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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 ar

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
    - nickthemagicman 8y ago
      There's what's called evidence based therapy. Things like cognitive behavioral therapy and other methods. Every therapist learns about it. Nothing is 100% effective on every person. But on large groups it has statistically positive impacts on study vs control groups.
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.

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
  - nickthemagicman 8y ago
    There's what's called evidence based therapy. Things like cognitive behavioral therapy and other methods. Every therapist learns about it. Nothing is 100% effective on every person. But on large groups it has statistically positive impacts on study vs control groups.

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.