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PaperclipPerfector  10mo ago (text post)   26363 thread views

Culture War Roundup for the week of January 8, 2024

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I plan to become a psychiatrist, and I think therapy is overrated, at least when considering the vocal segment of the Overly Online who think everyone should be in therapy.

But it is possible to overhype something that is good for some people, some of the time, and the research I've read shows that therapy is pretty effective for many mental disorders, often being considered the first line intervention, such as for depression, anxiety, and so on.

And there are many different types of therapy, from the bullshit Freudian and Lacanian kind to the much better validated CBT. The thing is, even the shittiest forms of therapy that exist, such as the former two examples that are built off pure pseudoscience, work empirically, being better than placebo (or at least no therapy at all), though CBT is usually better. I wager much of the benefit in any of them is purely from the simulation of a helpful, non-judgemental "friend" who'll let you vent to your hearts content and won't tattle on the pain of their friend-card being retracted, and while you could substitute that for an actual friend, apparently those are getting harder to come by and have scheduling conflicts.

Besides, most reputable therapists (especially the ones who aren't into the Freudian crap) at least pay lip-service to the notion that their clients should always be temporary, and that they should be directed elsewhere if several sessions show no benefit. And if the client is showing up to sessions after they're satisfied it's not working, then I lay the blame for their stupidity on them. If they still want to go, well apparently they're getting their money's worth somehow. People go for haircuts and manicures even when the damn keratin just keeps growing back, and barbers aren't a scam.

Don't discount the value of "Freudian" psychotherapy. Part of this is driven by the usual "all the good ideas associated with this have been stolen and become core tenants of the successors" bit. You'd be surprised how much of his stuff is still present and useful.

The other piece is that the "true successor" actually works great. Psychodynamic psychotherapy is probably the most direct on that front, and if you talk to someone who knows CBT, DBT, and Psychodynamic therapy well they'll point out it is mostly all the same shit just with different words for the same concepts.*

The thing CBT primarily does differently is that it attempts to operationalize things by adding in components of homework, written self reflection and so on, but the fundamental insights are essentially the same.

It's tempting to think they are "different classes" but it's more like going to a calculus lecture, and then doing another course with the same content but you get problem sets afterwards.

There are purists out there, especially in Europe but generally people just roll their eyes at them.

Care to share those studies? How many of them are longitudinal?

I originally read that on the Wikipedia page, and when I tried to hunt down the citations, linkrot has eaten the Google Books excerpt that was supposedly cited, at least the one supposedly claiming that metanalysis showed they were all equivalent. However, after some hunting, I did find that claim in a different, well cited meta analysis down below.

https://en.wikipedia.org/wiki/Psychotherapy

Large-scale international reviews of scientific studies have concluded that psychotherapy is effective for numerous conditions.[8][22]

One line of research consistently finds that supposedly different forms of psychotherapy show similar effectiveness. According to The Handbook of Counseling Psychology: "Meta-analyses of psychotherapy studies have consistently demonstrated that there are no substantial differences in outcomes among treatments". The handbook states that there is "little evidence to suggest that any one psychological therapy consistently outperforms any other for any specific psychological disorders. This is sometimes called the Dodo bird verdict after a scene/section in Alice in Wonderland where every competitor in a race was called a winner and is given prizes".[151]

Further analyses seek to identify the factors that the psychotherapies have in common that seem to account for this, known as common factors theory; for example the quality of the therapeutic relationship, interpretation of problem, and the confrontation of painful emotions.[152][153][page needed][154][155]

Outcome studies have been critiqued for being too removed from real-world practice in that they use carefully selected therapists who have been extensively trained and monitored, and patients who may be non-representative of typical patients by virtue of strict inclusionary/exclusionary criteria. Such concerns impact the replication of research results and the ability to generalize from them to practicing therapists.[153][156]

However, specific therapies have been tested for use with specific disorders,[157] and regulatory organizations in both the UK and US make recommendations for different conditions.[158][159][160]

The Helsinki Psychotherapy Study was one of several large long-term clinical trials of psychotherapies that have taken place. Anxious and depressed patients in two short-term therapies (solution-focused and brief psychodynamic) improved faster, but five years long-term psychotherapy and psychoanalysis gave greater benefits. Several patient and therapist factors appear to predict suitability for different psychotherapies.[161]

Meta-analyses have established that cognitive behavioural therapy (CBT) and psychodynamic psychotherapy are equally effective in treating depression.[162]

The bolded section is the one I can't easily verify, at least not when it's 9 am and I've been up all night studying.

Specifically regarding CBT, I found the following metanalysis-

https://pubmed.ncbi.nlm.nih.gov/23870719/

Results: A total of 115 studies met inclusion criteria. The mean effect size (ES) of 94 comparisons from 75 studies of CBT and control groups was Hedges g = 0.71 (95% CI 0.62 to 0.79), which corresponds with a number needed to treat of 2.6. However, this may be an overestimation of the true ES as we found strong indications for publication bias (ES after adjustment for bias was g = 0.53), and because the ES of higher-quality studies was significantly lower (g = 0.53) than for lower-quality studies (g = 0.90). The difference between high- and low-quality studies remained significant after adjustment for other study characteristics in a multivariate meta-regression analysis. We did not find any indication that CBT was more or less effective than other psychotherapies or pharmacotherapy. Combined treatment was significantly more effective than pharmacotherapy alone (g = 0.49).

Conclusions: There is no doubt that CBT is an effective treatment for adult depression, although the effects may have been overestimated until now. CBT is also the most studied psychotherapy for depression, and thus has the greatest weight of evidence. However, other treatments approach its overall efficacy.

And when speaking of CBT as applied to more psychiatric conditions:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/

We identified 269 meta-analytic studies and reviewed of those a representative sample of 106 meta-analyses examining CBT for the following problems: substance use disorder, schizophrenia and other psychotic disorders, depression and dysthymia, bipolar disorder, anxiety disorders, somatoform disorders, eating disorders, insomnia, personality disorders, anger and aggression, criminal behaviors, general stress, distress due to general medical conditions, chronic pain and fatigue, distress related to pregnancy complications and female hormonal conditions. Additional meta-analytic reviews examined the efficacy of CBT for various problems in children and elderly adults. The strongest support exists for CBT of anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. Eleven studies compared response rates between CBT and other treatments or control conditions. CBT showed higher response rates than the comparison conditions in 7 of these reviews and only one review reported that CBT had lower response rates than comparison treatments. In general, the evidence-base of CBT is very strong. However, additional research is needed to examine the efficacy of CBT for randomized-controlled studies. Moreover, except for children and elderly populations, no meta-analytic studies of CBT have been reported on specific subgroups, such as ethnic minorities and low income samples.

Addressing the specific claims of similar efficacy to the forms of therapy based on pseudoscientific principles:

CBT for depression was more effective than control conditions such as waiting list or no treatment, with a medium effect size (van Straten, Geraedts, Verdonck-de Leeuw, Andersson, & Cuijpers, 2010; Beltman, Oude Voshaar, & Speckens, 2010). However, studies that compared CBT to other active treatments, such as psychodynamic treatment, problem-solving therapy, and interpersonal psychotherapy, found mixed results. Specifically, meta-analyses found CBT to be equally effective in comparison to other psychological treatments (e.g., Beltman, Oude Voshaar, & Speckens, 2010; Cuijpers, Smit, Bohlmeijer, Hollon, & Andersson, 2010; Pfeiffer, Heisler, Piette, Rogers, & Valenstein, 2011). Other studies, however, found favorable results for CBT (e.g. Di Giulio, 2010; Jorm, Morgan, & Hetrick, 2008; Tolin, 2010). For example, Jorm and colleagues (2008) found CBT to be superior to relaxation techniques at post-treatment. Additionally, Tolin (2010) showed CBT to be superior to psychodynamic therapy at both post-treatment and at six months follow-up, although this occurred when depression and anxiety symptoms were examined together.

Compared to pharmacological approaches, CBT and medication treatments had similar effects on chronic depressive symptoms, with effect sizes in the medium-large range (Vos, Haby, Barendregt, Kruijshaar, Corry, & Andrews, 2004). Other studies indicated that pharmacotherapy could be a useful addition to CBT; specifically, combination therapy of CBT with pharmacotherapy was more effective in comparison to CBT alone (Chan, 2006).

Anyway, therapy seems to beat placebo, and works synergistically with drugs, even if you cynically notice that therapy based off nonsense does much the same thing as more considered approaches, but it's not in dispute that it works. At least I have the consolation of being able to throw drugs at people instead of just talking at them if/when I'm a licensed shrink, for all the quibbling about if SSRIs work, ain't nobody claiming their ADHD isn't being helped when they're zooted up on stimulants.

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