Therapies for Conditions with no Effective CBT Protocols

[Intrusive Thots]

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Currently, in the second semester of my Ph.D. and we have been going over each of the most common diagnoses and their associated evidence-based treatments in our intervention class. Our first-year practicum is coming up in the summer months, and I will be attending the adult mental health clinic for our hospital-affiliated outpatient center.

This semester has been dominated by CBT so far. As much as I admire the flexibility of things like the Unified Protocols for many mental health conditions, I have been expanding my reading and understanding of non-CBT therapies. So far, I have been exploring metacognitive and acceptance and commitment therapy, but I hope to explore others when the time becomes available.

This experience piqued my interest in what conditions with a relatively high base rate (compared to other psychological disorders) don't have any evidence base for being treated with CBT. To clarify, I'm not asking which conditions have a more robust literature base supporting a treatment over CBT, but rather those that have no evidence base at all for being effectively treated with a CBT-related therapy.

Thank you.

 

[Ollie123]

No evidence base at all or just not a strong one? I'm legit hard-pressed to think of something with a reasonably high base-rate there isn't evidence to support the use of CBT. Evidence is there for all the psychology bread & butter diagnoses and even many of the more obscure ones. There are very specific drug classes no one has explicitly run a trial testing as a separate class (i.e. I don't think one has been done for PCP) but they have exceedingly low base rates of use. Certainly there are some with clearer physiological origins that are still in the DSM that no one could conceivably expect CBT to directly impact (e.g. obstructive sleep apnea - though even there are usually other poor sleep habits that can be treated, intellectual or cognitive disorders - e.g. you aren't going to "treat" learning disorders or Parkinson's with CBT though it can be helpful for managing consequences). The evidence for PMDD seems flimsy. I imagine there are some personality disorders where no studies have been done.

 

[PsyDr]

Patients with a chief complaint of "I'm just not happy".

 

[Intrusive Thots]

I appreciate the response, Ollie. Maybe I should broaden the scope a little bit and ask for interesting presentations or somewhat rare diagnoses that may fit the parameters that I mentioned above.

 

[futureapppsy2]

No evidence base at all or just not a strong one? I'm legit hard-pressed to think of something with a reasonably high base-rate there isn't evidence to support the use of CBT. Evidence is there for all the psychology bread & butter diagnoses and even many of the more obscure ones. There are very specific drug classes no one has explicitly run a trial testing as a separate class (i.e. I don't think one has been done for PCP) but they have exceedingly low base rates of use. Certainly there are some with clearer physiological origins that are still in the DSM that no one could conceivably expect CBT to directly impact (e.g. obstructive sleep apnea - though even there are usually other poor sleep habits that can be treated, intellectual or cognitive disorders - e.g. you aren't going to "treat" learning disorders or Parkinson's with CBT though it can be helpful for managing consequences). The evidence for PMDD seems flimsy. I imagine there are some personality disorders where no studies have been done.

Second this--I would say that PDs outside of BPD would be the biggest diagnostic categories where we lack solid EBTs in a lot of cases. I also might include anorexia nervosa in adults--family-based treatment works well in children/adolescents/some young adults, but we don't have anything with comparable long-term remission and return-to-functioning rates in adults.

 

[Sanman]

The first barrier I see with this question is that you are asking for something that can be difficult to ascertain given the system we function in. I have patients on my panel with PD (usually cluster B folks that are a pain for everyone to deal with). However, there is no axis II dx in the system for them. There is a depression dx to justify their meds and I may manage things like suicidality, depressive episodes, and sleep problems with CBT. However, given the lack of treatment options for NPD, there is little interest in creating paperwork and a plan of care. Hence no formal dx. I see this all the time with dementia patients. There is very little that can be done to manage behaviors, so all of them bounce back from the ER with a dx of schizophrenia and an anti-psychotic. Bottom line... we dx what we treat, not what we cannot.

 

[Intrusive Thots]

Gives me something to think about Sanman, thank you.

 

[CheetahGirl]

I was going to say the same: Personality Disorders may not have a solid treatment evidence-base with cognitive behavioral therapies. Cluster B, specifically BPD, has much support with DBT. However, high risk suicidality and complex PTSD* (which is often qualified under chronic or "severe mental illness") are also conditions, which are not always addressed sufficiently with various CBTs out there. BTW ACT (Acceptance and Commitment Therapy) teach wonderful skills, as well as Motivational Interviewing...so both would be great to explore for practicality.

*Our SDN PTSD folks may jump on me for this, because many evidence-based trauma therapies are derived from CBT principles, but a simple ABC model may not sufficiently address chronic sxs in an effective way. (I was involved in short-term/12-week psychodynamic treatment for high-risk suicidality in combat Veterans, which anecdotally allowed us to get in and out the Veteran's trauma quickly to evaluate the guilt and shame contributing to the suicidal ideation. I am fortunate to have been trained by the P.I., who had run the same study on Vietnam Veterans and we were exploring OEF/OIF/OND Veterans, but this mentor sadly passed away before we finished the study). So, YES! There are a lot of therapies out there to learn & try, but we tend to rely on the ones with high validity, reliability and replicability.

 

[clausewitz2]

Hikikomori, to the extent you believe it is a phenomenon independent of currently established DSM categories. It does seem to be substantially less culture-bound than previously thought and I am currently struggling with a young man who fits criteria I have seen proposed to a T. Telehealth means I am seeing some people who would just never show up to an office appointment.

 

[smalltownpsych]

Our disorders are diagnosed based on clusters of symptoms. Some medications and some therapeutic techniques are better at treating some of those symptoms than others. We also have patients for whom the common EBTs don’t work. That’s who I spend most of my time treating. I still use tested and proven cognitive and behavioral strategies, I just have to also add in some other stuff to the mix. Easiest to explain is MI. If a patient is in the first stage of change, ain’t nothing going to work. I also rely heavily on DBT since many of my clients fit into the category here that has some good evidence.

Finally, I go old school with utilizing more psychodynamic concepts such as object relations and attachment stuff to conceptualize the interpersonal and treat that. Hard to develop EBTs for that because of all the variables and messy constructs, but if one looks into the neurobiology of attachment and understands how one nervous system interacts with another and sees how important interpersonal patterns are in symptom development and persistence of those symptoms, then one might find some of these frameworks effective.

 

[cara susanna]

I was going to say the same: Personality Disorders may not have a solid treatment evidence-base with cognitive behavioral therapies. Cluster B, specifically BPD, has much support with DBT. However, high risk suicidality and complex PTSD* (which is often qualified under chronic or "severe mental illness") are also conditions, which are not always addressed sufficiently with various CBTs out there. BTW ACT (Acceptance and Commitment Therapy) teach wonderful skills, as well as Motivational Interviewing...so both would be great to explore for practicality.

*Our SDN PTSD folks may jump on me for this, because many evidence-based trauma therapies are derived from CBT principles, but a simple ABC model may not sufficiently address chronic sxs in an effective way. (I was involved in short-term/12-week psychodynamic treatment for high-risk suicidality in combat Veterans, which anecdotally allowed us to get in and out the Veteran's trauma quickly to evaluate the guilt and shame contributing to the suicidal ideation. I am fortunate to have been trained by the P.I., who had run the same study on Vietnam Veterans and we were exploring OEF/OIF/OND Veterans, but this mentor sadly passed away before we finished the study). So, YES! There are a lot of therapies out there to learn & try, but we tend to rely on the ones with high validity, reliability and replicability.

Speaking as one of those folks, I don't think I disagree--any effective PTSD treatment needs to work in some aspect of behavioral change, not just cognitive restructuring. Even CPT would argue that (the idea is that you need to accumulate evidence against your stuck points, and you do that by decreasing avoidance).

 

[Fan_of_Meehl]

Currently, in the second semester of my Ph.D. and we have been going over each of the most common diagnoses and their associated evidence-based treatments in our intervention class. Our first-year practicum is coming up in the summer months, and I will be attending the adult mental health clinic for our hospital-affiliated outpatient center.

This semester has been dominated by CBT so far. As much as I admire the flexibility of things like the Unified Protocols for many mental health conditions, I have been expanding my reading and understanding of non-CBT therapies. So far, I have been exploring metacognitive and acceptance and commitment therapy, but I hope to explore others when the time becomes available.

This experience piqued my interest in what conditions with a relatively high base rate (compared to other psychological disorders) don't have any evidence base for being treated with CBT. To clarify, I'm not asking which conditions have a more robust literature base supporting a treatment over CBT, but rather those that have no evidence base at all for being effectively treated with a CBT-related therapy.

Thank you.

Spend time with your patient assessing, observing and interacting with them. Develop a comprehensive clinical case formulation. Of course, DSM diagnoses are fairly important (you wouldn't want to miss bipolar I disorder, or opiate addiction or delirium, for instance) but the intervention model currently being taught in some graduate schools that treatment plans write themselves once you have made a DSM diagnosis is, in my opinion, sub-standard and just plain wrong.

Where do they stand on the transtheoretical model of behavior change? Do they see their suffering as something at least possibly under their control or are they still in pre-contemplation? Are they suicidal/homicidal or currently at risk for other or self-harm? Do they come to therapy appointments regularly or do they miss most of them? What do they say when they return about their having missed the appointment? Do they seem to have an external (rather than internal) locus of control when it comes to failing to fulfill obligations? Do you think that maybe other people in their lives may be experiencing this as well. What do you feel as a therapist/person when they make excuses over and over again about why they missed? Is this relevant information and could it generalize to other relationships that they have?

What prevents you from utilizing the theories underlining CBT 'techniques' with this patient in the form of assessment that will lead to an individualized clinical case formulation? What are their patterns of thoughts and beliefs? How are they hierarchically organized (e.g., specific automatic thoughts in a situation vs. rules/attitudes/assumptions (intermediate beliefs) vs. schemas/ core beliefs. I really liked the CBT literature from the 60's - 90's better than much of the stuff today because the authors really seemed to go a lot more into detail regarding the theoretical bases of the approach as well as how it borrowed from and even interfaced with other dominant theoretical schools or approaches at the time. There are tons of relevant lines of research in clinical psychology (including, for example, evolutionary theory and sociobiological influences on behavior) that may be applied to inform your case formulation.

If you get out of graduate school and *only* have {(1) make a diagnosis ---> (2) 'plug and chug' patient into a pre-scripted formalized and manualized protocol treatment with every single agenda already pre-written ---> (3) patient cured} approach to psychotherapy assessment, case formulation, and treatment then you won't (in my opinion) be fully prepared to competently practice. But that's just me.

 

[smalltownpsych]

Spend time with your patient assessing, observing and interacting with them. Develop a comprehensive clinical case formulation. Of course, DSM diagnoses are fairly important (you wouldn't want to miss bipolar I disorder, or opiate addiction or delirium, for instance) but the intervention model currently being taught in some graduate schools that treatment plans write themselves once you have made a DSM diagnosis is, in my opinion, sub-standard and just plain wrong.

Where do they stand on the transtheoretical model of behavior change? Do they see their suffering as something at least possibly under their control or are they still in pre-contemplation? Are they suicidal/homicidal or currently at risk for other or self-harm? Do they come to therapy appointments regularly or do they miss most of them? What do they say when they return about their having missed the appointment? Do they seem to have an external (rather than internal) locus of control when it comes to failing to fulfill obligations? Do you think that maybe other people in their lives may be experiencing this as well. What do you feel as a therapist/person when they make excuses over and over again about why they missed? Is this relevant information and could it generalize to other relationships that they have?

What prevents you from utilizing the theories underlining CBT 'techniques' with this patient in the form of assessment that will lead to an individualized clinical case formulation? What are their patterns of thoughts and beliefs? How are they hierarchically organized (e.g., specific automatic thoughts in a situation vs. rules/attitudes/assumptions (intermediate beliefs) vs. schemas/ core beliefs. I really liked the CBT literature from the 60's - 90's better than much of the stuff today because the authors really seemed to go a lot more into detail regarding the theoretical bases of the approach as well as how it borrowed from and even interfaced with other dominant theoretical schools or approaches at the time. There are tons of relevant lines of research in clinical psychology (including, for example, evolutionary theory and sociobiological influences on behavior) that may be applied to inform your case formulation.

If you get out of graduate school and *only* have {(1) make a diagnosis ---> (2) 'plug and chug' patient into a pre-scripted formalized and manualized protocol treatment with every single agenda already pre-written ---> (3) patient cured} approach to psychotherapy assessment, case formulation, and treatment then you won't (in my opinion) be fully prepared to competently practice. But that's just me.

Hey, wasn't that what I said? 😉

 

[Fan_of_Meehl]

Hey, wasn't that what I said? 😉

You, me, and even Stephen C. (Hayes)!

 

[smalltownpsych]

You, me, and even Stephen C. (Hayes)!

I do think one of the key points you made that bears repeating was the importance of understanding the theoretical underpinnings and how that provides the ability to implement the techniques and even integrate others. I see how this neglect of understanding of theory is a problem for clinicians who claim DBT as well. So many cannot even explain what the D is for. If one cannot understand the theoretical underpinnings then one is little better than a coach helping someone practice worksheet skills by rote without actually enacting any change. Of course, Marsha emphasizes the utility of coaches and it’s part of her model, but she also assumes that a qualified, skilled, and well-rounded psychotherapist, such as herself, is integrating this with all of the other models and applicable philosophies and principles of psychotherapy, learning, and development.

As I think about this, I am thinking that it requires a unique combination of creative and analytical thinking to truly be an effective psychotherapist regardless of model. Also, that is why I get so exhausted by this work. It really isn’t the emotional toll, it’s the cognitive load. The emotional challenging cases occur and is part of that load, but I think it’s a mistaken assumption to think that’s what makes this job so hard. Figuring out what to do and why you’re doing it is probably the hardest part.

 

[summerbabe]

Good discussion, I'll add one more point to what @Fan_of_Meehl and @smalltownpsych have written regarding clinician error/missteps:

I do a decent amount of DBT and if I have an appropriately diagnosed patient who shows up regularly, is open to treatment, practices skills with me in session, and is not having success, I'll immediately look inward and try to identify points of clinician error/misstep.

This almost ways turns out to be poor assessment on my part such as not successfully fully understanding the current problem at hand, which then leads to not applying the most relevant skill(s) from the most relevant DBT module(s).

In the CBT context, it would be akin to thinking like you're working on a core belief/Stuck Point when you're actually in the realm of automatic thoughts.

You can still march through the protocol at that level and easily check all of the boxes and then come out wondering why the patient didn't respond as much as you anticipated. And answer those inquiries with hypotheses such as "they weren't as engaged with homework as they could have been".

When I think about training in psychotherapy, this level of detail as well as instilling this type of reflection as a possible professional aspiration, seems lacking, including at what we would consider to be top-notch programs.

At the risk of over-generalizing, some super empirically-heavy clinical psych PhDs may be the worst offenders in that students are trained to rigidly always only turn to the scientific base, rather than also inward.

 

[Sanman]

Good discussion, I'll add one more point to what @Fan_of_Meehl and @smalltownpsych have written regarding clinician error/missteps:

I do a decent amount of DBT and if I have an appropriately diagnosed patient who shows up regularly, is open to treatment, practices skills with me in session, and is not having success, I'll immediately look inward and try to identify points of clinician error/misstep.

This almost ways turns out to be poor assessment on my part such as not successfully fully understanding the current problem at hand, which then leads to not applying the most relevant skill(s) from the most relevant DBT module(s).

In the CBT context, it would be akin to thinking like you're working on a core belief/Stuck Point when you're actually in the realm of automatic thoughts.

You can still march through the protocol at that level and easily check all of the boxes and then come out wondering why the patient didn't respond as much as you anticipated. And answer those inquiries with hypotheses such as "they weren't as engaged with homework as they could have been".

When I think about training in psychotherapy, this level of detail as well as instilling this type of reflection as a possible professional aspiration, seems lacking, including at what we would consider to be top-notch programs.

At the risk of over-generalizing, some super empirically-heavy clinical psych PhDs may be the worst offenders in that students are trained to rigidly always only turn to the scientific base, rather than also inward.

While agree that this is what high level psychotherapy should be like, it is a bit apples and oranges. Protocols and manualized therapy are about standardizing a decent product rather than providing a custom product. Much akin to off the shwlf vs custom kitchen cabinets. Much like the cabinets, the former works better in large systems for the average person with limited funds while the latter is more of a boutique service. The question is what is your program preparing you for exactly?

 

[smalltownpsych]

Good discussion, I'll add one more point to what @Fan_of_Meehl and @smalltownpsych have written regarding clinician error/missteps:

I do a decent amount of DBT and if I have an appropriately diagnosed patient who shows up regularly, is open to treatment, practices skills with me in session, and is not having success, I'll immediately look inward and try to identify points of clinician error/misstep.

This almost ways turns out to be poor assessment on my part such as not successfully fully understanding the current problem at hand, which then leads to not applying the most relevant skill(s) from the most relevant DBT module(s).

In the CBT context, it would be akin to thinking like you're working on a core belief/Stuck Point when you're actually in the realm of automatic thoughts.

You can still march through the protocol at that level and easily check all of the boxes and then come out wondering why the patient didn't respond as much as you anticipated. And answer those inquiries with hypotheses such as "they weren't as engaged with homework as they could have been".

When I think about training in psychotherapy, this level of detail as well as instilling this type of reflection as a possible professional aspiration, seems lacking, including at what we would consider to be top-notch programs.

At the risk of over-generalizing, some super empirically-heavy clinical psych PhDs may be the worst offenders in that students are trained to rigidly always only turn to the scientific base, rather than also inward.

I agree with a lot of what you said except for the conjecture about the more empirically-heavy being worse. I could easily argue the counterpoint that the less empirically rigid is where the woo-woo crap is going to come from. The research base is foundational in my mind which implies both the starting point and also keeping solidly grounded. I might criticize the limitations of people never getting off the ground and tend to push in that direction, but trying to get the woowoo folks grounded is something I pretty much give up on.

 

[R. Matey]

What prevents you from utilizing the theories underlining CBT 'techniques' with this patient in the form of assessment that will lead to an individualized clinical case formulation? What are their patterns of thoughts and beliefs? How are they hierarchically organized (e.g., specific automatic thoughts in a situation vs. rules/attitudes/assumptions (intermediate beliefs) vs. schemas/ core beliefs. I really liked the CBT literature from the 60's - 90's better than much of the stuff today because the authors really seemed to go a lot more into detail regarding the theoretical bases of the approach as well as how it borrowed from and even interfaced with other dominant theoretical schools or approaches at the time. There are tons of relevant lines of research in clinical psychology (including, for example, evolutionary theory and sociobiological influences on behavior) that may be applied to inform your case formulation.

Same. When one of our faculty retired, they gave me all of their old CBT books from this era (a pretty extensive collection) and I really appreciate the level of depth, discussion, and thought that goes into case formulations much more so then the recent stuff that I read that is far more data driven (e.g., "well, use mindfulness because it works"). Much of the resistance I've encountered to cognitive (and behavioral) therapy is people with a very surface-level understanding of the theory behind it. We can argue about whether or not its constructivist or rational or whether the informational processing prepositions of the day make sense in light of the evolving literature in social cognition, but usually people can't get past the vague references to stoicism and "positive thinking."

Edit: Also how I got interested in reading psychoanalytic theory since trying to understand what cognitive therapy was reacting beyond a level of comprehension needed to pass the EPPP. I don't identify with it, but I have more respect for it than I used to.

 

[WisNeuro]

Same. When one of our faculty retired, they gave me all of their old CBT books from this era (a pretty extensive collection) and I really appreciate the level of depth, discussion, and thought that goes into case formulations much more so then the recent stuff that I read that is far more data driven (e.g., "well, use mindfulness because it works"). Much of the resistance I've encountered to cognitive (and behavioral) therapy is people with a very surface-level understanding of the theory behind it. We can argue about whether or not its constructivist or rational or whether the informational processing prepositions of the day make sense in light of the evolving literature in social cognition, but usually people can't get past the vague references to stoicism and "positive thinking."

Edit: Also how I got interested in reading psychoanalytic theory since trying to understand what cognitive therapy was reacting beyond a level of comprehension needed to pass the EPPP. I don't identify with it, but I have more respect for it than I used to.

Agree 1000%. Almost every single time I've engaged in a discussion with someone who is vehemently anti-CBT, I just ask why, and their explanations make it abundantly clear that they really have no understanding of the CBT framework beyond a few buzzwords. And, they also usually misunderstand what those buzzwords even mean. There are definitely valid criticisms of CBT, and every other therapeutic framework, but by and large, many simply want to hate on it for no real reason aside from it fits their narrative at the time.

 

[Shiori]

I got my masters at a place with a heavy emphasis on CBT. We shared classes with the PhD students, so they were taught similarly. I also went to a PhD program that was also almost exclusively CBT-based. There was not a very deep dive into theory in either of those situations. It was really focused on getting us ready for research and externship. Most classes would give a week or two to theory where we would get a PowerPoint of the same 10 psychologists with about 2-10 minutes spent on each. Then we would talk about the sessions. Finally, we would have diversity day where we would get a crash course in adapting things to "other" kinds of folks. I'd be curious how many other programs are similar. I also wonder if CBT gets some of the hate because it is "prescribed" so often and prescribed poorly. The VA EBT templates come to mind.

 

[Fan_of_Meehl]

Agree 1000%. Almost every single time I've engaged in a discussion with someone who is vehemently anti-CBT, I just ask why, and their explanations make it abundantly clear that they really have no understanding of the CBT framework beyond a few buzzwords. And, they also usually misunderstand what those buzzwords even mean. There are definitely valid criticisms of CBT, and every other therapeutic framework, but by and large, many simply want to hate on it for no real reason aside from it fits their narrative at the time.

110% this. Also, people thinking that 'CBT' = worksheets. I mean, worksheets can be utilized in CBT, but the choice of worksheet, the timing of their use in therapy, and their customization to fit the needs of the client should always be paramount and theory/case-formulation driven. Implementing cognitive-behavioral therapy is far more than a video game where you get 'points' per worksheet completed and are trying to get a 'high score' from that.

 

[clausewitz2]

Implementing cognitive-behavioral therapy is far more than a video game where you get 'points' per worksheet completed and are trying to get a 'high score' from that.

Says you, sounds like you just need to git gud, noob.

 

[smalltownpsych]

Agree 1000%. Almost every single time I've engaged in a discussion with someone who is vehemently anti-CBT, I just ask why, and their explanations make it abundantly clear that they really have no understanding of the CBT framework beyond a few buzzwords. And, they also usually misunderstand what those buzzwords even mean. There are definitely valid criticisms of CBT, and every other therapeutic framework, but by and large, many simply want to hate on it for no real reason aside from it fits their narrative at the time.

As a more psychodynamically oriented clinician, I make fun of the CBT folk all the time and they tend to give it right back.
Actually, I appreciate the insights and techniques from multiple perspectives and if someone is just using buzzwords, regardless of orientation, it quickly becomes apparent and they add little to the conversation. The worst are actually the plethora of MA counselors that say they use a client-centered approach to cover up that they don't really know what they are doing or why they are doing it.

 

[Fan_of_Meehl]

Says you, sounds like you just need to git gud, noob.

Man...I'm stuck with an old graphics card setup from the late '90's

 

[R. Matey]

I got my masters at a place with a heavy emphasis on CBT. We shared classes with the PhD students, so they were taught similarly. I also went to a PhD program that was also almost exclusively CBT-based. There was not a very deep dive into theory in either of those situations. It was really focused on getting us ready for research and externship. Most classes would give a week or two to theory where we would get a PowerPoint of the same 10 psychologists with about 2-10 minutes spent on each. Then we would talk about the sessions. Finally, we would have diversity day where we would get a crash course in adapting things to "other" kinds of folks. I'd be curious how many other programs are similar. I also wonder if CBT gets some of the hate because it is "prescribed" so often and prescribed poorly. The VA EBT templates come to mind.

I've never set foot in a VA so I don't know about that part, but I suspect that you're right about the poor presentation equals mischaracterization, and probably not for just CBT. Part of that might also be temperamental for therapists, but that's harder to prove. I know for myself, I was trained first as a mental health counselor (e.g., person-centered), but quickly discovered that person centered techniques were insufficient for people experiencing acute psychosis, severe depression, personality disorders etc so I started attending CBT trainings at the suggestion (read: insistence) of my post-master's licensing supervisor. My Ph.D. program coursework honestly was great on multicultural stuff and we had two faculty that really emphasized CBT. For like in-depth theory though, I did a lot of my own study partly out a fear of incompetence and just general interest.

 

[Fan_of_Meehl]

I do think one of the key points you made that bears repeating was the importance of understanding the theoretical underpinnings and how that provides the ability to implement the techniques and even integrate others. I see how this neglect of understanding of theory is a problem for clinicians who claim DBT as well. So many cannot even explain what the D is for. If one cannot understand the theoretical underpinnings then one is little better than a coach helping someone practice worksheet skills by rote without actually enacting any change. Of course, Marsha emphasizes the utility of coaches and it’s part of her model, but she also assumes that a qualified, skilled, and well-rounded psychotherapist, such as herself, is integrating this with all of the other models and applicable philosophies and principles of psychotherapy, learning, and development.

As I think about this, I am thinking that it requires a unique combination of creative and analytical thinking to truly be an effective psychotherapist regardless of model. Also, that is why I get so exhausted by this work. It really isn’t the emotional toll, it’s the cognitive load. The emotional challenging cases occur and is part of that load, but I think it’s a mistaken assumption to think that’s what makes this job so hard. Figuring out what to do and why you’re doing it is probably the hardest part.

The part about 'requiring a unique combination of creative and analytical thinking to truly be an effective psychotherapist' is so key.

I also think that it takes a flexibility in 'titrating/adjusting' the amount of structure (imposed 'order') in the therapeutic encounter vs. lack of formal structure ('chaos') to be clinically competent. The worst therapists are those who try to impose too much structure/order and who try to religiously impose order in their sessions (as if 'order = good', 'chaos/freedom = bad') regardless of the context or--at the opposite end of the spectrum--therapists who NEVER impose any structure in their sessions (the whole 'supportive therapy', read, 'let's just let the patient ramble on and talk about anything and just nod and say um humm' therapy).

The most fundamental problem with how the VA, as an organization, conceptualizes psychotherapy is that they tend to be operating according to the assumption that their therapists are either conducting: (a) 'supportive therapy' which completely lacks any structure at all and is totally inefficacious, or they are conducting (b) 'evidence-based psychotherapy' which they (despite the APA definition of EBP stating otherwise) ONLY define as 'alphabet manualized pre-scripted invariant CBT protocol for syndrome/diagnosis.' Where the vast majority of veterans lie (especially when they first present for therapy) is between those two extremes (in terms of what they will be receptive to and cooperative with). This is the most 'in-your-face' reality that appears totally lost on mental health administration/leadership in the organization today. All of the training appears to be geared toward saying your algorithm is: 1) implement CBT protocol for syndrome/diagnosis to remission of illness and then discharge, or, failing that either 2a) refer them for a 'supportive therapy' or 'psychoed' / warehousing group or 2b) impose unilateral (i.e., the patient doesn't agree) termination on the patient...as if that is even possible in the system that they have engineered with its '#BeThere' 'no-wrong-door' 'wraparound services' 'eliminate suicide' 'Mental Health Treatment Coordinator For Life' and entitlement philosophies.

When you're doing your best work as a therapist, you are 'riding the seam' and the gap between 'chaos and order,' between 'structure and 'holding environment'' on a moment-to-moment basis with your patient and continually assessing if they are 'with you' and if they are responsive to and responding to the intervention and making course adjustments flexibly as needed. If you watch old masters of CBT (e.g., Aaron Beck doing Cognitive Therapy for Depression), you'll notice this type of flexibility in action.

It just so happens I was watching YouTube vids earlier today where school teachers were lamenting that their administration always invalidated their concerns/input and just gave them orders and instructions on how to teach but never listened to their input which is based on their education/training and experience. So, this is a very generalized phenomenon that society is dealing with today and isn't particularly limited to psychotherapy, mental health, or even medicine. The top-down, algorithmic, brute force, authoritarian approach is the current implicit paradigm of how one 'administrates' anything today and it is beyond pathetic.

 

[smalltownpsych]

The part about 'requiring a unique combination of creative and analytical thinking to truly be an effective psychotherapist' is so key.

I also think that it takes a flexibility in 'titrating/adjusting' the amount of structure (imposed 'order') in the therapeutic encounter vs. lack of formal structure ('chaos') to be clinically competent. The worst therapists are those who try to impose too much structure/order and who try to religiously impose order in their sessions (as if 'order = good', 'chaos/freedom = bad') regardless of the context or--at the opposite end of the spectrum--therapists who NEVER impose any structure in their sessions (the whole 'supportive therapy', read, 'let's just let the patient ramble on and talk about anything and just nod and say um humm' therapy).

The most fundamental problem with how the VA, as an organization, conceptualizes psychotherapy is that they tend to be operating according to the assumption that their therapists are either conducting: (a) 'supportive therapy' which completely lacks any structure at all and is totally inefficacious, or they are conducting (b) 'evidence-based psychotherapy' which they (despite the APA definition of EBP stating otherwise) ONLY define as 'alphabet manualized pre-scripted invariant CBT protocol for syndrome/diagnosis.' Where the vast majority of veterans lie (especially when they first present for therapy) is between those two extremes (in terms of what they will be receptive to and cooperative with). This is the most 'in-your-face' reality that appears totally lost on mental health administration/leadership in the organization today. All of the training appears to be geared toward saying your algorithm is: 1) implement CBT protocol for syndrome/diagnosis to remission of illness and then discharge, or, failing that either 2a) refer them for a 'supportive therapy' or 'psychoed' / warehousing group or 2b) impose unilateral (i.e., the patient doesn't agree) termination on the patient...as if that is even possible in the system that they have engineered with its '#BeThere' 'no-wrong-door' 'wraparound services' 'eliminate suicide' 'Mental Health Treatment Coordinator For Life' and entitlement philosophies.

When you're doing your best work as a therapist, you are 'riding the seam' and the gap between 'chaos and order,' between 'structure and 'holding environment'' on a moment-to-moment basis with your patient and continually assessing if they are 'with you' and if they are responsive to and responding to the intervention and making course adjustments flexibly as needed. If you watch old masters of CBT (e.g., Aaron Beck doing Cognitive Therapy for Depression), you'll notice this type of flexibility in action.

It just so happens I was watching YouTube vids earlier today where school teachers were lamenting that their administration always invalidated their concerns/input and just gave them orders and instructions on how to teach but never listened to their input which is based on their education/training and experience. So, this is a very generalized phenomenon that society is dealing with today and isn't particularly limited to psychotherapy, mental health, or even medicine. The top-down, algorithmic, brute force, authoritarian approach is the current implicit paradigm of how one 'administrates' anything today and it is beyond pathetic.

Completely agree and very well put. I like that concept of walking the line between structure and chaos. Structure can be too rigid, but too much flexibility can lead to chaos. As you outlined it occurs in lots of contexts besides therapy rooms. As a clinical director of a couple of residential programs, that is definitely a line we had to walk.

This is a little off the original topic, but you started me thinking and since I am obsessed with my new business that is where my mind always goes. One goal of my new company will be to help clients who are coming from highly structured environments to make the transition to independent community living. The way that this is going to be done is actually almost revolutionary as I ride that line between support/structure/rules/security/safety and independence/autonomy/freedom to make bad choices/risk. When I say almost revolutionary, I might actually mean crazy. How can I have a treatment program that is unstructured enough to not be a treatment program? I was talking to my former boss about just this dynamic the other day. What is a little ironic is he used to say that my job at his company was to help bring order to his chaos.

 

[msc545]

The unspoken problem with CBT is that it won't work for anyone that doesn't have at least a moderate amount of OCD.

 

[EmotRegulation]

There are so many people who come to therapy who don't meet criteria for specific disorders (or meet criteria for several, or *should* be given a personality disorder diagnosis but people seem to forget about all personality pathology except BPD and when it's super flagrant narcissism or something), and CBT can be helpful for many of those clients. CBT is also not for everyone; some people will be unable to do cognitive restructuring and others will flat-out refuse.

I do entirely get why PhD programs teach new clinicians to match empirically supported treatments to a diagnosis--it's a good way to instill values of science in clinicians which is still sorely needed considering some of the crappy pseudoscience or flat out non-science-based therapists working in mental health. I also get that new clinicians are nervous and want to do well (this is the hallmark of a new clinician per the developmental model of supervision), and thus want to use empirically supported treatments as studied, and they also want to use their diganostic skills from psychopathology class. I work with a lot of new clinicians and all of these things make sense to me. And yet....I much prefer working with more advanced trainees who understand that we treat *people* and not diagnoses, that people are messy and rich and nuanced and that therapy can be too. It's not unscientific to rely on empirically supported principles of change and to use the knowledge of basic science (social psych, cognitive, developmental) to understand how a client operates and thus what they might need to grow. Yet this is not the kind of "Step 1. Diagnose, Step 2. Find CBT manual to treat Step 1" therapy that new clinicians often think it is.

My challenge is trying to let the new clinicians go through the process to GET to a more nuanced point without getting impatient.

 

[hum1]

We, clinicians, are being misled into believing that mental health problems are medicalized symptoms that can be diagnosed, treated, and resolved by manualized, simplified, impersonal, scripted treatments that focus on abstract entities called diagnoses, which are purely descriptive abstract entities that can be very far away from our patient's subjective experience and suffering, but more with the goal to decrease the clinician's anxieties about having to navigate a meaningful treatment with a patient.

We are being scammed by the neo-liberal mentality that focuses on profit and cost reduction into believing that mental health issues can be treated by short term, simple and easy to apply standardized treatments. The aim being not restoring the patient to health, allowing for a meaningful life, or providing the opportunity for real psychic growth and change to happen, but "to correct" patient's "distorted" cognitions in order to convince them, albeit in a temporary way, that their thinking is wrong, thus allowing for patients to return to being part of the work force production and to being happy consumers, meaning to participate as a member of society which nowadays has been reduced to increasing your credit score points.

For anyone who wants to take the red pill from the matrix:

https://www.youtube.com/channel/UCS_rv5vYv4HfTchv_beiqhQ

 

[WisNeuro]

Ugh, this same old garbage that keeps trotting out cherry picked stats and misleads about what CBT actually is? Nothing new in this tripe. Pass. Come back when you want to have a discussion in good faith. Also, I'd stay away from Red Pill analogies unless you want to get lumped in with QAnoners and Incels.

 

[hum1]

Ugh, this same old garbage that keeps trotting out cherry picked stats and misleads about what CBT actually is? Nothing new in this tripe. Pass. Come back when you want to have a discussion in good faith. Also, I'd stay away from Red Pill analogies unless you want to get lumped in with QAnoners and Incels.

I just think it is important to be critical about our profession and contextualize science in societal discourses. I don't really know what QAnoners and Incels are. I am old, I've watched the Matrix on the cinema 🙂

 

[WisNeuro]

I just think it is important to be critical about our profession and contextualize science in societal discourses. I don't really know what QAnoners and Incels are. I am old, I've watched the Matrix on the cinema 🙂

It's very important to be critical about our profession. In all aspects. But, in reading your description of CBT, it is very clear that you do not understand much at all about CBT. You believe in some sort of caricature of CBT with no understanding of it's underlying principles or goals.

 

[Fan_of_Meehl]

I w

Good discussion, I'll add one more point to what @Fan_of_Meehl and @smalltownpsych have written regarding clinician error/missteps:

I do a decent amount of DBT and if I have an appropriately diagnosed patient who shows up regularly, is open to treatment, practices skills with me in session, and is not having success, I'll immediately look inward and try to identify points of clinician error/misstep.

This almost ways turns out to be poor assessment on my part such as not successfully fully understanding the current problem at hand, which then leads to not applying the most relevant skill(s) from the most relevant DBT module(s).

In the CBT context, it would be akin to thinking like you're working on a core belief/Stuck Point when you're actually in the realm of automatic thoughts.

You can still march through the protocol at that level and easily check all of the boxes and then come out wondering why the patient didn't respond as much as you anticipated. And answer those inquiries with hypotheses such as "they weren't as engaged with homework as they could have been".

When I think about training in psychotherapy, this level of detail as well as instilling this type of reflection as a possible professional aspiration, seems lacking, including at what we would consider to be top-notch programs.

At the risk of over-generalizing, some super empirically-heavy clinical psych PhDs may be the worst offenders in that students are trained to rigidly always only turn to the scientific base, rather than also inward.

I was just thinking also that in the VA system (and probably in community based treatment settings, as well) we simply don't have enough clinicians to properly meet the demand for psychotherapy services so we end up having to have caseloads of 100+ clients at any one time which guarantees that you're unable to see the vast majority of your clients on anything approaching a weekly basis. There is definitely a case to be made for a significant 'dose/response' effect to active psychotherapy (I believe empirical research, specifically on CBT of depression demonstrated this, as well) and it occurs to me that it may be particularly important when dealing with complex cases involving personality disorder, severe symptoms, and/or co-morbidities. Another empirical (in the sense of direct observation, evidence from my senses) fact appears to be that VA MH departments are creating more and more non-clinical (non-provider) positions without caseloads (or extremely small caseloads) while 'closing out' or eliminating full-time provider positions. Then, when caseloads get 'too big' to properly handle, the blame is placed squarely on the shoulders of the full-time providers for not being 'efficacious' or responsible enough in treating their (likely 100+ client) caseloads. Beats anything I've ever seen.

 

[Fan_of_Meehl]

Currently, in the second semester of my Ph.D. and we have been going over each of the most common diagnoses and their associated evidence-based treatments in our intervention class. Our first-year practicum is coming up in the summer months, and I will be attending the adult mental health clinic for our hospital-affiliated outpatient center.

This semester has been dominated by CBT so far. As much as I admire the flexibility of things like the Unified Protocols for many mental health conditions, I have been expanding my reading and understanding of non-CBT therapies. So far, I have been exploring metacognitive and acceptance and commitment therapy, but I hope to explore others when the time becomes available.

This experience piqued my interest in what conditions with a relatively high base rate (compared to other psychological disorders) don't have any evidence base for being treated with CBT. To clarify, I'm not asking which conditions have a more robust literature base supporting a treatment over CBT, but rather those that have no evidence base at all for being effectively treated with a CBT-related therapy.

Thank you.

If you want to see a masterful account of how a well-trained cognitive-behaviorally trained practitioner utilizes the theoretical and empirical literature to conceptualize, 'case-formulate,' and successfully treat (complete with quantitative reduction in assessed symptom measures) a case of 'dissociative identity disorder' to a state of significant clinical improvement (sadly, no 'cure'), then check out William O' Donahue and Scott D. Lilienfeld's book Case Studies in Clinical Psychological Science: Bridging the Gap from Science to Practice. I think they do a fantastic job of applying objective, scientific (and empirically-grounded) principles to conceptualizing the case from a multitude of perspectives but--most centrally--cognitive-behavioral and applied behavioral perspectives and logically proceed to empirically test these hypotheses (through the intervention and measurement loop) with this individual patient in a single-case design (loosely) format. It's as good an example of any that I have ever encountered in the literature of showing people how to competently do CBT for a case without a diagnosis that 'fits' with the literature on 'what diagnoses can we treat with CBT?' Basically, it shows that you don't necessarily 'need' a diagnosis to cooperate with you if you understand properly how to be a good clinical scientist who is steeped in the CBT literature (broadly speaking...that is, not just specific outcome studies but the literature on the development and testing of theories as a whole) and 'evidence-based' practice and scientific reasoning.

 

[Sanman]

I was just thinking also that in the VA system (and probably in community based treatment settings, as well) we simply don't have enough clinicians to properly meet the demand for psychotherapy services so we end up having to have caseloads of 100+ clients at any one time which guarantees that you're unable to see the vast majority of your clients on anything approaching a weekly basis. There is definitely a case to be made for a significant 'dose/response' effect to active psychotherapy (I believe empirical research, specifically on CBT of depression demonstrated this, as well) and it occurs to me that it may be particularly important when dealing with complex cases involving personality disorder, severe symptoms, and/or co-morbidities. Another empirical (in the sense of direct observation, evidence from my senses) fact appears to be that VA MH departments are creating more and more non-clinical (non-provider) positions without caseloads (or extremely small caseloads) while 'closing out' or eliminating full-time provider positions. Then, when caseloads get 'too big' to properly handle, the blame is placed squarely on the shoulders of the full-time providers for not being 'efficacious' or responsible enough in treating their (likely 100+ client) caseloads. Beats anything I've ever seen.

Not having enough clinicians is part of the problem. The other issue is that we don't have appropriate goals or referrals. Psychotherapy can be better utilized when there are realistic outcomes. You are not curing complex PTSD in 10 sessions or less. Sometimes, 10 sessions are what is needed to convince a patient to properly engage in treatment. Either stop with the fixed sessions or accept realistic goals. This happens in many places in healthcare, not just mental health. The system generally has no patience.

 

[BuckeyeLove]

Please don't tell me that red pill bro logic has made it's way over to SDN

 

[WisNeuro]

Please don't tell me that red pill bro logic has made it's way over to SDN

Didn't it make its way to the social forums years ago?

 

[R. Matey]

And yet....I much prefer working with more advanced trainees who understand that we treat *people* and not diagnoses, that people are messy and rich and nuanced and that therapy can be too. It's not unscientific to rely on empirically supported principles of change and to use the knowledge of basic science (social psych, cognitive, developmental) to understand how a client operates and thus what they might need to grow. Yet this is not the kind of "Step 1. Diagnose, Step 2. Find CBT manual to treat Step 1" therapy that new clinicians often think it is.

My challenge is trying to let the new clinicians go through the process to GET to a more nuanced point without getting impatient.

There are legitimate critiques to throw at CBT, but to explicitly tie it to syndrome for treatment that is required in the VA overlooks that the VA has similar requirements for ACT, DBT, IPT etc... So while it's true that protocols for treatment do exist, case formulations also do guide treatment. And I recognize that each theory has it's limits, but so-called "patient complexity" in my experience, is typically used as cover for technical eclecticism. So, in light of that, I'd be curious to hear how you train clinicians to account for "whole person." I think I know, but I'd like to have a discussion if you're open.

We are being scammed by the neo-liberal mentality that focuses on profit and cost reduction into believing that mental health issues can be treated by short term, simple and easy to apply standardized treatments. The aim being not restoring the patient to health, allowing for a meaningful life, or providing the opportunity for real psychic growth and change to happen, but "to correct" patient's "distorted" cognitions in order to convince them, albeit in a temporary way, that their thinking is wrong, thus allowing for patients to return to being part of the work force production and to being happy consumers, meaning to participate as a member of society which nowadays has been reduced to increasing your credit score points

This is just flatly wrong and only shows your misunderstanding of the paradigm.

 

[hum1]

It's very important to be critical about our profession. In all aspects. But, in reading your description of CBT, it is very clear that you do not understand much at all about CBT. You believe in some sort of caricature of CBT with no understanding of it's underlying principles or goals.

You are right in complaining that I am emphasizing one limited aspect of CBT and simplyfying it in order to make my argument and perhaps that is not fair of me, nor of others that make the same mistake. But you are wrong when you state that I don’t know the underlying philosophical foundations of CBT as I’ve read its major texts, went through my training in a CBT focused psyd program, and had to apply CBT in my clinical work. In fact, all other clinical approaches were highly discouraged and devalued (I actually had a teacher who stated in class that if one uses psychoanalytical psychotherapy that will get you into trouble, e.g. if you ever go to court you could never get away of not being accused of malpractice if you use psychoanalytic methods).

Please don't tell me that red pill bro logic has made it's way over to SDN

I don’t know what you are talking about. I am using the red pill as an analogy to ideology as in critical theory, and discourse as in Foucault. I just found the discussions from the YouTube link very interesting since they dismantle some of the political, ideological, and methodological myths of our profession.

This is just flatly wrong and only shows your misunderstanding of the paradigm.

Then it is not only my misunderstanding. Many others write about how clinical practices and CBT (and this could be extended to psychology, psychotherapy, etc in general) intersect with neoliberalism and the pressures of the market. But I am interested in knowing what your thoughts are.

 

[R. Matey]

Then it is not only my misunderstanding. Many others write about how clinical practices and CBT (and this could be extended to psychology, psychotherapy, etc in general) intersect with neoliberalism and the pressures of the market. But I am interested in knowing what your thoughts are.

I think you should familiarize yourself with the basics of CBT before you read its critiques. That way you can see if those critiques are fair, instead of taking them prima facie. I'm not much of a Marxist, but I think we can find agreement that economics have pressured theorists into calling certain treatments time-limited when the "boots on the ground" story is actually much more complicated.

 

[Sanman]

You are right in complaining that I am emphasizing one limited aspect of CBT and simplyfying it in order to make my argument and perhaps that is not fair of me, nor of others that make the same mistake. But you are wrong when you state that I don’t know the underlying philosophical foundations of CBT as I’ve read its major texts, went through my training in a CBT focused psyd program, and had to apply CBT in my clinical work. In fact, all other clinical approaches were highly discouraged and devalued (I actually had a teacher who stated in class that if one uses psychoanalytical psychotherapy that will get you into trouble, e.g. if you ever go to court you could never get away of not being accused of malpractice if you use psychoanalytic methods).

While rather hyperbolic, there is a reason that psychoanalytic clinics take cash. They do not work under the modern insurance-based model of care. In a forensic context, you might have difficulty defending your use of a lot of techniques without an established literature base. Most of these shortcomings do not apply to modern psychodynamic therapy. You seem to be conflating CBT with modern insurance based care. The two are not the same. As others have mentioned and you seem to admit, you are not giving CBT a fair shake. You seem to be doing so based to the shortcomings of your program (per your responses). Mine taught and exposed us to a multitude of theories from the different schools of psychology.

 

[hum1]

While rather hyperbolic, there is a reason that psychoanalytic clinics take cash. They do not work under the modern insurance-based model of care. In a forensic context, you might have difficulty defending your use of a lot of techniques without an established literature base. Most of these shortcomings do not apply to modern psychodynamic therapy. You seem to be conflating CBT with modern insurance based care. The two are not the same. As others have mentioned and you seem to admit, you are not giving CBT a fair shake. You seem to be doing so based to the shortcomings of your program (per your responses). Mine taught and exposed us to a multitude of theories from the different schools of psychology.

I work in a psychoanalytic clinic that takes insurance. I am not aware of any insurance company that specifically refuses to pay psychoanalytic psychotherapy, or any other modality in specific.

Not sure about forensics but there is an considerate number of articles and meta analysis that claim that psychodynamic psychotherapy is an effective treatment for a variety of disorders. The Austen Riggs website used to have a compilation of articles but I could not find it. Of course I am very skeptical about psychotherapy efficiency and efficacy research irregardless of the modalities of psychotherapy since there are a lot of questionable studies.

It is true that CBT is not managed care. However one critique to manage care is that it overvalues psychotherapies that are easier to manualize, systematize, that use quantifiable outcome metrics, etc and CBT appears to be a better fit to this approach to health care, and at the same time, excluding other psychotherapy modalities that do not focus on the criteria evaluated and valued by managed care. This also has an impact on funding for research since if CBT is advertised as the gold standard for psychological treatment, why waste money on researching other modalities? A lot has been written about this, a great article would be "Philip Cushman Will Managed Care Change Our Way of Being?"

It was great that you had a program that was balanced in terms of the different schools of psychology/psychotherapy. I find those to becoming rarer.

 

[clausewitz2]

Ugh, this same old garbage that keeps trotting out cherry picked stats and misleads about what CBT actually is? Nothing new in this tripe. Pass. Come back when you want to have a discussion in good faith. Also, I'd stay away from Red Pill analogies unless you want to get lumped in with QAnoners and Incels.

I am 100% in agreement with you otherwise but I think you'll find few people as contemptuous of red pill logic as incels. The black pill is a whole 'nother thing.

 

[WisNeuro]

I am 100% in agreement with you otherwise but I think you'll find few people as contemptuous of red pill logic as incels. The black pill is a whole 'nother thing.

I must be out of the loop. I was not aware of any other "pills" but red and blue. But, I should not be surprised that the more *****ic segments of society have continued to grow their delusional mythos.

 

[BuckeyeLove]

I think you'll find few people as contemptuous of red pill logic as incels.

Aren't they the target of red pill logic? Like, red pill bros ("Chads?") love trolling incels is what i thought. Stuff is weird.

 

[clausewitz2]

Aren't they the target of red pill logic? Like, red pill bros ("Chads?") love trolling incels is what i thought. Stuff is weird.

Yes, precisely, Chads are definitely the arch-enemy. They are often people who tried the red pill thing and are convinced it is BS that doesn't work. Thus things are hopeless and they are doomed to loneliness forever because they have the wrong facial structure etc. etc. A common motto is LDAR, i.e. "Lay Down and Rot." It's a population that I think has a lot of need for therapy for various indications but they are very suspicious of "normie" logic.

 

[WisNeuro]

Can we just send a giant ship loaded with incels and their incel king, Jordan Peterson, into space, so they can die in a search for some sort of incel paradise that they want? It'll probably spare us from a few dozen mass shootings in the near and intermediate term future.

 

[hum1]

I can see that my red pill analogy created a lot of thoughts here. Well, at least I've learned what an incel is 😀