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From an empirical perspective, the theories of psychotherapy are profoundly uninteresting. Debate has raged for decades about the dodo bird verdict - the hypoth

From an empirical perspective, the theories of psychotherapy are profoundly uninteresting. Debate has raged for decades about the dodo bird verdict - the hypothesis that all psychotherapies have equivalent outcomes - but the data has rendered that debate moot. Psychotherapy is effective, but only marginally better than placebo. The differences in efficacy between various modes of psychotherapy are statistically insignificant and undoubtedly clinically insignificant. People receiving psychoanalysis improve at basically the same rate as people receiving CBT or IPT or ACT or a raft of other interventions that loosely resemble psychotherapy. In the most basic sense, it doesn't matter whether Freud was a genius or a fraud; entertaining his theories, even if only to criticise them, is a distraction at best. The bottom line is that people tend to feel a bit better when they talk about their problems with someone who is attentive, supportive and non-judgemental. That's a valuable insight, but it's inherently limited and it's never going to yield the kind of treatments that we want and need. https://onlinelibrary.wiley.com/doi/10.1002/wps.20941 https://onlinelibrary.wiley.com/doi/10.1002/wps.20941

Slowlydying 3y ago
The study compares types of psychotherapy and commonly used medication. Both work about equally well, but neither has a large effect. This mostly shows that the effect size of psychological interventions in general is small. But it sometimes helps, and as someone who has benefitted from psychotherapy I'm deeply grateful. The fact that psychotherapy works about as well as medication is pretty impressive, considering some of these medications have serious side effects.
cccybernetic 3y ago
This is a very limited perspective, reducing Freud and the development of psychotherapy theory to, as you put it, feeling “a bit better”. Freud was as much a mystic, philosopher, and literary genius as he was a psychiatrist. I've found his ideas to be extraordinarily deep and they have influenced my life and thinking in profound ways.
- tsimionescu 3y ago
  But if his ideas, when applied, don't work, or offer at best mild improvements, why would you take them seriously as philosophy or even mysticism?
  - cccybernetic 3y ago
    I see your point, but honestly, the only way I can respond to your question is with more questions. Why do we expect deep psychological or philosophical insights to make things better for us, or lead to “improvements”? Why do we think that a profound revelation will bring clarity and resolution to our lives? It could just as well make us more crazy. There’s the famous case of the “Rat Man”. Whether Freud cured him is up for debate, though he most likely didn’t. But it’s a deep mediation on neurosis, obsession, cognitive dissonance, love, hate. It raises more questions than it answers but it's incredibly insightful. It gets at the heart of human fragility and I think that's something to take seriously.
    - tsimionescu 3y ago
      > Why do we expect deep psychological or philosophical insights to make things better for us, or lead to “improvements”? That's a fair point. We shouldn't necessarily expect them to. However, we do need some way to evaluate if they are real deep insights or just an interesting fantasy. IF Freud's ideas are just not true, if our psyche is not really divided in id, ego, and super-ego, if our early childhood experiences are not so formative etc - is it really fair to call it a deep insight? I'd say that, IF that turns out to be the case, then no, it wasn't a deep insight, it was just an interesting fantasy, no different from the deep lore of the Elves of Tolkien. Not without value, but lacking in philosophical or psychological value. So, the big question is how we should tell if his insights are true or not, before using them to change our way of thinking about ourselves and others. And evaluating how they are successful or not at their stated purpose, while not proof, is at least evidence in this direction.
qumpis 3y ago
So therapy is not effective as per the paper. This seems like an astounding conclusion. Has anyone read the paper in detail and has a deeper opinion?
- throwup238 3y ago
  The metastudy compares against "placebo or treatment as usual" which means the placebo group is getting some kind of therapy, just not the specific kind tested. If this metastudy is accurate, it means that therapy is effective but your choice of therapy method doesn't matter very much.
- derbOac 3y ago
  I'm pretty familiar with that literature for professional reasons and the linked paper provides a pretty fair assessment, or at least it's consistent with my impressions overall. One thing worth noting that's been skimmed over, maybe because of the target article, is that second-order meta-analysis and review concludes that psychotherapy and pharmacotherapy efficacy have both been overestimated or overstated, and that the combination of both is more effective on average than either alone. This is also consistent with my impressions. There's a lot that could be said about it. First, like a lot of academics, there's a lot of inflated hype and publication bias. It applies to behavioral and mental intervention research as well as other things, so you end up with overstated effects of interventions. Second, both psychiatry and clinical psychology suffer from a certain amount of insecurity about being seen as "real sciences." As a result, I think (this is just my personal opinion) there's a certain tendency to apply poorly-fitting models from other fields to treatment research, sort of blindly, and it results in poor investigation of underlying mechanisms. Writing this out, it might not be obvious what I mean by this to someone outside the field, but one way of explaining it is that intervention research in psychopathology (pharmacology or psychotherapy) has historically been distracted by concerns about emulating "real scientific disciplines", and as a result a certain amount of self-criticism that might have resulted in faster improvements (by shedding actual dead ends) were not pursued, and research into methods and approaches (for approaching interventions in general) that are more uniquely suited to behavior and psychological phenomena were kind of neglected. I think this trend continues. Basically people in a lot of very high-profile institutions are afraid to say their grade A "empirically supported" interventions aren't so great, or not actually better than other, supposedly "grade B" interventions, because they're afraid it will be jumped on as a sign of weakness of the discipline, rather than of rigorous attempts at improvements. To be fair to these people, a lot of the time that is what happens to these fields: instead of saying "well that was a good idea that didn't work out, good people in the field are looking at this closely", some critics will tend to target the entire field as being incompetent. This is counterproductive, really, and sometimes it looks like a lose-lose position for those in the field. Third, there is fairly strong evidence that different treatments work well for some people but not others, but that we don't really have a good way to predict what will work for whom. So, for example, the efficacy for drug A might be sort of small to modest overall, but high for one subset of people, and low for another subset of people; the efficacy for psychotherapy B follows similar patterns. This is one reason why combination treatments work: you're kind of applying a shotgun approach with the idea that one thing will stick. People have tried to predict what works for whom but it doesn't work out so well in a replicable sense. As someone else noted, a more accurate way of understanding things is that there's little evidence for the general differential efficacy of one intervention over another in most cases (most things tend to have about the same probability of "working" on their own, and that probability is lower than you might think based on the way they're sometimes discussed in the literature).

Slowlydying 3y ago

The study compares types of psychotherapy and commonly used medication. Both work about equally well, but neither has a large effect. This mostly shows that the effect size of psychological interventions in general is small. But it sometimes helps, and as someone who has benefitted from psychotherapy I'm deeply grateful. The fact that psychotherapy works about as well as medication is pretty impressive, considering some of these medications have serious side effects.

cccybernetic 3y ago

This is a very limited perspective, reducing Freud and the development of psychotherapy theory to, as you put it, feeling “a bit better”. Freud was as much a mystic, philosopher, and literary genius as he was a psychiatrist. I've found his ideas to be extraordinarily deep and they have influenced my life and thinking in profound ways.

tsimionescu 3y ago
But if his ideas, when applied, don't work, or offer at best mild improvements, why would you take them seriously as philosophy or even mysticism?
- cccybernetic 3y ago
  I see your point, but honestly, the only way I can respond to your question is with more questions. Why do we expect deep psychological or philosophical insights to make things better for us, or lead to “improvements”? Why do we think that a profound revelation will bring clarity and resolution to our lives? It could just as well make us more crazy. There’s the famous case of the “Rat Man”. Whether Freud cured him is up for debate, though he most likely didn’t. But it’s a deep mediation on neurosis, obsession, cognitive dissonance, love, hate. It raises more questions than it answers but it's incredibly insightful. It gets at the heart of human fragility and I think that's something to take seriously.
  - tsimionescu 3y ago
    > Why do we expect deep psychological or philosophical insights to make things better for us, or lead to “improvements”? That's a fair point. We shouldn't necessarily expect them to. However, we do need some way to evaluate if they are real deep insights or just an interesting fantasy. IF Freud's ideas are just not true, if our psyche is not really divided in id, ego, and super-ego, if our early childhood experiences are not so formative etc - is it really fair to call it a deep insight? I'd say that, IF that turns out to be the case, then no, it wasn't a deep insight, it was just an interesting fantasy, no different from the deep lore of the Elves of Tolkien. Not without value, but lacking in philosophical or psychological value. So, the big question is how we should tell if his insights are true or not, before using them to change our way of thinking about ourselves and others. And evaluating how they are successful or not at their stated purpose, while not proof, is at least evidence in this direction.

qumpis 3y ago

So therapy is not effective as per the paper. This seems like an astounding conclusion. Has anyone read the paper in detail and has a deeper opinion?

throwup238 3y ago
The metastudy compares against "placebo or treatment as usual" which means the placebo group is getting some kind of therapy, just not the specific kind tested. If this metastudy is accurate, it means that therapy is effective but your choice of therapy method doesn't matter very much.
derbOac 3y ago
I'm pretty familiar with that literature for professional reasons and the linked paper provides a pretty fair assessment, or at least it's consistent with my impressions overall. One thing worth noting that's been skimmed over, maybe because of the target article, is that second-order meta-analysis and review concludes that psychotherapy and pharmacotherapy efficacy have both been overestimated or overstated, and that the combination of both is more effective on average than either alone. This is also consistent with my impressions. There's a lot that could be said about it. First, like a lot of academics, there's a lot of inflated hype and publication bias. It applies to behavioral and mental intervention research as well as other things, so you end up with overstated effects of interventions. Second, both psychiatry and clinical psychology suffer from a certain amount of insecurity about being seen as "real sciences." As a result, I think (this is just my personal opinion) there's a certain tendency to apply poorly-fitting models from other fields to treatment research, sort of blindly, and it results in poor investigation of underlying mechanisms. Writing this out, it might not be obvious what I mean by this to someone outside the field, but one way of explaining it is that intervention research in psychopathology (pharmacology or psychotherapy) has historically been distracted by concerns about emulating "real scientific disciplines", and as a result a certain amount of self-criticism that might have resulted in faster improvements (by shedding actual dead ends) were not pursued, and research into methods and approaches (for approaching interventions in general) that are more uniquely suited to behavior and psychological phenomena were kind of neglected. I think this trend continues. Basically people in a lot of very high-profile institutions are afraid to say their grade A "empirically supported" interventions aren't so great, or not actually better than other, supposedly "grade B" interventions, because they're afraid it will be jumped on as a sign of weakness of the discipline, rather than of rigorous attempts at improvements. To be fair to these people, a lot of the time that is what happens to these fields: instead of saying "well that was a good idea that didn't work out, good people in the field are looking at this closely", some critics will tend to target the entire field as being incompetent. This is counterproductive, really, and sometimes it looks like a lose-lose position for those in the field. Third, there is fairly strong evidence that different treatments work well for some people but not others, but that we don't really have a good way to predict what will work for whom. So, for example, the efficacy for drug A might be sort of small to modest overall, but high for one subset of people, and low for another subset of people; the efficacy for psychotherapy B follows similar patterns. This is one reason why combination treatments work: you're kind of applying a shotgun approach with the idea that one thing will stick. People have tried to predict what works for whom but it doesn't work out so well in a replicable sense. As someone else noted, a more accurate way of understanding things is that there's little evidence for the general differential efficacy of one intervention over another in most cases (most things tend to have about the same probability of "working" on their own, and that probability is lower than you might think based on the way they're sometimes discussed in the literature).