have been harmed before we come to the conclusion that something like this can be harmful.
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I definitely agree that one could always study the efficacy of the treatment--even if it were shown to be efficacious, though, I would still personally be uncomfortable with it because I don't like the idea of providing clients with explanatory systems/mechanisms which cannot themselves be demonstrated. That's my primary reason for not being super comfortable with psychodynamics--we know they can work very well for some folks, but being unable to demonstrate the existence of the psychodynamic unconscious and the other assumptions of the model makes me shy away from embracing it. I understand that not everyone has that same hangup, though--I just personally feel most comfortable using explanatory/meaning-making systems which can be demonstrated, even if those demonstrations are not perfect.

That said, I am sure many people report feeling better when engaging with an IFS therapist, but we all know that self-reports of feeling more heard and validated do not always translate to objective improvements in symptoms and functional capacity.
 
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PsychSupreme said:
Also, interestingly enough, IFS was the modus operandi of the Castlewood Institute, which most here will know was notorious for accepting patients with severe eating disorders as inpatients, only for many of those same patients to end up diagnosed with DID and full of confabulated memories of early childhood abuse. The institute was sued into oblivion and now either doesn't exist or has been rebranded enough to shed its reputation.
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Oh wow, you opened up a can of memories I forgot I had. Castlewood is still around, it’s called Alasana now, got bought out by private equity, and is expanding faster than it can provide quality care (along with the rest of the eating disorder treatment landscape, sigh.)
 
chicandtoughness said:
Oh wow, you opened up a can of memories I forgot I had. Castlewood is still around, it’s called Alasana now, got bought out by private equity, and is expanding faster than it can provide quality care (along with the rest of the eating disorder treatment landscape, sigh.)
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Operative word being forgot, and not repressed!
 
People in our field keep making up crap like IFS and DBT (without regard to efficacy) because it makes them money!
 
msc545 said:
People in our field keep making up crap like IFS and DBT (without regard to efficacy) because it makes them money!
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I have seen bad therapy called DBT in the community, but everything I have seen points to fairly extensive research about its efficacy. Some has been conducted independently of the Linehan institute as well. Patients of mine that have had good DBT skills training have tools that they can use. One challenge of implementation is that DBT is not psychotherapy and is not a replacement for psychotherapy. So a patient with significant trauma would still need good old fashioned exposure work from a well trained psychotherapist. DBT includes psychotherapy but doesn’t lay out the explicits of that work other than how to address the overall behavioral strategy of some of the safety concerns and the structure of the therapeutic frame. Of course, since many clinicians struggle with these core fundamentals, this alone can be of much use.
Your post makes me wonder if you know DBT that well and since I think that this body of work is one of the most important things in our field in the last 20 years so have to challenge it. 😊
 
There are methodological flaws in the research that supposedly demonstrates efficacy. In order to benefit from this "treatment" at all, people have to continue to go to it at a frequency that is not sustainable. People who "graduate" from DBT often "relapse" in a fairly short time after.

Other than that, I suppose it's fine.
 
msc545 said:
There are methodological flaws in the research that supposedly demonstrates efficacy. In order to benefit from this "treatment" at all, people have to continue to go to it at a frequency that is not sustainable. People who "graduate" from DBT often "relapse" in a fairly short time after.

Other than that, I suppose it's fine.
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Any citations to this effect for us to peruse?
 
msc545 said:
There are methodological flaws in the research that supposedly demonstrates efficacy. In order to benefit from this "treatment" at all, people have to continue to go to it at a frequency that is not sustainable. People who "graduate" from DBT often "relapse" in a fairly short time after.

Other than that, I suppose it's fine.
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I don’t know about the flaws in the research, but the relapse into maladaptive behaviors is consistent with what I see. Given that the prevailing belief in the field that BPD was untreatable and we should curtail how many we worked with prior to DBT, I have witnessed a dramatic shift in outcome and treatment. Also, I don’t think “relapse“ necessarily means treatment didn’t work. As I tell people, patterns repeat and we are looking for a decrease in frequency, intensity, and duration as opposed to an all or none perspective. That makes more sense with substance use than it does with maladaptive patterns related to intense fears of abandonment. I also think that continued treatment and/or support and a recognition of a more lasting continued vulnerability to stress after an intensive phase of DBT is essential.
 
cara susanna said:
I am fairly positive that research has shown the exact opposite, in fact. Plenty of studies have demonstrated that improvements from DBT are maintained post tx
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That was my impression. Particularly when you look at treatment gains within the realm of PDs. That's why I was curious if the poster was talking out of their ass like usual, or had something of substance to contribute.
 
smalltownpsych said:
I don’t know about the flaws in the research, but the relapse into maladaptive behaviors is consistent with what I see. Given that the prevailing belief in the field that BPD was untreatable and we should curtail how many we worked with prior to DBT, I have witnessed a dramatic shift in outcome and treatment. Also, I don’t think “relapse“ necessarily means treatment didn’t work. As I tell people, patterns repeat and we are looking for a decrease in frequency, intensity, and duration as opposed to an all or none perspective. That makes more sense with substance use than it does with maladaptive patterns related to intense fears of abandonment. I also think that continued treatment and/or support and a recognition of a more lasting continued vulnerability to stress after an intensive phase of DBT is essential.
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So in essence, you think that it partly works but after time it loses its effectiveness? If so, I certainly do not want to offer that "treatment" to people knowing it will fail eventually, and also knowing that people with BPD are often quite dangerous.
 
msc545 said:
So in essence, you think that it partly works but after time it loses its effectiveness? If so, I certainly do not want to offer that "treatment" to people knowing it will fail eventually, and also knowing that people with BPD are often quite dangerous.
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This describes the majority of non-surgical treatments in medicine. Do you think internists are a bad idea?
 
clausewitz2 said:
This describes the majority of non-surgical treatments in medicine. Do you think internists are a bad idea?
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And I'm not so sure what 'loses its effectiveness' means (precisely) in this context.

Does the poster mean that the valid (and generally effective) empirically-supported principles of behavior change ("coping skills") such as mindfulness/relaxation, self-monitoring, identifying/challenging cognitive errors, behavioral activation, exposure, problem-solving, assertiveness, etc., somehow become INERT or ineffective for the patient over time in the form of coping strategies for the patient or is the patient simply 'relapsing' back into ineffective practices, meaning they need a refresher course on the (quite) effective techniques?

Sounds to me like a stretching of the 'medical metaphor' as applied to behavioral interventions.

Language can be tricky here.

The 'protocol-for-[DSM]-syndrome' mindset is to be contrasted with the more idiographic process-based perspective.

Protocols don't 'treat' syndromes.


Patients can be taught effective coping skills and strategies based on solid clinical science and can either be effective or ineffective in implementing them. Enduring behavior change is often quite difficult after returning to the original environments within which dysfunctional strategies originated.
 
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cara susanna said:
Omg I got a bunch of downvotes for saying that self harm is ineffective coping

In the therapists subreddit
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Going to that sub is its own form of self-harm. You've got a masochistic streak.
 
cara susanna said:
Omg I got a bunch of downvotes for saying that self harm is ineffective coping

In the therapists subreddit
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One of the things I will say frequently is that self harm is easier for me to treat than a substance addiction becuase it doesn’t work as well. Replacing it with a more adaptive and effective method such as learning to recognize and express your emotions in a caring relationship beats self harm pretty easy. Drugs of abuse on the other hand tend to easily “win” that comparison. In short, it is pretty low on the effective coping ladder. As far as whether it is adaptive or maladaptive, that’s a little different question. Im pretty sure that ways of improving mindfulness, emotional regulation, interpersonal effectiveness, and distress tolerance are way more in the adaptive camp than either ways of coping.
 
msc545 said:
So in essence, you think that it partly works but after time it loses its effectiveness? If so, I certainly do not want to offer that "treatment" to people knowing it will fail eventually, and also knowing that people with BPD are often quite dangerous.
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No. It can alleviate the symptoms and teach skills that are lasting, but it doesn’t mean that the person isn’t vulnerabke to relapse and probably needs ongoing less intensive treatment. Especially to work on the interpersonal effectiveness component of DBT which is the hard part for all of us anyway. Dealing with people. The research doesn’t really address this as much because it is more intangible and harder to measure and longer term, but I still think that someone who at their core has a long-standing chronic pattern of unstable relationships is going to need extra work on that. Marsha Linehan says that is the way she sees it pretty directly. Of course, you can always do that through becoming a zen master the way she did since psychotherapists weren’t willing or able to help her but a long term practice of some sorts is kind of assumed.
 
Given the typical course of mental health and the state of intervention science, I'm hard pressed to think of cases where "It partly works but after time loses its effectiveness" doesn't apply. Maybe exposure treatments for the rare "truly pure" case of PTSD/phobia, or primary insomnia due to obviously-terrible sleep hygiene?

It certainly applies to all psychological interventions for MDD, GAD, SUDs, EDs and most any other bread & butter diagnoses I can think of. Let's be real, curative therapy is the exception and not the rule.

Am I misunderstanding something?
 
Ollie123 said:
Given the typical course of mental health and the state of intervention science, I'm hard pressed to think of cases where "It partly works but after time loses its effectiveness" doesn't apply. Maybe exposure treatments for the rare "truly pure" case of PTSD/phobia, or primary insomnia due to obviously-terrible sleep hygiene?

It certainly applies to all psychological interventions for MDD, GAD, SUDs, EDs and most any other bread & butter diagnoses I can think of. Let's be real, curative therapy is the exception and not the rule.

Am I misunderstanding something?
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Nah.. I think we're potentially conflating two different things...one is based on an idiographic perspective (judging the efficacy of specific skills taught), the other on a more normative/average (across a number of subjects) perspective (judging the DBT 'package' in terms of loss of tx effects for the avg pt over time at f/u).

I think most would agree that the principles upon which, say, a DBT protocol or treatment package are based are sound and can be effective (leading to sx reduction DURING the initial course of therapy) but this doesn't mean that some (even a good many) such patients may 'relapse' and cease utilizing effective coping skills learned in therapy (and suffer an increase in symptoms) some time later at followup.
 
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cara susanna said:
Omg I got a bunch of downvotes for saying that self harm is ineffective coping

In the therapists subreddit
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1702609464316.jpeg
 
smalltownpsych said:
No. It can alleviate the symptoms and teach skills that are lasting, but it doesn’t mean that the person isn’t vulnerabke to relapse and probably needs ongoing less intensive treatment. Especially to work on the interpersonal effectiveness component of DBT which is the hard part for all of us anyway. Dealing with people. The research doesn’t really address this as much because it is more intangible and harder to measure and longer term, but I still think that someone who at their core has a long-standing chronic pattern of unstable relationships is going to need extra work on that. Marsha Linehan says that is the way she sees it pretty directly. Of course, you can always do that through becoming a zen master the way she did since psychotherapists weren’t willing or able to help her but a long term practice of some sorts is kind of assumed.
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I agree, but I also note that people with BPD are rarely able to engage in the sort of long-term treatment that might be effective.
 
clausewitz2 said:
This describes the majority of non-surgical treatments in medicine. Do you think internists are a bad idea?
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No of course not, but then again internists don't usually misrepresent what they are doing.
 
msc545 said:
I agree, but I also note that people with BPD are rarely able to engage in the sort of long-term treatment that might be effective.
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If suddenly a treatment were available that arrested the development of a highly deadly cancer and extended survival by 5 years above other treatments, but still usually ended in progression of disease and death, that treatment would immediately become standard of care in oncology. I’m sorry, but I don’t understand how DBT for BPD is pseudoscientific or being misrepresented simply because the individuals receiving treatment are vulnerable to relapse. DBT inarguably is effective at increasing QOL and reducing symptom severity above and beyond alternative options and as such is reasonably the standard of care.
 
PsychSupreme said:
If suddenly a treatment were available that arrested the development of a highly deadly cancer and extended survival by 5 years above other treatments, but still usually ended in progression of disease and death, that treatment would immediately become standard of care in oncology. I’m sorry, but I don’t understand how DBT for BPD is pseudoscientific or being misrepresented simply because the individuals receiving treatment are vulnerable to relapse. DBT inarguably is effective at increasing QOL and reducing symptom severity above and beyond alternative options and as such is reasonably the standard of care.
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I don't think reason or facts will work in this specific argument.
 
PsychSupreme said:
If suddenly a treatment were available that arrested the development of a highly deadly cancer and extended survival by 5 years above other treatments, but still usually ended in progression of disease and death, that treatment would immediately become standard of care in oncology. I’m sorry, but I don’t understand how DBT for BPD is pseudoscientific or being misrepresented simply because the individuals receiving treatment are vulnerable to relapse. DBT inarguably is effective at increasing QOL and reducing symptom severity above and beyond alternative options and as such is reasonably the standard of care.
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You are arguing a false equivalency. DBT research is very flawed - something you would presumably know if you were to read it. It is misrepresented often as a "cure" for BPD which it is not. It may or may not increase QOL for friends and relatives of people with BPD (if they have any left), but it is very doubtful that it improves QOL for people who have BPD. That said, I also note that QOL is not a quantitative measure of anything. It is the "standard of care" only because there is nothing else, and at least it gives foolish therapists something to hang on to. I say "foolish" because only a foolish person attempts to treat BPD given that it is untreatable.

At best, DBT is a bandaid, and not a very good one.
 
msc545 said:
You are arguing a false equivalency. DBT research is very flawed - something you would presumably know if you were to read it. It is misrepresented often as a "cure" for BPD which it is not. It may or may not increase QOL for friends and relatives of people with BPD (if they have any left), but it is very doubtful that it improves QOL for people who have BPD. That said, I also note that QOL is not a quantitative measure of anything. It is the "standard of care" only because there is nothing else, and at least it gives foolish therapists something to hang on to. I say "foolish" because only a foolish person attempts to treat BPD given that it is untreatable.

At best, DBT is a bandaid, and not a very good one.
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You’ve still yet to answer any request for explanation as to why you find the research flawed. It also seems like you carry a very unhealthy and stigmatizing attitude toward people with BPD, who are demonstrably not untreatable and hopeless…it really just seems like you’re arguing out of misplaced emotions than anything.
 
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PsychSupreme said:
You’ve still yet to answer any request for explanation as to why you find the research flawed. It also seems like you carry a very unhealthy and stigmatizing attitude toward people with BPD, who are demonstrably not untreatable and hopeless…it really just seems like you’re arguing out of misplaced emotions than anything.
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Read the research yourself, and keep your amateur eval comments to yourself, "Supreme".
 
msc545 said:
Read the research yourself, and keep your amateur eval comments to yourself, "Supreme".
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Translation: "I can't actually explain why I think it's bad research so I'll just keep skirting requests to explain myself and demonstrating my ignorance about a whole clinical population by saying that they're untreatable."

Either back up your claim that the research is flawed and weak, or stop saying it.
 
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msc545 said:
You are arguing a false equivalency. DBT research is very flawed - something you would presumably know if you were to read it. It is misrepresented often as a "cure" for BPD which it is not. It may or may not increase QOL for friends and relatives of people with BPD (if they have any left), but it is very doubtful that it improves QOL for people who have BPD. That said, I also note that QOL is not a quantitative measure of anything. It is the "standard of care" only because there is nothing else, and at least it gives foolish therapists something to hang on to. I say "foolish" because only a foolish person attempts to treat BPD given that it is untreatable.

At best, DBT is a bandaid, and not a very good one.
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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.
 
cara susanna said:
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.
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You do run into this attitude among medical folks sometimes, because they have learned for the purposes of a multiple choice exam at some point that "BPD = refer for DBT" in the same way "syphillis = treat with penicillin." It can also be a way for some psychiatrists to dismiss folks with BPD, "go to DBT (and get out of my office)". More dissemination of GPM is starting to change this (most folks with BPD probably don't need super-specialized treatment if structured correctly) but it's a thing that happens.

EDIT: Zero shade towards DBT, I totally agree about its utility.
 
clausewitz2 said:
You do run into this attitude among medical folks sometimes, because they have learned for the purposes of a multiple choice exam at some point that "BPD = refer for DBT" in the same way "syphillis = treat with penicillin." It can also be a way for some psychiatrists to dismiss folks with BPD, "go to DBT (and get out of my office)". More dissemination of GPM is starting to change this (most folks with BPD probably don't need super-specialized treatment if structured correctly) but it's a thing that happens.

EDIT: Zero shade towards DBT, I totally agree about its utility.
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Fwiw, I totally agree with you. Psychiatry always refers for DBT without actually seeing if the patient 1) wants it and 2) is able to engage. I actually read that there is a push amongst BPD experts to despecialize treating BPD, and promote that these pts can potentially benefit from any type of therapy (I'm not sure how that addresses what I see as the main issue of provider burnout, though...)

I used to give a seminar on DBT for our psychiatry residents and that was the number one thing I tried to convey: the patient HAS to be committed to the therapy for it to work. This isn't like prescribing a pill.
 
cara susanna said:
Like, here's one of the early studies

jamanetwork.com

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 jamanetwork.com
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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.
 
cara susanna said:
Like, here's one of the early studies

jamanetwork.com

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 jamanetwork.com
Click to expand...
This study has multiple serious methodological errors that render the results essentially unreliable.
 
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