Different methods of therapy appear to be equally effective despite having theoretical foundations which are conflicting with each other. The common aspect between different therapies seems to be "having someone to talk to", so I'm inclined to believe that really is what's behind the success.
> Different methods of therapy appear to be equally effective despite having theoretical foundations which are conflicting with each other. The common aspect between different therapies seems to be "having someone to talk to", so I'm inclined to believe that really is what's behind the success.
Just because talking is the common trait, doesn't mean that that's evidence that that is all it is. Paying someone to help you with the problem is also a common trait (and ironically, that is, no doubt, a contributory factor), but that isn't all that therapy is.
Let's say that there are three ways to solve a problem, and depending on context that we're not terribly good at determining, one of those ways will work quite often, one will work some of the time, and the other will be a disaster... but there's an equal probability that each of those ways are equally likely to fall in to each of those categories. Statistically, one could claim that how you solve the problem is not behind the success. In a sense, that would be correct, because the real determinant of success would be being lucky with the solution you chose to employ. While one could imply though that really it's nothing more than being lucky at choosing the solution, in reality without all of what's involved in that choice, the problem will remain.
There may be a kernel of truth in this, but it depends on why you're seeing a therapist. For treatment of OCD, for example, or phobias, there are specific protocols that yield results, but they do not respond to just "having someone to talk to."
Other kinds of conditions, like depression and anxiety, respond to a wider range of therapy styles. But those aren't the only conditions that people seek to treat through talk therapy. (And it's also an exaggeration to say that just having any conversation will help to treat anxiety and reopression. But it is probably true that treatment of these conditions is less technical and responds to a much wider range of styles.)
> Different methods of therapy appear to be equally effective despite having theoretical foundations which are conflicting with each other. The common aspect between different therapies seems to be "having someone to talk to", so I'm inclined to believe that really is what's behind the success.
This isn't true. Different methods work better for different problems. I've been in behavior health for 7 years now. It's having someone with a lot of education to talk to, someone with education in social and psychological problems and healthy coping mechanisms.
From what I understand, therapy success rates are quite low, with only cognitive behavior therapy showing notable progress. That isn't to say all the others are categorically useless, only that in the majority of cases, they seem to be ineffective or harmful.
They don't attempt to measure it, but they do teach approaches like "unconditional positive regard" and other techniques that allow a practitioner to demonstrate (or at least seem to demonstrate) a higher level of emotional intelligence.
A big part of therapy is also rapport. Many people go through many therapist before finding one that works for them. In part, you can think of this as the market performing the assessment your'e referring to.
They don’t attempt to measure it because it not something that’s even properly defined with any rigour. Any person who seriously uses the phrase is going to have their own completely individual idea of what it means, and there’s no reason the think any therapist would have this nebulous quality, or even that their idea of what it means has any similarity to your idea of what it means.
I suppose I agree — "emotional intelligence" is probably not the word I would have used, writing on a blank slate. I think the idea is better captured in the concept of rapport, which is really just a function of clients' subjective experience working with a given therapist. A therapist can learn techniques to increase the chances of establishing a good rapport with a given client, but I'd be inclined to leave it at that.
I'm implying that data shows that efficacy of therapy depends on concrete factors (~5 of them discussed in the video). it's not "just someone to talk to".
This is very true, and I would add to it that the dominant paradigm in most therapy these days (at least those forms coming from a Cognitive Behavioural Therapy background) have "graduation" as an explicit goal: the client feels like they've addressed what they want to address and no longer need the ongoing relationship.
This is largely due to a crisis in the field in the late 70s/early 80s when several studies demonstrated that talk therapy had outcomes no different than no therapy. In both cases, some got better, some got worse, some didn't change. CBT was a direct result of that, prioritizing and tracking positive outcomes, and from CBT came a lot of different approaches, all similarly focussed on being demonstrably effective.
Talk therapy isn't a cure-all, but it's definitely more results-oriented than it was 50 years ago.
I think the preying part of therapy is that there's just no defined stop condition. There's no such thing as "healthy" in mental health. You get chemo until you go into remission or you die. You take blood pressure meds until you have a better lifestyle and body composition and don't need them anymore, etc. There's no analogue for "you're healthy now, go away so I can help others", and so therapy goes on forever until the patient stops for whatever reason.
> I think the preying part of therapy is that there's just no defined stop condition.
There's no defined stop point for physical development either... Top performing athletes still have trainers, and nobody sees that as a problem. If it's mental development though, it must have a stop point?
Top performing athletes are better than me at being athletes.
Meanwhile, the more therapy someone does, the more miserable they are compared to me. I’m the Usain Bolt of mental health compared to them. Makes me think their trainer is an idiot.
> Meanwhile, the more therapy someone does, the more miserable they are compared to me.
Is this based on empirical statistical analysis, or are you maybe projecting your perception on to anecdotes? How are you quantifying misery? What are the units? Are there people that are less miserable than you? Do you know how much therapy they've done, or if they've done therapy at all?
> I’m the Usain Bolt of mental health compared to them. Makes me think their trainer is an idiot.
There's a lot of people that think they're Usain Bolt. Most of them are not.
I suppose we’ll see in the next twenty years. I rate my chances and I don’t rate those of the chronically therapized. But hey, let the chips fall where they may.
The stop point is obvious to the individual and the therapist. I'm dealing with someone that prefers to stop rather than actually self-reflection.
There is nothing stopping them from exiting therapy. The therapist may be aware that the person is still a basket case but if they are non-violent they are free to roam.
> The stop point is obvious to the individual and the therapist.
It's not at all. There are plenty of stories of people who realized that therapy was just causing them to ruminate on their problems, and that the therapist was just milking them for years before they wised up and walked away. That's not what I call "obvious".
> What a ridiculous analogy. "Athlete" is a career.
The athlete is the extreme example, but there are obviously people who are not career athletes that don't have a defined stop point with employing a trainer (maybe you could say "death" is the stop point).
Most everyone who goes to spinning class isn't a career athlete. Some of them are terribly out of shape, and some of those people just want to get in shape. Others may already be in shape, but see the spinning class as a way to either improve or maintain their conditioning. None of this is deemed ridiculous.
I'm curious, it's considered the norm to regularly see a doctor or dentist, do you think they're preying on their patients?
> What is being developed, exactly?
Mental health. There's obviously a more involved answer, but if you don't know it already, it's unlikely I'll be able to educate you with a comment on social media.
> but there are obviously people who are not career athletes that don't have a defined stop point with employing a trainer
And many of them are being bilked as well. The fitness industry is notoriously filled with hucksters and scams, and "trainers" rarely have any real training in kinesiology or exercise science.
> I'm curious, it's considered the norm to regularly see a doctor or dentist, do you think they're preying on their patients?
Once a year for a health checkup. Is that the norm for therapy?
> Mental health. There's obviously a more involved answer
The more involved answer is that "mental health" is not well-defined, so it's not developing anything. The only therapies that have shown to have any empirical validity, like CBT, train the user in tools to change their own behaviour and thinking, then it's on the user to employ the tools. Does a family doctor call you in once a week and watch you take the pills that address your physical ailment?
The best analogy for psychiatric therapy is physical therapy for recovering from an injury or surgery, except physical therapy has a well-defined end condition, which is when you understand how to do the exercises yourself. Then it's on you to do them. This is just not the norm for "mental health" therapy.
Nail on the head, thanks. I'm deeply uncomfortable with anything that combines paying for a service with a social element. Feels like an unstable equilibrium.
I guess the skill is riding the line, but that doesn't feel very enjoyable.
> And many of them are being bilked as well. The fitness industry is notoriously filled with hucksters and scams, and "trainers" rarely have any real training in kinesiology or exercise science.
Many people are being bilked for almost any service one might name. There are tons of products and services with no defined stop point (heck, pretty much the entire CPG category is for products and services with no defined stop point). There are tons of products & services where the vast majority of customers are unable to discern if they are being scammed or not. Heck, when you order sushi there's notoriously a far from trivial chance that you're not getting the fish that you thought you were getting. We don't think of restaurateurs as being hucksters and scam artists (some no doubt are, but it's ridiculous to paint them all with the same brush).
My point isn't that it's impossible that they are being bilked. It's that there are all kinds of products & services that people get with no defined stop point, where customers could unknowingly be scammed, but we don't consider that to be evidence that they are being bilked. There are products and services that are beneficial for the customer even if there is no defined problem and no defined end point.
For your typical customer, spinning class isn't a class you go to until you achieve some goal. It's a service provided to help you do exercise you no doubt wanted to do anyway, in a community/context that you wanted to do it in, with the guidance of someone who ostensibly knows how to structure the process better than you do. You could very well do the spinning all by yourself, or you could organize a spinning class on your own, but you pay the professional because you expect to get better results without expending as much time or energy yourself.
Sure, there are people who claim that, if you just take the spin class, you will lose 100 lbs or become an Olympic athlete, and those people are absolutely hucksters and scam artists. There are people that will tell you that voting for the right/wrong politician will change your life (either for the better or worse). There are people who will tell you that buying gold will ensure financial security and make you a fortune. There are scams about buying jewelry. There are investment funds that claim to be able to consistently beat the market, or that will protect your money through any market collapse... and in all those cases there's no defined stop point. The product is the prop, not the scam. Sure, in the context of the scam the prop isn't worth it, but that doesn't mean anyone offering the prop is scamming you. Physical training services, votes, gold, jewelry, investment funds, etc. aren't all bunk.
> Once a year for a health checkup. Is that the norm for therapy?
So now it's the frequency that's the issue, rather than not having a defined stop point?
> The more involved answer is that "mental health" is not well-defined, so it's not developing anything.
That's your answer. That's not my answer, and it's not the answer.
> The best analogy for psychiatric therapy is physical therapy for recovering from an injury or surgery, except physical therapy has a well-defined end condition, which is when you understand how to do the exercises yourself.
I don't think you appreciate how limited your perspective on this is. Not everything is a problem that can be fixed.
This presumes that the only possible physical therapy service is education. My mother suffers from late-stage dementia. She is at risk for falling whenever she walks, and performing more involved physical activities absolutely requires guidance. It is literally impossible to educate her out of this situation, so the only stop point for the service is death. While family does sometimes provide these services for her, there's little doubt that the professionals we hire to provide these services for her are able to do the job better and more consistently than we can; there's little doubt that she is physically and mentally healthier as a consequence of their services, and that her physical & mental health would begin to decline within days of terminating those services. Now, I don't know that their particular form of physical therapy is empirically valid, and I guess they could be scamming us, but in the vast majority of cases, providing these services is not a scam. It's offensive to claim otherwise.
Now, my sister-in-law has the reverse situation: she has a physical problem and requires mental health services. She suffers from COPD that will kill her unless something else gets to her first. Above and beyond the physical condition, it is very hard for her to cope with it mentally. Again, family provides her with support, but it's not enough. She employs a mental health therapist to address her anxiety, depression and suicidal ideation. There's maybe some feint hope that the therapist will educate her to a state where she no longer experiences suicidal ideation, but nobody expects the anxiety & depression to go away, because COPD is an anxiety and depression invoking condition... a well educated, rational, COPD patient can be anxious and depressed. You could say that, with or without professional service, the failure rate is nearly 100% (helpful to consider in the context of comments about the failure rate for mental health therapy). So there's no defined stopping point for the therapy short of death. In this particular case, it's a CBT therapist, but even if it wasn't, what she needs is more than education; she needs support. While we can't rule out that she's being scammed, in the vast majority of the cases, providing these services is not a scam. It's offensive to claim otherwise.
> The more involved answer is that "mental health" is not well-defined, so it's not developing anything.
I'll try one last metaphor:
Nutrition is not well defined. We have broad ideas about what is and isn't good for you, but the specifics of what is "good nutrition" are variable & contextual; while one can have well defined nutritional goals, many people do not. There's a ton of "nutritionists" who have no formal training, who don't exercise science. There are short order cooks with no formal training, who don't exercise science. If a grocer has formal training, it is far more likely in business or marketing than anything involving nutrition. There is no defined stop point where you no longer need food. There are plenty of scams involving nutritional guidance or foods (just the categories "health food" and "diet plans" are littered with scammers). Despite all that, there is no compelling argument that restaurants, chefs, grocers, or other nutritional services are intrinsically scammers. I'm pretty sure that, if I don't eat, my health will deteriorate, and I have a hard time believing that a professional either guiding my nutritional choices or outright providing nutrition for me is intrinsically scamming me. They could well be providing me a valuable service where I get better nutrition with less time and effort than if I tended to it without them.
I get it. You are convinced therapy is intrinsically a scam, and part of the reason for that is most customers for therapy cannot reliably discern if they are being scammed or not. I'm far from an expert on the subject, so for all I know, you are right. However, the arguments you are presenting are not compelling arguments.
> So now it's the frequency that's the issue, rather than not having a defined stop point?
You have a physical problem, you go to the doctor and he fixes the problem or gets you the information you need to manage your problem. That's the stop point for medical intervention.
You have a mental health problem, you go to a therapist for a mental health intervention, and now you're in weekly therapy for years. Not so much an intervention, more like a new part time job.
Yearly checkups is not a counterpoint to this general trend. A yearly mental health checkup could be totally reasonable, but that's not the norm.
> Not everything is a problem that can be fixed.
The real issue here is that you keep bringing up outliers like your mother's palliative care and I keep talking about the norm, ie. that most people in therapy are not like your mother. Therapy has become fashionable. Everyone is "working on themselves" and plenty of therapists like patients that are well off and so can pay regularly.
> I get it. You are convinced therapy is intrinsically a scam
No, that's not the point I'm making. At best, you could maybe case what I'm saying as "the therapy industry/fad is a scam, and plenty of therapists, psychologists and psychiatrists are feeding into it".
There are people that legitimately need therapy to develop coping strategies to address trauma or retrain maladaptive behaviours, because even as ineffective as it sometimes is, it's better than nothing. My point is that a lot of people who go to therapy probably don't need therapy, and even if they do they don't need as much as they think they do, the techniques in therapy are not very effective even in the best case, and that therapists are not incentivized to stop seeing patients that are paying them well and triage to cases that need more urgent intervention and probably can't pay them regularly.
Part of this is probably because of the US's dysfunctional medical system, and another part is because psychology and psychiatry has not had a good track record for empirically sound practices. It's getting better but has some ways to go.
> The real issue here is that you keep bringing up outliers like your mother's palliative care and I keep talking about the norm, ie. that most people in therapy are not like your mother.
So, if the customer is dying (and we're all dying), it's not a scam, but if the same service is provided to someone else, it's a scam? That almost sounds like, (...wait for it...), the service isn't the scam.
> Therapy has become fashionable.
Nothing worse than services that have become fashionable.
> Everyone is "working on themselves" and plenty of therapists like patients that are well off and so can pay regularly.
Nothing quite like customers who can afford to pay for your services. Mercedes dealers tend to focus on those people too. ;-) Is it your position then that services that only wealthier people can afford are a scam? Is it not possible that they're receiving some benefit from the service that others would benefit from if they could somehow afford them?
> My point is that a lot of people who go to therapy probably don't need therapy, and even if they do they don't need as much as they think they do, the techniques in therapy are not very effective even in the best case, and that therapists are not incentivized to stop seeing patients that are paying them well and triage to cases that need more urgent intervention and probably can't pay them regularly.
Ice cream is similarly a scam, because a lot of people don't need ice cream, but they think they do. The ice cream is not very effective for them even in the best case, and ice cream makers are not incentivized to stop selling it to people who don't need it.
I sometimes recommend Dr David Burns' Feeling Good podcast[1], and he is big on measuring and testing and stop points. Instead of 'tell me about your mother' his style of Cognitive Behavioural Therapy (CBT) is called TEAMS in which the T stands for Testing, and it involves:
- Patient choosing a specific mood problem/feeling they want to work on.
- A mood survey, where the patient rates their own level of e.g. anxiety, depression, fear, hopelessness. (e.g. out of 5 or 10).
- Therapy session, following his TEAMS CBT structure. Including patient choosing how much fear they'd like to feel (e.g. they want to keep a little bit of fear so they don't endanger themselves, but don't want to be overwhelmed by fear, 5% or 20%, say).
- A repeat of the mood survey, where the patient re-assesses themselves to see if anything has improved. There's no units on the measures because it's self-reported, the patient knows if the fear is unchanged, a little less, a lot less, almost gone, completely gone, and that's what matters.
That gives them feedback; if there is improvement within a session they know something in the session helped, if several sessions go by with no improvement they know it and can change things up and move away from those unhelpful approaches in future with other patients, and if there is good improvement - patient is self-reporting that they are no longer hopeless about their relationship status, or afraid of social situations, or depressed, to the level they want, then therapy can stop.
He's adamant that a single 2hr session is enough to make a significant change in many common mood disorders[2], and this "therapy needs to take 10 years" is a bad pattern and therapists who don't take mood surveys and before and after every session are flying blind. With feedback on every session and decades of experience, he has identified a lot of techniques and ways to use them which actually do help people's moods change. I liken it to the invention of test cases and debuggers (and looking at the output from them).
I agree some therapists are starting to come around on this, but even what you describe is somewhat flawed due to placebo effects, eg. some always feel better from any kind of talk, probably as a result of someone paying attention to their problems.
You might be able to overcome this effect by quantitatively tracking this across many sessions to some degree, but I think it's still always the patient that has to walk away, and never the therapist who says, "you're good, go on now".
I think you're mistaken, at least in a lot of cases. All CBT based therapies I've had have started with a clear discussion about what the problem is, and what the solution looks like in terms of my happiness and mental well-being. In all cases, my therapist has "graduated" me, telling me that they don't think I need to continue (or having me say that I'm comfortable now stopping regular therapy).
CBT and its derivatives very strongly attend to individual effectiveness and view therapy that goes on endlessly as a sign that the real problem isn't being addressed, and that no therapy is considered effective unless it ends. Individual therapists might be bad actors, but the field itself is now admirably focussed on finite, positive results.
It’s implying that this is the case for many people, not all. Which it is, in my experience. Particularly since the advice you gave:
> then you should get another therapist
Seems to be fairly ubiquitous. “Find a therapist you like”/“shop around”/etc. leads a lot of people to find people who will tell them what they want to hear. Sometimes what people want to hear is how to practice CBT - but in that case, such people are probably going to be using AI to work on CBT.
Yeah I have found there is very little you get from therapy that you can't get from a mixture of journalling, learning CBT methods, having a routine (which includes regular exercise) and trying lots of different methods of making friends that you assess maturely for their reliability. Maybe meditation if you're into that. All of these things are free and require effort, personal effort and intention being what will actually improve your life anyway, whether you use therapy or not. This makes therapy seem like a scam for anything other than dealing with a very dire short period of isolation.
GP's not saying that, what GP is saying is "good luck trying to talk to your therapist if you stop paying $$$".
I do think therapists are one of the professions that will be naturally displaced by LLMs. You're not paying them to be your friend (and they are usually very clear on that), so any sort of emotional connection is ruled out. If emotions are taken away, then it's just an input/output process, which is something LLMs excel at.
I would argue the opposite: a good therapist isn't just offering back-and-forth conversation, they're bringing knowledge, experience and insight into the client after interacting with them. A good therapist understands when one approach isn't working and can shift to a different one; they're also self-reflective and very aware of how they're influencing the situation, and try to apply that intelligently. This all requires reflective and improvisational reasoning that LLMs famously can't do.
Put another way, a good therapist is professionally trained and consciously monitoring whether or not they're misleading you. An LLM has no executive function acting as a check on its input/output cycle.
Not in the least. LLMs don't introspect. LLMs have no sense of self. There is no secondary process in an LLM monitoring the output and checking it against anything else. This is how they hallucinate: a complete lack of self-awareness. All they can do is sound convincing based on mostly coherent training data.
How does an LLM look at a heptagon and confidently say it's an octagon? Because visually they're similar, octagons are relatively more common (and identified as such) while heptagons are rare. What it doesn't do is count the sides, something a child in kindergarten can do.
If I were working in AI I would be focussing on exactly this problem: finding the "right sounding" answer solves a lot of cases well enough, but falls down embarrassingly when other cogitive processes are available that are guaranteed to produce correct results (when done correctly). Anyone asking chatgpt a math question should be able to get back a correctly calculated math answer, and the way to get that answer is not to massage the training data, it's to dispatch the prompt to a different subsystem that can parse the request and return a result that a calculator can provide.
It's similar to using LLMs for law: they hallucinate cases and precedents that don't exist because they're not checking against nexis, they're just sounding good. The next problem in AI is the layer of executive functioning that taps the correct part of the AI based on the input.
I feel like this is easier said than done. There's not a great way (that I know of) to evaluate the quality/potential helpfulness of therapists... if only there were a Steam-like review system for them! There's ratemds.com, but not a lot of people use it, since there's not a central marketplace to find therapists to begin with (that I know of). I would love to be able to find good therapists locally and/or online. It just seems like such an expensive gamble every time.
When I was younger, I went through many therapy sessions with multiple professionals of different kinds (psychologists, psychiatrists, MFT (marriage and family therapists, social workers, etc.).
A couple of them were wonderful: thoughtful, caring, helpful, providing useful guidance with a compassionate ear.
Another couple tried to be helpful but were still in training themselves (this was at a college) and couldn't really provide any useful guidance.
One was going through a divorce of her own at the time and ended up crying in many of our sessions and having to abort them to deal with her own emotions – it was a tough time for her, and she's only human. I often tried to console her, but she wouldn't let me, so it made for a very awkward situation lol.
One of them had one a single session with me, charged me for it, and then told me she couldn't help me and to go somewhere else.
But the worst of them was an older guy who, despite the referrals and my history, thought I was faking mental illness. He dared me to attempt suicide, and when I eventually did (not because of him, but a separate romantic failure), he chuckled in my face and said, "Heh, you finally tried it, huh? Didn't think you would." This was an older psychiatrist in a small town – either the only one there, or one of very few – the kind of sleazy place that had a captive market and a whole bunch of pharma ads in the lobby, with young female pharma reps going in and out all day. What a racket =/ If I were wiser then, I would've reported him to the board and news media.
So, anecdotally, my success rate with therapists was only 2/7. To be fair, I was a pretty fucked up teenager and young adult, but still... the point is that "just find a better therapist" is often a difficult process. Depending on your insurance and area, there may not even be any other therapists with a waiting list of less than a few months, and even if you can get in, there's no guarantee they are good at their jobs AND a good fit for your personality and issues.
Think it's hard to find good devs? At least our line of work produces some measurable output (software/apps that run, or not, according to specs). How do you even measure the output of a therapist? Improvements to someone's life aren't going to happen overnight, and many never report back; the best successes may not bother to leave a review, the worst failures may end up dead before spreading the word. The rest probably just run out of sessions allowed by their insurance and try to move on with their lives, with unknown levels of positive or negative change.
