The Science of How to Evaluate Therapists | Hacker News Reader

The Science of How to Evaluate Therapists

thomastberry.com

14 pointsthelettere17 comments

I'm curious what others thoughts are on the choices one is confronted with when mental illness or significant distress surfaces. Psychotherapy, medication or informal help? If psychotherapy, which therapist? What algorithm for making this decision do you use?

In my own experiences the rough sketch of ideal characteristics mentioned match up with whom I have found helpful. Practically, I've found the issue a nuanced one; I've had times where I was focused so much on finding a great therapist that I overlooked ones who were "good enough", and others where I settled for someone who was not helpful at all. The balance is elusive, and that no objective criteria is helpful in evaluating a therapist made a difficult choice more difficult still.

What I've learned is that word of mouth recommendations may be most helpful, as the pattern of effective therapists is surprisingly consistent across clients (although by no means perfect). Of course this method may be hampered by the general public silence on the subject and the stigma that still exists in some quarters - which is very much alive and kicking in my circles.

Note that there is a divide between clinical psychologists, who also do private practice, and psychotherapists. CP are more expensive, but also worth evaluating.

Now for more anecdotal part: neither type has that much time to think about your problem and most likely spend time between sessions thinking about their newest patients. So I would advise against seeing the same one for more than 6 months unless you see consistent progress.

Technically there are clinical social workers, clinical psychologists, counseling psychologists, counselors, and psychiatrists - all of whom typically perform some form of psychotherapy, at least here in the US. Whom will be more expensive typically depends more on years of experience and demand than which division they fall under.

And I don't follow your second point.

In the UK there is a separate profession (and qualifications) of psychotherapists. They don't necessarily have a qualification in psychology or psychiatry, or work as a social worker. I thought this was true also in the US?. (Anyone can call themselves a counselor in the UK. Not sure what qualification clinical social workers have).

My second point was simply that pragmatically, an hour or less per week, which is how much time you see any of these practitioners, is not all that much time, and during an actual session they have to deliver the therapy. Most decent practitioners will spend some of their time outside actual sessions thinking about their patients, and human nature is that they will probably think most about the newer ones. Unless your therapy needs no serious 'course corrections' after the first few months, it is probably easier to find a new therapist than to get an existing one to rethink. As I said, this is based on my anecdotal (but unfortunately very long) experience; take it how you will.

In the US the regulations differ, and depend on the discipline (i.e. it is not unusual for a therapist to meet qualifications for one state, but move to another and no longer be able to practice without further education or testing). There is no actual "psychotherapy" discipline so named - just the collection of ones I mention above.

However, in the vast majority of states the terms counselor or psychotherapist or psychologist or any number of related terms are protected by law for those who are licensed by a psychotherapeutic discipline alone. The only popular categorization of those who perform psychotherapy-like services here that anyone can use is "coaching" - but that's sort of therapy for well people looking to reach for the stars - they are barred from treating people with serious disturbances.

On your second point, I find that an interesting idea. I do wonder though what the correlation is between the amount of time a therapist spends thinking about a particular client and their case and that case outcome. The research I've seen indicates that generally a good therapist (one whose clients achieve consistently better than average outcomes) does so regardless of the number of clients he has, or how disturbed his clients are.

Out of curiosity, have you gravitated towards a particular type of therapy (CBT, psychodynamic, existential, ect)? Not because the treatment type matters a great deal, but its been shown that certain personality types tend to congregate in different theoretical orientations.

Random thought that just popped in my head - I wonder whether one of the reasons why CBT is getting less effective is because it has attracted many therapists who feel pressured to do it because of its public relations successes rather than any deep affinity with its principles.

> I wonder whether one of the reasons why CBT is getting less effective

No it's probably about better placebo controls.

Pain meds in US: https://news.ycombinator.com/item?id=10351230

Anti depressant meds: http://onlinelibrary.wiley.com/doi/10.1002/wps.20241/abstrac...

Better response to placebo is not a new thing, and is not limited to psychological therapies. (These are all the same source, but lots of discussion.)

https://news.ycombinator.com/item?id=783912

https://news.ycombinator.com/item?id=1032149

https://news.ycombinator.com/item?id=3015479

Yes but some placebos work better than others. Why is that?

If only there were some source we could look to in order to find this out...

To be a bit more explicit - the finding of that study was not that efficacy had gone down relative to placebos, but rather that the absolute efficacy of CBT is going down. The authors of the study actually suggest that the reason its becoming less effective is because of the opposite of your suggestion - it's going down because the placebo response is likely getting weaker in CBT (1). Which goes back to my original point about the factors that influence of efficacy of placebos - and of course, to the parent article. I think this would have been a much more productive conversation if you had just read it first before replying.

(1) https://uit.no/Content/418448/The%20effect%20of%20CBT%20is%2...

In England: I'd read the NICE guidance for the condition.

Here's what they say for OCD (One of the World Health Organisations top 10 debilitating illnesses).

http://pathways.nice.org.uk/pathways/obsessive-compulsive-di...

http://www.nice.org.uk/guidance/cg31

Here's what they say about bi polar: http://www.nice.org.uk/guidance/cg185

That would tell me what I should expect, and guides what I'd do next. There are a bunch of different routes into mental health treatment. (And, luckily, with things like CBT there are routes out quite quickly.)

If a short course of CBT was needed I'd ask my GP, or self refer (can do that in my area, may not be able to everywhere in England). If I wanted rapid access to a face to face therapist I'd do some web searching but I'd make sure the therapist was a member of BACP. (British Association for Counselling and Psychotherapy) (But make sure to check with BACP too, sometimes people lie about their registrations.)

But sometimes people have more immediate needs, and they may find themselves taken to a place of safety by police (under a section 136 (of the mental health act)) or detained by nurses or doctors (very short sections) or longer sections by a team of two doctors and a social worker (might not be a social worker, but another professional).

Or they go in "informally", as a voluntary patient.

You're right about stigma. Australia has a great campaign "Soften the fuck up" - http://www.softenthefckup.com.au/ and there's something similar in UK "Time to Change" http://www.time-to-change.org.uk/

CBT has succeeded in its public relations battle at being labeled the "scientific" treatment - but as the parent article notes, there is no actual scientific basis for that contention. Governments and industry certainly prefer the it though, as your links show.

Out of curiosity, why do you believe that making sure a therapist is a member of the BACP is important?

Parent article is low quality rant with little substance. Exactly the same claims can be made of pain medications (ranging from opiates to paracetamol) but we don't get anti-analgesia rants similar to this anti-psychology stuff.

I don't think membership of BACP is important - I'd far rather get therapy from the NHS. The BACP register is accredited by Department of Health, so has some credibility. BACP accreditation means practitioners meet some minimal levels of competence, experience, and safety. (And some people lie about their registration, so that's a useful sign that they're probably not the right person to get therapy from.)

That the same claims can be made of pain medications (and indeed most of medicine) was one of the primary points of the parent article - which makes me question whether you even read it.

Your second paragraph I don't know what to say in response to, other than that all the research I've seen indicates that there is no relationship between any of the (NHS or whatever) accreditation requirements and outcomes, or any that indicate that accredited therapists (by any licensing body) achieve better outcomes than those who are unaccredited.

@Mods: the flag was because this needs to be marked NSFW due to the picture at the top of the page.

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A picture of an artistic nude statue is NSFW?

Yes, and in very poor taste IMHO.

If the boss comes by with that image taking up half the screen, he's not going to assume you are researching what makes for good therapy, hence the acronym "NSFW".

I don't know anyone who gets their erotic jollies from looking at statues - but maybe I'm weird. It's the shot that frames the opening scene of Tony's first and last meeting with Melfi, which seemed fitting. If someone is so sensitive to representations of nudity, then they are unlikely to have seen the Sopranos and therefore unlikely to get much from this article beyond a perfunctory summary of the research - which can be had easily elsewhere.

I should probably have qualified my original comment.

I can recognize the artistic merit and value of such imagery where appropriate, and while I didn't know where the image was from (TIL!), I knew it had been included for a very good reason.

I was just snap-reacting to the "woop, that wouldn't have been great to open on lunch break" thing, for its' own sake. Basically what sam_goody said.

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