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Comment by titanomachy | Hacker News Reader

I’m floored by the suggestion that professional training as a therapist does not produce a statistically significant improvement in ability to treat mental health conditions.

It’s interesting that one comparison they offered was between advice from a random professor versus a session with a therapist. I can remember several helpful conversations with kind, older professors during difficult times. Maybe we should identify people whose life experiences naturally make them good counselors and encourage them to do more of it, instead of making young adults pay $200k for ineffective education and a stamp saying they can charge for therapy.

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Speaking as a tenured professor of clinical psychology, this part kind of irked me a bit. It's not exactly false but it's a little misleading (like some other parts of the essay).

Lots to say about it but this is a finding that has been reported intermittently for decades. However, it's being spun a little misleadingly.

Note that the author says that untrained professors were selected for their ability to be warm and empathetic. It's not everyone (we all know not everyone is warm and empathetic), and even trainees learn very very early (like immediately in their first term) the basics of therapy. Not everyone is warm and empathetic, and people going into clinical psychology are sort of self-selected in their empathy to start with.

This research is kind of being taken out of context too. Wampold, one of the authors cited (who I have the greatest respect for) is very big on "nonspecific factors", meaning things like empathy, good social skills, and so forth. His studies in general tend to be focused not on "does training matter?" but "do specific therapy protocols matter, or is it about the clinician's social/relationship skills?"

If you want some kind of medical standards, you can't just say "oh it's ok, everyone can just be warm and empathetic". You have to train on it, grade it, hold it to some standard. Otherwise you get manipulative, self-serving therapists who do harm in the long run (the length of a study versus real settings is another issue).

Another issue is that many of these issues are not unique to psychology. In lots of medical scenarios it's been shown that the amount of training needed to competently do a wide variety of procedures is lower than current standards in the US require. Experienced clinicians in many fields have acquired biases that interfere with practice, young trainees are much more worried about performance and are more open-minded and so forth (on average a little; not trying to stereotype).

A huge, enormous volume of studies over many years have shown that therapy works compared to all sorts of placebos and controls; that some therapists are reliably better than others; but that what makes therapy "work" overall is not what protocol-driven therapies (CBT etc) assert. It's not so much that training isn't necessary, it's that the field has has been obsessed with scientific details that, although well-intended, don't matter, and healthcare in general is full of phenomena that we'd rather not admit.

Thanks for writing this, appreciate the point of view of someone who knows what they’re talking about. I guess my gripe is that the time-consuming and expensive training process isn’t able to reliably elevate a random young practitioner to the helpfulness level of “wise and patient professor who is offering their time to mentor and counsel even though it’s not in their job description”… but that is in fact a very high bar to hit.

It’s not surprising that some people are naturally good therapists just from a lifetime of observing people, and also not surprising that some of those people end up in teaching-focused academic jobs.

I guess you can train people to be empathetic if they’re motivated in the right ways but just lacking the skill. It makes sense that it’s a big part of counselor training.

"healthcare in general is full of phenomena that we'd rather not admit."

What kind of things are you talking about?

The obvious example would be the placebo effect. Drug/vaccine trials are the only area of science I can think of that are routinely held up as pinnacles of rationality, the outputs of which all Good Citizens must take on faith, and yet which attempt to control for some sort of paranormal force in which people can unconsciously fix their own bodies through psionic abilities.

This regularly happens and nobody seems the slightest bit curious about why. That is, when you think about it, totally mad. I'd suggest it's got to be either:

1. The only psychology mystery worth investigating, or

2. A sign that clinical trials are actually mostly junk science

Either would be hard to admit.

"some sort of paranormal force in which people can unconsciously fix their own bodies through psionic abilities."

I think you are being very dismissive there.

After all, the placebo effect happens in your body, which your mind inhabits. These are not two separate systems interacting by some magical means. This is one system with various subsystems that interact all the time.

Concrete mechanism of the placebo effect is still unknown, but the observation that your immune system can be influenced by your mental state isn't in itself magical. Our bodies respond to all sorts of mental states. We get red in face when embarassed, and sometimes must run to the toilet when scared etc.

All this "psionic" "paranormal" label stuff would only apply if someone could do it to other people without them even knowing.

Sure, but I think most people would place very hard limits on what you can do to just think yourself better. Your mind can't cure cancer, eliminate viruses, regrow arms etc. Yet we routinely design clinical trials as if it can. And ... nobody seems to think this is in any way strange!

Placebos have been studied. Most studies have found that, while placebos are effective for treating pain, they are mostly not effective outside of that, when compared to receiving no treatment at all.

Some people really do become spontaneously cured of diseases, yes - it happens all the time, and is something worth studying further. But the idea that the placebo effect is what causes it, is not really well-founded.

Clinical trials do use placebos all the time, even when studying things that don't involve pain.

Somewhat notoriously some trials give patients a placebo that's actually another drug, as otherwise people could unblind themselves by not suffering side effects. The COVID vaccine trials did this. It doesn't make sense if you think the placebo effect only influences perception of pain, as otherwise you could lose the placebo entirely and double your statistical power (compare against a synthetic control group).

As much as that’s an eye-catching headline, even the author admits it was a bad study that hasn’t been reproduced.

If the author told you their psychology study was reproducible, not dismissing it would be the other category of error.

Which I think is a critical aspect of the author's argument: the lack of replication.

There's a lot of factors at play. As I mentioned in my main comment, the study naturally has a metric fuckton of variables and noise which makes even basic experiments extremely difficult, but there are other factors like willingness to close that gap (is it surprising few want to climb a treacherous mountain?), as well as the whole structure of academia and the way metrics are formed. How do you create a foundation when you're not only not incentivized to replicate but actively dis-incentivized? How do you explore that mountain which certainly has many pitfalls and uncertain paths when you must publish frequently?

Those problems are not remotely isolated to psychology, but they have a huge and crazy difficult mountain to climb and should we be surprised that few try to climb it when attempting to do so is far more likely to lead to academic success rather than helping the field make their way up? Even if you don't fall off? It can take a long time to actually capitalize on those gains. I do think this is a conversation academia needs to have. Everything in place is logical and makes sense, they were done for good reasons, but I think we need to be honest that exploration is just a highly risky business. You'll never make it across the ocean, to the moon, or to other worlds if you are unwilling to lose a few people (researchers who never make any impact) or risk a have a few conmen (researchers who make shit up).Ironically, if you try too hard to prevent these from happening, you'll be doomed to only have them (you'll only explore just beyond the fence and you'll hear stories of what is imagined far beyond; either identical to just outside the fence or wild stories. But you'll never know until you go). We can inch our way out or we can be brave. I think unfortunately it is only explorers who can tell the brave from imaginative. It sucks, but is this not the nature of it? A story as old as stories are. But we wouldn't be where we are if we didn't engage in risky business.

It sounds to me like you are justifying a continuance of frauds that masquerade as scientific. The danger here is is not just direct effects but also what they displace. One can not actually do psychological studies beyond the test of chemical remedies anymore. The entire field is overrun with charlatans and 101 classes to make more of them because they will all be treated as valid enough to fund and they are all much more exciting than the scientific process.

Oh dear god no. You can check my comment history to see I rant about that frequently. I with in ML and dear god is there so much fraud.

What I arguing for is honesty. It's perfectly okay to do work where there's a high level of uncertainty *UNDER THE CONDITION THAT YOU ARE UPFRONT WITH THAT UNCERTAINTY.* Short of that is at best deceptive. I'll encourage you to look at my recent comment history because I've said a lot about that.

But what I'm trying to discuss in the previous comment is the systematic and structural components that encourage this deceptive and fraudulent behavior. Because if we don't recognize why it happens then we can't really solve it. Sure, we can hit a reset button and it'll go away, but it's we don't recognize the pressures that push the fields in these directions then it is just going to happen again.

The reason I'm arguing that we have to take risks is because many of these pressures are created by naive metrics that attempt to measure things that are not realistically measurable (so of course the metrics get hacked. It's literally Goodhart's law in action). But there are so many issues at play. The lack of incentivization of replication means few people earnestly read the works of others. It means science doesn't actually happen because the whole fucking point is replication. People aren't even reading the papers of their peers in their own departments! Literally the person in the office next to them!

The whole academic structure is screwy. You train someone for years to become an expert researcher (grad student) and then immediately put them in a manager role (professor)? The fuck were we doing that training for? I get managers, but with so many admins in universities why are professors doing less and less research? Advising grad students isn't research as every grad student will tell you their professor doesn't get details.

I could go on. But my point is the system is fucked up and overrun by bureaucrats who are risk adverse. They'd rather rely on metrics they are unwilling to understand than acknowledge that they live in a world that is fuzzy and chaotic. That kind of blindness is for religion and conspiracies, not science.

There was another research that indicated that the therapeutical framework that the therapist uses has no influence on the probability of postive outcome. What mattered more is whether a therapist was able to form a meaningful connection with a patient.

> professional training as a therapist does not produce a statistically significant improvement in ability to treat mental health conditions.

It produces a statistically significant improvement, just not with people who are already gifted at it. You can get not gifted people and teach them to be not worse than gifted. It is not much, but it is not nothing either.

It seems that gifted people with zero trainig are just as good in this activity as people with years of formal training on average who self-selected to undergo that training. I'm not sure if that's true of any other activity.

Where did it say the education was ineffective? There are reasons to believe it is not the only path to being effective at helping others, but that does not invalidate that if you spend a few years learning tools and techniques and pattern matching to behaviors, you have a valid toolkit in front of you for being a therapist.

Now, it is a valid argument whether or not it should be required (and there is no requirement to label yourself as a "coach"), and the price tag on it is of course always a consideration. But being dismissive of higher education is just as silly as being overly dependent on it.

Part of the problem is the therapists (and medical practitioners in general) are often forbidden from doing the thing they were trained to do for a variety of reasons: risk and liability, patient turnaround, standardization. These things can get in the way of doing the right thing in the times where that is known. That’s before considering the ambiguous cases.

Can you give some examples?

Want to prescribe medication because you think it is the best treatment -> insurance company says no

This happens literally millions of times per day.

Therapists do no prescribe medication, because they are not doctors. You need a psychiatrist or other doctor for that.

GP says “and medical practitioners in general.”

> often forbidden from doing the thing they were trained to do for a variety of reasons

you forgot to add `insurance company rules` to your list.

I think a lot of people just never find the right therapist and then assume all therapists are terrible.

It’s interesting because even the most staunch opponents of mental health talk therapy have people in their life they talk to, they just don’t consider them therapists.

But this begs the same question: if mental illness really is what psychologists say it is, and if treatment is a learnable skill, then the practitioner shouldn't matter that much assuming his training was good.

But most evidence suggests that some "je ne sais quoi" has to exist in the therapeutic relationship.

In other words, Freud was right about Transference as a necessary ingredient to psychotherapy (and probably about a lot else that is still too controversial to talk about or pass IRB muster).

Isn't the "je ne sais quoi" just feeling safe to be themselves and open? Whatever that means for each person

Well, sure, but "people in their life that they talk to" aren't really therapists. They're functioning quite differently - they can have a personal involvement that a therapist, ethically, isn't permitted to have. The sorts of things someone talks to with their friends overlaps with but is also often quite distinct from the sort of thing a therapist is probing for. There's no direct financial incentive to keep the "patient" coming. And they're making no claim to, broadly, help someone improve their overall mental health - people vent to their friends because it feels nice, not because it's necessarily constructive.

I promise you no therapist who is not engaging in illegal behavior cares about you coming back. This is pure delusion.

So the patient is holding the therapist wrong?

Although I agree it's a matter of finding the right therapist, I think that undersells the problem a fair bit.

There are large barriers to trialing a lot of therapists, and finding the right one can be like finding a needle in a haystack. Therapy is quite expensive, and many therapists already have a full caseload. And the pool of therapists is very homogeneous: essentially, a ton of well-off white women who might not have the tools or shared experiences to facilitate a helpful therapeutic alliance with individuals coming from a broader background than they're comfortable with.

In my experience, most staunch opponents of mental health talk therapy are people who have serious issues and really do not want them to be talked about and fixed. Issues like bad anger management when they want to keep the anger out of anger, eating disorder which makes you not want to heal, because you might get cured and fat.

There is such a thing as being unhappy about actual therapy that did nothing or harmed you. But you see the staunch opponents who never been at therapy and have only movie understanding of it having tons of strong opinions or fear.

"Just one more therapist bro" is what defenders of modern psychology use. It is always your fault the therapist didn't work out. Always your fault you aren't trying hard enough. There can never be systemic issues.

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