The APA & EDMR

[Young Grasshoppa]

I dunno...honestly, I think that their publicly announced position on the definition (tri-partite) of 'evidence-based therapy' is one of the few things recently that APA has 'gotten right.'

We older psychologists remember way back in the dinosaur 1990's when we were in training and they rolled out this new term 'empirically-validated' to describe a handful of protocol/manualized therapies that had at least one methodologically sound outcome trial under their belt.

Then they had to 'back off' of that term a little bit and it got reframed as 'empirically-supported.'

Then, at some point, I suppose out of medical envy and chasing of reimbursement (which I understand), it morphed into 'evidence-based' (to sound similar to 'evidence-based' medicine).

There certainly are psychologists who use the term 'evidence-based' therapy to mean only manualized/protocol treatments. It's how they may employ the term and may be what they imply when they use it but I don't think I've ever seen an explicit definition of the term to mean only the manualized alphabet therapies. I think that the reliance on manualized, step-by-step, one-size-fits-all, cognitive-behavioral protocol therapies--though definitely having their place in psychotherapy and doing a lot of good for the field--have had unfortunate side effects such as teaching an entire generation of therapists that manualized psychotherapy is the 'one true way' and that anyone not using a manual is 'not doing evidence-based therapy.' It has also lessened the (critical) role of individualized clinical case formulation specific to the client and idiographic (functional) assessment. These are some of the things that a renewed focus on process-based therapy is designed to remediate.

Fascinating.

Quantifying the highly individualized pieces of a clinical case and particular assessment and then examining the efficacy of the process-based therapy is a huge challenge. I would love to see this approach succeed. The human condition is much deeper and more nuanced than can be properly captured by any protocol-to-syndrome approach.

On the other hand, protocol-to-syndrome approaches are much much simpler to study. They have clear unambiguous implementation that leads to straightforward RCTs with very compelling evidence for efficacy.

Do you think that process-based research will be able to come up with clear implementation and solid evidence? Or has it already?

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[AcronymAllergy]

Fascinating.

Quantifying the highly individualized pieces of a clinical case and particular assessment and then examining the efficacy of the process-based therapy is a huge challenge. I would love to see this approach succeed. The human condition is much deeper and more nuanced than can be properly captured by any protocol-to-syndrome approach.

On the other hand, protocol-to-syndrome approaches are much much simpler to study. They have clear unambiguous implementation that leads to straightforward RCTs with very compelling evidence for efficacy.

Do you think that process-based research will be able to come up with clear implementation and solid evidence? Or has it already?

There's the Unified Protocol from Barlow et al., as an example of a transdiagnostic intervention.

 

[Sanman]

I dunno...honestly, I think that their publicly announced position on the definition (tri-partite) of 'evidence-based therapy' is one of the few things recently that APA has 'gotten right.'

We older psychologists remember way back in the dinosaur 1990's when we were in training and they rolled out this new term 'empirically-validated' to describe a handful of protocol/manualized therapies that had at least one methodologically sound outcome trial under their belt.

Then they had to 'back off' of that term a little bit and it got reframed as 'empirically-supported.'

Then, at some point, I suppose out of medical envy and chasing of reimbursement (which I understand), it morphed into 'evidence-based' (to sound similar to 'evidence-based' medicine).

There certainly are psychologists who use the term 'evidence-based' therapy to mean only manualized/protocol treatments. It's how they may employ the term and may be what they imply when they use it but I don't think I've ever seen an explicit definition of the term to mean only the manualized alphabet therapies. I think that the reliance on manualized, step-by-step, one-size-fits-all, cognitive-behavioral protocol therapies--though definitely having their place in psychotherapy and doing a lot of good for the field--have had unfortunate side effects such as teaching an entire generation of therapists that manualized psychotherapy is the 'one true way' and that anyone not using a manual is 'not doing evidence-based therapy.' It has also lessened the (critical) role of individualized clinical case formulation specific to the client and idiographic (functional) assessment. These are some of the things that a renewed focus on process-based therapy is designed to remediate.

God, you're old. I'm like 120 according to this board and I wasn't in training in the 90s.

While I think process based approaches are important, manualized protocols have more utility when you are 'moving the meat' and have a younger or less trained work force. Thinking (which is what clinical case formulation is after all) is slowly becoming a task for those that can afford the luxury.

 

[WisNeuro]

God, you're old. I'm like 120 according to this board and I wasn't in training in the 90s.

While I think process based approaches are important, manualized protocols have more utility when you are 'moving the meat' and have a younger or less trained work force. Thinking (which is what clinical case formulation is after all) is slowly becoming a task for those that can afford the luxury.

You are definitely the whitest, oldest, most cis-male person on this board

 

[Fan_of_Meehl]

Fascinating.

Quantifying the highly individualized pieces of a clinical case and particular assessment and then examining the efficacy of the process-based therapy is a huge challenge. I would love to see this approach succeed. The human condition is much deeper and more nuanced than can be properly captured by any protocol-to-syndrome approach.

On the other hand, protocol-to-syndrome approaches are much much simpler to study. They have clear unambiguous implementation that leads to straightforward RCTs with very compelling evidence for efficacy.

Do you think that process-based research will be able to come up with clear implementation and solid evidence? Or has it already?

In a very real sense, it's already "been done."

What is old is new again.

If you look at how Beck and even Barlow practiced, what they did was closer to the process-based (theory-driven, individualized case formulation) approach. It's how I was trained. It's really more about attending to the role of THEORY as applied to the individual case rather than a simple 'make diagnosis' --> apply protocol.

Unfortunately, the rich theoretical bases of cognitive, behavioral, and cognitive-behavioral TECHNIQUES/INTERVENTIONS don't appear to be emphasized near as much in modern CBT writings as they did 20+ years ago. Though a bit outdated, keep/collect the books from 20+ years ago and read some of the classic papers that are widely cited. You'll benefit tremendously.

Everyone is emphasizing 'empiricism' at the nomothetic/population level and focusing on outcome studies adopting the protocol-for-syndrome approach but the crucial role of THEORY (especially applied theory with the individual patient combined with collaborative empiricism (via behavioral experiments, self-monitoring, etc.)) cannot be over-stated...in science, generally, or in scientifically-informed psychotherapeutic practice. Case formulation grounded in theory is becoming a lost art but I think it's the 'sine qua non' of effective psychotherapy.

 

[Shiori]

I have appreciated the work of Louis Cozolino as a way to dig into what we're trying to achieve as clinicians. Sometimes he'll go off into the woo of psychology, but I think he does a decent job of acknowledging when there isn't a strong evidence base for his assertions other than his gut and anecdote.

I liked The Making of a Therapist and Why Therapy Works.

 

[Sanman]

You are definitely the whitest, oldest, most cis-male person on this board

 

[smalltownpsych]

Training during the 90s? Wow! I was still dreaming of my own warehouse and distribution business back then while I was setting up a computer automated inventory and billing for a small company that did this. Literally replaced pen and paper logs and individually typed up bills and saved about 40 hours of labor per month.

 

[Young Grasshoppa]

In a very real sense, it's already "been done."

What is old is new again.

If you look at how Beck and even Barlow practiced, what they did was closer to the process-based (theory-driven, individualized case formulation) approach. It's how I was trained. It's really more about attending to the role of THEORY as applied to the individual case rather than a simple 'make diagnosis' --> apply protocol.

Unfortunately, the rich theoretical bases of cognitive, behavioral, and cognitive-behavioral TECHNIQUES/INTERVENTIONS don't appear to be emphasized near as much in modern CBT writings as they did 20+ years ago. Though a bit outdated, keep/collect the books from 20+ years ago and read some of the classic papers that are widely cited. You'll benefit tremendously.

Everyone is emphasizing 'empiricism' at the nomothetic/population level and focusing on outcome studies adopting the protocol-for-syndrome approach but the crucial role of THEORY (especially applied theory with the individual patient combined with collaborative empiricism (via behavioral experiments, self-monitoring, etc.)) cannot be over-stated...in science, generally, or in scientifically-informed psychotherapeutic practice.

I so appreciate this perspective.

You have the benefit of being apparently, the oldest psychotherapist on the board... As a newbie entering a world that has for a full generation so embraced manualized protocol-to-syndrome therapies propped up by outcome studies, my question is:

Are there any research universities left who operate with a combination of theory-driven process-based training together with solid research?
Where do I find a place that actually focuses on this long lost art along with its research?

@Shiori - Those books look interesting. Looking forward to a good read. Thanks!

Case formulation grounded in theory is becoming a lost art but I think it's the 'sine qua non' of effective psychotherapy.

While my gut tells me this is right, do you know of any papers that substantiate the claim that practice without theory suffers significantly?

 

[Sanman]

I so appreciate this perspective.

You have the benefit of being apparently, the oldest psychotherapist on the board... As a newbie entering a world that has for a full generation so embraced manualized protocol-to-syndrome therapies propped up by outcome studies, my question is:

Are there any research universities left who operate with a combination of theory-driven process-based training together with solid research?
Where do I find a place that actually focuses on this long lost art along with its research?

Most funded clinical psych doctoral programs will do this to one degree or another. Finding the education is not the hard part. EBP protocols are largely a practice level issue. It the payors that push this stuff not the ivory tower. Unless your clientele has deep pockets and trusts your abilities, most will only get time limited protocols.

 

[Fan_of_Meehl]

I so appreciate this perspective.

You have the benefit of being apparently, the oldest psychotherapist on the board... As a newbie entering a world that has for a full generation so embraced manualized protocol-to-syndrome therapies propped up by outcome studies, my question is:

Are there any research universities left who operate with a combination of theory-driven process-based training together with solid research?
Where do I find a place that actually focuses on this long lost art along with its research?

@Shiori - Those books look interesting. Looking forward to a good read. Thanks!

While my gut tells me this is right, do you know of any papers that substantiate the claim that practice without theory suffers significantly?

I think the approach you may be looking for is an idiographic measurement-based care approach where you track patient responsivity to your intervention over time. Beyond that, at the nomothetic level, you're looking at the mediation/moderation literature in terms of what facilitates psychotherapeutic outcomes.

"Practice without theory..."

What in the Hell would that even look like

Oh..wait a minute...I work for VA...we call that "supportive therapy" and the evidence that it doesn't work is all over the place

 

[Sanman]

"Practice without theory..."

What in the Hell would that even look like

Oh..wait a minute...I work for VA...we call that "supportive therapy" and the evidence that it doesn't work is all over the place

Walk outside of your office and count the number of veterans coming for a PTSD social group with their emotional support animal in tow.

 

[Young Grasshoppa]

I think the approach you may be looking for is an idiographic measurement-based care approach where you track patient responsivity to your intervention over time. Beyond that, at the nomothetic level, you're looking at the mediation/moderation literature in terms of what facilitates psychotherapeutic outcomes.

Definitely looking for something like that.

The article you posted before really lays out the issues beautifully! Very exciting frontiers.

Are there any solid textbook/summary texts or websites/organizations that are dedicated to moderation/mediation literature or research on PBT components and implementation or do I have to just find articles one by one?

 

[Fan_of_Meehl]

Definitely looking for something like that.

The article you posted before really lays out the issues beautifully! Very exciting frontiers.

Are there any solid textbook/summary texts or websites/organizations that are dedicated to moderation/mediation literature or research on PBT components and implementation or do I have to just find articles one by one?

There's a good book on Process Based Therapy by Hayes and Hofmann. Just Google it, should come right up.

 

[cara susanna]

In the opinion of the psychologists here are there any interventions that are evidence-based besides CBT and exposure therapy?

I'm a bit reluctant to reply to you since you basically said that I can't read, but...

The 2023 VA/DoD clinical practice guidelines for PTSD indicate that the top tier recommended treatments, meaning the ones with the highest quality and most studies to support them, are prolonged exposure, cognitive processing therapy, and EMDR. There is a second tier that is suggested, meaning there is some good research supporting them but they're not quite at the level of the top tier: written exposure therapy (which is also exposure based), present-centered therapy (not exposure-based or even trauma-focused), and cognitive therapy (CBT). Generally, the most effective treatments seem to be ones that target unhelpful or negative beliefs and avoidance of both external and internal trauma cues.

Also, for future reference, exposure therapy is a type of CBT. PE is considered CBT, for instance. CBT is a large umbrella that includes many, many different protocols.

I should add that there is some controversy around the second tier and there are some top people in the field who think that it was unfair to categorize them lower, and disagree with the methodology that was used to determine them as lower tier: see US Veterans Affairs and Department of Defense 2023 Clinical Guideline for PTSD

 

[Fan_of_Meehl]

I'm a bit reluctant to reply to you since you basically said that I can't read, but...

The 2023 VA/DoD clinical practice guidelines for PTSD indicate that the top tier recommended treatments, meaning the ones with the highest quality and most studies to support them, are prolonged exposure, cognitive processing therapy, and EMDR. There is a second tier that is suggested, meaning there is some good research supporting them but they're not quite at the level of the top tier: written exposure therapy (which is also exposure based), present-centered therapy (not exposure-based or even trauma-focused), and cognitive therapy (CBT). Generally, the most effective treatments seem to be ones that target unhelpful or negative beliefs and avoidance of both external and internal trauma cues.

Also, for future reference, exposure therapy is a type of CBT. PE is considered CBT, for instance. CBT is a large umbrella that includes many, many different protocols.

I should add that there is some controversy around the second tier and there are some top people in the field who think that it was unfair to categorize them lower, and disagree with the methodology that was used to determine them as lower tier: see US Veterans Affairs and Department of Defense 2023 Clinical Guideline for PTSD

I know that in our PCT we're starting to utilize the written exposure therapy protocol for folks who can't/won't agree to do a 'tier 1' evidence-based protocol.

Most admins at VA appear to promote a dichotomous 'evidence-based protocol' (PE/CPT/EMDR) or 'supportive therapy' but we really need to reconceptualize the degree of empirical support, structure, and client-effort to lie on a continuum and to--while strongly encouraging the protocols with the highest degree of empirical support, structure, and effort--be willing to be flexible and engage clients where they are at and see what (if anything) they're willing to do in therapy (and document it). Some of my chart notes are fun to read. I was trained extensively in applied behavior analytic approaches and the almost literal 'hand over hand' prompting I have to engage in to get clients to hold a clipboard (with paper) and pen in their hand and write one sentence at a time is downright comical.

I think that more familiarity with the body of writings explicating the theoretical foundations of cognitive-behavioral approaches would help some folks just starting out to make better sense of all the acronyms/protocols and what they have in common and what makes them distinctive.

 

[WisNeuro]

I know that in our PCT we're starting to utilize the written exposure therapy protocol for folks who can't/won't agree to do a 'tier 1' evidence-based protocol.

I think that more familiarity with the body of writings explicating the theoretical foundations of cognitive-behavioral approaches would help some folks just starting out to make better sense of all the acronyms/protocols and what they have in common and what makes them distinctive.

This is like someone with easily treatable cancer being all like "I'll pass on the chemo/rads/removal surgery and just opt for powdered rhino horn and some dried snake gizzard tea."

 

[Fan_of_Meehl]

This is like someone with easily treatable cancer being all like "I'll pass on the chemo/rads/removal surgery and just opt for powdered rhino horn and some dried snake gizzard tea."

We may start serving 'powdered rhino horn and dried snake gizzard tea' at some point.

If veterans thought it would help them climb the service-connection ladder, they'd eat/drink that in a heartbeat.

Practically speaking, what is being accomplished by offering (and attempting to implement) less intensive forms of intervention is a form of assessment (that can be documented) regarding what the veteran actually will do vs. what they say they will do. When that same veteran comes back around in a year or so...I can reference my notes from the prior episode so I don't feel like I'm completely starting from scratch.

 

[cara susanna]

This is like someone with easily treatable cancer being all like "I'll pass on the chemo/rads/removal surgery and just opt for powdered rhino horn and some dried snake gizzard tea."

In general I agree with this, however...

WET has really solid evidence. It's just newer, so there's less of it. There have already been trials showing it's non-inferior to CPT. One of the main people who developed the psychotherapy CPG, Dr. Hamblen, was very open that she thinks someday WET will make it to Tier 1. WET also has a lower discontinuation rate.

 

[Sanman]

I know that in our PCT we're starting to utilize the written exposure therapy protocol for folks who can't/won't agree to do a 'tier 1' evidence-based protocol.

Most admins at VA appear to promote a dichotomous 'evidence-based protocol' (PE/CPT/EMDR) or 'supportive therapy' but we really need to reconceptualize the degree of empirical support, structure, and client-effort to lie on a continuum and to--while strongly encouraging the protocols with the highest degree of empirical support, structure, and effort--be willing to be flexible and engage clients where they are at and see what (if anything) they're willing to do in therapy (and document it). Some of my chart notes are fun to read. I was trained extensively in applied behavior analytic approaches and the almost literal 'hand over hand' prompting I have to engage in to get clients to hold a clipboard (with paper) and pen in their hand and write one sentence at a time is downright comical.

I think that more familiarity with the body of writings explicating the theoretical foundations of cognitive-behavioral approaches would help some folks just starting out to make better sense of all the acronyms/protocols and what they have in common and what makes them distinctive.

I like WET as a tier 2. It is a shorter protocol, easier for a non-trauma services clinician to initiate, and one that is more fits into my model care than PE or CPT. I have used it when some of my folks have bounced back from trauma services. While it is not ideal, I can understand the frustration of folks that don't want to sit in a group they don't like until it is their turn for individual therapy. In the milder PTSD cases I have done, it has seemed helpful. Though, you really need to be able to read the writing and see if they are doing what they are told.

 

[WisNeuro]

In general I agree with this, however...

WET has really solid evidence. It's just newer, so there's less of it. There have already been trials showing it's non-inferior to CPT. One of the main people who developed the psychotherapy CPG, Dr. Hamblen, was very open that she thinks someday WET will make it to Tier 1. WET also has a lower discontinuation rate.

I was definitely being overly facetious/hyperbolic here. I was more commenting on someone declining a gold standard for no good reason. In the community, it's usually for EMDR/Brainspotting/smudge sticks/thoughts and prayers/etc.

 

[Sanman]

I was definitely being overly facetious/hyperbolic here. I was more commenting on someone declining a gold standard for no good reason. In the community, it's usually for EMDR/Brainspotting/smudge sticks/thoughts and prayers/etc.

I was on reddit reading a SW comment on how much better their practice was since they specialized in those two things. They were only getting motivated patients and beating referrals off with a stick. It's funny when all the benefits mentioned are for the therapist and not the patient.

 

[WisNeuro]

I was on reddit reading a SW comment on how much better their practice was since they specialized in those two things. They were only getting motivated patients and beating referrals off with a stick. It's funny when all the benefits mentioned are for the therapist and not the patient.

SW is the epitome of "not knowing what you don't know."

 

[cara susanna]

I like WET as a tier 2. It is a shorter protocol, easier for a non-trauma services clinician to initiate, and one that is more fits into my model care than PE or CPT. I have used it when some of my folks have bounced back from trauma services. While it is not ideal, I can understand the frustration of folks that don't want to sit in a group they don't like until it is their turn for individual therapy. In the milder PTSD cases I have done, it has seemed helpful. Though, you really need to be able to read the writing and see if they are doing what they are told.

The WET people are VERY insistent that it works with moderate to severe PTSD (and I have anecdotal clinical experience that also supports this). I like WET because it doesn't have homework.

 

[psych.meout]

In a very real sense, it's already "been done."

What is old is new again.

If you look at how Beck and even Barlow practiced, what they did was closer to the process-based (theory-driven, individualized case formulation) approach. It's how I was trained. It's really more about attending to the role of THEORY as applied to the individual case rather than a simple 'make diagnosis' --> apply protocol.

Unfortunately, the rich theoretical bases of cognitive, behavioral, and cognitive-behavioral TECHNIQUES/INTERVENTIONS don't appear to be emphasized near as much in modern CBT writings as they did 20+ years ago. Though a bit outdated, keep/collect the books from 20+ years ago and read some of the classic papers that are widely cited. You'll benefit tremendously.

Everyone is emphasizing 'empiricism' at the nomothetic/population level and focusing on outcome studies adopting the protocol-for-syndrome approach but the crucial role of THEORY (especially applied theory with the individual patient combined with collaborative empiricism (via behavioral experiments, self-monitoring, etc.)) cannot be over-stated...in science, generally, or in scientifically-informed psychotherapeutic practice. Case formulation grounded in theory is becoming a lost art but I think it's the 'sine qua non' of effective psychotherapy.

This is a thing of the past? This is a huge component of my doctoral program and every supervisor I've had has emphasized this. Maybe my program is weird?

 

[Fan_of_Meehl]

This is a thing of the past? This is a huge component of my doctoral program and every supervisor I've had has emphasized this. Maybe my program is weird?

Nah...maybe it's not. Maybe it's still around in graduate education. Maybe it's even mainstream. Just seems like there's more of an emphasis on manualized protocols and techniques/worksheets instead of underlying theory. It's something other colleagues have commented on, as well, but maybe it's not as strong of a change as I made it out to be.

 

[aim-agm]

Incidentally, I suddenly have a mysterious urge to create a therapy combining EMDR and WET called "Writing And Triangular Eye Rotation" so someone can published a dismantling study titled "WATER is WET"

 

[Fan_of_Meehl]

Incidentally, I suddenly have a mysterious urge to create a therapy combining EMDR and WET called "Writing And Triangular Eye Rotation" so someone can published a dismantling study titled "WATER is WET"

You got me with the visual of someone implementing the triangular-pattern repeated eye movements for therapeutic effect, lol.

Were you, by any chance, strolling along a pastoral path in the woods and thinking about a past traumatic incident while tracking the triangular paths of a monarch butterfly hovering in front of you as you experienced a sudden--but unmistakable--diminution in your trauma-related distress that resulted in the psychogenic outbreak of the phrase 'Eureka!' (exclamation mark included) etched on the tender skin of your forearm?

You should write a book. Then a treatment manual. Then build a cathedral ($trike that--a PYRAMID).

They will come.

 

[aim-agm]

This is like someone with easily treatable cancer being all like "I'll pass on the chemo/rads/removal surgery and just opt for powdered rhino horn and some dried snake gizzard tea."

It feels so bizarre how many people will eschew profoundly and reliably effective treatment in favor of stuff for which the evidence base is best described as "it probably doesn't hurt, I guess?"

It's a little more dramatic with meds because of the relative speed of effect compared to psychotherapy, but the following has happened more than a few times -
1st appointment: Individual describes history of severe, persistent symptoms and how they are worn down so much that they are willing to try anything, even medications. We start first-line medication for condition.
2nd appointment: Awkward because medication has put symptoms into remission and we have nothing to talk about.

Psychotherapy and medications just generally work for mental illness, to the point that we can reasonably expect not just remission of symptoms with treatment, but cure (stable remission without continued intervention) in a way that no other illness group other than infectious disease (and maybe oncology) even comes close to.

 

[aim-agm]

You got me with the visual of someone implementing the triangular-pattern repeated eye movements for therapeutic effect, lol.

Were you, by any chance, strolling along a pastoral path in the woods and thinking about a past traumatic incident while tracking the triangular paths of a monarch butterfly hovering in front of you as you experienced a sudden--but unmistakable--diminution in your trauma-related distress that resulted in the psychogenic outbreak of the phrase 'Eureka!' (exclamation mark included) etched on the tender skin of your forearm?

You should write a book. Then a treatment manual. Then build a cathedral ($trike that--a PYRAMID).

They will come.

Great idea.

I think the pyramid will include a waterfall, which the cult members patients can walk into with their traumas written on whiteboards, where they can wash away the trauma from the trauma scored upon the boards and in their body.

I could also start a line of Monarch Water - high pH for when your borderline personality disorder "complex PTSD"* is bringing you down, low pH for when it is brining you up. Or I might save on supplies and have "high pH water water and "low pOH water" (pOH is a measure of alkalinity, high pH=low pOH)

Posthumously, I will release the "WATER is WET" paper, which will bear the subtitle "Puns are, in fact, the highest form of humor if you take them far enough"

 

[Sanman]

Nah...maybe it's not. Maybe it's still around in graduate education. Maybe it's even mainstream. Just seems like there's more of an emphasis on manualized protocols and techniques/worksheets instead of underlying theory. It's something other colleagues have commented on, as well, but maybe it's not as strong of a change as I made it out to be.

I think the issue here is the recent focus on the shortage of well trained professionals and that psychology is simply not equipped to fill the gap due to the level of resources required to educate one. Manualized protocols are easier to teach quickly to lesser trained folks. The problem is that those lesser trained folks in any area are never content to sit under the thumb of another professional.

 

[WisNeuro]

I think the issue here is the recent focus on the shortage of well trained professionals and that psychology is simply not equipped to fill the gap due to the level of resources required to educate one. Manualized protocols are easier to teach quickly to lesser trained folks. The problem is that those lesser trained folks in any area are never content to sit under the thumb of another professional.

The issue here is that manualized protocols only really work if one has a comprehensive understanding of the underlying therapy modality. As in, you will likely not be good at PE/CPT if you haven't been well trained in CBT.

 

[Young Grasshoppa]

This is a thing of the past? This is a huge component of my doctoral program and every supervisor I've had has emphasized this. Maybe my program is weird?

Awesome. I'd love to know more about which programs focus sufficiently on this.

FanMeehl's post about Process-based therapy was a deep rabbit hole for me. Fascinating stuff.

It seems, according to Steven Hayes, that while there may be programs who train in functional analysis and the like, the world of research has done next to nothing in giving us evidence-based recommendations to advise best-practice for case-formulation and the art of applying the theory to each individual.

Is anyone aware of any body of research that does give evidence for how functional analysis is done best besides for Process-based therapy?

Anyone here work with Mindgrapher, Psychflex or any other Process-Based Therapies?

 

[aim-agm]

The issue here is that manualized protocols only really work if one has a comprehensive understanding of the underlying therapy modality. As in, you will likely not be good at PE/CPT if you haven't been well trained in CBT.

Manualized protocols are like sheet music. Quality of performance depends on training with the instrument.

 

[Sanman]

The issue here is that manualized protocols only really work if one has a comprehensive understanding of the underlying therapy modality. As in, you will likely not be good at PE/CPT if you haven't been well trained in CBT.

If the fundamentals of EBPs like CBT and problem-solving therapy can be taught to African grandmothers with success. Surely, we can train a masters level provider to have adequate expertise in these protocols. Now, whether we actually bother to do so in this country is a separate issue.


A group of grandmothers in Zimbabwe is helping the world reimagine mental health care - The Boston Globe

The Friendship Bench | Centre for Global Mental Health

Manualized protocols are like sheet music. Quality of performance depends on training with the instrument.

Agreed. While a most of us will never perform as masterfully as Yo-Yo Ma or any other highly trained concert musician , many people are proficient enough to engage in an enjoyable performance at the high school and college level. Similarly, while many therapists may never reach the level of proficiency that an experienced doctoral level provider reaches, surely they can reach adequate proficiency. There are several studies showing that expertise plays a larger role in outcomes when manualized therapies are not utilized. I'm sure there is a great analogy here about how great musicians, particularly jazz musicians, can improvise masterfully without sheet music and experienced well trained clinicians may be even more effective than a manualized therapy, but sheet music is a helpful aid for those without those skills.

 

[WisNeuro]

If the fundamentals of EBPs like CBT and problem-solving therapy can be taught to African grandmothers with success. Surely, we can train a masters level provider to have adequate expertise in these protocols. Now, whether we actually bother to do so in this country is a separate issue.


A group of grandmothers in Zimbabwe is helping the world reimagine mental health care - The Boston Globe

The Friendship Bench | Centre for Global Mental Health




Agreed. While a most of us will never perform as masterfully as Yo-Yo Ma or any other highly trained concert musician , many people are proficient enough to engage in an enjoyable performance at the high school and college level. Similarly, while many therapists may never reach the level of proficiency that an experienced doctoral level provider reaches, surely they can reach adequate proficiency. There are several studies showing that expertise plays a larger role in outcomes when manualized therapies are not utilized. I'm sure there is a great analogy here about how great musicians, particularly jazz musicians, can improvise masterfully without sheet music and experienced well trained clinicians may be even more effective than a manualized therapy, but sheet music is a helpful aid for those without those skills.

In several conversations I've had with midlevels who "practice" CBT in thgeir therapy practices, I still have yet to meet someone who seems like they understand it beyond a surface level. This is likely one of the reasons that some people have a negative reaction to "manualized treatments." Too many providers who went to a shorty workshop, but never received adequate training in the underlying theory, and they don't know how to manage variations from the manual.

 

[Sanman]

In several conversations I've had with midlevels who "practice" CBT in thgeir therapy practices, I still have yet to meet someone who seems like they understand it beyond a surface level. This is likely one of the reasons that some people have a negative reaction to "manualized treatments." Too many providers who went to a shorty workshop, but never received adequate training in the underlying theory, and they don't know how to manage variations from the manual.

The more you stray from the manual, the more expertise matters. That said, what would they be like as therapists if there was no manual?

 

[WisNeuro]

The more you stray from the manual, the more expertise matters. That said, what would they be like as therapists if there was no manual?

Nonspecific "supportive therapy" for everyone!

 

[RxPsych]

In several conversations I've had with midlevels who "practice" CBT in thgeir therapy practices, I still have yet to meet someone who seems like they understand it beyond a surface level. This is likely one of the reasons that some people have a negative reaction to "manualized treatments." Too many providers who went to a shorty workshop, but never received adequate training in the underlying theory, and they don't know how to manage variations from the manual.

This same thing happens in my current doctoral program, unfortunately. Most of my peers say manualized treatments are "robotic" and "invalidating" and don't understand that you can deviate from the standard approach based on the client while still adhering to the overall protocol.

 

[WisNeuro]

This same thing happens in my current doctoral program, unfortunately. Most of my peers say manualized treatments are "robotic" and "invalidating" and don't understand that you can deviate from the standard approach based on the client while still adhering to the overall protocol.

Whenever someone says this about CBT to me, I always ask them to explain. Nearly universally, these people have little to no understanding of what CBT actually is. It's like the ignorance of "CBT is gaslighting" people, it's comically misunderstood to the point of being laughable. I do feel bad for some patients who are not actually getting CBT when an incompetent provider says that's what they are doing, though.

 

[Fan_of_Meehl]

Whenever someone says this about CBT to me, I always ask them to explain. Nearly universally, these people have little to no understanding of what CBT actually is. It's like the ignorance of "CBT is gaslighting" people, it's comically misunderstood to the point of being laughable. I do feel bad for some patients who are not actually getting CBT when an incompetent provider says that's what they are doing, though.

Agreed. The first thing I was trained on by a mentor (who publishes books on how to do good CBT) was the absolute necessity of tending to the therapeutic relationship...without that, you're not doing Cognitive (behavioral) therapy.

 

[cara susanna]

Oh yeah, Reddit has taught me that people have no idea what CBT actually is. I love when they bash CBT but then praise ACT, DBT, ERP, etc

 

[WisNeuro]

Yeah, people on Reddit generally have zero actual knowledge of CBT, and they have absolutely no idea what the actual definition of gaslighting is.

 

[R. Matey]

Yeah, people on Reddit generally have zero actual knowledge of CBT, and they have absolutely no idea what the actual definition of gaslighting is.

I experience gaslighting as any time someone disagrees with me.

 

[WisNeuro]

I experience gaslighting as any time someone disagrees with me.

Last night my toddler did not want to take a bath, I wish he would stop gaslighting me.

 

[Sanman]

Last night my toddler did not want to take a bath, I wish he would stop gaslighting me.

Yours too? Where do these toddlers get the nerve?

 

[WisNeuro]

Yours too? Where do these toddlers get the nerve?

He's also fostering a toxic home/work environment with his needless demands and one-sided relationship. I'm not sure I can deal with his total disregard of my work/life balance. I'm also pretty sure that he's enabling late stage capitalism. Ugh.

 

[R. Matey]

He's also fostering a toxic home/work environment with his needless demands and one-sided relationship. I'm not sure I can deal with his total disregard of my work/life balance. I'm also pretty sure that he's enabling late stage capitalism. Ugh.

I hear ya. Even though mine are getting a UBI, they are still complaining about inequitable resource distributions based on earnings. Socialists.

 

[Justanothergrad]

I'm a bit reluctant to reply to you since you basically said that I can't read, but...

The 2023 VA/DoD clinical practice guidelines for PTSD indicate that the top tier recommended treatments, meaning the ones with the highest quality and most studies to support them, are prolonged exposure, cognitive processing therapy, and EMDR. There is a second tier that is suggested, meaning there is some good research supporting them but they're not quite at the level of the top tier: written exposure therapy (which is also exposure based), present-centered therapy (not exposure-based or even trauma-focused), and cognitive therapy (CBT). Generally, the most effective treatments seem to be ones that target unhelpful or negative beliefs and avoidance of both external and internal trauma cues.

Also, for future reference, exposure therapy is a type of CBT. PE is considered CBT, for instance. CBT is a large umbrella that includes many, many different protocols.

I should add that there is some controversy around the second tier and there are some top people in the field who think that it was unfair to categorize them lower, and disagree with the methodology that was used to determine them as lower tier: see US Veterans Affairs and Department of Defense 2023 Clinical Guideline for PTSD

I agree with all that, and also, we don't know mechanisms. the Studies on trauma are open to this, most fail to study domains despite their differences in treatment effectiveness, and a lack of control for other explainable factors / dismantling studies. CPT for instance, differentially impacts the vatious clusters. I hate the whole 'tier one treatment' when we can't indicate what part of treatment works, or that it works better than others (relative efficacy) when people pick what they want for services (efficacy). EMDR gets picked on because of its prior dismantling studies and magic eye movement, but even the creator has noted the less important part of that component in some papers.


I feel like we need to stop acting like we can rank order processes we don't understand. I don't like emdr, but it's not the real problem. the issues present in it are present in all studies and we lack an ability as a field to set evidence based barriers effectively (see d12 recent workgroup statement by the Tolin group re application for EST- this full thing may not be public i dont recall )

 

[Justanothergrad]

He's also fostering a toxic home/work environment with his needless demands and one-sided relationship. I'm not sure I can deal with his total disregard of my work/life balance. I'm also pretty sure that he's enabling late stage capitalism. Ugh.

mines a welfare queen and won't change his own diaper- relying on the system instead. Not a single self diaper change in 8 weeks!!