Bad Psychology I : Depth Psychotherapy

[Dancing David]

Bad psychology; hopefully the first of many threads about what makes for bad psychology and to educate people about psychology. (And what makes for good psychology.)

I have a real bias against almost all psychodynamic or psychotherapeutic approaches. I was schooled at a behavioral school and in my fifteen years as a social worker I worked mainly from a behavioral and resource based model. I especially have a problem with the existential models of counseling;

Which led me here and to this concept: Depth Psychotherapy.
http://www.existential-therapy.com/DepthPsychotherapy.htm

The field of psychotherapy today is involved in a large debate over which approach to therapy is best. The most heated of these debates is between the solution-focused therapies and the depth psychotherapies. This debate is problematic in many ways. While there is reason to be concerned about some approaches to therapy (i.e., rebirthing therapy), most approaches are valuable . Oftentimes, different approaches to therapy reflect different values about what life outcomes people desire. While most therapies share some values on therapeutic outcomes (e.g., decreased problematic symptoms, increased life satisfaction), what is meant by these outcomes differs.

The diverse therapy approaches also attain some different outcomes. For example, the various depth psychotherapies value self-awareness much more than the solution-focused psychotherapies. While both approaches may decrease depression, they will achieve this differently which will bring different byproducts. An important and highly valued byproduct for the depth psychotherapies is an increased self-awareness.

This gets me to my bias in schooling and training:
1. All treatments should be goal oriented.
2. All treatments should have a measured metric for gauging success.
3. All treatments should be time limited and short term. (twelve weeks.)

I dislike the idea of someone paying for treatment when they are getting spiritual counseling. It is unethical to charge someone a huge amount for
-no outcome with benefit
-no measured success in symptom reduction
-no exit strategy
Long term treatment is bogus, all treatment should be short term and goal focused. It is unethical to charge someone for no measured benefit. And it is even worse to tell them they must wait years for that benefit, if it ever comes.
If someone has multiple issues then they should each be addressed in a twelve week time frame in succession.

More after comments, there are many straw men in the above quotation.

 

[drkitten]

This gets me to my bias in schooling and training:
1. All treatments should be goal oriented.
2. All treatments should have a measured metric for gauging success.
3. All treatments should be time limited and short term. (twelve weeks.)

I'm afraid that that eliminates much of modern medicine, especially the third. I know a number of diabetics, for example, who are on insulin. I know a number of asthma sufferers who are on Advair. I know a few people who are on various mood-alteration drugs such as anti-depressants. I know a number of cardiac patients who are on a veritable pharmacopia.

And I know a number of people who have been on diet/exercise programs for years.

I don't know any transplant patients (that I know of, anyway), but my understanding is that they tend to be on a fairly hefty regimen of anti-rejection drugs.

All of these people can reasonably expect to be on these drugs for the remainder of their lives.

Should we abandon kidney transplants because patients are still on drugs after twelve weeks? Should we instead perform dialysis for twelve weeks, and then send them home to die?

 

[aggle-rithm]

One of the biggest myths that persists in psychotherapy -- one that I bought into hook, line and sinker for many years -- is that insight leads to salvation. As soon as you realize the root cause of your overeating, for instance, you will no longer have any need to overeat.

The genius is that, if you continue to overeat after discovering the root cause, then you obviously haven't discovered the REAL root cause...

 

[Hound01]

This gets me to my bias in schooling and training:
1. All treatments should be goal oriented.
2. All treatments should have a measured metric for gauging success.
3. All treatments should be time limited and short term. (twelve weeks.)

1. Agreed. If there is no goal you can just meander all over the place.
2. Agreed. Isn't this the same as 1. above?
3. Good idea and I feel inclined to agree but what about if, despite your best efforts, you haven't reached your goal in 12 weeks?

 

[Uncayimmy]

One of the biggest myths that persists in psychotherapy -- one that I bought into hook, line and sinker for many years -- is that insight leads to salvation. As soon as you realize the root cause of your overeating, for instance, you will no longer have any need to overeat.

Where exactly would one find that myth? Doctors? Patients? Both? I always understood it to be that once you find the root cause of a behavior, you can address it. For example, "The reason I want to eat is that I feel belittled by my spouse, which reminds me of my childhood when my father would be belittle me and my mother would give me a snack to cheer me up. Therefore, rather than feed my body I will try something else to improve my emotional state."

I've seen first-hand people use the root cause as an excuse, but I have not encountered anyone who was surprised that discovering the root cause didn't cure them.

 

[Uncayimmy]

I'm afraid that that eliminates much of modern medicine, especially the third. I know a number of diabetics, for example, who are on insulin. I know a number of asthma sufferers who are on Advair. I know a few people who are on various mood-alteration drugs such as anti-depressants. I know a number of cardiac patients who are on a veritable pharmacopia.

The time limit I can see, but how do those things lack goals or metrics?

 

[aggle-rithm]

Where exactly would one find that myth? Doctors? Patients? Both?

Mostly, pop psychology and popular culture.

For instance, there was a MASH episode where Hawkeye began suffering from an extreme allergic reaction. Somehow, they were able to determine that his problem was psychological, and got the shrink to talk to him. As soon as he realized that his allergic reaction was caused by his conflicted feelings over a childhood incident, the problem miraculously went away.

This was just one example, and I think accurately reflected what the general public expected of psychiatry at the time.

 

[Dancing David]

Hi Dr. K, this is in specific reference to psychology and counseling/therapy.

I am myself someone who has taken antidepressants for a very long time, blood pressure medications less so, I am talking about psychodynamic counseling here.

I did not think I needed to make a caveat.

What do you think about talk therapy that is not time limited and goal focused?

I'm afraid that that eliminates much of modern medicine, especially the third. I know a number of diabetics, for example, who are on insulin. I know a number of asthma sufferers who are on Advair. I know a few people who are on various mood-alteration drugs such as anti-depressants. I know a number of cardiac patients who are on a veritable pharmacopia.

And I know a number of people who have been on diet/exercise programs for years.

I don't know any transplant patients (that I know of, anyway), but my understanding is that they tend to be on a fairly hefty regimen of anti-rejection drugs.

All of these people can reasonably expect to be on these drugs for the remainder of their lives.

Should we abandon kidney transplants because patients are still on drugs after twelve weeks? Should we instead perform dialysis for twelve weeks, and then send them home to die?

Do you really thaink that modern medicine is part or existentialism, jungian. fruedian, gesalt or 'depth psychotherapy'?

 

[Dancing David]

One of the biggest myths that persists in psychotherapy -- one that I bought into hook, line and sinker for many years -- is that insight leads to salvation. As soon as you realize the root cause of your overeating, for instance, you will no longer have any need to overeat.

The genius is that, if you continue to overeat after discovering the root cause, then you obviously haven't discovered the REAL root cause...

Well, I would also argue that CBT is based upon insight into the here and now.

 

[Dancing David]

1. Agreed. If there is no goal you can just meander all over the place.
2. Agreed. Isn't this the same as 1. above?

Nope , unfortunately you can have a goal of symtom reduction with using a metric to measure it.

3. Good idea and I feel inclined to agree but what about if, despite your best efforts, you haven't reached your goal in 12 weeks?

This is a crucial part of the CBT model, if you are not getting improvement in symptoms within a shorter time period (like by week three) then the goals and treatment need to be adjusted. In this case I think that either an examination of life stressors or psychiatry would usually be warranted.

Adjustment of the goals and treatment is crucial, desensitization often involves a step back from the goal state to allow the client to find an area where they can have symptom reduction.

Sometimes you have to work on getting to the car in the parking lot before you can get to driving it somewhere.

 

[Dancing David]

Where exactly would one find that myth? Doctors? Patients? Both? I always understood it to be that once you find the root cause of a behavior, you can address it. For example, "The reason I want to eat is that I feel belittled by my spouse, which reminds me of my childhood when my father would be belittle me and my mother would give me a snack to cheer me up. Therefore, rather than feed my body I will try something else to improve my emotional state."

I've seen first-hand people use the root cause as an excuse, but I have not encountered anyone who was surprised that discovering the root cause didn't cure them.

The problem is that in these 'depth therapies' there is an assumption that you have to know the 'causes' to make an effect.So the clients is assumed to have to spend years getting to tehse issues.

Considering the amount of trauma based anxiety and depression, I think it is a mistake to re-traumatise people and pretend that it will help them.

Seriously, if you read current existential, freudian models, they really do not like the idea of treating the symptoms through behavioral strategies.

 

[drkitten]

What do you think about talk therapy that is not time limited and goal focused?

I think it's a strawman that you've created.

It's fairly common, for example, for a person to see a psychologist/psychiatrist with symptoms of depression and to be prescribed a series of antidepressants. Sometimes they work, sometimes they don't. There's enough variability in individual responses to any particular drug that you can't impose a time limitation on a course of drugs, or even measure whether or not they're working at intermittent stages. It's fairly common to see the patient not respond at all for "a long time" and then suddenly report feeling better. It's also fairly common for the patient not to respond at all and the psychiatrist needs to try a different drug, different dosage, or different regime.

In other words,
* You only know in extremely vague terms (patient self-report) what needs to be done, so there's no "goal" beyond "help the patient."
* You don't know whether or not the patient will respond at all to any particular sort of treatment
* You don't know at what time course the patient will respond if he responds at all.
* It's not possible to measure whether or not the patient is "improving"; they either self-report feeling better (in which case you're done), or they don't.

But that's exactly what you're criticizing talk therapists for. You're setting a bar that Prozac can't meet.

 

[porch]

* It's not possible to measure whether or not the patient is "improving"; they either self-report feeling better (in which case you're done), or they don't.

I think, and I hope, that most behaviorist therapists would ask their clients for more detailed self reporting than just "How are you feeling?". For example, someone with severe depression may have spent every weekend for the past year hiding inside their apartment doing nothing. If they've been seeing a therapist for three weeks, they may report that they don't feel any better. At the same time, if they report that last Saturday they went out for a coffee with a coworker, and that Sunday they went to a ball game, I'd consider those reports indicative of some success.

 

[drkitten]

I think, and I hope, that most behaviorist therapists would ask their clients for more detailed self reporting than just "How are you feeling?". For example, someone with severe depression may have spent every weekend for the past year hiding inside their apartment doing nothing. If they've been seeing a therapist for three weeks, they may report that they don't feel any better. At the same time, if they report that last Saturday they went out for a coffee with a coworker, and that Sunday they went to a ball game, I'd consider those reports indicative of some success.

Yes, but the problem is that if the patient reports no improvement, that doesn't mean that the patient isn't improving. This is true whether we're talking about "talk therapy," behavior therapy, or Prozac. So there aren't any useful metrics, because "zero" doesn't mean "zero."

 

[Dancing David]

I think it's a strawman that you've created.

It's fairly common, for example, for a person to see a psychologist/psychiatrist with symptoms of depression and to be prescribed a series of antidepressants. Sometimes they work, sometimes they don't.

You may find we are in total agreement.

There's enough variability in individual responses to any particular drug that you can't impose a time limitation on a course of drugs, or even measure whether or not they're working at intermittent stages. It's fairly common to see the patient not respond at all for "a long time" and then suddenly report feeling better. It's also fairly common for the patient not to respond at all and the psychiatrist needs to try a different drug, different dosage, or different regime.

In other words,
* You only know in extremely vague terms (patient self-report) what needs to be done, so there's no "goal" beyond "help the patient."
* You don't know whether or not the patient will respond at all to any particular sort of treatment
* You don't know at what time course the patient will respond if he responds at all.
* It's not possible to measure whether or not the patient is "improving"; they either self-report feeling better (in which case you're done), or they don't.

But that's exactly what you're criticizing talk therapists for. You're setting a bar that Prozac can't meet.

Hmm, I will have to consider my response carefully as I do not want to shoot from the lip.

I am first off limiting what I am saying to talk therapy, not to medication management. That is another issue. I am not a doctor although I have worked with many psychiatrists that I have respected and only a very small number that I haven't.

I think that the paradigm for talk therapy is very different from the paradigm for diagnosis and prescription of medication. We may disagree upon that. Before I go through each point there are some ideas that bias my thinking;

-the theory behind talk therapy is crucial, theories like Freud's, Jung's and other abstracted psychodynamic models is very vague and abstracted with little if any research basis. Behavioral interventions on the other hand are based in a very well grounded theory and have a somewhat stronger research basis, exposure based panic as a result of trauma or entrainment is much more established than the 'id' or 'penis envy'.


-the model or theory makes a huge difference in the intake/assessment phase. In a behavioral, life skills or resource model, the interview will be structured and specific areas will be targeted and explored. Goals may or may not be set at the intake time, however clear areas to examine will be delineated.

Now to the specific point which I think we will actually agree upon.

First off medication prescription and management is a very different beast than talk therapy, although the best results come from the two in combination. So some of the issues with medication response are very different from talk therapy. In that stabilization of a medical situation is crucial in one and the framework for talk therapy may be related to reality, or it may not.

To the specifics:

You only know in extremely vague terms (patient self-report) what needs to be done, so there's no "goal" beyond "help the patient."

I am certain that your assessment and diagnosis is more specific then that when you are dealing with patients. I have no need to elaborate on that.

A structured interview, of which there are many is crucial is counseling assessment, and it must be focused by the theory of intervention. So there is the general information gathering and demographics, then there is the symptom profile and life skills portions. In behavioral terms the assessment will immediately begin to focus on where the symptoms are highest and life functioning is impeded. This is not true in any of the more abstracted models, they believe that the client must wallow through and unstructured morass.
In the second meeting is when the client will begin to identify which symptoms they want to address or which area of life functioning they want to improve. Then the precursors, antecedents and responses and choices are enumerated. A metric is established and the baseline begins.
Say the individual has anxiety about work, the specific antecedents , precursors and responses are evaluated. Measurement of anxiety will begin. Strategies to decouple or desensitize the client are implemented.

This is preferred by me to some exploration of childhood and examination of relations with authority figures.

I believe it is the goal of good talk therapy to identify ASAP what the goal state is and how the steps will be made to get there. Just as when you as a doctor identify diabetes, you begin to look at what changes will impact the condition. You will not examine what happened when there mother was baking, but what they are eating now and what behaviors they have now.

You don't know whether or not the patient will respond at all to any particular sort of treatment

that is the beauty of a behavioral model. You do know that you will impact what the client can change. If they need to desensitize to a trigger, then that is where you start. You do not need to examine what their father did when they beat them up or why. You need to help this person avoid PTSD in response to male figures. If you need to help them decouple generalization to all male figures you will do that as the course progresses.

But part of the assessment is that the client has identified exactly what they want to change, and the behavioral model will work. Not in the presence of flaming biological symptoms that interfere, so medical treatment may have to start first.

You don't know at what time course the patient will respond if he responds at all.

Not in behavioral interventions, you should be begin to see change within a very short time period, now some goals are more complex than others and may require a great deal of reassessment and goal modification.

But if you have what is termed a sleep hygiene problem, then behavioral interventions should have an impact with a very short term.

It's not possible to measure whether or not the patient is "improving"; they either self-report feeling better (in which case you're done), or they don't

I am sure your are not so vague in your own practice.

If the client reports that they have panic attacks in response to seeing a cat, then that is a measurable metric.

You can set an observation at half hour intervals to asses something like “depressed moods and current thoughts”, scales can be devised and customized, the goal is to decouple the thoughts and feelings and change the behavioral patterns.

Or you can set easier behavioral metrics such as “combing hair in morning’, ‘changing clothes’ and ‘walking to the corner’.

Symptoms are not usually that vague, if I have to wash my hands every five minutes, I can sure measure that.

Now this is all very different from the more psychotherapy approach, where it is assumed you will spend three to five years before any effective change occurs.

Now I am talking about medium to low levels of symptomology, in say people who are living with borderline behaviors even a strict behavioral model can take years to have a sustained effect, but in DBT changes will start to occur with the first month of intervention.

 

[Dancing David]

Yes, but the problem is that if the patient reports no improvement, that doesn't mean that the patient isn't improving. This is true whether we're talking about "talk therapy," behavior therapy, or Prozac. So there aren't any useful metrics, because "zero" doesn't mean "zero."

There are useful metrics and they are set as part of the process, the problem with Talking to Prozac, is that is uses the BDI (Beck Depression Inventory) as a tool for judging response to treatment. A life quality scale and specific symptom scales will give a better measure. The BDI is useful for determining if depression exists, however it is a terrible tool for judging response to treatment. There is no scaling for frequency that would determine a response to treatment. If I have suicidal ideation once a day or thirty times a day, it will score roughly the same. So it is better to set a metric which measures frequency of suicidal ideation throughout the day and see how that changes, than to just ask "Did you have suicidal ideation today."

Now granted with a receptor turn over of six weeks response to medical treatment will be different.

Talk therapy is worthless other than supportive in the presence of florid symptoms.

CBT is shown to be effective as a sole treatment only in the mild to moderate level of symptoms.

And in moderate to severe symptoms dual treatement is most effective.

 

[drkitten]

Now I am talking about medium to low levels of symptomology, in say people who are living with borderline behaviors even a strict behavioral model can take years to have a sustained effect,

I think this proves the point I was making, frankly.

You're holding talk therapy to a higher standard than you hold any other form of medicine, and complaining that it doesn't meet that standard.

If you're saying that in some cases, behavior therapy is more effective than talk therapy, we're in agreement. If you're saying that talk therapy is largely useless, we're still in agreement. But you don't need to make this elaborate setup about 'oh, it takes longer than twelve weeks to work' or 'oh, some cases don't have metrics' when those exact same complains are often true throughout medicine.

Do not worry about the mote in your fellow med-student's eye when you've got a huge beam in your own and all that. The reason talk therapy doesn't work isn't because it takes more than twelve weeks to get results. The reason talk therapy doesn't work is because it tends not to work at all, no matter how long you have.

 

[Dancing David]

I think this proves the point I was making, frankly.

You're holding talk therapy to a higher standard than you hold any other form of medicine, and complaining that it doesn't meet that standard.

Talk therapy is not medicine. And when I said sustained effect I mean a global improvement in functioning and a lack of peri-suicidal behavior. In DBT the goals are met in the same sort of time frame, there are just multiple ones.

When did talk therapy become medicine? It is not , in most cases the 'therapist' is not an MD or even a PHD.

If you're saying that in some cases, behavior therapy is more effective than talk therapy, we're in agreement.

CBT is talk therapy.

If you're saying that talk therapy is largely useless, we're still in agreement.

I do not say all talk therapy is useless, I am saying that just about any model that is not based in CBT is useless. CBT is talk therapy.

But you don't need to make this elaborate setup about 'oh, it takes longer than twelve weeks to work' or 'oh, some cases don't have metrics' when those exact same complains are often true throughout medicine.

It only takes longer in situation where there are going to be multiple successive or concurrent goals. As in DBT, concurrently you will start with reduction of peri-suicidal acting out, monitoring of symptoms and reduction to abstinence from substance abuse. There are also likely to be medication monitoring goals and resource goals.

Then as those are met, the metrics are changed, the bar is raised or new goals are developed.

I do think you may not understand the model. You work on successive and co-current goals, each with a twelve week time frame. Each step is limited but the whole process is going to be longer than twelve weeks.

But my point is that in fruedian, jungian, gestalt and existential therapy, there are no goals, there are no metrics, and not making any progress towards higher functioning is considered part of the process.

Do not worry about the mote in your fellow med-student's eye when you've got a huge beam in your own and all that.

I have to ask, where are you from? What makes you have any idea that most psychology/therapy/counseling and talk therapy is practiced by doctors or med-students?

Where I am in Illinois and in most states of the US, the vast majority of talk therapy is dome by people who might have a bachelor's or master's degree at most. there are some with clinical degrees or education degrees and the like that are licensed to practice counseling or talk therapy. I was a case manager and able to do ‘counseling’ as an MHP (Mental Health Professional) under the supervision of a QMHP (Qualified MHP). I have a bachelor’s degree. In DV counseling you just need to take a 40 hour training and you can counsel people.

But most is not done by MDs or PhDs.

The reason talk therapy doesn't work isn't because it takes more than twelve weeks to get results.

I have research to back my claims, what data do you have? My claim is that CBT is effective, it uses concrete goals, metrics and short time frames.

The reason talk therapy doesn't work is because it tends not to work at all, no matter how long you have.

That is strange, you do not know what you are talking about CBT is talk therapy. Behavioral interventions are based in talk therapy. Behavioral therapy/counseling is talk therapy/counseling. In fact in some cases people who call themselves gestalt or existential will practice CBT but call it the flavor that they prefer. They still use behavioral interventions.

May I ask where you live and why you think these things? My point is in direct opposite to yours, CBT is talk therapy/counseling. It is very effective and it happens in short term frames.

Please do not lump the mumbo-jumbo therapy in with CBT.