6 ms·

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 (LP

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.
  - nyolfen 8y ago
    for all we know they exacerbated their patients symptoms
    - smt88 8y ago
      Well, from the comment I was responding to, the implication I took from "no great outcomes" was "no great change, either positive or negative". But technically, yes, you're right.
- boomboomsubban 8y ago
  >And most shrinks and counsellors in my case atleast are unable to establish authority. If you continuously end up in situations where you're seeing mental health professionals, you might consider just accepting their authority without the need to jump through your hoops.
  - pdpi 8y ago
    Speaking from experience, seems to me the GP’s need to make people jump through hoops to earn their trust is a damned important part of _why_ they need those professionals in the first place.
    - boomboomsubban 8y ago
      At a certain point you need to consider their success rate against your own. Realizing that and accepting they may be able to help is an important step.
      - pdpi 8y ago
        Right — but it’s a pretty damn big first step. I can think of a fair few people who were never capable of taking that step
        jm__87 8y ago
        You can't help someone who doesn't want to help themselves.
        GW150914 8y ago
        I mean, if someone is shot, you can still surgically intervene without them having to participate. It’s true in psych that you have to help yourself, but it’s also true that’s probsbly a valid critique of the art rather than science that is psych. Talk therapy has more in common with spiritual guidance or shamanism than medicine, except where the actual medicine enters the fray in the form of drugs and surgery. If you’re willing to help yourself, talking to someone is often helpful, but that’s been known for thousands of years. A real intervention doesn’t require someone to help themselves; an appendectomy doesn’t require patient participation and motivation.
- overton 8y ago
  +1 I'm pretty sure multiple rounds of CBT made my anxiety disorders worse. The approach attracts hyper-rationalist types who aren't willing to say anything other than "Your thinking patterns are wrong, you need to fix them." No serious discussion of trauma, identity issues, or relationships. Pure gaslighting. Recently, I finally realized that what I needed was some serious introspection and an empathetic therapist who would help me work through it. For all the bluster about psychoanalysis being quackery, I'm not sure you can disagree with its basic premise that maladaptive personality traits are likely to come from the social context you spent most of your first ~18 years in.
  - jm__87 8y ago
    Wouldn't many of your thinking patterns have come from your childhood and teenage years? How did none of this come up when you did CBT? Also, how did you do CBT without serious introspection? It sounds like the therapist you did CBT with just wasn't very good.
  - nickwalton00 8y ago
    I've found that for my anxiety ERP based therapy is much more effective because often anxiety isn't a matter of your rational brains understanding but rather trained responses of your subconscious.
- DanBC 8y ago
  It's frustrting when you ask someone how they know this works or how effective it is and they give you blank looks. It feels like a failure of informed consent. > The CBT ppl just blink at me like the question is not on their manual. What country? In England the IAPT programme (the main source of CBT) has extensive data collection on outcomes (probably the largest collection in the world) and a focus on getting more and better evidence to improve the service. Chapter 3 and 6 of the IAPT manual are about evidence based practice and gathering better data: https://www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual.pdf https://www.england.nhs.uk/wp-content/uploads/2018/06/the-ia... The data sets are here: https://digital.nhs.uk/data-and-information/publications/statistical/psychological-therapies-report-on-the-use-of-iapt-services https://digital.nhs.uk/data-and-information/publications/sta... The latest (Jun 12 2018) says this ---begin quote--- Key Facts In April 2018 there were: -- 119,304 new referrals; -- 85,145 referrals that entered treatment; -- 47,296 referrals that finished a course of treatment, of which; -- 89.4 per cent waited less than 6 weeks and 98.9 per cent waited less than 18 weeks to enter treatment; -- 44,222 started their treatment at caseness, with 51.9 per cent moving to recovery. ---end quote--- There's some jargon there, but that's explained in the executive summary: https://files.digital.nhs.uk/D3/B3FC5F/iapt-month-apr-2018-exec-sum.pdf https://files.digital.nhs.uk/D3/B3FC5F/iapt-month-apr-2018-e... tl;dr: CBT is somewhat effective; it's more effective if you have CBT that follows the high intensity model (14 to 20 weeks, one hour per week, face to face one to one with a qualified therapist).
lambdasquirrel 8y ago
There’s a rub to all this in that all the good therapists are licensed, but not all licensed therapists are good. Anecdotally, therapy is at least as much art as it is science. There will always be those things that science cannot answer, that “logic” cannot provide a sufficient answer for. But yoga, meditation, art, dance, all these other things are also difficult to measure and quantify, and, we apply scientific rigor with various levels of failure to them. How do you know someone has really meditated? You don’t. How do you know someone has had a good dance? You kinda don’t know that either. There is a basis for understanding this from an engineering perspective, and it’s right there in what you just said — that outcomes are not correlated with educational background of the clinician. Sound like programming at all? Programming is also as much art as it is a science. So therapy is no sure thing. That much, to me, is fine. And that’s the other rub. If you want to get something out of therapy, you’ll only get out as much as you get in. There can be no shortcuts blaming things you don’t like, nor idealizing the things you want to like. We can talk standards and rigor all day. But there’s no getting around having an internal compass of honesty, and a desire to apply that honesty to one’s life. That’s what a therapist (or therapy group) should be for you — an objective voice that questions your view of things while letting you be heard, as well as creating a safe environment for you to unwind the dark corners of the mind that are normally difficult to reflect upon on one’s own. Even there it is up to you to reflect on what happened afterwards. Your therapist cannot follow you all the way.
- bad_user 8y ago
  Programming isn’t really a science, not because it is art, but because for a discipline to be a science it needs to be based on empirical evidence and “formal sciences” like math and computer science don’t pass the test. Programming isn’t art either, not because you can’t do art via programming, of course you can, art happens whenever human hands are involved in the production process, my point being that we’ve romanticized programming for too long and it’s unhealthy. Programming has more to do with engineering and plumbing than it does with sciences and art.
  - dozzie 8y ago
    The word you were looking for is "craft".
jkaplowitz 8y ago
You listed a lot of specific licensed professions, titles, and degrees. Across much of the US and Canada, words like "therapist" and "psychotherapist" are unregulated titles and practices, if not claimed to count as one of the licensed professions I know for sure that this is true at least in New York where my mother is a (licensed PhD-holding) psychologist, and in Quebec where I live now, but I think this is typical. "Psychologist" and "psychiatrist" are of course regulated, as is "social worker," but the generic unregulated therapy terms lead to lots of underqualified people doing bad diagnosis and treatment.
- jschwartzi 8y ago
  In my home state Therapist is a regulated term, as is Counselor. There are two different licenses, LMHC and MFT with LMHC being a good indicator that you're not going to a quack. MFT does have some educational requirements but they're satisfied by religious vocational training. It was a helpful filter for me.
- nickbarnwell 8y ago
  I am only familiar with the laws of OR, WA, MA, CA, and CO – the states where I'm considering doctoral programs – but "therapist" and "counsellor" are regulated and require one have a license to advertise with them. "Life coach" is the only title I am aware of that is completely unregulated across the US. Psychoanalytical Therapist is perhaps the caveat you're thinking of? I know in New York it is a regulated title, and it may be possible to practice independently without a Counselling or Social Work degree provided one isn't billing insurance or advertising as a "psychotherapist".
  - jkaplowitz 8y ago
    Here is NY's list of licensed professions: http://www.op.nysed.gov/prof/ http://www.op.nysed.gov/prof/ Psychoanalyst is a regulated title, as are certain mental health professional titles which include the words therapist or counselor as part of the title. But neither therapist or counselor standing alone nor psychotherapist is regulated there. (Nor is psychoanalytical therapist, unless something like case law has found that to be too confusingly similar to psychoanalyst.) I'm not disputing your examples from other states. Just saying that these titles are significantly ambiguous across North America because of their inconsistent status, and therefore there's no standard of treatment which one can assume for them without knowing the precise state or province in question.
com2kid 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. A giant % of therapists around my area advertise that their treatment methodology is "eclectic". Trying to find someone who follows even CBT is almost impossible. I have seen at least a few people advertising themselves as following Freudian principles. So there is that. > Licensure is not all over the place. The quality of programs that provides those licenses are. And thousands of hours of training under someone who is not very good, does not lead to a good practitioner. I'm not saying all therapists are bad, but I'd say that picking a therapist at random will have about as good of luck as picking a mechanic at random: Greater odds of your wallet being emptied than your problem being fixed. Finding an honest and talented practitioner is hard. > Studies have demonstrated that treatment outcomes are not strongly correlated with clinicians' educational background Isn't that a huge problem? Imagine if that was the case for any other medical profession! "The surgical techniques we teach in school, and charge a lot of money and put students deep into debt for, aren't shown to be any better than someone coming off the street with a hacksaw and a really good smile." Now that said, I've met people entering LMHC programs who obviously didn't need the credentials, their natural understanding of people was blatantly better than what 80% of their courses would cover. But those people are the obvious exception.

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.
- nyolfen 8y ago
  for all we know they exacerbated their patients symptoms
  - smt88 8y ago
    Well, from the comment I was responding to, the implication I took from "no great outcomes" was "no great change, either positive or negative". But technically, yes, you're right.
boomboomsubban 8y ago
>And most shrinks and counsellors in my case atleast are unable to establish authority. If you continuously end up in situations where you're seeing mental health professionals, you might consider just accepting their authority without the need to jump through your hoops.
- pdpi 8y ago
  Speaking from experience, seems to me the GP’s need to make people jump through hoops to earn their trust is a damned important part of _why_ they need those professionals in the first place.
  - boomboomsubban 8y ago
    At a certain point you need to consider their success rate against your own. Realizing that and accepting they may be able to help is an important step.
    - pdpi 8y ago
      Right — but it’s a pretty damn big first step. I can think of a fair few people who were never capable of taking that step
      - jm__87 8y ago
        You can't help someone who doesn't want to help themselves.
        GW150914 8y ago
        I mean, if someone is shot, you can still surgically intervene without them having to participate. It’s true in psych that you have to help yourself, but it’s also true that’s probsbly a valid critique of the art rather than science that is psych. Talk therapy has more in common with spiritual guidance or shamanism than medicine, except where the actual medicine enters the fray in the form of drugs and surgery. If you’re willing to help yourself, talking to someone is often helpful, but that’s been known for thousands of years. A real intervention doesn’t require someone to help themselves; an appendectomy doesn’t require patient participation and motivation.
overton 8y ago
+1 I'm pretty sure multiple rounds of CBT made my anxiety disorders worse. The approach attracts hyper-rationalist types who aren't willing to say anything other than "Your thinking patterns are wrong, you need to fix them." No serious discussion of trauma, identity issues, or relationships. Pure gaslighting. Recently, I finally realized that what I needed was some serious introspection and an empathetic therapist who would help me work through it. For all the bluster about psychoanalysis being quackery, I'm not sure you can disagree with its basic premise that maladaptive personality traits are likely to come from the social context you spent most of your first ~18 years in.
- jm__87 8y ago
  Wouldn't many of your thinking patterns have come from your childhood and teenage years? How did none of this come up when you did CBT? Also, how did you do CBT without serious introspection? It sounds like the therapist you did CBT with just wasn't very good.
- nickwalton00 8y ago
  I've found that for my anxiety ERP based therapy is much more effective because often anxiety isn't a matter of your rational brains understanding but rather trained responses of your subconscious.
DanBC 8y ago
It's frustrting when you ask someone how they know this works or how effective it is and they give you blank looks. It feels like a failure of informed consent. > The CBT ppl just blink at me like the question is not on their manual. What country? In England the IAPT programme (the main source of CBT) has extensive data collection on outcomes (probably the largest collection in the world) and a focus on getting more and better evidence to improve the service. Chapter 3 and 6 of the IAPT manual are about evidence based practice and gathering better data: https://www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual.pdf https://www.england.nhs.uk/wp-content/uploads/2018/06/the-ia... The data sets are here: https://digital.nhs.uk/data-and-information/publications/statistical/psychological-therapies-report-on-the-use-of-iapt-services https://digital.nhs.uk/data-and-information/publications/sta... The latest (Jun 12 2018) says this ---begin quote--- Key Facts In April 2018 there were: -- 119,304 new referrals; -- 85,145 referrals that entered treatment; -- 47,296 referrals that finished a course of treatment, of which; -- 89.4 per cent waited less than 6 weeks and 98.9 per cent waited less than 18 weeks to enter treatment; -- 44,222 started their treatment at caseness, with 51.9 per cent moving to recovery. ---end quote--- There's some jargon there, but that's explained in the executive summary: https://files.digital.nhs.uk/D3/B3FC5F/iapt-month-apr-2018-exec-sum.pdf https://files.digital.nhs.uk/D3/B3FC5F/iapt-month-apr-2018-e... tl;dr: CBT is somewhat effective; it's more effective if you have CBT that follows the high intensity model (14 to 20 weeks, one hour per week, face to face one to one with a qualified therapist).

lambdasquirrel 8y ago

There’s a rub to all this in that all the good therapists are licensed, but not all licensed therapists are good. Anecdotally, therapy is at least as much art as it is science. There will always be those things that science cannot answer, that “logic” cannot provide a sufficient answer for. But yoga, meditation, art, dance, all these other things are also difficult to measure and quantify, and, we apply scientific rigor with various levels of failure to them. How do you know someone has really meditated? You don’t. How do you know someone has had a good dance? You kinda don’t know that either. There is a basis for understanding this from an engineering perspective, and it’s right there in what you just said — that outcomes are not correlated with educational background of the clinician. Sound like programming at all? Programming is also as much art as it is a science. So therapy is no sure thing. That much, to me, is fine. And that’s the other rub. If you want to get something out of therapy, you’ll only get out as much as you get in. There can be no shortcuts blaming things you don’t like, nor idealizing the things you want to like. We can talk standards and rigor all day. But there’s no getting around having an internal compass of honesty, and a desire to apply that honesty to one’s life. That’s what a therapist (or therapy group) should be for you — an objective voice that questions your view of things while letting you be heard, as well as creating a safe environment for you to unwind the dark corners of the mind that are normally difficult to reflect upon on one’s own. Even there it is up to you to reflect on what happened afterwards. Your therapist cannot follow you all the way.

bad_user 8y ago
Programming isn’t really a science, not because it is art, but because for a discipline to be a science it needs to be based on empirical evidence and “formal sciences” like math and computer science don’t pass the test. Programming isn’t art either, not because you can’t do art via programming, of course you can, art happens whenever human hands are involved in the production process, my point being that we’ve romanticized programming for too long and it’s unhealthy. Programming has more to do with engineering and plumbing than it does with sciences and art.
- dozzie 8y ago
  The word you were looking for is "craft".

jkaplowitz 8y ago

You listed a lot of specific licensed professions, titles, and degrees. Across much of the US and Canada, words like "therapist" and "psychotherapist" are unregulated titles and practices, if not claimed to count as one of the licensed professions I know for sure that this is true at least in New York where my mother is a (licensed PhD-holding) psychologist, and in Quebec where I live now, but I think this is typical. "Psychologist" and "psychiatrist" are of course regulated, as is "social worker," but the generic unregulated therapy terms lead to lots of underqualified people doing bad diagnosis and treatment.

jschwartzi 8y ago
In my home state Therapist is a regulated term, as is Counselor. There are two different licenses, LMHC and MFT with LMHC being a good indicator that you're not going to a quack. MFT does have some educational requirements but they're satisfied by religious vocational training. It was a helpful filter for me.
nickbarnwell 8y ago
I am only familiar with the laws of OR, WA, MA, CA, and CO – the states where I'm considering doctoral programs – but "therapist" and "counsellor" are regulated and require one have a license to advertise with them. "Life coach" is the only title I am aware of that is completely unregulated across the US. Psychoanalytical Therapist is perhaps the caveat you're thinking of? I know in New York it is a regulated title, and it may be possible to practice independently without a Counselling or Social Work degree provided one isn't billing insurance or advertising as a "psychotherapist".
- jkaplowitz 8y ago
  Here is NY's list of licensed professions: http://www.op.nysed.gov/prof/ http://www.op.nysed.gov/prof/ Psychoanalyst is a regulated title, as are certain mental health professional titles which include the words therapist or counselor as part of the title. But neither therapist or counselor standing alone nor psychotherapist is regulated there. (Nor is psychoanalytical therapist, unless something like case law has found that to be too confusingly similar to psychoanalyst.) I'm not disputing your examples from other states. Just saying that these titles are significantly ambiguous across North America because of their inconsistent status, and therefore there's no standard of treatment which one can assume for them without knowing the precise state or province in question.

com2kid 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. A giant % of therapists around my area advertise that their treatment methodology is "eclectic". Trying to find someone who follows even CBT is almost impossible. I have seen at least a few people advertising themselves as following Freudian principles. So there is that. > Licensure is not all over the place. The quality of programs that provides those licenses are. And thousands of hours of training under someone who is not very good, does not lead to a good practitioner. I'm not saying all therapists are bad, but I'd say that picking a therapist at random will have about as good of luck as picking a mechanic at random: Greater odds of your wallet being emptied than your problem being fixed. Finding an honest and talented practitioner is hard. > Studies have demonstrated that treatment outcomes are not strongly correlated with clinicians' educational background Isn't that a huge problem? Imagine if that was the case for any other medical profession! "The surgical techniques we teach in school, and charge a lot of money and put students deep into debt for, aren't shown to be any better than someone coming off the street with a hacksaw and a really good smile." Now that said, I've met people entering LMHC programs who obviously didn't need the credentials, their natural understanding of people was blatantly better than what 80% of their courses would cover. But those people are the obvious exception.