Comment by ajb | Hacker News Reader

Comment by ajb | Hacker News Reader

Psychological Therapy, of any kind, has an intrinsic dilemma:

* Because the therapy is asking the patient to do something that, at some level they don't want to do and think is going to be painful, therapists generally have to exert significant effort to persuade the patient to continue to the point where they benefit.

* Most (all?) Psychological therapies have a high failure rate. A significant fraction of the patients won't be helped, and so the persuasion above is harming a large fraction of patients (the opportunity cost of a failed therapy, which generally takes months, is huge)

I have not seen this problem acknowledged at all by the psychological professions. There ought to be a good deal of research into how to decide the optimal stopping point, and making sure that the operation of a therapy causes the least possible harm to those is doesn't help. But my impression is that the cognitive dissonance of delivering an intervention that will help some, but expensively fail many, is too much for most therapists. They generally continue to believe that the patient would be helped if they held on for long enough, and don't provide any support for a rational process for deciding when to give up on a given approach, resulting in the kind of gaslighting and blaming described here.

Speaking from experience, you analysis is spot on and this is a very common coping method in social work as well.

It is done because otherwise in the 9/10 cases where things do not improve, you feel you have failed. Much easier if the client fails you instead.

You can tell yourself, "well, maybe next time they'll get better -- after all, it takes many relapses before people kick a drug habit!"

This is a lot easier to swallow than "Oh god this stuff barely is working at all, I'm mostly just a gigantic resource suck and the money I'm paid would be much better spent getting this person stable housing and other support--but that's a lot less attractive to tax payers."

I got out of social work when I had that realization. Initially I coped by saying I was a "Good Person" in a helping profession, so I never looked too deeply into whether any of this horse shit actually was "evidence-based."

Every Psych 101 class should cover the current findings on efficacy of psychotherapies. But they never do, for obvious reasons.

> (the opportunity cost of a failed therapy, which generally takes months, is huge)

To say that someone is harmed by finding out what doesn't work is a bit of a stretch. You can only talk about opportunity costs meaningfully if the costs of each opportunity (those taken and those not taken) are known beforehand. To say the opportunity cost of a failed therapy is part of an intrinsic dilemma is to say that not knowing what will work is an intrinsic flaw to all decision making. While it may be true, it is neither meaningful to point out, nor exclusive to therapy.

Many people go through several different programs before they find one that works for them. The fact that you might have to narrow down which one works for you is not "harm".

"To say that someone is harmed by finding out what doesn't work is a bit of a stretch."

Conversion therapy

Bloodletting

Rydalin

12 step / AA

Every quak remedy that ever existed

Good grief there's an infinity of things that are more harmful than doing nothing at all, and cost a lot in real harm just "to find out what doesn't work", and yes of course even mere conversation vs drilling holes in your skull can be harmful all the way up to death and even collateral death other people when someone they love is essentially killed or abused.

Do I really have to contextualize my statements that much? Has reading comprehension on YC sunk that low? Obviously, I'm saying this in the context of things that might work; if there are, say, 12 remedies that have been shown to work for some people, and you don't know which one will for you, then narrowing down the range is not harm. We're talking about opportunity costs, not whether shooting yourself in the head is a bad thing or not.

My use of the word "harm" has distracted you from the main point.

The dilemma I am talking about is an emotional one, not a dilemma of decision. The therapist must persuade the patient that the treatment could work, but they know that it is quite likely not to work. They should be emotionally committed to the the therapy, and persuade the patient to be emotionally committed to the therapy, while at the same time recognising that there should come a point at which the therapist should recommend stopping and trying something else.

And while it isn't working the patient is suffering. A patient isn't in a state of stasis, like a computer program being debugged. While they have a chronic illness, it uses up their resources, of energy, time, money, social and professional capital, and ultimately, will to live. and it's very hard for the therapist to be rational about when to stop. Because giving up on the therapy requires recognising that the therapy they chose to deliver, and advocated for, may have caused the patient to suffer for longer than some alternative. And if the patient's resources are depleted enough, they may not now have a good shot at getting the alternative to work.

If people could be coldly rational about this, you'd be right, it's just a question of trying one thing after another until something works. But therapists have emotions, and those emotions cause them to commit to a therapy long past the time when rationally the patient would be better off trying something else. And that is harm.

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