Where's the science? The sorry state of psychotherapy (10/8/2009)

10/8/2009 7:16:55 AM MST

It's not just psychotherapy that is in a sorry state. It is the whole medical profession. The are like rats chewing on the slowly expiring body of the American public health.

10/8/2009 8:22:47 AM MST

I agree with you David. As a Crisis Clinicians with CBT, DBT and Trauma training it is the APA, and other medical professions that have gotten in the way of delievery of these services. I happen to know that The Trauma Center in Boston (Dr. Bessel Van de Kolk) announced he had clinical data that found a direct correlation with abuse to brain injury. He sent boes of the data for APA review and received a terse two paragraph response. When the medical professions start listening to thier mental health practicitioner then maybe there will be some hope. Anything else is just the cry of a wounded and dying panther as far as I am concerned.

10/8/2009 10:27:46 AM MST

One risks appearing foolish to debate the central premise of this article. Of course, all clinicians would benefit (as presumably would our clients) from the advancement of science and its practice in psychotherapy. My issue with the authors is, in my opinion, their arrogance toward other practioners (they even turn on their colleagues, inferiors that they are with only PsyD's). I find their attitude dismissive and short sighted, if not totally self serving. Their survey of EBP bears evidence of "cherry-picking" as it conveniently leaves out other "Evidence Based" approaches such as EMDR. They appear to be guilty of "partaking of the CBT kool aid". Psychotherapy is not the same as Medicine. Psychotherapy has as it's core the art of connecting with another human being in a manner that fosters hope and empowers your client to make decisions to bring about change in their lives. Simply presenting the scientific evidence supporting a specific modality is only half of the task (if at that). As for the "rest of us", the unmentionable other disciplines; we, by the authors own words, probably don't have the intelect to even understand the wisdom and infallibility of science. I would suggest that the authors come out into the real world. Perhaps a more apt title for their organization would be "Psychological Science in the Interest of Ph.D. Psychologists".

10/8/2009 9:05:58 PM MST

I am in the process of getting my Ph.D. in psychology. One of the problems I have with the move towards "evidence based" therapies is that no one has ever defined exactly what is success in these therapies. CBT comes out best in some of this research because it defines success as ridding the client of symptoms, not a difficult thing to show, but neither is it in any way success in the area of mental health.

There are a lot of ways of doing therapy successfully, it depends on the client what works. Some do very well with CBT and related therapies, DBT and other mindfullness therapies are also good. One need only look at the era of "schools of therapy" when various therapists came out with their ideas about how to make therapy work, everything from Rogers passivity to Albert Ellis' Rational Emotive Therapy. Each of them portrayed itself as the answer to how to do therapy, and they were all wrong, except for the clients for whom they were right. If one looks at it from one direction it can be said that Buddhism is the oldest form of psychotherapy, it being a way to help people live in the world, but it only works for some people, even in its most austere form, Zen.

What I would say is that a therapist must know many therapeutic techniques and fit the therapy to the client, rather than try to use the medical model to shove the client into the therapeutic technique.

10/9/2009 10:07:22 AM MST

I was diagnosed with depression, bi-polar and a whole host of other related conditions. I got a shrink, that told me I should list 6 things that i can do. Hell, I can't even barely get out of bed, let alone complete 6 tasks. They never counseled me on developing tools to deal with my mental state. i had one shrink that chastised me for drinking coffee in the AM and brought out the DSM IV manual to show me the effects of coffee, then sometime later i found him smoking behind a building - now who is he to call the kettle black - anyway he got fired.

10/9/2009 12:21:29 PM MST

GOOD FOR YOU JACKIE! FIRST, a physician must be trustworthy! SECOND, he must do NO HARM! (Chastizing does no good and can erode a clients self-esteem) THIRD, every patient has a talent/redeeming quality to encourage. I COULD GO ON---MY MOM ALWAYS SAID IF YOU HAVE NOTHING GOOD TO SAY ABOUT A PERSON, KEEP YOUR #@!! MOUTH SHUT. MDs must encourage for self improvement to happen. And patient must have confidence to make those changes. ----sign me, HANGING IN THERE!

10/9/2009 6:08:24 PM MST

it isn't just the problems descrtibed here but actually maybe about to get worse as some payors (ie insurance, medicaid,medicare, etc) will only pay for the therapies they deem worthy and not the most effective.

10/10/2009 9:00:39 AM MST

The statement that "cognitive-behavioral therapy (CBT) has been shown to be the most effective treatment for PTSD and has the fewest side-effects" tells me the author of this article has not seen the latest tests with EFT (Emotional Freedom Technique), a tapping procedure that can help PTSD victims resolve their own issues, once the technique is learned by them, within days or weeks, not years.

Looks like, if the therapists learn EFT, the patient will be better off. However, there are considerably fewer fees for the therapist, since the PTSD sufferer can help themselves. Hmmmmm, I wonder if EFT will really catch on in the medical community?

10/10/2009 12:30:49 PM MST

There is a great deal of good research out there about psychotherapy.

While it is undoubtedly true that CBT is an important and effective technique--one which all therapists need to be familiar with and prepared to use--it is also true that is among the easiest of psychotherapy techniques to study on a short-term basis.

Longer-term psychotherapies also have an evidence base, but long-term randomized, controlled studies are much more difficult and expensive to conduct. There is an evolving research base supporting longer-term psychodynamic psychotherapies for treating chronic depression, and chronic interpersonal problems (including so-called personality disorders).

Many individuals have already tried CBT, and it has not helped sufficiently for them.

There are some comparative studies, looking at CBT vs. another psychotherapy technique, or vs. medication, and many of these studies show that the different techniques are nearly equivalent. However, perhaps for a given individual, one particular technique might work best. I think it is important not to get too dogmatic about some particular style of therapy being best.

I don't care much for the title here: "the sorry state of psychotherapy" --- I feel that this kind of cynical journalistic title is unhelpful to those who might be ambivalently thinking about starting therapy for their problems, but who are already cynical or doubtful about the potential usefulness of psychotherapy.

So I encourage people to seek help for their problems -- whether it be CBT or some other type of therapy -- and evaluate the effectiveness for themselves.

10/11/2009 9:58:04 AM MST

As a clinician I work with CBT with clients who have drug and alcohol difficulties. Cognitive Behavioral Therapy is particularly effective with addictions because it cuts to the chase getting to addictive logic which tends to have its own particular rationale. I find that humor and creativity help clients work through their behavioral piece and it is less difficult for them to take action. Ninety-five percent of therapy is taking action--sometimes you get clients to do that with CBT and other times compassion works--certainly positive regard and the core basics. Talk therapies are great and feel great, but the therapies that engage clients to apply tools and take actions have proven more effective.

I agree that what we do as clinicians have to have a scientific basis. We can't just use a technique "because it feels right"--I'd like to think my years of training and education gave me some skills to know what I'm doing to the point if I make an intervention it's because I know it is effective based on studies with people that have those same symptoms.

When we work with people we are working with broken hearts and lives and we are working with traumas and tragedies and lots of pain and whatever your theoretical orientation it is important to keep that in mind and approach this with humility and respect for the great changes the mind and body are capable of while also giving treatment that is based in clinical skill and knowledge about the interventions you are using.

10/12/2009 9:41:32 AM MST

Blame the insurance companies and the VA. The most effective treatment is to use short-term antidepressant therapy to put a floor on the depression that is part of PTSD. CBT takes time to engage in and training,but neither the VA nor most insurance companies will pay for long term therapy. PTSD has not been diagnosed as a psychosis. Follow-up supportive group therapy is also very effective (read Doonesbury???), but a VA facility of some sort has to be close by or at least someone who is familiar with PTSD, particularly a vet.I feel so sad because it is the same old turf war over the same dollars with patients stuck in the middle. My husband, a military retiree, is severely depressed.
The PTSD group he was in was the best thing that ever happened to him. There were men from World War II just beginning to talk about their experiences in the war. People can't just think happy thoughts and the insurance preference of 15 minutes with a psychiatrist every few months falls very short.

10/12/2009 12:59:12 PM MST

It is amazing that 80% of these types of problems are resolved by us in a very short period of time using techniques that are backed by science, just as stated above, but not used by them, but used by us at thewillssstem.

10/13/2009 7:20:29 AM MST

Madnana Said: "People can't just think happy thoughts and the insurance preference of 15 minutes with a psychiatrist every few months falls very short."

I second that!!!! They just threw the anitidepressant of the month, some Abilify and Klonazapam after me and that was all i got with the standard 15 min session, it totally screwed up my disability claim. I am trying to get off the state dole and collect my fed SSD, that I paid for dearly when I was a productive worker for almost 30 yrs! The state mental health worker said they weren't there to help me get my disability but only there to provide the bandaid - what a crock!