Effectiveness of Therapy?

[Mary S]

52 minutes ago, Eve B said:

 I usually know what "warmth" is when I feel it. A "warm" person is inviting and welcoming, and you feel safe, relaxed, and comfortable in their company.  Warm people are approachable and can more easily gain trust from strangers. Kindness, friendliness, and affection are part of behaving warmly. Warmth attracts closeness, but there can also be sincere warmth and fake warmth. People can pretend to be "warm" just as therapists can act like they care.

Thanks!

 

52 minutes ago, Eve B said:

 I'm not sure why this thought was stuck in my head all day, but the therapy relationship reminds me of Cheez Whiz-- it's an imitation product that tries to mimic the real thing. I didn't know that Cheez Whiz wasn't even real cheese!  https://www.thedailymeal.com/eat/what-cheez-whiz

Nice (at least, amusing) metaphor.

[Mary S]

I just came across this article discussing what makes therapy work [when it does] and what types of further research are needed.

https://www.researchgate.net/publication/318242080_Common_versus_specific_factors_in_psychotherapy_Opening_the_black_box

[Eve B]

From Mary's link:

"Limitations of the Existing Evidence Base"

"Trials typically enroll study populations that are un-representative of people attending for treatment in clinical environments, and often their findings are not generalizable across different ethnicities and cultures. Second, the intervention tested differs substantially from how it might be provided in other contexts: therapists are trained in manuals tailored to the study’s population, typically monitored for compliance, and often employed by a research group with an allegiance to the positive outcomes for their brand."

"Additionally, the dissemination of findings leads to further bias. Negative trials are less likely to be reported, thereby inflating effect sizes."

[zygomaticus]

1 minute ago, Eve B said:

"Trials typically enroll study populations that are un-representative of people attending for treatment in clinical environments, and often their findings are not generalizable across different ethnicities and cultures. Second, the intervention tested differs substantially from how it might be provided in other contexts: therapists are trained in manuals tailored to the study’s population, typically monitored for compliance, and often employed by a research group with an allegiance to the positive outcomes for their brand."

"Additionally, the dissemination of findings leads to further bias. Negative trials are less likely to be reported, thereby inflating effect sizes."

This coheres with what I've read. It's a nice snap-shot of the systemic problems that litter what ends up being promoted as 'empirical'. The biases are varied and significant. To this I would add the comparative studies that hamper the (clearly unfavoured by the researchers) model by restricting it by the protocols of the other model. For example, I recall this presentation about a comparative study concerning trauma therapy in which there was a cognitive-behavioural group and a psychodynamic group. In the latter, the novices being trained in the method received less training time than their counterparts and were instructed to change the subject every time the client mentioned the trauma, kind of like being tasked with tying your shoe-laces with your teeth being compared to Shiva having a crack with all six of her hands! In Behaviour modification a practitioner is told that being attentive to a client's pain would be to 'reinforce' the problem and hence be unhelpful. They would either look for incompatible alternatives as 'differential reinforcers' or ignore the client's feelings regarding the trauma and swiftly move on to signpost to diagrams of how healthy thinking works. Other models, however, do not take this perspective, and although the psychodynamic model in no way guarantees an empathic therapist, and some are most certainly detached and try to present the whole 'blank screen' neutrality, they certainly shouldn't change the subject. They're most likely to probe deeper, and there certainly isn't any prohibition against displaying compassion (at least not from what I've read or from the training I received).

In this scenario, unless one knows the respective tenets of the comparative models, biases may not be evident to the casual observer, or, for instance, the media, that seem to tend to accept what they're told by academic sources without barely anything in the way of fact-checking (and certainly buy into the notion that only someone with a PhD is qualified to comment, which excludes all clients that don't also have a doctorate in the discipline). Before you know it, with a powerful enough confluence of promoting factors - all of the biases, and say the pharmaceutical industry aligning themselves to the formula of CBT + anti-depressants, the 'truth' becomes: this works; that doesn't.

By the way, I am no advocate of the psychodynamic model, it's just an example. The reverse could just as easily happen, depending on the bias of the researchers. I have no allegiance whatsoever in terms of models - I am, like Masson, an abolitionist - but I do believe some models are more harmful and pernicious than others.

In terms of research, there is a MASSIVE skew demographically in terms of most subjects in most studies being undergraduates that are mugged on campus, with a substantial portion of them likely to be psychology majors from what I've heard (because the researchers have the most access to them). This means that these are young people predominantly who either choose prohibitive levels of debt or have parents that can afford to finance their further education - this is NOT a cross-section of society. Obviously, given the limits of social mobility, certain sections of society are very likely to be under-represented. Certain nations are also going to be over-represented, and yet there appears to be a culture of extrapolating results as if they apply to humanity as a whole, from what I've seen.

Journal bias is a HUGE issue across the sciences. Positive research is much more likely to be reported. Journals are heavily influenced by commercial interests: advertisers. This influence transfers across to the institutions, predictably, as well as individual academics who are restrained by the entire culture (as are department heads) whilst being under pressure to publish SOMETHING.

There is a selection process in research that doesn't translate to real-world factors. Subjects are typically screened prior to being allowed into studies so that there is greater scope for a successful outcome, more complex cases being excluded. And, although research is typically limited in duration, so is the selling-point of models like CBT. Any therapist in private practice being so parsimonious in their choice of clients must either be independently wealthy and hell-bent on proving their healing excellence or on a collision course with bankruptcy. In reality, therapists are likely to take on clients without such checks and balances, even if they stay solvent without much gain for the client.

[Mary S]

5 hours ago, zygomaticus said:

... To this I would add the comparative studies that hamper the (clearly unfavoured by the researchers) model by restricting it by the protocols of the other model. For example, I recall this presentation about a comparative study concerning trauma therapy in which there was a cognitive-behavioural group and a psychodynamic group. In the latter, the novices being trained in the method received less training time than their counterparts and were instructed to change the subject every time the client mentioned the trauma, kind of like being tasked with tying your shoe-laces with your teeth being compared to Shiva having a crack with all six of her hands!

Aargh! Unethical and unscientific.

5 hours ago, zygomaticus said:

In this scenario, unless one knows the respective tenets of the comparative models, biases may not be evident to the casual observer, or, for instance, the media, that seem to tend to accept what they're told by academic sources without barely anything in the way of fact-checking (and certainly buy into the notion that only someone with a PhD is qualified to comment, which excludes all clients that don't also have a doctorate in the discipline). Before you know it, with a powerful enough confluence of promoting factors - all of the biases, and say the pharmaceutical industry aligning themselves to the formula of CBT + anti-depressants, the 'truth' becomes: this works; that doesn't.

Yes, that's my impression as well. Unfortunately, when I first tried therapy, although I was well-educated in a STEM field and used to critiquing research in my field, I was ignorant of just how sloppy the standards were in psychology. However, I was often appalled by the unwillingness of therapists to give me their reasons for what they were doing -- and also appalled by the reasons they did give on the rare occasions when they did give reasons. It just didn't make sense to me.

 

5 hours ago, zygomaticus said:

In terms of research, there is a MASSIVE skew demographically in terms of most subjects in most studies being undergraduates

This is something I was not aware of. I was in my forties when I first tried therapy, so twenty or so years older than the typical reasearch subjects. (Although I'm not sure much if any of what therapists tried on me was claimed to be "empirically supported" -- all too often, it just seemed like their whim. They almost never offered reasons for what they were doing, and when I asked for reasons, they gave responses like, "I have my reasons," "Because I want to know," "Are you sure you're not second-guessing me?", "Do you realize you're asking me to give up my control?", "Consider me to be something like a computer; what you say  goes in, mixes around with my training and experience," or "I get the feeling that you think this should be an intellectual discussion" -- with a tone of disdain on the word "Intellectual". They acted as if I was supposed to leave my brain and education outside their office door.

5 hours ago, zygomaticus said:

Journal bias is a HUGE issue across the sciences. Positive research is much more likely to be reported.

My therapy experiences motivated me to learn more about  shoddy research practices in a number of fields. This goes beyond the things you have mentioned,  including what is sometimes known as "the replication crisis", which pervades the social sciences and is also all too common in the natural sciences. A large part of it is inappropriate understanding of statistical procedures and of when they are or are not appropriate. The Wikipedia article at https://en.wikipedia.org/wiki/Replication_crisis can give some idea of the problem (although there is lots of technical detail left out).

[Eve B]

So can we say that the evolution of therapy and the psychology profession has worsened or improved since Freud's time?

Freud Was a Fraud: A Triumph of Pseudoscience:

"Freud was trained as a scientist, but he went astray, following wild hunches, willfully descending into pseudoscience, covering up his mistakes, and establishing a cult of personality that long outlived him."

"His advocacy of cocaine was irrational. He wanted to justify his own use of the drug, which he took for migraines, indigestion, depression, fatigue, and many other complaints; and he presented it as a panacea. He claimed it was harmless, refusing to see clear evidence that it was addictive."

"He came to specialize in a 'disease of the rich,' hysteria, which could never be cured and which generated a continuing stream of income."

"He made things up as he went along, constantly changing his theories and methods but not making any actual progress towards a successful treatment."

"He was preoccupied by sex, presumably because of his own problems in that area."

"He claimed that his critics weren’t entitled to pass judgment on psychoanalysis because they didn’t understand it."

 

Untangling the Complicated, Cotroversial Legacy of Sigmund Freud:

"Freud often worked backward, finding “scientific” excuses for various behaviors and then working to “prove” those theories. This logic is also a typical argument against psychoanalysis’s efficacy — that it works mostly by placebo effect, with people responding simply because they feel like they’re being listened to, not because of any more scientific explanation."

 

[Mary S]

Things from this list that fit my therapy experience:

"following wild hunches, willfully descending into pseudoscience, covering up his mistakes"

'"He made things up as he went along, constantly changing his theories and methods but not making any actual progress towards a successful treatment." "

"often worked backward, finding “scientific” excuses for various behaviors and then working to “prove” those theories"

[Eve B]

Maybe anybody who works in the therapy profession can't avoid behaving like Freud the Fraud to some degree at some point in their practice because of the nature of the relationship structure?

[Mary S]

5 hours ago, Eve B said:

Maybe anybody who works in the therapy profession can't avoid behaving like Freud the Fraud to some degree at some point in their practice because of the nature of the relationship structure?

I'd say it's something more like "anybody who works in the therapy profession can't avoid behaving like Freud the Fraud to some degree at some point in their practice because of the nature of  their reasons for becoming a therapist and their training". 

[Eve B]

21 hours ago, Mary S said:

"the nature of  their reasons for becoming a therapist and their training"

Ask anyone in the field what their reasons are for becoming a therapist, and isn't their usual response to "help" people? The power dynamic of therapy's relationship structure seems to be what they're taking advantage of and claiming that it's for the client's benefit.

[Mary S]

7 hours ago, Eve B said:

Ask anyone in the field what their reasons are for becoming a therapist, and isn't their usual response to "help" people?

I think that for many therapists, "to help people" means "to be appreciated" or to "change people to be what the therapist wants them to be," which might be very different from what the client wants to be, or from being psychologically healthy.

[Eve B]

How therapists "help" is often as vague as the process itself, so maybe it's inevitable that they won't ever see eye to eye with their clients? It just keeps reaffirming the necessity and importance of listening empathetically to honest client feedback and responding appropriately instead of reacting like they're (the therapists) the ones being harmed. 

[Mary S]

7 hours ago, Eve B said:

How therapists "help" is often as vague as the process itself, so maybe it's inevitable that they won't ever see eye to eye with their clients?

I think it's an overreach to say that "they won't ever see eye to eye with their clients?" I think the milder assertion, "It' may be inevitable that there are some clients that they won't see eye to eye with" fits reality better.

7 hours ago, Eve B said:

 It just keeps reaffirming the necessity and importance of listening empathetically to honest client feedback and responding appropriately instead of reacting like they're (the therapists) the ones being harmed. 

I'd say that listening respectfully (respecting individual differences) rather than "listening empathetically", because what a therapist considers "empathetic" behavior might in fact show strong misunderstanding  of the client's perspective.

[Eve B]

Listening respectfully doesn't mean therapists will understand their clients either.  I've had a few therapists who seemed polite and respectful, but I could tell they still didn't know what to do to effectively help me. Showing empathy should also include showing respect, but I think better empathy means a therapist will try harder to work with their clients' needs.

[Mary S]

6 hours ago, Eve B said:

Listening respectfully doesn't mean therapists will understand their clients either.  I've had a few therapists who seemed polite and respectful, but I could tell they still didn't know what to do to effectively help me. Showing empathy should also include showing respect, but I think better empathy means a therapist will try harder to work with their clients' needs.

In my experience, "empathy' is a word that can mean very different things to different people, which is why I have skepticism about its value -- whether or not empathy is helpful depends on what kind of "empathy" a therapist shows -- and different clients may need different types of empathy.

[Eve B]

Seems like effective therapy goes back to the "good (or good enough) fit" theory then. Why should clients be expected to pick the right fit therapist when there could be greater emphasis on training therapists to have better bedside manners and flexible approaches to their clients' issues? 

[Mary S]

I looked at one of CHris Hoff's short videos, Cheerleading in Therapy. His position, is that cheerleading is often not a good thing in therapy, since it is judgmental. My own opinion is that I would not care to have a therapist assume a cheerleading role, because it seems pushy and/or intrusive to me.

Hoff proposes as a better alternative being curious, and asking questions pursuing that curiosity. He gives examples such as "where are you now" or about "how they are making meaning at the present" I can't agree with him on this point. In general,  I dislike being treated as an object of curiosity. -- to me, being asked questions from a position of curiosity is asking me to do the asker a personal favor. In ordinary life, we sometimes do personal favors for others, but I see a therapist asking a client to do a personal favor as a boundary violation.

I think that a better alternative than either of these is remaining open-minded. There are some questions that are consistent with being open-minded, and that I probably would not mind a therapist asking, but the example questions Hoff gives do not seem open-minded to me -- they are too focused. Questions that fit this "open-minded"  frame of mind include questions that give non-extreme options. For example, "Would it be helpful if I did X, or would that just introduce a complication that would be unhelpful right now?", or "Would it be better if I did A or B, or  can you suggest an option better than either of those?" or "Please give me whatever information you can and are willing to give at this time that you think I need to know in order to help you".

[Eve B]

20 hours ago, Mary S said:

For example, "Would it be helpful if I did X, or would that just introduce a complication that would be unhelpful right now?", or "Would it be better if I did A or B, or  can you suggest an option better than either of those?" or "Please give me whatever information you can and are willing to give at this time that you think I need to know in order to help you".

It may be too much to expect these well-educated therapists to ask questions that show such common sense and courtesy. 

[Mary S]

I just case across this paper in the Show Notes for Very Pad Therapy podcast #41: https://jonathanshedler.com/wp-content/uploads/2018/05/Shedler-2018-Where-is-the-evidence-for-evidence-based-therapy.pdf . It seems very good. However, it may need to be taken with a grain of salt, since the author has also written an article called  The Efficacy of Psychodynamic Psychotherapy , which I have not yet read.

[Eve B]

So this author is saying that psychotherapy is still effective despite flimsy evidence? Since psychology is really a pseudo-science anyway, I guess that kind of wishy-washiness is fitting.

[Mary S]

13 hours ago, Eve B said:

So this author is saying that psychotherapy is still effective despite flimsy evidence? Since psychology is really a pseudo-science anyway, I guess that kind of wishy-washiness is fitting.

He is criticizing the types of therapy that are called "evidence based" (e.g., cognitive-behavioral). However, he seems to be an advocate of psychodynamic therapy. Note that he does use the word "efficacy" in promoting it, which seems to be a waffle-word. I did glance at his paper on it, but haven't read it thoroughly. I might get back to it at some point, but the glance was not inviting.

[Eve B]

https://jonathanshedler.com/wp-content/uploads/2018/05/Shedler-2018-Where-is-the-evidence-for-evidence-based-therapy.pdf

From the above link, "evidence-based" is supposed to apply the following 3 criteria:

1) “Relevant scientific evidence - no longer counts, because proponents of 'evidence-based' therapies ignore evidence for therapies that are not manualized and scripted.  'Evidence-based' does not actually mean supported by evidence; it means manualized, scripted, and not psychodynamic. 

2) Patients’ values and preferences - also do not count because patients are not adequately informed or offered meaningful choices.

3) Clinical judgment - also no longer matters, because clinicians are often expected to follow treatment manuals rather than exercise independent judgment."

The way I see it, "evidence-based" needs to have supportive data or it's not evidence! If therapists respected patients' values/preferences and used common sense clinical judgment, maybe there would be more successful outcomes or, at least, less harm caused.

[zygomaticus]

I can understand the point he's trying to make, but only insofar as I think the 'evidence-based' badge of honour is a baseless piece of self-promotion and as far as evidence goes all models are much of a muchness - roughly they are equally ineffective.

Patients' choices and informed consent are pretty much non-existent in most settings, but I agree that it's even worse with the manualised stuff, because the script is basically seen as the only valid method, so if a patient/client veers away, the practitioner must get them back on script, and that's when the dirty tricks are employed. Clients aren't given options, they are corralled down a set path with very few variables at play in how anything gets expressed. At least psychodynamic therapy can be somewhat explorative, so that the client has more of a voice.

Flexibility in how a clinician applies 'evidence-based' models is extremely limited, they will literally repeat the same script, the same phrases, the same rewards and punishments over and over again, regardless of what variety may exist in how the client tries to present their problems. Not that psychodynamic practitioners have as much freedom as proponents of that model might claim, they still have the theory drilled into them as trainees, they still have supervisors applying course-correction, they also have practice demonstrated to them by their own mandatory therapy. With psychoanalysis, the compulsory analysis may have to come from a narrow range of experienced analysts and be voluminous, all before accreditation is achieved. Also, there is a very real dependency upon referrals within these circles, meaning an economic imperative to stick to an orthodoxy is present.

I like the paper in the link, it actually echoes much of what I've heard and read before, but there is an elephant in the room, if the author is arguing that psychodynamic therapy should be considered to have the same level of efficacy as the so-called evidence-based models, and he does this after outlining just how ineffective those models are, well, it's not exactly the best endorsement.

What isn't being tested in all of the research, from what I can tell, is just how much of a factor clients seeking to please their clinicians by reporting improvements is, or indeed if and why clients might feel pressured to report positive results. my pet hate is what I consider to be coercive and manipulative practices like operant conditioning: if you repeatedly get punished for reporting no improvements, isn't there a potential for ultimately telling the clinician what they want to hear, if only to get them off your back? I personally suspect these are meaningful factors that contribute to positive results and hence skew the figures. Without such misleading reporting, presumably the efficacy rates for clients getting better and staying better would be even more woeful than they already are.

[Mary S]

5 hours ago, zygomaticus said:

What isn't being tested in all of the research, from what I can tell, is just how much of a factor clients seeking to please their clinicians by reporting improvements is, or indeed if and why clients might feel pressured to report positive results. my pet hate is what I consider to be coercive and manipulative practices like operant conditioning: if you repeatedly get punished for reporting no improvements, isn't there a potential for ultimately telling the clinician what they want to hear, if only to get them off your back? I personally suspect these are meaningful factors that contribute to positive results and hence skew the figures. Without such misleading reporting, presumably the efficacy rates for clients getting better and staying better would be even more woeful than they already are.

Good point. I also suspect that "getting worse" is not tested for (or at least only a limited type of "getting worse" is recorded, while the client might be getting worse in other ways that are consequences of the therapy but not asked about, and dismissed if the client brings them up).

[Eve B]

How would it be possible to collect more accurate data regarding true positive and negative outcomes, then?