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  #1  
Old 01-15-10, 10:21 PM
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Therapy Techniques: Science vs. Experience

I just read an interesting article describing a debate in the psychology profession over, essentially, whether cognitive-behavioral therapy, which is asserted to have the most scientific support for its effectiveness, and to work more quickly than other techniques, should be adopted by all therapists:

Quote:
In a November report that's attracting controversy the way couches attract loose change, three professors charge that many mental health practitioners are using antiquated, unproved methods and that many clinical psychology training programs lack scientific rigor.

On the one side sit the report's authors and other like-minded psychologists who say that too many clinicians favor personal experience over scientific evidence when deciding on a patient's treatment. They are particularly unsettled by the number of therapists -- especially from training programs that grant a higher degree known as doctor of psychology, or PsyD -- who ignore the most-studied type of treatment: cognitive behavioral therapy.

"Too many clinical psychologists tell us they don't look to research, they don't look to science," says Timothy Baker of the University of Wisconsin, lead author of the report, published in the journal Psychological Science in the Public Interest.

On the other side of the fight are psychologists who say that what matters most is not the type but the quality of mental health treatment and who fear that the push toward cognitive behavioral therapy -- which is cheaper but not effective for everyone -- is being used by insurance companies to cut down on costs.

The new report's authors and their supporters "are largely people who not only don't practice themselves -- and therefore have no idea what would be relevant to practice -- but have a tremendous disdain for people who do practice," says psychologist Drew Westen of Emory University.

At the core of the debate is a difference over how clinical psychologists approach therapeutic practice.

One group, largely academic, believes psychology should follow a medical model, addressing specific ailments with specific treatments developed and tested for that purpose. This group overwhelmingly embraces cognitive behavioral therapy that -- briefly put -- aims to correct misguided beliefs and reactions that contribute to mental disorders.

A mounting pile of research shows that cognitive behavioral therapy can effectively treat anxiety disorders, post-traumatic stress disorder, depression, bulimia and substance abuse problems. The method has performed as well as antidepressant medication in treating depression in recent studies. What's more, patients receiving cognitive behavioral therapy have shown less likelihood of relapse than their medicated peers because the therapy teaches them how to handle their disorder.

That is not how the other camp sees the situation. This group, largely practicing therapists, prefers a less confining treatment method that emphasizes a strong relationship between therapist and patient. It tends to favor more traditional approaches such as psychodynamic therapy, in which the therapist plumbs the patient's unconscious, or humanistic therapy, which stresses self-determination.

This camp says that these methods are harder to test than cognitive behavioral therapy, which follows a step-by-step treatment plan.

The scientific reputation of cognitive behavioral therapy has left many with the impression that all other therapies are unproved -- quack methods, invented by clinicians on the fly -- but that's sensationalism, says psychologist John Norcross of the University of Scranton, Pa. He says there's plenty of support for traditional psychotherapies from careful case studies and data collected by therapists working in clinics.
(I cut and pasted paragraphs from the article, to try and convey the gist of both arguments, but it's really worth reading the whole thing)
http://www.latimes.com/features/heal...352,full.story

When I took an intro to psychology course in college, I asked a psychiatrist about the effectiveness of the various therapy techniques I was reading about. (existential, humanistic, gestalt, etc.) He said they were all quite effective, provided their developer was your therapist (i.e. humanistic therapy is very effective if your therapist is Carl Rogers). Implicit in the answer is that none(or most) of them don't work in practice, if followed rigidly. His idea, I think, was that everyone had to find something that worked for them.

I'm not a therapist, but I've been in therapy off and on a number of times over the years. None of my therapists ever told me which, if any, of these approaches they were using, but thinking back on it it's not terribly difficult to figure out. Personally, the one that seemed least helpful to me seemed to follow a psychodynamic approach.(although perhaps it was my fault for being able to recall my dreams so rarely) and the one that I found most helpful, seemed to mix cognitive-behavioral therapy with 'coaching'.

I'm curious as to what others, therapists and patients, think about this debate, and have found effective. I think the question raised in the article is a difficult one. If one technique has proven to be more effective more quickly than others, it seems obvious that it should be the first choice. On the other hand, at the level of the individual therapist, if someone through trial and error has found a unique approach that they find works best for them and their patients, a study doesn't necessarily disprove their belief. They can say, correctly, that they weren't the one administering the therapy found less effective than CBT, and thus that their unique approach wasn't tested.
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Old 01-16-10, 12:25 AM
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Re: Therapy Techniques: Science vs. Experience

Personally, I'm more on the CBT side based on the science and my own personal experience.
The science right now favors CBT and I think based on the huge volume of research in favor of it, it is safe to say it should the first line of treatment in most therapy. It shouldn't be the only one of course, but therapists shouldn't just dismiss it and run to other unproven methods because they don't like being constrained. Even if they have found a different method of therapy that has worked for some people, the first method they try with each individual patient should be CBT.
Science says it works, and even without my own positive personal experience with CBT (which I wouldn't expect to convince anyone else), that is enough for me.
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Old 01-17-10, 02:31 PM
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Re: Therapy Techniques: Science vs. Experience

APSJ

I had to do some work to figure out how to approach this. This has been an ongoing discussion in the field for quite a while and I do not see any easy solution to resolve it. For what they are worth, these are some of my thoughts.

First I am going to say that when Cognitive Therapy works, it works well. This has been shown over and over and there is no question of this. For depression, anxiety, and similar issues nothing beats it.

Now having said that, I am going look at some of the aspects of private practice.

A private practitioner, to be successful, must depend to a good extent on referrals from satisfied ex patients and professionals who refer patients to the therapist. The private practitioner, at least one who prefers to eat, must take care of the needs of the patient and referral sources. In the academic world this is not a priority, they get paid anyway especially if they have tenure.

To work in private practice, the therapist here must be aware and sensitive to several variables that operate here.

First is the patient. What works for that person? What does that individual respond or resonate to? Some simply to get out in a safe environment feelings held within themselves. Some want to change specific behaviors. Some simply need a place to talk and be accepted. Some do not know what they really want, just that they are really unhappy. The needs and combination of needs is almost endless and no single therapy will attend to all of them.

The needs of the patient must be kept foremost in the mind of the practitioner if the therapist is to be successful. If you do not address or at least seem to address these needs, the patient is very likely to drop out. The article mentioned a 40% drop out rate. No private practitioner could survive this high of rate of those who start and don't come back or complete the therapy. The patient must feel their individual needs are being met and if any therapy does not do this then progress probably will likely not happen and dropping out occurs.

The second is the personality of the therapist. What works for the individual practitioner? What fits the personality of the therapist? What kind of patient do they have the best success with? If someone tries to use methods in which they do not really believe then that will be sensed and trust probably will not occur.

A third factor is the relationship between the patient and the therapist. One of the cardinal rules (at least in my opinion) is the therapist must be, in Carl Rogers words, "genuine". They must be "real" to the patient. To paraphrase the immortal words of Flip Wilson "What you see is what you get." That is the basis of trust. Many, and I am one, feel that trust is the key factor and therapy is the "Art of the Relationship".

For many Cognitive Therapy does not work on that level and other methods do. From the article:
"[Cognitive-behavior therapy] is deliberately designed to ignore any relevant features of the personality of the individual If the therapist's methods do not resonate with the patient then success will be limited."

When the need is to change specific behaviors or feelings, Cognitive behavioral methods work very well. So many, however, come for other reasons or combination of reasons and the therapist must find ways of addressing the whole person, not just a set of symptoms. In private practice, you must treat the person and the more successfully one can do this the more successful the practice.

In most therapeutic relationships, when the chemistry does not work it does not work. The lack of establishing a trusting, caring relationship pretty much guarantees the therapy will not be successful. There are exceptions to this but I suspect not too many.

Again, many feel from experience that therapeutic success depends on the relationship between the therapist and the patient. The studies in the article really do not seem to address this all that much but for many therapist and patients this is the prime key. Also this is where a strictly cognitive therapist may fail. For many, this is strictly a nuts and bolts approach to solving a very specific problem and not much effort is placed on the relationship.

Now while I like cognitive based methods, I see it as a part of a toolbox of therapeutic tools. Cognitive Therapy especially the more collaborative one described by Beck resonates well with me and someone like myself would be most effective with patients who also resonated well to those methods. It is just part of who the therapist is all practitioners need to be very aware of themselves in this regard. For me, I like the team approach to find what works for the individual, the therapist, and the issues both bring with them.

To recap: While Cognitive Therapy works well for many situations it is far from a "cure all" at least in my opinion.

To survive in private practice, one must be attuned to the needs of the patient and use what methods that will produce progress. In academic settings, one can better choose the patients seen and do not have the nasty necessity of making a living from satisfied patients and referral sources.

Most practitioners that I know use Cognitive methods but only as a part of the tool box used to craft the therapy to fit the individual.

From this I feel that to limit practitioners to just Cognitive Therapy would be a disservice to the patients and, at least in private practice, this should be our first concern (although getting paid ranks right up there).

I like the last statement in the article: "I don't care what psychotherapy the person is getting," Lambert says. "I care whether they're responding."


APSJ, this covers only some aspects of the article and I hope is fits some of what you wanted to address. I was limited in time as I was getting ready for a visit from two of my children, my delightful daughter in law and my beautiful seven month granddaughter and I wanted to respond in a timely manner.

PS, it was a great visit.

Take care,

Dizfriz
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Old 01-19-10, 04:09 PM
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Re: Therapy Techniques: Science vs. Experience

Dizfriz,
That seems a very rational response to the issue, and certainly fits with my experience.

While I think the approach that worked at all with me ultimately was CBT of a sort, I can say with some certainty that if it had been tried earlier in my life, it would not have. It involved a lot of pointed, sometimes uncomfortable questions about the way I was thinking(and speaking) about things, and 'homework' involving pushing the bounds of what I was comfortable with. At the time, I had sought out this doctor, and was determined to make progress, and was able to set aside my instinctive aversion (and occasional anger) at the things he questioned me about, and told me to do.

I tend to think that if someone had tried this approach with me earlier in my life, particularly while I was in high-school, I would have never returned after the first session, no matter how much pressure was put on me to do so.

To a certain extent, it seems like common sense to me that people go to therapists with different needs, and a one-size-fits-all approach will never be appropriate. I know that some people get an enormous benefit from just being able to vent their problems to someone who will listen sympathetically (and who may be legally obligated not to disclose what they say). It seems like common sense to me that if someone went to a therapist clearly wanting to unburden themselves of a problem, cutting them off and starting in on CBT would likely only keep them from coming back.
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Old 01-26-10, 10:29 AM
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Re: Therapy Techniques: Science vs. Experience

I just came across this article. I wonder if it's a coincidence they came out so close together?

Quote:
According To New Study, Psychodynamic Psychotherapy Brings Lasting Benefits


Psychodynamic therapy focuses on the psychological roots of emotional suffering. Its hallmarks are self-reflection and self-examination, and the use of the relationship between therapist and patient as a window into problematic relationship patterns in the patient's life. Its goal is not only to alleviate the most obvious symptoms but to help people lead healthier lives.

"The American public has been told that only newer, symptom-focused treatments like cognitive behavior therapy or medication have scientific support," said study author Jonathan Shedler, PhD, of the University of Colorado Denver School of Medicine. "The actual scientific evidence shows that psychodynamic therapy is highly effective. The benefits are at least as large as those of other psychotherapies, and they last."

The eight meta-analyses, representing the best available scientific evidence on psychodynamic therapy, all showed substantial treatment benefits, according to Shedler. Effect sizes were impressive even for personality disorders - deeply ingrained maladaptive traits that are notoriously difficult to treat, he said. "The consistent trend toward larger effect sizes at follow-up suggests that psychodynamic psychotherapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended," Shedler said. "In contrast, the benefits of other 'empirically supported' therapies tend to diminish over time for the most common conditions, like depression and generalized anxiety."
http://www.medicalnewstoday.com/articles/177110.php
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