Cognitive behavioural therapy is falling out of favour
theguardian.com
theguardian.com
CBT requires a lot more work from both the patient and the therapist. I can easily believe that as it's become more popular, it's being applied less well or to populations where it's less appropriate.
Anecdotally, in my experience, there are enormous differences between therapists. I have had very ineffective treatment which did seem a lot like "just get happy, stop thinking bad thoughts". And I've had effective treatment where a perceptive person cut straight through to reveal my self-defeating patterns and gave me skills to do better. It's a constant battle but I'm glad I did it this way.
CBT isn't for everyone or every problem. But I would be surprised if the main insights were totally wrong.
Medication was the life preserver for me when I finally got myself to accept that I would never be able to deal with this alone. Medication gave my brain some well deserved rest, let me take stock from a more balanced point of view.
CBT was my ladder to climb out of hell. Without CBT I would be still where I was those years ago, just less affected by it. Sitting in a room that was on fire, but just not caring about it that much, that's still a shitty place to be in.
The important thing about CBT was for me that it gave me tools to work with. A chisel for my mind so to speak. It is not at all about talking oneself into happiness, for me it was about NOT talking oneself into sadness. About giving me the logical framework to force myself to see good things where they were, instead of focusing on the bad things. It gave me ways to correctly differentiate between tackling bad situations and just glooming about non-issues.
I'm pretty sure without CBT my life would be nowhere where it is right now, so i'm very glad for its existance and would recommend anyone in a similar situation to try it with a GOOD therapist (mine was a guardian angel, battling the worst parts of my reasoning when I wasn't strong enough to do so).
Still, if you did have that set of tools going in, but for whatever biological reason it didn't matter, then I would guess that CBT would be dust in the wind for you.
Exactly. one tool you learn is how your thoughts/feelings/actions interact:
You cannot control your feelings, but they do influence your thoughts. You can control your actions, but they can influence at least some of your feelings. You can control some of your thoughts, which will influence your feelings.
(I may not have stated this exactly correctly, but the gist is the same ). So basically you learn that if you begin "investing" in healthier actions and thoughts (i.e. not sulking or self-pity or rumination), it will slowly pay off in less negative feelings.
No it doesnt' solve every single problem in your life, but a big part of depression is "learned helplessness" [1], and learning about thoughts/feelings/actions can be the first tool to counter this.
1. If you're reasonably intelligent, it's easy to see how CBT "works" within a few sessions, and afterwards you can fall into a trap of telling the therapist what you "should" say according to CBT. Because there's a very specific goal of avoiding negative thoughts and thinking patterns, it's easy to exaggerate your level of success in order to "please" the therapist, rather than admitting that you've not make any progress.
2. My larger problem is that CBT puts a primacy on thoughts over emotions that I'm not sure is warranted. The thesis is that you have a established negative thought, such as "social situations make me nervous", which becomes a self-fulfilling prophecy, and so you are always nervous in social situations.
However, I am not sure that this is truly the order of things, at least for me. I observed that, even when I studiously avoided negative thoughts like this, the underlying emotions were still often present. Being confronted with a social situation produced a physiological response that included anxiety. I might consciously rationalise that response with a thought like "this is a social situation, and social situations make me nervous", but the underlying response existed regardless.
Freudian psychotherapy has a lot of wacky ideas about unconscious desires and whatnot, but it does at least acknowledge the idea that there is something within people beyond the rational, conscious mind, and that it it can be the stronger force. In contrast, CBT seems to be a therapy born from the opposite viewpoint: that the primal, subconscious, animal brain is entirely subordinate to the rational, conscious mind. Perhaps that's true for the people who developed the therapy, but it isn't true for me.
Not BPD but my experience with CBT and anxiety was that I could see my response was illogical but I didn't believe myself it at the same time. So when the therapist asked about this assumption I had that influenced my thinking he was able to show me it was illogical, I was able to say 'I know in my head', but at the same time - I don't believe you in my gut. His solution to this was exposure. If you are put in the situation and you personal assumption is proven to be untrue or it's is sufficiently challenged enough times then you can start to believe it's illogical.
This was an issue for me and I asked about it. Will I ever be able to experience the situation without having to use CBT to deal with it. The response was you need to practice. Using CBT makes it easier for you to confront the situation and makes you less likely to excuse yourself from it. And over time the situation will become more normalised and those emotions will go away. Personally I have found that to be true. If I ensure I regularly engage socially the emotions are rarely bad. If I fall out of practice for a month or two it is a struggle at the beginning again but eventually with enough practice I'm fine again. So the CBT isn't a cure but a tool to help you engage in the situation instead of avoiding it and then over time the emotionally response improves. Just like if you start a new challenging job you might be nervous you don't know enough but you learn and slowly it becomes easier until you reach a point where you have no 'negative' emotions going to work everyday.
My understanding of how CBT works is not like that. If you think about the mechanics work, to know it's a social situation you get sensory input which turns to nerve impulses which go into your neural network which figures it's a social situation which then activates many neural pattern recognition circuits in parallel - for it being scary based on instinct or past experiences or imagination. That all happens unconsciously - you're probably setting off thousands of pattern recognisers and the conscious bit of your brain is only fast enough to really be aware of one or two at a time.
CBT works by rewiring that at your leisure so you can rubbish the unfortunate pattern recognisers maybe relating to some bad experience and enhancing positive ones by say recalling when things went well in reality (or imagination). But if it works you should just feel better in social situations without active thinking required at the time.
The additional the article raises about lower standards of training as it scales is also an interesting one, and could possibly apply further to other fashionable "therapies" in things such as fitness and project management.
That would seem to be a testable hypothesis that would make for a great finding if it was seen to be true.
That makes sense to me. From my experience you have to be willing to take small events in your life and read into them/pull them apart in great detail. If you can't understand the root issue (the reason you react to your thoughts/feelings in a certain way) by examining your thoughts in that way then you can't really put into practice the basic tenets of CBT. Maybe it depends on the therapist but from my perspective it seemed like quite an intellectual way of dealing with your problems.
Anything that has been researched is immediately accepted as truth https://news.ycombinator.com/item?id=12300577
What exactly is a good basis for mental health research then in your opinion? twisi the scientific method is basically all you've got even if it doesn't work as well as it does in other types of research. Yet what other options do you have besides anecdotes and woo?
So if you want to know broadly of CBT works then science is your only realistic option.
* you didn't interview enough people from different backgrounds * you didn't control for the specific psychological conditions of your interviewees or what treatments/medications were in play at the same time or before / after the program * you didn't test your question set to ensure that it doesn't have leading questions or questions can otherwise influence the results * and so on.
I could go on, but the point is anecdotes are not _nothing_ but they pale in comparison to a well built scientific study. If you want to really know if a type of treatment works well and who it works well for with a minimum of bias then science is by far the best option. It's normal and fine to use anecdotes to guide personal day to day decisions in life, but if you want to make broad claims that are taken seriously by professionals trying to say help folks manage mental health issues then we have a higher standard than anecdote and rightly so.
I say - use the best method that you reasonably can use and see where it gets you. If that's science then great, but often you need to get by with a lesser method and that is ok.
It is part of a type of psychology called "Positive psychology", that works with how to be happier and how not to fall into depressions. This is in contrast to the traditional "disease model", which is only about curing psychological problems, or as the Author states "Making miserable people, less miserable".
See the authors TED talk: http://www.ted.com/talks/martin_seligman_on_the_state_of_psy...
He's a very prominent doctor and at one point was President of the APA. You can read more about his credentials here: https://en.wikipedia.org/wiki/Martin_Seligman
"The present meta-analysis is not without limitations. First, this study only included depression, thus, excluding CBT trials aimed at treating other diagnosis, such as anxiety, posttraumatic stress, eating, schizophrenia, and sleep disorders. There is no reason to expect the present findings to generalize to these disorders. In particular, anxiety disorders, which include a heterogeneous group of disorders that probably yield different time trends, have been subjected to the CBT approach. The clinical presentations of, for example, panic, obsessive– compulsive, and posttraumatic stress disorders are very different, as are the CBT approaches used. A meta-analysis of five trials comparing cognitive therapy with exposure therapy to treat obsessive– compulsive disorder (Ougrin, 2011) did not indicate a decline for the newer trials."
The paper (linked to in the article): https://uit.no/Content/418448/The%20effect%20of%20CBT%20is%2...
It's not a simple bandage over a cut. It's the sort of thing that a parent or religion might teach to a child over years of growing up.
Bottom line: sometimes half-assing it can still have decent results.
I am so tired of second rate journals running rehashes of other researcher's work and pawning it off as a "ground breaking examination of the data". Anyone in the field of medicine will tell you that meta-analysis is the least credible form of "research".
I find the Guardian author's first hypothesis most credible. There are a lot of bad therapists out there. It is well established in surgical studies that results for a procedure will be less positive in study sites that are not centers of excellence as the surgeons are less practiced and less skilled. Surgeons and therapists are not stamped from a machine. As the commercial says, "your mileage may vary". Put another way, what do they call the person who graduates last in their class in med school? Doctor.
For any medical ailment of any consequence you might face you will be well served to find the best and most experienced provider available to you.
Meta-analyses are often used in so creating so called evidence based medicine standards which are sometimes cost cutting efforts dressed up like research.
As a trauma surgeon recently said to me recently, "They said they designed it using evidence based medicine. They didn't say whose evidence".
Basically people who practice CBT think that people who practice psychodynamic/existential-humanistic spend too much time analyzing things that may not matter with less direct evidence that it works. The other half(myself included) think that CBT is too much of a quick fix, and that yeah, you may want to have 6 sessions of skill building to solve your problems, but that will only provide a short term solution.
The reality is probably somewhere in the middle, and the skills taught by CBT are probably important. And if you have poor coping mechanisms or antagonistic thought patterns CBT is important, but it won't touch the underlying issues.
The funny thing about this article and the talk about the "placebo affect" is that to a certain extent many types of therapy are about integrating experiences: coming to an understanding about events in your life and the context in which they take place. The other thing that is linked most highly to success in therapy is the strength of the relationship between therapist and client(with a few caveats. The research shows this relationship should embody a few things and obviously it could be strog and unhealthy if there's something unethical going on).
But basically, talking about the placebo affect in mental health is kind of a funny thing. There are studies that look at placebo affects to certain therapies, but in general, since the goal is to feel better, if you think it worked and your supposed to feel better, should I come back and say don't feel better?(barring concerns about it being a short term effect). When the goal is to think you feel better, how(and why) do you suss out the difference. What I've always wondered, is do we think about the placebo affect the wrong way? Instead of seeing as something that disapproves efficacy, should we think about it as a power we should try and harness?
Have there been many studies looking at how the client-therapist relationship itself effects the client? Wouldn't having a non-judgmental person with whom you can comfortably confide it, whom you know is making a concerted effort to help you improve your well being, have some noticeable improvement on your condition, regardless of whether they were a trained professional?
Or put another way, is there anyone who finds themselves in therapy largely because they have no close friends?
Studies saying "this new thing works" have an obvious appeal, particularly in a field searching for something beyond classic psychotherapy. So when CBT first appeared, studies with strong, positive results may have been favoured.
Studies saying "the mainstream thing doesn't work", or "this mainstream thing doesn't work as well as we thought" also have obvious appeal. Now that CBT is mainstream, research showing that it is less effective that thought, or not effective in particular types of cases, may be more likely to be published.
It is not about denying thoughts. It is not about telling yourself that you are happy, when you are not.
It can't treat severe depressions, but it can treat mild ones, and it can lower the amount of medication needed to treat severe ones.
You can think about it as "good posture for your mind". Nobody wants a bad posture, but lots of people have it, and some have it so bad, that they get pains so severe they cannot work. Some people with back pain take pain medication, and never solve the problem, but can go on with their lives.
For some people, there are external influences on their posture that cannot be negated by exercise and they do need to change their environment.
Some do need an operation with everything that entails, but most just need to fix their posture: Do the right exercises and stretches and they won't need medication or operations.
If you are depressed because of your abusive boyfriend, then CBT's answer is not "stop thinking about it" or "just think happy thoughts when you're being beaten" it is "get the fuck out of it".
In the case of a fever, that might be enough, but for psychological disorders it is not so likely.
That might actually likely be enough. The reason why you have psychologist using CBT as therapy and not just self-help books is to identify if it is enough.
My point was that there are typically unconscious thoughts that lead to disorders, and fixing those disorders at the surface without finding the root is likely to cause them to reappear later, in the same or different form. E.g. aspirin will not cure malaria.
> CBT is in part about finding the flaws in your thinking that fucks you up.
That is, it focuses on conscious thought rather than unconscious. It seems to be enough only in the more benign cases.
you're assuming a false relationship between level of consciousness and severity. Case in point: war veteran with PTSD. His PTSD is from getting shot at, not from a disrupted relationship with his mother when he was 5.
case 2: patient has a phobia of flying. therapist gradually deconstructs the phobia using CBT methods, until the patient finally gets in a plane and flies.
Subconscious issues are not correlated to severity.
As for the second case, the "deconstruction" of a phobia is more characteristic of psychoanalysis than CBT.
Most people don't seem to realise that the celebrated prefrontal cortex is the youngest and in a way weakest part of the brain. It surrounds older structures that don't work much different than in reptiles.
Changing your thoughts is easy, changing the attached emotions, fight/flight responses etc., who might even trigger the thoughts in the first place is incredibly hard.
It takes time, the right corrective and endless patience and iterative practise.
I like to think that somewhere there's a discussion board for psychologists and they're talking about, say, using R and how it sucks or not.
As a side note we have a moderately successful CBT app so I have definitely spent plenty of time in the 'source code' of CBT methodology. It isn't bad or good anymore that C is bad or good. It's a tool that's useful when applied to the problem for which it is best suited.
Unfortunately, given the realities of health insurance payments, it's a tool often overused due to its 'promise' of fast results (compared to psychotherapy for instance.)
The real problem isn't CBT, it's an attitude by payers that mental health treatment can be quantified as easily as physical health. That leads to writing webpages in C so to speak.
In the psych community though the CBT vs. Psychotherapy debate reaches similar passions as debating PHP versus Rails. (Fix my analogies as appropriate, but you get the idea.)
I much prefer mindfulness methods where you immediately think "is this thought useful to me at all?" and if it isn't, you put it out of your mind. Meditation helps with this, as it trains your brain to be able to let go of thoughts.
As a fan of zen/mindfulness and as I'm going through CBT currently, I definitely feel some friction between the two approaches.
The placebo effect, and effects like it, happen everywhere. Everything given with a good or bad attitude will have some beneficial or detrimental effect. In that sense this article isn't that interesting.
What I think is more interesting is combining the interaction between inexperienced therapists and the placebo effect. Well trained psychologists have a stronger -- and I'd guess more nuanced -- belief of when CBT is useful and how it is useful. Since they have that belief, it has the potential to create a positive placebo. I always have to think of the Pygmallion effect and similar effects.
People who treat patients CBT but are inexperienced do not have that enthusiasm and have a weaker belief that it will work. Maybe they only think intellectually that it would work, but don't feel an emotional tsunami of conviction -- in particular cases -- that it will work. It's easier to have that when you know that in 7 out of 10 particular cases it worked really well (i.e., having experience).
That would be my guess anyways.
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Now I read a couple of comments with people giving the sentiment that they think CBT is nonsense. Allow me to address that.
When I looked into CBT (@ 17/18 yo) and its pseudoscientific brother -- reframing in NLP -- I noticed that it was all about changing perspective. Learning to see that multiple emotional perspectives can be equally true was mind blowing for me. I came to the conclusion that I might as well pick the most positive one. I learned a couple of nuances on the way. For example, for some goals it's useful to hold multiple positive and negative perspectives at the same time.
I used it even today, now that I think of it. I was learning Django and it took me 4 hours to write simple custom email validation. I had a bug, a very simple one if you know the framework, but I don't. I was pissed after 4 hours, I felt like I wasted my time. I found the bug though :)
Since I didn't want to feel pissed I looked for a reframe. The reframe was: it's the first time that I learned to debug in Python with pdb, read source code from a framework so intensely, have a better understanding in transferable skills since I have experience with gdb and have the guts to debug the framework and understand it, for the first time. While I didn't progress much in writing actual code, my confidence in tackling issues in Python has grown tremendously. After thinking this I felt pretty good and figured that tomorrow it would be another day. So yea, I didn't progress in my initial goal (completing a tutorial) but I got something way more cooler for it in return. Now, if I hadn't known CBT I would've stopped at my first thought and stayed pissed, I'd then enter a lot of thought trains that would go to destructive places.
So yes, changing perspectives works. I also call it 'simple CBT'.
And when heavy stuff happens, then it doesn't completely cure you (perhaps reduces the pain by 5 to 20% IME, got no scientific sources). In many ways that's because the pain from the problem does not only stem from cognitive distortions -- e.g. generalizing the slightest thing to a negative epic scale -- which is the main assumption that CBT makes. If you lose a person (breakup, passing away, etc.), for example, you also need to be reconditioned since a lot of habits are still there that are only applicable to the other person which may trigger an immediate pain. You can't just think your way out of that, and the "behavioral" part of CBT will take a longer time and may not work (habit formation and destruction is a difficult topic).
Disclaimer: studied psych., I know a lot more about reframing than CBT (I skimmed a couple of texts and was like "hey that looks like reframing"). So my knowledge is not a 100% sharp and may miss important details. I read a book about ACT and compared that with CBT.
I've known some people who have seemingly indestructible self confidence, bordering on delusional, and this seems to be how they do it. I don't particularly want to be delusional, but I'd rather be happy than right.
Me too, to add: I'd rather be both ;)
Recent studies have called into question the initial reports of effectiveness of psychotherapies, CBT included, or perhaps in particular. I won't go into detail here, but in a phrase all kinds of established therapies tend to eventually be observed to follow the classic "rule of thirds". More or less about a third of the treatment cohort will get better, a third remain the same and a third are worse. Proportions vary of course, but that's the idea.
What it comes down to is that CBT, interpersonal therapy, psychodynamic therapy and a thousand variants can be helpful for certain problems, but quite often a combination of approaches is needed for optimum outcome.
It's not unlike software development, a "team" of tools is necessary to actually get from initial concept to production release. It's a complex non-linear process, at least as much art as technology must be applied to get there.
I can attest after decades in the trenches that treatment for behavioral conditions runs in a parallel form, the art and science of applying relational and medical tools is distinctly complex, as it's necessary to tailor the approach to each individual. The salient point is no two people ever have the same illness.
CBT can be no more effective than the skill and talent possessed by the therapist and patient working as a team .
EDIT: Its cheapness is one reason it's been pushed so heavily in the UK.
Cognitive behavioral therapy is basically the same thing but it boils down to: "it feels bad when I think about this" / "well don't think about that then".
Like meditation is about not thinking, but it doesn't mean you try to never have a though again... it just means you have a degree of control over when you put gas on that fire and when you let it burn down.
If we wish to treat depression, we should focus on life not being so depressing to begin with, not persuading people that actually it isn't once they have already spiraled into despair.
I resent that you make a false assumption, having been through CBT so many times I feel I might even have a better knowledge of it than professionals whose only experience is from a text-book.
Additional: Occassionally I may forget to take it and I won't feel any different however those around me pick up on it straight away as I become reclused and start constantly sweating.