Book Review: All Therapy Books
slatestarcodex.com
slatestarcodex.com
My wife practices Cognitive Behavioral Therapy (CBT), and the foundation of her approach and all CBT books on her bookshelf is that CBT in fact doesn't change anything at all. You will still have symptoms (depression, anxiety, etc.) after CBT, but the goal of CBT is to help you manage those symptoms and live a meaningful life despite those symptoms. It's reasonable to doubt that such an approach can work, but Scott's article entirely misses that this approach can even exist. I suspect that this is a latent bias due to his psychiatrist training. (Psychiatrists are trained to use medicine to reduce/eliminate symptoms, and that is their primary measure of success; psychologists use therapy, and the reduction/elimination of symptoms is not necessarily their primary measure of success.)
I just did a quick search on amazon for CBT books, however, and found that most results are things like "CBT for Dummies" and "Teach yourself CBT in 7 weeks". These are not books for doctors, but books for laymen that are merely self-help books with a veneer of science/therapy to help the book sell. Who knows what sort of crap is in these books.
There is also a handy CBT app called Quirk that I'd also recommend checking out https://www.quirk.fyi/
>The good news is that anxiety, guilt, pessimism, procrastination, low self-esteem, and other "black holes" of depression can be cured without drugs. In Feeling Good, eminent psychiatrist, David D. Burns, M.D., outlines the remarkable, scientifically proven techniques that will immediately lift your spirits and help you develop a positive outlook on life.
[EDIT] in fact despite looking superficially like a fairly sober and complete post, I believe the parent might be a poster child for "shallow dismissal".
https://slatestarcodex.com/2015/07/16/cbt-in-the-water-suppl...
There's definitely a discussion about whether CBT should always be the therapy of choice. Personally, I think you need to be at the right spot for CBT to be effective. For me, I was a functional person who could somewhat identify what I didn't like about my mental state and was very open to trying to improve. I'm guessing CBT is probably not as effective if you're experiencing severe mental health problems or breaks in reality, or if you have milder symptoms but don't want help/change. Sometimes when I'm really down, CBT essentially feels like "you're sad because you're too stupid to be happy!" At the same time, I imagine every therapy works better if a person is at an okay spot and open to change. And CBT can probably help people all over the spectrum to various degrees.
If you're experiencing mental health problems, give The Feeling Good Handbook a try! It's a large workbook where you read and work through written exercises. Very helpful to me so I try to evangelize it when I can (and give out copies to people I know who struggle). I never tried in person therapy but that'd also be immensely helpful too. The great thing about CBT is how simple it is though, so reading a book (aka bibliotherapy) for a self-motivated patient can do the trick. Indeed, he spends the first chapter reviewing studies that claim bibliotherapy is just as successful as in person therapy. (Not sure what I think of that... I imagine book readers are more self-motivated than the average in-person patient but they were experimental studies so I'm sure that's already controlled for... nevertheless, bibliotherapy was good for me.
About me: I lost my dad in high school, my mom in college, and my sister to suicide after graduating. Pair that with an interesting childhood (alcoholic mom, bipolar sister) albeit a financially comfortable childhood. It was (and still can be) an incredibly hard stretch of time. At the same time, I was exceptionally gifted at school and really looked up to my teachers so I was and am very lucky and traditionally successful. If you're struggling, get help! Take responsibility! Your mind CAN change in small but subtle ways in how you frame your life and the daily happenings of it.
I'm bipolar. CBT is ineffective for problems that aren't resulting from bad thoughts. But it just as important as medication for my treatment plan.
CBT is absolutely critical to maintaining stability when I am rational. Stopping bad thoughts before they get time to spiral out of control significantly reduces the severity of my symptoms.
While CBT can't fight irrational thoughts resulting from my mood swings, it's taught me what I can and can't change. As a result, I know when to switch to a different coping skill to get through a bad day.
As far as in-person therapy goes, a therapist is a guide. They can point you in the right direction and provide a different perspective.
The evidence for CBT for things like psychosis is mixed. The English NICE say that CBT should be offered to everyone who has psychosis, and to most people at risk of developing psychosis. https://www.nice.org.uk/guidance/cg178/chapter/1-Recommendat...
Other people think the NICE committee is biased (and I think they're probably right) https://twitter.com/Keith_Laws/status/1205833799826890752?s=...
Sometimes people point to the English IAPT scheme (which offers mainly CBT) as evidence of lack of effectiveness of CBT for depression. They say that it only works for about 60% of the people who try it.
I think this is a misunderstanding of the data, which can be found here: https://digital.nhs.uk/data-and-information/publications/sta...
IAPT has 4 tiers. The higher tiers are delivered face to face, one to one, with an experienced therapist, and you get up to 16 weeks of therapy. The lower tiers might be group work, or telephone based, or maybe even delivered over computer. If you have a therapist they may be less experienced. And you get 5 weeks of therapy. But the results of all these tiers are mashed together.
how can a human being not have these. Even my cat has these from time to time.
> CBT [...] help[s] you manage those symptoms and live a meaningful life despite those symptoms
So... it... does actually change things?
I'll be explicit rather than flippant: giving someone tools to manage symptoms and live a full life can be a huge change.
Nicely spotted. This is certainly a good point to question.
The article reads to me as (intentionally) hyperbolic, in a dry humor kind of way. Perhaps the author is frustrated with the state of things. Anyway, I feel like "change everything" can be considered a stand in for "effect any change more than other therapeutic methodology."
With that reading, the main point that stands out to my eye is that CBT or any methodology is no more effective than the next. They are all the same basic process, just with different dressings.
As an extreme example, even far-field woo like Dianetics can boast the kind of therapeutic help you describe. This makes it seem like the particulars of CBT are mere detail and the thing that is working is mostly the patient's earnest work toward some form of "better."
You're describing Acceptance and Commitment Therapy, not CBT.
https://en.wikipedia.org/wiki/Acceptance_and_commitment_ther...
>psychologists use therapy, and the reduction/elimination of symptoms is not necessarily their primary measure of success
Aaron T. Beck invented both CBT and the most widely used instruments for measuring the severity of depression and anxiety symptoms (the Beck Depression and Anxiety Inventories). CBT was the first psychotherapy to a) explicitly make the reduction of symptoms the primary goal and b) measure the success of therapy using standardised questionnaires to quantify symptomatic reduction. Using a repeatable psychotherapeutic model to measurably reduce the symptoms of psychiatric illness is pretty much the raison d'etre of CBT. Beck's work is by no means immune from the "eureka" anecdote of a patient suddenly entering remission thanks to the acute insights of $theoreticalModel.
https://en.wikipedia.org/wiki/Cognitive_behavioral_therapy
>found that most results are things like "CBT for Dummies" and "Teach yourself CBT in 7 weeks". These are not books for doctors, but books for laymen that are merely self-help books with a veneer of science/therapy to help the book sell. Who knows what sort of crap is in these books.
Both CBT for Dummies and Cognitive Behavioural Therapy: Teach Yourself were written by qualified and accredited psychotherapists.
I don't think "placebo effect" is an adequate term when the benefit from a therapy derives from the work patients put in. It's more like dieting than like a drug. Faith in the program helps people invest the required work and persevere through difficulties and setbacks. The impulse to give up, to take a break, to skip the work today, this impulse preys on doubt. In this dynamic, the differences in inherent effectiveness between one method and another can be dwarfed by the power of one treatment having superior marketing and inspiring people to work harder, persist through greater discomfort, and eventually have a greater likelihood of achieving results — which will of course be credited to the theoretical ideas underpinning the therapy instead of the marketing.
You're suggesting the therapy has a dose-response, and as perception of the therapy changes, patients are motivated less and so they get smaller doses.
What Alexander is suggesting there is that for a given level of work that a patient put in (i.e. for a constant dose), the placebo effect has been reducing due to a "miracle effect" halo that is fading over time.
I.e. he is explicitly talking about just the placebo effect here.
Diagnosis of the deep anxiety is probably the biggest challenge. On a side note I found my dreams were very good at helping me find them by presenting situations which encouraged non anxious behaviour, which contrast to the anxious behaviour I would take in the dream - this disparity between what the situation demanded and how I behaved would highlight the deeper anxiety. I got very into the subject and wrote a paper on it: https://psyarxiv.com/k6trz, which was discussed in some depth on HN: https://news.ycombinator.com/item?id=19143590
FWIW, some books. "Structure of Magic" I & II are the first two books and are a good place to start from to see the origins of the latter work. TRANCE-Formations is a rich text on theraputic hypnosis. And then there's the Core Transformation Process, an algorithm for profound spiritual growth.
https://www.goodreads.com/book/show/964154.The_Structure_of_...
https://www.goodreads.com/book/show/821993.The_Structure_of_...
https://www.goodreads.com/book/show/956297.Trance_Formations
https://www.goodreads.com/book/show/369813.Core_Transformati...
Hypnosis in general and Neurolinguistic Programming specifically are regularly panned by skeptics, and have not been scientifically well-documented, yet there is definitely "something there".
I'd love to "do science" to NLP, but I'm not qualified and have other things to do. (I got rid of my depression and the urge to study psychology waned.)
> am a bit curious about why you would say that calling the practice not scientific is not undeserved.
It's just that a lot of practitioners and promoters haven't been completely scrupulous IMO about making NLP out to be more scientifically-grounded than it is.
Unlike physical issues, where fixing a broken leg is the same regardless of the patient, emotional and psychological issues require trial and error, but most people don’t understand why it’s necessary to try different solutions, so they just assume it’s all quackery, and avoid the problem entirely.
I worry about this a lot too. We tend to make sense of the world through the stories we apply to our experience, but with unreliable memories and a desire to find a story that fits what we want to think, confirmation bias even about our own identities leads us to false conclusions.
This could create more engagement and enthusiasm on the part of of the therapist leading to better outcomes.
It's not a therapy book really; it's listed in the self-help genre. Still, I love it because it talks about all the problems with self-help books. The author goes to motivational talks, finds a person who grudgingly and unenthusiastically yell, "I'm so motivated" and later tells the author his trip to the talk was paid for by the parks department he worked for; he don't really want to be there.
The author does a deep dive into what's wrong with the motivation book culture in general, how we should not be afraid of our failures or how the quest to feel good all the time might be to our detriment. It's a great read.
The article here seems to be arguing more that all therapy books are either the same or claim their method is better when it's not significantly different, or they promise exergerant claims of totally turning ones life around when they really don't; how therapy is often a slow though out process with gradual changes.
It seems to fit inline with stuff in The Antidote from the perceptive of self-help books. It's a good read.
This essay about SSRIs was one of my first exposures to his writing, and I found it very interesting.
https://slatestarcodex.com/2014/07/07/ssris-much-more-than-y...
The linked essay is setting context for a series of reviews on various therapy books.
Also I used to teach listening skills, which everyone agrees are basic to being a good therapist. I did several workshops with therapists at mental health clinics, and it was quite shocking how many of them were awful listeners.
That means if you find yourself with a destructive therapist, you need to leave as fast as possible. And how do you tell? I would say the best sign is if you feel comfortable talking to the therapist and feel like they value you as a person, or feel yourself tighten up around them.
One of fathers of this idea was the psychologist Carl Rogers. He didn't have much to say about personal historical causes. But back in the 1950's he developed the theory that success in psychotherapy depended on the therapist being empathic, affirming, and honest. He and his associates went on to do a number of studies that seemed to confirm the idea pretty well.
To be fair to Alexander, therapy research and literature has the kind of weird duality he points out, and it permeates academics as well, where the problems he mentions are maybe even worse. Everyone does know about the dodo bird effect, but then people either embrace it or they ignore it.
A big problem is the exact same thing that's permeating all of medical science, which is a huge pressure to obtain grants and notoriety for discovering a cure. There's much more rewards for overhyping than being sober in science. You could replace therapy with drugs in his essay and it would read the same. In fact, I sincerely was confused for a bit by his figure because the exact same sorts of figures have been published about psychiatric medications, and it took me a while to be sure what he was talking about.
One thing that's maybe not immediately clear to the general public is that with psychiatry and psychology there's an additional pressure to "be scientific" which then often backfires in the way he's witnessing. Both psychiatrists and psychologists are the targets of witch doctor labels, which then leads to this behavior where researchers and theorists jockey to outdo themselves in being "real scientists". The good part of this is that then you get a ton of randomized controlled studies and so forth, but the downside of this is you end up with this additional reason to promote your drug or therapy as being somehow better than treatment as usual, or to denigrate other interventions as being "unscientific". That is, certain things (e.g., CBT in therapyland, or arguably things like prozac in medicationland) become banners that you're expected to carry if you want to be part of the "real science" club. Criticizing the efficacy of these interventions implicitly doesn't just mean criticizing those particular interventions, or criticizing the specificity of their mechanisms, it means you get labeled as not being on board with the "real science" club. It is just one more reason for hype, in addition to the typical hype that is flooding biomedical research at the moment.
Alexander mentions that he feels like he's never seen "sudden, extraordinary, long-lasting" effects of therapy. I'd suggest it's one of those situations where you get to pick 2 of 3, nothing more.