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Have we overestimated the effectiveness of psychotherapy?

144 points by laurex 8y ago

Simulacra 8y ago
It depends. What do you think?
- jowsie 8y ago
  Severely underrated comment.
com2kid 8y ago
Problems with therapy: A. No standards of treatment. It is therapists choice, and therapists are free to pick and choose whatever they want. Because results are so hard to measure, therapists who are really bad at their job can continue to operate, dragging overall results for the field down. B. Licensing requirements are all over the place. From psychologists with PhDs from well established institutions, to people who got an online professional degree. The type of training someone receives heavily impacts their approach to therapy, and the quality of their education determines how high quality their treatment program can be. For fun sometime, pay the arm and a leg it costs to get a full battery of psychology tests done from a psychologist. You'll get a personality test and an actual IQ score. It takes a long time (multiple sessions each lasting a couple hours), but you will get to see the real scientific part of psychology. I actually got a practical result out of it. My doctor was able to tell me that the reason I kept dropping cups was due to a co-morbid congenital condition. Apparently a certain % of people who have an underdeveloped optic nerve also have weak grip strength. The grip strength trainer I bought has more than paid for itself in saved cups and glasses.
- lstodd 8y ago
  Good for you and I'm glad that you've got your condition under control. But no amount of standards and licensing can help one who's slowly killing himself due to their conditons. If anything, increased red tape will only raise prices and do nothing to the quality of help. Source: own experience. $/hour never correlates to help/hour, and any regulation just drives $ up, no positive effect on help/$.
  - nickthemagicman 8y ago
    You're saying you don't agree with standards and licensing in medical professions?
    - lstodd 8y ago
      I say that in psychotherapy tighting up standards and licensing does not result in tangible benefits beyond a quite low threshold compared to other medical professions. I think it's because no one knows shit wrt psychology, tons of books written nonwithstanding. It's all intuition. And those tons of books written which I read because I took my condition seriously only reinforce this opinion. May the peace be with you. You don't want to take a look at the other side.
    - pessimizer 8y ago
      https://en.wikipedia.org/wiki/Dodo_bird_verdict https://en.wikipedia.org/wiki/Dodo_bird_verdict I don't know that there's convincing evidence that medically-certified talking is any more effective than any other talking (if that talking is without significant ulterior motive.) There is, however, evidence that talking about your problems helps. Therefore there is a case to be made that getting people talking about their issues is more important than the qualifications of the people they talk about those issues to. Hell, in 12-step programs and other support groups, people with similar problems just talking to each other clearly helps.
      - mmt 8y ago
        > Hell, in 12-step programs and other support groups, people with similar problems just talking to each other clearly helps. I would take issue issue with the word "clearly", as there is controversy, at least according to Wikipedia (which you referenced). Perhaps "arguably" is a better word. https://en.wikipedia.org/wiki/Twelve-step_program#Effectiveness https://en.wikipedia.org/wiki/Twelve-step_program#Effectiven... > It would be an error to assume the effectiveness of twelve-step methods at treating problems in one domain translates to all or to another domain, therefore readers are directed to relevant sections in each group's article. [2] https://en.wikipedia.org/wiki/Effectiveness_of_Alcoholics_Anonymous https://en.wikipedia.org/wiki/Effectiveness_of_Alcoholics_An... > While newer studies have suggested an association between AA attendance and increased abstinence or other positive outcomes, older studies and studies done outside of the United States have not
- 0xcde4c3db 8y ago
  A1. Independently of their efficacy, each school's explanations of how their therapy approach works range from plausible-but-unproven (some aspects of some CBT approaches) to blatant pseudoscience (EMDR, psychoanalysis). Many constructs used to describe personality and behavior are little more than ad hoc descriptions with no grounding in a more general theory.
  - laretluval 8y ago
    This is also true for many other branches of medicine.
    - 0xcde4c3db 8y ago
      Many explanations of medical issues and treatments lack accuracy or explanatory power, sure. Doctors disagree all the time on diagnosis and treatment. But in psychotherapy it's like having a neurologist tell you that your diabetes is caused by compression of a lumbar nerve while a gastroenterologist tells you that it's caused by an intestinal obstruction.
- sonnyblarney 8y ago
  One could cut much deeper: No accepted view of what the mind and consciousness really are, no model for the mind, no accepted view of 'what normal is', and no real way to truly identify and diagnose most supposed disorders. For things like schizophrenia maybe we can help. But for things like 'depression' we're still walking around in the dark, notwithstanding good progress on some specific things.
  - SubiculumCode 8y ago
    I don't see the fundamental difference between schozophrenia and depression in terms of why one is more or less valid as a target for treatment.
    - barry-cotter 8y ago
      Their point was not that one is less valid than the other as a target for treatment but that we have a slightly better grasp of depression’s etiology than schizophrenia’s.
- gonnadoit05 8y ago
  The entire Mental Health Industry needs to be redone. Insurance problems and number of sessions are the biggest problems. Some people have such severe issues that they need possibly up to 5 times a week. But with out-of-pocket therapy sessions costing $300/hr at places like Beth Israel Hospital, there’s just no way anybody could afford that. Planning is the first step towards first degree anything, teehee, but I can’t go back unless I get 5. I have thousands of more ideas on how to improve the mental health industry.
- nickbarnwell 8y ago
  A) With regard to "no standards of treatment", that is not the case, at least in the US. Licensing and professional bodies for both Masters-level clinicians (LPCs, LMHCs, MFTs, MSWs and others) and Doctorates (PhDs, PsyDs) effectively mandate therapists rely on evidence based practices, and insurance companies are quick to push highly manualised behavioural therapies. Private practice is one thing, but treatment outcomes are tracked in CMH settings as well as IP psychiatric settings. B) Licensure is not all over the place. At a bare minimum, an independent clinician in the US will have several thousand hours of client contact (e.g. group facilitation), a thousand to fifteen hundred hours of 1:1 counselling with clients, a hundred hours of supervision, and have taken two years of graduate level coursework on psychology and psychotherapy, with the curriculum on its way to being standardised nationwide by CACREP. Studies have demonstrated that treatment outcomes are not strongly correlated with clinicians' educational background, and that the perceived therapeutic alliance is the strongest predictor of success. There are problems with psychotherapy research, but they're mostly those shared with the rest of the sciences.
  - gusts 8y ago
    pfft I like to ask every doc I go to, what outcomes they have produced in cases like mine and how many such cases they see a year. The CBT ppl just blink at me like the question is not on their manual. And one even said no great outcomes but here are the things you should do. Why would I spend my time doing them if they haven't produced results? I mean these are nice people with good intentions but so is a priest in a church or a temple. The whole thing feels half baked. Ya ya I know reprogramming the mind is complex and this is a work in progress. But my experience from work and coaching team sports is people follow authority figures when in doubt/outcomes are unknown. And most shrinks and counsellors in my case atleast are unable to establish authority.
    - deleted 8y ago
      [deleted]
    - smt88 8y ago
      Outcomes are meaningless without control groups. The providers you spoke to may not have stunning reversals of illness to show you, but keeping someone from sliding into a worse state is an important function of therapy and impossible to measure. For all you know, they may have prevented dozens of suicides that year.
- JamesBarney 8y ago
  In addition you have that the research is not nearly as careful as pharmaceuticals and even they run into tons of issues.
- barry-cotter 8y ago
  There’s a reason there’s little agreement on standards for treatment or licensure. The only thing we have solid evidence helps in therapy/counselling/psychotherapy is a strong client therapist relationship, the therapeutic alliance. Up until recently the literature suggested cognitive behavioural therapy worked better than other schools but the case for that isn’t looking great lately either. Therapy is hard and it only works if the client works at it. They can even work at it on their own, but they must work at it. Bibliotherapy, using a CBT workbook, works as well as a therapist if you actually do it but a therapist is an expensive means of ensuring you follow a programme. > Is Professional Training Worth the Bother? A Review of the Impact of Psychotherapy Training on Client Outcome > Abstract This article reviews the research literature on the effectiveness of paraprofessional counsellors and the impact of psychotherapy training on client outcome. Methodological and conceptual difficulties that have hampered previous research in this area are noted, and several well‐designed individual studies are highlighted. The existing evidence supports the efficacy of paraprofessional counsellors, although professional training may lead to better outcome in specific areas, such as greater client retention, briefer therapy, and better overall wellbeing for clients. However, methodological limitations of the research prohibit definitive conclusions. Guidelines for future research are offered.
- arthurofbabylon 8y ago
  I’d argue that A. and B. aren’t necessarily problems. After all, if it’s hard to quantify and empirically measure, wouldn’t the hypothetical standards be arbitrary? I’ll speak from personal experience: the most effective psychotherapy treatment I’ve received is very “unconventional,” with emphases on philosophy, meditation, and physical activity in nature. Those experiences have hugely impacted me in positive ways. When an entity doesn’t know how to standardize or effectively certify, but does so anyway, we get quack systems as a result.
  - mercer 8y ago
    How'd you go about finding such a form of treatments?
- orblivion 8y ago
  Here's what comes to my mind. There's this notion that if it isn't scientific it isn't serious. But if you want to take a scientific approach to everything, you won't be able to navigate life. If someone gives you personal advice on how to find a trustworthy contractor for your roof, do you demand a scientific study? I'm not a scientist, so correct me if I'm wrong, but it seems that science is by far the best method of finding truth within pretty small parameters. A law of physics. The effects of one particular chemical on a certain kind of animal. Etc. For complicated things the best thing you can do is make a really simple model of it and draw a conclusion from that. The other details are anecdotes. Again, people say to avoid trusting anecdotes, but it's what we live by all the time day to day. So when it comes to psychotherapy, it's an art form. Especially given the multiple incompatible schools of thought. It's not that much of a science. If a lot of people swear by it, well, maybe it's a placebo (though what would that even mean for psychotherapy?). Or maybe there's something to it for a decent number of people.
  - mmt 8y ago
    When it comes to health, yes, I prefer science. To me, that falls well within the same category as laws of physics, where the best method of finding truth is science. Even picking a roofing contractor (or anything else that merely has to do with money or material possessions), I may not demand all the trappings of the scientific method, but, if possible, I want at least some of them, like data, and borrowing methodologies and reasoning. Relying on the advice/authority of a single other person is unappealing, unless I believe that other person actually did the research I would have done. Sometimes, though, it's not possible. If a tree fell through the roof, it may not matter who the "best" one is, only the good-enough one available now.
- pas9ur0i3jjdj 8y ago
  I'm a tenured professor of clinical psychology who doesn't focus on therapy in research, but who does focus on meta-analysis. A. This either true or not true depending on how you look at it. There are standards of treatment, but the differential evidence in favor of any given treatment is usually poor except in some cases so it is difficult to justify any particular approach. There is no reason to mandate a specific treatment from a licensed professional if there's no strong evidence in favor of it over any other. B. Licensing requirements are all over the place, but in some ways they are overly stringent. The licensing requirements per se aren't the problem, they're the admitting standards of certain programs, and the abuses of for-profit degree programs, which can actually be quite predatory. By the time a psychologist is licensed, the level of clinical training experience required by most states is probably equivalent to a psychiatrist. Many psychologists with bio backgrounds from reputable PhD programs (note many of these students do neuroscience or genetics research of some sort) have the odd experience at a particular point in their careers of being unlicensed but being more familiar with psychiatric issues (including drugs) than first or second-year psychiatry residents. The meta-analysis in this piece is interesting, but not novel. Similar things have been shown in other meta-analyses in the past. If you asked me to summarize the literature on therapy from a meta-analytic perspective, this is what I would say: There is strong evidence that therapy is effective, from all sorts of randomized controlled designs with all sorts of controls (behavioral, pharmeceutical controls of all sorts). There is little evidence of differential efficacy between therapies overall. This means that, e.g., there is no real evidence that CBT is more efficacious than psychodynamic therapy, despite what you might think or have been told. There is some evidence that for very specific targeted outcomes (e.g., reduction of a particular type of behavior), some therapies are better, but not for general outcomes. There is evidence of publication bias. If you adjust for this, the positive effect of therapy does not go away, but it does reinforce the lack of differential efficacy. CBT and behavioral studies as a literature show the largest publication bias in previous second-order meta-analyses. (I want to point out that drug therapies also have problems with publication bias, as do all sorts of other scientific studies. This is a problem with science at the moment.) The effect of individual therapist dwarfs that of therapy type. That is, there is strong evidence that there are very good therapists, but we don't really understand what they are doing. There is some evidence that therapist-client match and cohesiveness, is important. So if you don't feel like things are working with your therapist, try a different approach. Incidentally, this is also true of drugs; trials show that people might fail with one drug but succeed with another. I want to point out that treating (or hell, assessing and measuring) mental illness is a difficult problem, regardless of how you approach it. The ambiguities in the field are not because people are just stupid. There are very intelligent people who have been working on these things from many angles, and things are complicated and multilayered, from genes to social systems. Many good ideas just don't work, or don't work the way you'd think.
themodelplumber 8y ago
> Evangelou and his team conclude that the field of psychotherapy research needs to work harder to ensure that negative results are published as well as good news results, especially given the findings of another recent paper suggesting that the field has a problem with undeclared researcher allegiance to particular therapeutic approaches. And from that other recent paper: > Reviews with a conclusion in favour of psychological therapies (vs pharmacological interventions) were at high risk for a spin in conclusions For a field so rich in therapeutic models, I find it somewhat surprising that people are not more educated, walking in to visit with a therapist, as to what kind of model or therapy is being used, and what alternatives might be available. I'm not a psychologist myself but rather a coach, and I love taking little breaks with my clients to move to a meta-perspective and walk them through the variety of models we can use together. Eventually they learn that each model has key leverage points as well as key weaknesses, and tying oneself to a single model as if it has no significant blind spots can quickly put one's desired outcomes at risk. Maybe some psychologists here can weigh in; perhaps this is already a thing in the therapy world.
- projektir 8y ago
  > For a field so rich in therapeutic models, I find it somewhat surprising that people are not more educated, walking in to visit with a therapist, as to what kind of model or therapy is being used, and what alternatives might be available. This seems like a bizarre expectation to me. People walking in about a stomach problem generally don't know much about that subject, either. I'm not sure what the ratio is, but unless you only see people from a very narrow background, I don't really see why the average person would be educated in psychological techniques any more than they're educated in types of rock.
softwaredoug 8y ago
From the article: > For the reader undertaking psychotherapy or who knows someone who is, it is worth keeping some perspective: this is just one critique and the weight of evidence still suggests that psychotherapy is, more often than not, beneficial.
- beagle3 8y ago
  Does anyone have dependable reference for that?
s-shellfish 8y ago
I've shared similar sentiments in various threads, but yes, for some people psychotherapy has an adverse effect. I honestly believe this happens because the person getting therapy does not respond well to hyperfocus on themselves. There's a point at which oneself must be able to say 'yes, I'm okay, I don't need help anymore' and modern psychotherapy doesn't really have anything beyond 'algorithms' to really establish that. Once labeled ill, it feels like it can be with you forever. I'm sure some mental health care professionals believe that's an essential crutch mentally ill people need, but from personal experience it can be just as handicapping as it is intended to be helpful. Sometimes people just want to know they'll be psychologically fine independently, and that's not something psychotherapy can prove to a person while guiding them. It's not an easy problem, but it exists. Also, pointing out problems doesn't mean oneself created them. It's something humanity needs to work on collectively.
meesterdude 8y ago
> For the reader undertaking psychotherapy or who knows someone who is, it is worth keeping some perspective: this is just one critique and the weight of evidence still suggests that psychotherapy is, more often than not, beneficial. It's good to bring a more critical eye to the field - but be mindful that it's still overall beneficial. My own experience has lead me to find it helpful, but not able to really address the core of issues. And maybe that's too much to ask for - but it's certainly not something they object to trying to address.
leot 8y ago
Certain treatments have outcomes with high variance even when practiced perfectly. Combined with no clear way to evaluate whether the treatment is being applied well, this makes it difficult for practitioners and patients to evaluate treatment quality. Which discourages expertise development in the first place (why bother working really hard when the results are hard to pin down anyway?).
Ensorceled 8y ago
I’ve had terrible martial arts instructors, inept teachers, ineffective professors, one brutal physiotherapist. I presume that there are a fair share of bad psychotherapists as well. That some people do not see improvement should not be surprising.
- sonnyblarney 8y ago
  I don't think anyone would suggest that there should be perfectly consistent outcomes, rather, on the whole that outcomes should be positive. We know there will be poor performers. The study is suggesting that 'on the whole', there are negative outcomes, implying that 'most psychotherapists' are just bad at what they do, or more likely, there's a more fundamental issue with the nature of psychotherapy itself.
- projektir 8y ago
  All these things have something in common. Martial arts is definitely an area where I don't give it much stock because a lot of it seems rather iffy. If that's where therapy is, it'd be good to know.
deleted 8y ago
[deleted]
ShabbosGoy 8y ago
The only psychotherapy we need is from plant medicines. DMT and psilocybin are natural plant teachers that can help us through the traumas we go through in our life.
- ClassyJacket 8y ago
  I'd add MDMA in there as well. It's had good results in testing for PTSD (look up MAPS) and it changed my life for sure. Not a plant, but I hold onto no idealism about that.
  - ShabbosGoy 8y ago
    I agree with you. LSD trips gave my life new meaning.
  - wavefunction 8y ago
    It was commonly synthesized from sassafras oil (safrole) so you can add it to the list I think: https://erowid.org/archive/rhodium/chemistry/safrolefaq.html https://erowid.org/archive/rhodium/chemistry/safrolefaq.html
- gsaga 8y ago
  Add cocain and weed to that list as well
  - ShabbosGoy 8y ago
    Wow very intelligent. Your comment really made me think.
    - dang 8y ago
      Please don't respond to a bad comment with a worse one, and certainly not by getting personally nasty. https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html
wavefunction 8y ago
You need some people in your life you click with.
tombh 8y ago
I'm not psychotherapy's biggest fan, but I did do 2 years training in it, and I must say the world is a better place for psychotherapy's existence. Because before psychotherapy we were cutting bits of people's brains out and electrocuting them. For all Freud's frankly odd theories he was the first big name to stand up and suggest that well intentioned dialogue was enough to help traumatised people. It's not rocket science, we don't need any big theories or research to know that talking helps. And of course by that same token some combinations of client and therapist are going to be constructive and some damaging. I believe psychotherapy is first and foremost an institution of accountability not academic theory.
- cat199 8y ago
  > we were cutting bits of people's brains out and electrocuting them in some cases. in other cases not. see also: monasticism, healthy spiritual/religious practices.
  - tombh 8y ago
    indeed. in fact i got into psychotherapy via meditation, which is actually my preferred therapeutic practice.
  - Noos 8y ago
    ...monasticism was never healthy. I really defy someone to read the Rule of Saint Benedict and not think of a modern prison at least once. Monasticism is even considered spiritually dangerous at times, and is linked to its own specific sin, Acedia: https://en.wikipedia.org/wiki/Acedia https://en.wikipedia.org/wiki/Acedia I recommend Kathleen Harris's The Noonday Demon for a good account of that. If anything, monastic life would destroy you if you suffered from depression, not heal you.
- maxerickson 8y ago
  Electroconvulsive therapy is still practiced. It is done under anesthesia and better calibrated than the horror show people tend to imagine. https://www.mayoclinic.org/tests-procedures/electroconvulsive-therapy/about/pac-20393894 https://www.mayoclinic.org/tests-procedures/electroconvulsiv...
methodover 8y ago
I’ve wondered for a long time about crowdsourced “therapy” — a kind of it, anyway. I don’t want to just hear myself talk for an hour, which is usually what therapy amounts to for me anyway. I want other perspectives. I want to hear other people whove been through what I’ve been through talking deeply and honestly about their lives. And I want enough perspectives that I can figure out for myself what modes of thinking, strategies, etc, I might make the most use of. The problem is most people are incredibly closed. Myself included. We don’t talk about our internal mental life as it relates to the outside world. Well, we do - but not with much transparency. And we don’t talk about our personal histories, our childhoods, our teenage years, etc. We don’t talk about the intimate details of our lives. (And we really shouldn’t; to be clear. Not in a way that can be traced back to us. Much of personal histories are deeply embarrassing.) And yet, we’re supposed to figure out on our own what’s normal and what isn’t. I feel like I’ve spent literally years learning things that other people figured out a long time ago. I’ve been thinking for a while about making a website that’s 100% anonymous (but moderated), but encourages people to write honestly about their own lives. No advice. It wouldn’t be about advice. It’d be only a repository of individual experiences. I feel like such a site, if done well, could be a real boon to people who are struggling to figure out life, as I was.
- taneq 8y ago
  Online forums are great for this. At various points in my life I've spent times on forums which provided exactly what you're talking about - a chance to talk openly and anonymously with other people who've faced the same challenges.
- smt88 8y ago
  There is a group model similar to what you describe called DBT, and it's a standard treatment for borderline personality disorder. It's been around for decades. It seems to be useful for many conditions.
- serpix 8y ago
  There can be no real connection without showing your own wounds. Your wounds also heal when you look into the eyes of another human telling you their fear and trauma with tears in their eyes. You connect with the experience of very humbling and deep empathy as the pain and feelings you share are the same. They are universal. You are not separate and you become to understand that you were never broken or incomplete or different. This is the power of sharing yourself with others. We are not here alone and were never supposed to figure thins out alone.
dnenandz 8y ago
I have undergone CBT with 5 therapists and so I am quite experienced with it. Every time I have been left completely and utterly disappointed. One of the unfortunate problems I faced with psychotherapy was the convenient shift of outcome being dependent on the quality of care given by the therapist to the mental fortitude of the patient following through on their exercises. In every case it was my fault that I wasn't progressing, and I found this to be extremely frustrating. It would go something like "Did your CBT methods help you not have a panic attack?", "No they didn't work and I threw up and collapsed in a Starbucks bathroom". "Oh well just practice more and identify those bad thoughts better and earlier and do some more breathing exercises and it will work out fine!" My very last encounter with psychotherapy is when I went to a doctor and explained that CBT doesn't work for me and that I was looking for someone else who practiced other methods, and yet again they claimed that I needed more practice and that I probably had not mastered CBT. Although we don't practice lobotomies anymore, if you have severe issues mental health treatment is still in the stone age.
- SteveCoast 8y ago
  Try EMDR? I met an EMDR person once who I think roughly accurately describes CBT as how to deal with issues, and EMDR solves them so you don't have to deal with them in the first place. Worth a try.
  - ParanoidShroom 8y ago
    I tried this, ended up with no results and down a few hundred euros. It might work, depending on the person and the person teaching/applying it. Not for me though.
- shakna 8y ago
  It's sad the CBT is pushed to the forefront by regulation and funding, but there are certain conditions where we know it may not help, and beyond that may be harmful. I know for GAD, SPD and similar illnesses where anxiety is a core component, that a combination of methods, where at least one is DBT, is one of the recommendations. However, there are fewer practitioners for it.
- 8y ago
robbrown451 8y ago
What I'd like to see is a comparison of psychotherapy to just paying a normal person with common sense but no psychological training to sit and listen and talk to people to help with their issues. I'm convinced that the latter would be more effective most of the time, but I'd love to see it studied.
- projektir 8y ago
  Same, I often feel that therapy is filling in a gap that really should be filled by friends and communities. Therapists at least have the training to not tell depressed people to cheer up, though.
  - felix_nagaand 8y ago
    Ironically friends and family are usually the first to recommend therapy.
  - gonnadoit05 8y ago
    Haha, someone finally called it out. The people who should be listening to these emotional stories should be your friends. The fact that there’s an entire industry means that Human being are lonelier than ever before.
  - J-dawg 8y ago
    I’m stuck in this situation at the moment. I’m seeing a therapist but my main problem is loneliness. I find I look forward to our sessions just because I get the chance to talk to someone for an hour, but I’m not sure whether I’m gaining much else from the therapy.
- tim333 8y ago
  I saw a study once - at least it was mentioned in my psychology text book that the results were about the same.
  - robbrown451 8y ago
    I'd be very interested in seeing that study or text book.
pmoriarty 8y ago
Therapy has really helped me, for a number of reasons: - It helped reduce my stress level and helped me cope. - My therapists have made constructive, useful suggestions and provided insights that I hadn't thought of on my own. - I've faced and dealt with things I've avoided facing and dealing with on my own. - I've come to understand myself much better. Those things alone are worth their weight in gold for me. That said, I've completely avoided CBT and related short-term, "evidence-based" therapies. Instead, I've preferred to work with therapists who have more of a Jungian, depth psychology approach, which are a much better fit for me. In addition to therapy, in recent years I've been eating a lot healthier, started exercising and supplementing nutrients that I was deficient in and all of these changes have had a very positive effect on my mood, health, and energy level. I also journal a lot, and that also helps me to destress and put things in perspective. It's often almost as good as talking to someone. Back to the subject of therapy: I believe it's absolutely critical to find a therapist that you like, respect, and can easily talk to and open up to. The other half of the equation is your own willingness and ability to put in the hard work of both confronting the difficult issues you need to in therapy and following through outside of therapy. Without all of these things coming together, the results are likely to be disappointing.
carapace 8y ago
I happen to have some knowledge and experience with something called "Neuro-Linguistic Programming". It's a rigorous but unscientific body of ideas and techniques that roughly amounts to an "operating system" for the human mind. (From the POV of a computer programmer it is interesting to note that the origin of NLP involved the analysis of videos of therapy sessions of a few highly effective therapists[1], done with the aid of Chomsky's Transformational Grammar, which of course is related to the Chomsky hierarchy of grammars...) I've always been disappointed that whenever people "do science to" NLP it seems to fall flat. I have to assume the studies are flawed somehow because I personally know damn well the techniques work. Yet the wikipedia entry is all about how it's a pseudoscience. It's a very frustrating situation. [1] Virginia Satir, Fritz Perls, and Milton Erickson, I believe were the main ones.
- tomhoward 8y ago
  I have a similar experience with a mix of therapies I've undertaken over the past few years. The main ones I've used are NET, kinesiology, EFT/tapping and holotropic breathwork, and a bit of Erickson hypnotherapy. I've been aware of NLP and dabbled in it a little about 10 years ago, but ended up finding the abovementioned approaches more effective for my issues. But they seem to work at the same level; like NLP, NET and kinesiology focus on finding incongruence in the body and mind, and undertaking a learning/healing process to enable transitioning to a state of congruence. After 6-7 years of this work, I've almost completely overcome chronic fatigue, anxiety (social & general) and depression, as well as several other symptoms I can now recognise in retrospect (possibly a combination of borderline/histrionic/narcissistic PD symptoms). There is some research indicating the effectiveness of NET [1], but it will have a hard time gaining mainstream acceptance given its origins/professional associations and the specifics of the treatment. It's also super-hard to do a full-scale trial for these kinds of treatments, as it's very difficult to assemble cohorts of subjects with similar enough symptoms, and the it takes years for really profound changes to happen. So it's hard to imagine who would have the funds and the timeframes required to undertake the kind of study that would be necessary to properly test this stuff - not to mention who would have the incentive, given that there's no drug patent pot of gold at the end. Yet year by year I keep doing these practices and my life keeps getting better, while I watch on as other people I know keep persisting with conventional psychology and psychiatry, without a whole lot of success beyond the superficial. I've come to understand enough about what keeps the status quo in place to no longer be frustrated by it. My approach now is to share my experiences with whomever is interested, and trust that those who need/want to know about will take notice give it a try when they're ready. Enough people have given these techniques a shot and gotten great results that I'm optimistic that more widespread acceptance can happen eventually, somehow. [1] http://www.onefoundation.org/current-research-updated/ http://www.onefoundation.org/current-research-updated/
raverbashing 8y ago
Proponents of more "evidence based" psychotherapies usually oversell their "scientific" rigour (even if there are several question on their reproducibility) while usually leaving the patient's own characteristics in the background plane (or just ignoring it). Realizing what you are feeling/thinking and being able to say that is halfway to the solution. And yes, it is very dependant on practitioner and on the patient's own willingness. (In the same way exercise is good but if you run 100m per day or lift light weights at the gym it won't do much)
wskinner 8y ago
This article could be summarized in two sentences, both of which should be unsurprising to most HN readers: 1. Publication bias means that the reported results for efficacy of psychotherapy are likely to be stronger than the actual efficacy. 2. Observational studies showed a negative relationship between mental health outcomes and psychotherapy. The clickbait title aside, 1 is not really news as this bias affects every field, especially social science, and has been widely reported. 2 is basically a no-op. You cannot under a causal relationship based only on observational studies. Full stop. The idea that people who developed poor mental health sought professional help is if anything more plausible than the clickbaity alternative.
Pica_soO 8y ago
Its glorified navel gazing. You can see everything in a navel, especially a lot of you and how that severed connection from your mother started all this trouble. In the end, its some sort of synthetic friendship, which in a ultra-individualistic society has become rare. But its not resulting in good advice like true friendship. Its resulting in pushing egomaniac tendencies onwards. Imagine a psychotheraphist not giving libertarian advice. "You should integrate more into your family, visit your brother more often, sacrifice a part of your life to the commons, so that the commons is more willing to sacrifice parts of its life to you.." "I had a very bad vibe with that psychotherapist, i came to be unrepressed and he pushed for even more repression. In fact i think, i need therapy to overcome this therapy..."
crawfordcomeaux 8y ago
A big issue I see is this idea of judging outcomes as positive/negative, instead of accepting people's processes. After starting therapy, I cut off communication from my parents at least twice. Is this a positive example of someone who's codependently avoiding their parents or someone learning to detach from their parents? Trick question: it's both. Another issue with measuring effectiveness is we aren't gathering information about the therapists' beliefs/mindsets. I dropped a therapist because she started adopting my own parents' financial insecurities, shouted "you're going to run out of money" at me a couple times during a session. Anxiety over money was a key issue for me, so I asked her multiple times not to repeat messages to me that might reinforce my thinking. She ended the session with a comment about running out of money, so I dropped her. I've since gotten over my money anxieties to the point that I've essentially taken a vow of service & poverty as I try to minimize my participation in capitalism. While I'm happy and love my new life free from worrying about money or how to meet my needs, I don't know if this would be considered a desirable therapeutic outcome when considering the rest of society. Of course, society's wellbeing is also really subjective and we are slow to evaluate our culture for long-term effects. I also started practicing Nonviolent Communication 2.5 years ago. For a while, I was kind of robotic in my communication style after, since I was structuring most sentences as "When (I|you) <observation without evaluation>, (I|you) feel <emotions without evaluation>, because (I|you) need <specific human need without specifying strategy for meeting the need>." Is this temporary rigidity considered negative? What about any person who sticks with the language they use throughout their life? We program ourselves & each other with our words and I view therapy sessions as guided debugging sessions where I work to figure out ways I've programmed myself or been programmed that are unsustainable. This perspective is therapeutically useful to me & the success of my therapy sessions has deepened, as a result. These days, therapy is more of a safe guard to keep me in check as I play with my mind and perceptions, though I'm still working on my anxiety with writing. I don't know how any of that can be accounted for in these studies and while I may be an outlier, I know that learning to pay attention to outliers is how innovations can come about.
dboreham 8y ago
The big problem with therapy is that it is too expensive to be available to most people. We need to find some viable alternative that doesn't depend on paying a very costly human to listen for an hour a week.
- LoSboccacc 8y ago
  there are also a lot of quacks around. doesn't help that psychotheraphy really lacks a solid background in medicine tbh. we're only scratching the surface of the deep mind structures and issues stemming from there and how they all relate to trauma or even what trauma actually is and yet pretend like we can cure ailments talking people out of it.
bachbach 8y ago
My suspicion is that many people going to therapy are lacking in one or more items from the basic hierarchy of needs. I went to therapy once. In hindsight I'd have been better off with a girlfriend and friend companionship. I'd ask myself. 1. Am I getting good quality sleep? 2. Am I getting good quality food? 3. Am I interacting with people socially? 4. Am I sexually active? 5. Am I physically active to the point of breaking sweat? The mental and physical are intertwined and it is easy to forget to take care of yourself. Your machine requires maintenance. I don't only mean sometimes take it easy - that too - but also people can grow very neurotic by ignoring their social and sexual needs, and like a machine - we are meant to perform functions - without which we can suffer aka a certain amount of physical or mental stress is good for us and we can err by doing too little or too much.
- themodelplumber 8y ago
  For a lot of people, deeply subjective-analytical thinking of this sort is very brittle, and they lack the experience that would teach them what to do even if they knew they were lacking some important thing on the hierarchy. It also happens that some very depressed and anxious people will e.g. read only the "criticisms" portion of the Wikipedia page for the hierarchy concept, and determine in the end that what they need is an experienced professional rather than a possibly-unscientific concept. This is really sad to observe, because their inability to be open to certain kinds of information can make them more dependent, not less.
  - bachbach 8y ago
    It is easy to dismiss 'get laid' as boorish and interpret 'did you get enough sleep?' or get out more' as semi-accusatory, because we're prone to thinking crude feedback is less apt for us, we must be more complex than this. Look at the rise of ASMR videos. Millions of people desire an experience,a simulation, of being touched in a non-sexual way. This isn't a critique of ASMR - it's fine - but there's this simple need at the heart of it - little different to those gorillas grooming each other. There's a running gag in AMSR circles where the ASMR viewer is interrupted by somebody and reacts by <laptop lid slam> pretending they were watching porn. Hackerspaces and makerspaces are a great thing. I heard a quote recently "Women communicate, men shoulder to shoulder".
davidy123 8y ago
When I worked in the health system, specifically around pain relief, there was a comparison of different approaches. Among them was "distraction therapy." That phrase has stuck with me, and I think it applies to many therapies people are mentioning here. It's basically a variation of "hit your head so you don't notice your sore elbow." But with the right application I think it can be entirely positive. If the attention required of therapy X shifts you away from problem Y, even if it's not really "helpful" on its own, then it's an excellent therapy. This is why some people realize they'd rather get a gym membership than therapy sessions. That said, I think psychotherapy, as an intentional focus on underlying or neurochemical issues, can go much deeper than this approach and should be considered by many people (though positive results could themselves be considered a 'distraction' if they don't address an inherent problems).
jm__87 8y ago
My viewpoint on mental health: how you feel at any given moment and how long that feeling will persist will depend on the structure of your brain and the environment in which your brain is in. There are a huge number of variables at play. This environment includes things like: baseline levels of chemical signalling of various kinds going on in your brain (this is plainly apparent when you do any sort of perception or mood altering substance which significantly changes the chemical signalling in your brain); physical health of the body attached to the brain; inputs from your senses and any feelings that may be arising as a result of these inputs; beliefs and assumptions about the world in which you're in; and finally structural considerations of your brain (e.g. is some part of your brain damaged or non-existent). For some people, the majority of problems lie in the "beliefs and assumptions about the world" variable and for these people, therapy is the answer. I imagine for the large majority of people, therapy may give some minor benefits but if you don't attend to your own physical and emotional needs on a regular basis, you are going to feel like garbage. This means eating a healthy diet (with enough calories), getting some exercise, spending time with family and friends, taking some time for yourself to relax and unwind. For those with persistent chemical signalling or structural problems in their brains, they may have to do way more to feel right, including getting on the right drugs and therapy for emotional support. It may suck, but we can only play the hand we're dealt. A few more thoughts on this topic: the world we live in now is so different from the one humans evolved in. We eat different food and eat way more frequently than our ancestors did. We exercise way less and spend very long periods of time in low to medium stress situations instead of short periods of time in high stress situations, which is what our stress response system evolved for. Many of us live semi-isolated lives thinking about how we can help ourselves as individuals instead of living in small to medium sized groups thinking about how we can help ourselves within the context of the group (you would likely have to be doing prosocial things with higher regularity). While there are many advantages of living in the world we now live in as compared to how our paleolithic ancestors lived, there are some incompatibilities with how we have evolved and I think we should be doing more as a society to address these issues.
perseusprime11 8y ago
The untold truth is that therapy is not for all people. Similarly, meditation is not for all people either. For some people, neither therapy nor meditation really work. For those people, medication to elevate mood is the only real option. I have seen too many therapists exploit this and raise hopes of their patients and try CBT for a long time without results. Just like any disease, you need to manage this and there is nothing wrong in taking medication to fix yourself.
totierne2 8y ago
I participated in 3 CBT sessions 10 years ago I asked what will I get out of 6 sessions (the most my employer would pay for). The therapist said I would know my problems but not solved any of them. I did not attend any further sessions. I am a male programmer with bipolar. I did try a excel based survey labelled CBT which quantified where I was on general personality traits which was OK and free. I did read some popular therapy books. I could probably do with more work focussed excutive coach lite training if I could avoid the bad ones. I called works employee helpline recently, after a manic episode, I will see how that goes, it is more of a seen to be doing something rather than letting mania (occasionally) take its natural course.

144 points by laurex 8y ago

Simulacra 8y ago

It depends. What do you think?

jowsie 8y ago
Severely underrated comment.

com2kid 8y ago

Problems with therapy: A. No standards of treatment. It is therapists choice, and therapists are free to pick and choose whatever they want. Because results are so hard to measure, therapists who are really bad at their job can continue to operate, dragging overall results for the field down. B. Licensing requirements are all over the place. From psychologists with PhDs from well established institutions, to people who got an online professional degree. The type of training someone receives heavily impacts their approach to therapy, and the quality of their education determines how high quality their treatment program can be. For fun sometime, pay the arm and a leg it costs to get a full battery of psychology tests done from a psychologist. You'll get a personality test and an actual IQ score. It takes a long time (multiple sessions each lasting a couple hours), but you will get to see the real scientific part of psychology. I actually got a practical result out of it. My doctor was able to tell me that the reason I kept dropping cups was due to a co-morbid congenital condition. Apparently a certain % of people who have an underdeveloped optic nerve also have weak grip strength. The grip strength trainer I bought has more than paid for itself in saved cups and glasses.

lstodd 8y ago
Good for you and I'm glad that you've got your condition under control. But no amount of standards and licensing can help one who's slowly killing himself due to their conditons. If anything, increased red tape will only raise prices and do nothing to the quality of help. Source: own experience. $/hour never correlates to help/hour, and any regulation just drives $ up, no positive effect on help/$.
- nickthemagicman 8y ago
  You're saying you don't agree with standards and licensing in medical professions?
  - lstodd 8y ago
    I say that in psychotherapy tighting up standards and licensing does not result in tangible benefits beyond a quite low threshold compared to other medical professions. I think it's because no one knows shit wrt psychology, tons of books written nonwithstanding. It's all intuition. And those tons of books written which I read because I took my condition seriously only reinforce this opinion. May the peace be with you. You don't want to take a look at the other side.
  - pessimizer 8y ago
    https://en.wikipedia.org/wiki/Dodo_bird_verdict https://en.wikipedia.org/wiki/Dodo_bird_verdict I don't know that there's convincing evidence that medically-certified talking is any more effective than any other talking (if that talking is without significant ulterior motive.) There is, however, evidence that talking about your problems helps. Therefore there is a case to be made that getting people talking about their issues is more important than the qualifications of the people they talk about those issues to. Hell, in 12-step programs and other support groups, people with similar problems just talking to each other clearly helps.
    - mmt 8y ago
      > Hell, in 12-step programs and other support groups, people with similar problems just talking to each other clearly helps. I would take issue issue with the word "clearly", as there is controversy, at least according to Wikipedia (which you referenced). Perhaps "arguably" is a better word. https://en.wikipedia.org/wiki/Twelve-step_program#Effectiveness https://en.wikipedia.org/wiki/Twelve-step_program#Effectiven... > It would be an error to assume the effectiveness of twelve-step methods at treating problems in one domain translates to all or to another domain, therefore readers are directed to relevant sections in each group's article. [2] https://en.wikipedia.org/wiki/Effectiveness_of_Alcoholics_Anonymous https://en.wikipedia.org/wiki/Effectiveness_of_Alcoholics_An... > While newer studies have suggested an association between AA attendance and increased abstinence or other positive outcomes, older studies and studies done outside of the United States have not
0xcde4c3db 8y ago
A1. Independently of their efficacy, each school's explanations of how their therapy approach works range from plausible-but-unproven (some aspects of some CBT approaches) to blatant pseudoscience (EMDR, psychoanalysis). Many constructs used to describe personality and behavior are little more than ad hoc descriptions with no grounding in a more general theory.
- laretluval 8y ago
  This is also true for many other branches of medicine.
  - 0xcde4c3db 8y ago
    Many explanations of medical issues and treatments lack accuracy or explanatory power, sure. Doctors disagree all the time on diagnosis and treatment. But in psychotherapy it's like having a neurologist tell you that your diabetes is caused by compression of a lumbar nerve while a gastroenterologist tells you that it's caused by an intestinal obstruction.
sonnyblarney 8y ago
One could cut much deeper: No accepted view of what the mind and consciousness really are, no model for the mind, no accepted view of 'what normal is', and no real way to truly identify and diagnose most supposed disorders. For things like schizophrenia maybe we can help. But for things like 'depression' we're still walking around in the dark, notwithstanding good progress on some specific things.
- SubiculumCode 8y ago
  I don't see the fundamental difference between schozophrenia and depression in terms of why one is more or less valid as a target for treatment.
  - barry-cotter 8y ago
    Their point was not that one is less valid than the other as a target for treatment but that we have a slightly better grasp of depression’s etiology than schizophrenia’s.
gonnadoit05 8y ago
The entire Mental Health Industry needs to be redone. Insurance problems and number of sessions are the biggest problems. Some people have such severe issues that they need possibly up to 5 times a week. But with out-of-pocket therapy sessions costing $300/hr at places like Beth Israel Hospital, there’s just no way anybody could afford that. Planning is the first step towards first degree anything, teehee, but I can’t go back unless I get 5. I have thousands of more ideas on how to improve the mental health industry.
nickbarnwell 8y ago
A) With regard to "no standards of treatment", that is not the case, at least in the US. Licensing and professional bodies for both Masters-level clinicians (LPCs, LMHCs, MFTs, MSWs and others) and Doctorates (PhDs, PsyDs) effectively mandate therapists rely on evidence based practices, and insurance companies are quick to push highly manualised behavioural therapies. Private practice is one thing, but treatment outcomes are tracked in CMH settings as well as IP psychiatric settings. B) Licensure is not all over the place. At a bare minimum, an independent clinician in the US will have several thousand hours of client contact (e.g. group facilitation), a thousand to fifteen hundred hours of 1:1 counselling with clients, a hundred hours of supervision, and have taken two years of graduate level coursework on psychology and psychotherapy, with the curriculum on its way to being standardised nationwide by CACREP. Studies have demonstrated that treatment outcomes are not strongly correlated with clinicians' educational background, and that the perceived therapeutic alliance is the strongest predictor of success. There are problems with psychotherapy research, but they're mostly those shared with the rest of the sciences.
- gusts 8y ago
  pfft I like to ask every doc I go to, what outcomes they have produced in cases like mine and how many such cases they see a year. The CBT ppl just blink at me like the question is not on their manual. And one even said no great outcomes but here are the things you should do. Why would I spend my time doing them if they haven't produced results? I mean these are nice people with good intentions but so is a priest in a church or a temple. The whole thing feels half baked. Ya ya I know reprogramming the mind is complex and this is a work in progress. But my experience from work and coaching team sports is people follow authority figures when in doubt/outcomes are unknown. And most shrinks and counsellors in my case atleast are unable to establish authority.
  - deleted 8y ago
    [deleted]
  - smt88 8y ago
    Outcomes are meaningless without control groups. The providers you spoke to may not have stunning reversals of illness to show you, but keeping someone from sliding into a worse state is an important function of therapy and impossible to measure. For all you know, they may have prevented dozens of suicides that year.
JamesBarney 8y ago
In addition you have that the research is not nearly as careful as pharmaceuticals and even they run into tons of issues.
barry-cotter 8y ago
There’s a reason there’s little agreement on standards for treatment or licensure. The only thing we have solid evidence helps in therapy/counselling/psychotherapy is a strong client therapist relationship, the therapeutic alliance. Up until recently the literature suggested cognitive behavioural therapy worked better than other schools but the case for that isn’t looking great lately either. Therapy is hard and it only works if the client works at it. They can even work at it on their own, but they must work at it. Bibliotherapy, using a CBT workbook, works as well as a therapist if you actually do it but a therapist is an expensive means of ensuring you follow a programme. > Is Professional Training Worth the Bother? A Review of the Impact of Psychotherapy Training on Client Outcome > Abstract This article reviews the research literature on the effectiveness of paraprofessional counsellors and the impact of psychotherapy training on client outcome. Methodological and conceptual difficulties that have hampered previous research in this area are noted, and several well‐designed individual studies are highlighted. The existing evidence supports the efficacy of paraprofessional counsellors, although professional training may lead to better outcome in specific areas, such as greater client retention, briefer therapy, and better overall wellbeing for clients. However, methodological limitations of the research prohibit definitive conclusions. Guidelines for future research are offered.
arthurofbabylon 8y ago
I’d argue that A. and B. aren’t necessarily problems. After all, if it’s hard to quantify and empirically measure, wouldn’t the hypothetical standards be arbitrary? I’ll speak from personal experience: the most effective psychotherapy treatment I’ve received is very “unconventional,” with emphases on philosophy, meditation, and physical activity in nature. Those experiences have hugely impacted me in positive ways. When an entity doesn’t know how to standardize or effectively certify, but does so anyway, we get quack systems as a result.
- mercer 8y ago
  How'd you go about finding such a form of treatments?
orblivion 8y ago
Here's what comes to my mind. There's this notion that if it isn't scientific it isn't serious. But if you want to take a scientific approach to everything, you won't be able to navigate life. If someone gives you personal advice on how to find a trustworthy contractor for your roof, do you demand a scientific study? I'm not a scientist, so correct me if I'm wrong, but it seems that science is by far the best method of finding truth within pretty small parameters. A law of physics. The effects of one particular chemical on a certain kind of animal. Etc. For complicated things the best thing you can do is make a really simple model of it and draw a conclusion from that. The other details are anecdotes. Again, people say to avoid trusting anecdotes, but it's what we live by all the time day to day. So when it comes to psychotherapy, it's an art form. Especially given the multiple incompatible schools of thought. It's not that much of a science. If a lot of people swear by it, well, maybe it's a placebo (though what would that even mean for psychotherapy?). Or maybe there's something to it for a decent number of people.
- mmt 8y ago
  When it comes to health, yes, I prefer science. To me, that falls well within the same category as laws of physics, where the best method of finding truth is science. Even picking a roofing contractor (or anything else that merely has to do with money or material possessions), I may not demand all the trappings of the scientific method, but, if possible, I want at least some of them, like data, and borrowing methodologies and reasoning. Relying on the advice/authority of a single other person is unappealing, unless I believe that other person actually did the research I would have done. Sometimes, though, it's not possible. If a tree fell through the roof, it may not matter who the "best" one is, only the good-enough one available now.
pas9ur0i3jjdj 8y ago
I'm a tenured professor of clinical psychology who doesn't focus on therapy in research, but who does focus on meta-analysis. A. This either true or not true depending on how you look at it. There are standards of treatment, but the differential evidence in favor of any given treatment is usually poor except in some cases so it is difficult to justify any particular approach. There is no reason to mandate a specific treatment from a licensed professional if there's no strong evidence in favor of it over any other. B. Licensing requirements are all over the place, but in some ways they are overly stringent. The licensing requirements per se aren't the problem, they're the admitting standards of certain programs, and the abuses of for-profit degree programs, which can actually be quite predatory. By the time a psychologist is licensed, the level of clinical training experience required by most states is probably equivalent to a psychiatrist. Many psychologists with bio backgrounds from reputable PhD programs (note many of these students do neuroscience or genetics research of some sort) have the odd experience at a particular point in their careers of being unlicensed but being more familiar with psychiatric issues (including drugs) than first or second-year psychiatry residents. The meta-analysis in this piece is interesting, but not novel. Similar things have been shown in other meta-analyses in the past. If you asked me to summarize the literature on therapy from a meta-analytic perspective, this is what I would say: There is strong evidence that therapy is effective, from all sorts of randomized controlled designs with all sorts of controls (behavioral, pharmeceutical controls of all sorts). There is little evidence of differential efficacy between therapies overall. This means that, e.g., there is no real evidence that CBT is more efficacious than psychodynamic therapy, despite what you might think or have been told. There is some evidence that for very specific targeted outcomes (e.g., reduction of a particular type of behavior), some therapies are better, but not for general outcomes. There is evidence of publication bias. If you adjust for this, the positive effect of therapy does not go away, but it does reinforce the lack of differential efficacy. CBT and behavioral studies as a literature show the largest publication bias in previous second-order meta-analyses. (I want to point out that drug therapies also have problems with publication bias, as do all sorts of other scientific studies. This is a problem with science at the moment.) The effect of individual therapist dwarfs that of therapy type. That is, there is strong evidence that there are very good therapists, but we don't really understand what they are doing. There is some evidence that therapist-client match and cohesiveness, is important. So if you don't feel like things are working with your therapist, try a different approach. Incidentally, this is also true of drugs; trials show that people might fail with one drug but succeed with another. I want to point out that treating (or hell, assessing and measuring) mental illness is a difficult problem, regardless of how you approach it. The ambiguities in the field are not because people are just stupid. There are very intelligent people who have been working on these things from many angles, and things are complicated and multilayered, from genes to social systems. Many good ideas just don't work, or don't work the way you'd think.

themodelplumber 8y ago

> Evangelou and his team conclude that the field of psychotherapy research needs to work harder to ensure that negative results are published as well as good news results, especially given the findings of another recent paper suggesting that the field has a problem with undeclared researcher allegiance to particular therapeutic approaches. And from that other recent paper: > Reviews with a conclusion in favour of psychological therapies (vs pharmacological interventions) were at high risk for a spin in conclusions For a field so rich in therapeutic models, I find it somewhat surprising that people are not more educated, walking in to visit with a therapist, as to what kind of model or therapy is being used, and what alternatives might be available. I'm not a psychologist myself but rather a coach, and I love taking little breaks with my clients to move to a meta-perspective and walk them through the variety of models we can use together. Eventually they learn that each model has key leverage points as well as key weaknesses, and tying oneself to a single model as if it has no significant blind spots can quickly put one's desired outcomes at risk. Maybe some psychologists here can weigh in; perhaps this is already a thing in the therapy world.

projektir 8y ago
> For a field so rich in therapeutic models, I find it somewhat surprising that people are not more educated, walking in to visit with a therapist, as to what kind of model or therapy is being used, and what alternatives might be available. This seems like a bizarre expectation to me. People walking in about a stomach problem generally don't know much about that subject, either. I'm not sure what the ratio is, but unless you only see people from a very narrow background, I don't really see why the average person would be educated in psychological techniques any more than they're educated in types of rock.

softwaredoug 8y ago

From the article: > For the reader undertaking psychotherapy or who knows someone who is, it is worth keeping some perspective: this is just one critique and the weight of evidence still suggests that psychotherapy is, more often than not, beneficial.

beagle3 8y ago
Does anyone have dependable reference for that?

s-shellfish 8y ago

I've shared similar sentiments in various threads, but yes, for some people psychotherapy has an adverse effect. I honestly believe this happens because the person getting therapy does not respond well to hyperfocus on themselves. There's a point at which oneself must be able to say 'yes, I'm okay, I don't need help anymore' and modern psychotherapy doesn't really have anything beyond 'algorithms' to really establish that. Once labeled ill, it feels like it can be with you forever. I'm sure some mental health care professionals believe that's an essential crutch mentally ill people need, but from personal experience it can be just as handicapping as it is intended to be helpful. Sometimes people just want to know they'll be psychologically fine independently, and that's not something psychotherapy can prove to a person while guiding them. It's not an easy problem, but it exists. Also, pointing out problems doesn't mean oneself created them. It's something humanity needs to work on collectively.

meesterdude 8y ago

> For the reader undertaking psychotherapy or who knows someone who is, it is worth keeping some perspective: this is just one critique and the weight of evidence still suggests that psychotherapy is, more often than not, beneficial. It's good to bring a more critical eye to the field - but be mindful that it's still overall beneficial. My own experience has lead me to find it helpful, but not able to really address the core of issues. And maybe that's too much to ask for - but it's certainly not something they object to trying to address.

leot 8y ago

Certain treatments have outcomes with high variance even when practiced perfectly. Combined with no clear way to evaluate whether the treatment is being applied well, this makes it difficult for practitioners and patients to evaluate treatment quality. Which discourages expertise development in the first place (why bother working really hard when the results are hard to pin down anyway?).

Ensorceled 8y ago

I’ve had terrible martial arts instructors, inept teachers, ineffective professors, one brutal physiotherapist. I presume that there are a fair share of bad psychotherapists as well. That some people do not see improvement should not be surprising.

sonnyblarney 8y ago
I don't think anyone would suggest that there should be perfectly consistent outcomes, rather, on the whole that outcomes should be positive. We know there will be poor performers. The study is suggesting that 'on the whole', there are negative outcomes, implying that 'most psychotherapists' are just bad at what they do, or more likely, there's a more fundamental issue with the nature of psychotherapy itself.
projektir 8y ago
All these things have something in common. Martial arts is definitely an area where I don't give it much stock because a lot of it seems rather iffy. If that's where therapy is, it'd be good to know.

deleted 8y ago

[deleted]

ShabbosGoy 8y ago

The only psychotherapy we need is from plant medicines. DMT and psilocybin are natural plant teachers that can help us through the traumas we go through in our life.

ClassyJacket 8y ago
I'd add MDMA in there as well. It's had good results in testing for PTSD (look up MAPS) and it changed my life for sure. Not a plant, but I hold onto no idealism about that.
- ShabbosGoy 8y ago
  I agree with you. LSD trips gave my life new meaning.
- wavefunction 8y ago
  It was commonly synthesized from sassafras oil (safrole) so you can add it to the list I think: https://erowid.org/archive/rhodium/chemistry/safrolefaq.html https://erowid.org/archive/rhodium/chemistry/safrolefaq.html
gsaga 8y ago
Add cocain and weed to that list as well
- ShabbosGoy 8y ago
  Wow very intelligent. Your comment really made me think.
  - dang 8y ago
    Please don't respond to a bad comment with a worse one, and certainly not by getting personally nasty. https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html

wavefunction 8y ago

You need some people in your life you click with.

tombh 8y ago

I'm not psychotherapy's biggest fan, but I did do 2 years training in it, and I must say the world is a better place for psychotherapy's existence. Because before psychotherapy we were cutting bits of people's brains out and electrocuting them. For all Freud's frankly odd theories he was the first big name to stand up and suggest that well intentioned dialogue was enough to help traumatised people. It's not rocket science, we don't need any big theories or research to know that talking helps. And of course by that same token some combinations of client and therapist are going to be constructive and some damaging. I believe psychotherapy is first and foremost an institution of accountability not academic theory.

cat199 8y ago
> we were cutting bits of people's brains out and electrocuting them in some cases. in other cases not. see also: monasticism, healthy spiritual/religious practices.
- tombh 8y ago
  indeed. in fact i got into psychotherapy via meditation, which is actually my preferred therapeutic practice.
- Noos 8y ago
  ...monasticism was never healthy. I really defy someone to read the Rule of Saint Benedict and not think of a modern prison at least once. Monasticism is even considered spiritually dangerous at times, and is linked to its own specific sin, Acedia: https://en.wikipedia.org/wiki/Acedia https://en.wikipedia.org/wiki/Acedia I recommend Kathleen Harris's The Noonday Demon for a good account of that. If anything, monastic life would destroy you if you suffered from depression, not heal you.
maxerickson 8y ago
Electroconvulsive therapy is still practiced. It is done under anesthesia and better calibrated than the horror show people tend to imagine. https://www.mayoclinic.org/tests-procedures/electroconvulsive-therapy/about/pac-20393894 https://www.mayoclinic.org/tests-procedures/electroconvulsiv...

methodover 8y ago

I’ve wondered for a long time about crowdsourced “therapy” — a kind of it, anyway. I don’t want to just hear myself talk for an hour, which is usually what therapy amounts to for me anyway. I want other perspectives. I want to hear other people whove been through what I’ve been through talking deeply and honestly about their lives. And I want enough perspectives that I can figure out for myself what modes of thinking, strategies, etc, I might make the most use of. The problem is most people are incredibly closed. Myself included. We don’t talk about our internal mental life as it relates to the outside world. Well, we do - but not with much transparency. And we don’t talk about our personal histories, our childhoods, our teenage years, etc. We don’t talk about the intimate details of our lives. (And we really shouldn’t; to be clear. Not in a way that can be traced back to us. Much of personal histories are deeply embarrassing.) And yet, we’re supposed to figure out on our own what’s normal and what isn’t. I feel like I’ve spent literally years learning things that other people figured out a long time ago. I’ve been thinking for a while about making a website that’s 100% anonymous (but moderated), but encourages people to write honestly about their own lives. No advice. It wouldn’t be about advice. It’d be only a repository of individual experiences. I feel like such a site, if done well, could be a real boon to people who are struggling to figure out life, as I was.

taneq 8y ago
Online forums are great for this. At various points in my life I've spent times on forums which provided exactly what you're talking about - a chance to talk openly and anonymously with other people who've faced the same challenges.
smt88 8y ago
There is a group model similar to what you describe called DBT, and it's a standard treatment for borderline personality disorder. It's been around for decades. It seems to be useful for many conditions.
serpix 8y ago
There can be no real connection without showing your own wounds. Your wounds also heal when you look into the eyes of another human telling you their fear and trauma with tears in their eyes. You connect with the experience of very humbling and deep empathy as the pain and feelings you share are the same. They are universal. You are not separate and you become to understand that you were never broken or incomplete or different. This is the power of sharing yourself with others. We are not here alone and were never supposed to figure thins out alone.

dnenandz 8y ago

I have undergone CBT with 5 therapists and so I am quite experienced with it. Every time I have been left completely and utterly disappointed. One of the unfortunate problems I faced with psychotherapy was the convenient shift of outcome being dependent on the quality of care given by the therapist to the mental fortitude of the patient following through on their exercises. In every case it was my fault that I wasn't progressing, and I found this to be extremely frustrating. It would go something like "Did your CBT methods help you not have a panic attack?", "No they didn't work and I threw up and collapsed in a Starbucks bathroom". "Oh well just practice more and identify those bad thoughts better and earlier and do some more breathing exercises and it will work out fine!" My very last encounter with psychotherapy is when I went to a doctor and explained that CBT doesn't work for me and that I was looking for someone else who practiced other methods, and yet again they claimed that I needed more practice and that I probably had not mastered CBT. Although we don't practice lobotomies anymore, if you have severe issues mental health treatment is still in the stone age.

SteveCoast 8y ago
Try EMDR? I met an EMDR person once who I think roughly accurately describes CBT as how to deal with issues, and EMDR solves them so you don't have to deal with them in the first place. Worth a try.
- ParanoidShroom 8y ago
  I tried this, ended up with no results and down a few hundred euros. It might work, depending on the person and the person teaching/applying it. Not for me though.
shakna 8y ago
It's sad the CBT is pushed to the forefront by regulation and funding, but there are certain conditions where we know it may not help, and beyond that may be harmful. I know for GAD, SPD and similar illnesses where anxiety is a core component, that a combination of methods, where at least one is DBT, is one of the recommendations. However, there are fewer practitioners for it.
8y ago

robbrown451 8y ago

What I'd like to see is a comparison of psychotherapy to just paying a normal person with common sense but no psychological training to sit and listen and talk to people to help with their issues. I'm convinced that the latter would be more effective most of the time, but I'd love to see it studied.

projektir 8y ago
Same, I often feel that therapy is filling in a gap that really should be filled by friends and communities. Therapists at least have the training to not tell depressed people to cheer up, though.
- felix_nagaand 8y ago
  Ironically friends and family are usually the first to recommend therapy.
- gonnadoit05 8y ago
  Haha, someone finally called it out. The people who should be listening to these emotional stories should be your friends. The fact that there’s an entire industry means that Human being are lonelier than ever before.
- J-dawg 8y ago
  I’m stuck in this situation at the moment. I’m seeing a therapist but my main problem is loneliness. I find I look forward to our sessions just because I get the chance to talk to someone for an hour, but I’m not sure whether I’m gaining much else from the therapy.
tim333 8y ago
I saw a study once - at least it was mentioned in my psychology text book that the results were about the same.
- robbrown451 8y ago
  I'd be very interested in seeing that study or text book.

pmoriarty 8y ago

Therapy has really helped me, for a number of reasons: - It helped reduce my stress level and helped me cope. - My therapists have made constructive, useful suggestions and provided insights that I hadn't thought of on my own. - I've faced and dealt with things I've avoided facing and dealing with on my own. - I've come to understand myself much better. Those things alone are worth their weight in gold for me. That said, I've completely avoided CBT and related short-term, "evidence-based" therapies. Instead, I've preferred to work with therapists who have more of a Jungian, depth psychology approach, which are a much better fit for me. In addition to therapy, in recent years I've been eating a lot healthier, started exercising and supplementing nutrients that I was deficient in and all of these changes have had a very positive effect on my mood, health, and energy level. I also journal a lot, and that also helps me to destress and put things in perspective. It's often almost as good as talking to someone. Back to the subject of therapy: I believe it's absolutely critical to find a therapist that you like, respect, and can easily talk to and open up to. The other half of the equation is your own willingness and ability to put in the hard work of both confronting the difficult issues you need to in therapy and following through outside of therapy. Without all of these things coming together, the results are likely to be disappointing.

carapace 8y ago

I happen to have some knowledge and experience with something called "Neuro-Linguistic Programming". It's a rigorous but unscientific body of ideas and techniques that roughly amounts to an "operating system" for the human mind. (From the POV of a computer programmer it is interesting to note that the origin of NLP involved the analysis of videos of therapy sessions of a few highly effective therapists[1], done with the aid of Chomsky's Transformational Grammar, which of course is related to the Chomsky hierarchy of grammars...) I've always been disappointed that whenever people "do science to" NLP it seems to fall flat. I have to assume the studies are flawed somehow because I personally know damn well the techniques work. Yet the wikipedia entry is all about how it's a pseudoscience. It's a very frustrating situation. [1] Virginia Satir, Fritz Perls, and Milton Erickson, I believe were the main ones.

tomhoward 8y ago
I have a similar experience with a mix of therapies I've undertaken over the past few years. The main ones I've used are NET, kinesiology, EFT/tapping and holotropic breathwork, and a bit of Erickson hypnotherapy. I've been aware of NLP and dabbled in it a little about 10 years ago, but ended up finding the abovementioned approaches more effective for my issues. But they seem to work at the same level; like NLP, NET and kinesiology focus on finding incongruence in the body and mind, and undertaking a learning/healing process to enable transitioning to a state of congruence. After 6-7 years of this work, I've almost completely overcome chronic fatigue, anxiety (social & general) and depression, as well as several other symptoms I can now recognise in retrospect (possibly a combination of borderline/histrionic/narcissistic PD symptoms). There is some research indicating the effectiveness of NET [1], but it will have a hard time gaining mainstream acceptance given its origins/professional associations and the specifics of the treatment. It's also super-hard to do a full-scale trial for these kinds of treatments, as it's very difficult to assemble cohorts of subjects with similar enough symptoms, and the it takes years for really profound changes to happen. So it's hard to imagine who would have the funds and the timeframes required to undertake the kind of study that would be necessary to properly test this stuff - not to mention who would have the incentive, given that there's no drug patent pot of gold at the end. Yet year by year I keep doing these practices and my life keeps getting better, while I watch on as other people I know keep persisting with conventional psychology and psychiatry, without a whole lot of success beyond the superficial. I've come to understand enough about what keeps the status quo in place to no longer be frustrated by it. My approach now is to share my experiences with whomever is interested, and trust that those who need/want to know about will take notice give it a try when they're ready. Enough people have given these techniques a shot and gotten great results that I'm optimistic that more widespread acceptance can happen eventually, somehow. [1] http://www.onefoundation.org/current-research-updated/ http://www.onefoundation.org/current-research-updated/

raverbashing 8y ago

Proponents of more "evidence based" psychotherapies usually oversell their "scientific" rigour (even if there are several question on their reproducibility) while usually leaving the patient's own characteristics in the background plane (or just ignoring it). Realizing what you are feeling/thinking and being able to say that is halfway to the solution. And yes, it is very dependant on practitioner and on the patient's own willingness. (In the same way exercise is good but if you run 100m per day or lift light weights at the gym it won't do much)

wskinner 8y ago

This article could be summarized in two sentences, both of which should be unsurprising to most HN readers: 1. Publication bias means that the reported results for efficacy of psychotherapy are likely to be stronger than the actual efficacy. 2. Observational studies showed a negative relationship between mental health outcomes and psychotherapy. The clickbait title aside, 1 is not really news as this bias affects every field, especially social science, and has been widely reported. 2 is basically a no-op. You cannot under a causal relationship based only on observational studies. Full stop. The idea that people who developed poor mental health sought professional help is if anything more plausible than the clickbaity alternative.

Pica_soO 8y ago

Its glorified navel gazing. You can see everything in a navel, especially a lot of you and how that severed connection from your mother started all this trouble. In the end, its some sort of synthetic friendship, which in a ultra-individualistic society has become rare. But its not resulting in good advice like true friendship. Its resulting in pushing egomaniac tendencies onwards. Imagine a psychotheraphist not giving libertarian advice. "You should integrate more into your family, visit your brother more often, sacrifice a part of your life to the commons, so that the commons is more willing to sacrifice parts of its life to you.." "I had a very bad vibe with that psychotherapist, i came to be unrepressed and he pushed for even more repression. In fact i think, i need therapy to overcome this therapy..."

crawfordcomeaux 8y ago

A big issue I see is this idea of judging outcomes as positive/negative, instead of accepting people's processes. After starting therapy, I cut off communication from my parents at least twice. Is this a positive example of someone who's codependently avoiding their parents or someone learning to detach from their parents? Trick question: it's both. Another issue with measuring effectiveness is we aren't gathering information about the therapists' beliefs/mindsets. I dropped a therapist because she started adopting my own parents' financial insecurities, shouted "you're going to run out of money" at me a couple times during a session. Anxiety over money was a key issue for me, so I asked her multiple times not to repeat messages to me that might reinforce my thinking. She ended the session with a comment about running out of money, so I dropped her. I've since gotten over my money anxieties to the point that I've essentially taken a vow of service & poverty as I try to minimize my participation in capitalism. While I'm happy and love my new life free from worrying about money or how to meet my needs, I don't know if this would be considered a desirable therapeutic outcome when considering the rest of society. Of course, society's wellbeing is also really subjective and we are slow to evaluate our culture for long-term effects. I also started practicing Nonviolent Communication 2.5 years ago. For a while, I was kind of robotic in my communication style after, since I was structuring most sentences as "When (I|you) <observation without evaluation>, (I|you) feel <emotions without evaluation>, because (I|you) need <specific human need without specifying strategy for meeting the need>." Is this temporary rigidity considered negative? What about any person who sticks with the language they use throughout their life? We program ourselves & each other with our words and I view therapy sessions as guided debugging sessions where I work to figure out ways I've programmed myself or been programmed that are unsustainable. This perspective is therapeutically useful to me & the success of my therapy sessions has deepened, as a result. These days, therapy is more of a safe guard to keep me in check as I play with my mind and perceptions, though I'm still working on my anxiety with writing. I don't know how any of that can be accounted for in these studies and while I may be an outlier, I know that learning to pay attention to outliers is how innovations can come about.

dboreham 8y ago

The big problem with therapy is that it is too expensive to be available to most people. We need to find some viable alternative that doesn't depend on paying a very costly human to listen for an hour a week.

LoSboccacc 8y ago
there are also a lot of quacks around. doesn't help that psychotheraphy really lacks a solid background in medicine tbh. we're only scratching the surface of the deep mind structures and issues stemming from there and how they all relate to trauma or even what trauma actually is and yet pretend like we can cure ailments talking people out of it.

bachbach 8y ago

My suspicion is that many people going to therapy are lacking in one or more items from the basic hierarchy of needs. I went to therapy once. In hindsight I'd have been better off with a girlfriend and friend companionship. I'd ask myself. 1. Am I getting good quality sleep? 2. Am I getting good quality food? 3. Am I interacting with people socially? 4. Am I sexually active? 5. Am I physically active to the point of breaking sweat? The mental and physical are intertwined and it is easy to forget to take care of yourself. Your machine requires maintenance. I don't only mean sometimes take it easy - that too - but also people can grow very neurotic by ignoring their social and sexual needs, and like a machine - we are meant to perform functions - without which we can suffer aka a certain amount of physical or mental stress is good for us and we can err by doing too little or too much.

themodelplumber 8y ago
For a lot of people, deeply subjective-analytical thinking of this sort is very brittle, and they lack the experience that would teach them what to do even if they knew they were lacking some important thing on the hierarchy. It also happens that some very depressed and anxious people will e.g. read only the "criticisms" portion of the Wikipedia page for the hierarchy concept, and determine in the end that what they need is an experienced professional rather than a possibly-unscientific concept. This is really sad to observe, because their inability to be open to certain kinds of information can make them more dependent, not less.
- bachbach 8y ago
  It is easy to dismiss 'get laid' as boorish and interpret 'did you get enough sleep?' or get out more' as semi-accusatory, because we're prone to thinking crude feedback is less apt for us, we must be more complex than this. Look at the rise of ASMR videos. Millions of people desire an experience,a simulation, of being touched in a non-sexual way. This isn't a critique of ASMR - it's fine - but there's this simple need at the heart of it - little different to those gorillas grooming each other. There's a running gag in AMSR circles where the ASMR viewer is interrupted by somebody and reacts by <laptop lid slam> pretending they were watching porn. Hackerspaces and makerspaces are a great thing. I heard a quote recently "Women communicate, men shoulder to shoulder".

davidy123 8y ago

When I worked in the health system, specifically around pain relief, there was a comparison of different approaches. Among them was "distraction therapy." That phrase has stuck with me, and I think it applies to many therapies people are mentioning here. It's basically a variation of "hit your head so you don't notice your sore elbow." But with the right application I think it can be entirely positive. If the attention required of therapy X shifts you away from problem Y, even if it's not really "helpful" on its own, then it's an excellent therapy. This is why some people realize they'd rather get a gym membership than therapy sessions. That said, I think psychotherapy, as an intentional focus on underlying or neurochemical issues, can go much deeper than this approach and should be considered by many people (though positive results could themselves be considered a 'distraction' if they don't address an inherent problems).

jm__87 8y ago

My viewpoint on mental health: how you feel at any given moment and how long that feeling will persist will depend on the structure of your brain and the environment in which your brain is in. There are a huge number of variables at play. This environment includes things like: baseline levels of chemical signalling of various kinds going on in your brain (this is plainly apparent when you do any sort of perception or mood altering substance which significantly changes the chemical signalling in your brain); physical health of the body attached to the brain; inputs from your senses and any feelings that may be arising as a result of these inputs; beliefs and assumptions about the world in which you're in; and finally structural considerations of your brain (e.g. is some part of your brain damaged or non-existent). For some people, the majority of problems lie in the "beliefs and assumptions about the world" variable and for these people, therapy is the answer. I imagine for the large majority of people, therapy may give some minor benefits but if you don't attend to your own physical and emotional needs on a regular basis, you are going to feel like garbage. This means eating a healthy diet (with enough calories), getting some exercise, spending time with family and friends, taking some time for yourself to relax and unwind. For those with persistent chemical signalling or structural problems in their brains, they may have to do way more to feel right, including getting on the right drugs and therapy for emotional support. It may suck, but we can only play the hand we're dealt. A few more thoughts on this topic: the world we live in now is so different from the one humans evolved in. We eat different food and eat way more frequently than our ancestors did. We exercise way less and spend very long periods of time in low to medium stress situations instead of short periods of time in high stress situations, which is what our stress response system evolved for. Many of us live semi-isolated lives thinking about how we can help ourselves as individuals instead of living in small to medium sized groups thinking about how we can help ourselves within the context of the group (you would likely have to be doing prosocial things with higher regularity). While there are many advantages of living in the world we now live in as compared to how our paleolithic ancestors lived, there are some incompatibilities with how we have evolved and I think we should be doing more as a society to address these issues.

perseusprime11 8y ago

The untold truth is that therapy is not for all people. Similarly, meditation is not for all people either. For some people, neither therapy nor meditation really work. For those people, medication to elevate mood is the only real option. I have seen too many therapists exploit this and raise hopes of their patients and try CBT for a long time without results. Just like any disease, you need to manage this and there is nothing wrong in taking medication to fix yourself.

totierne2 8y ago

I participated in 3 CBT sessions 10 years ago I asked what will I get out of 6 sessions (the most my employer would pay for). The therapist said I would know my problems but not solved any of them. I did not attend any further sessions. I am a male programmer with bipolar. I did try a excel based survey labelled CBT which quantified where I was on general personality traits which was OK and free. I did read some popular therapy books. I could probably do with more work focussed excutive coach lite training if I could avoid the bad ones. I called works employee helpline recently, after a manic episode, I will see how that goes, it is more of a seen to be doing something rather than letting mania (occasionally) take its natural course.