LadyHalcyon

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Found this article interesting, especially the part about APA's role in the situation. Also, anyone read the book CBT: The Cognitive Behavioural Tsunami? Gotta admit, it's a pretty good title.


"Judge Spero’s ruling may have pulled us from the brink of the abyss into which mental health services in Britain have fallen, in which a bean-counting managerialism has yielded corrupted science, widespread treatment failure, and a general dehumanization of social life, as described by Farhad Dalal in CBT: The Cognitive Behavioural Tsunami (Routledge, 2018)."


" Meanwhile, it should be of little surprise that the American Psychological Association’s own Guidelines program strikingly resembles UBH’s in both focus and conclusions, given that several UBH executives contributed to the formulation of the APA’s Guidelines for the treatment of PTSD, obesity and depression, with more to come in the pipeline. The APA’s decision to restrict the basis of their overviews of treatment effectiveness to studies that defined diagnosis by symptom checklist and equated short-term symptom remission with outcome has yielded Guidelines that uncannily resemble those issued by UBH, and which are now viewed as likely to constitute efforts to mitigate against the financial effects of parity."
 
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DynamicDidactic

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I just read the description of the book but never heard of it. I am not against reading it but the book seems to retread the same tired arguments concerning behaviorally-based treatments.

My favorite example of the symptom reduction vs. underlying condition debate is this study (https://psycnet.apa.org/record/2011-25413-001) from Linehan et al. (2006) that examined DBT vs community nonbehavioral experts (think dynamic therapists). After years of, mostly dynamic, complaints that DBT (and other CBTs) only treat symptoms rather than underlying conditions Linehan asked the dynamic supporters to think of the outcomes to examine. Years of asking for their input on "what" and "how" to measure what they believed was better example of the underlying condition. The dynamic therapists came up with the idea of introject (I still don't know what that means). They picked the measure that best operationalizes introject. The study was set up to even out as many confounds as possible (e.g., therapist allegiance, institutional prestige, expertise, supervision) and strength internal validity. At the end, DBT still performed better at improving introject.

I am not sure how we can scientifically understand how and what treatments work unless we stick to measurable and falsifiable phenomenon. This is especially true of health treatments that rely on public money. If the public is in some way paying for a health treatment it must be demonstrated as scientifically effective.

Not sure about this lawsuit, few details are provided in the link. I wouldn't look at an insurance company for best practices. But if someone asks me if they should go see a DBT therapist or an expert dynamic therapists for severe suicidality, the evidence indicates you are likely going to have 50% less attempts in DBT.
 

MamaPhD

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"The APA’s decision to restrict the basis of their overviews of treatment effectiveness to studies that defined diagnosis by symptom checklist and equated short-term symptom remission with outcome has yielded Guidelines that uncannily resemble those issued by UBH, and which are now viewed as likely to constitute efforts to mitigate against the financial effects of parity."

The DSM is fodder for many a straw man, isn't it?
 
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psych.meout

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I just read the description of the book but never heard of it. I am not against reading it but the book seems to retread the same tired arguments concerning behaviorally-based treatments.

My favorite example of the symptom reduction vs. underlying condition debate is this study (https://psycnet.apa.org/record/2011-25413-001) from Linehan et al. (2006) that examined DBT vs community nonbehavioral experts (think dynamic therapists). After years of, mostly dynamic, complaints that DBT (and other CBTs) only treat symptoms rather than underlying conditions Linehan asked the dynamic supporters to think of the outcomes to examine. Years of asking for their input on "what" and "how" to measure what they believed was better example of the underlying condition. The dynamic therapists came up with the idea of introject (I still don't know what that means). They picked the measure that best operationalizes introject. The study was set up to even out as many confounds as possible (e.g., therapist allegiance, institutional prestige, expertise, supervision) and strength internal validity. At the end, DBT still performed better at improving introject.

I am not sure how we can scientifically understand how and what treatments work unless we stick to measurable and falsifiable phenomenon. This is especially true of health treatments that rely on public money. If the public is in some way paying for a health treatment it must be demonstrated as scientifically effective.

Not sure about this lawsuit, few details are provided in the link. I wouldn't look at an insurance company for best practices. But if someone asks me if they should go see a DBT therapist or an expert dynamic therapists for severe suicidality, the evidence indicates you are likely going to have 50% less attempts in DBT.
There's also the issue of therapists projecting their own beliefs about treatment onto patients. Even if we accept the claims that cognitive and behavioral interventions are just addressing symptoms and not the underlying condition (which I don't necessarily agree with), that may be fitting with the patient's treatment goals. Yes, of course, they would love to be "cured" of the underlying condition, but often reducing their symptoms so that they are in less distress or are capable of being more functional in their daily lives is exactly what they are looking for.
 

Mindfulpsych22

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"The APA’s decision to restrict the basis of their overviews of treatment effectiveness to studies that defined diagnosis by symptom checklist and equated short-term symptom remission with outcome has yielded Guidelines that uncannily resemble those issued by UBH, and which are now viewed as likely to constitute efforts to mitigate against the financial effects of parity."
[/QUOTE]

This whole "treating the symptoms instead of the underlying causes" has never made any sense to me and seems to be a relic from a disease/medical model mis-applied to psychology or old psychoanalytic theories about the development of pathology. In our current psychiatric diagnostic system, there are no blood tests, brain imaging, or reliable lab tests to "diagnose" anything or confirm that someone really "has" a particular pathology. For better of worse, we have constructed our framework of differentiating and classifying pathology based off of reported subjective feelings, behaviors, and impairment. For example, we diagnose someone with PTSD based off of symptoms they report- nightmares, physical reactivity to trauma reminders, withdrawal, etc. If the patient participates in exposure and no longer experiences the reactivity, nightmares, and stops avoiding safe cues, you have appeared to change both the "condition" and the symptoms. By changing these things, the person has also altered their internal models regarding perception and behaviors around trauma-related stimuli. What would be the "underlying condition" left to treat?


This view also seems to assume that the condition of the brain is static and that changing observable symptoms does not influence our long-term psychology in any meaningful way. Feelings, behaviors, beliefs, physiology are all intertwined in such a way that affecting one often influences change in an entire complex system of connections. We know that behavior therapy (and any new learning really) changes the structure and functioning of the brain.

I agree that I wish our insurance system was set up to allow clinicians to do more to address the effects of larger existential problems that influence human suffering and to make it easier for people to access services without needing a "diagnosable" mental health condition. I can't see though how removing any safe guards of evaluating the risks and efficacies of current treatments for recognized mental health conditions does anything to foster this.

On an anecdotal note, psychodynamic/eclectic therapists seem no more likely to do things that foster improvement in psychological science (instead they seem to criticize or dismiss it more than make recommendations to improve it), study their approaches and adjust procedures based on the results, or "humanize social life." Many CBTs and CBT therapists actively focuses on helping clients enhance connections and engagement in their social lives/communities. For example, DBT makes a specific point of trying to foster supportive relationships between clients and encourages them to interact socially outside of treatment. DBT therapists often meet with clients outside the office to facilitate their engagement in activities in the community.
 
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DynamicDidactic

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Just to be clear, I am not an anti-psychodynamic person. I simple believe we have good evidence to indicate certain treatments work for certain disorders. If you have the typical mild/moderate depression, feel free to use either psychodynamic, humanistic, CBT, or many other types of treatments. If you have PTSD or are highly suicidal, the evidence indicates that not all therapies work the same.

This may be a good time to bring this up

For a long time, there has been support for the relationship as the therapeutic mechanism. Unfortunately, we do not have strong evidence for that either.
 
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LadyHalcyon

LadyHalcyon

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I was more interested in this sentence:

Given that several UBH executives contributed to the formulation of the APA’s Guidelines for the treatment of PTSD, obesity and depression, with more to come in the pipeline.
 

DynamicDidactic

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I was more interested in this sentence:

Given that several UBH executives contributed to the formulation of the APA’s Guidelines for the treatment of PTSD, obesity and depression, with more to come in the pipeline.
It seems important to include representation from managed care on APAs guidelines. That alone does not make me suspicious. I know some of the people on the PTSD guidelines and trust them thoroughly.
 
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Ollie123

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Agree with DD it seems a little conspiracy-theory-ish to assume that just because there are some managed care representatives on the guidelines it invalidates them. They are a stakeholder in this. Its also pretty stupid. Folks with untreated mental illness are high utilizers. They have worse outcomes and more complications across the board. Insurance companies know this. If we can "treat the source" effectively, believe me...they'll back us on it. They just don't want someone on 10 years of $150/week opiates in lieu of fixing the broken arm...when after the ten years they still have to pay someone else to fix the broken arm.

The article does raise some relevant issues for the broader field, albeit possibly unintentionally. The notion about treating the "source" of the issue obviously gets a little complicated given how we currently define disorders, but I do think keeps the door open for more intensive interventions when appropriate (of course...I'm thinking inpatient ECT, neurostimulation, on-site ABA and not necessarily thrice-weekly psychoanalysis, but whatever it takes...). I think its highly relevant for substance use, which is often the odd one out. Detox is not treatment for addiction. It can be a part of treatment for addiction, but counseling can also be a part of treatment for cancer. Yet its often much easier to get detox approved (if the individual is insured, which is really a separate matter) than an inpatient or IOP for substance use.


RE: Analysis - Analysts have had longer than anyone else to prove themselves and can't seem to get their acts together to do so. Don't like our measures? Fine, you pick (see above). Though I think you'll find that the symptoms tend to align with patient complaints and that you aren't the ultimate arbiter of what constitutes suffering. Think we're over-focused on suffering? Great, love positive psychology. Pick your positive/aspirational outcome and go for gold. Oh, you feel managed care is unduly limited and analysis works it just takes long? Fine, set up a multi-year RCT protocol with follow-up and match for treatment length. Can't manualize? It helps, but its not strictly necessary for RCTs so fine...skip it. Pick your 5 best, we'll pick our 5 best and we'll see who gets further and how fast they go.

On the rare occasions analysts sum up the energy to seriously try at science-ing, they almost invariably do a terrible job. They then point fingers at everyone around them and whine about how no one understands their genius. They're like the sullen emo teenagers of the psychotherapy world.
 
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erg923

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Agree. A payer certainly has a right to be involved in the logistics and methods used to complete the job/services they are paying for. This is exactly why insurance companies employ MDs and PhDs, rather than just actuaries and MBAs.
 
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WisNeuro

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Yeah, there are plenty of issues on both sides here. Many insurances are still paying some providers for an insane amount of hours for basic dementia evals and the like. Honestly, I see more unnecessary care being delivered/paid for, than necessary care being denied.
 
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PSYDR

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"But you will see for yourself that much has been gained if we succeed in turning your hysterical misery into common unhappiness."- Freud
 

Ollie123

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"But you will see for yourself that much has been gained if we succeed in turning your hysterical misery into common unhappiness."- Freud
I actually fully agree with that statement. Most therapies touch on it in various ways.

Its also far from impossible to operationalize or measure.
 

erg923

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Yeah, there are plenty of issues on both sides here. Many insurances are still paying some providers for an insane amount of hours for basic dementia evals and the like. Honestly, I see more unnecessary care being delivered/paid for, than necessary care being denied.
This is my experience as well, at least in dealing with outpatient MH services and MH/SUD IOP utilization.

Having payers cover MH well-checks/check-ups with a psychiatric/MH professional is reasonable. However, having payers mandated to pay for bi-monthly or monthly maintenance therapy in the absence of current symptoms would be cost prohibitive. If this was the case, companies would be paying for therapy for many years for over a quarter of the US population. It's also not good practice to do this, as it would create undue/unneeded dependence on therapeutic relationships. We see enough of that already via current bad practice.
 
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