Therapy Experience Associated with Negative Changes in Personality
sciencedirect.com
sciencedirect.com
If you're new to scientific papers, the heuristic to use is: Read the Abstract, Introduction, and the Discussion/Conclusion. Methods & Results are boring and numbery, and you can dive into those later.
I highly recommend reading the whole General Discussion section. It's four pages. The main idea is that:
- There are previous well-controlled studies that show the benefits of therapy, but
- When we are simply observing a cohort of people, the people who have some form of therapy experience a decline in positive indicators and a rise in negative indicators. (Indicators like self-esteem, depression, etc)
This might be because:
1. The therapy did help, relatively, but because of the strong force from a patient's trauma, they were still generally doing poorly. But it could have been worse.
2. Because of the broad definition of "therapy experience" and the limited data in the survey, maybe this is mostly capturing people who only received a few sessions, and didn't continue long enough to receive the benefits, or in the case of the US cohort, only received drugs.
3. Maybe everyday therapists are kinda shitty? The therapists selected for controlled studies are always up to date with modern techniques. The paper said it more eloquently:
> The third explanation concerns therapists who deliver therapy. Again, in a controlled intervention, treatment integrity is often one of the highest priorities of the research protocol. In contrast, implementation of empirically supported therapy in real-world settings may not happen with as much structure or rigor.
I think these are all good hypotheses, but the 3rd explanation is pretty scandalous.
Hence, even with the best therapist, the patient may be fighting an uphill battle.
Also, many patients are hard to convince that medication may be helpful, so again - uphill battle.
Finally, for some issues we know that they have a strong genetic component (Anorexia?), but there are no good medications for it yet.
I imagine that controlled studies correct for underlying psychiatric symptoms, but in real practice this is often omitted. Kind of like the point #3 you mentioned.
From personal experience: I had some amazing therapists over the years. Really good, helped me with all the issues and traumas I had in my life. But until I got diagnosed with ADHD and received proper medication, my life was indeed getting worse and worse.
The therapists helped me to get water out of a ship, but it was a psychiatrist who helped me find out the hole and patch it up.
As you travel down the road towards being a psych. professional - you tend to subscribe a school of thought about behavior and personality, and there are a few to choose from (e.g. people are generally self-directed and will solve their own problems given the opportunity, or behavioural problems have their roots in learning - so training is required) - and depending on your opinion you'll eventually subscribe to a treatment modality that resonates with what you believe (the extreme version of this is abandoning psychology & switching to medicine / psychiatry because you believe behavior is simply a neurochemical process).
Serious personality disorders are very difficult to treat, which brings me to my next point. The Big-Five factor model used to determine change over time does not factor diagnosis, so we don't really get a picture of what the cohort looks like. We know nothing about patient history or reason for seeking therapy (i.e. have you been evaluated admitted to a psychiatric ward in the past? have you suffered from substance abuse problems?). And finally, the big question that would be useful is "what problems caused you to seek therapy?" Depression vs. hearing voices in one's head vs. got divorced because I like to drink are all very different issues.
I would like to have seen at least three more measures: reason for treatment, length of treatment and therapy modality used.
However, I will say that stating that "new research proves that therapy doesn't work" will get you a click or two ;-)
Ironically this probably isn't only because doing things brings happiness, but because more experience means more context, and more context means more understanding. The only way to gain a better understanding of your life is to have more types of experiences, sitting there and thinking about it within the framework of the experiences you've already had generally isn't that useful.
E.g. the best way to understand why a previous relationship didn't work out is to have more relationships.
This ignores all the people who are leaving a trail of destruction in their wake without much self-awareness or guilt.
then
> The people I know who do improve
Despite the contradiction here, it sounds like some people do find something on their quest, and that thing is to start taking real action.
What does that mean? Sounds interesting.
Everyone I know who says shit like that publicly is like that. Most people don't share stuff like that unless they are assholes.
> The most pressing issue that emerges is why these results run counter to the hundreds of more controlled, clinical intervention studies, which largely show positive effects of therapy not only on measures of distress and well-being, but also personality traits.
In addition, the discussion section states:
> Thus, whereas individuals reported seeing a therapist in our observational research, they may not have seen them long enough to induce positive change. Further, it could be that some people started therapy because of a traumatic life event and actually declined at a less rapid rate than if they had not sought therapy.
As always, I think the answer is to wait and see. While they've noticed a correlation in two studies, it isn't that they've contradicted all of the prior evidence about therapy. Still, a neat read though.
Unfortunately, I think a lot of the therapy out there is the first type, which for me, and most (I suspect), just makes the negative spiral worse. You spend MORE time thinking about what's wrong with you then you did before (if that were possible).
The second approach was life changing for me. I learned to let go of the past, and focus on what I'm doing which works (which, surprise surprise, leads to more of such behavior). And interestingly enough, the therapy was relatively short term: something like three months, once a week. And that was almost ten years, marriage, and three kids ago--and I'm still practicing to good effect what I learned in that brief time.
So my advice to anyone who will listen who's in therapy or interested in it is this: seek out a counselor or therapist who focuses on short term therapy which focuses on present action and positive (desirable to you) outcomes. Every other approach, IMHO, is a waste of time and money...And may make you more worse off in the end. These people can be hard to find, but they're worth their weight in gold.
This reminds me a bit of the movie Awakenings, where one of the patients who came out of his coma was upsetting his mother. His mother was so used to him being this passive and lovable manchild that she couldn't handle him when he became assertive, spoke back to her, and wanted to spend time with young ladies and not with his mother. She never saw him go through a proper teenage rebellion stage and he wanted to live life immediately and really had no time for mother anymore because he just wanted to pursue his crush. To his mother, the therapy was a failure because she was no longer happy with him.
I also think there's an element of becoming jaded as one gets older, generally. The more experience you have with people, life, etc the more you realize we really are not good creatures and a lot of the wonderful optimism we've been taught be in a spiritual, social, or familial environment are often wrong, if not entirely false and people are just simply predictable animals fighting for resources. Therapy and other methods of self-discovery often lead to these self-discoveries and can really lead to a certain level of 'depressive realism.'
I read somewhere the happiest people are the ultra-religious and cult members. Everything is explained and everything is simple to them as a singular and unquestionable authority gives them all the answers. Therapy in the western tradition is pretty much the opposite of that. I guess you have to ask yourself if you want to be delusional and happy or realistic and perhaps have a good chance at being content with life and with occasional happiness and accepting of negative situations when they come.
I suspect most people's idea of a mentally healthy person don't fit in with what its actually like to be mentally healthy. Its not all smiles and laughter. Its also toughness and resiliency and the ability to say 'no' to you. If your friend came back from therapy like this, you'd think it was a failure, but I suspect he feels much more validated in life and much more autonomous.
What if your "common sense" is wrong? What if it has been doing harm? You should embrace the statistical rigor going into therapy.
And also, "appropriate resource" is something that society can and should change. We ought to be able to hit any depressed person with a shot of ketamine, but it's still restricted and has the negative label of being a "Drug" and a "horse tranquilizer", despite it's effective history of use in serious surgery and it's current use in combat medicine in Afghanistan.
no random assignment.
bad temporal proximity of data gathering on personality.
methodological poking about at the badness of controlled vs observational studies. basically study recruitment as a selection effect.
It's also worth noting that data collection was entirely done through surveys; so, another explanation could be that therapy simply made people more aware of pre-existing personality deficits, that they were then able to more accurately report.
And further, even if the results are valid, it doesn't invalidate the benefits of therapy; most therapy methods are built around helping the patient. Its possible that therapy improves the subjective quality of the patient's life at the expense of some external qualities (or pretense thereof.)
That's not the case-- they were measuring for subjective quality, and it was subjective quality that declined. I posted the PDF of the paper in my top-level comment, but the Psychological measurements they were looking at in the German cohort were self-esteem, life satisfaction, and depression. The US cohort was measured for self-esteem, chronic stressors, and depression.
Not because the content itself is good or bad, but because it is precisely someone struggling with this stuff who has a high likelihood of walking away from the article with the wrong message.
I understand that we're all responsible for our decisions etc., but this is really out of our wheel house and hopefully the people in need of therapy consult with professionals before acting on anything that bubbles up here.
If your health care system gives you the option, that is.
Here in the UK, someone diagnosed with depression or anxiety by their primary care physician is likely to receive no more than six sessions of CBT, often after a wait of many months. Private psychotherapy costs £60-£100 per session, which is totally unaffordable for many people.
We have a chronic shortage of psychiatric inpatient beds and very poor follow-up care. People who are hospitalised after a suicide attempt are often discharged the same day with little more than a prescription for antidepressants and the promise of a home visit by a community nurse.
Sadly, the UK isn't an outlier.
I agree with this bit. Although it's important to recognise that hospitalisation for suicidal thinking or suicide attempts probably isn't helpful, and that people need much better crisis team stuff, and that is being mostly addressed via Crisis Concordat work. (And what people need long term is much better prevention).
> Here in the UK, someone diagnosed with depression or anxiety by their primary care physician is likely to receive no more than six sessions of CBT, often after a wait of many months
IAPT wait times are published. Here are some recent figures: http://content.digital.nhs.uk/searchcatalogue?productid=2447...
> In November 2016 there were:
> 126,126 new referrals
> 87,961 referrals entered treatment
> 49,189 referrals finished a course of treatment, of which:
> 88.8 per cent waited less than 6 weeks and 98.5 per cent waited less than 18 weeks to enter treatment
> 45,607 started treatment at caseness, with 48.9 per cent moving to recovery
Your comment "often after a wait of many months" is inaccurate when 88% start treatment within 6 weeks and nearly everyone else starts in less than 5 months. (That over 6 week time wait is worrying, and I hope people have been rigorously triaged)
The executive summary says that about 64% of people going through IAPT achieve recovery: http://content.digital.nhs.uk/catalogue/PUB23389/IAPT-month-...
The other problems with current IAPT provision include
* lack of one to one provision - it's sometimes provided in groups;
* the lack of face to face provision - it's sometimes provided by computer or telephone
* reduced time per session and reduced number of sessions
In practice, less than 37% of patients are getting prompt and appropriate treatment. The rest are fobbed off with utterly inappropriate therapy, dissuaded from starting or otherwise nudged off the waiting list.
I've heard countless stories from both professionals and service users about blatant manipulation of the IAPT stats. Stories of referrals being "lost in the system" are commonplace. Many services are providing an initial appointment within the 6 week target, but then placing patients on an internal waiting list for further treatment. Many patients with complex needs are simply dropping out, rather than being progressed through the stepped care model.
All this is against a backdrop of massive cuts to "specialist services", i.e. anything that isn't IAPT. The story I'm consistently hearing from practitioners and patient advocacy groups is that the service is failing the most vulnerable patients with the greatest need. Patients with mild depression and anxiety are getting the low-intensity treatment that they need in a prompt manner, but patients with more complex needs are simply being swept under the carpet.
You know what would help get more people who need help into therapy? If therapy clinics allowed you to schedule a first session without having to call them! If you're suffering from anxiety and depression, then the thought of some receptionist asking you why you want to schedule an appointment is pretty terrifying.
And I think there are things between censorship and featuring anything that sounds sensational. One of the primary criticisms of mainstream science journalism is that it will take one recent study and focus on it excessively, giving readers a false impression. The same concern on Wikipedia is known as "undue weight": https://en.wikipedia.org/wiki/Wikipedia:Neutral_point_of_vie...
I don't think HN is above criticism on this.
Instead, ignoring the how and why of a crap situation and simply working to improve your situation will improve your outlook on it.
Do stuff to make life better and you will feel better as if by magic. Just ignore the problems until they manage to disappear on their own.
One step in front of the other.
1 > 0.
But there's evidence in favor of the opposite of the action you propose - people who see their problems and reversals as external and don't bother too much about them are much less prone to depression, according to the data. That doesn't mean they are successful or nice, of course.
Repeating an earlier comment: the entire point of modern evidence based therapies is to help people avoid focusing inward on problems and negativity.
"Just ignore the problems" doesn't work for people who have problems which are, you know, actually serious.
Those interested might be well advised to read their history and learn about the work that Stan Grof and Walter Pahnke were doing before the drug war crackdown.