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Comment by gusts | Hacker News Reader

pfft I like to ask every doc I go to, what outcomes they have produced in cases like mine and how many such cases they see a year. The CBT ppl just blink at me like the question is not on their manual. And one even said no great outcomes but here are the things you should do. Why would I spend my time doing them if they haven't produced results?

I mean these are nice people with good intentions but so is a priest in a church or a temple. The whole thing feels half baked. Ya ya I know reprogramming the mind is complex and this is a work in progress. But my experience from work and coaching team sports is people follow authority figures when in doubt/outcomes are unknown. And most shrinks and counsellors in my case atleast are unable to establish authority.

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+1 I'm pretty sure multiple rounds of CBT made my anxiety disorders worse. The approach attracts hyper-rationalist types who aren't willing to say anything other than "Your thinking patterns are wrong, you need to fix them." No serious discussion of trauma, identity issues, or relationships. Pure gaslighting. Recently, I finally realized that what I needed was some serious introspection and an empathetic therapist who would help me work through it. For all the bluster about psychoanalysis being quackery, I'm not sure you can disagree with its basic premise that maladaptive personality traits are likely to come from the social context you spent most of your first ~18 years in.

Wouldn't many of your thinking patterns have come from your childhood and teenage years? How did none of this come up when you did CBT? Also, how did you do CBT without serious introspection? It sounds like the therapist you did CBT with just wasn't very good.

I've found that for my anxiety ERP based therapy is much more effective because often anxiety isn't a matter of your rational brains understanding but rather trained responses of your subconscious.

Outcomes are meaningless without control groups. The providers you spoke to may not have stunning reversals of illness to show you, but keeping someone from sliding into a worse state is an important function of therapy and impossible to measure. For all you know, they may have prevented dozens of suicides that year.

for all we know they exacerbated their patients symptoms

Well, from the comment I was responding to, the implication I took from "no great outcomes" was "no great change, either positive or negative". But technically, yes, you're right.

It's frustrting when you ask someone how they know this works or how effective it is and they give you blank looks. It feels like a failure of informed consent.

> The CBT ppl just blink at me like the question is not on their manual.

What country? In England the IAPT programme (the main source of CBT) has extensive data collection on outcomes (probably the largest collection in the world) and a focus on getting more and better evidence to improve the service.

Chapter 3 and 6 of the IAPT manual are about evidence based practice and gathering better data:

https://www.england.nhs.uk/wp-content/uploads/2018/06/the-ia...

The data sets are here: https://digital.nhs.uk/data-and-information/publications/sta...

The latest (Jun 12 2018) says this

---begin quote---

Key Facts

In April 2018 there were:

-- 119,304 new referrals;

-- 85,145 referrals that entered treatment;

-- 47,296 referrals that finished a course of treatment, of which;

-- 89.4 per cent waited less than 6 weeks and 98.9 per cent waited less than 18 weeks to enter treatment;

-- 44,222 started their treatment at caseness, with 51.9 per cent moving to recovery.

---end quote---

There's some jargon there, but that's explained in the executive summary: https://files.digital.nhs.uk/D3/B3FC5F/iapt-month-apr-2018-e...

tl;dr: CBT is somewhat effective; it's more effective if you have CBT that follows the high intensity model (14 to 20 weeks, one hour per week, face to face one to one with a qualified therapist).

>And most shrinks and counsellors in my case atleast are unable to establish authority.

If you continuously end up in situations where you're seeing mental health professionals, you might consider just accepting their authority without the need to jump through your hoops.

Speaking from experience, seems to me the GP’s need to make people jump through hoops to earn their trust is a damned important part of _why_ they need those professionals in the first place.

At a certain point you need to consider their success rate against your own. Realizing that and accepting they may be able to help is an important step.

Right — but it’s a pretty damn big first step. I can think of a fair few people who were never capable of taking that step

You can't help someone who doesn't want to help themselves.

I mean, if someone is shot, you can still surgically intervene without them having to participate. It’s true in psych that you have to help yourself, but it’s also true that’s probsbly a valid critique of the art rather than science that is psych. Talk therapy has more in common with spiritual guidance or shamanism than medicine, except where the actual medicine enters the fray in the form of drugs and surgery. If you’re willing to help yourself, talking to someone is often helpful, but that’s been known for thousands of years.

A real intervention doesn’t require someone to help themselves; an appendectomy doesn’t require patient participation and motivation.

I mean, if someone is shot, you can still surgically intervene without them having to participate.

Okay, this is clearly not what we were talking about. Sorry I was not more specific in my statement to generalize to all scenarios, ever.

Edit: I think it is also a pretty fair assumption that if someone is shot or their appendix is about to burst, they would want help. The key difference here is that someone who is shot is not capable of helping themselves - with regards to many things people go to therapy for, the only way to fix your problems is going to be taking some actions yourself.

Consent is one thing “my appendix is killing me, help!” while actually doing the work yourself is another. Obviously any intervention requires consent to really work, but once you’ve consented to the appendectomy your role ends. You don’t have to actively engage in your own surgery past the act of wanting it. By contrast merely consenting to therapy isn’t enough, you have to do a lot of hard work as well. The fact that the hard work of everything from overcoming neuroses and anxieties to battling substance abuse is the patient doing the work suggests something about the nature of therapeutic intervention as “treatment” rather than advice-giving.

For the most part, people see a psychotherapist because they've got problems that they feel unable to fix on their own. Awareness of resistance to the psychotherapeutic process is almost as old as psychotherapy - it's a central concept in Freudian psychoanalysis.

"You have to be willing to help yourself" is perilously close to "psychotherapy only works on people who are capable of changing of their own volition", which calls into question the entire purpose of psychotherapy. If I could change my way of thinking through sheer force of will, why would I pay a professional $100 an hour to sit and listen while I do it? It evokes the classic defence of the quack - the spoon only bends if you truly believe in the power of the mind.

If that problem is framed as "some patients are too sick to treat", then at least it shifts the burden of responsibility onto the therapist; it's not the patient's fault that the psychotherapist lacks the neccesary tools to facilitate change. Blaming the patient for having a bad attitude just makes the profession of psychotherapy look ineffectual.

It's not really about being able to change yourself, it's about wanting to change so much that you're willing to put in the work. When I did it I had to unlearn a bunch of mental habits, but I also had to change my environment and seek things that were outside of what I knew. Therapy would have done nothing for me if I had let the therapist do all the work. I'm my case the work was to find a new way of living that is aligned with who I am and what I want for myself.

When I went in I had some major anxiety problems, and by working with my therapist I was able to identify where those problems came from. I started taking steps to change how I lived so I wasn't as anxious anymore.

While it does require your participation for success, you are paying the professional for the tools to help yourself. And sometimes others aren’t able to help themselves, and the professional’s job is to help them discover how to.

Blaming the patient for having a bad attitude just makes the profession of psychotherapy look ineffectual.

What sort of magic are you expecting from psychotherapy? You're paying someone to help you solve your problems. You're not paying someone to solve your problems for you.

Modern advertising is based on psychology. It works surprisingly well even when people try to resist it.

Advertisers nudge you to do something you sort of already want to do. The amount of effort required to buy things is minimal and buying things you want to buy is usually enjoyable.

On the other hand, going to therapy is forcing yourself to do something that is difficult, sometimes painful and requires a lot of effort and resources (both time and money). I don't see the relationship between voluntarily going to therapy and advertising inducing you to buy things.

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